TYPICAL children frequently share their interest about their world with others. When sharing an experience about an object or event they engage in “joint attention” with another person. Joint attention describes a mutual mental focus between 2 or more individuals purely to share an experience. The intersubjective nature of the communicative exchange makes it particularly social.
The developmental course of joint attention abilities begins with face-to-face affective exchanges between an infant and a caregiver, and characterizes the initial (0–5 month) phase of nonverbal communication development (Trevarthen & Hubley, 1979). At approximately 5 months the child develops an interest in objects. At this point, communication involves the coordination of the child's and caregiver's attention with respect to a third object or event. These prelinguistic, triadic exchanges characterize communication between 6 and 18 months of age (Bakeman & Adamson, 1984).
Theoretically, the ability to engage in joint attention lies within a framework of intentional communication. Communicative intent requires the ability to understand purposeful signals produced by others and to use expressive signals to affect the behavior or attitudes of others (Harding, 1983). Intentional communication may be analyzed along 2 major dimensions. The first dimension is the specific intent or function of communication. The desired intent of a social communicative act might be to regulate another person's behavior or, as in the case of joint attention, might simply be to share interest with them. For example, a child may request mom's help with a toy (requesting function), or share excitement in an event (joint attention function). The second dimension is the means children use to express those intents. Communicative means may range from prelinguistic gestures (such as giving, pointing and showing) and vocal behavior to the use of language (such as commenting and questioning). In normal communicative development, the child's expression of a variety of intents through prelinguistic means is gradually replaced by more sophisticated means (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979).
The significance of young children's ability to engage in joint attention with others has been examined in typically developing children. Increasing evidence suggests that prelinguistic joint attention abilities are associated with early language skills in these children (Carpenter, Nagell, & Tomasello, 1998; Tomasello & Farrar, 1986; Tomasello, Mannle, & Kruger, 1986; Tomasello & Todd, 1983). The presumed importance of joint attention in a normative model of child development holds potential for further understanding the possible precursors to language development in atypical populations.
The objectives of this paper were 2-fold. Our first goal was to examine joint attention within the context of the parent-child relationship. We will study joint attention within both typical and atypical development, particularly in children with Down syndrome, in children who are deaf, and in children with autism. Second, we will suggest specific recommendations for intervention.
THE PARENT-CHILD DYAD-A TRANSACTIONAL RELATIONSHIP
Much of the research in joint attention examines the child's communicative behaviors within the context of a parent-child dyadic interaction. As we review the research in dyads with a typical child and those with an atypical child, both child and parental contributions to the communicative interaction will be discussed. We will begin with a brief conceptual model of the nature of the relationship between child characteristics and parent behaviors.
The work of leading researchers studying parent-child interaction in the 1960s and 1970s (Bell, 1968, 1974; Lewis & Rosenblum, 1974; Schaffer, 1977) culminated in the well-established view that the parent-child relationship is characterized by mutuality, bidirectionality, and reciprocity. Parents and children are highly adaptive and responsive to each other's signals and characteristics. Thus, both the parent and the child continually influence the relationship in a dynamic manner, such that the interaction may be characterized as transactional in nature. It is acknowledged, however, that this view does not necessarily translate into equality of influence or of purposefulness between the parent and the child, especially during the early years.
In general, in the typical literature, contingent parent behaviors have been associated with positive child outcomes (eg, Tomasello & Farrar, 1986). In contrast, studies of children with mental retardation have found that mothers tend to be more directive with their children (Marfo, 1991). A misguided, indeed speculative, view emerged that maternal directiveness must account at least in part for the poor developmental outcomes associated with mental retardation. Such a view suggests that high occurrences of maternal directive behaviors are not only atypical, but also inherently problematic. Indeed, very few studies have examined this relationship directly. Rather, when viewed from a transactional approach, it is likely that parents of children with mental retardation modify their behavior as a function of their child's contribution to the interaction. For example, Scorce and Emde (1982) found that mothers of children with Down syndrome adjusted their responsiveness threshold to such a degree that they reacted significantly more to very low intensity emotional signals than mothers of typical children generally do. Thus, child pathology does not inevitably result in an aberrant dyadic interaction, as some parents learn to compensate for their children's diminished or deviant capabilities. At least some of the differences in the interaction styles of parents of atypical children may be the result of modifications from feedback they receive from their children. Being different, however, is not necessarily negative; in fact some of the obvious different parental interaction strategies may be unintentionally designed to serve repair and facilitative functions.
