575725 research-article2015
AUT0010.1177/1362361315575725AutismChiang et al.
Original Article
Efficacy of caregiver-mediated joint engagement intervention for young children with autism spectrum disorders
Autism 1–11 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361315575725 aut.sagepub.com
Chung-Hsin Chiang1,2, Ching-Lin Chu3 and Tsung-Chin Lee4,5 Abstract Joint attention intervention for children with autism spectrum disorders was focused on improving joint engagement and joint attention skills. The purpose of this study was to develop a caregiver-mediated joint engagement intervention program combined with body movement play to investigate the effects of joint engagement/joint attention skills in young children with autism spectrum disorders. A quasi-experimental research design was conducted. A total of 34 young children with autism spectrum disorders aged 2–4 years were separated into an intervention and a control group. The program consisted of 20 sessions, 60 min per session, twice a week, for the target child and his or her parent. The results indicated that child-initiated supportive and coordinated joint engagement was greater for the intervention group compared with the control group at 3-month follow-up. This demonstrated that our joint engagement intervention could enhance joint engagement, especially coordinated joint engagement for young children with autism spectrum disorders. The limitations of the study and future directions were discussed. Keywords autism spectrum disorders, caregiver-mediated intervention, joint attention, joint engagement
Background Joint attention (JA) is defined as a child’s capacity to share attention between a social partner and an object or event in a triadic pattern, including (a) initiating JA, such as showing, pointing, and giving, and (b) responding to JA, such as responding to a point (Mundy and Burrette, 2005). Development of JA occurs around 9–15 months in typical development; however, children with autism spectrum disorders (ASD) can exhibit impairment from infancy through the adolescent period (Ozonoff et al., 2010; Sigman and Ruskin, 1999). This impairment is frequently associated with lagged and aberrant development of language ability (Charman et al., 2003; Wu and Chiang, 2014). Thus, targeting core social deficits earlier, such as JA, was believed to be one of the important topics in early intervention for children with ASD (Kasari and Patterson, 2012). Different kinds of JA interventions, such as specialistmediated, parent-mediated, or even preschool-teachermediated, aiming to increase JA skills, have been validated in young children and toddlers with ASD in single subject design and even randomized controlled trial (RCT) design (Ingersoll, 2012; Kaale et al., 2012; Kasari et al., 2006, 2010; Whalen and Schreibman, 2003). However, one issue
requires clarification before deepening the exploration of the outcome of JA intervention. What is the nature of JA in JA intervention? Carpenter and Liebal (2011) identified two definitions of JA used by researchers. The first one refers to “the intentional co-orientation of two or more organisms” doing something intentionally so as to end up focusing on the same thing as the other. The second definition places more focus on the coordination aspect of JA and sharing attention. Carpenter and Liebal (2011) argued that attending to the same thing as one’s partner is not enough to qualify as JA. It is also crucial that both partners 1Department
of Psychology, National Chengchi University, Taiwan Center for Mind, Brain and Learning, National Chengchi University, Taiwan 3Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan 4Department of Education, National Chengchi University, Taiwan 5MA Program of Counseling and Guidance, National Chengchi University, Taiwan 2Research
Corresponding author: Chung-Hsin Chiang, National Chengchi University, No. 64, Sec. 2, ZhiNan Rd., Wenshan District, Taipei 11605, Taiwan. Email: [email protected]
2 should know that they are attending to the same thing. Carpenter and Liebal (2011) used one behavior as evidence of JA, that is, gaze alternation, as an example, and suggested that gaze alternation alone is not adequate to establish the existence of JA. Moreover, even a mutual look is not enough, since two individuals might happen to examine each other’s focus of attention at the same time and accidentally make eye contact. They suggested that a mutual “sharing look” as described by Hobson and Hobson (2007) constitutes the best evidence of true JA. Carpenter and Liebal’s (2011) arguments provided robust evidence for our measurements in JA. Specifically, we found that most evidence used in the field of JA intervention falls into two categories. The first is JA skills measured as in Early Social-Communication Scales (ESCS; Mundy et al., 2003), and the second is the joint engagement (JE) state measured as in Communication Play Protocol or parent– child interaction (Adamson et al., 2004, 2009; Ingersoll, 2012; Kaale et al., 2012; Kasari et al., 2006, 2010). ESCS is a structured play-based tool to assess nonverbal communication ability, such as JA skills (Mundy et al., 2003), including (a) initiating JA, such as showing, pointing, giving, and gaze alternation, and (b) responding to JA, such as responding to a point. In coding ESCS, coders are trained to record the gestures depending on the single behavior displayed for the same object between the examiner and the child, such as eye contact, alternate gaze, or point. When coding the JE state, the child and the parent are actively involved with the same object or event. In coding the supported JE state, the child is not required to actively acknowledge the parent’s participation. However, in coding the coordinated JE state, the child and the parent are engaging with the same referent, and the child actively and repeatedly acknowledges the parent’s participation. Comparing the two kinds of definitions of JA, the coordinated JE state is closer to the type of evidence of JA suggested by Carpenter and Liebal (2011) and Hobson and Hobson (2007). Regarding JE intervention, Kasari et al. (2010) used RCT design and examined whether caregiver-mediated JA intervention could improve JE between caregivers and toddlers with ASD. The results revealed that the immediate treatment (IT) group made significant improvements in JE compared to the waitlist control group; the IT group also demonstrated significant gains in the responsiveness of JA and the diversity of functional play acts after 1 year post-intervention. To analyze JE, Kasari et al. (2010) combined both supported JE and coordinated JE to explain the effect of JE. However, if a strict definition of JA as the outcome variable is followed, separating coordinated JE from supported JE may be optimal for exploring the effect of JA intervention. To advance the development of JE, the aim of the study was to modify Kasari et al.’s (2010) work, using a new version of caregiver-mediated JE intervention for young children with ASD to explore whether adding “creative
