Preschool Based JASPER Intervention in Minimally Verbal
Children with Autism: Pilot RCT
Kelly Stickles Goods•Eric Ishijima•
Ya-Chih Chang•Connie Kasari
Published online: 11 September 2012
? Springer Science+Business Media, LLC 2012
novel intervention (JASPER, Joint Attention Symbolic
Play Engagement and Regulation) on 3 to 5 year old,
minimally verbal children with autism who were attending
a non-public preschool. Participants were randomized to a
control group (treatment as usual, 30 h of ABA-based
therapy per week) or a treatment group (substitution of
30 min of JASPER treatment, twice weekly during their
regular program). A baseline of 12 weeks in which no
changes were noted in core deficits was followed by
12 weeks of intervention for children randomized to the
JASPER treatment. Participants in the treatment group
demonstrated greater play diversity on a standardized
assessment. Effects also generalized to the classroom,
where participants in the treatment group initiated more
gestures and spent less time unengaged. These results
provide further support that even brief, targeted interven-
tions on joint attention and play can improve core deficits
in minimally verbal children with ASD.
In this pilot study, we tested the effects of a
Autism ? Minimally verbal ? Intervention
Children with an autism spectrum disorder (ASD) are a
phenotypically heterogeneous group. Many of the children
have limited spoken language at the time of diagnosis. The
majority will go on to use spoken language by the time they
enter school at age five. Some children, approximately
25–30 % gain very little spoken language during the pre-
school years, and for these children targeted and novel
interventions are likely needed. For example, in one study
of 84 children with autism who were followed from 2 years
of age nearly 30 % of the children had no or few consistent
words at age 9 years (Anderson et al. 2007). These findings
were noted despite the fact that children were in intensive
behavioral interventions from a young age.
Using spoken language by age 5 years remains the most
important goal of early intervention as these children are
found to have the best social outcomes (Billstedt et al. 2007;
initiating joint attention skills have better spoken language
skills later (Dawson et al. 2004; Mundy et al. 1990), and that
interventions that teach these skills can improve spoken
language outcomes (Kasari et al. 2008, 2012). Other social
communication skills (e.g., requesting and responding to
joint attention) are easier to improve, and may also have
positive effects on child outcome. Responding to joint
attention (e.g., following a point to a picture) predicts pre-
school children’s language outcome 8 years later (Sigman
and Ruskin 1999), and a summary variable of all social
communication gesture use (behavior regulation and joint
attention gestures, responding and initiating) also predicts
better outcomes (Charman et al. 2005; Watt et al. 2006).
Although significant progress has been made in identi-
fying core features of autism and developing effective
interventions for preschool-age children with this disorder,
these efforts have generally overlooked children who do
not make significant progress in spoken communication,
K. S. Goods (&)
Center for Autism Research and Treatment, Semel Institute
for Neuroscience and Human Behavior, University of California,
760 Westwood Plaza, Semel 67-464, Los Angeles, CA 90024,
E. Ishijima ? Y.-C. Chang ? C. Kasari
Division of Psychological Studies in Education, Center
for Autism Research and Treatment, Semel Institute for
Neuroscience and Human Behavior, University of California,
Los Angeles, USA
J Autism Dev Disord (2013) 43:1050–1056
and children who are the most developmentally impaired.
Studies usually require children to have a certain devel-
opmental age or IQ prior to entry into an intervention trial
(Dawson et al. 2009; Landa et al. 2011; Lovaas 1987;
Smith et al. 2000). Therefore, we know little about how the
children with the most significant impairments can change
using specific and novel intervention approaches.
Interventions that are implemented for preschool chil-
dren with autism commonly use applied behavior analysis
approaches to teach children. While many children make
remarkable gains in social and communication skills, oth-
ers make slow or limited progress. For children who do not
make progress with the usual curriculum, a focus on these
core areas (engagement, play, and social communication)
may be even more important. Therefore, limiting the
sample to children who do not make progress may give us
more information on what is possible in addressing core
deficits of joint attention and play diversity.
