414 A. L. Wagner et al.

activities are to be conducted in naturalistic set- the developmental needs of each child, and the
tings, such as the child’s home. intervention is structured around the typical de-
One Type 2 study on the JAML approach is velopmental sequences of joint attention and
reported in Table 20.2. Schertz and Odom (2007) symbolic play (Kasari et al. 2010). Consequently,
explored the effectiveness of the JAML approach intervention goals for each child stem from the
through a single-subject multiple baseline design. child’s initial developmental assessments. The
The sample included three subjects diagnosed parent-mediated model of JASPER is organized
with ASD between 20 and 28 months of age. Par- around ten learning modules: (1) setting up the
ent–child dyads were videotaped for 10 minute environment; (2) allowing the child to initiate an
play sessions during a baseline period and during activity; (3) playing within established routines;
each week of treatment. Videos were coded for (4) facilitating and maintaining states; (5) scaf-
the number of 10-second intervals in which the folding and engagement state; (6) facilitating
child was engaged in one or more of the four joint joint engagement; (7) allowing the child to initi-
attention behaviors: (1) focusing on faces, (2) ate communication; (8) recognizing and respond-
turn taking, (3) responding to joint attention, and ing to the child’s joint attention skills; (9) imitat-
(4) initiating joint attention. Parent–child dyads ing and expanding language; and (10) generaliz-
received between 11 and 16 in home parent- ing skills to other routines. JASPER is typically
coaching sessions over a 9–26 week period. Each administered in a laboratory setting by a trained
of the three toddlers surpassed baseline perfor- interventionist, with the goal of skill generaliza-
mance levels of displays of all four joint attention tion to the child’s natural environment.
behaviors during parent–child play in compari- JASPER meets all five components of a de-
son to baseline levels. The addition of some Type velopmental approach to treating young children
1 studies on the efficacy of this approach would with autism. The creators of these approaches
add to the evidence base for JAML. self-identify the treatments as “developmen-
tal.” JASPER also uses behaviorist principles
in conjunction with principles from develop-
Joint Attention and Symbolic Play mental science. Treatments are based on typical
Engagement Regulation (JASPER) developmental sequences for joint attention and
symbolic play, and are delivered in the context
Whereas JAML focuses primarily on joint atten- of relationships with an interventionist or the par-
tion, JASPER focuses on joint attention and also ent. JASPER is a child-centered and play-based
includes a focus on developing the symbolic play model. As previously mentioned, this approach
skills, another known deficit of young children is a targeted intervention, focusing on joint at-
with ASD. JASPER is a targeted intervention on tention and/or symbolic play skills. JASPER can
these two developmental skills, which impact be administered by trained interventionists in a
children’s social and communication develop- laboratory setting or through parent-mediated in-
ment. The JASPER approach was developed tervention with a focus on generalizing the skills
by Connie Kasari and colleagues at the Univer- to the child’s natural environment.
sity of California Los Angeles, and has evolved There are three studies investigating the JAS-
alongside 10 years of studies on using this ap- PER approach described in Table 20.2, all of
proach with children under the age of 3 years. which are rated as Type 1 studies (Nathan and
Although JASPER was originally administered Gorman 2002, 2007). Kasari et al. (2006) con-
by trained interventionist working directly with ducted a randomized controlled intervention
the children in a laboratory setting, more recent study of joint attention intervention, symbolic
studies include a parent-mediated intervention. play intervention, and a control group (It is im-
JASPER incorporates behaviorist principles portant to note that the Kasari et al. 2008 study is
in conjunction with developmentally informed a follow-up study of the sample from the Kasari
practices. The treatment is individualized to meet et al. 2006 study). The sample consisted of 58
20  Developmental Approaches to Treatment of Young Children with Autism Spectrum Disorder 415

