作息本位與早期療育 的概念 -...
TRANSCRIPT
長庚大學早期療育研究所
黃靄雯 副教授
E-mail: [email protected]
國立臺北教育大學藝術館國際會議廳M405
105年7月16日星期六 上午9:00-10:30
作息本位與早期療育(介入)的概念
以家庭為中心-作息本位模式應用研討會
☆指導單位:衛生福利部社會及家庭署
☆主辦單位:中華民國發展遲緩兒童早期療育協會
第一~七章
實踐兒童早期療育/介入的觀點
介入成效或效益觀點
兒童發展過程的可塑性、家庭[照顧者]/專業發展成效
人權/人道觀點
以家庭為中心、兒童/照顧者參與、融合、共融
經濟觀點
兒童及家庭的長遠考量/利用家庭增能節省社會資源
http://depts.washington.edu/chdd/guralnick/pdfs/dev_sys_model_EI_IYC_10_01.pdf
http://files.eric.ed.gov/fulltext/EJ785946.pdf
https://uclinks.ucsd.edu/xmca/attachments/1426/10-CD%20Sameroff%20Unified%20Theory.pdf
Participation-based goal setting and intervention/ implementation
Implementation/ intervention outcome/ evaluation
Professional outcomes
Family outcomes
Child outcomes
Parent/caregive
r/teacher-child
relationship
Family-professional
partnership
Professional participation
Family
(Parents/Caregivers)
Participation
participation
Child participation
Ecomap & RBI
Collaborative consultation
Informal support Quality of life Professional
development/ Virtual team (Hwang, 2016)
早期療育(介入)之變革
由舊有的 “提供各種兒童及家庭服務” 進展至 “增加兒童及家庭參與的機會”。
• 舊有概念,家庭藉由專業服務往往處於被動接受服務之角色,療育目標的訂定
及規劃可能是專業單向提供,主要的療育方式為提各種治療及介入,目標在於
發揮兒童最大潛能(Capacity) ,包括智力、語言、音樂、體育等學科潛能。
近年強調以家庭為中心(Family-centered) 的概念,家庭與專業採協力模式
(Collaborative)模式,專業藉由引導 (Coaching)讓家長主動與專業共同討論並設
定符合生活情境需求之目標。
• 療育的主要方法在於提供參與的 “機會”,主要目的在於讓孩子發展出能力
(Capability),此能力包括參與日常生活、適應度、社會互動及自信 。
早期介入之演進
以家庭為中心的概念 (Family-centeredness)
自然環境 (Natural environments)
融合及嵌入式介入 (Inclusion and embeddedness)
介入模式的需求 (The Need for this Model)
概念模式統整模式實務模式
Mcwilliam, R. A., 譯者:黃靄雯, 康琳茹, & 蘇慧菁. (2015). 作息本位之早期介入:藉由常規支持幼兒及其家庭. 台北: 華騰文化股份有限公司.
McWilliam, R. A. (2014). Future of Early Intervention With Infants and Toddlers for Whom Typical Experiences Are Not Effective. Remedial and Special
Education.
