자폐스펙트럼장애 영유아 대상 M-CHAT의 신뢰도 및 타당도 연구 = Reliability and Validity of Modified Checklist for Autism in Toddlers(M-CHAT) for Infants and Toddlers with Autism Spectrum Disorder

다국어 초록 (Multilingual Abstract)

In this study, the Modified Checklist for Autism in Toddlers, which is used domestically and internationally as a screening tool for autism spectrum disorder for infants, was conducted on infants and toddlers between 16 months and 47 months old to verify their reliability and validity, and to examine the usefulness of M-CHAT.
Subjects were infants and toddlers aged 16 to 47 months and parents. 69 infants and toddlers with autism spectrum disorder and 29 infants and toddlers with typically development participated in the government-led "Integrated Early Selection Tools and Service Development of Infant Autism Growth Fitness" study (Social Services of the Ministry of Health and Welfare R & D Task Number: HI14C2719).
Instruments were M-CHAT, which translated 23 questions of original authors on the Web site of Robins into Korean, Child Behavior Checklist for Ages 1.5-5(CBCL 1.5-5), and Childhood Autism Rating Scale (CARS).
Data analysis was conducted inter-item correlation analysis and technical statistics of M-CHAT, and frequency analysis was performed to identify characteristics of each question, and response frequency and response rate for each question in the autism spectrum disorder group and typically development group. Reliability was verified by internal consistency also test-retest reliability, and concurrent validity was verified by correlation analysis with CBCL and CARS. ROC Curve, discriminative analysis, sensitivity and specificity were checked, and statistically set cut-off values were checked by logistic regression.
The findings are as follows. The total Kuder-Richardson Formula 20’s α of M-CHAT was 0.90 (p<0.01), also test-retest reliability was 0.70 (p<0.01) from the high-variety six-question screening criteria of M-CHAT and 0.76 (p<0.01) from the overall 23-question screening criteria, proving high reliability of the instrument. The coefficient of correlation between the high-variety six-question screening criteria of M-CHAT and the CBCL DSM overall development problem sub-scale T was 0.60 (p<0.01), and the coefficient between the overall 23-question screening criteria of the M-CHAT and CBCL DSM overall development problem sub-scale T score was 0.55 (p<0.01). In addition, the coefficient of correlation between the high-variety six-question screening criteria of M-CHAT and the CARS total scores was 0.66 (p<0.01), and the coefficient between the overall 23-question screening criteria and the CARS total scores was 0.63 (p<0.01), proving concurrent validity of M-CHAT.
As a result of ROC Curve, the application of the high-variety six-question screening criteria of M-CHAT was found to be 84% sensitivity and 86% specificity based on the total score of 0.5 point, and the application of the overall 23-question screening criteria of M-CHAT was confirmed to be 74% sensitivity and 86% specificity based on the total score of 3.5. As a result of the discriminant analysis, the method of applying the high-variety six-question screening criteria was found to have a sensitivity of 0.84 and a specificity of 0.86, and the overall 23-question screening criteria application method was found to have a sensitivity of 0.81 and a specificity of 0.76.
The logistic regression results showed that the cut-off value representing the highest sensitivity and specificity in the high-variety six-question screening criteria of M-CHAT was one point, and that the cut-off value representing the highest sensitivity and specificity in the overall 23-parameter screening criteria was two points. After lowering the screening criteria for the high-variety six-question screening criteria from two cut-off values to one point, the categorization rate for autism spectrum disorder group was 0.84, and the rate for typically development group was 0.86. And after lowering the overall 23-question screening criteria from three cut-off values to two points, the categorization rate for autism spectrum disorder group was 0.91, and the classification rate for typically development group was 0.55. Downgrading both cut-off criterias could increase the classification rate of autism spectrum disorders.
This study is meaningful in verifying the reliability and validity of M-CHAT for infants and infants with autism spectrum disorder between 16 months and 47 months in Korea, and we hope that M-CHAT will be more useful in the domestic field in the future.

국문 초록 (Abstract)

