Joint Attention Part II

The brew continues in Joint Attention Part II. Mike and Dan review research on the correlation between joint attention, imitation, language development (verbal/vocal behavior) and play. From this, they focus on a specific research-based method designed to promote joint attention--namely following a point (both proximal and distal) as well as gaze shift, then leading others with point and gaze shift. The idea of joint attention as a constant mode of presentation, along with contingent imitation and linguistic mapping, in creating a dynamic, child-directed, play-based environment is elaborated. This allows for more and more adult-directed instruction as needed toward specific targets and goals, like imitation, while maintaining the most important motivating operation--play.

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Transcript

SPEAKER_00: 0:00

Hey Mike, how do you feel about today? Feeling pretty good about it?

SPEAKER_01: 0:04

I think today's a great day, Dan.

SPEAKER_00: 0:06

I couldn't agree more. Like you say, any day that you wake up and your name's not in the obituary, you're off to a good start. Speaking of which, today's also a great day to start your own podcast. Whether you're looking for a new marketing channel, you have a message you want to share with the world, or just think it'd be fun to have your own talk show, like we did. Podcasting is an easy, inexpensive, and fun way to expand your reach online. Maybe learn something. Now, Buzzsprout is hands down the easiest and best way to launch, promote, and track your podcast. It's what we use. Your show can be online and listed at all of the major places podcasts can be found, like Apple Podcasts, Spotify, Google Podcasts, et cetera, within minutes of you finishing your recording. You know, podcasting isn't hard when you have the right partners. And the team at Buzzsprout is passionate with helping you succeed. Join over 100,000 people just like us sharing their message, already using Buzzsprout as the conduit to get their message across the world.

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SPEAKER_00: 1:46

Cheers. Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on Tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_01: 2:42

All right, all right, all right. Welcome to another installment of ABA on Tap. I am your co-host, Mike Rubio, along with...

SPEAKER_00: 2:53

Daniel Lowery. Good to see you, Mike. Good to see you, brother. Daniel.

SPEAKER_01: 2:56

Good to be back again. We're hitting the ground running, knowing that we had a delay in starting season three, but here we are trying to get the second episode out quickly. We ended up doing a part one on joint attention that laid down all the historical groundwork and why we happened upon the idea of joint attention. We're obviously not the first ones, but we're excited about our integration into the treatment model and how it kind of took a place Before imitation in many ways, particular to our early start learners or those kiddos under the age of three.

SPEAKER_00: 3:31

Part one, just a little history lesson on how we got here, how Mike's expertise in various different realms was able to synthesize to get us to this joint attention piece. And. Hopefully, by the end of this series on joint attention, for those of you that are practicing ABA, you'll be incorporating it into your programs, and those of you that are consumers will go to your ABA providers, and if they don't have joint attention programs in focus, you'll be asking them to change the way they do things. So without further ado, let's talk about All

SPEAKER_01: 4:05

right, so I'm going to have to take a little bit of a historical step back yet again, just briefly, to talk about the idea of imitation. And as far as the literature I look back at in terms of our purposes or the integration into behavior analysis, so to speak, it was our dear friend and mentor Lovaas in 1966 that maybe early on first or maybe one of the first to introduce the idea of teaching verbal and nonverbals in respect to to a verbal SD. This could very likely be the origination of one of our... Traditionally favorite SDs. Do this. So we're talking about imitation here. Do what? This,

SPEAKER_00: 4:50

right? Are you watching

SPEAKER_01: 4:52

me? Do this.

SPEAKER_00: 4:53

That's

SPEAKER_01: 4:53

nonverbal imitation. Wait, do you want an object? That's a whole separate program. We can't bring those together. Well, I'm not sure why, but we're going to try to debunk that myth. Yes, you can do it that way, but you can also do it the way in which we're elaborating here. Do this. All right. Are you watching? Yes. You weren't attending, so you can't imitate me nonverbally. But that's a minus. You get my point. Okay. So then we look at the idea of imitation with objects now much more recently in 2002 with Carpenter, Pennington, and Rogers in a study they did in correlating joint attention. Looking at correlation with joint attention in preschool-age children with ASD and the idea that object imitation preceded joint attention in the ASD sample, a pattern that's reversed in neurotypical children by most developmental accounts. So we've got an interesting little race or competition here developing between... joint attention and imitation, and how it develops first or its present first, depending on the sample in the study. Nice little crossroads, right? Knowing that we've got these early start learners that maybe are lacking the joint attention toward the imitation. Whatever it is, we can hit both of these pieces immediately. And then now we've got these other pieces coming up in the research, right? We've got play. And we've got language development. And all of these appear to be correlated. Super exciting knowing that this is hitting all our deficits with regard to the way our clients are assessed and then referred for services, right? Typifying the treatment. So historically, joint attention or early intervention in autism has prioritized imitation skills. But... knowing that specific to these early start kiddos, we kind of have a competition here. So instead of prioritizing imitation, the idea is now to maybe prioritize or at the very least put in parallel this idea of joint attention. And it doesn't have to be in program mode, meaning that what we're talking about is more joint attention as a mode of presentation. You're always doing these things with sight and sound and moving things around the visual and auditory field to get your kiddos to look around and take in their entire environment. 360 degrees, very different from taking a visual card and being able to manipulate it right in front of their face, which is also very helpful, right? But now this idea is the other part of that. We know the cards. Heart on the card, the visual. We know that part. The part is now getting that card, or better yet, the world to be in a full 360-degree panorama. And that's where joint attention comes in, right? So we want you to imitate, but if you're not attending, then how are you going to imitate becomes the question. So that was one starting point there. So... If we look at joint attention from a neurotypical view, we're talking about a skill that should be fully resolved between 15 and 18 months. Now, what is joint attention? Very, very briefly, we're talking about gaze shift, not fixed eye contact, which is something that traditionally we've been more keen on in ABA, but gaze shift, pointing, following a point, following, leading with eye gaze, or better yet, let me put this better, following somebody's point, proximally or distally, following somebody's gaze shift, proximally or distally, being able to orient to an auditory stimulus with a gaze shift, no matter where in your visual field, maybe particularly behind you, because that gives us the most salient response in terms of response to an auditory stimulus. And notice I'm saying that very poignantly. We'll talk more about that later, for sure. So you're able to follow that from other people. And then more importantly, because you've done that, now you're able to lead with your pointing, proximally, distally, as well as your eye gaze. And maybe somewhere in there, you start throwing in some vocalizations, knowing that joint attention... along with play, along with imitation, are going to have a collateral effect on language development. And we could take any of those pieces out of that equation and have three of them, knowing that any three of them are going to have a collateral effect on that fourth missing on the list.

