Electronic Theses and Dissertations

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Title:
Joint engagement and attachment patterns in infants with visual impairments

Author:
Urqueta Alfaro, Andrea

Acceptance Date:
2015

Series:
UC Berkeley Electronic Theses and Dissertations

Degree:
Ph.D., PsychologyUC Berkeley

Advisor(s):
Kihlstrom, John, Orel-Bixler, Deborah

Committee:
Zhou, Qing, Sterponi, Laura

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JointEngagementandAttachmentPatterns
inInfantswithVisualImpairments



by


AndreaUrquetaAlfaro




Adissertationsubmittedinpartialsatisfactionofthe
requirementsforthedegreeof
DoctorofPhilosophy
in
Psychology
inthe
GraduateDivision
ofthe
UniversityofCalifornia,Berkeley









Committeeincharge:
ProfessorJohnF.Kihlstrom,CoChair
ProfessorDeborahA.OrelBixler,CoChair
ProfessorLauraSterponi
ProfessorQingZhou

Spring2015






JointEngagementandAttachmentPatterns
inInfantswithVisualImpairments





Copyright2015
by
AndreaUrquetaAlfaro
 1

Abstract


JointEngagementandAttachmentPatterns
inInfantswithVisualImpairments

by

AndreaUrquetaAlfaro
DoctorofPhilosophyinPsychology
UniversityofCalifornia,Berkeley
ProfessorJohnF.Kihlstrom,CoChair
ProfessorDeborahA.OrelBixler,CoChair

Thisdissertationreportsontwoearlychildhooddevelopments,jointengagement
andattachmentpatterns,andexploresapossiblerelationshipbetweenthetwoinasample
of20infantswithvariouslevelsofvisualimpairments,withoutadditionaldisabilities.Joint
engagementandsecurityandorganizationofattachmentpatternshavebeenassociated
withpositivedevelopmentaloutcomes,suchasbetterlanguageandsocioemotionalskills,
betterperformanceintheoryofmindtests,andreducedriskforpsychopathology.Thereis
aneedforresearchonthesetopicsinthepopulationofchildrenwithvisualimpairments,
andtherelationshipbetweenjointengagementandattachmentpatternshasnotbeen
exploredinthispopulation.
Study1focusesonjointengagement,thatis,infantscoordinationoftheirattention
betweenasocialpartnerandanexternalfocusofsharedinterest.Infantsandtheir
caregiverswerevideotapedduring30minutefreeplaysessionsattheirhomes.Videos
werecodedtoestablishthedurationofjointengagementepisodes,andtheoveralltime
dyadsparticipatedinit.Resultsshowedthatallinfantstestedparticipatedinjoint
engagementandthatthepercentageoftimeitrepresentedofthe30minutefreeplay
sessionsignificantlyincreasedbetweenages12and18months.Theaveragedurationof
singleepisodesofjointengagementincreasedbutonlyapproachedsignificance.Thelevel
ofeachinfantsvisualimpairmentwasdescribedasreductionsfromnormsinvisualacuity
andcontrastsensitivityasmeasuredusingbothvisualevokedpotentialandpreferential
lookingtechniques.Ofthevisualmeasurements,infantsreductionincontrastsensitivity
measuredwithpreferentiallookingtechniquepredictedinfantspercentageoftimeinjoint
engagementacrossages.Thisfindingsupportstheimportanceofconsideringcontrast
sensitivitylevels,ratherthanonlythoseofvisualacuity,inresearchwiththispopulation.
Study2focusesonattachmentpatterns.Infantsandtheircaregiversunderwentthe
StrangeSituationParadigmwithaddedinstructionstoaccommodatefortheperceptual
needsofinfantswithvisualimpairments.Resultsshowedthatallbut1ofthe27SSPs
collectedweredeemedclassifiable.Mostattachmentpatternsweresecure,ranging
between56%intheyoungergroupofinfantstested,and70%intheoldergroup.

Attachmentscodedasdisorganizedrangedbetween22%and6%intheyoungerandolder
groupsrespectively.
Study3explorestherelationshipbetweeninfantssecurityofattachmentandthe
percentageoftimetheyparticipatedinjointengagementwiththeircaregiversduringfree
play.Resultsdidnotfindasignificanteffect.Thisisinlinewiththemixedresultsinthe
literatureontheconnectionsofattachmentandjointengagement,whichnotonlyvariesin
thefindingofsignificanteffectswithinagivenpopulation,butalsovariesbetweenthe
resultsindifferentpopulations.

Contents

Contents.i

ListofTables.iv

ListofFiguresv

Preface..vi

1.Study1:Percentageoftimeinfantswithvisualimpairmentsandtheircaregiversspend
injointengagementanditsrelationshiptoinfantsvisualacuityandcontrastsensitivity..1

1.1Background1
Development.3
Relationshipwithotherdevelopmentalskills..4
Nonvisualjointengagement...6
Jointengagementinchildrenwithvisualimpairments..7
Study1aims12
1.2Methods.13
Participants.13
Procedures...20
Observationalprocedure20
Observationalconditions21
Codes:Jointengagementandnonjointengagement22
Jointengagement.22
Nonjointengagement..23
Codingprocedures..26
Agreement26
Reliability..27
Comprehensivevisionexamination.27
Demographicsurvey..28
Dataanalysis...28
Reliabilityofcoders28
Agechangesintheamountoftimeinfantswereinjointengagement...29
Relationshipbetweeninfantstimeinjointengagementandvisuallevels.30
1.3Results31
Reliabilitystatistics31
Agechangesintheamountoftimeinfantswereinjointengagement..31

 ii

Agechangesintheaveragedurationofjointengagementevents35
Relationshipbetweeninfantstimeinjointengagementandvisuallevels.37
Infantsvisuallevels...37
Modelsofjointengagement..39
Participantsandage...39
Relationshipbetweenindependentvariables39
Acuityandcontrast.41
1.4Discussion42

2. Study 2: Attachment patterns in infants with visual impairments based on the Strange
SituationParadigm.48

2.1Background.48
Development..49
StrangeSituationParadigm..50
Attachmentpatterns..51
Disorganization.52
Relationshiptocaregiversbehaviors.52
Relationshipwithotherdevelopmentalskills...53
Attachmentininfantswithvisualimpairments54
Study2aims57
2.2Methods.59
Participants.59
Procedures...60
StrangeSituationParadigm...60
Videorecordingsetting62
StrangeSituationParadigmsetting..63
Codes...64
Attachmentpatterns:secure,avoidant,resistant64
Disorganization.66
Codingprocedures..67
Dataanalysis...68
Reliabilityofcoders68
Distributionofattachmentpatterns68
2.3Results68
Reliabilitystatistics68
Attachmentpatterns..69
Disorganization.73
2.4Discussion74

3.Study3:Exploringtherelationshipbetweenjointengagementandattachmentininfants
withvisualimpairments..79

3.1Background.79
Theoreticalrelationbetweenattachmentandjointengagement..79
Research81

 iii

Study3aims85
3.2Methods.86
Participants.86
Procedures...87
StrangeSituationParadigm...87
Homevisits..87
Dataanalysis...89
3.3Results89
Relationshipbetweenjointengagementandsecurityofattachmentatage1..89
Relationshipbetweenjointengagementandsecurityofattachmentatage2..89

3.4Discussion91

References93

Appendixes...102
Appendix1:Jointengagementcodingprotocol.102
Appendix2:Demographicsurvey..107
Appendix3:Comparisonofsecureattachmentpatternssubtypes..109
Appendix4:Comparisonofavoidantattachmentpatternssubtypes.110
Appendix5:Comparisonofresistantattachmentpatternssubtypes.110

 iv

ListofTables

1.1:Study1subjectsages.............................................................................................................................15
1.2:Kapparesult,jointengagement .........................................................................................................31
1.3:Twotailedunequalvariancettests(WelchsCorrectiontodegreesoffreedom)results
forcomparisonofthepercentageoftimeinjointengagementatages1and2....................33
1.4:Twotailedttests(Welchscorrectiontodegreesoffreedom)resultsforcomparisonof
averagedurationofjointengagementepisodesatages1and2. ................................................36
1.5:InfantsreductionfromVAandCSnormsatage1 ..................................................................... 37
1.6:InfantsreductionfromVAandCSnormsatage2 .................................................................... 37
1.7:Twotailedttests(Welchscorrectiontodegreesoffreedom)resultsforcomparison
ofinfantsvisualreductionsfromnormsatages1and2 ................................................................ 38
1.8:Relativeimportanceofacuityandcontrastmeasuresforpredicting
jointengagement .............................................................................................................................................. 41
1.9:Modelsofjointengagement................................................................................................................ 42

2.1:Study2subjectsages ............................................................................................................................ 59
2.2:SummaryoftheStrangeSituationParadigmepisodes........................................................... 60
2.3:StrangeSituationParadigminstructions ...................................................................................... 61
2.4:SSPbehavioralcodesscoresexamples .......................................................................................... 65
2.5:Kapparesult,securityofattachment .............................................................................................. 69
2.6:Kapparesult,disorganizationofattachment .............................................................................. 69
2.7:Subjectsattachmentpatternsatages1and2............................................................................ 72

3.1:Findingsontherelationshipbetweenattachmentandjointengagement ..................... 85
3.2:Study3subjectsagesathomevisits .............................................................................................. 88
3.3:Twotailedttests(Welchscorrectiontodegreesoffreedom)resultsforcomparisonof
percentageoftimeinjointengagementatages1and2 ................................................................. 90

ListofFigures

1.1:Study1subjectsagedistribution .................................................................................................... 16
1.2:Infantsrace/ethnicity........................................................................................................................... 17
1.3:Caregiverseducationallevel.............................................................................................................. 18
1.4:Familiesannualincome ....................................................................................................................... 19
1.5:FamiliescompositeSES ....................................................................................................................... 20
1.6:Standardsetoftoysusedinthejointengagementsessions................................................. 21
1.7:Codingdecisionflowchart .................................................................................................................. 25
1.8:Jointengagement(withSEMs)atages1and2withtoys1and2 .......................................... 34
1.9:Scatterplotofparticipantspercentagesoftimeinjointengagement,fortoys1and2,
collapsedacrossages.Regressionresults(withequivalentPearsoncorrelationshown)
.35
1.10:Relationshipbetweenpairsofvariables.Lowerleft:ScatterplotsandLOESS(locally
weightedpolynomialregression)fits.Diagonal:histogramofresponses.Upperright:
Spearmansrhocorrelation ......................................................................................................................... 40

2.1:ToysusedinStrangeSituationParadigm ..................................................................................... 63
2.2:Attachmentpatternsdistributionatage1 ................................................................................... 70
2.3:Attachmentpatternsdistributionatage2 ................................................................................... 71
2.4:Disorganizedattachmentpatternsatage1 ................................................................................. 73
2.5:Disorganizedattachmentpatternsatage2 ................................................................................. 74

 vi

Preface

Visualimpairmentsencompassawiderangeofvisualabilities,includingnolight
perception(totalblindness),lowvision(warrantingaccommodationslikeBraille)and
visualimpairment(reducedvisualacuityrequiringlargeprintor>3xmagnification).Only
aminorityofchildrenwithvisualimpairmentsistotallyblind(Lueck,2004).
TheWorldHealthOrganization(WHO)estimates,asof2010,theglobalpopulation
ofchildrenbetweenages014yearswithvisualimpairmentsis19million.Ofthese,17.5
millionchildrenhavelowvisionand1.4millionareblind(WorldHealthOrganization,
2012).Theetiologyofvisualimpairmentandblindnessvariesglobally.
Accordingtoa2012surveyofschoolsfortheblindintheUnitedStates,thetop
threecausesofchildhoodvisualimpairmentarecorticalvisualimpairment,opticnerve
hypoplasia,andretinopathyofprematurity(Kongetal.,2012).InWesternsocietiesthe
majorityofthesechildrenpresentwithadditionaldisabilities(Sonksen,&Dale,2002).
Visualimpairmentsaretypicallydefinedandexpressedintermsofvisualacuity
(abilitytoseedetail),andrangebetweentheminimaldegreeofvisualimpairment(visual
acuityof20/70)tothegreaterdegree(visualacuityof20/400orworse).Awayto
interpretthevisualacuityfractionistothinkofthenumeratorasthedistancetheperson
needstobeinordertoseeatargetthatsomeonewithnormalvisioncanseeatthedistance
expressedbythedenominator.Forexample,apersonwithavisualacuityof20/40cansee
aletterwhenheis20feetawayfromitwhileapersonwithnormalvisioncanseetheletter
fromadistanceof40feet(Flom,2004).
Researchoninfantswithvisualimpairmentscommonlyreportsonlytheirvisual
acuitylevels,howeverseveralothervisualfunctionscanbeimpacted.Visuallyimpaired
childrenwithsimilarlevelsofvisualacuitycandifferinhowthoseothervisualfunctions
arereduced.Forinstance,areducedabilitytonoticedifferencesinbrightnesscontrast
sensitivitywilladddifficultiestoachildsclinicalpicture,beyondthechallengescaused
byhisreducedvisualacuity(OrelBixler,2014).
Thewayvisualimpairmentsinfluencedevelopmentvariesgreatlydependingon
howmuchresidualvisionthechildhas.Forinstance,developmentalskillsreportedtobe
achievedbyinfantswithvisualimpairmentsatalateragethansightedpeersshowthe
greatestlagsinthosewiththemostseverelevelsofvisualimpairmentse.g.,nolight
perceptionorlightperceptionatbest(Dale&Salt,2007).
Additionally,childrenwithsimilarvisualimpairmentscandevelopatdifferentrates
dependingontheirfamiliesaccesstodevelopmentalcounseling,andmorebroadlyonhow
societyingeneralmediatesthesocialandphysicalworldforthesechildren.Thepresence
ofadditionaldisabilitiesplaysasignificantroletothepointthatfindingsfromstudieswith
infantswithadditionaldisabilitiesshouldnotbeautomaticallyextendedtothosewithout
them.
Thisdissertationsaimsaretostudyinasampleof20infantswithvisual
impairmentswithnoadditionaldisabilities,andtheircaregivers,twoearlydevelopments:

 vii

theabilitytocoordinateattentionbetweenasocialpartnerandanexternalfocusofshared
interestjointengagementandtheabilitytoidentifyonesmaincaregiverandtoseek
herwheninathreateningsituationattachmentbehavior.Italsoexplorestheexistenceof
arelationshipbetweentheseinfantsattachmentpatternsandparticipationinjoint
engagementwiththeircaregivers.
Unlikepreviousresearchthathadfocusedsolelyoninfantshavingthemostsevere
levelsofvisualimpairments,thesestudiesreportoninfantswithvarieddegreesofvisual
impairmentsandthusprovideinformationthatismorerepresentativeofthevisually
impairedpopulation.Also,unlikemostresearchonthispopulation,thevisual
measurementscollectedarenotcircumscribedtoassessmentsofvisualacuity,butalso
includecontrastsensitivity.
Study1reportsthepercentageoftimeinfantsandcaregiversparticipatedinjoint
engagementduringa30minutefreeplaysession,aswellastheaveragedurationofsingle
jointengagementepisodes.Italsolooksattherelationshipbetweenthesepercentagesand
theinfantsreductionfromnormsforbothvisualacuityandcontrastsensitivity.
Study2reportstheapplicationtotheseinfantsofalaboratoryprocedureforthe
classificationofattachmentpatternstheStrangeSituationParadigmandthe
distributionofpatternsfoundinthesample.
Study3comparesthepercentageoftimeinfantswhohadasecureattachment
versusinsecureattachmentpatternspentinjointengagementwiththeircaregivers.

