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Expert Systems with Applications 39 (2012) 5233–5242

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An intelligent model for the classification of children’s occupational

therapy problems
Yu-Ling Yeh a,b,⇑, Tung-Hsu Hou b, Wen-Yen Chang c
Department of Industrial Engineering and Management, Nan Kai University of Technology, Nantou, Taiwan
Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Taiwan
Department of Rehabilitation, Yuan Sheng Hospital, ChangHua, Taiwan

a r t i c l e i n f o a b s t r a c t

Keywords: Objectives: In Taiwan, the classification of real problems of children with appropriate occupational ther-
Children occupational therapy apy is a difficult job for the therapist. The complexities of 127 attribute values to be evaluated in the
Artificial neural network assessment, the misleading diagnosis which may be made by the pediatrician and the shortage of man-
Classification and regression trees power cause of high workload for the therapist. The design of an easy to use and effective classification
model is therefore an important issue in children’s occupational therapy treatment. This study accord-
ingly applies an artificial neural network (ANN) and classification and regression tree (CART) techniques
to skeleton an intelligent classification model in order to provide a comprehensive framework to assist
the therapist to raise the accuracy when categorizing children’s problems for occupational therapy. These
categories with critical attributes under the guidelines of the American Occupational Therapy Association
(AOTA) are discussed, in order to assist the therapist for precise assessment and appropriate treatment.
To the best of our knowledge, no research has yet been conducted on the problems’ characteristics in chil-
dren’s occupational therapy.
Methods: Based on the advice and assistance of the therapists and occupational therapy treatment
needed, 127 outpatients from a regional hospital in Taiwan between 2007 and 2010 were selected as
the data sets for problems in children occupation classification. This study accordingly suggests an intel-
ligent model for the classification which integrates ANN and CART. The major steps in applying the model
include: (1) building an ANN higher performance trained model; and (2) adopting CART to the trained
model and building in previous steps, to extract the critical attributes of children occupational problems.
Results: The results showed that artificial neural network had a higher accuracy, up to 84%, with evenly
distributed datasets. Then high performance of the trained neural network had been extracted for the
rules by using the classification tree approach in the classification and regression trees application. Most
important of all, this study indicated that some of the rules can correctly identify up to 67% of the prob-
lems of the children with 100% confidence, which is much better than the current evaluations being used.
Moreover, the tree with a binary variable of age and 8 predicators were found and listed afterward, such
as, gross coordination, upper left muscle tone, interpersonal skill, proprioceptive and vestibular, visual,
visual stimulus input for influence of emotional and movement, swallowing, and dressing. Actual imple-
mentation showed that the intelligent classification model is capable of integrating ANN and CART tech-
niques to clarify children’s occupational therapy problems with considerable accuracy.
Conclusions: The model could be employed as a supporting system in making decisions regarding chil-
dren problems with occupational therapy classifications and treatment. The rules extracted from CART
were helpful to therapists in classifying what category the real problems of the children belonged to. This
study expected that more machine learning techniques will certainly play an essential role in future chil-
dren occupational therapy applications.
Ó 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Occupational therapy is not only for adults but also for children.
Occupational therapy can fulfill various needs that children have,
⇑ Corresponding author at: Department of Industrial Engineering and Manage- such as fun activities to improve their cognitive abilities, physical
ment, Nan Kai University of Technology, Nantou, Taiwan. and motor skills and enhancement of their self-esteem and a sense
E-mail address: (Y.-L. Yeh). of accomplishment.

0957-4174/$ - see front matter Ó 2011 Elsevier Ltd. All rights reserved.
5234 Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242

