Does Teaching Joint Attention Improve Language in Children With Autism Spectrum Disorder? Purpose The purpose of this review was to examine the effects of interventions targeting joint attention (JA) on language outcomes of children with autism spectrum disorder (ASD). Method Five databases were searched for studies meeting inclusion criteria for JA treatments. The articles were reviewed in ... Article
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Article  |   February 01, 2017
Does Teaching Joint Attention Improve Language in Children With Autism Spectrum Disorder?
Author Affiliations & Notes
  • Stacy S. Manwaring
    Department of Communication Sciences and Disorders, University of Utah, Salt Lake City, UT
  • Ashley L. Stevens
    Department of Educational Psychology, University of Utah, Salt Lake City, UT
  • Disclosures
    Disclosures ×
  • Financial: Stacy S. Manwaring has no relevant financial interests to disclose. Ashley L. Stevens has no relevant financial interests to disclose.
    Financial: Stacy S. Manwaring has no relevant financial interests to disclose. Ashley L. Stevens has no relevant financial interests to disclose.×
  • Nonfinancial: Stacy S. Manwaring has no relevant nonfinancial interests to disclose. Ashley L. Stevens has no relevant nonfinancial interests to disclose.
    Nonfinancial: Stacy S. Manwaring has no relevant nonfinancial interests to disclose. Ashley L. Stevens has no relevant nonfinancial interests to disclose.×
Article Information
Special Populations / Autism Spectrum / Part 1
Article   |   February 01, 2017
Does Teaching Joint Attention Improve Language in Children With Autism Spectrum Disorder?
Perspectives of the ASHA Special Interest Groups, February 2017, Vol. 2, 11-26. doi:10.1044/persp2.SIG1.11
History: Received August 8, 2016 , Revised November 1, 2016 , Accepted November 13, 2016
Perspectives of the ASHA Special Interest Groups, February 2017, Vol. 2, 11-26. doi:10.1044/persp2.SIG1.11
History: Received August 8, 2016; Revised November 1, 2016; Accepted November 13, 2016

Purpose The purpose of this review was to examine the effects of interventions targeting joint attention (JA) on language outcomes of children with autism spectrum disorder (ASD).

Method Five databases were searched for studies meeting inclusion criteria for JA treatments. The articles were reviewed in two phases: titles/abstracts followed by full text. This resulted in 21 studies meeting inclusion criteria. The authors independently extracted and coded key variables related to participants, study design, intervention, JA, and language outcomes.

Results Of the 21 studies, 17 were original studies and 4 reported on follow-up analyses. More than half reported utilizing a combined treatment approach to target JA that included behavioral and developmental strategies. Ten of the 20 studies that examined expressive language reported significant gains for the JA treatment group, with 4 of 10 reporting receptive language gains for the JA group.

Conclusions While the majority of studies to date have focused on expressive language, results of this review provide generally equivocal and moderate support for improvement in language outcomes for children with ASD receiving JA interventions. Continued research related to JA intervention delivered in community settings is needed to determine critical features that may lead to the greatest changes in language.

Children with autism spectrum disorder (ASD) vary significantly in their understanding and use of language. Although language impairments are not specific to ASD, they are common enough to warrant status as a specifier in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V; American Psychiatric Association, 2013). Early research on language outcomes in ASD indicated that more than half of children with ASD fail to acquire spoken language (National Research Council, 2001); however, more recent studies estimate that 25–30% of children with ASD remain minimally verbal (Tager-Flusberg & Kasari, 2013). A variety of factors, such as nonverbal cognition, imitation, and gesture use, have been found to predict language development in children with ASD (e.g., Luyster, Kadlec, Carter, & Tager-Flusberg, 2008; Thurm, Lord, Lee, & Newschaffer, 2007).
Joint attention (JA) has also been examined as a predictor of language, with substantial literature providing evidence of a strong relationship between JA and both receptive and expressive language development in children with ASD (for recent review see Bottema-Beutel, 2016). JA involves shared attention between at least two people on an object or event, with both people knowing they are attending to the same entity (Tomasello, 1995). Although exact definitions vary, JA behaviors can be divided into two separate but related classes: (a) responding to joint attention (RJA) and (b) initiating joint attention (IJA). RJA involves the child following another person's attentional directive (e.g., a child looks in response to a parent pointing to a dog while saying, “Look, a dog!”). IJA involves the child directing another person's attention through eye contact, gesture, and/or vocalization to share interest on an object (e.g., child points to a dog and looks between a parent and the dog as if to say, “Look! Do you see what I see?”).
JA typically emerges across the first year and a half of life (Bakeman & Adamson, 1984; Corkum & Moore, 1995) and is thought of as a prerequisite to spoken language. Deficits in JA are among the earliest indicators of ASD. Research indicates that protodeclarative JA (defined above) is specifically impaired in young children with ASD, even in contrast to requesting or imperative functions (Shumway & Wetherby, 2009), and is particularly important for the development of language in ASD (Carpenter & Tomasello, 2000; Charman et al., 2003; Mundy, Sigman, & Kasari, 1990; Sigman et al., 1999).
Given the consistent associations found between JA and language, researchers have developed a variety of interventions directly targeting JA. Many of these treatments specifically focus on young children, with a goal of enhancing language development during this critical period. Intervention strategies to teach JA have been broadly categorized as behavioral (utilizing traditional applied behavior analytic strategies) or developmental (incorporating developmental principles and sequences). In recent years, interventions have incorporated a combined developmental and behavioral approach. Termed “Naturalistic Developmental Behavioral Interventions (NDBI),” this combined approach includes interventions that “are implemented in natural settings, involve shared control between child and therapist, utilize natural contingencies, and use a variety of behavioral strategies to teach developmentally appropriate and prerequisite skills” (Schreibman et al., 2015, p. 2411).
Previous reviews have examined results of treatment studies as they relate to JA outcomes (e.g., Murza, Schwartz, Hahs-Vaughn, & Nye, 2016; White et al., 2011), with findings suggesting that targeting JA results in improved JA outcomes. Given the association between JA and language, we may assume that directly targeting JA will lead to improvements in language; however, to our knowledge, the literature has not been systematically reviewed to examine language-related outcomes of interventions targeting JA. The purpose of this review is to provide a synthesis of the collateral effects of JA treatments on language abilities of children with ASD.
Methods
To identify articles for inclusion, a search was conducted in five electronic databases (ERIC+Education Full Text, PsychInfo, CINAHL, PubMed, and Scopus) using the following parameters: joint attention or joint engagement and autis*  or Asperger*  or pervasive development* and language. Prior to the search, inclusion/exclusion criteria were determined. Inclusion criteria included: (a) peer-reviewed journal article written in English; (b) human participants with one group identified as having ASD (or at high-risk for developing ASD); (c) participants do not have hearing loss or visual impairment; (d) randomized controlled trial (RCT), quasi-experimental group design or single-subject experimental design with JA taught or targeted in intervention; and (e) a measure of receptive and/or expressive language. Searches were not restricted by date. For purposes of this review, the term “joint attention” needed to be directly identified in the article as one intervention component. Studies that did not explicitly state that JA was targeted were not included.
The search process for final study selection is outlined in Figure 1. Articles were reviewed by both authors independently in two phases (i.e., title/abstract followed by full text review) using Covidence systematic review software (2016) . Discrepancies among reviewers were resolved through consensus. Twenty-one studies met the inclusion criteria. Extraction and coding of the 21 articles were completed individually by both authors. Data were compiled on the following study characteristics: (a) age of participants, (b) design, (c) intervention characteristics, (d) type of JA taught (i.e., IJA, RJA), and (e) both JA and language outcomes.
Figure 1.

Study Selection Flow Chart.

 Study Selection Flow Chart.
Figure 1.

Study Selection Flow Chart.

×
Results
Summary of Included Studies
An overview of the 21 studies that met criteria for inclusion is provided in Table 1. Seventeen original studies are described below, along with participant and treatment characteristics from Kasari, Freeman, and Paparella (2006), since four studies that conducted follow-up analyses to Kasari et al. (2006)  were included in the final review.
Table 1. Summary of Study Characteristics.
