Parent initiations and child responses during interaction between children with autism spectrum disorder and their parents

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Parent initiations and child responses during interaction between children with

autism spectrum disorder and their parents

Gunita Mudhar

Master Thesis

Master’s in Special Needs Education Department of Special Needs Education

Faculty of Educational Sciences University of Oslo

Spring 2020

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Parent initiations and Child responses during interaction between children

with autism spectrum disorder and their parents

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2020

Parent initiations and Child responses during interaction between children with autism spectrum disorder and their parents

Gunita Mudhar

http://www.duo.uio.no/

Print: University of Oslo

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Abstract

Objective: The present study aimed to investigate parent nonverbal initiations and child responses during joint attention episodes between preschoolers with autism spectrum disorder (ASD) and their caretakers (or parents). Method: A total of 50 participants diagnosed with ASD between the chronological ages of 48 to 60 months and one of their parents were included. The current study expands and draws upon video recordings of 10-min play dyads between parents and children from a randomized controlled trial (RCT) design investigating short- and long-term effects of pre-school based social-communication treatment for children with ASD (Kaale et al., 2014). Video recordings of play were re-coded to assess different parent and child joint attention behaviors based on a predefined coding scheme with operational definitions. Results: The most frequent parent initiation was pointing towards a toy or object, and the most frequent child response was towards parent showing a toy. Moreover, child nonverbal responses were most frequent compared to child verbal responses. Correlation analysis revealed a positive association between total parent initiations and total child responses, where parent showing appeared to the have strongest association between total child responses. Lastly, regression analysis showed all individual parent initiations explained 77.9% of the variance in total child responses, where parent showing was the strongest predictor of total child responses. Conclusion: Despite the fact it is not possible to conclude on the direction of the effect, results suggest parents’ nonverbal joint attention initiations, especially parent showing of toys seems to be effective in eliciting a response in preschoolers with ASD.

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Preface

I would like to express my gratitude to those individuals who have supported me throughout my thesis project. First, I would like to thank my advisor, Anett Kaale, for her continuous guidance and support and allowing me to take part of her study. This dissertation could not have been possible without your hard work and effort. Thank you to the Division of Mental Health and Addiction at Oslo University Hospital for creating a nurturing environment which enabled me to assess the video recordings needed for the present study. Thank you to the IT services at the University of Oslo for allowing me to borrow equipment for my thesis.

I would like to thank the various professors in the Special Needs Department at the University of Oslo for their efforts in imparting their passion and vast knowledge towards myself and fellow students. Lastly, to my dearest friends and family, thank you for your support and

encouragement

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List of Abbreviations

JA Joint Attention

IJA Initiating Joint Attention RJA Responding to Joint Attention

IBR Initiating Behavioral Regulation/Requests in Joint Attention

ASD Autism Spectrum Disorder

DSM-V Diagnostic and Statistical Manual of Mental Disorders PDD-NOS Pervasive Developmental Disorder- not other specified ICD-10 International Classification of Diseases

PDPM Parallel and Distributed Processing Model

RCT Randomized Controlled Trial

ADOS Autism Diagnostic Observation Schedule ADI-R Autism Diagnostic Interview-Revised

IQ Intellectual Quotient

ESCS Early Social Communication Scales RDLS Reynell Developmental Language Scales MSEL Mullen Scales of Early Learning

SB-5 Stanford-Binet Intelligence Scales

IV Independent Variable

DV Dependent Variable

VIF Variation Inflation Factors

REC Regional Committees for Medical Health Research Ethics TSD Services for Sensitive Data

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List of Tables and Figures

Table 3.1 Children Characteristics 20

Table 3.2 Joint attention definitions for Parent initiations and Child responses 24

Table 3.3 Parent Demographics 25

Table 3.4 Skewness and Kurtosis values for Parent initiations and Child responses 30 Table 3.5 Multicollinearity results for Parent point, show, and give 36 Table 4.1 Descriptive statistics for Parent initiations and Child responses 42 Table 4.2 Correlation matrix for Parent initiations and Child responses 44 Table 4.3 Regression analysis for Parent initiations and Child responses 45 Figure 3.1 Example of Data for Coding Scheme of Joint attention behaviors 22 Figure 3.2 Scatterplot of regression standardized residuals and predicted value 37 Figure 3.3 Normal probably plot of regression standardized residual 38 Figure 3.4 Bivariate scatterplot between Parent point and Child response 39 Figure 3.5 Bivariate scatterplot between Parent show and Child response 39 Figure 3.6 Bivariate scatterplot between Parent give and Child response 40 Figure 4.1 Mean statistics for Total child responses to Parent point, show, and give 43

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1.0 Introduction

1.1 Statement of Problem

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with onset in infancy or early childhood. The disorder is characterized by persistent deficits in social communication/

interaction and restricted, repetitive patterns of behavior (American Psychiatric Association, 2013). A considerable amount of research has been committed in identifying social impairments in ASD, including qualitative differences of nonverbal, social reciprocity, and spontaneous sharing of enjoyment and interests (Crowell et al., 2019; Sullivan et al., 2007). A major focus of this research places emphasis on joint attention.

Joint attention generally refers to the ability to coordinate attention between people and objects (Mundy, Sigman, Ungerer, & Sherman, 1986). Episodes of joint attention provide a reference for language learning and social competence development; two skills that are evidently recognised as being core areas of disturbance in ASD (Bakeman & Adamson, 1984; Moore & Dunham, 1995; Mundy, Sigman, & Kasari, 1994). Theoretically, acquisition of joint attention may function as a pivotal skill, meaning gains in this area of development may provide a foundation for learning other untrained social-cognitive skills and abilities, including pretend play, theory of mind, and social motivation (Baren-Cohen, 1992, Charman et al., 2003, Delinicolas & Young, 2007, Mundy et al., 2007, Murray et al., 2008, Rollins & Snow, 1998, Schertz & Odom, 2004, Schietecatte et al., 2012, Tomasello et al., 1993, 1996, as cited in Murza et al., 2016).

The heterogeneity and growing prevalence rates of ASD (Sullivan et al., 2007; Özerk, 2016) present potential challenges associated with supporting children, demanding parents and educators to meet the differentiated developmental needs of children with ASD. This draws attention to the provision of effective joint attention interventions that target and optimize

language learning and social competence development as the following capabilities function as a pivotal skill, in turn, ultimately enabling children with ASD to better interact with individuals and their surroundings.

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1.2 Rationale for Study of the Problem

Children with ASD display deficits of behaviors indicative of joint attention, such as initiating joint attention (IJA) and responding to joint attention (RJA) (Sigman, Mundy, Sherman, &

Ungerer, 1986; Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). Deficits of joint attention skills include but are not limited a marked reduction in the use of eye contact, affect and gestures for the purpose of sharing, turn taking sequences, verbalizations, and conventional gestures such as pointing and showing (Mundy, Sigman, Ungerer, & Sherman, 1986; Mundy, Sigman, & Kasari, 1990).