There is the need for research to address the questions of how much directiveness is necessary to provide an optimal learning environment and how much constitutes excessive control with potential deleterious effects. Thinking about joint attention then, within the context of a transactional relationship, provides a framework for examining what the atypical child brings to the interaction and why parents differ in their interaction styles.
UNDERSTANDING JOINT ATTENTION CONCEPTUALLY
Researchers have approached the study of joint attention in 2 ways. Some studies have examined joint attention as a context or state, with caregiver and child jointly attending to the same object (Bakeman & Adamson, 1984; Tomasello & Farrar, 1986). For example, a parent and a child looking at a picture book together, with both the parent and the child drawing each other's attention to the pictures by pointing and labeling, may be viewed as an ongoing dyadic state of joint attention. Other studies have defined joint attention as a category of nonverbal communication gestures (eg, showing and pointing) that serve a declarative or sharing communicative function.
Since researchers have approached the study of joint attention from different perspectives, this article will review the literature in each disability population with reference to various elements of joint attention. The first concerns who initiates and/or manages topics within joint attention episodes. A second consideration is the amount of time children and caregivers spend in joint attention episodes. A third variable concerns caregiver strategies (other than topic control) within joint attention episodes in relation to child characteristics, or the child's contribution to joint attention episodes. Analysis of these different elements in each disability population will encompass the concept of joint attention both as a state and as declarative gestures.
Parent-typical child dyads
Either member of the dyad may initiate joint attention. The caregiver could choose the toy or topic upon which the attention of the dyad is directed. In this event, the child would have to follow the caregiver's lead in order to achieve joint attention. On the other hand, the child could choose the toy or topic upon which the attention of the dyad is focused, and joint attention would be achieved because the caregiver follows the child's lead.
Language learning in children is facilitated when parents follow the child's lead and provide language input contingent on the child's topic or focus of interest (eg, Akhtar, Dunham, & Dunham, 1991; Barnes, Gutfreund, Satterly, & Wells, 1983; Cross, 1977; Harding, 1983; Rocissano & Yatchmink, 1984; Tomasello & Farrar, 1986; Tomasello & Todd, 1983). Young children learn words more readily when they are given labels for things they are already attending to spontaneously than when adults attempt to redirect their attention and label a different referent (Tomasello, 1988; Tomasello & Farrar, 1986).
One reason contingent caregiver language may facilitate language acquisition is that the field of possible referents becomes limited to those aspects of the environment to which the child is immediately attending. Language contingent with the child's focus of attention decreases the cognitive load and increases the likelihood that the child will be able to make the association between words and their referents (Bruner, 1975; Snow, 1984).
Parent-atypical child dyads
Researchers have considered topic control in relative depth with children who were deaf and who had parents with and without deafness themselves. Mothers who themselves are deaf appear to be highly contingent on their children's attentional focus. Thus, Harris, Clibbens, Chasin, and Tibbitts (1989) showed that mothers with deafness signed within the child's preexisting focus the majority of the time (72%–98%). Also, there is evidence that these mothers are distinguished by their ability to simply wait and allow the child's visual needs to pace the interaction. In fact, Spencer, Bodner-Johnson, and Gutfreund (1992) found that for mothers and babies who were both deaf, waiting was by far their most frequent response, constituting 70.4% of the period coded in the study.