Summary of Study Characteristics.×
Study Sample Size Mean Age in months Study Design Type of JA Taught Intervention JA Intervention Model Dosage (for Tx group) Time to follow-up
Casenhiser et al. (2013)  Tx: 25 Tx: 42.5 RCT IJA Developmental Individualized Developmental approach administered by clinician with caregiver consultation/coaching Two hrs/wk for 12 months, 15–20 min parent consult/session Post-tx (12 months)
Relationship-based vs. Community
Cnt: 26 Cnt: 46.4
Chang et al. (2016)  Tx: 38 Tx: 48.9 RCT RJA/IJA JASPER vs. Waitlist community control (usual preschool curriculum only) Combined developmental and behavioral approach with teacher consultation/ coaching Eight wks: Two 15 min coaching sessions/day for 4 wks then 2–3 days/wk 1 month post-tx
Cnt: 28 Cnt: 51.6
Drew et al. (2002)  Tx: 12 Tx: 21.4 RCT RJA/IJA Social-pragmatic joint attention focused parent training program vs. Local services Developmental approach using a parent training consultant model Three-hr home-visit every 6 wks. Parent trained to provide ~30–60 min of “set aside” time/day Post-tx (mean=12.3 months)
Cnt: 12 Cnt: 23.6
Gulsrud, Kasari, Freeman, & Paparella (2007)  a Tx: Tx: 42.7 RCT RJA/IJA Joint attention vs. Symbolic play Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) Post-tx
Cmp: 17 Cmp: 43.1
Gulsrud, Helleman, Freeman, & Kasari, (2014)  a , b Tx: 14 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 6 &12 months;
5 years
Cnt: 11 Cnt: 41.9
Cmp: 14 Cmp: 42.6
Jones et al. (2006)  Tx: 5 Range MBL probe RJA/IJA Joint attention instruction (RJA followed by IJA) Combined developmental and behavioral approach administered by teachers (Study 1) and parents (Study 2) Study 1: Pulled out from preschool for 1–4 sessions/day Varied
25–36
Study 2:1 session every 2–4 wks
Kaale et al. (2014)  Tx: 34 Tx: 47.6 RCT IJA Joint attention + Preschool vs. Preschool only Combined developmental and behavioral approach with teacher coaching Two 20-min sessions daily for 8 wks 12 months
Cnt: 27 Cnt: 50.3
Kasari, Paparella, Freeman, & Jahromi (2008)  a Tx: 20 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) 6 & 12 months
Cnt: 17 Cnt: 41.9
Cmp: 19 Cmp: 42.7
Kasari, Gulsrud, Freeman, Paparella, & Hellemann (2012)  a Tx: 15 42.0 RCT RJA/IJA Joint attention vs. Symbolic Play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 5 years
Cnt: 11
Cmp: 14
Kasari et al. (2014)  Tx: 30 Tx: 74.2 Sequential multiple assignment randomized trial RJA/IJA JASPER + Enhanced Milieu Teaching (EMT) vs. JASPER + EMT + Speech Generating Device Combined developmental and behavioral approach administered by clinician with parent training Range of 2–3 1-hr sessions/wk for 24 wks 12 weeks
Cmp: 31 Cmp: 77.3
Kasari et al. (2015)  Tx: 43 Tx: 30.7 RCT RJA/IJA JASPER Parent Mediated Model vs. Psychoeducational Intervention Combined developmental and behavioral approach administered by clinician with parent coaching Two 30-min sessions/wk for 10 wks 6 months
Cmp: 43 Cmp: 32.3
Landa et al. (2011)  Tx: 25 Tx: 28.6 RCT RJA/IJA Assessment, Evaluation, and Programming System (AEPS) + Interpersonal Synchrony vs. AEPS Combined developmental and behavioral approach provided by clinician with parent training/education Two and a half hrs/day, 4 days/wk for 6 months 6 months
Cmp: 25 Cmp: 28.8
Oosterling et al. (2010)  Tx: 36 Tx: 35.2 RCT IJA Focus Parent Training+Care-as-usual vs. Care-as usual; (Tx based on Drew et al. 2002) Developmental approach using a parent training consultant model Four weekly 2-hr sessions with parent groups; Individual 3-hr home visits every 6 wks for one year Post-tx (mean=15 months)
Cnt: 31 Cnt: 33.3
Paul et al. (2013)  Tx: 12 Tx: 42 Quasi-experimental IJA Milieu Communication vs. Rapid Motor Imitation Antecedent Combined developmental and behavioral approach administered by clinician; parent responsivity training Thirty-six 45-min sessions over 12 wks 2 wks; 3-6 months
Cmp: 10 Cmp: 51.6
Pollard et al. (2012)  Tx: 3 Range MBL across participants IJA Script Fading Behavioral approach administered by clinician Not reported 6 wks
48–84
Rogers et al. (2006)  Tx: 5 Tx: Range 29–57 Single subject (A-B-A) across participants IJA Denver Model Communication Curriculum vs. PROMPT Combined developmental and behavioral approach administered by clinician with parent training Twelve weekly 1 hr sessions by clinician; Daily 1 hr by parent at home Post-tx (12 wks from start)
Cmp: 5
Cmp: Range
20–65
Schertz et al. (2013)  Tx: 11 Tx: 24.6 RCT RJA/IJA Joint Attention Mediated Learning vs. Community Developmental approach administered using a parent-mediated tx model ~15 weekly home-based sessions; Parents spent 30 min/day 4 & 8 wks post-tx
Cmp: 12 Cnt: 27.5
Van der Paelt et al. (2016)  Tx: 30 Tx: 51.8 Non-RCT of Community intervention RJA/IJA Imitation/JA vs. Applied Behavior Analysis vs. Treatment as Usual Combined developmental and behavioral approach administered by clinician Total tx time mean=259 (102) min/wk Post-tx (6 months from start)
Cnt: 35 Cnt: 49.1
Cmp: 20 Cmp: 44.5
Vismara et al. (2013)  Tx: 8 Range MBL across participants RJA/IJA Early Start Denver Model parent model (via telehealth) Combined developmental and behavioral approach parent training/coaching provided to parents 12 weekly 1.5 hr sessions and three 1.5 hr monthly follow-up sessions 3 months
18-45
Whalen et al. (2006)  Tx: 4 50 MBL across participants RJA/IJA Joint attention training (RJA followed by IJA) Combined developmental and behavioral approach administered by clinician Phase 1: 3 wks Post-tx and 3-month follow-up
Phase 2: ~2 wks; mastery required before moving phases
Zercher et al. (2001)  Tx: 2 75.6 MBL across participants RJA/IJA Integrated Play Group Developmental approach with coaching provided to typical peers 8-10 tx sessions and 5 maint sessions (1/wk) 5 wk maint phase
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
Table 1. Summary of Study Characteristics.
