J Autism Dev Disord (2007) 37:1562–1575

DOI 10.1007/s10803-006-0290-z

ORIGINAL PAPER

Promoting Joint Attention in Toddlers with Autism:

A Parent-Mediated Developmental Model
Hannah H. Schertz Æ Samuel L. Odom

Published online: 10 November 2006

Ó Springer Science+Business Media, LLC 2006

Abstract Joint attention, a foundational nonverbal Introduction

social-communicative milestone that fails to develop
naturally in autism, was promoted for three toddlers The research reported here studied an approach to
with early-identified autism through a parent-mediated, promoting joint attention in toddlers with autism that
developmentally grounded, researcher-guided inter- considers developmental foundations and builds on the
vention model. A multiple baseline design compared existing parent–child relationship (Schertz, 2005a).
child performance across four phases of intervention: Models appropriate for younger children with autism
focusing on faces, turn-taking, responding to joint are a high priority for the field because with earlier and
attention, and initiating joint attention. All toddlers effective intervention, we can expect superior long-
improved performance and two showed repeated term outcomes (National Research Council, 2001;
engagement in joint attention, supporting the effective- Volkmar, Lord, Bailey, Schultz, & Klin, 2004). As
ness of developmentally appropriate methods that early identification efforts improve with effective
build on the parent–child relationship. A complemen- toddler screening programs (e.g., Robins, Fein, Barton,
tary qualitative analysis explored family challenges, & Green, 2001; Stone, Coonrod, & Ousley, 2000), this
parent resilience, and variables that may have influ- need becomes more urgent.
enced outcomes. Intervention models appropriate for Joint attention is defined as visually coordinating
toddlers with autism are needed as improved early attention with a partner to an external focus, showing
identification efforts bring younger children into early social engagement and an awareness of the partner’s
intervention services. mutual interest for the purpose of ‘‘commenting’’
rather than ‘‘requesting’’ (Carpenter & Tomasello,
Keywords Joint attention
Early intervention
2000; Mundy & Stella, 2000; Schertz, 2005b). Like
Toddlers
Parent mediation
Autism receptive and expressive verbal language, joint atten-
tion appears in both responding and initiating forms
and is demonstrated by following another’s eye gaze or
H. H. Schertz
S. L. Odom
point, or by showing or pointing to objects (Kasari,
Department of Special Education, Indiana University,
Bloomington, Indiana, USA Freeman, & Paparella, 2001). This important founda-
tional competency crosses three domains of early
H. H. Schertz (&) development (Schertz & Odom, 2003) by supporting
School of Special Education, College of Education and
theory of mind or an awareness of others’ mental states
Behavioral Sciences, University of Northern Colorado,
Box 141, Greeley, CO 80639, USA (Baron-Cohen, 2000), language learning (Carpenter,
e-mail: hannah.schertz@unco.edu Nagell, & Tomasello, 1998; Paparella & Kasari, 2004),
and social development (Adamson & Russell, 1999).
Present Address:
During the first year of life, precursors of joint
S. L. Odom
Frank Porter Graham Child Development Institute, attention are typically evident in a natural progression
University of North Carolina, Chapel Hill, USA through face-to-face engagement in the first months,

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involvement with objects by mid-year and, by the last autism, emphasizing early social skills and child initi-
quarter of the year, response to joint attention over- ation.
tures from caregivers (Adamson & Bakeman, 1991). Relationship-based approaches (Greenspan & Wie-
Typically appearing in the first year as a passive der, 1999; Klein, 2003; Prizant, Wetherby, & Rydell,
response that relies heavily on caregiver support, joint 2000) can address social-communication needs within a
attention is fully consolidated by about 18 months developmental framework. McCollum (1984) transmit-
(Adamson & Russell, 1999). ted generalizable principles rather than specific skills to
Disruption in the development of joint attention help parents adjust their interactive style to match
is unique to autism, providing one of the earliest infant characteristics. Cognitive-mediational approaches
discernable markers of autism in toddlers. When also use relationships to promote children’s internal
compared to control groups with typical development, learning capacity. Theories of ‘‘cognitive modifiabil-
developmental delay, and language delay, groups with ity’’, based on Vygotskian thought, emphasize trans-
autism show difficulties with joint attention that cannot actional aspects of socially based learning to influence
be explained by general cognitive or language differ- child motivation, self-efficacy, and desire for learning
ences (McArthur & Adamson, 1996; Mundy, Sigman, (Feuerstein, 1980; Haywood, Brooks, & Burns, 1992).
Ungerer, & Sherman, 1986). These findings suggest a Butera and Haywood (1992) advocated a cognitive
need to study intervention models that directly target model to help children with autism process the
development of joint attention and to compare results complexities of social communication.
with more traditional approaches that focus on sym- Accommodation to a social world, an emerging
bolic communication. challenge for toddlers, is supported by parent–child
In a study designed for the exclusive purpose of interaction in joint attention encounters. Typically,
promoting joint attention in young children with parent initiative is prominent in the early stages of
autism, Whalen and Schreibman (2003) used natural- joint attention development (Adamson & Bakeman,
istic behavior modification to elicit joint attention in 4- 1991) and the level of early caregiver scaffolding (i.e.,
year-olds with autism. Using physical and verbal support provided to enable success) relates to the
prompts, interspersal of mastered tasks, task choice, infant’s later ability to initiate joint attention
and contingent reinforcement, their intervention (Vaughan et al., 2003). Maternal responsivity was
resulted in moderate gains, but limited skill mainte- found to mediate communication development in
nance, which was attributed to the lack of planned young children with developmental delays and autism
parent involvement. Kasari et al. (2001) suggest that (Kaiser & Hemmeter, 1996; Mahoney & Perales,
generalizability limitations may also result from a 2003; Yoder & Warren, 1999) and, if the interaction
reinforcement-based, externally motivated approach to supports joint attention, parent-mediated intervention
promoting what is a spontaneous, internally generated could extend through much of the child’s waking
form of early communication. hours. Ingersoll and Dvortcsak (2006) promoted
Other intervention considerations surround issues of generalization and maintenance of professionally
developmentally appropriate practice for toddlers trained child skills in their group training program
(Bredekamp & Copple, 1997). In a consensus-building for parents of young children with autism. Klein
effort to guide practices for young children with (2001) placed parents in a more central role in a
autism, the National Research Council (2001) identi- parent-mediated relationship-based intervention that
fied intensity of services as critical, although its supported early cognitive development. Compared to
importance is questioned by others (Bono, Daley, & controls, the experimental group realized superior
Sigman, 2004; Prizant & Wetherby, 1998). Toddlers cognitive outcomes that were sustained in 3-year
may be less adaptive than older children to intensive, follow-up measures.
highly structured, adult-directed, skill-based approaches The purpose of the current study was to determine
and some have called for early intervention models the effectiveness for toddlers with early-identified
that move beyond promoting isolated skills to consid- autism of a model that initiated intervention before
ering family systems, child engagement, integrated and age three, promoted joint attention by building on its
authentic intervention, and variable response to inter- developmental precursors, and used the parent–child
vention (Bryson, Rogers, & Fombonne 2003; Howlin & relationship to mediate child learning. A secondary
Moore, 1997; Pretti-Frontczak & Bricker, 2004; Volk- purpose was to study possible transactional influences
mar et al., 2004). Dawson and Osterling (1997) among family factors, intervention-related variables,
advocated a developmental approach for toddlers with and intervention outcomes.

