Improving Social Communication through Joint Attention: Interventions to Support Training for Children with Autism Amy Cohen, Ph.D, BCBA; Maigret Fay, M.Ed, BCBA

Presentation Overview What is joint attention? Why is joint attention important? Considerations/ Decision Making for implementing JA training Whalen model Schertz model Take home messages

What is Joint Attention? Joint Attention (JA) is recognized as one of the earliest forms of communication in young children and involves coordinated attention between a social partner and an object or event in the environment (Taylor, 2009) The capacity to use gesture and eye contact to coordination attention with another person to share the experience of an interesting object or event

What is Joint Attention? JA is a child shifting his gaze between you and an object It allows a child can communicate with you about his interests (Sussman, 1999) Usually develops between 9-18 months in typical children (Taylor, 2009).

What is Joint Attention? A ---> B ---> C A) adult initiates interaction B) child looks at object/event and looks back to adult C) child receives social reinforcement from adult (Taylor, 2009)

Components of Joint Attention Following adult gaze and point Eye contact: checking back with adult Gaze alternation between object and adult Reciprocal commenting about objects - From Taylor, 2009

Example of Joint Attention

Typical Development of Joint Attention 2-3 months: infants smile in response to parents smile or voice 8 months: follow a parents gaze (e.g., parent looks at the clock, infant will follow) 10-12 months: follow a point, then look back at parent 12-14 months: initiate a point 15-16 months will draw a parents attention to an object of interest with sound, point, looking back and forth

Joint Attention Impairments in ASD joint attention deficits responding to joint attention bids(RJA) initiating joint attention bids (IJA) difficulty shifting attention from one thing to another fewer displays of positive affect along with joint attention behaviors Limited motivation to respond to/engage in social interactions referencing mouth instead of eyes

Typical Peers and ASD illustrations Autism Speaks Video Glossary: http://autismspeaks.player.abacast.com/asdvideogloss ary-0.1/player/autismspeaks

Joint Attention Lack of joint attention is a core feature of autism Research has differentiated children with ASD and other developmental disabilities based on joint attention http://www.youtube.com/watch?v=tif4U3OjT2M&feature=y outube_gdata_player

Why is Joint Attention Important? JA is a key prerequisites to learning from other (along with receptive language) ability to focus on people & objects at the same time is a prerequisite for communication better joint attention skills are associated with better language development (Bono, Daely, Sigman, 2004), *Language => improved prognosis children with ASD who display more intact joint attention skills exhibit better outcomes w/ respect to development of cognitive, language and symbolic play skills (Sigman & Ruskin, 1999) identified as a pivotal behavior If you and your child are focused on the same topic, you can share ideas about that topic. When you share a common focus with another person, you have what is called “joint attention.”

Child without Joint Attention Andrew doesn’t seem to hear his father call him over and over. He can’t respond to speech when he is so engrossed in looking at his cup.

Intervention Planning it is possible to improve joint attention behaviors in children with ASD targeting joint attention skill development appears to be an important component for early intervention Component skills to target: Making eye contact Following a point Looking back to check in Commenting about objects Showing objects to others/directing others attention - Taylor, 2009

Group Activity: Follow my Eyes to the Prize Count off by sevens Determine who will be the first group “leader” The group leader should select another group member to be the communicative partner without speaking, just using eye contact The group leader should then guide the partner’s attention to an object in the environment using only eye contact and eye gaze (no speaking) Once the partner has accurately guessed what item the leader is looking at, the partner becomes the leader and selects the next person as described above Continue until all group members have been a leader and partner

Considerations/ Decision Making for Implementing JA training Who will be teaching? Parent vs. teacher What setting will the teaching occur in? Home vs. group classroom vs. 1:1 setting Which approach will be most conducive to child’s learning? Consider learner profile, instructor and setting

Considerations/ Decision Making for Implementing JA training Two intervention models will be described today: Whalen and Schertz  Different teaching approaches are based on different theories Whalen’s model is similar to Discrete Trial: Adult directs. Cue and Prompt attention at person or object and reinforce. Schertz’s model is similar to Floortime, RDI: More open ended and following child’s lead.  