Study1

Percentageoftimeinfantswithvisualimpairmentsand
theircaregiversspendinjointengagementandits
relationshiptoinfantsvisualacuityandcontrast
sensitivity

1.1Background

Jointengagementreferstochildrensabilitytocoordinateattentiontowardasocial
partnerandanobjectofmutualinterest.Intheliterature,thisisalsoreferredtoasjoint
attention,secondaryintersubjectivityandsharedattention.Priortotheemergenceofjoint
engagement,infantsattendseparatelytopeopleandobjects.Sightednewborns
preferentiallylookathumanfaces,bothschematicandveridicalones(MacchiCassia,
Turati,&Simion,2004),andtheirinterestinfacetofaceinteractionwithotherhumansis
atitspeakbetweentheagesof3and5months(Bigelow,2003).By56monthsofage
infantsattendmoretoobjects,anddyadicinteractionswithsocialpartnersdecrease
(Adamson&McArthur,1995).Withtheemergenceofjointengagementtowardtheendof
thefirstyearoflife,infantsstarttoattendtobothpeopleandobjectswithinthesame
interactions(Adamson,Bakeman,Deckner&Nelson,2014;Bakeman&Adamson,1984).
AccordingtoBakemanandAdamson(1984),ifduringanepisodeofjoint
engagementthechilddoesnotactivelyacknowledgethecaregiversparticipation,thisis
labeledsupportedjointengagement.Forexample,thecaregivermightshowherinfanta
pompom,whereuponthechildstartstoattendtoit.Inthissituation,thecaregivers
actionsinfluencetheinfantsinteractionwiththeobject;thechildisawareofthe
caregiversaction,buthisattentionremainsprimarilyontheobject.
Incontrast,ifduringjointengagementthechilddoesactivelyacknowledgethe
caregiversparticipation,forinstance,bylookingbackandforthbetweenthecaregivers
faceandtheobjectthatisthecommonfocusofinterest,thentheepisodeislabeled
coordinatedjointengagement.Coordinatedjointengagementcanbeinitiatedbythe
infantorbyhissocialpartner.Eachcandosobyeitherfollowingintotheothersalready
establishedfocusofattention,e.g.,thechildlooksinthesamedirectionthemotheris
lookinguntilhefindshervisualtarget;orbydirectingtheothersfocusofattention,e.g.,
themotherpointsoutthetargettotheinfant(Adamson,Bakeman,Deckner&Nelson,
2012;Adamsonetal.,2014).
Thedistinctionbetweenthetwotypesisdescriptive;itdoesnotimplythat
coordinatedisbetterthansupported.Whethersupportedorcoordinated,jointengagement

requiresthatthecaregiversinvolvementwiththeobjectsomehowinfluencethechilds
engagementwithit.
Theprototypicexampleofcoordinatedjointengagementthatis,thechildand
socialpartnerattendtothesamefocusandthechildalternateshisattentionbetweenthe
twoisalsoanindexinstudiesoftherelatedconceptofjointattention.However,even
thoughresearchersofbothcoordinatedjointengagementandjointattentionusethesame
behavioralindex,theyvaryintheirclaimsofwhatthisimpliesfortheinfantssocial
cognitiveunderstanding.Inthisdissertationssummaryofresearchfindings,termsusedby
theresearchauthorswillbefollowed,yetthereadershouldkeepinmindthatdespitethis
differenceinterminology,studiesofcoordinatedjointengagementandjointattention
referencethesameobservablebehavior.
Someauthorspositthatchildrenwhoparticipateinjointattentionhavethe
cognitiveunderstandingthattheyandtheirsocialpartnerareattendingorcouldattendto
thesamestimuli.ForTomasello(1995,2007;Tomasello&Carpenter,2007)forinstance,
theemergenceofjointattentionmarksthechildsinitialunderstandingofothersas
intentionalagentsinthesenseofhavinggoalsandmentalrepresentationsthatinformtheir
actions.Fromthisperspective,thechildisnotmerelysequentiallyalternatingattention
betweentheobjectandsocialpartnerbutisattendingtothesocialpartnersfocusof
attention(Carpenter,Nagell,&Tomasello,1998;Tomasello,Carpenter,&Liszkowski,
2007).
Forotherauthorshowever,jointattentiondoesnotneedtoentailsuchalevelof
socialcognition;insteaditcanbeexplainedastheresultofassociativelearning.Through
repetition,thechildhaslearnedthatifhelooksbackandforthbetweenasocialpartner
andtheobjectofsharedinterest,arewardingconsequencewillensue;thecaregiverwill
smileandspeaktothechild,and/orgivetheobjecttohim(Baldwin,1995,Corkum&
Moore,1995;Dunham&Dunham,1995).
Withrespecttocoordinatedjointengagement,itsdefinitionrequiresthechildto
voluntarilyandrepetitivelynoticethesocialpartnersroleintheirattentiontoacommon
focusbutitdoesnotmakeclaimsabouttheinfantscognitiveunderstandingofothersas
intentionalagents(Adamsonetal.,2014;Bakeman&Adamson,1984).
Thisdifferenceininterpretationleadstodiversetakesonwhetherdeclarative
and/orimperativeactsinvolvejointattention(orcoordinatedjointengagement).In
declarativeacts,theactionofshowingtheexternalfocustothesocialpartneristhegoalin
andofitself,andiscitedasevidencethatthechildconsidersthesocialpartnerasanagent
whoseintentionalitycanbeinfluenced.Inimperativeacts,theactionofshowingthe
externalfocusisnotthegoalpersebutratherisameanstoobtainsomethingelse.Ifthe
childshowsanobjecttothecaregiverbecausehewantshertogiveittohim,itisnot
necessarilythecasethatthechildunderstandsherasanintentionalagent.Rather,thechild
canunderstandthesocialpartnerasameanstoanend,andtheimperativeactcanbethe
resultofassociativelearning.Throughrepeatedexperiences,thechildhaslearnedthat
whenatoyhedesiresisoutofhisreachandtheadultisnearby,hewillgainaccesstothe
toyifhepointsitouttotheadult.Someauthorsreachacompromiseregardingimperative
actsandconsiderthemasinvolvingjointattentionifgazeswitchesbetweenthesocial
partnersfaceandthedesiredobjectarepartoftheinfantsimperativeact.Arichersocio
cognitiveinterpretationconsidersonlydeclarativeactsbutnotimperativeones,whereasa
leanerinterpretationwouldincludeboth(Carpenteretal.,1998;Gmez,2007).

Jointengagementandjointattentionrefertotheactualtriadicsocialinteraction
involvingtheinfant,socialpartnerandsharedexternalfocusaswellasthechildsabilityto
participateinthem.Eventhoughstudiestendtofocusonthechildsbehavior,forinstance
bymeasuringthetimeswheninfantsswitchgazebetweenthesocialpartnerandobject,
thecaregiversparticipationisstillarequirement.Whenviewedasagoaldirected
partnership,jointengagementrequiressocialpartnerswho,whennecessary,arewillingto
relinquishoradjusttheirsetofgoalstosuittheirpartners.Evidencefromstudieswithlow
birthweightinfants,orthosewithDownSyndromeorAutism,haveshownthatjoint
engagementissusceptibletointeractivemiscoordinationandrequiresworkonthepartof
bothpartnerstoestablishandmaintainit(Raver&Leadbeater,1995).
Ifthechildtriestogetthesocialpartnertoattendtoasharedfocusandthepartner
doesnotdoso,thisisnotjointengagementassocialinteraction.Instead,thechild
attemptedtoinitiateonesuchinteraction,whichdoesspeaktothechildsjointengagement
abilities,butjointengagementasatriadicsocialinteractionhasnotoccurred.
Indeed,socialpartnersbehaviorhasconsequencesonthecharacteristicsofthe
jointengagement.Exploratoryplayinpreandfullterm6montholdinfantsincreases
whenmothersusestrategiestomaintaintheirinfantsalreadyestablishedfocusof
attentionortointroducetoyswheninfantsareunengaged,butnotwhenusedtoredirect
theinfantsattention(Landry,1995).Bothnaturalisticandexperimentalstudiesshowthat
whensocialpartnersfollowtheinfantsalreadyestablishedfocusofattentionratherthan
redirectit,infantsengageinmoreconversationalturns,andshowgreatercomplexityof
semantic,syntacticandconversationalskills(Tomasello,1988;Tomasello&Farrar,1986).
Incontrast,dyadsspendlesstimeinjointattentionwhenthemotherpersistsmoreoftenin
redirectinginfantsattentiondespitetheinfantsrefusaltoshiftfocus.Inanotherexample,
studiesshowthatparentsofnonverbalchildrenwithautismusemoreliteralmeansrather
thansymbolstodirecttheirinfantsattention,whichdecreasestheseinfantsexposureto
symbols(Raver&Leadbeater,1995).

Development

Studiesof6to18montholdinfantsshowthatsupportedjointengagement
emergesbeforecoordinated.By69months,babiesbegintoswitchgazebackandforth
betweencaregiverandobject,initiateandrespondtoobjectorientedgazeandpointing,
andattendtothecaregiverinordertodisambiguateunfamiliarstimuli(i.e.,social
referencing).Sooninfantsstarttousegesturestoshareattentiontoafocusexternaltothe
socialinteraction;andbyabout13months,infantsreadilyengageinnonverbalreferential
communicationwithasocialpartneraboutapresentobject(Adamsonetal.,2015;
Bakeman&Adamson,1984,1986).
Adamsonetal.(2004)longitudinallystudiednormallysightedinfantsfrom18to30
monthsofage.Babieswerevideotapedwhileinteractingwiththeircaregiversina
structuredplayingsituation.Caregiversweregiveninstructionstoinitiatesceneswith
theirinfantsaimedatinteracting,requesting,commenting,andnarrating.Acrossall
observedages,themeanpercentageoftimeinfantsparticipatedinsupportedjoint
engagementrangedfrom50%to56%,andincoordinatedjointengagementfrom16%to
21%.

Bythelasthalfofthesecondyear,symbolsarebeingincorporatedwithinjoint
engagement.Forinstance,theuseofwordsallowsthedyadtorefertoabsentobjectsor
internalstates,ortohighlightanaspectofthesituation.Besideslanguageunderstanding,
symbolsareincorporatedintheformofpretenseactsusinganobjectasifitissomething
elseandsymbolicgestures.Thissymbolinfusedjointengagementincreasesdramatically
between18and30monthsofage.Inonestudy,itrosefrom8%to49%of30minutechild
motherobservations.By3.5yearsofage,theamountinfantsengagedinitreachedaceiling
ofabout80%,yetthroughage5.5yearsitsfocusbecamemorecomplexandtheinfants
increasinglytookamoreactiverole(Adamsonetal.,2014;Adamsonetal.,2004;Adamson
&Bakeman,2006).

Relationshipwithotherdevelopmentalskills
Learningofobjectspropertiesandfunctions
Studieshavelinkedinfantsparticipationinjointengagementandjointattention
withseveralpositivedevelopmentaloutcomesinsightedchildrenforone,infants
learningofobjectspropertiesandfunctions.Bigelow(2004)reportedthat12monthold
sightedchildrenshowedmoreuseofobjectsinfunctionalplayconventionaluseof
objects,e.g.,dialingthetoytelephone;puttingalidonacupduringjointattention.
Childrensfunctionalplaywithinjointattention,butnotoutsideofit,correlatedwith
functionalplaywhenthechildwasalone.Incontrast,outsideofjointattention,children
showedmorestereotypicalplay(e.g.,mouthing,banging,fingeringasingleobject).
Languagedevelopment
Jointengagementhasbeentiedtoadvancesinlanguagedevelopment.Observational
studiesfoundthatinfantsfirststartedtoutterwordswithacommunicationalfunction
withinroutineinteractionswiththeircaregivers.Intheseroutines,childandcaregiverpaid
attentiontoapredictablesetofstepsinvolvingreferencetoobjects,whichmadeiteasier
forthenonverbalchildtodeterminewhatadultswerereferringtowiththewordsthey
utter(Bruner,1975,1995;Tomasello,1988).Longitudinalstudiesofinfantsandtheir
mothersshowedthatthetimetheyspentinjointattention,whetherwithinroutinesorin
novelsituations,positivelyrelatedtoinfantsvocabulary(Tomasello&Todd,1983).The
cumulativetimechildrenspentinsymbolinfusedsupportedjointengagementbetween
ages18and30monthsmadeasignificantcontributiontothepredictionoftheirexpressive
andreceptivelanguagescoresat30monthsofage(Adamsonetal.,2004).
Supportforthisrelationshipalsocomesfromstudiesthatfocusedoninfantsskills.
Experimentaldatashowedthat1619montholdsightedinfantslearnedtomatchan
adultsutteredwordtotheobjecttheadultwasgazingateveniftheinfantsthemselves
wereatthemomentattendingtoadifferentobject(Baldwin,1991).Infantswhoshoweda
greatercapacitytomatchmothersdirectionofgazeat6monthsofage,hadlarger
receptivevocabulariesat12months,andlargerexpressivevocabulariesat18,21,and24
months(Morales,Mundy,&Rojas,1998).Twelvemontholdchildrensabilitytofollowa
socialpartnersdirectionofgazeandpointinggesture,and18montholdchildrensability
touseeyecontactforinitiatingjointattentionepisodes,bothpredictedreceptivelanguage
skillsat24months,aftercontrollingforgeneralaspectsofcognitivedevelopment(Mundy
etal.,2007).
Thisrelationshiphasalsobeenreportedinchildrenontheautisticspectrum.

Mundy,Sigman,andKasari(1990)studiedchildrenwithautismwhohadfewerthanfive
wordsofexpressivelanguage.ItwasnottheirIQ,mentalandchronologicalage,nor
languagelevelatstudyentrance,butrathertheirabilitytousegesturestoengageinnon
verbaljointattentione.g.,extendingatoytowardthesocialpartnersface,that
predictedtheirexpressiveandreceptivelanguagescoreswhentheyweretested13months
later.Toth,Munson,Meltzoff,andDawson(2006)found,in3to4yearoldautistic
children,thattheirabilitytousetheireyegaze,showing,and/orpointingtoshareattention
hadthestrongestassociationtotheirconcurrentlanguagescoresascomparedtotheir
imitationandtoyplayskills.
TheoryofMind
Jointengagementhasimplicationsfortheacquisitionofatheoryofmind,thatis,the
understandingthatpeoplehavementalrepresentationslikeperceptions,beliefsand
desiresthatguidetheirbehavior.Successfulcompletionoftheoryofmindtestsrequires
thechildtodifferentiatebetweenhisownstateofmindwiththatofanotherperson.Thisis
evidencethatthechildunderstandsthatmentalstatesareindividuallyanchoredandthat
hisownperspectiveisnotnecessarilythesameothershaveofasharedsituation.For
instance,inaversionofthefalsebeliefparadigm,thechildispresentedwithanobjectsuch
asacandyboxandaskedwhathethinksisinside.Typicallychildrenwouldsaycandy.
Thenthechildisallowedtoseethatinsteadthecandyboxcontainssand,andisaskedwhat
wouldapeersayisinsidethecandyboxwhenfirstpresentedwithit.Childrenwho
understandfalsebeliefwillsaythepeerwillbelieveitcontainscandy.Childrenwhodonot
willattributetothepeerthesameknowledgetheythemselveshaveofthetruecontentand
saysand.
Longitudinalstudiesfoundthatchildrensperformanceinjointattentiontasksat20
months(e.g.,turningtogazeatasocialpartnerwhensheblockedtheinfantsaccesstoa
toy)predictedchildrensperformanceintheoryofmindtasksat44monthsofage
(Charmanetal.,2000).Childrenshigherperformanceinthefalsebelieftaskatpreschool
agecorrelatedwithmoretimespentincoordinatedjointengagementatages1821
months,andsymbolinfusedjointengagementbetween27and30months(Nelson,
Adamson,&Bakeman,2008).
Socioemotionaldevelopment
Morales,Mundy,Crowson,Neal,&Delgado,2005foundthatthe6monthold
infantsabilitytofollowasocialpartnersgazedirectionwassignificantlypositively
correlatedtotheseinfantsuseofstrategiesforemotionalregulationatage24months.
Also,theinfantsparticipationincoordinatedjointengagementlabeledcollaborativeby
theauthorsat24monthswassignificantlypositivelycorrelatedtotheirconcurrent
emotionalregulationskills.Inanotherstudy,12montholdinfantswhoshowedagreater
abilitytolooktowardtheobjectasocialpartnerwaslookingandpointingati.e.,
respondingtojointattentionbidsweresignificantlymorelikelytouseattentionself
regulationstrategiesinadelaygratificationtask(VaughanVanHeckeetal.,2012).Ina
sampleofatriskchildreni.e.,cocaineexposeditwasfoundthatthemoretimesthey
initiatedjointattentionbetweenages1218months,thelessdisruptivebehaviorse.g.,
teasesotherstudentswerereportedbytheirteacherswhenchildrenwere36months
old.Resultsalsoshowedthatchildrensabilitytorespondtosocialpartnersbidsforjoint
attentionnegativelypredictedwithdrawnbehaviorsandpositivelypredictedsocial
competence(Sheinkopf,Mundy,Claussen,&Willoughby,2004).

