臺灣博碩士論文加值系統

在過去的十幾年，西方國家開始逐漸注意到智能障礙者可能有精神健康的需求，他們一致的認為智能障礙者也有可能表現與一般人有相似情緒上的困擾，甚至智能障礙者比一般智力正常的人更脆弱的發展成精神疾病。然而，由於重度及極重度之智能障礙者因有限的語言表達能力，無法將個人的情感、想法和信念表達出來以方便醫療專業人員診斷。有鑑於此，國外學者發展許多用於篩選不同障礙程度之智能障礙可能有精神疾病問題的評估量表，用以協助相關專業人員提供進一步精神醫療服務之用。反觀，台灣目前服務智能障礙者的機構都開始面臨智能障礙者合併精神疾病的狀況，亟需一個評估工具協助篩選智能障礙是否合併精神疾病的可能性，再加上重度及極重度智能障礙者比較困難被發現有合併精神疾病的狀況，因此特別從國外眾多評量工具中挑選重度身心障礙者診斷性評估工具第二版（DASH-II）進行中文版的心理計量研究，期望未來可以在台灣使用，協助所有服務重度及極重度之智能障礙者的專業人員提供醫療服務之依據。
本研究採橫斷式（cross-section）研究，以非隨機取樣法中的立意取樣台灣苗栗以北的啟智教養機構之重度或極重度智能障礙者（N=100），晤談其主要照顧者進行DASH-II中譯本和成人發展性障礙精神症狀檢核表（PAS-ADD Checklist Revised），以內在一致性信度檢驗、皮爾森相關法及羅吉斯迴歸進行統計分析。
研究結果顯示DASH-II中譯本各分量表的內在一致性與原英文版本相似，α介於.473~.823之間，三個向度的評分者間信度幾乎完全吻合，Kappa值分別為.982(頻率)、.952（持續時間）及.983（嚴重程度）。而DASH-II中譯本具有良好的效標關聯效度，與同為用於篩選智能障礙者有無精神疾病問題的成人發展性障礙精神症狀檢核表各分量表間達顯著相關；另外，以羅吉斯迴歸分析DASH-II中譯本13個分量表，初步分析結果顯示13個分量表具有解釋和預測效果，以Hosmer-Lemeshow檢定分析，其整體迴歸模式適配性尚可，顯示DASH-II中譯本尚具建構效度。
整體而言，DASH-II中譯本的信效度尚可，可用於台灣的重度及極重度智能障礙者篩選有無潛在的精神疾病問題。不過，除了廣泛性發展障礙/自閉症分量表外，DASH-II中譯本其餘分量表仍缺乏單獨的效度檢驗，因此臨床工作者需要依據至少兩個分量表上的分數超過切截分數，才可以篩選其具有潛在的精神疾病。

In the last ten years, Western countries gradually noticed that people with intellectual disabilities have the needs of mental health. They were thought to have the same emotional disturbance of normal individuals. People with intellectual disabilities seem to be more vulnerable for developing psychiatric disorders. Since people with severe and profound intellectual disabilities have limited verbal communication, they cannot express their personal emotions, thoughts, and beliefs for clinicians to diagnose. Several assessment tools in foreign countries have been developed for screening possible psychiatric disorders in individuals with different levels of intellectual disabilities, and clinicians can use assessment tools to help those who are experiencing psychiatric disorders receive mental health services. However, in Taiwan, clinicians working with people with intellectual disabilities face the situation that those individuals may have comorbid psychiatric disorders. The clinicians need an assessment tool to assess psychopathology in people with intellectual disabilities. In addition, diagnosing mental illness in people with severe and profound intellectual disabilities can be difficult. Among the numerous assessment tools in foreign countries, this study selected the Diagnostic Assessment for the Severely Handicapped Revised (DASH-II) and evaluated its psychometric properties in Taiwan. We hope DASH-II can provide useful information to assist people with intellectual disabilities in receiving mental health services.
This was a cross-sectional study. The participants (N=100) were recruited purposefully by interviewing the caregivers of individuals with severe and profound intellectual disabilities in institutions located north of Miaoli. They were administered the Diagnostic Assessment for the Severely Handicapped Revised (DASH-II) and Psychiatric Assessment Schedule for Adults with Developmental Disabilities Checklist Revised (PAS-ADD Checklist Revised). The statistical methods of Cronbach’s alpha coefficient, Pearson correlation, and logistic regression were applied in this study.
The internal consistency of the DASH-II Chinese version subscales was similar to the original English version. Cronbach’s alphas ranged from .473 to .823. The interrater reliability of the three dimensions was almost perfect. The Kappa coefficients of the interrater reliability were .982 for frequency, .952 for duration, and .983 for severity rating. The DASH-II Chinese version had good criterion validity. Every subscale of the DASH-II Chinese version correlated moderately with each of the subscales of the PAS-ADD Checklist Revised Chinese version. Furthermore, the DASH-II Chinese version had good construct validity. The results of the Hosmer-Lemeshow test confirmed the regression model fit of the logical regression, which supported the explanatory and predictive abilities of the DASH-II Chinese version.
The results of this study showed that the DASH-II Chinese version appeared to have adequate reliability and validity. It can be used in Taiwan to screen people with severe and profound intellectual disabilities for latent psychiatric disorders. Except for the pervasive developmental disorders/autism subscale, the other subscales of the DASH-II Chinese version still lack specific validation. So clinicians using the DASH-II Chinese version to screen for latent psychiatric disorders in people with severe and profound intellectual disabilities were recommended to rely on having at least two subscales with scores above the cutoff scores.