Though children with ASD experience deficits in both IJA and RJA skills, studies have shown RJA deficits may decrease in severity of development, while IJA remains impaired (Charman, 1998; Mundy, Sigman, & Kasari, 1994). These findings suggest IJA may be the most robust form of joint attention and one of the earliest markers of an autism diagnosis (Baron-Cohen, Allen, & Gillberg, 1992; Charman, 1998; Osterling & Dawson, 1994).

It is not to say responding to joint attention (RJA) does not provides useful insight in joint attention deficits in children with ASD. The presence or absence of RJA skill mediates language learning and appears to be the greatest predictor of later language (Bottema-Beutel, 2016;

Mundy, 2013; Sullivan et al., 2007). Deficits in RJA are detrimental to early social learning as it is likely to cause the child to miss out on effective learning opportunities (Jones & Carr, 2004).

However, RJA impairments are less evident for children with ASD who show more advanced levels of cognitive development, suggesting RJA is relatively open to modification (Jones &

Carr, 2004; Mundy & Sigman, 2006). In fact, a considerable amount of intervention research targets RJA changes in children with ASD, in which primary caretakers (or parents) are directly involved (Jones et al., 2006; Jones & Feeley, 2007; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Rocha et al., 2007; Schertz & Odom, 2007, as cited in Meindl & Cannella-Malone, 2011).

Early joint attention learning is situated in parent-child relationships, wherein an interactive context is provided intending to promote children’s learning through the assistance of mediating learning and opportunities provided by parents (Klein, 1996; Mundy, 2013; Vygotsky, 1978, as cited in Mundy & Sigman, 2006). Given that ASD is a multifaceted disorder demands parents to

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utilize different approaches of support in facilitating joint attention that is more consistent to the child’s developmental level (Crowell et al., 2019; Sullivan et al., 2007). Such parent support falls under a continuum of behaviors, for instance nonverbal behaviors including conventional

gestures like pointing, showing, and giving. In fact, a considerable number of interventions targeting ameliorating core deficits focus on preverbal forms of communication, in conjunction with behavioral strategies including prompting, shaping and fading, and preferred items where child outcomes have been favorable (Kaale et al., 2012, 2014; Jones, 2009; Jones et al., 2006;

Kasari et al., 2006; Rocha et al., 2007; Rogers et al., 2006; Taylor & Hoch, 2008; Vismara &

Lyons, 2007; Whalen & Schreibman, 2003; Yoder & Stone, 2006, as cited in White et al., 2011).

Theoretically, children with ASD tend to be more responsive towards nonverbal parent initiations because they are developmentally closer to the child’s current level of capabilities (Shertz et al., 2013). While research supports such parents’ behaviors and their effects on joint attention development, there is more to be learned about parents’ contributions to children’s joint attention, and to break down parental behaviors to determine if there are differences in the type of parents’ behaviors that may facilitate joint attention in children with ASD. For instance, a handful of studies have reported the frequency of parental nonverbal behaviors under one measure (Adamson et al., 2001; Rocha et al., 2007; Siller & Sigman, 2002; Taylor & Hoch, 2008; Vismara & Lyons, 2007; Whalen & Schreibman, 2003, as cited in White et al., 2011).

However, little is known about the frequency levels of such initiations separately and the overall effects of those individual behaviors, that is, which behaviors are most effective at eliciting responses in children with ASD. In the present study, parent nonverbal initiations (e.g., point, show, and give) and child responses (non-verbal and verbal) were investigated along with parent initiation effects on child responses in preschoolers with ASD.

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1.3 Statement of Purpose

The purpose of the present study was to better understand the impact of parents’ behaviors on children’s responses by investigating (a) parents’ non-verbal initiating bids during play

interactions with their child and (b) child’s nonverbal and verbal responses to parents’ initiation bids. More specific, the following research questions addressed were:

1) A. How much and what type of initiations (i.e. point, show, and give) were observed among parents?

B. How much and what type of responses (i.e. non-verbal and verbal responses) were observed among children?

2) What is the relationship between parent initiations and child responses?

3) Do parent initiations predict child responses and what type of parent initiation seems to elicit most child responses?

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2.0 Background

2.1 Autism Spectrum Disorder

Our understanding of autistic spectrum disorder (ASD) has changed overtime, evident in changes to diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders manual

(DSM-V). The American Psychiatric Association (2013) replaced the term Pervasive

Developmental Disorder- not other specified (PDD-NOS) with a new umbrella term “Autism Spectrum Disorder”, consolidating four previous separate categories of autism (e.g. Autistic disorder, Asperger’s syndrome, Childhood disintegrative disorder, and Pervasive development disorder-not other specified).

The criteria for ASD is organized into two symptom domains (social communication/interaction and repetitive, restricted behaviors) containing seven symptom areas. Deficits in social

communication/interaction include social-emotional (e.g., reduced sharing of interests, affect, failure to initiate and respond to social interactions) and nonverbal communicative (e.g.,

difficulties in understanding and using gestures) impairments, along with deficits in developing and understanding relationships. Examples of repetitive, restricted behaviors include repetitive use of objects, motor movements, and speech. Highly restrictive, fixated interests that are abnormal, and inflexible adherence to routines or ritualized patterns (e.g., distress at small changes, difficulties in transitions) are additionally included. Sensory issues is a newly added symptom under the restricted/repetitive domain, which includes hyper- or hypo- reactivity (lights, sounds, tastes, touch) or unusual interest in stimuli (staring at lights, spinning objects, etc.) (American Psychiatric Association, 2013).

Diagnosis is still based on symptoms causing functional impairment. Further, symptoms must emerge in early childhood, but may not be fully recognized until social domains exceed capacity.

The severity level of ASD is marked by using an assessment scale (level 1-3) based on the level of support needed for daily function. In addition, specification of accompanying intellectual and language impairment, associated neurodevelopmental or behavioral disorders and known

medical or genetic condition or environment factors are made (American Psychiatric Association, 2013;World Health Organization, 2019).

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2.2 Joint Attention

Joint attention generally refers to as set of behaviors that serve to facilitate and enable two individuals either verbally or non-verbally to communicate about, or “jointly attend to” a third object or event (Meindl & Cannella-Malone, 2011). The capacity of joint attention behaviors begin to develop between 3 to 6 months of age (D’Etremont, Hains, & Muir, 1997; Morales, Mundy, & Rojas, 1998; Scaife & Bruner, 1975, as cited in Van Hecke et al., 2007). They are then elaborated and differentiated in several forms through at least 18 months of age (Bates, 1976; Carpenter, Nagell, & Tomasello, 1998; Seibert, Hogan, & Mundy, 1982, as cited in Van Hecke et al., 2007).

One form involves the ability follow the direction of gaze, head turn, and/or pointing gesture of another person (Scaife & Bruner, 1975, as cited in Van Hecke et al., 2007), known as

Responding to Joint Attention skill (RJA: Seibert et al., 1982, as cited in Van Hecke et al., 2007).

