不同方法干预3~6岁轻中度孤独症谱系障碍儿童共同注意的效果

doi:10.3969/j.issn.1006-9771.2024.08.003

摘要/Abstract

摘要：

目的比较回合操作教学法(DTT)、关键反应训练(PRT)及DTT结合PRT干预3~6岁轻中度孤独症谱系障碍(ASD)儿童共同注意的效果。

方法 2023年1月至2024年3月，上海市泰亿格儿童康复中心36~72月龄ASD儿童39例，随机分为DTT组、PRT组和混合组，分别接受DTT、PRT以及DTT结合PRT，共10周。干预前后采用ASD儿童共同注意评估量表进行评定。

结果 DTT组脱落2例，PRT组脱落1例，最终纳入36例。干预方法(F = 11.225, P < 0.001)和干预阶段(F = 416.935, P < 0.001)主效应均显著，交互效应显著(F = 10.501, P < 0.001)，混合组干预期和迁移期评分最优(P < 0.05)。

结论 DTT和PRT均能提升ASD儿童共同注意，两者结合效果更佳。

关键词: 孤独症谱系障碍, 儿童, 共同注意, 回合操作教学法, 关键反应训练

Abstract:

Objective To compare the effect of discrete trial training (DTT), pivotal response treatment (PRT) and a combination of DTT and PRT on joint attention in children aged three to six years with mild to moderate autism spectrum disorder (ASD).

Methods From January, 2023 to March, 2024, 39 children with ASD aged 36 to 72 months in Tiger Children's Rehabilitation Center in Shanghai were randomly divided into DTT, PRT and combination groups, who received DTT, PRT and a combination of DTT and PRT, respectively, for ten weeks. They were assessed with Joint Attention Assessment Scale for children with ASD before and after intervention.

Results Two cases in DTT group and one case in PRT group dropped down, resulting in a final sample of 36 cases. The main effects of group (F= 11.225, P< 0.001) and time (F= 416.935, P< 0.001) were significant, as well as the interaction (F= 10.501, P< 0.001), and the combination group was the best during intervention and follow-up (P < 0.05).

Conclusions Both DTT and PRT may improve joint attention in children with ASD, and the combination of DTT and PRT is the best.

Key words: autism spectrum disorder, children, joint attention, discrete trial training, pivotal response treatment

中图分类号:

R749.93

杨宇然, 王茜, 陈翠翠, 杜晓新. 不同方法干预3~6岁轻中度孤独症谱系障碍儿童共同注意的效果[J]. 《中国康复理论与实践》, 2024, 30(8): 888-893.

YANG Yuran, WANG Qian, CHEN Cuicui, DU Xiaoxin. Effect of different interventions on joint attention in children aged three to six years with mild to moderate autism spectrum disorder[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(8): 888-893.

