Joint Attention As a Primary Target for Intervention in a Young Child with ASD

Volume 4, Issue 5 March 2010 EBP briefs

A scholarly forum for guiding evidence-based practices in speech-language pathology

Joint Attention as a Primary Target for Intervention in a Young Child with ASD

Summer Perkins and Erin Brooker Lozott EBP Briefs

Editor Chad Nye University of Central Florida

Editorial Review Board Frank Bender Anita McGinty Private Practice University of Virginia Bertha Clark Judy Montgomery Middle Tennessee State University Chapman University Gayle Daly Barbara Moore-Brown Longwood University Anaheim Union High School District Donna Geffner Jamie Schwartz St. John’s University University of Central Florida Joan Kaderavek Sheila Ward University of Toledo Detroit Public Schools Cheryl Lang Detroit Public Schools

Managing Director Tina Eichstadt Pearson 5601 Green Valley Drive Bloomington, MN 55437

Cite this document as: Perkins, S. & Lozott, E. B. (2010). Joint attention as a primary target for intervention in a young child with ASD. EBP Briefs, 4(5), 1–7. Bloomington, MN: Pearson.

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NCS Pearson, Inc. 5601 Green Valley Drive Bloomington, MN 55437 800.627.7271 www.PearsonClinical.com Produced in the United States of America. 1 2 3 4 5 6 7 8 9 10 11 12 A B C D E Joint Attention as a Primary Target for Intervention in a Young Child with ASD

Summer Perkins, M.S., CCC-SLP Erin Brooker Lozott, M.S., CCC-SLP

Scenario Sandra, Sunshine Elementary school’s SLP, was concerned that the current IEP language goals did not Autism spectrum disorders (ASD) is a category of include social language (i.e., pragmatic language) goals, neurological disorders with deficits in three areas: social despite social language being a core deficit of autism. interaction, communication and repetitive, and restricted J.A.’s teacher invited Sandra to observe J.A. to assess attention and interests. Recent research (Kogan et al., his current language use and social interaction. Upon 2009) supported by initial data collected by the Center entering the class, Sandra noted J.A. was playing by for Disease Control (CDC) indicates that ASD is on the himself at the train center. He was playing with two rise, with 1 in 91 children between ages 3 and 17 years trains, using the dialogue from his favorite episode of a diagnosed with ASD. One of the early nonverbal popular train television show and re-enacting the communication behaviors that accompanies verbal television show with the trains. Sandra immediately interaction is joint attention—the ability to collaboratively observed that J.A. was not initiating joint attention with engage another individual in oral and social peers or adults. She went over to the train center, picked communication. up the crane, and said, “Wow! Look at this crane,” J.A. School-based speech-language pathologists (SLPs) responded to joint attention after 7 seconds and looked at will have more children with ASD on their caseloads as a the crane. J.A. was inconsistent in his response to joint result of earlier identification. To best serve these children, attention. When two other children came over to the train school-based SLPs must know the behaviors associated area and initiated joint attention about the tunnel with ASD and be able to implement the best intervention through words J.A. did not respond. Sandra attempted to practices available. SLPs will play an integral role in engage one more response to joint attention from J.A. educational teams, determining intervention goals that about the green train through gesture and words, with no target the student’s language deficit and the social response. J.A. continued to repeat the television show communication core deficits of autism. dialogue with his two trains. During a 30-minute observation, J.A. had no initiations for joint attention and only demonstrated one response to joint attention. Case Study Clinical Questions J.A. is a 4-year-old boy with an ASD diagnosis of autism. He recently transferred from another school In thinking about her observations of J.A., Sandra district to Sunshine Elementary School, where he was remembered an article presented in her district-sponsored, placed in the pre-kindergarten, varying exceptionalities quarterly discussion group on joint attention. The article classroom. J.A. has an individualized education plan (IEP) by Wetherby and Prizant (2002) indicated that joint from his previous school district with four attention is a core and distinguishing deficit in ASD and, communication goals: therefore, a possible target for intervention. To determine if joint attention was an appropriate goal and before • using a carrier phrase (i.e., I want, I see), deciding on an intervention strategy for J.A., Sandra • using pronouns, decided to conduct a literature review to answer the following critical questions: • labeling classroom vocabulary, and 1. What is the definition of joint attention and its • stating the function of objects. effects on social communication function?

