坐立不安：一名特殊教育需求學生的案例研究

亨利·博索萊伊

坐立不安：一名特殊教育需求學生的案例研究
A Case Study on a Student with Special Educational Needs
原文發佈於大清帝國論壇《【嘉七恩科會試】坐立不安：一名特殊教育需求學生的案例研究》

Through the rise of inclusive education in both primary and secondary schools, students with special educational needs (SEN) have been considered a challenge for teachers and conventional teaching methodologies. As future teachers, we may also feel disturbing and difficult to deal with students with SEN and their learning styles, but it is our responsibility to help them fit into society, achieve their full potential and to ensure that they are provided with the possible opportunities to learn in equity. To further develop skills in providing a helping hand to students with special educational needs, this essay will introduce an actual case of special educational needs, while at the same time exploring and evaluating multiple methods to feasibly help the student in the described case from a teacher’s point of view.

Case Background

In the YouTube video (Now News, 2019), an 11-year-old child named Carson is the protagonist of a story in the television programme. The video is presented in interviews with Carson, his mother and his triathlon coach on his behaviour and symptoms, and also included excerpts of observations of him doing homework at home and participating in the triathlon class. It can be seen from the video that Carson would suddenly start drawing while originally doing revision exercises. He also told the reporter that he would feel uncomfortable and have difficulty sitting still for a long period of time and, therefore, has to leave the seat, stand up or go to the toilet immediately to make himself feel better. He also would leave his seat during lessons at school. From his mother’s account, Carson could be easily triggered and had previously physically attacked his classmates during conflicts. She claims that Carson’s mouth would go faster than his brain and that he is talkative and uncontrollable when getting along with others.

On the other hand, however, Carson does have strengths that may cancel out his weaknesses. His mother mentioned in the interview that Carson would be happy staying along with his friends, and would sometimes feel too energetic and excited when acquainted with them. She also mentioned that he does not compare himself with others and is able to learn and improve from the mistakes he made. From the observation throughout the video, he also has an optimistic personality and is passionate and vibrant most of the time. He is, moreover, interested in doing sports, especially cycling, and has participated in triathlon classes and competitions.
 
Cause Analysis

The aforementioned symptoms exhibited by Carson can be concluded as inattention, hyperactivity and impulsivity. This indicated and affirmed the idea that he is highly possible to be suffering from attention deficit hyperactivity disorder (ADHD), As shown in Table 1 (American Psychiatric Association, 2013), Carson’s symptoms are fulfilling six of the DSM-5 criteria for the disorder, which meets the standard for him to be confirmed as an ADHD patient. Carson’s symptoms could further be classified as the predominantly hyperactive-impulsive subtype of ADHD (ADHD-PH/I), as he is more of a hyperkinetic person and exhibits more characteristics of the ADHD-PH/I subtype.

Table 1
Fulfilled symptoms of Carson under the DSM-5 classification of ADHD-PH/I

Symptoms	Fulfilled
1. Often fidgets with or taps hands or feet or squirms in seat.	✓
2. Often leaves seat in situations when remaining seated is expected.	✓
3. Often runs about or climbs in situations where it is inappropriate.	✓
4. Often unable to play or engage in leisure activities quietly.	✓
5. Is often “on the go,” acting as if “driven by a motor”.	✓
6. Often talks excessively.	✓
7. Often blurts out an answer before a question has been completed.	✗
8. Often has difficulty waiting for his or her turn.	✗
9. Often interrupts or intrudes on others.	✗

Note: From “Diagnostic and Statistical Manual of Mental Disorders: DSM-5,” by American Psychiatric Association, 2013

3-Tier Model of Intervention

To provide help for the aforementioned student possibly with ADHD, teachers could implement the 3-tier support model to better develop strategies in learning and teaching. In the following section, this essay would further design intervention methods to help students in various domains, including learning and social interaction skills.
 
Tier 1: Universal support
Through the 3-tier support model, the school and teachers could implement support on the school, form or class level. Tier 1 strategies are usually linked with quality teaching within the classroom. Through observation, teachers could discover the factors that caused students’ unsatisfactory academic results, and apply corresponding teaching methodologies to help them improve in the related aspects, especially for students that have been diagnosed to be with special educational needs.

