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Methods to improve joint attention in young

children with autism: a review

This article was published in the following Dove Press journal:

Pediatric Health, Medicine and Therapeutics
19 May 2015
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Tanya Paparella Abstract: We provide an overview of studies in the past 10 years (2004–2014) that have aimed
Stephanny F N Freeman to improve joint attention (JA) in young children at risk for, or with, autism spectrum disorder.
Thirteen randomized controlled trial (RCT) interventions were found, which received particular
Department of Child Psychiatry and
Biobehavioral Sciences, University of focus. Three studies used intervention methods with a developmental orientation and focused on
California Los Angeles, Los Angeles, caregiver-mediated methods. Others used combined developmental and behavioral approaches
CA, USA
and delivered intervention via trained interventionists, caregivers, and teachers. Interventions
ranged widely in density, both with respect to the amount of intervention delivered weekly and
the total duration of intervention. Fourteen single-subject research design (SSRD) studies and
one quasi-experimental pre–post design study were also included. Notably absent in the RCTs
were studies using only behavioral methods, while behavioral methods dominated in the SSRDs.
The outcomes of the RCTs using combined behavioral and developmental methods generally
demonstrate short-term social communication gains. While some studies demonstrated long-
term maintenance and positive outcomes in related areas such as language, many did not. The
mixed results for language outcomes indicate a need for further investigation. In addition, future
studies should further examine participants’ developmental readiness and intervention dose in
relation to outcome, as well as aim to isolate active ingredients of interventions.
Keywords: intervention, joint attention, joint engagement, language, randomized controlled
trial

Introduction
Joint attention (JA) is the ability to share experiences and interests about objects and
events with others. Whereas neurotypical children develop a range of verbal and non-
verbal social communicative skills within the first 2 years of life, children with autism
spectrum disorders (ASDs) present with delayed and atypical social development.1
Children with ASD use less communicative gestures, such as pointing and showing,
to establish a shared focus of attention. They are also less likely to spend time in joint
engagement (JE) when a child and a social partner are involved with the same object
or event. This is concerning as children who engage in more JA and JE may facilitate
Correspondence: Tanya Paparella increased social learning opportunities for themselves. Further, JA skills and longer
Department of Psychiatry and
Biobehavioral Sciences, time in JE are linked to language acquisition, which in turn facilitates social skill
University of California Los Angeles, development.2–7 Initiating skills are strongly related to spoken language development,
78-243A Neuropsychiatric Institute,
760 Westwood Plaza, Los Angeles, responding to JA (eg, following another person’s gaze to join their focus) predicts
CA 90024-1759, USA preschool children’s language outcome 8 years later, and a summary variable of all JA
Tel +1 310 825 0147
Fax +1 310 825 0676
gesture use (both initiating and responding) also predicts better social outcomes.4–10
Email [email protected] Even when spoken language is not specifically targeted, interventions that improve

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JA appear to facilitate language development.11,12 The effects in September 2014. The search was restricted to materials
of treatments aiming to increase JA have been assessed in a published in peer-reviewed journals between January 2004
growing number of randomized controlled trials (RCTs). and September 2014. Keyword search terms were autism,
In this review, we focus on RCT interventions that have intervention, and JA or JE. This search identified 324 stud-
aimed to improve JA in young children with ASD and pro- ies for possible inclusion. Removal of duplicates yielded
vide an overview of results of research in the past 10 years. 167 manuscripts. Next, a review of titles and abstracts was
Second, we also summarize the outcomes from single-subject conducted with a Level 1 Screening (autism, age, and JA
research design (SSRD) studies and a group experimental intervention), excluding 43 original and 2 review articles
design study. whose references were examined, thus resulting in 122 full
manuscripts to be reviewed. The Level 1 Screening (autism,
Defining social communication age, and JA intervention) was then applied to the full manu-
Many would argue that all communication is inherently script because, at times, the abstract did not provide enough
social, because by definition it involves at least two people information for judgment. This yielded 56 manuscripts. The
engaging with one another with the aim of achieving mutual inclusion and exclusion criteria defined below were then
understanding.13 Indeed, in the literature on neurotypical devel- applied to the full text, resulting in 28 articles that met all
opment, communication that is social or not social is seldom inclusion criteria. In all, there were 13 RCTs, 1 group experi-
differentiated. This is not the case for young children with ASD, mental, and 14 SSRD articles (Figure 1).
where it is important to distinguish between communication
used for a social reason (JA) versus communication to regulate Inclusion and exclusion criteria
another person’s behavior (requesting) because the former is A set of inclusion and exclusion criteria was applied to the
impaired to the extent that it is considered a core deficit, while manuscripts obtained from the search. Included studies had
the latter is less affected.1,14,15 Although communication to the following features:
regulate another’s behavior is to some extent social, because it 1. Used a quantitative, RCT design, group experimental
involves a social partner, the underlying reason for the com- design, or SSRD.
munication is not inherently motivated by a desire to share 2. Were published in the English language.
with others. Thus, in this review, only studies that targeted JA 3. Were published in a peer-reviewed journal between
as an outcome were included. RCT studies that measured com- January 2004 to September 2014.
munication more generally without a clear differentiation of 4. Included participants between the ages of 1 year and 7 years
motivation as outlined above (eg, Hanen’s “More than Words” diagnosed with an ASD or were at risk for an ASD.
program) were excluded.16 Researchers have approached the 5. Examined an intervention for which JA or JE was
study of JA in two ways. Some studies have examined JA as an outcome. This excluded communication that
a context or state, with adult and child jointly attending to the was solely to request, protest, or regulate another’s
same object for a period of time.17,18 For example, a parent and behavior. It also excluded communication that was
a child looking at a book together, with both drawing each not clearly defined (eg, an outcome variable that com-
other’s attention to the pictures by pointing and labeling, may bined requesting and JA gestures, interaction in which
be viewed as an ongoing dyadic state of JE. Other studies the function/nature of the interaction was not clearly
have measured JA gestures for sharing purposes (eg, showing described as JE).
and pointing) to define both responding (RJA) and initiating 6. Included measurement of JA as a direct target. ­Studies
(IJA) behaviors. Thus, child responses to caregiver JA bids were excluded if JA was measured as a collateral
(eg, following an adult point with eye gaze) and children’s JA outcome.
initiations (eg, holding up something for another person to see,
or pointing at something themselves) are accounted for. Results
A total of 13 RCT studies were found based on these terms.
Methods Most were conducted in the USA, with one each from
Search strategy Norway, Belgium, and the UK. The number of participants
Six electronic databases (PsycINFO, Melvyl, PubMed, across studies ranged from 15 to 152. Three studies used
ERIC, Google Scholar, ASHA Journals) covering education, intervention methods with a developmental orientation and
medicine, communication, and psychology were searched focused on caregiver-mediated methods. Other studies used

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Dovepress Methods to improve joint attention in ASD

Identification
324 Records identified through 6 electronic databases

Screening 167 Manuscripts after duplicates removed

Reference sections of
167 Abstracts screened 43 Excluded 2 review articles
screened62,63
Eligibility

122 Full articles screened 66 Excluded

Inclusion criteria applied;

28 Excluded
28 articles met inclusion
Included

13 RCT 1 Group experimental 14 Single subject

Figure 1 Flow chart for eligibility for inclusion in study.

