The Relationship Between Joint Attention, Play and Imitation Skills, with Cognitive Outcomes in Preschoolers with Autism Spectrum Disorder

Background:  

Research evidence suggests that presence of early social behaviours such as joint attention, imitation and play skills, are associated with better cognitive and language outcomes in children with Autism Spectrum Disorder (ASD), although these findings need further replication with larger clinic samples. 

Objectives:  

This study aims to determine i) how joint attention, play and imitation skills are associated with cognitive abilities of children with ASD at 2-4 years old, and ii) how early social behaviours, cognitive abilities of children with ASD at 2-4 years old are associated with cognitive abilities of the children at 5-6 years old, in a clinic sample. 

Methods:  

A retrospective medical records review was conducted for 484 children with ASD who underwent a diagnostic assessment at 2-4 years old from 2009-2011 within a child development specialist clinic in Singapore. Measures of joint attention, play and imitation skills were taken from the Autism Diagnostic Observation Schedule (ADOS), which was the standard behaviour observation tool used for ASD diagnostic evaluations within the clinic. A variety of cognitive assessments were used to measure cognitive abilities of the children at 2-4 years old and at 5-6 years old. Standard scores that provide estimates of a child’s non-verbal reasoning abilities were used where available. The children’s cognitive assessment results were categorized into Adequate (IQ≥80) or Delayed (IQ<80). A proportion of the children completed a cognitive assessment at 2-4 years old (n=291, 246 boys), as cognitive assessments were optional for ASD diagnostic evaluations. A smaller selection of those children had their cognitive assessment results at 5-6 year old available in their medical records (n=187, 160 boys). 

Results:  

Logistic regression analyses indicate that ratings on functional and make-believe play significantly predicted cognitive assessment results at 2-4 years old, and ratings on initiation of joint attention and a child’s cognitive assessment results at 2-4 years old significantly predicted cognitive assessment results at 5-6 years old. 

Conclusions:  

Children with ASD who demonstrated better play with toys/objects were more likely to have adequate cognitive assessment results at 2-4 years old. Children who obtained adequate cognitive assessment results at 2-4 years old, were more likely to show similar results at 5-6 years old. Children with ASD who were better at initiating joint attention with others at 2-4 years old, were more likely to have adequate cognitive assessment results at 5-6 years old. Children who direct others’ attention to objects of interest to them, may respond better to cooperative learning approaches, which can better facilitate their cognitive development. 

These results highlight significant relationships between joint attention and play, for cognitive abilities of children with ASD. Interventions that target joint attention and play in children with ASD can be further investigated to determine if developing joint attention and play skills in children with ASD can improve their cognitive outcomes.