This document summarizes research on the efficacy of early intervention for toddlers with autism spectrum disorders. It discusses how early intervention can improve social communication and pragmatic skills through a focus on joint attention. Several studies are examined that show parent-mediated intervention is effective at improving joint attention between parents and children with ASD. Interventions involve parents and teachers using toys, games, and activities to elicit responses to and initiation of joint attention. Long-term follow up studies found cognitive and communication improvements even after intervention ended, showing lasting benefits of early intervention for toddlers with autism.

1. The Efficacy of Intervention with Infants/Toddlers with Autism Spectrum Disorders
Ericka Dahlman
ComDis 481 Speech and Language Disorders

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The Efficacy of Intervention with Infants/Toddlers with Autism Spectrum Disorders
Intervention, or therapy, can have a long lastingeffect on an individual.Children,particularly with a learning
impairment, can potentially benefit from all types of intervention. Children on the Autism Spectrum face many challenges.
Autism Spectrum Disorder (ASD), as stated by Mayo Clinic,is “a serious neurodevelopmental disorder thatimpairs a child's
ability to communicate and interact with others.” This disorder involves limited repetitivebehaviors that can cause
impairment in multipleareas of functioning,especially socially.Around the age of 18 months, Autism can be detected,
however not often until the ages of 2 or 3. Many are skeptical on the effectiveness of intervention with toddlers with
Autism Spectrum Disorders,however with the aid of intervention, children with Autism will improvein their early pragmatic
skills and social communication functioningwith their parents.
Many are not aware of the specifics thatAutismentails. Autismspectrum disorder (ASD) and Autism aregeneral
terms for a group of complex disorders of brain development (Autism Speaks). As stated above, ASD impairs a child’s
communication skills;therefore ASD can be associated with an intellectual disability.The U.S. Centers for DiseaseControl
(CDC) identify “1 in 68 American children as on the Autism spectrum--a ten-fold increasein prevalencein 40 years.” This
statistic isconsidered to be explained by improved diagnosisand awareness. Children thatare diagnosed with Autism face
numerous difficulties.
One of the main difficulties children with Autism experience is impairmentin early pragmatics.Early pragmatics
consists of jointattention, gaze following,eye contact, and so on. If a child seems to be content on his or her own, may not
always respond to their name, or may not bringtoys to another person, absence of jointattention becomes apparent. The
ability to engage with others non-verbally and the ability to talk are connected. Jones, Carr,and Feeley state in Multiple
Effects of Joint Attention Intervention for Children with Autism, “Joint attention occurs when two people, for example a
young child and his or her parent, shareattentional focus on interesting objects and events in their environment,” (782).
Joint attention is a very important function becauseit focuses distinctly on social interactions with another person aboutan
object or experience in their environment. For children with Autism, impairment in jointattention is based on the deficits
related to the function of jointattention. Early intervention can focus on the deficits in jointattention and work to improve
that communication skill in children with Autism.
Intervention practices arederived from the field of Applied Behavior Analysis (ABA). ABA is a scientificapproach to
understandingbehavior and how the environment affects it; behavior refers to the actions and skills,environmentrefers to
influences (social or physical) thatcould potentially changethe one person’s behavior. ABA focuses on bringingpositive
changes in behavior.
Jones, Carr, and Feeley examined a few studies relatingto the intervention effectiveness in children with teachers
and parents. The researchers examined the intervention effectiveness with teachers. Teachers used discrete trial
instruction and pivotal response to observe initiatingjointattention and respondingto other’s jointattention cues. The
teachers used toys that were best to elicitjointattention and received results indicatingimprovement in jointattention
skills after the intervention. To continue the intervention, Jones et. al involved the parents of the children to expand the
jointattention. The parents used the same toys as the teachers, however when the toys were mastered, the parents

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incorporated additional toys and objects in natural activities. Results indicated parentinvolvement as a key component to
teaching jointattention.
