|Year : 2022 | Volume
| Issue : 4 | Page : 522-529
The use of goal attainment scaling in the acupuncture of children with intellectual disability
Si-Jia Zhang1, Dong Lin1, Li-Li Lin1, Shi-Yi Qi1, Meng Gong1, Shi-Bin Li2, Jie Zhang2
1 College of Acupuncture, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian Province, China
2 Department of Rehabilitation, The People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian Province, China
|Date of Submission||29-May-2021|
|Date of Acceptance||07-Sep-2021|
|Date of Web Publication||21-Jul-2022|
Dr. Dong Lin
College of Acupuncture, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian Province, 350122
Source of Support: None, Conflict of Interest: None
Objective: The therapeutic effect of acupuncture is often evaluated based on the experience and judgment of acupuncturists and the subjective feelings of patients. Thus, we investigated the suitability of goal attainment scaling (GAS), an objective outcome measurements, to evaluate the responsiveness of children with intellectual disability to acupuncture therapy. Methods: This is an assessor-blinded, single-group cohort study that included 17 children with intellectual disabilities. The therapeutic effect of acupuncture was assessed by the T scores of GAS at four time points during the 3-month treatment. The responsiveness of GAS to acupuncture therapy was measured using the standardized response mean (SRM). Results: Compared with control, the 4-, 8-, and 12-week scores improved significantly after treatment (P < 0.01, P ≤ 0.001, P ≤ 0.001), with significant differences between each month (P < 0.01, P ≤ 0.001, P ≤ 0.001). Furthermore, all periods assessed GAS (to measure the therapeutic effect of acupuncture) showed marked responsiveness (SRMs >0.8). Conclusion: GAS is responsive in evaluating individual changes in the acupuncture treatment of children with intellectual disabilities. It is a feasible tool to match both the needs of children with intellectual disabilities and the clinical characteristics of acupuncture.
Keywords: Acupuncture, goal attainment scaling, intellectual disability
|How to cite this article:|
Zhang SJ, Lin D, Lin LL, Qi SY, Gong M, Li SB, Zhang J. The use of goal attainment scaling in the acupuncture of children with intellectual disability. World J Tradit Chin Med 2022;8:522-9
|How to cite this URL:|
Zhang SJ, Lin D, Lin LL, Qi SY, Gong M, Li SB, Zhang J. The use of goal attainment scaling in the acupuncture of children with intellectual disability. World J Tradit Chin Med [serial online] 2022 [cited 2022 Dec 1];8:522-9. Available from: https://www.wjtcm.net/text.asp?2022/8/4/522/351509
| Introduction|| |
Intellectual disability (ID) is a disorder with onset during the developmental period. It includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. Since the Federal Statute in the US (Public Law 111-256, Rosa s Law) has replaced the term mental retardation (MR) with ID, research journals now use the term ID.
At present, the screening and diagnosis of ID in children mainly rely on a series of complex and professional scales. These scales are also indicators of clinical efficacy. This current standard works well for some. However, there are many populations, such as children living in the South Eastern regions of China, for whom it would be extremely difficult to apply these scales because they are cared for by their illiterate grandparents and suffer poor living conditions and language-challenged environments. Therefore, to address these gaps, we need to introduce a new assessment tool, such as the goal attainment scaling (GAS), which is not limited by culture or education.
False-negative outcomes and negative actions are inevitable, if parents of preschooler only receive a “wait and see” response from healthcare practitioners after expressing concerns of their kid's intellectual ability. And the child will miss the best time for treatment because the brain exhibits a high degree of plasticity during the preschool period. Appropriate intervention would offer the child the greatest potential to learn. Although it is true that a subset of these children will not continue to meet the criteria for ID over time, introducing a patient needs-oriented scale during this transition would most likely allow for improved intervention services and clinical evaluation, both of which are vital to improving developmental outcomes.
