Journal of Convergence for Information Technology Vol. 11. No. 8, pp , 2021 e-issn DOI :

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1 Journal of Convergence for Information Technology Vol. 11. No. 8, pp , 2021 e-issn DOI : 뇌성마비아동의대동작기능과먹고마시기기능, 구강운동기능의상관관계연구 민경철 1, 문용선 1, 서상민 2* 1 서울특별시어린이병원재활의학과작업치료실작업치료사, 2 세명대학교작업치료학과교수 Relation between Gross Motor Function and Eating and Drinking Ability, Oral Motor Function in Cerebral palsy Kyoung-Chul Min 1, Yong-Seon Moon 1, Sang-Min Seo 2* 1 Occupational Therapist, Department of Rehabilitation, Seoul Metropolitan Children s Hospital 2 Professor, Department of Occupational Therapy, Semyung University 요약본연구는뇌성마비아동의대동작기능과먹기, 마시기기능, 구강운동기능과의상관관계를확인해보고, 뇌성마비아동의대동작기능의심한정도에따른연하재활의필요성을확인하기위해시행되었다. 뇌성마비진단을받은아동 61 명을대상으로대동작기능분류체계 (GMFCS), 먹기와마시기기능분류체계 (EDACS), 구강운동기능검사 (OMAS) 를사용하여대동작기능, 먹고마시기기능, 구강운동기능수준을평가하고각기능간상관관계를확인하였다. 본연구의결과는대동작, 먹고마시기기능, 구강운동기능사이에서유의한상관관계를보였다. 즉, 대동작기능저하가심할수록먹고마시기기능과구강운동기능저하역시낮은기능수준을보였다. 본연구를통하여뇌성마비아동의섭식활동을평가하고치료함에있어, 아동의대동작기능에따른먹고마시기기능, 구강운동기능에대한확인이필요할것으로보인다. 주제어 : 뇌성마비, 연하장애, 섭식장애, 먹기와마시기기능분류체계, 구강운동기능검사 Abstract Goal of this study is to perform the correlation about Gross motor function, eating-drinking function, and oral motor function, to identify necessity for invervention of feeding disorders on severity of the function of children with cerebral palsy. Subjects were 61 children diagnosed with cerebral palsy. The subject were evaluated for oral motor function, feeding function by GMFCS, EDACS, OMAS. The results of this study showed a significant correlation between gross motor function, eating and drinking functions, and oral motor functions. That is, the more severe the deterioration of the motor function, the lower the functional level of eating and drinking and oral motor function deterioration. In evaluating and treating the eating activity of children with cerebral palsy through this study, it seems necessary to check the eating and drinking function and oral motor function according to the gross motor function. Key Words : Cerebral palsy, Dysphagia, Feeding disorder, Eating and Drinking Ability Classification system, Oral motor ability scale *This work was supported by the research grant of Korean Academy of Dysphagia Rehabilitation of 2021 * Corresponding Author : Sang-Min Received June 3, 2021 Revised June 27, 2021 Accepted August 20, 2021 Published August 28, 2021

