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Are joint attention and executive function related in young children with autism and other developmental disabilities?

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Are joint attention and executive function related in young children with autism and other developmental disabilities?
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LaPorte, Alison
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37 leaves : ; 28 cm

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Autism in children ( lcsh )
Autistic children ( lcsh )
Attention in children ( lcsh )
Developmental disabilities ( lcsh )
Attention in children ( fast )
Autism in children ( fast )
Autistic children ( fast )
Developmental disabilities ( fast )
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theses ( marcgt )
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Includes bibliographical references (leaves 34-37).
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Department of Psychology
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by Alison LaPorte.

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Full Text
ARE JOINT ATTENTION AND EXECUTIVE FUNCTION RELATED IN YOUNG
CHILDREN WITH AUTISM AND OTHER DEVELOPMENTAL DISABILITIES?
by
Alison LaPorte
B.A. Denison University, 1996
A thesis submitted to the University of
Colorado at Denver
in partial fulfillment of the requirements
For the degree of
Master of Arts
Psychology


The thesis for the Master of Arts
degree by
Alison M. LaPorte
has been approved by
JenniferHolmberg


LaPorte, Alison Michelle (M.A., Clinical Psychology)
Are Joint Attention and Executive Function Related in
Young Children with Autism and other Developmental Disabilities?
Thesis directed by Temporary faculty member Susan Hepburn
ABSTRACT
Joint attention is a social ability commonly deficient in young children with
autism. It is critical to developing relationships, involving the use of eye contact,
affect, and gestures for the purpose of directing and following attention (Loveland &
Landry, 1986; Wetherby & Prutting, 1984). In one study, joint attention ability was
found to be associated with executive function (McEvoy, Rogers, and Pennington,
1992). Children with autism have shown deficits in executive function, which
involves the processes underlying cognitive flexibility. What is not yet understood is
how joint attention and executive function may be related.
The purpose of this study is to determine whether there is a relationship
between joint attention and executive function in young children with autism and
other developmental disabilities. Specifically, this study aims to: Develop a multi-
source measure of JA from scientifically validated measures, replicate the work of
Sigman and Mundy (1989) by examining group differences in joint attention,
examine group differences in executive function, and examine the relationship
between joint attention and executive function in young children with developmental
disabilities.
Participants were all children between the ages of 24 and 48 months,
diagnosed with autism (n=21) and other developmental disabilities (n=18), matched
by chronological (x=34 mos.) and mental age (x=21 mos.). The DD group was
comprised of children with other developmental disabilities, but with no diagnosis of
autism.
Four measures were used to create the measure of joint attention. The
measures include the Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter,
DiLavore, & Risi, 1999), the Autism Diagnostic Interview (ADI; Lord, Rutter, &
LeCouteur, 1994), the Parent Checklist for Autism in Toddlers (Parent CHAT;
Baron-Cohn, Allen, & Gillberg, 1992), and Examiner CHAT (Baron-Cohn et al.,
1992). Two measures, the Spatial Reversal (SR) task (Kaufman, Leckman, & Ort,
1989) and the Windows task (Russell, Mauthner, Sharpe and Tidswell, 1991) were
used to measure cognitive flexibility (i.e. set-shifting and inhibition, respectively).
Reliability analysis revealed an internal consistency of .90 (p<.05) for the JA
measure. The two groups were found to be significantly different in JA, F (1,37) =
in


This abstract accurately represents the content
recommend its publication.
Signed
Susan Hepburn


DEDICATION
I dedicate this thesis to my incredibly patient, understanding, and generous parents for
their unconditional support of and belief in me. Thank you for never allowing me to
settle for less than what I am capable of and for never doubting my potential.


ACKNOWLEDGEMENT
I will never be able to express enough gratitude to my mentor, Susan Hepburn, for her
countless hours of assistance and advice. Thank you to Sally Rogers, Beth Wehner,
and the other investigators responsible for conceptualizing this study for trusting me
with your work.


CONTENTS
Tables...................................................................28
CHAPTER
1. INTRODUCTION...............................................1
DSM-IV Criteria for Autistic Disorder...................1
Executive Function Deficits and Autism..................3
Executive Dysfunction Theory............................5
Measurement of Executive Dysfunction....................6
Joint Attention and Autism..............................7
Joint Attention and Autism Diagnosis....................8
Relationship between Executive Function and Joint Attention.10
Purpose of the Study........................................11
2. STUDY ONE METHOD..........................................13
Participants...........................................13
Measures...............................................15
Data Collection and Analysis...........................17
Procedures.............................................18
3. STUDY ONE RESULTS.........................................19
4. STUDY TWO METHOD..........................................20
Participants...........................................20
Measures
.20


Procedures
,21
Data Collection and Analysis........................22
5. STUDY TWO RESULTS.......................................23
6. DISCUSSION..............................................24
References.................................................34


TABLES
2.1. Descriptive characteristics of participants............................28
2.2 Items measuring joint attention ability.................................29
3.1 Reliability of joint attention items................................30, 31
3.2 Group differences in joint attention ability...........................32
5.1 Descriptive data of executive function performance by group.............33


