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Efficacy of Caregiver Training to Establish Joint Attention of Children with Autism

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Material Information

Title:
Efficacy of Caregiver Training to Establish Joint Attention of Children with Autism
Physical Description:
1 online resource (194 p.)
Language:
english
Creator:
Zimmer, Katherine
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Special Education, Special Education, School Psychology and Early Childhood Studies
Committee Chair:
Jones, Hazel
Committee Members:
Lane, Holly Barnes
Conroy, Maureen Almaz
Vollmer, Timothy Raymond

Subjects

Subjects / Keywords:
attention -- caregiver -- early -- intervention -- joint -- reading -- shared -- storybook
Special Education, School Psychology and Early Childhood Studies -- Dissertations, Academic -- UF
Genre:
Special Education thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
The purpose of this study was to investigate the effects of training caregivers of children with autism to use the Meaningful Interaction through Storybooks (MITS) intervention during storybook reading.  Caregivers were taught four interactive reading behaviors in attempt to increase the children’s joint attention skills.  A multiple probe, multiple baseline across participants was used to examine the effectiveness of the MITS intervention.  Results of the study revealed that caregivers were able to effectively implement the intervention.  They also maintained and were able to generalize the skills they learned after the training was completed.  In addition, increases on the children’s joint attention skills and expressive language was seen.  As a result, these preliminary findings support that MITS training produced changes in mothers’ storybook reading behaviors, influencing increases in children’s joint attention skills.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Katherine Zimmer.
Thesis:
Thesis (Ph.D.)--University of Florida, 2013.
Local:
Adviser: Jones, Hazel.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2013
System ID:
UFE0045758:00001

MISSING IMAGE

Material Information

Title:
Efficacy of Caregiver Training to Establish Joint Attention of Children with Autism
Physical Description:
1 online resource (194 p.)
Language:
english
Creator:
Zimmer, Katherine
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Special Education, Special Education, School Psychology and Early Childhood Studies
Committee Chair:
Jones, Hazel
Committee Members:
Lane, Holly Barnes
Conroy, Maureen Almaz
Vollmer, Timothy Raymond

Subjects

Subjects / Keywords:
attention -- caregiver -- early -- intervention -- joint -- reading -- shared -- storybook
Special Education, School Psychology and Early Childhood Studies -- Dissertations, Academic -- UF
Genre:
Special Education thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
The purpose of this study was to investigate the effects of training caregivers of children with autism to use the Meaningful Interaction through Storybooks (MITS) intervention during storybook reading.  Caregivers were taught four interactive reading behaviors in attempt to increase the children’s joint attention skills.  A multiple probe, multiple baseline across participants was used to examine the effectiveness of the MITS intervention.  Results of the study revealed that caregivers were able to effectively implement the intervention.  They also maintained and were able to generalize the skills they learned after the training was completed.  In addition, increases on the children’s joint attention skills and expressive language was seen.  As a result, these preliminary findings support that MITS training produced changes in mothers’ storybook reading behaviors, influencing increases in children’s joint attention skills.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Katherine Zimmer.
Thesis:
Thesis (Ph.D.)--University of Florida, 2013.
Local:
Adviser: Jones, Hazel.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2013
System ID:
UFE0045758:00001


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1 EFFICACY OF CAREGIVER TRAINING TO ESTABLISH JOINT ATTENTION OF CHILDREN WITH AUTISM By KATE ZIMMER A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FO R THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2013

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2 2013 Kate Zimmer

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3 To all the families living with autism, a heartfelt thank you for all their dedication, hard work, passion, and focus in m akin

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4 ACKNOWLEDGMENTS I would first like to thank my dissertation committee: Dr. Hazel A. Jones, Dr. Holly B. Lane, Dr. Maureen A. Conroy, and Dr. Timothy R. Vollmer. I truly appreciate their guidance and support during thi s process. Extra appreciation is extended to my committee chairperson, Dr. Hazel A. Jones, as her suppo rt, encouragement, and time has allowed me to reach my goals. I owe thanks to the parents and children who were willing to participate in this study. W ithout their commitment and time, this study would not have been possible. Their desire to create a better world for their children is inspiring. I want to thank some special women who started this journey with me and kept me sane: Susie Helvenston, Krist in Murphy, Sherri Prosser, and Page White. Their words of encouragements understanding, and laughs kept me going. A special thanks to Page White for what seemed like endless hours of coding videos. I am tremendously grateful to my family members for th eir support, especially my husband, Jeff. His words of encouragement, love, and support meant more to me than he will ever know. Next, I offer my sincere appreciation to my parents, in laws, sister, and sister in law who gave countless hours of their tim e to watch and care for our sweet baby boy. And to Evan, I thank him for making each day brighter; he has taught me more than he will ever know.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 9 LIST OF FIGURES ................................ ................................ ................................ ........ 10 LIST OF ABBREVIATIONS ................................ ................................ ........................... 11 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTORY REMARKS ................................ ................................ ................ 13 Background for the Study ................................ ................................ ....................... 14 Autism Defined ................................ ................................ ................................ 14 The Importance of Joint Attention ................................ ................................ ..... 16 The development of joint attention ................................ ............................. 17 Joint attention a nd development of language skills ................................ .... 17 Joint Attention Impairment in Autism ................................ ................................ 19 The Importance of Early Intervention ................................ ............................... 21 Effective early interventions for the autism population ............................... 22 ................................ ................................ ............. 23 Interest boosting shared storybooks ................................ .......................... 24 Statement of Problem ................................ ................................ ............................. 25 Purpose of Study ................................ ................................ ................................ .... 25 2 LITERATURE REVIEW ................................ ................................ .......................... 27 Introduction ................................ ................................ ................................ ............. 27 Review of Joint Attention Literature ................................ ................................ ........ 27 Joint Attention Literature Review ................................ ................................ ............ 28 Joint Attention Interventions Using Discrete Trail Training ............................... 29 Interventionist led ................................ ................................ ....................... 29 Interventions with a caregiver component ................................ .................. 33 Interpretations of DTT research findings. ................................ ................... 35 Joint Attention Interventions Using Naturalistic Intervention Methods .............. 36 Clinician led ................................ ................................ ................................ 37 Interventions with a caregiver component ................................ .................. 39 Interpretation of naturalistic intervention research findings ........................ 43 Interventions Using Both DTT and Naturalistic Intervention Methods .............. 45 Clinician led ................................ ................................ ................................ 45 Interventions with a caregiver co mponent ................................ .................. 48 Interpretation of DTT and naturalistic intervention research findings ......... 53

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6 Review of Shared Storybook Reading Literatur e ................................ .................... 54 Importance of Shared Storybook Reading ................................ ....................... 55 Shared Storybook Reading and At Risk Population ................................ ......... 57 Methods for Shared Storybook Reading Literature Review .............................. 60 Shared Reading Interventions with Children with Language and Developmental Delays ................................ ................................ .................. 61 Interventionist led ................................ ................................ ....................... 62 Caregiver component ................................ ................................ ................. 67 Interpretation of shared reading interventions with children with language and developmental delays ................................ ...................... 74 Shared Reading Interventions with Children with Autism Spectrum Disorder .. 77 Interventionist led ................................ ................................ ....................... 77 Interventionist led ................................ ................................ ....................... 79 Interpretation of shared reading interventions with children wit h autism spectrum disorder ................................ ................................ ................... 82 Statement of Problem ................................ ................................ ............................. 84 3 METHOD ................................ ................................ ................................ ................ 86 C riteria for Participation and Selection of Participants ................................ ............ 87 Children ................................ ................................ ................................ ............ 87 Caregivers ................................ ................................ ................................ ........ 88 Participants ................................ ................................ ................................ ............. 88 Dyad 1: Jon and his caregiver: ................................ ................................ ......... 88 Dyad 2: Jess and his caregiver: ................................ ................................ ....... 89 Dyad 3: Dave and his caregiver ................................ ................................ ....... 90 Dyad 4: Jay and his caregiver ................................ ................................ .......... 91 Materials ................................ ................................ ................................ ................. 92 Assessment Instruments ................................ ................................ .................. 92 Caregiver Training Material ................................ ................................ .............. 93 Books ................................ ................................ ................................ ............... 93 Setting ................................ ................................ ................................ ..................... 94 Study Design ................................ ................................ ................................ .......... 94 Measurement Procedures ................................ ................................ ....................... 95 Dependent Measures ................................ ................................ ....................... 95 Independent Variable ................................ ................................ ....................... 97 Experimental Procedures ................................ ................................ ........................ 97 Pre baseline Phase ................................ ................................ .......................... 97 Baseline ................................ ................................ ................................ ............ 98 Intervention Phase ................................ ................................ ........................... 98 MITS Instruction/Review ................................ ................................ ............ 98 Dyad Reading Probe ................................ ................................ .................. 99 Investigator/Caregiver Coa ching ................................ .............................. 100 Maintenance ................................ ................................ ................................ ... 100 Generalization ................................ ................................ ................................ 101 Data Collection ................................ ................................ ................................ ..... 101 Analyzing Data ................................ ................................ ............................... 102

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7 Interobserver Agreement ................................ ................................ ................ 102 Treatment Integr ity ................................ ................................ ......................... 104 Social Validity ................................ ................................ ................................ 105 4 RESULTS ................................ ................................ ................................ ............. 109 Interobserver Agreemen t ................................ ................................ ...................... 109 Interobserver Agreement for Unstructured Joint Attention Assessment ......... 109 guage During Play Session ................................ ................................ ................................ ....... 110 Interobserver Agreement for Primary Dependent Variables ........................... 110 s MITS strategies ........................ 110 ................................ .... 110 ge. ....................... 111 Intervention Results ................................ ................................ .............................. 111 Dyad 1: ................................ ................................ ................................ ........... 112 Baseline phase for ................................ ............ 112 Baseline phase for Dyad 1: Jon. ................................ .............................. 112 ................................ ....... 113 Intervention phase for Dyad 1: Jon. ................................ ......................... 113 ................................ ..... 114 Maintenance phase for Dyad 1: Jon. ................................ ....................... 114 ................................ ... 115 Generalization phas e for Dyad 1: Jon. ................................ ..................... 11 5 ................................ ................................ .................. 116 ................................ ............ 116 Baseline phase for Dyad 2: Jess. ................................ ............................. 116 ................................ ....... 116 Inte rvention phase for Dyad 2: Jess. ................................ ........................ 117 ................................ ..... 118 Maintenance phase for Dyad 2: Jess. ................................ ...................... 118 ................................ ... 118 Generalization phase for Dyad 2: Jess. ................................ ................... 119 ................................ ................................ ............... 119 ................................ ......... 120 Baseline phase fo r Dyad 3: Dave. ................................ ............................ 120 ................................ .... 120 Intervention phase for Dyad 3: Dave. ................................ ....................... 121 ................................ ... 122 Maintenance phase for Dyad 3: Dave. ................................ ..................... 122 ................................ 122 Generalization phase for Dyad 3: Dave. ................................ .................. 123 regiver ................................ ................................ .................. 123 ................................ ............ 124 Baseline phase for Dyad 4: Jay. ................................ .............................. 124 ................................ ....... 124 Intervention phase for Dyad 4: Jay. ................................ ......................... 125

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8 Main ................................ ..... 126 Maintenance phase for Dyad 4: Jay. ................................ ........................ 126 egiver. ................................ ... 127 Generalization phase for Dyad 4: Jay. ................................ ..................... 127 Social Validation Measure ................................ ................................ .................... 127 Summary ................................ ................................ ................................ .............. 129 5 DISCUSSION ................................ ................................ ................................ ....... 138 Research Question #1 ................................ ................................ .................... 138 Research Question #2 ................................ ................................ .................... 144 Research Question #3 ................................ ................................ .................... 147 Implications ................................ ................................ ................................ ........... 149 Limitations ................................ ................................ ................................ ............. 154 Conclusion ................................ ................................ ................................ ............ 155 APPENDIX A TABLES OF JOINT ATTENTION STUDIES ORGANIZED BY TOPICS ............... 157 B TABLES OF SHARED STORYBOOK READING STUDIES ORGANIZED BY TOPICS ................................ ................................ ................................ ................ 161 C MITS COLLECTION CHECKLIST & CODING SHEET ................................ ......... 164 D UNSTRUCTURED JOINT ATTENTION ASSESSMENT ................................ ...... 169 E CAREGIVER HANDBOOK ................................ ................................ ................... 170 F CHILD INTEREST INV ENTORY ................................ ................................ .......... 176 G TREATMENT FIDELITY ................................ ................................ ....................... 178 H SOCIAL VALIDITY ................................ ................................ ................................ 179 I LIST OF BOOKS USED IN STUDY ................................ ................................ ...... 181 J DEMOGRAPHIC & BACKGROUND INFORMATION ................................ ........... 182 LIST OF REFERENCES ................................ ................................ ............................. 185 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 193

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9 LIST OF TABLES Table page 3 1 Books used based on Child Interest Inventory ................................ ................. 106 3 2 Definition of MITS strategies to be implemented by caregivers ........................ 107 3 3 ................................ ................................ .... 108 3 4 Definitions and examples of expressive language sample done by child ......... 108 A 1 Summary of joint attention interventions using discrete trial training ................ 157 A 2 Summary of joint attention interventions using pivotal response training ......... 158 A 3 Summary of joint attention interventions using both discrete trial training and pivotal response training ................................ ................................ ................... 159 B 1 Summary of shared reading interventions with language and developmental delays children ................................ ................................ ................................ .. 162 C 1 Definition of MITS strategies to be implemente d by caregivers ........................ 164 C 2 ................................ ................................ 166

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10 LIST OF FIGURES Figure page 4 1 Caregiver and child behaviors per minute ................................ ........................ 130 4 2 Caregiver MITS per minute per phase. ................................ ............................. 132 4 3 ................................ .... 134 4 4 age per minute per phase ................................ ......... 136

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11 LIST OF ABBREVIATIONS ABA Applied Behavior Analysis ADI R Autism Diagnost ic Interview ADOS G Autism Diagnostic Observation Schedule Generic AS ASD Autism Spectrum Disorder CRC Complete Reading Cycle DTT Discrete Trial Training IJA Initiation of Joint Attention JA Joint Attention MITS Meaningful Interaction s Through Storybooks NELP National Early Literacy Panel PDD NOS Pervasive Developmental Disorder Not Otherw ise Specified (PDD NOS) PDD Pervasive Development Disorder PI Pervasive Interest PRT Pivotal Response Training RJA Response to Joint Attention SES So cioeconomic Status

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12 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EFFICACY OF CAREGIVER TRAINING TO ESTABLISH JOINT ATTENTION OF CHILDREN WITH AUTISM By Kate Zimmer August 2013 Chair: Hazel A. Jones Major: Special Education The purpose of this study was to examine the effectiveness of a caregiver implemented intervention of children with autism during storybo ok reading. Caregivers were taught four interactive reading strategies in an attempt to increase attention skills. A multiple probe, multiple baseline across participants was used to examine the effectiveness of the Meaningful Interactio ns Through Storybooks ( MITS ) intervention. Results of the study displayed that caregivers were able to effectively implement the MITS intervention. In addition, caregivers were able to maintained and generalize the MITS intervention after the training wa s comp leted. In addition, increases i ills and expressive language were observed As a result, these findings support that the MITS intervention was able to produced changes in caregivers

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13 CHAPTER 1 INTRODUCT ORY REMARKS world around them through joint interactions. Described as two persons sharing attention on the same external object through the use of gaze or ge stures, joint attention (JA) learning of a variety of object labels, thus enabling a child to make sense of language around them (Jones & Carr, 2004; Murray et al., 2008; Vis mara & Lyons, 2007). For children with autism the lack of joint attention results in the difficulty of the acquisition of language and social skills (Schertz & Odom, 2007; Vismara & Lyons, 2007). Through the use of joint attention interventions positive results have been shown for children with autism in the areas of responding to joint attention bids and initiation joint attention with others (e.g., Ingersoll & Schreibman, 2006; Isaken & Per Holth, 2009; Jones & Feely, 2007; Martin & Harris, 2006; Taylo r & Hoch, 2008; Whalen & Schreibman, 2003). One daily routine, not yet examined as an early intervention to increase joint attention, is called shared storybook reading. Shared storybook reading is a natural activity in which a parent and child partake in communicating, shared joint attention, and it advocates the growth of language and social participation, two core deficits for children with Autism Spectrum Disorder ( ASD ) The aim of this study is to examine the effectiveness of a caregiver implemente d intervention. Through shared storybook reading, this intervention is designed to increase joint attention in young children who are o n the autism spectrum. Chapter 1 define s ASD, describe s joint attention and language problems ASD children display, and depict s the importance of early intervention to better develop these

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14 skills. Chapter 2 examines the ea rly interventions that assist young children with ASD in develop ing joint attention and the benefits of shared storybook reading interventions are analyz ed. Chapter 3 discusses the methodology, intervention, data collection, treatment integrity, and social validity in further detail. Next, Chapter 4 dis plays the results of the study. Chapter 5 discusses the results, implications for future research, and limitations of the study. Background for the Study Autism Defined In 1956, Kanner and Eisenberg provide d the first diagnostic criteria for autism. ritualistic behavior behaviors that were observed by Kanner and Eisenberg are still seen in the current diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR; American Psy chiatric Association [APA], 2004). Classified as a Pervasive Development Disorder (PDD) individuals with autism are commonly characterized as having delays or abnormal developments in social and communicative development. In addition, these individuals often show restricted and stereotyped patterns of behavior and/or interest (APA, 2004). Experts frequently refer to autism as a spectrum disorder due to the range of symptoms and skills individuals display. For the purpose of this proposal, ASD will inc lude the conditions of autism, Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS), and Language delays and impairment are the hallmark features of individuals with ASD. These deficits include difficulty using spok en language, making gestures, an

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15 inability to imitate, and/or sustain appropriate conversation are among the most common reasons for initial referrals of young children suspected of having autism (Thurm, Lord, & Lee, 2006). Although there is heightened aw areness, an increase in early identification, and expanding research on ASD, the majority of children are not diagnosed until after they reach the age of 4 (Centers for Disease Control and Prevention [CDC], 2012). This is problematic, as research indicate s that early intervention leads to significant developmental gains for children with ASD (Ingersoll & Gergans, 2006; Jones & Carr, 2004; Mundy & Crowson, 1997). The number of children diagnosed with autism has increased greatly during the last decade. Ac cording to the Centers for Disease Control and Prevention (CDC, 2012) approximately 1 in 88 children has an autism spectrum disorder marking a 23% increase in the past two years. Although there have been numerous theories that attempt to explain the incre ase in the number of children identified as having symptoms of autism, there is still no known cause. What researchers do know is that the number of itself, bette r diagnostic tests, more inclusive classification guidelines, misdiagnosis, or number of people in this country ( Steuernagel, 2005, p. 138). With the multifaceted nature of A SD combined with the current lack of genetic or/and biologic markers for early and consistent identification, the study of factors leading to a diagnosis of ASD has become a challenging task (Tomanik, Pearson, Loveland, Lane, & Shaw, 2007). Professionals use a variety of screening tools, observations, and evaluations to diagnose this disorder. A diagnosis of autism according to International Classifications

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16 of Diseases Tenth Revised (ICD 10) and the DSM IV TR (American Psychiatric Association, 2004) invol ves a multidisciplinary evaluation method that includes a detailed developmental history, description of current behaviors, assessment of cognitive and language abilities, and observations of functioning in a variety of settings. Once the information is g athered there is a consensus on the data collected (e.g., standardized diagnostic instruments in combination with clinical judgment, and at least two or more professionals within the ASD field). Today, the Autism Diagnostic Interview (ADI R) and the Autis m Diagnostic Observation Schedule Generic (ADOS G) are two of the most common standardized diagnostic tools (Le Couteur, Haden, Hammal, & McConachie, 2008). The Importance of Joint Attention In recent years, there has been a wave of early interventions t hat focus on joint attention behaviors (Nozomi, Tsuchiya, Yamamoto, & Nakamura, 2008). Although there ar e numerous definitions of JA, the commonly accepted critical components of joint attention are described as two persons sharing attention on the same e xternal object through the use of gaze, head turn, or making gestures. Joint attention is considered a object labels, thus enabling a child to make sense of langua ge around them (Jones & Carr, 2004; Murray et al., 2008; Vismara & Lyons, 2007). Children with ASD have notable difficulties with JA research has demonstrated that young children use JA to help them comp rehend the world around them. From gaining knowledge of novel words to understanding the JA plays a pivotal role in language

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17 acquisition. It is widely noted that a deficit in joint attention is one of the earl iest and most common signs of autism ( Dube et al., 2004 ). The development of joint attention Joint attention (JA) typically begins to occur between the ages of 9 to15 months. Although numerous definitions of JA are found throughout the literature, the ter m is commonly classified into two forms: response to joint attention and initiation of joint attention (Bakeman & Adamson, 1984; Dube, MacDonald, Mansfield, Holocomb, & Ahearn, 2004; Jones, Carr, & Feeley 2006 ). Response to JA is the earliest form of joi nt communicative partner in their environment (Dube et al., 2004). As the child develops, this response becomes more sophisticated; the child focus shifts from an object to the caregiver and then back to the object. Eventually children pair the gaz e alternation with gestures and with age, incorporate speech (Jones et al., 2006). Initiation of JA takes rs around 12 months of age (Bruinsma, Koegel, & Koegel, 2004). This form of JA uses conventional to JA, initiation of JA becomes more complex with growth, pairing g estures with alternative gazes and eventually language (Jones et al., 2006). Joint attention and development of language skills The main function of JA is social, as children utilize JA to interact with another person about an object or event in their en vironment (Jones & Feeley, 2007; Mundy & Crowson, 1997). For example, when a young child sees a dog they might point or look attention, an adult typically comments on th e object of JA with a comment, such as,

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18 and events, children start to associate objects with the spoken word. Joint attention labels to the correct object of interest (Mundy, Sullivan, & Mastergeorge, 2009). The relationship between JA and language development has been long acknowledged ( Farran t, Murray, & Flectcher, 2011 ; Tomasello & Todd, 1983). For example, Tomasello and To on language development during mother child play. The typically developing children were between the ages of 12 to 18 months and were observed during natural play interaction with their mothers. Tomasello and Todd reported that the amount of time the overall vocabulary. The study was replicated comparing singletons to twins (Tomasello, Mannle, & Kruger, 1986) and results were similar, showing positive correlation between the amount of time a child was engaged in joint attention at 15 months to vocabulary size at 20 months. More recently, Farrant et al. (2011) examined the relationship between socio emotional e language development. Ninety five caregiver/child dyads participated, and the results of the discriminant functions analysis suggest that socio emotional engagement fosters communi cation skills. Farrant et al. accomplished this through creating a model that they tested with a group of typically developing children and then with children who had a specific language impairment. The children with language deficits had significantly l ower socio emotional engagement due to lower child imitation, joint attention, and

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19 conversation skills. They reported that the skill of JA is naturally found throughout socio emotional engagement; consequently these interactions facilitate the growth of J A and warrant further research. Children with a deficit in JA will have difficulties with shared experiences. The l ack of shared interactions makes it significantly difficult to acquire language as th e development of JA skills are critical for these dev elopmental milestones (Woods & Wetherby, 2003). Early identification of children with ASD with a deficit in JA is essential. Once a child is identified with ASD the focus can be on providing effective communication interventions that will benefit their future social and academic functioning. Joint Attention Impairment in Autism Children with ASD have significantly more difficultly following head turns, eye gaze, and pointing than their typically developing peers (Ingersoll & Gergans, 2006; Jones & Carr 2004; Jones & Feeley, 2007; Murray et al., 2008; Vismara & Lyons, of autistic children lend s credence to the idea that important indicators of language occur prior to v attention between an object and a person ultimately allows them to understand the expressions and gestures being used by others (Mundy). ddresses the development of language and JA skills in autistic children as compared to their development in child ren with developmental languages delays. They concluded that specific language deficits that characterize autism are developmentally related t o the failure of JA mechanisms in infancy and early childhood. Due to the impairment of JA that children with ASD

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20 display, the syntax and semantics of language that are usually acquired during this pertinent stage of development are repressed. Therefore, the strategies and techniques that are acquired to use the pragmatics of language effectively need to be explicitly taught. Murray et al. (2008) examined the relationship between JA and language in 20 children with ASD. Using the receptive language subte st of the Mullen Scales of Early Learning (MSEL) and Mean Length of Utterance (MLU) and Type Token Ratio for correlated with receptive language scores as well as the le language scores were and longer response utterances were given. The implications of this study suggest that JA interventions could influence as the interactions between child and adult yield positive gains. Typically developing children acquire language through everyday experiences because they are immersed in interactions that increase their language opportunitie s (Miller, 2010). Joint attention plays a critical role in these language enriched and simultaneously acquiring language from those around them. Increasing J A abil ity in children with ASD, both enhances their interaction with others and expands their language skills. Research suggests that JA is a necessary precursor for language acquisition and that in order for children with ASD to increase their language skills JA needs to be explicitly taught (Jones et al., 2006; Mundy & Crowson, 1997; Rudd Cain,

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21 2008). Although there is an abundance of research on the importance of JA, there is a limited agreement on how best to teach this skill to young children with ASD. The Importance of Early Intervention Receiving early interventions in a timely manner can be a critical factor in long term outcomes for children with ASD (Jones & Carr, 2004). Early identification of ASD can be difficult due to the requirement of observa ble behavioral attributes. Steele and the importance that early intervention can play in creating a foundation for later learning. Due to language delays and impai rments, child ren with ASD often experience social deficits. Young children with ASD have particular difficulties in understanding spoken words; especially abstract words, due to the elusive nature of these words (Rocha, Schreibman, & Stahmer, 2007). The social manifestations can cause isolation, difficulty in making eye contact, and an inability to develop appropriate peer relationships. Due to the heightened awareness of this disorder, there has been an increase in the amount of research focusing on th e cause, preventions, and treatments of ASD, particularly in the area of early intervention. The National Research Council (2001) indicates the positive impact that early intervention has had with individuals on the spectrum. There are many studies that examine early intervention programs that use specific interventions to support children with ASD in acquiring and developing language and communication skills (e.g., Vismara & Lyons, 2007; Whalon, 2004). For example, Delprato (2001) reviewed 10 controlled studies in which early interventions targeted a form of language performance (e.g., receptive language, yes/no responses, descriptive responses) to young children with ASD. Positive gains were found in all

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22 studies examined, though it should be noted that those studies using naturalized interventions were more effective in language gains than those using discrete trail training (DTT) In addition, Wood and Wetherby (2003) reviewed evidenced based interventions for children with autism. They, too, reporte d that children with ASD who receive early intervention are more likely to be successful later on in life, as children More recently, Rickards, Walstab, Wright Rossi, Simpson, and Reddihough (2008) study assessed 54 children with ASD after 12 months of early intervention Cognitive development was sustained in children who received the extra home based intervention improv ement as compared to the control group. Children with ASD experience an increase in successful response to intervention as demonstrated by research. The promotion of positive interactions is vital as researchers are seeing positive long term outcomes (D elprato, 2001; Schretz & Odom, 2007; Wood & Wetherby, 2003). Early intervention is an integral part of school readiness for children with ASD. The type of intervention, however, is a matter of some debate due to the array of interventions available. Eff ective early interventions for the autism population Typical children naturally learn from the environment around them; unfortunately, for the majority of children with ASD this is not always the case. Researchers have conducted numerous studies to ident ify the most effective ways to teach new skills to children with autism and discrete trial and naturalistic intervention model techniques have been particularly effective strategies used in early intervention. Both DTT and naturalistic intervention models are based on the principles of Applied Behavior Analysis

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23 (ABA) (Smith, 2001). DTTs are behaviorally based interventions with highly structured methods and are the primary approach to teach children novel skills. The main components of DTTs include instr uction, prompting, response, consequence, and inter trial intervals (Whalen & Schreibmam, 2003). Naturalistic intervention mode ls, although structured, follow a more naturalistic behavioral plan. Naturalistic intervention components are responding to mult iple cues and stimuli, improving child motivation, increasing self management capacity, and increasing self initiations. This method is based on a play format allowing the interventionist to be flexible and adapt to the individuals needs (Isaksen & PerHolth, 2009; Vismara & Lyons, 2007). Although teaching new skills th rough DTT and naturalistic intervention models to the ASD population have been successful, there are a few studies that examine the effects of teaching JA using DTT and naturalistic intervention model strategies. i nvolvement Children are recei ving an ASD diagnosis at a younger age than ever before and consequently these children are spending more and more time with their caregivers in their home environment (Jones & Feeley, 2007). Therefore, it is becoming necessary for effective interventions to be conducted in the home environment. Naturalistic early interventions allow caregivers and interventionists to develop a collaborative vision on partnership and a natura listic early intervention allow the family to feel comfortable in implementing the intervention throughout their daily life ( Pierce, Munier, & Myers, 2009) The importance of including caregivers in the intervention process is well documented (Bagnato, 20 07; Cosden, Koegel, Koegel, Greenwell, & Klein, 2006; Crowe, Norris, & Hoffman, 2000; Fletcher, Perez, Hooper, & Clauss en, 2005; Schertz & Odom, 2007).

