臺灣博碩士論文加值系統

背景與目的 腦性麻痺兒童在溝通上的問題會因大腦受損程度而有所差異，出現智力受損、語言障礙或動作言語和清晰度表現不佳的情形，但過去對於語言功能及動作言語上的研究較著重在學齡或是青少年，另外也較少去追蹤此族群兒童的動作言語表現的影響因素，所以長期追蹤腦性麻痺兒童語言功能和動作言語的相關研究將會有助於預後預測及早期介入的目標訂定。本研究目的包含：(1)探討不同嚴重度腦性麻痺兒童語言能力及口腔動作功能、聲學分析與語音清晰度的表現；(2)探討不同嚴重度腦性麻痺兒童的語言能力及口腔動作功能、聲學分析與語音清晰度隨時間之改變(追蹤六個月)；(3)探討腦性麻痺兒童動作嚴重度、個人因素、家庭因素、語言能力、口腔動作功能與語音清晰度之相關性；(4)找出預測腦性麻痺兒童動作言語表現的決定因素。
方法 本研究欲招募4到8歲腦性麻痺兒童27名以及典型發展兒童21名。利用粗大動作功能分類系統(GMFCS)根據腦性麻痺兒童動作表現分為動作障礙輕度(LevelⅠ和Ⅱ)及重度(LevelⅢ和Ⅳ)兩組。所有受試者依據其能力接受臨床評估和聲學評估。臨床評估包含基本資料填寫，使用兒童口語產出動作評估(VMPAC)評估個案非口語及口語的基本口腔動作功能；語言能力部分以標準化測驗工具修訂畢保德圖畫詞彙測驗(PPVT-R)評估個案基本的詞彙認知能力，以修訂學前語言障礙評量表(PLS-R)評估受試學前兒童語言理解及表達的能力，而學齡兒童以修訂語言障礙評量表(LS-R)做評估；利用華語構音∕音韻臨床測驗工具將腦性麻痺兒童音韻錯誤類型作分類，接著以同樣的語言樣本評出子音正確百分比(PCC)清晰度得分。聲學評估會以標準化的錄音工具錄製受試者的語音樣本，再以聲學分析軟體母音第一(F1)、第二共振峰(F2)、第一和第二共振峰差異(F2-F1)、母音空間、嗓音起始時間(VOT)、噪音持續時間、爆破沖直條及鼻共振峰等參數的分析。所有受試者在首次評估後第六個月做二次追蹤評估。統計方式：利用單因子變異數分析比較不同動作嚴重度兒童之間語言能力及動作言語的表現；再利用重複數量變異數分析比較追蹤前後的差異；使用相關及回歸分析找出影響動作言語的決定因子。
結果 在研究主題一中，三個組別受試者的基本背景資料並無顯著的差異，在追蹤前的基準資料中，兩個腦性麻痺兒童組以典型發展兒童組別之間在[ㄚ]音的F1、F2以及F2-F1、母音空間的數據上顯示在舌位移動上出現顯著侷限的趨勢(p<.05)；另外有聲和無聲子音的嗓音起始時間因嚴重度的增加有顯著拉長(p<.05)；擦音爆破沖直條以及鼻音等變項在嚴重度越高的組別比例也顯著較高(p<.05)，口腔動作評估VMPAC各項分數及語音清晰度PCC分數也因嚴重的增加在動作控制以及清晰度顯著變差(p<.001)，詞彙理解PPVT-R與語言能力(PLS-R或LS-R)的表現並未出現顯著差異。在經過六個月追蹤，除了口腔功能評估中的一般動作控制和局部口腔動作有時間上的進步達顯著(p<.05)，其餘變項在時間和組別效應皆未呈現顯著。在研究主題二當中，利用線性迴歸發現腦性麻痺型態(r2=.761, P <.001)和詞彙理解PPVT得分(r2=.856, P <.001)與一般動作控制最為相關；平均F1[ㄚ](r2=.467, P =.001)和年齡(r2=.643, P <.001)與局部口腔動作表現最為相關；年齡(r2=.449, P =.001)、PPVT-R(r2=.681, P <.001)和有聲子音嗓音起始時間(r2=.777, P <.001)與連續性表現最為相關；與整體表現最為相關的因子為平均F1[一](r2=.404, P =.002)、有聲子音嗓音起始時間(r2=.563, P <.001)、PPVT-R(r2=.686, P <.001)以及年齡(r2=.733, P <.001)；語音清晰度則與擦音爆發音比例平均(r2=.700, P <.001)和F2[ㄚ] (r2=.824, P <.001)最為相關。
結論 研究顯示腦性麻痺兒童粗大動作表現與聲學分析、口腔動作以及語音清晰度的表現有顯著相關，根據追蹤的結果發現，腦性麻痺兒童在時間的發展上語言功能進步的幅度並未達典型發展兒童相同時間下的進步幅度，透過追蹤研究找出數項腦性麻痺兒童發展過程中影響其口腔動作功能以及語音清晰度的因子，給予未來治療師在擬定介入方針時，可做為參考的目標。