Summary of Study Characteristics.×
Study Sample Size Mean Age in months Study Design Type of JA Taught Intervention JA Intervention Model Dosage (for Tx group) Time to follow-up
Casenhiser et al. (2013)  Tx: 25 Tx: 42.5 RCT IJA Developmental Individualized Developmental approach administered by clinician with caregiver consultation/coaching Two hrs/wk for 12 months, 15–20 min parent consult/session Post-tx (12 months)
Relationship-based vs. Community
Cnt: 26 Cnt: 46.4
Chang et al. (2016)  Tx: 38 Tx: 48.9 RCT RJA/IJA JASPER vs. Waitlist community control (usual preschool curriculum only) Combined developmental and behavioral approach with teacher consultation/ coaching Eight wks: Two 15 min coaching sessions/day for 4 wks then 2–3 days/wk 1 month post-tx
Cnt: 28 Cnt: 51.6
Drew et al. (2002)  Tx: 12 Tx: 21.4 RCT RJA/IJA Social-pragmatic joint attention focused parent training program vs. Local services Developmental approach using a parent training consultant model Three-hr home-visit every 6 wks. Parent trained to provide ~30–60 min of “set aside” time/day Post-tx (mean=12.3 months)
Cnt: 12 Cnt: 23.6
Gulsrud, Kasari, Freeman, & Paparella (2007)  a Tx: Tx: 42.7 RCT RJA/IJA Joint attention vs. Symbolic play Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) Post-tx
Cmp: 17 Cmp: 43.1
Gulsrud, Helleman, Freeman, & Kasari, (2014)  a , b Tx: 14 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 6 &12 months;
5 years
Cnt: 11 Cnt: 41.9
Cmp: 14 Cmp: 42.6
Jones et al. (2006)  Tx: 5 Range MBL probe RJA/IJA Joint attention instruction (RJA followed by IJA) Combined developmental and behavioral approach administered by teachers (Study 1) and parents (Study 2) Study 1: Pulled out from preschool for 1–4 sessions/day Varied
25–36
Study 2:1 session every 2–4 wks
Kaale et al. (2014)  Tx: 34 Tx: 47.6 RCT IJA Joint attention + Preschool vs. Preschool only Combined developmental and behavioral approach with teacher coaching Two 20-min sessions daily for 8 wks 12 months
Cnt: 27 Cnt: 50.3
Kasari, Paparella, Freeman, & Jahromi (2008)  a Tx: 20 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) 6 & 12 months
Cnt: 17 Cnt: 41.9
Cmp: 19 Cmp: 42.7
Kasari, Gulsrud, Freeman, Paparella, & Hellemann (2012)  a Tx: 15 42.0 RCT RJA/IJA Joint attention vs. Symbolic Play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 5 years
Cnt: 11
Cmp: 14
Kasari et al. (2014)  Tx: 30 Tx: 74.2 Sequential multiple assignment randomized trial RJA/IJA JASPER + Enhanced Milieu Teaching (EMT) vs. JASPER + EMT + Speech Generating Device Combined developmental and behavioral approach administered by clinician with parent training Range of 2–3 1-hr sessions/wk for 24 wks 12 weeks
Cmp: 31 Cmp: 77.3
Kasari et al. (2015)  Tx: 43 Tx: 30.7 RCT RJA/IJA JASPER Parent Mediated Model vs. Psychoeducational Intervention Combined developmental and behavioral approach administered by clinician with parent coaching Two 30-min sessions/wk for 10 wks 6 months
Cmp: 43 Cmp: 32.3
Landa et al. (2011)  Tx: 25 Tx: 28.6 RCT RJA/IJA Assessment, Evaluation, and Programming System (AEPS) + Interpersonal Synchrony vs. AEPS Combined developmental and behavioral approach provided by clinician with parent training/education Two and a half hrs/day, 4 days/wk for 6 months 6 months
Cmp: 25 Cmp: 28.8
Oosterling et al. (2010)  Tx: 36 Tx: 35.2 RCT IJA Focus Parent Training+Care-as-usual vs. Care-as usual; (Tx based on Drew et al. 2002) Developmental approach using a parent training consultant model Four weekly 2-hr sessions with parent groups; Individual 3-hr home visits every 6 wks for one year Post-tx (mean=15 months)
Cnt: 31 Cnt: 33.3
Paul et al. (2013)  Tx: 12 Tx: 42 Quasi-experimental IJA Milieu Communication vs. Rapid Motor Imitation Antecedent Combined developmental and behavioral approach administered by clinician; parent responsivity training Thirty-six 45-min sessions over 12 wks 2 wks; 3-6 months
Cmp: 10 Cmp: 51.6
Pollard et al. (2012)  Tx: 3 Range MBL across participants IJA Script Fading Behavioral approach administered by clinician Not reported 6 wks
48–84
Rogers et al. (2006)  Tx: 5 Tx: Range 29–57 Single subject (A-B-A) across participants IJA Denver Model Communication Curriculum vs. PROMPT Combined developmental and behavioral approach administered by clinician with parent training Twelve weekly 1 hr sessions by clinician; Daily 1 hr by parent at home Post-tx (12 wks from start)
Cmp: 5
Cmp: Range
20–65
Schertz et al. (2013)  Tx: 11 Tx: 24.6 RCT RJA/IJA Joint Attention Mediated Learning vs. Community Developmental approach administered using a parent-mediated tx model ~15 weekly home-based sessions; Parents spent 30 min/day 4 & 8 wks post-tx
Cmp: 12 Cnt: 27.5
Van der Paelt et al. (2016)  Tx: 30 Tx: 51.8 Non-RCT of Community intervention RJA/IJA Imitation/JA vs. Applied Behavior Analysis vs. Treatment as Usual Combined developmental and behavioral approach administered by clinician Total tx time mean=259 (102) min/wk Post-tx (6 months from start)
Cnt: 35 Cnt: 49.1
Cmp: 20 Cmp: 44.5
Vismara et al. (2013)  Tx: 8 Range MBL across participants RJA/IJA Early Start Denver Model parent model (via telehealth) Combined developmental and behavioral approach parent training/coaching provided to parents 12 weekly 1.5 hr sessions and three 1.5 hr monthly follow-up sessions 3 months
18-45
Whalen et al. (2006)  Tx: 4 50 MBL across participants RJA/IJA Joint attention training (RJA followed by IJA) Combined developmental and behavioral approach administered by clinician Phase 1: 3 wks Post-tx and 3-month follow-up
Phase 2: ~2 wks; mastery required before moving phases
Zercher et al. (2001)  Tx: 2 75.6 MBL across participants RJA/IJA Integrated Play Group Developmental approach with coaching provided to typical peers 8-10 tx sessions and 5 maint sessions (1/wk) 5 wk maint phase
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
×
The mean ages of participants ranged from 18 to 84 months. Ten studies were reported as RCTs, two quasi-experimental group design, and six single-subject experimental design. Of the 12 group design studies, 6 compared a group receiving JA intervention to a control group (e.g., community preschool program; Casenhiser, Shanker, & Stieben, 2013; Chang, Shire, Shih, Gelfand, & Kasari, 2016; Drew et al., 2002; Kaale, Fagerland, Martinsen, & Smith, 2014; Oosterling et al., 2010; Schertz, Odom, Baggett, & Sideris, 2013). The remaining studies compared outcomes from a JA intervention to a psychoeducational intervention for parents (Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015), rapid motor imitation antecedent (Paul, Campbell, Gilbert, & Tsiouri, 2013), or a combination of a control and a comparison group (Kasari et al., 2006; Van der Paelt, Warreyn, & Roeyers, 2016). In addition, one study compared two groups of children receiving the Assessment, Evaluation, and Programming System for Infants and Children (AEPS) curriculum, using a combined developmental and behavioral approach (Landa, Holman, O'Neill, & Stuart, 2011). AEPS includes goals for JA; however, one treatment group (Interpersonal Synchrony) received “many more orchestrated opportunities to respond to and initiate joint attention” than the comparison group (p. 16). Finally, one study compared a JA intervention with and without a speech generating device (SGD; Kasari et al., 2014). In this study, minimally verbal children with ASD were randomized to Joint Attention Symbolic Play (JASP) + Enhanced Milieu Teaching (EMT) with or without an SGD (used to model ≥ 50% of all spoken communication).
The six single-subject design studies examined a range of JA treatments. Two examined the Denver Model, a developmental approach and curriculum that utilizes a combination (naturalistic behavioral) of teaching strategies (Rogers et al., 2006; Vismara, McCormick, Young, Nadhan, & Monlux, 2013). Rogers et al. (2006)  compared the Denver Model communication curriculum to Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT), a neurodevelopmental approach for speech production disorders (Chumpelik, 1984). Vismara et al. (2013)  utilized a parent training model via telehealth. Other JA treatments included script fading (Pollard, Betz, & Higbee, 2012), an integrated play group with typically developing peer coaches (Zercher, Hunt, Schuler, & Webster, 2001), and systematic instruction of RJA followed by IJA (Jones, Carr, & Feeley, 2006; Whalen, Schreibman, & Ingersoll, 2006).
A range of interventions and treatment models were used to target JA. Eleven of the 17 original studies, as well as Kasari et al. (2006), targeted both RJA and IJA. The remaining six studies targeted IJA only. The majority of studies (n=13 of 17) included a parent or teacher training component. One study used a behavioral approach, five used a developmental approach, and 11 used a combined developmental and behavioral approach (along with Kasari et al. (2006) . Length of treatment ranged from five weeks to one year. Treatment dosage varied and was reported quite differently across studies. The time to follow-up ranged from immediately post intervention to five years.
Child Language Outcomes
Language outcomes are summarized in Table 2. Of the 21 studies, 10 measured both receptive (RL) and expressive (EL) language separately, and an additional 10 measured EL only. Three studies included a combined measure of receptive and expressive language, with two of those also measuring them separately. Language measures varied across studies, and included both broad and domain-specific (i.e., vocabulary) standardized measures, as well as spontaneous measures of language.