SPEAKER_00: 9:14

So would it be too much of a truncated definition of joint attention to say joint attention is the ability to orient to either an auditory or visual stimulus and an individual in succession in either order, either the individual first so that they can show you the auditory or visual stimulus or the stimulus first so that you can show the individual. Is that too truncated?

SPEAKER_01: 9:36

No, I think that's a really good way. It's a very good colloquial description. And I like the way you put it in the sense that something about looking at somebody's face shifting to some other stimulus in the environment, whether in their hand or otherwise, and then looking back at somebody's face, right? So now I'm going to introduce this, and then I'm going to want you to elaborate a bunch more on this as you see fit. But now this idea that comes into the joint attention model, this idea of proto-imperative or proto-declarative behaviors, right? Proto-imperative means that I am looking at you, getting your attention, making you follow my gaze and my point, for example, towards something high up on the shelf, and then looking back at you, in that point, I'm either sharing that site with you, or maybe I'm asking you to get it for me. The difference between those two is what in the developmental research or developmental framework we call proto declarative or proto imperative behavior. I'm going to pass that right over to you because I know you got something to say.

SPEAKER_00: 10:42

Yeah. So the way I like to think about it, again, correct me if I'm wrong, is I like to think about it as you and me or me and another individual are in an escape room and we can't talk. And how am I going to communicate where things are in this escape room for the other person? And I'm going to have to orient to them, see what they see, and point or direct their attention to objects, and then how do they communicate where things are in the escape room To me, without talking. That's kind of how I think about it. I don't know if that's an accurate visual representation, but basically that idea. There's things and there's a person. How do I communicate where those things are or what those things are to that person without talking? And how does that person communicate where and what things are to me without talking?

SPEAKER_01: 11:29

And we're talking about pointing and gaze shift specifically, right? But now gestures reaching your gaze shift by itself without looking at somebody. You're pointing by itself if somebody's visually oriented to you. All the other permutations. excuse me, that I like to joke about. So in ABA, we have this ideal response, right? I'm going to use a very specific and important example to our demonstration today, and that's the idea of response to name. An auditory stimulus, right? So we have defined that operationally as the child is doing something with their gaze directed somewhere else. We call their name, and we expect them to orient their gaze to wherever the speaker is standing, okay? Now, traditionally, what we've done is we've measured that distance, right? So one foot, two foot, three foot. I just saw that this weekend at a conference, a very excellent presentation on the use of gestures, which had proto-declarative and proto-imperative stuff. I wish I remembered the presenter's name. It was an excellent presentation. But when it came down to the way they listed their targets, yes, we were right back to a very traditional approach and sort of listing this distance, knowing that once you jointly attend and you can demonstrate that you're orienting your gaze to the source of an auditory stimulus Then the idea of distance is irrelevant.

SPEAKER_00: 12:53

Is there any substantiated research in that a difference between responding to name two feet and three feet away? It seems like that's, again, just ABA being overly truncated and coming up with arbitrary things inside and outside of the room might make sense or immediate and non-immediate area. But three feet and four feet, like...

SPEAKER_01: 13:13

And ultimately what we're talking about is a vocal response, right? So you bring up a great point. I think what happened here is that knowing that by and large a good percentage of our clients would be nonverbal, nonvocal, then we have to expect this joint attention response to response to name because they can't just keep coloring and go, yeah, what do you want? which is going to be another way to respond in the future, knowing that you've got that vocal piece. So you're saying into the room, out of the room, yes. That's an excellent way to start conceptualizing it. We need to be a little less systematic in that sense, a little less quantified, if you will, without losing the power of our data, right? So that's been a very important... sort of shift in our thinking here knowing that we've got this idealistic response to an auditory stimulus or more specifically a response to name which now looking at some of the research and joint attention as applied to populations of young children with ASD and I have to immediately give a ton of credit to Laura Shriveman and some of the research in the early 2000s that was put out in the PRT model because without that there is no way we could have embarked on such a clear path, if you will, even though we're kind of blazing new trails, in combining these ABA-based practices like PRT and best practices in early childhood.

SPEAKER_00: 14:33

Shout out to Laura Schreibman. I think three of my units for my UCSD degree are courtesy of her. Good class. She's obviously very into PRT. Very informative class, though.

SPEAKER_01: 14:45

And just historically speaking, in case, and I hope I'm not getting this wrong, I know that the Robert and Lynn Kegel are definitely had been graduate students of Lovaas. I believe Schreibman fits the same mold. So we're talking about people that also were exposed to DTT very early on. Ron Leaf was another one of those. And then decided to sort of mold or progress or evolve that model, if you will, a little more. And all we're doing is undertaking it and saying, does it have to be so specified and recipe-oriented in terms of being specific to ASD? Or can we embed that treatment modality into just regular old interaction with a young child, right? So again, huge credit to Schreiben. and a lot of the publications that were used in the presentations that we're currently presenting or disseminating to people. And it's important to understand that base. We're not just inventing this correlation or this cross-disciplinary effort. There's real good basis for it, not just based on our experience, but even from the research base. DTT to PRT, that wasn't a huge leap. All we're saying is, well, PRT, in terms of its more open-endedness, I think it applies here. Another thing that I want to mention now is that we're talking about is a child or client-directed play-based effort. That's what people, I think erroneously, like to refer to as unstructured treatment. We've made a nice shift, I think, to really understand this better to say this is child-directed play-based treatment. As soon as this takes hold and we develop... a level of engagement and joint attention, then the idea for more structured or, better yet, adult-directed activity with more target specificity is going to be possible. And in fact, it's going to be possible in a way that we can never get to if we begin with our prompting hierarchy immediately. I can't prove that with data. Maybe there's research out there. Please do let us know if you know something like that. Maybe we end up doing it. The point is I feel very strongly about that. kiddos are spending less time, less and less time with those tantrums that maybe we caused that we were talking about in last episode. So, nice little tangent we went on there and that's screeched us back onto the road.