Abbreviation: RCT, randomized controlled trial.

combined developmental and behavioral approaches and testing a combined developmental behavioral approach
delivered intervention via trained interventionists, caregivers, included Interpersonal Synchrony (IS), Reciprocal Imita-
and teachers. Interventions ranged widely in density, with tion Training (RIT), and the Joint Attention and Symbolic
respect to the amount of intervention delivered weekly and Play/Engagement and Regulation Treatment (JASPER).22–24
the total duration of intervention. In addition, 14 more SSRD Indeed, JASPER dominated the RCTs in the past 10 years;
studies – most using a multiple baseline approach and one eight studies examined variations of JASPER treatment
using a group experimental design – were also identified. across multiple settings and delivery models (specialist,
caregiver, and teacher). Table 2.
Review and discussion
of RCT studies Methods with a developmental
In the 13 RCT interventions (refer to Table 1 for definitions orientation
of the outcome variables and Table 2 for study character- As the need for effective early intervention continues to be a
istics and findings), three developmental methods were focus, policy and practice recommendations have called for
tested, a Parent-Mediated Communication-Focused Treat- more developmentally appropriate and systematically deliv-
ment in Children with Autism (PACT), Focused Playtime ered interventions that can be easily carried out in the natural
Intervention (FPI), and Joint Attention-Mediated Learning setting, can be integrated into everyday experiences, and
(JAML).19–21 Of these, two were caregiver mediated and are supportive of the parent–child relationship.25 Caregiver-
designed to increase parent responsiveness.19,21 The studies mediated interventions are viewed as desirable because they

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Table 1 Definitions of IJA, RJA, and JE for the RCT outcome Table 1 (Continued)
variables Authors (year) Outcome variable definition
Authors (year) Outcome variable definition Landa IJA = unspecified, measured as directed using the
Goods IJA = composite variable: CJL + points + gives + et al (2011)22 Communication and Symbolic Behavior Scales
et al (2013)36 shows Developmental Profile
Green JE = proportion of time in parent–child mutual Lawton and IJA
et al (2010)19 shared attention Kasari (2012)35 • CJL
Ingersoll IJA • Point
(2012)23 • Eye contact • Show
• CJL • Give
• Point Supported engagement = unspecified, measured
• Show as directed using the Adamson, Bakeman, and
• Lower level = eye contact and CJL Deckner (2004)56 protocol
• Higher level = pointing and showing Schertz RJA = respond to parent bid for attention with a CJL
Kaale IJA et al (2013)21 IJA
et al (2012)38 • Show • CJL for the purposes of “showing”
• Point Wong RJA = child responds (attentional or behavioral) to
• Give (2013)37 point or show IJA
• JE
• Point
Child and the preschool teacher being actively
• Show
involved in the same object or event. SJE = child
JE = child and another are actively involved in the
did not overtly acknowledge the preschool
same object or toy.
teacher. CJE = both the child and teacher were
actively coordinating their attention to the shared • Supported = engagement is actively maintained
object or event and each other. Composite by other
variable created of SJE + CJE • Coordinated = child initiates or is actively
Kasari RJA involved with CJL to share attention
et al (2006)24 • Follow point Abbreviations: CJE, coordinated joint engagement; CJL, coordinated joint looks;
• Follow gaze IJA, initiating joint attention; JE, joint engagement; RCT, randomized controlled trial;
RJA, responding to joint attention; SJE, supported joint engagement.
IJA
• CJL
• Point are evidence based and parents can deliver the intervention
• Show
throughout the day, thereby maximizing density. In 2002,
• Give
JE Siller and Sigman26 showed in a prospective longitudinal
• Amount of time in child-initiated JE with parent study that early developmentally responsive parental behav-
Kasari RJA iors predicted long-term language outcomes of children with
et al (2010)33 • Follow point
• Follow gaze
ASD. Their study showed that parents who engaged with their
JE child during play using responsive strategies had children who
• Amount of time in child-initiated JE with parent made larger subsequent gains in language abilities over the
Kasari IJA
course of 10 years and 16 years than parents who were less
et al (2014)32 • Commenting
Kasari IJA responsive initially.
et al (2014)34 • CJL With language being a strongly desirable outcome and
• Point caregiver implementation a practical delivery model, three
• Show
studies examined the effectiveness of responsive styles of
• Joint attention language
JE parent interaction in a play context. These interventions
• Child and caregiver engaged with the same supposed that a naturally responsive and sensitive style of
activity and both aware of the roles of the other
caregiver interaction could be adapted to facilitate increased
Kasari RJA
et al (2014)20 • Follow point communication and social engagement in young children
• Follow gaze with ASD. In general, responsive interactions were those
IJA wherein a parent followed in and joined the child’s actions
• CJL
using contingent language and/or actions. The approach
• Point
• Show encouraged child choice and parents were to follow their
• Joint attention language child’s lead, join their focus, and build on the interaction in
(Continued) a nondemanding style.

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 Table 2 RCT study characteristics and findings on IJA, RJA, and JE
Authors Sample size Mean CA (MA), Methods Mean/fidelity Outcome (measure[s])
Dovepress

(year) both in months

Goods et al N=7 Tx; 48.73 (17.21); JASPER, preschool, specialist delivered 2×/wk, 88.27% No change on IJA (ESCS, teacher–child
(2013)36 N=8 control 54.68 (13.91) 30 min, 12 wks play interaction)
Green et al N=77 Tx; 45 (27.0);† PACT clinic-based parent-mediated 2×/wk for Median of 13.4 out of No change on JE, shared attention,
(2010)19 N=75 control 45 (25.3)† 2 hrs for 6 mo plus 1×/mo booster 6 mo 14 criteria per session language (caregiver–child interaction)
Ingersoll N=14 Tx; 39.3 (20.8);‡ RIT clinic–based, specialist delivered 3×/wk 94% RIT treatment effect on IJA (ESCS)
(2012)23 N=13 control 36.5 (17.9)‡ for 1 hr for 10 mo
Kaale et al N=34 Tx; 47.6 (25.6); JASPER preschool-based teacher-delivered 85% tabletop; 83% floor JASPER treatment effect on IJA to teachers and
(2012)38 N=27 control 50.3 (30.3) 6 hr initial training 20 min 2×/day for 8 wks JE with mothers, no effect on language (ESCS,
teacher–child play interaction)
Kasari et al 43.20 (26.29); JASPER clinic-based specialist-delivered 95% tabletop; 92% floor JASPER treatment effect on RJA, IJA, JE,