Table 2. Joint Attention and Language Outcomes.
Joint Attention and Language Outcomes.×
Study JA Outcome Language Outcome
Casenhiser et al. (2013)  IJA: JA > Control Receptive/Expressive Composite: No group differences (both groups improved) on standardized measure
Chang et al. (2016)  IJA: No group differences on semi-structured measure; JA > Control on teacher-child play interaction **Receptive: JA > Control on standardized measure
*Expressive: No group differences on standardized measure; JA > Control on spontaneous utterances during IJA episodes
Drew et al. (2002)  Not measured **Receptive: JA marginally higher than control on standardized measure (parent report) of vocabulary.
*Expressive: Significantly more children in JA group moved from nonverbal to single word or phrase speech (N = 7) than control group (N = 2); No group differences on standardized measure (parent report) of vocabulary
Gulsrud et al. (2007)  a IJA: JA > SP at final probe Expressive: No group differences on frequency of vocal/verbal responses made during probe activation.
Gulsrud et al. (2014)  a , b IJA: JA > SP & Control on growth rate of some IJA behaviors *Expressive: JA > Control on growth rate of standardized measure of vocabulary; JA and Comparison (SP) not significantly different
Jones et al. (2006)  RJA and IJA: Positive *Expressive: Positive (increase in phonemes and words produced during each JA opportunity)
Kaale et al. (2014)  IJA: JA > control Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Kasari et al. (2008)  a RJA: No group differences Receptive: No group differences on growth/rate of change on standardized measure
IJA: JA and SP > Control (JA and SP not different)
*Expressive: JA and SP > Control on growth/rate of change on standardized measure
Kasari et al. (2012)  a Not measured *Expressive: JA & SP > Control on standardized measure of vocabulary (no difference between JA and SP)
Kasari et al. (2014)  Not measured *Expressive: JA+Speech Generating Device > JA only on total spontaneous communicative utterances, total different word roots, and total number of comments on a natural language sample
Kasari et al. (2015)  IJA: No treatment effects Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Landa et al. (2011)  IJA: Trend toward significance for more frequent IJA in IS vs. non-IS Expressive: No group differences on standardized measure
Oosterling et al. (2010)  Not measured Receptive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary
Expressive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary; No group differences on direct observation of spoken language level
Paul et al. (2013)  Not measured Expressive: No group differences (both groups improved) on standardized measures (observation and parent report) of vocabulary; No group differences on standardized measure (parent report) of communication (Comparison but not JA group improved over time)
Pollard et al. (2012)  IJA: Positive Expressive: Mixed results on unscripted verbal statements during IJA bids
Rogers et al. (2006)  RJA: Mixed Receptive: Mixed for JA group and positive for Comparison group on standardized measure
Expressive: Mixed for both groups on number of words used per tx session; Mixed for JA group and positive for Comparison group on standardized measure
Receptive/Expressive Composite: Positive for JA group (mixed for Comparison) on standardized measure (parent report) of vocabulary
IJA: Mixed
Schertz et al. (2013)  RJA: JA > Control **Receptive: JA > Control on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Receptive/Expressive Communication: JA > Control on standardized measure (parent report)
IJA: No group differences
Van der Paelt et al. (2016)  RJA: No group differences Receptive: No group differences (both groups improved) on standardized measure
IJA: No group differences Expressive: No group difference (both groups improved) on standardized measure
Vismara et al. (2013)  IJA: Stable from baseline to intervention; Positive at follow-up **Receptive: Positive on standardized (parent report) measure of vocabulary
*Expressive: Positive on standardized (parent report) measure of vocabulary; Positive on functional verbal utterances during parent-child play activity
Whalen et al. (2006)  RJA and IJA: Positive at post-treatment; Mixed at follow-up *Expressive: Positive on spontaneous speech during language sample post-tx and follow-up (slight drops at follow-up)
Zercher et al. (2001)  RJA/IJA combined: Positive *Expressive: Positive on average number of verbal utterances directed to a peer
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
* Significant expressive language gains reported in JA intervention group
Significant expressive language gains reported in JA intervention group×
** Significant receptive language gains reported in JA intervention group
Significant receptive language gains reported in JA intervention group×
† Significant gains reported on composite measure of receptive/expressive language
Significant gains reported on composite measure of receptive/expressive language×
Table 2. Joint Attention and Language Outcomes.
Joint Attention and Language Outcomes.×
Study JA Outcome Language Outcome
Casenhiser et al. (2013)  IJA: JA > Control Receptive/Expressive Composite: No group differences (both groups improved) on standardized measure
Chang et al. (2016)  IJA: No group differences on semi-structured measure; JA > Control on teacher-child play interaction **Receptive: JA > Control on standardized measure
*Expressive: No group differences on standardized measure; JA > Control on spontaneous utterances during IJA episodes
Drew et al. (2002)  Not measured **Receptive: JA marginally higher than control on standardized measure (parent report) of vocabulary.
*Expressive: Significantly more children in JA group moved from nonverbal to single word or phrase speech (N = 7) than control group (N = 2); No group differences on standardized measure (parent report) of vocabulary
Gulsrud et al. (2007)  a IJA: JA > SP at final probe Expressive: No group differences on frequency of vocal/verbal responses made during probe activation.
Gulsrud et al. (2014)  a , b IJA: JA > SP & Control on growth rate of some IJA behaviors *Expressive: JA > Control on growth rate of standardized measure of vocabulary; JA and Comparison (SP) not significantly different
Jones et al. (2006)  RJA and IJA: Positive *Expressive: Positive (increase in phonemes and words produced during each JA opportunity)
Kaale et al. (2014)  IJA: JA > control Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Kasari et al. (2008)  a RJA: No group differences Receptive: No group differences on growth/rate of change on standardized measure
IJA: JA and SP > Control (JA and SP not different)
*Expressive: JA and SP > Control on growth/rate of change on standardized measure
Kasari et al. (2012)  a Not measured *Expressive: JA & SP > Control on standardized measure of vocabulary (no difference between JA and SP)
Kasari et al. (2014)  Not measured *Expressive: JA+Speech Generating Device > JA only on total spontaneous communicative utterances, total different word roots, and total number of comments on a natural language sample
Kasari et al. (2015)  IJA: No treatment effects Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Landa et al. (2011)  IJA: Trend toward significance for more frequent IJA in IS vs. non-IS Expressive: No group differences on standardized measure
Oosterling et al. (2010)  Not measured Receptive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary
Expressive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary; No group differences on direct observation of spoken language level
Paul et al. (2013)  Not measured Expressive: No group differences (both groups improved) on standardized measures (observation and parent report) of vocabulary; No group differences on standardized measure (parent report) of communication (Comparison but not JA group improved over time)
Pollard et al. (2012)  IJA: Positive Expressive: Mixed results on unscripted verbal statements during IJA bids
Rogers et al. (2006)  RJA: Mixed Receptive: Mixed for JA group and positive for Comparison group on standardized measure
Expressive: Mixed for both groups on number of words used per tx session; Mixed for JA group and positive for Comparison group on standardized measure
Receptive/Expressive Composite: Positive for JA group (mixed for Comparison) on standardized measure (parent report) of vocabulary
IJA: Mixed
Schertz et al. (2013)  RJA: JA > Control **Receptive: JA > Control on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Receptive/Expressive Communication: JA > Control on standardized measure (parent report)
IJA: No group differences
Van der Paelt et al. (2016)  RJA: No group differences Receptive: No group differences (both groups improved) on standardized measure
IJA: No group differences Expressive: No group difference (both groups improved) on standardized measure
Vismara et al. (2013)  IJA: Stable from baseline to intervention; Positive at follow-up **Receptive: Positive on standardized (parent report) measure of vocabulary
*Expressive: Positive on standardized (parent report) measure of vocabulary; Positive on functional verbal utterances during parent-child play activity
Whalen et al. (2006)  RJA and IJA: Positive at post-treatment; Mixed at follow-up *Expressive: Positive on spontaneous speech during language sample post-tx and follow-up (slight drops at follow-up)
Zercher et al. (2001)  RJA/IJA combined: Positive *Expressive: Positive on average number of verbal utterances directed to a peer
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
* Significant expressive language gains reported in JA intervention group
Significant expressive language gains reported in JA intervention group×
** Significant receptive language gains reported in JA intervention group
Significant receptive language gains reported in JA intervention group×
† Significant gains reported on composite measure of receptive/expressive language
Significant gains reported on composite measure of receptive/expressive language×
×
Expressive Language Outcomes
Ten of the 20 studies that examined EL reported significant gains for the JA treatment group (see Table 2), with three of these reporting on follow-up analyses to Kasari et al. (2006) . Six of the 10 were group studies, with the JA intervention group showing significantly greater improvement than controls on measures of spontaneous language (Chang et al., 2016; Drew et al., 2002), expressive vocabulary (Gulsrud et al., 2014; Kasari et al., 2012), or growth rate of language measured using a broad standardized measure (Kasari, Paparella, Freeman, & Jahromi, 2008). In addition, Kasari et al. (2014)  found that minimally verbal children receiving a JA intervention (JASP+EMT) paired with an SGD made significantly greater improvements on several measures of EL compared to children receiving the same JA intervention without an SGD.