Whalen Model Teaches child to respond to requests to shift their attention, first between objects and eventually between an object and another person’s face Very structured, clearly defined criteria for each step, and outlines correct versus incorrect responses (consequences) Involves videotaping three, 10 minute play sessions per week for each “level” or step Instructor is encouraged to implement intervention procedure in daily routines beyond the 10 minute taped sessions

Whalen Model Level 1: “Hand on” Level 2: “Tap” Level 3: “Show” Level 4: “Eye Contact” Level 5: “Follow a Point” Level 6: “Following Eye Gaze” Hand out chart from Jim with criteria and steps

Level 1: “Hand on” When child is engaged with another activity, an object is placed under their hand. A correct response is defined as manipulating or looking at the new object for 5 seconds. All correct responses are rewarded with continued access to the new object or object previously used (approximately 1 minute) and social praise. Incorrect responses are addressed by re-presenting a desired object following a 5 second inter-trial break and providing a physical prompt. Prompted responses are rewarded by access for approximately 20 seconds. The criteria for progression for all response levels is 80% accuracy during 2 out of 3 sessions.

Level 2: “Tap” When child is engaged with another activity, an object is placed in front of them and tapped. A correct response is defined as manipulating or looking at the new object for 5 seconds. All correct responses are rewarded with access to the new object or object previously used (approximately 1 minute) and social praise. Incorrect responses are addressed by re-presenting object following a 5 second inter-trial break and providing a physical prompt. Prompted responses are rewarded by access for approximately 20 seconds. The criteria for progression for all response levels is 80% accuracy during 2 out of 3 sessions.

Level 3: “Show” When child is engaged with another activity, an object is placed in front of them (shown). A correct response is defined as manipulating or looking at the new object for 5 seconds. All correct responses are rewarded with continued access to the new object or object previously used (approximately 1 minute) and social praise. Incorrect responses are addressed by re-presenting the object following a 5 second inter-trial break and providing a physical prompt. Prompted responses are rewarded by access for approximately 20 seconds. The criteria for progression for all response levels is 80% accuracy during 2 out of 3 sessions.

Level 4: “Eye Contact” The child is required to make eye contact with partner when a bid for attention is made (“look”). The reward for a correct response is access to the object for 1 minute and social praise. Incorrect response is addressed by representing the object after 5 second break and providing a gestural prompt – hold object at eye level.

Level 5: “Following a Point” Once eye contact is established with the child; turn head and point to object. A correct response involves the child turning toward the direction of object. The correct response is rewarded with access to the new object or continued access to the object they had been using for 1minute and social praise. If child makes an incorrect response re-present the instruction (“look” + point) and a physical prompt (move head in direction of the object) is used. Prompted responses are rewarded with access to a new or previously obtained object for 20s and social praise. Once the child is following the point, the child will be expected to look back to the adult. This closes the joint attention circle.

Level 6: “Eye Gaze” Eye contact with the child is established; turn head and look toward the object. A correct response involves the child turning toward the direction of object. The correct response is rewarded with access to the new object or continued access to the object they had been using for 1 minute and social praise. If child makes an incorrect response re-present the instruction (“look” + point) and a physical prompt (move head in direction of the object) is used. Prompted responses are rewarded with access to new or previously obtained object for 20 seconds and social praise. Once the child follows the eye gaze, the child will be expected to look back to the adult. This closes the joint attention circle.

Whalen Level 1: Hand on

Whalen Level 2: Tap

Activity with Whalen Model Pair up, 1 person will be the “child” and the other will be the adult Practice the prompting in each of the six levels Take turns as adult and child Practice the correction procedure as well as the protocol for correct responding Discuss implementation with a child

Schertz Model Focuses on 3 areas of social communication: Focusing on Faces Taking turns in back-and-forth play Sharing attention about things he is interested in Less structured than Whalen model Decisions to move on based on viewing videos, not specific criteria Uses natural strengths of family/ teacher, “going with the flow” & teaches the adult to follow the child’s lead Involves planning longer play time sessions (30-60 minutes) and video taping sessions Play sessions are encouraged to be 30-60 minutes per day Parents are taught to wait expectantly a little longer than usual

Schertz Model There are 5 principles for mediating the child’s learning within each of the 3 stages: 1. Focusing 2. Organizing and planning 3. Encouraging 4. Giving meaning 5. Expanding On faces Making predictable routines Using praise/ reinforcement Adult exaggerates responses to child’s gaze/ initiations etc

Focusing on Faces Why it is important: An early form of social communication which helps children pick up on social signals and form bonds. Child will see others’ reactions to things that happen. Will lay the ground work for other forms of social communication. Child will learn that looking at your face is different than looking at other things in environment.