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Method administered the Childhood Autism Rating Scale

(CARS; Schopler, Reichler, & Renner, 1988), resulting
Participants in scores for all children in the ‘‘severely autistic’’
range. Parent-initiated independent evaluations from
The participants were three parents of toddlers with research hospital clinics subsequently confirmed diag-
autism. Eligibility criteria were child age less than noses of autism for all three children.
36 months at entry and strong early markers of autism. All parent participants were mothers and the three
The first three eligible families who agreed to commit toddlers were boys. Child A’s mother was age 27 and a
to the intervention were accepted for participation. To high school graduate with self-reported dyslexia and
recruit participants, pediatricians in two group prac- depression. Child A, age 24 months at enrollment was
tices agreed to administer the Modified Checklist for an only child. He received Part C-funded early inter-
Autism in Toddlers (M-CHAT; Robins et al., 2001) at vention services limited by parent choice to one hour
all 18- and 24-month well child checks, providing a weekly. Child B’s mother, 32 years of age, was a
researcher-generated letter to identified families that college graduate with special education work experi-
invited their participation in the study. Concurrently, ence. Child B, who entered the study at age 33 months,
Part C-funded early intervention providers in a multi- had a diagnosis of epilepsy. He received 7–8 h weekly
county area were requested to administer the M-CHAT of Part C-funded early intervention services and
for children they identified as having disproportionate transitioned to Part B preschool services during his
delays in social and communication development. The participation in the study. Two older siblings, both
researcher re-administered the M-CHAT to identified boys, had also received Part C services. Child C’s
willing families by interview. Although it is a screening mother, age 23, was a high school graduate who
and not a diagnostic instrument, the M-CHAT has reported that she had diagnoses of dyslexia, ADHD,
shown strong sensitivity (identifies 85–95% of true bipolar disorder, and previous addiction to narcotics.
positives, depending on exclusion criteria) and speci- Child C, age 22 months at entry, also had two older
ficity (correctly excludes 93% of children who will not siblings who had received early intervention services.
be diagnosed) in field tests (Dumont-Mathieu & Fein, The family participated in Part C-funded services 2 h
2005). M-CHAT results for participants were repli- weekly and his mother reported that Child C had
cated on the Pervasive Developmental Disorders diagnoses of asthma and epilepsy. All three mothers
Screening Test-II (PDD-ST-II; Siegel, 2001) and the reported pregnancy complications resulting in ex-
researcher-developed Infant Social-Communication tended bed rest. Developmental assessment results
Questionnaire (ISCQ) (Schertz, unpublished). Diag- were gathered from early intervention providers.
nostic clinics in the region were reluctant to diagnose Screening and assessment scores are presented in
autism in children under age 3; however, the researcher Table 1.

Table 1 Developmental assessment scores in months, autism screening results, and CARS ratings
Domain Child A CA = 23 mos.: DPIT Child B CA = 28 mos.: HELP Child C CA = 20 mos.: HELP

Gross motor 21.5 (20/23) 24 (18/30) 19.5 (18/21)

Fine motor 13.5 (12/15) 20 (18/22) 13 (12/14)
Cognitive 17.5 (16/19) 16.5 (11/22) 15 (9/21)
Communication 7 (6/8) 12 (6/18) 10.5 (9/12)
Adaptive 13.5 (12/15) 15 (14/16) 12.5 (9/16)
Social/emotional 4 (3/5) 21 (15/27)a 15 (9/21)
Mean 12.8 18.1 14.2
Autism screening by parent report at enrollment: number/percent of screening items failed
M-CHATb 16/70% (critical: 6/100%) 14/61% (critical: 3/50%) 16/70% (critical: 5/83%)
PDD-ST-II 14/100% 11/79% 9 / 64%
ISCQ 14 of 18/78% (1 blank) 17 of 19/89% 17of 19/89%
CARS ratingsc 52 40.5 45
Note: CA = chronological age; DPIT = Developmental Programming for Infants and Toddlers; HELP = Hawaii Early Learning
Profile; M-CHAT = Modified Checklist for Autism in Toddlers; PDDST-II = Pervasive Developmental Disorders Screening Test-II;
ISCQ = Infant Social-Communication Questionnaire; mo = months; CARS = Childhood Autism Rating Scale
a
This reported score was inconsistent with parent report of approximately 9 mos
b
Failure of at least 3 total or 2 ‘‘critical’’ items indicates need for diagnostic evaluation
c
‘‘Severely autistic’’ range = 37–60 with higher scores representing more severe level of autism

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Design Greenspan and Weider (1999), Klein (2003), McCollum

(1984), and Prizant et al. (2000).
A mixed methods research design can serve purposes To explore underlying family and intervention-
not achievable through quantitative or qualitative related variables that may have influenced child
methodologies carried out alone, including comple- performance and to shed light on parents’ understand-
mentarity, defined as enhancement through explora- ing of, progress with, and response to their role in the
tion of overlapping or related data (Johnson & intervention, a complementary qualitative research
Onwuegbuzie, 2004). In the current study, comple- design was implemented using data from audiotaped
mentarity of data was achieved through the combina- parent–researcher discussions and parent notes. The
tion of single subject multiple baseline and qualitative qualitative analysis explored influences that may have
research designs. The single subject design was imple- played a role in observed changes. Data from initial
mented across targeted outcomes for the purpose of parent interviews and weekly parent–researcher con-
documenting causal relationships between the inter- versations included intervention-related concerns and
vention and child performance in the four levels of other parent-identified issues. Initial interview ques-
social-communicative competency: focusing on faces, tions included the M-CHAT items and questions that
turn-taking, responding to joint attention, and initiat- explored the children’s development, parents’ desires
ing joint attention. This design, replicated across the related to parent–child communication, and parents’
three participants, resulted in a graphic depiction of conceptions of the parent-professional role. Parents’
changes in child performance for each level. The daily notes included descriptions of children’s partic-
inclusion of multiple participants with staggered move- ipation in daily parent–child interaction.
ment from baseline into intervention conditions iso-
lated changes attributable to the intervention from Intervention Procedure
those possibly related to external factors such as
maturation. A sufficient number of data points dem- Intervention sessions were conducted in families’
onstrated stable patterns for baseline and intervention homes. To promote interaction, parents played face-
conditions. to-face games using toys that were present in the
Although single subject design studies typically home. The Joint Attention Mediated Learning
report on structured behavioral and skill-based inter- (JAML) manual (Schertz, 2005c) provided a frame-
ventions using measures that correspond to elicited work for parent–child interaction. The manual’s con-
skills, this study applies the design to nonverbal social tent focused on developmental foundations of joint
communication outcomes that are not directly ‘‘trained’’ attention and the format was modeled on the Affective
through a structured reinforcement-based approach. Cognitive Enabling: Mediating Learning Strategies
Rather, in Heflin and Simpson’s (1998) conceptualiza- curriculum (Kahn & Hosaka, unpublished), a curric-
tion, this model can be classified as ‘‘relationship based’’ ulum targeting parent mediation of infant cognitive
in that it fosters parent–child interaction in a planned, learning. At the end of the baseline period, the
but open-ended format within the context of the researcher provided parents with an oral and written
relationship rather than through a skill-based approach overview of mediated learning principles (adapted
that reinforces specific skills in isolation or as ends in from Klein (2003)) as they relate to development of
themselves. In the current study, the intervention joint attention and as children progressed, explana-
targeted relationship-based competencies through the tions and suggested activities were provided for each
open-ended medium of parent–child interaction and did of the four intervention phases.
not employ a specific program of reinforcement apart Phases were introduced in sequence, along with
from that derived naturally from the interaction. Sim- descriptions of targeted competencies and their impor-
ilarly, Ingersoll and Dvortcsak (2006) distinguished tance. Two levels comprised each phase, the first relying
between ‘‘direct’’ and ‘‘indirect’’ teaching methods with on parent initiative and the second seeking more
direct methods including naturalistic behavioral ap- initiative from the child. Rather than rigid prescriptions,
proaches that use learning theory techniques (e.g., suggested activities were intended to help parents
Kaiser & Hemmeter, 1996; Koegel & Schreibman, envision ideas of their own to encourage their child’s
1996) and indirect methods including developmental best response. Suggested activities were linked to
approaches that focus on parent–child interaction and earlier-presented mediated learning principles.
emphasize parent responsivity. Using this framework, Focusing on faces strategies were aimed at increas-
the current study employs indirect methods. In these ing child tolerance for looking at faces, the single
respects, the approach aligns with those described by greatest difference found between 12-month-olds later