Another type of skill involves the child’s use of eye contact and/or deictic gestures (e.g., pointing or showing) to spontaneously initiate coordinated attention with a social partner. This type of protodeclarative act (Bates, 1976, as cited in Van Hecke et al., 2007) is referred to as Initiation Joint Attention skill (IJA: Seibert et al., 1982, as cited in Van Hecke et al., 2007). These behaviors serve as social functions, in that the goal involves the sharing of experiences with others and develop social understanding (Bates, 1976; Mundy, 1995; Rheingold, Hay, & West, 1976, as cited in Van Hecke et al., 2007).

Characterized by the overt and conventional aspects of visual attention skills, such as hand gestures (e.g., pointing) or facial expressions (e.g., looking) towards an object or parent, dyadic joint attention exchanges can be observed frequently among most primary parent-child dyads over the course of the first few months (Bakeman & Adamson, 1984; Mundy et al., 1990). At this stage, infants consistently respond to adults’ bids for attention (Butterworth, 1995;

Tomasello; 1995, as cited in Jones & Carr, 2004). An adult’s bid typically takes the form of shifting his or her gaze or head, combined with a conventional gesture such as pointing in conjunctin with a verbal utterance. According to Bakeman and Adamson (1984), the sequential developmental course of joint attention spans through much of infancy. During this time, infants’

joint attention actions become more complex and sophisticated where triadic joint attention

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becomes apparent by means of protodeclarative acts; (Bates, 1976, as cited in Van Hecke et al., 2007) to spontaneously initiate social coordination of covert aspects of attention, such as sharing a state of intention between self, other, and an object (Bakeman & Adamson, 1984).

Alternatively, attention coordination may also be used for less social, but more instrumental purposes. For example, infants and young children may use eye contact and gestures to initiation attention coordination with another person in order to elicit help in obtaining an object or event.

This is referred to as a protoimperative act (Bates, 1976, as cited in Van Hecke et al., 2007) or Initiating Behavior Regulation/Requests (IBR: Siebert et al., 1982, as cited in Van Hecke et al., 2007).

2.3 Joint attention and ASD

ASD provides an important perspective of the significance of joint attention because of social impairments central to the diagnosis, namely deficits in social interaction and communication.

Not only that, a deficit in the development of joint attention has been proposed as a core component of ASD and one of the earliest symptoms, evident before 1 year of age and often before any diagnosis has been made (Baron-Cohen, Allen, & Gillberg, 1992; Charman et al., 1998; Osterling & Dawson, 1994). Compared with children with intellectual disability or specific language delay, matched for developmental level, only young children with ASD show deficits in joint attention (Charman, 1998; Landry & Loveland, 1989, Mundy, Sigman, Ungerer, &

Sherman, 1986). A substantial amount of research has demonstrated deficits in both responding to and initiating joint attention bids in preschool children with ASD (Sigman, Mundy, Sherman,

& Ungerer, 1986; Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). Behavior impairments include but are not limited to the inability turn taking sequences, pointing, showing, gaze- following and making eye contact (Mundy, Sigman, Ungerer, & Sherman, 1986).

However, impairment of both IJA and RJA changes over the course of development. Sometime after about 30-months mental age, young children with ASD who show more advanced cognitive development begin to demonstrate the ability to RJA bids, whereas IJA remains impaired

(Charman, 1998; Mundy, Sigman, & Kasari, 1994). These changes provide evidence for a dissociative relation between RJA and IJA development as well illustrate the importance of

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function in understanding this impairment. The social motivation account proposes in contrast to RJA, the prototypical function of IJA distinctively involves spontaneous seeking to share interest and a pleasurable experience about an object or event with another person (Goodhart & Baron- Cohen; 1993; Loveland & Landry, 1986; Mundy & Gomes, 1998, as cited in Jones & Carr, 2004). Therefore, IJA seems to be more robust form of joint attention and a “core deficit”

compared to RJA in children with ASD (Baron-Cohen, Allen, & Gillberg, 1992; Charman, 1998;

Osterling & Dawson, 1994).

The early deficit in joint attention experience in infancy in children with ASD has been found to persist throughout childhood, and possibly throughout a lifespan (Whiteley et al., 2019). For instance, studies suggest the variability in joint attention skills in pre-school predict variability in language acquisition and social development later in childhood (Siller & Sigman, 2008; Stanton- Champan et al., 2012).

2.4 Joint Attention and Language

Joint attention is theoretically and empirically related to two core areas of disturbance in autism:

language and social development Bakeman & Adamson, 1984; Moore & Dunham, 1995;

Mundy, Sigman, & Kasari, 1994). Bruner (1983) suggests joint attention provides a format for language acquisition, in which adults often apply labels to objects during joint attention episodes.

In fact, joint attention is both concurrently and predictively related to language ability in both typically developing children and those with ASD (Loveland & Landry, 1986; Markus, Mundy, Morales, Delgado, & Yale, 2000; McCathren, Warren, & Yoder, 1996; Mundy & Gomes, 1998;

Mundy, Sigman, & Kasari, 1990, 1994, as cited in Jones & Carr, 2004).

In a study of typically developing children, Mundy and Gomes (1998, as cited in Jones & Carr, 2004) demonstrated that RJA for joint attention predicted receptive language ability (the ability to understand information) and IJA predicted expressive language ability (the ability to put thoughts into words or sentences). However, preschoolers with ASD display deficits in

nonverbal cognition, receptive language, and expressive language in comparison to children with other developmental delays (Ellis Weismer, Lord, & Esler, 2010). More intriguing, young

children with ASD experience deficits in gaze alternation (alternating gaze between the object

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and adult, rather than looking where the other person is looking), a behavior that notably improves vocabulary acquisition and is considered an essential RJA skill (Jones & Carr, 2004).

In a meta-analytic review, Bottema-Beutel (2016) found the greatest moderator of effect size in both expressive and receptive language was ASD diagnosis and RJA, further indicating RJA to be the greatest predictor of later language ability.

2.5 Joint Attention and Social Development

As previously mentioned, children with ASD are more likely to experience deficits in social development. For instance, Travis, Sigman, and Ruskin (2001) found that for individuals with ASD, IJA was related to measures of social competence and prosocial behaviors (e.g.,

engagement with peers on the playground). Joint attention is theoretically related to an

individual’s ability to simultaneously be aware of the self and other towards an object of interest (Tomasello, 1995, as cited in Mundy & Sigman, 2006). However, young children with ASD experience deficits in awareness of the perception of the self and other, consequently hindering other related social-cognitive abilities, including pretend/symbolic play and theory of mind (Jarrold, Boucher, & Smith, 1993; Baron-Chohen et al., 1985, as cited in Jones & Carr, 2004).

Pretend play consists of acting as if something were the case (e.g., a child pretending that a banana is a telephone) (Leslie, 1987, as cited in Jones & Carr, 2004) and theory of mind is the ability to take the perspective of another person (Baron-Cohen, Leslie, & Frith, 1985).

2.6 Caregiving/Scaffolding Model of Joint Attention

Early joint attention learning often takes place in unstructured, incidental situations where parents provide an interactive context wherein children are assisted through mediating learning and provided with opportunities for language learning and social development (Klein, 1996;

Mundy, 2013; Vygotsky, 1978, as cited in Mundy & Sigman, 2006). This is especially relevant in parent-child dyads in children with ASD who show impairments in the processes that mediate and motivate orientation towards social targets (Chevailler et al., 2012; Jones & Carr, 2004;

Mundy, Sigman, Ungerer, & Sherman, 1986; Mundy & Sigman, 2006; Siller & Sigman, 2008;

Vismara &Lyons, 2007).