The remaining studies reporting EL gains were single-subject design (n=4). These studies found that all children receiving the JA intervention improved on measures of spontaneous language (Jones et al., 2006; Vismara et al., 2013; Whalen et al., 2006; Zercher et al., 2001), with one study also reporting increases in expressive vocabulary (Vismara et al., 2013).
All 10 studies that found gains in EL in the JA intervention group targeted both IJA and RJA. Of the seven studies that measured IJA as an outcome, all reported increases in IJA. Four of these studies also examined RJA outcomes, with three reporting increases (Jones et al., 2006; Whalen et al., 2006; Zercher et al., 2001).
Receptive Language Outcomes
Of the 10 studies that measured RL (excluding receptive/expressive composites), four reported significant gains for the JA intervention group (see Table 2). Three of these studies were group design, with the JA group showing significantly greater improvement than controls on broad measures of RL (Chang et al., 2016; Schertz et al., 2013) and receptive vocabulary (Drew et al., 2002). The single-subject design study also found that all children receiving the JA intervention showed improvements on receptive vocabulary (Vismara et al., 2013). Three of these studies also reported gains in EL, described above (Chang et al., 2016; Drew et al., 2002; Vismara et al., 2013).
These four studies targeted both IJA and RJA, included children younger than 48 months, and utilized parents and/or teachers as the interventionists in a consultation model. Three of these studies measured JA as an outcome, with two reporting increases in IJA (Chang et al., 2016; Vismara et al., 2013) and one reporting increases in RJA but not IJA (Schertz et al., 2013).
Receptive/Expressive Language Composite Outcomes
Three studies utilized a composite measure of receptive/expressive language. One reported significantly greater gains in receptive/expressive communication for the JA group compared to a control group (Schertz et al., 2013). A second study reported positive gains in receptive/expressive vocabulary for all children receiving JA intervention compared to a comparison treatment group of PROMPT (Rogers et al., 2006).
Language Changes in Comparison Groups
Of the 17 original studies included in this review, six included a comparison treatment group (see Table 1). In relation to changes in EL, four of these studies reported that the JA and comparison treatment groups improved similarly (Kasari et al., 2015; Landa et al., 2011; Paul et al., 2013; Van der Paelt et al., 2016). One single-subject design study reported more positive gains on a standardized measure of EL in the comparison treatment group (PROMPT) compared to the children receiving the JA intervention (Denver Model), although the JA group showed more positive gains than the comparison group on a measure of receptive/expressive vocabulary (Rogers et al., 2006). Three of these six studies also measured RL. Two reported no group differences, with both the JA and comparison groups improving similarly (Kasari et al., 2015; Van der Paelt et al., 2016). One reported RL gains in the comparison group, with mixed findings in the JA group (Rogers et al., 2006).
In addition to the six studies just described, four follow-up studies to Kasari et al. (2006)  reported on a comparison group (symbolic play) in addition to a control group. These studies found no differences between the JA and symbolic play groups on EL or RL outcomes (although both groups improved significantly more than the control group).
Discussion
The purpose of this review was to examine language-related outcomes of interventions targeting JA in children with ASD. A total of 21 studies were included. Prior to discussing results, there are several limitations that should be considered. First, given the specific search methods utilized, not all treatment studies that have targeted JA were included. Related, definitions of JA are variable in the literature. This review was aimed at interventions targeting JA related to commenting (IJA) or responding to others' comments (RJA); however, definitions of JA in the included studies were sometimes unclear, and it was not possible to determine in all cases whether the type of JA targeted specifically focused only on protodeclarative vs. protoimperative forms. Second, language outcomes were analyzed in a subjective manner, such that we did not conduct analyses to determine the significance of the language outcomes based on the JA interventions, and effect sizes were not calculated. Third, other potentially important variables were frequently not reported on in the studies (e.g., pre-treatment language level, symptom severity, and socio-economic status), but could potentially be important contributors to the study results. Finally, studies were not assessed for risk of bias. The following discussion should be read in light of these limitations.
Overall, results suggest generally equivocal and moderate support for improvement in RL and EL outcomes for children with ASD receiving JA interventions. Half (10/20) of the studies that measured EL independently from RL reported gains in EL for the JA intervention group, while 40% (4/10) reported RL gains. While some JA treatment groups had significantly better language outcomes than control groups (e.g., community preschool), none had significantly better language outcomes than the comparison groups, such as children receiving symbolic play (Kasari et al., 2006) or rapid motor imitation (Paul et al., 2013) interventions. In the majority of cases, both JA treatment and comparison groups improved similarly, suggesting that a range of interventions are likely useful for improving language outcomes in children with ASD, with JA being one important component.
While examination of specific study characteristics may provide insight into studies with more positive language outcomes in the JA treatment group, the significant variation in the actual treatments, dosage, participants, study methodology, and lack of replication limit knowledge about the real-world application and effectiveness of these JA treatments. Despite these limitations, below we attempt to summarize the studies, and more specifically, intervention characteristics associated with better language outcomes.
All studies reporting gains in language (12 of 21) utilized interventions that targeted both RJA and IJA. No interventions targeted only RJA, and those targeting both did not explicitly compare growth in each aspect of JA as moderators or mediators of language outcomes. Results from a recent review suggest that RJA plays a significant moderating role in the development of both RL and EL (Bottema-Beutel, 2016). Given the potentially significant contribution of RJA to language development, it may be important for JA interventions to specifically target RJA.
Another common theme among studies reporting gains in language was the use of a combined treatment approach including both naturalistic/developmental and behavioral teaching techniques. Although it is not within the scope of this paper to review the details of the interventions, there appears to be significant overlap among differently labeled interventions with respect to specific behavioral and naturalistic strategies used. Also, findings suggest that both comprehensive treatment programs that include JA as one treatment component, as well as focused interventions that only target JA, have the potential to improve language outcomes; however, interventions and definitions of JA were not described well in some studies, limiting full understanding of the impact of specific intervention components. Despite the differences in treatment models, there were no significant differences in the language outcomes of the comprehensive treatments compared to the more focused interventions, suggesting that JA instruction may be incorporated into a comprehensive intervention, which may be a more feasible method for clinical practice.
Another important aspect of the interventions was the method for explicitly teaching JA. The focused JA intervention studies targeted JA skills through direct teaching and a hierarchical approach. For example, in Kasari et al. (2006), children were taught a variety of JA skills including coordinated joint looking, showing, giving to share, and pointing (initiating and following) to mastery (including a generalized context) before the next, more advanced skill was taught. Behavioral principles, including hierarchical prompting and positive reinforcement were used, as well as naturalistic milieu instruction. Similarly, two studies used a two-phase treatment targeting RJA prior to IJA (Jones et al., 2006; Whalen et al., 2006), during which children were required to meet mastery criterion for each behavior before a new, more advanced skill was taught. Both methods were grounded in the theoretical notion that JA skills can be broken down into smaller steps and taught systematically.
