behavioral assessment of joint attention: a methodological report

Behavioral assessment of joint attention:

A methodological report

Rebecca MacDonald a,*, Jennifer Anderson a, William V. Dube b,Amy Geckeler a, Gina Green a,1, William Holcomb a,

Renee Mansfield a, June Sanchez a

a The New England Center for Children, 33 Turnpike Road, Southborough, MA 01772-2108, USAb University of Massachusetts Medical School, Shriver Center, USA

Received 18 September 2003; received in revised form 15 July 2004; accepted 23 September 2004

Abstract

This paper describes a highly structured assessment protocol with objective behavioral measures

for joint attention responding and initiation. The assessment was given to 26 children diagnosed with

autism spectrum disorders and 21 typically developing children, aged two to four years. Interobserver

agreement was high for all behavioral measures. Children with autism had relatively minor deficits in

joint attention responding and more severe deficits in joint attention initiation, relative to typically

developing children. These results replicate those reported in previous research. The protocol can be

used reliably to assess behavior indicative of joint attention responding and initiation in typically

developing children and children with autism.

# 2005 Elsevier Ltd. All rights reserved.

Keywords: Behavioral assessment; Joint attention; Shifting gaze; Autism

The term joint attention has been used in the cognitive developmental literature to refer

to young children’s use of ‘‘gestures and eye contact to coordinate attention with another

person in order to share the experience of an interesting object or event’’ (Mundy, Sigman,

& Kasari, 1994). Early-developing joint attention behaviors include shifting gaze between

Research in Developmental Disabilities 27 (2006) 138–150

* Corresponding author.

E-mail address: [email protected] (R. MacDonald).1 Gina Green is now affiliated with the University of North Texas and San Diego State University.

0891-4222/$ – see front matter # 2005 Elsevier Ltd. All rights reserved.

doi:10.1016/j.ridd.2004.09.006

an object or event in the environment and a familiar person. Joint attention may also

include combining gaze shifting with pointing to an object or event. Nonverbal joint

attention emerges between 9 and 18 months in typically developing children (Bakeman &

Adamson, 1984). More advanced levels of joint attention are characterized by the use of

gestures like pointing and reaching or showing a toy to a person. These topographies vary

with the developmental level of the child. Younger children may use only eye contact, but

older children tend to use a combination of conventional gestures that may include eye

contact, pointing, and showing (Siebert, Hogan, & Mundy, 1984).

Deficits in joint attention have been well documented in children with autism

(Carpenter, Pennington, & Rogers, 2002; Mundy et al., 1994). These children fail to orient

to speech sounds or social stimuli (Dawson, Meltzoff, Osterling, Rinaldi, & Brown, 1998),

show deficits in the ablity to follow the gaze of another person (Leekam, Lopez, & Moore,

2000), and often fail to look where others point (Leekam, Hunnisett, & Moore, 1998).

Related problems in declarative pointing and showing (Baron-Cohen, 1989) and in

referential looking (Charman et al., 1997) have been reported in children with autism. For

example, Charman et al. found that all children with autism looked at a mechanical toy

when it was activated but did not exhibit gaze switches between the toy and an adult, who

was present. Recent studies of early social-communication skill development in children

with autism have found that they have the greatest deficits in nonverbal joint attention skills

and relatively less difficulty with the development of social turn-taking and nonverbal

requesting (Mundy et al., 1994).

Deficits in joint attention have been associated with difficulties in subsequent language

development (Delgado et al., 2002; Mundy, Sigman, & Kasari 1990). Declarative gaze

switching ability at age 20 months has been positively related to language gains and

decreased social-communication deficits at 42 months in children with autism (Charman,

2003). Developmental level has also been shown to be correlated with the emergence of

gaze following in young children with autism (Leekam & Moore, 2001).

Mundy and colleagues suggested that the assessment of joint attention in children

with autism may be helpful in determining responsiveness to early intervention (Kasari,

Freeman, & Paparella, 2001; Mundy & Crowson, 1997; Mundy & Neal, 2001).

Although initiating joint attention bids has been identified as an important target for

early intervention (Mundy et al., 1994), relatively few studies have documented

effective interventions for ameliorating joint attention deficits in young children (Kasari

et al., 2001; Lewey & Dawson, 1992; Whalen & Schreibman, 2003). Gewirtz and

Pelaez-Nogueras (1992) demonstrated that responding to maternal facial cues following

social-referencing can be conditioned in infants, and suggest that a similar learning

process may be occurring for the acquisition of joint attention. Whalen and Schreibman

(2003) used a six-step programmed instruction model to establish responding to joint

attention in 4-year-old children with autism. Additionally, they found that children who

mastered this skill went on to acquire joint attention initiation following similar

instruction.

