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Parent Question about Referencing and Joint Attention

A while ago a parent asked me about the difference between referencing and Joint Attention. Joint Attention is a relatively new concept in the behavioral literature with a few studies being conducted prior to this century but most studies occurring within the past 10 years. Because of this, the skill and techniques to teach the skill is a little trickier to explain. Research is still being conducted on effective ways to teach Joint Attention which I will discuss later in this blog. While I do focus on teaching Joint Attention with my clients, I also decided to send this question to some of my BCBA colleagues to get their input on the topic as well. First I will provide my response and then responses from 2 other BCBAs who kindly shared their input on the topic. 

When I first read this question, my initial response was simply: Joint attention is a more complex skill whereas referencing is one of the precursor skills that a child would need in order to engage in Joint Attention. I didn’t have much more of an explanation than that but after reading input from my colleagues, I am now better able to explain what I meant. 

Steve Ward, BCBA provided an excellent explanation of the difference between referencing and Joint Attention. He also provided some of the techniques that he uses for teaching Joint Attention. Here is Steve’s response:

Referencing refers to looking at others, especially others' eyes, for a variety of reasons, including things like: attending to name, looking for information about the location of a reinforcer, waiting for the answer to a question, checking for emotional reactions, etc. 

Joint attention is a higher skill than simple referencing, requiring the learner to: 

1. Demonstrate motivation to direct anothers' attention to an item or event, 
2. Recruit that person's attention, 
3. Direct that attention toward the item/event, 
4. Monitor that person's attention to assure that it is fixed on the relevant item or event.  

It is very important to note that this should not be called "joint attention" if the motivation is merely to receive the relevant item. It is only “joint attention” if the motivation is to share the experience of the item with the other person.

In terms of skills, I frequently start teaching joint attention by establishing all of the components of the skill under motivation for tangible gain (e.g., the learner wants a cookie).  I'll begin by requiring attention mands, teaching learners to point at reinforcers that are out of reach, and teaching them to repair the actions of a deficient listener.  One exception to this is a learner who either naturally demonstrates, or can easily be taught, that our reactions to items/events is very interesting to them.  In that case, I use that natural motivation to shape responses that direct my attention to an item/event.  Another program I'll introduce is essentially a very early version of "show-and-tell", particularly for items a learner has produced, about which they can brag.  I use a lot of reinforcement for this bragging, preferably social, but tangible if necessary.  

For simple referencing, the first thing I do, especially during pairing, is capture as many spontaneous demonstrations of referencing as possible, and look for ways to contextually reinforce.  I may walk around with small tangible reinforcers and occasionally say the learner's name, and reinforce looking toward me within a second or 2.  I sometimes play "Hide-the-prize" (taken from RDI).  I can almost always establish strong referencing by playing Red Light/Green Light (described in the play book I mentioned).  For slightly more advanced learners, I can usually get some referencing by teaching Hotter/Colder (also described in the play book).

 -Steve Ward, BCBA www.wholechildconsulting.com  (352)425-2063

I would like to thank Steve for his excellent description and explanation of some activities to do to help develop Joint Attention and Referencing skills. I also would recommend using activities from RDI (Relationship Development Intervention). It is important to note that there are not very many studies (at least that I know of) indicating the effectiveness of the RDI protocol but the exercises in the RDI book serve as wonderful ideas for relationship developing programs to do with a child. For each activity in the book, there is also a description of which skills the activity is targeting such as eye contact, gaze shifting, etc. 

Toby Stahlschmidt-Kah, M.A., BCBA also provided me with a powerpoint and poster presentation that she did which focused on a literature review of Joint Attention. A summary of the presentation is below:

1. Research on Joint Attention started in the 1970s, however the focus has shifted over time from defining Joint Attention to determining techniques on how to teach Joint Attention
2. Some points on Joint Attention from a behavioral perspective:
1. The initiative behavior observed at the beginning of a JA behavioural chain such as gaze shifting, could be seen as a mand for someone else’s behaviour of attending ‘to’ an object which is different, than a mand ‘for’ an object.
2. Contingencies of behaviour are important to demonstrate this concept.
3. A change in motivating variables sets the occasion for different behaviours. 
4. The likelihood a child will or will not look to an adult at the onset of the interesting event, is contingent on whether or not the adult-mediated consequence has a positive value for the child, and also depends on the individual’s learning history; if in the past looking to an adult has yielded reinforcing effects

1. Both form and function define JA behavior. This means that you cannot just teach a child to look at an object and then look at you and call this joint attention. In order to have really taught the skill of JA the child must be looking from the object to the person in order to determine if the person is sharing in the experience. 