Conclusions
Findings from this review indicate significant variability across studies in JA interventions and associated language outcomes of children with ASD. Overall, slightly more studies examined and reported increases in EL than RL; however, there were a limited number of studies that measured RL. Although it is beyond the scope of this review to outline the details of the various JA interventions that resulted in language gains, the results have implications for speech-language pathologists and other providers working with young children with ASD. First, when developing a treatment program that includes targeting expressive and/or receptive language development, clinicians may consider first evaluating JA abilities. If a skill deficit is present, targeting both RJA and IJA, as needed depending on the individual child's JA profile, may be useful for promoting growth in language. In addition, results indicate that a combined approach that includes both naturalistic/developmental, as well as behavioral strategies to target JA skills, may result in greater language gains. This combined approach might entail, for example, following the child's lead/motivation to identify items of interest in natural settings, using a developmental framework while applying a variety of behavioral strategies (e.g., using a hierarchical approach to break down JA skills into smaller, sequential steps), and utilizing high levels of natural contingencies and positive reinforcement. Finally, while the majority of studies utilized lab-based methodologies, precluding generalization to community-based settings and interventionists, a small number of studies used a consultation or coaching model with parents or teachers in community- or home-based settings. Results from these studies suggest that involving parents and teachers in targeting JA skills may result in improved language outcomes, particularly for RL. Continued research in community settings is needed to determine the critical child and intervention characteristics that lead to change in language, and which children may benefit most from which interventions to maximize language outcomes for young children with ASD.
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Footnote
* denotes that the search included any additional terms (e.g., autism, autistic, Aspergers, etc).
denotes that the search included any additional terms (e.g., autism, autistic, Aspergers, etc).×
Figure 1.

Study Selection Flow Chart.

 Study Selection Flow Chart.
Figure 1.

Study Selection Flow Chart.

×
Table 1. Summary of Study Characteristics.
Summary of Study Characteristics.×
Study Sample Size Mean Age in months Study Design Type of JA Taught Intervention JA Intervention Model Dosage (for Tx group) Time to follow-up
Casenhiser et al. (2013)  Tx: 25 Tx: 42.5 RCT IJA Developmental Individualized Developmental approach administered by clinician with caregiver consultation/coaching Two hrs/wk for 12 months, 15–20 min parent consult/session Post-tx (12 months)
Relationship-based vs. Community
Cnt: 26 Cnt: 46.4
Chang et al. (2016)  Tx: 38 Tx: 48.9 RCT RJA/IJA JASPER vs. Waitlist community control (usual preschool curriculum only) Combined developmental and behavioral approach with teacher consultation/ coaching Eight wks: Two 15 min coaching sessions/day for 4 wks then 2–3 days/wk 1 month post-tx
Cnt: 28 Cnt: 51.6
Drew et al. (2002)  Tx: 12 Tx: 21.4 RCT RJA/IJA Social-pragmatic joint attention focused parent training program vs. Local services Developmental approach using a parent training consultant model Three-hr home-visit every 6 wks. Parent trained to provide ~30–60 min of “set aside” time/day Post-tx (mean=12.3 months)
Cnt: 12 Cnt: 23.6
Gulsrud, Kasari, Freeman, & Paparella (2007)  a Tx: Tx: 42.7 RCT RJA/IJA Joint attention vs. Symbolic play Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) Post-tx
Cmp: 17 Cmp: 43.1
Gulsrud, Helleman, Freeman, & Kasari, (2014)  a , b Tx: 14 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 6 &12 months;
5 years
Cnt: 11 Cnt: 41.9
Cmp: 14 Cmp: 42.6
Jones et al. (2006)  Tx: 5 Range MBL probe RJA/IJA Joint attention instruction (RJA followed by IJA) Combined developmental and behavioral approach administered by teachers (Study 1) and parents (Study 2) Study 1: Pulled out from preschool for 1–4 sessions/day Varied
25–36
Study 2:1 session every 2–4 wks
Kaale et al. (2014)  Tx: 34 Tx: 47.6 RCT IJA Joint attention + Preschool vs. Preschool only Combined developmental and behavioral approach with teacher coaching Two 20-min sessions daily for 8 wks 12 months
Cnt: 27 Cnt: 50.3
Kasari, Paparella, Freeman, & Jahromi (2008)  a Tx: 20 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) 6 & 12 months
Cnt: 17 Cnt: 41.9
Cmp: 19 Cmp: 42.7
Kasari, Gulsrud, Freeman, Paparella, & Hellemann (2012)  a Tx: 15 42.0 RCT RJA/IJA Joint attention vs. Symbolic Play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 5 years
Cnt: 11
Cmp: 14
Kasari et al. (2014)  Tx: 30 Tx: 74.2 Sequential multiple assignment randomized trial RJA/IJA JASPER + Enhanced Milieu Teaching (EMT) vs. JASPER + EMT + Speech Generating Device Combined developmental and behavioral approach administered by clinician with parent training Range of 2–3 1-hr sessions/wk for 24 wks 12 weeks
Cmp: 31 Cmp: 77.3
Kasari et al. (2015)  Tx: 43 Tx: 30.7 RCT RJA/IJA JASPER Parent Mediated Model vs. Psychoeducational Intervention Combined developmental and behavioral approach administered by clinician with parent coaching Two 30-min sessions/wk for 10 wks 6 months
Cmp: 43 Cmp: 32.3
Landa et al. (2011)  Tx: 25 Tx: 28.6 RCT RJA/IJA Assessment, Evaluation, and Programming System (AEPS) + Interpersonal Synchrony vs. AEPS Combined developmental and behavioral approach provided by clinician with parent training/education Two and a half hrs/day, 4 days/wk for 6 months 6 months
Cmp: 25 Cmp: 28.8
Oosterling et al. (2010)  Tx: 36 Tx: 35.2 RCT IJA Focus Parent Training+Care-as-usual vs. Care-as usual; (Tx based on Drew et al. 2002) Developmental approach using a parent training consultant model Four weekly 2-hr sessions with parent groups; Individual 3-hr home visits every 6 wks for one year Post-tx (mean=15 months)
Cnt: 31 Cnt: 33.3
Paul et al. (2013)  Tx: 12 Tx: 42 Quasi-experimental IJA Milieu Communication vs. Rapid Motor Imitation Antecedent Combined developmental and behavioral approach administered by clinician; parent responsivity training Thirty-six 45-min sessions over 12 wks 2 wks; 3-6 months
Cmp: 10 Cmp: 51.6
Pollard et al. (2012)  Tx: 3 Range MBL across participants IJA Script Fading Behavioral approach administered by clinician Not reported 6 wks
48–84
Rogers et al. (2006)  Tx: 5 Tx: Range 29–57 Single subject (A-B-A) across participants IJA Denver Model Communication Curriculum vs. PROMPT Combined developmental and behavioral approach administered by clinician with parent training Twelve weekly 1 hr sessions by clinician; Daily 1 hr by parent at home Post-tx (12 wks from start)
Cmp: 5
Cmp: Range
20–65
Schertz et al. (2013)  Tx: 11 Tx: 24.6 RCT RJA/IJA Joint Attention Mediated Learning vs. Community Developmental approach administered using a parent-mediated tx model ~15 weekly home-based sessions; Parents spent 30 min/day 4 & 8 wks post-tx
Cmp: 12 Cnt: 27.5
Van der Paelt et al. (2016)  Tx: 30 Tx: 51.8 Non-RCT of Community intervention RJA/IJA Imitation/JA vs. Applied Behavior Analysis vs. Treatment as Usual Combined developmental and behavioral approach administered by clinician Total tx time mean=259 (102) min/wk Post-tx (6 months from start)
Cnt: 35 Cnt: 49.1
Cmp: 20 Cmp: 44.5
Vismara et al. (2013)  Tx: 8 Range MBL across participants RJA/IJA Early Start Denver Model parent model (via telehealth) Combined developmental and behavioral approach parent training/coaching provided to parents 12 weekly 1.5 hr sessions and three 1.5 hr monthly follow-up sessions 3 months
18-45
Whalen et al. (2006)  Tx: 4 50 MBL across participants RJA/IJA Joint attention training (RJA followed by IJA) Combined developmental and behavioral approach administered by clinician Phase 1: 3 wks Post-tx and 3-month follow-up
Phase 2: ~2 wks; mastery required before moving phases
Zercher et al. (2001)  Tx: 2 75.6 MBL across participants RJA/IJA Integrated Play Group Developmental approach with coaching provided to typical peers 8-10 tx sessions and 5 maint sessions (1/wk) 5 wk maint phase
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
Table 1. Summary of Study Characteristics.