Parent facilitated involvement is crucial for a child’sdevelopment. Increased jointengagement between caregivers
and toddlers with Autism improve development. In other intervention environments, the child may acquirea jointattention
skill butwill notassociateor generalize itto their natural environment, home. Kasari,Gulsrud,Wong,Kwon, and Locke
state that, “…parent-mediated models become an important consideration in teachingjointattention skillsto infants and
toddlers with Autism,” (1046). The researchers believemost parents are competent enough to improve their child’s joint
attention skills.Kasari et. al required an intervention consisting of 24 caregiver-mediated gatherings alongwith a follow-up
1-year later.Children and parents were divided into two groups:Immediate treatment group and waitlistcontrol group.
Behavioral and developmental procedures were used, alongwith targeted initiationsand responses of jointattention skills,
and jointattention skillswithin play based routines. Kasari et.al received results indicating thatthe immediate treatment
group made significantimprovements in targeted areas of jointattention engagement compared to the waitlistcontrol
group. Joint attention engagement between parent and child builds onto the parent-child relationship (Schertzand Odom,
2006).This parent-child relationship supports thechild’s challengeof accommodatingto a social world. Children can
cognitively develop and develop communication skillseasier and faster if they connect with the parent and form a parent-
child relationship.
Parent-mediated intervention techniques consist of activities,or strategies, to help the parents create their own
ideas that encourage their child to give the best response. Intervention activities,or strategies,areface-to-face, turn taking,
respondingto jointattention (parent’s initiative),and initiatingjointattention (child’s initiative) (Schertzand Odom, 2006).
Face-to-face activities,or strategies,area top focus with children with Autism, due to the challenges they have with eye
contact and social cues. Face-to-faceactivities includemirror play or vocal games such as Patty Cake. Another
communication challengechildren with Autism have is turn taking. Turn takingis a component of joi ntattention. Turn
takingactivities aregames such as Go Fish or Candyland.
Because parent-child relationship is crucial to a child’s communication development, therapists focus on the
responseand initiation of jointattention. The parent initiatingjointattention requires the child to respond to the joint
attention. Once some eye contact is given,parents aredirected to hold a toy closeto their face, and encourage the child to
look at their parents’ faceand the toy. Initiatingjointattention by the child occurs when the child alternates eye contact
between the toy or object and the parent’s face, but only if the child is tryingto drawthe parent’s attention to the toy or
object. During these play sessions,itis importantfor the child to enjoy interactingwith their parent (Schertz and Odom,
2006).The parent should incorporatenew activities with activities thechild already knows and enjoys. Although parent-
mediated intervention techniques can be effective, some believe there are limitationswith this strategy.
A question that arises iswhether or not 1 hour, or any specific timefragment, of weekly therapy can lead to lasting
changes in non-verbal children with Autism. Early intervention for children with ASD is correlated to cognitive, language,
and/or social improvements (Landa and Kalb,2012).Many areskeptical regardingthis ,due to the slightamount of
knowledge on the strength of these languageimprovements after early intervention. Rebecca Landa and Luther Kalb
examined forty-eight children receiving an evidence-based intervention lasting6-months.The researchers measured the
severity of Autism, cognitive, and communication ability in thechildren by using standardized measures of preintervention,

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postintervention, short-term and long-term follow-up. This study proved that early intervention in children with ASD has
significantimprovements in cognitive scores from pre- to postintervention. ASD severity reductions were also shown from
pre- to postintervention. Duringthe 6-month period after completing the intervention, the researchers did not observe
change in cognitiveand communication scores;however, significantincreases in ASD severity were observed (Landa and
Kalb,2012).The researchers gave a long-term follow-up period and detected a significantincreasein cognitiveand
communication scores.