Autism movement play” to the intervention can improve JE, especially coordinated JE. “Creative movement play” is defined as a kind of naturalistic approach that explores body movement elements, such as the shape, speed, strength, and rhythms of a child in a playful way (Lee, 2002). This movement process allows the child to experiment with new ways of being for pursuing affective synchrony (Meekums, 2002). The rationale of adding “creative movement play” to the JA intervention was based on the theoretical perspective of Trevarthen and Aitken (2001). They suggested that young children with ASD are impaired by intersubjective dysfunction. Trevarthen and Aitken (2001) proposed that before learning the first word for communication, infants develop from primary intersubjectivity around 2–6 months to secondary intersubjectivity around 9 months. Primary intersubjectivity usually occurs in a “person-to-person game,” indicating mutual regulation of one another’s interests and feelings in intricate, rhythmic patterns and exchanging multimodal signals and imitations of vocal, facial, and gestural expressions. Secondary intersubjectivity, or “person-person-object awareness,” is a kind of mutual attention and sharing of experience to discover meanings and to experiment with the aid of a parent’s guidance, such as JA and shared attention. Secondary intersubjectivity is similar to the concept of coordinated JE. Consequently, for facilitating primary intersubjectivity and achieving a kind of interaction that could unfold through the attuned movement patterns between caregiver and child, we added “creative movement play” into our caregiver-mediated JE intervention. It is worth noting that one other teaching strategy named “Reciprocal Imitation Training (RIT)” developed by Ingersoll and her colleagues (Ingersoll, 2012; Ingersoll and Schreibman, 2006; Ingersoll et al., 2007) might be similar to “creative movement play.” RIT is also a naturalistic behavioral intervention that teaches imitation of objects, gestures, and vocalization to children with ASD through affect-laden interactions with a responsive interventionist or caregiver (Ingersoll and Germans, 2007; Ingersoll and Schreibman, 2006). However, at least three differences should be pointed out. First, the theoretical bases are different: ours is referred from the development of infant intersubjectivity (Trevarthen and Aitken, 2001), but RIT is based more on the imitation issue in ASD. Second, the assessment and intervention methods are also different: ours is to observe the child’s movement vocabulary and movement elements to build up interpersonal relationships and encourage exploration of the body experience, which gives him or her an opportunity to express his or her body in a free and creative way, whereas RIT is focused more on imitation of toys, gestures, or vocalization. Third, we used certain terms, such as mirroring, instead of imitation. Mirroring involves imitation of the child’s movements, emotions, or intentions, by the interventionist, which constitutes an essential therapeutic component of dance/movement therapy (Koch and
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Chiang et al. Table 1. Participant characteristics at baseline for the JE-intervention group and control group. Control group (N = 16)
JE-intervention group (N = 18)
p value
Mean (SD)
Range
Mean (SD)
Range
CA DQ MSEL MA NVMA VMA ADOS Com RSI Play RRB
39.46 (8.58) 62.28 (17.9)
27.07–55.63 35.8–91.4
35.91 (8.58) 60.72 (15.47)
23.97–47.57 40.2–84.6
1.21 0.27
0.24 0.79
23.64 (5.51) 25.06 (4.43) 22.22 (7.82)
14.75–33.75 17.5–36 12–37
21.43 (6.75) 23.78 (6.80) 19.08 (7.35)
10.75–39.75 12.5–42.5 9–37
1.04 0.64 1.21
0.31 0.52 0.24
5.63 (1.78) 11.13 (2.33) 2.88 (1.20) 3.25 (1.48)
2–8 7–14 1–4 1–6
5.17 (1.20) 10.00 (2.14) 3.06 (1.21) 2.67 (1.41)
3–7 6–14 1–4 1–6
0.89 1.47 −0.44 1.17
0.38 0.15 0.67 0.25
t
JE: joint engagement; SD: standard deviation; CA: chronological age (month); DQ: developmental quotient; MSEL: Mullen Scale of Early Learning; MA: mental age; NVMA: nonverbal mental age (age equivalent VR + FM/2); VMA: verbal mental age (age equivalent VC + VE/2); ADOS: Autism Diagnostic Observation Schedule; Com: Communication total; RSI: Reciprocal Social Interaction total; RRB: restricted, repetitive behavior total; VC: verbal comprehension; VR: visual reception; VE: verbal expression.
Fischman, 2011). The mirroring process aims to enhance emotional resonance between the dyad for sharing and reflection, enabling the child to increase awareness of the other’s movement (Adler, 2003).
Methods Design The study reported pre- and post-intervention and 3-month follow-up data collected in a quasi-experiment research design (Kazdin, 2002). Participants were young children with ASD attending either the intervention group (n = 18), which received our JE intervention, or the control group (n = 16), which received general community-based service. Group membership was based on each parent’s personal choice after explanation of the program. Parents chose to attend the control group for three reasons. First, most of their children received a stable and intensive early intervention program in the community, so these parents decided to get a regular assessment and consultation from our team as a control group. Second, a few parents first signed up for the intervention group, but needed to wait for 2 months because we had only a limited number of qualified interventionists. During the waiting period, they withdrew their signature and arranged for their children to attend other intensive early intervention programs in the community. And then, they agreed to join as a member of control group. Third, the intervention group was full and the parents decided to attend as a control group.
Participants A total of 48 children with ASD were recruited between the spring of 2010 and winter of 2013. They were referred from
child psychiatric or pediatric physicians and also recruited by word of mouth from the parents who had attended our evaluation in the northern area of Taiwan. All of the children with ASD met the inclusion criteria of (a) a chronological age (CA) of 2–4 years; (b) a confirmed Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) diagnosis of autistic disorder and pervasive developmental disorder–not otherwise specified (PDD-NOS) by a research team performing a comprehensive diagnostic assessment procedure, including semi-structured observation of the child using Autism Diagnostic Observation Schedule (ADOS) (Lord et al., 2000), a parent interview Autism Diagnostic Interview–Revised (ADI-R) (Rutter et al., 2003), and clinical judgment; and (c) the developmental quotient (DQ; mental age (MA)/CA × 100) was higher than 30 on Mullen Scale of Early Learning (MSEL; Mullen, 1995) based on Rogers group’s suggestion (Rogers et al., 2006). Signed informed consent was obtained from all of the parents. Participants were excluded if (a) they had a severe sensory–motor impairment or identified genetic or metabolic disorder or (b) both items of Showing and of Spontaneous Initiation of JA in ADOS were 0. One boy (CA = 40 months, DQ = 110) was excluded due to that both of the above items were 0 assessed by ADOS module 2. For the intervention group, two parents and their children declined participation due to their feeling that the required travel was too burdensome. One child and his parent in the intervention group were stopped due to one interventionist ceasing the work due to a personal issue. The final sample of the intervention group was 18 children (see Table 1). A total of 26 children with ASD were eligible as a control group and assessed with the same procedure as the above description. Children were matched to the intervention group based on CA, verbal/nonverbal MA, DQ, and symptom severity. Therefore, 16 children with ASD (15 autistic
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Table 2. Parental characteristics at baseline for the JE-intervention group and control group.