With the development of Chinese medicine, some researchers have shown that acupuncture is an effective and safe approach for curing various kinds of neurodevelopmental disorders (ND), such as ID, autism, spectrum disorder, and attention deficit hyperactivity disorder. Moreover, acupuncture is a suitable treatment for patients with uncertain signs of disability due to its safety and absence of adverse side effects. Although acupuncture has a great effect in treating ID, its efficacy cannot be measured using normal scales, such as the Gesell Development Scale and the Webster scale. Acupuncture and rehabilitation often support each other. In rehabilitation research, a large number of items in standardized measures are intended to cover all aspects of functioning and to benefit the measure's sensitivity to change at a group level. However, when assessing individuals in acupuncture practice, changes may easily be missed because only a few items show changes against a large number of unchanged items. The major feature of acupuncture therapy is individualized treatment, which allows acupuncturists to set treatment strategies flexibly according to the patients' different symptoms and needs. Furthermore, acupuncture can focus on multiple therapeutic targets simultaneously. Its result affects the body through a potential mechanism (”intervention effect”), which manifests in the daily life activities of patients in different ways. In the past, the therapeutic effect of acupuncture was evaluated based on the experience and judgment of acupuncturists and the subjective feelings of patients. Therefore, establishing ways to evaluate the effect of acupuncture objectively and fit the needs/preferences of families at the same time is a meaningful research area.
The GAS, introduced by Kiresuk and Sherman, is often used as an endpoint for quantifying therapeutic outcomes in populations with very heterogeneous symptoms, especially for rare diseases. Acupuncture meets the diverse needs of individuals, which includes patients with rare diseases to some extent. The core advantage of GAS is that it captures subtle changes in performance, which cannot be detected through normal outcome measures. GAS focuses on results that are meaningful to the individual. Moreover, the process of individualized formulation and evaluation is less limited by the dialect and literacy levels of the individuals and their families. Therefore, the meticulous and meaningful changes demonstrated in children with ID can be highlighted to reflect the improvement in individualized goals in acupuncture treatment utilizing a GAS-based assessment tool. However, to the best of our knowledge, a standardized appraisal process for the use of GAS in acupuncture research has not been conducted, and its responsiveness to assess acupuncture clinical efficacy has not been proven.
Thus, the purpose of the present study was to assess the responsiveness of the GAS to acupuncture therapy. Our aim was to test the compatibility of GAS and acupuncture based on the clinical treatment of children with ID and to establish a clinical efficacy evaluation system in accordance with the characteristics of acupuncture.
| Methods|| |
All children with ID were recruited, screened, and enrolled in the Department of Rehabilitation of the People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine. From March 1, 2015, to September 30, 2015, we recruited a total of 22 children with ID who met the inclusion criteria, and the male: female ratio was 1.2:1. This study was approved by the medical ethics committee of the hospital (2014-028-02) and registered with the Chinese Clinical Trial Registry (Chi-CTR-ICR-15006197). All patients provided written informed consent. The inclusion criteria for the study included three parameters: (1) significant below average intellectual functioning and adaptive behavior, (2) between the ages of 1 and 6, and (3) the parents agree and cooperate. The exclusion criteria for the study included two parameters: (1) inability to perform an IQ test (WPPSI-IV) and (2) computed tomography or magnetic resonance imaging showing a large area of head lesions. The deciduous criteria are the inability to complete the course due to personal reasons.
This is an assessor-blinded, single-group, cohort study. The screening process was performed by the chief doctor of the acupuncture department, who verified the child's conditions and measured the intelligence development level of the children. The research assistant contacted the family and arranged an appointment to explain the study design and sign the written consent form if their children met the inclusion criteria. The baseline assessments included IQ and GAS. Eligible participants received treatment from researchers. The assessment schedule is presented in [Table 1].
Goal attainment scaling
For children with ID, the parents and a GAS-trained doctor helped identify the goals together according to their current development characteristics. This step takes a certain amount of time because the doctor must understand the patient's condition in depth to formulate a clear and one-dimensional goal and grade them. All goals should conform to the SMART criteria (specific, measurable, achievable, relevant, and timed). According to the actual situation, the number of goals for each patient can be different, and three to five goals are the most appropriate. Examples of unidimensional goals that follow the SMART criteria are presented in [Table 2].
Some goals may be more important or more difficult than others. Thus, applying a simple scoring system for weighting is needed. In general, we asked the parents to set values for the importance of each goal, and the doctors should measure and set the values for the difficulty of achieving each goal. In this way, the weights of the goals that constitute the GAS scores are formed: Weight = importance × difficulty.