By contrast, many studies have shown that hearing mothers of children who were deaf tended to try to redirect the child's attention the majority of the time (Cheskin, 1982; Henggeler & Watson, 1984). Topic control was similar whether hearing mothers used an auditory oral communication approach or a total communication approach with their children who were deaf (Musselman & Churchill, 1992). Furthermore, this style did not diminish despite substantial language gains by the children between the ages of 4.5 and 7 years. Hearing mothers of children who were deaf also tended to wait, but only for a small percentage of the interaction (16%) (Spencer et al., 1992). Mothers who were deaf showed unrelated mother behaviors to previous child acts only 7% of the time, whereas hearing mothers did so 41% of the time (Gregory & Barlow, 1989).
A recent longitudinal study examined topic control in parent-child dyads with a child with autism. Siller and Sigman (2002) found that parents of children with autism demonstrated contingent (synchronous) behaviors as much as did parents of typical children during four 30-second play interactions. The typical children and children with autism were similar in terms of language ability and the amount of time they spent attending to toys. Of particular note is that parents of children with autism who showed higher levels of contingent behavior had children who made significantly more gains in language development and joint attention skills over a period of 1, 10, and 16 years. It seems then that a normative developmental model may indeed hold true for children with autism. However, it is important to determine if these trends hold up during more extended periods of parent-child dyadic toy play, and if they hold up for children with autism who are significantly more impaired.
Research in the area of topic control then has focused primarily on the frequency of caregivers' attempts to direct their infant's attention to toys. Studies often consider child characteristics in analyzing parental initiations. Landry and Chapieski (1989) took into account whether the child was unengaged or already engaged with a toy when caregivers attempted to direct their attention. Since children with disabilities vary in their attention, their interest in toys, and their responses to communication, it may be that parental directives function differently across disability groups, or for certain child characteristics. Spencer et al. (1992) coded how long parents waited before gaining their child's attention. It may be useful to examine frequencies and mean length of waits for moms across different disabilities in relation to child responses.
In summary parents vary in how they establish topic control. Future research should study the effects of specific maternal attention-directing techniques (eg, physical guidance, giving a toy, verbal commands) on children's responses. Second, the relationship between topic control and language outcomes should be explored. While the research on normally developing children has indicated that interactions contingent on the child's focus seems to facilitate language acquisition, we cannot necessarily assume that what holds true for typical children in fact directly applies to all children with developmental differences.
PROPORTION OF TIME IN JOINT ATTENTION EPISODES
Parent-typical child dyads
A second potentially important influence on children's language development is the amount of joint attention maintained between the caregiver and the child. Longer episodes of joint attention between the infant and the caregiver are predictive of language skill in typical infants (Tomasello & Farrar, 1986; Tomasello et al., 1986; Tomasello & Todd, 1983). More specifically, researchers have shown that mothers who spend less time in joint attention have children with smaller initial vocabularies and slower syntactic development (Harris, Kasari, & Sigman, 1986; Tomasello & Farrar, 1986).
Parent-atypical child dyads
There is little research on the topic of length of joint attention episodes in atypical populations. Harris et al. (1996) found that caregivers of children with Down syndrome maintained more attention to toys and spent more time in joint attention than did caregivers of children with typical development matched on mental age. However, the total time spent in joint attention did not seem to be as significant as (1) the average length of joint attention episodes and (2) following the child's focus of attention. The authors found that maintaining attention to toys selected by the children and longer average lengths of joint attention episodes were associated with better receptive language skills 13 months later.
The paucity of research in the literature with respect to this element of joint attention in atypical populations is surprising. Clearly, information on the relationship between time spent in joint attention and specific aspects of language development across disability groups would further our understanding of this variable with respect to normative development. In reporting such data, future studies should take care to analyze not only the amount of time in joint attention, but also the mean length of joint attention episodes.