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identified with and without autism (Osterling & Daw- Table 2 Fidelity of parent–child mediation: percentage of ses-
son, 1994) and an avenue for the child to discern social sions with full, partial, or no fidelity; number of scheduled
sessions attended; and duration of participation
cues. Examples included using interactive face-
oriented vocal games with strong rhythms, pairing Extent of fidelity Dyad A Dyad B Dyad C
looks to the face with expressions of affection, making
Full fidelity: Notes were 8% 85% 70%
the parent’s face hard to avoid, imitating facial provided, addressed
gestures, and mirror play. Turn-taking activities aimed appropriate phase of
to promote reciprocity, a component of joint attention, intervention, and revealed
and included imitation of child-initiated gestures, parent understanding of
intervention plans
responding to child actions as if they were intended Partial fidelity: Notes were 46% 0% 0%
as interactions, embedding parents’ actions into the provided but showed lack of
child’s isolated repetitive play, following the child’s fidelity with correct
lead, pausing for the child’s response after the parent’s intervention phase or lack of
conceptual understanding
turn, and playing teasing games. Responding to joint No fidelity: Notes were not 46% 15% 30%
attention strategies targeted shared attention to objects provided for the session
through supportive parent initiations. For example, Number of intervention sessions 14 16 11
parents were encouraged to introduce a toy after attended
Duration of intervention in 16 26 9
establishing eye contact, hold the toy close to their weeks
faces when offering it to the child, and use excitement
Note: Children A and B were scheduled for once weekly and
or suspense to encourage the child to look between a
Child C for twice weekly sessions. Parent notes from a full week
toy and the parent’s face. Finally, initiating joint were considered as a set for calculation
attention activities encouraged the child to engage the
parent’s attention in relation to an object by expressing agreement level of .89. Naı̈ve to the baseline or
excitement about the child’s play with a toy or intervention condition, the coder observed each 10-s
introducing ‘‘surprise’’ bags or wrapped packages. interval from weekly videotaped 10-min parent–child
Parents were requested to spend approximately one interaction sessions (60 segments per session) for
hour daily in face-to-face parent–child interaction, occurrence of targeted outcomes. Focusing on faces
selecting and implementing activities in routine and was coded if the child looked at any part of his
planned interactions and to describe child performance mother’s face during the interval. Turn-taking required
in brief daily notes. Weekly sessions with the research- the child to perform one of at least two actions as part
er included a review of parent notes, videotaping of a of a full turn-taking routine completed within no more
10-min parent–child interaction session for data anal- than two consecutive intervals. Responding to joint
ysis, introduction of new material, joint planning for attention was credited if the child responded to the
the upcoming week, and discussion of parent concerns. parent’s attempt to draw his attention to an object by
Dyads A and B were scheduled for once weekly and alternating looks between the parent’s face and the
Dyad C for twice weekly sessions, but actual partici- object for the apparent purpose of sharing interest.
pation was closer to once weekly for Dyad C. The Initiating joint attention was coded if the child alter-
number and duration of sessions in which the families nated looks between the parent’s face and an object for
participated are presented in Table 2. Intervention was the apparent purpose of drawing the parent’s attention
discontinued for Children B and C when they had to the object (i.e., ‘‘showing’’). Interobserver agree-
progressed through the four phases of intervention and ment (Kappa), calculated on 25% of videotaped
showed multiple instances of initiating joint attention. sessions, was .86 for focusing on faces (range = .73 to
Intervention was discontinued for Child A after mutual .96), .82 (range = .47 to 1.00) for turn-taking, .80
agreement by his mother and the researcher that his (range = .66 to .92) for responding to joint attention,
response to the intervention had reached a plateau. and .87 (range = .73 to .92) for initiating joint attention
with a mean Kappa agreement of .84.
Data Collection and Analysis Qualitative data were collected from initial inter-
views, weekly sessions, and daily parent notes. Audio-
Parents were informed of the four targeted outcomes recordings yielded 257 pages of field notes for analysis.
before data collection began, allowing them to elicit These notes were coded, organized into categories, and
their child’s best performance during the baseline analyzed for emergent themes that centered on the
condition. An experienced early intervention provider relationship of the intervention to child progress,
was trained on coding criteria to an average Kappa parent-voiced challenges, and indicators of resilience.

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QSR NVivoÓ software provided a structure for orga- and a new phase introduced. To establish fidelity of
nizing and coding the qualitative data. Triangulation, parent–child mediation, daily parent notes were
achieved through convergence within and across the reviewed for indications that parents had demonstrated
qualitative and quantitative data, strengthened the an understanding of and adherence to the active phase
credibility of conclusions. For example, parent re- of intervention in their reports of daily parent–child
sponses to a social validity questionnaire supported activities. The percentage of notes that showed full,
qualitative descriptions of child changes and parent partial, and no fidelity was calculated and is presented
reports of child progress converged with videotape data. in Table 2. Parents B and C showed close fidelity with
All parent participants were offered an opportunity to weekly intervention plans while Parent A showed
verify and clarify qualitative data and conclusions and difficulty with conceptual understanding of turn-taking
the one parent who accepted reported agreement with and joint attention, resulting in less adherence to the
no recommendations for changes. A second experienced appropriate phase of intervention in reported daily
early intervention provider, working from six randomly activities.
selected transcripts, identified codable items and found
that 97% were addressed in researcher memos, that all
quotes were represented accurately, and that all associ- Results
ated interpretations and conclusions in the final report
were supported by source data. Quantitative
In fidelity of intervention measures, a comparison of
weekly audio transcriptions to child outcomes con- Changes in child performance were reflected as the
firmed that intervention phases were introduced number of 10-s intervals during weekly 10-min video
sequentially in researcher guidance to parents. When segments in which the child engaged in focusing on the
a child showed multiple instances of the targeted parent’s face, turn-taking, responding to parents’ joint
outcome in a phase in each of at least two sessions, attention overtures, and initiating joint attention
and both the parent and researcher agreed that the encounters with the parent. These data are shown in
child was ready to move on, the phase was reinforced Fig. 1 with child progress tracked through the ordered

Child A Child B Child C

Looks to Parent's Face
Number Intervals with

Baseline 60
60 Baseline FF intro. FU 60 Baseline FF intro. FU
FF introduced FU
50 50 50
40 40 40
30 30 30
20 20 20
10 10 10
0 0 0

TT intro. TT intro. TT intro.