The goal of the current study was to test whether an
intervention focused on a developmentally based approach
for teaching joint engagement, joint attention, and play
skills could improve social communication outcomes in
children who traditionally have been excluded from inter-
vention trials. Children who participated in the study were
diagnosed with autism, were currently in intensive 30-h per
week ABA-based interventions for at least 1 year, and
could say fewer than 10 spontaneous, functional words.
The goal was to determine if a brief intervention (24 ses-
sions over 12 weeks) could significantly improve children’s
social communication skills on independent assessments,
and when observed in their classroom.
A total of 15 preschool aged children with autism were
recruited from a non-public autism specialty school from
2008–2010. All of the participants received a minimum of
30 h per week of behaviorally based interventions, as well
as speech and occupational therapies. Participants were
included in the present study if they were between 3 and
5 years old, had a clinical diagnosis of autism, attended the
non-public school, and used less than 10 spontaneous,
functional, and communicative words by parent and tea-
cher report and during the baseline or entry assessments
(assessments described below).
Table 1 Descriptives, mean (SD), across time
n = 8
n = 8
n = 6
n = 7
n = 7
n = 5
CA 54.68 (10.25)60.55 (9.36)48.73 (11.68) 58.84 (10.98)
MA13.91 (3.85)17.21 (3.91)
DQ26.67 (10.12)37.70 (15.21)
VR21.50 (4.44)22.42 (3.26)
FM19.13 (4.29)21.71 (3.04)
RL8.63 (4.66)13.86 (7.36)
EL6.38 (3.74)10.86 (7.76)
VC12.00 (0.34)12.05 (0.38)12.14 (0.41) 14.59 (5.36)
EL11.93 (0.09)11.95 (0.16)13.63 (4.57)14.52 (5.38)
Play Types17.13 (6.83)11.50 (5.10) 14.33 (9.69)21.14 (7.58)11.00 (8.74)22.00 (10.17)
IJA0.75 (2.12)2.13 (2.80)1.00 (1.73)2.57 (4.39) 2.14 (4.85)0.40 (0.89)
IBR 1.88 (1.55) 1.38 (0.92)3.20 (2.39) 5.00 (3.70)1.71 (1.38)4.00 (1.87)
IJA0.20 (0.45)0.25 (0.50) 1.50 (3.21) 0.60 (1.34)
IBR 0.20 (0.45)0.00 (0.00) 1.50 (1.76)4.80 (4.49)
Unengaged (%)57.40 (34.11)35.00 (16.08)44.50 (14.86)12.60 (10.85)
All developmental variables are reported in months; CA chronological age; MSEL variables for the Mullen Scales of Early Learning; RDLS
Reynell Developmental Language Scales; SPA Structured Play Assessment; ESCS Early Social Communication Scales
J Autism Dev Disord (2013) 43:1050–10561051
The university’s Internal Review Board approved the
study. Recruitment fliers were handed out at the school.
Parents who were interested in the study contacted the
study staff directly to complete an initial phone screen.
Parents were then sent consent forms that were sent con-
sent forms that were signed prior to beginning the study
The sample was diverse with over half of the children
identified as African-American, Hispanic, or Asian. The
51.9 months, mental age was 15.45 months, and develop-
mental quotient was 31.81 (see Table 1).
Participants completed a series of baseline assessments
prior to study entry (see Fig. 1). All participants were
assessed again 12 weeks later at entry, to verify stability in
skills that would be the target of the intervention (play and
social communication gestures). After completion of the
entry assessments, participants were randomly assigned to
either the Treatment or Control group. Group assignment
was completed using a block randomization to ensure that
there was a manageable caseload of treatment versus
control participants at a given time (see Fig. 1 for more
detail). The randomization was completed using a random
number generator in SPSS. The treatment phase lasted
three months, and was followed by exit assessments.
