Randomized Controlled Trial: Joint Attention Mediated Learning

Background: Our primary aim was to determine the efficacy of the Joint Attention Mediated Learning (JAML) intervention for promoting joint attention between toddlers with autism spectrum disorders (ASD) and their caregivers and to determine maintenance effects. The JAML program is a parent-mediated, relationship-based, developmentally oriented intervention focused primarily on supporting joint attention learning. The research was conducted from sites in Indiana, Kansas/Missouri, and North Carolina.

Objectives: Our objectives were to assess JAML’s: (a) effects on preverbal social communication for toddlers with ASD (b) social validity, and (c) maintenance of effects across time.

Methods: 127 toddlers, aged 16 to 30 months, and their parents participated in a randomized controlled trial to assess effects of JAML on four preverbal social communication outcomes: focusing on face (FF), turn-taking (TT), responding to joint attention (RJA), and initiating joint attention (IJA). Eligibility was determined by the ADOS-T. Principles of mediated learning supported parents’ conceptual learning and their promotion of preverbal social communication targets for their toddlers. Experimental group participants received 32 weeks of individualized home-based support to promote their toddlers’ social communication. Following post-assessment, control participants received instruction on the independent use of JAML materials. Using the Precursors of Joint Attention Measure (for which reliability had been established), coders blinded to group assignment observed intervals of parent-child interaction videos for the occurrence of targeted outcomes.

Results: Experimental and control groups showed no significant differences on pre-intervention measures; however, strong evidence of differential change between groups over time (in favor of the experimental group) was found from pre- to post-test for all four outcomes. These differences remained at six-month follow-up for FF, TT, and RJA. Post-assessment differences showed effect sizes of 1.24 post-intervention and 1.06 at 6-month follow-up for FF, .95 and 98, respectively, for TT, 2.80 and 4.71, respectively for RJA, and .85 and .57, respectively, for IJA. Inter-observer agreement (Kappa) reliability from blinded coders was .81 for FF, .72 for TT, 69 for RJA, and .74 for IJA. Parent and interventionist implementation fidelity with their intervention protocols was 98.6 and 99.5%, respectively, for ratings of satisfactory or better quality. Inter-observer agreement was 99% on both parent and interventionist fidelity measures. In an assessment of social validity (acceptability to parents) for those receiving JAML, a large majority strongly agreed with the acceptability and importance of JAML’s goals, the parents’ active role in the intervention, the support received to promote their toddlers’ learning, their toddler’s progress in the intervention, and their hopefulness about the child’s future and confidence in their own ability to promote their children’s learning. Descriptive data on other services received will be presented.

Conclusions: Joint attention, a competency associated with later language, social, and cognitive competence, is an achievable goal for toddlers with autism. Parents were able to translate key content and process components into everyday interactions. JAML’s developmental focus, beginning with social regard for others’ faces and proceeding to more advanced forms of preverbal social communication, maps onto emerging findings on early differences in social orientation in autism.