There are two kinds of manners for the children to have proper are artificial neural networks (Haykin, 1994) and decision trees
and professional treatment by the therapist in Taiwan. First, when (Breiman, Friedman, Olshen, & Stone, 1984; Quinlan, 1986, 1993).
some of the children exhibit abnormal behaviors, such as, living The predictive accuracies obtained with neural networks are often
dependence, playing impairments, or learning deficits, these unu- significantly higher than those obtained with other learning para-
sual behaviors make their parents seek assistance from pediatri- digms (Andrews, Diederich, & Tickle, 1995). Decision tree algo-
cians. Then, professional could provide a precise evaluation and rithms execute fast, are able to handle a high number of records
assessment, in accordance with the symptoms and behaviors of with a high number of fields with predictable response times, handle
the children. A certain diagnosis and appropriate treatment would both symbolic and numerical data well and are better understood
be assigned and provided for the children. The treatment may in- and can easily be translated into if-then-else rules (Krishnan,
clude medication and rehabilitation for symptom alleviation and Sivakumar, & Bhattacharya, 1999). Decision trees have been pre-
ability promotion. The promoting skills might rely on the occupa- ferred when a good understanding of the decision process is essen-
tional therapist. Second, when children are discovered by campus tial especially in medical diagnosis and classification. Recent work in
guidance counselors with problems of learning, playing and/or rules extraction from neural networks (Craven, 1996; Craven &
interacting, and living then further assessment is arranged. Chil- Shavlik, 1994; Fu, 1994; Towell & Shavlik, 1993) suggested that it
dren with the above mentioned deficits would have been sent to was possible to get comprehensible representations of the knowl-
see either a pediatrician or a guidance counselor to assess the child edge stored in neural networks.
for occupational therapy that is appropriate for their needs. How- This paper developed an intelligent model for early classifica-
ever, the deficits of the children, which are mentioned on the tion of real problems through the computerized analysis of chil-
anamnesis, were usually written in general terms such as, learning dren assessment data. The classification model included two
delay, learning disorders, development delay, or attention deficit stages. The first stage classified the real problems of children
hyperactivity disorder. These terms can only be referenced for using neural networks. The second stage proceeded to further
the therapist because they do not correspond to the guidelines of identify the attributes of the real problems with the classification
occupational therapy which have been defined by the American and regression tree – CART, so as to provide appropriate
Occupational Therapy Association – AOTA. Thus, the therapists treatment.
need to evaluate nearly 127 attribute values during the first time The structure of this paper is organized as follows. Section 2
assessment to categorize the real problems and prepare appropri- presents a comprehensive literature review on children’s occupa-
ate treatment for the children. After 3–6 months, the therapists tional therapy, neural networks, and CART. Section 3 details the
need to take a phase assessment again for particular children in or- experiment settings, design and procedures. The results of classi-
der to review the treatment. All of the therapists must follow these fication rules and system validation are presented and discussed
procedures for every phase evaluation. Unfortunately, all the in Section 4. Section 5 concludes the paper and details issues that
assessments must be done manually and are not accessed through require further study.
a computerized system. As (Chu & Chang, 2009) survey showed
that every 100,000 people have 8.2 therapists to serve in Taiwan,
but compared with others areas in Asia; it showed that there are
23 therapists in Japan and 18 therapists in Hong Kong for every 2. Related work
100,000. Obviously, there is an occupational therapy manpower
deficiency in Taiwan. The workload and complexity of doing the 2.1. Children’s occupational therapy
occupational therapy patient assessment are important compo-
nents for therapists. Thus, easily classification of the real problems Current occupational therapy for children states that the activ-
is significant for the therapists, as it increase efficiency and pro- ities for children of occupational therapy are everything children
motes better quality in occupational therapy treatment, thus, do to recover themselves. According to Allen, Pratt, and Smith
decreasing the workload on therapists. The categorized attributes (1996) these activities could be classified into three categories,
of particular problems could be referenced for the therapist in activities of daily living, activities of work and productivity, and
accordance with the guidelines of occupational therapy. In the fu- activities of play and leisure.
ture, these attributes will be the training materials for new thera- The main objective of occupational therapy for children is to
pists and setup parameters for the decision support system. Most maintain the children or individual in a healthy condition and have
previous researches on occupational therapy have mentioned what them deal with fine motor skills for playing and learning. Occupa-
was the optimal treatment for patients (Aki & Turan, 2008; Baldelli, tional therapists can meet children’s needs by working on fine mo-
Boiardi, Ferrari, Bianchi, & Bianchi, 2004; Gomi, Taras, & Granet, tor skills so that children can grasp and release toys and develop
2007; Klatt, 2009; Linehan, Cochran, Mar, Levensky, & Comtois, good handwriting skills. They also address hand-eye coordination
2000; Richards et al., 2005; Roberts, Vegher, Gilewski, Bender, & to improve play skills, such as hitting a target, batting a ball, or
Riggs, 2005), stress of the therapists (Ferguson, Carlson, Zivnuska, copying from a blackboard. Besides, an occupational therapist
& Whitten, 2010; Kim, 2007; Robiner, 2006), and the mechanism could also help children with severe Developmental delays in
of therapy (Gazzola & Stalikas, 2004; Rivard, Hollis, Darrah, Madill, learning some basic tasks, teaching children with physical disabil-
& Warren, 2005). However, they have not yet been able to deal ities the coordination skills required to feed themselves, evaluating
with massive and complicated amounts of data, such as the enor- each child’s needs for specialized equipment, or working with chil-
mous data collected continuously through health examinations dren who have sensory and attention issues to improve focus and
and medical treatment. Therefore, more effective approaches are social skills (American Occupational Therapy Association – AOTA,
needed to analyze such massive and complicate amounts of data. 1993).
For example, machine learning techniques may provide useful According to AOTA, children with the following medical prob-
solutions. To the best of our knowledge, this is the first attempt re- lems may benefit from occupational therapy: birth injuries/birth
lated to categorizing data related to assessment of children’s prob- defects, sensory processing/integrative disorders, traumatic inju-
lems in occupational therapy. ries (brain or spinal cord), learning disorders, autism, development
Over the past few decades, machine learning techniques have disorders, mental health or behavioral problems, cerebral palsy,
been applied to many real-life industrial problems with success cancer, or severe hand injuries etc. (Occupational Therapy Basics,
(Langley & Simon, 1995). Two of the commonly used techniques 2007).
Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242 5235