To ensure the reliability and validity of the results, acupuncture therapists need to combine the situation of the children and the wishes of their families to formulate the five-level scoring standards for each goal. Because the goals of children with ID are progressive, which is different from the regressive goals of the elderly, they usually take “0” level as the expected goal, “ - 1” as the initial state, “ - 2” as the catch-up goal whose basic state is far away from the expected but has treatment potential, “1” level as beyond the expected, and “2” as far beyond the expected.
In this study, the patients underwent 3 months of treatment. According to the monthly division, we conducted individual GAS evaluations at the baseline and each stage of treatment, with four rounds of data collection.
Considering that the weight is set, we used the formula algorithm of the T score to calculate the GAS score. The T value summarizes the performance of multiple goals, which can eliminate the difference between individual goals and the influence of the number of goals. According to the formula, a T score of 50 or above is generally considered to indicate a clinically significant improvement.
Wi is the assigned weight to the setting goal; Xi is the numerical GAS level of each goal (between −2 and +2), and ρ is the expected correlation of the whole scale, which commonly approximates to 0.3.
T value shows as a unified value and can compare the effectiveness of interventions within and between individuals.
Conventional rehabilitation therapy
The schedule of conventional rehabilitation includes (1) cognitive dysfunction perceptual training in 30 min, (2) speech training in 30 min, (3) occupational therapy in 30 min, and (4) sensory integration training in 30 min. Each class was performed 5 days a week.
The rehabilitation training programs were patient- and task-specific. The goals set in the GAS can be used to guide the clinical decision-making processes. First, possible obstacles to achieving a certain goal are listed. Later, these issues were prioritized and integrated into the training program of the relevant rehabilitation course.
The acupuncture therapy adopts the method of acupoint selection by alternating scalp acupoints and Chang Qiang (DU1).
Using four acupoints in the therapy of Jin San Zhen (jin three needles), which includes Sishenzhen (1.5 cun to four sides of DU20), Zhisanzhen (DU24 and GB13 in each side), Niesanzhen (the first one is straight from the tip of ear to 2 cun of the hairline, the other two are 1 cun beside each side), and NaoSanZhen (DU17 and GB19 in each side). The cun depends on the proportional units of the body [Figure 1].
|Figure 1: The schematic diagram of scalp acupoints. (a) Niesanzhen, (b) NaoSanZhen, (c) Zhisanzhen, (d) Sishenzhen|
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| Operation method|| |
Seat the child, disinfect the local skin, choose a filiform needle with a size of 0.30 mm × 25 mm, acupuncture from the scalp to the galea aponeurotica angulated into 20°~30°, needles retained for 40 min, and twirl quickly at 10-min intervals.
Chang Qiang (DU1)
Midway between the tip of coccyx and anus located in the prone position.
| Operation method|| |
Let the child stay in the prone position, disinfect the local skin, choose a filiform needle with a size of 0.30 mm × 50 mm, acupuncture quickly and horizontally and pass upward along the supraspinous ligament with the needling depth about 25–40 mm, manipulate strong stimulus for 1 min without retaining needles [Figure 2].
The responsiveness of GAS to acupuncture therapy was measured using the standardized response mean (SRM). The value of SRM below 0.2 is regarded as nonresponsive, between 0.2 and 0.5 is referred to as moderately responsive, and the value of 0.8 is considered to be markedly responsive. The formula is as follows: 
The statistical analyses of the data were performed using the SPSS, version 25.0 (IBM Corp., Armonk, NY, USA). The normality data were expressed as mean ± standard deviation (X ± SD), and the data that did not meet normality were expressed as median (Mdn). The paired t-test and the Wilcoxon signed-rank test were used to compare the treatment results of four repeated measurements, and the level of significance was set at P < 0.05.
| Results|| |
The study flowchart is shown in [Figure 3]. A total of 22 children with ID (10 girls and 12 boys) were included in the study. Five individuals (22.73%) withdrew their consent during the process, and their scores were not included in the analyses. The participants were entered into the complementary treatment of acupuncture and rehabilitation 6 days a week for 12 weeks and evaluated every 4 weeks.