图/表 6

表1

表2

表3

表4

表5

表6

参考文献 35

[1]	MCDOWELL C, BRYANT M. Sibling-based treatments for autism spectrum disorder: a systematic review[J]. Int J Syst Ther, 2024, 35(2): 227-244.
[2]	American Psychiatric Association. Diagnostic and statistical manual of mental disorders[M]. 5th ed. Washington, D.C.: American Psychiatric Association, 2013: 58-62.
[3]	NYSTROM P, THORUP E, BOLTE S, et al. Joint attention in infancy and the emergence of autism[J]. Biol Psychiatry, 2019, 86(8): 631-638.
[4]	SHEINKOPF S J, MUNDY P, CLAUSSEN A H, et al. Joint attention and reciprocal social interaction in preterm and full-term infants: a longitudinal study[J]. Dev Neuropsychol, 2018, 43(2): 119-129.
[5]	CHIAROTTI F, VENEROSI A. Epidemiology of autism spectrum disorders: a review of worldwide prevalence estimates since 2014[J]. Brain Sci, 2020, 10(5): 274.
[6]	BOTTEMA-BEUTEL K. Associations between joint attention and language in autism spectrum disorder and typical development: a systematic review and meta-regression analysis[J]. Autism Res, 2016, 9(10): 1021-1035.
[7]	MURZA K A, SCHWARTZ J B, HAHS D L, et al. Joint attention interventions for children with autism spectrum disorder: a systematic review and meta-analysis[J]. Int J Lang Commun Disord, 2016, 51(3): 236-251. doi: 10.1111/1460-6984.12212 pmid: 26952136
[8]	MUNDY P, NOVOTNY S, SWAIN-LERRO L, et al. Joint-attention and the social phenotype of school-aged children with ASD[J]. J Autism Dev Disord, 2017, 47(5): 1423-1435. doi: 10.1007/s10803-017-3061-0 pmid: 28229349
[9]	孙美琦. 自闭症谱系障碍儿童共同注意干预的个案研究[D]. 大连: 辽宁师范大学, 2021.
	SUN M Q. A case study of joint attention intervention for children with autism spectrum disorder[D]. Dalian: Liaoning Normal University, 2021.
[10]	LOGAN K, IACONO T, TREMATH D. Aided enhanced milieu teaching to develop symbolic and social communication skills in children with autism spectrum disorder[J]. Augment Altern Commun, 2024, 40(2): 125-139.
[11]	SANDBANK M, BOTTEMA-BEUTEL K, CROWLEY S, et al. Project AIM: autism intervention meta-analysis for studies of young children[J]. Psychol Bull, 2020, 146(1): 1016-1028.
[12]	骆小燕. 关键反应训练在学前自闭症儿童共同注意个训中的应用[J]. 现代特殊教育, 2020(23): 65-67.
[13]	GOODS K S, ISHJIMA E, CHANG Y C, et al. Preschool based JASPER intervention in minimally verbal children with autism: pilot RCT[J]. J Autism Dev Disord, 2013, 43(5): 1050-1056. doi: 10.1007/s10803-012-1644-3 pmid: 22965298
[14]	WONG C, ODOM S L, HUME K A, et al. Evidence-based practices for children, youth, and young adults with autism spectrum disorder: a comprehensive review[J]. J Autism Dev Disord, 2015, 45(7): 1951-1966. doi: 10.1007/s10803-014-2351-z pmid: 25578338
[15]	KASARI C, FREEMAN S, PAPARELLA T. Joint attention and symbolic play in young children with autism: a randomized controlled intervention study[J]. J Autism Dev Disord, 2006, 47(6): 611-620.
[16]	瞿玲玲, 程茜. 孤独症谱系障碍儿童共同注意行为试验研究[J]. 中国康复理论与实践, 2017, 23(10): 1190-1194. doi: 10.3969/j.issn.1006-9771.2017.10.014
	QU L L, CHENG Q. Behavior evaluation of joint attention in children with autism spectrum disorders[J]. Chin J Rehabil Theory Pract, 2017, 23(10): 1190-1194.
[17]	MULLEN E M. Mullen Scales of Early Learning[M]. Circle Pines, MN: American Guidance Service Inc., 1995.
[18]	何丹. 应用行为分析在自闭症儿童干预中的运用[D]. 成都: 四川师范大学, 2015.
	HE D. The use of applied behavior analysis in intervention for children with autism[D]. Chengdu: Sichuan Normal University, 2015.
[19]	李婵. DTT与PRT教学对自闭症谱系障碍儿童共同注意缺陷的干预研究[D]. 南京: 南京师范大学, 2018.
	LI C. Intervention of DTT and PRT teaching on common attention deficit in children with autism spectrum disorder[D]. Nanjing: Nanjing Normal University, 2018.
[20]	胡嘉铨, 祝丽玲, 姜志梅. 近20年有关孤独症谱系障碍早期筛查工具研究的可视化分析[J]. 中国康复理论与实践, 2023, 29(11): 1304-1315. doi: 10.3969/j.issn.1006-9771.2023.11.008
	HU J Q, ZHU L L, JIANG Z M. Early screening tools for autism spectrum disorder in the past two decades: a visualized analysis[J]. Chin J Rehabil Theory Pract, 2023, 29(11): 1304-1315.
[21]	BAKEMAN R, DECKERNER D F, et al. From interactions to conversations: the development of joint engagement during early childhood[J]. Child Dev, 2014, 85(3): 941-955. doi: 10.1111/cdev.12189 pmid: 24266591
[22]	耿立蒙, 刘聪聪, 李玲, 等. 运用心理教育量表(第3版)评估孤独症谱系障碍儿童心理行为特征[J]. 中国康复理论与实践, 2023, 29(9): 1035-1039. doi: 10.3969/j.issn.1006-9771.2023.09.006
	GENG L M, LIU C C, LI L, et al. Psychological and behavioral characteristics of children with autism spectrum disorder using Psycho-educational Profile (Third Edition)[J]. Chin J Rehabil Theory Pract, 2023, 29(9): 1035-1039.
[23]	柯晓燕. 孤独症谱系障碍早期识别与早期诊断的现状与挑战[J]. 中国儿童保健杂志, 2023, 31(3): 238-240. doi: 10.11852/zgetbjzz2023-0013
	KE X Y. Status and challenges of early recognition and early diagnosis of autism spectrum disorder[J]. Chin J Child Health Care, 2023, 31(3): 238-240.
[24]	黄丕丕, 杨碧雪, 张梅. 近十年我国孤独症干预方法的研究热点分析: 基于CNKI数据库的CiteSpace分析[J]. 心理月刊, 2024, 19(9): 11-14. doi: 10.19738/j.cnki.psy.2024.09.003
	HUANG P P, YANG B X, ZHANG M. Analysis of research hotspots on autism intervention methods in China in the past decade: CiteSpace analysis based on CNKI database[J]. Psychol Mon, 2024, 19(9): 11-14.
[25]	STONE-HEABERLIN M, HARTLEY N, LYNCH J D, et al. Implementation of a parent-mediated discrete trial teaching intervention for children with autism spectrum disorder[J]. Behav Anal Pract, 2023, 16(1): 302-306.
[26]	DAWSON G, BERNIER R, RING R H. Social attention: a possible early indicator of efficacy in autism clinical trials[J]. J Neurodev Disord, 2012, 4(1): 1-12.
[27]	KRYNAUW J, PEDRO A. Neuro-feedback intervention efficacy for treating children with autism spectrum disorder[J]. J Psychol Afr, 2018, 28(3): 249-251.
[28]	田旭梅, 肖廷廷, 彭敏, 等. DTT与PRT应用于自闭症儿童的比较研究[J]. 教育教学论坛, 2019(29): 111-112.
	TIAN X M, XIAO T T, PENG M, et al. Comparative analysis of DTT and PRT in autistic children[J]. Educ Teach Forum, 2019(29): 111-112.
[29]	王振洲. 自闭症儿童DTT与PRT干预模式的对比研究[J]. 重庆文理学院学报(社会科学版), 2015, 34(1): 109-113.
	WANG Z Z. Contrast research of DTT and PRT intervention model for children with autism[J]. J Chongqing Univ Arts Sci (Soc Sci Ed), 2015, 34(1): 109-113.
[30]	KOEGEL L K, KOEGEL R L, ASHBAUGH K, et al. The importance of early identification and intervention for children with or at risk for autism spectrum disorders[J]. Int J Speech-Lang Pathol, 2014, 16(1): 50-56.
[31]	WATANABE T, LAWSON R P, WALLDEN YSE, et al. A neuroanatomical substrate linking perceptual stability to cognitive rigidity in autism[J]. J Neurosci, 2019, 39(33): 6540-6554. doi: 10.1523/JNEUROSCI.2831-18.2019 pmid: 31213484
[32]	BAL V H, KIM S H, CHEONG D, et al. Daily living skills in individuals with autism spectrum disorder from 2 to 21 years of age[J]. Autism, 2015, 19(7): 774-784.
[33]	徐秀, 邹小兵, 柯晓燕, 等. 孤独症谱系障碍婴幼儿家庭实施早期干预专家共识[J]. 中国循证儿科杂志, 2021, 16(5): 327-332.
	XU X, ZOU X B, KE X Y, et al. Expert consensus on early intervention in families with autism spectrum disorders[J]. Chin J Evid Based Pediatr, 2021, 16(5): 327-332.
[34]	宋虎杰, 赵宁侠, 杜晓刚, 等. 综合疗法对孤独症谱系障碍患儿的效果[J]. 中国康复理论与实践, 2020, 26(8): 960-963. doi: 10.3969/j.issn.1006-9771.2020.08.016
	SONG H J, ZHAO N X, DU X G, et al. Effect of comprehensive treatments on Autism Spectrum Disorder[J]. Chin J Rehabil Theory Pract, 2020, 26(8): 960-963.
[35]	肖石花, 李晶. 自然发展行为干预在孤独症早期干预中的应用[J]. 心理科学进展, 2023, 31(12): 2350-2367. doi: 10.3724/SP.J.1042.2023.02350
	XIAO S H, LI J. Implementation of naturalistic developmental behavioral interventions: an early intervention program for children with autism spectrum disorder[J]. Adv Psychol Sci, 2023, 31(12): 2350-2367. doi: 10.3724/SP.J.1042.2023.02350

