MONTREAL – Intensive intervention programs that focus on joint attention using a child-directed teaching approach can affect change in autistic children's attention states, and potentially improve social functioning and their long-term prognosis, Tanya Paparella, Ph.D., said at the 5th International Meeting for Autism Research.
Joint attention–which refers to the propensity of a child to engage others' attention through eye contact, referential eye gaze, and pointing as a way to share their experience of objects or events–is a critical area in normal development that typically emerges between the ages of 9 and 15 months. Studies have indicated that joint attention behaviors lay the foundation for later emerging skills, including more complex expressive language and symbolic play.
Impairment in the development of joint attention is characteristic of children with autism spectrum disorders, and it is one of the core deficits addressed in the Early Childhood Partial Hospitalization Program (ECPHP) in the division of child psychiatry at the University of California at Los Angeles. The ECPHP is a 12-week program for children with autism between the ages of 2 and 7 years in which structured, intensive, individualized treatment is provided to 12 children at a time for 6 hours per day, 5 days per week.
The comprehensive program is made up of direct intervention in core areas of functional deficit: educational, behavioral, and social intervention plans; parent education and support; and liaison with community agencies. All children in the program receive speech therapy, occupational therapy, and recreational therapy interventions. They also are seen individually or in therapeutic groups to promote language usage, socialization, and appropriate interaction with others, Dr. Paparella said in a poster presentation.
In a study designed to assess whether participation in a comprehensive treatment intervention can affect the development of joint attention behaviors, Dr. Paparella and her colleagues evaluated the outcomes of 10 ECPHP participants using an observational measure designed to examine the proportion of time each child spent in any of six engagement states.
The states of engagement were defined as: unengaged, in which the child is not involved with any object or event; onlooking, whereby the child is observing another's activity but is not taking part in it; object engaged, in which the child is focused solely on an object by himself, minus any type of communication with another person; person engaged, where the child is engaged in an interaction with another person but does not shift his or her attention between the person and object; supported joint attention, in which the child and another individual are actively involved in the same object, but the child shows little awareness of the other's involvement; and coordinated joint attention, where the child actively attempts to coordinate his or her attention to both another person and the object resulting in a shared social experience.
All of the children were evaluated using the Mullen Scales of Early Learning, which assess early cognitive ability and motor development. Of the 10 children–6 males and 4 females with a mean age of 38 months–4 were defined as lower functioning based on their Mullen scores; 6 were considered higher functioning.
At four equally spaced time points during the 12-week program from the time of admission to discharge, each child was observed for 15 minutes in each of four different contexts, including one-on-one instruction, structured play, circle time, and unstructured play. For observational coding, each 15-minute session was divided into 30-second time intervals, at the end of which the child's predominant engagement state was recorded. For each time point, a total score for each state was calculated across all four contexts to represent the mean number of intervals that the child was engaged in a specific engagement state.
Over the 12-week study period, “all of the children demonstrated decreases in the proportions of time spent in unengaged and on-looking states, and all increased the proportion of time spent in person-engaged, supported joint attention, and coordinated joint attention states,” Dr. Paparella reported. The trajectories of change in the various engagement states varied, depending on the child's functional level, she noted. “The four lower-functioning children showed good increases in the lower-level engagement states and more gradual trajectories of change with the successively advanced states.” In contrast, “the higher-functioning children showed dramatic increases in the more socially complex joint attention states.”
The ability to change autistic children's attention states–and, in particular, to aid in the development of joint attention behaviors–through intensive behavioral intervention may play an important role in developing more complex social behaviors and communication skills, Dr. Paparella said. Simply decreasing the amount of time spent in passive states relative to active, engaged states can have a substantial impact on how children with autism experience the world. Further studies are needed to examine which aspects of the intervention have the most impact on attention states, she said.