發展性動作協調障礙 Developmental Coordination Disorder 簡稱 DCD 國立成功大學職能治療學系 徐永玟

DCD 定義 - 心理疾病診斷統計手冊 DSM-IV 日常活動中有關運動協調的表現顯著低於其生理年齡或智力應有的水準 不協調或動作發展慢 前一項障礙顯著妨礙其學業表現或日常活動 影響學業與日常生活功能 此障礙並非一般性的醫學狀況所造成 若有智力障礙，此運動困難的情形也遠超過其通常的影響 不是肢體或智能障礙所導致

類似名詞釋義與比較 笨拙兒童(clumsy child syndrome) 發展性協調動作障礙 (developmental coordination disorder, DCD) 特殊動作功能發展障礙包含DCD (WHO， ICD-10) (Specific developmental disorder of motor function including DCD) 動作運用障礙 (dyspraxia)

類似名詞釋義與比較 注意力- 動作控制 - 知覺缺陷 (deficits in attention, motor control, and perception, DAMP) 非語文型學習障礙 (non-verbal learning disabilities, NLD) 感覺統合障礙 (sensory integration dysfunction)

盛行率 年齡 盛行率 出處 5-11 5～6% DSM-IV 6-12 5.7 % Canada, 1996 7 4.9 % 因調查方法本質、及使用定義的不同而有所差異。 年齡 盛行率 出處 5-11 5～6% DSM-IV 6-12 5.7 % Canada, 1996 7 4.9 % Sweden, 1999 10 3.1-3.9 % Norway, 1992 6-9 4.7-6.7 % Singapore, 1994 & 2001 4-6 5.5 % Tainan, 2002 7-8 3.5 % Taiwan, 2002 9-10 17.9 % 吳昇光，2002

桃園經驗 幼稚園教師藉由篩選表推薦 26 / 418 （female 8 / 211; male 18 / 207） ~ 老師會進行Group discussion ~

桃園經驗 國小教師藉由篩選表推薦 小一 7 / 203（3.45%） 小二 6 / 237（2.53%） 小一 7 / 203（3.45%） 小二 6 / 237（2.53%） 小三 8 / 188（4.26%） 一位老師意願特別高 小四 5 / 251（1.99%） 小五 1 / 229（0.4%） 可能原因？ 不重要 推薦意願 生態情境是否觀察得到 但老師若推薦出則 DCD 機率大為提升

男女比例 男女比例 出處 相當 或 女生稍高 男生多 3：1 2：1 (嚴重DCD) 3：2 4~7 ：1 Piek & Edwards, 1997; Scott,et al, 1984 男生多 3：1 Henderson & Hall, 1982; Losse et al., 1991; Maeland, 1992; Sovik & Maeland, 1986 2：1 (嚴重DCD) Piek & Edwards, 1997; Hsu, 2002 (4~6歲) 3：2 Hsu, 2002 4~7 ：1 Kadesjo & Gillberg, 1999

其他問題 課外活動表現較差 低成就 低自尊 自我概念問題 情緒行為問題 人際社會障礙

DCD兒童的預後 長大會好？ 長期追蹤研究的發現 （ Loose et al, 1991; Fox & Lent, 1996; Cantell, et al., 2003) 篩選 年齡 追蹤 仍有 DCD 出處 5～6 15～17 87％ Losse et al, 1991 6~12 11~17 50~75% Van Dellen, 1990; Geuze & Borger, 1993 6 12~14 78% (12) 40% (14) Soorani-Lunsing et al.,1992,1993, 1994 5 11,15, 17 62% (11) 46%(15,17) Cantell et a., 1994 7 21 58% (DCD+ADHD) Rasmussen & Gillberg , 2001

