ISSN (Print) ISSN (Online) Commun Sci & Dis 2014;19(1):45-59 Original Article Communication P

ISSN 2288-1328 (Print) ISSN 2288-0917 (Online) Commun Sci & Dis 2014;19(1):45-59 Original Article Communication Profiles of School-Aged Children with Social Communication Disorder and High- Functioning Autism Yeon Sun Jin a, Soyeong Pae b a Department of Neuropsychiatry, Eulji Medical College Hospital, Seoul, Korea b Department of Speech Pathology & Audiology, Hallym University, Chuncheon, Korea Correspondence: Soyeong Pae, PhD Division of Speech Pathology and Audiology, Hallym University, 39 Hallymdaehakgil, Chuncheon 200-702, Korea Tel: +82-33-248-2214 Fax: +82-33-256-3420 E-mail: spae@hallym.ac.kr Received: December 15, 2013 Revised: February 13, 2014 Accepted: March 5, 2014 Objectives: The aim of the present study was to ascertain the profiles of communication between school-aged children with social communication disorder (SCD) and children with high-functioning autism (HFA). Methods: The participants in this study included forty-five school-aged children with SCD, HFA, and TD. This present study used the Korean Test of Problem Solving, which is a behavior observation in a structured task representing a small group classroom setting, as well as the test of theory of mind (ToM). Results: First, there were no significant differences between the three groups on the Korean Test of Problem Solving. Second, in the structured task representing classroom setting, there were significant differences in the total amount of social communication (SCD < TD) as well as in the, frequency of verbal (SCD < HFA, TD) and nonverbal (HFA < SCD, TD) behaviors. Furthermore, There were significant differences initiations among groups; prosocial (SCD < TD), irrelevant (HFA > SCD, TD), and assertive (HFA > TD) behaviors. While there were significant responsive among groups; prosocial (TD > SCD, HFA), passive (SCD > HFA, TD), irrelevant (HFA > SCD, TD), and assertive (HFA > SCD, TD) behaviors. Finally, there was also a significant difference in the theory of mind among groups (HFA < SCD, TD). Conclusion: This study revealed that the children with SCD showed similar communicative behaviors in initiations with TD children except prosocial behaviors. Interestingly enough the children with SCD seem to be very passive in responsiveness. These results could be used to guide the assessment and/ or intervention for school-aged children with SCD. The findings of this paper will support the guideline of the assessment and/or intervention for school-aged children with communication disorders. Keywords: Social communication disorder, High-functioning autism, School-aged children, Social communication skills, Theory of mind (ToM) 인간관계는의사소통과중요한관계를갖는다. 의사소통을하기위해서는사람들 ( 화자와청자 ), 메시지, 채널, 피드백 ( 반응 ), 맥락과같은요소들이필요하다 (Copper & Simons, 2006). 성공적인상호관계는실제맥락속에서타인과상호작용하며의사소통하는것을말하는것으로이것이충족되었을때즐거움과효율성을갖게된다 (Marans, Rubin, & Laurent, 2005). 이를위해서는적절한의사소통능력 (communication competence) 과사회적능력 (social competence) 을갖추어야한다 (Goldstein, Kacemarek, & English, 2002). 사회적의사소통능력은적절한형태의사회적능력과의사소통능력이기능적으로충족될때나타난다. 이러한특정기능들을성취하기위한행동의선택은맥락에따라매우다양하다 (Baltaxe, 1977; Crick & Dodge, 1994; Rubin & Kransnor, 1986). 사회적의사소통의정의는문헌에따르면아주기본적인것부터구체적인기술까지다양하다 (Coggins, Timler, & Olswang, 2007; Goldstein et al., 2002; Olswang, Coggins, & Timler, 2001; Timler, Vogler-Elias, & Mcgill, 2007). 이를정리하면사회적의사소통이 Copyright 2014 Korean Academy of Speech-Language Pathology and Audiology This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. http://www.e-csd.org 45

Yeon Sun Jin, et al. Communication profiles of School-Aged Children with SCD and HFA 란, 다양한사회적맥락 ( 대화상대자, 상황등 ) 에서구어적또는비구어적행동수단을사용하여효율적으로상호작용하는것으로삶속에서친밀감을형성하는데있어중요한능력이다 (Jin & Pae, 2013). 학령기아동의사회적의사소통의영역을살펴보기위해학령기아동을대상으로한사회적의사소통관련논문을수집하여분석하였고 American Speech-Language-Hearing Association (ASHA) 에서제시하고있는사회적의사소통의구성요소를정리하였다. 종합하면사회적의사소통영역은사회적의사소통수단 (Andersen- Wood & Smith, 2000; ASHA, 2013; Kowalski, 2005; McGee, Feldman, & Morrier, 1997; Muir, Tanner, & France, 1992; Murdock, Cost, & Tieso, 2007; Murray, Farrington, Sekol, & Olsen, 2009), 사회적의사소통기능 (Adams & Lloyd, 2005; ASHA, 2013; Kowalski, 2005; McGee et al., 1997; Muir et al., 1992; Murdock et al., 2007; Murray et al., 2009; Sharrow, 1990), 담화 (Adams & Lloyd, 2005; Baltaxe & D Angiola, 1992; Kowalski, 2005; Muir et al., 1992; Sharrow, 1990), 사회적상호작용행동유형 (ASHA, 2013; Kowalski, 2005; Muir et al., 1992; Murray et al., 2009; Olswang, Svensson, & Astley, 2010) 을포함하였다. 