【研究背景】
兒童外化行為的發展，不僅和兒童社會、情緒及行為的適應有關，且與其日後發展出嚴重的品性疾患、反社會型人格疾患、或犯罪行為的增加有關，故有探究其發展機制的重要性。回顧文獻發現，過去有些研究指出母親產後憂鬱會影響兒童外化行為的發展，而有些研究則發現母親的產後憂鬱與其子女的外化行為無關，此研究結果的不一致，可能與母親是否於有憂鬱再復發有關。此外，過去研究指出憂鬱再復發之母親相較於健康之母親，傾向使用更多不恰當的管教方式，如：過於介入、攻擊或批評的態度，以及過多的身體處罰或口頭責備管教兒童，甚至是造成兒童身體或心理的虐待；文獻並指出兒童早期受到虐待將影響其未來外化行為之發展。是故，本研究假設母親憂鬱的持續與兒童外化行為有關；而兒童在學齡前期遭受虐待為母親憂鬱再復發影響學齡中期兒童外化行為的中介因子。

【研究目的】
本研究旨在探討：兒童在學齡前期受到虐待是否扮演母親產後憂鬱再復發影響學齡兒童外化行為發展的中介因子。本研究假設：控制了兒童性別、年齡與母親的憂鬱分數後，當母親為曾罹患產後憂鬱且再復發者，其子代在學齡前期曾受到母親及家人身體、心理的虐待時，會增加兒童學齡中期發展出外化行為的危險性。

【研究方法】
本研究參與者為國科會研究計畫『產後憂鬱症之前因與後果』，於成大醫院婦產科門診長期追蹤的婦女及其子代，總共98對親子 (包括46位男童；52位女童)納入研究分析中。研究工具：由專業研究員使用中文版精神疾病診斷晤談量表-終身診斷版 (CMSADS-L)及目前診斷版 (Current CMSADS)評估母親憂鬱診斷，利用兒童行為與情緒量表 (CBECL/4-16)評估學齡中期兒童之外化行為，兒童虐待量表-學齡前版本 (CMQ-P)評估兒童知覺到的學齡前虐待。研究程序：於母親懷孕約36週時邀請其參與本研究，並獲得母親懷孕時的憂鬱終身診斷。之後分別於以下時間點 (產後八週、四個月、十二及十四個月、兒童三~五歲、六歲~七歲、八~九歲) ，使用電話晤談方式以追蹤母親當時的憂鬱症狀。最後於兒童九~十一歲時，邀請親子至專屬實驗室，以診斷晤談及相關量表填寫的方式，以獲得母親憂鬱症狀診斷及研究資料之收集。

【研究結果】
利用多元階層迴歸分析方式，進行本研究假設之驗證，結果發現：控制兒童年齡、母親憂鬱程度及兒童性別的影響後，母親憂鬱再復發組相較於母親健康控制組、母親單純產前或產後憂鬱組，會透過學齡前期兒童知覺到較多的虐待為中介，而顯著預期兒童外化行為的發展。

【結論與建議】
當母親有憂鬱症狀的再復發時，透過其與家庭成員對兒童心理或身體上的虐待，可影響兒童未來外化行為的發展。本研究結果建議給予社會大眾有關婦女產後憂鬱、兒童虐待的心理病理及因應策略的教育，並建議臨床工作者主動提供產後憂鬱母親之家庭，親子互動的諮詢及家庭支持系統重要性的心理衛教，減少兒童被虐待機會，則可能進一步減低兒童外化行為的發展。但本研究仍有部分限制，如：兒童外化行為僅有母親的報告資料，缺少其他如父親、老師的評估資料；另外，學齡前期的兒童虐待僅依賴兒童主觀所知覺到受虐情形的報告，未來可考慮其他研究室親子互動觀察等客觀資料的收集。

【Background and purpose】
The development of child externalizing behaviors not only is correlated to the child’s social, emotion and behavior adaptation, but is also related with later severe conduct disorder, antisocial personality disorder development, and may even increase the risk of delinquent behavior. Therefore, it is important to examine the mechanism in the development of externalizing behaviors. Prior researches indicated that maternal depression was an important risk factor in the development of child externalizing behaviors. Beside, previous studies found that maternal postpartum depression affected the development of child externalizing behavior; in comparison, other researches showed the two to be uncorrelated. This discordant finding might be due to whether maternal depression recurred or not. Additionally, prior researches revealed that early childhood maltreatment/abuse was the risk factor in the development of child externalizing behaviors. Mothers with depression recurrent had the tendency to use inappropriate discipline patterns, such as an intrusive, aggressive or criticizing attitude, physical punishment, and hostile interacting styles, leading to more physical or psychological abuse in comparison to healthy control mothers and mothers with one-time maternal postpartum depression. Prior researches indicated that children who suffer from severe psychological and physical abuse might be predictable for the development of child externalizing and aggressive behaviors Therefore, this study examined whether perceived preschool abuse mediated the effect of maternal recurrent depression on the externalizing behaviors among children during middle childhood. The present study clarified the importance of preschool abuse perceived by child in hope to understand the underlying mechanisms in the development of externalizing behaviors and to assist clinical diagnosis and intervention.