家長的認知 (Pless et al., 2001 – 37 DCD家長) 不同情境下的動作表現：較笨拙 行為的整體印象： 笨拙、緊張、活動量偏高，或害怕爬高、發展慢 溝通能力以及生理觀察： 部分有語言發展遲緩的情形；體重可能過重 在體能活動上的支持： 提供較多體能活動上的支持 對如何扮演好父母角色的感受： 擔心與不確定，想知道原因，不知如何幫助他 氣專業人員 氣小孩 在不同情境下的動作表現： 家長觀察到他們的小孩在遊戲場、在接受測驗時、在用餐穿衣等日常活動時顯得比其他兒童來得笨拙。 對DCD兒童行為的整體印象： 覺得自己小孩笨拙、緊張、活動量偏高，或害怕爬高、發展較慢。 溝通能力以及生理觀察： 部分家長發現他們小孩有語言發展遲緩的情形，或曾接受語言治療； 體重可能過重。 在體能活動上的支持： 有明顯動作障礙兒童的家長對他們小孩提供較多體能活動上的支持，會想是否該送小孩去學游泳、跳舞等技能。 對如何扮演好父母角色的感受： 較嚴重的DCD兒童父母有較多的擔心與不確定，知道小孩不對勁，但他們想知道原因，不曉得如何幫助小孩，擔心小孩未來的發展，不確定他們自己是否扮演好父母親的角色。 有些父母會表示他們覺得生氣，覺得專業人員不願傾聽、不關心，生氣檢查不出原因； 氣小孩懶惰、沒有動機做好事情。 在評估時則訝異小孩居然不會做某項動作，例如使用剪刀。 限制了他們的社交參與

DCD兒童的感覺、動作特質 視知覺

視知覺簡介 視知覺的功能： 知覺與動作是合一的 視覺在動作控制上扮演一個重要的角色 (anticipatory) apprehension and action 知覺與動作是合一的 We must perceive in order to move, but we must also move in order to perceive. 視覺在動作控制上扮演一個重要的角色 (anticipatory)

DCD兒童的基本視覺處理 Near/far visual acuity & contrast sensitivity no indications of impairments in DCD Ophthalmic test (visual acuity, visual fields, strabismus, binocular vision….) no sig. difference between DCD & controls Afferent visual pathways: no evidence of lesions in DCD Conclusion: no indications of deficits

DCD兒童的眼睛動作控制 Pursuit eye movements: OK A disturbed or delayed ability in DCD to coordinate the movements for the eyes with that of a moving target.

高階的視覺訊息處理功能 what vs. how system what vs. where system Where: 空間視覺 spatial vision (posterior parietal lobe) What: 物件視覺 object vision (inferior temporal lobe) what vs. how system How: 引導動作的知覺控制 (posterior parietal lobe) What: 辨認物件 景物、人等 (inferior temporal lobe) 臨床個案

DCD 兒童的視知覺障礙 Study results (DCD compared to normal kids): VP problems are more common Poor VP discrimination performances Poor performance on block design, object assembly, form & space, etc. tests Poor performance on TVPS & VMI tests Visual memory deficit (more affected by time delay)

DCD 兒童的視知覺障礙 後設分析 Meta analysis (50 studies): (Wilson & McKenzie, 1998) DCD were inferior on almost all measures of information processing. The greatest deficits: visual-spatial processing, (esp. tasks required a motor response) Conclusion: DCD perform poorly on VP tasks. However, no knowledge available on the degree to which VP & motor disorders co-occur.

Causality between VP and motor disorders in DCD Two lines of research Perception for apprehension and its relation with motor control in DCD (inconclusive) Perception for action in DCD: test the ability to use perceptual information for movement planning and control

2-1. Visual control of goal-directed arm movements in DCD Are DCD more dependent on visual feedback for movement control than normal children are? ability for anticipatory control (Van der Meulan et al.,1991) rely on feedback control (Rosbald & von Hofsten, 1994)

2-2. Catching moving objects How can DCD utilize visual information for prediction of a ball’s trajectory? Some possible explanations: VP problems A more general problem with predictions that is not specific to the visual system. Lack of experience with balls To catch a moving object  efficient movement performance (speed, movement units…)

2-3. Influence of visual information on the control of stance DCD in the “swinging room” (Wann, Mon-Williams, & Rushton, 1998) One subgroup of DCD had postural control problems & tended to use visual information in a similar way to nursery children.