Pediatric Health, Medicine and Therapeutics 2015:6

N=20 JA Tx;
(2006)24 N=21 play Tx; 42.67 (24.55); 30 min/day 5–6 wks language (ESCS, caregiver–child interaction)
N=17 control 41.94 (21.86)
Kasari et al N=19 Tx; 30.35 (19.83); JASPER clinic-based caregiver-mediated r=0.89 caregivers; JASPER treatment effect on RJA and JE
(2010)33 N=19 control 31.31 (18.57) 8 wks 30 min, 3×/wk r=0.86 interventionists (caregiver–child interaction)
Kasari et al N=31 Txa; 75 (47.16); JASPER + EMT§ + SGD;a JASPER + EMTb a=93.69%; b=94.26% JASPER+EMT+SGD treatment of increased
(2014)32 N=30 Txb 74 (48.00) clinic based. Stage 1: 1 hr, 2×/wk, 12 wks; comments (natural language sample)
Stage 2: 1 hr, 3×/wk, 12 wks
Kasari et al N=60 Tx; 41.9 (23.6); JASPER caregiver in-home-mediated 1 hr, 76% interventionist α=0.82 Treatment effect on IJA and increased JE
(2014)34 N=52 control 42.8 (26.3) 2×/wk for 12 wks diary, α=0.86 caregiver quality greater for the JASPER group (ESCS,
of involvement scale caregiver–child interaction)
Kasari et al N=32 Tx; 22.18 (14.32); FPI home-based specialists delivered 90 min, 96% interventionist No treatment effect on RJA, IJA, or language
(2014)20 N=34 control 22.56 (15.05) 1×/wk, 12 wks (ESCS, caregiver–child interaction)
Landa et al N=24 Tx; 28.6 (27.5);¶ IS classroom-based interventionist delivered P=0.047 to P,0.001 difference Approaching significant treatment effect for IJA
(2011)22 N=24 control 28.8 (31.1)¶ 4×/wk 2.5 hrs for 26 wks. Parent training, home between Tx and controls and shared affect (Communication and Symbolic
based 1×/mo, 1.5 hrs, parent education (38 hrs) for targeted behaviors Behavior Scales Developmental Profile)
Lawton N=9 Tx; 46 (30.3); JASPER classroom-based teacher-implemented 99% interventionist P,0.05 to ESCS, teacher–child interaction
and Kasari N=7 control 43 (33.8) 2×/wk 30 min for 6 wks P,0.001 difference between
(2012)35 Tx and control teachers
for targeted behaviors
Schertz et al N=11 Tx; 24.6 (21.0);# JAML caregiver-mediated in-home 1×/wk 90% parents; Treatment effect on RJA, no effect on IJA;
(2013)21 N=12 control 27.5 (25.9)# average 30 wks 89% interventionist (precursors of joint attention measure)59
Wong N=14 Tx, JA-SP 56.21 (36.25); JASPER classroom-based teacher-delivered 75% Treatment effect for both treatment groups on
(2013)37 N=10 Tx, SP-JA 54.50 (27.39); 1×/wk, 1 hr for 8 wks JE, IJA, and RJA (ESCS)
N=9 control 59.67 (30.38)
Notes: †Mullen non verbal mental age; ‡Bayley Non verbal, mental age; ¶Mullen visual reception T-Score; #Mullen receptive language mental age.

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Abbreviations: CA, chronological age; MA, mental age; SP, symbolic play; Tx, treatment, §EMT, enhanced milieu training; SGD, speech generating device; CJE, coordinated joint engagement; CJL, coordinated joint looks; ESCS, Early
Social Communication Scales; FPI, Focused Playtime Intervention; IJA, initiating joint attention; IS, interpersonal synchrony; JAML, Joint Attention Mediated Learning; JASPER, Joint Attention and Symbolic Play/Engagement and Regulation
Treatment; JE, joint engagement; MA, mental age; PACT, parent-mediated communication-focused treatment; RCT, randomized controlled trial; RIT, reciprocal imitation training; RJA, responding to joint attention; SJE, supported joint
engagement.

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Parent-mediated communication-focused treatment Although parental responsiveness improved, there were

Green et al19 tested a PACT strategy. The manualized treat- no treatment effects on child outcomes of RJA, IJA, or lan-
ment was organized according to normative prelinguistic and guage both posttreatment and after 1 year.
early language skill development. The aim of the intervention
was to increase parent responsiveness and sensitivity to child Joint Attention-Mediated Learning
communication and decrease mistimed parent responses. JAML is an interaction-based approach that directly and
Strategies used to develop the child’s communication included exclusively addresses the social functions of preverbal
action routines, familiar repetitive language, and pauses. communication by targeting engagement at progressively
Individual sessions were delivered to parent–child dyads complex levels within parent–child relationships. Schertz
by six trained speech and language therapists, mostly in et al21 tested the effects of their JAML intervention on the
specialist centers. After an initial orientation meeting, fami- acquisition of JA for toddlers with ASD.
lies attended biweekly 2-hour clinic sessions for 6 months The JAML intervention was structured with three
(total 18), followed by monthly booster sessions for 6 months. developmentally sequenced phases. In the “Focusing on
Between sessions, families were asked to do 30 minutes of Faces” phase, the child was scaffolded to look often to the
daily home practice, and video feedback was provided on parent’s face. In the “Turn Taking” phase, the child and
intervention strategies. The study achieved positive results in parent engaged in reciprocal repetitive play that acknow­
terms of increasing synchronous parental responses but did ledged the other’s shared interest by accommodating the
not affect child outcomes of social communicative respond- parent’s turn. Finally, toys were used to promote triadic
ing, initiating, shared attention, or language. engagement in the “Joint Attention” phase (both respond-
ing and initiating).
Focused playtime intervention The intervention delivery was guided by five principles
FPI was developed as a systematic intervention specifically of mediated learning. It emphasized “learning how to learn”
designed to increase parental responsiveness considering the about social communication through the parent–child rela-
evidence of long-term language gains.26,27 The primary goal tionship instead of training the parent in specific strategies.
of the following recently published RCT20 was to determine The principles applied to both toddler and parent learning.
whether a developmentally informed, low-intensity parent- For toddlers, parents used the principles to help their children
education intervention to increase parent responsiveness 1) focus their attention on the objectives in a phase (eg, Turn
(FPI) would improve children’s JA and language skills both Taking), 2) improve self-regulation, 3) develop confidence
postintervention and after 1 year. related to the phase goals, 4) recognize interaction cues that
Caregivers and their 66 toddlers at high risk for ASD are socially important, and 5) interact more frequently in a
were randomized into the FPI treatment or a control group. variety of settings and with different people.
Intervention strategies were organized into topics delivered As parents applied mediation principles to promote their
in a specific sequence. Topics included understanding the toddlers’ learning, intervention coordinators applied the same
child’s communication skills, how to create play routines, principles with parents in weekly home-based intervention
parent’s communication and language during play, the sessions. The approach was intended to develop parents’
importance of coordinated attention between parent and internalization of JAML’s aims so that they could apply
child, recognizing the child’s attentional cues, strategies to the principles within parent–child interactions and daily
support coordinated attention, responsiveness to the child’s activities.
bids for JA, and communicative gestures. Trained interventionists conducted at least 16 home-
In the first half of each intervention session, the parent– based intervention sessions with parents; however, if a child
child dyad engaged in play with the interventionist present. had not made sufficient progress in a phase, then sessions
The interventionist also demonstrated strategies related to were added. There was considerable variability in the time
the targeted topic and provided feedback on parent use of to intervention completion, with a range of 4–12 months
strategies and their child’s responses. In the second half, the (average of 7 months). In each session, parents interacted
parent received education without the child being present. with their toddlers for 10 minutes. The interaction was
During this session, the interventionist elaborated on the recorded and used to facilitate feedback focusing on the
targeted topic using video feedback, conventional teaching, targeted phase and the principles of mediated learning. In
a workbook, and weekly homework. the second part of the session, new material was introduced:

