發展遲緩/障礙嬰幼兒之ICF-CY功能剖面圖於專業間評估之應用

Abstract

背景與目的：發展遲緩與發展障礙（以下簡稱DD）嬰幼兒為早期介入重要對象。依據兒童及少年福利法與身心障礙者權益保障法，DD兒童應接受專業評估，並依評估結果提供適當服務。目前作為早療資格認定與團隊溝通之發展遲緩兒童評估綜合報告書（以下簡稱評估綜合報告書）主要依據發展觀點撰寫而成，並涵蓋少部份環境因素評估。世界衛生組織所推動之「國際健康功能與身心障礙分類系統－兒童及青少年版」（ICF-CY），強調活動與參與、環境之重要性，以及功能與其他因素之交互影響；並可作為現有評估報告探討之參考依據。因此，本研究針對三歲以下之DD嬰幼兒，有以下兩項目的：一、建立團隊評估與早療資格認定時所必須考慮的發展遲緩/障礙嬰幼兒核心位碼組（以下簡稱EDD位碼組）；二、將現有評估綜合報告書內容連結至EDD位碼組，以探究報告書內容。方法：首先針對熟悉ICF-CY與DD嬰幼兒功能之國際間專家與國內早期療育領域專家，以現有針對三歲以下嬰幼兒之ICF-CY核心位碼組為基礎，進行國際德爾菲調查，建立EDD位碼組。接著以臺大醫院2010年7-12月間20份三歲以下DD嬰幼兒之評估綜合報告書作為連結材料，由二位具有兒童發展與評估豐富經驗，接受過ICF-CY訓練，且熟悉連結規則之專業人員，將每份評估綜合報告書中內容進行意義概念識別，連結至EDD位碼組各位碼及給予限定值；並計算EDD位碼組與報告書必填部份與整份報告之平均位碼連結率與編碼（位碼＋限定值）連結率。結果：針對目的一，25位專家完成國際德爾菲調查。共有82個ICF-CY二位碼被納入EDD位碼組，包含活動與參與之28個位碼，身體功能之29個位碼，身體構造之10個位碼，與環境因素之15個位碼。針對目的二，20份評估綜合報告書共可識別4378個意義概念，其中1179個意義概念出自報告書必填部份，3199個意義概念出自各專業人員所附加填寫之評估結果。評估綜合報告書中必填部份與全部EDD位碼之平均位碼/編碼連結率為22%/19%，整份報告之平均位碼/編碼連結率則為57%/54%，較必填部份皆高出35%。整份報告中d成份之平均位碼/編碼連結率為88%/84%，b成份之平均位碼/編碼連結率為51%/50%，s成份之平均位碼/編碼連結率為15%/15%，e成份之平均位碼/編碼連結率為31%/21%。報告書中部份意義概念連結至個人因素與EDD位碼組以外之ICF-CY位碼，其中許多為與家庭有關之環境因素。結論：EDD位碼組包含三歲以下DD幼兒接受早療團隊評估與資格認定時所必須考慮的82個二位碼。以ICF-CY觀點，現有評估綜合報告書內容提供足夠有關活動與參與之資訊；但許多出自專業人員附加填寫部份，使得評估報告書品質易受專業人員個別性影響。較低的環境因素與身體構造連結率需進一步探究原因。未來評估綜合報告書之設計可考慮納入EDD位碼組，以全面性觀點描述DD幼兒之功能。

Background and purpose: Early assessment is important in providing early intervention services for infants with developmental delay/disabilities (DD). According to the By-laws of Children and Youth Welfare Act and the People with Disabilities Rights Protection Act, the eligibility determination for children with DD to receive early intervention services should be decided after assessment. Current Evaluation Reports, used for eligibility determination and inter-professional communication, are based on the developmental-specific viewpoint, and the impact of the environment is usually ignored. The International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY) published by WHO emphasized the importance of activities/participation and environmental factors, with functioning resulting from the interactions between components, could be used as a reference in exploration of current Evaluation Reports. For infants under three years of age and with DD, there are two purposes of this study: (1) To identify/derive an ICF-CY code set for infants with early delay and disabilities (EDD code set) for team initial evaluation and eligibility determination; (2) To explore the content of current Evaluation Reports in terms of ICF-CY, with linkage to the EDD code set. Methods: the EDD code set was developed through an international Delphi survey by a group of professionals who had experiences in conducting studies or implementing ICF-CY, and the professionals in the early intervention service system in Taiwan, based on current ICF-CY code sets for infants under three years of age. Then 20 Evaluation Reports for infants with DD from National Taiwan University Children’s Hospital (NTUCH) during July- December, 2010 were linked to the EDD code set table by two linking professionals with basic concept of child development and experience in evaluating and treating infants with DD, and were familiar with the framework and classification/coding structure. The meaningful concepts were identified in the Evaluation Reports, and then were linked to the EDD code set table and assigned generic qualifiers or denoted. The mean category linking percentage and code (category + qualifier) linking percentage of the EDD code set were calculated separately for the compulsory part and the whole report for content exploration. Results: (1) Twenty-five professionals completed the Delphi survey. A total of 82 ICF-CY second level categories were identified for the EDD code set, including 28 categories in Activities and Participation, 29 categories in Body Functions, 10 categories in Body Structures, and 15 categories in Environmental Factors. (2) There were 4378 meaningful concepts identified in the 20 Evaluation Reports, with 1179 concepts in the compulsory part, and 3199 concepts in the additional part. The mean category/code linking percentage for all categories of the compulsory part was 22%/19%. The mean category/code linking percentage of the EDD code set for all categories of the whole report was 57%/54%, both 35% higher than the compulsory parts. The mean category/code linking percentage of each component in the whole report were 88%/84% in the Activity and Participation (d) component, 51%/50% in the Body Function (b) component, 15%/15% in the Body Structure (s) component, and 31%/21% in the Environmental Factors (e) component. There were some meaningful concepts in the Evaluation Reports linked to Personal Factors component and other ICF-CY categories; many of them were family-related environmental factors. Conclusions: The EDD code set with 82 essential ICF-CY categories should be taken into consideration in the initial team evaluation for infants under three years of age with DD. The linkage of the 20 Evaluation Reports of one medical center to the EDD code set revealed that current reports contained sufficient activity and participation information, but less information was included in the compulsory part. Lower category linking percentages in Environmental Factors and Body Structures were noted and need further examination. Future design of the Evaluation Reports may add ICF-CY categories in the EDD code set to describe functioning for infants with DD, in a more holistic viewpoint.