A behavioral analysis of joint attention is likely to contribute to the development of

effective treatment protocols to teach skills such as the initiation of joint attention bids. To

begin such an analysis, it is first necessary to define objective criteria for measuring and

assessing the behavior in question. In this study we adapted and tested a set of tasks and

R. MacDonald et al. / Research in Developmental Disabilities 27 (2006) 138–150 139

measurement systems to define discrete behaviors characteristic of joint attention in young

children. Here we describe the assessment methods and present illustrative data for both

typically developing children and children with autism.

1. Method

1.1. Participants

Forty-seven children participated. Twenty-six were diagnosed with autism or pervasive

developmental disorder—not otherwise specified (PDD-NOS), and 21 were typically

developing children. Participant characteristics are shown in Table 1 (children with autism

or PDD-NOS) and Table 2 (typically developing children).

The autism and PDD-NOS group included twelve 2-year-olds, seven 3-year-olds, and

seven 4-year-olds. All children were diagnosed by community professionals who were not

associated with the treatment program. At the time of their participation, all of these

children were recently enrolled in the preschool or home-based components of the New

England Center for Children’s (NECC) Intensive Instruction Program, an intensive

R. MacDonald et al. / Research in Developmental Disabilities 27 (2006) 138–150140

Table 1

Participant characteristics of children with autism or PDD-NOS

Participant Gender Chronological age (year:months) Diagnosis

MKR F 2:1 Autism

DBN M 2:2 Autism

BZI M 2:3 PDD-NOS

JMN M 2:4 Autism

CCY M 2:6 Autism

NHU F 2:7 Autism

LJS M 2:8 Autism

ACR F 2:9 Autism

JBR M 2:9 Autism

RBR M 2:9 Autism

NVT M 2:10 Autism

MME F 2:11 PDD-NOS

DHL M 3:0 PDD-NOS

TPX M 3:2 Autism

JKO M 3:3 PDD-NOS

WLA M 3:4 Autism

JLT M 3:5 Autism

RZN F 3:6 PDD-NOS

ADL M 3:11 Autism

KNN M 4:1 Autism

EZI M 4:1 Autism

CCN F 4:2 PDD-NOS

JKY M 4:3 Autism

AOO M 4:4 PDD-NOS

JCV M 4:5 PDD-NOS

LMBY M 4:8 Autism

behavior-analytic treatment program; they had no previous exposure to intensive behavior-

analytic treatment. The assessment battery was administered within 6 months of entering

the NECC Intensive Instruction Program.

The typically developing group included seven 2-year-olds, seven 3-year-olds, and

seven 4-year-olds. All children were enrolled in an on-site daycare preschool classroom

run by NECC. Typically developing children were selected for participation solely on the

basis of chronological age, matched within 4 months to children with autism or PDD-NOS.

1.2. Setting

Assessment sessions were conducted in a small testing room that contained a child-sized

table and two chairs, a bookcase with toys and books, and a video camera on a tripod. The

child and the examiner sat facing one another knee-to-knee or diagonally across a corner of

the table when the assessment tasks were presented. Each session was videotaped. An

observer was present to assist in data collection and setting up assessment materials.

1.3. Assessment procedures

Joint attention subtests were added to an early skills assessment battery developed at

NECC. This battery is a direct observational assessment protocol designed to evaluate

performances on a range of skills commonly targeted for early intervention with children

with autism or PDD-NOS, including vocal and motor imitation, expressive communica-


Table 2

Participant characteristics of typically developing children

Participant Gender Chronological age (year:months)

ASW M 2:1

MCS F 2:3

MCK F 2:5

NCK M 2:5

HSN F 2:6

AFN F 2:8

CDY F 2:9

CDS F 3:1

JKN M 3:2

BCK M 3:2

DMI M 3:5

CPA F 3:6

GMY M 3:9

GSN F 3:11

SMN F 4:2

MYG F 4:2

KKY M 4:6

DAR F 4:9

HCK F 4:10

HLE F 4:10

ACK M 4:11

tion, and instruction-following skills (Anderson et al., 2000). The entire assessment took

approximately 45 min to administer. Examiners for the children with autism or PDD-NOS

were supervisors of the treatment program, but they were not involved in participants’

treatment on a daily basis.