Participants assigned to the Control group received the
regular school program for 30 h per week. Participants
in the Treatment group were pulled out from the same
classrooms as the Control group for 30-minute sessions,
twice a week for 12 weeks, to work with study personnel
on communicative gestures in a play-based treatment,
Fig. 1 Study design and
1052J Autism Dev Disord (2013) 43:1050–1056
JASPER (joint attention symbolic play engagement and
regulation; see Kasari et al. 2006; 2010 for more detail on
intervention content). The study interventionists were
graduate students in educational psychology, experienced
in intervention with young children with autism. Fidelity
was rated on sessions, with an average rating of 88.27 %
(SD = 5.75, range 80–100 %). Based on the entry assess-
ments, individual levels of play and joint attention and/or
requesting gestures were identified as mastered or emerg-
ing. Study personnel used toys that represented the child’s
interests within their mastered and emerging play levels.
Most participants were at a requesting level of gesture use.
Interventionists used the toys to help the child create play
routines that would facilitate joint engagement (reciprocal
interaction between interventionist and child around an
activity; i.e., play routine). Opportunities were embedded
within the play routines to elicit the targeted communica-
tion skill; this included waiting before performing steps of
a routine, expanding play within routines, and using bal-
Diagnosis of autism was confirmed for each child at base-
line using the Autism Diagnostic Observation Scale
(ADOS, Lord et al. 2000). The Mullen Scales of Early
Learning (MSEL; Mullen 1997) was used at baseline to
assess mental age (MA) and developmental quotient (DQ),
as well as four subscales of development: Visual Reception
(VR), Fine Motor (FM), Receptive Language (RL), and
Expressive Language (EL). The Reynell Developmental
Language Scales (RDLS; Reynell 1977) was used at base-
line and exit to assess each participant’s verbal compre-
hension (VC) and expressive language (EL). Assessments
were completed by assessors blind to treatment condition.
Structured Play Assessment (SPA)
The Structured Play Assessment isan experimentalmeasure
of play, completed with an independent assessor (Ungerer
and Sigman 1984). The structured play assessment was
completed at baseline, entry, and exit. The assessment is
later coded for play types, a measure of play diversity which
sums the number of unique spontaneous and functional play
acts (Lifter et al. 1993). Inter-rater reliability using intra-
class correlation coeffecient (ICC) was 0.84.
Early Social Communication Scales (ESCS)
assessors,designed toelicitspontaneousjoint attention(IJA)
and requesting (IBR) gestures from the participants (Mundy
et al. 1996, 2003). The ESCS was completed at baseline,
entry, and exit. Only spontaneous gestures were coded.
Reliability was measured using single measures ICC for the
composite variables: IJA (ICC = 0.85), IBR (ICC = 0.85).
Classroom Observation Measure (Class Obs)
The classroom observation measure (Wong and Kasari
(Adamson and Bakeman 1985) and spontaneous commu-
nicative gestures during 20 min of free play in the class-
room, with the child’s classroom teacher and/or aides at
entry and exit (Mundy et al. 1996; Mundy et al. 2003).
Engagement states were coded as unengaged, object,
onlooking, person, supported joint, or coordinated joint
engagement (Adamson and Bakeman 1985). Interval cod-
ing was used for the engagement states by blind coders;
observing for 50 s and coding for 10 s. Communicative
gestures (coordinated joint looks, points, gives, and shows)
were tallied and identified as being used for requesting
(IBR) or for joint attention (IJA). Reliability was analyzed
for engagement state (ICC = 0.92) and child gestures
(ICC = 0.74). The variables used for the present study was
the total frequency of spontaneous gestures and the per-
centage of time participants were in an unengaged state.
Due to the small sample size (n = 15 at baseline and entry,
n = 11atexit),non-parametricstatisticswereused.First,we
assessed whether there were any initial differences between
groups at the baseline or entry time points with the Kruskal–
Wallis test. Then, we tested whether the participants were
making significant change on the variables from baseline to
entry time points with the Wilcoxon signed-ranks test. Next,
at exit, as well as the effect size (Cohen’s d = M1-M2/
spooled). To assess whether the treatment group had made
significant change from entry to exit, we used the Wilcoxon
signed-rank test as well as calculated the reliable change
index, using the formula: SEDiff¼ SD1?
(Jacobson and Truax 1991; Evans et al. 1998).