본 연구는 영유아 대상 자폐스펙트럼장애 선별도구로 국내외적으로 사용되고 있는 개정판 영유아 자폐선별 검사(The Modified Checklist for Autism in Toddlers)를 자폐스펙트럼장애로 진단받은 16개월~47개월 영유아를 대상으로 실시해 신뢰도와 타당도를 검증하고, M-CHAT의 유용성을 살펴보고자 하였다.
연구대상은 국가적 차원에서 개발한 ‘영유아 자폐성장애의 통합적 조기 선별도구 및 서비스 개발’ 연구(보건복지부 사회서비스 R & D 과제번호 : HI14C2719)에 참가한 16개월에서 47개월 사이의 영유아와 부모로 자폐스펙트럼장애 집단은 69명, 일반 집단은 29명이었다.
본 연구의 측정도구는 Robins의 Website에 올려져있는 원저자의 23문항을 한글로 번역한 M-CHAT, 유아행동평가척도(CBCL 1.5-5)와 아동기 자폐증 평정척도(CARS)가 사용되었다.
자료 분석은 M-CHAT의 기술통계와 문항 간 상관을 분석하였고, 문항별 특성을 파악하기 위해 빈도분석을 실시하여 자폐스펙트럼장애 집단, 일반 집단의 각 문항에 대한 응답 빈도 및 응답 비율을 확인하였다. 내적 일치도, 검사-재검사 신뢰도로 신뢰도를 검증하였고, 공인 타당도 검증을 위해 유아행동평가척도, 아동기 자폐증 평정척도와의 상관분석을 실시하였다. ROC Curve, 판별 분석, 민감도, 특이도를 확인하고 로지스틱 회귀분석으로 통계적으로 설정된 절단값을 확인하였다.
본 연구 결과는 다음과 같다. M-CHAT의 문항 간 내적 일치도는 0.90(p<0.01)이며, 검사-재검사 신뢰도 지수는 M-CHAT의 고변별 6문항 선별 기준에서 0.70(p<0.01), 전체 23문항 선별 기준에서 0.76(p<0.01)으로 신뢰도가 높았다. M-CHAT의 고변별 6문항 선별 기준과 유아행동평가척도의 DSM 전반적 발달문제 하위척도 T 점수와의 상관계수는 0.60(p<0.01), 전체 23문항 선별 기준과 유아행동평가척도의 DSM 전반적 발달문제 하위척도 T 점수와의 상관계수는 0.55(p<0.01)로 공인타당도가 확인되었다. 그리고 M-CHAT의 고변별 6문항 선별 기준과 CARS 총점과의 상관계수는 0.66(p<0.01), 전체 23문항 선별 기준과 CARS 총점과의 상관계수는 0.63(p<0.01)으로 높은 공인타당도가 확인되었다.
ROC Curve 결과, M-CHAT의 고변별 6문항 선별 기준 적용 방식은 총점인 0.5점을 기준으로 한 경우 민감도 84%, 특이도 86%이며, M-CHAT의 전체 23문항 선별 기준 적용 방식은 총점인 3.5점을 기준으로 한 경우 민감도 74%, 특이도 86%로 확인되었다. 또한 판별 분석을 통한 고변별 6문항 선별 기준 적용 시 민감도는 0.84, 특이도는 0.86으로, 전체 23문항 선별 기준 적용 시 민감도는 0.81, 특이도는 0.76으로 확인되었다.
로지스틱 회귀분석 결과, M-CHAT의 고변별 6문항 선별 기준에서 민감도와 특이도가 제일 높은 통계적 절단값은 1점, 전체 23문항 선별 기준에서 민감도와 특이도가 제일 높은 통계적 절단값은 2점이었다. 고변별 6문항 선별 기준을 절단값 2점에서 1점으로 하향 조정한 후 정분류율을 산출 결과, 자폐스펙트럼장애 집단에 대한 정분류율은 0.84, 일반 집단에 대한 정분류율은 0.86이었으며, 전체 23문항 선별 기준을 절단값 3점에서 절단값 2점으로 하향 조정한 후 정분류율을 산출한 결과, 자폐스펙트럼장애 집단에 대한 정분류율은 0.91, 일반 집단에 대한 정분류율은 0.55로 나타났다. 두 가지 선별 기준 모두 절단값을 하향 조정했을 경우 자폐스펙트럼장애에 대한 정분류율이 높아질 수 있었다.
본 연구는 국내 16개월에서 47개월 사이의 자폐스펙트럼장애 영유아를 대상으로 M-CHAT의 신뢰도, 타당도를 검증한 것에 의의가 있으며, M-CHAT이 앞으로 국내 현장에서 더욱 유용하게 사용되기를 기대한다.

목차 (Table of Contents)

• Ⅰ. 서론·························································································1
• 1. 연구의 필요성 및 목적···························································1
• 2. 연구 문제·············································································4
• Ⅱ. 이론적 배경··············································································5
• 1. 자폐스펙트럼장애(Autism Spectrum Disorder, ASD)················5
• 1) 진단기준의 변화································································5
• 2) 자폐스펙트럼장애의 특징····················································6
• 3) 자폐스펙트럼장애 영유아의 특성··········································8
• 2. 자폐스펙트럼장애 조기 선별 및 조기 중재의 중요성················10
• 3. 자폐스펙트럼장애 선별도구···················································12
• 1) 부모보고식 설문지···························································12
• 2) 전문가에 의한 실시 도구··················································15
• 4. M-CHAT···········································································18
• Ⅲ. 연구 방법···············································································21
• 1. 연구 대상···········································································21
• 1) 대상의 선정····································································21
• 2) 연구 대상의 인구통계학적 특성·········································22
• 2. 측정 도구···········································································24
• 1) M-CHAT·······································································24
• 2) 유아행동평가척도(CBCL 1.5-5)········································25
• 3) 아동기 자폐증 평정척도(CARS)·········································25
• 3. 연구 절차···········································································26
• 4. 자료 분석···········································································27
• Ⅳ. 연구 결과················································································29
• 1. M-CHAT의 기술통계와 상관················································29
• 1) M-CHAT의 기술통계·······················································29
• 2) M-CHAT의 문항 간 상관·················································31
• 2. M-CHAT의 문항별 특성······················································33
• 1) 자폐스펙트럼장애 집단, 일반 집단 영유아의 M-CHAT 특성··33
• 3. M-CHAT의 신뢰도 분석······················································37
• 1) M-CHAT의 내적 일치도··················································37
• 2) M-CHAT의 검사-재검사 신뢰도·······································38
• 4. M-CHAT의 타당도 분석······················································42
• 1) M-CHAT의 공인 타당도··················································42
• 5. M-CHAT의 효과성 분석······················································47
• 1) M-CHAT의 민감도와 특이도············································47
• Ⅴ. 논의 및 결론···········································································57
• 참고문헌······················································································63
• ABSTRACT·················································································75
• 부록····························································································78