沙鵬 雷江華
【基金項目】 本文為全國教育科學“十四五”規(guī)劃2021年度教育部重點課題“基于融合性沙盤游戲的自閉癥兒童社會交往能力培養(yǎng)的研究”(DHA210379)的階段性研究成果。
【摘要】 為探究國外應用同伴介入法干預孤獨癥兒童社交行為的研究趨勢,對43篇相關文獻進行分析發(fā)現,在研究設計層面上,研究目標趨于提高孤獨癥兒童社交行為的表現能力,研究對象趨于選取低齡高功能的孤獨癥兒童,研究設計趨于選用單一被試實驗設計;在干預實施層面上,干預情境趨于選取融合教育情境,干預執(zhí)行同伴趨于標準統(tǒng)一且培訓內容精細,干預方法趨于整合多種方法發(fā)揮協同效應,干預策略趨于選取“混合型”策略。在此基礎上,我國后續(xù)相關研究的開展還應全面關注孤獨癥兒童社交行為的發(fā)展模式與軌跡并積極開展早期干預,同時要持續(xù)探索同伴介入法實施的可行性路徑,充分發(fā)揮其在推動孤獨癥兒童社交行為發(fā)展中的有效性。
【關鍵詞】 孤獨癥譜系障礙兒童;社交行為干預;同伴介入法
【中圖分類號】 G760
【作者簡介】 沙鵬,博士研究生,華中師范大學教育學院(武漢,430079);雷江華,教授,華中師范大學教育學院(通訊作者:huajianglei2003@163.com,武漢,430079)。
一、引言
孤獨癥譜系障礙(Autism Spectrum Disorders,以下簡稱ASD)是發(fā)病于兒童早期的精神性發(fā)育障礙,發(fā)病率超1%,名列我國兒童精神類疾病首位[1]。研究表明,社會交往障礙是ASD的核心癥狀[2],具體表現為ASD兒童較少出現社交行為,其在社交行為認知、參與等多方面存在著不同程度的缺陷,且社交行為缺陷對ASD兒童發(fā)展的負面影響是持久的[3-5]。因此,研究人員應加強對ASD兒童社交行為的研究。
元分析研究發(fā)現,基于行為主義取向的同伴介入法(peer-mediated intervention)在ASD兒童社交行為干預中的應用日益廣泛,且被美國國家孤獨癥中心等權威機構認定為是一種符合循證實踐標準的社交能力干預方法[6]。其有效性路徑為:由研究者培訓有社交能力的普通兒童作為干預執(zhí)行同伴,使其能與ASD兒童建立恰當的社交模式,強化ASD兒童適切的社交行為,從而提升ASD兒童的社交能力[7-9]。相比之下,國外研究人員應用同伴介入法干預ASD兒童社交行為的時間更早且成效較好。鑒于此,本文從研究設計層面與干預實施層面中的各個要素入手,梳理并分析國外相關干預研究的趨勢,以期為我國后續(xù)同類研究與實踐的開展提供啟示。
二、研究方法
首先,進行文獻檢索。以Web of Science、EBSCO ASP、ERIC以及ProQuest數據庫為文獻檢索來源,選擇主題(詞)為檢索項進行高級檢索,檢索式為(TS=autism OR autistic OR ASD)AND(TS=peer-mediated intervention OR PMI)AND(TS=social behavior OR social actions),文獻類型選擇“Article”,文獻語種選擇“English”,文章發(fā)表日期截止至2023年6月。其次,進行文獻篩選。參照PRISMA標準[10],文獻的納入標準為:①實證研究;②研究對象為經確診的ASD兒童;③采取了單一被試或隨機對照實驗設計。依據上述標準,共獲得43篇有效文獻,即本研究的樣本[11-53]。
三、研究結果
(一)研究設計層面的趨勢及其啟示
1.研究目標:趨于提高ASD兒童社交行為的表現能力
縱觀國外應用同伴介入法干預ASD兒童社交行為的研究,其根本目標在于提高ASD兒童社交行為的表現能力,并通過多元的形式具體展開。例如,Aldabas與Cardon等人以改善被試的社交行為技能為目標,發(fā)現基于同伴介入法的社交行為干預能增加ASD兒童社交語言的使用次數,豐富其社交語言的呈現形式,完善其社交語言的表達功能[54-55];Barber與Parsons等人以降低被試的社交行為缺陷程度為目標,發(fā)現基于同伴介入法的社交行為干預能促進ASD兒童社交知覺、社交溝通等方面的發(fā)展,從而減輕其社交行為缺陷的程度[56-57];Bambara與Watkins等人則以減少被試的社交問題情緒行為為目標,發(fā)現基于同伴介入法的社交行為干預能緩解ASD兒童抑郁、焦慮等不良社交情緒,減少其出現攻擊行為、強迫行為等消極社交行為的頻率[58-59]。此外,還有研究以ASD兒童社交品質、社交主動性、社交維持度等的改變?yōu)樽罱K的研究目標,均取得了不同程度的積極效果。
多元的研究目標為ASD兒童多樣的社交行為干預需求提供了多維的參考,也驗證了基于同伴介入法的干預有益于ASD兒童社交行為的發(fā)展。目前,國外相關研究對ASD兒童目標社交行為發(fā)展的評價多采用量化的形式,即觀測干預前后被試目標行為出現次數或主要看護者應用標準化工具評分的變化,然而個體的社交行為內涵深刻且外延深遠,單一的量化評價難以全面描述,故后續(xù)研究還應融入包括社交趨向、社交態(tài)度等要素目標的質性評價,以綜合描述ASD兒童的社交行為發(fā)展狀況。