Nonvisualjointengagement

Bydefinition,coordinatedjointengagementandjointattentioncanbeestablished
usingnonvisualcues;forinstance,whenachildfeelshishandandanadultshand
tactuallyexploringthesameobject.Indeed,andalthoughitmightseemobvious,the
amodalnatureofjointengagementisevidencedbythefactthatblindadultsshare
attention.Theycanshowanobjectbyplacingitintheotherpersonshands,ortheycanuse
languagetofollowordirectothersfocusofattention.Thereisalsoevidencethatsighted
childrencanidentifytheircaregiversattitudetowardapotentiallythreateningsituation
i.e.,socialreferenceusingvocalcuesalone(Leekman&Wyver,2005);andthatinfants
followahiddeni.e.,notvisuallyperceivedbythechildsocialpartnersdirectionofvoice
toitsfocusofattention(Rossano,Carpenter,&Tomasello,2012).
Yet,researchhasreliedheavilyoninfantsgazeswitchasitsindex.Mostresearch
usesatestingparadigmthatreliesonvisualbehaviorasit:a.presentsavisualstimulias
thepotentialsharedfocus,suchasasilenttoy;b.providestheinfantwithvisualcuesofthe
socialpartnersfocusofattention,e.g.,thesocialpartnergazesatthetoyorpointsatthe
toytothechild;andc.indexesthechildsjointattentionbythechildsgazeswitching
betweentoyandsocialpartner(Butterworth,1995;Scaife&Bruner,1975).
However,someauthorshaveacknowledgedthelimitationsofusinggazeswitchas
anindex.Carpenteretal.(1998)recognizeshowitfailstorecordepisodeswheninfantsare
visuallyattendingtothesharedfocuswhileattendingonlyauditorilytothesocialpartner.
AdamsonandBakeman(1985)positthatjointengagementreferstoastateofattention
thatisnotsolelybasedonpatternsofvisualgaze.Moreover,gazealonemaynotfullyindex
theintensityofthechildsinterestineithercaregiverorobject.Forinstance,achildsitting
onhercaregiverslapduringbookreadingmightgazeatthecaregiverwhentheshared
activitystartsbutfromthenongazeonlyatthebookandyetcontinuetobeawareofthe
caregiversparticipation.Insymbolinfusedjointengagement,thechildcansignalhis
acknowledgementofthecaregiversparticipationbyconformingtothecaregiversverbal
commandsregardinganobjectwithoutgazingather(Adamsonetal.,2004).
Aninfantwhohasnotdevelopedjointengagementalsodoesnotshowthecaregiver
emotionalreactionsinreferencetoobjects.Forinstance,aprejointengagementinfant
mightwantanobjectwhichisoutofhisreach,yethedoesnotsignalhisdesiretothesocial
partnereitherbyswitchinggazeorbyemotingtowardher(Adamson&Russell,1999).
AdamsonandBakeman(1985)studiedtheprevalenceofaffectduringperiodsofjoint
engagementandfoundthatin6to18montholdinfants,affectoccurredoftenwhenthey
firstbecameengagedwiththesameobjecttheirsocialpartnerwasmanipulating,andthat
inepisodeswiththeirmothers,infantscontinuedtoexpressaffectthroughoutjoint
engagement.Theintegrationofaffectintojointengagementincreasedwithage;at6
months,morethanathirdoftheinfants'affectiveexpressionsoccurredduringjoint
engagementwiththeirmothers;by18monthsthishadincreasedtoover60%.Therateof
infantaffectdidnotvarysignificantlybetweensupportedandcoordinatedjoint
engagement.Mundy,Kasari,&Sigman(1992)foundthatinfantswithameanage20.2
monthsdisplayedmorepositiveaffectinassociationwithjointattentionratherthanin

requestingacts.Itshouldbenotedthatalthoughtheauthorsdidnotconsiderrequesting
actionsasjointattentionduetoitsinstrumentalorimperativenature,theyincluded
infantsuseofeyegaze,pointingandshowingobjectstothesocialpartner.Theseresults
indicatedthatjointattentionbehaviorsnotonlyinvolvethecoordinationofattentionto
objectsandevents,butalsothecapacitytoshareaffectiveexperiencevisvisobjectsand
events.Someresearchershaveincludedaffectivesharingaspartofindexesforjoint
attentioninthecontextofimitativelearning(Carpenteretal.,1998).

Jointengagementinchildrenwithvisualimpairments

Givenresearchersfocusonvisualjointengagement,itisnotsurprisingthatthe
questionofhowinfantswithvisualimpairmentsdevelopjointengagementhasmanytimes
beenapproachedfromadeficiencyperspective.Researchersconsidertherolethatvision
playsinjointengagementinsightedchildrenandforeseethatinfantsimpairedorabsent
visualabilitieswillnegativelyimpactitsdevelopment.Forinstance,ithasbeenarguedthat
jointattentionsdevelopmentinblindchildrenwouldbedelayedsincetheyarenotableto
usethedirectionofotherpeoplesgazeasawaytodetectotherpeoplesintentionality(e.g.
MomlooksatatoyasasignalthatMomwantsthattoy).However,byrelyingontactual
andauditorycues,blindchildrenwouldultimatelyachievejointattentionandunderstand
themeaningofseeingasapprehendingorperceiving(BaronCohen,1995).
Thepresenceandseverityofriskfactorsforabnormalitiesinjointengagement
dependsonhowvisuallyimpairedinfantscaregiversandsocietyingeneralaccommodate
thesechildrensperceptualabilitiesandneeds.Forone,thepresenceofvisual
impairmentscanchallengetheestablishmentinearlydevelopmentofcontingentand
mutuallyresponsivemotherchildexchanges.Infantswithvisualimpairmentscanpresent
idiosyncraticbehaviors,whichifinterpretedbythecaregiveraslackofinterestinsocial
interaction,willdecreasetheopportunitiesforpositiveexchangesbetweenthem.Infants
withvisualimpairmentsarereportedtorespondtosocialinteractionwithdecreasedor
absenteyecontact,gazeorsmiling.Theymayquietandadoptlisteningstand(e.g.,turn
earindirectionofsound)wheninterestedinasocialpartnersvoice.Theyhavebeen
describedasquietandpassiveandmightbemoreirritableandlessresponsive(Lueck,
Chen,Kekelis,&Hartman,2008).Incomparisontosightedpeers,theseinfantsarereported
toshowdecreasedpositiveaffect,andincreasednegativeaffect,fewerperiodsofpositive
vocalizationsandmoreofnegativeones.Theyarealsosaidtoignoremothersbidsfor
socialinteractionandattempttoterminateinteractionbyavertinggazeandturninghead
andbodyawayfromcaregivers,andtoinitiateplayinteractionswiththeirmothersnine
timeslessoftenthantypicallydevelopinginfants(Cass,1998;Kekelis&Anderson,1984;
Rogers,1988;Rogers&Puchalski,1984).
However,inherpioneeringwork,Fraiberg(1977)describedblindinfantsas
showingdampenedormutedaffectbutstressedhowtheinfantshandsmovementsand
usesprovidedabetterindexoftheiremotionality.Forinstance,interestinobjectsor
peoplewasdemonstratedbyblindinfantsactivetactileexplorationofthem.This
observationwascorroboratedinadifferentsetofinfantsbyPreisler(1990),whoreported
thatintheagerangeof3to6monthstheblindandvisuallyimpairedinfantssheobserved
reactedtomothersapproachbyincreasingtheirmotoractivitylegsandarmswaving

andmakinglipandtonguemovements.Thisbegsthequestionastowhethertheseinfants
perceivedpassivityandlackofemotionalityarearesultofobserversbiasesregarding
whatindexesinfantsinterestandaffect.PrezPereira&ContiRamsden(2005)makea
relatedobservationwhentheyquestiontheevidencebehindtheclaimthatchildrenwith
visualimpairmentshavedifficultyinitiatingcommunicationwithothers.Theseauthors
noticethatcaregiversofchildrenwithprofoundvisualimpairmentsandblindnesshave
beenfoundtoinitiatecommunicationatahigherratethanthoseofsightedpeers.When
dataispresentedasproportionsbetweencaregiver/childinitiations,visuallyimpaired
childrenappearaslesslikelytoinitiateinteractions,comparedtosightedpeers.But,when
dataispresentedintermsoffrequencies,nodifferencesarefoundbetweenblindand
sightedinfants.
Second,blindinfantsshowimpairmentsinabilitiesthatinsightedchildrenare
deemedcrucialforperceivingthemselvesinrelationtoothers,suchasseeinghowothers
matchinfantsownfacialexpressions,detectingothersemotionalbodyexpressionsin
relationtopeopleandobjects,andfollowingotherpeoplesgazetotheirfocus.Toachievea
senseofinterpersonalagency,theseinfantsneedsocialpartnerstousenonvisualcuesin
ordertoattuneandcontingentlyrespondtotheinfantsbehaviors.Withoutthem,these
childrenhavefeweropportunitiestoperceivethattheiractionshaveaneffect,sometimesa
predictableone,onothers(Bigelow,2003).
Third,visualimpairmentscaninterferewithinfantsunderstandingthatobjects
existintheenvironment,evenwhentheyarenotcurrentlyavailabletoperception,and
thatobjectscanberetrievedindifferentlocationsintheenvironment.Childrens
experiencesreachingandgraspingobjects,lettingthemgo,searchingforandretrieving
them,contributetosuchunderstanding(Piaget,1957).Infantswithvisualimpairments
riskhavinglessoftheseexperiences.Oneissueistheageatwhichtheystartreachingfor
objects.Whereasreachingforobjectsinsightedinfantsisobservedby46monthsofage,
reachinguponhearingobjectssoundcuesemergeslater1012monthsinbothsighted
andvisuallyimpairedchildren.However,blindinfantscanreachforobjectstheyhad
previouslyfelttactuallyby7months.Itisthuscrucialforcaregiverstomodifythe
environmentsothatthesechildrenhaveearlytactileaccesstoobjects(Luecketal.,2008;
Warren,1984).Anothercontributingexperienceisinfantsnavigationoftheirenvironment
throughlocomotion.Byindependentlymovinginspace,infantsexperiencehowobjects
existenceisnottiedtoaspecificlocation.Theyalsonoticehowchangesinanobjects
locationmodifyhowitisperceived,eventhoughtheobjectitselfremainsthesame.
Childrenwithvisualimpairmentsarereportedtoachieveselfpropelledgrossmotor
abilitiesatalateragethansightedpeers,forexamplewalkingat1824monthsversus12
15(Adelson&Fraiberg,1974;Brambring,2006;Bueno&Toro,1994).Particularlyinthe
caseofchildrenwhoareblindorseverallyvisuallyimpaired,accesstoorientationand
mobilitystrategiesandtechnologye.g.,whitecanewillmediatetheamountof
experiencethesechildrenhavenavigatingtheirenvironmentsandencounteringandre
encounteringobjectsindifferentlocations.
Fourth,ifchildrenengagelesswithobjects,therewillbefeweropportunitiesfor
theircaregiverstointerprettheinfantsbehaviorsasactsofcommunicationregardinga
focusexternaltothedyad.Indevelopment,infantsinitialreferentialcommunicationmay
ormaynotbeintentional,butwhatiscrucialisforcaregiverstointerprettheinfants
actionsasreferringtoanexternalfocusthatcanbeshared(Bigelow,2003).Joint

engagementandparticularlycoordinatedjointengagementrelyoneachparticipants
abilitytorecognizewhentheotherrelatestoafocusexternaltothedyad.Thiswillbe
impairedifthesocialpartnershavedifficultiesidentifyingnonvisualattentionalcues
and/orrespondingtothembyactionsthatarewithintheperceptualcapabilitiesofthe
other.
Preisler(1990)madearelatedobservationwhenshenoticedthatbetweentheages
of10and12months,theblindinfantssheobserveddidagreatdealofvocalizationwhen
playingwithobjects,yettheywerenotsharingtheirexperienceswithobjectswiththeir
mothers.Theinfantsdidshowbehaviorsthatevidencedtheyhadnoticedanobjector
eventintheenvironment,forexamplebyaslightmovementoftheheadand/orbody
towardthesourceofsoundand/oracquiringastiffbodyposture.However,these
behaviorswerenotimmediatelyinterpretedbytheirmothersassignalinginfants
attentiontoanexternalfocus.
Ifthecaregivercannotcorrectlyidentifythechildsfocusofattention,shewontbe
abletojoininitandwillhavetorelymoreheavilyondirectingthechildsbehaviortoward
afocusdeterminedbythecaregiver.Ifchildrenwithvisualimpairmentsengagelessorata
lateragewithobjectsand/orifcaregiversfailtorecognizetheinfantsinterestonobjects,
thedyadwillhavefeweropportunitiestoengageinreferentialcommunication.Thereis
evidencethatsocialgamesbetweeninfantswithvisualimpairmentsandtheircaregivers
overrelyonrepetitivevocalgames,tothedetrimentofgamesinvolvingobjects(Dale&
Salt,2007;Preisler,1990).
Theideathatinfantswhoareblindarelikelytoachievejointattentionatalaterage
thansightedpeerswassupportedbyBigelows(2003)longitudinalstudyoftwo
congenitallyblindchildren.Thestudydefinedjointattentionasepisodesinwhichthechild
wasinvolvedwithobjectandsocialpartnerandawareofthepartnerssharinginthe
attentiontotheobjectofsharedinterest.Bigelowdevelopedherowncodingprotocol
consideringtheexistingliteratureonjointengagementandjointattention,andthe
behaviorssheobservedinthecollectedvideos.Thecodingprotocolidentifiedinfants
actionsthatincorporatednonvisualabilities,whichweresuggestiveofjointattention.
Thesebehaviorswereclassifiedintothreecategories,dependingonhowarguableitmight
bethatintheabsenceofinfantsgazeswitchtheydidnotinvolvejointattention.
Themostambiguousbehaviorswerelabeledpreliminary.Theyincludedinfants
useofadultsassocialtools;e.g.,childtactuallyscanstheadultsbodytothehandthatmay
holdanobject.Alsoencompassedwereactsbytheinfantsthatthesocialpartnercould
interpretascommunicativegesturesaboutobjects,whichwasevidencedbythemothersin
thestudyoftenchangingtheirscaffoldingresponsetothechild.Forinstance,theinfant
resistshavingatoytakenawayandthecaregiverrespondsbyceasingtakingitawayand
verballycommentingonthechildsdesiretocontinueplayingwithit.
Lessambiguousthanpreliminary,liberallyconstruedjointattentionbehaviors
involvedinfantscomprehensionorproductionoflanguage,andcouldbeinterpretedas
symbolinfusedjointattention.Forexample,whilemotherandinfantattendtothesame
objectthechildspontaneouslylabelsit.Inthiscase,theambiguityarisessincewithoutthe
childlookingbackandforthbetweenmotherandobject,itisunclearwhetherthechildis
communicatingtothecaregiverabouttheobjectorratherexpressingonlytohimself.
Includedinthiscategoryareinfantsimperativeacts.Forinstance,whenthechildnames
anactionthatcouldbeperformedwiththeobjectofmutualinterest,hecouldbeintending

 10

togetthecaregivertoperformtheactionandnottopurelycallherattentiontoit.Also
includedweretimeswhenthechildusedmothersverbaldirectionstolocateanobject
e.g.,whenthechildissearchingfortheball,themothersaysTheballisbyyourfoot,and
theinfantreachesinthatdirection.Lastly,liberallyconstruedjointattentionbehavior
encompassedinstanceswhenthechildchangedthewayheisengagedwithanobject
followingtheadultsrequeste.g.,thechildismouthingatoy,whenthemothersaysto
himNo,notinthemouth,bangit,andthechildstopsmouthingthetoyandstartshitting
thefloorwithit.Theambiguityinthesebehaviorsisthattheycouldbeinstancesof
supportedjointengagement;childrencouldbeusingtheadultsbehaviorasaformof
verbalscaffoldingfortheirownactionsonobjectsandnotbeattendingtotheadultswhen
engagedwiththeobjects.
Theleastambiguousbehaviorswerelabeledconservativelyconstruedjoint
attentionbehaviors.Herechildrenengagedinsocialinteractionwiththeirsocialpartner
inagamelikecontext,andanobjectwasanintegralpartoftheinteraction.Theyincluded
gamesinwhichthechildrepeatedlygaveanobjecttotheadultandthentookitagain;
repeatedlyretrievedanobject,eachtimeaftertheadulthadplaceditinanewlocation;or
labeledobjectssequentiallypresentedtohimbytheadult.Theyalsoincludedtimeswhen
anobjectwasincorporatedintoanestablishedgamewiththeadult,andthechild
demonstratedawarenessofthisaddition.AnexamplefromBigelowssampleconsistedofa
gameinwhichthemothermovedherhandrepeatedlyoverthechildsmouthwhilehe
producedvowelsounds.Thenabowlwasaddedasthemotherstartedmovingabowlback
andforthoverthechildsmouthwhilehevocalized.Theadditionoftheobjectchangedthe
soundsproducedbythegame.Thechildthenheldontothebowlwhilethemothermoved
itandbegantogiggleevidenceofthechildsawarenessofthisaddition.Lastly,
conservativelyconstruedjointattentionincludedgamesinwhichthechildcooperatedwith
anadultinthemanipulationofanobjectandtherewasevidencethatthechildwasaware
oftheadultsactionsontheobject.Anexamplefromthestudyrecountedaninfantand
motherplayingwithatoythatproducedsoundwhenastringwaspulled;thechildpulled
thestringwhilethemotherpulledbackonthetoy.Aftersometime,themotherstopped
participating.Inresponse,thechildswungthetoyatherseveraltimesandbegantofuss
untilthemotherwentbacktoplayingthegamewiththeinfant.
InBigelowsstudy(2003),twoinfantswerevideotapedmonthlyfor30minutes
interactingwiththeircaregivers.Onechildwasobservedbetweentheagesof1321
months.Thischilddemonstratedfirstpreliminarybehaviors(13months),thenliberally
construed(16months)andlastlyconservativelyconstrued(18months)behaviors.The
otherchildwasobservedfrom17to30monthsofage.Thisinfantshowedpreliminary
behaviorsatstudyentrance;conservativelyconstruedfromage23months;andliberally
construedstartingat25months.Bigelownoticedthatliberallyconstruedand
conservativelyconstruedjointattentionbehaviorsemergedincloseparalleltiming,which
suggeststhepossibilitythatbothcategoriesindicatesimilarjointattentionskills.Shealso
pointedoutthatallconservativelyconstruedjointattentionbehaviorswereinitiatedbythe
mothers,afterwhichthechildrenwereactiveinmaintainingtheinteraction.
Otherstudieshaveincludednotonlyblindchildrenbutalsothosewithvarious
levelsofresidualvision.Theirresultsshedlightintothedifferenceswithinthepopulation
ofvisuallyimpairedinfants.Inalongitudinalstudyof7blindand3severelyvisually
impairedinfantsPreisler(1990)videorecordedtheirnaturalisticinteractionswith