40 40 40
Showing Turn-taking
Number of Intervals

30 30 30

20 20 20

10 10 10

0 0 0

RJA RJA RJA

15 15 15 intro.
intro.
Number of Intervals

intro.
Showing RJA

10 10 10

5 5 5

0 0 0
Number of Intervals

20 IJA intro. 20 IJA

20 intro.
Showing IJA

15 15 15

10 10 10

5 5 5

0 0 0
1 3 5 7 9 11 13 15 17 1 3 5 7 9 11 13 15 17 19 21 1 3 5 7 9 11 13 15 17 19

Fig. 1 Individual child progress on targeted outcomes by phase of intervention. Note: FF = focusing on faces; TT = turn-taking;
RJA = responding to joint attention; IJA = initiating joint attention; FU = follow-up

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presentation of phases preceded by baseline conditions Table 3 Mean performance across conditions
of increasing duration. Before the intervention was Child Target Baseline Intervention Follow-up
introduced, the three toddlers showed varying levels of
focusing on faces and turn-taking, however none A FF 5 20 36
showed responding to or initiating joint attention, the TT 4 6 5
RJA 0 0 1
ultimate goal of the intervention. With intervention, IJA 0 0 1
Child A’s greatest area of improvement was focusing B FF 9 25 28
on faces with moderate progress in turn-taking and TT 8 16 15
slight progress with the two joint attention measures. RJA 0 3 10
IJA 0 5 3
Child B showed steady improvement in all phases with C FF 25 28 52
progress closely following the introduction of each new TT 0 7 6
phase. Child C, who engaged in focusing on faces RJA 1 4 6
before beginning intervention, progressed rapidly IJA 0 5 4
through the remaining three phases and showed Note: FF = focusing on faces; TT = turn-taking; RJA =
instances of joint attention before those phases had responding to joint attention; IJA = initiating joint attention
been formally introduced. In the intervention condi-
tion, each of the three toddlers surpassed baseline
performance levels for all four targeted outcomes.
B and C expressed satisfaction with the level of child
Generalization and Maintenance improvement in all intervention phases while Parent A
noted her son’s limited progress in joint attention
In alternative settings (kitchen, back yard, and restau- phases. Another indicator of parents’ commitment to
rant), all parents elicited the same range of child and acceptance of the intervention, participation in
performance that had been consistently observed in weekly sessions, varied across participants; however,
previous sessions. Although parents were not asked to all participated in most scheduled sessions.
continue the intervention at the conclusion of the
intervention phase, in 5-week post-intervention main- Qualitative
tenance measures, each child’s performance for every
phase was higher than his mean performance during Parents’ views of child progress, expressed in weekly
baseline conditions and exceeded mean intervention discussions with the researcher and in their daily notes,
condition levels for the majority of targeted compe- mirrored trends in the quantitative data. These qual-
tencies (see Table 3). itative data coalesced into five themes, providing
Social validity measures assessed the degree to insight into variables possibly associated with child
which goals, techniques, and outcomes of the inter- progress and suggesting implications for intervention
vention were acceptable to the three parents. A and future research: (a) parent fidelity with planned
researcher-developed five-point Likert scale question- intervention mediated child progress, (b) child pro-
naire allowed for differentiated levels of response as gress in social-communication development facilitated
recommended by Schwartz and Baer (1991). This reduced aggression, (c) physical activity motivated
approach to measurement of social validity diverges children to interact, (d) simplifying the presentation of
from that used in other joint attention intervention the parent’s face facilitated focusing on faces, and (e)
research which evaluated ‘‘normalcy’’ ratings (Whalen turn-taking activities based on face-to-face play pro-
& Schreibman, 2003) but was similar to the approach moted joint attention better than play with toys.
used in a recent study that provided training to parents The researcher provided planned and sequential,
of children with autism (Ingersoll & Dvortcsak, 2006). but informal guidance on the four phases of interven-
Parent responses, summarized in Table 4, indicated tion. To promote focusing on faces, the researcher
parents’ support for the importance and appropriate- provided explanations, possible activities, and affirma-
ness of intervention goals, their role in implementa- tion of parent competence.
tion, their participation in weekly sessions, activity He’s learning about social skills [and] communi-
suggestions, and level of intrusiveness. All parents cation.... You can think of success in terms of how
predicted better long-term child competence as a result long he can sustain that eye contact..., keeping
of the intervention and indicated improved confidence him engaged with you as long as he will tolerate
in their own ability to support child interaction. Parents it; moving your head toward or away from him

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Table 4 Parent assessment of research participation

Items M (range)

The purpose of the research study was to help your child share interest with you about objects and events as a 5 (5–5)
stepping stone to language and social development. This goal was important to me
I think that providing parent–child interaction activities throughout the day is important 5 (5–5)
I liked making my own decisions about which materials or toys to use in daily activities. Comments (Parent B): I 4 (4–4)
liked this part, but when things are most difficult, having ideas given to me
Making daily notes and discussing them with the researcher was important to help her understand what we did 4 (4–4)
during the week. Comments: (Parent B): It was important, but I think it helped me understand how the process
worked each week and gave me ideas for the next week
The amount of time spent with the researcher was about right (about one hour once weekly) 4.7 (4–5)
Activity suggestions for focus-on-faces, turn-taking, responding to joint attention, and initiating joint attention 4.7 (4–5)
were helpful
Weekly discussions with the researcher were helpful (e.g., explanations, guidance for the next week’s activities, 4.7 (4–5)
etc.)
Reviewing and discussing videotapes of me interacting with my child (i.e., a current or previous session) was 4.7 (4–5)
helpful. Comments (Parent B): This was very helpful to see progress
I am satisfied with my child’s progress in focusing on faces 5 (5–5)
I am satisfied with my child’s progress in turn-taking 4.3 (4–5)
I am satisfied with my child’s progress in responding to joint attention 3.7 (3–4)
I am satisfied with my child’s progress in initiating joint attention. Comment: (Parent B): Getting there 3.7 (3–4)
I believe the approach used with this study was no more intrusive than necessary and fit well with my family’s 4.7 (4–5)
needs
I feel I am more competent in helping my child to interact as a result of the intervention 4.7 (4–5)
I believe that my child will have better long-term social and communication skills because of this intervention 5 (5–5)
Note: 1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree

into his line of vision..., helping him to succeed by In the turn-taking phase, the researcher provided
making your face hard to avoid.... Your affective explanations and examples. ‘‘We want him to get into
involvement [gives] meaning to looking at faces. that reciprocal back-and-forth thinking..., to involve
you in his activity [so] it’s not just about him, but it’s
Parents’ internal debates and observations helped [also] about another person.’’. Parents showed creativ-
them work through issues and gain conceptual under- ity in building on their children’s interests. ‘‘I found
standing and buy-in as they progressed through the that if I keep it very light and very simple, and I don’t
phases. In the initial phase of focusing on faces, Parent demand too much of him, it becomes a pleasant
B reported, ‘‘I just feel so bad for him, because it seems experience’’ (Parent B). ‘‘I counted his toes, then I
like I have to calm him just to get him to [look at me].... patted the bottom of his foot, and when I did, he’d like
There are days when I think... he needs to have his own that, so every couple of seconds, he’d stick his foot
world for whatever reason.’’ Later she observed, ‘‘He back up and I’d pat it again.’’ Parent C reported on an
will look straight at you if he is wearing sunglasses and activity of stacking baby formula cans. ‘‘I had my hand
I think in his mind it’s ‘You can’t see my eyes.... I’m sitting right there and he... let me know [when it was
getting not just more eye contact and interaction when my turn] by giving me that little look’’. Children B and
he’s really happy, but also when he’s really mad’’. C both showed strong progress in response to turn-
Parent C described how she and her husband had taking intervention as seen in Fig. 1. Dialogue with
encouraged looks to their faces. ‘‘When we were Parent A showed that she had some difficulty concep-
talking to him, we noticed that his eyes would drift tualizing and eliciting reciprocity in turn-taking, relying
downwards, and... we’d kind-of touch him right there on a limited number of rote activities such as manip-
and his eyes would go toward our eyes.’’ All three ulating a busy box. It is not clear whether this factor or
parents were observed to easily conceptualize the the severity of her child’s autism contributed to his
focusing on faces phase of intervention and to integrate uneven response to the intervention.
it into parent–child interactions. This factor likely In the third and fourth phases of intervention, the
contributed to the rapid child progress observed during researcher described the relationship of joint attention
this phase (Note: Child C showed competency with to language and clarified parameters. In one example,
focusing on faces during the baseline phase). Parent A struggled to translate the concept of joint

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attention into daily interactions when she described Parents related difficulties, most prominently behav-
her child nonverbally asking for help putting beads into ioral challenges, that were associated with their chil-
a can. ‘‘He needs me to do it; he needs help.’’ The dren’s autism. Parent A connected her son’s tantrums
researcher clarified to distinguish this from joint to his restricted interests. ‘‘He’s so zombie into the
attention, ‘‘Yes, he’s requesting because he can’t do it movie lately. I don’t know how to get out of it. I turned
himself.’’ Recognizing the sharing aspect of joint off the TV..., then he just went into more of a fit, and
attention, Parent A offered, ‘‘His books are joint he punched and hit and went all out.’’ Early in the
attention because sometimes he’ll bring it and come intervention period, Parent B also wearied of her son’s
over and let us sit with him and look at it.’’ The constant demands. ‘‘In the morning I can be pretty
researcher again clarified that, ‘‘[We want] him to show good about it, but by [evening]..., I’m like, ‘You have to
you that he’s interested by looking at the book and take him. I don’t want to be touched; I don’t even want
then looking at your face.’’ Parent B revealed her to be looked at.’’ She also worried about empathy. ‘‘If
initial skepticism that her son could engage in joint one of the other boys gets hurt..., [he] may be
attention. ‘‘I would be surprised if he saw a novel thing interested in looking at the tears to try to figure out
and... looked at me as if to say ‘look, this is really where they came from, but he doesn’t seem to
neat’’’. Later however, she reported the first observed understand that means that someone’s hurt.’’ Parent
instance of initiating joint attention. Her son brought C expressed concern with her son’s aggression, noting
his portable video player to her and suddenly he that he began to engage in frequent head butting and
‘‘looked at the video... and then at my eyes and biting beginning at approximately 18 months of age.
smiled... I’m sure he was trying to show me his Parent B’s initial concerns about her son’s aggressive-
cartoon––for a couple of seconds, we enjoyed some- ness abated as he progressed through the intervention.
thing together’’. As illustrated in Fig. 1, Children B By parent report, Child C’s aggressive behaviors
and C showed a strong response to the intervention in continued throughout the intervention period with
phases 3 and 4 while Child A showed only isolated some reduction by follow-up; however, larger family
instances of joint attention. concerns may have helped to maintain his aggression.
The emergence of receptive and expressive verbal By observation and parent report, Child A’s aggressive
language at the end of the intervention, although not behavior showed no signs of abatement during the
included in quantitative measures because it was not a intervention or follow-up phases.
directly planned outcome, was voluntarily reported by During the intervention period, all participants
parents and observed by the researcher. This develop- struggled with the initial tentative nature of their
ment was notable with Children B and C, both of child’s diagnosis (a factor that compromised the
whom had engaged in joint attention in multiple process of coming to terms) and the struggles they
sessions. Child A achieved a level of competency with experienced obtaining a definitive diagnosis. Parent A
Picture Exchange Communication System (PECS) for reported that her doctor did not give her direct answers
requesting. Parent C described the beginnings of when she expressed initial concerns. When diagnosti-
receptive and expressive language. ‘‘[His grandmother] cians reported preferring to wait until age three to give
said, ‘See ya’ and he goes ‘Ee ya’. We asked if he a diagnosis of autism, she reported responding, ‘‘I’m
wanted [a soda] and he goes [shakes head ‘‘yes’’].... So stuck because there are a lot of things I need the
I think he’s starting to comprehend what we’re diagnosis for [eligibility for services; helping her
asking.’’ husband come to terms with their son’s difficulties].’’
Although not assessed quantitatively, parents vol- Parent B also reported experiencing initial uncertainty
unteered background information on the larger family about the source of developmental concerns and
experience that may have impacted intervention effec- sought out initial and later confirming diagnoses.
tiveness. They also described their own challenges and Parent C expressed relief at her son’s tentative early
resilience relative to their children’s needs. Emergent diagnosis. Although she questioned the diagnosis after
themes reflecting challenges included searching for a seeing intervention-related improvement, the original
diagnosis, limited child response to traditional services, results were confirmed. All mothers reported that their
co-occurrence of familial disabilities, and broader husbands followed a more difficult path in coming to
family stressors. Themes of parent resilience included terms with the diagnosis. Over the course of the
coming to terms with the child’s diagnosis and evolving intervention, two of the husbands left their families, a
views of the child’s potential and of their own move that both mothers attributed to the stress of
competence and self-efficacy. having a child with autism.