SPEAKER_00: 17:18

Keep bringing it to life. Concept of joint attention.

SPEAKER_01: 17:20

So what is it? It's all those things we just talked about. It's following somebody's gaze shift, following somebody's pointing to the point where you can use your gaze shift, your pointing, your vocalizations, your gestures to get somebody's attention and to use Dan's words to get somebody's attention. It's communicating effectively and fully without the use of vocal behavior. That's what we're talking about. So if you're good at joint attention and all these cues and behaviors, it's what we all do when we're in a foreign country. We don't speak the language. When you get around, this is the stuff you're using. And it's developmentally the basis, the foundation for, or a strong correlate, I should say, definitely an underlying factor in the development of language or verbal vocal behavior.

SPEAKER_00: 18:04

Happens all the time, right? Maybe you're out on a double date or something like that, and you want to show your buddy a stimulus that walks by, but you can't bring it up, so you're... I

SPEAKER_01: 18:17

don't think either one of us has been on a double date in a while.

SPEAKER_00: 18:19

No, no, we haven't. But hypothetically, you know, a stimulus walks by, but you can't talk about it out loud, right? Like a

SPEAKER_01: 18:25

nice car, you're saying.

SPEAKER_00: 18:26

A nice car, yes. The nachos come out of the kitchen. The dessert tray. Exactly. And you want to communicate that to your buddy that you should get the nachos, but you don't want your significant other to hear.

SPEAKER_01: 18:38

We might be getting in trouble for this one. We're going to continue on. So what do we know? Again, I have these four ingredients in the cauldron, right? Joint attention, imitation, play. Somewhere, all those three things are necessary for language, although obviously having more language is going to help your play skills and your imitation skills because now you can imitate and develop more vocabulary by imitating, vocal behavior, so on and so forth.

SPEAKER_00: 19:02

But what am I imitating if I can't attend to

SPEAKER_01: 19:04

something? Back to the root, right? That's what we're saying here is join the joint attention. It might be first in line in so-called neurotypical development. We're playing with that seesaw there. A little imitation, a little joint attention, a little imitation. It's a dance. We're going to go back and forth. Knowing that imitation might have much more clear targets in our programming that we want to see happen, but joint attention is going to be our constant mode of presentation to try to get this out. Now, what does the research say? Looking at Really, really important developmental research in linguistics. 1988, Elizabeth Bates, another UCSD product. Imitation is associated with the development of language and joint attention skills. Now, if we look at research in ASD, it tells us that imitation may be a primary deficit in ASD. So, if you can't... imitate, then how are the other correlates, joint attention, play, and language going to fare, being the question there, right? So now looking at the research in 1997, Stone et al., imitation of body movements and motor imitation and development of expressive language in children with ASD are highly correlated. So this is where we get the idea of nonverbal imitation without object, right, body movements, nonverbal imitation with object, That's now play, because if you're imitating somebody with a toy, guess what you're doing? You're playing. And the development of expressive language in children with ASD. So if you do these two things with kids, they fare better in language development. Okay, it makes total sense,

SPEAKER_00: 20:41

right? Man, nonverbal imitation with object. That's quite an over-task-analyzed way to come up with the term play.

SPEAKER_01: 20:49

And again, if you think about what imitation is in that sense now developmentally, I love that you say that, right? I do something, you do something, I do something, you do something. If you're a two-year-old, that's called. Parallel

SPEAKER_00: 21:02

play. No, I've just never thought about it like that. So just think about it from a, because I've always been in the field, so it's hard to think about it objectively or step outside yourself. But think about the difference between, even as a BCBA telling an RBT, hey, go play with a child versus, hey, go run these eight nonverbal imitation without object trials. Man, one is so much less enriched than the other one.

SPEAKER_01: 21:24

That's perfectly stated. Now, if you're adult directed, right, you come in and you've set the tone, you've set the schedule You've decided the activities. You've decided the toys, right? Completely adult-directed, quote-unquote structured. If we look at it from a parenting perspective, now you're an authoritarian parent as opposed to an authoritative parent or a child-directed therapist who comes in, builds a little rapport using some basic techniques, contingent imitation, linguistic mapping. We'll get more to those in a little bit. And then you get to learn from the child what they can actually do, what They are doing, so you can imitate that. They notice you. Now you can change the SD and get them imitating you. So it's all sort of correlated, and you're absolutely right. It's been our better practice as task-oriented, very analytical professionals to break everything down into these small, small pieces. An example I've used in the past, it's almost like you take your car apart to every single component, right? rebuilding that's going to be very different than if you just have certain components to piece back together. And that's what we've done, I think, traditionally, is we've taken the car fully apart, every screw, nut, and bolt, and then some spring flies off, and now you're rebuilding it, and it doesn't look the same, where we could have just reconfigured bigger chunks of it and made the car run more smoothly and more efficiently, right?

SPEAKER_00: 22:48

Absolutely. And we've never put them together to make the engine. We've just had them all be separate parts that didn't ever really... amount to anything other than this is a radiator and that's all this will be and this is the water pump.

SPEAKER_01: 23:01

Absolutely. From a developmental perspective, again, all these features we're talking about are correlated. So you know, asking the questions. Where does the difference come? Where does the bifurcation occur? Where it makes a difference between a child who remains quote-unquote neurotypical versus one that then goes on to face more, not more challenges necessarily, but challenges particular to traits of ASD, especially from a social perspective. So knowing that ASD affects all of these socio-communicative behaviors altogether, and imitation was traditionally our starting point in ABA, We ask the question again. Well, if joint attention is a correlate here, how do you imitate without jointly attending? Now, the answer is you get prompted to do so in some sort of errorless learning scheme. Not being critical of that. Those are very important tools in our toolbox. Don't put those away. Keep those handy if you need them. Again, we're shifting the paradigm here. These kids don't have autism, so we're trying to look at a more developmental framework and early childhood best practice with which to arrive at the imitation practice.