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24 The research indicates that interventions that involve caregivers have greater ma intenance and generali zation of their newly found skills. It is important for children with ASD to have multiple experiences that involve skills from their intervention because these experiences lead to adaptability and generalization of functional skills taught, especially whe n they are continuously practice d in their own home environment (Landa, Holman, Garrett Mayer (2007). The faster children can obtain these skills and use them effectively, the earlier these skills can be duplicated and lead to generalization. Adult child shared reading is a natural context with a predictable routine that involve s the parents in their home setting. This consistency and predictability allow s the children to feel secure in their environment (Ingersoll & Gergans, 2005; Jones & Feeley, 2007). Interventionists are increasingly using storybook reading to facilitate the communication and linguistic development of children who exhibit language impairment (Bellon, Ogletree, and Harn, 2000; Koppenhaver et al., 2001; Vogler Elias, 2009), yet few stu dies to date utilize this intervention with preschool age students with ASD, warranting further research. Interest boosting shared storybook s As stated earlier, one characteristic a child with ASD typically displays i s a restricted interest i n a particular topic or object. There are abundant storybooks available having to do with a wide range of topics and interest. Therefore, family members could build a connection to a child with ASD precisely through finding icted interest. Merging the evidence based practice of caregiver shared storybook reading with the restricted interest of a child with ASD, could potentially motivate the child to engage in joint attention, and as a result, increase their language acquisi tion skills.

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25 Statement of Problem Adult child shared reading is viewed as a natural context with a predictable routine. Interventionists increasingly use early interventions (i.e., joint attention and shared story book reading) to facilitate the communic ation and linguistic development of children who exhibit JA deficits and/or language impairment (Bellon, Ogletree, and Harn, 2000; Koppenhaver et al., 2001; Vogler Elias, 2009). A number of the interventions that will be discussed focus on teaching adults techniques aimed at increasing active child participation during these interventions (i.e., joint attention and shared storybook reading). Throughout the study adults were successful at learning a anguage engagement. As a result of adults increased their use of specific strategies (i.e., joint attention bids or reading expressive vocabularies, and language compl exity. The use of shared storybook reading strategies begins with the fundamental skill of JA Although these shared storybook reading studies touch on JA there are no studies to date that use shared storybook reading solely to establish JA in preschool age children. Purpose of Study The study utilized four reading strategies that were modeled from the four steps of the Complete Re ading Cycle (CRC) used in Crowe study. The intervention, called Meaningful Interactions throug h Storybooks (MITS), facilitate d the four reading strategies through an inte ractive reading experience for four caregiver/child dyads. The purpose of this study wa s to determine the effects of training caregivers of children with autism on the MITS interv ention during storybook reading on establish joint attention.

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26 The following research questions were addressed in the present study: 1. Will training caregivers to use Meaningful Interaction throug h Storybooks (MITS) intervention increase their use of the fou r reading strategies? 2. Does caregiver utilization of the four reading strategies during storybook reading facilitate joint attention skills in their child? 3. Does the MITS intervention result in an increase in verbal expressive language in children?

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27 CHAPTER 2 LITERATURE REVIEW Introduction The purpose of this study wa s to determine the effects of training caregivers of children with autism on the MITS intervention during storybook reading in order to establish JA This chapter presents a review of the liter ature related to (a) the effectiveness of JA interventions using discrete trial teaching and naturalistic instructional approaches to increase JA in children with autism, and (b) the effectiveness of shared storybook interventions on at risk, language and developmentally delayed, and ASD populations. The information from these two literature bases will be synthesized, and implications on these interventions with children with autism will be examined. This section concludes with a rationale for the strategi es selected in this study. This chapter is divided into two major sections. The first section reviews the literature of DTT and naturalistic early i ntervention studies that focus on increasing JA skills for young children with ASD. The second section rev iews the literature on how shared storybook reading improves joint interactions and early literacy skills among preschool students with language and developmental delays and children with autism. Review of Joint Attention Literature Methods for Joint Att ention Literature Review In collecting the data for this literature review I selected all of the databases that the University of Florida provides using a combination of the keywords: joint attention, joint engagement, language, preschool, autism, social skills, communication development disabilities, early intervention, intervention, caregiver, parent training, child development, pivotal response

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28 training, discrete trail training The criteria for inclusion in this review were the following: (a) the rese arch design was experimental or quasi experimental design; (b) intervention utilized DTT or naturalistic training components; (c) the outcome measure was JA ; (d) the participants were of preschool aged children (12 72 months); and (e) each participant had a diagnosis of autism spectrum disorder. In addition, articles were eliminated because they focused on a specific curriculum, rather than a face to face intervention with a focus on JA Nine articles were retained and an ancestral search was conducted to find the remaining 4 articles used for this paper. Due to the small amount of articles, a Google Scholar search was also conducted using the same keywords, though no articles that fix the criteria were found. Joint Attention Literature Review Thirteen studies met the criteria for inclusion in this review. Four studies included DTT interventions, four studies were naturalistic early interventions, and five studies had components of both DTT and naturalistic early strategies. Eight studies used a single subject design, three studies used group experimental designs, and two studies used mixed methods. After reviewing the articles, the research fell into the following categories: 1) Interventionist led interventions and 2) Interventions with a caregiver component. Appendix A (Table A 1 ) provides a listing and summary of all JA articles used in the literature review. Joint attention is known as a prominent attribute of autism and therefore is a pivotal skill that needs to be incorporated in early inter ventions (Jones & Carr, 2004). In the following section, I will present a review of the evidence based research on interventions that increase JA since 2003, discuss the implications of this research, as well as an overall summary of the JA literature.

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29 Jo int Attention Interventions Using Discrete Trail Training Discrete trial training is well known for effectively teaching novel skills to children on one instruction, and q uick trials that allow many learning opportunities for the child. The following four studies are JA interventions that use clinically trained people to conduct DTT methods to increase joint attention in young child with ASD. Appendix A (Table A 1) provid es a listing and summary of the articles (4 multiple baseline articles). Interventionist led Despite being criticized for its regimented approach, DTT interventions can be a powerful tool when working with children on the spectrum. This is illustrated in Martin and Harris (2006) multiple baseline with reversal design across three children with ASD. The authors evaluate the effectiveness of a program that taught children to respond to joint attention bids. Each child was of preschool age, had a diagnosis of ASD based upon DSM IV criteria, and failed to display normal levels of JA as assessed by Autism Diagnostic Interview Revised (ADOS). Two clinically trained people and the primary tion taught the were observed during baseline to make sure they did not display any significant levels of response to JA skills. After baseline was established each chi ld participated in response to JA training sessions. Over sequential phrases, lasting approximately 10 20 motivated objects were placed 3 5 feet from both the child and the trainer, then the

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30 physically prompt ed to help guide the m to a correct respons e, and then w ere reinforced for their correct responses. Throughout the sessions prompts were faded out so that each child was able to correctly respond on their own. Once participant responded to the bids for JA with at least 85% accuracy for two conse cutive trials, a time delay was response to JA and probes were conducted post intervention to see if their JA skills were maintained. Martin and Harris (2006) study sup ports previous early intervention studies on the positives effects of DTT interventions as the authors report that each child successfully responded to JA bids and these skills were maintained after the study ended and without the contingence of reinforcem ents. This suggests that children with ASD can be taught to attend to the social cues of the interventionist. Being able to follow social cues is an important foundational skill for these children to learn, as it will help in understanding social relatio nships and interactions later on in life. In addition, initiat ion of JA skills was not directly targeted probes were conducted to determine if any of the participants elicited bids for JA. The children displayed isolated incidents of initiation of JA, suggesting that initiation of JA skills is distinctive of response to JA skills and additional research is needed in this area. Researchers should be aware that the sample size limits the generalizability of these findings, though al l 3 participants were in the same preschool classroom, which warrants that changes in response to JA were probably caused by the intervention and not outside classroom factors.

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31 In 2008, Taylor and Hoch conducted a similar multiple baseline design that ass essed the effects of using prompts and social reinforcement on the response to JA and initiation of JA skills of three children with autism. Like the previous study (Martin and Harris, 2006), Taylor and Hoch (2008) baseline data confirmed that the childre n would intermittently respond to bids of JA. The interventionist placed novel and unusual comment on th e item, guide the child to look back to the clinician, then naturally reinforce the child (e.g., tickling or smiling). Common in DTT interventions, if the child did not respond correctly within the allotted time least to most prompting (e.g., gestural pro mpt to physically prompts) towards the object of interest and/or clinician was used. research of the positive impact DTT methods has on children with autism. Taylor and Hoc h (2008) added to previous research, that through the use of social reinforcement response to JA skills could be taught. It should be noted that because physical prompts were used during training, it is possible that the children were negatively reinforce d through avoidance of prompts, rather than being reinforced through social attention. JA increased their initiation of JA did not naturally occur. Children only in itiated JA when a checklist was used and preferred items were given as a consequence for correct responses. This leads credence that response to JA skills does not lead to the more complex initiation of JA skills and may require more direct intervention. It is

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32 important to note that the authors conducted only one probe that used a novel toy in a novel setting to check for generalization and maintenan ce of response to JA skills. Another clinician le d intervention conducted by Klein, MacDonald, Vaillanco urt Ahearn, and Dube (2009); studied the effects of JA training on three young boys with ASD. The training took place in a clinical setting lasting approximately 4 7 minutes over 32 sessions. Trials one and two taught the children to follow the experimente Children received access to preferred toys when correct responses were given. As seen in the previous DTT studies, least to most prompts were used to att ain a had master ed the gaze shift + look trials, delayed cue training was introduced. Following the same procedures, once a child gaze shift towards a preferred mechanical toy, the toy was activated (e.g., toy bounced or lit up). Throughout this phase a time delay was used to activate the toy, eventually having the child wait 5 seconds for the toy of interest to turn on. The child then moved on to contingent ac toy to be activated. The toy remained on for 5 seconds and the experimenter commented on the toy. Once the criterion was met, intermittent sessions were held to streng activated only six of the nine trial times, though the experimenter made a comment about the toy to the child for every correct response to establish responses as a conditioned r einforcer.

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33 The results of Klein et al. (2009) revealed favorable effects of the JA training, as there was an increase in gaze shift in children with ASD. Through ABA techniques and shift became associated with the activation of a re inforcing mechanical toy (which in ABA terms is called a discriminative control) consequently causing an increase in gaze shift behavior. Maintenance of gaze shift in participants was fairly high as seen in the success of the intermittent sessions. Despi positives effects researchers should be cautious of results. Although gaze shift constitutes JA gaze shift to novel toys and settings. In addition, such ABA te chniques are complicated and need to be supervised by ABA clinicians, making it difficult for researchers and parents to use these interventions in the everyday world. Interventions with a caregiver component Although teaching this population JA thro ugh DTT has been successful, only a few DTT studies incorporating parents in the JA intervention process have been conducted. The importance of including parents in the intervention process is well documented (Bagnato, 2007; Cosden, Koegel, Koegel, Greenw ell, & Klein, 2006; Crowe, Norris, & Hoffman, 2000; Fletcher, Perez, Hooper, & Claussen, 2005; Schertz & Odom, 2007) indicating that greater maintenance and generalization of previously acquired skills are applied in new environments (Ingersoll & Gergans, 2005; Jones & Feeley, 2007). Isaksen and Per Holth (2009) conducted a multi baseline design across four young children with ASD to increase their response to JA and initiation of JA skill using ABA techniques. The authors recognize the importance of par ent involvement and

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34 throughout the intervention. In addition, each parent took part in the training and was taught how to implement the components of the intervention in their home environment. school conducted the training. To assess response to JA and initiation of JA pre and post intervention the authors used a simplified versi on of the Early Social Communication Scale (ESCS m). All of the children showed some response to JA skills, though compared to typically developing children their age those skills were significantly impaired. The intervention consisted of three phases: t asks that required children to respond to JA, establish adult social responses as conditioned reinforcer, through turn taking activities. During phase one the child wa s taught to shift gaze between the trainer and the toy. If the child did not respond correctly, least to most prompts were used and faded on over later trials. When the child responded correctly to response to JA, they were allowed to choose a toy to pla y with. Once five correct consecutive responses were given, the child moved on to the next phase. Phrase two was designed using ABA techniques to create adult social responses (e.g., smiling and response to JA, if the trainer would smile and nod the child would get access to toy, if the trainer did not smile or nod; access to the toy would be blocked. Once the child linked the social response with access to toy, eac h task became more involved (e.g., head turns and commands) paired with social reinforcement before access to toy began available. Turn taking tasks (e.g., puzzles and block building) took place in phase three. A correct response to JA was marked when th e child took a block or puzzle and started

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35 to play. If the child did not show initiation to JA, the therapist took the materials away and reintroduced them after 10 seconds. If the child continued to display incorrect responses, least to most pro mpts wer e used. All children showed gains in response to and initiation of JA skills from their baseline data, though greater achievement was seen in response to JA skills. This is in conjunction with previous studies as initiation of JA is a more complex skill t o teach and maintained. Unlike previous studies (e.g., Whalen & Schreibman, 2003; Taylor & Hoch, 2008) Isaksen and Per Holth (2009) report that both response to JA and initiation of JA skills were generally maintained at the 1 month follow up. One explan ation could be the parent component, as children could have received more JA practice in a variety of settings. Secondly, to promote initiation of JA skills the use of normal social behaviors as a discriminative stimulus may have helped in greater mainten ance of that skill. Interpretations of DTT research findings. Based on the research reviewed, it appears that JA interventions that exercise DTT in their treatments demonstrate promising results (Isaksen & Per Holth, 2009; Klein et al., 2009; Martin & Har ris, 2006; Taylor & Hoch, 2008). Benefits of utilizing DTT strategies in JA interventions were seen in each study. For example, in each of the children took more trials than others to move onto the next session). DTT trials are useful because they provide children with a pre dictable controlled environment, while receiving intense amounts of treatment. Although this type of environment may be co mforting, the tight control does not allow for incidental teaching, so it becomes difficult for new skill s to generalize (Smith, 2001). This need for future research to focus in on the generalization of JA skills emerged across the DTT

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36 studies. Subsequen tly future studies may want to conduct JA intervention more natural settings and use novel stimuli (Isaksen & Per Holth, 2009; Taylor and Hoch, 2008). Additionally, because DTT interventions are rigid in method, parents often reported less satisfaction wi th DTT forms of treatment (Schreibman et al., 1991). The potential of using parents in DTT interventions is promising, as seen in Isaksen and Per Holth (2009) study. One reason the parent component may be scarce in these DTT studies is due to the complex nature of DTT strategies. These DTT techniques are based on behavioral learning theories and introduce unfamiliar terms, creating a comprehensive and complicated intervention in which intense training is needed. Therefore many researchers have utilized natura listic intervention models as they continue to use A BA techniques in more natural settings including families Joint Attention Interventions Using Naturalistic Intervention Methods A naturalistic intervention method uses objects of the st and common turn taking play activities to (Ingersoll and Schreibman, 2006; Koegel & Koegel, 2006). Koegel and Koegel (2006) dividuals with autism towards a typical developmental trajectory by targeting a broad number of behaviors and providing children with autism the opportunity to lead meaningful live in ralistic intervention approach in their studies to increase JA in preschool aged children with ASD. Appendix A (Table A 2) provides a listing and summary of the articles (2 multiple baseline articles, 2 mixed methods articles, and 1 experimental article).

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37 Clinician led Children with ASD demonstrate deficits in the ability to imitate others. This can be problematic for the acquisition of future social communicative behaviors (Ingersoll & Schreibman, 2006). In addition, there have been a few studies that show a link between imitation and JA in autism (e.g., Carpenter, Pennington, & Rogers, 2002). Pursuing these findings further, Ingersoll and Schreibman (2006) used naturalistic intervention strategies to teach children with ASD to imitate an action with an object thus increasing their JA skills. Using a multiple baseline design, across five young play, and JA skills. Each child was reported as having deficits in all areas of language, play, and JA using the ADOS G assessment. The intervention sessions took place in a clinical setting and were conducted by the first author and undergraduate research assistants. Baseline consisted of free play in which the therapist w ould only interact with child if he/she initiated the interaction. As exhibited in previous studies, all of the children showed small amounts of imitation, language, pretend play, and JA skills. This is typical in children with ASD as it is a spectrum di sorder where individuals appear to have a variety of skill levels. The intervention was comprised of five phases: no actions modeled by therapist, familiar actions with a toy that the child was engaged in, familiar and novel actions with the same toy that the child was playing with, familiar and novel actions with the same and a different toy. Phases were built off of each other and lasted approximately 2 weeks. Naturalistic intervention techniques were used throughout sessions as the therapist followed continuously about the actions they were doing. If the child copied the therapist action

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38 reinforcement was provided through a verbal praise. When the child did not imitate after three models, the therapist used least to mo st prompts and then praised the child. Data were collected using visual analysis as well as the Motor Imitation Scale the Joint Attention Assessment, and the Structured Laboratory Observation were used to assess imitation, JA, and generalization respecti vely. The rate in which children imitated significantly increased once the intervention took place and remained high post treatment indicating positive effects for the imitation intervention. Looking specifically at the dependent measure of JA, all of th e children showed increases in coordinated joint attention (or gaze shift). As the intervention increased in complexity it was noted that the children continued to engage in higher rates of JA, though only three h post treatment. Ingersoll and Schreibman (2006) acknowledge the two participants whose JA skills returned to baseline rate support previous research in which the removal of contingent imitation results in return to baseline rates of eye gaze. These dis crepancies in the maintenance of gaze shift seems to be contingent upon receiving a reinforcer, as previous research (Klein et al.; 2009) showed maintenance in gaze shift in children with ASD when paired with a reinforcement, therefore supporting the need for future research. Although Ingersoll and Schreibman (2006) claim that this study uses a more naturalistic behavioral approach, it lacks some major naturalistic components. For example, the intervention itself took place in a clinical setting. Followi ng this further, Koegel & Koegel (2006)

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39 examples future research may want to look a t the intervention being conducted by caregivers in a more naturalistic setting, thus creating a more effective JA intervention. Interventions with a caregiver component The skill of joint attention is considered a fundamental milestone for children to a cquire language. This vital skill builds upon a parent child relationship as children object associations (McDuffie, Yoder, & Stone, 2006) yet there are few JA studies that utilize caregivers in their interve ntions. Those that have a parent component report greater generalization and maintenance (Ingersoll & Gergans, 2005; Jones & Feeley, 2007; Klein et al ., 2009; Schertz & Odom, 2007). Schertz and Odom (2007) used a mixed methods design to determine the effe cts of an intervention that utilized the parent child relationship to increase JA in three children with ASD. The mixed method design was chosen so analysis could be done on both the intervention effects and a deeper understanding of how the parents felt about the overall process. The intervention effects were measured using a multiple baseline across 3 children with ASD and took place at the dyads homes supporting a more naturalistic approach. Schertz and Odom based their intervention on an open ended m odel, allowing the caregiver child interaction to be the indirect method of teaching the JA skills. This developmental approach permits natural reinforcements to occur spontaneously throughout the intervention, rather than using a specific reinforcement s chedule, as seen in DTT interventions. The model was designed to teach parents how to conduct activities that allowed their children to focus on their face, provided opportunities for turn taking, response to and initiation of JA in four phases. Focusing on face and turn taking activities were chosen as they are hypothesized to be

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40 behavioral precursors of JA, which would allow the child an easier transition into the response to JA and initiation of JA activities. Throughout the intervention, parents were interviewed and wrote weekly notes in which they describe their interactions with their child and how they felt their child performed. Schertz and Odom (2007) report ed two of the three children demonstrated gains in JA skills throughout the four interve ntion phases (focusing on face, turn taking, response to JA, and initiation of JA). Participant A showed gains only in focusing on face and turn taking, showing promise for future JA skills. Caregivers continued to use activities in different settings (e .g., backyard, restaurants) and reported that children continued to elicit same behaviors, showing that the children were able to generalize their JA skills. In addition, a 5 week post intervention maintenance measure was conducted and all children showed higher performance than in their intervention phase. intervention program. Caregivers were able to take the skills they were working on and continue to create opportu nities throughout the day. The qualitative data collected by Schertz and Odom acknowledges that caregivers felt their role as interventionist gave them more confidence to be more active in future interventions. Despite the positive outcomes of using car egivers in a naturalistic intervention there were a number of limitations. For example, although Schertz and Odom (2007) was actively engaged there was no emphasis o n how JA is a fundamental milestone in development. Caregivers did not understand the importance of JA in language and social developments and would benefit from having direct instruction in this area. In

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41 addition, the intervention did not train parents on specific techniques and although the researchers assumed a coaching role throughout the phases, greater gains might have been seen in if a mor e structured activity selection was given to parents to help more children through each phases of the intervent ion (e.g. Participant A). A typical characteristic of individual s with autism is a restricted interest on a particular topic or object (APA, 2000). Numerous studies use naturalistic intervention methods to teach JA (Kasari et al., 2010; Schertz and Odom 2007; Whalen & Schreibman, 2003) though few motivate children through the use of their restrictive interests. Vismara and Lyons (2007) expand Schertz and Odom (2007) mixed method design and examined the effects of using the restricted interests of thr ee young children with ASD as a stimulus to increase their JA skills in a single subject reversal design with a qualitative measure for interaction. The authors did not directly target JA, as they wanted to see if using objects of preferred interest would motivate children to engage with their caregiver therefore naturally increasing JA. During baseline parents were asked to play with their child like they normally would using perseverative interest toys (PI) and toys with no interest to the child (NP). Once baseline was established, the first author provided caregivers with overview training on naturalistic intervention techniques. During the intervention no direct teachings of JA skills occur. Instead, the first author would model the use of the natu each caregiver to become the main interventionist. This type of naturalistic training allowed the princip al investigator to coach the caregivers throughout the session.

