研究背景與目的
腦性麻痺孩童常因動作控制困難或伴隨其他障礙而影響學校生活的參與，進而影響其學習及未來的社會適應。因此，促進腦性麻痺孩童的學校活動參與是醫療與教育人員的共同目標。影響腦性麻痺孩童學校活動參與的因素包含多面向，包括孩童的特質（身體功能與構造，功能）以及環境因素，然而，目前尚無研究囊括多面向因素來探討與腦性麻痺孩童學校活動參與的關係，因此，本研究將同時探討腦性麻痺孩童的功能與環境因素，從多面向的角度來探討腦性麻痺孩童學校活動參與影響因子。
研究方法
研究樣本為全台各縣市國小、特殊學校及腦性麻痺協會以及醫院復健門診之腦性麻痺國小學童。研究參與者納入條件包括：(1)國小腦性麻痺學童，(2)主要照顧者與學校老師同意參與研究。排除條件包括：(1) 若學童為在家教育，不符合學校生活情境，(2)主要照顧者無法以國台語溝通，或無法讀寫中文。研究工具為學校功能量表(School Function Assessment, SFA)，請學校老師填寫以了解學童學校表現。SFA共分成三部份，其中第一部份「學校活動參與」及第三部份「學校任務表現」將用於本研究，分別評量學童之活動參與程度及學校生理、認知/行為任務表現。其他變項涵蓋孩童的身體功能與構造、活動與參與及環境因素等層面，以訪談家長或請家長、老師填寫相關問卷來蒐集。分析方法為先以多元逐步迴歸(Multiple Stepwise Regression)建立學校參與、從事學校肢體及認知行為任務表現三迴歸模型，找出其影響因子，其中，依變項分別為SFA第一及第三部分，獨立變項則為身體功能與構造、活動與參與及情境因素等變項。並進一步以路徑分析將此三迴歸模型結合，建立腦性麻痺孩童學校參與學校參與預測模型。
結果
共128位取樣自全台各縣市65間國小、4間特殊學校以及臺大醫院門診之腦性麻痺國小學童(平均年齡為9.88歲，標準差為1.96；68男童，60女童)。路徑分析顯示學校活動參與會直接受到三個因子影響，分別為孩童在學校肢體、認知/行為任務的表現，以及腦性麻痺的類型，而學校肢體任務及認知任務的表現又各有其影響因子，路徑分析模型適配度尚可(GFI = 0.98, AGFI = 0.91, CFI = 1.00, RMSEA = 0.000, x2 = 17.43, df = 25)。學校肢體任務的影響因子包括認知/行為任務的表現、日常生活功能、過動情況、下肢偏癱、動作障礙的嚴重程度以及學校大小；學校認知/行為任務表現的影響因子則包括日常生活功能、母親的國籍、智能受損、父母的社經地位、社交技巧、正向社會行為、學業表現以及在學校為接受特殊教育。影響學校的肢體任務表現及認知/行為任務表現的因子，則透過學校的肢體任務表現及認知/行為任務表現間接影響孩童的學校參與情況。此三迴歸模型分別解釋73%、85%以及79%的總變異量。
結論
此研究結果可協助醫療與教育工作者瞭解腦性麻痺孩童學校參與的影響因子，並建立腦性麻痺孩童學校參與之模型，包括結構和測量模型，且提供醫療與教育工作者介入之參考，期待透過改善這些影響因子以促進腦性麻痺孩童的學校參與。

Background
School participation in children with cerebral palsy (CP) is often restricted due to their motor impairments or accompanied disturbance of cognition, sensory, etc, which further affect their knowledge learning and socialization. Thus, for children with CP, the ultimate goal of rehabilitation and education is to facilitate their participation in school. The determinants of the school participation in children with CP encompassed multiple dimensions, including children’s functioning and contextual factors. However, to our knowledge, no study investigated the determinants of participation in school activities from multiple dimensions. Therefore, the aim of the study was to investigate the determinants of participation in school activities from a holistic view, including functioning and contextual aspects.
Method
Participants were 128 children with CP (mean age 9.88, SD 1.96) recruited from the following facilities: (1) 3 pediatric rehabilitation clinics, (2) 65 primary schools and 3 schools of special education, and (3) 2 Cerebral Palsy Associations. Inclusion criteria were (1) school-aged students, and (2) consents given from caregivers and school teachers. Exclusion criteria included (1) homeschooled children, and (2) caregivers who can not communicate/read in Chinese.
