臺灣博碩士論文加值系統

背景：自閉症類群障礙是一終身神經發展疾患，其核心缺陷症狀之一為認知彈性缺損，認知彈性泛指個體可以根據情境需求轉移不同的想法或行為的能力。目前臨床上最廣泛使用的神經心理評估工具為「威斯康辛卡分類測驗（Wisconsin Card Sorting Test, WCST）」和「劍橋心理認知衡鑑系統內外向度轉換測驗（Intra-dimensional/ Extra-dimensional Set Shift, ID/ ED）」，但過去研究並不一致。部份研究指出自閉症患者（ASD）具認知彈性缺損，部份研究指出ASD患者與一般正常發展受試者（TD）並無顯著差異，此不一致的發現可能是因年齡、智力和ADHD 症狀嚴重度影響。因此本研究將探討ASD組和TD組在不同年齡層、智力水準和ADHD症狀嚴重度的影響之下，在內在控制轉換WCST和外在線索轉換ID/ ED認知彈性測驗是否有顯著差異。

方法：WCST測驗納入年齡及智力配對之141位ASD組和94位TD組受試者；ID/ ED測驗亦納入年齡及智能配對之102位ASD組和102位TD組。首先以共變數分析比較控制年齡和智力影響之後，ASD組與TD組在認知彈性測驗表現是否具顯著差異；其次以年齡和智力分組，進行共變數分析比較ASD組與TD組在認知彈性測驗表現；最後分析ADHD 症狀和認知彈性測驗之相關，並且討論在控制ADHD症狀嚴重度的影響後，ASD組在認知彈性測驗之表現。

結果：內在控制WCST測驗發現ASD組表現顯著差於TD組。在兒童組（7-12歲）和高智力（FIQ> 100）組具顯著差異，ADHD不專心、過動/ 衝動症狀和WCST測驗表現呈現低相關，在控制ADHD症狀的影響後，ASD組和TD組仍達顯著差異。在外在線索轉換ID/ ED測驗則是跨年齡大小和智力高低一致發地發現ASD組和TD組具顯著差異，ADHD不專心、過動/ 衝動症狀和ID/ ED測驗表現呈現低相關，在控制ADHD症狀的影響後，發現ID/ ED所有測驗表現皆未達顯著差異，顯示ADHD症狀顯著干擾ASD患者在內外在線索轉換ID/ ED測驗之表現。

結論：本研究結果顯示內在控制WCST測驗可在7-12歲和FIQ> 100條件下，看到ASD組顯著缺損於TD組；外在線索ID/ ED測驗則可在控制ADHD的症狀影響後，於跨年齡大小和智力高低看到ASD組顯著缺損於TD組。

Background: Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder. Symptoms of the manifest ASD as impairments in cognitive flexibility, the ability to adaptive switch among multiple representations as a function of changing relevant cues in the environment. The most commonly used of cognitive flexibility is the Wisconsin Card Sorting Test (WCST) and the Intra-dimensional/Extra-dimensional Shift Task (ID/ED), but the previous studies on ASD have yielded mixed results, some studies showed impairments in cognitive flexibility in ASD than typical development (TD), but some argued that there are no differences between two groups. Previous studies have described that children with ASD (30-50%) suffer from comorbid with Attention deficit/ hyperactivity disorder (ADHD) symptoms, and several studies showed children with ADHD had poor performance in WCST. To date, only few studies examine the severity of comorbid ADHD symptoms, whether would influence the performance of cognitive flexibility in ASD.

Objectives: Previous studies argued the inconsistencies might be due to differences in participant characteristics like age, IQ, and co-occurring ADHD symptoms. The aim of this study was: (1) to split participant into age (children and adolescents) and FIQ subgroups (high-FIQ and low-FIQ) to investigate whether ASD group shows cognitive flexibility impairments than TD group on WCST and ID/ ED test (2) to investigate the influence of comorbid ADHD symptoms on WCST and ID/ ED test.

Methods: In WCST test, including 141 ASD and 94 TD matched by sex, age and FIQ. In ID/ ED test, 102 ASD and 102 TD also well matched.The computerized version of WCST and ID/ ED test were selected as cognitive flexibility measures. Symptoms in ASD were assessed by Autism Diagnostic Interview-Revise (ADI-R) and Social Communication Questionnaire (SCQ) , and in ADHD symptoms were assessed by Swanson, Nolan, and Pelham rating scale version IV (SNAP-IV).
For the analysis, firstly, group comparisons of demographic data were used independent t-tests. Secondly, Cohen's d was calculated to quantify the magnitudes of group effects in the differences of WCST and ID/ ED test. Lastly, the differences of WCST and ID/ ED test were examined through analysis of covariance (ANCOVA), whereby the analyses were controlled for the effects of the age FIQ and comorbid ADHD symptoms covariates.

Results: In the WCST, child and Higher-FIQ ASD group showed significantly worse than the TD group. In the ID/ ED test, across age and FIQ range all showed significantly worse than the TD group. Only ID/ ED test has main and interactive effects of comorbid ADHD symptoms.

Conclusions: The results show that, the internally controlled WCST test showed a significant difference between ASD and TD group in the 7-12 years old and FIQ> 100 conditions; the externally cued ID / ED test can stable found differences across age and intelligence level in control the impact on ADHD symptoms.