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42 Throughout the study data were collected on response to JA, initiation of JA, and qualitative measure of child caregiver interactions. Vismara and Lyons (2007) show positive results for the PI condition as all children began to initiate joint attention towards the PI stimulus without direct instruction. During the alternating treatment phase when both PI and NP were used all children continued to show initiation of JA even when the NP stimul us was present, though lower levels were exhibited. This gives creditability to Vismara and Lyons hypothesis that children will generalize joint attention initiations to other objects that are not of restrictive interest to them. Examining the quality of interactions Vismara and Lyons observed that using items of interest as motivation helps create more natural social interactions. Furthermore, it appears that using objects of interest combined with naturalistic intervention techniques helped to create o pportunities for meaningful child caregiver interaction that were mutually reinforcing, consequently increasing joint attention skills. This is an important discovery as previous studies (e.g., Martin & Harris, 2006; Taylor & Hoch, 2008) had a difficult t ime teaching initiation of JA skills. In a second study Kasari et al. (2010) randomly assigned thirty eight child parent dyads to an experimental group or a wait list group to determine the effects of a caregiver mediated joint engagement intervention. The child caregiver dyad met with a trained interventionist three times a week for a total of 8 weeks. A module was presented weekly to each caregiver explaining how to teach children with autism JA skills. In each session, a trained interventionist mode led skills and the caregiver was given opportunities to practice those skills with their child. Furthermore, the

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43 interventionist was able to coach the caregiver throughout the sessions, providing corrective feedback as well as praise. An ANCOVA was used t o compare the immediate treatment (IT) and waitlist control (WL) groups. Children in the IT group showed significantly more joint engagement and a decrease in object focus play compared to the WL group. In addition, children placed in the IT group showed greater gain in response to JA, though there was no difference in initiation of JA or an increase of symbolic play between groups. These findings are similar to Schertz and Odom (2007), asserting that initiation of JA skills is difficult to teach to chil dren on the spectrum and likely need longer and denser interventions (Kasari et al., 2010). fidelity in implementation, their child moved more fluently from object focus engag ement not. Due to high fidelity, those children were given more opportunities to participate in joint engagement, consequently increasing their response to JA. A regressio n analysis was also conducted and findings show that after controlling for pretreatment scores the authors also conducted a follow gains were maintained or improved in the areas joint engagement, response to JA, and types of play for the IT groups. Although these gains were sustained, the authors do not know what specific components of the interventions contribute to this claim. Interpretation of naturalistic intervention research findings As indicated previously, the primary goal of using naturalistic intervention strategies are to allow children with ASD the opportunity to learn new skills that are

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44 contextually relevant, whi ch may let them to be actively engaged in everyday living (Koegel & Koegel, 2006). Interventions involving naturalistic intervention methods create a more natural environment, making it easier to integrate the interventions yday routine. For example, natural turn taking activities, which occurred across all the above naturalistic method studies, can be replicated virtually anywhere. In addition, there is little need for tangible reinforcers as natural reinforcers occur duri ng the turn taking activities (Schreibman et al., 1991). The naturalistic intervention approach emphasizes the importance of parents as the primary agent (Koegel & Koegel, 2006). We see, with the exception of one study (Ingersoll & Schreibman, 2006), tha t the family involved was used as in integral part of the above JA interventions involving naturalistic strategies. Across those studies (Kasari et al., 2010; Schertz & Odom, 2007; Vismara & Lyons, 2007) positives JA gains were attain by all participants. In addition, numerous caregiver factors that affect treatment outcomes were evident (Kasari et al., 2010). Although an aim of caregiver mediated interventions is to train the caregivers so the child has ample opportunities to practice target skills thro ughout the day, if the intervention does not match the caregivers beliefs, or caregivers find it too difficult to execute, or the intervention lacks guidelines the probability of high fidelity implementation is low. Moreover, if caregivers do buy in to th e intervention, they still may not provide ample opportunities for a child to practice skills, thus reducing the effects of the JA intervention. Although Kasari et al. (2010) and Schertz and Odom (2007) specifically targeted initiation of JA skills both r eport that these JA skills did not improve even if the child made significant gains in response to JA skills. Based on the research reviewed it

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45 seems that initiation of JA skills may be difficult for young children with ASD to learn, even though in one st udy (Vismara and Lyons, 2007) minimal increases in initiation of JA were reported. Research suggests that JA is linked to motivation and therefore fits within the framework of naturalistic intervention methods (Kasari et al. 2010; Koegel & Koegel, 2006). Thus, by targeting motivation within JA interventions there may be greater gains in behaviors associated with JA in children with ASD. One could infer that initiation of JA skills are increased due to the motivational factor that using highly preferred o bjects provides, though a dditional research is needed. Overall the JA interventions that use naturalistic intervention strategies show promising effects in increasing JA skills in preschool children with autism. With this in mind, it is important that res earchers teach the intervention sessions in such a way that caregivers are knowledgeable and confident in their execution of the naturalistic intervention strategies, as the number of the trials (i.e. opportunities) depends on the engagemen t between caregi ver and child. Interventions Using Both DTT a nd Natural istic Intervention Methods The following five studies use a combination of DTT and naturalistic intervention strategies in their interventions to increase JA in preschool aged children with ASD. Appen dix A (Table A 3) provides a listing and summary of the articles (3 multiple baseline articles and 2 experimental article). Clinician led Whalen and Schreibman (2003) conducted a multiple baseline across participants intervention to assess five preschool aged children with ASD on the effectiveness of JA intervention using both DTT and naturalistic intervention strategies. In addition, the authors had six typically developing participants in the intervention so

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46 they were able to identify what typ ical preschool social behavior looks like. After baseline was established each child participated in joint attention training consisting of two phases: response to joint attention bids and making joint attention initiations towards an adult. In phase one the experimenter used DTT (e.g., inter trial intervals, reinforcer) to teach the children how to respond ap propriately to JA bids. Phase two provided opportunities for the children to engage in coordinated gaze shifting (i.e., child looks at object of interest (i.e., pointing to a picture on the wall with the purpose of sharing the experience with the experimenter). Following DTT and naturalistic protocol children with ASD were given an allotted amount to respond before least to most prompts were used to elicit correct respon se. This allotted time was based on the average time provided by the typically developing participants. To measure JA throughout the study the children with ASD were given the following assessments: Unstructured Joint Attention Assessment, Structured Labo ratory Observation (SLO), and Structured Joint Attention Assessment (adapted from ESCS). Typically developing children were not assessed, as they all showed response to JA and initiation of JA prior to study and were used to compare typically JA. Whalen and Sch reibman (2003) report that the response to joint attention training was effective, as all children successfully completed all trials. In addition, all children with ASD showed ze. Teaching initiation of JA was only effective for four of the five children as one participant was

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47 unable to coordinate their gaze shift, therefore unable to continue. Although teaching initiation of JA was effective, only one child with ASD showed si gnificantly gains in initiation of JA, while the remaining 3 participants had only slight increases in initiation of JA skills. For participants with ASD that completed the entire intervention, generalization of JA skills was assessed 3 months after the i nitial intervention. The four participants maintained responding to JA bids at high levels, while the three participants continued to show minimal initiation of JA skills. As with the other reported studies Whalen and Schreibman (2003) found it is easier to teach children with autism response to JA than initiation of JA skills, nominal gains were demonstrated by a few students. Low mental or low language age might have played a role for the child that was unable to complete the training. Typically childr en do not master initiation of JA until about 14 months of age and assessments participants showed some initiation of JA skills, their coordinated gaze decreased while poi nting continued to be seen. This could be due to the lack of caregiver training since pointing is more likely to be reinforced than the more complex skill of coordinated gaze. Kasari, Freeman, & Paparella (2006) examined the efficacy of a clinician led JA intervention on children with autism joint attention skills. Using an experimental design, Kasari et al. randomly placed 65 autistic children into treatment conditions of joint attention, symbolic play, or control group. Kasari et al. evaluated JA sk ills pre and post intervention by the following assessments: Early Social Communication Scales Structured Play Assessment and a 15 minute videotaped of each caregiver child. All interventions took place in a clinical setting and a trained graduate ass istant conducted

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48 the JA intervention for approximately 30 minutes a day, for an average of 5 6 weeks. Each session began with numerous trials in which the experimenter would use DTT strategies (e.g., verbal prompts, modeling, positive reinforcement) to te ach each participant a targeted JA skill. Following the DTT, the experimenter and child would move to the floor to practice the target JA skill using naturalistic strategies (e.g., ted JA skill was mastered (i.e., at least 3 times at both tables and floor) the child was then introduced to the next JA skill. Kasari et al. (2006) reported children who partook in the JA intervention displayed significant gains in responding to JA bids After the intervention, these children initiated more bids for JA during the mother child interaction sessions than children in the symbolic play and control groups. This illustrates that the children were able to generalize their JA skills, as the mot hers were not the treatment provider. Although the sample size adds to the power to this study, some limitations are the lack of follow Interventions with a caregiver comp o nent In 2007, Jones and Feeley conducted a multiple baseline design study to assess caregiver effectiveness in using DTT and naturalistic intervention techniques to increase response to JA and initiation of JA skills in three preschoolers with autism. The author and a graduate assistant presented information to each caregiver on the importance of JA, defined response to JA and initiation of JA skills, and explained th e intervention procedures. To ensure that each caregiver understood the procedures, the first author modeled the intervention with both parent and child present. The caregiver

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49 was then able to practice the intervention components with the first author ac ting as the child. As the caregiver started the intervention with their child, Jones or the graduate assistant continuously gave feedback and answered any additional questions the caregiver had. Staying true to DTT and naturalistic methods, the caregiver provided the child with numerous opportunities in quick succession. Once the child mastered response to JA skills, they were then taught initiation of JA skills. Similar to other studies (Klein et al., 2009) Jones and Feeley (2007) used mechanical toys that could be previous studies, least to most prompts, high rates of reinforcement, and objects of interest were used to elicit correct JA responses from the child. Jones and Feeley consequences (e.g., parent commenting on object of interest) as reinforcers. Chosen by the caregivers, the idiosyncratic behaviors were child preferred. Jones and Feeley believed that pairing idiosyncratic reinforcements with natural consequences would create a stronger reinforcement as the natural consequence of JA is social, a behavior which alone does not seem to be as reinforcing to children with ASD. In additi on, if it was noticed that the child did not seem interest in the reinforcement, an edible reinforcement was provide and eventually thinned out. Jones and Feeley (2007) results affirm that caregivers are able to effectively implement response to JA and i nitiation of JA intervention to their children. By the same token each child successfully illustrated both response to JA and initiation of JA skills respectively. Generalization of response to JA and initiation of JA skills were examined through baselin e probes (none demonstrated either JA skill) and 1 month after the

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50 intervention was completed. During the follow up generalization probes, with no prompting, all three participants demonstrated JA skills with the five generalization toys. However it shou ld be noted that all caregivers who participated in this study have been involved in other interventions with their child. Their previous experiences with the DTT and naturalistic strategies prior to this study may have influenced the results of this stud gaze alternating and pointing. However, after the researchers taught gaze alternating and pointing did the child master the initiation of JA suggestion benefits of d irectly teaching these skills. Rocha, Schreibman, and Stahmer (2007) took a previous therapist implemented intervention (Whalen & Schreibman, 2003) and examined the effects of using caregivers to implement the intervention on teaching response to JA to pre school children with autism using a single subject across dyads design. The study took place in a clinical setting and only after baseline was established caregivers were told they were going to be trained strategies that would help increase JA skills. A t the beginning of each training session, caregivers received direct instruction on the specific DTT and the naturalistic strategies they were to use. In addition, they were taught the importance of JA skills, the benefits of parent involvement, and activ ities that would provide their child with numerous opportunities to practice JA skills. To ensure that the caregivers understood the procedures, the trainers would ask caregivers to provide them with examples of how they would use certain activities to cr eate JA opportunities. Caregivers were able to ask questions throughout the training and once they showed proficient knowledge of the procedures the trainers would model JA techniques with the

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51 child. Next, caregivers were asked to implement the JA proced ures (initiating JA, prompting, and reinforcement of JA skills). Throughout the sessions the trainer coached and gave feedback. Additional instructions were faded and eventually the trainer left the room and would only give feedback through a one way mir ror if procedures were implemented incorrectly. Besides implementing the intervention in the clinical setting, caregivers were asked to execute the training components at home as well as other settings to ensure generalization of JA skills. Rocha et al. (2007) determined that all parents were able to implement the JA the ability to provide opportunities for response to JA in a variety of settings, as baseline showe d minimal JA bids from parents and subsequent growth in JA opportunities as the study continued. However, one caregiver did not implement the JA training at home though she was able to do so in the clinical setting. Perhaps this caregiver was dependent o n the trainer or did not buy into the intervention. Either way, further research is needed in this area as this may have influenced why the child conveyed minimal JA behavior at the 3 month follow bids for JA i Although Rocha et al did not directly targeted initiation of JA skills they highlight that children were displaying some initiation of JA skills. Though nominal, children would al ternate their gaze between the object of interest and caregiver, establishing coordinated JA In light of these findings one would be cautious in how to interpret

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52 abilit y to break down the effects of the time used to train and t he effects of specific phases. Few studies have been conducted examining the effects of JA interventions when implemented in a preschool setting. Kaale, Smith, and Sponheim (2012) implemented an e xperimental design study in which 61 preschool age children with ASD were randomly assigned to either an 8 week JA intervention or a control group. The purpose of this study was to see if a preschool mediated intervention would increase JA skills. Using a modified version of the JA intervention designed by Kasari show, point, and give. As in the previous study, interventionists were used to teach and coach each te acher on how to correctly implement the JA intervention. Based on DTT and naturalistic strategies, 34 preschool teachers delivered one on one intervention, twice a day, for 8 consecutive school weeks. The children with ASD in the intervention group conti nued to receive the preschool curriculum in addition to the intervention w hile the children in the control group only received their current preschool curriculum. Analyses of the data indicated that the children in the JA group as they were five times more likely to display initiation of JA skills during the 10 minutes of play, than the children in the control group. Subsequently, children in the JA group were able to generalize these skills during mother child play. On average children in the JA group we re jointly engage d with their mother 12.2% longer than a child from the control group. Alt hough it should be noted th at no significant difference was reported for children in the JA group being able to display initiation of JA skills. This is not uncomm on, as previous studies (e.g., Kasari et al., 2010; Schertz & Odom, 2007) attest to the difficultly

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53 of children with ASD being able to generalize JA skills to others beyond the intervention provider. With this in mind, future research should examine what the effects of longer interventions would have on child ren with ASD and JA skills conducted by providers with expertise in behavioral skills. This study affirms power through its large sample size, randomization, and generalization. Kaale et al. study is an asset to the growing literature of JA interventions, as there are very few studies out on preschool mediated component. Interpretation of DTT and naturalistic intervention research findings The research reviewed demonstrates that JA interventions successfully merged DTT and naturalistic intervention components to successfully teach children with autism JA skills. The use of sessions in which JA skills are broken down into small components ( e.g., DTT) using natural reinforcers in a naturalized sett ing show that these ABA strategies can be married into a productive intervention. Complementary to the findings in the previous section, the studies that used parents as the intervention provider demonstrate d that if given the effective methodology, paren ts can successfully implement DTT and naturalistic intervention methods in familiar settings. The effectiveness of parent implementation suggests that JA intervention can become an integral part of parent training programs (Jones and Feeley, 2007; Rocha e t al., 2007). The lack of caregiver training in the Whalen and Schreibman (2003) study may explain the decrease in response to JA and initiation of JA skills in follow up observations. In addition using parents allows for generalization of newly found sk ills and is an important measure when evaluating parent implemented interventions and should continue to be done in future JA intervention (Kasari et al., 2006; Rocha et al. 2007).

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54 The use of a highly preferred object is another theme that is seen througho ut these studies (Jones & Feeley, 2007; Rocha et al., 2007; Whalen & Schreibman). Although the children working on initiation of JA skills used the highly preferred toys most often it brings to question if the newly learned JA skills will generalize to n ovel objects and needs further research. Taken as a whole, these studies suggust that DTT and naturalistic intervention methods both bring important components to early intervention for children with autism and one method does not take precedence over the other. Review of Shared Storybook Reading Literature Joint attention is situated early on in the caregiver child relationship (Bakeman & Adamson, 1984). Typically these interactions happen during familiar routines and daily interactions. Shared storybo ok reading is a natural activity in which a caregiver and child partake in joint interactions that utilize JA skills (Fletcher, Perez, Hooper, and Claussen, 2005). In addition, shared storybook reading is an evidence based literacy intervention that has d emonstrated effectiveness in increasing emergent literacy skills for the majority of children (Beauchat et al., 2009; Fielding Barnsley & Pudie, 2003; Justice & Ezell, 2002; Justice, Kaderavek, Fan, Sofka, & Hunt, 2009; Lane & Wright, 2007). This interact ive intervention advocates the growth of language and social participation, two core deficits for children with ASD. This technique not only increases a variety of developmental skills for many children, but also allows parents to tailor the intervention The following section explains the following: a) the importance of shared storybook reading, (b) briefly defines the early emergent literacy skills impacted by storybook reading, (c) highlights the influence that shared storybook reading can have

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55 on the at risk population, and (d) evaluates how shared storybook reading improves developmental and early literacy skills among preschool students with disabilities, particularly children with autism. Importance of Shar ed Storybook Reading Beauchat et al. (2009) broadly define s when an adult reads to a child or children, pausing to engage in discussion about the the impact of young children has a significant, substantial, and positive impact both on young 2008, learning to read and write. Through shared story book reading, children are exposed to skills vital for social, language, and cognitive development (e.g., JA phonemic awareness, written language, and complex communication designs) (Bus, van IJzendoorn, & Pellegrini, 1995; Justice & Ezell, 2002; Lane & Wright; 2007). Children who partake in shared storybook reading are provided with opportunities to share a common expe rience with another individual, develop new concepts, increase vocabulary, develop listening comprehension skills, and engage in conversations about text through questions and answer sessions (Hay & Fielding Barnsley, 2007). The significant role that sha developmental stage is well documented (Goin, Nordquist, & Twardosz, 2004; Hay & Fielding Barnsley, 2007; Koppenhaver & Erickson, 2003; Lane & Wright, 2007; Lanter & Watson, 2008; Morgan & Meier, 2008). Research on shared storybook reading indicates the frequency with which a child is read to along with the caliber of adult child

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56 interaction increases the amount of language and literacy learning that transpires during this context (Crowe, Norris, & Hoffm an, 2004; Teale & Sulzby, 1986). These findings lend significant credence to the importance of the shared storybook reading experience and help s young children acquire the emergent literacy skills essential for later academic success (Bus et al., 1995). F or the purpose of this literature review, these emergent literacy skills have been categorized into five subskills: book knowledge, print awareness, phonemic awareness, alphabet knowledge, and oral language. Literacy s ubskills Book knowledge is an underst anding of how books work: how to hold a book correctly, turn pages, and read text from left to right (Beauchat et al., 2009). Although seemingly insignificant, research indicates that this experience begins to create an interest in books for preschool age d children, consequently contributing to Barnsley, 2007; Justice & Ezell, 2002; Morgan & Meier, 2008). Through joint storybook reading, children also begin to acquire print awareness s kills (Justice & Kaderavek, 2002). Print awareness is the ability to understand th at print, rather than pictures that carry meaning to tell a story (Johnston et al., 2008). According to a recent meta analysis (Mol et al., 2009), providing young children an opportunity to retell or act out a story they have heard, results in an improvement in their oral language and print related skills. In addition, Justice et al. (2009) correlates the print knowledge skills young children acquire in preschools and kinde Another emergent literacy skill that students gain through shared storybook reading is phonological awareness. This construct is often referred to as

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5 7 acknowledge structures of sounds (e.g. syllables, rhyme, initial sounds and phonemes) that arise in spoken language (Beauchat et al., 2009; Hay & Fields Barnsley, 2007). Torgeson and Burgess (1998) found that the two most powerful predict ors for reading success are letter name knowledge and phonemic knowledge. Yet another predictor of reading development is alphabet knowledge (Beauchat et al., 2009). Justice and Ezell abetic units (graphemes), including details and distinctive features of letters as well as the names of Morgan and Meier (2008) reported that children who exhibit a well developed oral vocabulary have the necessary skills to become competent readers. Their findings show that prerequisite for becoming a proficient reader because they are necessary for a child to Shared Storybook Reading and At Risk Population Ther reading performance at the beginning of first grade (Massetti, 2009). Children in poverty are at higher risk of literacy delays than children who come from affluent families. This achievement gap happens long before these children enter formal schooling. According to Hart and Risley (1995) report that low income children begin school with exposure to 15,000 less vocabulary words then children from higher SES environments. Numerou s studies highlight the difference in early literacy skills achievement between young children from low income households and those from affluent household s (Chaney, 1994; Hay and Fielding Barnsley, 2007; Justice & Ezell, 2002; Justice et al., 2009; Whiteh urst et al., 1994). These deficiencies are due in part to

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58 low SES families providing little or no literacy opportunities for their children (Goin et al., 2004). Research findings have chronicled that low SES children lack the exposure to language and voc abulary during shared storybook reading. Therefore, when these children enter school they demonstrate deficits in the literacy skills that are necessary for them to become proficient readers (Justice & Ezell, 2002; Lonigan & Whitehurst, 1998; Massetti, 20 09). Whitehurst et al. (1994) reported that low SES children entering first grade have an average of 25 hours of one on one picture book reading, whereas children from middle class homes enter with 1,000 to 1,700 hours. Whitehurst et al. go on to describ e the less than favorable preschool environments in which low SES children are enrolled. Justice and Ezell (2002) had similar findings, stating that preschools and daycare facilities located in poverty stricken areas had little to no literacy rich areas f or young children to explore throughout the day. It is noteworthy that there is no consensus on the relationship between low SES and emergent literacy skills. In the Hay and Fielding Barnsley (2007) literature review, SES alone was a weak predictor of re ading achievement; instead, it was the lack of social and literacy activities The shared storybook reading literature stresses the important role that parental uisition of literacy skills (Justice & Ezell, 2002; Whitehurst et al., 1994; Fielding Barnsley & Purdie, 2003). Parental beliefs regarding such as print awarenes s and oral language development (Justice et al., 2009). Whitehurst (1994) found that low SES mothers engaged in fewer instructive behaviors

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59 during joint reading, as compared to higher SES mothers. Justice et al. (2009) explain of the inherent and systematic stresses associated with Numerous studies have been conducted to see what types of interventions and evidence based strategies work best in shared storybook reading to increase low SES stud reading (Whitehurt et al., 1994; Justice & Kaderavek, 2002; Justice & Ezell, 2002). This promising method allows the child to become an active participant in the storybo ok information, and prompting the child to increase sophistication of his or her descriptions nd Ezell (2002) used dialogic storybook reading to increase print awareness in a study of at risk children. Justice et al. (2009) later conducted a similar study in which teachers of low SES students used dialogic reading with a print focus. Results show ed that preschool students made greater gains in print knowledge, alphabet knowledge, and name writing when read to using dialogic reading v ersus traditional reading. Whitehurst et al. (1994) lead a similar study but also taught low SES parents how to use dialogic reading in the home environment. Researchers also provided the school and the parents with books to allow the children to have a print rich environment in both settings. Numerous standardized language assessments were given to the children befo re and after the implementation of the intervention. The intervention was statistically significant and the children showed gains in expressive abilities and vocabulary development.

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60 Current research demonstrates the strong relationship between shared st orybook reading and the acquisition of literacy skills by low SES students. Throughout the read aloud experience, caregivers can engage children in meaningful discussions using new vocabulary in the context of the story. Children acquire additional oral language through child friendly definitions and repeating unfamiliar words (Beauchat et al., 2009; Lane & Wright, 2007). Methods for Shared Storybook Reading Literature Review In collecting the data for this literature review I selected all of the databas es the University of Florida provides and typed in a combination of the keywords: literacy, preschool, autism, intellectual disabilities, emergent literacy, disabilities, dialogic reading, home, reading, emergent reading, intervention, shared reading To reduce the number of articles retrieved, the publication date was changed to 1990. The criteria for inclusion in this review were the following: (a) the research design was experimental or quasi experimental design; (b) a face to face intervention using s hared storybook reading strategies; (c) the participants were of preschool aged children (12 72 months); and (d) each participant had a diagnosis of developmentally delayed, language impairment, or autism spectrum disorder. Of the 157 articles remaining, 153 were eliminated based on reading the titles and abstracts. Four articles were retained and an ancestral search was done and two additional articles were found. Due to the limited amount of articles that used the caregiver to implement shared storybook interventions (six articles), the search was widen ed to includ e clinician led interventions and a n additional four articles were found (Van Kleeck, Vander Woude, & Hammett, 2006; Lovelace, and Stewart, 2007; Bellon Hard & Harn, 2008; Bellon, Ogletree, & H arn, 2000).

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61 Ten studies met the criteria for inclusion in this review. Seven studies included developmentally and language delayed children, and three studies had children on the autism spectrum. Six studies used a single subject design and four used an experimental design. Appendix B provides a listing and summary of all the sha red storybook reading articles. Shared Reading Interventions with Children with Language and Developmental Delays veloping and at risk children have had an increased in the quantity and quality of joint participation and communication with their caregiver after participating in shared reading interventions, though there are very few studies focusing on children with l anguage impairments, developmentally delays, and other disabilities (e.g., autism) (Bellon Harn and Harn, 2008; Crowe, Norris, & Hoffman, 2004; Fielding Barnsley & Purdie, 2003; Hay & Fielding Barnsely, 2007). Fewer literacy experiences and deficits in ex pressive language, cognitive, behavioral, and social development are common traits that children with language and developmental delays share with children with ASD. Thus, given the similarity, comparable interventions should be implemented with autistic children (Bellon, Ogletree, and Harn, 2000; Vogler Elias, 2009; Whalon, Hanline, & Wood, 2007). Therefore, the following seven studies were chosen in particular because they focused on younger aged children with language and/or developmental delays partic ipating in a shared storybook reading intervention. After reviewing the articles, the research fell into the following categories: 1) Interventionist led interventions and 2) Interventions with a caregiver component. Appendix B (Table B 1) provides a li sting

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62 and summary of the articles (2 group experimental, 2 quasi experimental, and 3 multiple baseline designs). Interventionist led Caregivers of children with language impairments tend to interact less (e.g. ask less questions, give fewer comments) durin g shared storybook reading (Bellon, Ogletree, and Harn, 2000; Van Kleeck, Wouder, & Hammett, 2006; Whalon, Hanline, & Wood, 2007). This disconnect in the joint interaction is due to storybook reading being transactional in nature; caregiver and child natu rally influence one another (Bakeman & Adamson, 1984). For instance, a child that has difficulty interacting due to their language impairment influences the caregiver as the lack of interaction is not reinforcing for the caregiver to continue the reciproc al interaction needed in shared storybook reading. Therefore, children with language delays may not be exposed to valuable development skills, emergent literacy skills, and more complex language, such as literal and inferential language. Due to the lack of exposure, children with language impairments often have difficulties not only at the literal level, but also with inferential language used (Crowe et al., 2004; Van Kleeck, et al., 2006). Van Kleeck et al. (2006) study examined the effects of a shared storybook reading intervention on the literal and inferential language skills of 30 preschool students with language impairments. This randomized control group design, pre tested Structured Photographic Expressive Lan guage Test II (SPELT II) and the Columbia Mental Maturity Scale (CMMS) for nonverbal cognitive ability. In addition, the PPVT language, while the Preschool Language Assessment Instrument (PLAI) assessed both literal and inferential language. The average pretest score for both the PPVT III

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63 (M=77.30) and the PLAI (M=.84) were considered to be significantly lower than scores from typically developing children. The children in the treatment group participated i n one on one 15 minute shared storybook reading sessions, twice a week, for 8 weeks, while the control group received nothing. The intervention consisted of a graduate student asking children a variety of embedded scripted literal and inferential question incorrectly, the graduate student used prompting and/or modeling. All sessions were video and audio recorded and then coded to ensu re treatment fidelity. Post testing was using a repeated measures analysis of variance (ANOVA) or analysis of covariance (ANCOVA). Positive effects of the storybook inte rvention were seen in both the abilities. The control group did not show a signific ant difference in language pre and posttest. Literal and inferential language can be complicated skills for children with language impairments to acquire; less exposure adds to the problem. Van Kleeck et al. (2006) storybook intervention embeds questions that emphasize children to identify and recall information from the story. These li teral qu estions about the storybook create opportunities for the adult child dyad to move beyond the text and infer about feelings and events. During the intervention the graduate assistant scaffold questions and modeled more intricate language. These st rategies help the child contextualize language, and facilitate their comprehension of text. Although positive gains were seen

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64 in the treatment group, small sample size and immediate assessment of language skills after the intervention warrants future rese arch. In addition, it is not clear if the one on one storybook reading or the storybook intervention itself was the cause of positive gains, as the control group did not receive any treatment. Print awareness is an emergent literacy skill often used dur ing shared storybook reading. A strategy often use to increase print awareness is called print referencing This strategy is frequently embedded throughout the storybook session to explicitly j r oral language (Justice & Kaderavek, 2004). subject, multiple probe baseline across participants, assessed the use of non evocative, explicit print referencing during storybook reading to increase print awareness in children with language impairments. The 5 participants were between the ages of 48 60 months, scored 35% or less on the Concepts of Print Assessment (CPA), and received language intervention services. The 13 week intervention was conducted by the first a uthor and took place at an early learning center. During baseline condition, children were probed for their knowledge of print concepts. Their regular language services were continued throughout the course of this study. Once the language service conclu ded, the first author read a 10 minutes storybook. The storybook portion provided embedded opportunities for the child to work his/her targeted language IEP goals.