School participation and performance of both physical and cognitive/behavioral tasks were measured by the School Function Assessment (SFA). A range of variables related to children’s functioning, including body function and body structures, activity and participation, as well as context factors were measured by appropriate tools as the predictors of school participation. The determinants of school participation and performance of both physical and cognitive/behavioral tasks of children with CP were investigated using multiple stepwise regression models. Path analysis was used to explore the relationships between those three regression models, and build a path model of school participation.
Results
The final path model revealed that school participation was direct influenced by the performances of both physical and cognitive/behavioral tasks, as well as affected parts of CP. There were 6 determinants of the performance of physical tasks, including affected parts of CP, GMFCS level, hyperactivity, school size and daily function. The determinants of the performance of cognitive/behavioral tasks were daily function, mother’s citizenship, intellectual impairment, socioeconomic status, prosocial behaviors, social skills, receiving special education as well as academic performance. The determinants of performance of both physical and cognitive/behavioral tasks indirectly influenced the school participation. The three regression models explained 73%, 85%, 79% of the total variances respectively.
Conclusion
School participation was directly influenced by the performances of physical and cognitive/behavioral tasks, and affected parts. Both performances of physical and cognitive/behavioral tasks were respectively affected by variables related to body structure/function, activity, and contextual factors which indirectly influenced the school participation. Thus, intervention targeted at those factors may help children with CP to be better integrated into school. Besides, there are three concepts in school participation, including school attendance, participation in activities, social participation. As the SFA measured participation in activities which is only one aspect of the whole concept of school participation, further study on the determinants of social participation in school is warranted.

INTRODUCTION 1
LITERATURE REVIEW 7
TERMINOLOGY 7
INCLUSION AND SCHOOL PARTICIPATION 11
THE IMPORTANCE OF USING THE ICF AS A CONCEPTUAL FRAMEWORK 12
SCHOOL PARTICIPATION OF CHILDREN WITH CP 13
FACTORS INFLUENCING THE SCHOOL PARTICIPATION OF CHILDREN WITH CP 16
LIMITATION OF PREVIOUS STUDIES 24
THE PURPOSE OF THIS STUDY 25
PARTICIPANTS 25
VARIABLES IN RESEARCH AND MEASURES 26
PROCEDURE 33
STATISTICAL ANALYSIS 35
RESULTS 38
CHARACTERISTIC OF PARTICIPANTS 38
THE PATH MODEL OF PARTICIPATION IN SCHOOL ACTIVITIES 39
DISCUSSION 41
DETERMINANTS OF PARTICIPATION IN SCHOOL ACTIVITIES IN CHILDREN WITH CP 41
DETERMINANTS OF THE PERFORMANCE OF PHYSICAL TASKS IN CHILDREN WITH CP 42
DETERMINANTS OF THE PERFORMANCE OF COGNITIVE/BEHAVIORAL TASKS IN CHILDREN WITH CP 44
CONCLUSION 49
REFERENCES 50

Abidin, R. R. (1990). Parenting Stress Index-Short Form : Test Manual. Charlottesville, VA: Pediatric Psychology Press.
Abidin, R. R. (1995). Parenting Stress Index: Professional Manual. FL, USA: Psychological Assessment Resources.
Almqvist, L., & Granlund, M. (2005). Participation in school environment of children and youth with disabilities: A person-oriented approach. Scandinavian journal of psychology, 46, 305-314.
Asbjornslett, M., & Hemmingsson, H. (2008). Participation at school as experienced by teenagers with physical disabilities. Scandinavian Journal of Occupational Therapy, 15(3), 153-161.
Barnombudsmannen, B. (2002). Manga syns inte, men finns anda: BO-rapport till regeringen. Stockholm: Barnombudsmannen.
Beckung, E., & Hagberg, G. (2002). Neuroimpairments, activity limitations, and participation restrictions in children with cerebral palsy. Developmental Medicine and Child Neurology, 44(05), 309-316.
Bourdon, K., Goodman, R., Rae, D., Simpson, G., & Koretz, D. (2005). The Strengths and Difficulties Questionnaire: US normative data and psychometric properties. Journal of Amer Academy of Child & Adolescent Psychiatry, 44(6), 557.
Cans, C. (2000). Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol, 42, 9.