CHAPTER 1
INTRODUCTION
Autism is a complex developmental disorder that usually appears
within the first three years of life. Children with this disorder display severe
social and communication deficiencies (ASA, 2003; Bailey, Philips, & Rutter,
1996; Kanner, 1943). They often appear withdrawn and seem to prefer
aloneness to social interaction with their peers or parents (Kaplan & Saddock,
1998).
In order to be diagnosed with autism, children must meet criteria as
outlined by the DSM-IV-TR (2002).
DSM-IV-TR Criteria for Autistic Disorder (DSM-IV-TR. 2002)
A. A total of six (or more) items from (1), (2), and (3), with at least
two from (1), and one each from (2) and (3):
(1) Qualitative impairment in social interaction, as manifested
by at least two of the following:
(a) marked impairment in the use of multiple nonverbal
behaviors such as eye-to-eye gaze, facial expression,
body postures, and gestures to regulate social
interaction.
(b) failure to develop peer relationships appropriate to
developmental level
(c) a lack of spontaneous seeking to share enjoyment,
interests, or achievements with other people (e.g. by a
lack of showing, bringing, or pointing out objects of
interest)
(d) lack of social or emotional reciprocity
(2) Qualitative impairments in communication as
manifested by at least one of the following:
1


(a) delay in, or total lack of, the development of spoken
language (not accompanied by an attempt to
compensate through alternative modes of
communication such as gesture or mime)
(b) in individuals with adequate speech, marked
impairment in the ability to initiate or sustain a
conversation with others
(c) stereotyped and repetitive use of language or
idiosyncratic language
(d) lack of varied spontaneous make-believe play or
social imitative play appropriate to developmental
level.
(3) Restricted repetitive and stereotyped patterns of behavior,
interests, and activities, as manifested by at least one of the
following:
(a) encompassing preoccupation with one or more
stereotyped and restricted patterns of interest that is
abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, non-
functional routines and rituals.
(c) stereotyped and repetitive motor mannerisms (e.g.,
hand or finger flapping or twisting, or complex whole
body movements)
(d) persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the
following areas, with onset prior to age 3 years: (1) social
interaction, (2) language as used in social communication, or
(3) symbolic or imaginative play.
C. The disturbance is not better accompanied for by Retts
disorder or childhood disintegrative disorder.
Autism is the result of a neurological disorder that affects the
functioning of the brain (ASA, 2003). According to the Centers for Disease
Control and Preventionss 2001 report, autism affects anywhere from 2 to 6 in
1,000 individuals (ASA, 2003). Autism is four times more prevalent in boys
than in girls (ASA, 2003). There is no correlation between autism and
educational level, lifestyle, family income, race, or ethnicity (ASA, 2003).
2


Autistic disorder is categorized as a pervasive developmental disorder
(PDD). Pervasive developmental disorders are defined by the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR) as severe, persistent
impairments in the development of social interaction and communication, or
stereo-typed behavior, interests, or activities (2003).
Diagnosis of autism before the age of three is rare. In one survey of
770 families in the UK, the average age of diagnosis was 5.5 years, despite the
fact that parents typically reported concerns at 2.05 years (Howlin &
Asgherian, 1999). Detection of autism at a young age is critical because it
has been proven that early intervention improves long-term outcomes (Smith
& Lovaas, 1998).
Executive Function Deficits and Autism
Typically, children with autism display significant cognitive deficits,
with about 40% of autistic children meeting the criteria for Mental
Retardation (Kaplan & Saddock, 1997). One such deficit that has been found
in children with autism is impaired Executive Functioning (Frith, 2001).
Neuroimaging and neuroanatomical studies suggest that EF processes are
associated with the prefrontal cortex of the brain (Friedman & Goldman-
Rakic, 1994)).
3


Executive function directs our ability to adapt to environmental
changes (Frith, 2001). These skills influence the ability to appropriately plan
actions or strategies by integrating new information with previously acquired
knowledge. Examples of such processes include: planning, set-shifting,
inhibitory control, attentional shifting, and working memory (Hughes, 2001).
Frith (2001) found that deficits in executive function may result in the
inability to disengage attention, inhibit appropriate responses, and switch task
sets. Executive function ability is critical to the development of goal-directed
behavior (Hughes, 2001).
Consequences of executive dysfunction include difficulty handling
new or ambiguous situations despite sufficient performance of routine or well-
leamed tasks (Hughes, 2001). These predictions seem to fit the behavioral
characteristics of autistic individuals and this observation has been well-
supported by many independent investigations of executive dysfunction.
These studies consistently show that EF impairment in children with autism is
typically severe, persistent, and universal (Hughes, 2001; Pennington &
Ozonoff, 1996).
Although autistic children consistently display deficits in executive
functioning, EF deficits are also common in children with various other
developmental delays (Gioia, Isquith, Retzlaff, & Epsy, 2002). Some of the
literature suggests that people with autism have show greater impairments in
EFs than people with other developmental disabilities (Pennington & Ozonoff,
4


1996). It has yet to be determined, however, if EF impairment is a primary
characteristic of autism. It could be that the development of executive
function ability is hindered as a result of impairment in another area of
development.
Executive Dysfunction Theory
One hypothesis that may explain the abnormal social development
characteristic of autism is the Executive Dysfunction Theory (Ozonoff,
Pennington, & Rogers, 1991). This theory contends that the abnormal
development of executive function skills in autistic children may hinder the
childs ability to develop appropriate social skills. It suggests that social-
cognitive and socio-communicative impairment in autism is a symptom of a
fundamental impairment of competing action potentials in the frontal lobe
(Ozonoff, Pennington, & Rogers, 1991).
The theory that EF is a primary dysfunction in autism, however, has
not been consistently supported. Although executive function ability has been
successfully measured in young children with autism (McEvoy, Rogers, &
Pennington, 1993; Dawson, Meltzoff, Osterling, & Rinaldi, 1998), results
have suggested that differences in EF between autistic children and children
with other DDs may be dependant on age. McEvoy, et al. (1993) found
differences in EF ability between children with autism when compared with
5