또한성공적인사회적의사소통을위해언어능력, 사회인지, 실행기능등 (ASHA, 2013; Kowalski, 2005; Muir et al., 1992; Murray et al., 2009; Sharrow, 1990) 이포함된것을확인할수있었다. 의사소통능력을평가하는방법에는도구를이용한공식평가, 타인 ( 예, 교사, 부모, 또래 ) 의보고에의한설문지, 행동관찰방법등이있다 (Gallagher & Prutting, 1991; Timler, 2008). 의사소통행동을적절하게측정하기위해서는각평가방법의강약점을이해하고대상자의목표행동에따라적절한평가방법을선택해야한다. 도구를이용한공식평가는국내에서는문제상황을그림으로제시하여 원인이유, 문제해결, 단서추측 을묻는질문을하였을때언어로적절한대답을하는능력을살펴보는 언어문제해결력검사 (Pae, Lim, & Lee, 2000) 가있다. 이러한공식평가는아동의실제상황을확인해줄수없다는단점이있다. 타인의보고를통한설문지방법은 부모 / 교사 보고와 아동 보고방법이있다. 의사소통을위한설문지는국내에서는부재한상황이고국외의경우, Children s communication checklist-2 (CCC- 2: Bishop, 2003), Pragmatic profile (Semel, Wiig, & Secord, 2003), Assessment of peer relations (Guralnick, Neville, Connor, & Hammond, 2003), Pragmatic language skills inventory (Gilliam & Miller, 2006) 등이있다. 특히 아동기의사소통체크리스트-2 (CCC-2) 는 Bishop이 2003 년개발한것으로사회적 / 의사소통문제행동을살펴볼수있는체크리스트이다. 검사대상은 4세에서 16 세의아동이며체크대상자는부모, 교사, 혹은치료사가할수있다. 이체크리스트는 GCC, PRAG, autism/social 등의점수를확인할수있다. GCC는 general composite score 로전반적인의사소통손상을확인하는것으로사회적관계와관심영역을뺀나머지말, 구문, 의미, 응집성, 부적절한개시, 정형화된언어, 맥락사용, 비구어적의사소통의점수를합한것이다. PRAG는 pragmatic composite 로전체적인화용언어능력을포함하는것으로임상에서진단하기에매우효율적이라고하였다. 이지표는부적절한개시와정형화된언어, 맥락사용, 비구어적의사소통영역의점수를합한것이다. Autism/social 범주는사회적관계, 관심영역이포함되어있다 (Bishop, 2003). 이와같이설문지를통한평가는시간적으로효율적인반면에검사자가아동을반복적으로보게된경우아동에대한선입견으로척도를매길수있다는단점이있다. 마지막으로행동관찰방법은아동이접하는실제환경 ( 예, 학교 ) 에서행동을관찰하는방법과실제와유사한구조화된환경에서관찰하는방법이있다. 특히사회적의사소통능력에어려움이있는학령기아동들은보통교실활동참여, 또래와상호작용하는상황에서어려움에처한다고교사들이보고하고있다. 이러한행동특징은공식검사내에서는확인하기어렵기때문에 (Olswang, Cogins, & Svensson, 2007) 아동이접한교실환경에서측정이이루어져야한다. 하지만이러한평가방법은자연스러운상황에서행동을관찰하기때문에타당도측면에서이점이있으나시간적으로비효율적이고목표행동이낮은빈도로나타나는경우고려되지못한다는단점이있다. 또한 Powell, Burchinal, File와 Kontos (2008) 는교실활동을하는동안모든행동범주가발생할수도있지만동등하게발생되지않을수있다고하였다. 따라서이를보완하기위한방법으로실제교실상황과유사한조작적으로구조화한상황에서평가를할수있다. 사회적의사소통능력에어려움이있는아동들은또래와지속적인상호작용에어려움을갖게된다. 특히학령기아동같은경우, 양육자혹은유치원에서맺는관계와는달리학교교실내에서함께생활하는또래친구들도많게되고많은학습과제들을경험하게되는데이는다양한사회적환경들안에서상황정보없이예측하기어려운경우가많아교사혹은또래와상호작용할때효과적으로의사소통하는데어려움을겪게된다 (Olswang et al., 2007). 특히자폐범주성장애아동은사회적의사소통능력에손상이있다는많은보고가있다. 자폐범주성장애는사회적상호작용손상과의사소통의질적손상, 제한된관심범주가핵심특성이다 (Amer- 46 http://www.e-csd.org

학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선외 ican Psychiatric Association, 1994). 이러한손상이나행동특성은지능지수나장애의정도에따라다양한양상을보이는데예를들면, 의사소통의질적손상의경우에는평생토록구어수준이영아기에머물러적절한구어를사용하지못하는자폐성인이있는가하면 (Mirenda & Shuler, 1988) 고기능자폐처럼언어발달의지체를전혀혹은거의보이지않는경우도있다. 하지만고기능자폐는일상적인의사소통에서심각한문제를보이지않더라도임상적보고에서는원만한사회적상호작용을충분히저해할수있는의사소통상의질적손상이보고되고있다 (Church, Alisanski, & Amanullah, 2000). 선행연구를통해구체적으로살펴보면고기능자폐는표현측면에서는얼굴표정, 제스처표현, 타인에게사회적개시하기, 억양, 담화결속장치, 운율, 참조적의사소통에어려움을보인다고하였다 (Happe & Frith, 1996; Lord, Rutter, & Le Couteur, 1994; Martin & McDonald, 2003). 이해측면을살펴보면제스처, 신체언어이해, 감정해석, 유머이해에어려움을보인다고하였다 (Happe & Frith, 1996; Loveland et al., 1997; Martin & McDonald, 2003; Ozonoff & Miller, 1996). 또한대화시, 대화수정은비교적잘할수있으나 (Volden, 2004) 장황하게발화를하고사회적으로부적절한코멘트, 과도한상동발화, 현학적인언어의사용이많고관용어는적다고보고하고있다 (Dewey & Everard, 1974; Lord et al., 1994; Volden & Lord, 1991). 사회인지측면에서는사회적동기, 사회적인지, 사회적각성능력이부족한것으로나타났다 (Hilton, Graver, & La Vesser, 2007). 이처럼의사소통능력을살펴보기위한목적으로많은연구에서는자폐아동을대상으로한연구가대부분이다. 하지만언어치료사들은교육셋팅내 / 외에서자폐성향이동반되지않고구조적인언어는정상발달을하나언어를사회적맥락내에서사용하는것에어려움을겪는아동들을많이접하게된다고보고하고있다 (Bishop, 2000). 많은연구에서는이러한아동들을화용언어장애 (pragmatic language impairment, PLI) 라고명시하고있고이들을대상으로의사소통특성을살펴본연구들이진행되어왔다 (Adams & Llyod, 2005; Bishop, 2000; Bishop, Chan, Adams, Hartley, & Weir, 2000; Bishop & Norbury, 2002). 화용언어장애 (PLI) 의용어가사용된배경을살펴보면처음 Rapin과 Allen (1983) 은 developmental language disorder ( 발달언어장애 ) 라는용어를사용하였고이들을 autism ( 자폐 ) 과 specific language impairment ( 단순언어장애 ) 로분류하였다. 이후언어손상의증후를설명하기위해단순언어장애내에서 semantic-pragmatic deficit syndrome ( 의미-화용결함증후군 ) 용어를사용하게되었고여러용어가사용되다가 semantic-pragmatic language disorder ( 의미- 화용언어장애 : Bishop & Rosenbloom, 1987) 용어가남게되었다. Rapin과 Allen (1983), Adams와 Bishop (1989), Bishop 과 Adams (1989), Rapin (1996) 의연구에서는의미-화용언어장애를대상으로다양한연구를진행하였고이후 Bishop과 Rosenbloom (1987) 의연구에서의미-화용장애에서의의미 (semantic) 라는것이반드시화용과결합되는것이아니라고보고하였으며 Bishop (2000) 은의미-화용장애로진단된아동중에문법과의미문제를항상함께갖고있는것이아니다라고언급하면서 의미-화용장애 라는표기보다는 pragmatic language impairment (PLI, 화용언어장애 ) 라는새로운개념이더적합한것이라보았다 (Adams, 2001; Bishop, 2000). 