ADHD patients are usually easily distracted and forgetful, and they may have deficiencies in sensory processing as investigated by Shimizu et al. (2014). Teachers could apply diverse types of teaching approaches to facilitate better understanding and to better attract them to work as an aid in the academic domain. For example, the VARK teaching strategy, which includes the integration of visual, aural, read/write and kinesthetic sensories, could be used in the lesson for multi-sensory stimulation. This could help attract the student to focus on the lesson when integrated with interactive teaching methods. The teacher could also design class activities from time to time that could allow students to move within the classroom, which would help satisfy the desire of the SEN student to leave his seat.

Another possible implementation of tier 1 support is a group reward scheme that could be implemented in class to cater to different SEN students. This could be considered as a kind of group training for the student, and could suitably add up peer pressure to the student, which, according to Thompson et al. (2003), could improve their motivation to be well-behaved. To start with, class teachers could discuss with the class and set up several class rules for students to follow, such as keeping their desks tidy, sitting properly and keeping quiet in class. The class will then be divided into small groups of around 4-5 students. Subject teachers will assess with the highest score each week and could be rewarded with small gifts like stationery, stickers or snacks. The class rules and score record sheet should be displayed in a prominent position in the classroom to act as a reminder and encouragement.

To allow teachers to better manage the dedicated student, he could also be moved to the front row of the classroom. Teachers could monitor and observe the student's behaviour in class and get him controlled when he exhibits disorderly behaviours that may possibly affect the lessons. Sitting in the front row could also minimize distractions from windows or doors and allow the student to focus on the lesson.
 
Tier 2: Additional Support
When intervention methods in tier 1 are applied but are with low and unsatisfactory effectiveness, teachers should proceed to the implementation of tier 2 support, which is commonly defined as additional support for the dedicated student on top of the normal teaching methods or curriculum.

In tier 2 level support, the same-age peer tutoring method could be applied to provide more help to the SEN student on their learning progress. A typical example would be that teachers could invite competent students with high achievement in academic results, like the class monitor or other gifted students, to act as peer tutors. Peer-assisted learning strategies have been proved by Lorah (2003) and could be further extended to improve the student’s behaviour in the classroom. Carson could be arranged to sit next to or nearby the peer tutor and the two could be arranged in the same group during class activities and discussions. The peer tutor could help him with topics and problems that he does not understand in lessons as immediate support, at the same time act as a role model for him on appropriate classroom behaviours.
Teachers could also use small-group learning as one of the teaching methods as additional support to the dedicated student. Carson could be grouped with other students with similar learning difficulties and share similar learning objectives. With reference to the research and experiment done by Hart et al. (2011), ADHD students have been proven to have higher productivity and less off-task behaviour if small-group instruction methods are used, when compared to independent or whole-group learning.

Carson could also be arranged to participate in social skills workshops organised by the guidance team, school social worker or outside organizations after school. This would facilitate him in learning suitable social interaction skills, such as the appropriate tone and words used in communication with peers. He could also learn skills to control his own emotions when there is a conflict with peers and to develop the ability to politely express opinions instead of using physical confrontation.

Tier 3: Individualized Support
To further develop personalized assistance for Carson, teachers could work alongside social workers, educational psychologists, parents and the student himself to design an Individualized Educational Plan (IEP).
 
In the IEP, strategies implemented in the previous tiers would be continued, but at the same time adding more intervention methods as specialised support for Carson upon the ADHD symptoms he exhibits. More stakeholders are participating in support, including relevant professionals like educational psychologists, and the students’ parents for the implementation of support outside school time under the idea of home-school cooperation. The IEP is designed to be implemented in a period of 6 months, then could be revisited to review and evaluate the effectiveness and outcome of the strategies and short-term goals initially.

Individualized implementation in the IEP designed for the student includes the learning and social skills domains. Class teachers could add cue cards with colourful icons and text to Carson’s desk in the top left corner, which would be used to remind him to follow classroom manners, including not leaving his seat without teachers’ permission. Non-verbal cues are proven to be effectively affecting ADHD patients for classroom management purposes, as mentioned in the investigation by Geng (2011), and thus could be implemented to further improve his classroom behaviour.