matched controls at a mean age of 5.4 years. However, using the same EF
tasks, Wehner and Rogers (1994) found no difference between these groups
with a mean age of 3.5 years. These findings indicate that EF impairment
might emerge between these two ages, suggesting that EF dysfunction is not a
primary deficit in autism.
Measurements of Executive Function
Because development of the prefrontal cortex was thought to occur
later in development, most EF tests have been designed for the adult
population. Recently, some of these tasks have been modified to help identify
EF deficits in children. Several of these measures were used in the project
and each child that participated in the project completed multiple tasks
designed to measure EF capability. Two of these tasks, the Windows task
(Russell, Mauthner, Sharpe & Tidswell, 1991) and the Spatial Reversal task
(Kaufman, Leckman, & Ort, 1989), were used in analysis for this study. Both
tasks measure the number of perseverative errors of the child. Perseveration
is the continued attempt for the reward after that response has been
unsuccessful (more than once) and has therefore been unrewarded.
Perseverative responding in the Windows task (Russell et al., 1991) measures
the childs inhibition and the Spatial Reversal task assesses the childs set-
shifting ability (Kaufman, et al., 1989).
6


Joint Attention and Autism
The abnormal development of appropriate joint attention has proven to
be one of the most distinguishing features of autism (Dawson, Meltzoff,
Osterling & Rinaldi, 1998; Mundy, Sigman, Ungerer & Sherman, 1986).
Joint attention deficits have consistently been observed in young children with
autism, suggesting that the lack of this ability may be elemental to the etiology
of autism (Mundy, 1995; Mundy & Marcus, 1997).
Joint attention can be divided into two sub-categories: Response to
joint attention (RJA) and initiating joint attention (UA). Both of these social
skills are typically measured on tests used to detect autism and other pervasive
developmental disorders (Stahl & Pry, 2002). Response to joint attention
refers to the ability to observe and respond appropriately to the focus of
another individual. Behaviors such as following a point or a gaze are
examples of responding to joint attention (Stahl & Pry, 2002). Initiating joint
attention refers to the ability to use appropriate gestures and eye contact to
engage others (Mundy, Kasari, & Sigman, 1992). It also includes the
purposeful sharing of an object or experience (i.e. showing or pointing to an
interesting toy) with another person. Children with autism have shown marked
impairment in both initiating and responding to joint attention (Baron-Cohen,
1989; Landry & Loveland, 1988; Loveland & Landry, 1986; Mundy, Sigman,
Ungerer, & Sherman, 1986).
7


Joint attention and Autism Diagnosis
Joint attention has been the subject of much recent research because it
is one of the earliest indicators of autism (Charman & Baird, 2002; Baron-
Cohen, et al., 1996; Osterling & Dawson, 1994). Children with autism have
demonstrated less joint attention ability than matched controls with other
developmental disabilities (Sigman & Mundy, 1989). Morales, Mundy, &
Rojas (1998) found that individual differences in joint attention can be
detected as early as six months of age. In a study using retrospective
videotape analysis, children with autism showed marked impairments in
social, communicative, and joint attention behaviors at 12 months of age
(Osterling & Dawson, 1994). In this study, pediatricians correctly classified
91% of the infants as autistic based on coding of eye contact, pointing,
showing, and orienting to name. Therefore, detection of joint attention
dysfunction may prove to be critical in the early diagnosis of autism.
Diagnostic instruments used to detect autism and other Pervasive
Developmental Disorders screen for abnormalities in joint attention. The
measures which have demonstrated potential for diagnosing autism at a
younger age contain items that measure response to joint attention behaviors
(Scambler, Rogers, & Wehner, 2002). Some of these instruments include:
the Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore,
& Risi, 1999), the Autism Diagnostic Interview (ADI; Lord, Rutter, &
LeCouteur, 1994), the Parent Checklist for Autism in Toddlers (Parent CHAT;
8


Baron-Cohn, Allen, & Gillberg, 1992), and Examiner CHAT (Baron-Cohn, et
al., 1992). Each of these tests contains at least two items relating to joint
attention behavior. Two of these instruments, the ADOS and the Examiner
CHAT, are based on examiner report. These tests are based on the
observations of a person trained in the administration of the respective test.
The other two diagnostic tests, the ADI and the Parent CHAT, rely on parent
report, whereby the parent is asked to assess the childs abilities in various
domains. The examiner records the parents responses and scores the test
based only on this information.
Reliability analysis of these variables as a single measure of joint
attention has yet to be conducted. The reliability of these measures is
important for various reasons. If a reliability analysis reveals strong internal
consistency between these variables, these items can be combined, creating a
multi-source measure of joint attention. The practical implication of
significant reliability between these items is equally as important. It would
suggest that parents are a reliable source of information and can assess joint
attention ability as well as a trained examiner can through direct observation.
If parents are found to be a reliable source in determining joint attention
ability, earlier diagnosis may be possible, given that joint attention is one of
the earliest indicators of autism.
The following study includes a reliability analysis using several items
that measure joint attention within these instalments. This analysis will
9