2.2. Artificial neural networks tionships in the data. Also note that the number of hidden layer
nodes does not need to be the same as the number of input nodes
Artificial neural network (ANN) has received significant atten- (Wu, Huang, & Meng, 2008).
tion due to its demonstrated performance in classification. ANN ANN successfully provided a mean to medical diagnosis (Lisboa,
is one of the recent machine learning techniques that has gained Ifeachor, & Szczepaniak, 2000), for example, (Abbass, 2005; West &
wide acceptance since the 1990s (Razi & Athappilly, 2005). West, 2000) in breast cancer diagnosis, Marble and Healy (1999)
An artificial neural network is an information processing para- morbidity outcomes in trauma care, and (Zhou, Jiang, Yang, & Chen,
digm that is inspired by the way biological nervous systems, such 2002) lung cancer cell identification. As Archambeaua, Delbekeb,
as the brain, process information. The key element of this paradigm Veraartb, and Verleysena (2004) and Mobley, Schechter, Moore,
is the novel structure of the information processing systems. It is McKee, and Eichner (2000)mentioned, ANN provides accurate pre-
composed of a large number of highly interconnected processing dictions of coronary artery stenosis and visual perceptions in a vi-
elements (neurons) working in unison to solve specific problems. sual prosthesis for the blind. Besides, ANN provided a classification
ANNs, like people, learned by example. Many types of ANN models of patients’ development of septic shock while they stayed in
have been suggested in the literature (Bishop, 1995), with the most intensive care (Paetz, 2003).
popular one for classification being the multilayer perceptron
(MLP) with back propagation. The goal of this type of network is
to create a model that correctly maps the inputs to the outputs 2.3. Decision trees
using historical data so that the model can then be used to produce
the output when the desired output is unknown. MLP with back Decision trees are rapid and effective methods of classifying
propagation is typically composed of an input layer, one or more data set entries, and can provide good decision support capabili-
hidden layers, and an output layer, and each consists of several ties. A definition of a decision tree was given in Russell and Norvig
neurons. Each neuron processes its inputs and generates one out- (2002), as a construct which ‘takes as input an object or situation
put value that is transmitted to the neurons in the subsequent described by a set of properties, and outputs a yes/no decision.
layer. Fig. 1 provides an example of an MLP with one hidden layer Decision trees therefore represent Boolean functions’. The combi-
and one output neuron. nation of these Boolean yes/no responses into a hierarchical ‘tree-
The output of ith hidden neuron is then computed by processing like’ structure forms the shape of a decision tree as it is commonly
the weights inputs and its bias bi as follows: known. Fig. 2 provides the structure of a decision tree design.
! Mehta, Agrawal, and Rissanen (1996) emphasized the impor-
hi ¼ f h bi þ wij xj ð1Þ tance of classification in mining of large datasets, and also dis-
j¼1 cussed the wide range of uses that classification could be applied
in economic, medical and scientific situations. Applications of clas-
where wij denotes the weight connecting input xj to hidden unit hi. sification-based decision tree methods have predominated in sci-
Similarly, the output of the output layer is computed as follows: ence and medicine in recent years, and example being, Markey,
! Tourassi, and Floyd (2003) who applied a simple decision tree to
the classification of clinical specimens as diseased/non-diseased
y ¼ f output b þ wj xj ð2Þ
from lung cancer patients. Another example is Salzberg (1995)
and Salzberg, Delcher, Fasman, and Henderson (1998) who em-
with n being the number of hidden neurons and wj represents the ployed decision tree methods to identify DNA sections coding
weight connecting hidden units j to the output neuron. The transfer exons (the regions of a gene that contain the functional parts for
function fh and foutput allow the network to model nonlinear rela- producing proteins). Decision tree have also been applied to low

Fig. 1. Multilayer perceptron with one hidden layer.

5236 Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242

shown in Table 2. The last four groups of problems were considered

in our study.
Related obstacles of the children would be clarified according as
the 42 attributes with 127 different level values if selected. These
obstacles which corresponded with the three categories of prob-
lems are shown in Table 3. The problems with related attributes
were provided for the therapist to arrange appropriate treatments,
which included improving daily living skills, learning, playing, and
interaction with others. In our study, the number of cases which
were categorized into the last four groups of problem was 11, 6,
6, and 104.
We arranged two stages analysis for the experiment. The first
used a higher accuracy neural network model on the data sets. The
second was using CART to extract rules from the trained neural net-
works, which have higher performance in the first stage. The tool
employed in this study was the Clementine version 10.1 which
Fig. 2. A structure of decision tree. was developed by Integral Solutions Limited (2006).