第一章
家庭及專業合作模式之演進
年代 1950-1960s 1960-1970s 1980s 1990s-21st century
模式
諮商/心理治療
模式
(counseling/ps
ychotherapy
model)
家長訓練/家
長參與
(parent
training/involv
ement)
以家庭為中心
(family-centered
model)
協力/增能
(collective/empowerme
nt)
權力/能
力型態
(power)
Power over Power with Power through
決策 專業控制 (exerting control) 合作模式
(collaborating)
協同模式 (synergizing)
參與者 專業與父母 (通常是母親) 父母(通常是母親)
與專業
父母、家庭成員、朋友、
社區居民及專業
溝通模式 難以理解的專業術語、包持專
業與父母間的距離、專業主導
有禮且平等 有啟發性且關懷地動態
溝通
Adapted from: Turnbull et al, 2009;Table 27.1 &Table 27.2
早期介入服務
幼兒 (幼兒發展及生活參與)
照顧者效能及信心 (資訊、情緒、物資)
提供學習機會使幼兒藉由與環境互動來學習
藉由分享資訊、引導、觀察、傾聽、教學、指導、示範、合作諮詢、共同決策等來提供親職支
持及信心
Turnbull, A. P., Summers, J. A., Turnbull, R., Brotherson, M. J., Winton, P., Roberts, R., . . . Stroup-Rentier, V. (2007). Family Supports and Services in Early Intervention: A Bold Vision. Journal of Early Intervention, 29(3), 187-206. doi: 10.1177/105381510702900301 McW lliam, 2010 Dunst, C. J. (2006). Family support program quality and parent , family and child benefits. Winterberry Press Monograph Series. Guralnick, M. J. (2001). A Developmental Systems Model for Early Intervention. Infants & Young Children, 14(2), 1-18.
How?
What?
提供學習機會使幼兒藉由與環境互動
來學習
What?
How?
How?
促進兒童成效的路徑 (The pathways from services to child outcomes)
Engagement
Functional domains
Independence
Social relationship (McWilliams, et al)
(Guralnick, et al)
Employment
Income
Decrease social and health risk
Anderson, L. M., et al
Developmental domains
Anderson, L. M., et al. "The effectiveness of early childhood development programs- A Systematic Review." American Journal
of Preventive Medicine 24(3): 32-46.
Larson, R. W., & Verma, S. (1999). How children and adolescents spend time across the world: Work, play, and
developmental opportunities. Psychological Bulletin, 125, 701-736.
獲得技能以從事勝生產和服務
降低社會成本
https://www.homeworkmarket.com/sites/default/files/q4/29/10/effectiveness-ece.pdf
國際觀點對於早期介入的共識
每個國家國情文化不同,所應用的早期介入服務系統及流程也會不同
10個共同原則 (2008)
A Developmental Framework Informs all Components of the Early Intervention System and Centers on Families
Integration and Coordination at all Levels of the Early Intervention System are Essential
The Inclusion and Participation of Children and Families in Typical Community Programs and Activities are Maximized
Early Detection and Identification Procedures are in Place
Surveillance and Monitoring are an Integral Part of the System
All Parts of the System are Individualized
A Strong Evaluation and Feedback Process is Evident
True Partnerships With Families
Cannot Occur Without Sensitivity to Cultural Differences and an Understanding of Their Developmental Implications
Recommendations to Families and Practices Must be Evidence Based
A Systems Perspective is Maintained, Recognizing Interrelationships Among all Components
Guralnick, M. J. (2008). International Perspectives on Early Intervention : A Search for Common Ground. Journal of Early Intervention, 30, 90-101.
http://depts.washington.edu/chdd/guralnick/pdfs/International_perspectives_on_EI_JEI_2008.pdf
不列服務品項及專業別 不列安置機構 針對需求協調資源 Settings/resources as information choices
PSP/CSP/key worker Needs assessment/RBI/
ICF-linked checklists
Collaborative consultation
不是結案
Joint- consultation
http://depts.washington.edu/chdd/guralnick/pdfs/dev_sys_model_EI_IYC_10_01.pdf
以家庭為中心之介入
◦ 如何實踐~理論到實務(Casto, Mastropieri, 1986)提升成效
◦ 1986年以後的研究又稱為第二世代研究(second-generation research)此時方案之執行著重於
課程(curriculum)的選擇、介入時間的選擇(介入年齡由學齡前降
低至零歲甚至產前)、介入的頻率(frequency)及強度(intensity)
考慮孩童、家庭及親子互動等問題
注重兒童及家庭成效 (Dunst. 2009)
慮隨機抽樣及收集控制組
對研究個案的長期追蹤成效
積極進行成本效益分析、經濟評估 Dunst, C. J., & Trivette, C. M. (2009). Using Research Evidence to Inform and Evaluate Early Childhood Intervention Practices. Topics in Early Childhood
Special Education, 29(1), 40-52. doi: 10.1177/0271121408329227
Guralnick, M. J. (2011). Why Early Intervention Works-A Systems Perspective. Infants & Young Children, 24(1), 6-28.