Skepticismon the effectiveness of intervention with toddlers with Autism Spectrum Disorders is apparentin many
families.Some wonder why they, themselves, cannothelp their child on their own instead of placingthem in early
intervention. Research shows,however, that with the aid of intervention, children with Autism will improvein their early
pragmatic skillsand social communication functioningwith their parents. The earlier the diagnosisof Autismwith the early
placement in intervention will resultin earlier improvements in the child’s languageand communication skills.

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Annotated Bibliography:
Intervention in Infants/Toddlers with Autism
Oosterling,Iris,Visser,Janne, Swinkels,Sophie, Rommelse, Nanda, Donders, Rogier, Woudenberg, Tim, . . . Buitelaar,Jan.
(2010). Randomized Controlled Trial of the Focus Parent Trainingfor Toddlers with Autism: 1-Year
Outcome. Journal of Autism and Developmental Disorders, 40(12), 1447-1458.
This articlefocuses on the stimulation of jointattention and languageskillsthrough parent intervention. One of the
authors,Iris Oosterlingis affiliated with the Radboud University Nijmegen and focuses on research in psychiatry,primary
care, and clinical trialswithin AutismSpectrum Disorders.Janne Visser,also affiliated with the Radboud University
Nijmegen, focuses on Early Childhood Education,Parenting, parent-Child relationshipswithin AutismSpectrum Disorders.
Sophie Swinkels and Nanda Rommelse areaffiliated with the University Medical Center at St. Radboud Nijmegen and focus
on psychology and psychiatry of children. Rogier Donders is also affiliated with the University Medical Center at St. Radboud
Nijmegen, but focuses on epidemiology, diabetology and statistics.Jan Buitelaar is also affiliated with the Radboud
University Nijmegen and focuses on neurodevelopment. Oosterlinget. al examined language and jointattention skillsin
children aged 15 months with Autism Spectrum Disorder over a period of 12 months. The researchers sampleof children
totaled to 67. Oosterlinget. al required the parents to complete a Focus trainingon stimulatingjointattention and
languageskills.Researchers gaveassessments that tested developmental abilities and receptiveand expressivelanguage
skills.Results showed no meaningful differences based on the ‘intention to treat’ approach.However, Oosterlinget. al
observed slightimprovements of primary and secondary languagedevelopment in the experimental group than the control
group.
I found this articleon the Research@UWW databaseon the Andersen Library website. It was published in the Journal of
Autism and Developmental Disorders,which is a peer-reviewed scientific journal.This articleis useful to my review because
it includes research on early pragmatic skillsof children with Autism Spectrum Disorder and parent-mediated intervention
skills after completingintervention.
Landa, R., & Kalb,L. (2012).Long-term outcomes of toddlers with autismspectrum disorders exposed to short-term
intervention. Pediatrics, 130 Suppl 2, S186-90.
This articlefocuses on the long-term outcomes of toddlers with Autism Spectrum Disorder who received early intervention.
Rebecca Landa is affiliated with the Center for Autism, Kennedy Krieger Institute in Baltimore, Maryland and also Psychiatry
and Behavioral Sciences,The Johns Hopkins University School of Medicine in Baltimore, Maryland.Luther Kalb is also
affiliated with Psychiatry and Behavioral Sciences,TheJohns Hopkins University School of Medicine in Baltimore,Maryland.
Landa and Kalb examined the long-term outcomes of early intervention in children,aged 2, with Autism Spectrum
Disorders.The researchers study sampleconsisted of forty-eight toddlers with Autism Spectrum Disorders (ASD). The forty-
eight children received an evidence-based intervention lasting6-months. Severity of Autism, cognitive,and communication
ability were assessed by standardized measures of preintervention, postintervention, short-term and long-term follow-up.
The study proved significantimprovements in cognitivescores from pre- to postintervention. ASD severity reductions were
also shown from pre- to postintervention. Duringthe 6-month period after completing the intervention, cognitiveand

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communication scores did not change, however ASD severity increased significantly.Duringthe long-term follow-up period,
cognitiveand communication scores significantly increased.
