Toddlers and Families Together

Promoting Joint Engagement for Young Children with or At Risk for Autism Spectrum Disorder
Connie Wong
Frank Porter Graham Child Development Institute
University of North Carolina at Chapel Hill

RESULTS
Caregiver Perceptions
Furthermore caregiver responses to the
questionnaire and interview indicated overall
acceptability of the strategies and program.

RESULTS

METHOD
BACKGROUND

METHOD

Nate

Annie

Benjamin

Male
30
White

Female
23
Bi-Racial:
White,
African
American

Male
29

Race

Male
27
Bi-Racial:
White,
African
American

Little-No

Little-No

Moderate-Severe Moderate-Severe

97

71

77

86

31

27

42

---

College

College

Graduate School

---

Implementation of Intervention Strategies

Caregiver-Child Interaction
Visual analysis indicates a functional relationship
between the intervention and percentage of time spent in a
joint engagement state; specifically, increased level
changes were observed during the intervention phases for
all caregivers and their children.
Joint Engagement

Part Time

Full Time

Full Time

Full Time

Measures
Caregiver-child interaction: 10-minute video-recorded
interactions between the child and the primary
caregiver were coded for duration of joint engagement
states (adapted from Adamson, et al., 2004), which was then used to
calculate the percentage of time spent in a joint
engagement state during the interaction.
Joint engagement occurs when the child and another
person are actively involved in the same object or
toy. Joint engagement includes both supported and
coordinated joint engagement.
Caregiver Diary: At the end of treatment, caregivers
completed a brief questionnaire reporting on a fivepoint Likert scale (higher ratings indicate stronger
agreement) their ability (finding time, ease of
implementation, confidence, comfort) to implement the
treatment strategies.
Interview: Families also participated in a semistructured interview to provide their opinion about the
intervention.

90%

3
2
1
0

Finding Time

Easy to Implement

Garrett

Nate

Feel Confident

Annie

Feel Comfortable

Benjamin

Family Interview
Families also reported that the family
support/education sessions were the most helpful
aspect of the intervention.

70%
60%
50%
40%
30%
20%
10%
0%

Good to share
with other parents
and know that
[others] are
dealing with
similar things

100%
90%

Nate

80%
70%
60%
50%
40%
30%

10%

CONCLUSION

0%
100%
90%

Annie

80%

The results from this SCD provide

preliminary efficacy and social validity data
supporting the Together program.
However, further study needs to test the
program with a larger sample of children
and families in randomized controlled trial.
Furthermore, additional analysis is required
to examine caregiver outcomes of stress
and coping as well as child outcomes of
joint attention and play.
Overall, it may be beneficial to both
toddlers and families to use a group-based
model of intervention for families of young
children with or at risk for ASD.

70%
60%
50%
40%
30%
20%
10%
0%

90%

Intervention

Topics
Joint engagement
Practicing positive
behaviors
Managing difficult
behaviors
Looking
Pointing
Showing
Playing
Pretending

Benjamin

80%

Toddlers & Families Together Program

Eight weekly group sessions held on Saturday
mornings
Intervention Schedule
9:00
9:15
9:30
10:15

10:45

11:45

Check in: Free play

Together Time: Welcome
Learning session
Toddler skills session
Family support session
Snack & bathroom
Stations
Toy Play
Art
Music & Games
Together Play (CCX)
Together Time: Closing

Opened my eyes
and made me
more aware about
the importance
of attention and
(object) play

20%

Percentage of Time

Multiple probe baseline design across four toddlers

with or at risk for ASD and their families that
included an initial baseline period of 4, 6, 8, and 10
weeks then participation in the 8-week Together
intervention program, and followed by postintervention assessments.

Garrett

80%

100%

Design

100%

Percentage of Time

ADOS-2 Range
of Concern
MSEL Early
Learning
Composite
Mothers Age
(years)
Mothers
Highest Level
of Education
Employment
Status

White

Family Diary
Most family members felt comfortable and
confident with the strategies but did note that it
did take a little time to implement the strategies.

Joint Engagement

Percentage of Time

With an overarching goal of promoting socialcommunication development for children with ASD
through the Together program, the specific questions
of this study include:
Does participation in the program result in changes
in changes in joint engagement during play
interactions between the toddler and his/her
caregiver?
After participating, what are caregiver perceptions
of the strategies and the program?

Garrett
Gender
Age (months)

Results show increased caregiver implementation of

strategies during intervention and demonstrated family
acceptability of the intervention.

Percentage of Time

OBJECTIVES

Four families and their toddlers with or at-risk for ASD

Identified as children who would benefit from a
more developmental and autism evaluation on the
Modified Checklist for Autism in Toddlers (MCHAT)

Agreement

Participants
Research on early intervention programs targeting
toddlers with or at risk for autism spectrum disorder
(ASD) primarily involve individual sessions with
the caregiver and child in the home which may be
isolating or impractical for some families.
In Toddlers and Families Together (Together),
toddlers and their families participate in sessions
that focus on increasing joint engagement with their
child.
Young children with autism have significant
delays in the development of attention states that
involve sustaining joint engagement with others
(Adamson, et al., 2009).
Specifically, families have an opportunity to
practice strategies and receive feedback within a
context of everyday routines and activities for
toddlers within 3-hour long group sessions that also
include a family education/support segment to learn
and discuss strategies with a facilitator and other
caregivers while the toddlers are engaged in various
learning activities.

70%
60%
50%
40%
30%
20%
10%
0%
Weeks

Funded by HRSA MCHB grant #R40MC26197

This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number R40MC26197 and title Toddlers and Families together for grant amount $582,436 with
0% financed with nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

together@unc.edu