2.研究對象:趨于選取低齡、高功能ASD兒童
首先,基于社交行為缺陷在ASD兒童群體中的基礎性,國外研究人員多選取3—8歲低齡ASD兒童為被試。其次,基于ASD兒童個體的社交行為缺陷程度與表現差異顯著,低功能ASD兒童社交行為的干預效果難以考察,故研究人員多選取高功能ASD兒童為被試。判定標準為:一是障礙典型經權威專家診斷,符合《美國精神障礙診斷手冊-第五版》等高信度診斷工具中ASD的標準;二是不患有非發(fā)育障礙性神經障礙、重大軀體和神經系統(tǒng)疾病;三是處于邊緣以上智力水平,且具備指令聽從與行為模仿等能力。
集中選取低齡、高功能ASD兒童為被試有助于研究人員直觀考察應用同伴介入法干預ASD兒童社交行為的效果,分析其在不同維度的作用機制。但面對ASD兒童社交行為缺陷所固有的差異性,后續(xù)研究還應綜合選取不同性別、年齡段、障礙程度、安置形式的ASD兒童為被試,充分挖掘同伴介入法應用于不同ASD兒童群體的差異并據此為其匹配干預方案,使每名ASD兒童的社交行為均能得到適切發(fā)展。
3.實驗設計:趨于選用單一被試實驗設計
經統(tǒng)計分析,單一被試實驗設計在國外相關研究中的應用最為廣泛,這與同伴介入法的團體介入模式有關。從多基線的設計類型來看,常采用跨被試多基線設計,通過對彼此獨立的被試在不同階段目標社交行為變化的統(tǒng)計與處理表明干預的效果;而從撤銷的設計類型來看,常采用的則是A—B設計,基線期同伴不對被試采取干預措施,待研究人員觀測到被試目標干預行為趨于穩(wěn)定再告知同伴進入干預期。干預期同伴開始參照方案執(zhí)行干預,研究人員則采取時間取樣的形式考察同伴執(zhí)行干預的效果。在A—B設計的基礎上,還有研究采用了A—B—A—B或A—B—A—B—A設計,通過撤除再介入前后觀測數據的變化表明應用同伴介入法干預ASD兒童社交行為的有效性,并分析了其維持效度。此外,為了驗證研究結果的信效度,研究人員還普遍進行了觀察者一致性、干預忠誠度以及社會效度等檢驗。
單一被試實驗設計雖能直觀反映被試干預前后社交行為的變化,但因樣本容量有限,往往難以保證研究的外部效度。因此,后續(xù)研究可綜合隨機對照實驗設計,通過增加被試數量提高研究結果的推廣價值;也可綜合縱向跟蹤實驗設計,充分把握ASD兒童社交行為發(fā)展的關鍵期及其軌跡,并依此設定同伴介入的周期與強度,使ASD兒童的社交行為得以有序、高效地發(fā)展。
(二)干預實施層面的趨勢及其啟示
1.干預情境:趨于在融合教育情境中開展
隨著融合教育理念的大力推行,越來越多的ASD兒童有機會進入普通學校接受滿足自身發(fā)展需要的融合教育,而這也為同伴介入法的應用創(chuàng)造了條件?,F有研究中,多是以被試所處融合學校的常規(guī)教室、資源教室、操場或餐廳為干預場所,這些具備融合教育含義的場所為被試熟知且較容易排除無關刺激干擾,因而能在滿足ASD兒童對干預環(huán)境所固有的刻板性需求的同時,推動干預順利實施。同時,在設置干預活動時,研究人員也充分考慮了融合教育情境中的要素。例如,在干預活動的內容上,Strasberger等人認為,應綜合考量現有的融合教育資源與被試的參與興趣,增加被試與干預執(zhí)行同伴之間社交互動的機會,提升干預的效度[60];在干預活動的設計上,Kent等人指出,應遵循“低頻高效”的原則,合理設計干預活動的實施途徑,使其在融合教育情境中多維地開展,避免過于頻繁的“刻意設計”影響被試及其干預執(zhí)行同伴常規(guī)的學習生活[61];而在干預活動的強化上,Hansen等人提出,應以融合教育情境中常用的社會性強化為主,通過鼓勵性語言、點頭、豎大拇指、拍手等多種形式的強化,使被試始終處于高能動的狀態(tài)并自然地內化[62]。
多項研究結果顯示,ASD兒童的社交行為缺陷在融合教育情境中更為顯著,由于缺乏維持眼神交流、分享物品、對他人互動作出反饋等社交能力,其更容易在融合教育情境中遭受同伴排斥與社會孤立[63-64]。鑒于此,后續(xù)研究還應持續(xù)關注ASD兒童社交行為在融合教育情境中的發(fā)展,不斷延伸融合教育情境并開展跨情境的實驗研究,助力ASD兒童邁向更為廣闊的社會融合。與此同時,也應在不同的融合教育情境中合理運用同伴介入法,加強ASD兒童與同伴間的社交互動,并通過多元的學習模仿切實提升其在不同社交情境中的社交行為表現。
2.干預執(zhí)行同伴:趨于標準統(tǒng)一、培訓內容精細