1 ? r
Baseline and Entry characteristics
Developmental and demographic information is presented
in Table 1. First, we used the Kruskal–Wallis test to ensure
J Autism Dev Disord (2013) 43:1050–10561053
that there were no differences between the two groups prior
to treatment, at baseline and entry time points (Treatment
group n = 7, Control group n = 8). There were no statis-
tically significant differences between the groups at base-
line or entry on the outcome or developmental variables
(Table 2). Effect sizes were calculated, by group, for the
outcome variables at entry. While there was no effect of
group on play diversity (d = 0.13), there was a moderate
effect of group on time unengaged (d = 0.49) and a large
effect of group on initiated requesting gestures (d = 1.01)
Change from Baseline to Entry
We used a Wilcoxon signed-ranks test to assess significant
change from the baseline to entry time point (Treatment
group n = 7, Control group n = 8). Overall, participants
demonstrated a statistically significant decrease in their
play types on the SPA using a Wilcoxon signed-ranks test
(z = -2.74, p = 0.01) but did not demonstrate significant
change on the ESCS (Table 3).
Group Differences at Exit
To test for group differences at exit, we used the Kruskal–
Wallis test (Table 2). For diversity of spontaneous play, the
Treatment (n = 5) and Control (n = 6) groups were sig-
nificantly different, H(1, N = 11) = 4.09, p = 0.04. The
effect size for play diversity was d = 0.81, indicating a
large effect. During the class obs, participants in the
N = 11) = 3.87, p = 0.05. The effect size for percent time
unengaged was d = 1.63, a large effect. Participants in the
treatment group initiated more requesting gestures at exit
H(1, N = 11) = 6.61, p = 0.01. The effect size of treat-
ment group on requesting gestures was d = 1.51, also a
large effect. There were no significant differences on the
ESCS variables (IJA and IBR).
Change from Entry to Exit by Group
To assess change from entry to exit on the control and
treatment groups separately, the Wilcoxon signed-rank test
was used (Table 3). The Control group did not have sig-
nificant change on any of the outcome variables. Next, we
investigated change in the treatment group. First, we found
a significant increase in play types (z = -2.03, p = 0.04).
The RCI yielded a SEDiffof 3.71, suggesting that 80 % of
the participants had reliable increases from entry to exit.
Next, we looked at percent time unengaged and found a
significant decrease for the treatment group (z = -2.02,
p = 0.04). Using the RCI, the SEDiff for percent time
unengaged was 8.80 and 80 % of the treatment group
reliably decreased in their time unengaged. Last, we tested
the frequency of requesting gestures used during the class
obs. We did not find a significant change in IBR
Table 2 Group differences
(Kruskal–Wallis test, H) by time
MSEL Mullen Scales of Early
Learning; RDLS Reynell
Scales; SPA Structured Play
Assessment; ESCS Early Social
Chronological age1.62 0.200.27 0.60
Verbal comprehension1.240.27 0.810.37
Expressive language0.050.820.81 0.37
Initiating joint attention2.520.110.430.51 0.410.52
Initiating requesting 1.240.27 0.370.550.740.39
Initiating joint attention0.340.560.001.00
1054J Autism Dev Disord (2013) 43:1050–1056
(p = 0.22). The RCI yielded SEDiffof 1.31 with only 40 %
of the treatment group significantly increasing in IBR.
Participants did not display significant change from entry
to exit on the ESCS variables (IJA and IBR).
Targeted interventions focused on joint attention and
requesting, joint engagement, and play skills can improve
social communication abilities of children with autism
(Kasari et al. 2006, 2008, 2010). For children with the most
impairment, these interventions can also make change,
with moderate to large effect sizes in a small sample.
This study tested whether a limited dose of intervention
could effect change on core deficits of young children with
autism—engagement, play diversity, and social communi-
cation. In this study, 24 sessions were distributed over
12 weeks. While this was a relatively brief and low density
intervention, there were strong results for improving
diversity of play on an experimental measure and some
indication of decreasing time spent unengaged in their
classroom settings. Both of these findings were in gen-
eralized settings, with different adults and environments
than the intervention. Results were mixed, but also prom-
ising for improving generalized initiated requesting ges-
tures. Although targeted, there was no improvement in
generalized joint attention gestures.