SPEAKER_00: 24:10

Sounds like if I'm going to get prompted to go through imitation, then the reinforcer is probably going to be artificial or external. Because otherwise, if it was internal, I would have already imitated. I

SPEAKER_01: 24:23

love that you brought that up, and I hope we come back to this topic later. Or maybe we elaborate on it now. But one of the things that we have a lot of trouble with traditionally in ABA is the idea of generality. And the idea of generality, in my opinion, one of the reasons it's so difficult is because of our pervasive use of extrinsic motivators.

SPEAKER_00: 24:42

Absolutely,

SPEAKER_01: 24:43

yep. So what we're talking about here is that we are starting with joint attention, linguistic mapping. That is how our conditioning works. That's how we're going to begin to condition ourselves as reinforcers. We're paying attention with everything they're doing and everything they're saying.

SPEAKER_00: 25:00

Exactly. We've conditioned ourselves just as reinforcer-deliverers typically, right? Nicely phrased. It doesn't really make sense that I touch my nose, and I touch my nose to get an M&M. So if I want an M&M in the future, I touch my nose. Why not? that it's completely decontextualized. There's no imitation from that prompting perspective. It has no functionality other than to show that an individual can touch their nose, but how are they going to go from that to knowing what their nose is or know why they touch their nose or anything like that? So let's join attention as we'll talk about the alternative way outside of imitation techniques taught through sheer physical prompting will make a much more enriched experience.

SPEAKER_01: 25:44

And again, we don't put the prompting away as much as we might wait for a more clear line of consent from a young child as opposed to assuming that based on their size and age and the fact that we've got consent of the parent, we can come in and motor them around. There's many other reasons to motor them around that are going to be much more play-based and actually motor-based and important for that reason, but the consent piece also comes in here. So we've got an intrinsic Yeah, you're right. being cultivated as a reinforcer. That's awesome, man. That's actually socialization, right?

SPEAKER_00: 26:33

Interaction. Good word.

SPEAKER_01: 26:35

Interaction. There you go. There you go. So one of the really important things that I alluded to earlier was this idea of eye contact versus gay shift. We have... And that's why I think a lot of people in the neurodivergent community right now are talking about the discomfort that they've got in having to fix their eye contact on somebody's face. You know, we're doing that to each other right now. It feels awkward even though we're in the same room and we know each other well. But you never really talk to people like that. If you think about it, the way you talk to people is gestures, you're listening to, you're saying hi to somebody behind them as you listen. There's a lot of joint attention, gaze shift, pointing, reorienting to the speaker and reorienting to something else, back to the speaker's face, down to your hands, grabbing a drink, putting the fork in your mouth. It's all

SPEAKER_00: 27:22

attention-based. Something crazy happens away from you. You're looking at that and orienting to the person.

SPEAKER_01: 27:27

And from our task analytical perspective, we've always had this really linear approach, right? You're going to look right at me and stare into my eyes as we speak, and you better do it.

SPEAKER_00: 27:37

You are not being hypnotized. You are getting sleepy.

SPEAKER_01: 27:40

Yeah. So really, knowing that our eye contact is never fixed, in fact... Communication is often involved, even if we're trying to look at something in a fixed manner, our eyes naturally move side to side. right? There's a saccadic eye movement. It's never really fixed. So when we start talking about gaze shift, that's very exciting. It's much more functional than this idea that you have to orient to somebody's face to be polite and eye contact is a deficit. It becomes more developmentally based. The reason it's good to look at somebody's face like you were saying earlier is that now you look at an object in your hand, for example, you look at them, they tell you the name of that object, you get to hear the word and see the word as it's shaped from their mouth.

SPEAKER_00: 28:23

So that's an ABA we'd call reflexivity, symmetry, and transitivity, right? Taking a stimulus and putting it in three different modalities.

SPEAKER_01: 28:31

That's perfect. Thank you for making that so clear. That's exactly right. We're hitting all of those pieces, all in one. And we're doing so naturally based on natural interest and engagement within this child-directed, play-based environment. Okay. Super, super important. Again, going back to this idea now of response to name with this idea of gay shift and the ideal response we're looking for in ABA, we've traditionally used as a fixed target, right? RTN. Sure. What we came up with that was very exciting from this joint attention piece is how do you teach that? It's not that we're going to prompt the speaker's gaze toward– or the listener's gaze toward the speaker.

SPEAKER_00: 29:15

We're going to say their name more and more and more, right?

SPEAKER_01: 29:17

And then whenever they actually turn around for whatever reason, because we're one foot there, we'll give them the M&M. Again, these things, by and large, can work. But we came up with what I feel is a better idea, which is it's not up to the child– to do this, but for us from the very beginning to let them know that if we want their attention, we get down to their line of sight and we call their name. And guess what happens pretty consistently when you do that to a child? They look right at your face. Imagine that. I am modeling the very behavior I'd like this two-year-old to do, but instead traditionally we might have called their name from some distance and then prompted their little face up toward the direction of the speaker, whether or not their gaze shift was actually moving in that direction. So again, these are all things that came out of this joint attention model in saying, so if I'm actively seeking gaze and then shifting that gaze... And doing this contingent imitation linguistic mapping, at some point then, instead of calling your name right in front of your face, I'm going to call it from a little bit to the side. And if you're accustomed to seeing my face when I call your name, because you look at it when it's not right in front of you, you're going to shift your gaze to where I'm at. No matter where I'm at, whether it's one foot, five foot, ten feet, whether it's raining, it's this RBT, that RBT, it doesn't matter because now name means something, and it's never gone through some sort of extinction-based inadvertent procedure where it got called over and over and over and over again to no appropriate response.

SPEAKER_00: 30:45

Yep, and I think programmatically, one of the things that was most useful and enlightening and tangible is changing these programs from response to name to response to RAS, response to auto And that's really the prerequisite because then you're figuring out, because some of the clients that we work with don't respond to any auditory stimuli. That's an issue that we got to work on. But 90, 95% respond to auditory stimuli, not their name. They'll respond to the iPad turning on. If somebody bangs, they'll turn and orient to it. but they won't respond to their name. And again, what we would do traditionally is just keep calling their name and mark it as minuses, but it's not on them. It's on us because we're the reason that one auditory stimulus, again, the name is no different than an air conditioner turning on a fighter jet overhead. It's just one example of an auditory stimulus. One of those they don't respond to. Why? Because it's been conditioned. So it's on us to change it, kind of like you're saying. So that changing response to name to response to auditory stimulus, number one has been... I think really enlightening and beneficial for the clients, but also for the parents and the therapist to realize, oh, it's on us to change, not them.