2 서론뇌성마비는유아기시기에비진행적뇌병변으로인하여, 운동및자세조절, 감각, 인지, 의사소통및행동장애뿐만아니라섭식활동등에영구적인장애를보이는가장흔한소아기뇌병변장애이다 [1-6]. 이중섭식활동은 (Feeding activity) 은감각, 운동, 인지및행동등의요소가복합적으로관여하며, 성장과발달에주요한영향을미친다 [7,8]. 또한섭식활동을통해새로운음식, 다양한맛과질감등을경험하고, 섭식활동과관련된다양한도구를사용하고익힐수있기때문에섭식활동은일상생활속에서필수적인작업수행영역으로인식되는중요한기능이다 [9]. 하지만뇌성마비아동의 75~86% 는섭식활동에문제를가지고있다 [3]. 뇌성마비유형에따른비율은경직형사지마비 (Spastic quadriplegia) 는 86%, 경직형편마비 (Spastic hemiplegia) 와경직형양하지마비 (Spastic diplegia) 는 37% 정도로보고되고있다 [4, 5]. 섭식문제의원인으로는구강운동및감각의문제, 삼킴기능및씹기기능의문제등을포함한구강-인두단계에서나타나는문제가주로보고되고있다 [10,11]. 이러한구강-인두단계의문제는뇌성마비아동의몸통자세유지및조절, 근긴장도조절능력의저하로인하여나타나머리조절에영향을주어턱, 입술, 혀, 물렁입천장등의구강내구조물들의기능적인움직임저하시키는것이다 [12,13]. 선행연구에따르면, Marcus 등 [14] 은뇌성마비아동의운동발달저하및자세유지의문제는구강내구조물들의협응능력에영향을주어삼킴및씹기능력의제한을가져와다양한재질의음식섭취를어렵게한다고하였고, Gisel 등 [15] 은뇌성마비아동의몸통과머리등의올바른자세정렬이얼굴및구강내근육등섭식과관련된구조물들의조절및움직임에영향을주는주요한요소임을주장하였다. 또한 Benfer 등 [10] 과 Parkes 등 [12] 은뇌성마비아동을대상으로대동작기능, 구강운동기능, 연하장애기능평가를시행하여, 뇌성마비아동의구강운동기능및섭식문제발생이높고, 대동작기능이좋지않을수록씹기, 침흘림, 삼킴및섭식장애의심각도가증가되는결과를확인하여뇌성마비아동들의대동작기능에따른연하재활치료의필요성을제시하였다. 이렇듯뇌성마비아동의몸통의안정성은머리움직 임에안정성을제공하고, 또한몸통과머리의안정성은구강구조물들의정렬, 섭식활동에필요한턱, 혀, 입천장등의효율적인움직임에영향을미친다 [16,17]. 따라서뇌성마비아동의성공적인섭식활동을위해서는몸통과머리의안정성등을포함하는대동작기능이효율적으로발달되어야하며 [18], 뇌성마비아동의섭식활동을위한치료적중재역시대동작기능의심각도와연관성을확인하여접근하는것이중요하다고할수있다 [6,12,19]. 이에본연구는몸통및목가누기등의대동작기능이섭식능력, 구강운동기능과의상관성이높다는선행연구의결과를바탕으로국내뇌성마비아동의대동작기능과섭식능력의상관관계를확인하고자하였다. 또한이를통해뇌성마비아동의연하재활치료있어구강부위에만국한된자극및치료접근을넘어선대동작기능에따른종합적인연하재활치료를통한섭식능력및구강운동기능향상을위한이론적근거를마련하고자한다. 2. 연구방법 2.1 연구대상본연구는서울시에위치한어린이병원에내원한뇌성마비진단을받은아동들중보호자의동의를받은 61명을대상으로하였다. 대상자는먹기와마시기기능분류체계 (Eating and drinking ability classification system :EDACS) 와구강운동능력척도 (Oral motor ability scale : OMAS) 검사시행이가능한최저연령인 3세이상을선정하였다. 대상자의연령은평균 72±29개월, 성별은남자 44명, 여자 17명이었다. 뇌성마비분류는운동양상에따라경직형 ( 사지마비 (28 명 ), 양하지마비 (24명), 편측마비 (5명)), 무정위형 (4명), 운동실조형 (0명) 뇌성마비로구분하였으며, 대상자의특성은 Table 1과같다. 2.2 연구과정및연구도구 연구과정대상자는대동작기능상태에맞게일반의자, 보조의자, 피더시트등에앉아검사를시행하였다. 검사는대동작기능분류체계 (Gross motor function classification system : GMFCS), 먹기와마시기기능분류체계 (Eating