2. Does intervention improve joint attention behavior? Effects of Joint Attention on Language 3. Does intervention improve social language and other and Other Social Communicative communicative functions? Functions 4. Is teaching joint attention educationally relevant and Mundy and Crowson (1997) suggested that joint critical for J.A.? attention is pivotal and that increases in joint attention With a clearer understanding of the definition and may lead to secondary and indirect changes in increases in nature of joint attention, and its relationship to language language ability and social skills, and decreases in abnormal and social communication skills, Sandra began searching behaviors. Menezes and Perissinoto (2008) argued that for research evidence that would assist her in deciding joint attention is foundational to language development how to implement a joint attention treatment program in general. In addition, several authors have demonstrated for J.A. associations between joint attention and later language ability in typically developing children (Mundy & Gomes 1996; Carpenter et al., 1998). Shumway and Wetherby Background (2009) have shown that for children 18 to 24 months with a diagnosis of ASD the most compelling predictor of verbal Definition of Joint Attention performance is the rate of acquisition of joint attention behaviors. Taylor and Hoch (2008) suggested that a greater Children engage in joint attention to interact with response to joint attention was associated with higher levels another person about an object or event in their of receptive language. Joint attention has also been environment (Mundy & Crowson, 1997), conveying the moderately correlated with nonverbal cognitive level message, “Look with me at this interesting object or event.” (Shumway & Wetherby, 2009), the development of This interaction involves the adult commenting about the symbolic and pretend play, and object imitation (Whalen object or event (e.g., “Yes, that’s a doggy!”) and looking & Schriebman, 2006). with the child at the object. Jones, Carr, and Feeley (2006) When assessing the predictability of joint attention defined joint attention as “when two people, for example for later language use, Mundy, Sigman, and Kasari (1990) a young child and his or her parent, share attentional focus found that the level of joint attention skills the child on interesting objects and events in their environment” exhibited at 3 years 9 months was positively associated with They argue that this ability to share attention to an object their language ability one year later. No other behavior (i.e., or event is particularly social in character and when social interaction, requesting, and language ability) was children engage in this activity, they are directing the other associated with language at follow-up. Similarly, Sigman person to join in a communicative exchange. and Ruskin (1999) and Bono, Daley, and Sigman (2004) Authors and scholars typically describe two types of concluded that response to joint attention was positively joint attention, (1) response to joint attention (RJA) and associated with gains in expressive language at age 12 (2) initiation of joint attention (IJA) (Mundy, Sullivan, & years. These studies indicated that joint attention behaviors Mastergeorge, 2009; Jones, Carr, & Feeley, 2006; measured at 4 years old were associated with social and Menezes & Perissinoto, 2008). According to Mundy et peer group behaviors at 12 years old. al., infants are able to demonstrate RJA by following a line of gaze, gestures, or head posture of the other person. Searching for Evidence of Intervention Infants also are able to demonstrate their use of IJA by Improving Communicative Functions indicating to the listener that there is a common point of reference or event to attend to in the environment. Mundy et al. pointed out that RJA and IJA emerge by age Study Inclusion Criteria 4 to 6 months. These two joint attentions are part of a Studies included in the review had to meet the following system, which integrates one’s visual attention with the criteria: (a) joint attention, (b) children with autism, external information of another person’s visual attention. (c) intervention or treatment, and (d) language outcomes. The types of attention are viewed as core skills in the These terms were used in various combinations for all development of interactive social skills. database searches. Sandra began her literature review using