선행연구에서화용언어장애아동의특징을살펴보면구조적인언어는정상적으로유창하게사용하나화용에어려움을겪는다고한다 (Botting & Conti-Ramsden, 1999; Rapin & Allen, 1983). 이러한사회적언어사용제한으로비교적조용하고자신감이부족한모습으로보여지거나 (Dockrell, Messer, George, & Wilson, 1998) 혹은적절한정보의양제공제한 (Bishop, 2000; Bishop et al., 2000) 을보인다고하였다. 또한대화를위해구조적인형태는잘갖추어져있으나반응하기와개시하기에제한을보인다고하였다 (Bishop & Adams, 1989; Bishop & Norbury, 2002). 더불어항상그런것은아니지만화용언어장애는언어의미해석어려움, 화자의의도이해어려움, 사회인지영역제한 (Shields, Varley, Broks, & Simpson, 1996) 의특징을보인다고한다. 이러한화용언어장애의특성은임상적으로보통실행기능과관련있다고보고하고있고 (Oram, Fine, Okamoto, & Tannock, 1999; Tannock & Schachar, 1996), 사회인지, 마음이론등을포함하여특성을보고하고도있다 (Bishop & Baird, 2001; Geurts et al., 2004; Martin & McDonald, 2003). 또한화용언어장애에서화용의어려움이충동적인행동문제와상관이있다는보고도있었다 (Ketelaars, Cuperus, Jansonius, & Verhoeven, 2010). 이러한어려움은항상나타나지않고특정맥락에서만발생하기때문에 (Botting & Conti-Ramsden, 1999; Toppelberg & Shapiro, 2000), Bishop (2000) 과 Bishop 등 (2000) 은 화용언어장애 (prag matic language impairment) 는그아동들의집단이있는환경 ( 예, 교실등 ) 안에서확인하기를권고하였다. 최근에는이러한화용언어장애와자폐범주성장애를구별하는것에대한의문을갖게되었고 (Bishop, 2000) 화용언어장애는자폐범주성장애진단준거로는충분하지않다고보고가되면서 (Bishop & Norbury, 2002; Botting & Conti-Ramsden, 1999) 화용언어장애와자폐범주성장애간의관계에대해임상적으로주요이슈로되고있다. 또한이들의관계를설명하기위해서다양한가설이제 http://www.e-csd.org 47

Yeon Sun Jin, et al. Communication profiles of School-Aged Children with SCD and HFA 시되고있다. 첫째, 화용언어장애는자폐스펙트럼장애와분류된다 (Adams, 2001; Bishop & Norbury, 2002; Conti-Ramsden, Smikin, & Botting, 2006). Bishop (2000) 의연구와 Bishop과 Norbury (2002) 의연구에서자폐스펙트럼장애아동의주특징인또래관계혹은흥미영역에제한을보이지않더라도화용에어려움이있는아동이있다고보고하였고화용언어장애는자폐를분류하는의사소통, 사회적상호작용, 흥미의세가지문제가항상나타나지않는다고하였다. Bishop과 Norbury (2002) 의연구에서는자폐범주성장애아동은부적절한억양과톤이동반된상동언어를사용한반면화용언어장애아동은사회적의사소통이어려웠고비구어적의사소통수단의경우는적절한특성을보였다. 또한자폐에게보이는또래관계혹은관심 (interests) 측면에서어려움을갖지않는다고하였다 (Bishop, 2000). 둘째, 화용언어장애는자폐스펙트럼장애와는분명한차이가없다 (Brook & Bowler, 1992; Shields et al., 1996). 이는화용언어장애는비전형적인혹은경미한형태의자폐라는것이다. 선행연구를살펴보면화용언어장애는 DSM-4 기준으로분류하였을때 pervasive developmental disorder not otherwise specified (PDD-NOS), atypical autism, 아스퍼거증후군혹은고기능자폐로진단되어진다고하였다 (Buitelaar & van der Gaag, 1998; Prior et al., 1998). Shields 등 (1996) 은화용언어장애집단과자폐집단간마음이해과제를실시하였는데유사한특징을갖는다고하였다. 셋째, 화용언어장애는자폐스펙트럼장애의특징을보이긴하지만자폐집단의하부그룹으로보기도하였다 (Bishop & Rosenbloom, 1987; Boucher, 1998; Rapin, 1996;). 자폐스펙트럼장애가보이는증상들이진단준거에서약하게나타나는것으로이들을 PLI-high 라고하였다 (Bishop & Norbury, 2002; Botting & Conti-Ramsden, 1999). 최근 DSM-V 에서는이러한화용언어장애를대상으로한연구들을근거로새로이 사회적 / 화용의사소통장애 (social/pragmatic communication disorder, SCD) 라는진단명을추가하였다. 사회적의사소통장애는구어적 비구어적수단을사회적으로적절하게사용하는것에지속적인어려움을보인다. 구체적인특징은사회적목적에맞게의사소통하기에어려움 ( 예, 인사하기, 정보공유하기, 사회적맥락에맞게적절할수단사용하기등 ), 맥락혹은청자의요구에적절하게의사소통을변경하는것에어려움 ( 예, 놀이터보다교실내에서말하는것이어려움, 성인보다아동과대화에서차이가있음, 공식적인자리에서언어사용피하기등 ), 대화와이야기규칙따르기어려움 ( 예, 대화차례지키기, 규정된상황에서구어적, 비구어적신호를사용하는방법알기등 ), 명확한진술이아니라모호한의미를가진언어에서이해어려움 ( 예, 유머, 은유등 ) 이동반된다고하였다. 이러한어려움들로인해결국효율적인의사소통, 사회적참여, 사회적관계, 학업성취, 직업수행등에서기능적으로어려움을갖는다고보고하고있다 (American Psychiatric Association, 2013). 언어치료사들은교육셋팅내 / 외에서자폐성향이동반되지않고구조적인언어는정상발달을하나언어를사회적맥락내에서사용하는것에어려움을겪는사회적의사소통장애아동들을많이접하게된다고보고하고있지만 (Bishop, 2000) 이론적으로그리고임상적으로그들의특징을명확하게확인하기위한연구는국내에서는부재한상황이다. 또한사회적의사소통장애는고기능자폐아동과함께계속혼돈이있다. 따라서본연구의목적은다양한평가방법을통해한국의사회적의사소통장애의특성을고기능자폐아동집단, 일반아동집단과비교하였을때어떠한차이가있는지에대해살펴보고자하였다. 본연구는사회적의사소통장애와고기능자폐아동의의사소통능력을다양한평가방법을통해살펴보았다는것에의미가있고추후평가및중재방향에대한유용한기초자료가될것으로사료된다. 연구방법연구대상및연구대상선정검사도구본연구의대상은서울및경기지역의초등학교 1학년에서 6학년아동으로사회적의사소통장애, 고기능자폐아동, 일반아동집단간 15명씩총 45명을대상으로하였다. 학년별로살펴보면각집단은 1학년 2명, 2학년 3명, 3학년 3명, 4학년 3명, 5학년 3명, 6학년 1 명으로일치시켰다. 연구대상선정검사도구는자폐선별을위해사회적의사소통설문지 (SCQ: Yoo, 2008), 동작성지능을살펴보기위해한국-웩슬러아동지능검사 -III (K-WISC-III: Kwak, Park, & Kim, 2001), 언어능력을살펴보기위해수용 표현어휘력검사 (REVT: Kim, Hong, Kim, Jang, & Lee, 2009), 학령기아동언어검사 (LSSC: Lee, 2007) 의하위검사로문장이해하기와복문만들기평가를실시하였다. 그리고아동이접한사회적맥락내에서의사소통특성을살펴보기위해아동기의사소통체크리스트-2 (CCC-2: Bishop, 2003) 를사용하였다. 사회적의사소통설문지는부모의보고를통해자폐스펙트럼장애를선별하는도구이다. 총 40개의문항으로구성되어있으며 예 / 아니오 로답하여 10분이내에완성할수있다. 문항은사회적상호 48 http://www.e-csd.org