Conclusion VP and motor disorder co-occur, but the degree these disorders overlap remains unknown. The failure to find substantial correlations between performance on traditional perceptual tests and motor performance could be explained by a proposed dissociation between two visual systems

Conclusion One problem may be a lack of progression from a visual feedback probing strategy to a more mature anticipatory control strategy. Still lack basic understanding of the motor problems in DCD (heterogeneous).

DCD兒童的感覺、動作特質 動作控制

DCD 兒童的動作控制問題 動作反應、動作時間明顯較慢 Significantly slower reaction, movement, and response times 適時、調速的控制有困難 Universal difficulty with timing control 力量控制經常有困難 Frequent difficulty with force control 各種動作表現的變異性較高 variability to performances on a wide variety of motor tasks

DCD 兒童的動作控制問題 動作較容易受干擾的影響 Grater vulnerability to perturbations of movement 無法快速因應動作要求的改變 Inability to adapt quickly to changes in movement demands 較依賴視覺來維持平衡與姿勢控制Tendency to rely on vision for maintaining balance/postural control 較依賴近端肌肉控制來調節平衡 Tendency to rely on proximal muscle control to regulate balance

DCD 兒童的動作控制問題 在感覺訊息的整合上較同儕差，尤其是視覺與本體覺訊息 Poorer intersensory integration than peers especially with regard to mapping visual and proprioceptive information 使用不同於正常兒童的神經肌肉/動作控制策略來調節兩側協調 Use of different neuromuscular/motor control strategies to regulate bimanual coordination

DCD 兒童的動作控制問題 年齡雖然增長，但動作控制的缺陷仍持續存在，與中樞神經系統的障礙有關而不是發展遲緩造成 Tendency for deficiencies in motor control to persist with age and to be more related to CNS dysfunction than to developmental delay

DCD兒童動作慢且變異性大的因素 Slower Reaction time Slower Movement time Vulnerable to speed & accuracy control demands Short jerky movements

適時、調速的控制 Timing control Poor rhythmic coordination or timing of movements Age-developmental effects Potential underlying factor Difficulty with force control executing smooth flex.-ext. movements of the index Grater vulnerability to perturbations Adapt slowly to changes study the bilateral motor control Different motor control strategies

DCD 兒童的平衡與姿勢控制 Sway characteristics Postural synergies Sway more & tend to rely on vision for maintaining balance Postural synergies Stand on a force platform with unexpectedly perturbation Tendency to rely on proximal muscle control to regulate balance DCD：proximal-distal pattern of muscle activation Neuromuscular aspects of postural control (standing) DCD exhibited significantly greater amplitude of muscle activity Force output of the proximal was greater than that of the distal muscles.

個人研究結果 研究目的：探討DCD與正常兒童在感覺處理能力之差異

研究工具 Movement ABC Peabody Picture Vocabulary Test（PPVT-R） 中文修訂版 （陸莉、劉鴻香, 1994） SIPT（Motor Accuracy, Kinesthesia & Finger Identification） VMI中文版 prone extension test Sensory Profile 中文版 兒童活動量表

結論 & 討論 DCD在感覺處理相關測驗的表現，明顯較差 母親感受上(SP)，DCD明顯較差的項目： DCD兒童通常活動量較高。 情緒, 動作協調& 專注力 符合文獻所提，易有人際互動、情緒、低自尊等問題 DCD兒童通常活動量較高。 施測時間拉長,且與MABC%呈負相關 愈笨拙兒童，視知覺和視覺動作缺陷情況愈明顯 本研究：笨拙程度與MAc有顯著相關，但與VMI則否

DCD兒童的評估與治療

DCD 兒童的評估 Given our emerging understanding of DCD, approaches to assessment will continue to develop and change. Frameworks: Functional Motor development neurobehavioral

量表、問卷 Questionnaire Interview (history review) Strengths & weaknesses of checklist Issues in teacher’s questionnaire Tests MABC Checklist Developmental Coordination Disorder Questionnaire (DCDQ, Grade1-6 )