PARENTAL BEHAVIORS AND CHILD CHARACTERISTICS IN JOINT ATTENTION EPISODES
For hearing mothers of hearing children, contingent joint attention is facilitated by the fact that the parent can comment simultaneously on the object of the child's focus. While the child looks at the object, the mother talks about it and the auditory input is overlaid on the joint visual focus (Leung & Rheingold, 1981). Moreover, caregivers who do this more frequently have children with better verbal skills (Akhtar et al., 1991; Tomasello et al., 1986; Tomasello & Todd, 1983). In these dyads then, the complimentary use of vision and hearing greatly facilitates both the initiation and the maintenance of joint attention episodes.
Establishing contingent joint attention in this manner presents a simplistic picture, however, since strategies used by parents, both to establish joint attention and within joint attention episodes, can vary widely. A question of interest therefore lies in identifying specific parental behaviors/strategies in atypical dyads of varying etiologies, and their relationship to child language outcomes. With regard to this question, the majority of the research in the atypical literature comes from studies of hearing mothers and mother-child dyads where both the mother and the child were deaf.
When a child with deafness is born into a hearing family, parents need to adapt their communication for a child who is relying mainly, if not exclusively, on the visual mode. In the absence of auditory input, children who are deaf must share their visual input between their environment and language. Unlike hearing children, children who are deaf must look away from the object of interest to receive any communication directed toward them. Many studies have now reported that hearing mothers of children who are deaf experience difficulty in establishing effective communication within a joint focus (Erting, 1985; Mather, 1987; Scroggs, 1983; Spencer et al., 1992; Swisher, 1991; Swisher & Christe, 1989). A consistent finding is that hearing parents speak or sign without first getting their child's visual attention (Erting, 1985; Mather, 1987; Scroggs, 1983; Swisher, 1991). For example, mothers may point to an object and immediately begin signing about it, as if the child could look at 2 things at once. Swisher and Christe (1989) studied the behavior of a small group of hearing mothers of 4–6-year-old children who were deaf. They found that in the cases where the mothers pointed to a picture just before signing, the children were not oriented to receive the beginning of the signed utterance about 50% of the time. Spencer et al. (1992) reported that in their study almost 90% of maternal responses occurred during the child's object gaze, not after. Unfortunately, by using a simultaneous auditory visual style of teaching (providing language input while the child is focused on an object), hearing mothers of children who are deaf lose opportunities to provide meaningful language input in joint attention.
In direct contrast to hearing mothers of children who are deaf, mothers and children who both are deaf seem to provide an exemplary model of adaptive communication. These mothers are notable for their frequent use of sequential rather than simultaneous communication. On the basis of their own experiences, mothers who are deaf realize that the parent must have the child's visual attention before signing. They allow their child who is deaf to attend to an object, then get the child's attention, and only then comment on what the child has seen (Prendergast & McCollum, 1996; Wood, 1981).
Studies by Spencer and her colleagues with mothers and children who both were deaf showed the workings of such a sequential interactive style. In their 1992 study, Spencer et al showed that only 20% of the mothers' responses occurred during the child's object gaze, while 80% of maternal signs occurred after the child had returned attention to the mother. They noted that these moms also turned to look at or point to the object either before or after signing. This visual pointing may serve to associate the object and the sign for the baby, thus compensating for the sequential rather than simultaneous nature of her response.
When these mothers are not employing a sequential interactive style, they modify their simultaneous communication in various ways to accomplish contingent interaction with their children. One modification involves where the mother performs the sign. They frequently move their bodies and hands within their children's visual field so that the children can gaze at an object while also receiving signed language (Harris et al., 1989; Maestas & Moores, 1980). For example, mothers might reach out and sign “car” above a toy car at which a child is looking so that the child can simultaneously attend to both the sign and the object to which it refers (Harris et al., 1989). A slightly different strategy was reported by Spencer et al. (1992) where the mother seemed to help the baby make the symbol-object connection by beginning the sign with her hand near the object and then continuing to sign as she drew the child's attention back to herself. Mothers who are deaf use a number of other methods for establishing and maintaining communicative joint attention with their infants who are deaf. They maintain almost constant physical and visual contact with their child, sometimes producing a sign on the infant's body (Launer, 1982; Maestas & Moores, 1980), and signs are held for a longer period of time than for adults (Masataka, 1992) and are often repeated, thus increasing the time during which a sign is available to the infant for processing (Masataka 1992).