SPEAKER_01: 31:54

And you can certainly prioritize name on that list of targets. We're not saying no. And in fact, what we found is you don't even have to specify the targets by and large. You just have to keep presenting auditory stimuli in a way that they can demonstrate gay shift toward that and then provide the adequate reinforcement, whatever that might be. By and large, we've dropped... a lot of stimuli that were designated for extrinsic reinforcement, right? We don't use that anymore. The stimuli that are there just play stimuli, right? The play becomes the motivating operation, as we like to say, in which to practice these skills. And then now you're just... You're interacting with a two-year-old. But we've got our treatment expertise embedded in those so-called trials. Discrete trials traditionally have been sequential, all in one concentrated chunk of time. And all we're doing is spreading those out now with joint attention as a mode of presentation, spreading all those trials out to whenever they're feasible, whenever the SD becomes appropriate or accessible. And that's it. That's it. Let's do, with this idea of, we're talking about task analysis, for example. With DTT, traditionally task analysis identify a series of steps toward a behavioral sequence or a learning set, right? So hand washing, labeling colors, perceptive first, expressive next. I'm not saying that's wrong. It's actually very analytical. But developmentally speaking, does it happen in this continuous fashion, or is it a little bit more of a hodgepodge, right?

SPEAKER_00: 33:29

No, no. You learn running before you learn swimming. You can never learn swimming before running. You can never learn them concurrently. There's a specific way that we have to teach actions, and prepositions have to learn up before you learn down.

SPEAKER_01: 33:44

And then further, mastery criteria, as we all know it, and statistical analysis have largely guided the presentations or the intervention, your trial types, right? So that's the mode of presentation. A lot of people have, I think, mistakenly, and I'd love to debate anybody that wants to come on this and actually research the topic more, not debate to win, but debate to be informed, that we've taken that mode of presentation as necessary the therapeutic piece, not as the important statistical analysis piece to let us know that this ABA stuff leveled the playing field, that individuals with autism learn under the same procedures and conditions that the rest of us learn with some certain deficits like imitation oh, what about if they're attending? So now attending and the amount of trials seem to be the overriding variables here. So I can safely say, confidently say, ABA has leveled the playing field with the differences of are you paying attention to me? And maybe you need to practice this a little bit more than your peer, but by and large, that's what ABA is telling us. So the idea that we've sort of set these mastery criteria and these sequential presentation pieces comes into question, right? So while systematic in its methodology A DTT presentation style can also overly contextualize or maybe decontextualize targets, leading to concerns with generality. Sure. So I've already picked them. It doesn't matter whether you like them or not. This is based on some sort of milestone that's developmentally appropriate, but maybe or maybe not that we assess your need for it. And then, you know, furthermore, you may not be engaged. So I can be all– we can be as systematic as we want. If the child's not jointly attending or engaging– then our hopes to imitate are going to be diminished.

SPEAKER_00: 35:30

You're going to need, what, 40, 50 trials at least before you can move on to the next target, right? Probably with some margin of error because the individual is not imitating appropriately.

SPEAKER_01: 35:42

So we ask the question, does our DTT presentation style historically make an environment more enriched historically? Does an Ikea

SPEAKER_00: 35:58

table and chair count as enrichment?

SPEAKER_01: 36:01

Depending on what you're presenting on it and what's around you, right?

SPEAKER_00: 36:05

White walls. Anything other than white walls is distracting.

SPEAKER_01: 36:08

Because we were trying to limit the amount of distraction based on the... unease of the behavior that we were seeing, these kids weren't jointly attending. Exactly. It has to be because they're overstimulated. I'm not saying it's completely wrong, but it can't be the general premise either. So knowing that we're picking the targets, we're picking the stimuli, we're picking the way in which they have to sit and attend... Is that an enriched environment, or is that an environment we consider enriched? The enriched environment is going to be, by and large, whatever their home is, in this case, because it's in-home intervention. And then it becomes about our actions and, yes, the stimuli we bring, but more importantly, the stimuli that they interact with. Because if they don't interact with it, it doesn't matter if it's present in the environment. It's not going to provide enrichment. That's a good point. And for Nald's research on socioeconomic strata and why certain kids excel and why others don't from a socioeconomic perspective, she talked about enriched environments, which fit really nicely here in saying, wow, our practices kind of take enrichment away from the environment. Now, again, we did it with good reason, but can we reintroduce it now that we have this premise of, no, these kids don't have autism. So we're going to put all those assumptions aside, and we're going to start from just a basic developmental framework.

UNKNOWN: 37:24

Okay.

SPEAKER_00: 37:24

In the prior historical perspective of ABA, or the historical delivery of ABA, it was enriched, but it was enriched for the therapist to be able to hit as many different targets as they can to get as many different data points as they can throughout the entirety of session versus with joint intention in the more latter PRT-centric methodology, it's much more child-enriched.

SPEAKER_01: 37:46

Right, right. So we're taking the targets from what they're able to do already and then expanding and varying from that framework as opposed to just picking developmentally appropriate targets, which again, there's nothing wrong with. But if the child's not engaging with those pieces, then it doesn't matter how developmentally appropriate they are if they're not happening. Absolutely. So yeah, that's where the child-directed part comes in versus the adult-directed part. I want to make something very clear. This, by and large, this approach is allowing us to get more adult-directed as needed in our treatment. So it's not to say that it always stays child-directed, play-based. The play-based, I encourage everybody to keep as a motivating operation, certainly for any client five and under. That's what kids that age, little humans that age, should be doing, in my opinion. But the rest of it, in terms of adult-directedness and target specificity, Again, I contend that it gives you a better opportunity to establish that, knowing that you front load, you put all your time in on building that rapport, truly building that rapport, as well as instructional control, not just instructional control. So in the past, I think we've confused those two things and used them interchangeably, knowing that if a kid is working for the M&M, well, you've built rapport. Not necessarily. It's probably M&M based.