Chen, K., Hsieh, C., Sheu, C., Hu, F., & Tseng, M. (2009). Reliability and validity of a Chinese version of the pediatric evaluation of disability inventory in children with cerebral palsy. Journal of Rehabilitation Medicine, 41(4), 273-278.
Cunningham, S., Thomas, P., & Warschausky, S. (2007). Gender differences in peer relations of children with neurodevelopmental conditions. Rehabilitation Psychology, 52(3), 331.
Doubt, L., & McColl, M. (2003). A secondary guy: physically disabled teenagers in secondary schools. Canadian Journal of Occupational Therapy, 70(3), 139-151.
Egilson, S. T., & Traustadottir, R. (2009). Participation of students with physical disabilities in the school environment. Am J Occup Ther, 63(3), 264-272.
Eriksson, L. (2005). The relationship between school environment and participation for students with disabilities. Developmental Neurorehabilitation, 8(2), 130-139.
Eriksson, L., Welander, J., & Granlund, M. (2007). Participation in everyday school activities for children with and without disabilities. Journal of Developmental and Physical Disabilities, 19(5), 485-502.
Hemmingson, H., & Borell, L. (2002). Environmental barriers in mainstream schools. Child Care Health Dev, 28(1), 57-63.
Hemmingsson, H., Borell, L., & Gustavsson, A. (2003). Participation in school: School assistants creating opportunities and obstacles for pupils with disabilities. OTJR OCCUPATION PARTICIPATION AND HEALTH, 23, 88-98.
Huang, I. C., Sugden, D., & Beveridge, S. (2009). Assistive devices and cerebral palsy: the use of assistive devices at school by children with cerebral palsy. Child Care Health Dev, 35(5), 698-708.
Imms, C. (2008). Children with cerebral palsy participate: a review of the literature. Disabil Rehabil, 30(24), 1867-1884.
Johnson, A. (2002). Prevalence and characteristics of children with cerebral palsy in Europe. Developmental Medicine and Child Neurology, 44(09), 633-640.
Landau, S., & Bogus, R. (1997). New International Webster''s Concise Dictionary of the English Language: Trident Press International.
Law, M., Petrenchik, T., King, G., & Hurley, P. (2007). Perceived environmental barriers to recreational, community, and school participation for children and youth with physical disabilities. Arch Phys Med Rehabil, 88(12), 1636-1642.
Mancini, M. C., & Coster, W. J. (2004). Functional predictors of school participation by children with disabilities. Occup Ther Int, 11(1), 12-25.
Mancini, M. C., Coster, W. J., Trombly, C. A., & Heeren, T. C. (2000). Predicting elementary school participation in children with disabilities. Arch Phys Med Rehabil, 81(3), 339-347.
Mc Manus, V., Corcoran, P., & Perry, I. J. (2008). Participation in everyday activities and quality of life in pre-teenage children living with cerebral palsy in South West Ireland. BMC Pediatr, 8, 50.
Mcneela, E., Shevlin, M., & Kenny, M. (2004). Participation in higher education for students with disabilities: an Irish perspective. Disability &# 38; Society, 19(1), 15-30.
Michelsen, S. I., Flachs, E. M., Uldall, P., Eriksen, E. L., McManus, V., Parkes, J., et al. (2009). Frequency of participation of 8-12-year-old children with cerebral palsy: a multi-centre cross-sectional European study. Eur J Paediatr Neurol, 13(2), 165-177.
Morris, C., Kurinczuk, J. J., Fitzpatrick, R., & Rosenbaum, P. L. (2006). Reliability of the manual ability classification system for children with cerebral palsy. Dev Med Child Neurol, 48(12), 950-953.
Muris, P., Meesters, C., & van den Berg, F. (2003). The Strengths and Difficulties Questionnaire (SDQ). European child & adolescent psychiatry, 12(1), 1-8.
Nadeau, L., & Tessier, R. (2006). Social adjustment of children with cerebral palsy in mainstream classes: Peer perception. Developmental Medicine and Child Neurology, 48(05), 331-336.
Odding, E., Roebroeck, M., & Stam, H. (2006). The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disability & Rehabilitation, 28(4), 183-191.
Ostensjo, S., Brogren Carlberg, E., & Vollestad, N. (2003). Everyday functioning in young children with cerebral palsy: functional skills, caregiver assistance, and modifications of the environment. Developmental Medicine and Child Neurology, 45(09), 603-612.