Prior to each joint attention subtest a stimulus preference assessment was conducted to

identify one item (either food or a toy) likely to function as a reinforcer for each child.

Preferred items were presented at the end of each subtest independent of the occurrence or

nonoccurrence of the targeted joint attention behavior.

The subtests for joint attention were based on tasks described in the Early Social

Communication Scales (ESCS) developed by Mundy, Hogan, and Doehring (1996). Two

subtests assessed responding to joint attention bids, and three subtests assessed the

initiation of joint attention.

1.4. Joint attention responding subtests

1.4.1. Following a point to pictures

For this subtest, the examiner presented a folder containing six pages, with one picture

on each page. The folder was opened and laid flat in front of the child. The examiner

pointed with an extended index finger to the picture on the left page until the child looked at

it or for a maximum of 5 s, then the picture on the right page until the child looked at it or

for a maximum of 5 s, turned the page, and repeated this procedure for the remaining

pictures.

1.4.2. Following a point to pictures

This subtest used six target items that had been placed throughout the assessment room

prior to the test session: a picture on the wall behind the child at eye level, another picture

on the wall to the right of the child at eye level, a picture on the ceiling directly over the

child’s head, a toy on a shelf to the left of the child at eye level, a toy on the floor diagonally

across from the child, and a person behind the examiner approximately 8 ft away. The

examiner said ‘‘Look’’ and pointed to each target item with either a distal or contact point

until the child looked at the item or for a maximum of 5 s.

For each of these subtests, if the child looked at the item, the examiner responded with a

brief verbal comment (i.e. ‘‘Good’’ or ‘‘It’s a cat’’). At the end of the subtest the examiner

delivered the selected reinforcer, independent of the occurrence or nonoccurrence of joint

attention.

1.4.3. Response definitions

Joint attention responding occurred if the child oriented the head and eyes in the

direction of examiner’s pointing prompt within 5 s. The examiner scored occurrence or

nonoccurrence of responding during the assessment.

1.5. Joint attention initiation subtests

Joint attention initiation was assessed with two toy activation subtests and one book

presentation subtest.


1.5.1. Toy activation task (bear)

For this subtest a mechanical bear was located directly in front of the child at the end of

the assessment table, out of reach and approximately 3 ft from the child. After the child was

seated at the table, the examiner activated the bear by stepping on a switch located on the

floor under the table and observed the child for 15 s while the bear was activated, and an

additional 5 s after the toy was turned off.

1.5.2. Book presentation task

For this subtest the examiner opened and presented on the table in front of the child a

book containing several pictures on each page (My First Look At Noises; Yorke, 1991). The

examiner said ‘‘What do you see?’’ and allowed child to look at the book, touch the

book, or turn the pages for 20 s. The examiner held the book open if the child tried to

close it.

1.5.3. Toy activation task (elephant)

For this subtest a mechanical elephant was located on the floor diagonally across from

the child, out of reach and approximately 4 ft from the child. After the child was seated at

the table, the examiner activated the elephant by stepping on a switch located on the floor

under the table and observed the child for 15 s while the elephant was activated and an

additional 5 s after the toy was turned off.

For each of these subtests, if the child looked at the toy or book and shifted his or her

gaze directly from that object to the examiner, or gestured to the object while looking at

it, or made a verbal comment or question about the object while looking at the object,

the examiner responded with a brief verbal comment (e.g., ‘‘Wow’’, ‘‘That’s an

elephant’’ or ‘‘It’s a truck’’). If none of these behaviors occurred, the examiner remained

silent until the presentation period ended. At the end of the subtest the examiner

delivered the selected reinforcer, independent of the occurrence or nonoccurrence of

joint attention.

1.5.4. Response definitions

All initiation responses were scored from videotapes by trained observers. Responses

were scored if they occurred during the toy activation or book presentation period. The toy

activation period began when the toy was turned on and lasted until 5 s after it was turned

off. The book presentation period began when the book was opened on the table and lasted

until it was removed.

Gaze shift occurred if the child alternated looking at the object and the examiner during

the toy activation or book presentation period. Frequency of gaze shifts per activation or

presentation period was scored. A gaze shift was defined as the child observing of the

object and then looking directly from the object to the examiner. Subsequent gaze shifts

were scored if the child then immediately looked from the examiner back to the object, and

so forth. For example, one gaze shift was scored if the child looked directly from the object

to the examiner. Two gaze shifts were scored if the child looked at the object, then at the

examiner, then back at the object. If the child looked away from either the object or the

examiner, the gaze shift sequence ended. A new gaze shift began if the child looked at the

object again, and then looked at the examiner.