3 170 and drinking ability classification system : EDACS), 구강운동능력척도 (Oral motor ability scale : OMAS) 순으로진행되었다. 검사자는아동의앉기, 서기, 걷기 등의대동작기능을직접확인하였으며, 대상아동이실 제먹을수있는단계의음식 ( 죽, 이유식, 진밥, 일반밥, 과자류, 물등 ) 과도구 ( 수저, 빨대, 컵등 ) 를사용하여먹 기와마시기, 씹고삼키기, 구강운동기능을관찰하였다. Table 1. Characteristices in subject Characteristices Age(month) 72± Sex Classification of cerebral palsy 연구도구 Spastic type Male 44(72%) Female 17(28%) n Quadriplegia 28(46%) Diplegia 24(39%) Hemiplegia 5(8%) Atheotoid 4(7%) Ataxia 0(0%) 동작기능분류체계 (Gross motor function classification system : GMFCS) GMFCS 는대동작기능에따라 5 단계로분류하는검 사도구로, 연령에따라 2~18 세의뇌성마비아동을연 령별로구분하여검사가가능하다. 기본적인단계구분 은 I) 제한없이걸을수있음, II) 제한 ( 균형, 지구력, 계 단레일등 ) 이있지만걸을수있음, III) 실내에서손으 로잡을수있는이동보조도구 ( 지팡이, 워커등 ) 사용 하여걸을수있으나외부 ( 지역사회, 먼거리 ) 에서바 퀴있는보조도구사용, IV) 도움받아앉고, 독립적으 로움직이기어려움, 수동휠체어나전동보조도구 ( 전 동휠체어등 ) 사용가능, V) 머리, 몸통조절에심각한 제한이있고, 이동에완전한도움이필요함으로분류되 어단계가높을수록대상아동의대동작기능어려움이 많다는것을나타낸다. 검사자간신뢰도는 2 세미만 r=0.55, 2~12 세 r=0.75 이었다 [20]. 마실수없고튜브영양법을고려할수있는수준까지 5단계로나뉘어있으며, 내용은다음과같다. I) 안전하고효율적으로먹고마심, II) 안전하게먹고마시지만, 효율에서약간의제한이있음, III) 안전하게먹고마시는데약간의제한이있으며, 효율에서제한이있을수도있음, IV) 안전하게먹고마시는데현저한제한이있음, V) 안전하게먹거나마실수없음-영양공급을위해튜브영양법을고려할수있음으로단계가높을수록섭식기능이저하됨을나타낸다. 검사자간신뢰도는 Kappa=0.72, 내적상관계수 (ICC)=0.93이었다 구강운동기능검사 (Oral motor ability scale : OMAS) OMAS는뇌성마비아동의구강운동기능측정을위해 Ortega 등 [22] 이개발한구강운동평가이다. 아동에게직접수저로음식을먹이고, 빨대를빠는움직임관찰을통해입다물기, 입술다물기, 음식조절하기, 씹기, 빨대빨기, 액체조절하기등의활동을통해구강운동기능을 0) 수동적, 1) 기능저하, 2) 다소기능적, 3) 기능적수행의 4단계로측정하는도구로점수가높을수록구강운동기능이높음을나타낸다. 검사자간신뢰도 Kappa > 0.85, 검사자내신뢰도 Kappa > 0.90 이었고, 건강한아동과비교를통한구성타당도는모든항목에서유의미한차이를보였다. 2.3 자료수집및분석본연구는 2020년 1월 1일부터 2020년 6월 30일까지총 6개월간내원한아동을대상으로직접적인평가를통하여자료를수집하였다. 보호자에게연구의목적에대해설명하고아동의참여에동의한경우에만참여하도록하였다. 대상자의일반적특성파악을위해빈도, 평균, 표준편차등의서술적통계를사용하였다. 대동작기능, 기능적구강운동기능, 섭식기능간의상관관계는피어스만상관관계를통해분석하였으며, 통계프로그램은 SPSS version 21을사용하였다 먹기와마시기기능분류체계 (Eating and drinking ability classification system : EDACS) 먹기와마시기기능분류체계는 3 세이상의뇌성마 비아동의먹기와마시기능력을평가하기위해 Sellers 등 [21] 이고안한평가도구이다. 안전하고효율 적으로먹고마실수있는수준에서안전하게먹거나 3. 연구결과 3.1 대동작, 먹고마시기, 구강운동기능결과경직형양하지마비아동의대동작기능의경우, II단계 5명, III단계 5명, IV단계 8명, V단계 5명으로고르

4 171 게분포되었고, 먹기및마시기기능에서는 I 단계 1 명, II 단계 11 명, III 단계 8 명, IV 단계 4 명이었고결과는 Table 2 와같다. 