Teaching assistants or the second teacher in a co-teaching classroom are also designed to provide extra help to Carson. This could be considered a variant of the “One Teaching, One Drifting” teaching strategy, and could provide help and direct him in the good manners of participating in conversations and discussions.

Counselling Skills

As ADHD students would be easily distracted and could have negative relationships with their classmates, which could possibly lead to emotional difficulties or even anxiety and depression. As teachers, it is also important to apply counselling skills to comfort him and straighten him out.

Teachers could use the rational emotive behavioural therapy (REBT) method and the ABCDE model to facilitate the designated student’s cognitive restructuring. Carson could be taught about the relationships between the activating event, beliefs and consequences. The ABCDE model could help him in developing a positive interpretation of different obstacles that he faces. The REBT framework would also help “stresses the importance of developing rational self-statements that are theoretically and empirically opposite of the unhealthy beliefs” (Doyle & Terjesen, 2006), and thus work as a counselling theory that could work as a guidance for Carson to develop positive thinking.
 
Despite the REBT framework, teachers could also utilize the cognitive behaviour therapy (CBT) approach. Under the CBT framework, the five aspects model could be implemented, which includes evaluation and reflections of a certain experience on the situation, and the student’s thoughts, behaviours, feelings and physical reactions during the incident. According to Wright et al. (2002), the five aspects model could assist better both sides in identifying and clarifying the problem and the focus of counselling. For a more specific example, Carson could be invited to fill in a worksheet on the five aspects as a reflection after a misbehaved action in class, and teachers could then together evaluate the incident with him. This could help set up a goal and let the student understand the underlying reasons that he should be well-behaved in class.

Conclusion

As teachers-to-be, students with special educational needs like Carson are not going to be rarely seen. SEN students take up around 7.74% of primary and secondary students in Hong Kong (Alliance for Promoting Special Educational Policy and Legislation, 2019), and this has been a rising trend in recent years. It is crucial for us teachers to show a helping hand to these children, assist them to effectively learn at school, further develop their strengths and help them conform to peers. Despite that the methods mentioned in this essay, like the 3-tier intervention model and the individualized educational plan, are well-evaluated in the actual implementation in the past years, teachers should still be able to develop a specialised way for every single SEN student and apply suitable strategies to reach the aforementioned goals.

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中文譯本
注：本文由 DeepL 人工智能協助翻譯，並經過人工潤色，部分內容或跟英文原文內容稍有出入。

隨著融合教育的概念在中小學教育階段的興起，有特殊教育需要的學生可能會選擇在傳統學校就讀，但這也是對教師及傳統教學方法的一大挑戰。作為一名未來的教師，我們在面對有特殊教育需要的學生時可能也會感到困擾，但我們仍有責任協助他們融入社會，充分發揮他們的潛能，並確保他們能夠擁有盡可能與其他學生一樣的學習機會。為了更好的了解及學習向有特殊教育需要的學生提供教育時的方法及技能，本文將通過一個有特殊教育需要的實際案例，從教師的角度探討並評估幫助所述案例的可行方法。

案例背景

在 Now 電視台（2019）的《杏林在線》片段中，訪問了十一歲的簡煒晉、他的母親和鐵人三項的教練，並介紹了他的行為和症狀，還播放了他在家中完成學校作業和參加鐵人三項課程的部分觀察片段。從影片中可以看出，煒晉在完成作業的途中會突然開始畫畫，他更告訴記者，若長時間需要安坐不動便會感到不適，故要馬上離開座位、站起來或上廁所來舒緩這種感覺。在學校上課期間，他也曾因此離開座位。根據簡母的描述，由於煒晉很容易會被激怒，曾在衝突中對同學動手打架。她也指出煒晉的嘴比他的腦子轉得快，且非常健談，與他人相處的時候也會無法自控。

但除此以外，煒晉也有他自己的優點。簡母在訪問中提到，煒晉很喜歡與好友們相處，會因此感到精力充沛、興奮不已。煒晉也不會與他人攀比，並能夠從自己犯過的錯誤中學習和改進。從影片中也可觀察出其樂觀的性格，在大部分時間都能充滿活力。此外，他也熱愛運動，尤其喜愛騎自行車，並曾多次參加鐵人三項的課程和比賽。