Mother’s age Mother’s education in years Father’s age Father’s education in years Social Economic Status Indexa Mother’s vocationb Home management Others Father’s vocationb Electronics Others Family income per year Below 1 million (NT dollars)c Above 1 million (NT dollars) Family patterns Extended family Nuclear family Stem familyd
Control group (N = 16), mean (SD)
JE-intervention group (N = 18), mean (SD)
t/χ2
p value
37.06 (4.33) 12.44 (6.46) 38.38 (4.70) 14.13 (5.86) 37.06 (4.33) N
36.61 (4.12) 15.50 (4.29) 40.83 (7.60) 14.78 (4.45) 36.61 (4.12) N
0.31 −1.65 −1.12 −0.37 −1.03
0.76 0.11 0.27 0.71 0.31
0.75 12 4
11 7
5 11
4 14
8 6
10 8
2 9 5
0 11 7
0.39 0.55 0.93 0.30
0.36
0.01
2.42
JE: joint engagement; SD: standard deviation; NT: New Taiwan. aSocial Economic Status Index obtained from Huang (1998). bOnly the largest one is listed. c1 million NT dollars is approximately equivalent to US$32,000. dIndicates that the nuclear family and the child’s grandparent(s) live together.
disorder, 1 PDD-NOS) were included as the final control group (see Table 1). Of these, 10 children were excluded because they did not match the intervention group. Additionally, parental characteristics were also matched between the JE-intervention group and the control group (see Table 2).
Procedures and measures After obtaining informed consent from the parents, the research team assessed each child before starting the JE-intervention or the control list. Children were assessed with ADOS (Lord et al., 2000), and the parents were administered the ADI-R (Rutter et al., 2003) to validate the initial clinical diagnosis made by the referring physicians. A battery of child developmental assessments was administered, including MSEL (Mullen, 1995), ESCS (Mundy et al., 2003), the Reynell Developmental Language Scales (RDLS; Reynell and Gruber, 1990), the Structured Play Assessment (SPA; Kasari et al., 2006), and the parent–child interaction (Kasari et al., 2010). Parents were interviewed to complete a demographic questionnaire regarding the background characteristics of the target child and family members and the target child’s history of any type of intervention. These assessments were repeated at the end of the intervention for the JE-intervention group and also reassessed after 8 weeks for the control group. A 3-month follow-up was also repeated, using the same assessments for
the JE-intervention group, and again reassessed after 16 months for the control group. Since the intervention effects of cognitive, language, and play abilities will be reported in another article, only the details of the measures of JA and JE were mentioned here. Early Social-Communication Scale (ESCS; Mundy et al., 2003). ESCS is a structured play-based tool that assesses nonverbal communication ability, separated by requesting, social interaction, and JA. Since the study only focused the measure of initiating joint attention (IJA), including alternate gaze, showing, giving, and pointing, only items related to IJA were chosen for the ESCS measure. Intraclass correlation coefficient (ICC) was 0.94 for alternate gaze and 0.81 for pointing, based on a 20% sample coded by three independent coders who were blind to the child’s group status and time point. Since the frequency of showing and giving was small, we used π as interrater reliability and found 100% for showing and 94% for giving. Parent–child interaction. A 15-min videotaped interaction was collected for each parent–child dyad for the engagement states at the start of the intervention as baseline, at the end of the intervention, and at the 3-month follow-up assessment. The types of engagement states in the parent– child dyad were based on the suggestion of Adamson et al. (2004). Following Kasari et al. (2010), parents were asked to play freely and normally at home with their ASD child
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Chiang et al. Table 3. Definition of engagement state (from Adamson et al., 2004; Kasari et al., 2010). Engagement state
Definition
Unengaged/other engagement
Includes unengaged, in which the child may be uninvolved with objects, or an activity, in which the child may be scanning the room as if looking for something to do; and other engagement, in which the child is watching the mother’s activity, often intently, but is not taking part in that activity. If the child engages with objects or symbols, it is not included. The child is involved in playing with objects or symbols, manipulating or exploring toys, and ignoring the other is an attempt to engage the child’s interest. The child and parent are actively involved with the same object or event, but the child is making no overt acknowledgment of the parent’s participation. Additionally, (a) although imitating gestures or words/vocals are produced, they are not done for the purpose of maintaining JE and (b) using JA skills, but not sharing play. Child-initiated or parent-initiated SJE is also coded. The child and parent are actively involved with the same object or event, and the child is actively and repeatedly acknowledging the parent’s participation. In other words, the child is coordinating his or her attention to both parent and an object, or an event that they are sharing. Additionally, (a) the child initially uses JA skills, such as imitating gestures or producing words/vocals for maintaining JE and (b) two people share playing. Child-initiated or parentinitiated CJE is also coded.
Object engagement SJE
CJE
JE: joint engagement; JA: joint attention; SJE: supported joint engagement; CJE: coordinated joint engagement.
using a standard set of toys, including dolls, dishes, puzzles, trucks, shape sorters, and blocks. The child’s behaviors in the dyad were segmented into mutually exclusive engagement states which describe the child’s attention to people and objects. Four types of engagement states were coded: (a) unengaged/other engagement; (b) object engagement; (c) supported JE; and (d) coordinated JE. Additionally, child-initiated and parent-initiated engagement states were also coded (see Table 3). Each engagement state was counted second-by-second, and the total time was 900 s (15 min). The percentage of each engagement state compared with the total was used for analysis. Two independent raters, blind to the timepoint and child’s group status, calculated reliability for randomly selected 25% of the tapes (26 assessments). ICCs were as follows: unengaged/other engagement was 0.98; object engagement was 0.94; child-initiated supported JE was 0.86; parent-initiated supported JE was 0.88; child-initiated coordinated JE was 0.85; parent-initiated coordinated JE was 0.92; and the mean ICC was 0.91. These results indicated a great reliability.