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65 The intervention condition was conducted similarly to baseline (i.e., language service, fol lowed b y a 10 minute storybook session) with the addition of non evocative strategies (e.g., commenting, tracking, and pointing to print concepts) during the storybook reading portion. The non evocative strategies were used to bring print related concepts participant, using a book that was not previously read. Data was collected from the CPA probes, calculated (percent correct), and then graphed. Through visual inspection of the data, all children had immediate improvements in their first CPA probe (range= 45% 50%), th ough there was a greater variability in the final intervention probe (range= 35% 80%). To assess generalization letter) using a new book. The generalization scores wer e less than the final intervention probes (range= 35% 50%) but higher than baseline (>35%). Love lace impairments are able to learn print concepts through the use on non evocative, explicit referencing. Increasing the opportunities to expose children with language impairment to print knowledge in a non invasive way is valuable as it promotes print awareness without the demands of having the child vocalize answers. Although this study shows promises for children with language impairments, this study had several limitations. sessions, and 8 sessi ons) and it is unknown if this a ffected the results. Print knowle dge

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66 was only assessed by one measure (CPA). In addition, the validity of the CPA needs to standardized assessment tool. Furthermore, due to the small sample size and the intervention being implemented in one setting, the generalizability of the study is unclear. Effective with both typically developing and at risk children, scaffolding is used to increase emergent literacy skills. Bellon systematic application of prompts (p.112). Bellon Harn and Harn used scaffolding as an intervention strategy during repeated storybook reading with a 6 year old girl diagnosed with moderate to severe mental retardation. The young girl, Emi ly, had developmental delays in gross and fine motor, language, social, and self help skills. When the study began, Emily primarily used one word utterances to communicate about objects or actions and two word (p.114). The two treatment conditions were scaffolding only and scaffolding in conjunction with an augmentative and alternative communication (AAC) device. Baseline data was not collected; instead a multi element design was used to compare speech output. The three scaffolding strategies of wh questions, modeling, and expansion were alternatively implemented during the two treatment conditions. Storybooks were selected based on redundant text, interesting pictures, and plots that were meaningful to the child. In both conditions the use of scaffolding increased communicative behavior and phonological complexity while decreasing off topic utterances. The participant demonstrated an increase in initial and final consonant sound, a literacy skill that was no t present before intervention.

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67 The addition of an AAC device in the school context allowed a student who once had a difficult time communicating with her environment, become an active participant (Bellon Harn & Harn; 200 8). The number of child initiated on topic utterances was greater during the AAC condition, then at any other time. This is an important factor because of the intrinsic difficulty children with language and developmental delays face during literacy activ ities. Some children may require an AAC device, which they may or may not have access to in the environment in which shared reading takes place, making it difficult for the child to communicate (Koppenhaver et al., 2007). Other children simply do not und erstand the task or question that is being asked of them and, as a result, cannot be taught in the traditional way (Basil & Reyes, 2003; Goin et al., 2004). Although this study shows promise for children with severe language impairments further research i s needed as the sample size was based on one child. Furthermore, it component was added. Caregiver component ilitates the establishment of JA 215). The joint focus on the story allows the caregiver to better understand and l to a caregiver when their child displays language impairments. In 1996, Dale and Cole conducted an experimental design study in which 33 mother child dyads were randomly assigned to either a dialogic reading intervention or a language focused comparison group. The purpose of this study was to determine the effects of the caregiver implemented interventions on children (36 72 months) with language delays. Before the experiment

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68 began, each child was assessed using the y and General Cognitive Index (GCI) for general cognitive measures and the PLAI for the free playing (depending on intervention group) with their child and Mean Length of Utterance (MLU) was assessed at this time. (DRTP). This video explained numerous strategies th at facilitate language during storybook reading. The comparison group watched a conversational language training program (CLTP) which show caregivers ways to encourage and promote language during free and after viewing their assigned video were given opportunities to discuss what they watched, as well select toys or books to use with their child. Care implement their assigned intervention for approximately 8 weeks. Post testing was videotaped at the end of intervention using the same toys or books used during the pretest sessions. Videotapes were used to collect data and then tra nscribed to assess language. Moreover, two coding system were created and used to analyze interactions between caregiver and child. Caregivers in the DRTP intervention had si gnificant increases in their overall engagement, asking more questions, imitating, and expanding behaviors. Caregivers in the CLTP intervention only had an increase in expansion. Although there was an

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69 increase in MLU for all children pre to posttest, it is noteworthy that children in the dialogic reading intervention had more significant changes in MLU and in the number of different words they produced. Dale and Cole (1996) study adds to the growing research that supports shared storybook reading creates opportunities for children to hear and practice more complex language, thus increasing their overall language skills. This study also shows promise short amount of time. Research shows the impact that caregiver s can have on their language skills acquired by children with language delays during storybook reading should be assesse d (Kasari et al., 2006; Rocha et al. 2007). Likewise, this study did not monitor the implementation of either language interventions. Additional monitoring and coaching could have strengthened the interventions treatment fidelity, as there is no record o f how they were imple ment ed Fielding Barnsley and Purdie (2003) intervention supports the positive impact the effects of an eight week dialogic reading home intervention with developmentally delayed children. The 26 children (mean age 70.2 months) in the experimental group were matched with the 26 children (mean age 70.5 months) in the control group. The PPVT III, Rhyme Recognition Test Concept s of Print Test (CAPS), and the Recognition of Initial Consonant Sound and Alphabet (RICSA) were administered to all children two weeks before formal intervention reading instruction. Additional word identification and spelling assessments were given to e ach child based on an abridged assessment

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70 version used in a similar study (Liberman, Rubin, Duques & Carlisle, 1985). The The Reading Together series. Videos illustrating t he use of dialogic reading during shared reading were given to the caregivers to watch. Caregivers were also asked to read to their child at least five times during the intervention. Although there was no statistical difference in alphabet knowledge for e ither group, the results demonstrated that the intervention group scored significantly higher in picture vocabulary, initial consonant, rhyme, and print concepts than the control group. Even with all the literacy barriers young developmentally delayed chi ldren face, Fielding Barnley and Purdie (2003) provide evidence that dialogic reading has a positive effect on shared storybook reading and should be encouraged. The use of dialogic reading is beneficial as it provides opportunities for the development of new content, introducing new vocabulary, and practicing complex language (Hays and Fielding Barnsley, 2007). Due to the small sample size, interpretation of results s hould be carefully examined. Furthermore, the authors did not describe the abridged version discussion of the reliability and validity of these instruments is warranted. In addition, Fielding Barnsley and Purdie did not observe how the caregiver implemented the intervention. Future research should consider more rigorous treatment fidelity guid elines for a stronger study. Studies have documented that caregivers of childr en with language impairment

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71 Crow e Norris, & Hoffman, 2003). Crowe et al. (2003) assessed the effects of training six caregivers to use an interactive reading int ervention called Complete Reading Cycle (CRC) with preschool students (between 38 41 months) who displayed impairments in language development. The Slosson Intelligence Test (SIT), Preschool Language Scale 3 (PLS tual and expressive communication ability. A single subject multiple baseline across subject design was facilitated to implement the CRC intervention. The caregivers were trained in the CRC four essential components: Attentional Vocative, Query, Response and Feedback. The primary investigator taught the caregiver the four CRC components as steps. The throughout the implementation of the intervention. Video recordin gs were taken from the baseline, tr aining, and maintenance phases. Data form the recordings data w ere collected, and analyzed. Through the use of CRC there was a significant increase in the number of child and parent interactions. Communicative turns between child/parent dyads also had significant increases. The children also showed gains in communication initiations throughout the story session. Moreover, four of the children spoke more words at the follow up s ession than during baseline. Studies ha ve shown that children with language impairments engage differently then their typically developing peers during caregiver child storybook readin g (Ezell & Justice, 1998; Crowe, 2000; Crowe et al., 2003). Crow e et al. study displays how interactive readin g strategies can increase joint interactions during storybook reading. Such strategies create opportunities for children with language impairments to engage

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72 to initiate c ommunication about th e text. These joint interactions help clarify the text for resea rch is needed in this area as a small s ample size was used. Although all children d in the data. The background and experience of each caregiver could have also played a role in the implementation of the intervention. Controlling for such factors, would give the study more power. Justice, Skibbe, McGinty, Pia n ta, and Petrill (2011) assessed the practicability, efficacy, and social validity of a print knowledge, caregive r implemented, storybook reading intervention on children with language impairments. This experimental design was composed of 62 caregivers and their children. Caregivers chosen to be in this study, had to be able to read at a fourth grade level, assesse d by the Wide Range Achievement Test (WRAT). Each child was evaluated by two subtests in the Test of Language Development (TOLD) to reaffirm the presence of language impairments. In addition, the children were pre and post tested for their print concept and alphabet knowledge with Preschool Awareness Literacy Screening for PreK (PALS) and Upper Case Alphabet Recognition subtest (PWPA) respectively. The dyads were randomly assigned to one of three groups: print referencing (treatment group), picture foc used, or sound focused condition. After initial screenings, caregivers were given written and verbal instructions on how to implement their respective intervention. Caregivers were ask ed to implement their intervention four

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73 times a week for 12 weeks, int roducing a new book each week. The treatment group (print referencing) integrated nine scripted questions about print concepts, letters, and words; picture focused condition integrated nine scripted questions focusing on the pictures, plot, characters, and action; and the sound focused had nine scripted questions about phonological concepts (e.g., rhyme, beginning sounds, and syllable structure). To ensure fidelity of implementation caregivers tape recorded and kept a written log on each book session. Mem bers of the study would fidelity check review logs and tap es for correct implementation. Analyses of data for Justice et al. showed significant differences in print concept knowledge between groups. The treatment group (print referencing) made significant ly more gains in print concepts than the picture focus group. However, the print referencing group did not see significantly greater gain when compared to the sound focused, though data showed an upward trend towards a significant difference. Surprisingly alphabet knowledge was considered not statistically significant for any group even though the print focus group specifically targeted letters. Authors randomly focused group to see if caregivers discuss print and/or l etters in a more general manner. Of the 16 picture focused sessions coded, who have children with language impairments need to be explicitly taught to embedded print awareness strategies into shared storybook reading (Justice & Ezell, 2002; Lovelac e & Stewart, 2007).

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74 In regards to social validity of this study, caregivers were asked to an onymously complete a questionnaire. Justice et al. highlighted that there were two significant differences between the treatment (print focused) and comparison groups (picture and sound experience. First, the caregivers in treatment group reported their children had higher satisfaction of the reading sessions then children in the comparison groups. Secondly, children in the print referencing group enjoyed the books more than the chi ldren in the picture and sound focused groups. With respect to the feasibility of the implementation of the intervention, about a quarter of the caregivers (14 dyads) were unable to complete the 12 vement were associated with attrition. The younger the caregiver and less education they had, the more likely they were to leave the study. Overall, Justice et al. intervention on caregiver implemented, shared storybook reading for children with language impairments were positive, supporting previous finding with print emergent literacy skills to cultivate through meaningful joint interactions. The rate of attrition, though common among stor ybook studies (e.g., Whitehurst & Lonigan, 1998), warrants further investigation. Moreover, the participants who finished the intervention were rather homogeneous (e.g. English speaking, older caregivers), future research should include a more diverse sam Interpretation of shared reading interventions with children with language and developmental delays The research re viewed demonstrated the child interactions duri ng shared storybook reading were influence d by the adult reading the book (Bruner, 1983; Bus et

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75 al., 1995; Hay & Fielding Barnsley, 2007; Johnston, et al., 2008). Hays and Fielding Barnsley (2007) explain that children with language delays are frequently less responsive and tend not to ask questi ons or initiate conversations about the story. The lack of oral communication between the adult and child lead to fewer opportunities to create interactions for language development, which leads to considerably less letter recognition, introduction of new vocabulary words, phonological awareness, and other literacy development skills (Bellon Harn & Harn, 2008; Hays and Fielding Barnsley, 2007; Koppenhaver et al., 2007; Marvin & Wright, 1997; van der Schuit et al., 2009). Shared storybook reading is transa ctional in nature, so it is important that the adult uses strategies to facilitate language, particularly when the child displays a language impairment (Bakeman & Adamson, 1984; Dale & Cole, 1996; Crow e et al., 2003; Lovelace & Stewart, 2007; Justice et al ., 2011). Complementary to the findings in JA research, scaffolding is commonly used to expand communication in a meaningful way between adult and child. This is an important strategy as it helps children expand their own vocabulary. Through the use of scaffolding in shared storybook reading, adults can facilitate language and speech patterns that increase, elaborate, and model new and unfamiliar vocabulary words in a context that can help a child expand their own vocabulary (Bellon Harn and Harn, 2008; Justice & Kaderavek, 2002; Lane & Wright, 2007). A n a example of a scaffolding strategy that is seen throughout shared storybook reading studies (Dale & Cole, 1999; Fielding Barnsley & Purdie, 2003; Crow e et al., 2003; Lovela ce & Stewart, 2007; Justice et al., 2011). Modeling language during shared reading (e.g., commenting on a picture) is another effective scaffolding strategy to elicit

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76 language (Van Kleeck et al., 2006). By the same token, expanding on what the child has said is an additional storybook strategy used throughout the studies to support children with language impairments (Kleeck et al., 2006; Lovelace & Stewart, 2007; Justice et al., 2011). Further research is needed, as it is not known if one scaffolding str ategy facilitates more language than another. An area of research that shows evocative explicit referencing during sha red storybook reading. Lovelace & Stewart (2007) study illustrates the use of non evocative tech niques can easily be incorporated during shared storybook reading and promote emergent literacy skills without demanding responses for the child. This warrants further research with children who have language impairments, as it seems they can still learn vital literacy skills without responding vocally Further research is needed in the area of JA in shared storybook reading interventions, as it is not explicitly targeted in any of the reviewed interventions. Although the studies imply that joint interact ions increased, special attention is needed foundational for the acquisition of language. ing shared storybook readings generally displayed positive results, complementing findings found in the JA literature review. Crowe et al. (2003) study provides evidence of an interactive reading intervention that was easy to teach caregivers, simple for caregivers to implement in the comfort of their own home, and had positives effect the child/parent other studies (e.g., Dale & Cole, 1996; Fielding Barnsley & Purdie, 2003; Justice et al.;

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77 s by stressing the importance of the adult interaction by providing a lit eracy rich experience. Overall, the caregiver led storybook interventions provided interactive strategies in a naturalistic manner T hese interactive strategies, paired with the natural interact ion of caregiver and child, have the potential to foster generalization of numerous emergent literacy skills. Shared Reading Interventions with Children with Autism Spectrum Disorder Althou gh numerous studies have been conducted with shared storybook intervention on typically developing and at risk children, there are a limited number of studies on the acquisition of emergent literacy skills using storybooks with young children with ASD. Th ere are only two studies and one dissertation found in which preschool aged children with ASD participated in a shared storybook reading to increase joint interaction and expressive communication (Bellon, Ogletree, and Harn, 2000; Koppenhaver et al., 2001; Vogler Eli as, 2009). Appendix B (Table B 2) provides a list and summary of all the ASD shared storybook reading articles (3 single subject articles). Current research has focused on hyperlexia (i.e., the ability to recognize words with little or no comp rehension of the word) and sight word instruction, in lieu of the acquisition of early literacy skills, such as JA (Koppenhaver & Erickson, 2003; Watson, Lanter, McComish, & Poston Roy, 2004). The failure to focus on the attainment of early literacy skill s is partly due to the complex nature of autism, which makes it difficult to construct and implement adequate language and communication interventions (Bellon et al., 2000). Interventionist led Bellon et al. (2000) combined scaffolding with shared storyboo k reading on a 3 year old boy with high functioning autism. A seven week intervention using a single

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78 extremely difficult to understand. During the baseline sessions, two stor ybooks were introduced using wh questions by a trained graduate assistant. The MLU data collected months (i.e., 1.8 morphemes), though the authors noted no other assess ments Throughout the treatment sessions five storybooks were introduce d using four scaffolding techniques: cloze procedure, binary choice, expansions and constituent questions. The cloze procedure technique is a pause that cues a child that they should p rovide information about the story. A binary choice is a strategy where the adults s strategy is used when the adult reading the story wants the child to elaborate on thei r response. When an adult wants specific information from th e child, a constituent question is used. There was a criterion for the storybooks chosen: contain a setting, events in the story had to be sequential, and have a result to the problem. In addit ion to the storybook, manipulative objects and activity were introduced with the storybook. For ins tance, in the story book Mrs. Wishy Washy a farm set ting and animals were brought out and the child could recreate the events of the story with scaffolding by the graduate assistant if needed. The objects were to sensory context to illustrate Each session was recorded, transcribed, and a checklist was used to record when a scaffolding pro cedure was used. The result s demonstrated an increase in storybook related utterances and a decrease in echolalia with the young boy. The use of scaffolding showed positive results and is in conjunction with previous studies that

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79 use scaffolding to incre ase language in children who show deficits in language. One should be cautious when interpreting the results, as the sample size is one child In addition, there was very little information given about the participant, no psychometric testing was reporte language is due to scaffolding, the activities with the manipulatives, or a combination of both, as an alternating treatment design was not used. Interventionist le d Koppenhaver et al. (20 01) conducted a study on the use of storybook reading in conjunction with an augmentative and alternative communication an (AAC) device to increase meaningful interactions between four mothers and daughters (between 39 72 months) diagnosed with Rett Syndro me, a disorder on the autism spectrum. All children displayed significant language impairments, as no intelligible speech was used. Bayley Scales of Infant Development (BSID II) and Vineland Adaptive Behavior Scale were used to assess age equivalent, 5 1 9 months, and 9 17 months respectively. Authors reported that the schools placed all the participants in the range of severe to profound intellectual disability, though no additional information was given. A multiple baseline design was used to conduct three intervention phrases. familiar and unfamiliar book that they believed their child would be interested in. Each caregiver was asked to read to their child at least two stories a week in their home environment. Baseline data was vi deo recorded to collect the way in which the mothers typically read and interacted with their daughter. The second phase of the intervention was handing splinting. This allowed the authors a nd parent to examine the effects of the use of hand splinting to prevent the stereotypical hand movements (seen in children

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80 with Rett Syndrome) that would otherwise interfere with learning. AAC devices were implemented in phase three of this study. Each family was given: a set of Picture Communication Symbols (PECS), a single message Big Mack, and a multi message Four In Line Cheap Talk. The AAC devices were set up to allow the children to communicate about the storybooks. During this phase, the authors examined the impact that a variety of assistive technologies had on storybook reading and communication between dyads. In phase four, parents were trained on effective storybook strategies, as well as strategies that would encourage their child to use AC C to communicate and give them meaning. For instance, one child yelled and looked at her mom when she turned to a picture of a cicada in the book The Very Quiet Cricke t encouraged their children to use the AAC devices to answer their questions through the use of prompting. The importance of wait time was taught, as well as the use of appropriate questioning to u se to maximize the use of the AA C devices. Limited by their own gestures and vocalization in phases one and two, little to no interact ion took place (only one participant pointed to pictures during phase two). However, once the introduction of the AAC device in conjunction with shared reading took place, a significant increase in labels and comments made between caregiver and child occu gains in accessing AAC devices, response and initiation to JA bids, and labeling and

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81 commenting of items in the storybook. The authors did note that the condition of familia r and unfamiliar books did affect the data and were combined. Koppenhaver et al. (2001) used storybooks to set up a predictable and familiar condition that encouraged communication between dyads. With the addition of AA C devices it created greater oppor tunities for joint interactions and exposure to emergent literacy skills through nonconventional ways. Though this study shows much promise, results should be interpreted with caution. The AAC devices used in this study are not a one fits all solution an d may not work for other children on the autism spectrum. Generalization and long term effects of the intervention were not assessed and future research to examine such things. Vogler d on Kaderavek and Rabidoux (2004) framework of literacy development, which had a pragmatic focus on the social aspects of shared literacy experiences, such as turn taking, JA and acceptance of a range of communicative behaviors. A single subject multipl e baseline across seven dyads was used to examine whether a parent implemented scaffolding strategies used during shared reading would increase children with ASD expressive language and parent/child engagement. The children were between the ages of 36 60 months and had an expressive vocabulary of 25 words. Parents met three times a week for four week s in which the primary investigator conducted direct instruction parent training, modeling, practice with constructive feedback, and independent practice wit h the child. During the session the parents were taught to increase four of the following strategies: praise/encouragement statements, pauses, attention getters, achievable models, recasts, cloze statements, wh questions,

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82 and vocabulary definitions. The child social fidence in facilitating reading sessions with their child. Vogler Elias (2009) also reports an increase of duration that the dyads spent reading. This is a valuable piece of data, given that children with ASD are reported to have fewer opportunities to p articipate in early literacy activities. Interpretation of shared reading interventions with children with autism spectrum disorder Children with ASD are likely to have impaired JA skills and social interactions, making the acquisition of emergent literacy skills particularly difficult (APA, 2000). Based on the research reviewed, it appears that caregiver and child can establish joint interaction through storybook reading as it creates an environment in which both parties are focused on the same external o bject (Dale & Cole 199 6; Lovelace & Stewart; 2007). As illustrated by the lack of research, there is a need for further research in the area of shared storybook reading with young children on the spectrum. It was noted that children with disabilities had more sporadic and limited access to literacy rich materials, such as books and pencils, than their non disabled peers (Bellon Harn & Harn, 2008; Goin et al., 2004; Koppenhaver et al., 2007; Marvin & Wright, 1997). Inadequate literacy experiences early in the academic difficulties later in spelling, reading comprehension, and reading fluency (Goin et al., 2004; Hays and Fielding Barnsley, 2007). The reasons for the lack of opportunities are varied. Some caregivers may have lower literacy expectations of children, simply due to the presence of a disability (the lack of the transactional communication). Others

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83 caregivers, may lack the motivation or understanding of the importance of emergent literacy activities (Basil & Reye s, 2003; Goin et al., 2004; Koppenhaver et al., 2007; van der Schuit et al., 2009). In addition, the speech, physical ability, and self care focused, placing opportunities for literacy development on the bac kburner (Basil & Reyes, 2003). Similar to the research on children with language impairments, positive a ffects were seen in children with autism when scaffolding strategies were introduced during 1; Vogler Elias, 2009). Scaffolding allowed the adults to guide the child through joint interaction during storybook reading. For instance, during reading an adult can use gestures or facial expressions to help a young child understand the meaning of a n ew word. This can be extremely beneficial to children with ASD, as many of them have to be explicitly taught gesture and vocabulary skills. Books with repeated vocabulary and predictable texts are important supports to use for children with language dela ys, as it will expose young children to quality language experiences (Johnston, et al., 2008). Storybook reading can create an environment that exposes children with ASD to skills in which they have deficits. Researchers recognize the importance of intens ive early intervention for young children across the autism spectrum (Jones & Carr, 2004; Loveland & Landry, 1986; Ortiz, Stowe, & Ar nold, 2001). Due to the varying degree of signs and symptom individuals with ASD exhibit, it is important for intervention s to be flexible in order to implemented interventions are one way to

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84 in the areas of language and communication skills throug h the use of parent implemented interventions (e.g., Koppenhaver et al., 2001; Vismara & Lyons, 2007; Schertz & Odom, 2007; Jones & Feeley, 2007; Vogler Elias, 2009). Considering that shared storybook reading is a natural activity in which a parent and ch ild partake in joint object, it advocates the growth of lan guage and social participation ( two core deficits for children with ASD) though more research is needed in t his area. As stated previously, further research is needed in the area of JA in shared s torybook reading interventions. To enhance early literacy development in children with language and developmental delays, researchers also suggest picking books that are meaningful, motivating, and engaging (Bellon Harn and Harn, 2008; Hays and Fielding B arnsley, 2007). The use of highly preferred object is a theme that is seen throughout JA studies and should also be examined with storybooks and children with autism. Research has implied that it is possible to support participation in literacy activitie s through adjusting the way caregivers approach shared reading, particularly with children with disabilities. Unfortunately, the lack of empirical research and longitudinal data on specific interventions to help increase literacy skills in children with a utism shows the desperate need for future r esearch to be conducted for children with ASD Statement of Problem Adult child shared reading is viewed as a natural context with a predictable routine. Inter ventionists are increasingly using storybook reading to facilitate the communication and linguistic development of children who exhibit language impairment. All of the interventions discussed focus on teaching adults techniques aimed at increasing active child participation during storybook reading. Throug hout, adults were

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85 engagement. As a result of adults increasing their use of reading strategies, progress omplexity, number of linguistic and social turns. All of these important components of cognitive learning begin with the fundamental skill of JA Although these studies touch on JA there are no studies to date that use shared storybook reading solely to establish JA in preschool age children.

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86 CHAPTER 3 METHOD The Meaningful Interactions th rough Storybooks (MITS) was used to train caregivers of young children with autism to increase their interactions during storybook reading. The MITS strategies: At tention Directing, Query, Model Response, and Feedback are adapted from the Complete Reading Cycle (CRC) developed to use with children with language impairments (Crowe, Norris, & Hoffman, 2003). In their original study, Crowe et al. trained caregivers to use the CRC four essential components: Attentional Vocative, Query, Response, and Feedback. Caregivers were taught the four through the CRC components during shared storyboo k reading. Significant increases in the number of child and parent interactions were observed and child participants showed gains in communication initiations throughout the story book session s The MITS strategies were adapted based on a pilot study with 2 caregiver child dyads. The four MITS strategies are defined as : (a) Attention Directing: noted as any verbal or nonverbal initiation (e.g., point) to establish joint focus (e.g., attention to the book), such as the pictures, events, attributes, or tex t; (b) Query: any communicative act nonverbal response; (c) Model Response: a ny semantically contingent response to the Query, if the child did not respond to the Query in verbal or nonverbal way within 5 seconds; and (d) Feedback: any comment serving to acknowledge, extend, restate, or clarify the response of the child o r provides an opportunity for the caregiver and the child to discuss material presented in the storybook Full s trategy definitions and examples are also provided in Appendix C (Table C 1). Each caregiver was taught the

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87 4 MITS strategies during individual sessions using direct instruction, modeling, practice, and feedback from the researcher. The purpose of Chapter 3 is to describe the methods and procedures used to conduct this study. This chapter is organized by the following: (a) the criteria for participation and selection of participants; (b) descriptions of the participants; (c) setting; (d) materials used; (e) research design; (f) measurement procedures; (g) experimental procedures; and (h) data collection and analysis procedures. C riteria for Participation and Selection of Participants The purpose of this study was to determine the effects of trai ning caregivers of children with autism to use four interactive reading strategies called MITS. The participants in this single subject, multiple probe across participants research stud y were f our children with autism and their primary caregivers. Childre n The children were between the ages of 24 and 39 months and ca me from English speaking homes. The children were nominated by the Orlando Center for Autism and Related Disabilities Center (CARD) regarding their initial eligibility. The criterion for par ticipation also included a diagnosis on the autism spectrum and an Unstructured Joint Attention Assessment adaptive fr om Loveland and La ndry (1986). Each child received a n independent dia gnosis of autism by an outside agency based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Addition Text Revision (DSM IV TR; Association American Psychiatric, 2000) or an autism diagnostic instrument (e.g., ADOS ADI R CARS 2 or SC Q ) During baseline, an

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88 was completed using the Unstructured Joint Attention Assessment (adaptive f rom Loveland & Laundry, 1896). Caregivers The primary caregiver of each child participant also participate d in this study. Once the caregivers agree d to partici pate, the primary investigator visit ed each par ticipant to determine if they m et all the criteria to be included in this study. The criterio n for participation include d : a completed informed caregiver consent form, completion of a C I nterest I nventory survey (Appendix F), and permission to Unstructured Joint Attention Assessment (adaptive from Loveland & La ndry, 1896). Participants After the caregi vers completed the informed consent forms to participate in the MITS study w ith their child, the researcher collected demographic and background information through a questionnaire ( Appendix J ) for each participant. The participants in the study were four caregivers and their children diagnosed with autism. The following describes each of the caregiver child dyads based on the information collected from the questionnaire, the Unstructured Joint Attention Assessment ( Loveland & La ndry, 1896 ) and the 5 min ute caregiver child play session. Dyad 1: Jon and his caregiver: Jon, a Hispanic male, was 35 months old when the study started. He was diagnosed with PDD NOS at the age of 2. During the study Jon was receiving speech therapy once a week and behavioral therapy two times a week. He was enrolled in a general education preschool classroom. Jon was the younger of two children. His older sister, 10 years old, was also on the autism spectrum.