SPEAKER_00: 39:02

It all depends on what that motivating operation is. It comes down to that. I'm not sure if you're going to touch base on that later or we should talk about that now.

SPEAKER_01: 39:10

What do you have in mind?

SPEAKER_00: 39:11

Yep. So just the motivating operation. And you'll talk about it with contingent imitation. But the joint attention, meaning that the experience is... is the motivating operation, the shared experience is the motivating operation versus the delivery of some tangible reinforcer being the motivating operation. And I'll talk about how that relates to manning and tacting a little bit later. But that joint attention piece is just creating that experience to be a motivating operation, which I think is what a lot of parents really struggle with later. And when we come in to work with them, they're like, well, my kid only does their homework to get the iPad or only interact with me to get the iPad? Well, because you've been an iPad deliverer for 18 years of that individual's life. So, join attention, and as we'll continue to talk about, it's a great way to establish us as the motivating operation, or the experiences with us to be a motivating operation.

SPEAKER_01: 40:05

And let's emphasize that as much as reasonable, because that is the key here. Again, more traditionally, we come in and instructional control means The child is paying attention to us and only us and our instruction. In this approach, what we're doing is we're flipping it on its head. Yes, we want that instructional control, but we come in by modeling that level of attention that we desire later. And I think that is the key for me. It makes us pay attention. It reminds us that we have to pay attention to the situation, not just the client pay attention to us. So it becomes reciprocal. And at some point, we'll talk about reciprocal imitation too, which is super exciting, something else that I'm taking from Schreibman and PRT specifically. That said, perfect segue. We get into the joint attention training. I needed an empirical base, right? I needed developmental theory. I needed good research and ABA treatment to show us the way. Somebody's done a procedure. Somebody's put a set of steps together somewhere that they tested and they said worked. And then we can jump off of that laboratory base, take it in the living room, as we like to say here. Enter Whelan and Schreibman and they're incredible. Really, really good publication back in 2003 on teaching joint attention skills. I don't have the title in front of me right now, but maybe before we end, I can give it to you. And this particularly outlines an empirically validated procedure to promote joint attention behaviors. So what we've done is we've taken this procedure and made it much more an active mode of presentation. And you recently had a chance to see me talk to some new professionals in the field, or at least new to our particular work environment, and describe this. And as I describe this today, I will use the same phrasing. I'm going to give the ideal presentation and response, knowing that in the living room, without the experimental controls, and even with experimental controls, you're going to hit a hole lot of variation so the idea is to keep dancing with this until you arrive at those desired responses and then reinforce them and make them continue to happen all right so the really cool part about this protocol is that it aligns beautifully with early childhood best practices so when we talk about contingent imitation and linguistic mapping those aren't intervention procedures those are just good ways to raise kids

SPEAKER_00: 42:25

again typifying the treatment that that The phrase just keeps coming back and coming back with this.

SPEAKER_01: 42:30

Yeah, no, for sure. So what we're talking about here is child-directed, open-ended activity, play-based, developmentally sound. We're not going off the developmental trajectory here. We're going to keep it just the same and treat these young kids like we would any two- or three-year-olds that just need good interaction, good play activity, all right? And this is how we promote play. an enriched environment, right? Increasing the variety of language or vocal behavior models through linguistic mapping. It still preserves and promotes the basis for discrete trial toward our needs for data. It just means that these trials aren't being presented sequentially and sometimes you're leaning on the incidental occurrence of these trials leading it forward. And it allows the trials to be contextualized appropriately through play. You're playing with the puzzle that has the rainbow that has all the colors. Guess what time it is? Time to talk about some colors you can also count those pieces so colors don't just mean colors they mean numbers another nice thing that we've done I think is instead of semantically categorizing our programs for colors, numbers, this, that, and the other, these are now just verbal operants.

SPEAKER_02: 43:40

Yes.

SPEAKER_01: 43:40

That's all. And as long as they get produced, we reinforce them. Whether they could talk about, again, traditionally we might look at a rainbow puzzle and say, oh, wait, why are you counting? You're supposed to be doing numbers. Well, there's a number of pieces to count. So whatever is contextually appropriate to the situation that's related to the developmental milestones and goals can be implemented.

SPEAKER_00: 43:59

And again, going back to our collaboration series, when we talked about how our job is just to basically get the behaviors under control. So whoever the person, whether it's the occupational therapist teaching the motor skills, or in this case the educational teacher teaching the targets, our job isn't necessarily to teach the targets. Our job is to get them to a position so that they can attend, or in this case jointly attend, so they can be receptive to the targets.

SPEAKER_01: 44:25

That's absolutely right. We... We have often, in our opinion anyway, and I'll speak for you, mistakenly identified target specificity. So we're looking at exemplars, where the target behaviorally is really jointly attending, pointing, shifting your gaze. That's behavior. Color, red, that's not a behavior. Identifying the color in some way, shape, or form, that's the behavior, and I think you're absolutely right. That has been a little bit of a misnomer, a little bit of an error in terms in how we've set up some of our programs traditionally, knowing that some people might be doing that still, and that's fine. I hope you're listening and not receiving this critically as much as understanding the framework and the shift, knowing that red, one, letter A, Those are all vocal behaviors. The way you semantically categorize them only serves to restrict your mode of presentation, which means you might be presenting colors because that's next on your program sheet when the child really has an interest in that numbers puzzle over there, and you're missing an opportunity to develop a lot of important behaviors in that moment.

SPEAKER_00: 45:33

Absolutely, yeah. And with making us the motivating operation, it also gives an opportunity for the child to reference us and seek out that instruction rather than us presenting instructions where the child is really indifferent or doesn't want us to be there to present the instruction. They're playing and they reference us to show us something. We interact, and that also might be our opportunity to present an instruction or not even necessarily an instruction. I want to kind of get away from that term to present an opportunity or a label or a stimulus for them to imitate or respond to. So

SPEAKER_01: 46:10

think about the way you just explained that. It's no longer just this unidirectional linear path. I present an SD. You do the defined behavior. I give you a predetermined consequence. Now you're saying that happens all around our world everywhere in a multilinear, multidimensional fashion. You're saying now that by paying attention, we're going to be able to be prepared with our training and our constant expertise to keep the interaction going where before it wasn't a bidirectional or reciprocal interaction. It was us setting the tone, setting the stage. Again, As I say these things, I know that I'm saying it in contrast. Obviously, these techniques, traditional techniques I'm talking about, are the only reason we can... you know, have a springboard, a platform from which to jump off of and be doing the things we're doing.