 11

caregiversfrom3to12monthsofage.Shereportedthatblindinfantshaddifficultiesin
sharingattentionaboutobjectsandthatevenverylowvisionpositivelyimpactedthis
ability.By7to9monthstheircaregiversinterpretedinfantsmanual/vocalexplorationof
objectsasasignofattentionandcommentedontheiractions,thusattemptingtoinitiate
jointengagement,buttheirinfantsdidnotseemtofollowin.Byage1year,joint
engagementwasstilldifficultforblindinfantsandcaregiverstoestablish.Preisler
observedmissedopportunitieswheninfantsevidencedtheirattentiontoexternalsounds
byleaningtheirbodiestowardthemandfreezingbodypositionsandfacialexpressions,but
suchactionswerenotinterpretedbythecaregiversasattemptsatsharingattentiontothe
sounds.
Theriskofmismatchedexchangesbetweenvisuallyimpairedinfantsandtheir
caregivershasbeensupportedbyseveralstudies.However,thisisnotaninevitable
consequenceandtheliteraturealsoreportscasesinwhichcaregiverslearnedtointerpret
theirinfantssignalsandadaptedtheircommunicationalmeansinwaysthatmadesense
fortheirinfants,particularlyduringtheirpreverbalyears(Als,Tronick,&Brazelton,1980;
Loots,Devis,&Sermijn,2003).
Tadi,Pring,andSonksen(2009)comparedsightedandvisuallyimpairedpreschool
childrensabilitytorespondtoadultsbidstoestablishsharedattention,maintainitand
shiftbetweenexternalfoci,duringtheadministrationofadevelopmentalassessment.
Comparedtosightedpeers,childrenwithallincludedlevelsofvisualimpairmentsscored
significantlyloweronestablishingandmaintainingsharedattention.Thosewhohadonly
lightperceptionorworseshowedasignificantlylowerabilitytoshiftattentionbetween
foci,thanbothchildrenwhowerelessseverelyvisuallyimpairedandthosewhowere
sighted.Inchildrenwiththemostseverevisualimpairments,scoresonexploration,
manipulation,recognition,andmeaningfuluseofobjectshadasignificantpositive
correlationwiththeirabilitiestomaintainandshiftattention.
Dale,Tadi,andSonksen(2013)concludedfromparentsresponsestoastandard
interview,that13yearoldchildrenwhohadonlylightperceptionorworseobtained
significantlylowersocialcommunicationskillsscoresthansightedpeers,withthegreatest
differencefoundforitemsrelatedtojointattention.Incontrast,childrenwhowereless
visuallyimpaireddidnotdiffersignificantlyfromsightedpeers.Twoquestions
differentiatedchildrendependingontheirvisualimpairmentlevel.Whenaskediftheir
infantssharedexperiencewithtoyandsharedinterestinevent,parentsofinfantswho
hadonlylightperceptionorworsewerelesslikelytorespondaffirmatively,whereasmost
parentsofinfantswhohadformvisionorbetterdidso.
Severalstudieshavepositedthatitisatageswhenblindandseverelyvisually
impairedinfantscanuseverbalcommunicationthattheycanreliablyparticipateinjoint
engagementwiththeircaregivers(Bigelow,2003;Lootsetal.,2003;Preisler,1990).
Atypicalitiesinvisuallyimpairedinfantsjointengagementarereportedamongthe
characteristicsofaphenomenonofdevelopmentalregressionandstasisthathasbeen
reportedinasubgroupofchildrenwhoareblindorseverelyvisuallyimpaired.This
developmentalregressionstartedroughlybetween15and27monthsrangingfrom11to
22percentofreportedsamples(Cass,Sonksen,&McConachie,1994;Dale,2005;Dale&
Sonksen,2002).
Atypicalitiesinvisuallyimpairedinfantsjointengagementarealsoamong
behaviorssomeauthorsconsiderautisticlikebehaviorsobservedinthispopulation.

 12

Thereisevidencethatchildrenontheautismspectrumeitherdonotshowjointattention
orhavedifficultiesparticipatinginit(Mundy,Sigman,&Kasari,1990;Colombietal.,2009).
Furthermore,theyspendlesstimeoncoordinatedjointengagementwiththeirparents
thantypicallydevelopingpeersandthosewhohaveDownSyndromewhereassupported
jointengagementseemsrelativelyspared(Adamson,Bakeman,Deckner,&Romski,2009;
Adamsonetal.,2012).Jointattentiondeficitsarecommonlyusedintheearlydetectionof
autism(Naberetal.,2007).
However,itisdebatedwhetherthesebehaviorsshouldbeconsideredassignsof
autism.Hobson(2005)arguesthatininfantswhocongenitallyhavenovisionoronlylight
perception,thereisnoclearboundarybetweenthosediagnosedashavingcomorbid
autismandthosewho,despiteshowingautisticlikebehaviors,donotmeetthediagnostic
criteriaforautism.Inhisview,thereisalikelykinshipinthepathogenesisofautistic
featuresandautisminblindandsightedchildren.Inbothpopulations,theyoriginatefrom
disturbancesinearlysocialexperiencesneededforthenormaldevelopmentofmindand
personality.Blindnessimpairsinfantsperceptionofpeoplesemotionalreactionsand
attitudestowardstheexternalworld.Autismimpairschildrensabilitytoestablish
empathyoridentificationwithothersemotionalreactionsandattitudestowardsthe
externalworld(Hobson,1986,1993;Sandler&Hobson,2001).
Incontrast,PrezPereiraandContiRamsden(2005)arguethattheautisticlike
behaviorsattributedtochildrenwithvisualimpairmentsareonlysuperficiallysimilarto
thoseobservedinchildrenwithautism.Onereasonforthisisthebehaviorsdifferent
originsineachpopulation.Childrenwithautismshowasubstantialdeficitintheircapacity
forempathy,astheycannotidentifywithothersattitudestowardasharedworld.In
contrast,congenitallyblindchildrenaredeprivedofanessentialsocioemotional
experienceforthedevelopmentofatheoryofmind,sincetheycannotseeothers
emotionalattitudesdirectedtothesharedworld.Itappearsbothcontrastingopinionsarise
fromsimilarobservationsontheoriginofvisuallyimpairedinfantsputativeautistic
behaviors,butwhereasHobsonseemstobasethediagnosisofautismonitsbehavioral
symptoms,PrezPereiraandContiRamsdenapplythediagnosesonlywhenthesymptoms
areduetoasubstantialempathydeficitdespitevisualaccesstoothersreferential
emotionalattitudes.

Study1aims

Thisstudyhastwoaims:
Thefirstaimistocontributetotheunderstandingofthedevelopmentofjoint
engagementininfantswithvisualimpairments.Specifically,thisstudywillreportthe
percentageoftimeinfantswithvisualimpairmentsandtheircaregiversparticipateinjoint
engagementduringa30minutefreeplayinteractionattheagestestedinthisstudy.Itwill
alsoreporttheaveragedurationofjointattentionepisodes.
Thelimitedresearchonjointengagementdevelopmentinchildrenwithvisual
impairmentsbringsintoquestionourcurrentabilitytodeterminewhatisthenormativein
thispopulation.Thisshouldbeassessedwithdatafromstudiesusingsamplesfromtheir
populationthataresensitivetotheadaptiveneedsdegradedorabsentvisionpresentsto

 13

themotherinfantdyad,andwhichcanleadtoindexesofjointengagementwhichmayor
maynorbesharedbysightedpeers.
Bycomparingvisuallyimpairedinfantsjointengagementratestothatofsighted
peersnormativedata,wecanonlystatedifferencesbetweentwopopulationsbutcannot
evaluatethenormalcyofonebasedonfindingsfromtheother.Rather,determining
whetherachildwithvisualimpairmentsisdelayedinjointengagementdevelopment
shouldbedoneincomparisontonormativetimesfortheirownpopulation.
Thepresentstudywilladvancetheknowledgerequiredtodeterminewhena
visuallyimpairedchildsjointengagementskillsshouldbeconsideredasearlyindexesof
autism,andthusreducethechanceofamisdiagnosis,whichcanincreasetheriskof
disturbancesinmother/visuallyimpairedchildbondingandmothersmisunderstandingof
theirinfantsbehaviors.
Thesecondaimofthisstudyistoinvestigatewhetherthereisarelationship
betweenvisuallyimpairedinfantspercentageoftimeinjointengagementandtheirvisual
impairmentlevelsexpressedasreductionsfromagenormsforvisualacuityandcontrast
sensitivity.Arelationshipbetweentheseinfantsvisuallevelsandtheaveragedurationof
theirjointengagementepisodeswillalsobeexplored.
Theliteraturereviewshowsthatmostifnotallpreviousstudiesonjoint
engagementreportedonlyinfantsvisualacuitylevels(visionfordetail)todeterminethe
extentoftheinfantsvisualimpairment.However,contrastsensitivity,thatis,theabilityto
detectdifferencesinthebrightnessoforsubtleshadesofgrayinlargeobjects(OrelBixler,
2014)isalsoofinterestwhenresearchinginfantsabilitytoshareattentionwithsocial
partners.Whereasvisualacuityreferstothesmallestdetailthatapersoncansee,contrast
sensitivitydescribesthesmallestamountofcontrastneededforsomeonetoseelarge
objects.Twoinfantswithsimilarlevelsofvisualacuitycanbehavedifferentlyintheir
abilitytodiscriminateobjectsagainsttheirbackgrounds.Thechildwiththehighest
impairmentincontrastsensitivitywillhavemoredifficultyseeingalargeobjectthatis
againstalowcontrastbackground.Contrastsensitivityisalsorelevantfornavigatingthe
environmente.g.,detectingstairsandcurbs,seeingarouteinlowcontrastssituations
suchasfogandfacediscrimination,i.e.,detectingthefaintshadowsinfacesthatcarrythe
visualinformationrelatedtofacialexpressions(LeaContrastSensitivity,n.d.).Thereis
alsoevidencethatcontrastsensitivityisabetterpredictorofvisualattentionthanvisual
acuity(OrelBixler,HaegerstromPortnoy,&Dornbush,1983).Althoughtypicallythereisa
correlationbetweenvisualacuityandcontrastsensitivity,whenvisionisabnormalthis
correlationisnotasstrongandthuscontrastsensitivitycannotbepredictedbasedon
visualacuity(HaegerstromPortnoy,2004).

1.2Methods

Participants

Thesamplewascomprisedof20infantswithvisualimpairmentswithoutadditional
disabilities.Ofthese,10werefemalesand10weremales.Duetothelowincidenceofthis
populationofinfants,theywererecruitedeitheraslongitudinal(N=7)orcrosssectional

 14

subjects(N=13),pertheircaregiverspreference.Thestudysprotocolwasapprovedby
UniversityofCalifornia,BerkeleysCommitteeforProtectionofHumanSubjects.Priorto
studyprocedures,informedconsentandmediareleaseauthorizationwasobtainedfromall
infantscaregivers.
InfantswererecruitedthroughthecollaborationoftheBlindBabiesFoundation,a
nonprofitthatprovidesdevelopmentalservicesforinfantswithvisualimpairments,and
thepatientpopulationintheInfant/ToddlerClinicandtheSpecialVisualAssessmentClinic
attheUCBerkeleySchoolofOptometry.Beforeagreeingtoenterthestudy,caregivers
wereprovidedwithinformationaboutitsaimsandproceduresandhadaninformational
meetingwiththeleadinvestigator,eitheroverthephoneorinperson.Atthattime,thelead
investigatoransweredanyquestionscaregivershadaboutthestudy.Afterwards,they
decidedwhetherornottheywantedtoparticipateinthestudy.
Sixteeninfantswerebornfulltermand4werebornprematurely.Thegestational
ageoftheprematurebabiesrangedfrom24to34weeks,withameanof30.75weeks(SD=
4.57weeks).Agesreportedinthisstudywerecorrectedforprematurity.Atstudyentrance,
allbuttwoinfantswerereceivinginhomeintervention,rangingfromonetotwo90
minutemonthlyvisitsbyspecialistsinthedevelopmentofvisuallyimpairedinfants.The
othertwoinfantswerebeingcounseledonalessregularbasisbymedicalandschool
professionals.
Infantswerevideotapedathomeinteractingwiththeircaregivers.Homevideo
recordingswerescheduledascloselyaspossibletoinfantsagesof12and18months.
Theseageswerechosensincepreviousresearchhadshownthatcoordinatedjoint
engagementemergestowardtheendofthefirstyearoflifeanditbecomesmoreprevalent
ataround18months(Adamsonetal.,2014;2015).Thecollectedvideosweredividedinto
twoagegroups:a.Age1infantsageisatorbelow1year,2months,28days;b.Age2
infantsageisatorabove1year,2months,29days.
Nineinfants(6females,3males)wereobservedatage1,meanfractionalageof1.08
or1year,28days(SD=0.12).Eighteeninfants(10females,8males)wereobservedatage
2,meanfractionalageof1.62or1year,7months,15days(SD=0.23).Seven(6females,1
male)infantswereobservedatbothages.Table1.1liststheinfantsandtheagesatwhich
eachonewasobserved.Figure1.1showstheagedistribution.

 15

Table1.1:Study1subjectsages.

Subject Age1N=9 Age2N=18

Number M=1.08SD=0.12 M=1.62SD=0.23
MinimumAge=0.91 MinimumAge=1.36
MaximumAge=1.24 MaximumAge=2.3
Years Months Days Years Months Days
1 1 1 25 1 6 25
2 0 10 29 1 5 1
3 2 3 8
4 1 0 12 1 5 26
5 1 2 28 1 6 9
6 1 1 4 1 6 4
7 1 6 7
8 1 0 1 1 6 0
9 1 5 9
10 1 2 26
11 0 11 23 1 6 3
12 1 9 18
13 2 0 5
14 1 7 26
15 1 9 28
16 1 6 17
17 1 0 10
18 1 6 22
19 1 8 16
20 1 4 11

 16

Figure1.1:Study1subjectsagedistribution.

 17

Infantsrace/ethnicitywereasfollows:White=6,Hispanic=5,Asian=2,African
American=1,and6hadmorethanonerace:WhiteandAsian=2,WhiteandHispanic=2,
WhiteandAfricanAmerican=1,White,Asian,HispanicandNativeAmerican=1.

Infants'Race/Ethnicity
AfricanAmerican

Asian

Hispanic
11
2 2
White
2
1 5 White+AfricanAmerican

6 White+Asian

White+Hispanic

White+Asian+Hispanic
+NativeAmerican

Figure1.2:Infantsrace/ethnicity.
Colorareasrepresentpercentage.
Valuesrepresentnumberofsubjects.

 18

Ofthecaregivers,onewastheinfantsbiologicalfather,onewastheadoptive
mother,andtheremaining18werethebiologicalmothers.Caregiversaverageageranged
from19to44years,withameanof31(SD=7).Caregiversrace/ethnicitywereasfollows:
White=11,Hispanic=5,Asian=2,AfricanAmerican=1,and1reportedmorethanone
race:White,Asian,Hispanic,NativeAmerican.Intermsoftheireducationallevel,3
reportedhavingamastersdegree,5abachelorsdegree,8moreofahighschooldiploma
(e.g.,technicalschool,associatedegree),2ahighschooldiploma,and2completedmiddle
school.

CaregiversEducationalLevel

MiddleSchool

3 2
HighschoolDiploma/
2 GED

MorethanHighschool
5

Bachelor'sDegree
8

Master'sDegree

Figure1.3:Caregiverseducationallevel.
Colorareasrepresentpercentage.
Valuesrepresentnumberofsubjects.

 19

Seventeenofthe20caregiversreportedtheirfamiliesannualincome.Theannual
incomedistributionwasheavierinthehighestbin,morethan$95,001(N=5);followedby
thelowerbin,$5,000$10,000,(N=3).

FamilyAnnualIncome

6 5
Frequency

5
4 3
3 2 2
2 1 1 1 1 1 1
1
0
5,00010,000

20,00125,000

35,00140,000

40,00145,000

45,00150,000

55,00160,000

60,00165,000

75,00180,000

80,00185,000

95001+
Income

Figure1.4:Familiesannualincome.

Percapitaincomewascalculatedbydividingthemidvalueoftheincomerange
reportedbycaregiverse.g.,37,500.5inthecaseof$35,00140,000bythenumberof
peoplelivingatthefamilyshome.Avalueof95,001wasusedwhencaregiversreportedan
incomeofmorethan$95,001.Fourfamilieshadapercapitaincomebelow$5,000;4
between$8,750and$15,833;5between$18,750and$20,833;2had$23,750;and2had
$31,667.
Thepercapitaincomevalueswerestandardized.Thedistributionofstandardized
percapitaincomeshowsthat10familieswereabovethesamplesmean;8within1
standarddeviation,and2between1and2standarddeviationsabovethemean.The
remaining8familieswerebelowthemean,4within1standarddeviationand4between1
and2standarddeviationsbelowthemean.
AcompositemeasurementofSESwascomputedaddingthestandardizedincome
percapitaandstandardizedcaregiverseducationallevel.Thedistributionofthecomposite
SESshowsthat8familieswerebelowthemean;5within1standarddeviation,2within1.5
standarddeviations,and1was2standarddeviationsbelowthemean.Theremaining10
familieswereabovethemean;7within1standarddeviation,and3between1and2
standarddeviationsabovethemean.Elevencaregiversreportedreceivingsometypeof
governmentfinancialaid.

 20

CompositeSES

2
1.5
1
0.5
SES

0
0.5
1
1.5
2
2.5
Subject
0 5 10 15 20

Figure1.5:FamiliescompositeSES.

