4. Methods
4.2. Measures
The measures were chosen following the definition of each domain in the ICF-CY.
According to the ICF-CY, health condition is defined in terms of disease and severity of disease (WHO, 2007). Thus, both child’s diagnosis of ASD and its severity as measured by Childhood Autism Rating Scale (CARS) were the independent variables.
Activity and Participation dimension:
Communication (d310-d369) is defined as general and specific features of
communicating by language, signs and symbols, including receiving and producing messages, carrying on conversations, and using communication devices and techniques (WHO, 2007).
Thus, the Chinese Psychoeducational Profile-third edition (PEP-3) Expressive Language (EL) which measure a child’s ability to express himself or herself by speaking or gesturing and Receptive Language (RL) subtests which measures a child’s ability to understand spoken language (Fu, et al., 2010) through observation by researchers in evaluation room will be represented as children’s communication in activity dimension. Besides, the Vinland Adaptive Behavior Scale-Chinese version (VABS-C) Communication domain which evaluates the receptive, expressive, and written communication skills of the child (Wu, Chang, Lu & Chiu, 2004) through observation by their parents in home will be represented as participation in communication in children with ASD.
In ICF-CY, mobility (d410-d489) is defined as moving by changing body position or location or by transferring from one place to another (WHO, 2007). Therefore, the CPEP-3 Fine Motor (FM) and Gross Motor (GM) domain which assess children’s ability to control different parts of their bodies (Fu, et al., 2010) through researchers’ observation in evaluation room will be represented as children’s motor in activity dimension, and the VABS-C motor
domain which evaluated gross and fine motor skills (Wu, et al., 2004) through parents’
observation in home will be represented as participation in motor. In ICF-CY, daily living skills included self-care (d510-599), domestic life (d610-669) and community, social and civic life (d910-d999). Self-care (d510-599) is defined as caring for oneself, washing and drying oneself, caring for one’s body and body parts, dressing, eating and drinking, and looking after one’s health (WHO, 2007). Domestic life (d610-669) is defined as carrying out domestic and every day actions and tasks (World Health Organization, 2007). Community, social and civic life (d910-d999) is defined as actions and tasks required engaging in organized social life outside the family, in community, social and civic areas of life (WHO, 2007). Therefore, the VABS-C Daily Living Skills domain that measures personal behavior as well as domestic and community interaction skills (Wu, et al., 2004) will be represented as participation in daily living skills. In ICF-CY, play is labeled as recreation and leisure (d920) and is defined as engaging in any from of play, recreational or leisure activity (WHO, 2007).
Thus, the VABS-C Play and Leisure Time subdomain which measures how children play and use the their leisure (Wu, et al., 2004) will be represented as participation in play skills.
Copying (d130) in basic learning which is defined as imitating or mimicking as a basic component of learning, such as copying, repeating a facial expression, a gesture, a sound or the letters (WHO, 2007) is measured by the CPEP-3 Visual-Motor Imitation (VMI) subtest which assesses children’s ability to imitate visual and motor tasks (Fu, et al., 2010).
In ICF-CY, socialization is labeled as interpersonal interactions and relationship (d710-d799) and is defined as carrying out the actions and tasks required for basic and complex interactions with people in a contextually and socially appropriate manner (WHO, 2007). Thus, the VABS-C Socialization domain which measures children’s play and leisure time, interpersonal relationships, and various coping skills (Wu, et al. 2004) through parents’
observation in home will be represented as participation in socialization.
Body function/structure dimension:
In body functions dimension of the ICF-CY, intellectual functions (b117) are defined as general mental functions, required to understand and constructively integrate the various mental functions (WHO, 2007) and are measure by the CPEP-3 Cognitive Verbal/Preverbal (CVP) subtest which measures children’s cognition and verbal memory (Fu, et al., 2010).
Moreover, in the ICF-CY, attention functions (b140) which are defined as specific mental functions of focusing on an external stimulus or internal experience for the required of time (WHO, 2007). Emotional functions (b152) which are defined as specific mental functions related to the feeling and affective components of the processes of the mind (WHO, 2007) are measured by the Child Behavior Checklist 1.5-5 which measures children’s emotional
problems such as Emotionally Reactive, Anxious/Depressed, Somatic Complaints, and withdrawn and behavior problems such as Attention Problems (Chen, Huang & Chao, 2009).