Intervention procedure The JE intervention was adapted from Kasari et al. (2010), a caregiver-mediated JE intervention for toddlers with ASD. Additionally, we merged “creative movement play” into our program, which was based on the authors’ past research experience with children and adolescents with ASD (Chiang et al., Submitted; Lee, 2010). “Creative movement play” was derived from the working strategy of dance/movement therapy, which actively addresses bodyinformed intersubjectivity (Lee, 2014; Samaritter and Payne, 2013). Three steps were intertwined for developing
“creative movement play.” Step 1 was to establish affective attunement with child. The interventionist picked up the child’s movement elements and mirrored both verbal and nonverbal action/sounds to improve affective attunement with the child. For example, if a child was lying and rocking on the floor, the interventionist might have mirrored his or her rocking rhythms or body parts such as shaking leg(s) on the floor with rhythmic sounds to enhance the dyad for affective attunement. In the affective attunement state, the child usually shows his or her positive affect for sharing. Step 2 was to create movement play routines. Once the child can enter the affective attunement state, a movement play routine begins. The interventionist can then follow it in the same way with vocal or verbal comment and wait for child’s lead to develop a new movement element or model and change the shape, speed, strength, or rhythm of the child’s movement to build up one or more movement play routines. Once three types of movement play routines were developed, step 3 could be continued. Step 3 was to facilitate the JE state. In this phase, based on the established movement play routine, the child and interventionist played with body movement together into the JE state. It means that during the developed movement play routine, the child could participate actively with the interventionist in the dyadic interaction and acknowledge the mutual attention and intention. Thereby, it facilitates JE state, especially the coordinated JE state. Once the interventionist worked well with the child, the parent was included to learn and practice under the interventionist’s supervision. There are two reasons for merging “creative movement play”: (a) theoretically, it connects the primary intersubjectivity to secondary intersubjectivity within a “person-person game” (Trevarthen and Aitken, 2001); and (b) practically, some of the children
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Table 4. The 10 modules of the JE-intervention program. Modules
Context
Module 1: Following and imitating/mirroring
In a child-centered approach, the caregiver observes child’s behaviors, which way he or she would like to start: toy play or body movement play. The caregiver learns to be more sensitive through imitating the toy play or mirroring the movement element(s) in a joyful way. Caregiver learns to establish play routines by following the child’s lead. This might be a scheme of a toy set play (e.g. knocking, cooking, etc.) or body movement play (e.g. stepping, rocking, etc.). Initially, the caregiver is encouraged to imitate more than demonstrate. When the frequency and quality of the kind of social exchange are decreased, or the child wants to play in another way but does not know how to start, the caregiver can model a new scheme of play. In movement play, it is also to enrich the child’s body expression with different shapes, speeds, strength, or rhythms. For increasing social communication in the dyad and enriching the joyful play, some strategies include increasing sharing positive affect, expansions, and violations. For assisting the child to connect with the caregiver sustainably, increase creative and joyful play and improve JE further; two kinds of play can be interchangeable under the similar interactive context. The caregiver models and prompts JA skills, such as point, give, and show, in a naturalistic manner with the child. The caregiver is taught techniques to wait for the child’s communication for his or her initiation. The module could move forward if the child is experiencing a tantrum, or with negative and disruptive behaviors. Strategies are provided for dealing with the child’s inappropriate emotion responses and improving his or her emotional regulation. A review of the program is provided. The caregiver learns to use the above strategies in daily life with the child.
Module 2 and 3: Establishing a play routine (toy play or body movement play) Module 4: Finding a balance between imitating/mirroring and demonstration
Module 5: Developing a more meaningful play routine Module 6: Flexible play between toy and body movement
Module 7: Facilitating sharing communication Module 8: Encouraging child’s initiating communication Module 9: Management of child’s emotional regulation
Module 10: Generalization JE: joint engagement; JA: joint attention. Modified the JE-intervention program of Kasari et al. (2010).
with ASD do not initially play with toys, and mirroring their body movements and playing creatively within a corporal relationship is one of the suitable strategies in the JE intervention. The JE intervention was developed into 10 modules (see Table 4), which were arranged individually for each parent–child interaction session. In total, there were 20 sessions, each session lasted for 60 min, two times per week, for 8 weeks. Three female trained interventionists (two are licensed clinical psychologists and one is a licensed dance/movement interventionist) worked with each dyad, consisting of 4–7 dyads per interventionist. Each interventionist was trained with two pilot subjects prior to starting the intervention and was supervised by the principle investigator in a group format for 1.5 h weekly throughout the duration of the study. Based on Kasari et al. (2010), the approach in each intervention combined responsive and facilitative interaction
methods with aspects of applied behavioral analysis. The 10 modules included following and imitating/mirroring, establishing a play routine (toy play or body movement play), finding a balance between imitation and demonstration, developing a more meaningful play routine, flexible play between toy and body movement, facilitating sharing communication, encouraging the child’s initiating communication, management of the child’s emotional regulation, and generalization. In each 60-min session, first 10 min consisted of reviewing the dyad homework film taped by the parent with the interventionist. Then, 40–45 min was arranged for the coaching of effective caregiver–child interaction with collaboration between the parent and interventionist, such as demonstration and modeling, guided practice, and feedback from the interventionist. In the last 5–10 min, the interventionist and parent discussed a handout, which summarized the main objectives of each module and assigned the goals of the homework.
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Chiang et al.
Fidelity
Engagement state
Utilizing the original fidelity form for the interventionist of Kasari et al. (2010) and modifying it, we rated fidelity of the interventionist to the treatment protocol which included the elements with body movement play strategy. A total of 16 objectives were established from the 10 modules for understanding how well they adhered to the treatment protocol, and 10 more objectives for training the parent were established for the interventionist. Two independent raters, who were blind to the treatment and groups from the videotapes at pre-intervention, post-intervention, and 3-month follow-up, randomly selected 20% of the samples on a three-point scale (0–2). The results showed high interrater reliabilities for the interventionist to treatment protocol (Cronbach’s α = 0.96). We also rated parents’ fidelity in following the treatment protocol using the same version of fidelity as for the interventionist. Of parent–child interactions during preintervention, post-intervention, and 3-month follow-up, 20% were rated, and the interrater reliability was also found to be quite good (Cronbach’s α= 0.70).
A one-way analysis of covariance (ANCOVA) was conducted to compare the effectiveness of the two groups (JE-intervention group and control group) in improving children’s JE. The dependent variable was each JE state category proportion score after the intervention (post) or at 3-month follow-up. The scores on the pre-intervention were used as the covariate to control for individual differences. Table 5 showed the time (seconds) of the proportion of each engagement state in the parent–child interaction during preintervention, post-intervention, and 3-month follow-up. Regarding the unengaged/other engagement state, after adjusting for pre-intervention scores, there was no difference at the post-intervention between the two groups (F(1, 31) = 0.13, p = 0.72, partial η2 = 0.004). However, there was a significant difference at the 3-month followup between the two groups (F(1, 31) = 5.84, p
AUT0010.1177/1362361315575725AutismChiang et al.