After testing the normality of the evaluation data of four repeated measurements, assumptions of normality were violated in some conditions (baseline scores: N = 17, S-W = 0.682, P ≤ 0.001; 12-week scores: N = 17, S-W = 0.839, P ≤ 0.01). Thus, the analysis of variance must be rejected. Therefore, we calculated the difference between each course and its difference from the baseline and then tested the normality of the difference values. The paired t-test was conducted for the difference value that met the normality, and the Wilcoxon signed-rank test for two related samples was performed for the combination that did not completely meet the normality.
The GAS scores of each treatment course showed significant statistical differences [Table 3] and [Figure 4]. Compared with the baseline scores (Mdn 35.60), the 4-week scores (Mdn 40.90) and 12-week scores (Mdn 57.45) both made a differential progress (Z = −3.061, P < 0.01, Z = −3.622, P ≤ 0.001, respectively). Similarly, the scores (X = 49.04, SD 4.74) at 8 weeks differed from that (X = 35.15, SD 2.23) of baseline (t = 9.87, P ≤ 0.001). Furthermore, to see if the scores improved differently for each treatment course, they were compared to their respective outcomes from the previous ones. There was a significant difference between 0-4 weeks and 5-8 weeks (t = −10.745, P ≤ 0.001), and between 5-8 weeks and 9-12 weeks (t = −11.198, P ≤ 0.001).
|Figure 4: T scores of goal attainment scaling.Compared with baseline or last month , **p<0.01, ***p≤0.001|
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The differences and SRMs of the baseline and follow-up T-scores are presented in [Table 3]. This shows that all periods evaluated by GAS to measure the therapeutic effect of acupuncture are markedly responsive (SRMs >0.8).
At the target level for all samples, regardless of the weight to the individual, the GAS scores maintained a median value of-1 after 4 weeks, 0 after 8 weeks, and 1 after 12 weeks. This means acceptable responsiveness of GAS at the group level. [Table 4] shows the frequencies of the scores and Chi-square values (χ2).
|Table 4: Frequency of goal attainment scaling scores at the target level|
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To provide a visual illustration of the progress in GAS rating in each period, we used percentages to represent the percentage of goals that stayed or reached a certain level. The result of each goal was first examined as a 5-category ordinal item and then dichotomized (achieved/not achieved), which was defined as a level of 0, +1, or +2 (Achieved) versus a level of −1 or −2 (not achieved). As shown in [Figure 5], at 4, 8, and 12 weeks, 41.43%, 84.29%, and 98.57% goals were achieved or exceeded, respectively.
| Discussion|| |
Responsiveness of goal attainment scaling as an outcome of acupuncture treatment
The formulation of acupuncture prescriptions is usually based on the specific symptoms and needs of patients. Acupuncture treatment is multi-target, which can consider the individual needs of patients at the same time. The GAS can comprehensively consider these multiple goals and show a T-score to quantify the effect of acupuncture treatment. Some scholars criticize that it is unreasonable for the T score to forcibly change the grade variable into a continuous variable. However, this algorithm is convenient for the establishment of outcome indicators for multi-target acupuncture treatment. A study pointed out that GAS takes into account individual preferences as a safeguard for the clinical relevance of this outcome measure. If patients' expectations of treatment are weighted by “importance,” the goals would provide important contributions for determining the effectiveness of the patients treatment program.
Our patients were children with developmental disabilities, which may lack insight into their own problems. In this case, their caregivers can be asked to help with goal setting. Although their disability prevents their involvement in setting their own goals, our research showed that GAS has certain responsiveness to evaluate the phased objectives and ends of children with ID in acupuncture treatment.
Acupuncture has a stable long-term effect on the goals of children with intellectual disability
We found that the progress was distributed in the 1st month, with a considerable number of children making no progress and some children making considerable progress >10 points. From the 2nd to the 3rd month, the growing T scores of most children were steady in the range of 6–10 points. This showed that the effect of acupuncture treatment on children with ID varies greatly from individual to individual in the early stage of treatment, but from a long-term perspective, it has a relatively stable long-term effect. Patients, caregivers, and doctors reached a consensus through effective communication during the formulation of various observation indicators of GAS. This process allows doctors to better adopt goal-directed treatment regimens. Grading and elaborating the level of goals can help participants see small, meaningful improvements over time, rather than focusing on persistent, hard-to-shake disabilities. This not only improves the confidence of patients and their families but also improves the degree of cooperation in later treatment and reduces the rate of treatment abandonment.