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Before the research intervention began, Parent B approach that built on developmental foundations of
reported that in spite of the high level of services joint attention and used the parent–child relationship
received, ‘‘I don’t think we’re helping him [with as the medium for intervention, harnessing parents’
traditional services]’’. She referred to the continual expertise and strong investment in their children’s
need to ‘‘lower the bar’’ of expectations and noted a developmental outcomes. Parents infused intervention
lack of progress over the two years her child had through play and in natural family routines, an
received services. This pattern was repeated with the approach that had secondary benefits for parents by
other two dyads. All participants reported co-occurrence helping them to envision both the child’s potential and
of learning disabilities or other developmental con- their own abilities as ongoing mediators of their
cerns among members of their immediate families. children’s learning.
Parents A and C reported on their own learning Results point to the possible importance of provid-
disabilities and mental health concerns. Parents B and ing a developmental foundation to support both
C noted developmental and medical concerns with symbolic communication and its precursor, joint atten-
siblings, including seizure disorders. Paternal aggres- tion. Joint attention research indicates that face-to-face
sion was reported by Parent C and income limitations engagement, social interaction, child initiation, and
contributed additional stressors for this family. Limited responding to joint attention may provide a develop-
support from extended family was cited to varying mental foundation for the child to freely initiate joint
degrees by all participants. attention social overtures to a partner (Adamson &
All participants were motivated to counteract these Bakeman, 1991).These developmental precursors to
challenges. They showed an interest in learning about initiating joint attention were operationalized in the
autism and progressed from focusing primarily on their current study as focusing on faces, turn-taking, and
children’s limitations toward increasing acceptance and responding to joint attention. Joint attention, in turn,
recognition of child potential. Parent B observed, ‘‘I am appears to provide a developmental foundation for
getting more awareness that I am here. It’s not just verbal language (e.g., Carpenter et al. 1998; Paparella
because he needs something... and I feel like that is huge & Kasari, 2004). Attention to others’ faces, an ability
progress’’. Parent A recognized progress with focusing that is compromised for infants later diagnosed with
on faces and Parent C expressed excitement with her autism, is a necessary component of joint attention
child’s use of receptive and expressive language. Parents because it allows the child to ascertain the partner’s
also invested in their own personal development, Parent interest in their mutual focus of attention. Turn-taking,
A by teaching herself to read and participating in an also a component of joint attention and a form of
autism support group; Parent B by creating a support reciprocity, further supports the interactional aspects
group for families, sharing her intervention experiences of joint attention. Turn-taking may lead most directly
at a national conference, and pursuing employment in a to joint attention if it is initially based on dyadic play
related field; and Parent C by learning about her rather than play with toys because it is engagement
children’s complicated medical issues and initiating with the parent that is a greater need for children with
licensed practical nurse training. All parents took firm autism than attention to objects. Initiating joint atten-
control of their children’s services. tion is typically built on a base of responding to joint
attention and this appears to have occurred with the
toddlers with autism in this study. Eliciting initiation of
Discussion joint attention required from the parent only a recep-
tive demeanor once this foundation had been laid.
This study provides evidence that in response to a Because of social difficulties in autism, the current
parent mediated, developmentally oriented, and inter- study was designed to build on the already established
action based intervention model, two of three toddlers parent–child relationship. The intervention did not
with early identified autism demonstrated joint atten- train parents in specific techniques; rather, parents
tion, a typical milestone that failed to develop natu- created activities that they believed would best encour-
rally. The third demonstrated progress with focusing age their child’s social participation across contexts and
on faces and turn-taking, hypothesized precursors of over time in the child’s natural environment. This
joint attention. Results complement Whalen and encouraged parents’ leadership in the intervention
Schreibman’s (2003) study which used behavior mod- while capitalizing on their expertise, intimate knowl-
ification to promote joint attention in older preschool- edge of the child, and strong investment in child
ers with autism. Achievement of child outcomes in the outcomes. The interventionist assumed a supporting
current study may be attributable to a family centered role, highlighting the purpose and goals of each phase,

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providing examples of activities that parents could (i.e., a single data point). A limitation with the
adapt, and tracking changes. intervention is that while many parents may prefer
The intervention addressed other difficulties inher- the flexibility and freedom of selecting or creating their
ent in more structured skill-based interventions. One own activities based on a sample of suggested activi-
concern is that joint attention is an abstract ability that ties, others (e.g., those challenged to conceptualize
is not easily ‘‘trained’’ (Kasari et al., 2001). The intervention goals) may benefit from more targeted
mediated learning approach addresses this concern as guidance and structure relative to activity selection.
well as related problems of generalization and main- Future studies are therefore needed to replicate and
tenance often reported in behaviorally oriented ap- extend this research. Qualitative findings also suggest
proaches. The aim of mediated learning approaches is questions for further study: Can simplifying the pre-
to affect the child’s desire to learn and interact rather sentation of the parent’s face facilitate focusing on
than to train specific skills through a system of external faces? How can turn-taking activities best be designed
rewards (Klein, 2003). Parents in this study appeared to lead to joint attention? What is the impact of joint
to have an instinctive grasp of how to mediate learning attention development on child aggression?
for their children but needed guidance on the meaning Research findings suggest implications for practi-
and importance of joint attention for future language tioners. First, recommended family-centered and
and social development. Parents with varying abilities family-guided practices (Sandall, McLean, & Smith,
were able to create opportunities to promote interac- 2000) for young children with disabilities should take
tional competencies when armed with general theoret- a more prominent role in early autism intervention as
ical knowledge and suggested strategies. Benefits were these findings demonstrated the potential efficacy of
also observed for parents themselves, who expressed such approaches. Second, building intervention from
greater confidence in their child’s potential and in their the parent–child relationship is a priority as children
role in effecting child changes. Importantly, these are identified at toddler ages during which the
changes were evident irrespective of their socioeco- relationship with the caregiver naturally serves as
nomic and educational experiences. the primary medium for social-communicative learn-
The interventionist’s role is more complex in this ing. Third, recommendations that services for young
model than in more traditional professionally imple- children with autism be intense should be examined
mented approaches. Interventionists must master the- in light of current findings that joint attention can be
ory and make it accessible to adult learners, provide effectively promoted for some toddlers with autism
situational coaching based on ongoing assessment of using once weekly intervention that supports devel-
parent understanding, serve as a sounding board and opmentally grounded parent–child interaction in natural
source of support relative to a wide range of parent family settings. This contrasts with models that call
concerns, bolster parents’ confidence in the possibility for intensive investment of intervention resources
of change, and recognize and affirm parents’ compe- that directly target specific skills, that are implemented
tence. This role relies on sharing theoretical knowledge by specialists, and that must be supplemented by
and posing questions that can include parents in the additional resources to promote generalization to
discovery process in ways that build on existing child natural environments. One factor that may have
and parent competencies (i.e., beginning at a skill level influenced response to the low intensity approach in
where both parent and child can experience success). the current study is the early age at which this
To address these needs, personnel training should intervention was initiated. Fourth, developmental
focus on theory related to joint attention, family precursors of joint attention (e.g., focusing on faces,
systems, and adult learning theory. The use of family turn-taking, etc.) and symbolic language (e.g., joint
case studies (e.g., McWilliam, 2000) can support attention) should be incorporated into intervention
understanding of complex family needs in times of for children with autism to lay the groundwork for
crisis, parents’ potential to promote early social com- more natural development of higher level competen-
munication development even in the face of serious cies. Fifth, because of the high levels of stress
child and parent challenges, and the individualization experienced by families who are in the initial stages
of parent education, coaching, and support strategies. of autism diagnosis, attention to larger family con-
Findings in the current study are limited by the small cerns may play an important role in a parent-
number of participants and by the fact that the implemented intervention and warrant further study.
intervention was implemented and reported by a single For example, future research could explore whether
researcher. Also, confidence in follow-up measures is fathers being more actively in the intervention might
qualified by the limitation of nonrepeated measures facilitate their process of ‘‘coming to terms’’, with

