個案報告：中低功能自閉症兒童相互注意協調能力的介入

Report on the Joint Attention Intervention with Two Low-to-middle Functioning Children with Autism

研究目的：本研究的主要目的在探討中低功能自閉症兒童進行相互注意協調能力的介入效果。研究方法：本介入方案參考Kasari、Freeman與Paparella（2006）的建議，結合區別嘗試訓練及自然教學法，對案童進行為期兩個月，每週3次，每次30分鐘，共計24次的介入。研究結果：初步分析發現，2名中低功能自閉症兒童在相互注意協調能力皆有所提升。個案甲的起始訓練能力為要求式的近距手指指示，訓練後能達到少量提示下的展示能力。個案乙的起始訓練能力為要求式的給予行為，訓練後能達到要求式的遠距手指指示。客觀的測量工具也支持2位案童在相互注意協調能力的進展，不過提升的程度有限。四個月的追蹤發現，案甲的家長認為案甲在家中的進展有限，但案乙的家長則較肯定介入帶來的進展。研究結論：對自閉症兒童進行相互注意協調能力的介入，初步證實帶來了效果。本文最後討論訓練相互注意協調能力的相關因素，並提出下一階段介入研究的準備。

Purpose: The deficit of joint attention (JA) is one of the core symptoms of children with autism or autism spectrum disorders. Recent research has demonstrated that the JA intervention can improve JA, play, and language ability in young children with autism. However, very few studies have focused on this topic in Taiwan. The goal of this study is to develop a JA intervention program for children with autism in Taiwan. This report describes the initial results of working with 2 low-to-middle functioning children with autism. Methods: Case A was a 59-month-old boy, whose mental age (MA), verbal mental age (VMA), and nonverbal mental age (NVMA) were 23 months, 16 months, and 30 months, respectively. We used the Mullen Scales of Early Learning (Mullen, 1995) as the measure for developmental ability. Case B was a 66-month-old girl, whose MA, VMA, and NVMA were 13 months, 6 months, and 20 months, respectively. The two children were diagnosed by the research team, which included 2 psychiatrists and 2 psychologists, using DSM-IVTR
and the Autism Diagnostic Observation Scales (Lord, Rutter, DiLavore, & Risi, 1999). The program was developed according to Kasari’s suggestion in ULCA (Kasari, Freeman, & Paparella, 2006), which combines discrete trial training and milieu teaching in a oneto- one training situation. Our JA intervention was applied 3 times a week, for a total of 24 sessions. Each session lasted approximately 30 minutes. During the session, discrete trial training and milieu teaching approaches were used in table time and floor time separately. In the table time, the child received approximately 5 to 8 minutes of discrete trial training with the therapist to prime the particular treatment goal. Both a prompt hierarchy (verbal prompt, model, physical prompt) and positive reinforcement were used to achieve the child’s appropriate responses. Following the table time training, the child worked on the same goal in a floor time session with the therapist. Principles applied during the floor time included following the child’s lead and interest in activities, talking about what the child was doing, repeating back what the child said, expanding on what the child said, giving corrective feedback, sitting close to the child and making eye-contact, and making environmental adjustments to engage the child. The floor time session was child-driven rather than adult-directed, and environmental manipulations were strategically used to facilitate the child’s social and communicative attempts. In addition, 2 other strategies were also applied in the floor time session. One strategy was to imitate the child’s actions with toys, and the second strategy was to use the child’s activity interests to develop play routines. The objective measures for the pre- and post tests were: the Early Social Communication Scales (Mundy, Hogan, & Doehring, 1996) and the Screening Tool for Autism in Toddlers (Stone, Coonrod, Turner, & Pozdol, 2004). Results: The results showed Case A developed his ability from proximal pointing for requesting to showing for JA in mild assistance. Case B improved her ability from giving for requesting to distal pointing for requesting. The objective measures manifested some JA progress in both children. However, only Case B was reported as progressing in JA by her parents in a 4-month follow-up. Conclusions: Our JA intervention for children with autism seems promising. Further studies are needed to explore some variables that influence the development of JA and to recruit more participants in experimental and control groups to learn the long term effects of the JA intervention in children with autism.