학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선외 작용 (reciprocal social interaction), 의사소통 (communication), 제한적이고반복적인상동화행동패턴 (repetitive and restrict behaviors and interests) 영역의 3가지항목으로이루어졌다. 자폐, PDD- NOS의경우, 절단점이 15점이상인경우라고하였고이설문지는자폐를진단하는데있어변별타당도가.88, 민감도는.75라고보고하였다 (Yoo, 2008). 또한 Reisinger, Cornish와 Fombonne (2011) 의연구에서는학령기화용언어장애집단과자폐범주성장애집단의차이를살펴보았을때집단간유의한차이가나타났다 (Reisinger et al., 2011). 한국-웩슬러아동지능검사 -III는만 6세에서 16세아동을대상으로전체지능, 언어성지능, 동작성지능을살펴볼수있다. 본연구에서는동작성지능을살펴보았다. 그리고언어능력은수용 표현어휘력검사와학령기아동언어검사를통해살펴보았다. 수용 표현어휘력검사는만 2세 6개월부터만 16세이상의어휘능력을살펴보는것이다. 학령기아동언어검사는초등학교 1학년부터 6학년아동의언어능력을살펴보는것으로본연구에서는하위검사중문장이해하기와복문만들기평가를실시하였다. 아동기의사소통체크리스트-2는 Bishop이 2003년에개발한것으로만 4세에서 16세아동을대상으로의사소통능력을살펴보는것이다. 본연구에서는아동기의사소통체크리스트를우리나라아동들에게적용하기위해영어에서한국어로번안하였다. 수정한문항은전체 70문항중 12문항이었다. 예를들어구문영역에서는한국어의문법을고려하여총 5문항을수정하였고말범주에서는총 5문항을한국아동이자주보이는오류로예를수정하였다. 의미범주및맥락사용범주에서는각 1문항씩수정하였다. 집단선정기준은 Norbury, Nash, Baird와 Bishop (2004) 의연구와 Bishop (2003) 을근거로일반아동집단은 GCC 55점이상인경우를포함하였다. 사회적의사소통장애집단과고기능자폐아동집단은 GCC 가 55점미만이고 PRAG가 17점미만인경우를포함하였다. Norbury 등 (2004) 의연구에서는 CCC-2는자폐장애, 아스퍼거증후군, 화용언어장애, 단순언어장애아동의의사소통능력을살펴보는데유용하다고하였다. 신뢰도및타당도를살펴본결과, 신뢰도는 r =.79로좋은내적일치도를보고하였고타당도검증결과, 각장애집단을살펴보는데유용하다고하였다. 본연구에서는 CCC-2에대한내용타당도를전문가들에게검증받았다. 평가자는학령기아동을대상으로평가및중재한경험이있는임상경력 3년이상의언어치료사 3인, 언어병리학박사과정 2인으로평가도구의각항목이의사소통능력을살펴보기위해타당한지를 1-5점 (1, 매우타당하지않음 ; 2, 타당하지않음 ; 3, 보통 ; 4, 타당함 ; 5, 매우타당함 ) 척도로평가하였다. 그결과평균 4.43의내용타당도가나타났다. 본연구에서고기능자폐아동집단선정기준은소아정신과또는 신경정신과에서자폐장애로진단받았거나혹은사회적의사소통 설문지를실시하였을때점수가 15 점이상이었다. 그리고 CCC-2 를 실시하였을때, GCC 는 55 점미만이었고 PRAG 는 17 점미만으로 나타났다. 사회적의사소통장애집단선정기준은소아정신과또는 신경정신과에서자폐장애, 비전형자폐, 아스퍼거증후군으로진단 받은적없거나혹은사회적의사소통설문지를실시하였을때점수 가 15 점미만이었다. 그리고 CCC-2 를실시하였을때, GCC 는 55 점 미만이었고 PRAG 는 17 점미만으로나타났다. 마지막으로일반아 동집단은자폐진단받은적없고 CCC-2 를실시하였을때 GCC 는 55 점이상으로나타났다. 세집단모두동작성지능점수는 85 이상 이었고언어평가를실시하였을때 REVT 와 LSSC 문법영역평가결 과, -1 표준편차이상이었다. 각집단선정기준과선정기준에따른연구대상아동특징은 Tables 1, 2 와같다. 연구절차및자료수집방법 본연구의검사는 2012 년 4 월부터 8 월까지연구원 1 명과보조연 구원 3 명이함께진행하였다. 검사는소음에방해되지않는학교및 센터의빈교실에서진행되었다. 본연구는사회적의사소통장애, 고기능자폐아동, 일반아동집 단간의사소통차이를살펴보기위해언어문제해결력검사, 행동 관찰, 마음이해검사를실시하였다. 도구를이용한공식검사는언 어문제해결력검사 (Pae et al., 2000) 를실시하였고아동 1 명과연구 자 1 명의형태로검사를진행하였다. 행동관찰을통해의사소통능력을살펴보는방법은 Jin 과 Pae (2013) 의자료수집방법으로진행하였다. 이연구에서는학령기아 동의사회적의사소통능력을살펴보기위해교실환경을반영한 Table 1. Standard of participant selection SCD (N = 15) HFA (N = 15) TD (N = 15) Autism diagnostic - + - SCQ < 15 > 15 < 15 CCC-2 GCC PRAG < 55 < 17 < 55 < 17 > 55 - REVT, LSSC > -1SD > -1SD > -1SD K-WISC-III > 85 > 85 > 85 SCD = social communication disorder; HFA = high-functioning autism; TD = typical development; SCQ= social communication questionnaire (Yoo, 2008); REVT= receptive and expressive vocabulary test (Kim, Hong, Kim, Jang, & Lee, 2009); CCC-2= children s communication checklist-2 (Bishop, 2003); LSSC = language scale for school aged children (Lee, 2007); K-WISC-III = Korean-Wechsler intelligence scale for children-iii (Kwak, Park, & Kim, 2001). http://www.e-csd.org 49

Yeon Sun Jin, et al. Communication profiles of School-Aged Children with SCD and HFA Table 2. Group characteristics of participants SCD (n= 15) HFA (n= 15) TD (n= 15) F Post-hoc test SCQ Reciprocal social interaction Communication Repetitive and restricted behaviors and interests CCC-2 GCC PRAG REVT Receptive Expressive 6.87 (4.15) 4.07 (1.83) 2.13 (1.92).73 (.88) 29.33 (10.87) 12.80 (2.96) 114.73 (29.38) 114.33 (33.23) 20.20 (3.57) 8.93 (1.94) 6.87 (1.88) 4.27 (1.09) 31.60 (17.57) 11.60 (8.80) 111.93 (31.32) 119.47 (23.85) 2.53 (1.30) 1.60 (.91).80 (.67).13 (.35) 80.80 (11.08) 40.33 (5.97) 116.13 (27.72) 117.67 (23.74) 120.329 78.700 59.366 106.167 69.223 97.484 LSSC Syntax comprehension 32.87 (2.23) 32.07 (2.34) 32.20 (2.83).447 K-WISC-III 106.67 (10.94) 105.60 (8.57) 102.33 (4.77) 1.061.079.136 HFA> SCD> TD* HFA> SCD> TD* HFA> SCD, TD* HFA> SCD, TD* SCD, HFA < TD SCD, HFA < TD Values are presented as mean (SD). SCD = social communication disorder; HFA = high-functioning autism; TD = typical development; SCQ = social communication questionnaire (Yoo, 2008); CCC-2 = children s communication checklist-2 (Bishop, 2003); GCC= general composite score (Bishop, 2003); PRAG= pragmatic composite (Bishop, 2003); REVT= receptive and expressive vocabulary test (Kim, Hong, Kim, Jang, & Lee, 2009); LSSC = language scale for school aged children (Lee, 2007); K-WISC-III = Korean-Wechsler intelligence scale for children-iii (Kwak, Park, & Kim, 2001). *p <.05. 구조화된환경내에서동일한기회를제공하여사회적의사소통행동을수집하였다. 교실환경은초등학교세곳을방문한후학령기아동이어려움에처하는환경을수집한후, Olswang 등 (2007) 의연구를참고로하여본연구자가구조적으로제작하였다. 활동은수업상황과협동놀이상황으로이루어졌고검사시간은약 30-35 분정도소요되었다. 구조화된평가는대상아동 1명당성인 3명 ( 연구자 1명, 보조연구자 2명 ) 이함께진행하였고연구자 1명은선생님의역할을하였고나머지보조연구자 2명은대상아동과함께책상에마주보고앉아과제를수행하는파트너의역할을하였다. 모든절차는제작된시나리오에맞추어대본을외워서진행하였고의사소통행동을기다리는시간이동일하였으며지정된시나리오외에비구어적단서를제공하지않도록주의하였다 (Jin & Pae, 2013). 