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resultant positive outcomes for families. Finally, before, or by seeing how something relates to other
relying on less formal and definitive diagnostic things he knows about.
protocols to identify high risk for autism during the 4. Encouraging: Toddlers learn best when they feel
toddler years may be important to permit initiation successful. You can help your child experience
of services before nonproductive patterns of interac- success by making activities challenging enough
tion are established. but not too hard, by pointing out what he did that
caused his success, by expressing affection when he
Acknowledgments This research was conducted as preparation is successful, and by showing him that you are
for a doctoral dissertation. The first author would like to
acknowledge the support and assistance of her advisor,
confident that he can succeed.
Dr. Samuel L. Odom and other members of her dissertation 5. Organizing and planning: Helping your child
committee including Dr. Susan Klein, and Dr. Gretchen Butera, experience order can boost his learning by helping
all of Special Education department at Indiana University, him see how what he is doing relates to the larger
and Dr. Naomi Swiezy from the Christian Sarkine Autism
world. If activities are structured, he can better
Treatment Center at Riley Hospital for Children. The author
also thanks the three parent participants for implementing the predict what comes next. He may be more willing
intervention, Shelley McAllister for coding the video data, and to do something that he does not like (but that is
Anne Wagner for reviewing the qualitative data. important for his learning) if he knows a preferred
activity will come later. Also, if activities happen in
a logical sequence, your child can better see the
Appendix A
connections between things. Structure is especially
helpful to promote learning for toddlers with social
Joint Attention Mediated Learning (JAML) Parent
and communication difficulties. You can help to
Manual (excerpt)
structure activities by
The following pages have ideas for helping your child
make progress in focusing on faces, turn-taking, and a. showing your child only the part he needs to
joint attention––all important to help your child know for what you want him to learn,
communicate and interact socially with others. Each b. helping him to keep his attention on one thing
idea or learning strategy is just that––an idea. Working at a time,
with the researcher, you will have other ideas that can c. reducing sights and sounds that may draw his
help reach similar goals. Each strategy is connected attention away from the activity,
with one or more learning principles, identified in bold d. helping him to understand ‘‘first ___, then
after each strategy. ____’’ (to know what comes next),
These learning principles show five ways to help e. moving gradually from simple tasks to ones that
children learn. The five learning principles are: are more complicated,
f. helping him to see how things are organized––
the relationships between things
1. Focusing: Helping your child to focus helps her
g. keeping objects in the same location; putting
look at or listen to something that can help her
toys in order at the end of play
learn, to share attention with you by looking at
h. helping him to understand the value of rules.
what you want her to see, or by showing you what
she wants you to see.
2. Giving meaning: You can help your child under- During play sessions, all of the time is not spent
stand the meaning of things by expressing your working on new and more difficult learning strategies.
feelings (such as excitement) when you are sharing It is important that your child enjoy interacting with
attention with him about an object or a happening. you and experience success most of the time. The
Giving meaning helps him to understand what targeted strategies will help him to learn new things,
parts are important to pay attention to because and these new activities should be mixed in with
they are special in some way. comfortable activities he already knows, enjoys, and is
3. Expanding: When you and your child are paying successful with. However, the purpose of the parent–
attention to something, you can help your child to child play sessions is for him to interact, so you should
expand his understanding of an object or event. expect your child to interact with you during all play
You do this by providing labels, by helping him see activities––he can be left to play with toys on his own at
something about an object that he had not noticed other times.

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Children learn best when they choose their activi- Dumont-Mathieu, T., & Fein, D. (2005). Screening for autism in
ties. You can help this to happen by following your young children: The Modified Checklist for Autism in
Toddlers (M-CHAT) and other measures. Mental Retarda-
child’s lead. You do this by joining into his play rather tion and Developmental Disabilities Research Reviews, 11,
than asking him to switch from something he is doing 253–262.
to an activity you want to do. However, you can guide Feuerstein, R. (1980). Instrumental enrichment: An intervention
him toward new activities when he loses interest with program for cognitive modifiability. Baltimore: University
Park Press.
an activity. The most important thing to remember is Greenspan, S., & Wieder, S. (1999). A functional developmental
to keep him engaged in interaction with you as long as approach to autism spectrum disorders. Journal of the
possible. Association for Persons with Severe Handicaps, 24, 147–161.
Suggested strategies for developing your child’s Haywood, H. C., Brooks, P., & Burns, S. (1992). Bright start:
Cognitive curriculum for young children. Watertown, MA:
social-communication skills are divided into four areas: Charlesbridge Publishing.
(1) focusing-on-faces, (2) turn-taking, (3) responding to Heflin, L. J., & Simpson, R. L. (1998). Interventions for children
joint attention, and (4) initiating joint attention. Each and youth with autism: Prudent choices in a world of
of these four areas is divided into two levels. With the exaggerated claims and empty promises. Part I: Intervention
and treatment option review. Focus on Autism and Other
first level, you are doing most of the work by showing Developmental Disabilities, 13, 194–211.
your child how to do things. In the second level of each Howlin, P., & Moore, A. (1997). Diagnosis in autism: A survey of
area, your child is expected to do more of the work by over 1200 patients in the UK. Autism, 2, 135–162. .
practicing the skills you have taught him. Ingersoll, B., & Dvortcsak, A. (2006). Including parent training
in early childhood special education curriculum for children
with autism spectrum disorders. Journal of Positive Behav-
ior Intervention, 8, 79–87.
References Johnson, R. B., & Onwuegbuzie, A. J. (2004). Mixed methods
research: A research paradigm whose time has come.
Adamson, L. B., & Bakeman, R. (1991). The development of Educational Researcher, 33, 14–26.
shared attention during infancy. Annals of Child Develop- Kaiser, A. P., & Hemmeter, M. L. (1996). The effects of teaching
ment, 8, 1–41. parents to use responsive interaction strategies. Topics in
Adamson, L. B., & Russell, C. (1999). Emotion regulation and Early Childhood Special Education, 16, 375–407.
emergence of joint attention. In P. Rochat (Ed.), Early Kasari, C., Freeman, S. F. N., & Paparella, T. (2001). Early
social cognition: Understanding others in the first months of intervention in autism: Joint attention and symbolic play.
life (pp. 281–297). Mahway, NJ: Erlbaum. International Review of Research in Mental Retardation, 23,
Baron-Cohen, S. (2000). Autism: Deficits in folk psychology exist 207–237.
alongside superiority in folk physics. In H. Tager-Flushberg, Klein, P. S. (2001). Mediational intervention for sensitizing
& D. J. Cohen (Eds.) Understanding other minds (pp 73–82). caregivers (MISC) in Ethiopia. In P. S. Klein (Ed.), Seeds of
York: Oxford University Press. hope (pp. 29–93). Oslo, Norway: Unipub Forlag.
Bono, M. A., Daley, T., & Sigman, M. (2004). Relations among Klein, P. S. (2003). A mediational approach to early intervention:
joint attention, amount of intervention, and language gain in Israel. In S. L. Odom, M. J. Hanson, J. A. Blackman, & S.
autism. Journal of Autism and Developmental Disorders, 34, Kaul (Eds.), Early intervention practices around the world
495–505. (pp 69–89). Baltimore: Paul H. Brookes.
Bredekamp, S., & Copple, C. (1997). Developmentally appropri- Koegel, R. L., & Schreibman, L. (1996). Fostering self-manage-
ate practice in early childhood programs (Revised edition). ment: Parent-directed pivotal response training for children
Washington, DC: National Association for the Education of with autistic disorder. In E. D. Hibbs & P. S. Jenson (Eds.),
Young Children. Psychosocial treatments for child and adolescent disorders
Bryson, S. E., Rogers, S. J., & Fombonne, E. (2003). Autism (pp. 525–552). Washington, DC: American Psychological
spectrum disorders: Early detection, intervention, educa- Association.
tion, and psychopharmacological management. Canadian Mahoney, G., & Perales, F. (2003). Using relationship-focused
Journal of Psychiatry, 48, 506–516. intervention to enhance the social-emotional functioning of
Butera, G., & Haywood, H. C. (1992). A cognitive approach to young children with autism spectrum disorders. Topics in
the education of young children with autism. Focus on Early Childhood Special Education, 23, 77–89.
Autistic Behavior, 6, 1–14. McArthur, D., & Adamson, L. B. (1996). Joint attention in
Carpenter, M., Nagell, K., & Tomasello, M. (1998). Social preverbal children: Autism and developmental language
cognition, joint attention, and communicative competence disorder. Journal of Autism and Developmental Disorders,
from 9 to 15 months of age. Monographs of the Society for 26, 481–495.
Research in Child Development, 63(4, Serial No. 255), 1–142. McCollum, J. A. (1984). Social interaction between parents and
Carpenter, M., & Tomasello, M. (2000). Joint attention, cultural babies: Validation of an intervention procedure. Child:
learning, and language acquisition. In A. M. Wetherby, & B. Care, Health, and Development, 10, 301–315.
M. Prizant (Eds.), Autism spectrum disorders (pp. 31–54). McWilliam, P. J. (2000). Lives in progress. Baltimore: Brookes.
Baltimore: Brookes. Mundy, P., Sigman, M., Ungerer, J., & Sherman, T. (1986).
Dawson, G., & Osterling, J. (1997). Early intervention in autism. Defining the social deficits of autism: The contribution of
In M. J. Guralnick (Ed.). The effectiveness of early non-verbal communication measures. Journal of Child
intervention (pp. 307–326). Baltimore: Brookes. Psychiatry, 27, 657–669.

