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J Autism Dev DisordDOI 10.1007/s10803-006-0137-7ORIGINAL PAPEREarly Predictors of Communication Development in YoungChildren with Autism Spectrum Disorder: Joint Attention,Imitation, and Toy PlayKaren Toth Æ Jeffrey Munson Æ Andrew N. Meltzoff ÆGeraldine DawsonÓ Springer Science+Business Media, Inc. 2006Abstract This study investigated the unique contributionsof joint attention, imitation, and toy play to languageability and rate of development of communication skills inyoung children with autism spectrum disorder (ASD).Sixty preschool-aged children with ASD were assessedusing measures of joint attention, imitation, toy play, language,and communication ability. Two skills, initiatingprotodeclarative joint attention and immediate imitation,were most strongly associated with language ability at age3–4 years, whereas toy play and deferred imitation werethe best predictors of rate of communication developmentfrom age 4 to 6.5 years. The implications of these resultsfor understanding the nature and course of languagedevelopment in autism and for the development of targetedearly interventions are discussed.Keywords Autism Æ Language Æ Communication Æ Jointattention Æ Imitation Æ PlayIntroductionIt is well established that there is tremendous variability inoutcome in autism. Long-term outcome studies have shownthat while a majority of individuals exhibit poor to verypoor outcomes, many individuals with autism go on toachieve adequate levels of academic, social, and occupationalfunctioning (Gillberg & Steffenburg, 1987; Lotter,K. Toth (&) Æ J. Munson Æ A. N. Meltzoff Æ G. DawsonDepartment of Psychology, UW Autism Center, CHDD,University of Washington, 357920, Seattle, WA 98195, USAe-mail: ktoth@u.washington.edu1978; Nordin & Gillberg, 1998; Sigman & Norman, 1999).In a recent study that followed children with autism fromage 2 to 9, as many as 40% were found to have goodoutcomes based on language and cognitive scores (Stone,Turner, Pozdol, & Smoski, 2003). One of the strongestpredictors of positive long-term outcomes for children withautism is the acquisition of spoken language (Bartak, Rutter,& Cox, 1975; Gillberg, 1991; Gillberg & Steffenburg, 1987;Lincoln, Courchesne, Kilman, Elmasian, & Allen, 1988;Lotter, 1978; Rutter, 1970). Early language ability (i.e.,meaningful speech by 5–6 years of age) has been associatedwith both later academic achievement and socialcompetence in individuals with autism (Howlin, Mawhood,& Rutter, 2000; Sigman & Ruskin, 1999; Venter, Lord, &Schopler, 1992). Given the critical importance of earlylanguage development for later prognosis, a better understandingof developmental factors that underlie, facilitate,and predict language acquisition in autism would shed lighton the nature of this disorder and allow for the refinementof targeted early interventions.Early abilities that have been associated with thedevelopment of language and communication skills both intypically developing children and children with autisminclude joint attention, imitation, and toy play. Jointattention—shared attention between social partnersin relation to objects or events—typically emerges by9–12 months of age (Adamson & Bakeman, 1985, 1991;Adamson & Chance, 1998; Brooks & Meltzoff, 2002;Bruner, 1983; Butterworth & Jarrett, 1991; Carpenter,Nagell, & Tomasello, 1998), with some aspects emergingas early as 6 months of age (Morales, Mundy, & Rojas,1998). By 12 months of age, most typical infants displayall aspects of joint attention, including sharing attention(e.g., through the use of alternating eye gaze), followingthe attention of another (e.g., following eye gaze or a123
J Autism Dev Disordpoint), and directing the attention of another (Carpenteret al., 1998). Through joint attention interactions, the infantbegins to link words and sentences with objects and events(Baldwin, 1995). Importantly, it is within the context ofjoint attention episodes that infants also begin to communicateintention by using sounds and gestures, such asreaching to request objects, and pointing and vocalizing todirect attention to objects. Joint attention skills correlate notonly with early language learning, but also with later languageability in typically developing children (Carpenteret al., 1998; Meltzoff & Brooks, 2004; Morales et al.,1998, 2000; Mundy & Gomes, 1998).Children with autism, however, show impairments injoint attention skills as compared to children with delayedand typical development (Bacon, Fein, Morris, Waterhouse,& Allen, 1998; Charman, 1998; Charman et al.,1998; Dawson, Meltzoff, Osterling, & Rinaldi, 1998;Dawson et al., 2002a, 2004; Mundy, Sigman, Ungerer, &Sherman, 1986; Sigman, Kasari, Kwon, & Yirmiya, 1992).Impairments in protodeclarative