Measuring the earliest forms of communication

As you may have realized (with frustration!) by now, we have limited options for evaluating the expressive communication skills of children who are minimally verbal. Enter: the Communication Complexity Scale (CCS), designed to measure just that. Prior papers have described the development of the CCS and determined its validity and reliability, but in this study, we get to see it in action with a peer-mediated intervention.

First, a little bit about the tool. It’s a coding scale—not a standardized assessment—that can be used during observations. Because prelinguistic communication skills often take time to develop with this population, this tool helps us think about all the incremental steps along the way and accounts for the variety of communicative modes the children might use. It’s a 12-point scale following this pattern:

December+graphics.jpg

The researchers found that the CCS could measure improvement in overall communication complexity and behavior regulation for preschoolers with autism after a peer-mediated intervention (the same one we reviewed here!).

So far in the research, the CCS has only been used during structured tasks meant to elicit communicative responses (see the supplemental material), such as holding a clear bag with toys where the child can see it, but can’t access it independently. We know it's crucial to observe our students in natural communication opportunities, though, so we'd have to be a little flexible in using the CCS during unstructured observations. The scale could definitely be useful when describing communication behaviors during evaluations or when monitoring progress. Wouldn’t it be much more helpful to say “The child consistently stopped moving (i.e. changed her behavior) in response to the wind-up toy stopping” instead of “The child was not observed to demonstrate joint attention”? Using the CCS, we have new ways of describing those “small” behaviors that really aren’t small at all!

NOTE: This study crosses over our Early Intervention vs. Preschool cut-offs, with kids from 2 to 5 years old. So is published in our School-Age section, too!

Find links to the scale and score sheets, here.


Thiemann-Bourque, K. S., Brady, N., & Hoffman, L. (2018). Application of the communication complexity scale in peer and adult assessment contexts for preschoolers with autism spectrum disorders. American Journal of Speech-Language Pathology. doi:10.1044/2018_AJSLP-18-0054

“Try this at home” isn’t enough

The effects of coaching on teaching parents reciprocal imitation training

4.png

There is an ever-growing research base for parent-implemented interventions for children with ASD, and for good reason! We know that in order for children with autism to make progress, they need high treatment intensity. The most cost-effective, naturalistic way of reaching that treatment intensity is by teaching their parents how to use intervention strategies with their children on a daily basis. The other side of this coin, however, is that we also know that treatment fidelity is an important factor in child outcomes; how closely parents adhere to the intervention will impact their child’s progress.  

This study looked at how one-on-one coaching affected parents’ ability to implement an evidence-based intervention for their child with ASD, and how their use of the strategies impacted their child’s outcomes. The intervention taught to parents was reciprocal imitation training (RIT). RIT is a naturalistic developmental behavioral intervention (NDBI; Schreibman et al., 2015) that teaches young children with ASD to spontaneously imitate within a social interaction. It uses naturalistic behavioral strategies such as following the child’s lead, modeling, prompting, and reinforcement.  

Three parents and their children with ASD participated in this study. The parents attended a training where they learned all of the ins and outs of how to do the intervention. Then they went home and video recorded their attempts to use the strategies once per day. After a few weeks, a clinician came to their home and provided coaching on the strategies once per week for 6-7 weeks. The researchers then went through the recordings and measured both the parents’ use of the strategies over time and the children’s growth in imitation skills. They found that parents were able to implement RIT with high accuracy (yay!), but only after individualized coaching support. While some of the parents improved significantly after the initial training, they all needed a therapist to come to their house and coach them in order to master the strategies. The children in the study all increased their spontaneous imitation, but only after their parents became consistent and accurate with at least some of the components of the intervention.

This study extends our understanding of the importance of coaching parents on strategies rather than relying solely on verbal instruction or suggestions. Here we have data to show how these parents needed more than just verbal instruction; they needed live feedback and training in order to use the strategies accurately and consistently, and only then did child outcomes improve. Providing parents with active coaching provides parents with the tools needed in order to support their children’s social communication. 

Note: If you are interested in learning more about RIT, you can check out this article. And here is the measure that the researchers used to evaluate the parents’ use of the strategies.

 

Penney, A. & Schwartz, I. (2018). Effects of coaching on the fidelity of parent implementation of reciprocal imitation training. Autism. doi: 10.1177/1362361318816688.

