http://www.eipd.vcu.edu/html/copa_jointattention.html
 

Joint Attention and Social Referencing

Joint attention occurs when two people share interest in an object or event and there is understanding between the two people that they are both interested in the same object or event.

Joint attention should emerge around 9 months of age and be very well-established by 18 months of age.

Why are we concerned about joint attention when we work with children with autism?

• Because it provides a critical foundation for social, cognitive, and language development.
• Because this is something that is very hard for almost all children with autism to do.

An important distinction: requesting versus true joint attention:

When a child points to something he/she wants and shifts his/her gaze to the parent and then back to what he/she wants, the purpose is non-social. Children with autism are generally pretty good at this – they are pretty good at getting what they want.

When a child points to something, not because he/she wants it but because he/she wants to show it someone else, the purpose is a social one. This is the joint attention we want to develop. In general, children with autism are not interested in these kinds of social interactions.

When we think about joint attention, we think about it two ways:

1. the child responding to another person’s bid for joint attention – example: a parent and child are playing together. The parent looks at and points to a toy car and says “look at that car!” The child responds by following the parent’s gaze and point, and so looks at the car. At about 12 to 14 months of age, the child will start to check back with the parent, alternating his/her gaze between the car and the parent, confirming that they are both still attending to the car.
   -Responding is easier than initiating (initiating is described in the next example)
   
2. the child initiating joint attention – example: child is holding a toy. He/she uses gestures (points to the toy, holds up the toy) plus gazes (looks at the parent and then back at the toy as if to say to the parent “hey, look at my toy!”) to get the parent to look at the toy too. As the child gets a bit older, he/she may add a vocalization as an additional way to get the parent’s attention so the parent will look at the toy.
   -Some feel that the initiating of joint attention by the child is more important because it shows that the child is socially motivated. One of the core deficits for a person with autism is social motivation.

Social referencing is also very important. Social referencing is characterized by a child looking at the adult to see if the adult is watching them and what they are doing. The child might look at the adult as if to say “Look at me…I’m doing something great!” or to check to see if what they are doing is OK or safe.

Strategies

The research is just emerging with some very preliminary strategies to develop joint attention and social referencing in young children. We do know from the research (Young Exceptional Children, Volume 9, Number 3) that toddlers:

1. benefit from less structured and more naturalistic approaches than what might be used with older children with autism
2. learn most easily through play and interaction with the adults who are most important in their lives (their parents!).

Here some strategies to build toward establishing joint attention and social referencing:

Focus on faces/develop eye contact. To develop joint attention and social referencing, your child should be encouraged to look at you. For many children with autism, this is especially challenging. There are some who believe that working on eye contact should not be a goal for a child with autism. Others feel that it is important to try to work on this skill because so much information can be learned from a person’s face and because, in our culture, it is considered to be socially appropriate to look at others when talking with/interacting with them. Some parents have found success by:

• having their child wear sunglasses at first,
• holding up their hands at their eyes like they were looking through binoculars at the time when they want their child to look at them,
• trying different positions (maybe the child on his/her back, looking up from the floor),
• trying different distances (maybe your child can look at you from 5 feet away but not two feet away),
• putting stickers on their faces or wearing funny hats, and/or
• looking in the mirror together to get eye contact instead of having the child look directly at their face.

Some additional strategies:

• as much as possible, be at the child’s eye level. It is hard for kids to look up continually at adults – try looking up for a while and notice how your eyes get tired. Notice how much easier and how much more comfortable it is to look straight ahead.
• stand in your child’s line of sight
• hold objects up to your eyes when you give them to your child – two inches from your face, right in front of the bridge of your nose. Try this using exciting toys and objects – maybe a toy that spins or lights - to catch your child’s attention
• use an animated voice and exaggerated expressions
• when the child wants something from you, say “if you want the ____, look in my eyes” – but ONLY do this with objects that are not necessary for the child to have. For example, do not do this with the child’s drinks or meals. However, if it is something optional but desired by the child, like maybe a new toy or a small snack, try this.

Remember that it can be very hard for a child with autism to look at you and listen to you at the same time. It also may be hard for your child to look at you while you are holding or touching him or her because some children with autism cannot process multiple senses at the same time. So it might be that he/she will look at you once you have finished talking.

