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研究生:羅慧珊
研究生(外文):Hui Shan Lo
論文名稱:影響腦性麻痺兒童中文書寫表現之相關因子
論文名稱(外文):Factors associated Chinese Handwriting Performance in Children with Cerebral Palsy
指導教授:陳嘉玲陳嘉玲引用關係
指導教授(外文):C. L. Chen
學位類別:碩士
校院名稱:長庚大學
系所名稱:早期療育研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2012
畢業學年度:100
論文頁數:127
中文關鍵詞:腦性麻痺中文書寫
外文關鍵詞:cerebral palsyChinese handwriting
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上肢功能較佳的腦性麻痺兒童(Cerebral Palsy,CP)通常被期望能夠與一般同儕學習書寫,然而,CP兒童除了肢體上受到損傷之外,其感覺、知覺能力也可能受到影響,而這些都是造成CP兒童書寫困難的因素。因此,本研究欲比較CP兒童及一般發展兒童書寫表現的差異,進一步比較不同嚴重度CP兒童書寫表現的差異,並找出影響CP兒童書寫表現的相關因子。
本研究招募30位CP兒童及31位一般發展兒童(年齡6-12歲),CP兒童以GMFCS分成LevelⅠ及LevelⅡ兩組。三組兒童以基本讀寫字測驗、中文書寫評估工具(CHAT)評估其書寫表現,包括:書寫總時間、書寫速度、紙上時間、空中時間、字體大小及著筆壓力分配模式等,並分析其書寫錯誤分數(包括:動作錯誤分數、視覺處理錯誤分數及總書寫錯誤分數)。另利用臨床測驗工具包括:視知覺技巧測驗(TVPS-3)、第二版布魯茵克斯-歐西瑞斯基動作精練度評量 (BOT-2)、拜瑞-布坦尼卡視覺-動作統整發展測驗 (VMI)、感覺史量表等評估個案知感覺-知覺-動作能力,及學校功能表現(SFA)評估腦性麻痺個案在學校之表現。以共變數分析(書寫總時間、書寫速度、紙上時間、空中時間)或變異數分析分析三組之間在各項度的差異,先以皮爾遜積差相關分析找出影響CP兒童及一般發展兒童書寫表現與感覺-知覺-動作的相關性,再利用逐步迴歸來找出影響CP兒童及一般發展兒童書寫表現的重要相關因子。另外,也找出CP兒童書寫表現與學校功能表現之相關性及重要性。
本研究結果顯示兩組CP兒童在視知覺部分分測驗、精細動作控制及協調能力,以及視覺動作整合能力表現上較一般發展兒童為差(p<.05),而LevelⅡ CP兒童在視覺順序記憶、精細動作控制及協調能力,以及視覺動作整合能力表現上較LevelⅠCP兒童為差(p<.05)。
另外,比較CP兒童與一般發展兒童的書寫表現發現,LevelⅡ CP兒童近端抄寫的書寫速度、空中時間及視覺處理錯誤分數較一般發展兒童為差 (p<.01),而LevelⅠ CP兒童的書寫速度、空中時間及視覺處理錯誤分數則與一般發展兒童沒有顯著差異。另外,兩組CP兒童在紙上時間、字體大小標準差、動作能力錯誤分數及書寫總錯誤分數上皆較一般發展兒童為大(p<.05)。兩組CP兒童及一般發展兒童在書寫時的著筆壓力分佈則沒有顯著差異。而比較兩組CP兒童的書寫表現可發現,LevelⅠ及LevelⅡ的兒童在書寫速度、紙上時間、空中時間、動作能力錯誤分數、視覺處理錯誤分數及總書寫錯誤分數上呈現顯著差異(p<.05)。
另外,從CP兒童及一般發展兒童的書寫表現及感覺-知覺-動作的迴歸分析可發現,在腦性麻痺兒童組中,操作協調能力為影響書寫速度、動作能力錯誤分數及總書寫錯誤分數的相關因子(R2=0.190-0.406),視覺動作整合能力則為影響視覺處理錯誤分數的相關因子(R2=0.206),然而年齡、感覺處理及視知覺能力亦為影響腦性麻痺兒童書寫速度及書寫錯誤分數的相關因子之一。而在一般發展兒童組中,年齡為影響書寫速度、視覺處理錯誤分數及總書寫錯誤分數的相關因子(R2=0.192-0.683),而視覺動作整合能力則為影響動作處理錯誤分數的相關因子(R2=0.119)。另外,分析腦性麻痺兒童的書寫表現及學校功能表現發現,腦性麻痺兒童的書寫總錯誤分數為其影響學校書寫活動表現及工作行為能力的重要相關因子(R2=0.309-0.382)。
從上述結果可得,其CP兒童書寫表現及感覺-知覺-動作能力仍較一般發展兒童為差,且不同嚴重度CP兒童書寫表現也有差異,而CP兒童感覺-知覺-動作能力的損傷也影響了其書寫表現,進而影響CP兒童在學校的書寫表現。本研究結果可提供臨床人員在處理CP兒童書寫問題時的參考依據,而未來研究可更進一步探討不同的書寫訓練對於CP兒童書寫表現之療效。
Children with CP who have good function on upper extremity are generally expected to learn to write alongside their peers. Nevertheless children with CP are not only had motor impairment but also had deficits of sensation, perception and cognition, which are important factors of handwriting. The aims of this study were to compare handwriting performance in children with CP and children with typical development (TD), to compare handwriting performance in children with CP with different severity, to establish the relationships of sensory-perceptual- motor and handwriting performance in the children with CP and the children with TD, to establish the relationships of handwriting performance and school function, and to clarify important factors affecting handwriting performance in children with CP and children with TD.
