자폐스펙트럼장애 아동을 위한 부모매개 의사소통 증진 프로그램이 부모와 아동의 의사소통 기술에 미치는 영향 = The Effects of a Parent-Mediated Communication Enhancement Program on Communication Skills of Children with Autism Spectrum Disorder and Parents

다국어 초록 (Multilingual Abstract)

Autism Spectrum Disorder（ASD） is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction together with restricted and repetitive patterns of behavior and interests. From early in development, children with ASD exhibit difficulties across the broad domain of social communication, including joint attention, communication initiation and response, and turn-taking, and these characteristics adversely affect language development and overall social adaptation. To support the communicative development of children with ASD effectively, early identification and early intervention during the developmental period—when neuroplasticity is at its peak—are of paramount importance. In particular, the importance of parent-mediated intervention has been continually emphasized, as parents spend the most time with their children and can provide repeated interaction within naturally occurring everyday contexts as the agent of intervention. Existing parent-mediated intervention programs, however, present several limitations. First, many studies have relied on small samples and short intervention periods. Second, with their focus on psychological and emotional components such as emotional support and parenting self-efficacy, studies that intensively measure improvement in children's communication abilities have been relatively scarce. Third, commercialized, single-theory-based programs have often been applied as they are, failing to address a range of communication skills systematically in accordance with developmental stages. Fourth, there has been a shortage of programs that integrate the linguistic characteristics of Korean—a high-context language marked by frequent subject ellipsis, meaning shifts according to particles and endings, and honorifics—and the sociocultural background of Korea, which is characterized by familism, high educational fervor, and achievement-oriented parenting. Accordingly, the present study developed the Parent-Mediated Communication Enhancement Program（P-CEP）, which flexibly integrates the strengths of Applied Behavior Analysis, Naturalistic Developmental Behavioral Intervention, Family-Centered Practice, the Developmental Social-Pragmatic Approach, and Self-Efficacy theory, and aimed to examine its effects on the communication skills of children with ASD and their parents, as well as on parenting self-efficacy. To this end, the following research questions were established. First, what effects does the parent-mediated communication enhancement program have on the communication skills of children with ASD? Second, what effects does the program have on the communication skills of parents? Third, what effects does the program have on parenting self-efficacy? The participants were seven dyads of children with ASD aged 2 to 6 years and their parents, residing in Gwangju and Jeonnam. The children were selected as those who had been diagnosed with ASD or as at risk for ASD by a professional diagnostic institution, or who scored 30 or above on the Korean Childhood Autism Rating Scale, Second Edition（K-CARS-2）; who had begun to show vocal imitation; and who fell within a language age of 6 to 35 months on the Sequenced Language Scale for Infants（SELSI）, thereby representing children at the early language stage. This study adopted a single-group pretest–posttest–maintenance design without a control group. The P-CEP was structured with session order determined according to the communicative developmental stages of children with ASD, and was conducted over a total of 12 sessions, comprising one pretest session, ten intervention sessions, and one maintenance test session. Each intervention session consisted of four procedures—theoretical instruction, explanation of specific intervention strategies, modeling by the interventionist and practice through role-play with feedback, and the assignment of home-based tasks—so that the learned strategies could be generalized within the home. The program incorporated a variety of communication intervention components, including analysis of communicative stages and functions, analysis of the parent's own communication style, reinforcement strategies, eliciting joint attention, interaction and emotional exchange, the use of imitation and gestures, child-led communication and following verbal directions, strategies to facilitate expressive language development, and asking the child questions. In particular, the ＂home visit for mid-program review＂ included in Week 6 constitutes a key distinguishing feature of this study that sets it apart from conventional clinic-based parent education. By directly observing parent–child interaction within the everyday home environment and providing individualized feedback and consultation on environmental arrangement, the home visit sought to moderate parents' burden regarding intervention performance and to enhance the feasibility of real-world application. For the measurement of dependent variables, children's language ability was assessed with the SELSI, and their vocabulary ability with the Korean MacArthur-Bates Communicative Development Inventory（K M-B CDI）. In addition, 15-minute video recordings of naturalistic play situations between children and parents were analyzed to measure total number and proportion of utterances, communication initiation（function/means）, children's communication responses（function/means）, turn-taking, joint attention ability, and the frequency of parents' verbal assistance. Communication initiation and response were coded by partially modifying the criteria of the Korean Communication and Symbolic Behavior Scale Developmental Profile（K-CSBS DP）, and joint attention was measured by dividing it into joint attention precursor skills（looking at the face, joint engagement） and joint