Targeting play and engagement were two skills that
were more directly, and immediately, related in this
population. Developing a diversity of play skills may
directly translate to increased engagement with toys and
activities in free-play settings in their classroom. The
specific focus, and finding, on play diversity is important.
Rather than teaching children how to play with specific
items or defined play scripts, we targeted developmentally
appropriate play within a range of toys. It may be that this
specific approach effectively facilitates generalization to
other settings, i.e., the classroom. It is important to mention
that classroom teachers and aides were not provided
training or recommendations about the intervention pro-
vided to their students. Additionally, the toys used in
intervention were not from the children’s classrooms.
These findings suggest that young, minimally verbal chil-
dren with autism can be taught and benefit from targeting
engagement in functional activities using a naturalistic
developmental/behavioral teaching approach.
There are several limitations to the study, most impor-
tantly the small sample size. Over two and a half years,
only 15 children with autism were identified as being non-
responsive to intensive behavioral interventions in this
particular school setting. Another limitation is that greater
changes were in initiating requesting gestures, yet initiating
joint attention gestures were also a specific focus of the
intervention. One factor may be the developmental readi-
ness for joint attention skills, and the real difficulty in
improving initiating joint attention skills in this sample of
children (Kasari et al. 2010). The short duration of the
intervention may have also been a factor. Development of
play and engagement may be among the first areas to
Table 3 Wilcoxon signed-
ranks test for change on
outcome variables from
Baseline to Entry for whole
group, and Entry to Exit by
The z value is presented for each
of the Wilcoxon signed-ranks
tests for change from Baseline
to Entry, and Entry to Exit,
along with the p value
ControlTreatment Whole group
Play types-1.82 0.07–1.990.05 –2.74 0.01
Unengaged (%)-0.82 0.41-2.02 0.04
J Autism Dev Disord (2013) 43:1050–10561055
change, but spontaneous communication may require more Download full-text
intervention time and practice.
In summary, this pilot intervention study shows promise
in improving play and engagement outcomes for children
identified as ‘nonverbal’ and making limited progress
despite receiving intensive behavioral interventions. Pro-
gress was made in a short period of time (12 weeks) with
a low dose of intervention (12 h), and changes were
observed in the child’s performance in their classroom, and
on independent assessments. Thus, future studies are war-
ranted that continue this line of investigation.
Autism Research grant 20072725. We appreciate the support of El-
isabeth Laugeson, PhD in the UCLA/HELP Group Alliance, Barbara
Firestone, PhD, staff of the Help Group Preschools, and especially the
children, parents, and teachers who participated in the study. The
study was partially supported by Autism Speaks grant 5666, NIH/
NICHD 1 P50-HD-055784, and Department of Health and Human
This study was supported by Organization for
Adamson, L. B., & Bakeman, R. (1985). Affect and attention: Infants
observed with mothers and peers. Child Development, 56(3),
Anderson, D. K., Lord, C., Risi, S., DiLavore, P. S., Shulman, C.,
Thurm, A., et al. (2007). Patterns of growth in verbal abilities
among children with autism spectrum disorder. Journal of
Consulting and Clinical Psychology, 75(4), 594–604.
Billstedt, E., Gillberg, I. C., & Gillberg, C. (2007). Autism in adults:
Symptom patterns and early childhood predictors. Use of the
DISCOin acommunity samplefollowed from childhood.Journal
of Child Psychology and. Psychiatry, 48(11), 1102–1110.
Charman, T., Taylor, E., Drew, A., Cockerill, H., Brown, J., & Baird,
G. (2005). Outcome at 7 years of children diagnosed with autism
at age 2: Predictive validity of assessments conducted at 2 and
3 years of age and pattern of symptom change over time. Journal
of Child Psychology and Psychiatry, 46(5), 500–513.
Dawson, G., Toth, K., Abbott, R., Osterling, J., Munson, J., Estes, A.,
et al. (2004). Early social attention impairments in autism: Social
orienting, joint attention, and attention to distress. Developmen-
tal Psychology, 40(2), 271–283.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson,
J., et al. (2009). Randomized, controlled trial of an intervention
for toddlers with autism: The early start Denver model.