마음이해과제는 Yang 등 (2008) 의문헌을참고하여믿음, 틀린믿음, 이차틀린믿음, 바람의도, 고등마음읽기과제 ( 애매한행동의미파악하기, 말의숨은뜻이해하기, 헛디딤말이해하기 ) 범주가포함된과제를사용하였다 (Yang et al., 2008). 문항은총 25문항이었고연구자 1명이아동에게과제를들려주고질문에답하기형태로검사를진행하였다. 측정방법및종속측정치본연구는도구를통한검사로언어문제해결력검사 (Pae et al., 2000), 구조화된상황에서사회적의사소통행동관찰 (Jin & Pae, 2013), 마음이해과제 (Yang et al., 2008) 를실시하였다. 언어문제해결력검사분석은언어문제해결력총점수, 하위범주 별로원인이유점수, 문제해결점수, 단서추측점수였다 (Pae et al., 2000). 사회적의사소통능력을살펴보기위한구조화된평가분석은검사를마친후 2-4일내에비디오테이프에녹화한자료를재생하면서아동의의사소통행동을본연구자가모두전사하였다. 그리고구조화된평가에서녹화한전체자료중수업시간 10분, 협동놀이시간 10분의동일한양을분석하였다. 종속측정치는총사회적의사소통발생빈도, 사회적의사소통수단별빈도, 사회적의사소통기능별개시하기와반응하기빈도를살펴보았다 (Jin & Pae, 2013). 마음이해과제는총 25문항이었고아동의응답은적절성을근거로 0점과 1점으로점수화한후이를합산하여점수를산출했다. 종속측정치는적절하게대답한마음이해점수였다 (Yang et al., 2008). 신뢰도및통계분석본연구에서는교실환경을구조화한환경내에서행동을관찰하여분석한것으로전사및분석신뢰도를실시하였다. 전사및분석신뢰도는학령기아동의중재경험이있는언어병리학석사학위를이수한언어치료사에게검사절차, 기록방법, 분석방법을설명한후두검사자간의일치율이 90% 이상이될때훈련을종료하였다. 신뢰도는전체의 20% 를전사하고분석하도록하여검사자간전사신뢰도와분석신뢰도를산출하였다. 그결과, 전사신뢰도는 96.88% 였고분석신뢰도는구어적수단은 90.24%, 비구어적수단은 89.86%, 개시하기는 96.34%, 반응하기는 90.28% 로나타났다. 그리고친화적행동은 90.28%, 소극적행동은 92.45%, 이탈적행동은 50 http://www.e-csd.org

학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선외 94.34%, 독단적행동은 95.64% 로나타났다. 학령기사회적의사소통장애, 고기능자폐아동집단, 일반아동집 단간차이가있는지를살펴보기위해일원분산분석을실시하였고 집단간의차이가어느집단간의차이인지를확인하기위해 Scheffe 사후검정을실시하였다. 연구결과 언어문제해결력 : 언어문제해결력총점수, 원인이유점수, 해결추론점수, 단서추측점수 언어문제해결력검사를실시하여언어문제해결력총점수, 원인 이유점수, 해결추론점수, 단서추측점수에서집단간차이를분석 한결과, 모든영역에서세집단간유의한차이를보이지않았다 (Table 3). 교실환경을구조화한환경에서행동관찰 : 총사회적의사소통 발생빈도, 사회적의사소통수단별빈도, 사회적상호작용 유형별개시하기와반응하기빈도 교실환경을구조화한환경에서행동관찰을통해사회적의사소 통수행을살펴본결과, 총사회적의사소통발생빈도는사회적의 사소통장애집단이일반아동집단보다유의하게낮은수행을보였 다 (F(2,42) = 4.834, p<.05). 사회적의사소통수단별로살펴보았을 때구어적수단빈도는사회적의사소통장애집단이두집단보다 유의하게낮은수행을보였고 (F(2,42) = 5.609, p<.05) 비구어적수단 Table 3. Analysis of variance for scores on Korean Test of Problem Solving by group SCD (N = 15) HFA (N = 15) TD (N = 15) F Posthoc test Total of scores 43.73 (17.32) 40.00 (14.02) 51.27 (16.10).154 - Cause & reason 15.00 (5.74) 13.47 (4.32) 17.13 (5.31).161 - Problem solving 16.47 (7.44) 14.67 (6.22) 19.20 (7.16).212 - Clue & prediction 12.40 (4.95) 11.87 (5.27) 14.87 (4.59).220 - Values are presented as mean (SD). SCD = social communication disorder; HFA = high-functioning autism; TD = typical development. 빈도는고기능자폐아동집단이두집단보다유의하게낮은수행을 보였다 (F(2,42) = 9.733, p<.05) (Table 4, Figure 1). Frequency 사회적상호작용행동유형별 ( 친화적, 소극적, 이탈적, 독단적 ) 개 시하기와반응하기의빈도특성을살펴본결과, 친사회적개시하기 빈도는일반아동집단이사회적의사소통장애집단보다유의하게 높은수행을보였고 (F(2,42) = 3.703, p<.05) 이탈적개시하기빈도는 고기능자폐아동집단이두집단보다유의하게높은수행을보였으 며 (F(2,42) =19.751, p<.05) 독단적개시하기빈도는고기능자폐아동 집단이일반아동집단보다유의하게높은수행을보였다 (F(2,42) = 3.569, p<.05) (Table 5, Figure 2). 친사회적반응하기빈도는일반아동집단이두집단보다유의 하게높은수행을보였고 (F(2,42) =14.689, p<.05) 소극적반응하기 빈도는사회적의사소통장애집단이두집단보다높은수행을보였 다 (F(2,42) =14.608, p<.05). 이탈적반응하기빈도 (F(2,42) =10.389, p<.05) 와독단적반응하기빈도 (F(2,42) = 5.091, p<.05) 는고기능자 폐아동집단이두집단보다유의하게높은수행을보였다 (Table 6, Figure 3). 50 45 40 35 30 25 20 15 10 5 0 Frequency of verbal behavior Frequency of nonverbal behavior SCD HFA TD Figure 1. Frequency of verbal/nonverbal behavior by group. SCD= social communication disorder; HFA= high-functioning autism; TD= typical development. Table 4. Analysis of variance for frequency of total social communication, verbal behavior and nonverbal behavior by group SCD HFA TD F p-value Post-hoc test Frequency of total social communication 35.27 (15.33) 41.67 (9.97) 48.60 (9.42) 4.834.013 SCD< TD Frequency of verbal behavior 26.33 (15.20) 37.27 (9.24) 37.40 (7.84) 5.069.011 SCD< HFA, TD Frequency of nonverbal behavior 8.67 (3.49) 4.40 (2.92) 11.20 (5.76) 9.733.000 HFA< SCD, TD Values are presented as mean (SD). SCD= social communication disorder; HFA= high-functioning autism; TD= typical development. http://www.e-csd.org 51