123
J Autism Dev Disord (2007) 37:1562–1575 1575

Mundy, P., & Stella, J. (2000). Joint attention, social orienting, Schertz, H. H. (2005b). Joint attention. In J. T. Neisworth, &
and nonverbal communication in autism. In A. M. Wetherby P. S. Wolfe (Eds.), Autism and pervasive developmental
& B. M. Prizant (Eds.), Autism spectrum disorders (pp. 55– disorders dictionary Baltimore: Brookes, (pp. 115).
77). Baltimore: Brookes. Schertz, H. H. (2005c). Joint Attention Mediated Learning
National Research Council (2001). Educating children with (JAML) manual. Unpublished manuscript.
autism. Washington, DC: National Academy Press. Schertz, H. H., & Odom, S. L. (2003). Joint attention and early
Osterling, J., & Dawson, G. (1994). Early recognition of children intervention with autism: A conceptual framework and
with autism: A study of first birthday home videotapes. promising approaches. Journal of Early Intervention, 27, 42–
Journal of Autism and Developmental Disorders, 24, 247– 54.
257. Schopler, E., Reichler, R. J., & Renner, B. R. (1988). The
Paparella, T., & Kasari, C. (2004). Joint attention skills and Childhood Autism Rating Scale (CARS). Los Angeles, CA:
language development in special needs populations: Trans- Western Psychological.
lating research to practice. Infants and Young Children, 17, Schwartz, I. S., & Baer, D. M., (1991). Social validity assess-
269–280. ments: Is current practice state of the art? Journal of
Pretti-Frontczak, K., & Bricker, D. (2004). An activity-based Applied Behavior Analysis, 24, 189–204.
approach to early intervention (3rd ed.). Baltimore: Paul H. Siegel, B. (2001). Pervasive Developmental Disorders Screening
Brookes. Test – II (PDDST-II): Stage 1 screener for primary care
Prizant, B. M., & Wetherby, A. M. (1998). Understanding the settings. Retrieved September 1, 2004 from http://eiiswest.
continuum of discrete-trial traditional behavioral to social- nsnet.org/Referral_Package/pddst2.pdf.
pragmatic developmental approaches in communication Stone, W. L., Coonrod, E. E., & Ousley, O. Y. (2000). Brief
enhancement for young children with autism/PDD. Semi- report – screening tool for autism in two-year-olds (STAT):
nars in Speech and Language, 19, 329–352. Development and preliminary data. Journal of Autism and
Prizant, B. B., Wetherby, A. M., & Rydell, P. J. (2000). Developmental Disorders, 30, 607–612.
Communication intervention issues for children with autism Vaughan, A., Mundy, P., Block, J., Burnette, C., Delgado, C.,
spectrum disorders. In A. M. Wetherby, & B. M. Prizant Gomez, Y., et al. (2003). Child, caregiver, and temperament
(eds.), Autism spectrum disorders: A transactional develop- contributions to infant joint attention. Infancy, 4, 603–616.
mental perspective (pp. 193–224). Baltimore: Paul H. Volkmar, F. R., Lord, C., Bailey, A., Schultz, R. T., & Klin, A.
Brookes. (2004). Autism and pervasive developmental disorders.
Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). Journal of Child Psychology and Psychiatry, 45, 135–186.
The Modified Checklist for Autism in Toddlers: An initial Whalen, C., & Schreibman, L. (2003). Joint attention training for
study investigating the early detection of autism and children with autism using behavior modification procedures.
pervasive developmental disorders. Journal of Autism and Journal of Child Psychology and Psychiatry, 44, 456–468.
Developmental Disorders, 31, 131–144. Yoder, P. J., & Warren, S. F. (1999). Maternal responsivity
Sandall, S., McLean, M. E., & Smith, B. J. (2000). DEC mediates the relationship between prelinguistic intentional
recommended practices in early intervention/early childhood communication and later language. Journal of Early Inter-
special education. Longmont, CO: Sopris West. vention, 22, 126–136.
Schertz, H. H. (2005a). Promoting joint attention in toddlers
with autism: A parent-mediated developmental model.
(Doctoral dissertation, Indiana University, 2005). Disserta-
tion Abstracts International, 66, 3982.

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