birth weight predication (Kitsantas, Hollander, & Li, 2006) and liver 3.1. Stage I: Neural networks
disease classification (Lin, 2009).
We applied the most common methodology of the decision tree, To achieve the objective of higher performance neural networks,
which is the classification and regression tree – CART in this study. we arranged and conducted the following two sub experiments. For
It was developed by (Breiman et al., 1984) and has been used since each sub experiment, two indexes were defined: (1) accuracy (Accu.)
1984, being one of the important components for machines learn- and (2) performance evaluation index (Perf.). The accuracy is defined
ing. This method uses recursive partitioning to split the training re- as follows:
cords into segments with similar output field values. CART starts
Number of correct prediction
by examining the input fields to find the best split, measured by Accu: ¼ ð3Þ
Total number of cases
the reduction in an impurity index which resulted from the split.
The split defines two subgroups, and so on, until one of the stop- The performance evaluation index indicated the statistics for
ping criteria is met. All splits are binary with there being only the trained neural network with symbolic outputs. This statistics,
two subgroups. A diversity of algorithms is available to measure reported for each category of the output field(s), are a measure of
impurities, such as Gini (Breiman et al., 1984), towing, and least- the average information content (in bits) of the model for predict-
squared deviation. CART models tend to be easier to understand ing records belonging to that category. It takes the difficulty of the
than some other model types – the rules derived from the model classification problem into account, so accurate predictions for
have a very straightforward interpretation. More details of the rare categories will earn a higher performance evaluation index
CART model building process can be found in (Breiman et al., than accurate predictions for common categories. If the model
1984; Steinburg & Colla, 1997). does no better than guessing for a category, the performance eval-
As our literature review shows, neither artificial neural networks uation index for that category will be null. This index was gener-
nor CART have been reported in the classification of real problems of ated by the Clementine for the last four groups of problems which
children in occupational therapy. were considered in this study. Therefore, the notation of perfor-
mance evaluation index is Perf.-4, Perf.-5, Perf.-6, and Perf.-7,
3. Materials and methods In the first experiment, the original data was divided into two
subsets of similar sizes and evenly distributing the four categories
The data sets were collected from the assessment of children, of problems. Each served as the training (first 60%) and validation
which were evaluated by therapists for rehabilitation treatment. (remaining 40%) data. The accuracy and performance evaluation
127 children in the Department of Rehabilitation at a regional hos- index were measured in predicating the validation data using
pital in south central Taiwan from 2007 to 2010 were selected as the model built with the training data. In the second experiment,
the cases in the data sets. The age of children was between from two subsets of original data were evenly divided. The first half
1 to 13, among them, 40 (31.5%) were diagnosed with mixed devel- 50% served as the training data and the other 50% as the valida-
opment delay, 37 (28.7%) with development delay, 23 (18.11%) tion data. The accuracy and performance evaluation index were
with attention deficit/hyperactive disorder – ADHD, 17 (13.2%) measured. In both of the above experiments, we applied the mul-
with cerebral palsy, 3 (2.3%) with mental retardation, 3 (2.3%) with tilayer perceptrons (an implementation of backpropagation artifi-
autism, 2 (1.55%) with down’s syndrome, 1 (0.77%) with learning cial neural network classifier by Clementine which will be
disorder, and 1 (0.77%) with motor delay. referred to as ANN hereafter). Within each sub-experiment, vari-
In order to know the exact problem of each child with certainty, ous parameters settings were applied for better prediction. In
the therapist prepared the assessment in accordance with the guide- the case of building the ANN, the method of pruning was chosen
lines which were defined by AOTA. Forty-two attributes with totally in this study. Pruning proceeds in two stages: pruning the hidden
127 levels values, in which gender and age are also included, were neurons and then the input neurons. Detailed parameters settings
evaluated for three categories as follows: (1) daily living problems, of the input, hidden, and output layer are provided as follows:
(2) body motor skills, and (3) sensory processing disorders. The attri-
bute values of the assessment are shown in Table 1. Actually, each (1) Input layer: each attribute listed in Table 1 has a different
child was not only classified into one of the categories listed above, number of choices; therefore, the total is 127 attribute val-
but also might be list in two or even all three of the categories; there- ues as the input neurons, in which gender and age are also
fore, seven combinations of problems may be categorized and are included.
Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242 5237

Table 1
125 attribute values of assessment.

Level values
Daily living – DL
Feeding and eating (DL-1) 1. Accomplish independence
Dressing (DL-2) 2. Accomplish by assistance
Bathing and showering (DL-3) 3. Accomplish by dependence

Body motor – BM
Gross coordination (BM-1) 1. Normal
Fine coordination (BM-2) 2. Partial
3. Delay
Oral motor control (BM-3) 1. Normal
2. Excessively sensitive
3. Excessively insensitive
4. Inflexible movement
Swallow-motor (BM-4) 1. Normal
2. Choked by liquid
3. Choked by semi-solids
4. Choked by solids
Left joint flexibility
Hip joint (BM-51) Knee joint (BM-52) 1. Normal
Ankle joint(BM-53) Shoulder joint(BM-54) 2. Tight
Elbow joint(BM-55) Wrist joint (BM-56) 3. Limited
Right joint flexibility
Hip joint (BM-61) Knee joint (BM-62) 1. Normal
Ankle joint(BM-63) Shoulder joint(BM-64) 2. Tight
Elbow joint(BM-65) Wrist joint (BM-66) 3. Limited
Muscle tone
Body (BM-71) 1. Low tension
Upper left (BM-72) Lower left (BM-73) 2. Normal
Upper right (BM-74) Lower right (BM-75) 3. Light high tension
4. Moderate high tension
5. High tension
6. Extreme high tension
Comprehension (BM-81) 1. Normal 2. Abnormal
Expression (BM-82) 1. Normal 2. Abnormal
Sensation (BM-9) 1. Normal 2. Abnormal
Emotional (BM-10) 1. Normal 2. Abnormal
Socialization (BM-11) 1. Normal 2. Abnormal