전체적으로는 GMFCS IV, V 단계가 45 명, EDACS IV, V 단계가 33 명으로대동작및섭식 기능저하아동이전체의 50% 가넘었다. Table 2. Score of GMFCS, EDACS Characteristices Spastic type GMFCS EDACS Ⅰ Ⅱ Ⅲ Ⅳ Ⅴ Ⅰ Ⅱ Ⅲ Ⅳ Ⅴ (n=61) Quadriplegia Diplegia Hemiplegia Atheotoid Ataxia Total OMAS 로측정한구강운동기능검사결과는 Table 3 과같으며, 각항목에서 1 점 ( 기능저하 ) 비율이가장높 아전반적인구강운동기술저하를확인할수있었으 며, 특히 6 번째항목인빨대빨기는 0 점 ( 수동적 ) 이 27 명으로가장많고 3 점 ( 기능적 ) 이 3 명으로가장적어수 행하기어려운섭식기능으로분석되었다. Table 3. Score of OMAS OMAS (n=61) Score Total =Mouth closure, 2=lip closure on utensil, 3=Lip closure during deglutition, 4=Control of food during deglutition, 5=Mastication, 6=Sucking straw, 7=Control of liquid during deglutition 3.2 대동작, 먹고마시기, 구강운동기능간상관관계 GMFCS 의수준에따른 EDACS, OMAS 점수분포 를확인한결과는 Table 4 와같으며, GMFCS 단계가 높아질수록 EDACS 의단계가같이높아지는것을확 인하였다. 예를들어 GMFCS I 단계인아동이 EADCS 도 I 단계인경우, CMFCS V 단계의아동이 EADCS 의 IV, V 단계인경우가 34 명으로전체 50% 이상의비율 을나타냈다. 또한 EDACS 단계와 OMAS 의점수분포 역시 GMFCS I 단계의경우전체항목모두 2, 3 점수 행으로기능이높은반면, GMFCS II 단계아동들은 OMAS 2, 3 점이 55 명, V 단계아동들의 OMAS 점수는 0,1 점이 21 명으로나타났다. Table 4. Score of OMAS, EDACS according to GMFCS (n=61) EDACS OMAS GMFCS Ⅰ Ⅱ Ⅲ Ⅳ Ⅴ s Ⅰ Ⅱ Ⅲ Ⅳ Ⅴ S : Score of OMAS, G=GMFCS, E-EDACS, O=OMAS, 1=Mouth closure, 2=lip closure on utensil, 3=Lip closure during deglutition, 4=Control of food during deglutition, 5=Mastication, 6=Sucking straw, 7=Control of liquid during deglutition Table 5 는대동작기능과먹고마시기기능의상관 관계를타나냈었다. 대동작기능과먹고마시기기능의 상관관계는양의상관관계로 r=.813 이었다. 이는대동 작기능수준이높을수록먹고마시기기능수준도높 아지는것을의미한다. 또한대동작기능과구강운동기 능의상관관계는음의상관관계로 r=-.685~-.726 의 범위로나타났다. 이는대동작기능수준이높으면높 을수록구강운동기능도높아진다고할수있다. 먹고 마시기기능과구강운동기능은음의상관관계로 r=-.828~-.876 의범위로나타났다. 이는먹고마시기 기능수준이높을수록구강운동기능또한높은수준의 상관관계로분석되었다.

5 172 Table 5. Score of GMFCS, EDACS O G G - E E.813 ** ** ** ** **.895 ** ** **.791 **.876 ** - O (n=61) ** **.838 **.903 **.886 ** ** **.882 **.935 **.872 **.909 ** ** **.803 **.839 **.814 **.851 **.820 ** ** **.887 **.875 **.844 **.880 **.886 **.859 ** - P<0.01, G=GMFCS, E-EDACS, O=OMAS, 1=Mouth closure, 2=lip closure on utensil, 3=Lip closure during deglutition, 4=Control of food during deglutition, 5=Mastication, 6=Sucking straw, 7=Control of liquid during deglutition 4. 고찰 본연구는뇌성마비아동의대동작기능수준에따 른섭식기능및구강운동기능의관계를확인하고, 이 를통한뇌성마비아동의연하재활치료를위한기초 자료분석을위해실시하였다. 본연구결과뇌성마비 아동의섭식기능과구강운동기능은대동작기능과유 의미한상관성을갖는것으로조사되었다. 뇌성마비아동의대동작기능과섭식기능, 구강운동 기술을연구한기존의문헌을살펴보면 Benfer 등 [10] 의연구에서는학령전기뇌성마비아동 120 명 (GMFCS Ⅰ=50, Ⅱ=17, Ⅲ=22, Ⅳ=11, Ⅴ=20) 을대상으로섭식 장애유병률을알아보았고, Schedule for oral motor assessment(soma), Dysphagia disorders survey(dds), Pharyngeal phase impairment, Saliva severity scale 를사용하여뇌성마비아동의삼 킴장애및구강운동기능의특성및관계를확인하였 다. 