Taking Turns Why it is important: Helps child to be reciprocal and include you in play. It is a building block for verbal communication in which we take turns in conversation speaking and listening. Child will learn to focus on both what he or she is doing and what you are doing.

Sharing Attention Why it is important: Helps child to broaden interests and pay attention to what others are interested in. This makes it easier to learn new concepts and words and builds communication skills. It is a form of nonverbal commenting, such that the child can have a conversation before learning to talk. Child will learn to experience pleasure when others are excited and showing him or her something.

Focusing on Faces: Examples of how to support each principle holding your head so child can see easily incorporate looking at your face into a game exaggerating expressions manipulate toys near your face

Focusing on Faces: Examples of how to support each principle 2. Organizing and planning Have rituals before transitions to new activities arrange toys in environment that encourage facial referencing and hide toys that encourage solitary play engage in songs with lots of repetition and predictability

Focusing on Faces: Examples of how to support each principle 3. Encouraging Be sensitive to difficulty of looking at faces if child resists, make expressions more predictable include soothing singing in language with child pair looking at face with things child likes

Focusing on Faces: Examples of how to support each principle 4. Giving meaning Pause unexpectedly while walking or playing be more unpredictable, put shoe on your head, or eat with a toy Have child search for your voice by hiding behind a screen and responding playfully when he looks behind screen

Focusing on Faces: Examples of how to support each principle 5. Expanding Collect close up photos of your face and sort from faces of strangers make a book of faces and discuss expressions simplistically have others wait for child to look before interacting

Activity with Schertz Model Come up with one example of how to work on each principal for either “Taking Turns,” or “Sharing Attention.” 1.Focusing 2. Organizing and planning 3. Encouraging 4. Giving meaning 5. Expanding

Data Collection for both models Data Sheet (JA) Intervention format__________________ Teacher name_______________________ Child name________________________ Date Phase Trial # + / - / (P) COMMENTS _____ _____ _____ _____ Number correct _____ = _____ (100) =______% Total trials

Activity Think of your target students Discuss where each child may be starting with joint attention skills (ex: some eye contact in response to gestures, no response at all to bids for attention, etc). Discuss which intervention would be most appropriate for each child and why. Determine how you might integrate the intervention into the child’s day including collecting data.

Activities to Incorporate into Classrooms to Address JA Freeze game I lost my voice Follow my eyes to the prize Look at my face to find the prize Imitation games  Try it together: Red light green light with faces

Video Example Follow my eyes http://www.youtube.com/watch?v=k1s4wNH4KcU&playne xt=1&list=PLA15F94F7622527FE

Take Home Messages Joint Attention is a pivotal, prerequisite skill for communication Joint Attention does not come naturally to most children with autism therefore it must be targeted in intervention Can be implemented across child’s routines and care providers; therefore, increasing the amount of teaching the child is exposed to

References Bono, M, M., Daley, T., & Sigman, M. (2004). Relations among joint attention, amount of intervention, and language gains in Autism. JADD, 34, 495-505. Delaney, E.M.,& Kaiser, A.P. (2001). The effects of teaching parents blended communication and behavior support strategies. Behavioral Disorders, 26, 93-116. Moes, D.R., & Frea, W.D. (2002). Contextualized behavior support in early intervention for children with Autism and their families. JADD, 32, 519- 533. Rocha, M., Schreibman, L. & Stahmer, A. 2009. Effectiveness of training parents to teach joint attention in children with Autism. Journal of Early Intervention. Sage Publications. Schertz, H.H. (2005). Joint Attention Mediated Learning manual. Unpublished manuscript.

References Schreibman, L., & Koegel, R.L. (1996). Fostering self management: Parent-delivered pivotal response training for children with autistic disorders. In E.D. Hibbs & P.S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders (pp. 525-552) Washington, DC: American Psychological Association. Sussman, F. (2007). Hanen More than Words Training Manual. A Hanen Center Publication, Toronto, Ontario (pp. 96-97, slide #10). Sussman, F. (1999) More Than Words; Helping Parents Promote Communication and Social Skills in Children with Autism Spectrum Disorder. A Hanen Center Publication, Toronto, Ontario. (pp. 20, 388). Taylor, B.A. (2009). Improving Joint Attention and Reciprocal Language Skills in Children with Autism (PowerPoint slides). Whalen, C. & Schreibman, L. 2003. Joint attention training for children with Autism using behavior modification procedures. Association for Child Psychology and Psychiatry, 44, 456-468.