儿童目标行为	提示等级	举例
完全失败	T1：语言+肢体动作提示	当幼儿无法跟随指示去看目标时，再次重复指导语“你看这只兔子”，并且轻轻扶住孩子头部，调整角度，看向训练者，再面向目标。
连续3次使用T1提示成功或肢体提示力度很轻	T2：语言+动作示范提示	当轻微触碰幼儿头部就可以成功看向目标时，再次重复指导语，并演示动作，告诉幼儿“可以向我一样，看着这只兔子”。
连续3次使用T2成功或主动关注教师行为	T3：语言提示	当幼儿主动观察教师动作或有视线接触时，教师可以再次重复指导语，“你看这只兔子，它有雪白的皮毛”。
有成功迹象但持续时间很短	T4：物理空间线索提示	幼儿目光在“兔子”上短暂停留但很快飘走，可以将“兔子”移近或用手指再次轻点目标。

变量	组别	n	$\bar{x}\pm s$	F值	P值
实际月龄	DTT组	11	58.727±8.223	0.797	0.459
	PRT组	12	53.667±10.021
	混合组	13	56.308±10.291
心理月龄	DTT组	11	40.818±7.222	0.429	0.655
	PRT组	12	43.583±7.452
	混合组	13	43.077±8.005

组别	n	基线	干预期	迁移期
DTT组	11	20.061±1.775	58.909±11.772	49.273±10.403
PRT组	12	20.057±1.255	67.667±17.159	59.667±15.156
混合组	13	20.103±0.810	81.539±11.200	76.000±11.343

变量	SS	df	MS	ηp²	F值	P值
干预方法	5001.042	2	2500.521	0.405	11.225	< 0.001
干预阶段	50384.234	2	25192.117	0.927	416.935	< 0.001
交互作用	2437.875	4	634.469	0.389	10.501	< 0.001

干预阶段		平均值差值(I-J)	标准误差	P值
基线期	干预期	-49.298	2.296	< 0.05
基线期	迁移期	-41.573	2.098	< 0.05
干预期	迁移期	7.725	0.667	< 0.05