Effects of Joint Attention Mediated Learning for toddlers with autism spectrum disorders: An initial randomized controlled study

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Abstract

The purpose of this study was to determine effects of the Joint Attention Mediated Learning (JAML) intervention on acquisition of joint attention and other early social communication competencies for toddlers with autism spectrum disorders (ASD). Twenty-three parents and their toddlers were randomly assigned to JAML or a control condition. Observational assessments were collected at pretest, posttest, and follow-up sessions, while standardized developmental measures were collected at pre- and posttest. Significant intervention-×-time interactions, favoring the intervention group, occurred for the observational measures Focusing on Faces and Responding to Joint Attention, with both having large effect sizes that maintained at follow-up. In addition, significant intervention-×-time effects, also favoring the JAML group were found for receptive language on the Mullen Scales of Early Learning and the Communication sub-domain of the Vineland Adaptive Behavior Scale. The observational measures Turn-Taking and Initiating Joint Attention and the Expressive Communication measure on the Mullen, while not showing significant differences between groups, revealed moderate effect sizes favoring the JAML group, suggesting that a study with more power could well detect significant differences on all of the measures. Findings support a focused, developmentally sequenced, systematic, and family aligned approach that targets preverbal social communication development within parent–child relationships.

Highlights

► JAML targets preverbal social communication for toddlers with autism. ► Toddlers improved on two measures of preverbal social communication. ► Toddlers also improved on standardized language measures not targeted by JAML. ► Large and moderate effect sizes across a range of variables were found. ► Parents rated JAML's goals, outcomes achieved, and intervention process highly.

Introduction

Successful efforts to identify children with autism spectrum disorders (ASD) at earlier ages have created urgency for intervention approaches that effectively address early challenges, that are developmentally appropriate for toddlers, and that support the parent–child relationship. Social communication is an ongoing challenge for children with ASD, an early marker for which is difficulty acquiring joint attention, or social sharing of attention with a partner about a focus of mutual interest (Mundy, 1995). Yet, to date, few interventions designed to promote joint attention for toddlers with ASD and their families have been examined in randomized studies. The purpose of this investigation was to conduct an initial efficacy study of the Joint Attention Mediated Learning (JAML) intervention for toddlers with ASD and their primary interaction partners.

The past decade ushered in a surge of interest in early intervention (EI) for toddlers with early signs of ASD. Early identification was advanced by reliable screening protocols (e.g., Robins, Fein, Barton, & Green, 2001), the American Academy of Pediatrics’ call for universal toddler screening for ASD (Johnson & Myers, 2007), and adaptation of the Autism Diagnostic Observational Schedule for toddlers (Luyster et al., 2008). The resulting increase in identified toddler-aged children with ASD opened the door for exploratory toddler research (listed in Schertz, Baker, Hurwitz, & Benner, 2011) that examined a variety of intervention approaches.

More recently, larger multi-site studies have begun to emerge as private and public funders prioritized EI research (Autism Speaks, 2011, Interagency Autism Coordinating Committee, 2005). To date, two multi-site randomized controlled EI studies involving toddlers with ASD and their families have reported findings. Dawson et al. (2010) reported significant improvement on IQ, adaptive behavior, and diagnostic category for toddlers who received the Early Start Denver Model (ESDM; Dawson et al., 2010). The ESDM combined developmental and behavioral approaches with parent training. Importantly, this study showed that toddler intervention could produce effects on standardized measures. A second study, conducted by Carter and her colleagues (2011), explored the Hanen “More Than Words” program. Delivered as a low-intensity short-term parent-implemented intervention, Hanen produced no main effects, but resulted in communication gains for a subgroup of toddlers who had lower initial levels of object interest.

As toddler intervention approaches are investigated, a need remains for models that, while achieving important outcomes, are also consistent with Part C of the Individuals with Disabilities Education Act (IDEA, 2004) and compatible with community EI systems. Part C policy and professional practice recommendations call for EI to (a) be situated in the natural environment and integrated into everyday experiences; (b) support the parent–child relationship and enhance family capacity to promote child learning; (c) promote an active child role in learning; and (d) use approaches that are systematically delivered and individually, developmentally, and practically appropriate (Bruder, 2010, Schertz et al., 2011). Congruence with EI principles, which provide a backdrop for decisions about how to focus and deliver intervention for infants and toddlers, is essential if research-informed models are to be replicated in community practice.

Section snippets

Considerations for intervention focus and process

Verbal communication is often the intervention focus of choice for toddlers with ASD. However, because preverbal forms of social communication are developmentally closer to the child's current capabilities, are foundational for verbal language (Mundy, Sigman, & Kasari, 1990), and are uniquely troublesome in ASD (Bakeman & Adamson, 1984), they have potential as a more appropriate and fruitful initial intervention target. Joint attention, which emerges in typical development between 9 and 12

Joint Attention Mediated Learning

The JAML intervention directly and exclusively addresses the social functions of preverbal communication, targeting engagement at progressively complex levels that begin just beyond the toddler's current capabilities. In the Focusing on Faces (FF) phase, the child is helped to look freely and often to the parent's face. In Turn-Taking (TT) the child engages with the parent in reciprocal repetitive play that acknowledges the other's shared interest by accommodating the parent's turn. Finally,

Participants

Toddlers under age 30 months were recruited in metropolitan and rural areas in Indiana, Kansas/Missouri, and North Carolina. Recruitment efforts focused on Part C providers, physicians, diagnostic centers, speech/language clinics, a university research database, and autism publications targeted to families. Eligibility was established if children met each of the following inclusion criteria: scores above the designated cut-off levels on the Autism Diagnostic Observation Scale (ADOS; Lord,

Results

The primary question addressed by this study was whether JAML had a significant effect on children's joint attention and language development relative to children in the control group. These outcomes were measured with observational and standardized assessments.

Discussion

Intervention models that are both effective and appropriate for toddler-aged children with ASD and their families are a pressing need as children are identified at younger ages. This study showed positive effects from a parent-mediated approach to promote foundational preverbal social communication. The JAML intervention resulted in more frequent attention to parents’ faces and responses to parents’ joint attention overtures. Importantly, it also resulted in significant improvement on separate

Acknowledgements

This project was supported by a grant from Autism Speaks, 1735. This funding source did not have a direct role in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

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