Every child is different and it may take some time to figure out when your child feels most comfortable looking at your face. Once the strategy is determined, work to increase the time your child will look at you.

Focus on play and turn-taking (much of this section is taken from James McDonald’s books). The work on eye contact, play and turn-taking could be done together so that there is a natural activity going on rather than just getting the child to look. Try to work toward a goal of keeping interactions going for at least ten minutes.

How will you know when you and your child are developing turntaking and becoming better and better play partners?

• your child will frequently and voluntarily try to play with you, initiating play more and more
• your child will stay in play with you for longer and longer periods of time. The number of turns each of you take will steadily increases. You will be taking turns with actions and words, sounds and/or gestures.
• your child will try to act and communicate like you
• your child will often prefer playing with you than playing alone
• your child’s play will begin to change and develop

Work on becoming play and turntaking partners with your child -

1. with objects (blocks, dolls, trucks, books, ball, toy house, coloring, etc.)
2. during the daily routine (getting dressed, riding in the car, getting ready for bed, taking a bath, looking in the mirror, etc.)
3. with you (gentle rough-housing games like playing “airplane” or ring around the rosey, pat-acake, tickling, peek-a-boo, making faces, hide and seek, etc.)

It is important to work on play and interactions in all three areas listed above!

The most important strategy: Matching – you do what your child does and say what your child says. Sometimes adults do and say things that are much too difficult for their child to say and/or perform and this can make it hard for the child to learn. When you match your child, you show that you accept your child and his abilities; this can build your child’s feelings of competence. Also, because you are doing what your child can already do, it is much easier for him to join in to play with you. This gives you the chance to build play and turntaking interactions and, over time, you should notice that your child is imitating you more. However, we don’t necessarily always want your child to simply copy exactly each thing you do – allow and be glad for creativity on the part of your child!

How to match your child:

1. play in the same activity as your child. Watch and then quietly join in. Children stay in interactions longer when they have some choice of what to do – so, when you let your child choose the activity and then you join in, the chances are that the play will last longer.
2. play as your child does – don’t be hesitant to act like a child when you play – move as your child moves, makes sounds the way your child makes sounds.
3. play as much or more than you talk (sometimes being quiet helps both you and your child focus more on the play)
4. use gestures, sounds and/or words like your child does. So, if your child is just learning to make sounds, use the same kinds of sounds and maybe add a word or two. If your child is using one word sentences, use one word sentences yourself – maybe sometimes add a second word.
5. when you talk, talk about things that have meaning for your child. Give a word to your child’s actions as you play (for example, if your child hits the drum, say “bang, bang, bang”)

When with your child and you wonder how to get an interaction going, remember this: when in doubt, imitate! And then wait.

When playing, try to:

1. take the same number of turns as your child (often adults take the most) – work to be a “balanced partner”
2. do something and then wait for your child to take a turn – imitate and then wait!!! Many children need some time to respond.
3. pay attention to the very smallest of behaviors (verbal and nonverbal) and respond to them as if your child was purposefully communicating with you. Example: your child is looking out the window. When your child looks out the window, stand beside him/her, look out the window yourself, point to something in the yard, and name it.
4. allow your child to control the choice of activity as much as you can in order to develop play and interactions
5. reduce as much as possible questioning and commanding your child and, instead, comment (but don’t comment too much). When an adult does too much questioning or commanding, it can make the child feel like the adult is in charge and also that the child must perform in some certain way that the adult wants. So, try to comment instead. Two examples: as your child picks up the ball, you say “ball.“ As your child looks at the doll in the bed, you say “dolly is sleeping.” When you comment, you are not putting any pressure on your child and you are showing your child how to talk. This helps play to be fun. Use questions and commands only when necessary.
6. respond more often to what your child does that is right than what he/she does that may be wrong (“water the flowers, not the weeds”). Right now you are focused on increasing interactions and so, as much as possible, accept what your child does as long as it is not hurtful to you, your child or to property.
7. be the most interesting thing in the room in order to keep the play going!

Once you have developed a play routine, change what you are doing slightly and see what your child does. Hopefully your child will imitate you and this will help you bring your child to the next level in play.

What do you do if you wait for your child to take a turn and he/she does not do anything?

1. give a signal (point or use any kind of exaggerated movement to get your child back into the interaction)
2. give a prompt (very light, friendly physical prompting of the action you desire – many children dislike being prompted and will participate to avoid the prompt)

What do you do when your child is ready to leave the interaction?