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Perhaps one of the most prominent and effective strategies to support and facilitate joint attention is the parents’ ability to “scaffold” the abilities of their infants well before their infants can demonstrate independent joint attention ability (Bruner, 1983; Danis, Bourdais, & Ruel, 2000;

Kaye, 1982, as cited in Mundy & Sigman, 2006). Scaffolding refers to a process by which a capable partner modifies a task based upon the emerging abilities of the child, or the child’s

“zone of proximal development” (Vygotsky, 1978). Parents can take advantage of the focus of interest of the child to stimulate social learning and development by interacting with the child around the shared focus of attention (e.g. such as making affective reactions or utterances towards the toy) by means of providing new information about the shared focus of attention (Adamson & Russell, 1999, as cited in Adamson et al., 2010; Mundy & Sigman, 2006).

Numerous empirical research highlights the role of parents scaffolding efforts towards children with ASD (Legerstee, Varghese, & Van Beek, 2002; Raver & Leadbeater, 1995; Roach, Barratt, Miller, & Leavitt, 1998; S. Landry, Smith, Miller-Loncar, & Swank, 1997, as cited in Mundy &

Sigman, 2006). A large amount of this research is discussed alongside with an interactive

approach formally known as parental responsiveness, which is characterized by reactions that are appropriate, timely, and contingent (Hasegawa, C. et al., 2015; Ruble, L., 2008; Watson, L., 2015, as cited in Crowell et al., 2019). For instance, a study of preschool children in a joint wordless picture book task concluded cohesive structuring by mothers was associated with preschool children’s social skills for both typical and children with ASD (Haven et al., 2014, as cited in Crowell et al., 2019).

Broadly speaking, parental responsiveness is associated with facial expressions, specifically more social smiling for all infants (Harker et al., 2017). A study of children’s high-risk siblings of ASD (HR) and typically developed children indicated the mothers of HR were more directive, that is, more skill focused and instructive compared to mothers of typically developing. When the mothers of HR toddlers were more directive, there was a decline in social smiling 9 months later (Harker et al., 2017; Nichols et al., 2014). Consistent with this, Patterson et al. (2014) found maternal responsiveness, in particular, behavior that follows the child’s lead predicted child- initiated joint attention, whereas mother-initiated joint attention was predicted by maternal directives in 2-3 year olds with ASD.

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More convincing research by Siller & Sigman (2002) concluded parents of young children with ASD synchronized their behaviors to their children’s focus of attention and activities as much as parents of children with typically developing children. More intriguing, parents of children with ASD who showed higher levels of synchronization not only developed better joint attention skills, but as well, language ability over a period of years than parents of children with ASD who exerted lower levels of synchronization. The strongest predictor of the child’s future gain in language skills was parents’ utterances that were synchronized but also undemanding (e.g., utterances that match the toy to which the child is engaged) (Siller & Sigman, 2002). This data coincides with language theories that acknowledge the role of adult’s in help shaping children’s social communication, an essential feature in joint attention (Bruner 1983, Tomasello, 1995, as cited in Akhtar & Gernsbacher, 2014).

Considering children with ASD experience a pronounced deficit in language acquisition, numerous interventions target joint attention behaviors mostly related to verbal communication (Schertz et al., 2013). However, research suggests parents of young children with ASD use a smaller proportion of verbal responses and more physical and object use towards their children with ASD in contrast to their typically developing children (Doussard-Roosevelt et al., 2003).

This finding supports the theoretical assumption that parents adjust their behaviors and employ preverbal forms of social communication (Schertz et al., 2013).

Coinciding with that, additional theorists argue interventions that focus on preverbal forms of social communication is perhaps more appropriate as they are developmentally closer to the child’s current capabilities and are viewed as a precursor for verbal language (Mundy, Sigman,

& Kasari, 1990). In fact, the efficacy of interventions targeting preverbal forms of social communication are widely replicated and reported, and often predict language competency (Bakeman & Adamson, 1984; Carpenter, Nagell, & Tomasello, 1998; Mundy, Sigman, & Kasari, 1990, as cited in Schertz et al., 2013). For instance, Schertz et al. (2013) examined the efficacy of the JAML, a parent-mediated approach which addresses preverbal communication, targeting four precursors of joint attention, such as focusing on faces (child looked once or more at the parent’s face), turn-taking (child performs one of at least two related actions in concert with a

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parent action), responding to joint attention (child alternated looks between parent’s face and object), and initiating in joint attention (alternative gaze with the purpose of drawing the parent’s attention to an object) in young children of ASD. Results indicated large effect sizes on focusing on face and responding to joint attention with significant time and treatment effects in contrast to modest effect sizes in turn-taking and in MSEL receptive and expressive language. This supports the theoretical argument that children with ASD are not only responsive towards parents’

preverbal forms of communication, but in addition understand and respond to simpler forms of preverbal communication (such as focusing on face in contrast to turn-taking) (Schertz et al., 2013). This argument is supported by Meindl & Cannella-Malone (2011) who indicated simple interventions that utilize basic physical prompting or conventional gestures tend to be more successful in RJA targeted interventions with children with ASD.

The empirical research presented thus far implies different modes of support displayed by parent’s influences joint attention development in typical children and children with ASD.

However, opposing research reveals children’s unique characteristics influence the type of support parents’ exercise. This sheds light into the theoretical transactional nature of parent-child relationships, which states both parent and child mutually influence one another (David &

Carter, 2008, Estes et al., 2013, Smith et al., 2008, Westman Andersson et al., 2017, as cited in Crowell et al., 2019). This is particularly relevant for parents of children with ASD, where Adamson et al. (2017) found measures of quality of parent scaffolding and follow-ins were significantly different for the children with ASD verses typically developed children. This is significant considering the particular strategies employed by parents with the intent of shaping their children’s behaviors can either promote or delimit child responses (Bell, 1971; Kasari, 1988, as cited in Kasari, Sigman, Mundy, & Yirmiya, 1988).

This is consistent with other findings that suggest parents of children with ASD spend more time attempting to elicit behaviors, initiate more frequently, and are generally more directive in their play perhaps as a strategy of increasing their children’s engagement in joint activities

(Cunningham, Reuler, Blackwell, & Deck, 1981; Eheart, 1982; Jones, 1977, as cited in Kasari, Sigman, Mundy, & Yirmiya, 1988). An explanation for these differences in parent behaviors includes parents are compensating for child behavior that is inadequate (Kasari, Sigman, Mundy,

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& Yirmiya, 1988; Harker et al., 2017; Patterson et al., 2014; Wan et al., 2013). Nonetheless, it is important parents of children with ASD employ joint attention behaviors that are most

appropriate to their child’s differentiated needs, that in turn, promote and enhance children’s learning and development.