I found this articleon the Research@UWW databaseon the Andersen Library website. It was published in the American
Academy of Pediatrics,which is a peer-reviewed scientific journal.This articleis useful to my review because itincludes
research on early pragmatic skillsand communication skillsof children with Autism Spectrum Disorder that have completed
an intervention program.
Kasari,Connie,Gulsrud,Amanda C., Wong, Connie, Kwon, Susan,& Locke, Jill.(2010).Randomized Controlled Caregiver
Mediated JointEngagement Intervention for Toddlers with Autism. Journal of Autism and Developmental
Disorders, 40(9), 1045-1056.
This articlefocuses on jointattention between caregivers and toddlers with Autism. One of the authors,Connie Kasari
obtains a Ph.D and is a professor of Psychological Studies in Education and Psychiatry atUCLA. Kasari isa foundingmember
of the Center for Autism Research and treatment and has actively been involved in Autism research for the past25 years.
Kasari ispublished on topics regardingsocial,emotional,and communication development and intervention in Autism.
Kasari Lab,founded and directed by Connie Kasari,has been actively involved in Autism research for over 25 years. Kasari is
one of the world’s leadingexperts in Autism research and treatment. Amanda Gulsrud is also affiliated with UCLA in the
Department of Psychiatry.Gulsrud’s research efforts focus on early identification and treatment of infants and toddlers
with Autism Spectrum Disorder.Gulsrud also conducts randomized controlled trails examiningjointattention,play,
engagement, and emotion regulation.Gulsrud has collaborated with Kasari on parent-mediated early intervention and
peer-mediated intervention in schools.Jill Lockeis currently affiliated with the Center for Mental Health Policy and Services
Research and the University of Pennsylvania and theCenter for Autism Research at The Children’s Hospital of Philadelphia.
Locke completed her doctorate in Educational Psychology atUCLA and has done research alongsideof Connie Kasari and
Amanda Gulsrud.Kasari et.al examined if jointattention intervention would resultin greater jointengagement between
caregivers and toddlers with Autism. The intervention consisted of 24 caregiver-mediated gatherings alongwith a follow-up
1-year later.Fifty-eight preschoolers with Autism were facilitated through interventionists in a laboratory setting.The
researchers’study used behavioral and developmental procedures, targeted initiationsand responses of jointattention
skills,and jointattention skillswithin play based routines.Results indicated thatimmediate treatment group made
significantimprovements in targeted areas of jointattention engagement compared to the waitlistcontrol group.The
immediate treatment group showed improvements in their responsiveness to jointattention.
I found this articleon the Research@UWW databaseon the Andersen Library website. It was published in the Journal of
Autism and Developmental Disorders,which is a peer-reviewed scientific journal.This articleis useful to my review because
it includes research on early pragmatic skillsin jointattention of children with Autism Spectrum Disorder and parent-
mediated intervention skills after completingintervention.

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Schertz, Hannah H., & Odom, Samuel L. (2007). Promoting Joint Attention in Toddlers with Autism: A Parent-Mediated
Developmental Model. Journal of Autism and Developmental Disorders, 37(8), 1562-1575.
This articlefocuses on promoting jointattention in toddlers with Autism that builds on the existingparent-child
relationship.Hannah Schertzobtains a Ph.D in Special Education atIndiana University Bloomington.Schertz has contributed
to research in jointattention in children with Autism. Samuel Odom is affiliated with the University of North Carolina at
Chapel Hill and focuses in Special Education and InclusiveEducation Research.Schertz and Odom examined jointattention
in three toddlers with early-identified Autismthrough a parent-mediated, researcher-guided intervention model. A baseline
strategy compared child performanceacross respondingand initiatingjointattention,focusingon faces,and turn-taking.
Results indicated that all threetoddlers improved performance and two toddlers showed repeated engagement in joint
attention.