The study included 30 children aged 7–12 years with cerebral palsy and 31 typically developing children of similar age. The Chinese handwriting assessment tool (CHAT) and comprehensive test of basic reading and writing were used to evaluate handwriting performance, including total writing time, writing speed, in-air time, in-ground time, pressure pattern, and errors scale et al. The clinical assessment tools include Test of Visual-perceptual skills -3rd (TVPS-3), Bruininks– Oseretsky Test of Motor Proficiency (BOT-2), The Beery-Buktenica Development Test of Visual-Motor Integration (VMI), sensory, and School Function Assessment (SFA).
Group differences in categorical demographic data (gender, dominant hand) were determined using the chi-square test. Group differences in continuous data were compared by a one-way ANOVA or ANCOVA with post-hoc Dunnett’s T3 multiple comparisons. Pearson’s correlation was utilized to determine the relationships between demographic data, clinical data, and handwriting performance. Multiple stepwise linear regression analysis was performed to characterize the relationship of handwriting performance with related variables. A p-value < .05 was considered as statistically significant.
The results showed that children with CP whose were significantly had poor performance in some subtests of TVPS-3, fine manual control, motor coordination, and visual-motor integration than children with TD(p<.05). The children with levelⅡ CP were significantly had poor performance in visual sequence memory, fine manual control, motor coordination, and visual-motor integration than children with levelⅠCP (p<.05). The results showed that children with LevelⅡ CP whose were significantly had poor performance of handwriting speed, in-air time, and visual processing error scores (VPES) than children with TD (p<.01). There were no significantly difference in handwriting speed, in-air time, and VPES between children with LevelⅠCP and with TD . The children with LevelⅠand LevelⅡ CP were significantly had poor performance of in-ground time, size SD, motor ability errors(MAES) and total errors(TES) than children with TD (p<.05). There were no significantly difference in handwriting pressure between children with CP and TD. There were significantly difference in handwriting speed, in-ground time, in-air time, MAES, VPES and TES between children with LevelⅠand LevelⅡ CP (p<.05).
The result of regression analysis showed that motor coordination is an important affected factor of writing speed, MAES and TES, and visual-motor integration is an important affected factor of VPES in CP group. Age and visual perception are also correlated factors that affecting writing speed and legibility in CP group. In TD group, age is an important affected factor of writing speed, VPES and TES, and visual-motor integration is an important affected factor of MAE. TES is an important factor associated written work and task behavior/completion in CP group.
Developing the sensory-perceptual-motor function of children with cerebral palsy would thus be possible, and they would be able to develop handwriting skill as a tool for their academic lives as healthy peers.