attention behaviors（responding, initiating）. Parents' parenting self-efficacy was measured using the Korean Parenting Efficacy Test（K-PET）, assessing the parenting self-efficacy index and the spousal parenting cooperation index along with their subdomains. The collected data were analyzed using SPSS, applying the Wilcoxon signed-rank test to pretest–posttest changes and posttest–maintenance changes, and the effect size r was calculated alongside statistical significance to interpret the magnitude of change. The results were as follows. First, with respect to the communication skills of children with ASD, language ability improved significantly in SELSI overall language and expressive language, and the number of expressive vocabulary words and receptive vocabulary words on the K M-B CDI also increased significantly. Although receptive language and grammar scores were not statistically significant, they showed large effect sizes. Regarding communication skills in the play situation, the total number of utterances and the proportion of child utterances among all utterances were not statistically significant but showed large effect sizes, indicating an increasing tendency; at the individual level, an increase in utterances was observed in six of the seven children. The total frequency of communication initiation was not significant, but the joint attention function among initiation functions showed a large effect size. In communication responses, the providing-information function and the vocalization means increased significantly, and the back-channeling function showed a large effect size. In joint attention ability, joint engagement among precursor skills increased significantly with a very large effect size. Meanwhile, child-initiated turn-taking showed no significant change, suggesting that turn-taking is a later-developing skill that is difficult to change within a short period through parent-mediated intervention alone. At maintenance, the rejection/confirmation response function and the gesture means increased significantly compared with posttest, and a large effect size was confirmed for looking at the face among joint attention precursor skills, indicating that the program's effects may persist in the form of delayed gains even after its conclusion. Second, with respect to parents' communication skills, parents' total number of utterances and the proportion of parent utterances among all utterances showed no statistically significant change; however, the proportion of parent utterances decreased from a pretest median of 91.11% to a posttest median of 83.09%, accompanied by a large effect size, suggesting that parents may have been shifting their interaction style from a directive, parent-led pattern toward a more responsive form that follows the child's lead. Parents' total frequency of communication initiation was not significant in the pretest–posttest comparison but increased significantly in the posttest–maintenance comparison. Among the subtypes of parents' verbal assistance, speech-prompting assistance increased significantly, and this was stably maintained at maintenance, demonstrating that parents continued to use, in everyday life, a verbal scaffolding strategy that helps children participate in communication on their own. Third, with respect to parenting self-efficacy, no statistically significant change appeared in the overall parenting self-efficacy index or in the competence and stability subdomains, although large effect sizes were confirmed for the overall index and stability. By contrast, significant changes were found in the overall spousal parenting cooperation index and in the agreement subdomain. This suggests that the program's effects influenced family-internal parenting interaction—that is, agreement and cooperation between spouses regarding the direction of parenting—earlier than they influenced the individual psychological state of parents. In addition, on the program satisfaction evaluation, all four domains of necessity, effectiveness, composition and content, and feasibility were rated highly, at 4.8 or above out of 5. Analysis of open-ended responses yielded five categories—awareness of the parent's role and influence, enhanced understanding of the child's behavior, acquisition of responsive interaction strategies and attitudinal change, the practicality of the program's composition and delivery, and willingness to continue practicing along with expectations for program dissemination— confirming that parents experienced high satisfaction and shifts in awareness through the program. This study is significant in that, to compensate for the limitations of existing single-theory-based programs, it developed and verified the effects of a parent-mediated communication enhancement program that integrates the strengths of various evidence-based theories and reflects the linguistic characteristics of Korean and the sociocultural background of Korea. Moreover, moving beyond measurement centered on emotional support, it systematically measured the communication skills of children and parents through finely differentiated quantitative and qualitative indices, and, through individualized coaching and immediate feedback provided in the Week 6 mid-program home visit, it enhanced the feasibility of real-world application that clinic-based intervention struggles to support. Although statistical significance could not be secured for some indices owing to the small sample size, large effect sizes were confirmed; this, together with the high satisfaction reported by the parents who participated directly, supports the practical utility of the program in clinical settings. However, given limitations such as the single-group design without a control group, the small sample size, and the incomplete control of concurrent rehabilitation therapy, future research is needed to compare experimental and control groups and to examine the long-term effects and individual differences of the program more precisely.