And more...

  • Do you find the coaching model challenging? You’re not alone! Sometimes it can feel like scientists are telling us what to do without considering how challenging it is to implement their interventions in the real world. That’s why articles like this one are so exciting for practicing SLPs. These researchers interviewed early intervention SLPs about their experiences attempting to implement the coaching model. They gleaned insight from SLPs about their barriers, benefits, and experiences, and perspective. The bottom line? SLPs see the value in the coaching model, but need more and better training and ongoing support in order to be confident and competent in using it.

  •  Did you know that onomatopoeia (words that represent sounds, like “buzz”) are especially common in infant’s speech? Liang discovered that onomatopoeia are phonologically easier to recall, plan, and produce, which explains why infants acquire them at such a young age. The easiest forms for infants to produce are CV words like “moo”, and words with consonant harmony like “pop.”

  • When it comes to diagnosing autism, we all have two goals—to do it as early as possible, and to do it as quickly as possible, because both factors lead to the child receiving early intervention services sooner, and this is key. Mayes’ study showed that using the condensed version of a commercially available interview and checklist—the Short Form of the Checklist for Autism Spectrum Disorder—was just as effective at identifying toddlers and preschoolers with ASD as the full Checklist. I don’t know about you, but the idea of being able to reliably and accurately identify young children with ASD using 6 instead of 30 items is pretty encouraging news!

  • Reisinger et al. examined data on the vocalizations of 11 young boys with a diagnosis of Fragile X and their caregivers compared to peers matched by chronological age and developmental age.  They found that caregivers of children with Fragile X vocalized less often and took fewer conversational turns than caregivers of typically developing children, possibly contributing to a cycle of poor language development and a less than ideal language environment.

  • As EI providers, we’re always looking for new ways to support children with ASD through collaboration and coaching. Shire and colleagues’ recent study looked at training teaching assistants (TAs) to provide the play-based intervention, JASPER—Joint Attention, Symbolic Play, Engagement, and Regulation—to toddlers with ASD in an early intervention classroom. Through extensive coaching and support from a supervisor during the first year and assistance from group leaders during the second year, the TAs were able to effectively implement the JASPER program. And, the children showed the same level of improvement in joint attention during the first and second year of the study. But, play skills only significantly improved during year one, when the TAs were receiving the highest level of support. These results suggest that training TAs and other support staff to provide language intervention with children with ASD can be effective, but if we want long lasting effects, we may need to provide a high level of consistent support.

  

Douglas, S., Meadan, H., Kammes, R. (2019). Early interventionists’ caregiver coaching: A mixed methods approach exploring experiences and practices. Topics in Early Childhood Special Education. doi:10.1177/0271121419829899.

Liang, C.E. (2019). Phonological motivation for the acquisition of onomatopoeia: An analysis of early words. Language and Learning Development. doi:10.1177%2F0142723714550110.

Mayes, S. D. (2019). Assessing toddlers and preschool children using the checklist for Autism Spectrum Disorder. Infants & Young Children. doi:10.1097/IYC.0000000000000136.

Shire, S. Y., Shih, W., Ya-Chih, C., Bracaglis, S., Kodjoe, M., & Kasari, C. (2019). Sustained community implementation of JASPER intervention with toddlers with Autism. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-018-03875-0.

Reisinger, D. L., Shaffer, R. C., Pedapati, E. V., Dominick, K. C., & Erickson, C. A. (2019). A pilot quantitative evaluation of early life language development in Fragile X syndrome. Brain Sciences. doi:10.3390/brainsci9020027 

Imitation: a simple and powerful strategy for parents of toddlers at-risk for ASD

While we all know that involving parents in early intervention for toddlers with ASD is important, knowing where to start can be another matter altogether. What if there was one simple and effective strategy that we could teach parents right off the bat--one they could master easily with a big impact? Imitation might fit that bill.

Imitation is a strategy you already have in your toolbox: it’s as simple as copying what a child says or does. It’s been researched in different forms for decades, and it belongs to a family of strategies called “responsive” language strategies. Other responsive strategies include following the child’s interests, avoiding questions and directions, and responding to his communication attempts.

The great thing about imitation as a strategy is that it naturally incorporates many components of other responsive strategies. If a parent is imitating his child, then he is probably following his child’s interests, reducing the number of questions he asks, and paying more attention to how his child is communicating. If we teach parents to imitate, maybe we won’t need to explicitly teach the other responsive strategies!

