即興音樂治療應用於自閉症類群障礙症兒童之個案研究

本研究主要目的在應用即興音樂治療於自閉症類群障礙症兒童，透過即興音樂治療歷程記錄，探討自閉症類群障礙症兒童的溝通動機與口語表達的改變情形。本研究採個案研究設計，以目的取樣，於南部某早療機構招募3~6歲兒童參與本研究；選入標準為經醫療機構確診為自閉症類群障礙症，且主要表現為低口語或無口語表達者，排除標準則為視覺或聽覺障礙、共病其他精神疾病(如：焦慮症)者、兒童之監護人不同意或無法配合進行本研究者，總計三名兒童參與本研究。即興音樂治療採用旋律型樂器、節奏型樂器及音效型樂器，並輔以音效型繪本，每週進行2次，每次30分鐘，執行期間為八週。資料收集方法包括治療過程影音紀錄及兒童之主要照顧者之訪談紀錄，並輔以標準化測驗工具「自閉症類群障礙檢核表(華文版)」(Checklist for Autism Spectrum Disorder-Chinese Version, CASD-C, 2017)及行為觀察記錄表，作為兒童臨床行為表現之評估。進行治療前先與兒童之家長進行告知同意並簽署參與研究同意書後，與兒童之家長及教師進行訪談記錄，以了解兒童在家庭與學校中的行為表現，並以自閉症類群障礙檢核表(CASD-C)評估個案障礙情形，研究過程以錄影器材及觀察記錄表為觀察紀錄工具。所得影音資料謄錄為文本，綜合訪談紀錄、CASD-C、觀察紀錄表，依治療歷程的階段性，探討兒童之音樂表現、臨床行為表現、口語或非口語表達、以及與研究者互動的轉變歷程脈絡，並從多方面的資料來源與研究者的反思的多方探討下，建立本研究的信實性。 研究結果顯示如下：一、 音樂治療的介入使個案藉由與音樂的連結，增加與他人及環境的情緒反應與感知，並進而能較快速地建立治療關係，以利活動的進行。二、 以半結構式的三階段方式進行即興音樂治療，對於異質性高的自閉症類群障礙症兒童而言，是合適且具彈性的活動方式。三、 以個案研究的方式進行，是對於自閉症類群障礙症兒童最適宜的研究方式，藉由個別的臨床實作觀察與紀錄，可深入分析個案在音樂或行為等方面的表現與反應。四、 藉由即興音樂治療，得以促進ASD兒童社會互動能力發展。個案在音樂治療活動中，除了音樂的表現也能藉由使用樂器或其他非語言的方式與他人溝通與互動。五、 藉由即興音樂治療，得以啟動低口語的ASD兒童語言能力發展。三位個案在活動療程終期，在口語方面提高了表達的意願。六、 三位個案的療程次數不同，由成效結果來看，療程次數的確會有影響，雖然一些國外的文獻提到短時間的治療就能達到效果，但是，由本研究結果來看，個案需要更多次療程的音樂刺激，來持續引導口語及非口語的使用，進而增加社會溝通與互動。 依據研究結果顯示，即興音樂治療對於促發自閉症類群障礙症兒童的溝通動機與口語表達行為反應有正面的影響。在進行即興音樂治療之後，家長與老師表示，可以感受到個案在與人的互動中有明顯的正向改變，因此，個案與同儕間逐漸可以發展良好的社交互動能力，發展出合宜社會行為、更能融入團體生活中，且將所學類化至家中。希望此類個別化設計的課程可以實際更廣泛運用在早療特殊教育上，讓兒童在學齡前得以在歡樂的氣氛中，逐漸建立與外界的連結，才有機會學習互動。 在此研究中，研究者的研究出發點是觀察自閉症類群障礙症兒童的臨床表現與歷程為主，以即興音樂治療模式為介入，研究者非使用單一的即興音樂治療模式，而是綜合使用即興音樂治療模式，採用三階段的半結構性形式，以及使用了即興音樂治療中的臨床音樂技巧，可算是一個前瞻性的綜合使用，自閉症類群障礙症的早期療育被證實有效，目前較常被使用的治療方式為行為治療（如：ABA行為改變技術、遊戲治療、TEEACH團體治療），治療目標多以提升生活適應功能為主，但是，自閉症為神經功能缺損的障礙這個事實並不會被改變，其神經缺損的部位同時也可能影響認知與語言的功能，雖然即興音樂治療被證實對於改善自閉症類群障礙症的核心障礙是有用的，但在臨床心理治療上較少有人使用音樂治療的方式，主要是因為使用音樂治療需要專業的音樂基本能力，並瞭解音樂元素與熟練的音樂技巧，本研究期望可以提供國內臨床心理師在自閉症兒童的心理治療領域一些臨床實作上的參考。

This study is an application of improvisational music therapy for children with autism spectrum disorder, to discuss the transform of the children's communication motivation and oral expression.This study is designed as a case study. To purposeful sampling, the participants are 3~6 years olds children from early treatment institution in south Taiwan. The selection criteria are that the participants are confirmed as autism spectrum disorder by medical institutions and with limited oral verbal abilities. Children with visual impairment, hearing impairment, comorbidity other mental illness (such as anxiety disorder), without the permission of guardians, or those who can't cooperate with this study are excluded. There are three children participated in this study. Improvisational music therapy uses melody instruments, rhythm instruments, and sound-effect instrument and with the assistant of sound-effect picture books. The therapy implement for eight weeks, twice a week, and 30 minutes for each time. The data are collected by audio records of therapy process and interview records with the children's primary caregivers; analyzed by Checklist for Autism Spectrum Disorder-Chinese Version, CASD-C, 2017 and behavior observation record form to evaluate children's clinical behavior.With the permission and research consent of guardians, the researcher interviewed the children's parents and teachers to understand the children's behavior at home and school and evaluated by CASD-C. The research process used video equipment and observation record form as observation record tool. The video information transcript as comprehensive interview record, CASD-C, and observation record sheet. According to the therapy process, discuss children's music performance, clinical behavior performance, oral or non-oral expression, the transformation process with