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89 year old mother, at the time of th e study. She was a student at a local college and the caregiver participating in the MITS intervention. he enjoyed seeing how things worked and would like to see improvement in his communication skills and interact more with h is peers. On the Unstructured Joint Attention Assessment (Loveland and Landry, 1986) Jon responded to nine out of the ten joint attention task. The only task Jon was unable to respond to was the shift gaze using gesture only task. During the 5 minute free play between child and caregiver, Jon used a variety of word and word combinations. He would occasionally initiate conversation and frequently responded to his caregiver. Jon averaged 4 single words per minute and 9 multiple word combinations per m inute. mother indicated on the C hild Interest Inventory that he played with cars, fire tr ucks, and trains most often. Jon enjoyed playing with computers, electronics, and flipping things on and off. Dyad 2: Jess and his caregiver: Jess, a 26 mon th old Caucasian male when this study started, was diagnosed with autism at 18 months of age. At the time of the study he was the youngest child of two children living in the home with his 4 year old sister. Jess was receiving speech therapy twice a week occupational therapy once a week and ABA therapy twice a week for 3 hours per session when the study bega n. He did not attend preschool. in this study, was a 32 year old stay at home mother. His parents were mar ried and living together. The father graduated from college and was wo rking as a nuclear electrician. She reported that Jess had strength

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90 in matching objects and wanted to see improvement in his verbal communication, as he had serve speech problems. On the Unstructured Joint Attention Assessment (Loveland and Landry, 1986) Jess responded to four out of the ten joint attention task. He was responsive to the pointing and showing for both gesture only and language plus gesture tasks. During t he 5 minute fr ee play between child and caregiver, Jess interacted very little with his caregiver. He would occasionally respond to his caregiver using can onical vocalization, though his caregiver seemed to have understood what he was saying. Jess averaged 1 canonical vocalization per minute, though no words or word combinations were coded. The Child Interest Inventory indicated that Jess played most often with cars, play dough, Mr. Potato Head, and puzzles. In addition, he like d to sort sha pes, match objects, and occasionally partic ipated in sensory experiences. Dyad 3: Dave and his caregiver Dave, a Caucasian male, was 39 months old when enrolled in this study. Dave was diagnosed with PDD NOS at the age of 27 months, though mother noted that they anticipated a ch ange to a classic autism diagnosis soon. Dave received speech two times a week, ABA therapy five times a week, and occupational therapy two times a week. He was also enrolled in a varied exceptionalities prekindergarten classroom 3 days a week for 3 hour s. Dave has a younger sibling an 18 month old, sister. The mother, and caregiver participating in this study, was 35 years old and currently working on her Ph.D. in biology at the local university. His father indicated that he had taken some college co urses, but no degree was ever obtained. At the time of the study, h retail shipping business. Through the

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91 questionnaire the mother wrote that some strengths Dave w ere that he was affectionate, skilled in visual puzzles, a rule follower and task oriented. Dave responded to four out of the five gesture only tasks in the Unstructured Joint Attention Assessment (Loveland and Landry, 1986). Shift gaze was the gesture only task that he did not respond to. In addition, Dave only responded to two out of the five language plus gesture task s He was unresponsive in all attempts of s hift gaze, During the 5 minute free play between child and caregiver, Dave interacted very little with hi combinations, averaging 1 multiple word combination per minute. According to the Child Interest Inventory the ob jects that Dave most often played enjoyed sensory experiences, especially licking and mouthing objects and was extremely visual sensory se eking (e.g., looking at objects very close and from all angles). Dyad 4: Jay and his caregiver Jay, a Hispanic male, was 30 months old when the study started. Jay was diagnosed with autism and expressive language and speech delays when he was 2 and half years old. Jay is echolalic, meaning he repeats words or sounds he has recently heard. therapy, occupational therapy, and ABA therapy once a w eek, in the home, respectively. Jay d id not attend preschool at the time of the study.

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92 in this study, was 35 years old. She stayed home with Jay at the time of the study has an associates degree a nd wa s working as an audio engineer. Jay was an only child, whose parents were married when the study started. When asked what some of were things, a For the Unstructured Joint Attention Assessment (Loveland and Landry, 1986), Jay responded to five out of the five language plus gesture task. He only responded to four out of the five gesture only tasks, not responding to the shift gaze without langua ge. During the 5 minute free play between child and caregiver, Jay did not use any canonical vocalizations or word combinations. He would occasionally repeat what his caregiver had said, but echolalia was not coded as expressive verbalization. His car he would answer with a word. A total of 8 s ingle words were coded for Jay. mother shared that he was interested in trains, cars Jay liked to participate in sensory experiences, such as: touch ing, lights, and tearing paper. Materials Assessment Instruments During the pre baseline phase, the investigator assess ed the children using The Unstructured Joint Attention Assessment (Appendix D). This assessment t ook approximately 15 minu tes for each child. It involved playin g with the child, at their home, in a relatively unstructured setting (no tables and chairs, no demands on the

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93 child, an d free access to toys). During t his time, the investigator use d gesture only (e.g., shifting gaze, pointing, and tapping) and language plus gesture probes (shifting was videotaped and scored for joint attention. was collected in a naturalistic context, (i.e., play session with caregiver) (Helimann, Nockerts, & Miller, 2010). This assessm ent took approximately 5 minutes for each child and too k place during free play between child and caregiver. The language sample was videotaped and coded for canonical vocalizations, single word s, and word combinations (Appendix C). Caregiver Training Material The primary researcher work ed one on one with t he ca regiver until the caregiver could implement the MITS intervention. During the training component of the interven tion phase, the researcher taught each caregiver how to implement the four reading strategies of MITS through the use of a research traini handbook explaining the basics of MITS (Appendix E), and handouts giving examples of appropriate prompts. Paper and pencil were utilized to check for comprehension. To an alyze the data, the researcher use d Quick Time, a computer v ideo software program to watch the recorded video sessions. Using the MITS Collection Coding Sheet (Appendix C) strategies were coded and then c alculated to rate Books Research suggests exposing children to books that they are interested in is a critic al factor in their success (Ortiz, Stowe, & Arnold, 2001). In this study, some of the books used were

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94 inventory indicate d would c ontain some books on trains (e.g., The Good Night Train or Inside Freight Trains ). Additional The selection criteria for the books were as follows: (a) ha d colorful illustrations, (b) were at or below a second grade readability level, (c) were of typical length, (d) were age appropriate, and (e) some books were interest was gathered from the caregiver through the Chil given at baseline and results can be seen in Table 3 1. Setting The baseline, intervention, maintenance and generalization phases were con ducted in the home of each d yad The ro oms had adequate lighting and were arranged in such a way that the caregiver and child could sit next to each other, so they were able to see and interact with each other an d the book during each session. Study Design A multiple probe, multiple baseline across participants design was used in this pr esent study (Horner & Baer, 1978). This type of design was used to determine: (a) if the MITS instruction was functio use of MITS strategies; ild of joint a ttention behav use of the MITS strategies resulted xpressive utterances. In addition, this type of design was chosen as the intervention was introduced to the participa nts at different times; allowing the investigator to evaluate threats to internal validity as well as demonstrating experimental control (Gast, 2010). Furthermore, the multiple baselines control led for developmental maturation and exposure to the

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95 treatmen t setting. This design wa s useful in evaluating immediate effects of t he intervention. Multiple probe baseline design also allow ed for fast and simultaneous collection of da ta, as it did not require continuous measurement of the strategies and behaviors. In addition, participants were not denied intervention (Horner & Baer, 1978; Gast, 2010) As required, baselines were staggered across the d yads (Gast, 2010). Multiple probes were used for participants that remained in baseline, while the other particip ants participated in true baseline prior to MITS instruction. Once Dyad 1 showed a stable baseline, the MITS intervention training beg an. Dyad 2 remain ed in baseline until a similar reliable baseline was displayed and a n upward trend in Dyad 1 interventi on d ata was established. Once this was evident, Dyad 2 be gan MIT S training. A replication bega n with Dyad 3 and Dyad 4, after the establishment of an upward trend of the first two dyads. Multiple probes were conducted during the baseline and maintenan ce phases, as it was more practical for the caregivers to video record their reading session intermediately rather than for an lengthy period of time (Horner & Baer, 1978). Continuous data were collected during the interv ention and generalization phases. Internal validity was strengthened through the staggering of the exp erimental process (Gast, 2010). Measurement Procedures Dependent Measures During the baseline, intervention, maintenance and generalization phases of this study, data were collected on three dependent measures:

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96 1. T he frequency of the 4 MITS reading strategies implemented by the caregiver during storybook reading per minute ; 2. frequency of the per minute ; and 3. frequency of the e utterances produced during the shared storybook reading per minute Thi s interactive reading intervention was composed of four strategies produced by the caregiver: Attention Directing, Query, Model Response, and Feedback. The four strategies are based on the work of Crowe, Norris, and Hoffman (2003). The four MITS strategies are defined as : (a) Attention Directing: noted as any verbal or nonverbal initiation (e.g., point) to establish joint focus (e.g., attention to the book), such as the pictures, even ts, attributes, or text; (b) Query: any communicative act to volunteer or (c) Model Response: a ny semantically contingent response to the Query, if the child did not re spond to the Query in verbal or nonverbal way within 5 seconds; and (d) Feedback: any comment serving to acknowledge, extend, restate, or clarify the response of the child o r provides an opportunity for the caregiver and child to discuss material presented in the storybook Operational defin itions and an example of each MITS strategy are presented in Table 3 2 For the purposes of this study joint attention is defined as two persons sharing attention on the same external object through the use of gaze, he ad turn, gestures or language. Each joint attention behaviors were represented in four subcategories: (a) Vocal Response to j oint a ttention (e.g., the c aregiver ask the child, the ; (b) Nonver bal Response to j oint a ttention (e.g., the c hild points to the bear and alternates eye contact to the caregiver) ; (c) Vocal Initiation of j oint a ttention (e.g., the c hild says to the caregiver,

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97 ; and (d) Nonverbal Initiation of j oint a ttentio n (e.g., a s the caregiver turns the page, the child sees the bear on the page & alternates eye contact between the be ar and the caregiver). ) work on joint attention with children with autism. Tabl e 3 3 lists specific types of joint attention behaviors that were used to code the analysis. Each behavior is operationally defined and further clarified with an example. Expressive language was represented in three subcategories: Canonical Vocalizations were defined as a rhythmic production of one or more consonant vowel sound s A s ingle Word was defined as any single word utterance, and Word Combination was defined as multiple word combinations in a single utterance (e.g., play ball) Table 3 4 lists d efinitions and examples used to code the analysis. Independent Variable The independent variable was the MITS intervention training. The primary investigator conducted the training The training was b roken into three parts and last ed approximately 30 m inutes in each session and described in the procedures section below Experimental Procedures Pre baseline Phase Prior to the beginning of the study, the researcher conduct ed an initial visit to the home of each potential participant to discuss the study and ask permission to assess the joint attention level of e ach child. Once car egiver consent was joint attention was assessed using the Unstructured Joint Attention Assessment (adapted from Loveland & L a ndry, 1896) and a sample of ea language was

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98 also taken through a 5 minute caregiver child free play session In addition, t he caregivers complete d the Child Interest Inventory (Appendix F). Baseline During the baseline h ome visits, the researcher instructed each caregiver to read to their child like they normally would, using books that they already ha d in their home. The researcher observe d and videotape d the reading sessions. Baseline data were gathered for a minimum of four sessions per dyad or until there wa s a stable trend. The researcher used the MITS Collection Checklist (Appendix C) to a nalyze videotapes to determine the number of MITS strategies used by the caregivers as well as responses to bids and initiation of joint attention by the child participants. Interv ention Phase The investigator conduct ed the trainings. Each training session was broken up into three segments and last ed approximately 30 minutes. The following three segments were used in the training: MITS I nstruction /R eview At the first train ing se ssion, the caregiver receive d a MITS manual (Appendix E). This session began with an introduction of the importance of joint attention, shared storybook reading, and the MITS strategies As the MITS strategies were explained, the researcher model ed the i nteractive skills and the caregiver was given opportuni ties to practice those skills using a storybook that was not used with the child (i.e., Cat in the Hat ). Su bsequent training sessions with the caregiver continue d with a review of the MITS reading stra tegies. The researcher would ask the caregiver to explain eac h strategy. If the caregiver were having trouble with a specific strategy the n the

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99 researcher would provide corrective feedback and would ask the caregiver to explain the missed strategy later on in the training session. Once the MITS strategies were reviewed, the caregiver was able to practice the MITS strategies with the researcher using storybooks that were not used in the study (i.e., If You Give a Mouse a Cookie, Goodnight Moon, The Very Hungry Caterpillar ) During this time t he researcher continue d to model, provide corrective feedback, and prais e. Once the training session was over, the caregiver would then read a book to the ir child. The MITS training sessions continued during the i ntervention phase until the caregiver was able to produce 7 or more spontaneous MITS strategies per minute consecutively for 3 sessions during reading probes with their child The researcher selected 7 MIT S per minute as the criteria as that was used in C rowe et al. (2003) Complete Reading Cycle study. The researcher reviewed each dyad reading probe using the MITS Collection Checklist and Coding Sheet (Appendix C) for the frequency count of the MITS behaviors. Dyad Reading Probe Following the MITS inst ructional review session, the caregivers had the opport unity to practice what they had learned. Eight books were given to the caregiver. Four books were the researcher selected the other four books The caregiver was in structed to give their child a choice of which book to read from a selection of three books. Once a book was read, the caregiver was not to read that book again during that phase. Video recording began when the caregiver start ed the sto rybook session wit h the child.

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100 Investigator/Caregiver Coaching After the reading probe, the investigator and caregiver watch ed the videotape, review ed and discuss ed the reading session. The coaching style used during the coaching portion of the intervention could be con sidered practice based coaching as the coaching was used to support and improve the use of the MITS strategies As th e caregiver and researcher watch ed the reading sess ion video, the researcher frequently pause d the video to address the posit ive exchanges between the caregiver and the child the s /or techniques to increase or fix communication between the dyad. Caregivers were allowed to stop the video to ask any questions they may have had, point out any positive exchanges they saw, and/or explain where they could have used additional MITS strategies. The coaching portion of the training allowed a more relaxed setting between the researcher and the caregiver, rather t han a more directive app roach. Reviewing the readi ng probe session videotapes allow ed the investigator and the caregiver to discuss where additional MITS strategies could have been used to increase caregiver child interaction. After participating in the MITS training, the careg iver needed to use a minimum of 7 MITS strategies per minut e, consiste ntly for three sessions before the caregiver was able to implement the MITS intervention independently. If the caregiver produced below 7 MITS strategies additional training was given. Maintenance Once the caregiver produced a minimum of 7 MITS strategies per minute consistently for three sessions the MITS training was completed and the caregiver was asked to use the MITS intervention with th eir child for a minimum of two times per we ek

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101 for two weeks. The caregivers chose the best time of day to read aloud, and this time was asked to remain consistent for the durat ion of the study. Caregiver s record ed each session using a Kodak video recorder. The caregiver was allowed to use any of the eight books given to them during intervention, continuing to allow the child to choose from a selection of three books. The investigator collect ed the recorded reading session videos e ach time the caregiver completed a read aloud. Follow up coaching sessions were implemented if the caregiver produced less than 5 MITS strategies during this phase. G eneralization Generalization of MITS skills was assessed through the use of four novel books, which were given to the caregivers by the researcher The caregiver was asked to complete at least 3 reading sessions using the unfamiliar books. The caregiver and child were videotaped reading the unfamiliar books and coded for the MITS strategies and child responses Data Collection The investigato r and a g raduate assistant collect ed data throughout the baseline, intervention, maintenance, and generalization phases using the MITS Collection Checklist (Appendix C) during the reading probe segment. The following data were collected: 1. Rate of the MITS strategy used by the caregiver ; 2. Rate of the 3. Rate of e xpressive utterances emitted by the child.

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102 Analyzing Data Visual analysis of level and trend of the data points on each graph was used within phases to determine if changes in the dependent variables occurred due to the independent variable and to determine condition length (Gast, 2010). Level stability for each caregiver was determined by calculating the median leve l for the dat a within the phase and us ing Gast (2010) recommended to determine stability. In addition, the data were examined visually to determine the trend of each phase. This was determined by assessing the trend direction using the freehand method through drawing a str aight line that intersects the data points. Finally, the percentage of non overlapping data points w ere calculated between adjacent conditions (Gast, 2010). Interobserver Agreement Gast (2010) defines interobserver agreement (IOA) as the extent to wh ich observers agree on the occurrence of the particular behavior in question. The researcher and a trained graduate assistant score d the videotap ed sessions for approximately 33 % of the session s (23 sessions total) to assess interobserver agreement on the MITS strategies language behaviors. The second observer became familiar with the coding definitions of the MITS strategies as the gr aduate assistant and the researcher had practiced coding from sample videos from the previous pilot study (see Appendix C for coding ma nual). They had to meet a training criterion (i.e., 80% IOA on 4 consecutive pilot study videos) before coding was start ed on the current study. The researcher and the graduate assistant independently

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103 coded for occurrence and nonoccurrence of each behavior, compared codes, and developed decision rules for each behavior. The decision rules were added to the MITS Collection Checklist and Coding Sheet (Appendix C). Once the training criterion was met, the interobserver agreement of each behavior (i.e., MITS strategies language) was determined as the researcher compared t he list of strategies and behaviors generated on the coding sheet from both the researcher and the graduate assistant (Appendix C). Occurrence of agreement was calculated using the time window method; meaning agreement was scored if behavior occurred with in 5 seconds of each other (Kern, Starosta, & Adelman, 2006). Then the researcher calculated the number of agreements and disagreements, divided by number of agreements plus disagreements, and multiplied by 100 for each behavior (Gast, 20 10). The coding s heets were created so that the researcher and second observer were able to record each time the behavior s occurred within the reading session (i.e., frequency count). Each box on the coding sheet represented 1 second each row was 10 seconds long, totalin g 1 minute every 6 th rows For example, if the observer saw the caregiver use a Query at the 32 second mark, the letter Q (abbreviations are located in Appendix C) would be placed in the fourth row, second box. If the observed dyad need all the ti me, the boxes were left blank. If additional time was needed, additional coding sheets were used. Once the data were collected, it was then co nverted to rate. This conversion allow ed the behavior counts to be a constant scale due to the variance in obser vation

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104 time that was encounter ed while working with children with ASD. An agreement of 80% or greater was required. Interobserver agreement was also calculated for the Unstructured Joint Attention Assessment (Loveland & Landry, 1986). The graduate assist ant watched the joint attention video recordings of the assessment and scored the joint attention task s Scoring sheets from both the researcher and graduate assistant were compared, and the number of agreements and disagreements were calculated. The res earcher divided the number of agreements by the number of agreements plus disagreements, and multiplied by 100 (Gast, 2010). The percent of agreement was then recorded for the Unstructured Joint Attention Assessment In addition, interobserver agreement w as also calculated for the 5 minute free graduate assistant and researcher watched the video recordings separately and scored separately. The number of agreements and di sagreements were recorded. The rate was calculated by diving the number of agreements by the total number of agreements plus disagreements, and multiplied by 100 (Gast, 2010). Treatment Integrity The investigator used the MITS Treatment Fidelity Checklist to assess caregiver training (Appendix G). The MITS Treatment Fidelity Checklist outline d components that the investigator must have taught during training to ensure treatment fidelity between caregivers. The investigator self evaluate d her implementati on of the training through the use of this checklist This evaluation was completed to ensure that the caregiver instruction was implemented consistently across caregivers

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105 Social Validity To establish the social validity of the MITS intervention, caregiv ers were asked to complete a questionnaire at the end of the intervention. The purpose of the questionnaire was to ga t her nine questions regarding the practicality and usefulness of the MITS intervention and its effects on their attention ski lls. Eight questions used a 5 point Likert scale and one question was an open response (Appendix H). It is important to evaluate the social validity, as the information gather ed y (Schwartz & Baer, 1991). The social importance and acceptability of the intervention is crucial for effective interventions (Wolf, 1978).

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106 Table 3 1. Books used based on Child Interest Inventory Participant Interest Books based on interest Books not b ased on interest Jay numbers, shapes Touch and Feel ABCs The Good Night Train Colors and Shapes Numbers Car Galore Inside Freight Train John Deere Touch and Feel Tractor Dear Zoo Hooray for Fish Zoo! Zoom into Spa ce Dave rockets, airplanes, trains, helicopters, puzzles, iPad The Good Night Train On the Launch Pad Dogs in Space Zoom into Space Roaring Rockets Amazing Airplanes Inside Freight Train Touch and Feel ABCs John Deere Touch and Feel Tractor Dear Zoo Zoo! Numbers Jess cars, fish, rhyming Commotion in the Ocean This Little Fish Hooray for Fish Tails Belly Button Book Numbers Touch and Feel ABCs John Deere Touch and Feel Tractor Dear Zoo Zoo! Colors and Shapes Jon cars, fire tru cks, trains sensory John Deere Touch and Feel Tractor Fire Trucks The Good Night Train Inside Freight Trains Touch and Feel ABCs Colors and Shapes Dear Zoo Zoo! Numbers Hooray for Fish This Little Fish *Complete list of books and au thors in Appendix I

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107 Table 3 2 Definition of MITS strategies to be implemented by caregivers MITS strategy Definition Example Attention Directing Any verbal or nonverbal initiation (e.g., point) to establish joint focus (e.g., attention to the book ), such as the pictures, events, attributes, or text. which serve to establish the topic or picture for discussion. Caregiver points to a picture of a dog and Query Any communicative act to volunteer or request verbal or nonverbal response. Queries include query. Queries can be open ended questions with an at tention directive plus query seconds, to allow the child time to respond. Caregiver give the child a binary choic e, bone or a Model Response Any semantically contingent response to the Query, if the child did not respond to the Query in verbal or nonverbal way within 5 seconds. Model Response includes answering the Query requests f answer). Waiting 5 seconds, then modeling the After waiting 5 second for the child to respond, the caregiver them models the appropriate Feedback Any comment serving to acknowled ge, extend, restate, or clarify the response of the child. Or provides an opportunity for the caregiver and child to discuss material presented in the storybook. The caregiver can clarify the response. While r eading a book about a dog, The caregiver acknowledges the child by saying,

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108 Table 3 3 Definitions of Type of joint attention Definition Examples Vocal Resp onse to Joint Attention After caregiver ask/gives a query, child vocalizes a canonical vocalization, word, or words answering query in conjunction with gaze alternation & positive affect to the caregiver Caregiver & child are reading a book about a bear. Caregiver ask s Nonverbal Response to Joint Attention Eye gaze: Child looks between object & caregiver in conjunction with gaze alternation & p ositive affect to the caregiver (e.g., smiling, laughing). or Point: Child extends finger toward object in conjunction with gaze alternation & positive affect to the caregiver Child & caregiver are reading a book about a bear. Child points to the bear & alternates eye contact to the caregiver Vocal Initiation of Joint Attention Child vocalizes a canonical vocalization word, or words about the book to their caregiver with gaze alternation and positive affect to the caregiver Child & caregiver are reading a book about bears. Child says to caregiver Non Vocal Initiation of Joint Attention Child initiates joint attention with eye contact or point & positive affect Child & caregiver are reading a book about a bear. As caregiver turns page, child see that bear on the page & alternate s eye contact between bear & caregiver Table 3 4 Definitions and examples of expressive language sample done by child Type of expressive language Definition Example Canonical vocalization Characterized as a rhythmic productions of one or more consona nt vowel (CV or CVCV) Child holds up an apple and Word Any single word utterance Word Combinations Any utterance in which the child uses multiple words

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109 CHAPTER 4 RESULTS The purpose of this stu dy was to determine the effectiveness of an intervention designed for caregivers to use with their child with autism. The research questions were: 1. Will training caregivers to use Meaningful Interaction through Storybooks (MITS) intervention increase thei r use of the four reading strategies? 2. Does caregiver utilization of the four reading strategies during shared storybook reading facilitate joint attention skills in their child? 3. Does the MITS intervention result in an increase in verbal expressive langu age in children? This chapter presents the results of the study. Interobserver Agreement Unstructured Joint Attention Assessment to establish the reliability of the scores. In addition, int erobserver evenly across baseline, intervention, maintenance, and generalization phases. Each use of the MITS strategies the chi computed for these strategies and behaviors. Interobserver Agreement for Unstructured Joint Attention Assessment The Unstructured Joint Attention Assessment averaged 85% interobserver agreement across all four children. For Jon (Dyad 1) IOA was 85%, Jess (Dyad 2) 90%, Dave (Dyad 3) 80%, and at 85% for Jay (Dyad 4)

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110 Interobserver agr eement for (i.e., canonical vocalizations, words, and word combinations) was 82.5% across all four children. For Jon (Dyad 1) IOA was 85%, Jess (Dyad 2) 85%, Dave (Dyad 3) 80%, and at 80% for Jay (Dyad 4) Interobserver Agree ment for Primary Dependent Variables As stated previously, to obtain IOA, a graduate assistant independently viewed and coded 33% of the video recordings across all phase s and participants. strategies For Dy ad 1 interobserver agreement was calculated on 6 out of 17 sessions and ranged from 78.7% to 91.5%. Mean agreement was 85.4%. Interobserver agreement was calculated on 6 out of 18 sessions for Dyad 2 and ranged from 80.4% to 93.2% with a mean agreement o f 86.8%. For Dyad 3 agreement was calculated on 5 out of 17 sessions and ranged from 80.2% to 97.3%. Mean agreement was 95.2%. Finally, agreement was calculated on 6 out of 17 sessions for Dyad 4. Interobserver agreement ranged from 80.2% to 94.7% with a mean agreement of 91.3%. For Jon (Dyad 1) interobserver agreement was calculated for 6 out of 17 sessions and ranged from 80.1% to 87.5%. Mean agreement was 83.6%. Interobserver agreement was calcula ted on 6 out of 18 sessions for Jess (Dyad 2) and ranged from 85.2% to 91.4% with a mean agreement of 88.7%. For Dave (Dyad 3) agreement was calculated on 5 out of 17 sessions and ranged from 80.1% to 94.2%. Mean agreement was 87.7%. Finally, agreement was calculated on 6 out of 17