2.7 Social-Cognitive Model of Joint Attention

With practice, parents of children with ASD become proficient at scaffolding differentiated actions to their children’s specific social interaction deficits and unique needs (Kasari, Sigman, Mundy, & Yirmiya, 1988). Practice effects of joint attention episodes not only effect parent support, but also influence’s children’s ability to effortless engage in joint attention

independently. In fact, the objective of parent support, such as scaffolding is the child may successfully complete the task and, in repetitions of this supported practice, come to perform these tasks independently (Vygotsky, 1978). The repeated practice of parent-child joint attention episodes enables cognitive modifiability, changes in cognitive structures in children that

ultimately help them become more capable at jointly attending to objects and events with parents independently (Feuerstein et al., 1979, Feuerstein, R. & Feuerstein, S., 1991, as cited in Tzuriel

& Weiss, 1998).

The Parallel and Distributed Processing Model (PDPM; Mundy et al., 2009) combines and expands on this notion, where children’s practice with the self, other, and object/event- referenced information processing during joint attention in infancy is affected by, and has an effect on distributed neural processing development. The repeated joint attention experiences provided by parents influences this distributed neural network, in that it enables effortless coordination of attention to external objects/events during social interactions.

Thus, the social coordination of overt aspects of visual attention embedded in early parent- child joint attention episodes provides information and experiences that promote the development of social coordination of more advanced aspects of attention (e.g., covert

attention), such as when social partners share attention to psychological phenomena including ideas, intentions, and emotions (Mundy et al., 2009; Mundy & Jarrold, 2010). This, in turn,

“…provides the basis for the development of coordinated attention to internal, cognitive

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representations of self and other which contributes to the foundation for symbolic thought and social cognition” (Mundy, Gwaltney, & Henderson, 2010, p. 410).

Research supports elements of the PDPM model wherein the development of joint attention from simple social communicative behaviors reflects an emerging understanding of others as

intentional agents that in turn contributes to an increase in intellectual development in typically developing children (Tomasello, 1995; Vygotsky, 1978, as cited in Gillespie-Lynch, 2013). For example, gaze direction experiments reveal 12-month-olds often follow the gaze direction of testers even if their eyes are closed. After 12 months, infants discriminate and follow the gaze of testers whose eyes are open, but not the gaze of testers whose eyes are closed. This suggests that upon joint attention exposure, infants’ understanding of the meaning of eye gaze of others improved (Brooks & Meltzoff, 2002).

A proposition of the PDPM model is that problems with the mutually exclusive cognitive processes involved, rather than processes from either domain alone may be the cause of joint attention impairments in children with ASD (Mundy, P., Gwaltney, M., & Henderson, H., 2010).

In agreeance, Courchesne & Pierce (2005) note children with ASD may be most vulnerable to complex cognitive developments and processes that require connectivity and integration of information across brain neural networks. Evidencesuggests young children with ASD appear to have more difficulty in social-cognition tasks, such as theory of mind, the ability to “mentalize,”

and imitation than other aspects of cognitive development (Baron-Cohen, 1995, Carpenter et al., 1998, Meltzoff & Brooks, 2008, Tomasello, 1995, as cited in Mundy & Jarrold, 2010).

Although a majority of research regarding PDPM highlights the association between deficits in IJA of children with ASD, certain social-cognitive processes emphasize the role of responding to the behavior of other people in the development of ASD (William, 2008, as cited in Van Hecke, Oswald, & Mundy, 2016). RJA is a particularly relevant concept for understanding social development and impairment because when a child follows a person’s attention shift, it can be argued that the child understands something about that person’s attention (Carptenter, Nagell, &

Tomasello, 1998, as cited in Sullivan et al., 2007). As stated in the PDPM, shared visual

attention is thought to be a principle skill on which social coordination with others is built, where

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experience is shared with others and shared meaning are negotiated. Practice effects of parent initiations provide learning opportunities for such coordination to occur (Mundy & Neal, 2001, Mundy et al., 1993, as cited in Mundy & Sigman, 2006). This is especially true in children with ASD who experience impairments in RJA and are likely to miss opportunities for social learning (Jones & Carr, 2004; Sullivan et al., 2007).

Since most young children with ASD experience deficits in social cognition and experience deficits in language skills, it is critical parents employ simpler, preverbal forms of

communication, such as conventional gestures as they are not too cognitively demanding and closer to the child’s developmental level (Mundy, Sigman, & Kasari, 1990). Such parental support is integral in children’s development, especially with parents of children with ASD in which meaningful, and appropriate learning opportunities are provided that nourish the development of several basic processes, in turn, scaffolds higher psychological process

development, ultimately leading to more sophisticated levels of joint attention in children with ASD (Corkum & Moore, 1998, Flom & Pick, 2003, Meltzoff & Moore, 1997, Mundy, 1995, Mundy et al., 2000, Trevarthen & Aitken, 2001, Wu, Kansaku, & Mark, 2004, as cited in Mundy

& Sigman, 2006).

2.8 Social Motivation Model

Intriguing, the PDPM not only provides the explanation of how the impairment of distributed neural processing network may have a robust effect on joint attention in relation to children with ASD, but also for related social symptoms (Mundy, Gwaltney, & Henderson, 2010).

Social motivation model theorizes the inclination of children with ASD to engage in joint attention interactions is influenced by a network of brain regions (Mundy & Sigman, 2006).

Mundy and Sigman (2006, as cited in Van Hecke et al., 2007) suggest social motivation may be associated with “…dimension of social competence that involves a tendency to express

agreeableness, interest in others, and positive emotions with peers, as well as adults” (p. 55).

Research suggests the systems and processes involved in social motivation are associated with neural processes related to understanding of social stimuli (e.g., facial affect), association of stimuli with positive reward value, and social orienting (Amador, Schlag-Rey, & Schlag, 2000;

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Eisenberger, Lieberman, & Williams; in press; Mundy 2003; Trevarthen & Aitken, 2001;

Wantanabe, 1996, as cited in Mundy & Sigman, 2006). Developmental scientists have shown there is an intrinsic motivation system in which children are predisposition to voluntarily orient to social stimuli, facial and vocal expressions of positive affect (Bard, Platzman, Lester, &

Hobson, 2002; Stern; 1985; Suomi, 1992; Trevarthen, 1979; Trevarthen & Aitken, 2001;

Valenza, Simion, Cassia, & Umilta, 1996, as cited in Mundy & Sigman, 2006). For example, Adamson and Bakeman (1985) have observed that from late in the first year through the second year, the exchange of positive affect becomes increasingly apparent and an essential component of infant-parent joint attention interactions in typically developing children.

However, early impairments in the brain’s reward circuitry in children with ASD reduce their motivation as they are not neurologically rewarded from social experiences (Chevallier et al., 2012; Vismara & Lyons, 2007). Existing research suggests young children with ASD

demonstrate a reduction to orient to the social world, and show a lack of social interest and understanding, marked by deficits in conventional gestures including showing, or pointing objects of interest (Charman, 1998; Mundy, 1995; Mundy & Crowson, 1997; Sigman & Kasari, 1995, as cited in Jones & Carr, 2004). Furthermore, eye-tracking experiments on children with ASD revealed impaired social orientation by looking more at the background than at the characters while watching static social photographs and being less responsive to social rewards such as verbal praise (Chevallier et al., 2012). Mundy and Gomes (1998, as cited in Jones &

Carr) conclude such behaviors are intentional, for social purposes that clearly involves the social motivation that truly defines the function of joint attention. Consequently, this impairment may create a negative feedback loop leading to fewer opportunities as they lack incentives to acquire social skills, such as joint attention and pragmatic language, ultimately depriving them of adequate learning opportunities (Jones & Carr, 2004).