Dispositions and intra-personal functions (b125) in the ICF-CY which are defined as
disposition to act or react in a particular way, characterizing the personal, behavioral style of an individual that is distinct from others (WHO, 2007) are measure by the Behavior Style Questionnaire-Chinese version (BSQ-C) which measures children’s temperament such as Activity level, Rhythmicity, Approachability, Adaptability, Response intensity, Mood, Persistence, Distractibility, and Threshold (Hsu, 2006). Sleep function (b134) which are defined as general mental functions of periodic, reversible and selective physical and mental disengagement from one’s immediate environment accompanied by characteristic
physiological changes (WHO, 2007) are measured by items related to sleep problems in the information questionnaire. In ICF-CY, perceptual functions (b156) in mental functions which are defined as recognizing and interpreting sensory stimuli (WHO, 2007), and sensory functions and pain (b210-b289) which are defined as the functions of the sense, seeing, hearing, tasting and the sensation of pain (WHO, 2007) are measured by the Short Sensory Profile-Chinese version (SSP-C) which measures children’s responses to sensory events in everyday life (Tseng & Cheng, 2008). Emotional functions (b152) which are defined as specific mental functions related to the feeling and affective components of the processes of the mind (WHO, 2007) are measured by the CPEP-3 Affective Expression (AE) subtest which measures the degree to which the child displays appropriate affective responses (Fu, et al., 2010). Global psychosocial functions (b122) in global mental functions which are defined as
general mental functions that lead to the formation of the personal and interpersonal skills needed to establish reciprocal social interactions (WHO, 2007) are measured by the CPEP-3 Social Reciprocity (SR) subtest which measures the social interactions between the child and others (Fu, et al., 2010).
Environmental factors:
With regard to the environmental factors, it is defined as the physical, social and
attitudinal environment in which people live and conduct their lives (WHO, 2007). In services, systems and polices (e510-e599), social dimension of the environmental factors, services are defined as providing benefits, structured programs and operations designed to meet the needs of individuals, systems are defined as administrative control and organizational mechanisms and are established by governments, and policies are defined as rule, regulations, conventions and standards established by governments (WHO, 2007). Thus, the social economic status (SES), the types, frequency and duration of the treatment in information questionnaire are represented as the social dimension of the environmental factors. Attitudes (e410-e499), the attitudinal dimension of the environmental factors, are defined as observable consequences of customs, practices, ideologies, values, norm, factual beliefs and religious beliefs (WHO, 2007). Therefore, the Parenting Stress Index-short Form which measure parenting stress based on the interrelationship between the child’s and the parents’ characteristics (Weng, 2003), the
positive Affect Index (PAI) which evaluated mother’s perceptions of positive affect with their children (Bengtson, 1990) are represented as the attitudinal dimension of the environmental factors.
Personal factors:
In ICF-CY, personal factors that are defined as contextual factors related to the individual (WHO, 2007) such as age and gender are measured by basic information questionnaire.
The measures selected according to the ICF-CY framework were listed as follows:
4.2.1. Measures administered directly to the child
4.2.1.1. Chinese Psychoeducational Profile-third edition (CPEP-3; Fu, et al., 2010) The CPEP-3 was translated from the Psychoeducational Profile-third edition (PEP-3, Schopler, Lansing, Reichler & Marcus, 2005). The PEP-3 is a standardized, norm-referenced scale, specifically designed for children with ASD, aged from 2 years to 7.5 years, to assist clinicians or educators in planning treatment or educational programs (Schopler, et al., 2005).
The PEP-3 consists of 172 items, which are combined to form 10 subtests [cognitive
verbal/preverbal (CVP), expressive language (EL), receptive language (RL), fine motor (FM), gross motor (GM), visual-motor imitation (VMI), affective expression (AE), social reciprocity (SR), characteristic motor behaviors (CMB), and characteristic verbal behaviors (CVB)] and
3 composites (communication, motor, and maladaptive behavior)(Schopler, er al., 2005).
Higher score indicated better performance or less maladaptive behaviors (Schopler, er al., 2005). The internal consistency ranges form 0.92 to 0.98 for the subtests and from 0.92 to 0.95 for the composites (Fu, et al., 2010). The inter-rater reliability ranges form 0.57 to 0.94 for the subtests, and from 0.63 to 0.89 for the composites (Fu, et al., 2010). The confirmatory factor analysis has confirmed that the PEP-3 contains three factors: communication, motor, and maladaptive behaviors (Schopler, er al., 2005).
4.2.2. Observational measures rated by researchers
4.2.2.1. Childhood Autism Rating Scale (CARS, Schopler, Reichler & Renner, 1988) The CARS is a 15-item behavior rating scale which is developed to help identify and diagnose autism in individuals aged over 2 years and older and to estimate the severity of the autistic disorder (Schopler, et al., 1988). It is completed by professional based on direct observation or parent interviews (Schopler, et al., 1988). Each of the 15 items is given a rating from 1 to 4, 1 indicated that a child’s behavior is within normal limits for a child of that age, 2 means that the child’s behavior is mildly abnormal, 3 indicated that the child’s behavior is moderately abnormal, and 4 indicated that the child’s behavior is severely abnormal.
