발달지연 환자의 종적 추적 관찰: 단일기관 연구
Longitudinal Follow-up Study of Children with Developmental Delay: Single Center Experience
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초록
목적: 발달지연은 학동기를 포함한 전체 소아의 5-10%에서 나타나는 비교적 흔한 질환으로 소아의 중요한 건강문제 중의 하나이다. 이들을 조기에 발견하여 적절한 조기 개입을 함으로써 장래에 초래될수 있는 장애를 줄일 수 있을 뿐만 아니라 사회적 부담과 비용도 줄일수 있어 조기 발견은 매우 중요하다. 이에 국민건강보험 일산병원 발달지연 클리닉에 내원한 환자 중 2번이상 추적 관찰된 환자를 대상으로 이들의 종적인 진단의 변화를 살펴보고, 최종진단이 ASD, ID, DLD의 경우, 이 세 질환을 초진 시 미리 판별할 수 있는 예측 인자를찾아봄으로써 적절한 조기개입을 하는데 도움을 받고자 본 연구를시행하였다. 방법: 2007년 8월-2013년 7월까지 국민건강보험 일산병원 발달지연 클리닉에 내원한 환자(총 733명) 중 2번 이상 방문한 환자 168명을 대상으로 하였다. 모든 환자는 진료 시 다학제적 접근방식에 따라소아신경과, 소아재활의학과, 소아정신과의 세 과를 동시에 방문 하였다. 초진시의 기본 검사로 언어평가, 발달평가 혹은 인지평가, 사회성및 행동평가, 청력검사를 실시하였고, 환자에 따라 아동기자폐증평정척도(CARS), MRI, 뇌파검사, 염색체 검사, 대사이상 검사 등을 선택적으로 시행하였다. 검사 결과 및 병력청취, 진찰소견을 바탕으로 초진시 내린 잠정진단과 재진 시의 최종진단의 변화를 의무기록 검토를 통해 후향적으로 살펴 보았다. 결과: 1) 1차 방문 아동들의 평균 연령은 2.78세(4-97개월)이며, 추적 방문 아동들의 평균 연령은 4.81세(24-136개월) 이었고, 평균 추적기간은 24.8개월(8-68개월) 이었다. 2) 환자들의 가장 흔한 주 호소는 언어지연이었다(71.5%). 3) 잠정 진단과 최종 진단의 차이는GDD와 DLD환자군에서 주로 관찰되었는데, 결국 최종진단 ID는 잠정진단 DLD에서보다 GDD에서 더 많이 이행되었으나(65.3% vs 42.3 %), ASD는 두 군에서 모두 비슷한 비율로 이행되었다(16.3 vs 19.2%). 4) 초진 시 DLD 환자군 증, 비언어성 인지발달지수(C-DQ)가 정상인환자일수록 장기적인 예후가 훨씬 양호하였다. 5) 이 변수들 중 세 군을 가장 영향력 있게 판별할 수 있는 예측 변수를 판별분석을 통해 확인해 본 결과, C-DQ (0.7436)가 가장 강력했고, 이후 SMS (0.6239), M_Q (0.6070), eye contact (0.4743), CARS (-0.3148), Rec_Q (0.2984), P_Q (0.2629)의 순서로 나타났다. 결론: 발달지연이 있을 때 경험 있는 의사의 정기적인 추적 관찰은매우 중요하며, 특히 1차 잠정진단이 GDD나 DLD 환자인 경우, 언어지연이 다른 영역에 비해 저명하면서(예; 자발어 없음) ASD의 예측 변수가 동반된 경우, ASD의 진단 기준에 합당하지 않더라도 최대한 일찍 집중적 조기 중재를 시작하는 것이 바람직하며, 장기적이고 주기적인 추적관찰이 필요하다.
Abstract
Pupose: Early detection of developmental delay is important because early intervention can reduce the disabilities that may arise in the future, as well as reduce social burdens and costs. In this study, we reviewed the changes of the diagnosis of patients who were followed up more than 2 times in the patients who visited the NHIS Ilsan Hospital Developmental Delay Clinic. In the cases whose final diagnosis were autism spectrum disorder (ASD), intellectual disability (ID), developmental language disorder (DLD), we performed this study to investigate the predictive factors of these diseases that can be discriminated in advance in order to provide appropriate early intervention. Methods: From August 2007 to July 2013, 168 patients who visited the NHIS Ilsan Hospital (total 733 patients) more than 2 times were included. All patients visited three departments (Pediatric Neurology, Rehabilitation & Psychiatry) at the same time according to a multidisciplinary approach. Speech evaluation, development & IQ test, social and emotional evaluation and hearing test were performed routinely. K-CARS, MRI, EEG, chromosome, and metabolic study were selected according to the patients. Review of medical records of children was performed retrospectively. Results: 1) The mean age of children at 1st and follow-up visit was 2.78 years (4-97 months) and 4.81 years (24-136 months) each. The mean follow-up period was 4.81 years (24-136 months). 2) The most common chief complaints of patients was language delay (71.5%). 3) The difference between the tentative diagnosis and the final diagnosis was mainly observed in the GDD and DLD patients. Eventually, the final diagnosis ID was diagnosed more in the GDD than in the DLD (65.3% vs 42.3%), but the diagnosis ASD was diagnosed similarly (16.3 vs 19.2%). 4) Long-term prognosis was better for patients with DLD who has higher nonverbal cognitive developmental quotient (C-DQ >70) at initial visit. 5) Result of the canonical coefficients by discrimination analysis showed that C-DQ (0.7436) was the strongest discriminating factor that predict the three groups, followed by SMS (0.6239), M_Q (0.6070), and eye Contact (0.4743), CARS (-0.3148), Rec_Q (0.2984), and P_Q (0.2629). Conclusion: Regular follow-up of experienced doctor is very important when a patient is delayed. If language delay is prominent compared to other areas & if discriminating factors of ASD are detected, it is advisable to initiate intensive early intervention with long-term periodic follow-up even if it does not meet the diagnostic criteria of ASD with long-term periodic follow-up.
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