從干預執(zhí)行同伴的選取標準來看,相關研究多選取與被試年齡相近且關系密切的同班同學、同住鄰居或同胞兄弟姐妹為干預執(zhí)行同伴,并提出參與要求,如無不良社交行為、社交行為表現與生理年齡相匹配、性格開朗且樂于助人、愿意接受干預培訓以及能保證參與研究全過程。就同伴介入的模式而言,相關研究普遍采用了小團體干預模式,為每名被試匹配2—6名干預執(zhí)行同伴,通過彼此精密的分工協作,共同推進ASD兒童社交行為的發(fā)展。
從干預執(zhí)行同伴的培訓內容來看,早期研究的培訓內容以單一操作為主,后期研究的培訓內容則日趨精細,可概括為三個階段。第一階段旨在了解ASD,誘發(fā)同伴執(zhí)行干預的動機。研究人員會帶領干預執(zhí)行同伴通過《小貓皮特和新伙伴》(Pete the Cat and New Guy)等經典繪本閱讀或兒童工具包(Kit for Kids)等系統(tǒng)課程學習了解ASD的特征,明白ASD兒童并不可怕,他們也需要接受教育,得到關懷,并通過深入思考自己能為ASD兒童提供哪些幫助使其深刻感受自身價值。第二階段旨在走近幫扶的ASD兒童,全面分析其社交行為缺陷。干預執(zhí)行同伴會在研究人員的引導下從第三視角觀察被試的社交行為表現,重點討論其不積極參與同學互動、經常出現不良社交行為的原因,并分析可行的改善措施,以增強干預執(zhí)行同伴對干預過程中突發(fā)狀況的預判與處理能力,使干預實施更為流暢有序。第三階段則旨在學會幫助ASD兒童,有效掌握同伴介入策略。在研究人員的示范講解下,干預執(zhí)行同伴需要掌握干預實施的基本流程與操作,實時關注被試的反應,態(tài)度積極并時刻銘記自己的使命,保證干預實施的信度與效度[65-69]。
同伴介入法能有效避免ASD兒童與成人干預執(zhí)行者之間的年齡代溝以及單向教導所導致的忽略自然社交氛圍等弊端,有助于ASD兒童將從同伴處習得的正向社交行為在現實的同輩社交情境中合理地應用并泛化。然而值得注意的是,高效度同伴介入法的實施過程極為復雜,有賴于同伴足夠的執(zhí)行力及研究人員的精準控制,故后續(xù)研究一是要繼續(xù)細化干預執(zhí)行同伴的培訓方案,并通過增加預實驗的方式考察同伴建立在理論基礎上的實際執(zhí)行能力;二是要進行觀察者一致性檢驗與干預忠誠度檢驗,在充分保證研究信效度的同時,提升干預實施的可操作性與可持續(xù)性。
3.干預方法:趨于整合多種方法發(fā)揮協同效應
在同伴介入法的應用上,多數研究將其與其他干預方法相整合,并發(fā)現有效的整合能產生協同效應。例如,Thiemann-Bourque等人整合了語音生成技術方法(Speech Generating Devices,以下簡稱SGD),發(fā)現同伴利用SGD執(zhí)行干預能提升被試的參與度并激發(fā)其社交動機,為后續(xù)社交行為發(fā)展夯實了基礎[70];McFadden等人則整合了關鍵反應訓練(Pivotal Response Training,以下簡稱PRT),發(fā)現同伴利用PRT執(zhí)行干預生態(tài)化效度較高,能潛移默化地幫助被試建立“出現恰當社交行為—獲取自然行為強化”的作用聯結,使被試的社交行為習得更為穩(wěn)固且更易泛化[71]。除上述直接將同伴介入法應用于ASD兒童社交行為發(fā)展的研究以外,還有部分研究間接地將同伴介入法應用于ASD兒童的社交行為發(fā)展之中。例如,Hansen等人應用同伴介入法干預被試的共同注意,結果發(fā)現,同伴介入帶來的共同注意能力提升能同時作用于被試社交觀察、社交表達等多方面社交行為的改善[72];Corbett等人則應用同伴介入法干預被試的心理理論,結果發(fā)現,同伴介入促進心理理論能力提高并帶動被試社交溝通、社交互惠等方面社交行為的發(fā)展[73]。
綜上所述,面對ASD兒童差異化的社交行為干預,有機整合同伴介入法與其他干預方法更為高效。但在具體實施中,研究人員應全面考察多種干預方法整合是否符合循證實踐標準、不同干預方法在推動ASD兒童社交行為發(fā)展中的作用關系等問題。同時,也可拓寬視域,深入探究整合性干預方法有效性的神經作用機制,從而多維度分析ASD兒童社交行為發(fā)展的可能性因素。
4.干預策略:趨于采取“混合型”策略
依據Odom等人的分類標準,同伴介入策略可分為四種類型:自由互動型、主動發(fā)起型、提示強化型、混合型[74]。其中,自由互動型指讓同伴與被試自由地社交互動,期待其能在與同伴的互動中發(fā)展社交行為;主動發(fā)起型指同伴在干預過程中主動發(fā)起與被試的社交互動,以誘發(fā)其產生社交行為;提示強化型指同伴在干預過程中對被試特定的社交行為進行提示與強化,以推動其有效習得恰當的社交行為;混合型指綜合運用主動發(fā)起型與提示強化型策略。統(tǒng)觀國外相關文獻,研究人員多采取混合型策略,認為主動發(fā)起有助于引發(fā)被試對目標社交行為的關注,而由多到少、由強到弱的提示強化則有助于增進被試對目標社交行為的理解與內化,進而使ASD兒童的社交行為得到全面發(fā)展。