Procedures

Observationalprocedure

Thirtyminutevideorecordingswereperformedateachinfantshome.Atotalof27
videosarereportedinthisstudy.Theirmeandurationis29.9minutes,standarddeviation
of0.1(6.03seconds).
Caregiverswereaskedtochoosearoomwithintheirhomewheretheywouldfeel
comfortableplayingwiththeirinfants.Inordertoobtainavideorecordingasclosetoa
360degreeviewofcaregiverandinfantaspossible,2cameraswithwideanglelenses
wereplaceddirectlyinfrontofandbehindthecaregiverandchild.Thisarrangement
maximizedthecaptureofthestudyparticipantsactivityeveniftheymovedinspace.

 21

Observationalconditions

Inordertoallowforthemostnaturalisticobservation,caregiverswereinstructedto
playwiththeirinfantsastheywouldnormallydo.Giventhatchildrenwithvisual
impairmentsbenefitfromrepeatedexplorationoftoysandperformattheirbestinfamiliar
environmentsandwithfamiliarobjects(Luecketal.,2008),duringthefirst15minutesof
thevideorecordingcaregiverswereaskedtousetheirinfant'stoys.Duringthevideo
recordingofthefirst15minutestheleadinvestigatorwaitedinadifferentroom.
Toaddressinfant'sexpecteddifferencesinsocioeconomicstatus,forthenext15
minutescaregiverswereprovidedwithastandardsetoftoysbroughtbythelead
investigator.Thisstandardsetoftoyswascompiledtakingintoconsiderationinfants
absentordegradedvisualabilities,andthusitincludedtoysthataffordedadiversityof
sensoryexperiences.Specifically:atoywith5finemotoroperatedpopupfigures;3
mittenswithadifferenttextureoneachside;aredmylarpompom;4differentrattles;2
bookswithsimpledrawings/picturesandseveraltextures;3bellsofdifferentcolorand
sound;aradiotoy;ametalliccontainer;apuffyballmadeofelastic;arollingredcar;6
singlecoloredwoodencubes(3yellow,1red,1green,1blue);2rectangleseachwith
singlecolor;4cylinderseachwithsinglecolor;acubewithdifferenttextureoneachside;8
bigLegopieces;ashaker;andalightuptoy(Figure1.6).

Figure1.6:Standardsetoftoysusedinthejointengagementsessions.


Whenthefirst15minutesofrecordingwerecompleted,theleadinvestigatorcame
intotheroom,gavethecaregiverabagwiththestandardsetoftoys,andhelpedherput
awaytheinfantstoys.Theleadinvestigatorlefttheroomuntilthesecond15minutesof
recordingwerecompleted.

 22

Codes:Jointengagementandnonjointengagement

Thisstudyfocusedontwobehavioralcodes:jointengagementandnonjoint
engagement.Thesecodesdefinitionsarebasedonthecodingprotocoldevelopedby
BakemanandAdamson(1984;Adamson&Bakeman,1985;Adamson,Bakeman&Deckner,
2004;Adamsonetal.,2012;Adamsonetal.,2014;Nelson,Adamson&Bakeman,2008).
Somemodificationsweredonetotheircodingprotocolbasedonpreliminaryobservations
ofthisstudysvideorecordings.Inwhatfollowsandwheneverappropriatesuch
modificationswillbeexplained.
Thecodingprotocolaimstosegmenttheinfantsactivitiesintotwomutually
exclusivebehavioralstates:
Jointengagement:whenthechildisconcurrentlyengagedwithbothanobjectanda
person.
Nonjointengagement:whenthechildisengagedsolelywithanobjectorsolely
withaperson.
Inthisstudyaninfantwasconsideredtobeinstateofengagementgiveneitherof
twoindicators:
Hewasattendingtotheobjectand/orpersonusinganyoneorcombinationof
sensorychannels.Forexample:theinfantlistenedtothemothersspeechortothe
musicemanatingfromatoy.
Hewasperforminganactionthatinvolvedtheobjectand/orperson.Forexample:
theinfantgrabbedandmovedthecaregivershandoratoy.Bydefinition,inthis
typeofsituationtheinfantwasalsoattendingtotheobject.

Jointengagement

Theinfantwasconsideredtobeinastateofjointengagementifhewasengaged
withthesameobjectoreventthatthecaregiverwasengagedwith,andifthecaregiverwas
involvedintheactivity.Forexample,thechildrolledaballtowardthecaregiver,the
caregiverrolleditbacktotheinfant,andsoon.UnlikeinAdamsonandBakemansprotocol
(Adamson&Bakeman,1984;Adamsonetal.,2014),inthisstudyifthecaregivercalledthe
childsattentiontoanobjectandasaconsequencethechildattendedtoit,thechildwas
consideredtobeinjointengagement,evenifhedidnoteventuallyactontheobject.Inthe
originalcodingprotocolthissituationwouldbecodedinsteadasnonjointengagement
sinceitwouldconsiderthatthechildwasnotactivelyengagedwiththeobject.Inthis
studysprotocol,suchqualificationofthechildsengagementwasnotrequired.Aslongas
thecaregiverintentionallycalledthechildsattentionandasaconsequencetheinfant
switchedhisattentionfromapreviousfocustosuchobject,thechildwasconsideredtobe
injointengagement.Butifthechildonhisownswitchedhisattentiontothecaregivers
engagementwiththeobject,withoutthecaregiverhavingcalledthechildsattentiontoit,
thiswascodedasnonjointengagement.
Thejointengagementcodedoesnotrequirethechildtoactivelyacknowledgethe
caregiversparticipationinthejointengagementwiththesameobject.Continuingwiththe
exampleabove,ifthechildfeltthevibrationsproducedbyhismotherstappingontheball
withoutshowinganyovertsignsofnoticingthemothersroleinthisexperience,thechild

 23

wouldbecodedasbeinginjointengagement.Thechildwouldalsobecodedasbeingin
jointengagementifbesidesfeelingthevibration,healsoturnedhisfaceandupperbody
towardmomandvocalizedtowardher.
However,ifthechildrolledtheballtowardthecaregiver,theballtouchedthe
caregiverandasaresultbouncedbacktothechildwhilethecaregiverwassearchingfor
somethingelseandthusnotattendingtothechildsaction,thechildwasnotcodedasbeing
injointengagement.Likewise,thechildwasnotcodedasbeinginjointengagementifthe
childwasattendingtothecaregiveractingonanobjectandthecaregiversattentionwas
onlyontheobject.Forinstance,thefatherstartedtoshakeapompom,theinfantturnedto
thecaregiverandlistenedtothepompomssound,andthefathercontinuedsolelyfocused
onshakingthepompom.
Achildwasalsonotcodedasbeinginjointengagementifthechildwasengaged
withanobjectwhilethecaregiverwasmerelynarratingtheinfantsactionwithout
participatinginit.Forexample,thechildwasbouncingaballwhilethemothersaid,You
wanttoplaywiththeballnow.However,ifafterthemothersspeech,thechildturned
towardherandlaughedwhilecontinuingtobouncetheball,andthemotherlaughedin
response,thiswouldbecodedasjointengagement.Similarly,ifthemotherthenstarted
tappingwithherhandsontheballandasaresultthechildstoppedbouncingitandfelt
withherhandsthevibrationsarisingfromthemomstapping,thechildwouldbe
consideredasbeinginjointengagement.Intheselasttwocases,themothersengagement
withtheobjectinfluencedthechildsengagementwithit.Intheformer,thechildwent
fromfocusingsolelyontheobjecttocoordinatinghisattentiontobothobjectandmother;
inthelatter,thechildmodifiedhisactionontheobjectasaconsequenceofthemothers
actiononit.

Nonjointengagement

Theinfantwasconsideredtobeinastateofnonjointengagementifhe:
a. Engagedonlywithapersone.g.,thechildlistenstothecaregiversspeech.
b. Engagedonlywithanobjecte.g.,thechildmouthsatoy.
c. Searchedforsomethingtoengagewithwithoutengagingwithanyobjectand/or
personfor3ormoreseconds.E.g.,thechildfleetinglytouchesseveraltoys.
d. Criedwithoutthisbeingpartofaninteractionwithaperson.E.g.,thechildcries
withoutattendingtoanyexternalfocuswhetherobjectorperson.
e. Observedthecaregiversactingonanobject,ifthecaregiverhadnotcausedthe
childtobeginattendingtoheractionontheobject.E.g.,themotherstarts
turningpagesofabook,andthenthechildstopshispreviousactionandlistens
tothesoundofthepagesbeingturned.(ButunlikeinAdamsonandBakemans
protocol,ifthecaregiverintentionallycalledtheinfantsattentiontoheraction
onthebook,andconsequentlythechildswitchedherattentionfromitsprevious
focustothecaregiversactiononit,thiswascodedasjointengagementevenif
thechilddidnoteventuallymanipulatethebook.)
f. Wasengagedwithhisownbodymovement,whetherherwholebodyoronly
partofit.E.g.,thechildshakesherheadsidetoside.Thisisanadditionaltypeof
situationfromBakemanandAdamsonsprotocol(Bakeman&Adamson,1984;
Adamsonetal.,2014).

 24

Asdefinedabove,thisstudysbehavioralcodedefinitionsaresociallybased.They
requirethecodertodecidewhethertheobservedbehaviorfulfillsthecodesconceptual
criteria.Theexampleslistedundereachcodeareexemplarsandnotexhaustivethatis,
thecodercanclassifyanobservedbehaviorunderaparticularcodeevenifitdoesnot
matchanyparticularexampleinthecodingprotocol(Yoder&Symons,2010).This
characteristicofsociallybasedcodedefinitionsisparticularlyusefulsincethisstudy
appliesacodingprotocoltoapopulationdifferentthantheoneitwasoriginallydesigned
for.Specifically,BakemanandAdamsons(1984)protocolwasoriginallydesignedforthe
studyoffullysightedchildren.However,researchershaveappliedtheprotocoltochildren
withautismspectrumdisorder(Adamsonetal.,2012;BottemaBeutel,Yoder,Hochman&
Watson,2014).
Thisstudyscodesaremutuallyexclusive;aparticularbehaviorcannotbecodedas
bothjointengagementandnonjointengagement.Theyarealsoexhaustivemeaningthat
theyoughttoaccountforalloftheobservedbehaviors(Bakeman&Quera,2011).
InBakemanandAdamsonsprotocol(Bakeman&Adamson,1984;Adamsonetal.,2014)
anengagementstate,whetherjointengagementornonjointengagement,mustlastatleast
3seconds.Variationsintheinfantsengagementthatlastlessthan3secondsarenotcoded
asaseparatestate.However,inthisstudythisrulewasonlyappliedfornonjoint
engagementepisodes.Preliminaryreviewofvideorecordingsshowedthatsomeofthe
infantsinthesampledidnotengagewiththeircaregiversinepisodesofjointengagement
thatlastedatleast3seconds.However,theydidengageinepisodesofjointengagement
thatlastedlessthan3seconds.Itwasdecidedthatamoreaccurateportraitofthejoint
engagementinthisstudyssamplewouldbeobtainedifsuchepisodeswereaccountedfor.
Thus,inthisstudythecodejointengagementdidnothavetolastatleast3seconds.It
shouldbenotedthatthevideosthatwerepreliminarilyreviewed,andwhichleadtothis
modification,arenotpartofthedatapresentedhere;insteadtheywerevideosofthe
infantsrecordedatagesnotreportedinthisstudy.Toseethefullcodingprotocol,please
refertoappendix1.Inordertoaidcoders,adecisionflowchartwasdeveloped(Figure
1.7).

 25

Figure1.7:Codingdecisionflowchart

 26

Codingprocedures

Thisstudyusedacontinuousbehaviorsampling;the30minutevideoswerecoded
intheirentirety.Althoughthismethodisthemosttimedemanding,itwaschosenbecause
itprovidesthemostcompletecoding.Behaviorswerecodedastimedeventsthatis,the
beginning and ending times of their corresponding codes were registered. Timed events
were chosen since states of engagement extend over time and thus their extension was
deemedmorerelevantthantheircounts(Yoder&Symons,2010).
Videoswerecodedinanexhaustiveandexclusivemanner;eachsecondofthe30
minute videos were coded as only one of the two studys codes. The resulting data files
consistedofasequenceofbehavioralcodeswiththeirbeginningandendingtimes,without
timegapsoroverlappingcodes.Thistypeofsystematicobservationalmeasurementallows
forthecalculationofmetricssuchasthepercentageoftimeagivencodewasobservedina
session.
Codersviewedavideountiltheyconsideredthatachangeinthechildsengagement
statehadoccurred.Thencodersreviewedtherelevantportionofthevideoasmanytimes
as needed in order to determine the seam between engagement states. Codes and their
durations were entered automatically into computer files using Mangold Internationals
INTERACT (http://www.mangoldinternational.com). A 30minute video took on average
12to16hourstocode.
Afirstcodertheleadinvestigatorcodedall30minutevideorecordings(N=27).
Forreliabilitypurposes,asecondcoderaresearchassistantcoded48.15%ofthetotal
sample(N=13).Ofthe13videosincludedinthereliabilitysampleandtoapproximatethe
studys full sample distribution in terms of ages, more videos corresponded to infants
observedatage2(N=9),andfewervideosatage1(N=4).
The first coder trained the second in the use of the coding protocol. The training
included: readings and discussions regarding the concept of joint engagement; review of
the coding protocol; and review of written and videotaped examples of behavioral codes.
Bothcodersweremaskedtotheinfantsvisualstatus.

Agreement

Prior to coding for reliability, coders worked on achieving an agreement criterion.

Thevideosusedforthisprocesswerenotincludedinthedatareportedinthisstudy.
Eachcoderindependentlycodedthesamevideo.Foreachvideo,codersconducted
exactpointbypointagreementchecks,thatis,theycomparedboththecodesassignedand
their onset and offset times. Coding disagreements were identified and discussed until
coders reached a consensus. When necessary, the coding protocol was updated to better
formulate its behavioral codes. These updates included: identification of new examples,
nonexamplesandnearnonexamplesofcodes;writtenclarificationsofthecodescriteria;
andthecreationofadditionalcodingrulestodisambiguateareasofdisagreement.
To assess the changes in coders agreement level two reliability statistics, Cohens
kappa and percentage agreement, were calculated for each video. There is no agreement
among researchers regarding gold standards for kappa values although some have been
proposed,e.g.,<.40=poor;.40.75=fairtogood;>.75=excellent.However,kappavalues
are influenced by several factors such as the prevalence of codes in the studys sample.

 27

Accordingtothisperspectivenogoldstandardisvalidbutratherakappavalueoughttobe
interpreted considering the factors that influence it. Given that factors such as behavior
prevalence are not available until the whole study sample is coded, and following the
literature in the social sciences, the agreement criterion for this study was defined as a
percentageagreementof8085%(Bruckner&Yoder,2006;Bakeman&Quera,2011;Sim
&Wright,2005;Viera&Garrett,2005;YoderandSymons,2010).

Reliability

Once the agreement goal was obtained, coders started the process of establishing
reliability using videos from the sample reported in this study. After both coders
independentlycodedavideo,Cohenskappaandpercentageagreementswerecalculated.If
the percentage agreement decreased noticeably between two coded videos, coders
reviewed their disagreements before coding the next case. No videos included in the
reliability sample were recycled. That is, none were recoded after the coders first
attemptdidnotreachthereliabilitycriterion.

Comprehensivevisionexamination

InfantsunderwentacomprehensivevisionexaminationintheClinicalResearch
CenterattheUCBerkeleySchoolofOptometry.Thecomprehensiveeyeexamination
includedastandardbatteryofassessments.Priortoexamination,acompletehistorywas
takenincludingareviewofanydrugsensitivitiesandpreviousmedicalrecords.Thevision
examinationincludedmeasurementsofocularalignment,fixationandmotility(an
assessmentofthepostureoftheeyes,whicheyeispreferredforfixation,andtheabilityto
movetheeyes),refractiveerror(focusingerroroftheeyestodeterminetheneedfor
glasses)andthehealthoftheeyes(integrityoftheanteriorandposteriorstructuresofthe
eyes).Thefollowingmeasuresofvisualabilitiesorvisionfunctionwereobtained:visual
acuity(abilitytoseefinedetails),contrastsensitivity(abilitytoseebrightnessdifferences),
colorvision,andconfrontationvisualfields(abilitytofindobjectsintheperiphery).
Duringthevisionexaminationeveryinfantreceivedeyedrops;atopicalanesthetic
(0.5%Ophthaine)followedbyacycloplegicagent(1%Cyclopentolate).Theseeyedrops
werenecessarytorelaxaccommodationforaccurateassessmentofrefractiveerror,andto
dilatethepupiltofacilitatetheocularhealthevaluation.Theinfantsreceivedsunglassesto
wearhomeaftertheexaminationsincedilatedpupilsmayincreasesensitivitytosunlight.
Measuresofvisionfunctionwereobtainedwithtestsusedroutinelyduringinfant
andtoddlereyeexaminations.Preferentiallooking(PL)testingprocedureswereappliedto
measurevisualacuity,contrastsensitivity,andcolorvisionbasedonthebehavioral
lookingresponsesoftheinfant(Teller,1997).Behavioralbasedmeasuresofvision
functionmaybeaffectedbothbythechildsvisualimpairmentandtheirperformance
ability.Forthisreason,anobjectivemeasureofacuity,suchasvisualevokedpotential
(VEP)testing,maybeamoreaccuratemethodofassessingvisualacuityofinfantsand
youngchildren.TheVEPprovidesgeneralinformationaboutgeniculocalcarinefunction
andoccipitalresponsestovisualstimuli.BecausetheVEPrepresentsaneuralresponse,
neitheraverbalormotorresponseisrequired.Toobjectivelymeasurevisualacuityand

 28

contrastsensitivity,thesweepVisualEvokedPotential(VEP)testwasperformed.This
procedurehaswellestablishednormsforinfants(Norcia,1994).
TheVEPmeasurementinvolvesrecordingthesmallelectricalsignalsthatare
generatedwithintheoccipitallobeofthebrainwhiletheinfantviewspatternreversing
stripesonavideomonitorlocatedat50cm.Torecordthesignals,5sensorswereplacedon
theinfantsscalpovertheoccipitallobeofthebrain.Conductivepastewasappliedbetween
thesensorsandthescalp,whichwererinsedawaywithwaterafterthemeasurements
weretaken.Thesensorsandpastecausednodiscomfort.Theinfantsmerelyneededto
attendtothevideomonitorforeachtensecondtrialduringwhichnineteendifferentblack
andwhitestripewidthswerepresented.TheamplitudeoftheVEPresponsedecreases
proportionatelyasthewidthofthestripesdecreasesacrossthetrial.Acomputeranalyzed
theVEPresponseandscoredthetrialtoindicatethefineststripewidththatelicitedaVEP
responseandthisstripewidthwasreportedasthevisualacuityoftheinfant.Similarly,
contrastsensitivitywasmeasuredbyalteringthecontrast(subtlebrightnessdifferencesor
shadesofgrey)ofthestripes.TheVEPproceduresusedinthisprotocolarestandard,not
experimental,clinicalprocedures.Eachcompleteeyeexaminationtookupto60minutes,
includingtimewaitingfordilationofthepupils,andthePLandVEPmeasurements.