그결과연구에참여한뇌성마비아동의 85% 에서 삼킴및섭식장애가나타났고, 특히 GMFCS Ⅴ 단계의 아동의유병률은 100% 였다. 또한, 대동작기능이낮을 수록삼킴및섭식장애유병률이높아유의한상관성 을보였다. 뇌성마비의유형에서는편마비, 하지마비뇌 성마비아동의 70% 에서구강운동기능문제를보였으 나운동이상증 (Dyskinesia) 과저긴장뇌성마비는비율 이낮아구강운동기능의문제가있음에도통계학적으 로유의하지않았다. 또한 Calis 등 [19] 은 GMFCS Ⅳ- Ⅴ 단계의뇌성마비아동 166 명을대상으로대동작기 능과구강기능간의유의미한상관성을보고하였다. 본연구에서는삼킴및섭식장애의유병률을조사하지는않았으나, GMFCS V단계아동에서섭식기능, 구강운동기능저하비율이높아서기존의연구결과와유사하였으며, 이는대동작기능저하가심한뇌성마비아동의섭식장애가능성을시사한다고할수있다. Benfer 등 [23] 의연구에서는학령전기뇌성마비아동 130명 (GMFCS Ⅰ=57, Ⅱ=15, Ⅲ=23, Ⅳ=12, Ⅴ=23), 정상발달아동 40명을대상으로 GMFCS, SOMA, DDS, Pre-speech assessment scale(psas) 평과결과뇌성마비아동이 93.8%(122명 ) 에서삼킴및섭식장애로나타났다. GMFCS V단계아동은 DDS 검사결과음식흘림, 음식이동, 씹기등에서 100% 의섭식장애가나타났으며, GMFCS Ⅲ-Ⅴ단계아동은고체음식의구강이동, 액체음식흘림에서정상아동과유의미한차이를보였다. 본연구에서도 GMFCS 단계에따라구강운동기능저하가관찰되었는데, GMFCS I단계아동이 OMAS 각항목별 2, 3점을수행하는데반하여, V단계아동은각항목에서 0, 1점수행비율이높아구강운동기능이저하되어기존연구결과를뒷받침하는결과로분석되었다. Goh 등 [24] 은뇌성마비아동 151명 (GMFCS Ⅰ=35, Ⅱ=40, Ⅲ=36, Ⅳ=26, Ⅴ=14) 을대상으로 EDACS 와다른기능척도분류체계시스템 (GMFCS, MACS 등 ) 과의상관관계를확인하였다. 그결과 EDACS와 GMFCS의상관계수는중간정도의상관관계를보였고 (r=0.574), 특히 GMFCS Ⅳ,Ⅴ단계아동과 Ⅰ 단계아동은 EDACS에서유의미한차이를보였다. 뇌성마비아동의 GMFCS와 EDACS 분류척도의일치율을살펴보면, 대동작기능이좋을수록섭식기능이좋은아동 (GMFCS Ⅰ-Ⅱ단계이면서 EDACS Ⅰ-Ⅱ 단계인아동 ) 은 Benfer 등 [10] 의연구에서 96.29%, Goh 등 [24] 의연구에서 98.66% 본연구에서는 90% 로높은상관관계를보였고, 대동작기능이좋지않을수록섭식기능이좋지않은아동 (GMFCS Ⅳ-Ⅴ단계이면서 EDACS Ⅳ-Ⅴ단계인아동 ) 의일치율은 Benfer 등 [10] 의연구에서 70.73%, Goh 등 [24] 의연구에서는 25%, 본연구에서는 68.88% 로측정되어대동작기능이섭식기능에미치는관계를확인할수있었다. 이처럼많은연구들이뇌성마비아동의대동작기능과구강운동기술, 먹고마시기기능과의연관성을시사하고있으며, 이는본연구의전반적인결과와일치한다. 특히본연구결과는 GMFCS Ⅳ,Ⅴ단계의대동작기능이저하된

6 173 뇌성마비아동에게서섭식및삼킴기능이심각한것으로보고되고있어, 뇌성마비아동의대동작기능이저하될수록구강운동기술및섭식기능이단계적으로저하된다는기존의연구들과유사한결과를도출하였다. 본연구의제한점은, 단일기관에내원한비교적적은수의뇌성마비아동을대상으로한조사로일반화에어려움이있다. 또한전체대상자중경직형뇌성마비의비율이높아 (85%, 사지마비 46%, 양하지마비 39%) 뇌성마비아동의분류형태에따른전반적인해석이추가되어야한다는문제가있어, 추후다양한형태의뇌성마비아동을대상으로한대동작기능과섭식기능및구강운동기능에대한상관관계연구가이루어져야할것으로보인다. 또한최근늘어나고있는 3세이전의조산, 발달지연아동의대동작기능과먹고마시기, 구강운동기능과의관계에대한체계적인연구또한필요할것으로사료된다. 본연구에서는확인하지못하였으나, 뇌성마비아동에서대동작기능손상이심할수록각성, 인지수준저하가영향을줄수있는요소도무시할수없기때문에, 추후추가로각성수준, 인지수준과먹고마시기기능, 구강운동기능과의상관관계확인을통한연하재활치료접근법에대한연구가진행되어야할것으로보인다. 또한본연구에서는대동작기능과먹고, 마시기기능, 구강운동기능의상관관계를비교하였지만추후연구에서는대동작기능이먹고, 마시기기능, 구강운동기능에미치는영향까지확인하는것이필요하다고할수있다. 하지만본연구의결과를통해임상에서는뇌성마비아동의섭식기능을증진시키기위해대동작기능증진접근법이필수적으로고려되어야하며, 섭식기능과관련된대동작기능수준에대한지속적인관찰이필요하다는것을확인하였다. 5. 