determine whether a unitary construct, measuring joint attention ability based
on multiple sources, can be developed.
HI: A reliable multi-source measure (including both parent and
examiner report), can be created using selected items from validated
diagnostic instruments measuring joint attention.
H2: This measure, if found to be reliable, will detect differences in
joint attention ability between children with autism and children with
other developmental disabilities.
Relationship between Executive Function and Joint Attention
Recent research has attempted to investigate the link between EF and
other features of autism in order to better understand the development of EF
impairment. Cognitive skills underlying EF have been associated with the
ability to disengage attention and switch tasks (Frith, 2001). In typically-
developing children, the period of development of early EF skills coincides
with the emergence of joint attention behavior (Butterworth & Grover, 1988),
suggesting that the development of executive function and joint attention may
be linked. There are limited data suggesting a correlation between executive
function and joint attention in children with autism. Children with autism have
been shown to lack flexibility in both thought (McEvoy, Rogers, &
Pennington, 1993; Wehner & Rogers, 1994) and attention (Bryson, Landry, &
Wainwright, 1997). McEvoy, Rogers, and Pennington (1993) found a
10


relationship between initiating joint attention and the behavioral response
inhibition (perseverative behavior). The less initiating joint attention
behavior, the greater the likelihood of perseverative responding.
What has yet to be investigated is the relationship between executive
and overall joint attention ability (considering both responding to and
initiating joint attention). The childs ability to follow a point or gaze could
conceivably be related to his/her set-shifting capabilities and the ability to
disengage attention. The child may not be able to shift his/her attention from
the current task in order to appropriately respond to the direction of another.
Therefore, executive function and joint attention deficits could be inter-
twined. It may be that a deficit in one area leads to a deficit in the other.
H3: There is a relationship between joint attention and
executive functioning in young children with autism.
Purpose of the Study
For the sake of clarity, this study was divided into two parts
representing two research objectives. The purpose of the first part of the study
is to examine the reliability of several joint attention measures and
subsequently compares joint attention ability between the children with autism
and the children with developmental disabilities. The objective of the second
study is to determine whether there is a difference in executive function
11


abilities between groups and to examine whether or not there is a relationship
between executive function and joint attention ability.
12


CHAPTER 2
STUDY ONE METHOD
Participants
Twenty-one children with autism, aged 26-41 months (x = 34.2),
were compared to 17 non-autistic children, aged 24 50 months (x = 35.6),
diagnosed with other developmental disabilities. Participant characteristics
are summarized in Table 2.1. Participants were recruited for a larger
longitudinal study conducted at the University of Colorado Health Sciences
Center. The purpose of the larger study is to explore the developing
phenotype in autism. Potential participants were recruited through various
health and early educational institutions and parent support groups in
Colorado.
Children were carefully evaluated based on information from medical
history, parent interviews, and laboratory observation (administered over the
course of 5 two-hour visits). A criterion for inclusion in the Autistic Disorder
(AD) group was agreed upon by experienced psychologists on the research
team. The children included in this group have met 4 of 5 of the following
criteria: 1) Previous diagnosis by a psychologist, psychiatrist, or physician; 2)
Current clinical diagnosis by an experienced psychologist; 3) Score on
ADOS-G meets criteria for spectrum disorder; 4) Score on ADI criteria meets
criteria for autism in both social and communication domains; and 5) Meets
13


criteria for autism on DSM-IV checklist. Children included in the autistic
group were required to meet criteria for autism on two of three diagnostic
measures (ADI-R, ADOS-G, and DSM-IV). In order to meet inclusion
criteria for the present study, participants were required to have completed at
least two of the measures being evaluated for reliability in joint attention
(ADI-R, ADOS, Parent/Examiner CHAT).
The comparison group was composed of children with various other
developmental disabilities (DD). All children included in this group failed to
meet diagnostic criteria for autism on both the ADI-R and the ADOS-G.
None of these children met diagnostic criteria as outlined by the DSM-IV. All
children in the DD group had previously been diagnosed with a
developmental disability; however, none had ever been diagnosed with
autism. All children in this group scored at least 1.5 standard deviations
below the mean in at least two domains in developmental assessment.
Diagnoses of these children included: Downs Syndrome (n = 7), Fragile X
syndrome (n = 4), Idiopathic DD (n = 5), and DD with other genetic
abnormality (n = 1). The Mullens Scale of Early Learning for infants
(Mullens, 1989) was used to match groups. There was no significant
difference between groups in chronological age (CA), overall mental age
(MA), verbal mental age (VMA), or non-verbal mental age (NVMA) (See
Table 2.1)
14


Measures
Mullen Scales of Early Learning (MSEL; Mullens. 1989). TheMSEL
is a measure, standardized on a nationally representative sample, which
assesses developmental functioning in children ages 3-60 months. The
Mullens test assesses development in 5 areas: gross motor, fine motor, visual
reception, expressive language, and receptive language. Each child included
in the present study was administered the MSEL according to standard
instructions. Overall mental age, non-verbal mental age, and verbal mental
age are calculated based on the childs MSEL score. Children from each
comparison group were matched according to results on The Mullens test.
The developmental quotient of each child (overall mental age/chronological
age 100) was calculated in order to better describe participants performance
on the Mullens test. Because of the young age of participants, floor effects
within this population are common. The developmental quotient is a
descriptive variable that provides a better means of comparing young children
with disabilities with children of other ages and developmental levels.
Autism Diagnostic Interview Revised (ADI-R) (Lord et aL 1994).
The ADI-R is a structured parent interview designed to diagnose the existence
and severity of autistic symptoms. It measures the childs functioning in three
areas: social relatedness, communication, and repetitive, restrictive behaviors.
The ADI-R is a measure that has been validated for the purpose of autism
diagnosis across ages and severity levels. Items on the ADI-R assess
15