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111 sessions for Jay (Dyad 4) Interobserver agreement ranged from 85.3% to 95.7% with a mean agreement of 90.8%. For Jon (Dyad 1) interobserver agreement was calculated for 6 out of 17 sessions and ranged from 79.3% to 87.2%. Mean agreement was 85.7%. Interobserver agreement was calculated on 6 out of 18 sessions for Jess (Dyad 2) and ranged from 82.3% to 90.1% with a mean agreement of 86.5%. For Dave (Dyad 3) agreeme nt was calculated on 5 out of 17 sessions and ranged from 81.3% to 94.3%. Mean agreement was 89.3%. Finally, agreement was calculated on 6 out of 17 sessions for Jay (Dyad 4) Interobserver agreement ranged from 83.2% to 94.7% with a mean agreement of 9 0.7 %. Intervention Results Baseline, intervention, maintenance, and generalization phases were conducted with each dyad. For each phase the researcher calculated the rate of MITS strategies the caregiver used (Figure 4 1). Furthermore, the researcher c alculated the rate of the results are presented in Figure 4 strategies presented on the same graph to determine if ca regiver utilization of the four reading strategies during shared storybook reading facilitated joint attention skills in the child. The MITS strategy rate was determined by dividing the total number of strategies the caregiver used (i.e., attention direc ting, query, model response, or feedback) by the was calculated by dividing the total number of behaviors the child produced (i.e., verbal response to joint attentio n, non verbal response to joint attention, verbal initiation of joint

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112 attention, and nonverbal initiation of joint attention) by the total number of minutes in the session (Gast, 2010). strategies use d per minute per phase was calculated and displayed in Figure 4 2 and are discussed below. behaviors per minute (Figure 4 as measured throughout the study, calculated per minute, presented in Figure 4 4, and are discussed below. Dyad 1: the study The dyad recorded five shared reading book sessions during the first week of the study. For the basel to read to Jon like she normally would using books found around their home. After baseline sessions were analyzed and calculated she averaged a ra te of 1.17 MITS, with a range of 0 .65 to 2.4 (Figure 4 1). His caregiver used the Attention Directing strategy 0 times throughout 0 .41 time per minute (range = 0 to 1.23), no Mo del Response strategy and the strategy of Feedback averaged 0 .82 per minute (range= 0 to 1.23) (Figure 4 2). Baseline phase for Dyad 1: Jon. During the baseline storybook reading sessions Jon averaged 1.62 joint attention behaviors per minute, with a r ange of 0 .65 to 2.88 (Figure 4 1). Jon vocally responded to joint attention bids from his caregiver an average of 1.15 per minute, and initiated joint attention bid an average of 0 .9 per minute. During this time Jon did not

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113 answer or initiate any joint attention bids nonverbally For expressive language Jon used an average of 0 .08 canonical vocalization, 0 .49 single words, and 1.3 word combinations per minute (Figure 4 4). After establishing a stable ba caregiver was instructed to present 3 storybooks (from the books provided by the researcher) to Jon and allow him to choose a book. After the first initial intervention training session, an immediate increase in MITS strategies strategies per minute. Throughout the intervention phase, his caregiver averaged 11.2 MITS strategies per minute (a range of 10 to 12.5). His caregiver continued to use 0 Attention Directing strategies throughout the intervention phase. The use of the Query strategy was an average of 5.73 per minute. The Model Response strategy was used an average of 0 an average of 5.73 per minute (Figure 4 2). MITS strategies per minu te consis tently for 3 sessions. As a result, the caregiver was placed in the maintenance phase. Intervention phase for Dyad 1: Jon. attention behaviors increased, averaging 9.03 joint attention behaviors per minute in this phase, ranging from 8.25 to 9.53 (Figure 4 1). Throughout the intervention phase, Jon averaged 8.76 verbal responses per minute, while his nonverbal responses averaged

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114 1.91 per minute (Figure 4 3). In addition, Jon verbally initiated joint attention 0 .9 times per minute, while he did not produce any nonverbal bids to initiate joint attention. The showed an accelerating trend, as well as a posit ive change in level between th e baseline and intervention phase. erbal expressive communication average d 0 .08 canonical vocalization, 0 .49 single words, and 1.23 multiple word combinatio ns during these sessions. The howed a positive ch ange in level between baseline and intervention phases. the researcher gave to her during the intervention phase. The researc her collected the videos after every session to ensure that the caregiver was using at least 5 MITS strategies strategies 5.8 per minute, an accelerating trend can be seen in Fi gure 4 caregiver averaged 8.12 MITS per minute during the maintenance phase A breakdown of the data show s that the caregiver used 0 Attention Directing strategies, an average of 4.89 Queries, 0 Modeling Responds, and 3.22 Feedback strategies pe r minute respectively. The data show ed d to use the MITS strategies once the coaching sessions were remov ed. Maintenance phase for Dyad 1: Jon. During the maintenance phase of the study, Jon average d 6.97 joint attention beh aviors per minute during the sessions (range = 4.9 to 7.8) (Figure 4 1). His verbal

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115 averaged 0 .7. His verbal and nonverbal initiations of joint attention per session were 1.53 and 0 .15 respectively (Figure 4 3). For expressive l anguage, Jon did not use any canonical vocalizations, though he did average 2.24 single words and 1.44 multiple word combinations per minute. Following the last session of the maintenance phase the caregiver continued to video tape their reading sessions using 4 new books given to the dyad by the completed and recorded 4 sessions. During the generalization phase, the caregiver averaged 7.6 MITS strategies per minute (Figure 4 1). This calculated to the use of the Attention Directing and the Model Response strategy to 0 times per minute. The Query strategy cal utilized the Feedback strategy an average of 3.92 per minute (Figure 4 2). Generalization phase for Dyad 1: Jon. During the generalization phase, Jon averaged 6.2 joint attention beh aviors per minute (range = 5.3 to 7) (Figure 4 1). Verbal response to joint attention bid was used an average of 3.92 per minute. Jon produced less than 1 nonverbal response per minute. Verbal initiation of joint attention did occur an average of 1.07 p er minute, though no nonverbal initiations were recorded. Jon averaged 1.9 single words and 1.3 multiple word combinations for expressive language. No canonical vocalizations were used during his generalization phase.

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116 During baseli baseline. ld to read to Jess like she normally would using books found around their home. After baseline sessions were analyzed and calculated she averaged 2.19 MITS per minute, with a range of 0 .96 to 3.5 (Figure 4 1). His caregiver used the Attention Directing s trategy an average of 0 .19 1.16, no Model Responses were used, and the strategy of Feedback averaged 1.16 per minute (Figure 4 2). Baseline phase for Dyad 2: Jess. Jess a veraged 1.24 joint attention behaviors per minute (range of 0 .96 to 2) as most reading sessions lasted approximately a minute during baseline. Jess vocally responded to joint attention bids from his caregiver an average of 1.35 per minute, being the only joint attention behavior he used during baseline. Canonical vocalization was the only form of expressive language Jess used, averaging 1.93 per minute. After determining the stability of the baseline dat caregiver and began to instruct her on using the four MITS reading strategies. Like She was instructed to present 3 storybooks to Jess and allow him to choose a book.

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117 an average of 8.19 MITS strategies per minute (Figure 4 1). Throughout the intervention phase, his caregiver averaged 8.5 MITS strategies per minute (a range of 7.77 to 9.24). For Attention Directing strategies his caregiver used 0 .89 per minute. The use of the Query strategy was an average of 4.26 per minute. The Model Response strategy was not used througho ut this phase session. This was unlike the more MITS strategies per min ute constantly over 3 sessions. As a result, the caregiver was placed in the maintenance phase. Intervention phase for Dyad 2: Jess. on how to implement the MITS strategies. He averaged 4.7 joint attention behaviors per minute in this phase, ranging from 3.6 to 5.78 (Figure 4 1). Verbal response to joint attention bids averaged 3.88 per minute. Jess nonverbal responses averaged 0 .44 per minute. For verbal initiation of joint attention, Jes s averaged 0 .37 per minute, while he did not produce any nonverbal initiation bids. The data showed a positive change in level between the baseline and intervention phase. vocal ization as he produced 3.96 per minute. In addition, Jess average 0 .29 single words a minute, though no word combinations were used. A positive change in level between baseline and intervention phases was seen.

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118 ver. read to Jess twice a week for two weeks using the books from the intervention phase. Videos were collected after every session to ensure that the the use of the MITS strategies averaged 8.01 MITS per minute during the maintenance phase (range = 6.32 to 9.25) (Figure 4 1). A breakdown of the data showed that the caregiver used 0 .25 Attention Direc ting strategies, an average of 3.62 Queries, 0 Modeling Responses, and 3.37 Feedback strategies per minute respectively. A v isual analysis of the data showed that d to use the MITS strategies when the coaching component was not pre sent Maintenance phase for Dyad 2: Jess. The data showed that Jess produced an average of 5.07 joint attention behaviors per minute during the maintenance sessions of this study (range = 2.2 to 7) (Figure 4 1). bids nonverbal responses averaged 0 .19 per minute. His verbal and nonverbal initiations of joint attention per minute were 0 .43 and 0 respectively (Figure 4 3). For expressive language Jess used an average of 4.47 canoni cal vocalizations per minute, 0 .32 single words per minute, and 0 word combinations per maintenance session. Following the last maintenance session, the caregiver was asked to continue to video record th eir reading sessions, this time using 4 new books given to the dyad by

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119 sessions, though she completed and recorded 4 sessions. During the generalization phase, the caregiver ave raged 8.5 MITS strategies per minute (range = 7.2 to 12.09) (Figure 4 1). The MITS strategy of Attention Directing was produced an average of 0 .43 per minute. The Query strategy averaged 4.46 per minute. The Model Response strategy was not used during t utilized the Feedback strategy an average of 3.94 per minute (Figure 4 3). These data show ed that the caregiver was able to generalize the use of the MITS strategies at a level that was higher than th e baseline data. Generalization phase for Dyad 2: Jess. Jess averaged 5.99 joint attention behaviors per minute (range = 4.06 to 9.1) during the generalization phase (Figure 4 1). He used an average of 4.9 verbal responses per minute to joint attention bid per session. Jess produced an average of less than 1 per minute nonverbal responses. Verbal initiation of joint attention did occur red on an average of 0 .43 per minute, though no nonverbal initiations were recorded. Jess continued to use canonical v ocalization as his primary communication form throughout the generalization phase, averaging 4.9 per minute. He did average 0 .35 single words per minute, though no word combinations were used. er video recorded 2 probe sessions during the first week of the study, and 1 the second week. Once Dyad 2 finished true baseline,

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120 For the baseline normally would using books found around their home. Baseline sessions were range of 0 .85 to 3.8 (Figure 4 1). Hi s caregiver used the Attention Directing strategy an average of 0 caregiver used the Query strategy an average of 1.27 times per minute, no Model Response strategies were used, and th e strategy of Feedback averaged 1.39 per minute. Baseline phase for Dyad 3: Dave. Dave averaged 1.79 joint attention behaviors per minute (range of 1.1 to 2.5) during the baseline sessions (Figure 4 1). Dave vocally responded to joint attention bids fr om his caregiver an average of 1.59 per minute, though he did not produce any nonverbal responses. Dave did verbal initiate joint attention 0.16 times per minute; however he did not use the nonverbal initiation behavior. For expressive language Dave used an average of 0 .86 canonical vocalizations per minute, 0 .57 single words per minute, and 0 .32 word combinations per maintenance session. After determining the stability of the baseline data, the research er met with caregiver was instructed to present 3 storybooks to Dave and prompted him to choose a book

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121 average 9.55 MITS strategies per minute. The caregiver averaged 8.43 MITS strat egies per minute (a range of 7.14 to 9.55) throughout the intervention phase (Figure 4 1). His caregiver used 0 .04 Attention Directing per minute during intervention session. The Query strategy caregive r produced 0 .42 Model Response strategies per minute and the Feedback strategy was used more frequently with an average of 3.19 times per minute. or more MITS strategies per m inute constantly over 3 sessions, therefore was placed in the maintenance phase. Intervention phase for Dyad 3: Dave. strategies his joint attention behaviors increased. Dave aver aged 4.6 joint attention behaviors per minute in this phase, ranging fr om 3.3 7 to 5.03 (Figure 4 v erbal response to joint attention bids a veraged 3.62 per minute and his nonverbal responses averaged 0 .21 per minute. For verbal initiation of jo int attention, Dave averaged 0 .72 per minute, though nonverbal was less than 1 per session ( 0 .04). The data showed a positive change in level between the baseline and intervention phase. xpressive communication showed an average of 1.02 canonica l vocalizations per minute. He did average 1.96 single words per minute. In addition, Dave used 1.32 multiple word combinations per minute. A positive change in level between baseline and intervention phases was seen.

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122 s caregiver. the intervention phase The videos were collected after every session to ensure that strategies per mi nute, during the maintenance phase (range = 7.35 to 7.8) (Figure 4 1). The data showed that the caregiver did not use any Attention Directing strategies during the maintena nce sessions, but averaged 3.7 Queries per minute. For the strategy of Modeling 0 .46 per minute and feedback strategies continued to use the MITS strategies after the coaching component was removed Maintenance phase for Dyad 3: Dave. During the maintenance phase, the data showed that Dave produced an average of 5.13 joint attention behaviors per minute during the sessions (range = 3. 9 to 6.58) (Figure 4 1). Verbal responses to joint attention bids were 3.61 per minute. His nonverbal responses to joint attention bids averaged 0 initiation of joint attentio n calculated to 1.01 per minute and his nonverbal initiation of joint attention was less than 1 per minute ( 0 .05). Dave 0 .7 canonical vocalizations per minute. He also produced 1.96 single words and 1.32 multiple word combinations per minute respecti vely. to video tape their reading sessions, this time using 4 new books chosen by the

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123 s caregiver was asked to complete 3 reading sessions, she completed and recorded a total of 3 sessions. The caregiver averaged 8.47 MITS strategies per minute (range = 8 to 8.98) during the generalization phase (Figure 4 1). The Attention Directing strat egy was not used during this phase. However, the MITS strategy the Model Response strategy an average of 0 .18 per minute. In addition, she utilized the Feedback strategy an average of 3.80 per minu caregiver was able to generalize the use of the MITS strategies at higher level than her baseline data. Generalization phase for Dyad 3: Dave. During the generalization phase Dave averaged 5.7 joint attention behaviors p er minute (range = 5 to 5.89) (Figure 4 1). For verbal responses he averaged 4.9 verbal responses to joint attention bid per minute. Dave produced an average of less than 1 nonverbal response per minute. He also produced on average 0 .62 verbal initiatio n of joint attention per minute, though no nonverbal initiations were recorded. Dave averaged 3.61 canonical vocalizations per minute during the generalization ph ase. In addition, he averaged 3. 17 single words per minute. Dave also produced 2.11 multiple word combinations per minute. sions during the first two weeks began true baseline after Dyad 3 had a st able true baseline.

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124 During the baseline phase, instructed to read to Jay like she normally would using books found around their home. The researcher analyzed and calculated the baseline ses sions. During this phase 0 .67 MITS per minute, with a range of 0 to 1.25 (Figure 4 1). The Attention Directing strategy was averaged 0 caregiver used the Query strategy an a verage of 0 .06 times per minute, no Model Responses were used, and the strategy of Feedback averaged 0 .42 per minute. Baseline phase for Dyad 4: Jay. During baseline sessions, Jay averaged 0 .7 joint attention behaviors per minute (range of 0 to 2.09) (Fi gure 4 1). Although he did not produce any verbal responses, Jay did average 0 .3 per minute for nonverbal response to joint attention. In addition, low amounts of verbal initiation and nonverbal initiation were seen, 0 .18 and 0 .12 per minute respectivel y. For expressive language Jay did not used any canonical vocalizations. He did average 0 .12 single words per minute, and 0 .18 multiple word combinations per baseline session. After establishing a stable the four MITS reading strategies. Like the prev 4 storybooks based on Jay During the intervention reading session storybooks to Jay and allow him to choose a book

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125 produced an average 8 MITS strategies per minute. Throughout the interve ntion phase, the caregiver averaged 8.07 MITS strategies per minute (a range of 7 to 9.22) (Figure 4 0 .40 Attention Directing per minute. The MITS Query strategy d an average of 0 .33 Model Responses per minute. The Feedback strategy was used more frequently calculating to 3.77 per minute. produce 7 or more MITS strategies per minute over 3 sessions. As a result, the caregiver was placed in the maintenance phase. Intervention phase for Dyad 4: Jay. strategies, as he averaged 4.46 joint attention behaviors per minute in this phase, ranging from 3.9 to 5.7 (Figure 4 1). Jay averaged 2.2 verbal responses to joint attention bids per minute. His nonverbal responses averaged 1.26 per minute. nonverbal initiation of joint attention averaged 0.14 per minute an d his verbal initiation averaged 0 .87 per minute. The data showed a positive change in level between the baseline and intervention phase. pressive communication showed an averaged of 1.15 canonical vocalizations per minute. In addition, Jay ave raged 0 .93 single words per minute. He also used an average of 1.08 single word combinations per minute. A positive change in level between baseline and intervention phases was seen.

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126 o Jay twice a week for two weeks using the books for the intervention phase caregiver was able to maintain the use of at least 5 or more MITS strategies even with the removal of coaching maintenance phase (range = 5.9 to 9. 7) (Figure 4 1). The data show ed that the caregiver averaged 0 .24 Attention Directing strategies per minute during the caregiver average d 3.98 Queries per minute. 0 .19 per minute. Feedback strategies averaged 3.78 per minute. A visual analysis of the data showed use the MITS strategies even when the coaching component was removed although a downward trend was observed in the data Maintenance phase for Dyad 4: Jay. During the maintenance phase sessions Jay average d of 5.12 joint attention behaviors per minute (range = 2.7 to 6.88) (Figure 4 1). Verbal responses to joint a ttention bids were calculated at 2.2 per minute. His nonverbal responses to joint attention bids averaged 0 attention calculated to less than 1 per minute ( 0 .54) and did not display any nonverbal initiation of joint attention. For expressive language Jay averaged 0 .99 canonical vocalizations per minute. Jay averaged 1.74 single words per minute and 1.5 multiple word combinations per minute.

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127 iver was also asked to continue to video tape their reading sessions, this time using 4 new books chosen by the researcher. Like previous sessions. During the generalization phase, the caregiver averaged 5.3 MITS strategies per minute (range = 4.8 to 6.2) (Figure 4 1). Attention Directing was used an average of 0 .12 per minute. Howeve r, the use of the MITS strategy Query was more frequent, as Response strategy an average of 0 .24 per minute and the Feedback strategy was used an average of 2.5 per minut caregiver was able to generalize the use of the MITS strategies at a level higher than her baseline data. Generalization phase for Dyad 4: Jay. During the generalization phase, Jay averaged 3.97 joint attention behaviors per minute (range = 3.14 to 5.6) (Figure 4 1). Jay average d 3.2 v erbal responses per minute and less than 1 nonverbal response per minute ( 0 .3). Jay also produced less than 1 verbal initiation of joint attention per minute ( 0 .54) and there were no nonverbal initiations were recorded. phase. He also averaged1.2 single words per minute and produced an average of 1.15 multiple word combinations per minute du ring this phase Social Validation Measure asked to complete the social validity questionnaire. The questionnaire was comprised

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128 of eight 5 point Likert type scale items and one free response question to obtain their opinion regarding the investigation. For the eight Likert type items, caregivers select ed from the following choices: strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree. All caregiv ers either agreed or strongly agreed that MITS training provided by the researcher was useful. Each caregiver either agreed or strongly agreed that the MITS intervention helped them to interact with their child during storybook reading. Furthermore, all caregivers disagreed that the training was too time consuming. When intervention 3 caregivers indicated that they agreed, while one caregiver indicated that they neither agreed nor disagreed. Each caregiver also indicated that they either agreed or strongly agreed that they would continue to use the MITS readings strategies in the future and they felt more confident when they read to their child. As a result of the inter vention, all caregivers agreed or strongly agreed that they believed they had more interaction with their child during storybook reading than before the intervention. All caregivers strongly agreed that other parents who have a child on the spectrum would be interested in learning the MITS strategies For the free response question, when asked to share any additional comments or concerns about the MITS interventions two caregivers indicated that they have incorporated some of the MITS strategies into the ir everyday routine when talking to their child. One caregiver clarified their statement about neither agreeing nor the true benefits of this program will become more obvious over a longer period of time

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129 than the duration of the study. For now, our skills at engaging our ASD child h ave Summary The purpose of this study was to determine if training caregivers to use the MITS intervention incre ased their use of the four reading strategies, if those four reading strategies facilitated joint attention skills in their child, and if the MITS intervention resulted in an increase in verbal expressive language in each child. The data demonstrated that caregivers could be trained to use the four reading strategies, as no caregiver needed additional coaching after the intervention phase. Furthermore, caregivers could generalize the MITS strategies to unfamiliar books and continued to use the MITS strate gies at higher rates than during baseline. Also, the results showed that when each caregiver used the four reading strategies an increase was observed in attention skills. In addition, the data demonstrated that there was an increase i n verbal expressive language for each child. The results of the social validation measure were promising. Caregivers agreed that the intervention was easy to implement and had a positive e ffect on increasing their interaction with their child during share d storybook reading.

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130 Figure 4 1 Caregiver and child behaviors per minute

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131 Figure 4 1 continued.

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132 Figure 4 2 Caregiver MITS per minute per phase A) Caregiver #1 MITS strategies B) Caregiver #2 MITS strategies C) Caregiver #3 MITS strategies D) Caregiver #4 MITS strategies 0 2 4 6 8 Baseline Intervention Maintenance Generalization Rate Per Minute Caregiver #1 Average Number of MITS Attention Directing Query Model Feedback 0 2 4 6 8 Baseline Intervention Maintenance Generalization Rate Per Minute Caregiver #2 Average Number of MITS Attention Directing Query Model Feedback 0 2 4 6 8 Baseline Intervention Maintenance Generalization Rate Per Minute Caregivers #3 Average Number of MITS Attention Directing Query Model Feedback A B C

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133 Figure 4 2 Continued. 0 2 4 6 8 Baseline Intervention Maintenance Generalization Rate Per Minute Caregiver #4 Average Number of MITS Attention Directing Query Model Feedback D

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134 Figure 4 number of JA behaviors B) Child #2 average number of JA behavior C) Child #3 average number of JA behavior D) Child #4 average number of JA behavior 0 2 4 6 8 10 Baseline Intervention Maintenance Generalization Rate per Minute Child # 1: Jon's Average Number of JA Verbal Response Nonverbal Response Verbal Initation Nonverbal Initiation 0 2 4 6 8 10 Baseline Intervention Maintenance Generalization Rate per Minute Child #2: Jess' Average Number of JA Verbal Response Nonverbal Response Verbal Initation Nonverbal Initiation 0 2 4 6 8 10 Baseline Intervention Maintenance Generalization Rate per Minute Child #3: Dave's Average Number of JA Verbal Response Nonverbal Response Verbal Initation Nonverbal Initiation A B C

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135 Figure 4 3. Continued. 0 2 4 6 8 10 Baseline Intervention Maintenance Generalization Rate per Minute Child #4: Jay's Average Number of JA Verbal Response Nonverbal Response Verbal Initation Nonverbal Initiation D

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136 Figure 4 verbal expressive language B) Child #2 verbal expressive language C) Child #3 verbal expressive langua ge D) Child #4 verbal expressive language 0 1 2 3 4 5 Baseline Intervention Maintenance Generalization Rate per Minute Dyad #1: Jon's Verbal Expressive Language Canonical vocalization Word Word Combination 0 1 2 3 4 5 Baseline Intervention Maintenance Generalization Rate per Minute Dyad #2: Jess' Verbal Expressive Language Canonical vocalization Word Word Combination 0 1 2 3 4 5 Baseline Intervention Maintenance Generalization Rate per Minute Dyad #3: Dave's Verbal Expressive Language Canonical vocalization Word Word Combination A B C

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137 Figure 4 4.Continued. 0 1 2 3 4 5 Baseline Intervention Maintenance Generalization Rate per Minute Dyad #4: Jay's Verbal Expressive Language Canonical vocalization Word Word Combination D

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138 CHAPTER 5 DISCUSSION Joint attention is a fundamental skill needed for language acquisition and social development ( Jones & Carr, 2004; Murray et al., 2008; Vismara & Lyons, 2007 ). Resea rch on teaching joint attention has established that caregivers are able to learn and implement intervention techniques aimed at skills (Ingersoll & Gergans, 2005; Jones & Feeley, 2007; Klein et al., 2009; Schertz & Od om, 2007). In addition, the shared storybook reading body of literature has also recognized that a caregiver can effectively implement a variety of strategies to support a Although shared s torybook reading is a natural activity that advocates caregiver and child participation through joint interactions, it has yet to be examined as a caregiver implemented intervention to increase joint attention. Therefore, t he purpose of this study was to determine the effects of training caregivers of children with autism on the M eaningful I nteraction T hrough S torybooks (MITS) interven tion during shared storybook reading The purpose of this chapter is to summarize and interpret the findings of the study i n relation to the research questions and the current literature. The research questions guide the discussion and interpretation of major findings. Next, the implications of the findings for future research and practice will be discuss ed. Then, the chapt er will conclude with a discussion of the limitations and summary of the study. Research Question #1 The first research question addressed the effectiveness of the MITS training to teach the caregivers to use the strategies. The researcher trained each c aregiver on the four MITS reading strategies using explanations of the strategies. Each caregiver