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Dovepress Methods to improve joint attention in ASD

either the next mediated-learning principle in the sequence Methods with a combined developmental
or a new intervention phase if appropriate. Multiple teaching and behavioral approach
tools were used, including handouts, daily activity logs, video Historically, clinicians and researchers have been polarized,
feedback, and video examples of other ASD toddlers and adopting either a behavioral or a developmental approach.
parents. Parents were expected to spend 30 minutes daily It is only in recent years that the unique strengths of both
dedicated to face-to-face interaction, as well as integrating methods have been combined to utilize their respective
the content naturally in daily activities. contributions.
Follow-up visits occurred 4 and 8 weeks after interven- In the following studies, developmental methods were
tion ended. The JAML intervention children showed sig- combined with a behavioral approach, offering the addition
nificantly more responses to parents’ JA bids, with a large of a direct and highly systematic approach for teaching skills.
effect size that was maintained at follow-up. IJA generated Behavioral strategies include priming of skills, use of a prompt
a modest effect size but did not reach statistical significance. hierarchy to shape skills, reinforcement to increase motiva-
Although language was not directly targeted in the interven- tion, repeated practice and targeting of successive smaller
tion, receptive language was significantly improved in the goals toward a larger goal, and ensuring generalization of
JAML group. skills. Behavioral strategies directly shape skills, provide
dense practice, and account for learning differences that char-
Summary acterize many children with ASD, particularly with respect
Three different developmentally-based interventions were to decreased naturalistic learning. On the other hand, the
used to target increased social communication in young developmental methods offer opportunity for child initiation
children with autism. Two of the interventions, PACT and and ideation, generalization to more natural learning environ-
FPI, did not elicit treatment effects on social communication ments, and account for attentional difficulties in that the adult
or language. The third intervention, JAML, did improve both follows in on the child’s attention and creates opportunities
children’s ability to respond to JA bids initiated by adults and for learning within the child’s existing attention focus.
the child’s receptive language. (Table 2).
It is notable that there were minimal treatment effects Interpersonal synchrony
in two studies and one improved the RJA but not IJA. One Landa et al22 evaluated the impact of supplementing a com-
explanation is that JA as a core deficit in autism may require prehensive intervention with a curriculum targeting social
much more direct teaching to facilitate change.20 While it is synchronous behaviors in toddlers with ASD. Fifty toddlers
important to target parental responsiveness, parent change were randomized to one of two 6-month interventions: IS
alone may not be enough to significantly affect areas of core or Non-IS.
deficit in the children. A second possibility is that some out- The Assessment, Evaluation, and Programming System
come targets of these studies were not yet observable in such for Infants and Children curriculum was used for both
developmentally young children.1 Although the children’s groups.28 The treatment group received a supplementary cur-
ages varied from ,30 months of age in the JAML and FPI riculum with increased and systematically focused learning
studies to 45 months of age in the PACT study, all of the opportunities targeting JA, including RJA, IJA, and sharing
children were developmentally around 2 years of age. positive affect. The instructional strategies included adult-
Specialist-delivered intervention also did not favor directed behavioral instruction such as discrete trial training
targeted outcomes; rather, it appeared that density of (DTT), behavioral strategies in the natural environment, and
intervention may have been a salient factor. The JAML developmental routine-based interactions wherein inter-
study delivered intervention once per week over 30 weeks. ventionists followed the child’s lead and expanded on child
­However, individual intervention sessions were added as language and behavior. The interventions provided identical
needed to facilitate child progress, which may have been intensity (10 hours per week in classroom), student-to-teacher
a salient strategy to facilitate change in skills. The FPI ratio (5:3), home-based parent training (1.5 hours per month),
intervention occurred once per week over 12 weeks, and and parent education (38 hours).
PACT was delivered every other week over 6 months in In this study, between-group differences for treatment
association with monthly booster sessions for the following effects of initiating JA and shared positive affect did not
6 months. All three studies reported high levels of interven- reach statistical significance but were trending in the direc-
tion fidelity. tion of significance.

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Reciprocal imitation training (SGD) to improve spontaneous communicative utterances in

Ingersoll23 (2012) used specialist-implemented RIT for minimally verbal children with autism. The SGD was used
3 hours per week over 10 weeks and improved IJA in to model a minimum of 50% of all spoken communication.
14 children with autism. RIT teaches imitation within the The study used a sequential multiple assignment randomized
context of social imitation using both behavioral and natu- trial (SMART) design to allow for individualization of dos-
ralistic ­strategies. Specific strategies used included model- age and timing of the intervention based on child response.
ing, contingent imitation of nonverbal and verbal behavior, The findings suggested that an intervention beginning with
and contingent language to describe the children’s actions. JASPER + EMT + SGD and intensification of that interven-
Treatment effects were maintained at a 3-month follow-up. tion in a second stage for children who were slow respond-
ers was successful in increasing commenting, which was a
Joint attention and symbolic play/engagement verbal expression of JA. This was in a short period of time
and regulation treatment in a relatively low-intensity treatment of 2–3 hours per week
JASPER is a manualized developmental/behavioral supplementing school-based education.
­intervention. It was not explicitly named JASPER in the
beginning stages; however, the foundation for the methods Caregiver mediated
was established in the first 2006 RCT and evolved since then Given the positive outcomes of specialist-delivered JASPER
in a series of studies across multiple settings with different in the original studies, it became a question as to whether par-
delivery models.24 ents could improve their child’s JA using similar strategies.11
To make the JASPER content more accessible to parents,
Interventionist/specialist delivered the core principles of the intervention were developed into
In an initial study, Kasari et al24 increased both RJA and modules. The modules were individualized to each dyad
IJA skills in young children with autism after specialist- so that the beginning point was determined from the initial
delivered treatment. Although language and affect were caregiver–child interaction session. Treatment included
not specifically targeted in the active treatment, follow-up interventionist coaching of the caregiver while engaging in
assessments showed effects on positive affect within JA 6 play routines. Coaching included direct instruction, model-
months and 12 months after intervention and on targeted ing, guided practice, feedback, and review of handouts that
JA skills and expressive language at 1 year and 5 years after summarized the main objectives of each module.
the end of treatment.11,12,29 This is notable as JA interventions Caregivers implemented the intervention with a high
rarely report on changes in the quality of children’s JA upon degree of fidelity and helped their toddlers move from primar-
follow-up. ily object-focused engagement states to increased levels of
In this intervention, JA gestures were taught directly JE and improved RJA. These improvements were maintained
using developmental norms to determine initial individual- over a 1-year follow-up.33 Unlike in the specialist-delivered
ized treatment objectives. Treatment combined discrete trial JASPER; however, IJA did not improve despite direct inter-
training (DTT) at a table with enhanced milieu teaching vention. In the early JASPER studies, initiations did improve
(EMT) on the floor. The principles of EMT included fol- but the intervention was therapist mediated and delivered
lowing the child’s lead, imitating the child, using contingent more densely as an everyday intervention.24 Also worth
language, sitting close to the child and making eye contact, considering is that the children were younger in the caregiver
making environmental adjustments to engage the child, and study than in the original RCT; perhaps again, developmental
developing play routines.30,31 readiness affected their ability to learn responding skills but
The results suggested that using a combination of a not initiations.
behavioral and a developmental approach was effective in In a second caregiver-mediated intervention, JASPER
improving JA in young children with autism. Indeed, the was used to coach low-resourced parents of children with
combined approach lent itself to frequent practice and direct ASD.34 All children improved in time spent in JE and IJA,
shaping of skills through the behavioral method on the one with significantly greater improvement by the JASPER
hand and ideation and generalization facilitated through the group. JE was maintained over a 3-month follow-up in the
developmental milieu method on the other. JASPER group, and IJA was maintained in both groups over
In a second interventionist-delivered intervention, time. Comparably, this study had a longer duration than the
Kasari et al32 tested the effect of a speech-generating device previous caregiver-mediated study, the children were older,