functioning in social relatedness, communication, and repetitive, restrictive
behaviors. The ADI-R was administered to parents of children in both groups.
Autism Diagnostic Observation Schedule Generic f ADOS-G) (Lord
et al.. 19991. The ADOS-G is based on examiner observation of a child in a
laboratory setting. It is largely play-based in nature and administration takes
approximately 30-45 minutes. There are four modules of the ADOS-G, each
appropriate for different levels of language ability. In the present study, each
child was given Module 1, designed for pre-verbal children. The ADOS-G
has been validated across different ages and severity levels in autism.
Each item on the ADOS-G is scored from 0-3, with 0 representing
mastery of a given ability and 3 representing the absence of that ability. For
the sake of comparison with other measures, a dichotomous scale was created
for the ADOS-G. Scores of 1-3 (indicating some level of deficiency in that
area) were re-scored as no (child does not demonstrate developmentally
appropriate ability in this area). A score of 0, indicating mastery in the
appropriate area, was re-scored as yes (child demonstrates developmentally
appropriate ability).
Checklist for Autism in Toddlers (CHAT: Baron-Cohn. Allen. &
Gillberg. 1992). The CHAT is a test that uses both parent interview and
examiner observation and is designed to screen children at risk for autism. It is
used to detect core features of autism as early as 18 months of age (Baron-
Cohen, Allen, & Gillberg, 1992; Baron-Cohen, Cox, Baird, Swettenham,
16


Nightingale, Morgan, Drew, & Charman, 1996). Although research on the
CHAT is limited, the initial findings provide much hope for potential earlier
diagnosis. The initial study (Baron-Cohen, Allen, & Gillberg, 1992) using the
CHAT revealed that children with symptoms of autism detected at thirty
months are showing two or more of the following at eighteen months: (a) lack
of pretend play, (b) lack of protodeclarative pointing, (c) lack of social
interest, (d) lack of social play, and (e) lack of joint-attention. The CHAT
detected all four cases of autism in a total sample of 91 eighteen-month-old
children. The CHAT is a screening tool that has demonstrated high sensitivity.
It is approximately 85% accurate in screening children at risk for autism and
100% accurate in screening children at risk for developmental delays
(Scambler, Rogers, & Wehner, 2001). One study (Baron-Cohen, et al, 1996),
using a sample of 16,000 children, found that consistent failure of three items
on the CHAT carries an 83.3% risk of autism (see Table 2.2).
Data Collection and Analysis
Missing values for all diagnostic (joint attention) measures were
replaced with group modes. No more than 15% of the data for any given
variable was missing. Inter-rater reliability analysis was conducted on each
measure for 20% of the cases for the respective variables. Inter-rater
reliability on each diagnostic and developmental measure was maintained at
85% or higher.
17


Procedures
The data used in the present study were gathered as part of a larger
longitudinal study funded by the Collaborative Programs for Excellence in
Autism Network, NICHD. The entire study was carried out under IRB
approval and families participated on a volunteer basis. Risks and benefits
were fully explained to each family and all any questions were answered
before consent forms were read and signed. Each childs mother was
interviewed about her childs development and behavior using the ADI-R.
The parents also completed a demographics questionnaire. The
developmental assessment was completed during a home visit for the majority
of the children in the AD and DD groups. The executive function tasks were
administered in the lab in most cases, along with other measures not reported
here.
18


CHAPTER 3
STUDY ONE RESULTS
Study one examined two questions. The first question asks whether
items used from various diagnostic instruments and multiple sources that
purport to measure joint attention in young children are reliable. The second
question then asks whether children with autism differ in joint attention ability
from children with other developmental disabilities.
Reliability analysis of joint attention variables revealed that the items
were internally consistent at the .05 level, with an alpha of .9005 (see Table
3.1). Items from all measures and sources (parent and examiner report) were
found to be reliable (See Table 3.1)
Joint attention items were collapsed into one single variable: a
unitary, multi-source measure of this construct. Group differences were
computed using a one-way analysis of variance. Children in the AD group
scored lower than the children in the DD group using this new measure F (1,
37) =45.45 (p<.01).
19


CHAPTER 4
STUDY TWO METHOD
Participants
(See STUDY ONE METHOD)
Measures
Spatial Reversal Task CKaufman. Leckman. & Ort. 1989). Spatial
Reversal (SR) task is an experimental EF test designed to measure Executive
Functioning in children. The test specifically tests the childs set-shifting
ability and perseveration using visual-spatial search tasks. In this task, the
examiner hides a reward (one perceived by the examiner to be highly
motivating to the child) behind a screen under one of two identical cups and
asked to find it. After the child is successful, the examiner continues to place
the reward under the same cup until the child correctly identifies the correct
cup in four consecutive trials. The examiner then reverses the hiding of the
reward to the other cup. After the child unsuccessfully searches for the
reward under the cup that initially hid the reward, further incorrect responses
are scored as perseverations. Twenty-three trials are administered (up to four
sets). Number of perseverations and number of correct responses were used
in analysis in the present study.
Windows Task (Russell, Mauthner, Sharpe. & Tidswell (1991).
Windows is another experimental executive function task that was designed to
20


measure EF in children. This task also measures perseverations and set-
shifting ability. This task requires a child to correctly identify one of two
clear boxes, the correct choice then being rewarded with an appropriate
reinforcer. The child is able to see the reward under the box that is not the
correct target and must learn that he/she must lift up the box with no reward
under it in order to receive the reinforcer. The child is scored according to the
number of trials administered before the child learns the rule (i.e. four
consecutive correct responses). Data from the Windows task used in the
present study were number of perseverations, or errors following an error, and
number of correct responses.
Procedures
Each administrator of executive function tasks was trained to be
reliable with the primary administrator (E. Wehner). The primary
administrator was present for a minimum of three administrations by the
administrator-in-training. Agreement on 85% of all trials must have been met
in order for the new administrator to conduct labs independently (See study
one).
Data Collection and Analysis
Missing values for all executive function measures were replaced with
group means. No more than 15% of the data for any given variable was
21


missing. Inter-rater reliability analysis was conducted on each measure for
20% of the cases for the respective variables. Inter-rater reliability on each
diagnostic and developmental measure was maintained at 85% or higher.
22