Palisano, R. J., Shimmell, L. J., Stewart, D., Lawless, J. J., Rosenbaum, P. L., & Russell, D. J. (2009). Mobility experiences of adolescents with cerebral palsy. Phys Occup Ther Pediatr, 29(2), 135-155.
Parkes, J., White-Koning, M., Dickinson, H., Thyen, U., Arnaud, C., Beckung, E., et al. (2008). Psychological problems in children with cerebral palsy: a cross-sectional European study. Journal of Child Psychology and Psychiatry, 49(4), 405-413.
Pivik, J., Mccomas, J., & Laflamme, M. (2002). Barriers and facilitators to inclusive education. Exceptional Children, 69(1), 97-109.
Pratt, B., Baker, K., & Gaebler-Spira, D. (2008). Participation of the child with cerebral palsy in the home, school, and community: A review of the literature. Journal of Pediatric Rehabilitation Medicine, 1(2), 101-111.
Prellwitz, M., & Tamm, M. (2000). How children with restricted mobility perceive their school environment. Scandinavian Journal of Occupational Therapy, 7(4), 165-173.
Richardson, P. (2002). The school as social context: Social interaction patterns of children with physical disabilities. American Journal of Occupational Therapy, 56(3), 296-304.
Rosenbaum, P., Paneth, N., Leviton, A., Goldstein, M., & Bax, M. (2006). A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol, 49, 7.
Rosenbaum, P., & Stewart, D. (2004). The World Health Organization International Classification of Functioning, Disability, and Health: a model to guide clinical thinking, practice and research in the field of cerebral palsy.
Rosenbloom, L. (2007). Definition and classification of cerebral palsy. Definition, classification, and the clinician. Dev Med Child Neurol Suppl, 109, 43.
Samson-Fang, L., Fung, E., Stallings, V., Conaway, M., Worley, G., Rosenbaum, P., et al. (2002). Relationship of nutritional status to health and societal participation in children with cerebral palsy* 1. The Journal of pediatrics, 141(5), 637-643.
Schenker, R., Coster, W., & Parush, S. (2005a). Participation and activity performance of students with cerebral palsy within the school environment. Disabil Rehabil, 27(10), 539-552.
Schenker, R., Coster, W. J., & Parush, S. (2005b). Neuroimpairments, activity performance, and participation in children with cerebral palsy mainstreamed in elementary schools. Dev Med Child Neurol, 47(12), 808-814.
Simeonsson, R. J., Carlson, D., Huntington, G. S., McMillen, J. S., & Brent, J. L. (2001). Students with disabilities: a national survey of participation in school activities. Disabil Rehabil, 23(2), 49-63.
UNESCO. (1994). The salamanca statement and framework for action on special needs education.
WHO. (2001). International classification of functioning, disability and health. Geneva: WHO.
WHO. (2007). International Classification Functioning, Disability and Health, version for Children and Youth. Geneva: World Health Organization.
Winter, S., Autry, A., Boyle, C., & Yeargin-Allsopp, M. (2002). Trends in the prevalence of cerebral palsy in a population-based study. Pediatrics, 110(6), 1220.
Yude, C., & Goodman, R. (1999). Peer problems of 9-to 11-year-old children with hemiplegia in mainstream schools. Can these be predicted? Developmental Medicine and Child Neurology, 41(01), 4-8.
Yude, C., Goodman, R., & McConachie, H. (1998). Peer problems of children with hemiplegia in mainstream primary schools. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 39(04), 533-541.
Yueh, K. (2006). A Study about the Relationship among Social-economic Status, Peer-relationship and Academic Achievement on Elementary School Children.
吳佳蓉, & 張德勝. (2003). 隔代教養學生與非隔代教養學生
學校生活適應之比較. 花蓮師院學報, 109-134.
李敦仁, & 余民寧. (2005). 社經地位, 手足數目, 家庭教育資源與教育成就結構關係模式之驗證: 以TEPS 資料庫資料為例 (pp. 1-48): 臺灣教育社會學研究.
孟瑛如. (2004). 國民中小學社交技巧行為特徵檢核表指導手冊. 台北市: 心理出版社.
黃森泉, & 張雯雁. (2003). 外籍新娘婚姻適應與子女教養問題之探討. 社會科教育研究(8), 135-169.