joint attention behaviors—sharingattention for purely social purposes—appearto be more severe than impairments in protoimperativejoint attention (e.g., requesting) behaviors in children withautism (Mundy et al., 1986; Mundy, Sigman, & Kasari,1990; Sigman, Mundy, Sherman, & Ungerer, 1986). Further,in preschool age children with autism, joint attentionis predictive of both current language ability, and futuregains in expressive language skills (Bono, Daley, &Sigman, 2003; Charman et al., 2003; Dawson et al., 2004;Landry & Loveland, 1988; Mundy et al., 1990; Mundy,Sigman, Ungerer, & Sherman, 1987; Rogers & Hepburn,2003; Sigman & Ruskin, 1999; Toth, Dawson, Munson,Estes, & Abbott, 2003). In a longitudinal study of socialcompetence and language skills in children with autism andDown syndrome, Sigman and Ruskin (1999) found thatprotodeclarative joint attention skills were associated withearly language ability for both groups, and predicted bothshort-term (i.e., 1 year later) and long-term (i.e., 8–9 yearslater) gains in expressive language ability for children withautism. Initiating protodeclarative joint attention in earlychildhood (3–6 years of age) was also correlated with laterpeer interactions (10–12 years of age). Further, protoimperativejoint attention skills correlated with early languageability and short-term, but not long-term, gains in expressivelanguage for children with autism. In a recent interventionstudy that targeted joint attention skills, youngchildren with autism showed greater gains in language12 months post-treatment compared to controls (Kasari,Freeman, & Paparella, 2004). It may be that joint attentionability lays a foundation not only for the development oflanguage, but also other complex abilities such as pretendplay and theory of mind, as argued by developmentaltheorists (Bruner, 1983; Carpenter et al., 1998; Meltzoff,2005; Meltzoff & Brooks, 2001) as well as in the literaturemore specifically focusing on children with autism(Charman, 1997, 2003; Mundy & Crowson, 1997; Sigman,1997).Motor imitation ability has also been associated with thedevelopment of language and social communication skills.In typically developing infants, the ability to imitate ispresent at birth. Neonates are able to imitate simple facialmovements, such as tongue protrusion and mouth opening(Meltzoff & Moore, 1977, 1997). By 9 months of age,infants are able to imitate actions on objects, both inimmediate and deferred contexts (Carver, 1995; Meltzoff,1988a). Infant imitation appears to serve several generalfunctions, providing the child with shared social experiences,a sense of mutual connectedness, and a means ofcommunication between social partners (Meltzoff, 2005;Trevarthen, Kokkinaki, & Fiamenghi, 1999). Throughimitation, infants also learn about others’ actions andintentions (Meltzoff, 1999; Uzgiris, 1981, 1999). Deferredimitation serves to index infant recall memory and thechild’s ability to produce actions based on stored mentalrepresentations of social events and action sequences (Klein& Meltzoff, 1999; Meltzoff, 1988b). It has been theorizedthat a failure to engage in early social imitative play mayinterfere with the development of joint attention, socialreciprocity, and later theory of mind abilities (Dawson,1991; Meltzoff, 1999, 2005; Meltzoff & Gopnik, 1993;Rogers & Pennington, 1991). Imitation not only plays animportant role in early social development, but has alsobeen shown to predict language ability in typically developingchildren (Bates, Benigni, Bretherton, Camaioni, &Volterra, 1979).While typically developing children demonstrate theability to imitate others from birth, children with autismdemonstrate significant impairments in object imitation,imitation of facial and body movements, and deferredimitation of actions on objects (Charman, 1997; Dawsonet al., 1998; Rogers, Bennetto, McEvoy, & Pennington,1996; Rogers, Hepburn, Stackhouse, & Wehner, 2003;Sigman & Ungerer, 1984; Stone, Ousley, & Littleford,1997). In children with autism, imitation skills have beenfound to correlate with early language ability (Dawson &Adams, 1984) and to predict later language ability (Charmanet al., 2000, 2003; Stone et al., 1997; Stone & Yoder,2001). In a recent study, immediate imitation of actions onobjects at 20 months correlated with receptive language at42 months in a small sample of children with autism(Charman et al., 2003). In a similar study, motor imitationat 24 months predicted expressive language ability at48 months, even after controlling for initial language level,in young children with autism (Stone & Yoder, 2001).Play—both functional and symbolic—is a third skilldomain that has been associated with language and social123
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