執行科學 知識轉譯 轉譯研究 2000年後
http://tec.sagepub.com/content/early/2008/12/29/0271
121408329227.short
Page 18
實證顯示-腦性麻痺
證實有效的
– Context-focused therapy: changing the task or the environment (but not the child)
to promote successful task performance.
– Goal-directed training/functional training: task specific practice of child-set goal-
based activities using a motor learning approach to improve self-care
– Home programmes: therapeutic practice of goal-based tasks by the child, led by
the parent and supported by the therapist, in the home environment
建議停止
– Neurodevelopmental therapy (NDT, Bobath): direct, passive handling and guidance
to optimize function, normalized movements, prevent contracture.
– Sensory integration (SI): therapeutic activities to organize sensation from the body
and environment (e.g. hammock swinging) , to facilitate adaptive responses,
Improved sensory organization, improved motor skills.
Novak, I., McIntyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., Stumbles, E., Wilson, S.-A., & Goldsmith, S. (2013). A systematic
review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine & Child Neurology, 55, 885-910.
http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/full
Page 19
實證顯示-神經動作發展障礙及高危險群
Preterm infants seem to benefit most from intervention that aims at mimicking the
intrauterine environment, such as NIDCAP intervention. After term age,
intervention by means of specific or general developmental programmes has a
positive effect on motor development. (Blauw-Hospers, C. H. and M. Hadders-Algra (2005). "A
systematic review of the effects of early intervention on motor development." Developmental Medicne and Child Neurology
47(6): 421-432.)
The data suggest two trends over time: (1) from child-focused to family-
focused orientation; and (2) from professionally directed guidance to
coaching based on equal partnership. (Dirks, T. and M. Hadders-Algra (2011). "The role of the
family in intervention of infants at high risk of cerebral palsy: a systematic analysis." Developmental Medicne and Child
Neurology 53 Suppl 4: 62-67.)
The few studies on early intervention in infants developing CP suggest that
programs that stimulate all aspects of infant development by means of family
coaching are most promising. More research is urgently needed. (Hadders-Algra, M.
(2014). "Early diagnosis and early intervention in cerebral palsy." Frontiers in Neurology 5.)
Page 20
實證顯示-自閉症類群障礙 (Autism spectrum disorder; ASD )
Studies of Lovaas-based approaches and early intensive behavioral
intervention variants and the Early Start Denver Model resulted in some
improvements in cognitive performance, language skills, and adaptive
behavior skills in some young children with ASDs (Warren, Z., et al. (2011). "A Systematic
Review of Early Intensive Intervention for Autism Spectrum Disorders." Pediatrics 127(5): E1303-E1311.)
21
引導家長(coaching of parents) 似乎是較有效的介入方式。
在足月以前的新生兒應著重於減低壓力 (stress reduction),足月
後的嬰兒應著重於刺激整體發展。
資料顯示,提供嬰兒充分的機會利用自發性的動作活動及能力來探
索環境及與環境 (人或物)互動,是達成發展預後 (包括功能性移動)
的良好策略。
利用現有家庭環境中的資源而非著重兒童身體功能損傷的參與本位
介入(Participation-based intervention)試驗正逐步推展。
分析兒童所處的環境/作息/學習機會將是進行新療法之前的評估步
驟。 * Hadders-Algra M. Challenges and limitations in early intervention. Dev. Med. Child Neurol. 2011;53(SUPPL.4):52-55.
Hadders-Algra, M. (2014). "Early diagnosis and early intervention in cerebral palsy." Frontiers in Neurology 5. * Mahoney, G. and F. Perales (2006). The role of parents in early motor intervention. Down Syndrome Research and
Practice 10(2): 67-73.
