Methods to improve joint attention in young children with autism: a review

Figures & data

Figure 1 Flow chart for eligibility for inclusion in study.

Abbreviation: RCT, randomized controlled trial.

Table 1 Definitions of IJA, RJA, and JE for the RCT outcome variables

Authors (year)	Outcome variable definition
Goods et al (2013)^Citation36	IJA = composite variable: CJL + points + gives + shows
Green et al (2010)^Citation19	JE = proportion of time in parent–child mutual shared attention
Ingersoll (2012)^Citation23	IJA
	• Eye contact
	• CJL
	• Point
	• Show
	• Lower level = eye contact and CJL
	• Higher level = pointing and showing
Kaale et al (2012)^Citation38	IJA
	• Show
	• Point
	• Give
	• JE
	Child and the preschool teacher being actively involved in the same object or event. SJE = child did not overtly acknowledge the preschool teacher. CJE = both the child and teacher were actively coordinating their attention to the shared object or event and each other. Composite variable created of SJE + CJE
Kasari et al (2006)^Citation24	RJA
	• Follow point
	• Follow gaze
	IJA
	• CJL
	• Point
	• Show
	• Give
	JE
	• Amount of time in child-initiated JE with parent
Kasari et al (2010)^Citation33	RJA
	• Follow point
	• Follow gaze
	JE
	• Amount of time in child-initiated JE with parent
Kasari et al (2014)^Citation32	IJA
	• Commenting
Kasari et al (2014)^Citation34	IJA
	• CJL
	• Point
	• Show
	• Joint attention language
	JE
	• Child and caregiver engaged with the same
	activity and both aware of the roles of the other
Kasari et al (2014)^Citation20	RJA
	• Follow point
	• Follow gaze
	IJA
	• CJL
	• Point
	• Show
	• Joint attention language
Landa et al (2011)^Citation22	IJA = unspecified, measured as directed using the
	Communication and Symbolic Behavior Scales
	Developmental Profile
Lawton and Kasari (2012)^Citation35	IJA
	• CJL
	• Point
	• Show
	• Give
	Supported engagement = unspecified, measured as directed using the Adamson, Bakeman, and Deckner (2004)^Citation56 protocol
Schertz et al (2013)^Citation21	RJA = respond to parent bid for attention with a CJL
	IJA
	• CJL for the purposes of “showing”
Wong (2013)^Citation37	RJA = child responds (attentional or behavioral) to point or show IJA
	• Point
	• Show
	JE = child and another are actively involved in the same object or toy.
	• Supported = engagement is actively maintained by other
	• Coordinated = child initiates or is actively involved with CJL to share attention

Abbreviations: CJE, coordinated joint engagement; CJL, coordinated joint looks; IJA, initiating joint attention; JE, joint engagement; RCT, randomized controlled trial; RJA, responding to joint attention; SJE, supported joint engagement.

