第五章 討論
第四節 研究貢獻、限制與未來建議
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意圖溝通技能相較而言已發展的較為成熟，不過僅有共享式注意力可顯著預測社 交情感症狀發展軌跡之分群，顯示該能力的發展對於日後社交情感症狀的變化有 重要之影響力。而兩組 ASDs 兒童在早期參與治療的經驗並無明顯差異，且接受 治療的時數多寡無法預測日後社交情感症狀發展軌跡之分群。關於早期療育經驗 對於症狀發展軌跡的影響力，仍為臨床實務所關注的重要議題，在本研究及目前 已發表的研究中（Darrou et al., 2010; Landa & Kalb, 2012），僅以參與在治療的時 數多寡做為分析之變項，然而，參與治療的時數是否真的可以反映出治療的效果？
治療強度愈高則兒童進步愈多的想法，似乎暗示著治療時數與療效之間呈現線性 的關係，但似乎此相關性並未如此直觀。
第四節 研究貢獻、限制與未來建議
本研究為台灣目前第一篇探討ASDs兒童於自閉性症狀發展軌跡之追蹤研究，
追蹤時間長達六年，橫跨幼兒期至學齡期，且有三個時間點的收案資料，可幫助 研究者瞭解台灣地區ASDs兒童的發展趨勢。近期研究開始以實證研究的方式回 應ASDs兒童發展軌跡異質性的議題，由本研究結果亦可看見ASDs兒童在自閉症 狀發展軌跡的異質性，且除了比較先前研究探討在認知功能、適應行為、療育經 驗上的差異，本研究也納入了與ASDs兒童之病理缺損更相關之指標－早期社會 溝通能力來做分析討論，在本研究結果也發現共享式注意力對於日後自閉症狀發 展軌跡的影響性，可供臨床介入者思考治療方案。另外，目前研究以ADOS的CSS 計分系統探討自閉症狀時，僅使用整體症狀做為測量症狀嚴重度的指標，本研究 更進一步納入兩核心症狀：社交情感與侷限重覆行為症狀做為測量指標，可發現 不同核心症狀隨時間有不同的發展軌跡。而在本研究也發現，相較於整體症狀之 發展軌跡，社交情感症狀之發展軌跡更可區辨ASDs與非ASDs兒童，建議可持續 瞭解何者在判別ASDs診斷上有較佳之區辨效度，幫助後續進行臨床診斷判別時 有更具效度的指標。最後，本研究發現ASDs兒童進入學齡期時，在自閉症狀有
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明顯上升，更顯嚴重，特別是在社交情感領域，這樣的症狀變化趨勢值得臨床實 務介入進一步思考學齡後ASDs兒童所面臨的困境及所需之協助。
關於ASDs患者在症狀發展軌跡的議題，目前研究多以診斷工具的分數做為 症狀嚴重度高低的指標，以長期追蹤測量的分數變化做為症狀嚴重度的變化。不 過即便是近期發展的ADOS-CSS計分系統，已嘗試將依據不同語言發展能力的模 組一至模組三進行整合與校正、並將不同年齡層對應至不同常模，在測量上可能 仍有其限制存在，像是僅以三個模組是否能完整地捕捉ASDs患者在各個發展階 段因自閉缺陷所呈現的行為症狀？如以本研究樣本年齡層為例，在T2和T3時皆 有受試者以模組三受測，不過T3為受試者進入小學的階段，應會面對不同的環境 與發展議題，或許以同樣的模組及題項來量測，難以完整地捕捉到該階段會呈現 出的行為症狀。關於如何更精確地定義與描述ASDs患者隨年齡增長而呈現的自 閉症狀發展軌跡，應是我們未來持續需思考的問題。
在研究限制上，相較於國際上的大樣本研究，本研究參與的受試者較少，可 能使得所呈現出的症狀軌跡分群現象較不穩定，亦無法排除受限於樣本人數小，
因此不同症狀發展軌跡之ASDs兒童於認知功能與適應行為之表現未達統計顯著 差異。另外，本研究樣本，不論是ASDs兒童或發展遲緩兒童，參與在治療課程 的密集度低，以及在設計資料蒐集時，僅有蒐集接受治療的時數，未能瞭解治療 的課程內容及品質，也未有考慮兒童在治療過程中的投入程度，然而治療的品質 與兒童投入在治療過程中的程度，可能更是影響療效之重要因子。建議未來研究 若欲探討早期療育經驗與預後之間的關聯時，除了量的資訊外，亦需納入質的資 訊一併討論。
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