The goals of children with intellectual disability and the trouble in scaling
It has been suggested that goals must be written in the categories of unidimensional and equidistance of scale levels, which were found difficult to achieve.
In this study, during the goal setting and scaling [see the examples in [Table 2]], we found that it was difficult to attribute definitive numerical values to some of the goals related to daily life. On the contrary, adjectives such as “unskilled” or “skilled” can better represent most intuitive feelings of the parents to reflect the curative effect. This is the contradiction between the objectivity of the experiment and the practicality in the clinic, which needs to be resolved.
In addition, we believed that the equidistant division of the target level is not required. On the one hand, there is no such thing as “distance” between making eye contact only with those close to you and being able to make eye contact with strangers. On the other hand, compared with an equidistant goal setting of walking 5/10/15 m without help, walking 2/10 m without help may have more practical significance. Both doctors and parents believe that the initial journey can be seen as a milestone and worthy of note. By contrast, if you can walk 5 m without help, there is not much difference with walking 10 m.
Furthermore, ID is characterized by complex multidimensional properties, and the resulting measurements must reflect this multidimensional nature. Meanwhile, GAS can cover multiple fields related to the child psychiatric population, such as motor development, cognition, and daily life activities. In this study, we found it difficult to define “unidimensionally” even in a single goal. For example, in the goal of language ability, aside from focusing on the number of words and the length of sentences the child has mastered, parents also care about speaking “Consciously” and “purposefully.” However, this includes the development of two different dimensions. In addition, the goal of “being able to read a book for 10 min alone and retell the content” inevitably requires both comprehension and concentration. Moreover, more ability is needed if we analyze them more deeply.
Therefore, in general, we classified and counted targets using only body parts. According to our study, the treatment goals (n = 70) selected by caregivers for children can be divided into the mouth (n = 20), upper limbs (n = 15), lower limbs (n = 13), brain (n = 12), eyes (n = 8), and spine (n = 2). Among them, 13 goals related to mouth mentioned about “active” and “conscious” language expression, 6 goals associated with upper limbs involved the “body language,” 4 goals of brain are about “simple command execution”, and the remaining 4 about eyes are related to “eye contact,” which above embodies the expectation that the parents want to communicate effectively with their children, verbally or nonverbally.
Motor ability is an external sign of intelligence for children during the early growth and development periods. In our study, the age range of the enrolled population ranged from 1 to 6 years, with most aged from 1 to 3 years. Therefore, in addition to the ability to communicate and interact (38.57%), goals related to motor ability (37.14%) also accounted for a high proportion in the formulation of GASs. The goals not only included gross motor, such as heading up, rolling over, sitting, climbing, standing, walking, stepping up and down, and jumping, but also contain fine motor skills, which involve finger movements such as grasping, holding a pen, using a spoon, spinning a bottle cap, and so on. There were also scattered functional goals, such as self-care (n = 6), focus (n = 5), purpose (n = 2), computational power (n = 1), and memory (n = 1).
This study is only an observational study on GAS as an indicator of clinical outcome of acupuncture, and there is no control group that only uses the measurement of GAS without acupuncture treatment. GAS has been demonstrated to be an independent intervention. Therefore, acupuncture and GAS both contributed to the efficacy of this study, which cannot be separated. Although GAS has been widely used in clinical rehabilitation studies, few studies have evaluated GAS on acupuncture treatment in children with ID. Thus, there are still significant knowledge gaps in the application of goal-setting theory to practice and research. In this study, the rationality of goal setting was artificially checked by acupuncturists with professional experience, which has not yet formed a relatively objective measurement standard. We will compare the GAS with other outcome measurement criteria. Finally, due to the small sample size of this study, a comparison was not obtainable.
| Conclusion|| |
In acupuncture treatment, it is still too early to empirically support the shift of the clinical practice paradigm to the full use of GAS as an outcome measure. However, this is a particularly satisfying finding, as our acupuncturists are working hard to identify an outcome tool that may fit the clinical characteristics of acupuncture to reflect meaningful changes.
We thank the patients and researchers involved in this study.
Patient consent was obtained from all patients.
Financial support and sponsorship
This study is supported by the National Natural Science Foundation of China (No. 82074521).
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]