The degree to which sharing an experience with another is rewarding for children with ASD varies from individual to individual, causing differences in the ability to engage in different types of joint attention skills, such as IJA, RJA, and IBR (Mundy & Sigman, 2006). For example, Kasari et al. (1990) incorporated ESCS ratings of joint attention with systematic ratings of facial

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effect and concluded children with ASD displayed equally low rates of positive affect (the extent to which a person experiences positive moods) in IJA and IBR, but not RJA.

The idea that sharing of positive affect experiences with others is affiliated with IJA, but not significantly RJA behavior in children with ASD suggests the two distinct forms of joint attention skills dissociate in the development of ASD (Mundy, 2013; Meindl & Cannella- Malone, 2011). Since RJA impairments are less evident for children with ASD who show more advanced levels of cognitive development, this implies RJA is relatively open to change, in which parents are responsible for RJA change and modification (Mundy & Sigman, 2006).

Though little evidence exists between the association of RJA and parent factors, Taylor & Hoch (2008) found intervention procedures that involve social reinforcements alone (e.g., adult

attending stimuli, defined as “visual indicators that the adult is aware of and attending to the item or event of interest” (Dube et al., 2004, p. 199, as cited in Taylor & Hoch, 2008) have found to be effective in targeting and increasing RJA in preschoolers with ASD for the purpose of social orientating, behaviors involving gaze alternation and pointing. However, it is not always the case that social contingencies alone function as a reinforcement or increase motivation for joint attention in children with ASD. Access to attending to stimulus through the means of tangible reinforcement may be required to maintain RJA bids.

A great deal of interventions examines the effectiveness of external contingencies in eliciting responses to joint attention in young children with ASD. For instance, the use of preferred objects employed by parents in learning opportunities has been found to increase the child’s intrinsic motivation to facilitate opportunities for social sharing (Gaylord-Ross, Haring, Breen, &

Pitts-Conway, 1984; R. L. Koegel, Dyer, & Bell, 1987, as cited in Vismara & Lyons, 2007).

Additionally, Doussard-Roosevelt et al., (2003) examined the different maternal approach characteristics that help elicit a social response in children with ASD and found nonverbal object approach (e.g., involved use of an object to engage in the child) to be most effective in

comparison to social cues (e.g., facial gestures or vocal cues) and physical approach (e.g., physical movement toward and/or contact with the child). Coinciding with what was mentioned earlier, this finding supports the theoretical assumption that children with ASD are more

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responsive towards parents’ nonverbal bids as they are closer to the child’s developmental abilities. Moreover, parents play an integral role in joint attention episodes, by providing

effective approaches of support that meet the differentiated developmental needs of their child.

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3.0 Methods

3.1 Study Design

The present study is based on data from the fourth measurement point (12-month follow-up) from a randomized controlled trial (RCT) design investigating short- and long-term effects of pre-school based social-communication treatment for children with autism (Kaale et al., 2014).

3.2 Study Participants

A total number of 45 mothers and 5 fathers participated in the present study, along with 50 children in total (N=50). The current study draws and expands upon the original RCT by Kaale et al. (2014) of 61 children who met the following criteria of (i) chronological age of 24-60 months, and (ii) ICD-10 diagnosis of childhood autism. Exclusion criteria includes obvious CNS

disorders (e.g. epilepsy, cerebral palsy), and non-Norwegian speaking parents. In addition to this, the present study excludes (i) four children under the chronological age of 48 months, (ii) four children being out of camera focus and tester interruption for equal to or more than one fourth of the video recordings (>200sec), (iii) two families who had moved during assessment process, and (iv) one mother whose back was against the camera for most of the video recording, making it difficult to code initiating bids.

In the original RCT (Kaale et al., 2014), diagnoses of childhood autism were set by a multi- disciplinary autism specialist center/CAMHC team, based on a comprehensive clinical evaluation (interviews and multiple observations by different professionals). A total of 49 children (80%) were tested with Autism Diagnostic Observation Schedule (ADOD) and/or Autism Diagnostic Interview-Revised (ADI-R). The remaining 12 children (20%) were tested through clinical assessment in the CHAMS (e.g. observation, interview with parents). Missing ADOS/ADI-R were due to site diagnostic practices, not child characteristics (Kaale et al., 2014).

Table 3.1 provides children characteristic information for the entire sample (N=50).

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Table 3.1 Children Characteristics

Mean/No.% SD Range Gender

Male 41 (82%)

Female 9 (18%)

Chronological Age 65.9 7.60 48-79

Intelligence Quotient (IQ)1 63.5 25.0 19-113 Receptive Language, raw scores2 36.7 19.5 3-65 Expressive Language, raw scores2 31.2 20.9 1-67 Children have one or more siblings 40 (85%)

Language between parent and child

Norwegian only 38 (36%)

Norwegian and one or more language 12 (24%)

1 based on Mullen Scales of Early Learning Scales (MSEL) and Stanford-Binet Intelligence Scales: Fifth- Edition (SB5), data missing for one child

2 based on Reynell Development Language Scales (RDLS)

3.3 Procedure

All measures including the tests of children’s language and cognitive level, and parent-child video recordings used in the present study were collected from Kaale et al. (2014) at data point four (12-month follow-up). They were conducted during one day at the local autism specialist center/CAMHC and administered by one of two experienced testers who were independent of the research group. Before the baseline assessment, the parents were asked to complete a

questionnaire on demographics. In the present study, recoding of videos was new, and conducted at the Oslo University Hospital, Oslo, Norway over a three-week period during the month of February, 2020. For recoding to occur, audio equipment such as a laptop and external drive were borrowed from IT services at University of Oslo. Recoding of the parent-child videos along with other instruments is described in further detail in the following section below.

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3.4 Instruments

3.4.1 Video Recording of parent-child interactions

In the original RCT by Kaale et al. (2014), ten-minute video recordings of parent-child play were used to assess joint engagement, child initiation of joint attention and some adult and children behaviors. The dyads were given the same standard set of toys, including a picture book, two phone toys, a car, building blocks, a ball, miniature figures, six large marbles, and a stuffed animal. The parents were instructed to play as they would typically do and encouraged to keep themselves and the child positioned towards the camera.

The present study draws upon the same video recordings but instead assesses parent initiations and child responses. This was achieved by recoding each play session into two following streams; identifying parent initiations and child responses. For the two streams, both joint attention (to share an interest or joy) and behavior regulation (to obtain) skills were measured.

A continuous coding strategy was employed where the coder (myself) was alert and recorded any occurrences of the targeted codes during the two streams (Chorney et al., 2015). Figure 3.1 displays a pen and paper coding scheme system with artificial data that was established by the master student (myself) and their supervisor containing targeted behaviors and scoring protocol.