Table 2 RCT study characteristics and findings on IJA, RJA, and JE

Authors (year)	Sample size	Mean CA (MA), both in months	Methods	Mean/fidelity	Outcome (measure[s])
Goods et al (2013)^Citation36	N=7 Tx; N=8 control	48.73 (17.21); 54.68 (13.91)	JASPER, preschool, specialist delivered 2×/wk, 30 min, 12 wks	88.27%	No change on IJA (ESCS, teacher–child play interaction)
Green et al (2010)^Citation19	N=77 Tx; N=75 control	45 (27.0);† 45 (25.3)†	PACT clinic-based parent-mediated 2×/wk for 2 hrs for 6 mo plus 1×/mo booster 6 mo	Median of 13.4 out of 14 criteria per session	No change on JE, shared attention, language (caregiver–child interaction)
Ingersoll (2012)^Citation23	N=14 Tx; N=13 control	39.3 (20.8);‡ 36.5 (17.9)‡	RIT clinic–based, specialist delivered 3×/wk for 1 hr for 10 mo	94%	RIT treatment effect on IJA (ESCS)
Kaale et al (2012)^Citation38	N=34 Tx; N=27 control	47.6 (25.6); 50.3 (30.3)	JASPER preschool-based teacher-delivered 6 hr initial training 20 min 2×/day for 8 wks	85% tabletop; 83% floor	JASPER treatment effect on IJA to teachers and JE with mothers, no effect on language (ESCS, teacher–child play interaction)
Kasari et al (2006)^Citation24	N=20 JA Tx; N=21 play Tx; N=17 control	43.20 (26.29); 42.67 (24.55); 41.94 (21.86)	JASPER clinic-based specialist-delivered 30 min/day 5–6 wks	95% tabletop; 92% floor	JASPER treatment effect on RJA, IJA, JE, language (ESCS, caregiver–child interaction)
Kasari et al (2010)^Citation33	N=19 Tx; N=19 control	30.35 (19.83); 31.31 (18.57)	JASPER clinic-based caregiver-mediated 8 wks 30 min, 3×/wk	r=0.89 caregivers; r=0.86 interventionists	JASPER treatment effect on RJA and JE (caregiver–child interaction)
Kasari et al (2014)^Citation32	N=31 Tx^a; N=30 Tx^b	75 (47.16); 74 (48.00)	JASPER + EMT^§ + SGD;^a JASPER + EMT^b clinic based. Stage 1: 1 hr, 2×/wk, 12 wks; Stage 2: 1 hr, 3×/wk, 12 wks	a=93.69%; b=94.26%	JASPER+EMT+SGD treatment of increased comments (natural language sample)
Kasari et al (2014)^Citation34	N=60 Tx; N=52 control	41.9 (23.6); 42.8 (26.3)	JASPER caregiver in-home-mediated 1 hr, 2×/wk for 12 wks	76% interventionist α=0.82 diary, α=0.86 caregiver quality of involvement scale	Treatment effect on IJA and increased JE greater for the JASPER group (ESCS, caregiver–child interaction)
Kasari et al (2014)^Citation20	N=32 Tx; N=34 control	22.18 (14.32); 22.56 (15.05)	FPI home-based specialists delivered 90 min, 1×/wk, 12 wks	96% interventionist	No treatment effect on RJA, IJA, or language (ESCS, caregiver–child interaction)
Landa et al (2011)^Citation22	N=24 Tx; N=24 control	28.6 (27.5);¶ 28.8 (31.1)¶	IS classroom-based interventionist delivered 4×/wk 2.5 hrs for 26 wks. Parent training, home based 1×/mo, 1.5 hrs, parent education (38 hrs)	P=0.047 to P<0.001 difference between Tx and controls for targeted behaviors	Approaching significant treatment effect for IJA and shared affect (Communication and Symbolic Behavior Scales Developmental Profile)
Lawton and Kasari (2012)^Citation35	N=9 Tx; N=7 control	46 (30.3); 43 (33.8)	JASPER classroom-based teacher-implemented 2×/wk 30 min for 6 wks	99% interventionist P<0.05 to P<0.001 difference between Tx and control teachers for targeted behaviors	ESCS, teacher–child interaction
Schertz et al (2013)^Citation21	N=11 Tx; N=12 control	24.6 (21.0);# 27.5 (25.9)#	JAML caregiver-mediated in-home 1×/wk average 30 wks	90% parents; 89% interventionist	Treatment effect on RJA, no effect on IJA; (precursors of joint attention measure)^Citation59
Wong (2013)^Citation37	N=14 Tx, JA-SP N=10 Tx, SP-JA N=9 control	56.21 (36.25); 54.50 (27.39); 59.67 (30.38)	JASPER classroom-based teacher-delivered 1×/wk, 1 hr for 8 wks	75%	Treatment effect for both treatment groups on JE, IJA, and RJA (ESCS)

Notes:

† Mullen non verbal mental age;

‡ Bayley Non verbal, mental age;

¶ Mullen visual reception T-Score;

# Mullen receptive language mental age.

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.

