Running head: EVIDENCE-BASED TREATMENTS

Evidence-Based Treatments
Mariana E. Hall
Touro University Nevada

EVIDENCE-BASED TREATMENTS

Joint Attention as Evidence-Based Treatment

During my first level II fieldwork experience I utilized an evidence based strategy termed
joint attention (JA). I learned about this strategy reading research articles that focused on
interventions for children with Autism Spectrum disorder (ASD). This intervention was very
appropriate for the population that I was working with because most of my clients were young
children who had either been diagnosed with ASD or who were not diagnosed due to their young
age but were suspected to have ASD. Typically developing children often demonstrate more goal
directed behaviors by the time they are between six and nine months old. By eleven months,
children begin to alternate their gaze between an object and a social peer. At thirteen months
children initiate joint attention by pointing at objects of interest. At fifteen months children
communicate and make requests from others frequently.
Autism is characterized by deficits in verbal communication, social interaction, and a
rigid repertoire of interests. According to the Diagnostic and Statistical Manual of the American
Psychiatric Association, autism is characterized by a lack of spontaneous seeking to share
enjoyment, interests, or achievements with other people. Joint attention (JA) and joint
engagement (JE) are core deficits seen in children with autism which interfere with the
development of language and social skills. JA includes the ability to attend to an object or event
of interest along with a social peer. This skill is often observed when a child displays behaviors
that include alternating gaze between the peer and an object, or pointing and showing the object
to the peer or social partner. On the other hand, JE includes simply being engaged in the same
object or event with a social partner. JE does not necessarily include acknowledging the social
partner (Kaale, Smith, & Sponheim, 2012).

EVIDENCE-BASED TREATMENTS

Joint attention can be divided into two components: (1) responding to joint attention
(RJA) initiated by others, and (2) initiating joint attention (IJA). While some children with
autism may develop RJA skills, most experience difficulties with IJA. This might be because
social motivation is a pre-requisite for IJA while it may not be a necessary requirement for RJA.
Protoimperative and protodeclarative requests are also skills that develop differentially in
individuals with autism. Protoimperatives are requests made to others with the intention of
fulfilling a need. On the other hand, protodeclaratives are intrinsically motivating for the sole
purpose of social sharing of an object or event. While individuals with autism are capable of
making protoimpertive requests, their ability to make protodeclarative requests are severely
impaired (Isaksen & Holth, 2009).
Responding to joint attention initiated by someone else should be done first. To
accomplish this, the research literature recommends using toys that promote surprise reactions
such as musical toys, toys that light up, or move around in order to help get the childs attention.
Good examples of these are toys such as Jack in the box, a falling tower of blocks, a music box
stopping, etc. In order to encourage the child to look back and forth between a peer and an object
of interest. The practitioner should exaggerate their reaction, verbal response, and facial
expression to the toy. When the child looks back and forth, the practitioner should reward the
child by saying good looking!, or by giving him or her a brief tickle, or giving five. In order
to teach a child to follow the gaze of a social partner, the research literature suggests to hide
objects of interest and providing body language as cues for the toys location such as pointing,
head turning, or eye gazing in the direction of the toy. These body language and cues should be
gradually extinguished as the child progresses. For example, once the child responds consistently

EVIDENCE-BASED TREATMENTS

to pointing, this cue should be substituted by more subtle cues, such as head turning, and then
shifting gaze in the direction of the toy (Blacher & Lauderdale, 2010).
Behaviors that demonstrate IJA include showing, pointing, and giving toys to an adult
social partner that could include a parent, a teacher, or a therapist. Once the ability to respond to
joint attention initiated by others is mastered, the ability to initiate joint attention can be
undertaken. The research examined individualized interventions that utilized a mix of
developmental and behavioral strategies. Sessions included table top training, and floor play.
During table top training, the practitioner followed the childs lead and worked on creating play
routines by talking about what the child was doing, prompting JA skills, and responding to JA.
During floor play, interesting toys were presented in a bag or hidden in order to encourage the
child to initiate JA. When necessary the therapist prompted JA by either asking What do you
have?, providing physical prompts, and/or exaggerating interest in the toy being examined. This
intervention resulted in an increase of JA skills (Kaale et al., 2012).
The studies suggest either providing an interesting toy or even within 3 feet in order to
get the childs attention for at least 2 seconds. It is expected that the child should be able to point
and alternate their gaze between the practitioner and the toy. The first time the practitioner
should call the childs name so the child will look at the practitioner and then point to the toy
telling the child do this. If the child does not answer to their name, the practitioner should take
the toy and trace a line from where the toy was back to the practitioners eyes in order to force an
alternate gaze. If the child does not imitate pointing, the practitioner should form the childs hand
into a point directed towards the toy or event after finishing the alternating gaze activity. Once
the child begins to consistently respond to the prompt the practitioner should give the child 2
seconds to point when seeing the toy or event. If the child does not respond within the two

EVIDENCE-BASED TREATMENTS

seconds the practitioner should give a partial prompt by saying the beginning of the childs name.
The goal is for the child to gaze back to the adult so the provider can give a reinforcing smile or
comment about the toy so both, the child and the practitioner can gaze back at the toy (Blacher &
Lauderdale, 2010).
Daniel is one of my clients who is suspected of having a diagnosis of Autism. He is six
years old and has two older siblings with Autism diagnoses. Daniel has developmental delays
and often does not look at people when he is talking to them. I often use verbal cues such as
eyes on me when I am demonstrating a task or showing him what he will be doing. I used an
activity in which he had to manipulate flubber in order to locate medium sized color balls hidden
within. When he finds them, he has to hand them to me in order to promote looking at the
activity and then back at me. I also use a magnet fishing game in which I point and tell them
which fish I want him to pick up so he will look at me and then at the fish. Sometimes I just look
at the fish and have him try to figure out which one I am looking at to promote the RJA
component.
Maddox is a seven year old client who has an actual diagnosis of Autism. I use a lot of
table top activities with him that require turn taking. For example, if we play Jenga, when I take
my turn, both, he and I, are looking at the tower and I ask him questions to encourage alternate
gaze from the tower to me. I ask questions such as Which one should I pull out?, This one?.
I also play games that he has played before that I have not played and ask him to teach me how
to play, in order to promote the IJA component. Getting Maddox to look at me can be
challenging and it can take several trials before he actually looks at me briefly. This is a skill that
Maddox really needs to develop because he often talks to people without looking at them and
unless he says their name to get their attention, people often are not sure of who he is addressing.

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Westley is a 14 year old client with Autism with whom I have used a lot of cooking
activities. When he performs the cooking and I need to re-direct him I often say his name only in
order to encourage him to look at me first and then I show him how to self-correct so as to
promote the RJA component. I often have to repeat his name several times before he actually
looks at me and sometimes I even have to give him a physical cue such as tapping his shoulder.
Even though my clients are a little older than the children addressed in the studies, the articles
mentioned that many of the participants slowly regressed unless the skills continued to be
practiced at home. Therefore, JA is a skill that needs to be constantly worked on for clients with
Autism (Isaksen & Holth, 2009).

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7
References

Blacher, J., & Lauderdale, S. (2010). Do you see what I see? Joint attention and its importance in
autism. Exceptional Parent, 40(11), 38-40.
Isaksen, J., & Holth, P. (2009). An operant approach to teaching joint attention skills to children
with autism. Behavioral Interventions, 24(4), 215-236. doi:10.1002/bin.292
Kaale, A., Smith, L., & Sponheim, E. (2012). A randomized controlled trial of preschool-based
joint attention intervention for children with autism. Journal of Child Psychology and
Psychiatry, 53(1), 97-105.