Demographicsurvey

Atstudysexit,caregiverswereaskedtocompleteademographicsurvey.The
surveyconsistedof9questionsregardingdemographicinformationoftheinfant,caregiver
andtheirfamiliese.g.,householdannualincome,infantrace/ethnicity(appendix2).
Caregiverswereinformedthatthepurposeofthisdatacollectionwastobetter
characterizethestudyssample.Theywerealsoassuredthattheiranswerswereprivate
andconfidential.Thesurveywasprovidedviaregularmailand/oremailperparents
preference,andtheychoseeitherofthesetwomailingsystemstoreturntheanswered
surveys.SpanishmonolingualcaregiverswereprovidedthesurveyinSpanish.

Dataanalysis

Reliabilityofcoders

Twocodersaresaidtobereliablewhentheybothassignthesamecodetothesame
observedbehavior.Inordertomeasurereliability,Cohenskappawascalculatedusingthe
GSEQprogram(Bakeman&Quera,2011).Unlikeotherstatisticssuchaspercentage
agreement,kappatakesintoconsiderationtheagreementthatcouldbearesultofchance
i.e.,asifcodersweretoassigncodesrandomly(Bruckner&Yoder,2006;Bakeman&
Quera,2011;Sim&Wright,2005;Viera&Garrett,2005;Yoder&Symons,2010).
Cohenskappawasoriginallyformulatedforsituationsinwhichthenumberof
codingdecisionswaspredetermined,andthusequalforbothobservers,e.g.,thenumber
ofquestionsinasurvey.Unlikethatsituation,thisstudydidnotpresentthecoderswitha
predeterminedandequalnumberofbehaviorstocode.Instead,partofthecodingprocess
foreachobserverconsistedindeterminingtheseamsbetweenevents.Aneventrefersto
anobservedbehaviorthatoughttobeassignedtoaparticularcode.Inasituationlikethis,

 29

thenumberofeventswillmostlikelybedifferentforeachcoder.Therefore,theclassical
kappaformulawasnotappropriateandamodifiedversionwasused(Bakeman&Quera,
2011;Bakeman,Quera&Gnisci,2009;Sim&Wright,2005).
Givenadifferentnumberofeventsperobserver,beforekappacalculationthetwo
sequencesofeventsonefromeachcoderneedtobealigned.Thiswasachievedusinga
timebasedalignmentinwhicheventswerealignedintermsofatimewindowcomposedof
thesamenumberofsecondsforeachcoder.Inpreviousresearchonjointengagement,a
toleranceof2secondswasallowed,whichleadto5secondwindowsbeingcomparedthe
currentsecondplus2beforeandafterit(Adamsonetal.,2014).Thecomparison
consideredeachsecondforcoder1andlookedforamatchinanytimeunitofthe5second
windowfromcoder2.Ifcoder2assignedthesamecodeascoder1inanyofthose5
secondsthiswascountedasanagreement(Bakeman&Quera,2011;Bakemanetal.,2009).
Sincethereisnouniversallyacceptedgoldstandardtoevaluatekappavalues,bias
andprevalenceindexesandmaximumkappawerecalculatedtoaidtheinterpretationof
theobtainedkappa.Thebiasindexexpressestheextenttowhichcodersdisagreeonthe
proportiontheydetermineacodeaspresentorabsent.Ifthereisalargebias,thevalueof
kappaishigherthanwhenbiasisloworabsent.Theprevalenceindexmeasuresthe
existenceofaneffectduetotheprevalenceofthecode.Ahighprevalenceindexindicates
thattheprevalenceofthecodespresenceiseitherveryhighorverylow.Insuchcase,
chanceagreementishighandthekappavalueisthusreduced.Maximumkappareportsthe
valuewhencodersagreetothemaximumextentpossiblegivenobserverbias.Whenthere
arefewerthanfivecodes,especiallytwoasinthisstudy,lowervaluesofkappaare
acceptable.Finally,codersaccuracywascalculatedbasedontheobtainedkappavalueand
codesbaserates.(Bruckner&Yoder,2006;Bakeman&Quera,2011;Sim&Wright,2005;
Yoder&Symons,2010).

Agechangesintheamountoftimeinfantswereinjointengagement

Studieswithsightedinfantsshowthattheamountoftimetheyspendinjoint
engagementincreaseswithage(Adamsonetal.,2014;Adamsonetal.,2004;Adamson&
Bakeman,2006).Todeterminehowtheamountoftimeinfantsinthisstudywereinjoint
engagementchangedwithage,thepercentageoftimejointengagementwascodedwas
calculatedforeachvideousingInteract(http://www.mangoldinternational.com).
Percentageswerecalculatedseparatelyfor:
a.Toys1:thefirst15minutesofvideorecording,wheninfantsusedtheirowntoys
b.Toys2:thesecond15minutes,wheninfantsusedthestandardsetoftoys
providedbytheinvestigator.
Todifferentiateresultsdependingonthelengthofthejointengagementepisodes,
percentageswerecalculatedseparatelyfor:
a.Jointengagementepisodesofanyduration.
b.Jointengagementepisodesthatlastedatleast3seconds.
Then,theaverageandstandarddeviationofthepercentageoftimeinjoint
engagementwerecalculatedseparatelyforinfantsinage1andinfantsage2.All
calculationsweredoneusingR(TheRFoundationforStatisticalComputing,Vienna,
Austria).

 30

Todetermineifthedifferenceinthemeanpercentagesatage1versusage2were
significant,twotailedttestswithWelchscorrectiontodegreesoffreedomwere
calculated.TheWelchscorrectiontoallowforunequalvariancewasusedgiventhe
unequalnumberofinfantsineachagegroup.
Todetermineiftherewasasignificantdifferenceintheaveragelengthofjoint
engagementeventsbetweenages1and2,twotailedttestswithWelchscorrectionto
degreesoffreedomwerecalculated.
AlltteststatisticsweredoneusingR(TheRFoundationforStatisticalComputing,
Vienna,Austria).

Relationshipbetweeninfantstimeinjointengagementandvisuallevels

Todetermineiftherewasasignificantrelationshipbetweeninfantsvisualfunction
andtheamountoftimetheyparticipatedinjointengagement,regressionanalysiswas
calculatedwithinfantsage,visualacuityandcontrastsensitivityasindependentvariables,
andpercentageoftimeinjointengagementasthedependentvariable.
Visualacuityimprovesduringthefirstfewyearsoflife.Adultlevelsofacuityare
reachedbytheendofthefirstyearwhenmeasuredwiththeVEPbutnotuntil3yearsof
agewhenmeasuredwithpreferentiallookingtechniques.Visualacuityisexpressedin
termsofthelogoftheminimumangleofresolutionorlogMAR.Each0.1inlogMAR
correspondstoonelineonaneyechart.Forexample,normalvisualacuityof20/20
correspondstologMAR=0;anacuityof20/200acuitycorrespondstologMAR=1,thatis,
adifferenceof10linesontheeyechartbetweenthepersonsacuityandthenorm.Since
visualacuitynormsvarydependingoninfantsages,eachinfantsreductioninvisualacuity
fromtheagenormwascalculated(inlogMAR)foreachofthetwoproceduresused,VEP
andPL.
Contrastsensitivityhasamorerapidrateofdevelopmentthanvisualacuity,
reachingnearadultlevelsbyoneyearofagewithbothVEPandPLtechniques.Contrast
sensitivityvaluesforboththeVEPandPLwereexpressedasthelowestdetectable
contrastinpercentages.ThecontrastlevelsavailableontheMr.Happytesttargetsranged
fromamaximumof80%(nearlyblackandwhite)totheloweravailablecontrastof1.6%.
ThecontrastlevelsontheVEPtesttargetsrangedfrom80%to0.1%Michelsoncontrast.
Todetermineiftherewasasignificantdifferenceinthevisualimpairmentlevels
representedatage1andage2,twotailedttestswithWelchscorrectiontodegreesof
freedomwerecalculatedforeachofthefourvisualmeasurementsvisualacuityand
contrastsensitivityresultsbasedonbothvisualevokedpotentialandpreferentiallooking.
Todetermineiftheresultsfromthevisualevokedpotentialandpreferentiallooking
werecorrelated,correlationswithincontrastandacuitymeasureswerecomputedusing
Spearman'srho,asthesemeasuresdidnotappearNormalbasedonQQplots(exceptthe
preferentiallookingmeasureofacuity,whichappearedapproximatelyNormal).

 31

1.3Results

Reliabilitystatistics

Thekappa value was.85 regardlessof which ofthe twocoderswas considered as

thefirstinthekappacalculation(Table1.2).Themaximumkappawas.991.Thevaluesof
kapparangefrom1to1.Avalueof0signifiesthatcodersagreedatnomoreorlessthan
chance would allow for. Values below zero indicate agreement below chancei.e.,
potential systematic disagreements between observers; positive values represent
agreementabovechancewithavalueof1beingperfectagreement.
The bias index was 0.001 and the prevalence index was 0.35. The base rate of the
codejointengagementwas.32,andthatofnonjointengagementwas.68.Consideringthe
baseratesandtheobtainedkappaof.85itwasestimatedthatobserversaccuracyranged
between0.95and0.99(Bruckner&Yoder,2006;Sim&Wright,2005).


Table1.2:Kapparesult,jointengagement.

.85Timeunitkappa,window=2seconds.
93%Percentageagreement.
1.00.99Maximumvalueofkappa.
Numbersincellsrepresentseconds.

Coder2
Joint NonJoint
Totals
Engagement Engagement
Joint
6,762 798 7,560
Engagement
Coder1
NonJoint
753 15,043 15,796
Engagement
Totals 7,515 15,841 23,356

Agechangesintheamountoftimeinfantswereinjointengagement

Toys1

Whenjointengagementeventsofanydurationwereconsidered,theaverage
percentageoftimeinjointengagementatage1(M=27.67,SD=15.87,N=9)was
significantlydifferentthantheaverageatage2(M=43.85,SD=22.90,N=18),twotailed

 32

ttestwithWelchscorrectiontodegreesoffreedomt(22.07)=2.14,p=0.436(Table1.3,
Figure1.8).
Whenonlyjointengagementeventsthatlasted3secondsormorewereconsidered,
asignificantdifferencewasalsofoundbetweenage1(M=26.93,SD=15.77,N=9)andage
2(M=43.04,SD=23.32,N=18),twotailedttestwithWelchscorrectiontodegreesof
freedomt(22.44)=2.12,p=0.045(Table1.3,Figure1.8).
Twooutofthesevenlongitudinalsubjectsshowedadecreaseinpercentageinjoint
engagementbetweenages1and2.Inonecasethepercentagedecreasedby20.26points;
intheother,by15.18points.

Toys2

Whenjointengagementeventsofanydurationwereconsidered,nosignificant
differencewasfoundbetweenage1(M=27.09,SD=16.78,N=9)andage2(M=37.11,SD
=22.49,N=18),twotailedttestwithWelchscorrectiontodegreesoffreedomt(20.89)=
1.30p=.208(Table1.3).
Likewise,whenonlyjointengagementeventsthatlasted3ormoresecondswere
considered,nosignificantdifferencewasfoundbetweenage1(M=26.41,SD=16.48,N=
9)andage2(M=35.95,SD=22.70,N=18),twotailedttestwithWelchscorrectionto
degreesoffreedomresultt(21.34)=1.24,p=0.227(Table1.3).

 33

Table1.3:Twotailedunequalvariancettests(WelchsCorrectiontodegreesoffreedom)
resultsforcomparisonofthepercentageoftimeinjointengagementatages1and2.

PercentageofTimeinJointEngagement,
Mean(SD)
teststatistic
Metric Age1 Age2 pvalue

(N=9,ageM=1.08, (N=18,ageM=1.62,
SD=0.12,min=0.91, SD=0.23,min=1.36,
max=1.24) max=2.3)
Joint 27.67(15.87) 43.85(22.90) t(22.07)=2.14 0.044*
engagement
anylength
toys1
Joint 27.09(16.78) 37.11(22.49) t(20.89)=1.30 0.208
engagement
anylength
toys2
Joint 26.93(15.77) 43.04(23.32) t(22.44)=2.12 0.045*
engagement
>=3seconds
toys1
Joint 26.41(16.48) 35.95(22.70) t(21.34)=1.24 0.227
engagement
>=3seconds
toys2

 34

Figure1.8:Jointengagement(withSEMs)atages1and2withtoys1and2.

Itisnoteworthythatatage1thepercentagesoftimeinjointengagementwithtoys
1(M=27.67,SD=15.87)andtoys2(M=27.09,SD=16.78)weresimilarwhereasatage2
thereisadecreaseinthepercentageoftimeinjointengagementfromtoys1(M=43.85,SD
=22.90)totoys2(M=37.11,SD=22.49).Thechangeinthepercentageoftimeinjoint
engagementfromtoys1totoys2forage1(M=0.58,SD=16.60)andage2(M=6.74,SD=
19.55)werenotsignificantlydifferent,twotailedttestwithWelchscorrectiontodegrees
offreedomt(18.71)=0.86,p=0.403.Giventhattheorderoftoys1and2werenot
counterbalanceditisnotpossibletodeterminewhatisdrivingthedifferenceinresults
withtoys1(significant)andtoys2(notsignificant);factorscouldincludethetypeoftoys,
passingoftime(i.e.,subjectsfatigue),ordifferentamountsofcaregiversscaffoldingatthe
twoages.

 35

Eventhoughnosignificantdifferencewasfoundinthepercentageoftimeinjoint
engagementwithtoys2betweenages1and2,collapsingacrossthepercentageoftimein
jointengagementiscorrelatedbetweenthetwosetsoftoys,agesthereisapositive
correlationbetweenthepercentageoftime,Pearsontestr=.37,p=0.001(Figure1.9).
Thissuggeststhatinfantswhoinrelationtotheiragegroupperformancehadahigh
percentageoftimeinjointengagementwithtoys1alsohadahighpercentagewithtoys2.

Figure1.9:Scatterplotofparticipantspercentagesoftimeinjointengagement,fortoys1
and2,collapsedacrossages.Regressionresults(withequivalentPearsoncorrelation)
shown.

Agechangesintheaveragedurationofjointengagementevents

 36

Giventhatasignificantchangeinaveragepercentageofjointengagementwasfound
regardlessoftheexclusionofepisodesshorterthan3seconds,agechangesinaverage
durationweredoneconsideringjointengagementeventsofanylength.

 37

Toys1

Anearlysignificanttrendwasfoundbetweentheaveragelengthofjoint
engagementeventsatage1(M=13.04,SD=5.82,N=9)andage2(M=33.97,SD=42.32,
N=18),twotailedttestwithWelchscorrectiontodegreesoffreedomt(18.21)=2.10,p=
0.054.

Toys2

Nosignificantdifferencewasfoundbetweenages1(M=13.22,SD=7.13,N=8)
andage2(M=21.44,SD=30.31,N=18),twotailedttestwithWelchscorrectionto
degreesoffreedomt(20.44)=1.09p=0.288.

Table1.4:Twotailedttests(Welchscorrectiontodegreesoffreedom)resultsfor
comparisonofaveragedurationofjointengagementepisodesatages1and2.