Yeon Sun Jin, et al. Communication profiles of School-Aged Children with SCD and HFA Table 5. Analysis of variance for initiation behavior for each social interaction types by group Initiation behavior SCD HFA TD (N = 15) F p- value Post-hoc test Prosocial 12.07 (8.53) 16.13 (6.08) 19.60 (8.39) 3.703.033 SCD< TD Passive.53 (1.55).67 (.26) 0 (0) 1.535.227 - Irrelevant.80 (3.09) 7.27 (4.71) 0 (0) 19.751.000 HFA> SCD, TD Assertive.33 (.72).60 (1.59) 0 (0) 3.569.037 HFA> TD Values are presented as mean (SD). SCD = social communication disorder; HFA = high-functioning autism; TD = typical development. Table 6. Analysis of variance for responsive behavior for each social interaction types by group Responsive behavior SCD HFA TD F p- value Post-hoc test Prosocial 16.07 (8.12) 18.00 (6.87) 28.40 (5.67) 14.689.000 TD> SCD, HFA Passive 5.27 (4.81).33 (.62).47 (1.06) 14.608.000 SCD> HFA, TD Irrelevant.20 (.56) 1.80 (2.78) 0 (0) 10.389.000 HFA> SCD, TD Assertive 0 (0).13 (0.35) 0 (0) 5.091.010 HFA> SCD, TD Values are presented as mean (SD). SCD = social communication disorder; HFA = high-functioning autism; TD = typical development. 32 28 24 Prosocial Passive Irrelevant Assertive 32 28 24 Prosocial Passive Irrelevant Assertive Frequency 20 16 12 Frequency 20 16 12 8 8 4 4 0 0 SCD HFA TD SCD HFA TD Figure 2. Frequency of initiation behavior for each social interaction types by group. SCD = social communication disorder; HFA = high-functioning autism; TD= typical development. Figure 3. Frequency of responsive behavior for each social interaction types by group. SCD = social communication disorder; HFA = high-functioning autism; TD= typical development. 마음이해점수사회적의사소통장애, 고기능자폐아동, 일반아동집단을대상으로집단간차이를분석한결과, 마음이해점수는고기능자폐아동집단이다른두집단보다유의하게낮은수행을보였다 (F(2,42) = 7.753, p<.05) (Table 7, Figure 4). 논의및결론본연구는다양한평가방법을통해한국의사회적의사소통장애집단이고기능자폐아동과일반아동집단과비교하였을때어떠한차이가있는지를다양한평가방법을통해살펴보았다. 첫째, 언어문제해결력검사를통해세집단간언어문제해결력총점수, 원인이유점수, 해결추론점수, 단서추측점수에서차이가있는지를살펴본결과, 세집단간유의한차이가나타나지않았다. 실제언어문제해결력검사는논리적인사고과정을언어화하는상위언어기술을측정하기위하여고안된검사도구로언어를통한문제해결능력과의사소통능력을살펴보기위한도구이다 (Pae et al., 2000). 따라서임상현장에서도학령기아동중언어문제뿐만아니라화용및의사소통에문제가있는아동에게언어문제해결력검사만으로문제를평가하고강약점을확인한다는것은다소제한적일수있다. 따라서이를보완하기위한방법을확인해볼필요가있다. 둘째, 교실환경을구조화한환경에서행동관찰을통해집단간차이를살펴본결과, 사회적의사소통장애집단은총사회적의사소통발생빈도가낮고고기능자폐아동집단보다비구어적수단을더높은빈도로사용하였다. 이는사회적의사소통장애는언어능력이정상발달을할지라도상호작용시, 최소한의역할만한다는선행연구결과 (Bishop, 2000; Botting & Conti-Ramsden, 1999) 를지지하는것으로나타났다. 실제로본연구의구조화된평가내에서사회적의사소통장애집단은자신의의견을명확하게표현해야하는상황이나반응하기에서구어로의사를표현하는것보다는눈짓, 고개등비구어적수단을사용하여상호작용하는모습이빈번하게나타났다. 또한협동놀이상황에서함께과제를수행해야하는보조연구자들보다는교사역할을했던연구자에게더의사소통의도를표현하였다. 이와는달리고기능자폐아동집단은사회적 52 http://www.e-csd.org

학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선외 Table 7. Analysis of variance for total scores of ToM by group Total scores of ToM 의사소통장애집단보다구어적수단빈도에서유의하게높은빈도 가나타났고비구어적수단빈도는다른두집단보다유의하게낮은 빈도가나타났다. 선행연구에서는고기능자폐의경우, 발화의양이 많지만장황하다는보고가있기때문에 (Lord et al., 1994; Volden & Lord, 1991) 구조화된환경내에서의구어표현이맥락에비추어 적절한지아닌지에대해구체적으로살펴볼필요가있다. 비구어적 수단의경우많은선행연구에서자폐아동의경우비구어적수단사 용에제한이있다는연구결과와일치하는것으로나타났다 (Baltaxe, 1977; Dewey & Everard, 1974; Murdock et al., 2007). 실제본 연구의구조화된평가내에서는고기능자폐아동집단은비구어적 수단중얼굴표정과부차언어사용에서보다낮은빈도가나타났 다. 또한사용을하더라도맥락에맞게적절하게사용하는것에제 한을보였다. 예를들어협동놀이상황에서타인 ( 보조연구자 B) 이 기분이좋지않을때걱정하는표정보다는낚시놀이를보고웃거 나혹은타인을걱정하는말투로목소리의강도를속삭이는것이 아니라부적절하게큰강도로의사소통하는모습등이나타났다. 사회적상호작용행동유형별개시하기와반응하기측면에서는 사회적의사소통장애집단은일반아동보다친사회적개시하기와 반응하기의빈도에서유의하게낮은빈도를보였다. 소극적반응하 기는사회적의사소통장애집단이다른두집단보다유의하게높은 빈도를보였다. SCD HFA TD F p- value Post-hoc test 14.13 (5.31) 9.60 (3.68) 15.67 (3.99) 7.753.001 HFA< SCD, TD Values are presented as mean (SD). SCD = social communication disorder; HFA = high-functioning autism; TD = typical development; ToM= theory of mind. Score 25 20 15 10 5 0 SCD HFA TD Figure 4. Total scores of ToM by group. SCD = social communication disorder; HFA= high-functioning autism; TD= typical development; ToM= theory of mind. 본연구의구조화된평가내에서사회적의사소통장애아동의행동예를살펴보면연필을요청해야하는상황에서요청하지않고비구어적으로연구자를쳐다보거나연필심이짧다고연필을비구어적인형태로보여주는모습이나타났다. 그리고질문지를보고정보요청하기를해야하는상황에서도마찬가지로비구어적으로쳐다보거나주위를두리번거리는행동만있지요청하기와같은개시하기의행동에제한을보였다. 놀이상황에서는연구자가아동을오해하는문제상황에대해진술을해야하는데 몰라요 의미로구어로반응하거나비구어적인형태로고개젓기와고개끄덕이기형태가주로나타났고적절하게언급하기혹은진술하기를하지못하였다. 이후보조연구자가오해를풀어주기위해상황에대해진술할때고개를끄덕거리며타인의대화내용에반응하였다. 이러한의사소통의어려움은사회적의사소통장애는상호작용시, 자신감이부족한모습으로보여지거나혹은적절한정보의양제공에제한이있다고보고하고있다 (Bishop, 2000; Bishop et al., 2000). 또한선행연구에서는이러한어려움은화자의의도이해와실행기능의제한과연결하여설명하고있다 (Bishop & Baird, 2001; Geurts et al., 2004; Martin & McDonald, 2003). 고기능자폐아동집단은이탈적개시하기빈도에서다른두집단보다유의하게높은빈도를보였고독단적개시하기빈도는일반아동집단보다유의하게높은빈도를보였다. 그리고이탈적반응하기와독단적반응하기에서고기능자폐아동집단이다른두집단보다유의하게높은빈도를보였다. 이러한고기능자폐의어려움은 Lord 등 (1994) 과 Murdock 등 (2007) 의연구에서는의사소통의도를표현하였을때맥락과는다른부적절한것이라는선행연구와일치한것으로나타났다. 이러한결과는선행연구에서고기능자폐의경우, 상호작용시사회적으로부적절한코멘트의빈도가높다고보고하였고 (Dewey & Everard, 1974; Volden & Lord, 1991) 타인과상호작용시반응하기보다는혼자놀이에빠지는경우가빈번하게나타난다고하였다 (Murdock et al., 2007). 고기능자폐의경우, 말하는사람의발화를맥락에적절하게해석하는데어려움을보여효율적인의사소통에어려움을보인다고하고있고 (Jolliffe & Baron-Cohen, 1999) 맥락적정보이해어려움은타인의마음이해능력과연결하여해석하고있다 (Hilton et al., 2007). 마지막으로적절하게대답한마음이해점수는고기능자폐아동집단이다른두집단에비해유의하게낮은수행을보였다. 선행연구에서는고기능자폐아동집단은마음이해에어려움이있다는보고가많다. 고기능자폐아동집단과사회적의사소통장애를대상으로마음이해특성을비교한연구를살펴보면사회적의사소통장애 http://www.e-csd.org 53