指導教授推薦書
口試委員會審定書
誌謝 iii
中文摘要 v
Abstract vii
目錄 ix
圖目錄 xii
表目錄 xiii
第一章 緒論 1
第二章 文獻回顧 4
第一節 自閉症類群障礙症之介紹 4
自閉症類群障礙的歷史沿革與診斷變革 4
第二節 自閉症類群障礙之認知理論探究 7
第三節 自閉症類群障礙執行功能探究 9
一、執行功能的發展模型 9
二、自閉症類群障礙與之認知彈性 11
三、內在控制轉換之認知彈性作業 13
四、外在線索轉換之認知彈性作業 21
五、認知彈性作業與ADHD症狀嚴重度的關聯性 28
第四節 研究問題與假設 30
一、研究問題與架構 30
二、研究問題與假設 30
第三章 研究設計與方法 34
第一節 研究對象 34
一、WCST臨床組樣本 34
二、WCST控制組樣本 34
三、ID/ ED臨床樣本 35
四、ID/ ED控制組樣本 35
第二節　研究工具 35
一、臨床篩選與診斷 35
二、症狀評估 37
三、認知彈性工具 39
第三節 研究流程 44
第四節 資料分析 46
第四章 研究結果 47
第一節 WCST結果摘要 47
一、WCST受試者相關變項分析 47
二、認知彈性WCST測驗之分析 49
第二節 ID/ ED結果摘要 56
一、ID/ ED受試者的相關變項分析 56
二、認知彈性ID/ ED測驗之比較分析 58
第三節 ADHD 症狀和認知彈性測驗結果摘要 65
一、ADHD 症狀和認知彈性測驗之相關 65
二、ADHD 症狀和認知彈性測驗表現之共變數分析 67
第五章 討論 69
第一節 研究結果摘要 69
第二節 WCST認知彈性測驗 71
第三節 ID/ ED認知彈性測驗 75
第四節 ADHD症狀與認知彈性測驗 81
第五節 研究限制 82
第六節 研究貢獻與臨床應用 84
參考文獻 85

表目錄
表2-1、回顧過去ASD在WCST測驗之研究摘要 15
表2-2、回顧過去ASD在ID/ ED測驗之研究摘要 25
表4-1、WCST受試者之基本人口變項 47
表4-2、WCST受試者之ASD組描述性統計資料摘要（N=141）48
表4-3、ASD組與TD組之WCST結果分析表 50
表4-4、兒童組（7-12歲）之WCST結果分析表 51
表4-5、青少年組（13-17歲）之WCST結果分析表 52
表4-6、低智力組（FIQ<=100）之WCST結果分析表 53
表4-7、高智力組（FIQ> 100）之WCST結果分析表 54
表4-8、ID/ ED受試者的基本人口變項 56
表4-9、ID/ ED受試者之ASD組描述性統計資料摘要（N=102）57
表4-10、ASD組與TD組之ID/ ED結果分析表 59
表4-11、兒童組（7-12歲）之ID/ ED結果分析表 60
表4-12、青少年組（13-17歲）之ID/ ED結果分析表 61
表4-13、低智力組（FIQ<=100）之ID/ ED結果分析表 62
表4-14、高智力組（FIQ> 100）之ID/ ED結果分析表 63
表4-15、ADHD 症狀與WCST測驗表現之相關分析表 65
表4-16、ADHD 症狀與ID/ ED測驗表現之相關分析表 66
表4-17、WCST測驗和ADHD症狀嚴重度之共變數分析表 67
表4-18、ID/ ED測驗和ADHD症狀嚴重度之共變數分析表 68

圖目錄
圖2-1、執行功能的發展曲線 10
圖2-2、內外向度規則轉換測驗（ID/ ED）流程示意圖 21
圖3-1、威斯康辛卡分類測驗（WCST）示意圖 40
圖3-2、內外向度規則轉換測驗（ID/ ED）示意圖 43
圖3-3、研究流程圖 45
圖5-1、WCST總嘗試數指標年齡發展圖 72
圖5-2、WCST總錯誤數百分比指標年齡發展圖 73
圖5-3、WCST持續性反應次數百分比指標年齡發展圖 73
圖5-4、WCST持續性錯誤次數百分比指標年齡發展圖 74
圖5-5、WCST類別完成數指標年齡發展圖 74
圖5-6、WCST總嘗試次數指標智力發展曲線圖 75
圖5-7、WCST持續性反應次數百分比指標智力發展圖 75
圖5-8、WCST持續性錯誤次數百分比指標智力發展圖 76
圖5-9、WCST概念水準反應百分比指標智力發展圖 76
圖5-10、ID/ ED總嘗試數指標年齡發展圖 78
圖5-11、ID/ ED總錯誤數指標年齡發展圖 78
圖5-12、ID/ ED內向配對總錯誤數指標年齡發展圖 79
圖5-13、ID/ ED總嘗試數指標智力發展圖 79
圖5-14、ID/ ED總錯誤數指標智力發展圖 80
圖5-15、ID/ ED內向配對總錯誤數指標智力發展圖 80

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