Table 3 Definitions of IJA, RJA, and JE for the single-subject outcome variables

Authors (year)	Outcome variable definition
Ferraioli and Harris (2011)^Citation40	RJA
	• Response to hand on toy
	• Response to tap toy
	• Response to show toy
	• Follow point
	• Follow gaze
	IJA
	• Coordinated joint looks
	• Point
Ingersoll and Schreibman (2006)^Citation41	CJL
Isaksen and Holth (2009)^Citation42	RJA
	• Follow proximal point
	• Follow distal point
	IJA
	• CJL with or without gesture and pointing
Jones (2009)^Citation43	IJA
	• CJL
	• CJL and pointing
	• CJL, pointing, and verbalization
Jones et al (2006)^Citation44	RJA
	• Response to adult point and vocalization with CJL
	IJA
	• Point to share with CJL
	JE
	• Supported = child and mother involved with the same object with little acknowledgment from the child of mother’s involvement though the mother may have made attempts to capture the child’s attention
	• Coordinated = child was actively involved with his/her mother and an object
Kim et al (2008)^Citation45	RJA
	• Follow point
	IJA
	• Eye contact
	• CJL
Klein et al (2009)^Citation46	RJA
	• Follow gaze
Krstovska-Guerrero and Jones (2013)^Citation47	RJA
	Gaze shift with positive affect
MacDuff et al (2007)^Citation48	IJA
	• Verbal bid (scripted and unscripted) for joint attention
	• Point
Martins and Harris (2006)^Citation49	RJA
	• Follow gaze with attention-getting phrase (eg, “name”)
Naoi et al (2007)^Citation50	IJA
	• CJL
	• Point
	• Physical interaction
	• Vocalization
Rocha et al (2007)^Citation51	RJA
	• Response to show
	• Follow point
	• Follow gaze
Shertz and Odom (2007)^Citation52	RJA
	• Responding to CJL
	IJA
	• CJL
Warren et al (2013)^Citation53	RJA
	• Follow gaze with attention getting phrase
	• Follow point and gaze with attention getting phrase
Warreyn and Roeyers (2014)^Citation54	RJA
	• Follow gaze
	IJA
	• Using nonverbal or verbal communication and eye contact to share interest

Abbreviations: CJL, coordinated joint looks; IJA, initiating joint attention; JE, joint engagement; RJA, responding to joint attention.

Table 4 Single-subject study characteristics and findings

Authors (year)	Sample size CA range in methods	Methods	Experimental design	Joint attention outcome
Ferraioli and Harris (2011)^Citation40	N=4; 41–64 min	Sibling-mediated PRT and DTT	MBL single-subject; multiple probe	RJA: 4/4+; IJA: 1/4+
Ingersoll and Schreibman (2006)^Citation41	N=5; 29–45 min	Naturalistic imitation training	MBL single-subject by participant	IJA: 2/5+
Isaksen and Holth (2009)^Citation42	N=4; 44–64 min	ABA-based	MBL single-subject by participant	RJA and IJA: 4/4+
Jones (2009)^Citation43	N=2; 38 and 59 min	DTT and PRT	MBL single-subject by participant	IJA: 2/2+
Jones et al (2006)^Citation44
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)^Citation45	N=10; 39–71 min	Music therapy; play	MBL single-subject; comparison design	Pooled scores for RJA and IJA favoring music therapy
Klein et al (2009)^Citation46	N=3; 49–75 min	ABA-based	MBL single-subject by behaviors	RJA: 3/3+
Krstovska-Guerrero and Jones (2013)^Citation47	N=3; 34–51 min	DTT	MBL single-subject by participant	RJA: 3/3+
MacDuff et al (2007)^Citation48	N=3; 36–60 min	ABA-based	MBL single-subject by participant	IJA: 3/3
Martins and Harris (2006)^Citation49	N=3; 44–58 min	ABA-based	MBL by participants’ reversal	RJA: 3/3+
Naoi et al (2007)^Citation50	N=3; 59–95 min	Functional training: preferred toys as targets, modeling, social reinforcement	MBL by participants	IJA: 3/3+
Rocha et al (2007)^Citation51	N=3; 26–42 min	DTT and PRT	MBL by participants	RJA: 3/3+
Schertz and Odom (2007)^Citation52	N=3; 20–28 min	Joint attention–mediated learning	MBL single-subject by behaviors	RJA: 2/3+; IJA: 2/3+
Warren et al (2013)^Citation53	N=6; 30–52 min	Robot-mediated interaction	MBL single-subject by behaviors	RJA: 5/6+
Warreyn and Roeyers (2014)^Citation54	N=18 Tx; (55–80 min); N=18 control (49–84 min)	Combination of developmental and behavioral methods	Quasi-experimental design, pre–post	RJA treatment effect; IJA no treatment effect

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.

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