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Dovepress Methods to improve joint attention in ASD

and more time was spent with the interventionist; however, the ­intervention focused more on curriculum content and
the intervention was less dense (two versus three times per less on adhering to a specific treatment approach. Results
week). showed that teachers significantly improved their children’s
JE, RJA, and IJA within a classroom setting.
Teacher implemented Most recently, the efficacy of JASPER was replicated in a
Because most young children with autism attend preschool, Norwegian study, wherein JASPER was delivered in addition
a further natural progression of using JASPER was to deter- to the mainstream preschool program by preschool teachers
mine whether teachers in preschools could be successful in to children with ASD. Treatment effects showed improved
improving JA. Four classroom-based studies all demonstrated IJA with teachers, which generalized to significantly longer
clear JASPER treatment effects. Lawton and Kasari35 pub- duration of JE with their mothers, and at 1-year follow-up,
lished the first RCT of a teacher-implemented intervention similar to specialist-delivered treatment, preschool-based
for preschoolers with autism. This intervention was delivered treatment appeared to produce small, but possibly clinically
at a lower dose than previous JASPER interventions and important, long-term changes in children’s initiation of JA
teachers implemented the treatment. Targeted strategies were with teachers.38,39 The treatment did not affect language or
presented to teachers in modules and again individual coach- global ratings of social functioning and communication.
ing was used. Modules included recognizing and responding
to child IJA, methods for facilitating and maintaining JE, and Summary
allowing the child to initiate communication. The coaching Overall, these studies22–24,32–38 suggest that a combination of
protocol included elements such as correctly judging the behavioral and developmental methods is generally effec-
level of support the dyad required, providing brief feedback tive in improving JA. It seems to matter less which specific
about what strategies were working, and helping the teacher approach is used, although JASPER and RIT appear to be
develop routines with the child. more effective. Rather, it may be that direct targeting of skills
Results showed that public preschool teachers success- through behavioral methods such as modeling, shaping, and
fully learned how to improve the frequency of IJA and JE. It prompting, along with contingent responding to child atten-
is noteworthy not only that JASPER intervention improved tion and ideation, is what facilitates change.
such difficult-to-teach skills but also that child and teacher Remarkably, JASPER appeared to be effective when
treatment effects were found during regularly occurring pub- delivered not only by clinicians but also by caregivers in
lic preschool activities. A limitation is the lack of follow-up homes and by teachers in preschools, emphasizing the
data to assess the long-term impact of the treatment’s effects. validity of the intervention content. The generalization to
In contrast, a relatively brief and low-density intervention natural environments without adverse effects on outcomes
using JASPER for minimally verbal children (fewer than is extremely promising. Furthermore, JASPER was effective
10 spontaneous functional words) with ASD in a nonpublic in the context of both general education and self-contained
preschool setting was not effective in improving generalized special education classrooms when delivered by teachers
JA gestures.36 with different methodologies and the teachers benefited, as
A third study involved 14 different classroom teachers indicated by significant positive outcomes in their ­students.37
using the JASPER principles but incorporating signifi- The exception in this group of studies was the lack of
cantly greater variability in intervention delivery than used improvement in social communication in minimally verbal
­previously.37 The intervention adopted an individualized children using JASPER.36 Perhaps for minimally verbal
approach, wherein teachers could choose to implement activi- preschoolers, we must revisit again the developmental readi-
ties for the whole class, in small groups, and/or in one-to-one ness for JA skills at approximately 1 year or less expressive
individualized settings. They could also choose to implement language age at entry.1 Further, the short duration and group
the intervention strategies using a range of intervention intervention delivery (in contrast to longer, individual, direct
methods and approaches. For example, in behaviorally-based instructional methods generally used for this population) may
classrooms using DTT, teachers received training on how to have affected the lack of improvement in this critical core
task analyze those skills, then target and integrate JA into their deficit. This may be the case as shown in the individualized
existing curricula. In other classrooms, such as those with blended EMT + JASPER intervention.32 IS was another
children showing more advanced developmental abilities, combined method that did not achieve clear change in JA
teachers targeted JA during group instruction. In this case, skills despite a 6-month fairly dense intervention. In this

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Table 3 Definitions of IJA, RJA, and JE for the single-subject Table 3 (Continued)
outcome variables Authors (year) Outcome variable definition
Authors (year) Outcome variable definition Rocha et al (2007) 51
RJA
Ferraioli and RJA • Response to show
Harris (2011)40 • Response to hand on toy • Follow point
• Response to tap toy • Follow gaze
• Response to show toy Shertz and RJA
• Follow point Odom (2007)52 • Responding to CJL
• Follow gaze IJA
IJA • CJL
• Coordinated joint looks Warren RJA
• Point et al (2013)53 • Follow gaze with attention getting phrase
Ingersoll and CJL • Follow point and gaze with attention
Schreibman (2006)41 getting phrase
Isaksen and RJA Warreyn and RJA
Holth (2009)42 • Follow proximal point Roeyers (2014)54 • Follow gaze
• Follow distal point IJA
IJA • Using nonverbal or verbal communication
• CJL with or without gesture and pointing and eye contact to share interest
Jones (2009)43 IJA Abbreviations: CJL, coordinated joint looks; IJA, initiating joint attention; JE, joint
• CJL engagement; RJA, responding to joint attention.

• CJL and pointing

• CJL, pointing, and verbalization
study, it may be that treatments received by both groups
Jones et al (2006)44 RJA
• Response to adult point and vocalization were not clearly differentiated. Another possible variable
with CJL affecting outcome may have been which specific IJA skills
IJA were targeted; however, this remains unclear as they were
• Point to share with CJL
not specified.22 Evidence of high fidelity among the teach-
JE
• Supported = child and mother involved with ers across studies was extremely encouraging. It is notable
the same object with little acknowledgment that few studies have follow-up data probably due to the
from the child of mother’s involvement difficulty in conducting research in school settings and thus,
though the mother may have made attempts
maintenance of skills and longer-term outcomes remain an
to capture the child’s attention
• Coordinated = child was actively involved area for further investigation. Moreover, given the positive
with his/her mother and an object effects of RIT, it is hoped that further research with caregiver
Kim et al (2008)45 RJA and teacher delivery models will be investigated.
• Follow point
IJA
• Eye contact Single-subject and quasi-
• CJL experimental studies
Klein et al (2009)46 RJA Although RCTs to improve JA are the focus of this review,
• Follow gaze
we include group design and SSRDs to provide a broader
Krstovska-Guerrero RJA
and Jones (2013)47 Gaze shift with positive affect overview of the treatment research in this area.40–54 These
MacDuff et al (2007)48 IJA studies are presented in summary format in Tables 3 and 4.
• Verbal bid (scripted and unscripted) for The treatment research base becomes more than double
joint attention
when these smaller studies are included, a testament to the
• Point
Martins and RJA increased efforts in the past decade to experiment with differ-
Harris (2006)49 • Follow gaze with attention-getting phrase ent methods to improve JA. In sum, in quasi-experimental and
(eg, “name”) SSRD studies, there has been success in teaching both RJA
Naoi et al (2007)50 IJA
and IJA. Whereas none of the RCT studies used behavioral
• CJL
• Point
methods to increase JA, nearly all of the SSRD studies did.
• Physical interaction The majority of these interventions were clinician delivered,
• Vocalization one was parent delivered, one was sibling mediated, and one
(Continued) was robot mediated. With a primarily behavioral approach,

