自閉症類群幼兒共享式參與家長訓練之療效研究

The Efficacy of Caregiver Mediateded Joint Engagement Intervention for Young Children with Autism Spectrum Disorders

朱慶琳(Ching-Lin Chu)

指導教授 ： 姜忠信 ； 翁嘉英

國立中正大學/社會科學院/心理學系/博士(2014年)

摘要

研究目的：當代對自閉症兒童之共享式注意力(joint attention, JA)及共享式參與(joint engagement, JE)之介入方案研究證實雖有療效，但存有日常生活情境不易類化、不具分享性及療效結果不穩定等限制。本研究旨在以加入舞蹈治療創造性取向概念之JE家長訓練方案，探討對自閉症類群幼兒，於具分享性之JE/JA的治療效果及其伴隨療效。
研究方法：採準實驗研究設計，共有34名2歲至未滿4歲自閉症類群幼兒參與本研究，含介入組(N = 18)及配對生理年齡、語文非語文心理年齡、發展商數及症狀嚴重度之對照組(N = 16)。介入組幼兒接受每週兩次、每次一小時、共計20次一對一親子介入。訓練家長使用三大教法：跟隨模仿、建立遊戲常規及提升JE狀態，舞蹈治療之創造性取向涵蓋於此三教法之中。
療效評估透過半結構評估及標準化評估工具，由獨立施測者於介入前、介入後、及追蹤三個月之三時間點施測。主要療效評估包含共享式參與狀態及共享式注意力技能，分別以親子遊戲、及早期社會溝通量表評估而得。伴隨療效評估為心理發展、語言、社會化適應行為及遊戲能力，由穆林發展量表、文蘭適應行為量表第二版及結構遊戲評估而得。
研究結果：結果指出與對照組相較，介入組在三個月追蹤時的兒童引發支持性及協調一致的JE較佳。兩組在後測之JE與後測及三個月追蹤之JA雖無顯著差異，但在三個月追蹤時有視覺接收及語言理解的伴隨療效。家長執行內容真確度僅與家長引發支持性JE相關。介入反應好壞者之家長真確度並無顯著差異。但當幼兒前測發展商數較低者，JE介入會比發展商數高者在兒童引發JE有較佳療效。
結論：本研究發現，加入創造性舞蹈治療的方式所進行的JE家長訓練方案，可有效地提升兒童引發的JE，尤其是以分享為主的協調一致的JE，並有伴隨效果，顯示增加舞蹈治療之介入方式有其價值。不過，影響介入反應的相關因素須考慮之。家長在介入階段仍須帶幼兒接受其他早期療育，在家中執行介入的質量有限。最後，提出本研究限制、未來研究方向及臨床應用。

關鍵字

自閉症類群 ； 共享式注意力 ； 共享式參與 ； 家長訓練 ； 舞蹈治療

並列摘要

Purpose: Joint attention (JA) interventions for children with autism spectrum disorders (ASDs) were focused on improving of joint engagement (JE) and JA skills. Although recent literature demonstrated positive outcomes, but those JE and JA skills were limited with poor generalization, lacked of sharing and unstable efficacy. The purpose of this study was to develop caregiver mediated JE intervention program adding the perspective of creative dance/movement therapy, to investigate the effects of the JE/JA skills and their collateral abilities in young children with ASDs.
Methods: A quasi-experimental research designs was conducted. Thirty-four young children with autism spectrum disorders ages 2-4 were recruited. The intervention group (N=18) matched to the comparison group (N=16) on chronological age, verbal mental age, nonverbal mental age, developmental quotient (DQ), and symptom severity. Program was consisted of 20 sessions with one hour a session and twice a week. Each session was arranged for the target child and his/er mother. Three major kinds of teaching strategies including following and imitation, forming a play routine, and facilitating JE state were used in the intervention program. The creative dance/movement therapy was used throughout these strategies.
Intervention outcomes were collected through unstructured activities and standardized tools/tasks by independent testers at both pre- and post- intervention and 3 months follow-up. The primary outcome measures were JE and JA, assessed from the caregiver–child paly and the Early Social Communication Scales, respectively. The collateral effects measures were mental development, language, socialization, and play skills, assessed by the Mullen Scales of Early Learning, the Reynell Developmental Language Scales, Vineland Adaptive Behavior Scales-Second Edition, and Structured Play Assessment.
Results: Results indicated that children-initiated supportive and coordinated JE were greater for the intervention group compared with the comparison group at 3 months follow-up. There were no significant differences between the two groups on JE at post-intervention and JA both at post-treatment and 3 months follow-up. Besides, the improvement of collateral abilities as visual reception and receptive language were persistent 3 months after intervention. Caregiver’s fidelity was only significantly correlated to supportive JE. There was no significant difference on caregiver’s fidelity between the good and poor responders after intervention. For the children beginning intervention with the lowest DQ levels, the JE intervention could improve their children-initiated JE outcome significantly than did the children with high DQ levels.
Conclusions: Results showed while adding the creative dance/movement therapy approach into the JE intervention could enhance children-initiated JE, especially the coordinated JE with sharing, and the collateral abilities. Adding dance therapy into the program had its unique contribution. Factors which influenced the responsiveness of intervention should be considered. Due to caregivers were burdened with bringing their children to receive the varied early intervention services, the quality and quantity of conducting the home program was limited. Finally, research limitations in the current study were discussed. The authors also provided some ideas for the future studies and clinical practice.

並列關鍵字

caregiver mediated intervention ； autism spectrum disorders ； joint attention ； joint engagement ； dance therapy

參考文獻

江淑蓉、姜忠信、彭雅凌、林家慶(2012)。共享式注意力多元介入方案療效研究：三名學前中高功能自閉症男童的探究。特殊教育研究學刊，37(2)，59-84。

李宗芹(2011)。創造性身體運作中的心理轉化─以個案翔翔為例。運動文化研究，18，41-78。

李素貞(2009)。自閉症幼兒相互注意協調能力介入效果的研究。國立台灣大學心理學研究所碩士論文(未出版)。

姜忠信、彭雅凌、江淑蓉(2010)。個案報告：中低功能自閉症兒童相互注意協調能力的介入。中華心理衛生學刊，23，125-151。

黃鈺菁、鳳華(2007)。學齡前自閉症兒童相互注意協調能力學習成效初探之研究。特殊教育研究學刊，32，121-141。