Sensory processing disorders – SD

Proprioceptive and vestibular (SD-1) 1. Normal 2. Abnormal
Tactile (SD-2) 1. Normal 2. Abnormal
Visual (SD-3) 1. Normal 2. Abnormal
Auditory (SD-4) 1. Normal 2. Abnormal
Multi sensation (SD-5) 1. Normal 2. Abnormal
Tension and endurance related (SD-6) 1. Normal 2. Abnormal
Postural control related (SD-7) 1. Normal 2. Abnormal
Body movement related (SD-8) 1. Normal 2. Abnormal
Sensory input for the influence of emotional (SD-9) 1. Normal 2. Abnormal
Visual stimulus input for influence of emotional and movement (SD-10) 1. Normal 2. Abnormal
Interpersonal skill (SD-11) 1. Normal 2. Abnormal
Expression of behavior (SD-12) 1. Normal 2. Abnormal
Response threshold (SD-13) 1. Normal 2. Abnormal

(2) Hidden layer: we set the number of hidden layers (H = 1, 2); In addition, the persistence number of cycles is set to (p = 800)
while iterating each layer the momentum term is set to which the network continually trains until it has trained for the
(M = 0.1, 0.2, . . ., 0.9); the learning rate is set to specified persistence number of cycles without any improvement
(L = 0.1, 0.2, . . ., 0.9); and hidden neuron units are in accor- and the network stops training when it meets the 90% accuracy.
dance with the formula as follows: All the other default value parameters are kept unchanged.

Number of units in hidden layer

¼ min ð50; roundðlogðnr Þ logðki þ ko ÞÞÞ ð4Þ 3.2. Stage II: Decision trees

where CART represents a computational-statistical algorithm which

nr number of records in the training data; makes predictions in the form of a decision tree. Therefore, the
ki number of input units in the network; ANN trained model with higher performance would be provided
ko number of output units; for rule extraction using the CART. In general, the CART algorithm
(3) Output layer: four output units referred to the last four has two stages: tree growing and tree pruning. The Gini diversity
groups of problems. index, Gini(t), is chosen to minimize each terminal node,
5238 Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242

Table 2 4. Results and discussion

Problems’ categorization.