Additionally, the midpoints (1.5, 2.5, & 3.5) between four ratings are to be used when the behavior appears to fall between two categories. The total CARS score is computed by
summing the 15 individual ratings, ranging from 15 to 60. Higher score indicated more autistic behaviors (Schopler, et al., 1988). Children with scores below 30 are categorized as nonautistic. Scores ranging from 30 to 36.5 indicated mild to moderate autism while scores ranging from 37 to 60 indicated severe autism. The internal consistency is 0.94 (Schopler, et al., 1988). The average inter-rater reliability is 0.71 and the test-retest reliability is 0.88 (Schopler, et al., 1988). The diagnoses made by CARS were in agreement with those made independently by child Psychologist and psychiatrists (Schopler, et al., 1988).
4.2.3. Measures rated with parent interviews
4.2.3.1. Vineland Adaptive Behavior Scale-Chinese classroom edition (VABS-C; Wu, et al., 2004)
The VABS-C is translated from the Vineland Adaptive Behavior Scale (VABS) and designed to measure a child’s day-to-day adaptive functioning from 3 to 12 years of age (Wu, et al., 2004). The VABS-C assesses four domains of adaptive behaviors: Communication, Daily living skills, Socialization, and Motor skills (Wu, et al., 2004). The raw scores can be converted to age equivalent, standard scores, and a Composite Overall score can be derived, based on the sum of the sub-scale standard scores (mean = 100; standard deviation = 15).
Higher score indicates better performance. The split-half reliability of the whole scale is 0.91-0.99 (Wu, et al., 2004). The test-retest reliability is 0.62-0.95, and the inter-rater
reliability is 0.74-0.89 (Wu, et al., 2004). The discriminate validity is also examined (Wu, et al., 2004).
4.2.4. Parent questionnaires
4.2.4.1. Basic information questionnaire
The basic information questionnaire includes child’s personal factors such as age, gender, birth order, total number(s) of children in the family, epilepsy, medical condition, types of early intervention services (e.g. occupational therapy, speech therapy, or others), types of educational settings, hour(s) of early intervention/per week, and parental information such as educational level, occupation, age.
4.2.4.2. Child Behavior Checklist for Ages 1.5-5-Chinese version (Chen, et al., 2009)
The Chinese version of Child Behavior Checklist for Ages 1.5-5 (CBCL-C/1.5-5) was translated from the Child Behavior Checklist for Ages 1.5-5 in Achenbach System of Empirically Based Assessment (Achenbech & Rescorla, 2000). The CBCL-C/1.5-5 is a 99-item caregiver report which examines children’s emotional and behavior problems in children aged form 1.5 to 5 years by using 3-point scale which 0 for not true of the child, 1 forsomewhat true or sometimes true, and 2 for very true or often true based on preceding 2
months (Chen, et al., 2009). The CBCL-C/1.5-5 contains seven syndrome scales (Emotionallyreactive, Anxious/depressed, Somatic complaints, Withdrawal, Sleep problems, Attention problems, and Aggressive behaviors) and the seven scales merged into two broad band
syndrome scales (Internalizing and Externalizing) (Chen, et al., 2009). Internalizing problems consisted of the four syndrome scales, Emotionally reactive, Anxious/depressed, Somatic complaints, and Withdrawal. Externalizing problems consisted of the two syndrome scales, Attention problems, and Aggressive behaviors. Internalizing problems, Externalizing
problems, and Sleep problems are combined to form the Total Problems composite score. The severity of one syndrome of and individual is counted by summing the scores of its items. A T score ≥ 70 (at least two standard deviations above the mean for the general population) for a syndrome scale or a T score ≥ 63 for internalizing or externalizing problems were in the clinical range. Higher score indicates more emotional and behavioral problems. The internal consistency coefficients range from 0.66-0.95 (Achenbech & Rescorla, 2000). The test-retest reliability ranges form 0.80s-0.90s (Achenbech & Rescorla, 2000).
4.2.4.3. Behavior Style Questionnaire-Chinese version (BSQ-C; Hsu, 2006)
The Behavior Style Questionnaire – Chinese version (BSQ-C) was translated from the Behavior Style Questionnaire (McDevitt & Carey, 1978) by the child development research group of the Child Mental Health Center of National Taiwan University Hospital. The BSQ-C is a 72-item caregiver report which measures preschool children’s temperament (Hsu, 2006).