Toby’s presentation also included references to some of the studies that have been done regarding techniques to teach Joint Attention. Below is the description of these studies from Toby’s presentation:

1. Pierce and Schriebman (1995) found that Pivotal Response training led to gains in JA for 4th graders diagnosed with autism.
2. Leekam, Hunniesett, & Moore (1998) shaped JA Gaze shifting responding by using  remote controlled boxes with flip opening lids. The trainer would flip the lid on the box if the child followed their gaze. At first, the lid was flipped regardless of whether the child looked in the right direction. Then, the lid was only flipped if the child followed the experimenter’s gaze. 
3. Baker (2000) incorporated ritualistic behaviors into games that were played with the autistic children’s siblings. The study showed that positive supported and coordinated JA increased during the intervention and were maintained at 1 and 3 month follow-ups
4. Hwang & Hughes (2000) used social interactive training to increase JA for 3 preverbal autistic children. The training consisted of imitation of participant’s actions, presenting an expectant look, and naturally occurring reinforcement. The JA behaviors did not generalize though. 
5. Tsuchiya & Yamamoto (2001) presented preferred stimuli passing behind an adult who was facing the child. Guiding the examiner to look at the objects, referential looking, pointing and declarative responses all increased. 
6. Whalen & Schreibman (2003) used response training with 11 children teaching them 6 levels of skills: hand on object, tapping on object, showing of object, eye contact, following a point, and following a gaze to increase JA.
7. Robins, Dickerson, and Stribling (2004) used a Robot to increase JA for 3 children with autism. The children interacted with the robot and their ability to follow pointing and gaze of the examiner increased. 

Toby also sent me a description of how she focuses on Joint Attention and an article about Joint Attention. I have pasted her response here:

Something I really focus on when teaching JA, is the three-way relationship.  For example the child is taught to look from me, to the item they are showing, and back to me.  This is very different than a 2-way, where the child looks from me to an item, or from an item to me. I've used techniques from Per Holth (2005) for teaching JA. The article can be found here: http://www.eric.ed.gov:80/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/44/a8/82.pdf

-Toby Stahlschmidt-Kah, M.A., BCBA Email: tskbxservices@istar.ca

I would like to thank Toby for her thorough review of the literature on JA. It is important to note that Toby’s review included studies up to 2005. More studies on JA and techniques to teach JA can be found in the behavioral literature. 

Here are some additional articles and other resources regarding Joint Attention:

1. Article about the importance of Joint Attention and techniques to use to increase social interactions, motivation, and Joint Attention from a Speech Therapist’s perspective: http://speech-language-pathology-audiology.advanceweb.com/Editorial/Content/Editorial.aspx?CC=116835 
2. Another blog about Joint Attention and how a teacher is using technology to develop JA http://techpsych.blogspot.com/2009/03/establishing-joint-attention-with.html
3. Pivotal Response Treatments for Autism book by Koegal and Koegal ttp://www.amazon.com/Pivotal-Response-Treatments-Autism-Communication/dp/1557668191/ref=sr_1_1?ie=UTF8&s=books&qid=1264539179&sr=8-1
4. Overcoming Autism book by Koegal http://www.amazon.com/Overcoming-Autism-Finding-Strategies-Transform/dp/0143034685/ref=pd_bxgy_b_img_b
5. Relationship Development Intervention book by Gutstein http://www.amazon.com/Relationship-Development-Intervention-Young-Children/dp/1843107147/ref=sr_1_1?ie=UTF8&s=books&qid=1264539346&sr=1-1