a variety of resources available to her to find and evaluate the answering her questions. Sandra searched the American necessary information. These resources included: Speech Language Hearing Association (ASHA) website • internet sources (e.g., Google Scholar, PubMed), for information on how to evaluate the evidence. Her search brought her to the National Center for Evidence- • the local university’s on-line library system, Based Practice in Communication Disorders (N-CEP), • the Journal of Autism and Developmental Disorders and a recommendation for using the Scottish (J.A.DD) that she subscribed to from the years Intercollegiate Guidelines of Hierarchies of Levels of 2007-2009, and Evidence (SIGN) for evaluating research evidence for • articles from the local Center for Autism and Related clinical practice. Using the SIGN standards, Sandra rated Disabilities. the six included studies for research quality according the When Sandra conducted her online literature search, criteria presented in Table 1. she limited it to studies published between 2004 and the In analyzing the six studies, Sandra rated the Kasari, present. She obtained 271 potential citations from Google Freeman, and Paparalla, (2006) as a level Ib, indicating a Scholar and 157 citations from PubMed. Sandra collected well-designed randomized study, the strongest of the types full text copies of all articles that were specific to intervention for improving joint attention in children. of research design. This study, as a result, could receive From the full-text articles, Sandra identified six studies greater weight in Sandra’s decision-making process as it that fit her criteria of treatment of joint attention for meets a higher standard of research design that increases children with ASD. Five of the studies were single subject her level of confidence in the reported outcome(s). The and one was a randomized controlled trial (RCT). remaining five studies were level III studies, indicating well-designed, non-experimental studies. These five Evaluating Quality of Evidence studies were all single-subject designs. The results could Sandra needed to assess the quality of the six studies not be generalized to the population of interest. A to determine their scientific value and benefit in summary of the six studies is presented in Table 2.

Table 1. Scottish Intercollegiate Guidelines of Hierarchies of Levels of Evidence (SIGN)

Evidence Type Design Standard Ia Well-designed meta-analysis of >1 randomized Meta-analysis includes the quantitative summary of two or more controlled study randomized controlled trial studies in which post-treatment results are combined.

Ib Well-designed randomize controlled study A randomized controlled study is a study in which the participants are assigned to treatment or control groups immediately prior to implementation of the intervention. IIa Well-designed controlled study without A comparison post-treatment and control group study in which randomization participants may have been randomly selected but are assigned to groups on a non-random basis. IIb Well-designed quasi-experimental study Quasi-experimental studies include those studies in which participants are selected and assigned to treatment or control groups in a manner other than randomization. III Well-designed non-experimental studies, (i.e., Non-experimental studies would include pre-post single group design, correlational and case studies) single subject design, case study, or a correlational study.

IV Expert committee report, consensus conference, Expert evidence may include non-quantitative opinions, decisions, or clinical experience of respected authorities summaries by individuals or groups representing a professional position.

Note: The SIGN Guidelines of Levels of Evidence (2009) is adapted and reprinted with permission from the Scottish Intelligence Guidelines Network website: http://www.sign.ac.uk/methodology/index.html.

Table 2. Summary of Six Studies

Name of Number of Level of Study Type of Study Participants Evidence Treatment Outcome

Whalen & Single subject, n = 11 III Behavior modification Parent training is Schreibman, multiple baseline (5 with autism beneficial in teaching 2003 design across and 6 typical) and generalizing joint participants Ages 2:4–4:4 attention

Whalen, Single subject, n = 10 III 10-week joint attention Increase in: Schreibman, multiple baseline training program Ages 2:4–4:4 social initiations & Ingersoll, design was used across imitation 2006 all participant play spontaneous speech

Ingersoll & Multiple baseline n = 5 III Naturalistic behavioral Increase in: technique for teaching Schreibman, design across all Ages 2:4–4:5 imitation skills 2006 participants object imitation generalized skills to novel environments language pretend play joint attention

Jones, Carr, A multiple baseline n = 5 III Discreet Trial Training Increase in: & Feeley, probe design across and Pivotal Response Ages 2 to 3 yrs IJA and RJA 2006 the two joint Training expressive language attention skills (respond and initiate) social-communicative behaviors Peer-based joint attention instruction might be another promising avenue to pursue.