案例分析

煒晉在影片中所表現出的上述症狀，可大概歸結為注意力不集中、多動和衝動三項。根據表一（美國精神醫學學會，2013）所示，煒晉的症狀符合了《精神疾病診斷與統計手冊》（第五版）中的其中六項標準，可大概確認為罹患注意力不足過動症。由於煒晉表現出明顯過動的症狀，去案例可進一步歸類為注意力不足過動症的過動-衝動亞型。

表一
煒晉符合《精神疾病診斷與統計手冊》（第五版）中注意力不足過動症的過動-衝動亞型的症狀

症狀	是否符合
一、坐在椅子上動來動去、在位置上用手指頭敲打東西、 或用腳趾頭敲打地板。	✓
二、經常在被預期應該長時間坐著的情況下離開座位。	✓
三、四處東奔西跑、碰觸或玩弄視野內的任一或每一個物體。	✓
四、難以安靜的參與或從事休閒活動。	✓
五、一直在移動、做動作或「正在做某事」，似乎一直被馬達給驅動著。	✓
六、不停地講話，講話的頻繁度超出正常範圍。	✓
七、常常在還沒聽完或看完問題的時候就脫口說出自己認為的答案或衝動、急於作答。	✗
八、難以忍受延遲的滿足、難耐在遊戲或其他事情中因輪流所產生的等待時間。	✗
九、經常干擾他人或「闖入」他人之間的對話、活動或遊戲等活動。	✗

注：摘錄自美國精神醫學學會（2013）出版的《精神疾病診斷與統計手冊》（第五版）

三層支援模式

為了幫助如上述案例般患有注意力不足過動症的學生，教師可以採用三層支援模式，以更好地制定學與教的策略。本文將進一步設計實際的支援方法，分別在學習、社交互動技能等多項不同領域幫助患有注意力不足過動症的學生。

第一層：普及性支援
通過三層支援模式，學校和教師可以從學校、年級或班級層面實施支援措施。第一層支援策略通常與課堂的教學品質有關。教師可以通過觀測發現學生學業成績不如理想的緣由，並運用與之相對應的教學方法，以協助他們在相關方面有所改善，尤其是被診斷為有特殊教育需要的學生。由於注意力不足過動症患者較容易分心和健忘，Shimizu 等（2014）進行的研究也證明他們在感官處理方面存在一定的缺陷。教師可以採用並結合不同類型的教學方法，以促進學生更好的瞭解課程內容教師可在課程中使用 VARK 教學策略，其中整合了視覺、聽覺、讀寫和動覺，可以通過多感官刺激，再與互動教學法相結合，有助於吸引學生集中注意力。教師還可以布時設計一些課堂活動，讓學生在教室裡自由活動，有助於滿足有特殊教育需要的學生離開座位的欲望。

教師亦可在班級中實行小組獎勵計劃作為第一層支援，以此照顧有不同特殊教育需要的學生。根據 Thompson 等（2003）認為，這可以被視作對學生的集體訓練，並可以適當的增加學生的同儕壓力，從而提高他們的動力。首先，班導師可以與全體同學討論並制定數條班規，如保持課桌整潔、坐姿端正、上課保持安靜等，然後將班級分為多個四至五人組成的小組，並由科任導師每週對學生進行評分，最後對得分最高的小組給予文具、貼紙或零食等作為獎勵。班規和評分記錄表應張貼在教室的醒目位置，以起到提醒和鼓勵的作用。

若班別中有需要特殊管理的學生，教師也可以將其安排在教室的前排。教師可以更方便的監督和觀察該學生在課堂上的行為，並在其表現出可能影響課堂秩序的行為時可以更好的管控學生。坐在前排還可以減少門窗等事務對他的干擾，讓學生得以專注在課堂的內容上。

第二層：選擇性支援
當採用了第一層的干預方法，但效果並不理想時，教師應著手實施第二層的選擇性支援。第二層支援通常是指在一般教學方法或課程以外為有特殊教育需要的學生提供的額外支援。教師可以安排同齡的朋輩充當導師的角色，為有特殊教育需要的學生在學習進程上提供更多的幫助。教師可邀請學業成績優異、能力較佳的學生擔任朋輩導師。Lorah（2003）的研究中證實了同伴輔助學習策略的好處，並可以用以改善學生在課堂上的行為。在上述案例中，煒晉可以被安排坐在朋輩導師的附近，並安排他們在課堂活動和討論一組，並由後者協助解決課堂上不明白的課題，為他提供及時的支援，同時在課堂行為方面為他樹立榜樣。

