社交技巧訓練於改善自閉症類群青少年人際社交困難與校園霸凌涉入之成效

Abstract

背景：自閉症類群障礙是以人際溝通互動困難與侷限固著行為興趣，為核心症狀的發展障礙。雖然近二十年來台灣的早期療育逐步落實，改善了許多自閉症類群障礙兒童的症狀或發展困難，但社會適應及人際交往問題在青少年階段仍常持續存在，甚至惡化或延續至成年。隨著社交互動需求的增加及社交規則的複雜化，自閉症青少年面臨特別困難的時期。過去研究指出，自閉症青少年較其他時期經驗更強烈的孤獨與情緒困擾，缺乏社交網絡，並更易涉入校園霸凌。國內大樣本研究也發現，社交困難是霸凌的中介因子。儘管台灣已有多種青少年社交技巧訓練嘗試，但針對自閉症青少年提供具國際實證基礎的團體社交技巧訓練模式仍然稀缺。因此，亟需引入並本土化具有實證研究基礎的介入模式，以協助自閉症青少年解決在青春期面臨的進階問題 – 社交困難和校園霸凌。美國加州大學 Dr. Elizabeth Laugeson 所發展且經臨床試驗的社交技巧教育及增能方案（Program for the Education and Enrichment of Relational Skills, PEERS®）是一個專為自閉症設計的社交技巧訓練方案，結合了應對霸凌的策略，並已在多國文化背景下證實其有效性。儘管台灣已成功本土化 PEERS® 青年版本，但其青少年版本仍需進行文化適應調整，以確保能有效提升台灣自閉症青少年的社交技巧並減少校園霸凌。

目的：本研究旨在翻譯PEERS® 方案並進行文化調整，接著調查台灣青少年PEERS® 社交技巧訓練的可行性及可接受性，並進一步檢驗台灣青少年PEERS® 方案於提高自閉症青少年社交功能減少校園霸凌的有效性。

方法：首先將 PEERS® 方案進行繁體中文翻譯和台灣文化調整，建立自閉症類群障礙青少年團體社交技巧訓練之本土模式。接著進行台灣青少年PEERS® 社交技巧訓練的隨機分配對照試驗，研究參與者為21位臨床上符合自閉症類群障礙診斷的青少年及其家長隨機分配至立即治療組（10位青少年及其家長）與延遲治療組（11位青少年及其家長），依照台灣青少年PEERS® 方案之介入手冊執行社交技巧訓練。台灣青少年PEERS® 方案之接受度和可行性評估包括記錄青少年及家長出席率、青少年及家長參與滿意度和家庭作業完成率。為評估其提升社交技巧和減少校園霸凌的成效，則於治療前、治療後和4個月後的追蹤階段使用中文版青少年社交技巧知識測驗、中文版社交品質問卷–家長版和中文版校園霸凌經驗問卷進行測試。

結果：PEERS® 方案透過多專業人員組成的專家會議檢驗及參考一般發展的台灣青少年及成人審閱後的回饋建議，成功地進行了繁體中文翻譯和文化適應調整。儘管保留了原始介入手冊的大致結構和整體課程，還是對台灣青少年PEERS® 社交技巧訓練方案的介入手冊進行了些許調整以反映文化差異。參與者的平均出席率相當高，且無人退出。每堂課的平均滿意度指數、整體方案滿意度指數及每堂課回家作業的平均完成率亦高。再者，組別和時間的交互分析顯示，立即治療組在提高社交技巧知識（p < 0.001）和減少人際社交困難（p = 0.001）、社交技巧表現中的同儕衝突（p < 0.001）、總體校園霸凌（p < 0.001）、被霸凌（p < 0.001）及施霸凌（p = 0.012）方面的效果皆顯著優於延遲治療對照組。此外，比較兩組合併資料在治療前、治療後和4個月後的追蹤階段的改變，則顯示在提高社交技巧知識（p < 0.001）和減少人際社交困難（p < 0.001）、社交技巧表現中的同儕衝突（p < 0.001）、總體校園霸凌（p < 0.001）、被霸凌（p < 0.001）及施霸凌（p = 0.007）方面皆持續展現顯著的成效。