DurationofJointEngagementEpisodes,
Mean(SD)
teststatistic
Metric Age1 Age2 pvalue

(N=9,ageM=1.08, (N=18,ageM=1.62,
SD=0.12,min=0.91, SD=0.23,min=1.36,
max=1.24) max=2.3)
Average 13.04(5.82) 33.6(42.32) t(18.21)=2.10 .054.
duration
joint
engagement
anylength
toys1

Average 13.22(7.13) 21.44(30.31) t(20.44)=1.09 0.288
duration
joint
engagement
anylength
toys2

 38

Relationshipbetweeninfantstimeinjointengagementandvisuallevels

Infantsvisuallevels

Table1.5showsage1infantsreductionfromvisualacuity(VA)normsgroupedinto
4binsverymild,mild,moderate,severeandinfantsreductionsfromcontrast
sensitivity(CS)normsinto2binswithinnorm,belownorm.Resultsofthevisualevoked
potential(VEP)andpreferentiallookingtechnique(PL)areshown.Table1.6doesthisfor
age2.

Table1.5:InfantsreductionfromVAandCSnormsatage1.

Table1.6:InfantsreductionfromVAandCSnormsatage2.

Theaveragevisualacuityreductionfromnormbasedonthevisualevokedpotential
atages1(M=0.55,SD=0.31,N=9)and2(M=0.44,SD=0.22,N=18)werenot
significantlydifferent,twotailedttestwithWelchscorrectiontodegreesoffreedom
t(12.25)=0.98,p=0.34.Likewise,theaveragevisualacuityreductionfromnormbasedon
preferentiallookingatages1(M=0.54,SD=0.67,N=9)and2(M=0.54,SD=0.65,N=
18)werealsonotsignificantlydifferent,twotailedttestwithWelchscorrectionto
degreesoffreedomt(15.86)=0.03,p=0.98(Table1.7).
Theaveragecontrastsensitivityreductionfromnormbasedonthevisualevoked
potentialatages1(M=5.13,SD=2.57,N=9)and2(M=5.41,SD=2.53,N=18)werenot
significantlydifferent,twotailedttestwithWelchscorrectiontodegreesoffreedom

 39

t(9.79)=1.35,p=0.208.Likewise,theaveragecontrastsensitivityreductionfromnorm
basedonpreferentiallookingatages1(M=29.56,SD=18.24,N=9)and2(M=37.95,SD
=30.06,N=18)werenotsignificantlydifferent,twotailedttestwithWelchscorrectionto
degreesoffreedomt(13.20)=0.78,p=0.449(Table1.7).
Theseresultssuggestthatthelevelsofvisualimpairmentofbothvisualacuityand
contrastsensitivityrepresentedatages1and2arecomparable.

Table1.7:Twotailedttests(Welchscorrectiontodegreesoffreedom)resultsfor
comparisonofinfantsvisualreductionsfromnormsatages1and2.

Metric InfantsVisionReductionsfromNorms, teststatistic pvalue

Mean(SD)

Age1 Age2
(N=9,ageM=1.08, (N=18,ageM=1.62,
SD=0.12,min=0.91, SD=0.23,min=1.36,
max=1.24) max=2.3)
VEP 0.55(0.31) 0.44(0.22) t(12.25)=0.98 0.34
VisualAcuity
PL 0.54(0.67) 0.54(0.65) t(15.86)=0.03 0.98
VisualAcuity
VEPContrast 5.13(2.57) 5.41(2.53) t(9.79)=1.35 0.208
Sensitivity
PLContrast 29.56(18.24) 37.95(30.06) t(13.20)=0.78 0.449
Sensitivity

 40

Modelsofjointengagement

Participantsandage

Someparticipantswerelongitudinal,andwerethereforerepresentedtwiceinthe
data,atbothages1and2.Therefore,itwasinvestigatedwhetherarandomorfixed
interceptforparticipantwouldbenecessary,neitherofwhichwere.Modelswithrandom
interceptsforparticipantswerenotbetterthaninterceptonlymodelsfortoys1X2(1)<
0.001,p=1.000;nortoys2X2(1)=0.99,p=0.319.Modelswithfixedinterceptsfor
participantswerealsonotbetterthaninterceptonlymodelsfortoys1F(19,7)=0.63,p=
0.80;nortoys2F(19,7)=2.33,p=0.128.Therefore,interceptsforparticipantswerenot
includedinfurthermodels.
Agewasalsonotasignificantlinearpredictorofjointengagement,comparedtoan
interceptonlymodel,fortoys1F(1,25)=1.37,p=0.254,norfortoys2,F(1,25)=1.37,
p=0.254,andwasthereforenotincludedinfurthermodels.

Relationshipbetweenindependentvariables

Collapsingacrossages,thereisastrongpositivecorrelationinthetwoacuity
measures,Spearman'srhocorrelationr=0.80(95%CI:0.60,0.90),t(25)=6.64,p<0.001
(notusingaPearsoncorrelationbecauseVEPdatawasnotnormal,althoughPLlooked
aboutNormalbasedonQQplots).Likewise,collapsingacrossages,thereisastrong
positivecorrelationinthetwocontrastmeasures,Spearman'srhocorrelation,r=0.72
(95%CI:0.47,0.86),t(25)=5.22,p<0.001(notusingaPearsoncorrelationbecausethe
dataarenotNormal)(Figure1.10).

 41

Figure1.10:Relationshipbetweenpairsofvariables.Lowerleft:ScatterplotsandLOESS
(locallyweightedpolynomialregression)fits.Diagonal:histogramofresponses.Upper
right:Spearman'srhocorrelation.
Age:infantsages.
Acuity_vep:visualacuitymeasuredwithvisualevokedpotential.
Acuity_pl:visualacuitymeasuredwithpreferentiallookingtechnique.
Contrast_vep:contrastsensitivitymeasuredwithvisualevokedpotential.
Contrast_happy:contrastsensitivitymeasuredwithpreferentiallookingtechnique.

 42

Acuityandcontrast

Basedonthehighcorrelationsbetweenacuityandcontrastmeasures,itwaslikely
thatincludingallfourvariables,twoforcontrastandtwoforacuity,inamodelthat
predictsjointengagementwouldproduceproblemswithcollinearity(thiswasconfirmed
throughinspectionofthedesignmatrix'seigenvalues,severalofwhichwereclosetozero).
Therefore,forwardmodelselectionwasusedtobuildapredictivemodelofjoint
engagement(%),addingpredictorsinanorderbasedonrelativeimportance.Relative
importancewascalculatedasR2partitionedbyaveragingoverorders,asinLindeman,
Merenda,&Gold(1980,p.119ff),implementedinGromping(2006;Table1.8).


Table1.8:RelativeimportanceofacuityandcontrastmeasuresforpredictingJoint
engagement.

Toys1 Toys2
AcuityVEP 4.83x102 2.58x102
AcuityPL 5.59x102 3.08x102
ContrastVEP 4.87x102 2.58x102
ContrastPL 11.66x102 10.31x102

Forbothsetsoftoys(1and2),theselectedmodelofjointengagementincludedthe
singlepredictorofContrastPL(Table1.9).Thesemodelsweresignificantlybetterthan
interceptonlymodels.Addinganyoftheotherpredictorstothemodelsdidnotimprove
themodelfitsbasedonFtests(allp>0.241).

 43

Table1.9:Modelsofjointengagement.

Predictor Toys1 Toys2

Est.(SE) tvalue pvalue Est.(SE) tvalue pvalue

Intercept 44.37(4.79) 0.27 <0.001*** 39.52(4.57) 8.65 <0.001

***
ContrastPL 0.27(0.12) 2.18 0.039* 0.26(0.12) 2.22 0.036*

F(1,25)=3.76,p=0.039 F(1,25)=4.93,p=0.036
R2=0.17,Adj.R2=0.13 R2=0.16,Adj.R2=0.13
*p<0.05,**p<0.01,***p<0.001

Toconfirmthattheseresultswouldnothavechangedbasedontheorderofadded
predictors,modelsofjointengagementwereconstructedusingonlyAcuityPL,whichhad
thesecondgreatestrelativeimportanceafterContrastPL,andthesemodelswerenot
significantlybetterthaninterceptonlymodels:fortoys1,F(1,25)=1.23,p=0.279;fortoys
2,F(1,25)=2.17,p=0.153.

1.4Discussion

Thisstudysresultsprovideevidencethatinfantswithvariousdegreesofvisual
impairmentsparticipateinjointengagementbytheendofthefirstyearoflife.Allinfants
testedranginginagebetween10months,29daysand2years,3months,8days
participatedinjointengagementwiththeircaregivers.
Resultsalsoshowthatbetweenroughlytheendofthefirstyearandthemiddleof
thesecondyear,thepercentageoftimetheseinfantsandtheircaregiverswereinjoint
engagementsignificantlyincreased.Thisshowshowjointengagementinthispopulation
continuestodevelopafteritsemergence,atleastintermsofhowmuchtheyconstituteof
thetotaltimeofthedyadsfreeplay.
Bothoftheseresultscontributetotheunderstandingofwhatconstitutesnormative
timesofjointengagementdevelopmentinthispopulation,whichcanaidinthedifferential
diagnosisbetweentypicaldevelopmentinthisgroupofchildrenanddelaysthatwarrant
intervention.Italsocontributestotheworkofdevelopmentalinterventionists,sincepart

 44

oftheirroleistoinformparentsoftheknownuniquepatternsofdevelopmenttheir
visuallyimpairedinfantsmayexperience.
Despitethesignificantincreaseintheaveragepercentageinjoinengagementwith
toys2fromages1to2,twoinfantsshowedtheoppositepatternsastheirpercentages
decreased,inonecaseby20.26points;intheotherby15.18points.Severalpossible
factorscouldbeatplay.Oneisthattheseinfantswereexperiencingthedevelopmental
setbackphenomenondescribedintheliterature,whichincludesimpactsonjoint
engagement.Otherscanbecircumstantialfactorssuchascaregiverslowstaminalevels,
whichcouldhavedecreasedtheiramountofscaffoldingatage2.Thesetwoinfantswere
longitudinal;futureanalysisofthisstudysdatawillexplorethefactorsassociatedwiththe
observeddecreaseinjointengagement.Forinstance,onthematterofdevelopmental
setback,codingoftheseinfantslaterobservationscandetermineifthedecreaseinjoint
engagementcontinuedovertime.
Comparisonsbetweenthisstudysresultswithpreviousonesthatalsoreported
percentagesoftimeinjointengagementareproblematic.First,previousresearchwith
samplesofsightedinfantsinvestigatedadifferentpopulation.Comparisonsbetween
sightedandvisuallyimpairedchildrencanshedlightonthesimilaritiesanddivergences
betweeneachgroupsofchildrensdevelopment.Theycanalsoadvanceourunderstanding
ofchilddevelopmentingeneralasitmakesusrealizehowdiversepathwaysthantheones
seeninsightedchildrenleadtoequivalentdevelopmentaloutcomes.Aninteresting
exampleofthisistheresearchonsocialsmile.Priortostudieswithblindinfants,the
acceptedviewwasthatsocialsmilewasdependentonthevisualperceptionofthe
caregiversface.Thefacttheblindinfantsalsopresentedsocialsmiletotheircaregivers
voicesandhapticcueshaschangedthefieldsunderstandingofsocialsmile.
However,findingsonsightedinfantscannotbeusedasthestandardagainstwhich
todeterminewhatistypicalorabnormalinthedevelopmentofvisuallyimpairedinfants.
AsWarren(1978)argued,theenvironmenttowhichthevisuallyimpairedchildmust
adaptpresentsthemwithdifferentchallengesthantheonesitpresentstohissighted
peers.Ifablindchildrequiresmoretimetounderstandthatobjectsexistindependentof
hisimmediateperceptionofthem,thisisduetothedifferentdemandssuchcognitive
understandingpositsinachildwhoreliesonhapticandauditoryinformation.Itisnota
delay,anditisnotatypicaljustbecauseitisevidenttoobserversatalateragethanin
sightedchildren.
Second,somepreviousstudiesinjointengagementusedstructuredcontextsthat
providedpromptstothedyad.Presumablysuchstructuredsettingswouldlikelyincrease
theoccurrenceofjointengagementcomparedtofreeplaysettingsastheoneusedinthis
study.
Keepinginmindthesetwocaveats,BakemanandAdamsonslongitudinalstudy
(1984)seemsthemostappropriatetodrawcomparisonwiththefindingsofthisstudy.
Theyusedthecodingprotocolthisstudylargelyfollowedalthoughwithsome
adaptationsandvideotapedinfantsandtheircaregiversduringfreeplay,likethisstudy
didalthoughinsessionsthatlasted10minutescomparedtothe30minutesessions
recordedinhere.Thefollowingcomparisonsusecalculationsfromthisstudyconsidering
episodesthatlastedatleast3seconds,sincethatwasthecodingrulefollowedbyBakeman
andAdamson.

 45

Intheirstudy,12monthsightedinfantsengagedincoordinatedjointengagement
3.6%ofthetime,andinpassive19.3%ofthetime,withacombinedtotalof22.9%.Inthis
study,visuallyimpairedinfantsatage1(M=1year,28days)spendasimilaraverage
percentageoftimeinjointengagementof26.93%withtoys1,and26.41%withtoys2.
Intheirstudy,15montholdsightedinfantspercentagesoftimeinjoint
engagementwere11.2%and23.1%forcoordinatedandpassiverespectively,which
totaled34.3%.Atage18months,theoldestagereported,coordinatedrepresented26.6%
andpassive21.5%ofthetime;whichcombinedtotaled48.2%.Inthisstudy,visually
impairedinfantsatage2(M=1year,17months,15days),participatedinjoint
engagement43.04%ofthetimewithtoys1,and35.95%withtoys2.
Itshouldbenotedthatinthisstudy,BakemanandAdamsonsprotocolwasadapted.
Forinstance,episodescodedaspassivejointengagementwiththeadaptedprotocolcould
havebeencodedasobservingintheoriginalprotocol.Ameandurationcomparison
betweenthesestudiesisnotpossiblesinceBakemanandAdamsondifferentiatedbetween
coordinatedandsupportedjointengagementepisodeswhereasthisstudydidnot.
Thisstudychosetoassessvisuallyimpairedinfantsparticipationinjoint
engagementduringfreeplayepisodesratherthaninstructuredplayortestingsettings.
Ratherthanusingpromptstoencourageinfantandcaregivertoinitiateorrespondtobids
forjointengagement,thevideotapingsettingaimedtoallowthedyadtointeractinthe
mostnaturalisticwaypossiblegiventheconstraintsimposedbythecameraspresence.
Thedatacollectedinthiswaycontributesinformationregardingtheamountoftimeand
durationofsingleepisodesinwhichtheseinfantsandtheircaregiversshareinterestinan
externalfocuswhenlefttotheirowndevices.Incontrast,providingpromptstothedyad
canpotentiallyoverestimatetheamountofjointengagementtheseinfantsnaturally
participatein.
Theuseofafreeplaycontextcanpotentiallyunderestimatetheinfantsjoint
engagementskills.Supportedjointengagementrequiresanactivepartnerwho
intentionallysharesattentionwiththeinfant.Coordinatedjointengagementisnotas
dependantonthepartnersinvolvementforitsinitiationi.e.,thechildcaninitiatebutit
doesrequirethepartnersparticipationforitsoccurrenceasanactualsocialtriadic
interaction.Asdiscussedearlier,achildsbidforjointengagementthatisnotfollowedby
thesocialpartnerdoesnotconstitutejointengagementasasocialinteraction.Giventhe
bidirectionalnatureofjointengagement,itispossibleforinfantstoparticipateindiverse
amountsofitwithdifferentsocialpartners.Thus,itshouldbenotedthatthisstudydoes
notprovideafullreportontheinfantsabilitytoparticipateinjointengagement.Itis
possiblethatsomeofthechildrensperformanceswouldbehigherifpairedwithdifferent
socialpartnersand/orifcaregiverswereprovidedwithprompts.
Thisstudyfoundthatinfantslevelofcontrastsensitivitymeasuredwiththe
preferentiallookingtechnique,butnotwiththevisualevokedpotential,predictedthe
percentageoftimeinfantsspendinjointengagement.Comparedtothevisualevoked
potential,whichprovidesgeneralinformationabouttheoccipitalresponsetovisual
stimuli;thepreferentiallookingtechniquereportsthechildsbehavioraluseofvision
(Watson,OrelBixler,&HaegerstromPortnoy,2010).Thus,thisstudysfindingsuggests
thatthecriticalfactorishowinfantsarebehaviorallyusingtheircontrastsensititvity.
Apossibleexplanationofthisstudysfindingofarelationshipbetweencontrast
sensitivityandjointengagementreliesinthisvisualfunctionssignificanceforboth