Movement ABC Checklist 兒童 靜止 移動 環境 穩定 Section 1 Section 2 改變 Section 3 Section 4

Tests of motor proficiency Bruininks Oseretsky Test of Motor Proficiency (BOTMP, 4.6-14.6) 1978 Movement Assessment Battery for Children (MABC, 4-12) 1992 Peabody Developmental Motor Skills-2 (PDMS2, 0-7) 2000 Purdue Pegboard (4~) 1960

個人研究結果 MABC 應用於台南市兒童，以15%為切點，僅有5.5%可能有動作協調問題 有良好的施測者間信度與重測信度 居住區域＆母親教育對測驗表現無影響 有文化差異，因此應謹慎解釋測驗的結果

Visual-motor Tests Developmental Test fo visal-Motor Integration, 4th ed. (VMI, 3-18) Test of Visual Motor Skills-Revised (3-13.11) Developmental Test of Visual Perception II (DTVP II, 4-10) VMI-1997 TVMS-R-1995 DTVP2-1993

Functional Tests Pediatric Evaluation of Disability Inventory (PEDI, 0-7) Functional Independence for Children (WeeFIM, 0-18) School Function Assessment (SFA, Grade K-6) Conclusion: multiple steps PEDI-1992 WeeFIM-1994 SFA-1998

DCD兒童的治療介入 It may be the teacher (therapist) or the underlying teaching principles, not the specific intervention method, that accounted for any positive treatment effects. (Simundsson, Pedersen, Whiting, & Ingvaldsen, 1998)

General Principles 正確的評估 調整活動內容以符合個別兒童需求，並逐漸增加難度* 密集訓練* 經常給予正向回饋* 鼓勵兒童每天監測自己進步情形* 多與非動作專業人員合作， 如老師、家長

文獻中的治療方式 知覺動作訓練 Perceptual-motor training 感覺統合治療 Sensory integration therapy 運動覺訓練 Kinesthetic training 認知情感訓練 Cognitive affective training * 物理治療 Physiotherapy 活動導向的治療 Task-specific intervention

DCD 兒童的治療介入 將動作學習理論整合在療程中 Integrating motor learning theories in to practice 活動導向的治療 Task-specific intervention for children with DCD 感覺統合觀點看DCD兒童 DCD from a SI perspective

動作學習理論的原則 Stages of the learner Type of task Practice Type of feedback Random vs. Blocked Part vs. Whole task Type of feedback Intrinsic feedback Extrinsic feedback

應用動作學習理論 Steps: Techniques: Modern perspectives of ML: A clear identification of the action goal Ecological task analysis Develop a plan for intervention Techniques: verbal instructions Physical handling Demonstration Modern perspectives of ML:

DCD兒童的活動導向治療 A top-down approach Different systems frameworks All subsystems are equal contributors and interact to produce the final motor behavior. Newell’s (1986) interactive constraints model highlighted 3 sources of influences： child, task & environment

Child Task Environment Development Physiology Morphology Motivation Temperament Behavior Fitness health Task Focus Skill running catching swim stroke Environment Instruction Family School Social-cultural

DCD的經驗如何改變他們的身體系統 Neuromotor and perceptual-motor subsystems may be “inexperienced,” & the tuning of these systems will be limited. The musculo-skeletal systems of children of DCD develop differently due to a lack of appropriate levels of stimulation. Poor muscular power and limited flexibility result form a more sedentary lifestyle. Increased anxiety about physical activity, reported by girls with low levels of coordination, can interfere with skill acquisition. The quality of social support form family and friends can result in positive or negative contributions to skill development

應用活動導向治療 The motor tasks are developmentally and culturally appropriate. A whole-part-whole or a part-whole-part approach child: attempts the actual task therapist: actions of body components, task elements, & task dynamics

應用活動導向治療 Use extensive, complementary physical, visual and verbal prompts. Encourage guided exploratory approaches to task performance. Target important motor fitness elements that support effective task performance.