Original Article
Efficacy of caregiver-mediated joint engagement intervention for young children with autism spectrum disorders
Autism 1–11 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1362361315575725 aut.sagepub.com
Chung-Hsin Chiang1,2, Ching-Lin Chu3 and Tsung-Chin Lee4,5 Abstract Joint attention intervention for children with autism spectrum disorders was focused on improving joint engagement and joint attention skills. The purpose of this study was to develop a caregiver-mediated joint engagement intervention program combined with body movement play to investigate the effects of joint engagement/joint attention skills in young children with autism spectrum disorders. A quasi-experimental research design was conducted. A total of 34 young children with autism spectrum disorders aged 2–4 years were separated into an intervention and a control group. The program consisted of 20 sessions, 60 min per session, twice a week, for the target child and his or her parent. The results indicated that child-initiated supportive and coordinated joint engagement was greater for the intervention group compared with the control group at 3-month follow-up. This demonstrated that our joint engagement intervention could enhance joint engagement, especially coordinated joint engagement for young children with autism spectrum disorders. The limitations of the study and future directions were discussed. Keywords autism spectrum disorders, caregiver-mediated intervention, joint attention, joint engagement
Background Joint attention (JA) is defined as a child’s capacity to share attention between a social partner and an object or event in a triadic pattern, including (a) initiating JA, such as showing, pointing, and giving, and (b) responding to JA, such as responding to a point (Mundy and Burrette, 2005). Development of JA occurs around 9–15 months in typical development; however, children with autism spectrum disorders (ASD) can exhibit impairment from infancy through the adolescent period (Ozonoff et al., 2010; Sigman and Ruskin, 1999). This impairment is frequently associated with lagged and aberrant development of language ability (Charman et al., 2003; Wu and Chiang, 2014). Thus, targeting core social deficits earlier, such as JA, was believed to be one of the important topics in early intervention for children with ASD (Kasari and Patterson, 2012). Different kinds of JA interventions, such as specialistmediated, parent-mediated, or even preschool-teachermediated, aiming to increase JA skills, have been validated in young children and toddlers with ASD in single subject design and even randomized controlled trial (RCT) design (Ingersoll, 2012; Kaale et al., 2012; Kasari et al., 2006, 2010; Whalen and Schreibman, 2003). However, one issue
requires clarification before deepening the exploration of the outcome of JA intervention. What is the nature of JA in JA intervention? Carpenter and Liebal (2011) identified two definitions of JA used by researchers. The first one refers to “the intentional co-orientation of two or more organisms” doing something intentionally so as to end up focusing on the same thing as the other. The second definition places more focus on the coordination aspect of JA and sharing attention. Carpenter and Liebal (2011) argued that attending to the same thing as one’s partner is not enough to qualify as JA. It is also crucial that both partners 1Department
of Psychology, National Chengchi University, Taiwan Center for Mind, Brain and Learning, National Chengchi University, Taiwan 3Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan 4Department of Education, National Chengchi University, Taiwan 5MA Program of Counseling and Guidance, National Chengchi University, Taiwan 2Research
Corresponding author: Chung-Hsin Chiang, National Chengchi University, No. 64, Sec. 2, ZhiNan Rd., Wenshan District, Taipei 11605, Taiwan. Email: [email protected]
2 should know that they are attending to the same thing. Carpenter and Liebal (2011) used one behavior as evidence of JA, that is, gaze alternation, as an example, and suggested that gaze alternation alone is not adequate to establish the existence of JA. Moreover, even a mutual look is not enough, since two individuals might happen to examine each other’s focus of attention at the same time and accidentally make eye contact. They suggested that a mutual “sharing look” as described by Hobson and Hobson (2007) constitutes the best evidence of true JA. Carpenter and Liebal’s (2011) arguments provided robust evidence for our measurements in JA. Specifically, we found that most evidence used in the field of JA intervention falls into two categories. The first is JA skills measured as in Early Social-Communication Scales (ESCS; Mundy et al., 2003), and the second is the joint engagement (JE) state measured as in Communication Play Protocol or parent– child interaction (Adamson et al., 2004, 2009; Ingersoll, 2012; Kaale et al., 2012; Kasari et al., 2006, 2010). ESCS is a structured play-based tool to assess nonverbal communication ability, such as JA skills (Mundy et al., 2003), including (a) initiating JA, such as showing, pointing, giving, and gaze alternation, and (b) responding to JA, such as responding to a point. In coding ESCS, coders are trained to record the gestures depending on the single behavior displayed for the same object between the examiner and the child, such as eye contact, alternate gaze, or point. When coding the JE state, the child and the parent are actively involved with the same object or event. In coding the supported JE state, the child is not required to actively acknowledge the parent’s participation. However, in coding the coordinated JE state, the child and the parent are engaging with the same referent, and the child actively and repeatedly acknowledges the parent’s participation. Comparing the two kinds of definitions of JA, the coordinated JE state is closer to the type of evidence of JA suggested by Carpenter and Liebal (2011) and Hobson and Hobson (2007). Regarding JE intervention, Kasari et al. (2010) used RCT design and examined whether caregiver-mediated JA intervention could improve JE between caregivers and toddlers with ASD. The results revealed that the immediate treatment (IT) group made significant improvements in JE compared to the waitlist control group; the IT group also demonstrated significant gains in the responsiveness of JA and the diversity of functional play acts after 1 year post-intervention. To analyze JE, Kasari et al. (2010) combined both supported JE and coordinated JE to explain the effect of JE. However, if a strict definition of JA as the outcome variable is followed, separating coordinated JE from supported JE may be optimal for exploring the effect of JA intervention. To advance the development of JE, the aim of the study was to modify Kasari et al.’s (2010) work, using a new version of caregiver-mediated JE intervention for young children with ASD to explore whether adding “creative