Pediatrics, 125, 17–23.
Evans, C., Margison, F., & Barkham, M. (1998). The contribution of
reliable and clinically significant change methods to evidence-
based mental health. Evidence Based Mental Health, 1, 70–72.
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A
statistical approach to defining meaningful change in psycho-
therapy research. Journal of Consulting and Clinical Psychol-
ogy, 59(1), 12–19.
Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and
symbolic play in young children with autism: A randomized
controlled intervention study. Journal of Child Psychology and
Psychiatry, 47(6), 611–620.
Kasari, C., Gulsrud, A., Freeman, S., Paparella, T., & Hellemann, G.
(2012). Longitudinal follow-up of children with autism on joint
attention and play. Journal of the American Academy of Child
and Adolescent Psychiatry, 51(5), 487–495.
Kasari, C., Gulsrud, A., Wong, C., Kwon, S., & Locke, J. (2010).
Randomized controlled caregiver mediated joint engagement
intervention for toddlers with autism. Journal of Autism and
Developmental Disorders, 40(9), 1045–1056.
Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008).
Language outcome in autism: Randomized comparison of joint
attention and play interventions. Journal of Consulting and
Clinical Psychology, 76(1), 125–137.
Landa, R. J., Holman, K. C., O’Neill, A. H., & Stuart, E. A. (2011).
Intervention targeting development of socially synchronous
engagement in toddlers with autism spectrum disorder: A
randomized controlled trial. Journal of Child Psychology and
Psychiatry, 52(1), 13–21.
Lifter, K., Sulzer-Azaroff, B., Anderson, S., & Cowdery, G. E.
(1993). Teaching play activities to preschool children with
disabilities: The importance of developmental considerations.
Journal of Early Intervention, 17, 139–159.
Lord, C., Risi, S., Lambrecht, L., Cook, E. H, Jr, Leventhal, B. L.,
DiLavore, P. C., et al. (2000). The autism diagnositc observation
schedule-generic: A standard measure of social and communi-
cation deficits associated with spectrum of autism. Journal of
Autism and Developmental Disorders, 30, 205–223.
Lovaas, O. I. (1987). Behavioral treatment and normal educational
and intellectual functioning in young autistic children. Journal of
Consulting and Clinical Psychology, 55, 3–9.
Mullen, E. (1997). Mullen scales of early learning. Circle Pines, MN:
American Guidance Services.
Mundy, P., Delgado, C., Block, J., Venezia, M., Hogan, A., & Seibert,
J. (2003). Early Social Communication Scales (ESCS). Coral
Gables: University of Miami.
Mundy, P., Hogan, A., & Doelring, P. (1996). A preliminary manual
for the abridged Early Social Communication Scales. Coral
Gables, FL: University of Miami.
Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study of
joint attention and language development in autistic children.
Journal of Autism and Developmental Disorders, 20(1), 115–128.
Reynell, J. K. (1977). Reynell Developmental Language Scales.
Windsor: NFER Publishing Co.
Rutter, M., (1978). Diagnosis and definition of childhood autism.
Journal of autism and childhood schizophrenia, 8(2).
Sigman, M., & Ruskin, E. (1999). Continuity and change in the social
competence of children with autism, down syndrome, and
developmental delays. Monographs of the Society for Research
in Child Development, 64(1), 1–114.
Smith, T., Groen, A. D., & Wynn, J. W. (2000). Randomized trial of
intensive early intervention for children with pervasive devel-
opmental disorder. American Journal on Mental Retardation,
Ungerer, J., & Sigman, M. (1984). The relation of play and
sensorimotor behavior to language in the second year. Child
Development, 55(4), 1448–1455.
Watt, N., Wetherby, A., & Shumway, S. (2006). Prelinguistic
predictors of language outcome at 3 years of age. Journal of
Speech, Language, and Hearing Research, 49, 1224–1237.
Wong, C. & Kasari, C. (2012). Play and joint attention of children
with autism in the preschool special education classroom.
Journal of Autism and Developmental Disorders, 1-10. doi
1056 J Autism Dev Disord (2013) 43:1050–1056