These researchers did a small study in which they taught three parents of toddlers with ASD* to imitate their children’s actions, gestures, and words (the format of the sessions is fully described in the article!) Generally speaking, the sessions had these components:

  1. The therapist reviewed the parent’s questions or concerns that had come up since the previous session.

  2. The therapist explicitly taught the parent about why imitation is important and how to use it.

  3. The therapist played with the child and pointed out when she imitated the child.

  4. The parent played with the child while the therapist provided the parent with constructive coaching and feedback.

  5. The therapist summarized the session and answered the parent’s questions.

2.png

The results showed that all three of the parents were able to master the imitation strategy, and all three children made improvements in their social eye gaze. An extra cool bonus? As parents started imitating their children, the number of questions and directions they gave naturally decreased without the therapist explicitly instructing them to do so. Talk about getting some great bang for your buck! Imitation shows promise of being a simple and efficient “first strategy” to teach parents. 

*or suspected ASD

 

Killmeyer, S., Kaczmarek, L., Kostewicz, D., & Yelich, A. (2018). Contingent Imitation and Young Children At-Risk for Autism Spectrum Disorder. Journal of Early Intervention. doi:10.1177/1053815118819230.

Is early regression in autism a thing?

Short answer:

Sometimes!

Long answer:  

Note: What we’re talking about here = loss of language and other skills between 15 and 30 months of age in children with ASD (Barger et al., 2013).

First, it’s important to understand where data to answer this question comes from. Historically, it’s been from retrospective studies (parent report, home video). More recently, we’ve combined this with prospective studies (e.g. tracking infants at high familial risk of autism from birth, so you can measure as they grow!) The combination of the two is powerful, and has illuminated things not previously captured (e.g. declining visual attention in the first year for kids with ASD (Elsabbagh et al., 2013).

Second, what we’re measuring matters: skills slowly diverging from the typical path is different than a skill plateau, which is different than actual regression—and we have to keep this straight across studies. Also, how you measure it matters—for example, a decline in standard scores on tests over time could represent any of the previously-mentioned phenomena. Further, it’s likely that all three of these things exist in autism—it’s not a homogenous group! 

Finally, don’t forget that there are other conditions that are characterized by regression (e.g. Rett syndrome, Heller’s syndrome), and sometimes autism combined with something else (e.g. epilepsy) will show marked regression. So be aware that regression is associated with many childhood disorders.

But, yes, lots of studies point toward there being a notable group of children with autism who show true regression from infancy to toddlerhood. (Do any of you remember how there for a while we thought regression in autism wasn’t a thing, and the parents were wrong? Yeah… The parents weren’t wrong.)

Longer (and obviously the most thorough) answer:

Pearson, N. , Charman, T. , Happé, F. , Bolton, P. F. and McEwen, F. S. (2018). Regression in autism spectrum disorder: Reconciling findings from retrospective and prospective research. Autism Research, 11, 160–1620.

A bit more. We were chatting with Dr. McEwen about this article, and she had a helpful comment we wanted to share:

“…regression seems to occur gradually in some children, and a very slow loss of skills is likely to be harder to pick up than a sudden, dramatic loss of skills. The former might involve a gradual loss of social engagement, whereas the latter could be a child who suddenly loses language. So it's important for speech and language professionals to be aware that it's not just dramatic loss of language that they should be alert to.”

How gesture and word development intertwine in toddlers

We know that children with ASD have difficulty with gestures. If a child comes to us who doesn’t point to share attention, we have red flags waving in our heads. Children with ASD are delayed in their use of gestures, use them less frequently, and have a smaller repertoire. We also know that in typically developing children, gestures come before speech and predict later language abilities. Little research, however, has actually delved into what gesture development looks like in toddlers with ASD and how it relates to their overall language development. Does their gesture development follow a predictable sequence, and does that sequence match that of their TD peers? How are gestures and verbal language linked for toddlers with ASD?

These researchers examined the gesture development of 42 toddlers with ASD and found:

  • Toddlers with ASD’s gesture and language development followed a predictable path that mirrors typically developing peers. This path differed in one interesting and important way, though: typically developing children use pointing as a pre-verbal means of communication, but for many toddlers with ASD, pointing emerged after they began to use words.