Problem Problem description

The results of the two experiments in the first stage have been
number presented and interpreted and the implications to the classification
of the problems are discussed as follows.
1 Problem of daily living
2 Problem of body motor
3 Problem of sensory processing disorders 4.1. The results of the first experiment of neural networks
4 Problem of daily living and body motor
5 Problem of daily living and sensory processing disorders
6 Problem of body motor and sensory processing disorders The accuracy and performance evaluation index in the first
7 Problem of daily living, body motor, and sensory processing experiment are shown in Table 4. The learning rate between 0.1
disorders and 0.6 were not listed due to their low prediction accuracy while
the learning rate between 0.7 and 0.9 is listed as follows.
The learning rate between 0.8 and 0.9 had higher accuracy than
GiniðtÞ ¼ pðjjtÞpðijtÞ ð5Þ 0.7, but model 7 had the highest accuracy (80.77%), and the perfor-
i–j mance index for the three categories of problems was 1.649, 2.853,
and 0.035 respectively. The network structure of model 7 was with
where t is a node and i; j 2 C are class labels. p(j|t) is therefore the 99 input neurons, two hidden layers with 5 neurons in the first
conditional probability of observing a sample from class j at node layer and 4 neurons in the second layer, and output layer with 4
t. The prune tree method was selected in order to achieve a robust neurons. It implies that a higher learning rate has higher accuracy.
structure of tree; some error measurements and the degree of tree
complexity are considered. It uses an index that measures both the
4.2. Results of the second experiment of neural networks
misclassification risk and the complexity of the tree, since we want
to minimize both of these. This cost-complexity measurement is de-
The accuracy and performance evaluation index in the second
fined as follows,
experiment are shown in Table 5, and are presented using a similar
min Ra ðTÞ ¼ min fRðTÞ þ aj Te jg ð6Þ format as found in Table 4.
As the results presented in Table 5 show, the models 3, 26, and
e j is the number
where R(T) is misclassification risk of tree T, and j T 27 had the highest accuracy (84.13%) with two categories of prob-
of terminal node for tree T, then the term a represents the complex- lems being classified. It had the highest ratio for problems of daily
ity cost per terminal node for the tree. As a increases from 0, it pro- living and body motor skills at 1.841. The network structure of
duces a finite sequence of subtrees ( T1, T2, T3), each with model 3 was with 64 input neurons, one hidden layer with 2 neu-
progressively fewer terminal nodes. Cost-complexity pruning works rons, and output layer with 4 neurons.
by removing the weakest split. The maximum tree depth is set to 9. Comparing the results of two experiments, we found that the
All the other default value parameters are kept unchanged. Two ANN’s model built by dividing the original data evenly had higher
performance indexes are defined: (1) sensitivity to verify the num- performance.
ber of correct records to which the rule applied, as follows:
4.3. Rules extraction by using CART
Number of correct records prediction
Sensitivity ¼  100% ð7Þ
Total number of records
Since model 3 from the second experiment had the highest
and (2) the confidence for a scored record that is the proportion of accuracy (84%) its results were applied to the CART for further rule
weighted records in the data sets in the scored records’ assigned extraction. Fig. 3 displays the decision tree of CART classifying chil-
terminal node which belongs to the predicated category, as follows: dren’s problems requiring occupational therapy. When an optimal
tree was built, each terminal node was then associated with a set of
Nf ;j ðtÞ þ 1 rules. Table 6 summarizes the rules for each category of problems
Nf ðtÞ þ k from the optimal tree. The rules had been evaluated and approved
by the therapists for proper problems classification. As indicated in
where Nf ;j ðtÞ is the sum of frequency weights for records in category Table 6, the degree of sensitivity of rules by the validation sample
j for node t, and Nf ðtÞ is the sum of frequency weights for all records obtained using the CART analysis showed 100% and 66.67% with
in node t. rule 5-1 and 6-1 respectively. The confidence of the rules reached
100%, and this implies that the rules could correctly be classified
Table 3 into particular category with assuredness.
Related obstacles caused by three categories of problems. As shown in Fig. 3, age was the important predicator because it
was at the top node of the decision trees. An example of the termi-
Categories of Related obstacles
problems nal node 26 can be read as: ‘‘IF age is greater than 1.5 and less and/
or equal to 3.5 AND BM-1 is from partial to delay, AND BM-72 is
Daily living Obstacles to daily living, Developmental delay of gross
problems coordination, Developmental delay of fine motor from low tension to light high tension, AND sex is female, AND
coordination, Difficulty in communication and SD-11 is in abnormal status, THEN the classification belongs to
comprehension, Difficulty in interpersonal skill problem-7.
Body motor skills Limited in joint flexibility, disorders in muscle tone, The prediction of the decision trees under the trained network
Damage to function of sensory perception, disorders in
postural control, Difficulty in postural alignment,
reached 84.13%, relatively higher than the prediction of the deci-
disorders in visual–motor integration, Difficulty in sion trees itself which had only predicted 76.19%. It strongly signi-
motion fies that the methodology which was applied in this study had the
Sensory processing Disorders in cognitive integration, disorders in sensory best performance for prediction and classification.
disorders integration, Attention span problem, Emotions out of
As Fig. 3 and rule 4-1 from Table 6 indicates, that an age less
control, disorders in self-management, Intolerance of
frustration than 1.5 seems to be the critical point when a child’s daily activi-
ties were either fully dependent or needed assistance from his par-
Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242 5239

Table 4
Results of the first experiment of neural networks.

No. Learning Input layer Hidden layer 1 Hidden layer 2 Output layer Accu. Perf.-4 Perf.-5 Perf.-6 Perf.-7
rate neurons neurons neurons neurons (%)
1 0.9 104 13 – 4 75.00 0.956 – – 0.004
2 98 2 – 4 76.92 1.243 – – 0.007
3 111 8 – 4 73.08 0.550 – – 0.020
4 100 2 – 4 78.85 2.342 – 0.059 0.015
5 111 21 – 4 78.85 1.649 – – 0.015
6 57 20 15 4 67.31 0.145 – – 0.003
7 99 5 4 4 80.77 1.649 2.853 – 0.035
8 113 20 15 4 78.85 – – – –
9 104 20 15 4 76.92 0.101 – 1.754 0.030
10 113 14 8 4 80.77 1.649 – – 0.039
11 60 1 1 4 71.15 0.396 – – 0.015
12 0.8 98 2 – 4 78.85 1.243 – – 0.035
13 11 2 – 4 78.85 0.059 – – 0.019
14 109 20 – 4 76.92 0.101 – – 0.019
15 100 3 – 4 80.77 – – 2.853 0.019
16 109 2 – 4 80.77 1.649 – – 0.039
17 3 1 1 4 76.92 0.059 – – 0.035
18 109 4 3 4 78.85 1.649 – 2.159 0.030
19 109 9 7 4 69.23 1.649 0.059 1.754 0.026
20 109 10 10 4 78.85 – – – –
21 109 10 10 4 78.85 – – – –
22 22 1 1 4 76.92 1.243 0.059 – 0.051
23 0.7 88 2 – 4 76.92 1.243 – 0.059 0.030
24 12 2 – 4 71.15 0.732 0.059 – 0.037
25 109 6 – 4 78.85 1.243 – – 0.035
26 65 8 – 4 73.08 0.396 – 2.853 0.037
27 109 10 – 4 78.85 – – – –
28 70 1 1 4 75.00 0.55 – – 0.047
29 11 1 1 4 71.15 0.145 – – 0.060
30 55 1 2 4 71.15 0.956 – 0.059 0.015
31 109 10 10 4 78.85 – – – –
32 9 10 10 4 69.23 0.145 – – 0.032
33 109 10 10 4 78.85 – – – –

Accu. = accuracy, Perf. = performance evaluation index.