Landry and Chapieski (1989) compared the behavior of mothers with preterm infants and mothers of children with Down syndrome. The authors found differences in mothers' use of nonverbal attention-directing techniques, in that the mothers of infants with Down syndrome attempted more often to physically orient their infant's attention. Of note, however, is the fact that the infants with Down syndrome more often were not involved with any toy when the mothers attempted to direct them. As the authors noted, the greater frequency with which mothers introduced toys and physically oriented the attention of their infants may reflect these infants' less active involvement with toys on their own.
Other research has found that children with Down syndrome have difficulty shifting the focus of their attention (Harris et al., 1996; Landry & Chapieski, 1989). For example, Landry and Chapieski (1989) found that (1) mothers' attempts to interest their infants with Down syndrome in jointly attending to toys resulted more often in sustained attention to their mother's face than to the target toy and that (2) attention shifts often resulted in less manipulation of toys or no response at all. This information highlights the importance of minimizing attentional demands for children with Down syndrome and suggests that the success of mothers' specific verbal and nonverbal techniques depends on the mothers maintaining their infant's attention to a toy with which they are already engaged.
Research suggests that a deficit in the development of joint attention skills is a defining characteristic of young children with autism (Curcio, 1978; Mundy, Sigman, Ungerer, & Sherman, 1986; Wetherby & Prutting, 1984). Mundy, Sigman, and Kasari's study (Mundy et al., 1990) examined the degree to which individual differences in gestural joint attention skills predicted language development in children with autism. These researchers followed a group of 3½-year-old children with autism over 13 months, and found that at both timepoints declarative gestures were specifically impaired. Furthermore, declarative joint attention gestures were the strongest predictor of language level at follow-up, above both initial language level and IQ. Therefore, it seems that children with autism who do show some joint attention develop language skills that are superior to those of children who do not show these abilities (Mundy et al., 1990; Mundy, Sigman, Ungerer, & Sherman, 1987).
Parental joint attention behaviors have been examined only recently in children with autism. Siller and Sigman (2002) found that parents who made bids for joint attention that involved a toy already within the child's attentional focus had children with autism who initiated more frequent joint attention 1 year later. Also, contingent, undemanding verbal utterances by the parent turned out to be a strong predictor of the children's language skills 10 and 16 years later. Given the attentional difficulties and the play deficits of children with autism, it was particularly surprising that Siller and Sigman (2002) found the behavior of parents of children with autism to be mostly contingent in nature. Since the periods of play coded in this study were so brief (4 separate segments of 30 seconds each), it could be that parents of children with autism are responsive when their children are already engaged with an object. It would be interesting to see if these results hold up during longer periods of play where parents may need to work harder to keep their child engaged.
The studies of caregiver dyads with children who are deaf and those with Down syndrome give rise to several issues. The explanations proposed for nonresponsive behaviors of hearing mothers with children with hearing loss tend to center either on the mother or the child. Mothers may be seen as nonresponsive if their attitude or lack of knowledge interfere with them using more visual means of communication. Children with hearing loss may also be viewed as nonresponsive because of lower quantity and level of communicative behaviors.