國外應用同伴介入法干預ASD兒童社交行為的研究具有重要的參考價值。在此基礎上,我國研究人員還應立足各要素實際進行更深入的思考。一是基于社交行為缺陷是ASD兒童最初特征的實際,全面關注ASD兒童社交行為的發(fā)展模式與軌跡并積極開展早期干預,使其社交行為缺陷盡早得以補償。二是面對我國隨班就讀工作的實際,持續(xù)探索同伴介入法實施的可行性路徑,以充分發(fā)揮其在推動ASD兒童社交行為發(fā)展中的有效性,并力爭以社交行為的漸進式發(fā)展推動ASD兒童社會融合目標的逐步達成。
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Research on the Trends and Implications of Applying Peer-Mediated Method in Intervening Social Behavior of Children With Autism Spectrum Disorders Abroad
SHA Peng? ?LEI Jianghua
Abstract:In order to explore the research trend of peer-mediated intervention in social behavior of children with autism spectrum disorders abroad, 43 pieces of literature were analyzed. The results show that, at the research design level, the research goals tend to improve the performance ability of autistic childrens social behavior, the research objects tend to select young and high-functioning autistic children, and the research designs tend to choose a single subject experimental design; at the level of intervention implementation, the intervention context tends to be inclusive education context, the intervention implementation partners tend to be selected with unified standards and fine training content, the intervention methods tend to integrate multiple methods to exert synergistic effects, and the intervention strategies tend to be “mixed” strategies. On this basis, follow-up researches in China should pay attention to the development pattern and track of social behavior of children with autism spectrum disorder, then actively carry out early intervention. At the same time, it should continue to explore the feasibility of peer-mediated intervention, and give full play to its effectiveness in promoting the social behavior development of autistic children.
Key words:children with autism spectrum disorders; social behavior intervention; peer-mediated method
Authors:SHA Peng,doctoral candidate,School of Education,Central China Normal University(Wuhan,430079);LEI Jianghua,professor,School of Education,Central China Normal University(corresponding author,huajianglei2003@163.com,Wuhan,430079).
(責任編輯:幸琪琪)