【Method】
Participants were recruited from the project, “The causes and consequences of postpartum depression” at the OBS/GYN Department of a National Cheng Kung University Hospital. Ninety eight mother-child dyads (46 boys and 52 girls) were recruited in the final sample of this follow-up study. All mother participants were interviewed at 36 weeks of pregnancy to obtain their lifetime diagnostic status with the Chinese Modified Schedule for Affective Disorders and Schizophrenia - lifetime version. And were scheduled for follow-up interviews when the children were 8 weeks; 4, 12, 14 months and later at the ages of 3-5, 6-7, 8-9 and 9-11 years old using Chinese Modified Schedule for Affective Disorders and Schizophrenia – Current version. During the 9-11 year old interval, the externalizing behaviors of children were rated by mothers using the Child Behavioral and Emotional Checklist and the perceived preschool abuse was reported by the children using the Childhood Maltreatment Questionnaire-Preschool.

【Results】
Hierarchical regression analyses showed that controlled child age, child gender, and BDI, afterwards the maternal recurrent depression mediating through perceived preschool abuse had an impact on the externalizing behavioral problems of children.

【Discussion】
Our findings showed that the maternal recurrent depression and parent’s mental and physical abuse to their children will effect the development of child externalizing behavior. This study also suggested that psychological education should be given to the general population in regards to maternal depression and child maltreatment, and how to deal and cope with them. And the results provide clinical preventive and intervention guideline. Clinical workers should initiate concern in assessing parenting function and provide methods of appropriate interaction for family members that have maternal depression. If clinical workers have any indication that a family with postpartum recurrent depressive mother appear to be involved with child abuse, immediate reports should be given with intervention as soon as possible probably would reduce the child maltreatment and decrease the risk of developing child externalizing behaviors. There are some limitations in this study. First, child externalizing behavior was only based on maternal reports, alternative reports from the school teacher or father need to be considered in further studies. Second, child abuse was only based on children reports. Further researches can consider laboratory observations to improve objectivity. Third, only 175 participants among 413 were followed up in the present study.

中文摘要 II
英文摘要 IV
誌 謝 VI
目 錄 VIII
表目錄 X
圖目錄 X
附 錄 X
第一章 緒論 1
第一節 兒童外化行為之重要性 2
壹、兒童外化行為之定義及臨床表現 2
貳、兒童外化行為之盛行率及重要性 5
參、小結 6
第二節 母親憂鬱與兒童外化行為之關係 7
壹、母親憂鬱之種類及定義 7
貳、母親產後憂鬱之重要性及盛行率 8
參、母親憂鬱對兒童外化問題之影響 9
肆、小結 11
第三節 母親憂鬱、兒童虐待與兒童外化行為之關係 12
壹、兒童虐待之定義 12
貳、兒童虐待之測量演進 13
參、兒童虐待之盛行率 15
肆、兒童虐待對兒童外化問題行為之影響 16
伍、母親憂鬱對兒童虐待之影響 17
陸、小結 18
第四節 研究目的與假設 19
壹、研究目的 19
貳、研究假設 19
第二章 研究方法 20
第一節 研究參與者 20
第二節 研究工具 22
壹、中文版精神疾病診斷晤談量表-終身診斷版 (CMSADS-L) 22
貳、中文版精神疾病診斷晤談量表-目前診斷版 (Current CMSADS) 23
參、兒童行為與情緒量表 (CBECL/4-16) 24
肆、學齡前期兒童虐待量表 (CMQ-P) 25
伍、貝氏-憂鬱量表 (BDI) 26
第三節 研究流程 28
第四節 統計方式 30
第三章 研究結果 31
第一節 人口學變項之分析 31
第二節 變項間相關之分析 32
第三節 中介關係的驗證 33
壹、多元階層回歸分析驗證學齡前期兒童虐待的中介角色 33
第四章 結論、討論及建議 36
第一節 研究結果的總結 36
第二節 解釋與討論 36
壹、變項間關係的討論 37
貳、學齡前兒童虐待在母親產後憂鬱再復發對兒童外化行為發展影響之中介角色 39
第三節 研究限制與未來研究方向 43
第四節 研究貢獻與應用 44
第五章 參考文獻 45
一、中文文獻 45
二、英文文獻 46



【表 目 錄】
表一 參與者之人口統計學結果分析 57
表二 參與者與未參與者人口學變項比較 59
表三 重要變項間之相關表 60
表四 中介驗證統計表(以母親健康控制組為對照組) 61
表五 中介驗證統計表(以母親單純產前或產後憂鬱組為對照組) 63

【圖 目 錄】

圖一 學齡前期兒童虐待中介模式 19


【附 錄】

附錄一 兒童行為與情緒量表 65
附錄二 學齡前期兒童虐待量表 72
附錄三 貝氏-情緒量表 77

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