CHAPTER 5
STUDY TWO RESULTS
Study two asks two questions. The first question is whether there is a
difference in executive function abilities between children with autism and
children with other developmental disabilities. The second question asks
whether or not executive function and joint attention are related.
A one-way analysis of variance was used to compute group differences
in executive function abilities. No group differences were detected in any of
the EF categories (Windows # correct, Windows # perseverations, Spatial
Reversal # correct, Spatial Reversal # perseverations).
Bivariate correlation analysis was then conducted using the new joint
attention measure and each of the EF variables. No significant correlations
were found between joint attention and executive function abilities in either
group.
23


CHAPTER 6
DISCUSSION
The measures of joint attention were found to be internally reliable.
This means that information gathered from parents and trained examiners is
consistent. Parents can therefore be used as a valuable source of information
for the purpose of screening for autism at young ages. This finding is
important because, as previously noted, joint attention deficits are detectable
as early as 6 months of age (Mundy, 1998). If parents can be a reliable source
of information about joint attention ability, it may be possible to begin
diagnostic evaluation and subsequent intervention much earlier.
In addition to the practical implications of the rehability of parents for
obtaining information about joint attention ability, there is statistical relevance
as well. It is possible to combine parent report and examiner report measures
to form one valid, multi-source measure of joint attention ability. In this study,
after rehability analysis revealed internal consistency between these measures,
joint attention variables were collapsed into a single variable. Subsequent
mean comparison between groups revealed significant group differences
between the autistic disorder group and developmental delay group. These
results are consistent with the findings of Sigmund and Mundy (1989). Using
the newly created joint attention measure, reflecting both parent report and
examiner observation, results were consistent with previous studies that
24


demonstrate that children with autism show greater impairments in the area of
joint attention than children with other developmental disabilities.
Further research in the area of joint attention should explore whether
or not these differences are consistent and reliable over time. Studies that
incorporate different intervention strategies targeting joint attention might also
be done to determine whether or not joint attention ability can be improved in
children with autism.
Young children with autism and other developmental disabilities
performed similarly on executive function tasks. There were no group
differences in performance for the variables measured on neither the Windows
task nor the Spatial Reversal task. Furthermore, no relationship was found
between executive functioning and joint attention in children at this age. This
finding is contrary to previous studies conducted on older children that
indicated that these two constructs may be related. The results of this study are
inconsistent with the Executive Dysfunction Theory of autism (Ozonoff,
Pennington, & Rogers, 1991).
There may be several reasons for these inconsistent results. It could be
that joint attention and executive function are not related and represent
different cognitive abilities all together. Results support previous research
suggesting that executive function differences may emerge later in childhood
(Wehner & Rogers, 1994). It is possible, however, that there may be a floor
effect in the EF measures used in this study, making differences difficult to
25


detect at such young ages (Wehner & Rogers, 1994). It is also possible that
deficient joint attention skills inhibit the development of executive function
skills, causing diminishing executive function ability over time.
One area that needs further investigation is the general validity and
reliability of EF tasks used for young children with disabilities. Because the
tools have only recently been developed and revised for use with children,
very little evidence exists about their discriminant validity or reliability
(Hughes, 2001). It is quite possible that this study found no relationship
between joint attention and executive function because of the inability of these
tools to measure EF in children adequately.
Executive function is a construct that includes a variety of diverse skill
sets. Many tests have been used to tap different executive function abilities
such as planning, flexibility, set shifting, or inhibition (Ozonoff & Jensen,
1999). Although there are theoretical and empirical relationships between
these tasks, it is quite possible that they are each tapping into different specific
cognitive abilities. Much more research needs to be done in this area in order
to be able to draw research conclusions about executive functioning in young
children with disabilities.
Further research on executive function and joint attention should also
be done to determine the nature of the relationship between EF and JA over
time, if one in fact exists. If it is true that joint attention ability hinders the
development of executive function ability, then children that are more
26


impaired in the area of joint attention at young ages will show greater
impairments in EF later on. A study using joint attention data from children at
young ages (such as those used in this study) could be conducted to see if
greater impairments in JA at time 1 predict greater impairments in EF at time
2. Further research in this area will increase the likelihood of earlier diagnosis
of autism and will hopefully serve to increase the understanding of the
specific cognitive dysfunctions related to this complex disorder.
27


Table 2.1 Descriptive characteristics of participants
Autistic Disorder (n = 21) Developmental Delay (n
Gender
Ethnicity
M=16
F=5
Caucasians 0
African American=1
Chronological
Age
Mean (SD)
Range
Non-Verbal
Mental Age
Mean (SD)
Range
Verbal Mental
Age
Mean (SD)
Range
Overall Mental
Age
Mean (SD)
Range
Dev. Quotient
Mean (SD)
Range
Biracial=2
26-41
23.70 (4.2)
17-35
16.95 (6.9)
11-31
20.79 (6.3)
12-42
61.31 (19.5)
39-120
= 17)
M=11
F=6
Caucasians 4
Hispanic=1
Biracial=2
24-50
22.50 (5.B)
16-35
18.62 (6.0)
5-37
20.56 (5.3)
14-33
59.30 (14.7)
32-81
28