Summary of Study Characteristics.×
Study Sample Size Mean Age in months Study Design Type of JA Taught Intervention JA Intervention Model Dosage (for Tx group) Time to follow-up
Casenhiser et al. (2013)  Tx: 25 Tx: 42.5 RCT IJA Developmental Individualized Developmental approach administered by clinician with caregiver consultation/coaching Two hrs/wk for 12 months, 15–20 min parent consult/session Post-tx (12 months)
Relationship-based vs. Community
Cnt: 26 Cnt: 46.4
Chang et al. (2016)  Tx: 38 Tx: 48.9 RCT RJA/IJA JASPER vs. Waitlist community control (usual preschool curriculum only) Combined developmental and behavioral approach with teacher consultation/ coaching Eight wks: Two 15 min coaching sessions/day for 4 wks then 2–3 days/wk 1 month post-tx
Cnt: 28 Cnt: 51.6
Drew et al. (2002)  Tx: 12 Tx: 21.4 RCT RJA/IJA Social-pragmatic joint attention focused parent training program vs. Local services Developmental approach using a parent training consultant model Three-hr home-visit every 6 wks. Parent trained to provide ~30–60 min of “set aside” time/day Post-tx (mean=12.3 months)
Cnt: 12 Cnt: 23.6
Gulsrud, Kasari, Freeman, & Paparella (2007)  a Tx: Tx: 42.7 RCT RJA/IJA Joint attention vs. Symbolic play Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) Post-tx
Cmp: 17 Cmp: 43.1
Gulsrud, Helleman, Freeman, & Kasari, (2014)  a , b Tx: 14 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 6 &12 months;
5 years
Cnt: 11 Cnt: 41.9
Cmp: 14 Cmp: 42.6
Jones et al. (2006)  Tx: 5 Range MBL probe RJA/IJA Joint attention instruction (RJA followed by IJA) Combined developmental and behavioral approach administered by teachers (Study 1) and parents (Study 2) Study 1: Pulled out from preschool for 1–4 sessions/day Varied
25–36
Study 2:1 session every 2–4 wks
Kaale et al. (2014)  Tx: 34 Tx: 47.6 RCT IJA Joint attention + Preschool vs. Preschool only Combined developmental and behavioral approach with teacher coaching Two 20-min sessions daily for 8 wks 12 months
Cnt: 27 Cnt: 50.3
Kasari, Paparella, Freeman, & Jahromi (2008)  a Tx: 20 Tx: 43.2 RCT RJA/IJA Joint attention vs. Symbolic play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5–8 wk 6-hr/day preschool) 6 & 12 months
Cnt: 17 Cnt: 41.9
Cmp: 19 Cmp: 42.7
Kasari, Gulsrud, Freeman, Paparella, & Hellemann (2012)  a Tx: 15 42.0 RCT RJA/IJA Joint attention vs. Symbolic Play vs. Control Combined developmental and behavioral approach administered by clinician Pulled out 30 min/day (from 5-8 wk 6-hr/day preschool) 5 years
Cnt: 11
Cmp: 14
Kasari et al. (2014)  Tx: 30 Tx: 74.2 Sequential multiple assignment randomized trial RJA/IJA JASPER + Enhanced Milieu Teaching (EMT) vs. JASPER + EMT + Speech Generating Device Combined developmental and behavioral approach administered by clinician with parent training Range of 2–3 1-hr sessions/wk for 24 wks 12 weeks
Cmp: 31 Cmp: 77.3
Kasari et al. (2015)  Tx: 43 Tx: 30.7 RCT RJA/IJA JASPER Parent Mediated Model vs. Psychoeducational Intervention Combined developmental and behavioral approach administered by clinician with parent coaching Two 30-min sessions/wk for 10 wks 6 months
Cmp: 43 Cmp: 32.3
Landa et al. (2011)  Tx: 25 Tx: 28.6 RCT RJA/IJA Assessment, Evaluation, and Programming System (AEPS) + Interpersonal Synchrony vs. AEPS Combined developmental and behavioral approach provided by clinician with parent training/education Two and a half hrs/day, 4 days/wk for 6 months 6 months
Cmp: 25 Cmp: 28.8
Oosterling et al. (2010)  Tx: 36 Tx: 35.2 RCT IJA Focus Parent Training+Care-as-usual vs. Care-as usual; (Tx based on Drew et al. 2002) Developmental approach using a parent training consultant model Four weekly 2-hr sessions with parent groups; Individual 3-hr home visits every 6 wks for one year Post-tx (mean=15 months)
Cnt: 31 Cnt: 33.3
Paul et al. (2013)  Tx: 12 Tx: 42 Quasi-experimental IJA Milieu Communication vs. Rapid Motor Imitation Antecedent Combined developmental and behavioral approach administered by clinician; parent responsivity training Thirty-six 45-min sessions over 12 wks 2 wks; 3-6 months
Cmp: 10 Cmp: 51.6
Pollard et al. (2012)  Tx: 3 Range MBL across participants IJA Script Fading Behavioral approach administered by clinician Not reported 6 wks
48–84
Rogers et al. (2006)  Tx: 5 Tx: Range 29–57 Single subject (A-B-A) across participants IJA Denver Model Communication Curriculum vs. PROMPT Combined developmental and behavioral approach administered by clinician with parent training Twelve weekly 1 hr sessions by clinician; Daily 1 hr by parent at home Post-tx (12 wks from start)
Cmp: 5
Cmp: Range
20–65
Schertz et al. (2013)  Tx: 11 Tx: 24.6 RCT RJA/IJA Joint Attention Mediated Learning vs. Community Developmental approach administered using a parent-mediated tx model ~15 weekly home-based sessions; Parents spent 30 min/day 4 & 8 wks post-tx
Cmp: 12 Cnt: 27.5
Van der Paelt et al. (2016)  Tx: 30 Tx: 51.8 Non-RCT of Community intervention RJA/IJA Imitation/JA vs. Applied Behavior Analysis vs. Treatment as Usual Combined developmental and behavioral approach administered by clinician Total tx time mean=259 (102) min/wk Post-tx (6 months from start)
Cnt: 35 Cnt: 49.1
Cmp: 20 Cmp: 44.5
Vismara et al. (2013)  Tx: 8 Range MBL across participants RJA/IJA Early Start Denver Model parent model (via telehealth) Combined developmental and behavioral approach parent training/coaching provided to parents 12 weekly 1.5 hr sessions and three 1.5 hr monthly follow-up sessions 3 months
18-45
Whalen et al. (2006)  Tx: 4 50 MBL across participants RJA/IJA Joint attention training (RJA followed by IJA) Combined developmental and behavioral approach administered by clinician Phase 1: 3 wks Post-tx and 3-month follow-up
Phase 2: ~2 wks; mastery required before moving phases
Zercher et al. (2001)  Tx: 2 75.6 MBL across participants RJA/IJA Integrated Play Group Developmental approach with coaching provided to typical peers 8-10 tx sessions and 5 maint sessions (1/wk) 5 wk maint phase
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.
Note. Cmp = comparison; Cnt = control; IJA = initiating joint attention; JA = joint attention; MBL = multiple baseline design; RCT = randomized controlled trial; RJA = responding to joint attention; Tx = treatment.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), the original Joint Attention and Symbolic Play intervention study, which was not included in this review because language was not measured as an outcome. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
×
Table 2. Joint Attention and Language Outcomes.
Joint Attention and Language Outcomes.×
Study JA Outcome Language Outcome
Casenhiser et al. (2013)  IJA: JA > Control Receptive/Expressive Composite: No group differences (both groups improved) on standardized measure
Chang et al. (2016)  IJA: No group differences on semi-structured measure; JA > Control on teacher-child play interaction **Receptive: JA > Control on standardized measure
*Expressive: No group differences on standardized measure; JA > Control on spontaneous utterances during IJA episodes
Drew et al. (2002)  Not measured **Receptive: JA marginally higher than control on standardized measure (parent report) of vocabulary.
*Expressive: Significantly more children in JA group moved from nonverbal to single word or phrase speech (N = 7) than control group (N = 2); No group differences on standardized measure (parent report) of vocabulary
Gulsrud et al. (2007)  a IJA: JA > SP at final probe Expressive: No group differences on frequency of vocal/verbal responses made during probe activation.