目錄
指導教授推薦書
口試委員會審定書長庚大學博碩士論文著作授權書致謝
長庚大學博碩士論文著作授權書致謝 iii
致謝 iv
中文摘要 v
英文摘要 viii
圖目錄 xiv
表目錄 xv
第一章 緒論 1
第一節 研究緣起與研究動機 1
第二節 研究目的 4
第三節 研究問題與假設 5
第四節 重要名詞解釋 7
第二章 文獻回顧 9
第一節 書寫能力發展與相關因子 9
一、 書寫能力的發展與先備能力 9
二、 與書寫表現相關的知覺動作能力 10
第二節 書寫表現的評估 15
第三節 腦性麻痺兒童書寫特徵及可能影響因子 21
一、 腦性麻痺兒童的書寫特徵 21
二、 可能影響腦性麻痺兒童書寫表現的相關因子 22
第四節 書寫問題對學校表現的影響 27
第三章 研究方法 28
第一節 研究對象與收案流程 28
一、 受試者徵求過程 28
二、 研究對象選取標準 28
第二節 研究流程 30
第三節 研究儀器與設備 32
一、 中文書寫評估工具 32
二、 中文書寫評估流程 33
第四節 評估工具與施測方法 35
一、 評估模式 35
二、 樣本分類之工具 36
三、 臨床評估工具 36
四、 問卷 41
第五節 資料分析 43
第四章 研究結果 45
第一節 參與者基本資料 45
第二節 腦性麻痺兒童與一般發展兒童知覺-動作能力與書寫能力之比較 46
第三節 腦性麻痺兒童與一般發展兒童書寫表現與知覺-動作能力之相關分析 48
第四節 腦性麻痺兒童學校參與度相關因子分析 52
第五章 結果討論 53
第一節 研究主題一:探討腦性麻痺兒童與一般發展兒童在書寫表現上及知覺動作的差異 54
第二節 研究主題二:探討影響腦性麻痺兒童與一般發展兒童書寫表現相關因子 62
第三節 研究主題三:探討腦性麻痺兒童書寫表現與學校參與度之相關性 69
第六章 臨床建議與應用 71
第七章 研究限制 72
Reference 98
附錄1 長庚醫院人體試驗證明書
附錄2受試者同意書 107


圖目錄
圖3-1研究流程圖 31
圖3-2 CHAT呈現字樣 33
圖3-3兒童使用CHAT評估情形 34
圖3-4 國際功能殘障健康分類 36
表目錄
表2-1 感覺-知覺-動作能力對書寫技巧的影響 73
表3-1 操作能力分類系統 74
表3-2粗大動作功能分類系統 74
表3-3字體的清晰度 75
表4-1-1 個案基本資料 76
表4-2-1腦性麻痺兒童與一般發展兒童的視知覺能力表現 77
表4-2-2腦性麻痺兒童與一般發展兒童的動作控制及視覺-動作整合表現 79
表4-3-1腦性麻痺兒童與一般發展兒童在基本讀寫字測驗之差異 82
表4-3-2 腦性麻痺兒童與典型發展兒童的近端抄寫過程表現 83
表4-3-3腦性麻痺兒童與一般發展兒童的近端抄寫結果表現 85
表4-4-1腦性麻痺兒童書寫表現與基本資料、視知覺能力、動作控制及視覺-動作整合能力的相關性 86
表4-4-2一般發展兒童書寫表現與基本資料、視知覺能力、動作控制及視覺-動作整合能力的相關性 88
表4-4-3 腦性麻痺兒童書寫表現與感覺處理相關性分析 89
表5-1-1一般發展兒童書寫表現迴歸分析 91
統計分析採逐步迴歸分析表5-1-2 腦性麻痺兒童書寫表現迴歸分析 92
表5-1-2 腦性麻痺兒童書寫表現迴歸分析 93
表5-1-3 腦性麻痺兒童書寫表現及感覺處理迴歸分析 95
表6-1-1 腦性麻痺兒童書寫表現與學校日常生活功能表現相關性分析 97
表6-1-2腦性麻痺兒童書寫表現及學校日常生活功能迴歸分析 97
中文
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