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139 practice d the four MITS reading strategies with the researcher and then was coached with the child. A multiple baselin e design was used to assess how well the caregivers use d the strategies during the shared storybook reading sessions with their child. Looking at the increase in the level of the data between baseline and intervention, one can see that each caregiver demo nstrated an immediate increase in the use the of MITS strategies after the first MITS training (Figure 4 1) In addition, all caregivers wer e able to consistently produce seven or more MITS strategies per minute during the intervention phase The data su ggest s that the training sessions and the coaching provided during the intervention phase, was effective for increasing their use of the MITS strategies during the shared storybook reading sessions. The researcher may infer that the change observed in th e dependent variable strategies ) was due to the introduction of the independent variable (i.e., MITS intervention training) sequentially across the 4 dya ds at different points in time. The result was an imme diate change in the dependent variable following the first MITS intervention training (Kazdin, 1982). This finding is consistent with previous studies in which caregivers were able to learn and imp lement interventions aimed at increasing the jo int attention skills (Jones & Feeley, 2007; Kasari et al., 2010; Rocha et al., 2007; Schertz & Odom, 2007; Vismara & Lyon, 2007) During the maintenance phase, caregivers read aloud to their child using the practiced MITS strategies Dyads 1, 2, and 3 sho wed ascending trends during the maintenance phase (Figure 4 1). These results are similar to findings in previous

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140 shared book reading studies, in which the caregivers either improved or sustained their newly found reading strategies during follow up sessi ons ( Dale & Cole 1996 ; Crow e et al., 2004; Koppenhaver et al. 2001) Therefore, the caregivers were able to implement the MITS strategies by themselves ( i.e., maintenance phase) with relative ease and quickness. Although the caregiver in Dyad 4 (i.e., trend in the use of the MITS strategies during the maintenance phase, she did not fall below the 5 strategies per minute set prior to the phase as criterion for needing additional coaching. One possible explanation fo r this trend i was having difficulty finding time to implement the MITS intervention due to illness, family issues, and scheduling conflicts. One possible reason that caregivers were able to increase and/or maintain 5 or more MIT S strategies during the maintenance phase could be due to the fact that storybook reading is transactional in nature. In other words, the caregiver and child are naturally influence d one another (Bakeman & Adamson, 1984). For example, if after the first behaviors) would have decreased or remained se as the lack of interaction would not be reinforcing for the caregiver to continue the reciprocal interaction ne eded in shared storybook reading (Carpenter et al., 1998). Due to the transactional nature of shared storybook reading, one could hypothesiz e that if

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141 caregiver continuing to place bids for joint attention would be slim, though further research is needed to answer this question. During the generalization ph ase the caregivers were instructed to continue using the MITS strategies but to use unfamiliar books (e.g., books that were not used during the intervention and maintenance phases ) A ll caregivers continued to use a higher number of MITS strategies than at baseline, indicating that the caregivers were able to incorporate the reading strategies into their reading style as well as generalize the skills with unfamiliar books. It is important to note that once each caregiver implemented the MITS st rategies on their own, none of caregivers required additional coaching session s during the maintenance phase. This meant that all caregivers continued to produce 5 or more MITS strategies per minute without the guidance of the researcher. Data levels during the mai ntenance and generalization phase for all caregivers continued to be above baseline data. One may concluded that the framework and frequency of the MITS the context of reading a story with their child. Caregivers use of each M ITS strategies When examining the use of the were used more often than the Attention Directing and Model Response strategies. S imilar results were seen during the pilot study. The findings are discussed in more detail below. Query. All four caregivers showed the greatest gain in the Query strategy This indicat ed that care givers were able to go beyond just reading the text; the y were able to

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142 incorporate relevant questions about the story into the reading session One possible easiest to implement. Additionally, asking questions resulted in increased interaction between the caregiver and child. The natural back and forth conversation created by asking questions may have prompted the caregiver to use this strategy in order to continue the conversation. Another possibility for the increase may be that the c hildren were quicker to respond to the b ids for joint attention, as some of the selected books were based on their interest. Using storybooks with the interest of the child may have potentially motivated the child to engage in joint atte ntion Al though further research is needed in this area previous investigations found that children are more likely to respond to bids for joint attention when interventions create opportunities that specifically played to their interest (e.g., Isaksen a nd Per Holth, 2009; Jones & Feeley, 2007; Rocha et al., 2007; Vismara & Lyons, 2007). Feedback Use of the Feedback strategy also significantly increased for the four caregivers throughout the study This strategy allowed caregivers to expand on the ch answer through commenting, acknowledging extend ing, restating, or clarifying the response of the ch ild. This strategy provided an opportunity for the caregiver and child to discuss the materi al presented in the storybook. Previous research on shar ed storybook reading supports the notion that children are provided with opportunities to develop new concepts, increase vocabulary, develop listening comprehension skills, and engage in conversations about text through questions and answer sessions (Hay & Fielding Barnsley, 2007).

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143 Attention Directing. Although all caregiver s used the Attention Directing strategy it was not utilized as often as the Query and Feedback strategies The intent of the Attention Directing strategy was to create a ny verbal or nonverbal initiation (e.g., point) to establish joint focus (e.g., attention to the book) on pictu res, events, attributes, or text in the storybook. It is possible that the caregivers decided not to use this dy on the book. utilized the Attention Directing strategy the most out of all the caregivers. It may be that because he was the youngest child in the study (26 months) and his attention had to be recruited more often. Another pos sible reasons for the lack of the Attention Directing strategy may be due to the fact that the children exhibit ed some joint attention skills before the intervention took place as noted in the Unstructured Joint Attention Assessments (Loveland & Landry, 1 986). Finally, it may not have been necessary to use this strategy already engaged and focused on the book. Previous research also suggests that a child is more likely to en gage with their caregiver when they are focused on the same Kasari, 2004). Model Response. The Modeling Response strategy was not produced as often as the Query and F eedback strategies This strategy was contingent on a response to the Query, meaning if the child did not respond to the Query in verbal or nonverbal way within 5 seconds the caregiver was to model the appropriate response. The majority of the time the

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144 storybook, therefore the ne ed for the caregivers to use this MITS strategy might not have been necessary. Research Question #2 The second research question addressed the c the MITS strategies during shared storybook reading on the join t attention skills of the child. oint attention during the reading The results indicated that when the car egivers used the reading strategies during the reading session each child increased their overall rate of joint attention behaviors. This finding is consistent with previous research in which caregivers were able to learn and implement interventions aime d at increasing joint attention behaviors or engagement during storybook reading with their child who had a disability ( e.g., Bellon et al., 2000; Crow e et al., 2004; Dale & Cole, 1996; Fielding Barnsley & Purdie, 2003; Jones & Feeley, 2007; Justice et al. 2011; Kasari et al., 2010; Koppenhaver et al., 2001; Rocha et al., 2007; Schertz & Odom, 2007; Vismara & Lyon, 2007; Vogler Elias, 2009). use of joint attention behaviors, the d ata indicate d that the verbal and nonverbal r esponse behaviors (i.e., response to joint attention bids by the caregiver ) were used more often than the verbal and nonverbal i nitiation behaviors ( i.e., the child getting the caregiver to attend with him ) Th is finding is also consistent with previous studies where researcher s found that children with ASD frequently responded more to joint attention bids than initiating their own joint attention behaviors ( e.g., Ingersoll & Schreibman, 2006; Kasari et al., 201 0; Whalen and Schreibman, 2003). (Dyad 2) third data point in the maintenance phase for rate of joint attention behaviors

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145 was close to his baseline levels. Although caregiver produced 6.32 MITS strategies per minute du ring that session, providing numerous joint attention bids, a closer review of the video reading session revealed that Jess did not have joint focus on the book. One possible reason for the lack of focus and consequently lack of joint attention behaviors could be the book was not based on his interest (i.e., Touch and Feel ABCs phases, his data was stable throughout the intervention, maintenance, and generalization phases. The se fi ndings are discussed in more detail below. Verbal r esponse behavior All four of the child ren displayed t he greatest gains in their verbal r esponses to joint attention bids. This i n part was due t o the increase in uery strategy Durin g the study as the caregiver attention increased or decreased (i.e., MITS strategies (Dyad 1) variability throughout the study. For example greatest gains were seen during the intervention phase. He produced an average of 9.03 verbal responses to joint attention bids per minute, as his caregiver averaged 11.2 MITS strategies (i.e., bids for joint attention) per minute. During the mai ntenance phase, decreased, averaging 8.12 per minute. During the generalization phase, response seemed to stabilize with an ave rage of 3.92 behaviors per minute, as his caregiver recorded an average of 7.6 MITS strategies per minute. These results were similar to the rate of MITS strategies observed during the maintenance phase.

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146 Verbal response behaviors in Jess (Dy ad 2), Dave (D yad 3), and Jay (Dyad 4) increased during the intervention phase and remained relatively consistent throughout the reminder of the study. This may be attributed to the relatively consistent rate in strategies Nonv erb al r esponse behavior Three of the children produced minimal gains in their nonverbal response behavior. Jay (Dyad 4) produced an average of 1.26 nonverbal responses per minut e during intervention phase but decreased during the maintenance and generaliza tion phases. One possible reason for the decrease in nonverbal response behavior wa per minute during the maintenance phase and 3.2 per minute during the generalization phase During the intervention phase Jon (Dyad 1) produced an average of 1.91 nonverbal responses per minute, decreasing to 0 .7 per minute during the maintenance phase and i ncreasing to 1.88 per minute during the generalization phase verbal response behavior, one possibil ity for the decrease in nonverbal response behavior was the decrease in his car (Dyad 2) nonverbal response behaviors remained constant through the intervention, maintenance, and generalization phases. It is likely t hat this behavior use nonverbal responses. Dave (Dyad 3) did not use the nonverbal response behavior throughou t the study. It is possible that the lack of nonverbal respo nses was because he came into the study with a higher use of the verbal response behavior.

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147 Verbal initiation and nonverbal i nitiation behaviors. Child participants did not show significant gains in these initiations of joint attention behaviors. These re sults are similar to the results of previous studies as initiation of joint attention skills are more complex skill s to teach, learn, and maintain ( e.g., Ingersoll & Schreibman, 2006; Karsari et al., 2010; Schertz & Odom, 2007; Whalen & Schreibman, 2003). One possible explanation for the lack of these initiation behaviors could be because the MITS strategies the caregiver utilized during the reading sessions required responses from the child and did not teach the child initiation skills. Research Question # 3 The results of the current study indicated that after the caregivers received the MITS training and used the strate gies during the reading session s, each child increased thei r rate of ver bal expressive language (Figures 4 4). This finding is consistent with previous research in which caregivers learned a shared storybook reading intervention, implemented the strategies, and the results showed an increase in the language of the ir child who had a disability ( e.g., Crow e et al., 2004; Koppenhaver et al., 2001; Vogler Elias, 2009). In the present study, three of the four children increased the number and variety of expressive language they used to c o mmunicate with their caregiver. The only child who did not demonstrate an increase in the variety of verbal expression was Jess (Dyad 2) As mentioned in the participant description section of Chapter 3, Jess had speech production difficulties, which ma y have account ed (Dyad 3) increase in single word and multiple word combinations was observed during the generalization phase. One

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148 explanation for the increase could be that Dave found the books more engaging in the ge neralization phase. During the generalization phase, the choice of books came from any set of books not used in the intervention and maintenance phases. Therefore, the likelihood of selecting a book of interest was high. Jon (Dyad 1) began to use more s ingle words and multiple word combinations while decreasing the amount of canonical vocalization. This is not unusual since children will reduce the less sophisticated expressions when they find a more understandable and responsive method of communicating ( Dyad 4) expressive language as he had an increase in all three areas of expressive language. A n could be the increas the MITS strategies. Increasing bids for attention to the books created a more transactional experience between the caregiver and child (Crowe et al., 2004). The purpose of using the MITS strategies during s hared storybook read ing was to promote reading storybooks as a transactional activity. As a result, this study demonstrated the effectiveness of the strategies and the importan ce of their use by these caregivers to facilitate language, particu larly when the child has a langu age impairment (Bakeman & Adamson, 1984; Dale & Cole, 1996; Crow e et al., 2003; Lovelace & Stewar t, 2007; Justice et al., 2011). Complementary to the findings in the joint attention and shared storybook literature scaffolding questions is commonly used t o expand communication in a meaningful way b etween the adult and child. Bellon models that facilitate

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149 the M ITS strategies. Through the use of these MITS strategies in the storybook reading session s the caregiver facilitate d language and speech patterns that increase d elaborate d and model ed new a nd unfamiliar vocabulary words which helped expand their s vocabulary (Bellon Harn and Harn, 2008; Justice & Kaderavek, 2002; Lane & Wright, 2007). Implications The results of this study provided evidence that caregivers were able to effectively learn and implement the MITS intervention. Furthermore, the increa se in the strategies provided numerous joint attention bids, or opportunities, for their child to become an active participant in the storybook session These opportunities enable d the child to use their joint attention behavio rs (i.e., verbal response, nonverbal response, verbal initiation, and nonverbal initiation). Consequently, through the increase in interaction between the caregiver and child, growth of expressive language was s een in each child participant. This study ad ds to the literature base as it combines two bodies of rich literature. This study created interactive reading strategies that advocated caregiver and child participation through shared storybook reading, ultimately increasing joint attention. It is impo rtant to highlight that the children utilized in this study were on the autism spectrum, a population with limited research in shared storybook reading. The results have several implications for researchers and practitioners, and are discussed below. Impl ications for Future Research As previously stated, the caregiver child relationship is transactional in nature, signifying that caregiver and child mutually influence one another (Carpenter et al., 1998). The caregivers in this study were taught to go bey ond reading the storybook and

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150 to actively engage with their child during the shared reading sessions. The MITS intervention encouraged the caregivers to bring joint focus to the storybook (i.e., the Attention Directing strategy ask questions (i.e., the Query strategy ), model unanswered questions (i.e., Model Response strategy ), and provide feedback (i.e., Feedback strategy ). Using the MITS strategies during shared storybook reading allowed the caregiver and child to have joint f ocus on an object of interest, thus providing more opportunities for the child to respond and initiate joint attention bids. For caregivers, these strategies created a natural tur n taking activity Due to the naturalistic flow the MITS strategies caregi vers could replicate the strategies across different settings (i.e., play time) providing more opportunities for interaction between the caregiver and child that go beyond storybook time. A recommended a rea for future research would be to take a closer loo k at the specific types of Query questions the caregivers used (i.e., request for label, request for action, cloze procedure, binary choice, or open ended question). Looking at the particular types of questions used most often, least, or not at all could provide researchers with valuable information when working with children with autism. In the examination of the joint attention studies in Chapter 2 it was noted t hat many studies m child. Results of those studies showed that using objects of preferred interest motivated children with ASD to engage with their caregiver therefore naturally increasing joint attention (e.g., Jones and Feeley, 2007; Rocha et al., 2007; Vismara & Lyon, 2007; Whalen & Schreibman, 2003). In addition, an examination of the shared storybook reading literature suggests that exposing children to books that they are interested in is

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151 a critical factor in their success (Ortiz et al., 2001). Therefore, using boo ks based on to increase the likelihood of joint attention occurring though it should be noted that the caregiver also used storybooks of noninterest. It appears that using storybooks of interest c ombined with the MITS strategies helped create numerous opportunities for meaningful child caregiver interaction that were mutually reinforcing, consequently increasing joint attention and MITS strategies On the other hand, when a caregiver used books no stated interest there was little if than when the caregiver used a book of stated interest Further research is needed, as it is ignificantly affected by the selection of interest or noninterest book. Naturalistic early interventions, such as the MITS intervention, allow caregivers and interventionists to work together to help teach and develop critical skills in children with disab ilities. The importance of including caregivers in the intervention process has been well documented throughout the literature (Bagnato, 2007; Cosden, Koegel, Koegel, Greenwell, & Klein, 2006; Crowe, Norris, & Hoffman, 2000). The literature also indicate d that greater maintenance and generalization of previously acquired skills are achieved in new environments when caregivers are involved because they are able to pr actice and implement these new found skills throughout the day (Fletcher, Perez, Hooper, & Claussen, 2005; Schertz & Odom, 2007). Caregivers in this study were able to maintain and generalize the MITS strategies, but due to the relatively short time this intervention focused on maintenance a nd generalization skills, further research is warrante d.

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152 The MITS intervention allowed the caregiver and child to read in their natural environment, creating a predictable routine. This predictability and stability allow s children to feel secure in their environment while giving the caregiver opportunities t o facilitate interactions which focus on the communicative and linguistic development (Bellon, Ogletree, and Harn, 2000; Ingersoll & Gergans, 2005; Jones & Feeley, 2007; Koppenhaver et al., 2001; Vogler Elia s, 2009). Children participating in this study s howed an increase in expressive language throughou t the MITS intervention. Further generalized beyond the storybook sessions. Although the researcher conducted a coaching compon ent d uring the i ntervention phase of the study it was not done using a systematic method across participants. It is important to note that during this current study caregivers were active participants who reflected on their performance when watching thei r reading sessions on video, but due to the lack of treatment integrity for the coaching component, it would be difficult to report. Fu rther research is needed to create and use a more methodical manner of coaching when viewing the reading sessions with t he caregivers. response to joint attention b id s are measured and reported. As each MITS strategy required a response from the child (i.e., vocal response and nonverbal response to joint atten tion ) it would benefit the researcher to look at the bids for joint attention (i.e., MITS strategies) and report whether or not the child responded. Therefore reporting the a percent age of opportunities (i.e., the total nu mber of vocal and nonverbal joint attention occurrences divided by the total number of MITS strategies

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153 used, multiplied by 100) would be a more accurate way to measure to joint attention behaviors (Gast, 2010). Implications for Practic e The MITS strategies are interactive strategies that could potentially be beneficial for educators working with children with autism. Exposing children to important literacy experiences becomes complex for practitioners when their preschool students with ASD have deficits in joint attention. This is due to the fact that joint attention is a prerequisite skill for acquiring emergent literacy skills. Therefore, it is vital for early educators to work on increasing joint attention with children with ASD th roughout the school day. As illustrated by the lack of research, there is a need for further research in the area of shared storybook reading with you ng children on the spectrum. C urrent ASD research has focused on hyperlexia and sight word instruction, in lieu of the acquisition of early literacy skills, such as joint attention (Koppenhaver & Erickso n, 2003; Watson et. al, 2004). Below are some suggesti ons on how educators could use components of the MITS intervention to support joint attention and lang uage development in their classroom First, practitioners could utilize the MITS strategies during circle time allowing them to work on a variety of skills with numerous children in a relatively short amount of time The results of this study show ed that adults using MITS strategies create opportunities (or bids) for joint attention to occ ur. Th r ough the use of these strategies the practitioners could ask questions, pr ompt, and provide feedback. Therefore the practitioners becom e active listeners while the children are able to become active participants (Whitehurst et al., 1994).

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154 Second, the MITS strategies provide practitioners with the opportunity to become creative w hen introducing new language and vocabulary. During the storybook experience, adults can engage children in meaningful dialog using new vocabula ry in the context of the story. Through the use of child friendly definitions and repeating unfamiliar words c hildren will be able to a cquire additional oral language (Beauchat et al., 2009; Lan e & Wright, 2007). Third, throughout the MITS strategies the use of a 5 second wait time is implemented. Educators on average wait less than 1 second for a child to respond before they answer the question for the child or ask another question (Rowe, 1986) The addition of a 5 seconds wait time is an easy way to increase the number of opportunities a child has to communicate. Lastly, this study touches on the idea that using materials and objects of interest to the child could potentially motivate the chil d and natural ly boost their engagement. Practitioners can use this knowledge when preplanning and setting up their classroom to support more natural joint attention exchanges. Limitatio ns A number of factors may limit the findings of this study and should be consider when interpreting the results. First, the frequency in which the caregiver participated in shared storybook reading sessions outside the allot ted time is unknown. That is, the parents were asked to videotape at least 7 sessions. They may have read aloud with their child during other ti mes then those that were video recorded This might have affected their use of the MITS strategies. Second, although the investigator followed the MITS Treatment Fidelity Checklist, which outlined the components that were taught

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155 have been different for each caregiver These differences may have influenced the their ability to learn the MI TS inte rvention (Rocha, et al., 2007). Third, the presence of the investigator and use of video camera may have caused caregivers to utilize the MITS strategies at higher rates. Such may have been the case tion phase, as she displayed the most MITS strategies during this time The intervention phase was the only time in the study that the researcher was present for the caregiver/child reading sessions Fourth, despite the positive benefits of using a multi ple probe, multiple baseline across participants design the baseline data should have been longer for Dyads 3 and 4, but due to scheduling restrictions such data was not possible to collect. Fifth, there was no treatment integrity on the coaching during the intervention phase. The amount of coaching could have varied across caregivers, as there was not a systematic method to ensure all received the same amount. Keeping these limitations in mind, the results should be interpreted with caution. Conclusion Teaching children with autism to acquire joint attention skills comes with a unique set of challenges. To state that a single intervention will alleviate the deficit in joint attention that young children with autism have would be over simplistic, but res earch strongly supports the impact that early joint attention interventions can have. Children with a deficit in joint attention will have difficulties with shared experiences. The lack of shared interactions makes it significantly difficult to acquire l anguag e, as the emergent of joint attention skills are a critical developmental milestone (Woods & Wetherby, 2003). The results of this study suggest that caregivers can effectively implement the MITS strategies during shared storybo ok reading. These int eractive strategie s, pair ed

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156 with a storybook that has caregiver and child to become actively involved, thus increasing joint attention and language opportunities. More research is needed to understand how best t o assist children with ASD in acquiring joint attention skills that are necessary for language development. Unless future research is done on how to best facilitate these essential skills the gaps in effective interventions wi ll remain for children with ASD.

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157 APPENDIX A TABLES OF JOINT ATTENTION STUDIES ORGANIZED BY TOPICS Table A 1. Summary of joint attention interventions using discrete trial training Study Participants Experimental Design Intervention Type of JA measure Results Martin & Harris (2006 ) N=3 multiple baseline by participants DTT Time delay, preferred objects, tangible and social reinforcement RJA Positive Taylor & Hoch (2008) N=3 multiple baseline by participants DTT Prompting, social reinforcement, least to most prompting RJA IJ A Positive Klein et al. (2009) N=3 multiple baseline by participants DTT Time delay, contingent activation of a toy IJA Positive Isaken & Per Holth (2009) N=4 multiple baseline by participants DTT Eye gaze and pointing prompts, reinforcement of prefer red toys RJA IJA Positive DTT= discrete trial training. RJA= response to joint attention. IJA= initiation to joint attention.

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158 Table A 2. Summary of joint attention interventions using pivotal response training Study Participants Experimental Design Intervention Type of JA measure Results Ingersoll & Schreibman (2006) N=5 Multiple baseline across participants PRT Reinforcement verbal praise, model, least to most prompts, eye gaze shifting RJA: eye gaze shift IJA RJA: Positive IJA: Mixed Schert z & Odom (2007) N=3 Mixed methods Multiple baseline across participants, interviews, and parent notes PRT Parent training, focus on face, eye contact, turn taking, social commenting RJA IJA RJA: Mixed IJA: Mixed Vismara & Lyon (2007) N=3 Mixed meth ods Single subject reversal design and qualitative measure for interaction PRT Parent training, contingent rewards, natural reinforcers, toys based on perseverative interest IJA Positive Kasari et al. (2010) N=38 Experimental Group Design PRT Parent training, led RJA IJA Mixed RJA: Positive IJA: Negative PRT= pivotal response training. RJA= response to joint attention. IJA= initiation to joint attention.

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159 Table A 3. Summary of joint attention interventions using both discrete tri al training and pivotal response training Study Participants Experimental Design Intervention Type of JA measure Results Whalen & Schreibman (2003) N=5 Multiple baseline by participants DTT: inter trial intervals, prompting PRT: following st, receiving access to object of as a response reinforcer RJA IJA RJA: positive IJA: mixed Kasari, Freeman, & Paparella (2006) N= 56 Experimental Group Design DTT: inter trial intervals, least to most prompts PRT: floor play, follow ch RJA IJA RJA: positive in JA group and symbolic play group, not control IJA: positive in JA group and symbolic play group, not control Jones & Feeley (2007) N= 3 M ultiple probe across behaviors Parent training, DTT: inter trial intervals, lea st to most prompts, high rates of reinforcement PRT: objects interest, natural social reinforcements RJA IJA Positive Rocha, Schreibman, & Stahmer (2007) N=3 Multiple baseline by participants Parent Training DTT: inter trial intervals, prom pting PRT: following receiving access to object of as a response reinforcer RJA RJA: Positive IJA: increased although not directly targeted

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160 Table A 3. Continued Study Participants Experimental Design Intervention Type of JA measure Results Kaale, Smith, & Sponheim (2012) N=61 Experimental Group Design Preschool Teacher and Parent Component DTT: inter trial intervals, adult driven PRT: floor play, child led RJA (joint engagement) IJA Statistically significant ef fects were seen in the experimental and IJA than the control group DTT= discrete trial training. PRT= pivotal response training. RJA= response to joint attention. IJA= initiation to joint attention.