Most of the operational definitions of the different joint attention behaviors used in the present study was adapted from the Early Social Communication Scales (ESCS, Mundy et al., 2003), a widely-used assessment of non-verbal joint attention behaviors. Validity and reliability of the ESCS is high, with intra-class reliability correlations coefficients ranging between 0.79 to 0.97 (Gillespie-Lynch et al., 2013; Mundy, Sigman, & Kasari, 1994; Wong, 2013). It has been used in studies of children with typical development and ASD (Chiang et al., 2008). Additionally, the coder was provided with a coding system created by Kaale (unpublished) to help generate

additional coding definitions. Further explanation of joint attention behaviors, along with general rules, examples and non-examples of targeted behaviors for coding of joint attention skills are presented in Appendix A.

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ID X

Date 25/02/20 Time

Parent Point

Child Response

Verbal Response

1:15 | | -

3:45 | - -

7:24 | | -

8:57 | | |

Total 4 3 1

Time

Parent Show

Child Response

Verbal Response

0:45 | | |

5:54 | | -

9:24 | | |

Total 3 3 2

Time

Parent Give

Child Response

Verbal Response

1:23 | | -

6:46 | - -

Total 2 1 0

Figure 3.1 Example of Data for Coding Scheme of Joint Attention Behaviors

Parent Initiations

For the first stream, the coder (myself) watched each of the 50-ten-minute parent-child play interactions and specifically coded for non-verbal parent initiation behaviors, including point, show, and give individually. The time together with a frequency score/count was recorded under the respective headings when parents exhibited any of the three joint attention behaviors at any given time. Table 3.2 refers to the following joint attention behaviors and coding definitions.

Child Responses

For the second stream, a similar procedure as parent initiations was applied however instead of watching the videos for the full 10 minutes, the coder fast-forward to all the time recordings for parent initiations of point, show and give, and then coded for child responses. All children were given a duration of 5 seconds to respond to parent’s bids. Therefore, if response exceeded over 5 seconds, it was not recorded and accounted for.

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First, a judgment was made as to whether the child responded to parent initiations according to the coding definitions described in Table 3.2. If the child did respond, it was counted and recorded under the heading “Child Response” for one of the following three parent initiations respectively. For instance, if the child responded to the parent initiation “point,” it was recorded under the “Parent point” sub heading. Both nonverbal and verbal responses constitute as a child response; the former includes following parent’s point, alternative gaze, and reach/grab/take behaviors; and the latter includes the child uttering “Ja,” “Nei” or something else in Norwegian in association during play.

All child verbal responses for each parent initiation respectively were counted and coded not only under the “Child Response” heading, as well as simultaneously under a separate heading named child “Verbal Response.” It is noteworthy to mention the utterance “Nei” was included as a verbal response because the child actively responds to the parent’s initiation, even though they may refuse to accept parent’s bid. The Norwegian utterances “Ja” and “Nei” translates to “Yes”

and “No” respectively in English. If the child did not respond to the following joint attention behaviors mentioned under “Non-verbal” and “Verbal” response in Table 3.2, it was marked with an “-”, signifying as no response.

Upon completing coding for the two streams, each parent-child dyad received a total/ sum score for each of the three parent initiations by counting the number of times a particular code was recorded (Chorney et al., 2015). For example, a total score for parent point, parent show, and parent give variables were tallied and recorded respectively. Then, the total scores for these three initiations added together computed the total parent initiation variable. The same rule of thumb was applied to the “Child Response” and child “Verbal Response” headings where child response and child verbal response scores to parent point, show, and give respectively were individually calculated and then added together to formulate the total child response and total child verbal response variables. Figure 3.1 displays the scoring protocol for the variables in the present study. The computations for total parent initiations, total child response, and total child verbal response were calculated via SPSS.

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The total child nonverbal response variable was calculated by the total child response variable subtracted by the total child verbal response variable and the total child no response variable was computed by the total parent initiations variable subtracted by the total child response variable.

Both variables were computed through SPSS. All computations were performed for each parent- child dyad. Table 3.2 mentions the variables which are in bold and their following definitions.

Table 3.2 Joint attention definitions for Parent initiations and Child responses

Parent Initiations

Point The parent points with their index finger to the toy. Includes distal pointing, manipulating the toy, or if either parent or child has toy possession. Child does not have to be

looking towards parent when pointing

Show The parent shows the toy by holding it at eye level, can be close to the child or parent’s face. Parent can be manipulating toy and child does not have to be looking towards parent.

Do not code if parent’s arm extends more than 90 degree angle

Give The parent gives by extending their arm (equal to or more than 90 degree angle) towards the child’s body. Includes child not having to hold or grab the toy. Child can hold or

grab the toy and give it back Child Responses

Non-Verbal Response includes the following three responses italicized below;

Following parents point. The child follows parent point by pointing or looking towards the point of reference. Do not code if child is playing with toy, then parent points to the toy but

child does not follow parents point of reference

Alternate Gaze. The child alternates looking at the toy either in their or parents hand and then the parent’s face

Reach/grab/takes. The child does either of these three behaviors, it can be out of reach Verbal Response The child says “Ja,” “Nei,” or something else in Norwegian to parent

initiations

No Response Everything that is not mentioned under Non-verbal Response described above

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The researcher (myself) was the only person who coded for the following joint attention

behaviors applicable for the study. Thus, the present study lacked testing of inter-rater reliability.

Inter-rater reliability, which emphasises the importance of having two or more raters/coders to ensure the data collected in the study are correct representations of the variables measured (McHugh, 2012). Assumptions of inter-rater reliability are met when two or more coders obtain the same scores on the same variables being measured. Hypothetically speaking, for the present study, two or more coders would have similar frequency counts for the three parent initiations respectively and the child nonverbal and verbal responses. Reliability is important in research as it represents the extent to which data collected in a study are correct representations of the variables measured (McHugh, 2012).

3.4.2 Demographics questionnaire

A questionnaire (Kaale, unpublished) was used to collect demographic information about the child and the family. Prior to baseline assessment parents were asked to give information

regarding age of child and their gender, number of siblings, ethnicity, and socio economic status including education level. Parent demographic was only included in the sample characteristic, not the core analysis. Table 3.3 provides parent demographics information for the entire sample (N=50).

Table 3.3 Parent Demographics

Mothers Fathers

Education level1

Advanced degree 10 (20%) 13 (27%)

Completed degree 13 (27%) 8 (17%)

Completed high school 13 (27%) 15 (32%)

Vocational 6 (12%) 6 (13%)

Completed elementary school 7 (14%) 5 (11%) Ethnicity

Norwegian 33 (66%)

Other 17 (34%)

1missing data for one mother; missing data for three fathers

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3.4.3 Language level

The Norwegian standardization of Reynell Developmental Language Scales (RDLS; Hagtvet &

Lillestøen, 1985) was used to assess receptive and expressive language skills. The RDLS has two 67 items scales; Verbal Comprehension and Expressive Language. The former includes

questions with regards to receptive language skills, such as understanding nouns, verbs, and prepositions. The child was required to follow the examiner’s directions referring to

representations of objects, people, and animals. Questions were organized in order of increasingly difficult where directions become more abstract and complex. The Expressive Language scale assessed three sets of items: structure (from vocalizations to the appropriate use of syntactic structure, vocabulary (naming of objects, actions, and concepts), and content (the use of language to describe elements and actions) (Snell, Hindman, & Belsky, 2015).