목차 (Table of Contents)

• I. 서론 1
• A. 연구의 필요성 및 목적 1
• B. 연구문제 7
• C. 용어정의 7
• 1. 자폐스펙트럼장애 7
• 2. 부모매개 의사소통 증진 프로그램 8
• 3. 의사소통 기술 9
• 4. 양육효능감 9
• Ⅱ. 이론적 배경 11
• A. 자폐스펙트럼장애 아동의 발달 특성 11
• 1. 자폐스펙트럼장애 아동의 일반적 특성 11
• 2 자폐스펙트럼장애 아동의 의사소통 특성 14
• a 언어적 의사소통 특성 14
• b 비언어적 의사소통 특성 16
• B. 자폐스펙트럼장애 아동의 조기발견 및 조기개입 20
• C. 자폐스펙트럼장애 아동 부모매개 프로그램에 대한 선행연구 22
• 1. 부모매개 중재 프로그램의 최신 경향 22
• 2. ABA 기반 부모매개 중재 프로그램 23
• 3. NDBI 기반 부모매개 중재 프로그램 24
• a. Early Start Denver Model 25
• b. Project ImPACT 25
• c. JASPER 26
• 4. 발달-관계 기반 부모매개 중재 프로그램 26
• a. DIR/Floortime 27
• b. Responsive Teaching 27
• c. Hanen Centre의 More Than Words 28
• 5. 부모매개 중재 선행연구 분석 및 프로그램 개발을 위한 고려사항 28
• D. 자폐스펙트럼장애 아동의 의사소통 증진을 위한 요소 30
• Ⅲ. 연구방법 34
• A. 연구대상 34
• 1. 선정기준 34
• 2. 연구대상 모집 35
• 3. 연구대상 특성 35
• B. 연구도구 및 프로그램 36
• 1. 부모매개 의사소통 증진 프로그램을 위한 통합적 접근 모형 개발 36
• a. 응용행동분석 38
• b. 자연주의 발달행동중재 39
• c. 가족중심실천 이론 40
• d. 발달적 사회-화용론적 접근 41
• e. 자기효능감 이론 42
• 2. 부모매개 의사소통 증진 프로그램 구성 및 내용 43
• 3. 내용 타당도 47
• 4. 사회적 타당도 47
• C. 연구절차 47
• 1. 선별검사 48
• 2. 사전검사 48
• 3. 프로그램 실시 49
• 4. 사후검사 49
• 5. 유지검사 50
• D. 자료분석 50
• 1. 아동의 언어능력 및 어휘능력 51
• 2. 총발화 수 및 총 발화 비율 51
• 3. 의사소통 개시 52
• 4. 아동의 의사소통 반응 55
• 5. 아동이 시작한 차례주고받기 / 부모가 시작한 차례주고받기 55
• 6. 아동의 공동주의 능력 56
• 7. 부모의 언어적 도움주기 57
• 8. 부모의 양육효능감 58
• E. 통계적 처리 58
• F. 관찰자 간 신뢰도 59
• G. 중재 충실도 60
• Ⅳ. 연구결과 61
• A. 자폐스펙트럼장애 아동의 언어능력과 의사소통 기술 61
• 1. 자폐스펙트럼장애 아동의 언어능력 61
• 2. 자폐스펙트럼장애 아동의 의사소통 기술 62
• a. 아동의 총발화 수 및 전체 발화 중 아동 발화 비율 62
• b. 아동의 의사소통 개시 64
• c. 아동의 의사소통 반응 67
• d. 아동이 시작한 차례주고받기 70
• e. 아동의 공동주의 능력 72
• B. 자폐스펙트럼장애 아동 부모의 의사소통 기술 74
• 1. 자폐스펙트럼장애 아동 부모의 의사소통 기술 74
• a. 부모의 총 발화 수 및 전체 발화 중 부모 발화 비율 74
• b. 부모의 의사소통 개시와 부모가 시작한 차례주고받기 76
• c. 부모의 언어적 도움주기 78
• C. 자폐스펙트럼장애 아동 부모의 양육효능감 80
• D. 프로그램 만족도 81
• Ⅴ. 논의 및 결론 84
• A. 자폐스펙트럼장애 아동의 언어능력 및 의사소통 기술 85
• 1. 자폐스펙트럼장애 아동의 언어능력 85
• 2. 자폐스펙트럼장애 아동의 의사소통 기술 87
• B. 자폐스펙트럼장애 아동 부모의 의사소통 기술 96
• C. 자폐스펙트럼장애 아동 부모의 양육효능감 100
• D. 프로그램 만족도 102
• E. 연구의 제한점 및 제언 104
• 참고문헌 106
• 부록 128