Kasari, Randomized, n = 56 Ib Applied behavior Increase in: Freeman, & analysis and controlled Ages 3 to 4 yrs IJA and RJA Paparalla, intervention study developmental Generalization to home 2006 procedures of responsive and facilitative Play group increase in: interactive methods Play skills and schemas Generalization to home

Schertz & Mixed methods n = 3 III A parent-mediated, Increase in: developmentally Odom, 2007 research design Ages 1:8–2:4 IJA/RJA grounded, researcher- 75% had repeated guided intervention performance in IJA/RJA model. (Activities from the Joint Attention Mediated Learning [J.A.ML] manual)

Taylor & Multiple baseline n = 3 III Verbal behavior Specific instruction program including Hoch, 2008 design across all Ages 3–4 yrs required for teaching IJA participants a series of prompts and coordinating gaze and reinforcement shift between an object procedures and a person

According to N-CEP, an important measure of pivotal for future language and social skills development. intervention study quality is the degree to which an intervention is implemented in an appropriate and Teaching Joint Attention to Children replicable manner. That is, the experimenter actually with ASD carried out and reported the intervention method in the Sandra needed to combine her knowledge of the way described in the study, a concept sometimes referred child, her newly acquired knowledge of joint attention, as implementation fidelity. Sandra found that the the available evidence, and the ASHA guidelines for “Introduction to Critical Appraisal: Training Notes” on diagnosis, assessment, and treatment of autism spectrum the ASHA website provided the guidance she needed to disorders to determine if joint attention was an assess the implementation fidelity. She then posed three educationally relevant and evidenced-based, primary broad questions that she found within the training notes. intervention target for J.A. 1. Are the results valid? When looking at educational relevance, Sandra 2. What are the results? reviewed her observations of J.A. Sandra determined that J.A. had a definite deficit in joint attention. His social 3. How will these results help me work with my skills were also negatively affected. Consistent with the patients? findings of Bono, Daley, and Sigman, (2004), Sandra Though five of the six studies resulted in scores less learned from the included studies that joint attention is a than three out of three, Sandra thought these studies pivotal skill domain, which supported her idea that merited further appraisal because the majority of studies targeting joint attention directly would indirectly affect reported for the field of autism typically used a single- social and language skills. She concluded that creating subject design. Table 3 presents a summary of the level of goals that increase RJA and IJA would be educationally evidence for these studies. relevant. Sandra reached a preliminary conclusion that if she ASHA guidelines indicate that the most critical targeted joint attention directly and then language, social domain for prioritizing intervention goals should be and peer group behavior could be positively impacted. derived for the core deficits of ASD and the core Creating a communication goal specific to joint attention challenges that affect social adaptive functioning reflected on an IEP for J.A. would be educationally relevant and in aspects of joint attention. In examining the data from

Table 3. Summary of Levels of Evidence and Implementation Fidelity Score

Level of Are Results What are Application Name of Study Evidence Valid? the results? to Patients Whalen & Schreibman, 2003 III 3/7 4/4 Yes

Schertz & Odom, 2007 III 3/7 4/4 No

Whalen, Schreibman, & Ingersoll, 2006 III 3/7 4/4 Yes

Taylor & Hoch, 2008 III 3/7 4/4 No

Ingersoll & Schreibman, 2006 III 3/7 4/4 Yes

Jones, Carr & Feeley, 2006 III 3/7 4/4 Yes

Kasari, Freeman, & Paparalla, 2006 Ib 7/7 4/4 Yes

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