目錄
第一章 緒論------------------------------------------------------------01
第一節 研究動機----------------------------------------------------01
第二節 智能障礙的定義----------------------------------------------04
第三節 智能障礙者雙重診斷------------------------------------------08
壹、 雙重診斷歷史沿革------------------------------------------08
貳、 雙重診斷相關的理論及影響因素------------------------------09
參、 雙重診斷的盛行率------------------------------------------12
第四節 智能障礙者精神疾病症狀的表現--------------------------------15
壹、 挑戰性行為與雙重診斷--------------------------------------16
貳、 症狀表現--------------------------------------------------19
第五節 國外現行評估智能障礙者雙重診斷工具之內容探討----------------27
壹、 信效度的意義及種類----------------------------------------28
貳、 國外篩選智能障礙者有無精神疾病的評估工具或檢核表概述------30
第六節 研究目的與問題----------------------------------------------54
壹、 研究目的--------------------------------------------------54
貳、 研究問題及假設--------------------------------------------55
第二章 研究方法--------------------------------------------------------57
第一節 研究對象----------------------------------------------------57
第二節 研究程序----------------------------------------------------60
第三節 研究工具----------------------------------------------------62
第四節 資料分析----------------------------------------------------64
第三章 研究結果--------------------------------------------------------67
第一節 DASH-II中譯本信度檢測結果---------------------------------67
第二節 DASH-II中譯本效度檢測結果---------------------------------68
壹、 DASH-II中譯本之內容效度--------------------------------68
貳、 DASH-II中譯本之效標關聯效度----------------------------69
參、 DASH-II中譯本之建構效度--------------------------------76
第四章 討論------------------------------------------------------------81
第一節 DASH-II中譯本的穩定性及一致性-----------------------------81
第二節 DASH-II中譯本在臨床上應用的有效性-------------------------81
第三節 精神藥物在對DASH-II中譯本各分量表分數的影響--------------84
第四節 研究的限制與未來研究建議方向-------------------------------85
參考文獻---------------------------------------------------------------88
附錄一 對嚴重身心障礙的診斷性評估工具第二版原作者同意書---------------97
附錄二 參與臨床心理學研究同意書（家屬）-------------------------------98
附錄三 基本資料-------------------------------------------------------99
附錄四 參與臨床心理學研究同意書（工作人員）--------------------------100
附錄五 成人發展性障礙精神症狀檢核表原作者同意書----------------------101
附錄六 成人發展性障礙精神症狀檢核表中文翻譯作者授權同意書------------102
附錄七 DASH-II中譯本因素分析的結果----------------------------------103

圖目錄
圖1-1 智能障礙的理論模式-----------------------------------------------06
圖3-1 各量表間診斷之正確性---------------------------------------------70

表目錄
表1-1 智能障礙的病人同時有精神疾病之盛行率-----------------------------12
表1-2 不同障礙程度之智能障礙者其憂鬱症狀的表現-------------------------21
表1-3 不同障礙程度之智能障礙者其躁症症狀的表現-------------------------24
表1-4 不同障礙程度之智能障礙者其精神分裂症症狀的表現-------------------25
表1-5 不同障礙程度之智能障礙者其焦慮症狀的表現-------------------------27
表1-6 DASH-II八個分量表的效標關聯效度檢驗------------------------------46
表1-7 篩選智能障礙者有無精神疾病的評估工具或檢核表之概述---------------51
表2-1 受訪單位統計表---------------------------------------------------57
表2-2 受試對象障礙程度-------------------------------------------------58
表2-3 智能障礙者合併其他醫療診斷狀況-----------------------------------59
表2-4 內政部社會司對於智能障礙者的診斷準則-----------------------------61
表2-5 有無曾因情緒或行為問題就醫經驗在成人發展性障礙精神症狀檢核表之差異----63
表2-6 成人發展性障礙精神症狀檢核表與情緒行為問題就醫經驗邏輯回歸摘要表------64
表2-7 內容效度專家一覽表-----------------------------------------------65
表3-1 兩次研究各分量表的內在一致性結果---------------------------------67
表3-2 三位專家對各分量表所包含的題目之平均同意度-----------------------69
表3-3 DASH-II中譯本與成人發展性障礙精神症狀檢核表各量表之間的相關程度------72
表3-4 DASH-II中譯本與成人發展性障礙精神症狀檢核表各量表之間的正確性--------72
表3-5有無曾因情緒或行為問題就醫經驗在DASH-II中譯本各分量表分數之差異------74
表3-6有無合併精神障礙診斷在DASH-II中譯本各分量上分數之差異-----------75
表3-7有無合併自閉症診斷在「廣泛性發展障礙/自閉症」分量表分數之差異--------76
表3-8 DASH-II中譯本與因情緒或行為問題就醫經驗之羅吉斯迴歸分析摘要表---78
表3-9 「廣泛性發展障礙/自閉症」分量表分數與合併自閉症診斷羅吉斯迴歸分析摘要表----79
表3-10 DASH-II中譯本與合併精神障礙診斷羅吉斯迴歸分析摘要表------------80
表4-1 DASH-II中譯本各分量表在診斷合併精神障礙的鑑別力-----------------83
表4-2 有無服用精神藥物在DASH-II中譯本各分量表之差異-------------------85

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