Along similar lines, it has been suggested that the more directive tendencies of mothers of children with Down syndrome may be similar to the “lower-limit reaction” described by Bell (1979). Bell argued that parents' use of behaviors that provide more structure, responds to some behavioral characteristics of their developmentally delayed child and is intended to increase the child's level of responsiveness. If this argument holds true then this should be the same for low-responsive children regardless of disability. In fact, it seems that hearing mothers of children who are deaf may be demonstrating this same phenomenon, perhaps partly due to their difficulties in modifying their communication for their child. However, insufficient evidence exists at present for evaluating the proposed explanations. Neither the range of strategies used by mothers to accommodate their children's communicative needs nor the associations between specific strategies, various communicative contexts, and aspects of language development have been established.
In summary, a fair amount of research has considered joint attention abilities in different disability groups. However, our knowledge is quite fragmented. A comprehensive understanding does not yet exist of the different aspects of joint attention (state, gestures, topic control, etc) as they relate to different disability groups or to the importance of joint attention to language development in these children. Given our scattered knowledge, both within and across disabilities, continued research studies are warranted. But the knowledge we have gained thus far is important to consider in designing interventions.
IMPLICATIONS OF RESEARCH FINDINGS FOR PRACTICE
It seems necessary at this point to consolidate what we know so far with regards to implications for intervention. First, despite variation in the way that joint attention has been conceptualized, it seems fairly clear that joint attention skills are related to language development. Indeed, there is some evidence that joint attention could well play a predictive role in relation to language development. Young children's ability to link adult gestures with an object they are attending to emerges as a critical component of language learning. Thus, their attentional abilities become a critical contributor to their language learning, as is the ability of the adult to interact with the child in a style that maximizes the child's ability to attend both to the adult and to an object.
Implications from the research for varied populations of children suggest that intervention should be primarily focused on contingent interactions. We will provide examples of how to provide structure within contingent interactions, and different techniques to ensure adult responsiveness. A second focus should be on increasing the length of joint attention episodes. Lastly, the intervention methods and results of an experimental intervention to increase joint attention in children with autism will be presented.
Interestingly, for both typical children and atypical children, mounting evidence indicates that a contingent or responsive adult interactive style impacts children's language learning. Contingent responding requires an adult providing nonverbal or verbal input on a toy to which the child is already engaged. This technique seems to minimize the attentional demands on the child and allows him/her to more effectively process information from the adult. The ability of the adult to minimize attention shifts for the child is particularly critical for children who experience significant difficulties regulating their attention (eg, children with autism and children with Down syndrome).
A responsive interaction style also suggests that the adult follows the child's interests, thus allowing the child to choose the toy/activity or the “topic” of the interaction. While a responsive parental interaction style seems desirable, this does not necessarily mean that the parent should not structure the interaction. Indeed many children with autism require a lot of structure and many have difficulty engaging with objects. One might question how a parent can follow a child's lead if the child has difficulty initiating play with toys? Much depends on the adult's ability to set up the environment in a manner that will provide the child with play choices. This may require the parent to set out only 2 toys of high interest to the child, and then follow the child's interest with whichever toy he/she chooses. Furthermore, once the child engages with a toy (ie, chooses the topic of the interaction) the parent may be directive to differing degrees depending on the responsiveness of the child. Within the child's topic though, the parent could engage in a highly directive manner and still be contingent. For example, a parent providing contingent language on a child's interest may verbally ask the child to show the toy, or may physically prompt the child to point to pictures in a book. The parent then can directly structure the interaction to facilitate joint attention while maintaining interest on the child's choice of toy or activity. However, the child's interest in an activity is critical for both the likelihood that a child will initiate joint attention and also maintain a shared state for a sustained period of time.
Another way for a parent to indirectly facilitate joint attention is to violate a play routine within the child's existing attention. For example, if the child chooses a shape sorter, the parent may contingently respond to the child's interest by handing puzzle pieces for the child to insert. As a routine develops of the parent handing the child puzzle pieces, the parent might give the child a piece that clearly does not belong to that shape sorter. This type of violation may indirectly prompt joint attention on the part of the child (eg, a shared look), or provides the parent with a “natural” opportunity to prompt joint attention.