Autism movement play” to the intervention can improve JE, especially coordinated JE. “Creative movement play” is defined as a kind of naturalistic approach that explores body movement elements, such as the shape, speed, strength, and rhythms of a child in a playful way (Lee, 2002). This movement process allows the child to experiment with new ways of being for pursuing affective synchrony (Meekums, 2002). The rationale of adding “creative movement play” to the JA intervention was based on the theoretical perspective of Trevarthen and Aitken (2001). They suggested that young children with ASD are impaired by intersubjective dysfunction. Trevarthen and Aitken (2001) proposed that before learning the first word for communication, infants develop from primary intersubjectivity around 2–6 months to secondary intersubjectivity around 9 months. Primary intersubjectivity usually occurs in a “person-to-person game,” indicating mutual regulation of one another’s interests and feelings in intricate, rhythmic patterns and exchanging multimodal signals and imitations of vocal, facial, and gestural expressions. Secondary intersubjectivity, or “person-person-object awareness,” is a kind of mutual attention and sharing of experience to discover meanings and to experiment with the aid of a parent’s guidance, such as JA and shared attention. Secondary intersubjectivity is similar to the concept of coordinated JE. Consequently, for facilitating primary intersubjectivity and achieving a kind of interaction that could unfold through the attuned movement patterns between caregiver and child, we added “creative movement play” into our caregiver-mediated JE intervention. It is worth noting that one other teaching strategy named “Reciprocal Imitation Training (RIT)” developed by Ingersoll and her colleagues (Ingersoll, 2012; Ingersoll and Schreibman, 2006; Ingersoll et al., 2007) might be similar to “creative movement play.” RIT is also a naturalistic behavioral intervention that teaches imitation of objects, gestures, and vocalization to children with ASD through affect-laden interactions with a responsive interventionist or caregiver (Ingersoll and Germans, 2007; Ingersoll and Schreibman, 2006). However, at least three differences should be pointed out. First, the theoretical bases are different: ours is referred from the development of infant intersubjectivity (Trevarthen and Aitken, 2001), but RIT is based more on the imitation issue in ASD. Second, the assessment and intervention methods are also different: ours is to observe the child’s movement vocabulary and movement elements to build up interpersonal relationships and encourage exploration of the body experience, which gives him or her an opportunity to express his or her body in a free and creative way, whereas RIT is focused more on imitation of toys, gestures, or vocalization. Third, we used certain terms, such as mirroring, instead of imitation. Mirroring involves imitation of the child’s movements, emotions, or intentions, by the interventionist, which constitutes an essential therapeutic component of dance/movement therapy (Koch and
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Chiang et al. Table 1. Participant characteristics at baseline for the JE-intervention group and control group. Control group (N = 16)
JE-intervention group (N = 18)
p value
Mean (SD)
Range
Mean (SD)
Range
CA DQ MSEL MA NVMA VMA ADOS Com RSI Play RRB
39.46 (8.58) 62.28 (17.9)
27.07–55.63 35.8–91.4
35.91 (8.58) 60.72 (15.47)
23.97–47.57 40.2–84.6
1.21 0.27
0.24 0.79
23.64 (5.51) 25.06 (4.43) 22.22 (7.82)
14.75–33.75 17.5–36 12–37
21.43 (6.75) 23.78 (6.80) 19.08 (7.35)
10.75–39.75 12.5–42.5 9–37
1.04 0.64 1.21
0.31 0.52 0.24
5.63 (1.78) 11.13 (2.33) 2.88 (1.20) 3.25 (1.48)
2–8 7–14 1–4 1–6
5.17 (1.20) 10.00 (2.14) 3.06 (1.21) 2.67 (1.41)
3–7 6–14 1–4 1–6
0.89 1.47 −0.44 1.17
0.38 0.15 0.67 0.25
t
JE: joint engagement; SD: standard deviation; CA: chronological age (month); DQ: developmental quotient; MSEL: Mullen Scale of Early Learning; MA: mental age; NVMA: nonverbal mental age (age equivalent VR + FM/2); VMA: verbal mental age (age equivalent VC + VE/2); ADOS: Autism Diagnostic Observation Schedule; Com: Communication total; RSI: Reciprocal Social Interaction total; RRB: restricted, repetitive behavior total; VC: verbal comprehension; VR: visual reception; VE: verbal expression.
Fischman, 2011). The mirroring process aims to enhance emotional resonance between the dyad for sharing and reflection, enabling the child to increase awareness of the other’s movement (Adler, 2003).
Methods Design The study reported pre- and post-intervention and 3-month follow-up data collected in a quasi-experiment research design (Kazdin, 2002). Participants were young children with ASD attending either the intervention group (n = 18), which received our JE intervention, or the control group (n = 16), which received general community-based service. Group membership was based on each parent’s personal choice after explanation of the program. Parents chose to attend the control group for three reasons. First, most of their children received a stable and intensive early intervention program in the community, so these parents decided to get a regular assessment and consultation from our team as a control group. Second, a few parents first signed up for the intervention group, but needed to wait for 2 months because we had only a limited number of qualified interventionists. During the waiting period, they withdrew their signature and arranged for their children to attend other intensive early intervention programs in the community. And then, they agreed to join as a member of control group. Third, the intervention group was full and the parents decided to attend as a control group.
Participants A total of 48 children with ASD were recruited between the spring of 2010 and winter of 2013. They were referred from
child psychiatric or pediatric physicians and also recruited by word of mouth from the parents who had attended our evaluation in the northern area of Taiwan. All of the children with ASD met the inclusion criteria of (a) a chronological age (CA) of 2–4 years; (b) a confirmed Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) diagnosis of autistic disorder and pervasive developmental disorder–not otherwise specified (PDD-NOS) by a research team performing a comprehensive diagnostic assessment procedure, including semi-structured observation of the child using Autism Diagnostic Observation Schedule (ADOS) (Lord et al., 2000), a parent interview Autism Diagnostic Interview–Revised (ADI-R) (Rutter et al., 2003), and clinical judgment; and (c) the developmental quotient (DQ; mental age (MA)/CA × 100) was higher than 30 on Mullen Scale of Early Learning (MSEL; Mullen, 1995) based on Rogers group’s suggestion (Rogers et al., 2006). Signed informed consent was obtained from all of the parents. Participants were excluded if (a) they had a severe sensory–motor impairment or identified genetic or metabolic disorder or (b) both items of Showing and of Spontaneous Initiation of JA in ADOS were 0. One boy (CA = 40 months, DQ = 110) was excluded due to that both of the above items were 0 assessed by ADOS module 2. For the intervention group, two parents and their children declined participation due to their feeling that the required travel was too burdensome. One child and his parent in the intervention group were stopped due to one interventionist ceasing the work due to a personal issue. The final sample of the intervention group was 18 children (see Table 1). A total of 26 children with ASD were eligible as a control group and assessed with the same procedure as the above description. Children were matched to the intervention group based on CA, verbal/nonverbal MA, DQ, and symptom severity. Therefore, 16 children with ASD (15 autistic
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Autism
Table 2. Parental characteristics at baseline for the JE-intervention group and control group.