결론본연구에서는뇌성마비아동의대동작기능과섭식기능및구강운동기능간의상관관계를확인하여뇌성마비아동의연하재활치료에대한필요성및고려사항을확인하고자하였다. 연구결과뇌성마비아동들에게서나타날수있는섭식기능의어려움을확인할수있었으며, 대동작기능수준에따른섭식기능및구강운동기능간의단계적상관이나타났다. 특히경직형사지마비아동에서의섭식기능및구강운동기능의지연이눈에띄게나타나 는것으로조사되었다. 이는뇌성마비아동의치료방 향을설정하거나목표를세우는데연하재활치료를 고려해야하고, 특히대동작기능수준저하가심한아 동들에게우선으로고려되어야할문제중하나라는것 을나타낸다. 본연구결과를통하여임상에서대동작기능저하 가심한뇌성마비아동의연하재활치료필요성을이 해하고연하재활치료를통하여뇌성마비아동의삶의 질향상이동반되기를기대한다. REFERENCES [1] J. W. Gorter, P. L. Rosenbaum, S. E. Hanna, R. J. Palisano, D. J. Bartlett, D. J. Russell, S. D. Walter, P. Raina, B. E. Galuppi & E. Wood MD. (2004). Limb distribution, motor impairment, and functional classification of cerebral palsy. 46(7), [2] J. Arvedson. (2013). Feeding children with cerebral palsy and swallowing difficulties. European Journal of Clinical Nutrition, 67(2), S9-S12. [3] S. E. Morris & M. D. Klein. (2000). Pre-Feeding Skills: A Comprehensive Resource for Mealtime Development. San Antonio : Therapy Skill Builders [4] B. Rogers. (2004). Feeding method and health outcomes of children with cerebral palsy. The Journal of Pediatrics, 145(2), S28-S32. [5] K. Stein. (2000). Children with feeding disorders: An emerging issue. Journal of the Academy of Nutrition and Dietetics, 100(9), [6] I. Novak, M. Hines, S. Goldsmith & R. Barclay. (2012). Clinical prognostic messages from a systematic review on cerebral palsy. Pediatrics, 130(5), e1285-e1312. [7] J. S. Kim, Z. A. Han, D. H. Song, H. M. Oh & M. E. Chung. (2013). Characteristics of dysphagia in children with cerebral palsy, related to gross motor function. American Journal of Physical Medicine & Rehabilitation, 92(10), [8] E. A. Townsend & H. J. Polatajko. (2007). Advancing an occupational therapy vision for health, well-being, and justice through occupation. Ottawa : CTTC Building. [9] K. E. Williams, D. G. Field & L. Seiverling. (2010). Food refusal in children: A review of the

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8 175 문용선 (Yong-Seon Moon) [ 정회원 ] 2018 년 2 월 : 순천향대학교대학원 ( 이학석사 ) 2012 년 7 월 현재 : 서울특별시어린이병원재활의학과작업치료사 관심분야 : 연하재활치료, 아동작업치료 서상민 (Sang-Min Seo) [ 정회원 ] 2014 년 8 월 : 가톨릭대학교보건대학원인간공학및재활보건학 ( 보건 학석사 ) 2021 년 2 월 : 연세대학교일반대학원작업치료학과 ( 작업치료학박사 ) 2018 년 3 월 현재 : 세명대학교 작업치료학과교수 관심분야 : 연하재활치료, 아동작업치료

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