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Dovepress Methods to improve joint attention in ASD

Table 4 Single-subject study characteristics and findings

Authors (year) Sample size CA Methods Experimental Joint attention outcome
range in methods design
Ferraioli and N=4; 41–64 min Sibling-mediated PRT MBL single-subject; RJA: 4/4+; IJA: 1/4+
Harris (2011)40 and DTT multiple probe
Ingersoll and N=5; 29–45 min Naturalistic imitation training MBL single-subject IJA: 2/5+
Schreibman (2006)41 by participant
Isaksen and N=4; 44–64 min ABA-based MBL single-subject RJA and IJA: 4/4+
Holth (2009)42 by participant
Jones (2009)43 N=2; 38 and 59 min DTT and PRT MBL single-subject IJA: 2/2+
by participant
Jones et al (2006)44
Study 1 N=5; 25–36 min DTT and PRT; teacher admin MBL by behaviors RJA: 5/5+; IJA: 5/5+
Study 2 N=2; 26 and 36 min DTT and PRT; parent admin MBL by behaviors RJA: 2/2+; IJA: 2/2+
Study 3 N=2; 26 and 36 min DTT and PRT Pretest, posttest RJA: 2/2+; IJA: 1/2+; supported
JE: 1/2+; coordinated JE: 1/2+
Kim et al (2008)45 N=10; 39–71 min Music therapy; play MBL single-subject; Pooled scores for RJA and IJA
comparison design favoring music therapy
Klein et al (2009)46 N=3; 49–75 min ABA-based MBL single-subject RJA: 3/3+
by behaviors
Krstovska-Guerrero N=3; 34–51 min DTT MBL single-subject RJA: 3/3+
and Jones (2013)47 by participant
MacDuff N=3; 36–60 min ABA-based MBL single-subject IJA: 3/3
et al (2007)48 by participant
Martins and N=3; 44–58 min ABA-based MBL by participants’ RJA: 3/3+
Harris (2006)49 reversal
Naoi et al (2007)50 N=3; 59–95 min Functional training: preferred MBL by participants IJA: 3/3+
toys as targets, modeling,
social reinforcement
Rocha et al (2007)51 N=3; 26–42 min DTT and PRT MBL by participants RJA: 3/3+
Schertz and N=3; 20–28 min Joint attention–mediated MBL single-subject RJA: 2/3+; IJA: 2/3+
Odom (2007)52 learning by behaviors
Warren N=6; 30–52 min Robot-mediated interaction MBL single-subject RJA: 5/6+
et al (2013)53 by behaviors
Warreyn and N=18 Tx; (55–80 min); Combination of Quasi-experimental RJA treatment effect; IJA no
Roeyers (2014)54 N=18 control developmental and design, pre–post treatment effect
(49–84 min) behavioral methods
Abbreviations: ABA, applied behavior analysis; CA, chronological age; DTT, discrete trial training; MBL, multiple baseline; PRT, pivotal response training; Tx, treatment;
IJA, initiating joint attention; JE, joint engagement; RJA, responding to joint attention.

it is not surprising that with the exception of two studies, all Except for Warreyn and Roeyers (2014)54 who used their
focused on increasing specific skills rather than JA as a state. own unique pre–post assessment to measure JA, the SSRDs
Most targeted either RJA or a combination of RJA and IJA. charted behavioral observations of JA outcomes to demon-
Only three studies targeted IJA only. In this group of stud- strate change. Whereas the RCT studies used standardized,
ies with a stronger behavioral emphasis, use of shaping and accepted, and well-defined outcome measures of JA, the
skill approximation using less naturalistic methods was more SSRD studies exhibited significant variability in what they
evident. For example, one study taught child responding to measured and how they defined their outcomes (Table 3).
an adult bid for JA (showing) by first teaching the child to For example, RJA gaze following was defined in one study
respond to an adult hand on a toy, then respond to a tap on as following a point and gaze with an attention-getting
a toy, and then progressed to having the child respond to an phrase.53 In another, it was defined as following a gaze shift
adult showing a toy.40 While the methods were successful, with positive affect.47 Comparisons of treatment efficacy
the quality of child response does come into question. Of across studies is thus very difficult due to the differences
course, this pertains to all studies; however, regardless of the in outcome definitions and differences in skill complexity.
methods used, and to date, defining and measuring the quality The methods used in some of the SSRDs to teach IJA also
of children’s JA after treatment has received little attention. raise questions of validity with regard to the use of primary