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161 APPENDIX B TABLES OF SHARED STO RYBOOK READING STUDIES ORGANIZED BY TOPICS

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162 Table B 1. Summary of shared reading interventions with language and developmental delays children Study Participants Development & Language Delays Setting & Caregiver Component Experimental Design Interventio n Results van Kleeck, Vander Woude, Hammett (2006) N= 30 Age= 46 60 months Language impairments Preschool setting No caregiver component randomized control group design One on one literal and inferential language skill intervention Positive Lo velace & Stewart (2007) N= 5 Age= 48 60 months Language impairment Early learning center No caregiver component Multiple probe design across subjects Print concept shared storybook reading intervention Positive Bellon Hard & Harn (2008) N=1 Age= 72 months Development delays: gross motor, fine motor, language, social, & self help Clinical setting No caregiver component Multielement design across two conditions (Scaffolding & Scaffolding with AAC) Scaffolding & Scaffolding with AAC: includ ing wh questions, modeling, & expansion Scaffolding: Positive Scaffolding with AAC: Positive; more communicative behaviors Dale & Cole (1996) N= 33 Ages= 36 72 months Language delays Caregivers implemented intervention Experime ntal design Dialogic reading intervention or Conversational language training Positive Fielding Barnsley & Purdie (2003) N= 26 Ages: 70.2 70.5 months one or more had a history of reading disability Caregivers im plemented intervention Quasi experimental Dialogic reading intervention Positive Crowe, Norris, & Hoffman (2004) N=6 Ages: 38 41 months Language impairments Caregivers implemented intervention Multiple baseline across participa nts Complete Reading Cycle Positive

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163 Table B 1. Continued Study Participants Development & Language Delays Setting & Caregiver Component Experimental Design Intervention Results Justice, Skibbe, McGity, Piasta, Petrill (2011) N= 62 Ages: 48 60 mo nths Language impairment Caregivers implemented intervention Quasi experimental Print referencing, Picture focus, or Sound focus Positive Table B 2. Summary of shared reading interventions for children with autism Study Particip ants Autism Spectrum Disorder Setting & Caregiver Component Experimental Design Intervention Results Bellon, Ogletree, & Harn (2000) N= 1 Age= 46 months High functioning autism; speech & language delays Clinical setting No caregiver component Sin gle subject design Repeated storybook reading, wh questions, and scaffolding Positive Koppenhaver, Erickson, & Skoto (2001) N= 4 Age= 39 72months Rett syndrome Caregiver implemented intervention Multiple baseline across behaviors across participan ts Shared Storybook Reading; Positive Vogler Elias (2009) N=7 Age= 36 60 months home Caregiver implemented intervention Multiple baseline across participants Positive

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164 APPENDIX C MITS COLLECTION CHECKLIST & CODING SHEET T able C 1. Definition of MITS strategies to be implemented by caregivers MITS strategy Definition Example Attention Directing Any verbal or nonverbal initiation (e.g., point) to establish joint focus (e.g., attention to the book), such as the pictures, events, attributes, or text. which serve to establish the topic or picture for discussion. Point accompanied by plus label Tapping counts, code at beginning of tap Label plus pointing with no pause or tap is just considered normal reading behavior If point prompt happens within 5 seconds of query it does not count Caregiver points to a picture of a dog and Query Any communicative act to volunteer or request verbal or nonverbal response. Queries include query. Queries can be open ended questions with an attention directive plus query seconds, to allow the child time to respond. Must wait 5 seconds after question is a sked Label and wait 5 seconds After caregiver states query, start 5 seconds. Record at 5 second mark or as soon as child answer query; whichever comes first When feedback is in form of a query and/or inflection, mark as a query If caregiver givers query an d then prompts before 5 seconds is over do not count Caregiver give the child a binary choice, bone or a

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165 Table C 1. Continued MITS strategy Definition Example Model Response Any semantically contingent response to the Query, if the child did not respond to the Query in verbal or nonverbal way within 5 seconds. Model Response includes answering the Query answer). Waiting 5 seconds, then modeling the Code at the end of the model statement After waiting 5 second for the child to respond, the caregiver them models the appropriate Feedback Any comment serving to acknowledge, extend, restate, or clarify the response of the child. Or pr ovides an opportunity for the caregiver and child to discuss material presented in the storybook. The caregiver can clarify the response. When feedback is in form of a query, mark as query Do not have to wait 5 second after feedback is given in order to be marked Code feedback as soon as it happens While reading a book about a dog, The caregiver acknowledges the child by saying,

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166 Table C 2 Type of joint attention Definition Examples Vocal Response to Joint Attention (VR) After caregiver ask/gives a query, child vocalizes a canonical vocalization, word, or words answering query in conjunction with ga ze alternation & positive affect to the caregiver If child reads along with book, does not count as VR VR takes precedents over NVR Child has echoloicha Caregiver & child are reading a book about bear. Caregiver child responds, Nonverbal Response to Joint Attention (NVR) Eye gaze: Child looks between object & caregiver in conjunction with gaze alternation & positive affect to the caregiver (e.g., smiling, laug hing). O r Point: Child extends finger toward object in conjunction with gaze alternation & positive affect to the caregiver Child & caregiver are reading a book about a bear. Child points to the bear & alternates eye contact to the caregiver Vocal Ini tiation of Joint Attention (VI) Child vocalizes a canonical vocalization word, or words about the book to their caregiver with gaze alternation and positive affect to the caregiver If child reads along with book does not count as VI Child & caregiver are reading a book about bears. Child Non Voca l Initiation of Joint Attention (NI) Child initiates joint attention with eye contact or point & positive affect Child & caregiver are reading a book about a bear. As caregive r turns page, child see that bear on the page & alternates eye contact between bear & caregiver

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167 Table C 3. Definitions and examples of expressive language sample done by child Type of expressive language Definition Example Canonical vocalizatio n Characterized as a rhythmic productions of one or more consonant vowel (CV or CVCV) Child holds up an apple and Word Any single word utterance Words Combination Any utterance in which the child uses multiple words Chil

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168 Coding Sheet Dyad:____________________ Session #:__________ __ Length: _________ Min 0 1 2 3 4 5 6 7 8 9 10 1 10 11 20 21 30 31 40 41 50 51 60 Min 1 1 2 3 4 5 6 7 8 9 10 1 10 11 20 21 30 31 40 41 50 51 60 Min 2 1 2 3 4 5 6 7 8 9 10 1 10 11 20 21 30 31 40 41 50 51 60 Min 3 1 2 3 4 5 6 7 8 9 10 1 10 11 20 21 30 31 40 41 50 51 60 Min 4 1 2 3 4 5 6 7 8 9 10 1 10 11 20 21 30 31 40 41 50 51 60 Min 5 1 2 3 4 5 6 7 8 9 10 1 10 11 20 21 30 31 40 41 50 51 60

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169 APPENDIX D UNSTRUCTURED JOINT ATTENTION ASSESSMENT Adapted from Loveland & La ndry (1986) Gesture only task +/ +/ +/ Shift gaze after establishing eye contact with the child, the investigator shift gaze toward some object behind & to the side of the child Pointing the investigator points at some object and the child looks at or comments on the objected indicated Showing the inves tigator holds out an object so that the child can easily see it; the child is to look at or comment on the object Tapping Object the investigator touches the object of attention; the child is to look at or otherwise attend to the object Moving chil the object; the child must look at or comment on the object Language plus gesture task +/ +/ +/ Shift gaze after establishing eye contact with the child, the investigator s hift gaze toward some object behind & to the side of the child and Pointing and the child looks at or comments on the objected indicated Showing the invest igator holds out an object so that the child can easily on the object Tapping Object at or otherwise attend to the object or comment on the object

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170 APPENDIX E CAREGIVER HANDBOOK

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171 4 M ITS Initial Training Material s (Day 1) Strategy #1 Attention Directing on the book. This strategy uses a word, a combination of words, or a gesture, when trying to get your child to focus on the book. Your verbal or nonverbal cues can be used towards pictures, events, attributes or text that are located in the book. Verbal Examples Nonverbal Examples Say t Tap at a certain place in the Point to a certain plac e in the book Strategy #2 Query vocabulary. There are many types of questioning you can use to elicit respon ses from your child. Only ask one question at a time and give your child 5 seconds to respond. Types of Questioning Examples Queries include requests for labels Request action Cloze procedure He Binary choice Should he walk or run? Open ended questions What will happen now? 4 MITS Initial Training Material s (Day 1) Continued

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172 Strategy #3 Model Response The strategy Model Response will be used if your child did not respond to y our Query in verbal or nonverbal way within 5 seconds. When you use the Model Response strategy you will model the answer to the Query question you asked. use the book to practice. Types of Questioning Wait 5 seconds Model Res ponse Label: Wait 5 seconds That is a ______. Request action: Wait 5 seconds He is _____________. Cloze procedure: Wait 5 seconds Binary choice: Should he walk or run? Wait 5 seconds He should ________. Open ended questions: What will happen next? Wait 5 seconds I think that ________________. Strategy #4 Feedback The strategy Feedback is any comment serving to acknowledge, extend, restate, or clarify th e respons e of your child. The feedback strategy in the MITS provides an opportunity for you and child to discuss material presented in the storybook. e book to practice. Example of Feedback Answering a label: Rabbit Answering a request action The furry rabbit is running very quickly. Answering a cloze proce dure: He is eating a red juicy apple. Answering binary choice: He should walk Why do you think he should walk? Answering an open ended questions: I think he is scared. Why do you think the rabbit is scared?

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173 Strategy #1 Attention Directing book. This strategy uses a word, a co mbination of words, or a gesture, when trying to get your child to focus on the book. Verbal Examples Nonverbal Examples book attention Say the word Point to a certain place in the book Strategy #2 Query voca bulary. There are many types of questioning you can use to elicit responses from your child. Only ask one question Types of Questioning Examples Queries include requests for labels Request action Cloze procedure Binary choice Should he walk or run? Open ended questions What will happen now? Additional 4 MITS Training Continued

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174 Strategy #3 Model Response The strategy Model Response will be used if your child did not respond to your Query in verbal or nonverbal way within 5 seconds. When you use the Model Response strategy you will model the a nswer to the Query use one of the following books to practice: If You Give a Mouse a Cookie, Goodnight Moon, or The Very Hungry Caterpillar Types of Questioning Wait 5 seconds Model Response Label: Wait 5 seconds That is a ______. Request action: here? Wait 5 seconds He is _____________. Cloze procedure: ____. Wait 5 seconds Binary cho ice: Should he walk or run? Wait 5 seconds He should ________. Open ended questions: What will happen next? Wait 5 seconds I think that ________________.

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175 d Strategy #4 Feedback The strategy Feedback is any comment serving to acknowledge, extend, restate, or clarify the response of yo ur child. The feedback strategy in the MITS provides an opportunity for you and child to discuss material presented in the storybook. Example of Feedback Answering a label: Answering a request action Answering a cloze procedure: Answering binary choice:

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176 APPENDIX F CHILD INTEREST INVENTORY Sex:______ We are collecting basic information to help us se lect storybooks that best fit your 1. Name the object(s) or toy(s) that your child plays with most often. ____________________ _____________________ _____________________ _____________________ __________________ ___ _____________________ 2. Does your child take a particular interest in book(s)? Yes/No If yes, please ex plain:___________ __________________________________ ______________________________________________________________ 3. Is your child strongly attached to a specific item ( e.g. piece of clothing, doll, Yes/No If yes, please specify:_____________ _____________________________ ______________________________ _______________________________ 4. Does you r child sort objects? Yes/No If ye s, what type of objects:______ __________________________________ ______________________________________________________________ How does your child sort object (e.g. siz e, shape, color, etc.)_______ ______ __ ____________________________________________________________ 5. Does your child line up objects? Yes/No If yes, what type of objects:_________ _______________________________ ______________________________________________________________ How does your child line up object (e.g. size shape, color, etc.)_________ __

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177 ______________________________________________________________ 6. Does your child like to participate in sensory experiences? Yes/No If yes, explain the type of sensory experiences (e.g. touching things, hearing specific sounds, lights, smells, tearing paper, etc:____________________ ______________________________________________________________ 7. Does your child like to participate in sports or games? Yes/No What type of spor ts or games:_________________ ____________________ ______________________________________________________________ 8. Does your child like to see how things work? Yes/No If yes, what types of objects (e.g. computers, radios, TVs, clocks, etc.) ___________________________________________________________________ 9. Does your child like a certain cartoon or TV character? Yes/No If yes, please specify:_______ _____________________________________ _______________ ___________________ ___________________________ 10. Any additional information you believe would help us in selecting storybooks for your child, please feel free to share:_________ _____________________________ ____________________________________________ _______________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

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178 A PPENDIX G TREATMENT FID ELITY The MITS Treatment Fidelity Checklist outlines the components that must be taught during the training sessions to ensure treatment fidelity between caregivers. MITS Treatment Fidelity Checklist Reading Strategy Component Met Partial Absent 1. Di scussed the importance of joint attention for children with ASD. 2. Taught Attention Directing Explained that this includes any verbal or nonverbal initiation to establish joint focus (e.g., attention to the book), such as the pictures, events, attr ibutes, or text. 3. Taught Query Explained that this is any communicative act to volunteer or verbal or nonverbal response. Request act ended Introduced with an attention directive plus qu ery 4. Taught Model Response Explained that this includes any semantically contingent response to the query after waiting 5 seconds Model re sponse includes modeling the answer for desired Query requests for labels 5. Taught Feedback Explained that is any comment serving to acknowledge, response to Query (can be verbal or nonverb al). The feedback strategy provides an opportunity for the caregiver and child to discuss material presented in the storybook. previous utterance or response. 6. Reviewed all 4 reading strategie s : attention directing, query, model response and feedback

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179 APPENDIX H SOCIAL VALIDITY Social Validity Questionnaire Read each statement carefully. Five possible choices as to your level of agreement and disagreement have been placed after each st atement. For each of the statements, please circle the phrase that best describes your feelings about the statement. Circle only one phrase for each statement. Please be sure to answer every item. 1. The Meaningful Interaction through Storyboo ks (MIT S) intervention training helped me to interact with my child during storybook reading I strongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. 2. The training was too time consuming. I s trongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. due to the MITS intervention I strongly agree. I agree. I neither agree no r disagree. I disagree. I strongly disagree. 4. I will continue using the MITS reading strategies in the future. I strongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. 5. As a result o f this intervention, I feel more confident when reading to my child. I strongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. 6. As a result of this intervention, I believe there is more interacti on when reading to my child then before. I strongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. 7. Other parents who have child on the autistic spectrum might be interested in learning MITS reading strategies

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180 I strongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. 8. The instruction provided by the researcher prior to the maintenance phase was useful. I strongly agree. I agree. I neither agree nor disagree. I disagree. I strongly disagree. 9 Please feel free to share any additional comments or concerns about the MITS intervention. __________________________________________________________________ ______ ___________________ _____________________________________________________ ________________________________________________________________________ ___________________ _____________________________________________________

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181 APPENDIX I LIST OF BOOKS USED IN STUDY Book Title Publication Year Author Touch and Feel: ABC (Touch & Feel) 2012 DK Publishing John Deere: Touch and Feel: Tractor 2008 John Deere Co. Dear Zoo: A Lift the Flap Book 1982 Rod Campbell The Goodni ght Train 2006 June Sobel Zoo! Counting Book 2007 Lori C Froeb That's Not My Car 2004 Fiona Watt Baby Touch and Feel Colors and Shapes 2009 DK Publishing Numbers 2009 Sara Anderson Car Galore 2011 Pete Stein Hooray for Fish! 2005 Lucy Cousins a nd Megan Blane I Love Train s 2003 Philemon Sturges and Shari Halpern Inside Freight Trains 2001 Donald Crews Tails 2003 Matthew Van Fleet Belly Button Book 2001 Sandra Boynton Dogs in Space 1996 Nancy Coffelt Zoom into Space with the Shiny Re d Rocket 2009 TickTock Books Ltd Roaring Rockets 2000 Tony Mitton and Ant Parker Amazing Airplane 2005 Tony Mitton and Ant Parker Fire Trucks Touch and Feel 2011 DK Publishing On the Launch Pad 2004 Michael Dahl

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182 APPENDIX J DEMOGRAPHIC & BACKGROU ND INFORMATION Demographic & Background Information Please take your time and answer the questions carefully. The answers you will provide are very important and valuable for our research. If you have any questions, please feel free to ask. And if you do not wish to answer, please leave blank. Questions about Caregiver: 2. Male_______ Female _______ (check one) MM/DD/YYYY) : _______________________ __________ 4. Race/Ethnicity (please check one) ___White, non Hispanic ___ African America ___ Hispanic ___ Asian American ___ Mexican American ___ Other (____________) ___ American Indian/Alaskan Native 5. Education Level M other: ______________________________________________________ Father: ______________________________________________________ _______________________________ _______________ Demographic & Background Information Continue

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183 Please take your time and answer the questions carefully. The answers you will provide are very important and valuable for our research. If you have any questions, please feel fr ee to ask. And if you do not wish to answer, please leave blank. Questions about Child: 2. Male_______ Female _______ (check one) MM/DD/YYYY) : _________ ___________________________ 4. Race/Ethnicity (please check one) ___White, non Hispanic ___ African America ___ Hispanic ___ Asian American ___ Mexican American ___ Other (____________) ___ American Indian/Alaskan Native 5. Does your child have any other siblings? __________________ If yes, how many? _________ Ages? __________________________________ 6. When was your child diagnosed with Autism Spectrum Diagnosis (age)? _________________________________________ __________________________ (circle one) Autism or autistic disorder PDD NOS ____ _______________________________________________________________ (Line if explanation is needed) 8. Who diagnosed him/her? ___________________________________________ ___________________________________________________________________ 9. Wha t diagnostic assessments or tools were used? _______________________ ___________________________________________________________________

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184 ___________________________________________________________________ 10. Schooling: Has your ever been enrolled in preschool? __________________ Is your child currently enrolled in preschool? ____________________________ If yes, what type of classroom (general/ special education): _________________ _____________________________________________ ___________________ If yes, how often and how long does he/she go? __________________________ 11. Has your child received any outside services (examples: occupational therapy, speech, behavioral therapist)?______________________________ ________________ If yes, what type and for how long (example: speech; twice a week for 6 months): ___________________________________________________________________ ___________________________________________________________________ ________ ___________________________________________________________ 12. What are some areas of strengthens you see in your child?_______________ ___________________________________________________________________ _______________________________________________ ____________________ 13. What are some areas that you would like to see improvement in for your child?______________________________________________________________ ___________________________________________________________________

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185 LIST OF REFERENC ES American Psychiatric Association (2004). Diagnostic and statistical manual of mental disorders (5 th ed ). Washington, DC: American Psychiatric Association. Adamson, L. B., Deckner, D. F., & Bakeman, R. (2010). Early interest and joint engagement in t ypical development, Autism, and Down Syndrome. Journal of Autism and Developmental Disorders, 40 665 676. Bakeman, R. & Adamson, L.B. (1984). Coordinating Attention to People and Objects in Mother Infant and Peer Infant Interaction. Child Development 55, 1278 1289. Basil, C., & Reyes, S. (2003). Acquisition of literacy skills by children with severe disability. Child Language Teaching & Therapy 19 27 48. Retrieved from Professional Development Collection database. dio: 10.1191/0265659003ct242oa Ba gnato, S.J. (2007). Authentic Assessment: For Early Childhood Intervention New York: The Guilford Press. Bellon, M.L., Olgetree, B.T., & Harn, W.E. (2000). Repeated storybook reading as a language intervention for children with autism: A case study on the application of scaffolding. Focus on Autism and Other Developmental Disabilities, 15 52 58. Bellon Harn, M.L., & Harn, W.E. (2008). Scaffolding strategies during repeated storybook reading: An extension using a voice output communication aid. Focus on Autism and Other Developmental Disabilities, 2 112 124. Beauchat, K., Blamey, K., & Walpole, S. (2009). Building Preschool Children's Language and Literacy One Storybook at a Time. Reading Teacher 63 26 39. Bruinsma, Y., Koegel, R.L., Koegel, L.K. ( 2004). Joint attention and children with autism: A review of the literature. Mental Retardation and Developmental Disabilities 10, 169 175. Bruner, J. (1983). New York: W.W. Norton. Bruner, J. (1978). From comm unication to language. Cognition 3, 255 287. Bus, A. G., van IJzendoorn, M. H., & Pellegrini, A. D. (1995). Joint book reading makes for success in learning to read: A meta analysis on intergenerational transmission of literacy. Review of Educational R esearch 65 1 25. Carpenter, M., Pennington, B.E., & Rogers, S.J. (2002). Interrelations among social cognitive skills in young children with autism. Journal of Autism and Developmental Disorders, 32, 91 106.

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188 Justice, L.M., Kaderavel, J.N., Fan, X., Sofka, A., & Hunt, A. (2009). Acceleratin g based teacher child storybook reading and explicit print referencing. American Speech Language Hearing Association, 40, 67 85. Kanner, L. & Eisenberg, L. (1956). Early infantile autism 1943 1955. American Journal of Orthopsychiatry, 26, 55 65. Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children with autism: a randomized controlled intervention study. Journal of Child Psychology and Psychiatry, 47 611 620. Kaale, A., & Smith, L., & Sponheim,E. (2012). A randomized controlled trial of preschool based joint attention intervention for children with autism. Child Psychology and Psychiatry, 53, 97 105. Kasari, C., Gulsrud, A.C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism. Journal of Autism Development Disorder, 40, 1045 1056. Kazdin, A. (1982). Single case research designs: Methods for clinical and applied settings. New York: Oxford University Press. Kern, L., Starosta, K., & Adelman, B. E. (2006). Reducing pica by teaching children to exchange inedible items for edible items. Behavior Modification, 30, 135 158. Klein, J. L., MacDonald, R.,Vaillancourt G., Ahearn, W.H., & Dube, W.V. (2009). Teaching discrimination of adult gaze direction to children with autism. Research in Autism Spectrum Disorder 3, 42 49. Koegel, R.L., & Koegel, L.K., (2006). Pivotal Response Treatment for Autism Baltimore: Paul H. Brookes Publishing. Koppenhaver, D. A., & Erickson, K. A. (2003). Natural emergent literacy supports for preschoolers with autism and severe communication impairments. Topics in Language Disorders 23 (4), 283 292. Koppenhaver, D.A., Erickson, K .A., Skotko, B.G. (2001). Supporting communication of girls with Rhett Syndrome and their mothers in storybook reading. International Journal of Disability, Development and Education, 48 395 410. dio:10.1080/10349120120094284 Koppenhaver, D. A., Hendrix M. P., & Williams, A. R. (2007). Toward evidence based literacy interventions for children with severe and multiple disabilities. Seminars in Speech & Language 28 79 89. dio: 10.1055/s 2007 967932. Lane, H.B., & Wright, T.L. (2007). Maximizing the eff ectiveness of reading aloud. International Reading Association, 60, 668 675. doi:10.1598/RT.60.7.7

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189 Landa, R.J., Holman, K.C., Garrett Mayer, E. (2007). Development in toddlers with early and later diagnosis of autism spectrum disorders. General Psychiat ry, 64, 853 864. Lanter, E., & Watson, L. (2008). Promoting literacy in students with ASD: The basics for the SLP. Language, Speech, & Hearing Services in Schools 39 33 43. Lanter, E. (2009). Emergent literacy development in children with autism spectr um disorders. Dissertation Abstracts International 70, (UMI No. AAT 3352678 ) Retrieved March, 1, 2010, from Dissertations & Theses database. Le Couteur, A., Haden, G., Hammal, D., & McConachie, H., (2008). Diagnosing Autism Spectrum Disorder in Pre schoo l Children Using Two Standardized Assessment Instruments: The ADI R and the ADOS. Journal of Autism Developmental Disorder, 38, 263 372. Lovelace, S., & Stewart, S.R. (2007). Increasing Print Awareness in Preschoolers With Language Impairments Using Non Evocative Print Referencing. Language, Speech, and Hearing in Schools 38, 16 30. Loveland, K., & Landry, S. (1986). Joint attention and language in autism and developmental language delay. Journal of Autism and Developmental Disorder, 16 335 349. M assetti, G.M. (2009). Enhancing emergent literacy skills of preschoolers from low income environments through a classroom based approach. School Psychology 4, 554 569. Martin, M.P., & Harris, S.L., (2006). Teaching children with autism to respond to jo int attention initiations. Child and Family Behavior Therapy 28, 51 68. Marvin, C. A., & Wright, D. (1997). Literacy socialization in the homes of preschool children. Language, Speech, & Hearing Services in Schools 28 154 163. McDuffie, A., Yoder, P. & Stone, W. (2006). Fast mapping in young children with autism spectrum disorders. First Language 26, 421 438. Mol, S.E., Bus, A.G., & de Jong, M.T. (2009). Interactive book reading in early education: A tool to stimulate print knowledge as well as ora l language. Review of Educational Research 79 979 1007. Morgan, L.P., & Meier, C.R. (2008). Dialogic reading's potential to improve children's emergent literacy skills and behavior. Preventing School Failure 52 11 16. Mundy, P. & Crowson, M., (1997). Joint Attention and Early Social Communication: Implications for Research on Intervention with Autism. Journal of Autism and Development Disorder, 27 653 676.

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192 Van der Schuit, M., Peeters, M., Segers, E., Van Balkom, H., & Verhoeven, L. (2009). Home literacy environment of pre school children with intellectual disabilities. Jo urnal of Intellectual Disability Research 53 1024 1037. dio: 10.1111/j.1365 2788.2009.01222.x van Kleeck, A., Vander Woude, J., & Hammett, L. (2006). Fostering Literal and Inferential Language Impairments Using Scripted Book Sharing Discussions. Americ an Journal of Speech Language Pathology 15, 85 95. Vogler Elias, Dawn. (2009). A parent implemented shared storybook reading intervention for preschoolers with autism spectrum disorders State University of New York at Buffalo. Watson, L. R., Lanter, E. McComish, C., & Poston Roy, V. (2004). Enhancing the communication development of toddlers with autism spectrum disorders. Journal of Cognitive and Behavioral Psychotherapies 4 179 201. Whalen, C., & Schreibman, L., (2003). Joint attention training fo r children with autism using behavior modification procedures. Journal of Child Psychology & Psychiatry, 44, 456 468. Whalen, C., & Schreibman, L., & Ingersoll, B., (2006). The collateral effects of joint attention training on social initiations, positi ve affect, imitation, and spontaneous speech for young children with autism. Journal of Autism Developmental Disorders 36, 655 664. Whalon, K., Hanline, M.F., & Woods, J. (2007). Using interactive storybook reading to increase language and literacy skill s of children with autism spectrum disorder. Young Exceptional Children 11,16 26. Whitehurst, G. J., Arnold, D. S., Epstein, J.N., Angell, A.L., Smith, M., & Fischel, J.E. (1994). A picture book reading intervention in day care and home for children from l ow income families. Developmental Psychology 30 679 689. Wood, J.J., & Wetherby A.M., (2003). Early identification of an intervention for infants and toddlers who are at risk for autism spectrum disorder. Language, speech, and hearing services in schoo l, 34, 180 193. Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of applied behavior analysis 11 (2), 203.

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193 BIOGRAPHICAL SKETCH grandmother and mother were e ducators, so you could say her decision to become an educator was an inherent one. Some of her fondest childhood memorie s were of playing teacher after school in her mot was always creating art projects and helping other was fun and familiar to her Those experiences, as well as being surrounded by the educators in her family, undoubtedly played a part in leading Kate to her future career. After graduating high school Kate att e nded Florida State University (FSU) She only attended FSU for one year as Kate Leo University, in St. Leo Flori da. While there, Kate majored in Elementary E ducation and minored in a rt. Kate attributes her time playing a collegiate sport as helping her understand the value of teamwork, leadership, time management, responsibility, and discipline. After graduati ng with a degree in Elementary Education, she was a classroom teacher for four years before decidin g t o go back part time and get her m urriculum and i nstruction from the University of Central Florida. decision to go back to school stemmed from her desire to serve the needs of all her students in her multi age classroom, where she was expos ed to all types of interested in Autis m Spectrum Disorder was developed. Through her graduate experience, Kate understoo d the power of curriculum and her knowledg e of instruction grew so that she was able to use the proper tools and skills necessary to help all children feel successful and included within her classroom walls. After teaching in the el ementary setting for 7 years, Kate decided to teach a year at Valencia Community College in Orland o, Florida It was in this setting that she became

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194 interested in teaching at the post secondary level and her interest in researc h in early intervention began. As a doctoral student, Kate was supported by a federally funded grant from the USDOE Office of Special Education Programs Project RELATE : Research in Early Literacy and Teacher Education in the Department of Special Education, School Psychology, and Early Childhood Studies a t the University of Florida. She graduated with her Doctor of Philosophy in Special Education in the summer of 2013. Kate believes that her experiences at UF have been invaluable, as they helped her to develop new tools and skills that have helped her as a researcher as well as a teacher educator Kate is currently working a s an Assistant Professor at Kennesaw State University in their Inclusive Education Department. She is happily married to her incred ibly supportive husband, Jeff. They have a son named Evan and two dogs, Rosco and Boss, whom at times, create quite a chaotic household but also bring much joy and la ughter. When Kate is not working or writing, she enjoys spending time with family and friends, watching football, running, and boating.