SPEAKER_00: 46:58

So instead of you being this mean person who comes in with all the stimuli and tells me to match red 15 times, I'm playing with a car that happens to be red and you're identifying it as red when I look at you or I come to bring you the car and instead of you withholding it and making a contingent on me saying red, you're rolling it up and saying, look, the car goes up and putting context to the preparation That joint attention is... is so much more of a richer interaction and a bilateral or interaction, as you would call it.

SPEAKER_01: 47:36

It is. It is an interaction, again, for that very reason. And before, we think we're interacting with instructional control. Instructional control goes in one direction, usually. And that's not a problem. We're just saying that here, it's a bit truncated. Here, it's missing the other part, the reciprocal part of it. And socialization is a reciprocal process, for example, right? So maybe all these things that we're talking about are going to have a of our programming efforts to teach our clients to engage their environments and do so in a way that's socially significant for them as well as the people in their environment. So we're getting near the end here, believe it or not. What I'd like to do before we end is quickly go over these steps from the Schreibman articles to kind of try to demonstrate from an auditory perspective the best way possible how you might go through this. Maybe this will provide the impetus for us to start putting more visually-based materials available to our listeners.

SPEAKER_00: 48:30

Yeah, potentially check us out on YouTube. We may be demonstrating this as well. All right.

SPEAKER_01: 48:35

So I do want to say, Whelan and Schreibman, Joint Attention Training for Children with Autism Using Behavior Modification Procedures in the Journal of Child Psychology and Psychiatry, 2003. This is the exact publication where we have adapted this protocol and sort of modified it a little bit. What we did For our purposes, we looked at the lab procedure, and then we discussed 10,000 ways or so to utilize that lab procedure, knowing all the margins of error that could occur, knowing all the distractions that can occur when we're in somebody's living room. So starting with this part one, this idea of response training or proto-imperative pointing, And in this level one, you're training a response to an object that, in simple words, you've got your attractive stimuli. You bring them over to the child, one in each hand, as far apart as possible, so you can facilitate some sort of gaze shift as they reach and or point, hopefully, to grab a desired one. And in this case, you allow them to have that. And then you try to visually get them to orient to the item that you're now holding, the one they didn't choose. And ideally... they would put their hand on it, right? So this is the lab procedure. That's the ideal lab response. Now, why is it important that they put their hand on it as they're looking at the other item?

SPEAKER_00: 49:59

Symmetry, so they understand the, oh, they're looking at the other item, so that's joint attention. Right. In other words, if they don't

SPEAKER_01: 50:08

look at the item, the other item, they're touching it. What often follows your point? Your eyes. Your eyes. Right, exactly. So unless we're really disengaging our gaze, we're going to look at most people and point to them along with our eyes. So even though we're going to separate those two features here, it's only from a task analysis perspective and from the lab protocol perspective. But naturalistically speaking, those two things don't separate very often. Going into level two, we're now going to have trainer response to an object being tapped. So you might have two noise-making toys, again, the presentation with each hand far apart as reasonable so the child can shift their gaze and begin to either reach for one or shift their gaze for one as a way to man for it. You allow them to have it, and then you immediately walk behind that child and start making noise with the toy. In the lab procedure, they tapped it. I think that can be modified because we want that really salient response of them turning over their shoulder and looking.

SPEAKER_00: 51:09

So the first step one is the visual stimuli So they're engaging with one. Another stimulus in their visual field. Step two is now responding to the auditory stimulus.

SPEAKER_01: 51:20

Absolutely. Absolutely. All right. So now moving on to level three, you're doing everything that you did in level one and two in terms of the stimulus presentation. Okay. And now you're expecting the child to respond. engage with the new toy for at least five seconds. Okay, so now you've gotten them to touch it or maybe look over to it. You've gotten them to look over to it based on the noise in level two. And now ideally what we want is for them to put their selected toy down, engage with the toy we're offering, and then go back to the other toy. Now let's say that we're in the living room. That was the lab ideal response. We're in the living room and the child keeps the toy that you offered them What do you do? Do you reset and do an error correction

SPEAKER_00: 52:10

procedure? You might go back to step one or step two, or you might start imitating, imitating what they're doing with your current toy.

SPEAKER_01: 52:18

Meaning you just go ahead and grab the other toy and start doing something in order to redirect that joint attention, gaze shift, pointing. You could start asking for them back. You could do some negation practice. How often are our kids telling us no and we don't listen?

SPEAKER_02: 52:32

Yep,

SPEAKER_01: 52:33

absolutely. Thank you. This is the way we expand it, right? You make it an interaction, knowing that you have an ideal response you're trying to get to, what we often find is you identify four or five other responses that are also worth reinforcement because we're naturalizing the interaction.

SPEAKER_00: 52:46

As much as possible, we're going to avoid prompting, avoid taking that toy and avoid prompting in our older context of prompting, direct prompting them to pick up the second toy. We're going to have them be motivated to do that.

SPEAKER_01: 53:03

Now we're moving on to level four, which is something that, again, when I say these levels, we have a tendency in ABA to make things sequential and in order, meaning, oh, can't do level two until we've passed level one. No, I recommend that you do all these things as an active mode of presentation, mixing all of this stuff up, like manding with eye contact, right? Or gaze shift, meaning that I do the same presentation here in level four. I offer the two objects. The child reaches for one. I go ahead and give it to them, but before I release it into their hand, I make sure that their gaze shift is oriented to my face. And I would even add here, you might say the name of the object. Take advantage of that orientation towards your face to give some additional stimuli.

SPEAKER_00: 53:46

Now, a question came up in our last training group. A common way of doing that in ABA is to take an object and move it next to your eyes so they orient. What are your thoughts on that? And is that the best way or are there better ways of going about that?

