1. Autism EBP

2. Autism EBP group First meeting held in September 2010 53 group members, broad range of SPs in disability, community, ADHC, private practice, autism-specific preschools, specialised (e.g. ASPECT, ABI, CP), NGOs etc. CAPs completed : 14 + 3 summaries. Academic Link: Dr Jacqueline Roberts Presentation or sharing of resources component each meeting e.g. presentation by Dr Roberts, discussion of resources, new publications, community resources

3. Critically Appraised Topic In children with autism, does joint attention (JA) intervention improve social communication skills?

4. Topic Decided upon by group vote Wanted something clinically useful that could be applied to a range of SP settings Wanted a topic that was pivotal to the needs of children with autism JA is a critical requirement for language learning ( Whalen, 2003 ) Qualitative differences or a complete lack of JA is extremely common in children with autism (Kasari, 2010) Although a failure to talk may be of biggest concern to parents, “the underlying lack of JA is ultimately the most deleterious feature of autism” (Kasari, 2010)

5. Challenges in reviewing joint attention research Terms used vary in the literature (e.g. joint engagement, joint attention, shared attention) Interventions for autism often have multiple components (with JA being just one of these) which can confound conclusions that it was the JA intervention that produced the outcome e.g. Hanen, Denver Early Start Model, Building Blocks Children are often receiving other interventions at the same time as the study. Unreasonable to expect parents to discontinue all other interventions for their child Children with autism are very heterogeneous Ways of measuring the outcomes vary (e.g. functional words, spontaneous words, gesture, vocabulary size etc)

6. Under the general topic of JA we also looked at 2 sub-topics: Parent-mediated JA intervention Group-mediated JA intervention

7. What is joint attention? Refers to the development of specific skills that involve sharing attention with others through pointing, showing and coordinating looks between objects and people. It also involves the maintenance of these skills. At 9 months infant can follow a point but coordinated JA doesn’t develop until around 15-18 months of age in typically developing children (Rocha et al, 2007) Sharing the moment with others. Includes both: Responding to joint attention Initiating joint attention

8. Stages in JA Initiating joint attention: Coordinated Joint Look Showing Give to share Proximal Point Distal Point Responsive Joint Attention: Following proximal point Following distal point (Kasari, Freeman et al. 2008)

9. CAP 1: Whalen C & Schriebman L (2003) “Joint attention training for children using behaviour modification procedures”. Journal of Psychology and Psychiatry 44;3 pp 456-468 Single subject multiple baseline design n=11; approximately 4 years of age (5 with autism and 6 typically developing) Pre-treatment assessments then participated in baseline for 2-10 weeks. Experimental group : 2 treatment phases 1) response training: child was taught to respond to JA bids and 2) initiation training: child was taught to initiate JA bids Therapy 3 days/wk for 1.5 hours per day. Therapy: naturalistic behaviour modification technique using components of discrete trial and Pivotal Response Training Control group: Used to establish norms. No intervention.

10. Results Efficacy of training JA intervention effective for all children for responding to JA JA intervention effective for 4/5 children for initiating JA Generalisation of target behaviours to unstructured assessment Post treatment to 3 month follow up: 4/5 subjects maintained ability to respond to JA at levels higher than baseline. 1 went back to baseline levels Post treatment to 3 month follow up: 4 subjects increased ability to initiate JA, no difference in one subject Generalisation to naturalistic setting Post treatment to follow up: Decreases in JA were seen but 3/4 children still had higher levels than baseline

11. Clinical Bottom line When JA (both responding and initiating) was directly targeted using a behaviour modification program, all children showed improvements in JA. However, the generalisation and maintenance of these skills was not firmly established and further studies with larger sample sizes are required.

12. CAP 2: Kasari C, Gulsrud A et al. (2010) “Randomised controlled caregiver mediated joint engagement intervention for toddlers with autism” J Autism & Developmental Disorders; 40; pp 1045-1056 Design: Randomised controlled trial. N=38. Method Primary outcome measures: 1) Engagement states: 3 macro categories of engagement: unengaged/object engagement/joint engagement. 2) Frequency of joint attention skills (initiating and responding to joint attention) Secondary outcome measures: 1) Quality of caregiver involvement (using CQIS scale 1-5) 2) Parent adherence to treatment and competence (6 item self report; adherence to treatment measure) 3) Service Utilisation Measure: list of programs/therapies child engaged with during treatment.