Background and Purpose: Communication problems in children with cerebral palsy (CP) depended on the severity of brain damage. Mental impairment, language and speech disorders are the common associated problems in children with CP. Previous studies focus on language and motor speech dysfunctions in children with CP at school-age child, adolescents and adults. Few literatures identify the determinants for predicted the motor speech performance in these children. It is important issue to follow-up the language and motor speech functions in children with CP. These data will provide clinicians for outcome prediction and goal setting. The aims of this study: (1) to investigate the difference in motor speech functions among children with CP of different motor severities, and(2) to investigate the longitudinal in motor speech functions at 6 months follow-up phase among children with CP of different motor severities, and(3) the correlation between motor severity, personal factors, family factors, language ability and motor speech in children with CP, and(4) to identify the variables that can predict motor speech functions in children with CP.
Method: We collected speech samples from 27 children with CP having language ability greater than 3 years and 21 typically developing (TD) children. The participants’ ages ranged from 4 to 8 years. Children with CP were classified into two groups, Levels I-II and Levels III-IV, based on the Gross Motor Function Classification System (GMFCS). Children with CP underwent the assessments of Peabody Picture Vocabulary Test-Revised (PPVT-R), Percentage of Correct Consonant (PCC) and Preschool Language Scale-Revised (PLS-R) or School-age Language Scale-Revised (LS-R) due to its age. All speech samples were submitted to motor speech control for Verbal Motor Production Assessment for Children (VMPAC) and acoustic analyses for measures of the frequencies of the first two formants (F1 and F2) of corner vowels, vowel spaces, voice onset time (VOT) of voiced and voiceless consonants, and percentage of affricate and fricative burst spectrums and nasality. Children with CP will receive secondary assessment they had in pretest. Statistical analysis: analysis of variance was used to identify difference in language ability and motor speech among children with CP of different motor severities, repeated measurement of ANOVA was use to compare the change of language ability and motor speech among children with CP at follow-up and analysis of correlation was used to identify the variables related to motor speech performance.
Result: Study 1: There were no significant differences among three groups in terms of demographic data and language assessment including PPVT-R scores and PLS-R or LS-R scores. The baseline measurements show significant differences among three groups in F1, F2, and F2-F1of /a/, vowel spaces, VOT of voiced and voiceless consonants, percentage of fricative burst spectrums and nasality (p<.05). VMPAC and PCC scores both show significant decrement in children with worse motor severity (p<.001). After 6 month of follow, There were no significant differences between two CP groups in all speech variables besides general motor control and focal oromotor control of VMPAC. Study 2: Linear regression indicated general motor control related to CP subtype and PPVT-R scores (adjusted r2=.856, p<.001), focal oromotor control related to F1/a/ and age (adjusted r2=.643, p<.001), sequence related to age, PPVT-R scores and, VOT of voiced consonants (adjusted r2=.777, p<.001) and the average modified VMPAC scores related to F1/i/, VOT of voiced consonants, PPVT-R scores and age (adjusted r2=.733, p<.001).The PCC scores related to F2/a/ and percentage of fricative burst spectrums (adjusted r2=.824, p<.001).
Conclusion: These findings suggest the motor speech functions in children with CP are related to the severity of gross motor impairment. Most speech functions did not increase proportionally with increasing age in children with CP. It is important to plan appropriate verbal motor therapeutic interventions. Future study may examine strategies by the predicted factors for treating motor speech dysfunctions in children with CP.

目錄
指導教授推薦書
口試委員會審定書
授權書 III
中文摘要 V
英文摘要 VII
目錄 IX
第一章 緒論 1
第一節 研究背景及動機 -1-
第二節 研究目的 -6-
第三節 研究問題及假設 -7-
第四節 名詞解釋 -9-
第二章 文獻探討 -11-
第一節 典型發展兒童之語言及言語表現 -11-
第二節 動作言語的評估內涵 -17-
第三節 腦性麻痺兒童之語言及言語表現 -24-
第四節 腦性麻痺兒童動作言語之追蹤表現與影響因子 -30-
第三章 研究設計與實施 -33-
第一節 研究對象 -33-
第二節 研究設計及流程 -36-
第三節 研究工具及評估方式 -41-
第四節 資料處理 -50-
第四章 研究結果 -52-
第一節 基本資料分析 -52-
第二節 研究主題ㄧ之結果 -54-
第三節 研究主題二之結果 -61-
第五章 綜和討論 -65-
第一節 研究主題一之討論 -65-
第二節 研究主題二之討論 -76-
第六章 結論 -80-
第一節 臨床應用 -84-
第二節 研究限制 -84-
第三節 研究建議 -85-
參考文獻 -86-
西文部分 -86-
中文部分 -92-
圖目錄
圖2-1 母音的舌位四邊形 -20-
圖2-2 典型發展兒童子音特徵之聲譜圖 -22-
圖3-1 研究架構 -36-
圖3-2 研究步驟流程圖 -39-
圖3-3 受試者人數流動圖 -40-
圖4-1 母音三角空間圖 -55-
圖4-2 腦性麻痺兒童在有聲子音嗓音起始時間與典型發展兒童的差異 -56-
圖4-3 腦性麻痺兒童在擦音爆破音比例與典型發展兒童的差異 -56-
圖4-4 腦性麻痺兒童在鼻音共振峰與典型發展兒童的差異 -57-
表目錄
表2-1 國內一般發展兒童語音發展常用常模數據 -15-
表2-2 國外一般發展兒童語音發展常用常模數據 -16-
表2-3 聲學分析的語音特徵要素 -19-
表2-4 子音的構音位置及構音方式分類 -21-
表3-1 典型發展兒童的前位、後位母音 -49-
表3-2 受試者所接受之評估內容 -49-
表4-1 受試者基本資料 -94-
表4-2 聲學分析之母音參數的差異 -95-
表4-3 聲學分析之子音參數的差異 -97-
表4-4 口腔動作功能及語音清晰度的差異 -98-
表4-5 語言能力的差異 -99-
表4-6 皮爾遜相關分析結果 -100-
表4-7 逐步線性迴歸之預測因子 -102-
附錄 -103-
附錄ㄧ、聲學分析之再測信度與施測者間信度測量 -103-
附錄二、VMPAC之再測信度與施測者間信度測量 -104-
附錄三、清晰度之再測信度與施測者間信度測量 -105-
附錄四、中英文縮寫對照表 -106-
附錄五、人體試驗通過書 -107-
附錄六、同意書 -108-

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