1.5.5. Gestures

A gesture occurred if the child pointed toward an activated toy or picture in a book while

looking at the toy/book or the examiner during the activation or presentation period.

Occurrence/nonoccurrence of a gesture within the activation or presentation period was

scored.

1.5.6. Verbalizations

A verbalization occurred if the child made an intelligible comment or asked an

intelligible question about the toy or book while looking at the toy/book or the examiner

during the activation or presentation period. Occurrence/nonoccurrence of verbalizations

within the activation or presentation period was scored.

1.6. Interobserver agreement

Interobserver agreement data for joint attention responding were collected during the

assessment data by an independent observer. Interobserver agreement for joint attention

initiation were collected from videotape samples by an independent observer. Thirty-six

percent of assessment sessions were scored for interobserver agreement across children

with autism and typically developing children. Interobserver agreement for joint attention

subtest items was calculated by dividing the number of agreements by the number of

agreements plus disagreements and multiplying by 100%. Mean percent agreement for

joint attention responding was 100% for children with autism and 97% for typically

developing children. Percent agreement was calculated for all children on the occurrence

and nonoccurrence of each joint attention initiation response topography (gaze shifts,

gestures, and verbalizations). Mean percent agreement for joint attention initiations for

children with autism was 93% for gaze shifts (range 80–100%), 96% for gestures (range

71–100%), and 97% for verbalizations (range 80–100%).Mean percent agreement for joint

attention initiations for typically developing children was 96% for gaze shifts (range 75–

100%), 96% for gestures (range 83–100%), and 100% for verbalizations.

2. Results

2.1. Joint attention responding subtests

The data in Fig. 1 show individual child performances on the joint attention responding

subtestsbyageatassessmentforbothgroupsofparticipants.Twelve jointattentionresponding

opportunities were presented. Mean scores for children with autism were 9.6 (range 6–12)

for 2-year-olds, 10 (range 7–12) for 3-year-olds, and 11.14 (range 10–12) for 4-year-olds.

The score for all but one of the typically developing children was 12, regardless of age.

2.2. Joint attention initiation subtests

A composite score for joint attention initiations was calculated as the total number of

joint attention topographies (gaze, gesture, verbalization) exhibited at least one time across


the three joint attention initiation subtests (bear, book, elephant). A score of 9 was the

maximum possible for each child (all three topographies on all three subtests). The data in

Fig. 2 show the mean composite scores for each group of participants by age at assessment.

Mean scores for children with autism were 1.7 (range 0–5) for 2-year-olds, 1.3 (range 0–5)

for 3-year-olds, and 2.1 (range 0–4) for 4-year-olds. Mean scores for typically developing

children were 4.9 (range 1–8) for 2-year-olds, 5.6 (range 3–9) for 3-year-olds, and 6 (range

of 4–9) for 4-year-olds. The data in Fig. 3 show individual composite scores for children

with autism and typically developing children by age at assessment. Over one-half of the

children with autism had scores of zero or one; only two of the youngest typically

developing children had scores of one.

Fig. 4 shows the percent of children demonstrating gaze shifts, gestures, or

verbalizations to initiate joint attention for each group by age. Fifty-five percent of 2-

year-old children with autism used gaze shifts, 55% used gestures, and only 27% used

verbalizations. Twenty-nine percent of the 3-year-old children with autism used gaze

shifts, 43% used gestures, and 14% used verbalizations. Eighty-six percent of the 4-year-

old children with autism used gaze shifts, 57% used gestures, and 29% used verbalizations.

As shown in the righthand portion of Fig. 4, most of the typically developing children

used all three topographies. Eighty-three percent of 2-year-old typically developing

children used gaze shifts, 83% used gestures, and 67% used verbalizations. One hundred

percent of the 3-year-old typically developing children used gaze shifts, 86% used gestures,

and 67% used verbalizations. Eighty-six percent of the 4-year-old typically developing

children used gaze shifts, and they all used gestures and verbalizations.


Fig. 1. Individual child performance on the joint attention responding subtests by age at assessment for the

children with autism (striped bars), and the typically developing children (solid bars) for each age group (2-year-

olds, 3-year-olds and 4-year-olds).

