Parent implemented joint attention intervention for preschoolers with autism.

Introduction The absence of joint attention is one of the earliest symptoms of autism, reflecting the hallmark social disturbance that characterizes the disorder (Mundy & Crowson, 1997). Joint attention, first seen in infants between 9 and 12 months of age, involves two people sharing attentional focus on interesting objects and events (Bakeman & Adamson, 1984). Early joint attention behaviors involve children's use of eye gaze and conventional gestures. For example, a child might initiate joint attention, directing his mother's attention to a toy on the floor, by looking from the toy to his mother and back to the toy (i.e., gaze alternating) while simultaneously pointing at the toy. Alternatively, a mother might direct her child's attention by pointing and looking at an object while commenting on the object (e.g., What a fun toy!) to which the child responds by looking from the object to his mother and back to the object (i.e., gaze alternating). These joint attention interactions are considered uniquely social in that they result in an interaction between adult and child about the object/event. Joint attention is also related to social and language skill development, playing a significant role in typical development (Mundy & Gomes, 1998; Mundy, Sigman, & Kasari, 1990; Travis, Sigman, & Ruskin, 2001). Deficits in joint attention are evident in children with autism from very early in development (Baron-Cohen, Allen, & Gillberg, 1992; Charman et al., 1998; Osterling & Dawson, 1994). Infant screening and diagnostic instruments for autism, such as the Checklist for Autism in Toddlers (CHAT) (Baron-Cohen et al., 1992) and the Autism Diagnostic Observation Schedule (ADOS) (Lord, Rutter, DiLavore, & Risi, 1999), include assessment of deficits in joint attention as a marker for autism. In comparison to children with mental retardation or specific language delay (matched for developmental level), preschool children with autism show significant deficits in both responding to others' joint attention directives and initiating joint attention (Charman et al., 1998; Mundy, Sigman, Ungerer, & Sherman, 1986; Sigman, Mundy, Sherman, & Ungerer, 1986; Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). This impairment in joint attention discriminates 80% to 90% of children with autism from those with other developmental disabilities (Lewy & Dawson, 1992; Mundy et al., 1986). Because of the social nature of joint attention, its absence reflects the core social disturbance that characterizes autism (Mundy & Crowson, 1997). Joint attention is also related to two of the areas, social and communication development (Mundy & Gomes, 1998; Mundy et al., 1990; Travis et al., 2001), that are significantly impaired in individuals with autism (American Psychiatric Association, 2000). Thus, the development of effective intervention procedures to address joint attention deficits in young children with autism is of utmost importance. A handful of studies have examined intervention procedures to address joint attention deficits in children with autism with at least some improvement in targeted joint attention skills (e.g., Hwang & Hughes, 2000; Kasari, Freeman, & Paparella, 2001, 2006). Using a behaviorally based intervention, Whalen and Schreibman (2003) examined pivotal response training strategies (Koegel, Koegel, Harrower, & Carter, 1999; Pierce & Schreibman, 1995) with an emphasis on the use of child preferred materials, interspersing difficult tasks among easier ones, and using natural reinforcers as consequences for appropriate behavior to teach joint attention skills to 5 participants with autism (all 4 years of age). All participants acquired responding to others' joint attention directives and 4 of the participants acquired skills to initiate joint attention. More recently, we (Jones, Carr, & Feeley, 2006) also examined the use of a behavioral intervention consisting of discrete trial instruction and pivotal response training strategies to teach five 2-3 year old children with autism to both respond to others' joint attention directives and initiate joint attention. …