A similar picture emerges for children who are deaf and experience significant attentional demands to receive and convey communication. While no studies as yet have examined caregiver interactional behavior in relation to language development in children who are deaf, several intervention techniques seem to make intuitive sense in capturing contingent joint attention. First, the ability to wait seems particularly salient. More specifically, since visual attention is critical for these children, a key strategy may be the ability of the adult to wait for the child to shift visual attention before providing contingent input. The sequential communication style used by mothers and children who both are deaf requires waiting for the child to shift attention from the toy to the adult before the sign is delivered. When mothers and children who are deaf are not using a sequential communication style, they use techniques to modify a simultaneous communication style. These modifications include the mother signing within the child's visual field, or signing near the object and then continuing to sign successively closer to her body as she draws attention to herself. These same intervention techniques with children who are deaf may be applicable to other children who show attentional difficulties, such as children with Down syndrome or autism. Indeed the ability to wait may be essential for any child who requires a longer time to process information in any learning modality. For example, many children with autism take longer to process information than do typical children. An increased wait time by the parent may facilitate the child's ability to take in parental communication and reciprocate, or to initiate joint attention regarding something novel.
In parallel, a second important element is the length of joint attention episodes. While longer episodes of joint attention are predictive of language skill in typical infants, for children with Down syndrome the average length of a joint attention episode seems to impact language skills. Recent findings from an intervention study with preschool children with autism indicate similar findings. Kasari, Freeman, and Paparella (2001) found that the average duration of child-initiated joint attention episodes was related to expressive language gains. Intuitively, maintaining a joint focus around an object for an extended period of time, again relates to keeping attention shifts to a minimum. The ability to stay with a child's focus for an extended period can be a challenging task for parents. Examples of why parents will sometimes draw a child's attention away from a toy to something different include the following: when the pace of the interaction is slow, if they feel the child should be interested in a range of toys, or if the child is more focused on the toy than on interacting with the parent.
Recently, Kasari et al. (2001) reported preliminary findings on a controlled experimental intervention to increase joint attention skills in preschool children with autism. Based on much of the literature that highlights the importance of following the child's lead, and providing contingent input, teaching techniques that combined these normal developmental principles along with behavioral and milieu language teaching strategies were selected. Warren and Kaiser (1986) and Koegel and Koegel (1995) have described these latter techniques in detail. Principles of the intervention include following the child's lead and interest in activities, talking about what the child is doing, repeating what the child says, expanding on what child says, giving corrective feedback, sitting close to the child and making eye-contact, and arranging the environment to best facilitate play interaction. From our perspective, key aspects of this approach are making sure the play session is child-driven rather than adult-directed, and that environmental manipulations are strategically used to facilitate the child's social and communicative attempts. However, within this approach, direct structure was also implemented within the child's attentional focus. As touched on above, systematic prompts and violating routines were used by the adult to facilitate joint attention.
Although preliminary, the findings indicate very positive results (Kasari et al., 2001). Two factors seem important in producing communicative change during the milieu teaching sessions: imitating the child and engaging in play routines. A play routine was defined as a repetitive activity using a toy (or object) in which adult behaviors include predictable sequences, contingent on the child's actions. Indeed, in most cases, a predictable sequence occurred, such that the adult imitating the child led to a routine, which in turn led to joint attention episodes. Both imitation and play routines led to greater amounts of coordinated joint attention between the adult and the child with autism. Communicative behaviors such as meaningful words, pointing, shared looks to adult, and showing toys also increased over the intervention sessions. In-depth analysis of these data will provide important information on our ability to improve joint attention skills, and the outcome of these improvements to language development.
To sum up, then, improving the joint attention abilities (both state and gestures) of children with specific disabilities seems an important intervention target. The integration of research knowledge across and within disabilities should provide important information on specific intervention targets and successful treatment strategies.
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