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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
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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
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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
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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-
R. MacDonald et al. / Research in Developmental Disabilities 27 (2006) 138–150 141
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
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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.
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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.
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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
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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.
R. MacDonald et al. / Research in Developmental Disabilities 27 (2006) 138–150 145
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).
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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
R. MacDonald et al. / Research in Developmental Disabilities 27 (2006) 138–150146
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.
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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.
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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
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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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