Table 2.2 Items measuring joint attention ability
Measure Item description
ADI-R Pointing to express interest
ADI-R Showing and directing attention
ADOS-G Pointing to request and/or for shared attention
ADOS-G Showing (deliberate placement of object where it Can be seen by another person)
ADOS-G Response to joint attention (following gaze or point)
Parent CHAT Use of index finger (pointing) to indicate interest
Parent CHAT Showing objects to parents
Exam CHAT Observation of childs ability to follow point
Exam CHAT Childs ability to respond to request by examiner to Point at the light
29


Table 3.1 Reliability of Joint Attention Items
Joint attention Scale Scale Correlated Squared Alpha if
item mean if varia item multiple item
item nee total correlation deleted
deleted if correlatio
item n
delet
ed
ADI-R (30) Pointing to express 3.6709 7.890 .7620 .6525 .8793
interest 3
ADI-R (45) Showing/directing 3.6709 8.121 .6698 .5998 .8868
attention 1
ADOS-G (7) Pointing to request 3.7975 8.496 .5783 .4809 .8935
and/or for shared attention 9
ADOS-G (9) 3.8861 8.922 .4767 .3607 .8999
Showing (deliberate placement of object where it can be seen by another person) 8
ADOS-G (11) 3.7595 8.415 .5878 .4022 .8929
Response to joint attention (following gaze or point) 8
Parent Chat (A9) 3.4684 7.970 .7544 .7472 .8800
Showing objects to parents 1
Examiner Chat 3.5190 8.022 .7125 .5913 .8833
(B2) Observation of childs ability to follow point 1
30


Table 3.1 (Cont.)
Examiner Chat
(B4) Childs ability 3.6076 8.0107 .7049 .5590
to
respond to request
by examiner to point
at the light
.8839
31


Table 3.2 Group differences in Joint Attention ability
Autistic Disorder
(n=21)
Joint Attention Ability
F (1,37) = 45.45, p < .01
Mean (SD) 1.24 (1.7)
Range 0-6
Developmental
Delay
(n=17)
5.53 (2.9)
0-9
32


Table 5.1. Descriptive data of executive function performance by group
Autistic Disorder
(n=21)
Windows
(percentage correct)
Mean (SD) 58.78 (33.5)
Range 0-100
Windows
(percentage of
perseverations)
Mean (SD) 16.97 (.36)
Range
0-84
Spatial Reversal
(percentage correct)
Mean (SD)
Range
Spatial Reversal
(percentage of
perseverations)
Mean (SD)
Range
56.67 (18.9)
0-100
17.63 (17.0)
0-26
Developmental
Delay
(n=17)
49.09 (36.4)
0-100
15.00(21.1)
0-88
54.84 (15.8)
0-100
17.00 (21.2)
0-78
33


REFERENCES
American Psychiatric Association (1994). Diagnostic and Statistical
Manual of Mental Disorders. (4th ed.) Washington, D.C.: American
Psychiatric Association.
Autism Society of America website (2003) www.autism-societv.org.
Bailey, A., Phillips, W., & Rutter, M. (1996). Autism: towards an
integration of clinical, genetic, neuropsychological, and neurobiological
perspectives. Journal of Child Psychology and Psychiatry. 37, 89-126.
Baron-Cohen, S. (1989). Joint attention deficits in autism: Towards a
cognitive analysis. Development and Psychopathology. 1. 185-190.
Baron-Cohen, S., Allen, J., & Gillberg, C. (1992). Can autism be
detected at 18 months? The needle, the haystack, and the CHAT. British
Journal of Psychiatry. 161. 839-843.
Baron-Cohen, S., Cox, A., Baird, G., Swettenham, J., Nightingale, N.,
Morgan, K., Drew, A., & Charman, T. (1996). Psychological markers in the
detection of autism in infancy in a large population. British Journal of
Psychiatry. 168. 158-163.
Bryson, S. (1996). Brief report: Epidemiology of autism. Journal of
Autism and Developmental Disorders. 26. 165-167.
Butterworth, G. & Grover, L. (1988). The origins of referential
communication in human infancy. In L.Weiskrantz (Ed.), Thought without
Language. Oxford, England: Clarendon.
Charman, T. & Baird, G. Diagnosis of autism spectrum disorders in 2-
and 3-year old children. Journal of Child Psychology and Psychiatry (in
press).
Dawson, G., Meltzoff, A., Osterling, J., & Rinaldi, J., & (1998).
Neuropsychological correlates of early symptoms of autism. Child
Development. 69, 1276-1285.
Dawson, G, Meltzoff, A., Osterling, J., Rinaldi, J, & Brown, E. (1998).
Children with autism fail to orient to naturally occurring social stimuli.
Journal of Autism & Developmental Disorders. Vol 28(6) Dec 1998,479-485.
34