Yeon Sun Jin, et al. Communication profiles of School-Aged Children with SCD and HFA 가자폐범주성장애보다사회인지측면에서보다적은손상이있다고보고하고있다 (Botting & Conti-Ramsden, 1999). 특히자폐범주성장애와는달리사회적의사소통장애는동기 (motivation) 와사회적인식 (social awareness) 에서보다온전하다고하였다. 따라서본연구의결과는이러한특징을지지하는것으로나타났다. 만약자폐범주성장애로진단되지않고사회적의사소통장애로의심된아동들중에사회인지과제에서모두실패한경우오히려 자폐범주성장애 로명명될수있다고하였다 (Botting & Conti-Ramsden, 1999). 하지만사회적의사소통장애아동은 first-order 과제는적절하게수행하나 second-order 과제는어려움이있다는보고도있다 (Prior et al., 1998; Shields et al., 1996). 따라서추후연구에서는마음이해과제의유형에따라어떠한특성을보이는지살펴볼필요가있을것으로사료된다. 이전에사회적의사소통장애집단과고기능자폐아동집단간의의사소통차이를살펴본선행연구들은대부분체크리스트를통해서로다양한입장을보고하고있다. 첫째, 사회적관계와관심, 상동행동영역은사회적의사소통장애집단과고기능자폐아동집단을구별하는데유용하다고보고하고있다 (Norbury et al., 2004; Reisinger et al., 2011). Norbury 등 (2004) 의연구에서는아동기의사소통체크리스트-2에서 PRAG는고기능자폐아동집단이사회적의사소통장애집단보다유의하게낮은수행을보였고특히 I 영역인사회적관계 (social relation) 와 J 영역인관심 (interests) 범주가고기능자폐아동과사회적의사소통장애집단을살펴보는데유용하다고보고하였다. 또한 Reisinger, Cornish와 Fombonne (2011) 의연구에서도자폐범주성장애집단과사회적의사소통장애집단의차이는사회적상호작용과전형화된상동행동에서나타난다고보고하였다. 뿐만아니라 Bodfish, Symons, Parker와 Lewis (2000) 의연구에서도자폐아동이이러한상동행동의빈도가더높게나타나고더심각하다고하였다. 둘째, 또다른연구들에서는학령기사회적의사소통장애집단과고기능자폐집단을비교하였을때사회적관계와관심, 상동행동영역에서항상집단간차이가있는것은아니라고언급하고있다 (Brook & Bowler, 1992; Shields et al., 1996). 두집단의유사성은의사소통증상의심각성에따라차이가존재할수있다 (Bishop & Norbury, 2002; Botting & Conti-Ramsden, 2003). 이러한결과의가능성은학령기때고기능자폐아동은다른자폐범주성장애에서관찰될수있는행동문제보다적을수있다고보고하고있다. 이는고기능자폐아동들이학령기가되고, 보다높은수준으로성숙하게되면서이와같은행동의빈도가줄어들수있다고보고하고있다. 셋째, 또다른관점의선행연구에서는사회적의사소통장애를자폐스펙트럼장애의하부그룹으로보기도하 였다 (Bishop & Rosenbloom, 1987; Boucher, 1998; Rapin, 1996). 특히사회적의사소통장애중자폐스펙트럼장애가보이는증상들이진단준거에서약하게나타나는것으로이들을 PLI-high 라고언급하기도하였다 (Bishop & Norbury, 2002; Botting & Conti-Ramsden, 2003). Bishop 과 Norbury (2002) 의연구와같이현장에서자폐진단검사에서준거점수 (cut-off score) 에는점수가미치지않아자폐로진단받을순없지만자폐준거점수에가까운아동을만나게되었을때우리는언어치료사로서언어및의사소통에대한평가및중재에대한접근을고민해야한다. 뿐만아니라이들은자폐진단준거에는미치지못했지만그렇다고하더라도사회적의사소통장애집단과는다르게분류하여야할것으로사료된다. 본연구는선행연구에서더나아가언어문제해결력검사, 교실환경을구조화한환경에서행동관찰, 마음이해검사를통해세집단의차이를살펴보았다. 본연구결과를바탕으로종합한내용과시사하는바는다음과같다. 첫째, 이전의연구에서는언어능력이유사한사회적의사소통장애와고기능자폐의특성에대해많은혼돈이있어왔다 (Brook & Bowler, 1992; Gagnon, Mottron, & Joanette, 1997). 하지만본연구에서는사회적의사소통장애와고기능자폐아동을비교하였을때유사하지않음을확인할수있었다. 사회적의사소통장애집단과고기능자폐집단의차이가나타난행동은도구를통한공식검사에서는확인하는데제한을보였다. 하지만행동관찰을통해살펴보면총사회적의사소통발생빈도는사회적의사소통장애집단이유의하게낮은빈도를보였고구어적수단은적게사용하였고비구어적수단은보다많이사용하는것으로나타났다. 그리고고기능자폐장집단은구어적수단은높은빈도로사용하였고비구어적수단은낮은빈도로사용하였다. 상호작용유형별로개시하기와반응하기를살펴보면고기능자폐집단은이탈적개시하기빈도, 이탈적반응하기, 독단적반응하기에서유의하게높은빈도를보였고사회적의사소통장애집단은소극적반응하기가유의하게높은빈도로나타남을확인할수있었다. 마지막으로마음이해과제를실시하였을때고기능자폐아동집단이사회적의사소통장애집단과일반아동집단보다유의하게낮은수행을보였다. 둘째, 사회적의사소통용어를사용하였을때기술혹은진단적인측면에서가능성을확인하였다. 본연구에서는화용문제가때때로자폐범주성장애를위한준거가아닐수있다는것을확인하였다. Bishop과 Rosenbloom (1987) 은자폐범주성장애도아니고언어손상으로위한의사소통문제가아닌아이들을위해보다적절한이름으로확인하려노력하였다 (Bishop & Rosenbloom, 1987). 그래서화용언어장애라는용어 54 http://www.e-csd.org

학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선외 사용과그들의특징에대해기술하려고노력하였다. 이후 DSM-5 에서사회적의사소통장애라는용어가새로언급되었고이들의특징에대해이전화용언어장애의연구들을기반으로설명하였다. 이처럼본연구를바탕으로국외뿐만아니라국내에서도언어와인지적인영역에서손상이없고자폐범주성장애도아닌아이들중에의사소통에어려움이있는사회적의사소통장애가있다는것을확인할수있었다. 마지막으로학령기사회적의사소통장애, 고기능자폐아동과같이의사소통이손상된아동의수행능력을살펴보기위해서는학령기아동이자주접하는사회적맥락즉, 교실상황에서의수행을살펴봐야한다 (Conti-Ramsden, Crutchley, & Botting, 1997; Jin & Pae, 2011). 따라서부모나언어병리학자뿐만아니라교사의역할이굉장히중요하고또한관련분야의심리학자, 특수교사, 또래등과같이다양한파트너의역할이중요하다. 따라서본연구결과를바탕으로추후연구에서는평가및중재방향을제시하는데있어서다양한분야의파트너들과의협력이꼭필요할것으로사료된다 (ASHA, 2013). REFERENCES Adams, C. (2001). Clinical diagnostic and intervention studies of children with semantic-pragmatic language disorder. International Journal of Language & Communication Disorders, 36, 289-305. Adams, C., & Bishop, D. V. M. (1989). Conversational characteristics of children with semantic-pragmatic disorder. I: Exchange structure, turntaking, repairs and cohesion. British Journal of Disorders of Communication, 24, 211-239. Adams, C., & Lloyd, J. (2005). Elicited and spontaneous communicative functions and stability of conversational measures with children who have pragmatic language impairments. International Journal of Language & Communication Disorders, 40, 333-347. