1. まとめトップ

この記事は私がまとめました

平成29年7月24日に厚生労働省により児童発達支援ガイドラインが全国の自治体と医療機関に送付されたことを受けて、医療機関主導によるABA・TEACCHの手法による発達障害の療育プログラムの導入が始まる。対象となるのは各地の自治体により児童福祉法に基づく児童発達支援事業の指定を受けた社会福祉法人等の療育事業者だ。発達障害の改善については確立した治療法はないものの、カナダやアメリカではABAやTEACCH・PECSといわれる指導法・療育技法が国単位・地方の行政主体単位で広く普及しており、その効果は非常に高いとされている。これを受けて、厚生労働省では児童発達支援ガイドラインでは「児童発達支援の内容」の項目における「認知・行動」の区分の設定及び「構造化した環境の中で、生き生きと活動できる場となるように配慮」との文言で、ABA及びTEACCH・PECSの指導法・療育技法について示唆していた。従来の発達障害児童の発達支援では保育や一時預かりの水準に留まるものも多く、その療育成果については各領域の専門家からも疑問が呈されていたことに答えた形だ。
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000117218.html
http://www.worldnewsvalue197361.conglomerate.ro.im

発達障害者支援体制整備
 都道府県・指定都市において、発達障害者やその家族に対して,各ライフステージに対応する一貫した支援を行うため、保健所、保育所などの支援関係機関のネットワークを構築するとともに,ペアレントメンター(※1)の養成とその活動を調整する人の配置,アセスメントツール(※2)の導入を促進する研修会などの実施、家族対応力の向上を支援するペアレントトレーニング(※3)や当事者の適応力向上を支援するソーシャル・スキル・トレーニング(SST)(※4)の普及を推進しています。また,地域における発達障害児者の支援体制と社会参加を促す観点から,市町村や事業所への支援,医療機関との連携※5や困難ケースへの対応などを行う発達障害者地域支援マネジャーを発達障害者支援センターなどに配置することにより、地域支援機能の強化を図っています。
※1 ペアレントメンター: 発達障害者の子供を持つ親であって,その経験を活かし,子供が発達障害の診断を受けて間もない親などに対して助言を行う者。
※2 アセスメントツール: 発達障害を早期発見し,その後の経過を評価するための確認ツール。
※3 ペアレントトレーニング: 発達障害者の親が自分の子どもの行動を理解したり、発達障害の特性をふまえた褒め方やしかり方を学ぶための支援。
※4 ソーシャル・スキル・トレーニング(SST):発達障害者が集団生活を送る上で必要なノウハウを身につけるための支援
※5 医療機関との連携

ABAとは

Applied Behavior Analysis (ABA)
This is one of the most widely accepted therapies for children with autism spectrum disorder. ABA training is most effective if therapy begins when children are younger than age 5, although older children with ASD can also benefit.
ABA helps teach social, motor, and verbal behaviors, as well as reasoning skills, and works to manage challenging behavior. It’s based on teaching these skills through observation and positive reinforcement.
To get the most benefit from applied behavior analysis, your child will need extensive one-on-one therapy for 20 to 40 hours each week. A drawback is that this type of intensive therapy is expensive.ABA training is also most effective if you get training in it yourself. That way, you can teach your child and constantly reinforce positive behaviors. However, using it is very time-consuming and takes a lot of skill to get right.
But it will help your child generalize the skills he’s learned. It also will help lower the likelihood that your child will engage in unhealthy or negative behaviors.

WebMed
https://www.webmd.com/brain/autism/autism-therapies-aba-rdi-and-sensory-therapies#1

ABAの歴史

History of ABA
Dr. Ivar Lovaas, a behavioral psychologist, first applied ABA to autism at the Psychology Department at UCLA in 1987. He believed that social and behavioral skills could be taught, even to profoundly autistic children, through the ABA method. The idea was (and is) that autism is a set of behavioral symptoms which can be modified or "extinguished." When autistic behaviors are no longer evident to the observer, the assumption is that the autism itself has been effectively treated.
When he first began using ABA, Lovaas had no hesitation about employing punishments for non-compliance, some of which could be very harsh. This approach has been modified in most situations, but it is still in use in some settings.
In general, however, "punishment" has been replaced by "withholding of rewards." For example, a child who does not properly respond to a "mand" (command) will not receive a reward (reinforcer) such as a favorite food.

Whatever one's opinion about Lovaas's approach (and many people feel that ABA is both dehumanizing and inhumane), his idea turned out to be quite correct: many if not most children who receive intensive ABA training learn to behave appropriately at least some of the time -- and some even lose their autism diagnosis after years of intensive therapy.
Whether learning appropriate behavior is the same thing as "being cured" is, of course, a debatable question.
Over time, Lovaas's techniques have been studied and modified by therapists with slightly different visions of behaviorism. Techniques such as "pivotal response" and "language-based ABA" have become well-established autism treatments in their own right.