I found this articleon the Research@UWW databaseon the Andersen Library website. It was published in the Journal of
Autism and Developmental Disorders,which is a peer-reviewed scientific journal.This articleis useful to my review because
it includes research on early pragmatic skillsin jointattention of children with Autism Spectrum Disorder through a parent-
mediated intervention.
Jones, Emily A., Carr,Edward G., & Feeley, Kathleen M. (2006). MultipleEffects of Joint Attention Intervention for Children
with Autism. Behavior Modification, 30(6),782-834.
This articlefocuses on the effectiveness of jointattention in school and athome of 5 children with Autism and expressive
languageand social-communicativecharacteristics.Oneof the authors,Emily Jones, is affiliated with Long Island University
and obtains a Ph.D and BCBA-D. Jones’ research involves the development and demonstration of interventions of early
emerging deficits in young children.Edward Carr was affiliated with State University of New York at Stony Brook and the
Developmental Disabilities Institute.Carr’s research involves examiningalternativeexplanationsfor self-injurious behavior
among individualswith Autism. Kathleen Feeley obtains a Ph.D from University of Minnesota and is affiliated with the
Center for Community Inclusion,where sheis the director.Feeley’s specialties includeAutismEducation, Down syndrome,
and InclusiveEducation.Jones,Carr, and Feeley, examined three studies regardingjointattention. The firststudy involved
preschool teachers demonstrating the effectiveness of discrete trial instruction and pivotal responsetrainingstrategies to
teach jointattention to 5 children with Autism. The second study involved parents of two of the fivechildren also teaching
jointattention at home and in the community. The third study involved improvements in expressivelanguageand social-
communicativecharacteristicsof the children with Autism. Results indicated that jointattention skillsimproved in study
one. In study two, results indicated parentinvolvement as a key component to teachingjointattention. Results showed in
study three, participants improved more similarly to their peers in social-communicativecharacteristicsand jointattention
behaviors.
A peer of mine at the University of Wisconsin-Whitewater offered me this article.Itwas published in Behavior Modification,
which is a peer-reviewed scientific journal.This articleis useful to my review becauseit includes research on early
pragmatic skillsin jointattention of children with Autism Spectrum Disorder and a parent-mediated intervention after
completing the intervention.

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References
Autism spectrum disorder.(n.d.). Retrieved March 24, 2016,from http://www.mayoclinic.org/diseases -conditions/autism-
spectrum-disorder/basics/definition/con-20021148
Jones, Emily A., Carr,Edward G., & Feeley, Kathleen M. (2006). MultipleEffects of Joint Attention Intervention for Children
with Autism. Behavior Modification, 30(6),782-834.
Kasari,Connie,Gulsrud,Amanda C., Wong, Connie, Kwon, Susan,& Locke, Jill.(2010).Randomized Controlled Caregiver
Mediated JointEngagement Intervention for Toddlers with Autism. Journal of Autism and Developmental
Disorders, 40(9), 1045-1056.
Landa, R., & Kalb,L. (2012).Long-term outcomes of toddlers with autismspectrum disorders exposed to short-term
intervention. Pediatrics, 130 Suppl 2, S186-90.
Oosterling,Iris,Visser,Janne, Swinkels,Sophie, Rommelse, Nanda, Donders, Rogier, Woudenberg, Tim, . . . Buitelaar,Jan.
(2010). Randomized Controlled Trial of the Focus Parent Trainingfor Toddlers with Autism: 1-Year
Outcome. Journal of Autism and Developmental Disorders, 40(12), 1447-1458.
Schertz, Hannah H., & Odom, Samuel L. (2007). Promoting Joint Attention in Toddlers with Autism: A Parent-Mediated
Developmental Model. Journal of Autism and Developmental Disorders, 37(8), 1562-1575.
What Is Autism? (n.d.). Retrieved March 24, 2016, from https://www.autismspeaks.org/what-autism