  • For toddlers with ASD, as well as their TD peers, combining gestures with single words precedes and predicts when they will begin to use word combinations.

So what does this mean for us?

3.png

First, a point of caution: this study looked at the development of gesture use in toddlers with ASD, but this study design can’t tell us what causes what. Simply because combining words and gestures comes before phrase speech does not necessarily mean that teaching a child to combine words and gestures will result in a child using phrase speech. In order to make that claim, we will need a randomized controlled trial of an intervention that attempts to teach toddlers with ASD phrase speech through targeting gesture and word combinations.

Nonetheless, these findings lend some support to intervention approaches that follow typical development. If a child is not yet using words, targeting early gesture use may support intentional communication and first words. If a child is speaking but not combining his words and gestures together, targeting combining words and gestures may support the development of phrase speech. 

 

Talbott, M. R., Young, G. S., Munson, J., Estes, A., Vismara, L. A., & Rogers, S. J. (2018). The Developmental Sequence and Relations Between Gesture and Spoken Language in Toddlers With Autism Spectrum Disorder. Child Development. Advance online publication. doi: 10.1111/cdev.13203.

And more...

  • Dai et al. found that bilingual caregivers of children with ASD and DD can communicate with their children in both languages without adverse effect on their children’s language functioning. (Feel like you already knew that? Well here’s a citation for ya!)

  • Fusaroli et al. found that parents’ language complexity predicted the complexity of their toddler with ASD’s language four months down the road. This finding suggests that modeling grammatically rich and complex language for toddlers with ASD may benefit their language development (as opposed to over-simplified telegraphic speech). While we need an intervention study to tell us if that is truly the case, research has already demonstrated this for toddlers with language delays (which you can read about in a previous review here).

  • To get a better feel for how underserved and under-identified families access health information about development, Gallagher et al. conducted focus groups of parents of typically developing and children with disabilities who lived in an urban area and experienced low income and low literacy skills. The authors found that while these parents knew about a variety of sources of information, they experienced and reported barriers to health literacy resources (e.g., printed materials were too dense, or not literal enough). The parents in the focus groups offered suggestions for making developmental health information accessible to a more diverse audience. This is a good read if you are ever in a position to develop marketing or awareness materials.

  • EI SLPs sometimes encounter (and experience!) mom-guilt when serving families whose mothers work. This study was exploratory but offers us a bit of information we can share when the need arises. Laing and Bergelson found that 17-month-olds’ vocabulary measures of noun type and token did not differ significantly between toddlers of full-time working and stay-at-home mothers. Interestingly, toddlers who experienced mixed care (so their moms worked part time, or stayed home early and went back to work as their children got older), did have more noun types and tokens than kids who experienced one type of care.

  • McLeod et al. examined teacher–child interactions during Enhanced Milieu Teaching (EMT) sessions. All children in the study had DLD and attended Head Start. Two teacher inputs were linked to greater usage of target vocabulary words by children during EMT sessions: (1) following the child’s attentional or communicative lead and (2) providing vocabulary supports to teach or clarify the meanings of target words. We’ve written about parent-implemented EMT for children with DLD before. For more descriptive info about teacher input and child vocabulary go check out the article.

  • Can you screen “everybody” (e.g. via routine pediatricians’ checkups) and reliably catch autism early, between 14–36 months, without over-identification? Yes, probably! This meta-analysis by Sanchez-Garcia provides quantitative data in support of universal toddler screenings for ASD.

  

Dai, Y.G., Burke, J.D., Naigles, L., Eigsti, I.M., & Fein, D.A. (2018). Language abilities in monolingual- and bilingual- exposed children with autism or other developmental disorders. Research in Autism Spectrum Disorders. Advanced online publication. doi: 10.1016/j.rasd.2018.08.001.

Fusaroli, R., Weed, E., Fein, D., & Naigles, L. (2019). Hearing me hearing you: Reciprocal effects between child and parent language in autism and typical development. Cognition183, 1–18.

Gallagher, P. A., Greenberg, D., Campbell, J. M., Stoneman, Z., & Feinberg, I. Z. (2018). Early identification and connection to services among urban parents who have low income and low-literacy skills. Focus on Autism and Other Developmental Disabilities. Advance online publication. doi: 10.1177/1088357618794913.