Mother’s age Mother’s education in years Father’s age Father’s education in years Social Economic Status Indexa Mother’s vocationb Home management Others Father’s vocationb Electronics Others Family income per year Below 1 million (NT dollars)c Above 1 million (NT dollars) Family patterns Extended family Nuclear family Stem familyd
Control group (N = 16), mean (SD)
JE-intervention group (N = 18), mean (SD)
t/χ2
p value
37.06 (4.33) 12.44 (6.46) 38.38 (4.70) 14.13 (5.86) 37.06 (4.33) N
36.61 (4.12) 15.50 (4.29) 40.83 (7.60) 14.78 (4.45) 36.61 (4.12) N
0.31 −1.65 −1.12 −0.37 −1.03
0.76 0.11 0.27 0.71 0.31
0.75 12 4
11 7
5 11
4 14
8 6
10 8
2 9 5
0 11 7
0.39 0.55 0.93 0.30
0.36
0.01
2.42
JE: joint engagement; SD: standard deviation; NT: New Taiwan. aSocial Economic Status Index obtained from Huang (1998). bOnly the largest one is listed. c1 million NT dollars is approximately equivalent to US$32,000. dIndicates that the nuclear family and the child’s grandparent(s) live together.
disorder, 1 PDD-NOS) were included as the final control group (see Table 1). Of these, 10 children were excluded because they did not match the intervention group. Additionally, parental characteristics were also matched between the JE-intervention group and the control group (see Table 2).
Procedures and measures After obtaining informed consent from the parents, the research team assessed each child before starting the JE-intervention or the control list. Children were assessed with ADOS (Lord et al., 2000), and the parents were administered the ADI-R (Rutter et al., 2003) to validate the initial clinical diagnosis made by the referring physicians. A battery of child developmental assessments was administered, including MSEL (Mullen, 1995), ESCS (Mundy et al., 2003), the Reynell Developmental Language Scales (RDLS; Reynell and Gruber, 1990), the Structured Play Assessment (SPA; Kasari et al., 2006), and the parent–child interaction (Kasari et al., 2010). Parents were interviewed to complete a demographic questionnaire regarding the background characteristics of the target child and family members and the target child’s history of any type of intervention. These assessments were repeated at the end of the intervention for the JE-intervention group and also reassessed after 8 weeks for the control group. A 3-month follow-up was also repeated, using the same assessments for
the JE-intervention group, and again reassessed after 16 months for the control group. Since the intervention effects of cognitive, language, and play abilities will be reported in another article, only the details of the measures of JA and JE were mentioned here. Early Social-Communication Scale (ESCS; Mundy et al., 2003). ESCS is a structured play-based tool that assesses nonverbal communication ability, separated by requesting, social interaction, and JA. Since the study only focused the measure of initiating joint attention (IJA), including alternate gaze, showing, giving, and pointing, only items related to IJA were chosen for the ESCS measure. Intraclass correlation coefficient (ICC) was 0.94 for alternate gaze and 0.81 for pointing, based on a 20% sample coded by three independent coders who were blind to the child’s group status and time point. Since the frequency of showing and giving was small, we used π as interrater reliability and found 100% for showing and 94% for giving. Parent–child interaction. A 15-min videotaped interaction was collected for each parent–child dyad for the engagement states at the start of the intervention as baseline, at the end of the intervention, and at the 3-month follow-up assessment. The types of engagement states in the parent– child dyad were based on the suggestion of Adamson et al. (2004). Following Kasari et al. (2010), parents were asked to play freely and normally at home with their ASD child
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Chiang et al. Table 3. Definition of engagement state (from Adamson et al., 2004; Kasari et al., 2010). Engagement state
Definition
Unengaged/other engagement
Includes unengaged, in which the child may be uninvolved with objects, or an activity, in which the child may be scanning the room as if looking for something to do; and other engagement, in which the child is watching the mother’s activity, often intently, but is not taking part in that activity. If the child engages with objects or symbols, it is not included. The child is involved in playing with objects or symbols, manipulating or exploring toys, and ignoring the other is an attempt to engage the child’s interest. The child and parent are actively involved with the same object or event, but the child is making no overt acknowledgment of the parent’s participation. Additionally, (a) although imitating gestures or words/vocals are produced, they are not done for the purpose of maintaining JE and (b) using JA skills, but not sharing play. Child-initiated or parent-initiated SJE is also coded. The child and parent are actively involved with the same object or event, and the child is actively and repeatedly acknowledging the parent’s participation. In other words, the child is coordinating his or her attention to both parent and an object, or an event that they are sharing. Additionally, (a) the child initially uses JA skills, such as imitating gestures or producing words/vocals for maintaining JE and (b) two people share playing. Child-initiated or parentinitiated CJE is also coded.
Object engagement SJE
CJE
JE: joint engagement; JA: joint attention; SJE: supported joint engagement; CJE: coordinated joint engagement.
using a standard set of toys, including dolls, dishes, puzzles, trucks, shape sorters, and blocks. The child’s behaviors in the dyad were segmented into mutually exclusive engagement states which describe the child’s attention to people and objects. Four types of engagement states were coded: (a) unengaged/other engagement; (b) object engagement; (c) supported JE; and (d) coordinated JE. Additionally, child-initiated and parent-initiated engagement states were also coded (see Table 3). Each engagement state was counted second-by-second, and the total time was 900 s (15 min). The percentage of each engagement state compared with the total was used for analysis. Two independent raters, blind to the timepoint and child’s group status, calculated reliability for randomly selected 25% of the tapes (26 assessments). ICCs were as follows: unengaged/other engagement was 0.98; object engagement was 0.94; child-initiated supported JE was 0.86; parent-initiated supported JE was 0.88; child-initiated coordinated JE was 0.85; parent-initiated coordinated JE was 0.92; and the mean ICC was 0.91. These results indicated a great reliability.