Table 5
Results of the second experiment of neural networks.

No. Learning Input layer Hidden layer 1 Hidden layer 2 Output layer Accu. (%) Perf.-4 Perf.-5 Perf.-6 Perf.-7
rate neurons neurons neurons neurons
1 0.9 20 2 – 4 74.60 0.924 0.049 1.946 0.010
2 104 4 – 4 79.37 0.924 – – 0.023
3 64 2 – 4 84.13 1.841 – – 0.032
4 113 20 – 4 82.54 – – – 0.000
5 24 4 – 4 80.95 2.534 0.049 0.049 0.043
6 79 7 – 4 79.37 0.924 – – 0.023
7 113 5 5 4 80.95 1.147 – – 0.026
8 35 1 1 4 80.95 1.147 – – 0.026
9 109 13 10 4 71.43 0.231 – – 0.006
10 113 1 1 4 77.78 0.742 – – 0.020
11 0.8 28 2 – 4 71.43 0.336 0.049 – 0.006
12 19 2 – 4 80.95 1.147 – 3.045 0.023
13 109 18 – 4 79.37 1.147 – – 0.006
14 109 8 – 4 79.37 1.147 – – 0.006
15 109 13 – 4 82.54 1.435 – – 0.029
16 13 1 1 4 74.60 0.924 – – 0.028
17 100 3 2 4 77.78 0.083 – – 0.006
18 113 2 1 4 82.54 – – 2.351 0.013
19 113 1 1 4 77.78 0.742 – – 0.020
20 100 4 3 4 76.19 – – 1.099 0.017
21 0.7 102 4 – 4 80.95 1.435 – 2.351 0.023
22 102 2 – 4 79.37 1.147 0.049 – 0.023
23 50 4 – 4 79.37 1.147 – – 0.006
24 61 3 – 4 82.54 1.147 – 3.045 0.043
25 40 2 – 4 80.95 1.147 – – 0.006
26 61 1 1 4 84.13 1.841 – – 0.032
27 109 2 2 4 84.13 1.841 – – 0.032
28 109 5 5 4 80.95 1.435 0.049 – 0.026
29 76 2 2 4 74.60 0.454 – – 0.013
30 109 17 14 4 82.54 – – – 0.000

Accu. = accuracy, Perf. = performance evaluation index.

5240 Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242

Fig. 3. A decision tree of CART classifying children occupational problem.

ents. Meanwhile, rules 4-2, 4-3, and 4-4 indicated that IF the age Thus, a child’s functional communications, functional mobility,
was greater than 1.5, AND BM-1 was from partial to delay, AND and community mobility would be affected.
BM-72 was between low and light high tension might be the crit- As rule 6-2 shows that IF age was greater than 1.5, AND BM-72
ical attribute especially for problem-4. It implies that tension was was between low and light high tension, AND BM-1 was from par-
important to a child’s daily activities, and holding, catching, and tial to delay, AND SD-10 was in abnormal status THEN problem-6
grasping might be affected. Abnormal in basic motor movement is clarified. This rule is consistent with (Sanders & McCormick,
would affect to a child’s daily activities such as dressing, feeding 1993) who mentioned that almost 70% sensory input stimulus rely
and eating, bathing and showering, personal device care and even on visual stimulus input, if obstacles of visual input are encoun-
socialization. tered then a child’s perceptual processing, sensory integration,
As rule 5-1 expresses that IF age was greater than 1.5, AND BM- and even cognition might be affected. Besides, the gross coordina-
1 was from partial to delay, AND BM-72 was between low and light tion and muscle tone of children might result from the abnormal
high tension, AND SD-11 was in abnormal status THEN problem-5 sensory deficits in partial movement.
is classified. It appears that these attributes significantly corre- For problem-7, which was when children had deficits with liv-
spond with children deficits and disorders. Besides, SD-11 of sen- ing, learning, playing, and/or interacting, there was a relatively
sory processing has little consistency with a child’s motor skills. higher degree of sensitivity that will be discussed later. Rule 7-4
Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242 5241

Table 6
Extracted rules for each category of problem.