Epsy, K., Kaufmann, P., McDiarmid, M., & Gilshy, M. (1999).
Executive Functioning in Preschool Children: Performance on A-not-B and
other Delayed Response Format Tasks. Brain and Cognition.. 41 178-199.
Friedman, H., Goldman-Rakic, P. (1994). Coactivation of prefrontal
cortex and inferior parietal cortex in working memory tasks revealed by 2DG
mapping in the rhesus monkey. Journal of Neuroscience. 14: 2775-88.
Frith, C. (2001). A framework for studying the neural basis of
attention. Neuropsvchologia, 12. 1367-71.
Gioia, Gerard A; Isquith, Peter K; Retzlaff, Paul D; Espy, Kimberly A.
(2002). Confirmatory factor analysis of the Behavior Rating Inventory of
Executive Function (BRIEF) in a clinical sample. Child Neuropsychology.
Vol 8(4) Dec 2002. 249-257.
Howlin, P., & Asgherian, A. (1999). The diagnosis of autism and
Aspergers syndrome: Findings from a survey of 770 families.
Developmental Medicine and Child Neurology, 41, 834-839.
Hughes, C., Russell, J., & Robbins, T. W. (1994). Evidence for
executive dysfunction in autism. Neuropsvchologia, 32,477-492.
Hughes, C. (2001) Executive dysfunction in autism: Its nature and
implications for the everyday problems experienced by individuals with
autism. The development of autism: Perspectives from theory and research,
(pp. 255-275). xvii, 374pp.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous
Child. 2, 217-250.
Kaplan, H. & Sadock, B. (1998). Synopsis of Psychiatry. Baltimore.
MD: Lippincott, Williams, & Wilkins.
Kaufman, Leckman, & Ort (1989). The Spatial Reversal Task.
Landry, S. H. & Loveland, K. A. (1988). Communication behaviors in
autism and developmental language delay. Journal of Child Psychology and
Psychiatry, 29, 621-634.
Leekam, S. R. & Lopez, B. (2000). Attention and joint attention in
preschool children with autism. Developmental Psychology. 36, 261-273.
35


Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism Diagnostic
Interview-Revised: A revised version of a diagnostic interview for caregivers
of individuals with possible pervasive developmental disorders. Journal of
Autism and Developmental Disorders, 24(5). 659-685.
Lord, C., Rutter, M., DiLavore, P., & Risi, S. (1999). Autism
Diagnostic Observation Schedule WPS Edition. Los Angeles, CA: Western
Psychological Services.
Loveland, K. & Landry, S. H. (1986). Joint attention and lanuage in
autism and developmental language delay. Journal of Autism and
Developmental Disorders. 16. 335-349.
McEvoy, R. E., Rogers, S. J., & Pennington, B. F. (1993). Executive
function and social communication deficits in young children. Journal of
Child Psychology and Psychiatry. 34.563-578.
Morales, M., Mundy, P., & Rojas, J. (1998). Following the direction
of gaze and language development in 6-month-olds. Infant Behavior &
Development. 21. 373-377.
Mullen, E. (1989). The Mullens Scales of Early Learning. Cranston,
RI: T.O.T.A.L. Child, Inc.
Mundy, P., Sigman, M., Ungerer, J., & Sherman, T. (1986). Defining
the social deficits of autism: The contribution of non-verbal communication
measures. Journal of Child Psychology and Psychiatry. 27. 657-669.
Mundy, P., Sigman, M., & Kasari, C. (1993). The theory of mind and
joint-attention deficits in autism. In S.Baron-Cohen, H. Tager-Husberg, & D.
Cohen (Eds.), Understanding other minds: perspectives for autism (pp. 181-
203). Oxford University Press.
Mundy, P. (1995). Joint attention and social-emotional approach
behavior in children with autism. Development and Psychopathology. 7(1).
63-82.
Mundy, P. & Markus, J. (1997). On the nature of communication and
language impairment in autism. Mental Retardation and Developmental
Disabilities Research Reviews. 3. 343-349.
Mundy, P. & Crowson, M. (1997). Joint attention and early social
communication; Implications for research on intervention with autism.
Journal of Autism and Developmental Disorders. 27, 653-676.
36


Mundy, P. & Sigman, M. (1989). Specifying the nature of the social
impairment in autism. [Chapter] Autism: Nature, diagnosis, and treatment:
pp. 3-21.
Osterling, J. & Dawson, G. (1994). Early Recognition of Children with
Autism: A Study of First Birthday Home Videotapes. Journal of Autism and
Developmental Disorders. 24.247-257.
Ozonoff, S., Pennington, B. F., & Rogers, S. J. (1991). Executive
function deficits in high-functioning autistic children: Relationship to theory
of mind. Journal of Child Psychology and Psychiatry. 32.1081-1105.
Ozonoff, S., & Jensen, J. Specific executive function profiles in three
neurodevelopmental disorders. Journal of Autism and Developmental
Disorders. 29. 171-177
Pennington, B. F. & Ozonoff, S. (1996). Executive functions and
developmental psychopathology. Journal of Child Psychology and Psychiatry.
37*51-88.
Russell, J., Mauthner, N., Sharpe, S., & Tidwell, T. (1991). The
'windows task' as a measure of strategic deception in preschoolers and autistic
subjects. British Journal of Developmental Psychology. 9. 331-349.
Scambler, D., Rogers, S. J., & Wehner, E. A. (2001). Can the CHAT
differentiate autism from other severe delays in two-year-olds? Journal of the
American Academy of Child and Adolescent Psychiatry. 40.1457-1463.
Smith, T. & Lovaas, I. O. (1998). Intensive And Early Behavioral
Intervention with Autism: The UCLA Young Autism Project. Infants and
Young Children. 10.67-78.
Stahl, L. & Pry, R. (2002). Joint attention and set-shifting in young
children with autism. Autism. 6.4.
Wetherby, A. and Prutting, C. (1984). Profiles of communicative and
cognitive-social abilities in autistic children. Journal of Speech and Hearing
Research. Vol. 27 (31.364-377.
37