自閉症兒童中文書寫介入方案療效：隨機交叉型試驗

Abstract

書寫技巧對於學齡孩童是一項非常重要的功能性技巧，它與孩童的學業及社交參與是息息相關的。剛入學的孩童常常面對書寫相關的問題且書寫對於自閉症類群障礙症孩童更具挑戰。然而，目前仍沒有針對自閉症兒童中文書寫介入的相關研究。因此，研究者藉由中文書寫的視覺空間特性，設計一套針對自閉症兒童的書寫介入方案，來改善自閉症孩童的中文書寫問題。本研究的目的為驗證此方案的有效性。 本方案設計採用多個書寫介入相關理論如心理幾何理論、動作學習理論和認知訓練理論，以確保有效方案的建立。本方案包含36個活動，納入與書寫習習相關的基礎能力，如視知覺、精細動作及視動整合的訓練，並將中文書寫之特性整合入活動中。本研究為交叉型試驗設計，共招募了20名國小一年級和二年級的自閉症孩童，並且隨機分配到直接治療組和等待控制組。治療方案為期4週，每週2堂，共12小時。所有受試者將會進行三次評估。主要成效評估包含書寫易讀性和書寫速度，次要成效評估包含視知覺、精細動作和視動整合。孩童及照顧者對於方案的滿意度使用本團隊開發之問卷進行調查。在確定治療成效無延續效應(carryover effect)後，治療成效使用成對樣本T檢定進行治療和控制期之比較分析，方案滿意度則會以平均值和標準差來呈現。 研究結果中，本方案於主要成效（整體書寫易讀性、字體大小、部件大小、部件空間及筆畫正確性）以及次要成效（視知覺和手眼協調能力）都在治療期達到顯著更大的進步。然而，在其餘的主要（近端遠端抄寫速度）及次要成效（視動整合和動作協調）則未達到顯著更大的進步。此外，本方案也得到參與者及照顧者的高度評價及滿意度。參與者對方案表達高度接受度和動機，並認為方案對他們是重要且有幫助的；照顧者則對方案高度滿意，並表示願意推薦此方案。 本研究驗證了此方案為有效且照顧者及孩童友善的。此研究的發現提供臨床證據，支持整合中文書寫特性，書寫基礎能力訓練及認知策略，能有效加強自閉症兒童的書寫表現。本研究也提供關於自閉症兒童增進書寫表現的系統性方法，對臨床實踐具有重要意義。

Handwriting is crucial for academic and social engagement in children, but those with Autism Spectrum Disorder (ASD) face additional challenges. Previous studies have explored interventions combining sensorimotor and cognitive approaches for alphabetic handwriting in children with ASD, but there is a lack of programs specifically targeting Chinese handwriting. Chinese handwriting poses unique challenges due to differences from English handwriting and weak central coherence in individuals with ASD. This study aims to evaluate the effectiveness of the "Go Go Handwriting-ASD version" intervention program, which combines the mentioned aspects and focuses on the visual-spatial features of Chinese handwriting to enhance handwriting skills in children with ASD. The intervention program for improving handwriting in children with ASD incorporated psycho-geometric theory, motor learning theory, and cognitive training theories. A total of 36 activities targeting visual perception, fine motor skills, and visual-motor integration were designed to align with the unique properties of the Chinese writing system. The program was delivered over eight sessions within four weeks, totaling 12 hours of intervention. For the study, 20 first and second-grade children with ASD were recruited and randomly assigned to either the sequence A: treatment first or the sequence B: control first in a crossover-designed study. Baseline, assessment 1, and assessment 2 were conducted to evaluate handwriting performance, including legibility and speed, as well as fundamental skills such as visual perception, fine motor skills, and visual-motor integration, using six standardized assessments. Participants’ and caregivers'' acceptance and satisfaction were assessed using a self-developed questionnaire. The effectiveness of the intervention program was analyzed through paired t-tests, comparing the changes during treatment and control phases after the carryover effects were tested. Descriptive statistics were analyzed to present the acceptability and satisfaction levels. The intervention program demonstrated significantly greater improvements in the treatment phase for the primary outcomes (overall handwriting legibility, size of character, radical proportion, radical position, and stroke correctness) as well as secondary outcomes (visual perception and eye-hand coordination) However, there are no significant greater improvements in the remaining primary (near and far copy speed) and secondary outcomes (visual motor integration and manual coordination). In addition, the program received high appraisal and satisfaction from participants and caregivers. Participants expressed high acceptance and motivation for the program, rating it as important and helpful. Caregivers reported high satisfaction and willingness to recommend the program to others. The study indicated the program to be an effective caregiver and child-friendly program. These findings provide valuable clinical evidence supporting the integration of Chinese writing features, handwriting-related fundamental skills training, and cognitive approach to improve the handwriting performance of children with ASD. This study offers an alternative and systematic method to enhance handwriting performance in this population, which has important implications for clinical practice.