children diagnosed with autism between 3 and 4 week in a laboratory playroom setting. During
years of age. All 58 children were also enrolled treatment sessions, the interventionists covered
in 30 hour a week of an ABA early behavioral topics focused on increasing children’s joint at-
intervention in a hospital setting. The 58 children tention and symbolic play and coached the par-
were randomly assigned to a joint attention group, ent through direct instruction, modeling, guided
a symbolic playgroup, or a control group. Joint practice, and feedback. All parent–child dyads
attention and symbolic play interventions were were videotaped during a play interaction at time
conducted in one-on-one therapist-child sessions of enrollment, at the 8-week mark, and again
for 30 min per day for 5 to 6 weeks. Pre- and post- after 12 months. Children in the IT group made
intervention samples of child’s joint attention significant improvements in the amount of time
skills, play skills, and parent–child interactions they spent in joint engagement, responsiveness to
were collected. At post-intervention, children in joint attention, and in the diversity of their play
the joint attention group initiated more showing skills when compared to the WL group after the
behaviors and responded to joint attention bids 8 weeks of treatment. In addition, parents in the
from communication partner significantly more IT group displayed high fidelity to the JASPER
than children in the symbolic playgroup and the treatment approach. One year after the end of
control group. In addition, children in the sym- treatment, the IT group’s gains were maintained
bolic playgroup demonstrated more diverse types or improved when compared to the WL group,
of symbolic play and higher play levels in both indicating that this short-term, parent-delivered
the structured play assessment and the mother– intervention can have lasting effects on chil-
child interaction than children in either of the dren’s joint attention and play skills. The rigor-
other groups. This study demonstrates the speci- ous methods in these three Type 1 studies on the
ficity of intervention targets (joint attention or efficacy of the JASPER approach in improving
symbolic play). In 2008, Kasari and colleagues joint attention, play skills, and language in young
followed up this sample to determine if there children with ASD provide promise for this ap-
were differences between groups in language proach, however, replication studies with larger
development 12 months after the end of treat- sample size would strengthen these findings.
ment. This follow-up study found that children
in both the joint attention group and the symbolic
playgroup had showed significantly higher levels Relationship Development Intervention
of language development a year after treatment (RDI)
ended than the control group. In addition, chil-
dren who had the lowest language levels at the Relationship Development Intervention (RDI)
beginning of treatment showed greater gains in is a parent-delivered intervention for children
language development if they were randomized diagnosed with ASD. It attempts to address the
to the joint attention group. difficulties in perception, cognition, and emo-
The third study on the JASPER approach re- tion that children with ASD often face (Gutstein
ported in this review is also a Type 1 random- et al. 2007). More specifically, the goal of RDI
ized control study. This study differs from the is to improve the child’s social skills, adaptabil-
first two studies in that the intervention consisted ity, and self-awareness. The six objectives of the
of a parent-mediated joint engagement interven- intervention are to improve: (1) emotional refer-
tion (Kasari et al. 2010). The 38 child–parent encing, (2) social coordination, (3) declarative
dyads were randomly assigned to an immediate language, (4) flexible thinking, (5) relational in-
treatment (IT) group or a wait-list (WL) control formation processing, and (6) foresight and hind-
group. Children in the study were between 21 and sight (Autism Speaks 2011a). The intervention
36 months of age and all had a diagnosis of ASD. relies heavily upon the relationship between par-
Children in the IT group immediately received ents and their children, and utilizes a guided par-
8 weeks of treatment occurring three times per ticipation approach through which parents learn
416 A. L. Wagner et al.

to perceive and scaffold opportunities for their teaching procedure begins with the child’s verbal
child to respond in more flexible and thought- or nonverbal request, after which the parent or
ful ways and to engage more successful social therapist follows a specific sequence of prompts
exchanges. The comprehensive intervention is to help elicit language (e.g., modeling). Follow-
delivered in a naturalistic setting, as parents are ing the eliciting prompts, corrective prompts are
trained to create and capitalize upon teaching op- used as needed, and then the parent or therapist
portunities in the child’s everyday environment reinforces the child’s attempt by providing posi-
and activities (Gutstein and Sheely 2002). tive feedback and accessing the child’s requested
RDI contains four of the five criteria for a de- object while providing expansion of the child’s
velopmental approach to treating children with utterance (Kaiser et al. 2000).
ASD. The treatment is heavily dependent upon RPMT/milieu teaching contains four of the
the relationship between parents and children— five components of a developmental approach to
in fact, this component is central to the interven- treating children with ASD. It applies principles
tion’s delivery. Other adults do not work directly of developmental science to teach language to
with the children in this intervention; instead, children at a level appropriate to them. In addi-
they serve only to train parents in the theory, tion, it is child-centered and play based, focus-
principles, and components of the intervention, ing heavily on following a child’s lead in order
as well as to help parents develop the program to help elicit naturally occurring communicative
and discuss children’s treatment goals. RDI does attempts. Although it is a targeted intervention,
follow the sequence of typical development, and focusing on communication and language, both
is conducted in a naturalistic environment. therapists and parents can provide the interven-
There are no research studies investigating tion and it can be easily applied in a naturalistic
RDI that meet our search criteria. While one environment.
study emerged in our electronic searches (Guts- Three studies investigating RPMT/milieu
tein et al. 2007), the mean age of subjects within teaching are described in Table 20.2, all of which
the study was over 5 years. Further research in- are rated as Type 2 studies (Nathan and Gorman
vestigating RDI for toddlers and preschoolers 2002, 2007). Although, in general, we excluded
with ASD is warranted. studies investigating mixed interventions (e.g.,
PRT mixed with Picture Exchange Communica-
tion System (PECS)), we included studies inves-
Responsive Education and Prelinguistic tigating enhanced and modified versions of pure
Milieu Teaching (RPMT)/Milieu Teaching milieu teaching. Of the three studies investigat-
ing milieu teaching, two investigate enhanced
RPMT/milieu teaching is a naturalistic behav- milieu teaching, which incorporates environmen-
ioral intervention that uses specific behavioral tal arrangement to promote child engagement
teaching strategies such as prompting, shaping, with activities and communication partners, as
chaining, and reinforcement to teach language well as responsive interaction techniques to build
skills to young children with autism (Schreibman social, conversational interaction and to model
and Ingersoll 2011). The intervention capitalizes new language forms, into pure milieu teaching
upon a child’s intention to communicate and sys- procedures to prompt, model, and provide con-
tematically provides both models of language and sequences for the use of new language forms.
communication as well as naturally related social Both of these are single-subject, multiple base-
consequences for language and communication line studies, involving four and six participants,
attempts. Like Pivotal Response Training (PRT), respectively (Hancock and Kaiser 2002; Kaiser
RPMT/milieu teaching follows the child’s lead et al. 2000). Hancock and Kaiser (2002) investi-
and focuses on his moment-to-moment interests gated therapist-delivered enhanced milieu teach-
in order to increase motivation and opportuni- ing provided to three males and one female aged
ties for communicative learning. A typical milieu 35–54 months in a clinic for 24 15-min sessions,