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reinforcement as a consequence for JA initiations. This may meaningful manner and at least in the short term can be
be a means to an end in that the maintaining consequence is achieved by relatively brief interventions. This seems to bear
shaped over time from a nonsocial to a social consequence; out across several studies and also, interestingly, when one
however, without clearly establishing social attention as the looks at interventions with different philosophies but similar
function of IJA, it is difficult to say for certain that JA skills content, such as caregiver-mediated FPI and JASPER.20,34
are being exhibited. Furthermore, it appears that instruction on RJA will not
These comments are not intended to criticize behavioral necessarily increase IJA and vice versa. Thus, although RJA
methods used alone to teach JA as many studies demonstrate and IJA are both considered JA, they should be treated as
success but rather to highlight the need to pay close attention separate instructional objectives. Further, choosing what to
to details within each study to understand what was taught teach remains an interesting question. Children with autism
and the nature of the outcome achieved. do not follow typical developmental trajectories with regard
to JA. As a start, research should further investigate the rela-
Conclusion tionship between child characteristics and specific strategies,
While many years of research evidence clearly established but many questions remain regarding the effective methods
JA in ASD as a core deficit, it has only been within the past to significantly improve social communication in ASD.
10 years that empirical evidence has guided intervention. One question relates to the interaction between method
The outcomes of the studies reviewed generally demonstrate and strength of outcome. Given the large number of services
short-term improvements for targeted goals and, in some in which children with ASD participate, how can a child
cases, also long-term benefits and other related improve- gain these critical skills in an efficient and practical manner?
ments (language, affect). It is noteworthy that all 13 RTCs This would require a number of targeted studies examining
used direct observation and measurement of JA, with the dosage. A second question relates to the potential to modify
vast majority using either the Early Social Communication approaches that are currently being used as whole interven-
Scales or video coding of caregiver–child or teacher–child tions and curricula (eg, pivotal response training, applied
interactions to capture JA as an engagement state, or a behavior analysis, and Denver model).31,59,60 Many of these
combination of both approaches.17,55,56 Regardless, all used approaches have instructional targets related to JA, but no
standardized direct observation outcome measures, which RCTs have specifically measured social communication
reduced idiosyncrasy among outcome variables across outcomes; moreover, developmental readiness remains a
studies and allowed for greater transparency in examining question. Third, a couple of studies reviewed in this article
outcomes.57,58 One question relates to outcome difficulty. began to address the need for individualized and ongoing
Could positive outcomes be related to earlier-developing or assessment and modification of intervention goals and dura-
less-challenging skills? This does not appear to be the case tion to maximize progress, but this is an area that requires
as the majority of studies examined a similar range of skills considerably more attention.21,32 Indeed, the field is trend-
from less to more challenging, defined by the same measure- ing away from one-size-fits all treatment for children with
ment protocols. In addition, closer inspection shows, eg, that ASD.61 How to make modifications to the interventions given
JAML measured coordinated joint looks as an IJA outcome, child characteristics and rate of progress from a manualized
a very early developing skill, yet did not find a treatment intervention remains a challenging but important area for
effect on IJA.21 In contrast, most JASPER studies measured further investigation. In addition, a clear purpose of early
a range of skills, including those considered to be at lower JA interventions is to improve related language skills for
and higher levels.55 children with ASD as that relationship has been made very
When examining the contents of the interventions, when clear. Several RCTs did not demonstrate effect on language
placed within similar philosophies (eg, developmental vs and many did not investigate language outcomes; this should
combined), the concepts are somewhat similar. On the remain at the forefront of JA literature not only to improve the
basis of this review, it seems that the likelihood and impact quality of life for individuals with ASD but also to contribute
of effects are related more to the philosophy of approach to our understanding of how language develops. Related,
(combined), dense but practical implementation, and the further research should investigate continued maintenance
developmental considerations of the skills and abilities of of skills and also the long-term relationship between JA, lan-
the children involved. The findings do seem to indicate that guage, and more distal outcomes such as social competence.
direct, targeted instruction is needed to change skills in a Last, we recognize that this review is limited in that it only

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Dovepress Methods to improve joint attention in ASD

focused on studies that directly targeted JA as an outcome; 18. Tomasello M, Farrar MJ. Joint attention and early language. Child Dev.
1986;47:1454–1463.
however, a number of interesting RCTs have targeted treat- 19. Green J, Charman T, McConachie H, PACT Consortium, et al. Parent-
ment in other areas of development and found collateral mediated communication-focused treatment in children with autism
improvements in JA. (PACT): a randomized controlled trial. Lancet. 2010;375:2152–2160.
20. Kasari C, Siller M, Huynh LN, et al. Randomized controlled trial of
parental responsiveness intervention for toddlers at high risk for autism.
Acknowledgments Infant Beh Dev. 2014;37:711–721.
21. Schertz HH, Odom SL, Baggett KM, Sideris JH. Effects of joint atten-
The authors thank Joanne Kim for her assistance in edits to tion mediated learning for toddlers with autism spectrum disorders:
this manuscript. an initial randomized controlled study. Early Child Res Quarterly.
2013;28:249–258.
22. Landa RJ, Holman KC, O’Neill AH, Stuart EA. Intervention targeting
Disclosure development of socially synchronous engagement in toddlers with
The authors report no conflicts of interest in this work. autism spectrum disorder: a randomized controlled trial. J Child Psych
Psych. 2011;52:13–21.
23. Ingersoll B. Brief report: effect of a focused imitation intervention
References on social functioning in children with autism. J Autism Dev Disord.
1. Paparella T, Stickles K, Freeman S, Kasari C. The emergence of 2012;42:1768–1773.
joint attention and requesting skills in young children with autism. 24. Kasari C, Freeman S, Paparella T. Joint attention and symbolic play
J Communication Disord. 2011;44:569–583. in young children with autism: a randomized controlled intervention
2. Billstedt E, Gillberg IC, Gillberg C. Autism in adults: symptom pat- study. J Child Psych Psych. 2006;47:611–620.
terns and early childhood predictors. Use of the DISCO in a commu- 25. Bruder MB. Early childhood intervention: a promise to children and
nity sample followed from childhood. J Child Psych Psych. 2011;48: families for their future. Except Child. 2010;76:339–355.
1102–1110. 26. Siller M, Sigman M. The behaviors of parents of children with autism
3. Rutter M. Diagnosis and definitions of childhood autism. J Aut predict the subsequent development of their child’s communication.
­Childhood Schiz. 1978;8:139–161. J Autism Dev Disord. 2002;32:77–89.
4. Dawson G, Toth K, Abbott R, Osterling J, Munson J, Estes A. Early 27. Siller M, Hutman T, Sigman M. A parent mediated intervention to
social attention impairments in autism: social orienting, joint attention, increase responsive parental behaviors and child communication in
and attention to distress. Dev Psych. 2004;40:271–283. children with ASD: a randomized clinical trial. J Autism Dev Disord.
5. Mundy P, Sigman M, Kasari C. A longitudinal study of joint attention 2013;43:540–555.
and language development in autistic children. J Autism Dev Disord. 28. Bricker D. Assessment, Evaluation and Programming System for
1990;20:115–128. Infants and Children. Birth to Three Years. 2nd ed. Baltimore: Brookes
6. Paul R, Chawarska K, Cicchetti D, Volkmar F. Language outcomes in Publishing Co; 2002.
toddlers with ASD: a 2 year follow up. Aut Res. 2008;1:97–107. 29. Lawton K, Kasari C. Brief report: longitudinal improvements in the
7. Paul R, Campbell D, Gilbert K, Tsiouri I. Comparing spoken language quality of joint attention in preschool children with autism. J Autism
treatments for minimally verbal preschoolers with autism spectrum Dev Disord. 2012;42:307–312.
disorders. J Autism Dev Disord. 2013;43:418–431. 30. Warren SF, Kaiser AP. Generalization of treatment effects by young
8. Sigman M, Ruskin E. Continuity and change in the social competence language-delayed children; a longitudinal analysis. J Speech Hearing
of children with autism, Down syndrome, and developmental delays. Disord. 1986;51:239–251.
Monographs Soc for Res Child Dev. 1999;64:1–114. 31. Koegel RL, Koegel LK. Teaching Children With Autism: Strategies For
9. Charman T, Taylor E, Drew A, Cockerill H, Brown J, Baird G. Outcome Initiating Positive Interactions And Improving Learning Opportunities.
at 7 years of children diagnosed with autism at age 2: predictive validity Baltimore: Brookes Publishing Co; 1995.
of assessments conducted at 2 and 3 years of age and pattern of symptom 32. Kasari C, Kaiser A, Goods K, et al. Communication interventions for
change over time. J Child Psych Psych. 2005;46:500–513. minimally verbal children with autism: a sequential multiple assignment
10. Watt N, Wetherby A, Shumway S. Prelinguistic predictors of language randomized trial. J Am Acad Child Adoles Psych. 2014;53:635–646.
outcome at 3 years of age. J Speech Lang Hearing Res. 2006;49: 33. Kasari C, Gulsrud AC, Wong C, Kwon S, Locke J. Randomized con-
1224–1237. trolled caregiver mediated joint engagement intervention for toddlers
11. Kasari C, Paparella T, Freeman S, Jahromi LB. Language outcome in with autism. J Autism Dev Disord. 2010;40:1045–1056.
autism: randomized comparison of joint attention and play interventions. 34. Kasari C, Lawton K, Shih W, et al. Caregiver-mediated intervention
J Consulting Clin Psych. 2008;76:125–137. for low-resourced preschoolers with autism: an RCT. Pediatrics.
12. Kasari C, Gulsrud A, Freeman S, Paparella T, Helleman G. Longitudinal 2014;134:72–79.
follow-up of children with autism on joint attention and play. J Am Acad 35. Lawton K, Kasari C. Teacher implemented joint attention intervention:
Child Adol Psych. 2012;51:487–495. pilot randomized controlled study for preschoolers with autism.
13. Tomasello M. Origins of Human Communication. Cambridge: MIT J Consult Clin Psych. 2012;80:68–693.
Press; 2008:57–108. 36. Goods KS, Ishijima E, Chang Y, Kasari C. Preschool based JASPER
14. Shumway S, Wetherby A. Communicative acts of children with autism intervention in minimally verbal children with autism: pilot RCT.
spectrum disorders in the second year of life. J Speech Lang Hearing J Autism Dev Disord. 2013;43:1050–1056.
Res. 2009;52:1139–1156. 37. Wong C. A play and joint attention intervention for teachers of young
15. Volkmar F, Lord C, Bailey A, Schultz R, Klin A. Autism and pervasive children with autism: a randomized controlled pilot study. Autism.
developmental disorders. J Child Psych Psych. 2004;45:135–170. 2013;17:340–357.
16. Carter AS, Messinger DS, Stone WL, Celimli S, Nahmias AS, Yoder P. 38. Kaale A, Smith L, Sponheim E. A randomized controlled trial of
A randomized controlled trial of ‘Hanen’s ‘More Than Words’ in toddlers preschool-based joint attention intervention for children with autism.
with early autism symptoms. J Child Psych Psych. 2011;52:741–752. J Child Psych Psych. 2012;53:97–105.
17. Bakeman R, Adamson LB. Coordinating attention to people and objects 39. Kaale A, Fagerland MW, Martinsen EW, Smith L. Preschool-based social
in mother-infant and peer-infant interaction. Child Dev. 1984;55: communication treatment for children with autism: 12-month follow-up
1278–1289. of a randomized trial. J Am Acad Child Adol Psych. 2014;53:134–188.