Due to coronavirus, the researcher could not attain the manual and thus only had access to the raw scores on the Reynell Developmental Scales (RDLS) for receptive and expressive skills.

However, the children’s language scores was only included in the sample characteristic not in the core analyses. Thus, it did not influence the interpretation of the results. Reliability in the

Reynell Scales is high, with the test developer reporting median split-half reliability coefficients of 0.87 for both (Reynell & Gruber, 1990, as cited in Snell, Hindman, & Belsky, 2015). In Norway, it has been standardized and used in research and clinical practice for over 30 years with a high degree of reliability (Cameron, 2020).

3.4.4 Development abilities

Mullen Scales of Early Learning (MSEL; Mullen, 1997) is an individually administrated, norm- referenced measure that assesses four scales; visual perception, fine motor, receptive, and expressive language skills for children from birth to 68 months. T-scores (with a mean of 50 and a standard deviation of 10) were collected for the individual scales, and an Early Learning Composite which serves to provide an overall estimate of cognitive functioning. The MSEL included items where 1 indicated a correct response and 0 indicated an incorrect response.

Additional items included a 0-5 possible point range score, and on some items the task scores were summed to obtain the item score. The scale items were displayed in hierarchical order of difficulty, and scale administration was stopped after three consecutive wrong responses

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(Mullen, 1995, as cited in Bornman et al., 2018). In the original RCT by Kaale et al. (2014), forty-three children (70%) scored below the norm-referenced T-scores on one or more of the MSEL scales. Therefore, a developmental quotient (DQ/IQ) was computed based on the mental age on the four subscales divided by the chronological age.

Similarly, the Stanford-Binet Intelligence Scales: Fifth Edition (SB5; Roid, 2003) is an individually administrated test of cognitive abilities and intelligence, designed to assess

individuals between 2 and 85 years of age. The complete scale, the Full Scale IQ (FSIQ) consists of two subscales; Nonverbal (NVIQ) and Verbal (VIQ). Within the two subscales are five

subtests: The Fluid Reasoning (FR), Knowledge (KN), Quantitative Reasoning (QR), Visual Spatial Processing (VS), and Working Memory (WM). The Abbreviated Battery IQ (ABIQ) scale consists of two routing subtests (one verbal and one nonverbal) that are administrated first, in order to dictate the starting level for the Nonverbal (NVIQ) and Verbal (VIQ) tests (Coolican et al., 2008; Bain & Allin, 2005). In the original RCT, the Stanford-Binet Intelligence Scales:

Fifth Edition (SB5; Roid, 2003) was hand-scored using the technical manual.

Most of the children (78%) were tested with MSEL, but those scoring above the ceiling of MSEL were tested with SB5 (Kaale et al., 2014). In other words, when children were tested on one or more of the subscales on MSEL, they did not obtain three consecutive items where they received a score of 0. Therefore, this implies certain children may have mastered the more difficult tasks, resulting in a ceiling effect where children would achieve or be close to the highest possible score, such as a score of 1. On the contrary, if children gained three consecutive scores that were > 1, it suggests children did poorly on the task due to the items on a test being too difficult. This is known as a floor effect, where most individuals would obtain or be close to the lowest possible score, such as score of 0 (Wamper et al., 2010). When conducting a study, it is essential for researchers take caution of the following effects as both limit the range of data, increasing skewness and reducing variability (Cumming & Calin-Jageman, 2017).

Reliability of the Standard-Binet Intelligence Scales; Fifth Edition is strong, with average internal consistency reliabilities in the range of 0.91 to 0.98 at the full-scale (FSIQ). Concurrent validity evidence is strong with a reported correlation of 0.90 between the SB5 FSIQ and the

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SB4 Composite (Roid, 2003; as cited in DiStefano & Dombrowski, 2006). Additionally, reliability for the Mullen Scales for Early Learning (MSEL) is generally good, with an internal consistency ranging from 0.75 to 0.83 for the subtests and 0.91 for the overall Early Learning Composite. Construct and concurrent validity in MSEL is also reported to be good (Martin et al., 2007). Similar to RDLS, children’s cognitive ability scores was only included in the sample characteristic not in the core analyses. Thus, it did not influence the interpretation of the results.

3.5 Statistical Analyses

The purpose of the study was to investigate the frequency of parent initiations and children responses as well as the relationship between these behaviors; the former with descriptive statistics and the latter using correlation analysis, specifically Spearman’s rank correlation coefficient. Additionally, regression analysis was included in order to predict child responses based on parent initiations. All statistical analyses were done with SPSS 25.0.

The predetermined significance level, which in the present study is 0.05 is the criterion for deciding whether the results from the correlation and regression analyses are significant. If the p- value is less than p < 0.05, it is statistically significant. It indicates strong evidence for a

relationship between parent initiations and child responses, and parent initiations predicting child responses. This suggests there is less than a 5% probability that there is no relationship between parent initiations and child responses and parent initiations do not predict child responses. If the p- value is higher than 0.05, it is not statistically significant and indicates strong evidence for no relationship between parent initiations, and child responses and parent initiations do not predict child responses (Cumming & Calin-Jageman, 2017).

3.5.1 Descriptive Statistics

Descriptive statistics are ways of summarizing and organizing numerical data to make them more easily interpretable, including the mean (M), standard deviation (SD), range, skewness, and kurtosis (Colman & Pulford, 2008). The mean represents the sum of all the numbers in a variable divided by the amount of numbers of the variable. The standard deviation is a statistic that

measures the dispersion of a dataset relative to its mean. If the data points are further from the mean (and/or more spread out), a high deviation is apparent; whereas if the data points are closer

Parent initiations and child responses during interaction between children with autism spectrum disorder and their parents

Parent initiations and child responses during interaction between children with

autism spectrum disorder and their parents

Gunita Mudhar

Master Thesis

Master’s in Special Needs Education Department of Special Needs Education

Faculty of Educational Sciences University of Oslo

Parent initiations and Child responses during interaction between children

with autism spectrum disorder and their parents

Abstract

Preface

List of Abbreviations

Table of Contents

List of Tables and Figures

1.0 Introduction

1.1 Statement of Problem

1.2 Rationale for Study of the Problem

1.3 Statement of Purpose

2.0 Background

2.1 Autism Spectrum Disorder

2.2 Joint Attention

2.3 Joint attention and ASD

2.4 Joint Attention and Language

2.5 Joint Attention and Social Development

2.6 Caregiving/Scaffolding Model of Joint Attention

2.7 Social-Cognitive Model of Joint Attention

2.8 Social Motivation Model

3.0 Methods

3.1 Study Design

3.2 Study Participants

3.3 Procedure

3.4 Instruments

3.5 Statistical Analyses