新的療法尚待驗證
傳統治療缺乏療效可能的原因
單靠治療時段,介入劑量不足 (Dunst, 2005; Odom, 2011)。
介入內容及目標不整合,照顧者疲於奔命 (McWilliam, 2010;黃靄雯 等譯,
2014)。
技巧在不同情境轉移/類化困難 (Brown, 1998;Butler C, et al, 2001) (. However, the RCT
studies showed that the strength gain after 12 weeks of functional progressive resistance exercise strength training did not
improve mobility (Scholtes et al., 2010; Scholtes et al., 2012), and participation (Scholtes et al., 2012). (from chen, 2012)
傳統的介入可能未能鼓勵自發性解決問題的行為 (Hadders-Algra,2011)。
使用過多之正式支持,缺乏非正式支持 (McWilliam, 2010;黃 等譯, 2014)。
評估/時段療育 評估/時段療育
作息的重要性 家庭方面
助於父母適應親職角色,也對自己的親職技巧較有信心(Sprunger,
Boyce, & Gaines, 1985)。
在孩童方面
能增進孩童在行為及動機方面之社會化(Howe, 2002)。
規律作息在幼兒期能協助其順利轉銜進入幼托園所(handler, 1997)、協助發展其獨立性、安全感及信任感(Eastman, 1994; Kase, 1999b; Shimm &
Ballen, 1995)、及幫助衝動及過動的孩子自我控制(Pruitt, 1998)。
減少親子間衝突(Nelsen, Erwin, & Duffy, 1998)、提升親子互動品質(Berg,
1991)。
這些作用之機轉,乃源自於進行作息活動時親子間的互相交流(Transaction)。一旦建立規律作息,父母越容易掌握孩童的行為,也對自己的親職技巧感到滿意。
(Sara et al,2001;Cassidy,1992;Kase,1999;Handler,1997; Dunst, 2001)
時間上的規律性(Temporal Regularity):每天或每周出現,
有明確的開始或結束。這種規律性的重複出現可能受制於生
理時鐘(如飢餓或睡眠週期等)或週期性活動,如上班上學
等。
內在的規律性 (Internal Regularity):指當作息發生時,
家庭成員的互動型態都類似,即重復出現的既定互動型態。
目標導向活動(Goal-directed activity):作息被認為能
反映出家庭成員共同的目標,不同的作息活動乃是為了達到
不同的具體目標,如準備餐點及哄小孩就寢等。為生活上有
意義的情境。
日常作息為基礎 作息的特質
Allocated to Ordinary home visiting group (OHVG) (n=19)
符合條件的家庭 (n=54)
拒絕 (n = 16)
Allocated to Routine-based home visiting group (RHVG) (n=19)
隨機分配 (n=38)
收案
Stage I: Three-month baseline period
分組
Stage II: three-month intervention period
Stage IV: Six-month follow-up period after intervention
基準期
分析 (n=15)
期中評估(n=16)
Stage III: three-month intervention period
基準評估 (n=19)
追蹤 (n=16)
前測 (n=16)
分析 (n=16)
後測 (n=16)
基準評估 (n=19)
Stage I: Three-month baseline period
前測 (n=19)
Case lose -Injection of BOTEX (n =1) - Withdraw (n = 2)
Stage II: three-month intervention period
Case lose -Hospitalization (n =1) -Withdraw (n = 2)
期中評估 (n=16)
Stage III: three-month intervention period
後測 (n=16)
Stage IV: Six-month follow-up period after intervention
One case died from complications (n = 1) 追蹤 (n=15)
社經地位5等 × 矯正年齡(>18及≦18個月) ×礙嚴重度(發展商數>50及≦50)
介入期
追蹤期
基準期、實驗介入前、中、後、追蹤期之PEDI-C & CDIIT之各領域發展程度
作息本位訪談 依據發展測驗級卡羅萊納課程了解幼兒發展