Pediatric Health, Medicine and Therapeutics 2015:6 submit your manuscript | www.dovepress.com
77
Dovepress
Paparella and Freeman Dovepress

40. Ferraioli SJ, Harris SL. Teaching joint attention to children with 53. Warren ZE, Zheng Z, Swanson AR, et al. Can robotic interaction
autism through a sibling mediated behavioral intervention. Beh Interv. improve joint attention skills? J Autism Dev Disord. 2013. ­Available
2011;26:261–281. from: http://dx.doi.org/10.1007/s10803-013-1918-4. Accessed
41. Ingersoll B, Schreibman L. Teaching reciprocal imitation skills to young February 2, 2015.
children with autism using a naturalistic behavioral approach: effects 54. Warreyn P, Roeyers H. See what I see, do as I do: promoting joint
on language, pretend play and joint attention. J Autism Dev Disord. attention and imitation in preschoolers with autism spectrum disorder.
2006;36:487–505. Autism. 2014;18:658–671.
42. Isaksen J, Holth P. An operant approach to teaching joint attention skills 55. Mundy P, Sigman MD, Ungerer J. Defining the social deficits of autism:
to children with autism. Beh Interv. 2009;24:215–236. the contribution of non-verbal communication measures. J Child Psych
43. Jones EA. Establishing response and stimulus classes for initiating Psych. 1986;27:657–699.
joint attention in children with autism. Res Autism Spectrum Disord. 56. Adamson LB, Bakeman R, Deckner DF. The development of symbol-
2009;3:375–389. infused joint engagement. Child Dev. 2004;75:1171–1187.
44. Jones EA, Carr EG, Feeley KM. Multiple effects of joint attention 57. Wetherby AM, Prizant BM. CSBS DP Manual: Communication and
intervention for children with autism. Beh Modification. 2006;30: Symbolic Behavior Scales Developmental Profile. Baltimore: Paul H
782–834. Brookes; 2002.
45. Kim J, Wigram T, Gold C. The effects of improvisational music therapy 58. Yoder P, Symons FJ. Observational Measurement of Behavior. New
on joint attention behaviors in autistic children: a randomized controlled York: Springer; 2010.
study. J Autism Dev Disord. 2008;38:1758–1766. 59. Leaf R, McEachin J. A Work in Progress: Behavioral Management
46. Klein JL, MacDonald RPF, Vaillancourt G, Ahearn WH, Dube WV. Strategies and a Curriculum for Intensive Behavioral Treatment of
Teaching discrimination of adult gaze direction to children with autism. Autism. New York: DRL Publishing; 1999.
Res Autism Spectrum Disord. 2009;3:42–49. 60. Smith M, Rogers S, Dawson G. The early start Denver model: a com-
47. Krstovska-Guerrero I, Jones EA. Joint attention in autism: teaching prehensive early intervention approach for toddlers with autism. In:
smiling coordinated with gaze to respond to joint attention bids. Res Handleman JS, Harris SL, editors. Preschool Education Programs for
Autism Spectrum Disord. 2013;7:93–108. Children with Autism. 3rd ed. Austin, TX: Pro-Ed Corporation, Inc.;
48. MacDuff JL, Ledo R, McClannahan LE, Krantz PJ. Using scripts and 2008:65–101.
script-fading procedures to promote bids for joint attention by young 61. Sherr MR, Schreibman L. Individual behavioral profiles and predic-
children with autism. Res Autism Spectrum Disord. 2007;1:281–290. tors of treatment effectiveness for children with autism. J Consult Clin
49. Martins M, Harris SL. Teaching children with autism to respond to joint Psych. 2005;73:525–538.
attention initiations. Child Fam Beh Therapy. 2006;28:51–68. 62. Meindl JN, Cannella-Malone HI. Initiating and responding to joint
50. Naoi N, Tsuchiya R, Yamamoto J, Nakamura K. Functional training for attention bids in children with autism: a review of the literature. Res
initiating joint attention in children with autism. Res Dev Disablities. Dev Disablities. 2011;32:1441–1454.
2007;29:595–609. 63. White PJ, O’Reilly MO, Streusand W, et al. Best practices for teaching
51. Rocha ML, Schreibman L, Stahmer AC. Effectiveness of training joint attention: a systematic review of the intervention literature. Res
parents to teach joint attention in children with autism. J Early Interv. Aut Spectrum Disorders. 2011;5:1283–1295.
2007;29:154–172.
52. Schertz HH, Odom SL. Promoting joint attention in toddlers with
autism: a parent mediated developmental model. J Autism Dev Disord.
2007;37:1562–1575.

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