13. Treatment Treatment group: 19 chn with autism received joint attention intervention. Intervention was adapted from Kasari (2006&2008). 10 modules incorporating core principles of the intervention. 24 sessions in total for each child; 3 sessions per week for 8 weeks. Session= interventionist coaching caregiver and child in play routines. Developmental procedures of responsive and facilitative interaction methods as well as aspects of ABA. Follow lead/interest; imitating child’s actions; repeating back what child said; expanding what child said; giving corrective feedback; sitting close to the child/making eye contact and making environmental adjustments to engage the child. 30 mins of direct instruction/modelling/guided practice & feedback to parent-child dyad. Handouts given to parents after each module. 10 minutes at end to practice newly learned techniques. Control group: 19 chn with autism on WL. Offered treatment 8 weeks later Parents and children randomised into groups and matched for each group and both groups continued normal treatment

14. Results Primary Analysis Post intervention: Compared to the WL gp, the IT children: 1. Engaged in sig. less object-focused play 2. Engaged in sig. more joint engagement. 3. Showed greater responsiveness to joint attention 4. IT chn did not show greater initiations of JA. Overall, IT gp had greater improvement in 2/3 joint engagement state outcomes;1/2 responsiveness to joint attention outcomes. One year follow up for IT group: Maintenance and/or improvement occurred for states of joint engagement; joint engagement; responsiveness to joint attention. Secondary Analysis (factors related to outcome) Higher quality of caregiver involvement scores sig. predicted increased joint engagement scores post treatment. Neither parent-rated questions regarding adherence and competence predicted engagement, type of play or joint attention in caregiver-child dyad. Service utilisation: Total number of hours in alternative services did not predict any of the variables of interest for either gp.

15. Clinical bottom line Short term parent-mediated intervention targeting joint attention can result in significant improvements in some targeted areas of joint attention, including responsiveness to joint attention. Some of these targeted joint attention behaviours were maintained at a one year follow up. It is more difficult to teach (and maintain) the skill of initiating JA.

16. General trends Joint attention can be taught to some children with autism (with a range of severity) Parents can be trained to teach their children some JA skills. Teaching initiating JA is more difficult than response to JA. Difficulty initiating is common in autism generally. Children often had difficulty generalising and maintaining JA with new people or contexts (known to occur across skills in ASD) JA intervention can improve expressive language in some children but further research is required regarding improvements in receptive language skills

17. General trends Most studies were based on an approach that was grounded in applied behaviour analysis (ABA) and/or Pivotal Response Training (PRT), and taught skills at a table rather than within naturalistic play settings Studies varied widely in dosage and format Most studies were interventionist-mediated Not many studies looked at long-term follow up and maintenance of skills or only looked at this a few months post intervention Most studies had small sample sizes. Only one RCT. Outcomes varied and not always what SPs would define as “functional communication”

18. Future directions… Topics being voted upon. Suggestions include: early diagnosis and intervention, red flags, video- modelling, theory of mind Continue to meet at Croydon 5 x per year. Dates have now been set. Please contact leaders for details. Re-visit group numbers/membership

19. References Whalen C & Schriebman L (2003) Joint attention training for children using behaviour modification procedures. Journal of Psychology and Psychiatry. 44;3 pp. 456-468 Kasari C, Gulsrud A et al. (2010) Randomised controlled caregiver mediated joint engagement intervention for toddlers with autism. J Autism & Developmental Disorders; 40; pp. 1045-1056 Rocha M. L., Schreibman L., & Stahmer A. C. (2007) Effectiveness of Training Parents to Teach Joint Attention in Children with Autism. Journal of Early Intervention,Vol. 29, No. 2, 154 - 172 Kasari, C., Paparella, T., Freeman, S. Jahromi, L. (2008) Language outcome in Autism: Randomised Comparison of Joint Attention and Play Interventions. Journal of Consulting and Clinical Psychology, 76, 125-137.

20. Thank you Dr Jacqueline Roberts- our academic advisor Group members for sharing the job of compiling the CAPs and a very productive year Carissa Louwen for organising the room bookings Ann for helping while Meghan is away