感覺統合觀點看 DCD兒童 Developmental Dyspraxia vs. DCD Treatment of dyspraxia Developing Ideation Coordinately use 2 body sides Projected action sequences Addressing somatodyspraxia

SI Dysfunction Poor Dyspraxia Modulation Disorder 動作協調障礙 過度敏感或不敏感 感覺調節障礙 過度敏感或不敏感

感覺統合治療原則 Objectives (goals) are explicit & determined by clients & caregivers. Helping clients & caregivers reframe behaviors and difficulties is an important part of intervention. Clients and caregivers often implement aspects of intervention, particularly when the objectives depend on altering sensory modulation.

感覺統合治療原則 Even when DSI is found to limit clients’ performance, other factors may also be contributing to the difficulties. When present, these may require intervention of a different type. The form of intervention is determined through task analysis in which the limiting components of the targeted task are identified.

感覺統合治療原則 As much as possible, the form of intervention “mimics” or incorporates the limiting components of the targeted task. When DSI limits performance, intervention incorporates enhanced sensation. The type of sensation depend on the desired outcome.

感覺統合治療原則 Intervention activities demand an adaptive interaction. When improved motor performance is a crucial part of the objective, intervention activities incorporate appropriate amounts and types of practice and feedback.

ADHD 自閉症 學習障礙 感覺統合障礙 語言障礙 智力障礙 腦性麻痺

個人研究： DCD兒童感覺統合療效探討

研究目的 探討DCD兒童對感覺統合（簡稱SI）治療的反應 研究問題 DCD兒童實驗組和對照組，前後測分數差異是否達到顯著水準？

DCD 兒童篩選條件 年齡介於4-0至6-11 無任何神經心理疾病之診斷 智力正常：PPVT-R（修訂畢保德圖畫詞彙測驗）＞ 25 百分等級 MABC ＜15 百分等級

研究架構 - 實驗研究 前測（比較兩組之差異） DCD實驗組 DCD對照組 DCD兒童 12週/或24次感覺統合治療 後測（比較兩組之差異）

研究對象

研究工具 Movement ABC 感覺統合與運用能力測驗（SIPT） 拜瑞布坦尼卡視覺動作統整測驗（VMI） 動作精確度測驗（MAC） 運動覺測驗（KIN） 手指區辨測驗（FI） 拜瑞布坦尼卡視覺動作統整測驗（VMI） 伸展測驗（prone extension test） 感覺史量表 兒童活動量表

SI 治療 依循Ayres的感覺統合理論與治療原則 場地：成大職能治療學系 SI 治療室 治療師：作者 介入頻率：一週2次，共12週24次治療 治療過程

資料分析 獨立樣本 t 檢定 效果量 r = t2/(t2+df) 2-way ANOVA （二因子混和設計變異數分析）

研究結果

研究結果 ANOVA 分析： MABC 『墊腳尖走』＆感覺史『分心』

研究結果 SI 治療對 DCD 的療效 - significant Movement ABC：「接沙包」分項、 「障礙總分」(Leejrijse, 1999) 與「百分等級」 SIPT：「運動覺測驗」 感覺史（Sensory Profile）（分心）

研究結果 SI 治療對 DCD 的療效 - non-significant Movement ABC：精細動作項目 Grapho-motor tasks （VMI ＆MAc） 伸展測驗（prone extension） 手指區辨測驗

研究結論 SI治療可改善 DCD兒童的粗大動作協調能力、與分心的問題 MABC的總分、SIPT 的「運動覺測驗」、感覺史等可顯著地反映 SI 療效 SI的療效在短期內（12週）即可被MABC的總分偵測出，家長也可感受兒童分心行為的改善 SI的療效，個案年紀愈小者愈顯著 合併有其他問題的DCD個案，SI療效有限

研究限制 樣本小統計力低（ type II error 機率） 未隨機分派實驗組與對照組 未完全隱瞞個案組別，施測者易有偏頗 未進行追蹤評量