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

The Effectiveness of Multi-Component Joint Attention Intervention in Three Middle-to-high Functioning Boys with Autism

共享式注意力為自閉症兒童的核心缺陷之一，且與語言、社會互動、遊戲及模仿能力的發展有密切關係。本研究旨在探討使用合併取向，同時納入家長訓練的模式，對中高功能自閉症兒童進行JA介入的直接與伴隨能力成效。本研究採多重個案設計，以3名4歲2個月至4歲6個月的中高功能自閉症男童為對象，進行每週3次、每次30-45分鐘、為期兩個月共24次的介入。介入採取結合區別嘗試訓練與環境教學的模式，並加入家長訓練。介入成效由獨立於介入的施測者，以標準化與半結構式工具評估能力變化，並紀錄家長自陳式報告。評量時間點分為介入前、後與介入後3、6個月追蹤共4次，療效認定是將介入能力的進步程度與過去團體研究的顯著進步值相較，等同或超過該數值時，定義為具療效。結果發現，此介入模式能有效促進受試兒童的JA進展並達類化效果，特別是主動性JA的提升最明顯，且受試兒童的注意狀態與家長的回應性能力有正向關係。此外，JA介入也帶來語言理解、象徵性遊戲、社會互動能力的伴隨成效，能力進展的維持期約在3-6個月之間。總結來說，本研究的JA介入法確能對自閉症兒童帶來直接及伴隨能力的成效，與先前團體研究結果類似，但伴隨成效的維持期相對較短。未來研究可探討維持療效的因子，亦可以實驗法擴大樣本並納入控制組、受試對象可以降低年齡，安排不同訓練頻率與密集度，來探究介入成效。

Purpose: Joint attention (JA) is one of the core deficits in children with autism, associated with other developmental abilities such as language, play, social ability, and imitation. The current study uses multiple-case design with a combined approach for a JA intervention program including parent training to investigate the effects of JA and its collateral abilities for 3 children with middle-to-high functioning autism. Methods: Three 4- year old boys (CA = 48-52 months, MA = 26-30 months) with middle-to-high functioning autism were diagnosed with DSM-IV-TR (APA, 2000) and ADOS (Lord et al., 2000) by a multidisciplinary team including a psychiatrist, pediatrician, and psychologists. The children and their mothers participated in this individual program, conducted in 24 sessions and followed up 3 and 6 months later. The program included discrete trial training (DTT) and milieu teaching method adapted from Kasari et al. (2006, 2010). Parent training sessions were also simultaneously included in the program. Each child training session was approximately 30 minutes, 3 times per week, for a total of 24 sessions. The DTT and milieu teaching approaches were used on the table time and floor time separately. The JA intervention program for parents was based on the authors’ clinical experience and followed the Parent JA Intervention Manual (PJAIM). For the first half of the parent training from session 1 to 12, the interventionist used the PJAIM as a reference to explain to the parent what was going on from a one-way mirror while parents observed their child’s training session in the playroom. From sessions 13-24, the parent was invited to the playroom to interact with the child, guided by the interventionist for 15 minutes after the child’s training session. The intervention outcomes were collected through standardized tools/tasks, structured and unstructured activities by independent testers, and from parent reports. The threshold for intervention efficacy defined by these gain scores in our measurements equaled or exceeded those values in the interventional group of previous published studies. Findings: The results show that the 3 children improved their JA skills and joint engagement state after the JA intervention program. The children improved from pointing for requesting an object to showing/giving an object to a person, and developed from unengaged or object engagement to supported joint engagement in the postintervention test. Similar improvements are shown in the three-month follow-up test. Parent responsiveness was also highly associated with joint engagement between parents and children. Other collateral effects on relevant abilities including receptive language, symbolic play, and social ability were also noticeable, and were maintained 3-6 months. Conclusions/ Implications: The results support that children with autism receiving our JA intervention program improved their JA skills, joint engagement state, and relevant abilities, similar to previous studies; however, the maintenance was shorter. Further studies need to explore the variables that influence the effects maintained, and to include a large sample and a control group to extend to younger children with autism, and to evaluate efficacy while arranging different intensities or frequencies of parent training sessions.