Laing, C. & Bergelson, E. (2019). Mothers’ work status and 17-month olds’ productive vocabulary. Infancy, 24(1), 101–109.

McLeod, R.H., Kaiser, A.P., & Hardy, J.K. (2018). The relation between teacher vocabulary use in play and child vocabulary outcomes. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418812675

Sánchez-García, A.B., Galindo-Villardón, P., Nieto-Librero, A.B. et al. (2019). Toddler Screening for Autism Spectrum Disorder: A Meta-Analysis of Diagnostic Accuracy. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-03865-2.

Throwback (2009 & 2015): Speech delay? Language delay? Measuring it, and what’s common in toddlers with autism

For all the SLPs who work with younger children with autism (so ages 2–4), this one’s for you! The following is a review of two studies from the last decade that can help you understand and characterize the various expressive language profiles you may see in these children, as well as brainstorm therapy!

The first paper reports on a meeting of experts in early autism and language development. (NOTE: If you’re a science groupie who gets googly-eyes for big names, pop on over and look at the author list; #sofamous). The purpose of the group was to create a list of measures of the expressive spoken language of children with autism from 12 to 48 months of age. These benchmarks can be used in assessment (as part of a comprehensive assessment including parent report, natural language samples, and/or direct assessment), or to guide intervention.  

In the article, you’re provided with a chart (see Table 1) divided into “First Words (12–18 mos)”, “Word Combinations (18–30 mos)”, and “Sentences (30–48 mos)”. Then within each of those categories, you have measures for:

  • Phonology

  • Vocabulary

  • Grammar

  • Pragmatics

…and within each of those categories, the child must meet at least one marker, at minimum, to be placed within that category.  

So, for example, for the Sentences (30–48 mos): Phonology section, markers are:

  • 70%+ intelligible from a speech–language sample

  • Consonant inventory of at least 16–24 different consonants (75% correct), from a speech–language sample

  • Age equivalent score of at least 36 months on a standardized test (e.g. GFTA or other)

…and the child must meet the intelligibility criteria or the standardized test criteria in order to be considered as meeting that benchmark. 

Then, you’d look across the other measures to (so vocabulary, grammar, and pragmatics) to see where they fit in each of those categories. 

Overall, this provides a really nice way to consider data from multiple sources (and, importantly, to know which pieces of data to prioritize), and supports SLPs in describing the spoken expressive language of kids with ASD in a systematic fashion.

 

So, how do most kids with ASD perform with these benchmarks?

Aha! That’s what the next paper looked at.

The authors of this article evaluated over 100 kids ages 2–3 years old using the “Spoken Language Benchmarks” (what we just described! From the last paper.) They found:

Considering phonology, vocabulary/grammar, and pragmatics as three separate skill sets…

  • Most of the children’s lowest score was in pragmatics (of course, right?! They have autism…)

  • And the two most common profiles were:

    • phonology > vocabulary/grammar > pragmatics

    • phonology = vocabulary/grammar > pragmatics

    • See Table 3 for six other profiles observed, too! That table is really fascinating, seeing what’s most versus least common…

3.png

So let’s chat about this. Basically, they found that, “… phonology tends to be relatively intact for most individuals whereas pragmatic difficulties are nearly universal…” and “… in terms of pragmatics, 88% of the children fell into the Prelinguistic group, which reflects a developmental level of less than 12 months of age.”

Nearly half of the kids achieved higher phonology scores than vocabulary/grammar and pragmatics. So it’s an area of relative strength! And when we think about kids with ASD on our caseloads, I’m sure you can remember many kids fitting this profile—good speech skills, and expressive language and/or pragmatics not so much.

Overall, being able to weigh relative strengths of phonology, vocabulary, grammar, and pragmatics for our kids with ASD helps inform treatment, and also could be quite helpful in identifying which types of treatment tend to help which types of children with ASD in both clinical work and research.

 

Ellawadi, A.B., & Weismer, S.E. (2015). Using Spoken Language Benchmarks to Characterize the Expressive Language Skills of Young Children With Autism Spectrum Disorders. American Journal of Speech–Language Pathology, 24, 696–707.

Tager-Flusberg, H., Rogers, S., Cooper, J., Landa, R., Lord, C., Paul, R… Yoder, P. (2009). Defining Spoken Language Benchmarks and Selecting Measures of Expressive Language Development for Young Children With Autism Spectrum Disorders. Journal of Speech, Language, and Hearing Research, 52, 643–652.