Individual data in Fig. 5 show the total number of gaze shifts for each participant across

the three joint attention initiation subtests. The total number of gaze shifts for individual

children with autism or PDD-NOS ranged from 0 to 19 (mean 2.8) for 2-year-olds, 0–8

(mean 1.6) for 3-year-olds, and 0–5 (mean 2.4) for 4-year-olds. The total number of gaze


Fig. 2. Mean composite scores for children with autism (striped bars) and typically developing children (solid

bars) by age group.

Fig. 3. Individual composite scores for children with autism (striped bars) and typically developing children (solid

bars) by age group.


Fig. 4. Percent of children demonstrating gaze shifts (light striped bars), gestures (dark shaded bars), or

verbalizations (solid bars) to initiate joint attention, for children with autism (left portion of graph) and typically

developing children (right portion of graph) by age group.

Fig. 5. Total number of gaze shifts for each participant across the three joint attention initiation subtests for

children with autism (striped bars) and typically developing children (solid bars) by age group.

shifts for individual typically developing children ranged from 0 to 11 (mean 6.1) for

2-year-olds, 4–17 (mean 9.1) for 3-year-olds, and 0–16 (mean 5.4) for 4-year-olds. Twelve

children with autism never exhibited gaze shifts; only two typically developing children

never exhibited gaze shifts.

3. Discussion

The behavioral protocol described above provided objective measures of joint-attention

behavior based on relevant tasks from the ESCS (Mundy et al., 1996). High interobserver

agreement scores indicated that the protocol can be used reliably to assess behavior

indicative of both joint attention responding and initiation in typically developing children

and children with autism.

Results for joint attention responding showed that both children with autism and

typically developing children responded to the examiner’s pointing gestures on a majority

of opportunities. Two- and 3-year-old children with autism demonstrated fewer overall

responses to joint attention bids by the examiner than 4-year-old children with autism and

typically developing children, but the differences were relatively minor. This lack of

differentiation between groups could be an artifact of the use of a point in the joint attention

bid.We are now examining the relation between responding to joint attention bids when the

examiner uses a point versus when the examiner uses just a gaze. Our pilot data indicate

differences in performance between children with autism and typically developing

children.

Results for joint attention initiation showed that all three categories of measured

behavior (gaze shifts, gestures, and verbalizations) were observed in typically developing

children, but nearly half of the children with autism failed to use any form of responding to

initiate joint attention, with the exception of gaze shifts in 4-year-old children with autism

(used by 86% of children). Thus, the overall results replicate previously reported

differences in joint attention responding and initiation in children with autism, with deficits

that were much less severe for responding than initiation (Mundy et al., 1994; Whalen &

Schreibman, 2003). The near-typical use of gaze shifts in 4-year-old children with autism is

also consistent with previous data on joint engagement skills in this age group (Carpenter

et al., 2002). Interestingly, an analysis of composite scores for children diagnosed with

autism compared to children diagnosed with PDD-NOS showed few differences in

performance.

One concern regarding the standardization of procedures for measuring social

interaction has been the potential threat to ecological validity (Mundy et al., 1996). The

present results suggest that any degradation along this dimension was relatively minor:

standardization of procedures and rigorous administration guidelines were used, yet the

results showed clear differences between the behavior of children with autism and typically

developing children. These differences are similar to those reported in other studies using

semi-structured assessment procedures to measure individual differences in nonverbal

communication skills (Mundy et al., 1990, 1994).

Behavioral analyses of joint attention will be advanced by the development of

standardized assessment protocols and behavioral measurement systems that include (a) a


variety of topographies of behavior and (b) measurement of the temporal relation between

stimulus presentation and the child’s responses. The present paper described one such

protocol, and illustrated how it could be used to evaluate behavioral repertoires commonly

described in the developmental joint-attention literature. One topic for continued research

is the development of assessment techniques and experimental protocols to examine and

classify the maintaining consequences for joint attention behavior. This effort seems

especially important for initiating functional analyses of these response classes and the

development of effective remedial strategies.

Acknowledgements

The research reported here was supported by the New England Center for Children’s

(NECC) Intensive Instruction Program as part of a longitudinal research project conducted

by the Intensive Instructional Preschool and Home-based Programs; we thank Vincent

Strully and Katherine Foster. Gina Green’s work on this study was supported in part by

USPHS Research Grant No. PO1HD25995 from the National Institute of Child Health and

Human Development to the University of Massachusetts Medical School, Shriver Center.

We also thank Madhuri Vengala, Ellyn South, and Lisa Castellano for their assistance with

data collection and manuscript preparation. Portions of the data were presented at the

annual convention of the Association for Behavior Analysis, May 2002.

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behavioral assessment of joint attention: a methodological report

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