結論：高課堂出席率、高參與滿意度和高作業完成率，皆顯示翻譯並本土化修改後的PEERS® 社交技巧訓練對於台灣自閉症青少年是可接受且可行的。研究結果進一步表明，針對台灣自閉症青少年設計的PEERS® 社交技巧訓練，在提升人際社交技巧、改善校園霸凌涉入，以及減少社交困難具有顯著療效。因此，建議有社交困難的青少年 – 尤其是自閉症青少年，可藉由參加PEERS® 社交技巧訓練，改善其社交溝通和互動，從而降低校園霸凌涉入和其他社交困難。

Background: Individuals with autism spectrum disorder (ASD) have difficulties in social communication and social interaction since childhood, which may persist into adolescence or worsen. The increasing social demands and complicated rules faced by autistic adolescents during adolescence often result in more internalizing problems and school bullying. The Program for the Education and Enrichment of Relational Skills (PEERS®), an evidence-based social skills training designed explicitly for autistic individuals, integrates bullying-addressing strategies and has demonstrated effectiveness across cultures. Despite the success of the culturally adapted young adult PEERS® program in Taiwan, its adolescent version requires adaptation to Taiwanese culture.

Objective: The study aimed to establish a culturally adapted adolescent PEERS® program in Taiwan and then investigate the feasibility, acceptability, and effectiveness of the Taiwanese adolescent PEERS® program.

Methods: The PEERS® program was adapted and translated for Taiwanese adolescents. Using a randomized control trial design, the study investigated the acceptability and feasibility of the Taiwanese adolescent PEERS® program. Further, it examined effectiveness in enhancing social function and reducing school bullying among autistic adolescents. Twenty-one autistic adolescents were randomized to a treatment group (TG, n = 10) or a delayed treatment control group (DTG, n = 11). Feasibility and acceptability were assessed by recording attendance, treatment satisfaction, and homework completion. To evaluate its effectiveness in improving social skills and reducing school bullying among autistic adolescents, the Test of Adolescents Social Skills Knowledge, the Quality of Socialization Questionnaire–Parent, and the Chinese version of the School Bullying Experience Questionnaire, were administered to both groups at pre-treatment, post-treatment, and at the 4th-month follow-up.

Results: The PEERS® program was successfully translated and culturally adapted for Taiwanese adolescents, while maintaining the general structure and overall curriculum of the original treatment manual. No dropouts, and high attendance, overall program satisfaction, session satisfaction, and homework completion rates were observed. Group and time interaction analyses further revealed significant results, demonstrating greater magnitudes of improvement in social knowledge (p < 0.001), and reduction in social difficulties (p = 0.001), peer conflicts (p < 0.001), general school bullying (p < 0.001), victimization (p < 0.001), and perpetration (p = 0.012) in the TG compared to the DTG. Comparisons of combined data from two groups at pre-treatment, post-treatment, and four months after treatment showed significant improvement in social knowledge (p < 0.001), and reductions in social difficulties (p < 0.001), peer conflicts (p < 0.001), overall bullying (p < 0.001), victimization (p < 0.001), and perpetration (p = 0.007).

Conclusions: The high attendance, satisfaction, and homework completion demonstrated that the translated and modified program was acceptable and feasible. The findings further suggest that the PEERS® program tailored for Taiwanese adolescents effectively enhancing social skills, decreasing social difficulties, and reducing school bullying among autistic adolescents, with substantial effect sizes. Consequently, participation in the PEERS® program is recommended for adolescents with social difficulties, especially autistic adolescents, to improve their social communication and interactions to offset school bullying and other social problems related to adverse outcomes.