Problem Rule- Rules content Sensitivity Confidence

number number (%) (%)
4 4-1 if Age <= 1.5 40 100
4-2 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 20 100
and SD-10 in [Normal] and SD-1 in [Normal] and Age > 5.5 and DL-2 in [Accomplish independence]
4-3 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Female] 20 100
and SD-11 in [Normal] and BM-4 in [Choked by liquid]
4-4 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Moderate high tension] 20 100
5 5-1 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Female] 100 100
and SD-11 in [Abnormal] and Age > 3.5 and SD-3 in [Normal]
6 6-1 if Age > 1.5 and BM-1 in [Normal] and BM-11 in [Normal] 66.7 100
6-2 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 33.3 100
and SD-10 in [Abnormal] and BM-1 in [Partial] and Age > 4.5
7 7-1 if Age > 1.5 and BM-1 in [Normal] and BM-11 in [Abnormal] 2 100
7-2 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 13.46 100
and SD-10 in [Normal] and SD-1 in [Normal] and Age <= 5.5
7-3 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 1.9 100
and SD-10 in [Normal] and SD-1 in [Normal] and Age > 5.5 and DL-2 in [Accomplish by assistance]
7-4 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 55.77 100
and SD-10 in [Normal] and SD-1 in [Abnormal]
7-5 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 1.9 100
and SD-10 in [Abnormal] and BM-1 in [Partial] and Age <= 4.5
7-6 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Male] 5.77 100
and SD-10 in [Abnormal] and BM-1 in [Delay]
7-7 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Female] 13.46 100
and SD-11 in [Normal] and BM-4 in [Normal/Choked by semi- solid]
7-8 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Female] 3.85 100
and SD-11 in [Abnormal] and Age <= 3.5
7-9 if Age > 1.5 and BM-1 in [Partial/Delay] and BM-72 in [Low tension/Normal/Light high tension] and Sex in [Female] 1.9 100
and SD-11 in [Abnormal] and Age > 3.5 and SD-3 in [Abnormal]

Rule notation (n1–n2): n1 – problems notation, n2 – rule number.

had the highest degree of sensitivity in this category, it indicated 5. Conclusions

that IF age was greater than 1.5, AND BM-1 was from partial to de-
lay, AND BM-72 was between low and light high tension, AND SD- Children occupational therapy is one of the non-medication ther-
1 was in abnormal status, then it implied that disorders in muscle apies in the rehabilitation department. For the therapist, the classi-
tone and BM-1 caused obstacles to daily living, difficulty in motion, fication of children for what real problems are and what further
and intolerance of frustration. Moreover, abnormal status in SD-1 treatments should be provided have never been an easy job, partic-
caused disorders in balancing, coordination, and, body movement. ularly in Taiwan. An effective and intelligent classification model is
For rule 7-7, critical attributes is the same as rule 7-4, in addition, highly important for the occupational therapist. ANN or CART is used
BM-4 was from normal to being choked by semi-solids which in many medical applications as a classification method. This study
caused daily activities of feeding and eating to need assistance. accordingly employed ANN and CART techniques to structure an
In rule 7-2, ages greater than 1.5 and less than 5.5 were also critical intelligent classification model. In the first stage, ANN with its great-
attributes indeed. er predication capability of higher performance neural networks
When comparing problem-5 with problem-7, problem-7 model was built. In the second stage, CART extracted a set of rules
showed poorer sensitivity, for the reason was that, three kinds of from the trained network which could provide useful insight into
issues were considered in this category; therefore, the complexity the relationships between classifiable variables and output
of classification was increased resulting in the degree of sensitivity variables.
to decrease. Actual implementation showed that the intelligent classifica-
Refer to the literature review; none of the research discussed tion model was capable of integrating ANN and CART techniques
the classification of children’s occupational therapy problems. to classify real problems for children’s occupational therapy with
This study summarizes 9 attribute values for four categories of considerable accuracy. The study showed that the ANN classifier
problems, age, BM-1, BM-4, BM-72, DL-2, SD-1, SD-3, SD-10, could correctly identify above 80% of real problems. Also, the study
and, SD-11. With 127 attribute values being considered, higher proved that data sets distributed evenly had a higher predication
complexities of classification increased accordingly, but the accuracy rate. If proven feasible, artificial intelligence classification
attributes which were proposed by the methodologies applied in not only can save time, manpower and other medical resources,
this study were covered in three domains of activities. Further- but also have the advantage in eliminating possible human bias.
more, occupational therapist would refer to these attributes as It certainly confirmed that the 9 attribute values found in this
the classifiers of four problems in order to shorten the assessment study could be the classifiers for identifying problems easily and
time and save manpower during the assessment for the children effectively.
needing treatment. In addition, the therapist could handle the However, there is still some work to be done in the future. In
problems for each child effectively and provide appropriate treat- accordance with the results above, the proposed model has two
ment for these children accordingly in order to enhance and im- stages to classify the critical and important attributes on particular
prove their quality of living, ability to be independent, children occupational problems. The results of the validation study
educational skills, motor control, self-management, and cognitive indicated the usefulness of the proposed model to therapist. Since
integration. 127 attribute values were considered in this study, but only 9 attri-
5242 Y.-L. Yeh et al. / Expert Systems with Applications 39 (2012) 5233–5242

bute values were found, there should be some more attributes Kitsantas, P., Hollander, M., & Li, L. (2006). Using classification trees to access low
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