Throwback (2011): Increasing sound production through imitation therapy

4.png

Imitation is the sincerest form of flattery. However, every SLP has worked with a child who simply doesn’t imitate. No matter how many times we blow raspberries, make animal noises, or wave our arms wildly, we are met with blank stares. Yet imitation during early development is a crucial building block to successful communication. 

This study looked at a systematic method for teaching nonverbal toddlers the skill of imitation. All children in the study were 18–19 months old, showed minimal babbling, did not imitate sounds, and did not produce any phonetically consistent forms. All of the children scored lower than the 2nd percentile on the PLS-3 or PLS-4 scores. Sounds like your typical El late talker, right?

Back in 1972, Zedler developed a therapeutic technique referred to as Technique Imitation Therapy (IT) for use with young children who did not develop language as expected. He believed that a child’s language development is dependent on the child’s awareness that his or her own behavior can affect others. The idea is that providing opportunities for the child to direct an adult’s attention and actions, the child will realize that their own actions can influence others. With reinforcement (as always), the child should eventually be able to learn how to imitate.  

In the present-day study, clinicians implemented Imitation Therapy with 18–19-month-old toddlers 2–4 times per week in 50 minute sessions, until the child spontaneously imitated verbalizations at least eight times in two consecutive sessions. This took between 16–18 sessions for the group of children, or approximately 8 weeks.

Imitation Therapy consists of four steps, starting with the adult serving as the sole imitator of everything the child does and says, until the child realizes that the adult is imitating him/her. Next, when the child begins to do some basic imitation of the adult, he is positively reinforced. Then, the adult begins to only imitate the child’s oral movements or sounds produced. At the final stage, the adult and child imitate each other reciprocally, with the goal of the child imitating sounds consistently. At the end of the study, all children showed a significant increase in their sound production and repertoire of phonemes. Specifically, all children had at least 13 phonemes and produced 100+ sound productions per session. Talk about measureable progress! This article describes the procedure in great detail, so that any SLP could recreate IT at their next home visit.  

The authors do mention that small sample size and lack of a control group are limitations of this study. However, each of the children missed a week of therapy due to fall/spring break. During this break, they experienced a decrease in sound production, which subsequently increased when therapy was again initiated. This observation reinforces the evidence that IT may have been a factor in the children’s progress. At a minimum, imitation therapy appears to be a promising technique to try with nonverbal toddlers who struggle to imitate.   

 

Gill, C., Mehta, J., Fredenburg, K., Bartlett, K. (2011). Imitation therapy for non-verbal toddlers. Child Language Teaching and Therapy, 27(1), 97–108.

Throwback (2007): Helping parents develop joint attention skills

December Quotes, website.png

So, we know that deficits in joint attention skills are one of the earlier-appearing red flags for autism. We also know that early intervention for the autistic population should include tasks to develop joint attention. And early intervention should involve parents. Schertz and Odom (2007) combined these concepts and found that when parents take the lead in designing and implementing activities (with a little help/guidance from a professional) to promote joint attention skills, magic can happen—all three toddlers in this study improved their joint attention skills.

The researchers stress that the parents did most of the work. The parents came up with activities and carried through with their plans in natural environments. The interventionist took a backseat role; however, he or she also served as a teacher of theory and best-practice for the parents.

What activities did the parents do with their children? (Or, what can we as SLPs teach caregivers to do to promote joint attention skills?)

  • focusing of faces: mirror play, imitating facial expressions, putting the parent’s face in the child’s line of sight

  • turn-taking: responding to child’s actions as if the child were actually interacting with them, building in some pause time after the parent’s utterance to wait for the child’s response, imitation of the child’s gestures, working the parent into the child’s isolated play

  • responding to joint attention: sharing attention to the same object through parent initiations (making the toy exciting, and practicing looking between the toy and the parent’s face)

  • initiating joint attention: parents expressed excitement about the toy, or giving the child surprise gifts to increase excitement.

 

Schertz, H.H. & Odom, S.L. (2007). Promoting joint attention in toddlers with autism: A parent-mediated developmental model. Journal of Autism and Developmental Disorders, 37, 1562–1575.

Review written by: Knothe, C., Cordia, R., Meuschke, H., & Brumbaugh, K.