Intervention procedure The JE intervention was adapted from Kasari et al. (2010), a caregiver-mediated JE intervention for toddlers with ASD. Additionally, we merged “creative movement play” into our program, which was based on the authors’ past research experience with children and adolescents with ASD (Chiang et al., Submitted; Lee, 2010). “Creative movement play” was derived from the working strategy of dance/movement therapy, which actively addresses bodyinformed intersubjectivity (Lee, 2014; Samaritter and Payne, 2013). Three steps were intertwined for developing
“creative movement play.” Step 1 was to establish affective attunement with child. The interventionist picked up the child’s movement elements and mirrored both verbal and nonverbal action/sounds to improve affective attunement with the child. For example, if a child was lying and rocking on the floor, the interventionist might have mirrored his or her rocking rhythms or body parts such as shaking leg(s) on the floor with rhythmic sounds to enhance the dyad for affective attunement. In the affective attunement state, the child usually shows his or her positive affect for sharing. Step 2 was to create movement play routines. Once the child can enter the affective attunement state, a movement play routine begins. The interventionist can then follow it in the same way with vocal or verbal comment and wait for child’s lead to develop a new movement element or model and change the shape, speed, strength, or rhythm of the child’s movement to build up one or more movement play routines. Once three types of movement play routines were developed, step 3 could be continued. Step 3 was to facilitate the JE state. In this phase, based on the established movement play routine, the child and interventionist played with body movement together into the JE state. It means that during the developed movement play routine, the child could participate actively with the interventionist in the dyadic interaction and acknowledge the mutual attention and intention. Thereby, it facilitates JE state, especially the coordinated JE state. Once the interventionist worked well with the child, the parent was included to learn and practice under the interventionist’s supervision. There are two reasons for merging “creative movement play”: (a) theoretically, it connects the primary intersubjectivity to secondary intersubjectivity within a “person-person game” (Trevarthen and Aitken, 2001); and (b) practically, some of the children
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Autism
Table 4. The 10 modules of the JE-intervention program. Modules
Context
Module 1: Following and imitating/mirroring
In a child-centered approach, the caregiver observes child’s behaviors, which way he or she would like to start: toy play or body movement play. The caregiver learns to be more sensitive through imitating the toy play or mirroring the movement element(s) in a joyful way. Caregiver learns to establish play routines by following the child’s lead. This might be a scheme of a toy set play (e.g. knocking, cooking, etc.) or body movement play (e.g. stepping, rocking, etc.). Initially, the caregiver is encouraged to imitate more than demonstrate. When the frequency and quality of the kind of social exchange are decreased, or the child wants to play in another way but does not know how to start, the caregiver can model a new scheme of play. In movement play, it is also to enrich the child’s body expression with different shapes, speeds, strength, or rhythms. For increasing social communication in the dyad and enriching the joyful play, some strategies include increasing sharing positive affect, expansions, and violations. For assisting the child to connect with the caregiver sustainably, increase creative and joyful play and improve JE further; two kinds of play can be interchangeable under the similar interactive context. The caregiver models and prompts JA skills, such as point, give, and show, in a naturalistic manner with the child. The caregiver is taught techniques to wait for the child’s communication for his or her initiation. The module could move forward if the child is experiencing a tantrum, or with negative and disruptive behaviors. Strategies are provided for dealing with the child’s inappropriate emotion responses and improving his or her emotional regulation. A review of the program is provided. The caregiver learns to use the above strategies in daily life with the child.
Module 2 and 3: Establishing a play routine (toy play or body movement play) Module 4: Finding a balance between imitating/mirroring and demonstration
Module 5: Developing a more meaningful play routine Module 6: Flexible play between toy and body movement
Module 7: Facilitating sharing communication Module 8: Encouraging child’s initiating communication Module 9: Management of child’s emotional regulation
Module 10: Generalization JE: joint engagement; JA: joint attention. Modified the JE-intervention program of Kasari et al. (2010).
with ASD do not initially play with toys, and mirroring their body movements and playing creatively within a corporal relationship is one of the suitable strategies in the JE intervention. The JE intervention was developed into 10 modules (see Table 4), which were arranged individually for each parent–child interaction session. In total, there were 20 sessions, each session lasted for 60 min, two times per week, for 8 weeks. Three female trained interventionists (two are licensed clinical psychologists and one is a licensed dance/movement interventionist) worked with each dyad, consisting of 4–7 dyads per interventionist. Each interventionist was trained with two pilot subjects prior to starting the intervention and was supervised by the principle investigator in a group format for 1.5 h weekly throughout the duration of the study. Based on Kasari et al. (2010), the approach in each intervention combined responsive and facilitative interaction
methods with aspects of applied behavioral analysis. The 10 modules included following and imitating/mirroring, establishing a play routine (toy play or body movement play), finding a balance between imitation and demonstration, developing a more meaningful play routine, flexible play between toy and body movement, facilitating sharing communication, encouraging the child’s initiating communication, management of the child’s emotional regulation, and generalization. In each 60-min session, first 10 min consisted of reviewing the dyad homework film taped by the parent with the interventionist. Then, 40–45 min was arranged for the coaching of effective caregiver–child interaction with collaboration between the parent and interventionist, such as demonstration and modeling, guided practice, and feedback from the interventionist. In the last 5–10 min, the interventionist and parent discussed a handout, which summarized the main objectives of each module and assigned the goals of the homework.
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Chiang et al.
Fidelity
Engagement state
Utilizing the original fidelity form for the interventionist of Kasari et al. (2010) and modifying it, we rated fidelity of the interventionist to the treatment protocol which included the elements with body movement play strategy. A total of 16 objectives were established from the 10 modules for understanding how well they adhered to the treatment protocol, and 10 more objectives for training the parent were established for the interventionist. Two independent raters, who were blind to the treatment and groups from the videotapes at pre-intervention, post-intervention, and 3-month follow-up, randomly selected 20% of the samples on a three-point scale (0–2). The results showed high interrater reliabilities for the interventionist to treatment protocol (Cronbach’s α = 0.96). We also rated parents’ fidelity in following the treatment protocol using the same version of fidelity as for the interventionist. Of parent–child interactions during preintervention, post-intervention, and 3-month follow-up, 20% were rated, and the interrater reliability was also found to be quite good (Cronbach’s α= 0.70).
A one-way analysis of covariance (ANCOVA) was conducted to compare the effectiveness of the two groups (JE-intervention group and control group) in improving children’s JE. The dependent variable was each JE state category proportion score after the intervention (post) or at 3-month follow-up. The scores on the pre-intervention were used as the covariate to control for individual differences. Table 5 showed the time (seconds) of the proportion of each engagement state in the parent–child interaction during preintervention, post-intervention, and 3-month follow-up. Regarding the unengaged/other engagement state, after adjusting for pre-intervention scores, there was no difference at the post-intervention between the two groups (F(1, 31) = 0.13, p = 0.72, partial η2 = 0.004). However, there was a significant difference at the 3-month followup between the two groups (F(1, 31) = 5.84, p