介入者觀察找顧者與兒童互動,並與照顧者共同討論後,選擇欲設計目標
介入者教導照顧者並挑選目標
以GAS及COPM設定活動目標
將執行的流程填入「日常作息執行表」,並將活動目標填入「活動目標進度表」
將目標填入「活動目標進度表」
請照顧者每日協助嬰幼兒配合「日常作息執行表」執行,並將嬰幼兒活動目標達成狀況紀錄在「活動目標進度裡」
請照顧者於生活中協助嬰幼兒執行活動目標,並將嬰幼兒目標達成狀況紀錄在「活動目標進度表」裡
28
作息本位到宅介入 傳統到宅介入
計算比率改變指標 (Proportional Change Index; PCI) (Hauser-Cram &Krauss,1991;Wolery,1983)
29
U一般發展
U發展遲緩,有效介入
發展遲緩,無效介入
能力分數
年齡
作息本位介入模式來自於四個主要概念的實證執業及理論
以家庭為中心之實務 (Family-centered)
家庭系統及生態理論 (Family System and Ecological Theories)
跨專業服務輸送 (Transdisciplinary Service Delivery)
家庭訪視的複雜性 (Complexity of Home Visits)
理解不同型態的家庭
作息本位模式之緣起
Mcwilliam, R. A., 譯者:黃靄雯, 康琳茹, & 蘇慧菁. (2015). 作息本位之早期介入:藉由常規支持幼兒及其家庭. 台北: 華騰文化股份有限公司.
McWilliam, R. A. (2014). Future of Early Intervention With Infants and Toddlers for Whom Typical Experiences Are Not Effective. Remedial and Special
Education.
序
作息本位模式
以家庭為中心
三種支
持
有意義
的決策
機會
滿足家
庭需求
功能性
在作息
之中
由照顧
者執行
介入
http://robinmcwilliam3.wix.com/ram-group#!calendar/c1015
McWilliam, R. A. (2011).
早期介入設計來協助兒童生活中的成人,不是兒童
Early intervention was designed to assist the adults in a
child’s life, not the child.
若早期介入者支持照顧兒童的成人,兒童會得到越多重要的幫助
Children will actually receive more and more relevant
help if interventionists support the adults.
McWilliam, R. A. (2011). The Top 10 Mistakes in Early Intervention in Natural
Environments--And the Solutions. Zero to Three, 31, 11-16.
早期介入的對象是兒童及其家庭
早期介入服務提供者的服務對象
是家庭/家長/照顧者,不是兒童
兒童才是家庭/家長/照顧者的介入對象
“服務(service)” 和 “介入(intervention)”
不一樣喔!
成分 實務執行
了解家庭生態 生態圖 (Ecomap) 第四章
評估需求及擬定介入計畫的(功能性、以家庭為中心)
作息本位晤談(Routines-Based Interview; RBI)、參與本位目標
(participation-based outcomes)
見第六章
整合服務流程 主要服務提供者(primary service provider; PSP)
第八章及第九章
支持本位的到宅訪視
(Support-based home visits)
家庭諮詢 (Family consultation + 3 種支持supports (情緒、資訊、物質)
第十章
兒童照護合作諮詢
(Collaborative consultation to child care)
兒童照顧諮詢的整合式服務 (Integrated therapy) +教練模式 (coaching)
第十一章
Mcwilliam RA, 原著, 黃靄雯, 康琳茹, 蘇慧菁 譯. 作息本位之早期介入:藉由常規支持幼兒及其家庭. 台北: 華騰文化股份有限公司;
2014.
Retrieved from: http://robinmcwilliam3.wix.com/ram-group#!content1/co5k
作息本位模式成分
作息本位模式成分
息本位介入模式台灣作息本位晤談種子教師小營隊(Taiwan RBI Mini Boot Camp)
McWilliam 示範: http://www.mcwilliamconsulting.com/
正式支持 (Formal support)
居間支持
(Intermediate support)
居間支持
(Intermediate support)
非正式支持 (Informal support)
第四章