教師還可以在課堂中實行小組學習法，以此為有特殊教育需要的學生提供額外支援。煒晉可以和有相似學習困難的其他學生進行小組學習，並訂立共同的學習目標。Hart 等（2011）的研究和實驗表明，相比個別或全班學習，採用小組教學法的注意力不足過動症學生的學習效率更高，且偏離課堂活動的行為會發生的更少。另外，教師也可以安排煒晉在課餘時間參加由輔導組、學校社工或校外機構舉辦的社交技巧工作坊。類似的活動可以協助煒晉學習如何適當的進行社交，譬如與朋友之間交談時的適當語氣和用詞，也可以學習與他人發生衝突時控制自己情緒的技巧，以及培養以禮貌地表達意見取代肢體衝突的能力。

第三層：針對性支援
為了進一步為煒晉提供針對性的第三層支援，教師可以和社工、教育心理學家、家長和學生本人等多方一同設計個別化教育計畫。各參與方可以參與其中，並與前兩層的支援策略同時進行，但也會根據煒晉所表現出的注意力不足過動症症狀而增加更多的支援方法。在家校合作的理念下，教育心理學家等相關專業人士和學生家長等都會參與到支援策略當中，以便在課外時間仍能繼續實施對學生的針對性支援。個別化教育計畫的初始實施期為六個月，其後可以由參與各方重新審視和評估教育策略和短期目標的成效。

為學生設計的個別化教育計畫應要包括學習和社交技能兩個領域。班導師可以在煒晉課桌的角落貼上帶有彩色圖示和文字的提示卡，用於提醒他遵守課堂禮儀，包括未經老師允許不得離開座位等。非語言提示在 Geng（2011）的研究中被證實能有效的影響多動症患者的課堂管理，因此可以通過非語言提示來進一步改善他的課堂行為。助教或共同教學課堂中的第二位教師也可以為煒晉提供額外的協助，這可以說是「一人教學，一人游移」教學策略的一種變體，並可以幫助和指導他更好的參與交談和討論。

諮詢技巧

由於患有注意力不足過動症的學生較容易分心，與同學的關係也可能相對較不融洽，可能會導致情緒障礙，甚至焦慮和抑鬱。教師應運用適當的輔導技巧安慰和疏導學生。

教師可以使用理性情緒行為療法和 ABCDE 理論來促進學生的認知再建構。教師可以向煒晉講述事件、信念與結果之間的關係，並以此培養他在遇到困難和障礙時可以更積極的面對。理性情緒行為療法的框架也有助於「強調發展在理論和經驗上與不健康信念相反的理性自我陳述的重要性」（Doyle & Terjesen，2006），因此可以作為一種輔導理論，指導煒晉發展更積極的思維方式。

除了理性情緒行為療法外，教師也可以採用採用認知行為療法。在這個框架下，教師可以實施「五個範疇」的評估，包括對某一事件的評估和反思，以及學生在事件中的想法、行為、感受和身體反應。根據 Wright 等（2002）的研究，「五個範疇」評估模式可以更好的識別及澄清問題所在及輔導的重點。比如煒晉在課堂上有不當的行為後，教師可以邀請他填寫一份「五個範疇」的反思表，並和他一同就事件進行評估和反思。教師可以通過反思協助學生樹立目標，且讓他明白自己在課堂上應該表現良好的原因。

結論

作為准教師，像煒晉這樣有特殊教育需要的學生並不罕見。在香港，有特殊教育需要的學生約佔全體中小學生的 7.74%（全推動特殊教育政策及立法聯盟，2019），且近年來有越發上升的趨勢。對於教育工作者來說，我們應適時向這些孩子伸出援助之手，幫助他們在學校有效地學習，進一步發展他們的特長，幫助他們融入同齡人之中。儘管本文中提到的方法，如三層支援模式和個別化教育計畫等均在近年於學校中的實際實行時得到了不錯的評價，但教師仍應該為每一位有特殊教育需要的學生制定專門的教學方法，並運用合適的教學策略來實現前述的目標。

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參考資料

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