1. try to keep your child for one or two more quick turns (try gently holding your child if you need to) and then let your child do what he/she wants for a while. This teaches your child that staying a little more with people then allows him/her to get to do what he/she wants. This is an important social skill for children to learn.
2. remember to do everything you can to be more interesting than the things that may be distracting your child!

Focus on pointing.

Teach your child to comment (this is one way joint attention is initiated) by encouraging him/her to point to show an object of interest. Example: There is a toy truck. Shape the child’s fingers into a point, touch his/her pointed finger to the truck, and say “truck!”

Throughout the day, use the word “look” and then point to show objects of interest. When your child looks, bring the object back to you and you label it. Give your child the object to play with and join in the play too.

Point/touch what you are talking about rather than pointing to things across the room or even to things out of reach.

Move your finger from your child’s face to an object, saying “look.”

Hold a favorite toy that has some kind of on/off button. Prompt your child to point (even giving hand over hand guidance if you need to) and, once he/she points, make the toy work.

Take your child’s finger and point to pictures in a book as you say the name of the picture. Add sound effects and/or an exaggerated tone of voice to keep your child engaged.

Place a salient cue (for example, a ribbon) on your index finger that you use for pointing to draw attention to the pointing finger.

Cover up a favorite object with a cloth. Ask your child where it is. Point to show him/her that it is under the cloth. Have your child pull off the cloth (give some assistance if you need to) and then be very excited when he/she pulls the cloth off and point again to the object.

In a dark room, use a flashlight to point to favorite toys or people and label the objects as you shine the light on them.

Keep some favorite items out of reach so your child will have to point to show you what he/she wants.

Bring an object very close to your child’s face to gain attention, then lead the object back to its original place. Then prompt your child to look at it by labeling the object and pointing to/touching it.

Play with a toy together, like a toy car. Make sure you have his/her attention and then roll it away and point to it as it goes. Add a silly sound/motor sound as it moves away

When giving choices, have him/her point to the one he/she wants. If he/she just looks at the one he/she wants but does not point, give a physical prompt to help him/her point/touch the object.

This is a good strategy if your child likes music and dancing: Play favorite music and dance with your child. Intermittently stop the music and stop dancing. Prompt your child to point to the music (CD player, tape player, TV, whatever) in order to have the music and dancing start again. After a number of times, it is hoped that he/she will begin to point to the music to get it started again.

If he/she likes shopping/is interested in novel things, do a lot of pointing throughout shopping trips -pointing, touching, labeling and encouraging him/her to do the same. Many kids do a lot of reaching for things they want in stores so try to turn the reaching into pointing with you pointing too and labeling as you point.

If your child likes to play chase, pause when it is your turn to chase until your child looks back at you to see if you are coming

Focus on encouraging your child to shift attention from what he/she is playing with to what you have (in other words, helping your child respond to you when you show him/her something new – and then you both have your attention on the new object/toy together – joint attention!):

• first, as your child is engaged with a toy, you take your child’s hand and place it on a second toy. Both toys remain available to your child. What is hoped for is that your child will pay some attention to the second toy, even if he/she goes back to playing with the first.
  
  If your child does play with the second toy, you give your child some verbal praise. Try to be very animated – give a big “WOW” or make a silly face, etc. as just saying “good job playing with the blocks” might not be enough of a reinforcer.
  
  The natural consequence for joint attention and social referencing is that there is a social interaction between you and your child. However, we know that social interaction is not generally motivating for children with autism. So, we need to add whatever we can to the interaction to increase your child’s motivation to pay attention to what he/she is being shown. That is why you may need to be more animated when giving praise or having a positive reaction.
  
  If your child does not play with the second toy, you should gently physically prompt your child to play with it briefly and then give the animated verbal praise.
  
• second, do the same procedure as outlined above except, this time, hold the second toy in front of your child and tap on it to gain attention.
  
• third, do the same procedure as outlined above but do not take your child’s hand and do not tap on the second toy. Instead, say “look at the ____ I have.”

Focus on creating situations for your child to initiate a request for you to look at something that interests him/her. Try rearranging the environment, bringing in something new or different – anything to shake things up that might then encourage your child to want to get someone’s attention to then show what has changed.