ABAの基礎概念:罰と弱化

https://psych.or.jp/publication/world080/pw03/
スキナーが創始した行動分析学が扱う「罰」(punishment)は全くそれらとは異なり,近年では,強化と対称的なものであるという本来の意味に近くなるように「弱化」という訳語があてられています。今回の特集は「罰」ですが,本稿ではこれ以降「弱化」という用語を使います。行動分析学で用いられる弱化は,反応と結果との関係(行動随伴性)を表しています。まず,行動分析学における一般的な定義を示しましょう。「行動の直後の環境変化によって将来的なその行動の生起頻度が下がる」(Skinner, 1953;Azrin & Holz,1966)というものです。例えば,動物実験でよく用いられる場面であれば,ラットがレバーを押すと床から電気ショックが呈示されることで,レバー押しの頻度が下がること,日常場面では,友人に正直に意見をしたら反論されてその人との信頼関係を失ってしまい,正直に発言できなく(しなく)なったりすること,などが挙げられます。ある行動をした結果として何かが生じたり増えたりすることでその行動の生起頻度が下がることを正の弱化,何かがなくなったり減ったりすることでその行動の生起頻度が下がることを負の弱化と呼び,レバー押しの例は正の弱化,正直に意見する例は負の弱化に相当します。そして,何かが生じることで生起頻度が下がるとき,その何かを嫌子(負の強化子または正の弱化子),逆に何かがなくなることで生起頻度が下がるとき,その何かを好子(正の強化子または負の弱化子)と呼びます。いずれも自発した行動の結果によってその行動が起こりにくくなっています。

TEACCHとは

Structured Teaching--The TEACCH Method:
Structured teaching via the TEACCH method was developed by Professor Eric Schopler and many of his colleagues at the University of North Carolina at Chapel Hill. The TEACCH method is not considered an actual therapy but rather a therapeutic tool to help autistic individuals understand their surroundings.
Autistic individuals often have difficulty with receptive and expressive language, sequential memory, and handling changes in their environment. The TEACCH method provides the individual with structure and organization. This method relies on five basic principles; a brief description of each is provided below.
Physical structure
Physical structure refers to the actual layout or surroundings of a person's environment, such as a classroom, home, or group home. The physical boundaries are clearly defined and usually include activities like: work, play, snack, music, and transitioning.
Scheduling
A schedule or planner is set up which indicates what the person is supposed to do and when it is supposed to happen. The person's entire day, week, and possibly month, are clearly shown to the person through words, photographs, drawings, or whatever medium is easiest for the person to comprehend.
Work system
The work system tells the person what is expected of him/her during an activity, how much is supposed to be accomplished, and what happens after the activity is completed. The goal is to teach the person to work independently. The work system is also organized in such a way that the person has little or no difficulty figuring out what to do. For example, the activity or task should be performed from top to bottom and from left to right.
Routine

According to the TEACCH method, the most functional skill for autistic individuals is a routine which involves checking one's schedule and following the established work system. This routine can then be used throughout the person's lifetime and in multiple situations.
Visual structure
Visual structure refers to visually-based cues regarding organization, clarification, and instructions to assist the person in understanding what is expected of him/her. For example, a visual structure may involve using colored containers to assist the person in sorting colored materials into various groups or displaying an example of a stamped envelope when the person is asked to place stamps on envelopes.
The TEACCH method is primarily used to assist the autistic individual in better understanding his/her environment. The techniques described above are not faded out over time; but rather, they are to be consistently used across a variety of environments.

Autism.com
https://www.autism.com/treating_TEACCH

児童発達支援の療育事業者がこの療育プログラムを導入するには、児童福祉法に基づく児童発達支援事業の指定を受けていることに加えて、児童指導員や保育士等の有資格者のうち、ABAやTEACCHに関する一定の研修を修了した修了者や資格者を配置する等の一定の要件を満たす必要がある。従来の発達障害療育ではその有効性を客観的に図る機会が充分に確保されていなかったが、新しい療育プログラムではその療育の成果の測定は、SRS-2・MEPA-R・ECBI等といわれる国際的に標準化された評価尺度によって測定され、医師・臨床心理技術者といった専門家によってフィードバックが蓄積される仕組みとなっている。
http://autismnews69701.conglomerate.ro.im/

自閉症児に対するABA行動分析的介入の成果

[Behavioral intervention for preschool children with autism – outcome of parent-based Intervention].
https://www.ncbi.nlm.nih.gov/pubmed/28523969
Objective:
Early intensive behavioral intervention (EIBI) has proved to be an effective intervention for children with autism spectrum disorder (ASD). In this exploratory study, we evaluated the effects of a community-based service model with parents as active therapists.
Method:
13 children with ASD between 2 and 5 years of age at intake participated in the study. A waiting-list control design was employed. The children received 1 year of home-based EIBI for approximately 20 hours a week, their parents functioning as primary therapists. The waiting-list control group consisted of seven children who were tested 6 months before the intervention commenced. The intervention was based on the University of California at Los Angeles Young Autism Project model (UCLA YAP; Lovaas, 1981, 1987, 2003). The Psychoeducational Profile (3rd ed., PEP-3), the Parenting Stress Index (PSI), and the Childhood Autism Rating Scale (2nd ed., CARS 2) were used to measure outcome. In addition, a mental developmental index (MDI) was calculated on the basis of the Cognitive Verbal/Preverbal subscale of the PEP-3.
Results:
After 1 year of EIBI, we found a significant increase in the PEP-3 scores and MDI scores as well as a significant reduction in the CARS 2 scores. No significant changes were seen when participants were on the waiting list. The stress level of the parents did not change significantly and in fact showed overall a slight decrease.
Conclusion:
This model of providing EIBI appears to hold some promise. Comprehensive parental involvement did not affect their stress level. The study need to be replicated with a larger sample and an improved design.
KEYWORDS:
ABA; Early Intensive Behavioral Intervention; autism spectrum disorder; behavioral intervention; early intensive behavioral intervention; early intervention

(医学監修)
九州ベテルクリニック福岡精神科発達障害専門外来(才能外来)
http://asd.bethel.clinic
https://bethelclinic.wixsite.com/aspergeradhd

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