SPEAKER_01: 53:59

I think that is one way to do that. What I really want to reinforce in that comment is the notion that you're trying to actively work at aligning that gaze shift, at making... just the child look at your face, but making your face accessible to be looked at. So yes, do that or bring your face to the child. So yeah, thank you for bringing that up. Again, this is the important part of this conversation for sure. Maybe one of the more important parts is that dynamism. We were very unidirectional in traditional ABA. What this is doing is really making it a reciprocal interaction. I do, you do. It wasn't what I expected you to do for reinforcement. That's okay. Let's try again. There's no error correction here we're going to go with the context and the flow and keep things appropriate from an early childhood basis

SPEAKER_00: 54:44

it's all about maintaining those mo's if we start to withhold and lose that mo then then we're screwed and we got to deal with that whole tantrum

SPEAKER_01: 54:52

exactly exactly so moving on to the fifth level and now having the child follow your point toward an object now if you've done all the first four levels actively yes you might this might be a little more difficult you might have to wait on this one but the idea is that now you're slowly building that child's attention to sight and sound and then shifting it now to your finger and the flow of your finger to where it goes

SPEAKER_00: 55:16

so that's that's almost an expansion of level one of the visual stimulus so it's not the actual stimulus your finger now becomes a stimulus

SPEAKER_01: 55:24

it's absolutely the extension because your finger is not going to be defining where that desired stimulus is stimulus might be, right? Yes.

SPEAKER_00: 55:30

And almost in theory, like you said, it's not necessarily sequential. Depending on the situation, you could almost go from level one to level five, right?

SPEAKER_01: 55:37

Absolutely. In fact, I would say that in level five, as you're trying to get their visual attention to the item they didn't pick, you're modeling a lot of that gaze shift and kind of looking at the object and pointing at it. You're doing a lot of those things actively. Absolutely. So that's where our active mode of gaze shifting and pointing is going to have to occur, along with now contingent imitation and linguistic mapping. We've got our nice stew boiling here. All right, so they're following your point to finally level six, where you try to get them to follow your gaze based on the direction of your head turn, knowing that those things are very rarely going to happen separately unless you're quietly trying to get away in some escape room and you're looking at somebody straight in the eye and you're kind of looking to the side. I don't know if that makes any sense right now from an auditory perspective, but the point is that your eyes are going to follow your fingertips traditionally, as well as your head, and your head and your eyes are going to move in a directional synchrony.

SPEAKER_00: 56:35

And that could almost be after phase four, because phase four is about them referencing your eyes with the object, so you could almost theoretically skip level five in some circumstances, and as they're referencing your eyes, and then work on going straight to level six where they're referencing your eyes, and then you take that as the opportunity to now look at something and see if they imitate you looking at

SPEAKER_01: 56:57

something. That's absolutely Absolutely right. Now, that's them following joint attention cues. That graduates into, and I'm going to be a little brief about the second part, because we've actually been very brief in the development of the second part, leaving it very naturalistic and not necessarily following the research protocol. But part two, in terms of proto-declarative pointing, so proto-imperative, as you can see, was a lot about being able to ask for something. Right? Proto-imperative. Proto-declarative now is about sharing the experience. And there's two, or tacting.

SPEAKER_00: 57:30

So we call it proto-imperative manding in ABA and proto-declarative tacting in ABA. Exactly.

SPEAKER_01: 57:36

Exactly. And those are, by and large, as far as I can tell, pretty interchangeable. Just two different disciplines defining very similar behaviors.

SPEAKER_00: 57:43

I think Microsoft Word Spellcheck likes one group much better than the other group.

SPEAKER_01: 57:48

Microsoft Word Spellcheck does not like the protos at all. Okay. Yep, be warned. I'm looking at it on my screen. right here with a big red underline. So that comes down to two conditions. Excuse me. The first is the basic premise of having the child go show something to their parent or whatever direction. Basically send a message. You're working on a puzzle. Oh, go show your mommy. You finished the puzzle. You did some scribbling on a page. Go show your daddy your picture. Whatever it is, is now I'm taking something that I that I made and I'm sharing the experience and traveling to do so. Okay.

SPEAKER_00: 58:29

And the motivating operation there is parental attention, correct?

SPEAKER_01: 58:32

Well, yes. Yeah.

SPEAKER_00: 58:33

And maybe some sort of vocal reinforcement back from the parent. And

SPEAKER_01: 58:36

then from a joint attention perspective that we're going to get the parents pointing and or gaze shifting to get directed to that interaction, stimulus, child alike. Yep. Makes sense. Yep. Okay. Now the second one's a little harder to contrive. Um, Because in the lab, they had settings that were controlled, and they could put novelty in those settings. So they would get a child accustomed to a certain setting with certain pictures on the walls and toys that are available, and then they would make some novel stimuli available. And the idea is that that promotes the child to share that experience and go, oh, point and go, look, mom, that wasn't here last time, or some semblance of that. So that's a little harder to do in a home environment that you don't necessarily control. But books... are an easy way to present novel stimuli in an unexpected fashion such that a child might point to something on a page. So something that doesn't belong there, something that's new to the page, maybe it's a book that's new to them altogether that has familiar and preferred stimuli. Whatever it is that you can create novelty with which the child may be motivated to present a proto-declarative effort or a tact and go, oh, look, look at that. And again, this is going to happen with just gaze shifting. and pointing primarily, okay?

SPEAKER_00: 59:52

Absolutely. And in part three of our joint attention, I'll talk about how that relates to the verbal operants and how potentially tacting doesn't necessarily have to be in such a sequentially delayed presentation from manding.

SPEAKER_01: 1:00:06

I look forward to that. We're going to continue on this developmental trajectory and framework related to our efforts over the past three years and our personal work with Early Start Learners here in California. That is it for today. Thank you for your attention. We've taken you on a little bit of a longer ride on this ABA on Tap, but we always appreciate your questions, your commentary, you reaching out to ask us where we're at because our good buddy Dan was down for a little while. I forget the name of that. listener. We should have remembered, but somebody did reach out and say, hey, where are you guys at? It's like, oh, we're coming back. Don't worry. We've got a little bit of a delay. So thank you all out there who are listening and downloading around the world as far as we understand. That's super exciting. We hope you find this information useful.

SPEAKER_00: 1:00:53

And as always,

SPEAKER_01: 1:00:54

analyze responsibly. Cheers, brother. Cheers. ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.