Gulsrud et al. (2014)  a , b IJA: JA > SP & Control on growth rate of some IJA behaviors *Expressive: JA > Control on growth rate of standardized measure of vocabulary; JA and Comparison (SP) not significantly different
Jones et al. (2006)  RJA and IJA: Positive *Expressive: Positive (increase in phonemes and words produced during each JA opportunity)
Kaale et al. (2014)  IJA: JA > control Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Kasari et al. (2008)  a RJA: No group differences Receptive: No group differences on growth/rate of change on standardized measure
IJA: JA and SP > Control (JA and SP not different)
*Expressive: JA and SP > Control on growth/rate of change on standardized measure
Kasari et al. (2012)  a Not measured *Expressive: JA & SP > Control on standardized measure of vocabulary (no difference between JA and SP)
Kasari et al. (2014)  Not measured *Expressive: JA+Speech Generating Device > JA only on total spontaneous communicative utterances, total different word roots, and total number of comments on a natural language sample
Kasari et al. (2015)  IJA: No treatment effects Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Landa et al. (2011)  IJA: Trend toward significance for more frequent IJA in IS vs. non-IS Expressive: No group differences on standardized measure
Oosterling et al. (2010)  Not measured Receptive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary
Expressive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary; No group differences on direct observation of spoken language level
Paul et al. (2013)  Not measured Expressive: No group differences (both groups improved) on standardized measures (observation and parent report) of vocabulary; No group differences on standardized measure (parent report) of communication (Comparison but not JA group improved over time)
Pollard et al. (2012)  IJA: Positive Expressive: Mixed results on unscripted verbal statements during IJA bids
Rogers et al. (2006)  RJA: Mixed Receptive: Mixed for JA group and positive for Comparison group on standardized measure
Expressive: Mixed for both groups on number of words used per tx session; Mixed for JA group and positive for Comparison group on standardized measure
Receptive/Expressive Composite: Positive for JA group (mixed for Comparison) on standardized measure (parent report) of vocabulary
IJA: Mixed
Schertz et al. (2013)  RJA: JA > Control **Receptive: JA > Control on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Receptive/Expressive Communication: JA > Control on standardized measure (parent report)
IJA: No group differences
Van der Paelt et al. (2016)  RJA: No group differences Receptive: No group differences (both groups improved) on standardized measure
IJA: No group differences Expressive: No group difference (both groups improved) on standardized measure
Vismara et al. (2013)  IJA: Stable from baseline to intervention; Positive at follow-up **Receptive: Positive on standardized (parent report) measure of vocabulary
*Expressive: Positive on standardized (parent report) measure of vocabulary; Positive on functional verbal utterances during parent-child play activity
Whalen et al. (2006)  RJA and IJA: Positive at post-treatment; Mixed at follow-up *Expressive: Positive on spontaneous speech during language sample post-tx and follow-up (slight drops at follow-up)
Zercher et al. (2001)  RJA/IJA combined: Positive *Expressive: Positive on average number of verbal utterances directed to a peer
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
* Significant expressive language gains reported in JA intervention group
Significant expressive language gains reported in JA intervention group×
** Significant receptive language gains reported in JA intervention group
Significant receptive language gains reported in JA intervention group×
† Significant gains reported on composite measure of receptive/expressive language
Significant gains reported on composite measure of receptive/expressive language×
Table 2. Joint Attention and Language Outcomes.
Joint Attention and Language Outcomes.×
Study JA Outcome Language Outcome
Casenhiser et al. (2013)  IJA: JA > Control Receptive/Expressive Composite: No group differences (both groups improved) on standardized measure
Chang et al. (2016)  IJA: No group differences on semi-structured measure; JA > Control on teacher-child play interaction **Receptive: JA > Control on standardized measure
*Expressive: No group differences on standardized measure; JA > Control on spontaneous utterances during IJA episodes
Drew et al. (2002)  Not measured **Receptive: JA marginally higher than control on standardized measure (parent report) of vocabulary.
*Expressive: Significantly more children in JA group moved from nonverbal to single word or phrase speech (N = 7) than control group (N = 2); No group differences on standardized measure (parent report) of vocabulary
Gulsrud et al. (2007)  a IJA: JA > SP at final probe Expressive: No group differences on frequency of vocal/verbal responses made during probe activation.
Gulsrud et al. (2014)  a , b IJA: JA > SP & Control on growth rate of some IJA behaviors *Expressive: JA > Control on growth rate of standardized measure of vocabulary; JA and Comparison (SP) not significantly different
Jones et al. (2006)  RJA and IJA: Positive *Expressive: Positive (increase in phonemes and words produced during each JA opportunity)
Kaale et al. (2014)  IJA: JA > control Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Kasari et al. (2008)  a RJA: No group differences Receptive: No group differences on growth/rate of change on standardized measure
IJA: JA and SP > Control (JA and SP not different)
*Expressive: JA and SP > Control on growth/rate of change on standardized measure
Kasari et al. (2012)  a Not measured *Expressive: JA & SP > Control on standardized measure of vocabulary (no difference between JA and SP)
Kasari et al. (2014)  Not measured *Expressive: JA+Speech Generating Device > JA only on total spontaneous communicative utterances, total different word roots, and total number of comments on a natural language sample
Kasari et al. (2015)  IJA: No treatment effects Receptive: No group differences (both groups improved) on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Landa et al. (2011)  IJA: Trend toward significance for more frequent IJA in IS vs. non-IS Expressive: No group differences on standardized measure
Oosterling et al. (2010)  Not measured Receptive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary
Expressive: No group differences (both groups improved) on standardized (parent report) measure of vocabulary; No group differences on direct observation of spoken language level
Paul et al. (2013)  Not measured Expressive: No group differences (both groups improved) on standardized measures (observation and parent report) of vocabulary; No group differences on standardized measure (parent report) of communication (Comparison but not JA group improved over time)
Pollard et al. (2012)  IJA: Positive Expressive: Mixed results on unscripted verbal statements during IJA bids
Rogers et al. (2006)  RJA: Mixed Receptive: Mixed for JA group and positive for Comparison group on standardized measure
Expressive: Mixed for both groups on number of words used per tx session; Mixed for JA group and positive for Comparison group on standardized measure
Receptive/Expressive Composite: Positive for JA group (mixed for Comparison) on standardized measure (parent report) of vocabulary
IJA: Mixed
Schertz et al. (2013)  RJA: JA > Control **Receptive: JA > Control on standardized measure
Expressive: No group differences (both groups improved) on standardized measure
Receptive/Expressive Communication: JA > Control on standardized measure (parent report)
IJA: No group differences
Van der Paelt et al. (2016)  RJA: No group differences Receptive: No group differences (both groups improved) on standardized measure
IJA: No group differences Expressive: No group difference (both groups improved) on standardized measure
Vismara et al. (2013)  IJA: Stable from baseline to intervention; Positive at follow-up **Receptive: Positive on standardized (parent report) measure of vocabulary
*Expressive: Positive on standardized (parent report) measure of vocabulary; Positive on functional verbal utterances during parent-child play activity
Whalen et al. (2006)  RJA and IJA: Positive at post-treatment; Mixed at follow-up *Expressive: Positive on spontaneous speech during language sample post-tx and follow-up (slight drops at follow-up)
Zercher et al. (2001)  RJA/IJA combined: Positive *Expressive: Positive on average number of verbal utterances directed to a peer
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.
Note. JA = IJA = initiating joint attention; joint attention; RJA = responding to joint attention; SP = symbolic play.×
a Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.
Participants in these studies are from the pool of participants from Kasari et al. (2006), which was the original Joint Attention and Symbolic Play intervention study. See Kasari et al. (2006)  for details.×
b Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .
Participants in this study overlap with outcome data reported in Kasari et al. (2008)  and Kasari et al. (2012) .×
* Significant expressive language gains reported in JA intervention group
Significant expressive language gains reported in JA intervention group×
** Significant receptive language gains reported in JA intervention group
Significant receptive language gains reported in JA intervention group×
† Significant gains reported on composite measure of receptive/expressive language
Significant gains reported on composite measure of receptive/expressive language×
×
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