The BSQ-C contains 9 temperamental dimensions: Activity level (the amount of physical movement during daily routines), Rhythmicity (consistency of physiological functions, such as sleeping or toileting), Approachability-Withdrawal (the tendency to approach new objects or experiences), Adaptability (the ability to adjust or change behavior in socially desirable ways), Response intensity (the depth or magnitude of emotional response), Mood (the quality of an emotional reaction in either a positive or negative direction), Persistence (pursuit of challenging tasks), Distractibility (the effectiveness of extraneous environmental stimuli in interfering with ongoing behaviors), Threshold (the minimal amount of sensory stimulation necessary to elicit a response).
Parents rate their child on each item using a 7-point scale from 1 (the child almost never demonstrates a particular behavior) to 7 (the child almost always exhibits that behavior).
Higher scores for each dimension are indicative of greater difficulty. Specifically, if the dimension score is one standard deviation above the mean, the child is scored in the difficult range. The difficult temperament refers to high activity level, withdrawal form new stimuli, irregularity, low adaptability, high intensity, and negative mood (Hsu, 2006). Contrary, the easy temperament consists of adequate activity level, approach to new stimuli, regularity, intensity, high adaptability, and a positive mood (Hsu, 2006). The internal consistency is 0.84 (Wang, 2002) and the test-retest reliability is 0.38-0.73 (Chen, 1980).
4.2.4.4. Short Sensory Profile-Chinese version (SSP-C; Tseng & Cheng, 2008)
The SSP-C was translated from the Short Sensory Profile (SSP; Dunn, 1999). The SSP-C is as 38-item caregiver questionnaire and the items were selected from the Sensory Profile which was the most indicative in measuring children’s response to sensory events in everyday life (Tseng & Cheng, 2008). The SSP-C is used for children from 3 to 10 years of age and it is composed of 9 sections, i.e. Tactile sensitivity, Taste/smell sensitivity, Movement sensitivity, Underresponsive/seeks sensation, Auditory Filtering, Low energy/weak, and Visual/auditory sensitivity (Tseng & Cheng, 2008). Caregivers render their answers through a 5-point Likert scale (almost never = 5, seldom = 4, occasionally = 3, frequently = 2, almost always = 1) and higher scores indicated better sensory procession abilities (Tseng & Cheng, 2008). The test-retest reliability is 0.79 with a 3-week interval, and Cronbach alpha for internal
consistency ranger from 0.62-0.90 (Tseng & Cheng, 2008). The results of the discriminative validity study showed that all the section and factor scores of the SSP-C were significantly different between children with and without autism (Tseng & Cheng, 2008).
4.2.4.5. Parenting Stress Index-Chinese Short Form (PSI-CSF; Weng, 2003)
The PSI-CSF was translated from the Parenting Stress Index- short form (Abidin, 1995).
The PSI-CSF is a 36-item questionnaire which is designed to measure parenting stress based on the interrelationship between the child’s and the parents’ characteristics (Weng, 2003). The
target population of PSI-CSF is the patents of children aged from 1 month to 12 years (Weng, 2003). Parenting stress was reported on each item using a 5-Likert point scale that ranged from 1, strongly disagree, to 5, strongly agree. The total stress score is calculated by the summing the all item and provides a figure for overall level of parenting stress. The PSI-CSF consists of three subscales: Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child (Weng, 2003). The Parental Distress subscale is designed to measure an impaired sense of competence in the parenting role, lack of social support, role-restriction, depression, and conflict with one’s spouse. The Parent-Child Dysfunctional Interaction subscale presents that child fails to meet parents’ expectations, and interactions with the child are not reinforcing. The Difficult Child Subscale assessed the characteristics of the child that make him/her easy or difficult to manage. Higher scores on the subscales and PSI-CSF total score indicated greater levels of stress (Weng, 2003). While a raw score of total parenting stress ≥ 115 (or at of above the 90th percentile), or score of the Parental Distress ≥41, or score of the PCDI ≥ 37 or score of the Difficult Child ≥ 38, all strongly indicates Clinically
Significant stress in the parent-child dyad and their parents should seek professional
counseling. A raw score of total parenting stress within 65-103 (or within 15-80th percentile) indicates Normal range. The following internal reliability alpha coefficients have been reported: 0.947 for total stress, 0.902 for Parental Distress, 0.908 for P-CDI and 0.856 for the Difficult Child subscale (Weng, 2003).
4.2.4.6. Positive Affect Index (PAI; Bengtson, 1990)
The PAI is a 15-item caregiver report which is used to evaluate mothers’ perceptions of positive affect in their relationship with their son or daughter with ASD (Bengtson, 1990). The PAI contains ten items of positive affect toward the son or daughter with an ASD and five items of positive affect perceived to be reciprocated (Bengtson, 1990). Higher score indicates more positive affective relationship perceived by their mothers (Bengtson, 1990). Cronbach’s alpha was 0.88 for the Taiwanese mothers and 0.83 for the U.S. families (Lin, 2008)