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorder (4th ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorder (5th ed.). Washington, DC: American Psychiatric Association. American Speech-Language-Hearing Association. (2013). Social communication disorders in school-age children. http://www.asha.org/practice-portal/clinical-topics/social-communication-disorders-in-school-age-chil- dren/. Andersen-Wood, L., & Smith, B. R. (2000). Working with pragmatics: a practical guide to promoting communicative confidence. Bicester: Winslow Press. Baltaxe, C. A. M. (1977). Pragmatic deficits in the language of autistic adolescents. Journal of Pediatric Psychology, 2, 176-180. Baltaxe, C. A., & D Angiola, N. (1992). Cohesion in the discourse interaction of autistic, specifically language-impaired, and normal children. Journal of Autism and Developmental Disorders, 22, 1-21. Bishop, D. V. M. (2000). Pragmatic language impairment: a correlate of SLI, a distinct subgroup, or part of the autistic continuum? In L. B. Leonard & D. V. M. Bishop (Eds.), Speech language impairments in children: causes, characteristics, intervention and outcome (pp. 99-113). New York, NY: Psychology Press. Bishop, D. V. M. (2003). The children s communication checklist-2. London: Psychological Corporation. Bishop, D. V. M., & Adams, C. (1989). Conversational characteristics of children with semantic-pragmatic disorder. II: What features lead to a judgement of inappropriacy? British Journal of Disorders of Communication, 24, 241-263. Bishop, D. V. M., & Baird, G. (2001). Parent and teacher report of pragmatic aspects of communication: use of the children s communication checklist in clinical setting. Developmental Medicine & Child Neurology, 43, 809-818. Bishop, D. V. M., & Norbury, C. F. (2002). Exploring the borderlands of autistic disorder and specific language impairment: a study using standardised diagnostic instruments. Journal of Child Psychology and Psychiatry, 43, 917-929. Bishop, D. V. M., & Rosenbloom, L. (1987). Classification of childhood language disorders. Language Development and Disorders, 22, 61-81. Bishop, D. V. M., Chan, J., Adams, C., Hartley, J., & Weir, F. (2000). Conversational responsiveness in specific language impairment: evidence of disproportionate pragmatic difficulties in a subset of children. Development and Psychopathology, 12, 177-199. Bodfish, J. W., Symons, F. J., Parker, D. E., & Lewis, M. H. (2000). Varieties of repetitive behavior in autism: comparisons to mental retardation. Journal of Autism and Developmental Disorders, 30, 237-243. Botting, N., & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: the children in question. Autism, 3, 371-396. Botting, N., & Conti-Ramsden, G. (2003). Autism, primary pragmatic difficulties, and specific language impairment: can we distinguish them using psycholinguistic markers? Developmental Medicine & Child Neurology, 45, http://www.e-csd.org 55

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학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선외 국문초록 학령기사회적의사소통장애와고기능자폐아동의의사소통능력차이 진연선 1 배소영 2 1 을지병원정신건강의학과, 2 한림대학교언어청각학부 배경및목적 : 사회적의사소통장애란구어적 비구어적수단을사회적으로적절하게사용하는것에어려움을보이는것으로자폐와는다르다. 본연구의목적은다양한평가방법을통해한국의사회적의사소통장애의특성을살펴보고자하였고이들을고기능자폐집단과비교하였을때어떠한차이가있는지에대해살펴보고자하였다. 방법 : 연구대상은초등학교 1학년부터 6학년까지의학령기사회적의사소통장애, 고기능자폐, 일반아동집단각 15명씩총 45명을대상으로하였다. 이들의차이를살펴보기위해언어문제해결력검사, 교실환경을구조화한상황에서행동관찰, 마음이해과제를실시하였고수집된자료를분석하였다. 결과 : 첫째, 언어문제해결력검사에서는집단간차이가나타나지않았다. 둘째, 셋째, 교실환경을구조화한환경에서행동관찰을통해분석한결과, 총사회적의사소통발생빈도 (SCD < TD), 구어적수단빈도 (SCD < HFA, TD), 비구어적수단빈도 (HFA< SCD, TD) 에서집단간차이가나타났다. 그리고개시하기측면에서는친사회적 (SCD < TD) 이탈적 (HFA>SCD, TD) 독단적 (HFA>TD) 개시하기에서집단간차이가나타났고반응하기측면에서는친사회적 (TD> SCD, HFA) 소극적 (SCD>HFA, TD) 이탈적 (HFA> SCD, TD) 독단적 (HFA> SCD, TD) 반응하기에서집단간차이가나타났다. 마지막으로마음이해점수에서도집단간차이가나타났다 (HFA< SCD,TD). 논의및결론 : 본연구는학령기사회적의사소통장애와고기능자폐아동집단의차이를다양한평가방법을통해살펴보았다는것에의의가있다. 이는현장에서평가및중재방향에대한유용한기초자료를제공한것으로사료된다. 핵심어 : 사회적의사소통장애, 고기능자폐, 학령기아동, 사회적의사소통능력, 마음이해 참고문헌 곽금주, 박혜원, 김청택 (2001). 한국판아동용웩슬러지능검사 (K-WISC-III). 서울 : 도서출판특수교육. 김영태, 홍경훈, 김경희, 장혜성, 이주연 (2009). 수용 표현어휘력검사 (REVT). 서울 : 서울장애인종합복지관. 배소영, 임선숙, 이지희 (2000). 언어문제해결력검사. 서울 : 서울장애인종합복지관. 양혜영, 김혜리, 김경미, 구재선, 정명숙, 박은혜 (2008). 초등학생의마음이론과사회적능력의관계. 한국심리학회지 : 발달, 21, 31-47. 유희정역 (2008). 사회적의사소통설문지 (SCQ). 서울 : 학지사. 이윤경 (2007). 학령기아동언어검사도구개발. 언어청각장애연구, 12, 569-586. 진연선, 배소영 (2011). 사회적의사소통기술에관한국내문헌연구. 언어치료연구, 20, 143-165. 진연선, 배소영 (2013). 교실환경을반영한상황에서의학령기고기능자폐장애와단순언어장애아동의사회적의사소통능력. 언어청각장애연구, 18, 241-257. http://www.e-csd.org 59