researcher and discuss from various information resource and reflections of researchers to establish the reliability of this research.The findings from this study show that:1. The intervention of musical therapy connects the participants with music, improves his/her emotional response with other people and the environments, establishes the therapy relationship quickly and benefits the process of activities.2. With Semi-structure three-stage approach to conduct improvisational music therapy is a suitable and flexible activity for high heterogeneity ASD children.3. Case study is the most suitable research method for ASD children. By individual observation and records of clinical practice, to in-depth analysis the participants' performance or reaction in music or behavior.4. By the use of improvisational music therapy to promote ASD children's social interact ability. The participants can not only the performance of music, but also use instruments or others nonverbal ways to communicate and interact with other people during the music therapy.5. By the use of improvisational music therapy, activate ASD children's (with limited oral verbal abilities) language ability development. The three participants increase their willing to express in oral at the end of the therapy implement.6. The three participants have different sessions of treatment. The results of this study show the effect of the numbers of treatment. Although some foreign literature mentions short time treatment can achieve the effect. However, by the results of this study, the participants need more musical stimulate from the treatment to continue guide the use of oral and non-oral to increase social communication and interaction.According to the results of the study, improvisational music therapy has positive effects on ASD children's communicate motivation and oral expression. After improvisational music therapy, parents and teachers indicate that they feel the participants have obvious positive change when interact with other people. Therefore, participants and peers can gradually develop good social interact ability, suitable social behavior, better incorporate into group life, and extend to home. The researcher hopes this kind of individual designed class can actual use in early treatment special education widely. Let preschool children establish the connection with outside world gradually in cheerful atmosphere to have the chance to learn to interact.In this research, the researcher observes ASD children's clinical manifestations and process, and intervenes improvisational music therapy. The researcher did not use single improvisational music therapy, but complex improvisational music therapy: with Semi-structure three-stage approach, and clinical music skills in improvisational music therapy, which is a forward-looking complex use. Early treatment is proved effective for ASD. Behavior therapy (such as ABA behavior change technology, play therapy, and TEEACH group therapy) are often used, the goal of the therapy is to promote life adoption function. However, the fact that ASD is neurological deficit will not be changed. The neurological deficit part may effect cognitive and function. Although improvisational music therapy is proved effective for improve ASD children's main obstacles, music therapy is less used in clinical psychotherapy. The main reason is that use music therapy need professional music ability, understand music element and proficient music skills. This research expects to provide clinical psychologist some reference for ASD children's psychotherapy in clinical practice.