 46

mobilityandperceptionoffacialexpressions.Bothofthesearerelevantforthe
developmentofjointengagement.Navigatingtheenvironmentcontributestoinfants
understandingofobjectpermanenceandexpandstheopportunitieswithinwhichtheycan
shareattentiononanexternalfocuswithsocialpartners.Discriminatingfacialexpressions
canmakesocialpartnersmoresalientstimuliforinfantsandincreasetheirabilityto
mirroracaregiversfacialexpressions,facilitatingnonverbalexchangesbetweenthem.
Giventhatareviewoftheliteratureindicatedthatinmost,ifnotallprevious
research,infantsvisualimpairmentswereonlydescribedintermsofvisualacuity
reductions,thisstudysfindingunderscorestheimportanceofexpandingthevisual
functionsreportedwhenstudyingthedevelopmentofthispopulationofchildren.
Understandingbettertheroleofcontrastsensitivityinjointengagementcanaidnot
onlyourtheoreticalunderstandingofchilddevelopment,butcanalsohavepositive
practicalconsequences.Anoverrelianceonvisualacuityimpairmentscanleadtoinfants
whosevisualreductionsaremostgreatlyrelatedtocontrastsensitivitytonotqualifyfor
services,ortohavetheirbehaviorsmisunderstood.
Futureanalysisofthisstudysdatawillfocusonthejointengagementepisodesand
codetheminwaysthatdescribetheinteractions.Thisinformationcanberelevantfor
interventionists,asitcanidentifythespecificactivitiesvisuallyimpairedinfantsandtheir
caregiverscanengageinascontextsforthedevelopmentofjointengagement.
Unstructuredobservationsliketheoneusedinthisstudycanhaveanadvantageover
laboratoryparadigms.Thetypicalparadigmsusedtostudyjointengagementwere
designedforsightedchildren,andrelyheavilyonsightedbehavior.Evenifthesesituations
areadaptedforvisuallyimpairedinfantsbyattemptingtotranslatevisualbehaviorsinto
nonvisualones,thereistheriskofmissingmoreidiosyncraticwaysinwhichtheseinfants
achievejointengagement,thatarenoteasilyforeseenbysightedresearchers.
Anotherlineoffutureresearchrelatestothequestionofhowtoindexcoordinated
jointengagementwithoutrelyingongazeswitch.Onealternativeindexintheliteratureis
infantsspeechthatclearlyidentifiesthesocialpartnerandrelatesittothesharedactivity,
forinstancewhenthechildsaystothecaregiver,Mommyyourturn,whilegivingthe
objecttoher.However,thisislinguisticallytooadvancedfortheinfantsinthisstudys
sample.Thismethodologicalrestrictionamountstopreverbalvisuallyimpairedinfants
notbeingapopulationinwhichcoordinatedjointengagementcanbestudied.
Asawaytostartexploringthisquestion,whenthisstudyscodersidentifiedan
eventasjointengagement,theymadeapreliminarycodingdecisionastowhetherthey
thoughttheepisodewasofthetypesupportive,coordinated,orboth.Thelatteroptionwas
meanttoencompasseventsinwhichtheepisodestartedassupportedbutthenasthe
infantevidencedacknowledgingthecaregiversparticipationinthesharedactivity,became
acoordinatedone.Iftheeventwasclassifiedascoordinatedorboth,codersdecidedwhich
overtbehaviorsonthepartofthechildindicatedsotothem.
Theapproachtothecodingwasthattheinfantsbehaviorsthatindexcoordinated
jointengagementarepresumablyacombinationofactionsandarenotlimitedtoone
actionthatinvolvesjustonesense.Whenresearchersstudysightedinfantsandfocusour
attentionontheirgazeswitching,wearepresumablynotattendingtoseveralother
componentsofthechildsbehavior,suchastheorientationofhisbody,theuseofhishands,
andhishearingbehavior.Inanattempttocapturethis,codershadseveralcodesthat
aimedatincludingbehaviorsthatreliedonallsenses,plustheyhadtheoptiontoaddnew

 47

behavioralcodes.Onenewbehavioralcodethatclearlyemergedwasinfantsemotional
reactionsinreferencetotheexternalfocus,whetherpositivee.g.,laughingafteranaction
isperformedonthetoyornegativee.g.,cryingwhiletryingtorecoveratoythe
caregiverhadtakenaway.Thisisinlinewiththeworkofresearcherswhohavehighlighted
theincidenceofemotioninjointengagement.
Thenextstepinthislineofresearchwillbetolookatthecombinationofbehaviors
thatemergesfromthispreliminarycoding,andnotingwhichonestendtooccurtogether
andthecombinationofhowmanyofthemindicatedmoststronglytothecodersthatthe
jointengagementwascoordinated.Perhapsawaytorespondtothechallengeofstudying
coordinatedjointengagementinpreverbalvisuallyimpairedinfantsistodevelopanindex
thatcombinesseveralcomponentsintoone,ratherthanlookingforasinglenonvisual
equivalenttoinfantsgazeswitch.
Lastly,thecodingofthisstudysvideoshowedawidearrayofcaregiversuseof
objectsandhowtheymediatedtheirconventionalusetotheirvisuallyimpairedinfants.
Jointengagementisatypeofsocialinteractioninwhichthesocialpartnerinfluencesthe
infantsexperienceandinvolvementwithanobject.Intheseinteractions,sightedinfants
haveshownmorefunctionaluseofobjects.Forthistotakeplace,atleasttwoeventsmust
bepresent:amoreadvancedsocialpartnerdemonstratestotheinfanttheconventional
useoftheobject;theinfantperceivesthesocialpartnersactionswiththeobjectand
attemptsithimself.Theseelementsareatriskifthereisamismatchbetweenhowthe
caregivermediatesobjectsandthelearningstylesoftheirinfantswhoarevisually
impaired.Studieshavefoundthatasubgroupofchildrenwhoareblindorseverelyvisually
impairedshowadevelopmentalstasisorregressionstartingroughlybetween15and27
monthsofage.Oneofthereportedoutcomesisthelossofexplorativeandmanipulative
playbehaviorandthefailuretoemergeofmoreadvancedskills.Areasonablequestionis
whetherdifficultiesinjointengagementareacontributingfactorinthisphenomenon.
Futureanalysisofthisstudysdatacaninvestigatewhichcaregiversactionsduring
episodesofjointengagementcorrelatetoinfantshigherplayingskillsinparticulartheir
conventionaluseofobjects.
Thisstudyaimedtocontributedatathatrepresentedbetterthepopulationof
infantswithvisualimpairmentsbyincludingawidearrayofvisualhandicaps.Further
researchshouldexpandonthisgoalbyincludinginfantswhosemultipledisabilitiesinclude
visualimpairments.Preliminarydataanalysisoftwosubjects,whoduetoadditional
disabilitieswereexcludedfromthedatareportedinthisstudy,providessome
considerationsforsuchfutureresearch.Intermsofthevideorecordingsetting,the
arrangementofcamerasmightneedtobemodifiedwhenstudyinginfantswithsevere
multipledisabilities.Theseinfantsresponsescanbeextremelysubtleandtheywillnotbe
capturedbyvideocamerasthatfocusontheoverallscene.Ratheratleastonevideocamera
shouldbefocusedsolelyonthechildandzoomedinonhimasmuchaspossibletocapture
subtlefacialexpressionsandmotoricmovements.Thecodingprotocolalsowouldneedto
beaccommodatedtotheseinfantsparticularbehaviors.Forinstance,oneofthe
aforementionedexcludedsubjectstookacomparativelylongertimetofullyswitchher
attentionbetweenfoci;eventhoughshewouldturntowardatoythecaregiverwas
showingtoher,theinfantwouldcontinueherpriormanualmanipulationofadifferenttoy.
Acodingrulethataddressesthissituationistoconsidertheaddedbehaviorasthe
infantsattentionalfocus,inthiscase,theturningtowardtheobjectintroducedbythe

 48

caregiverisaddedtothechildspriormanipulationofadifferenttoyanditwouldbe
consideredthecurrentfocusofthechildsengagement.Decisionssuchasthisare
particularlyrelevantwhenthestudyinvestigatesthedurationofjointengagement
episodesasitclarifiestheironsets.

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Study2

Attachmentpatternsininfantswithvisualimpairments
basedontheStrangeSituationParadigm

2.1Background

Aninfantsattachmentbehaviorisactivatedwhenhefindshimselffacingchallenges
orthreatsfromtheenvironment,suchasencounteringanonfamiliarindividual.Itis
manifestedbyseekingproximityand/orcontactwithhisattachmentfigure(typicallythe
maincaregiver)throughvarioussignalingbehaviors.Thesebehaviorsincludesmiling,
crying,vocalizing,reaching,grasping,clinging,andfollowingtheattachmentfigure.An
infantwillshowattachmentbehaviorbytheendofhisfirstyearoflifeifaparticular
caregiverhasrespondedtotheinfantssignals.Fromanaffectivepointofview,attachment
formationsignalsthattheinfanthasestablishedanemotionalbondwithhiscaregiver
(Bowlby,1973,1980,1982;Weinfield,Sroufe,Egeland&Carlson,2008).
Accordingtoattachmenttheory,aspartofthehumanspeciesevolution,attachment
becamepartofinfantsinstinctivebehaviorsbecauseofitscontributiontotheirsurvivalin
humansenvironmentofevolutionaryadaptivenessespeciallyprotectingthemfrom
predators.Intodayshumanenvironment,attachmentbehaviorcontinuestohavea
survivalfunction.Wheninadangeroussituation,theinfantsriskofharmdecreasesby
remaininginproximitytotheattachmentfigure.Tosurvive,thechildneedsnotonlyto
moveawayfromthedangerssourcebuttoalsogotowardtheadultwhoisthemostlikely
toprotecthim.Thusfromanethologicalperspective,itservesthehumanspeciessurvival
forchildrentoidentifysuchanadulti.e.,hisattachmentfiguretoremaininher
proximityandtoactivelyseekproximitytoherwhentheyareinathreateningsituation
(Bowlby,1973,1982).
InBowlbys(1980)conceptualization,attachmentbehaviorisagoaloriented
system;itcontinuouslychecksthecurrentstateofaffairsagainstitsgoalofproximityto
thecaregiveranditusesrepresentationalmodelsoftheinfantsowncapacitiesandthe
relevantfeaturesintheenvironmenttoplananddeploybehaviorsconducivetothe
systemsgoal.Atagivenmoment,themanifestationofattachmentbehaviorvaries
dependingontheinfantsperceptionofthreat,andoftheattachmentfiguresaccessibility
andresponsiveness.Thus,themoreaccessiblethecaregiverisandthelessthreateningthe
circumstances,thelessattachmentbehaviorthechildwillexhibit,andviceversa.The
conditionsthatleadtothecessationofattachmentbehaviorsvarydependingonthelevel
ofarousalwithintheattachmentsystem.Thehigherthearousal,themorephysicalcontact
andreassurancewillberequiredfromtheattachmentfigure.

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Attachmentbehaviorrelatestoinfantsexploratorybehavior,whichmakesthechild
ventureintotheenvironmentbymeansofvisualexploration,manipulation,locomotion
andplay.Likeattachment,exploratorybehaviorhasasurvivalfunctionasitpromotesboth
learningaboutandadaptingtotheenvironment.Theattachmentfigureactsasasecure
basetowhichthechildcanphysicallyreturntoorreestablishcontactwiththrough
distantmeanse.g.,eyecontactbetweenhisexplorationsoftheenvironment.

Development

Humannewbornsdisplayseveralinnatepreattachmentbehaviors,including
crying,smiling,andlookingathumanfaces,whichtriggerotherscaregivingbehavior
towardthem.Attachmentbehaviorisnotinnatebutinsteadisdependentonaparticular
caregiverconsistentlyrespondingtotheinfantssignals,beginningwithhispreattachment
behaviors.Asthechildbecomesattached,hedevelopsaninternalrepresentationof
elementsrelevantforattainingthegoalofproximitytohisattachmentfigure.Thisinternal
workingmodelreflectsthehistoryoftheinfantsinteractionswiththeattachmentfigure,
andincludesrepresentationsofrelevantaspectsoftheinfanthimself,theattachment
figureandtheenvironment.Themodelisusedtounderstandandpredicttheinfants
relationshipwiththecaregiverandenvironment,andtoplan,monitor,recalibrate,and
terminateattachmentbehavior(Bowlby,1982,1973;Marvin&Britner,2008).
Thedevelopmentofattachmentunfoldsinsequentialphasesduringthefirstyears
oflife(Bowlby,1982;Marvin&Britner,2008).Duringtheirfirst8to12weeks,infantsdo
nothaveamentalgoalofproximitytothecaregiver,butdisplaybehaviorsthathavethe
predictableoutcomeofgeneratingcaregivingandaffectionfromadults.Infantsrespondto
stimuliinamannerthatincreasestheprobabilityofcontinuedcontactwithotherhumans,
forinstancebypreferentiallyattendingtohumanfacesandvoices.
Next,infantsbegintoresponddifferentlytofamiliarversusunfamiliarpeople,and
topreferentiallydirectattachmentbehaviorstowardmaincaregivers.Startingat6to9
monthsofage,childrenconsolidateattachmenttojustoneorseveralparticularcaregivers,
anddisplaynewattachmentbehaviors,mostofwhichinvolvetheirnewlyacquired
locomotionskills.Forinstance,infantsusetheirattachmentfiguresasasecurebasefor
exploration;theyventureintotheenvironment,intermittentlycheckingonattachment
figurespresence,andregainingproximity/contactwithher.Cognitively,childrenhave
internalimagesoftheattachmentfigureindependentoftheircurrentperceptionofher.
Theyalsohaveamentalimageofthegoalofproximitytoher,andcanmentallyselectthe
behaviorsthatarelikelytoachieveit.
From6to1824months,infantsincreasetheirwarinesstowardunfamiliarpeople,
andduringthepreschoolyearsusemoresophisticatedmentaloperationsastheystartto
considertheattachmentfiguresgoalsandbehavioralstrategies.Thesecognitiveabilities,
combinedwithinfantsdevelopingconversationalskillsandabilitytoinhibitbehavior,
allowforcaregiverandchildtonegotiateaplanforproximity,andfortheirrelationshipto
becomegoaloriented.
Researchstudieswithchildrenwholackedaparticularconsistentcaregiverinearly
developmentreportanarrayofnegativeconsequences.Theseincludeaninabilitytoform
attachmenttonewcaregivers,orattachmentformationbutwithlonglastingsocio

 51

emotionaldifficultiesi.e.,issuesunderstandingboundarieswheninteractingwith
strangers.Astudycompared1231montholdinstitutionalizedinfantswhohadspenta
meanof90%oftheirlivesinRomanianorphanagesandpeerswhohadneverbeen
institutionalized.Whereasallnoninstitutionalizedinfantshadaconsolidatedattachment
systemlateststageofattachmentdevelopment,only3outof95oftheinstitutionalized
childrendid(Zeanah,Smyke,Koga,Carlson,&theBEIPGroup,2005).Undersome
conditionshowever,attachmentcanbedevelopedafterearlysocialdeprivation.Astudy
assessedattachmentbehaviorin1536montholdpostinstitutionalizedinfants,whohad
beenadoptedafterspendingamedianof94.3%oftheirlivesinorphanages.By79months
afteradoption,90%oftheseinfantshadformedattachmentstotheiradoptivecaregivers.
However,comparedtononadoptedpeers,adoptedchildrenweremorelikelytoexhibit
disorientedorconflictedbehaviorstowardtheirattachmentfigures(Carlson,Hostinar,
Milner,&Gunnar,2014).

StrangeSituationParadigm

Ainsworth(1967)foundevidenceoftherelationshipbetweentheattachmentand
explorationbehavioralsystemsininfantslivingincountryvillagesinUganda.Infants
whoseattachmentwasdeemedinsecure(apprehensivelestcaregiverisinaccessibleor
unresponsive)tendedtoremainincloseproximitywiththemother,exploringthe
environmentverylittleornotatall.Incontrast,thosewhoseattachmentwasdeemed
securewouldleavethemotherssidetoexploretheenvironment.However,when
AinsworthlaterstudiedinfantsinBaltimore,sheobservedthatnearlyallbabies,regardless
ofthesecurityoftheirattachment,lefttheirmotherstoexplore.
ThisobservationledtothecreationoftheStrangeSituationParadigm(SSP),
reasoningthatheighteningtheinfantsstresslevelswouldallowfortheobservationof
individualdifferencesinattachment.TheSSPisastandardizedlaboratoryprocedurethat
aimstoactivateinfantsattachmentbehaviorbypresentingthemwithincreasingly
stressfulcircumstances.Specifically,theproceduretakesplaceinaroomnewtothechild,
itinvolvesanadultwhoisunfamiliartothechild(thestranger)whoattemptstointeract
withhim,andseparatesthechildfromhiscaregiver(Ainsworth&Bell,1970;Ainsworthet
al.,1978).
TheSSPprotocolisasfollows.Twochairsareononesideoftheroom,oneforthe
caregiverandanotherforthestranger,andasetoftoysisontheotherside.The
unfamiliarenvironmentandtoysaremeanttotriggerexploratorybehaviorintheinfant.At
first,caregiverandchildareintheroomalone,andthecaregiverfollowingpreviously
providedinstructionsattemptstointerestthechildinthetoys.Then,thestrangercomes
intotheroomandinteractswiththechildwhilethecaregiverisintheroom.Thecaregiver
subsequentlyleavesthechildalonewiththestranger.Thecaregivercomesback,comforts
thechildandattemptstorenewhisinterestinthetoys,asneeded.Meanwhile,thestranger
leavestheroom.Eventuallythecaregiverleavesagain;thistimethechildremainsalonein
theroom.Thestrangerreturnsandattemptstocomfort/playwiththeinfant.Finally,the
caregiverreturnsforasecondtime(Ainsworth,Bell&Stayton,1971;Ainsworthetal.,
1978).

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Attachmentpatterns

ThestudyofinfantsundergoingtheSSPleadtotheidentificationofpatternsof
attachment,basedonfourtypesoftheinfantsbehaviorstowardtheattachmentfigure
throughouttheprocedure,butparticularlyduringthetwotimestheyreunitedwithher.
Behaviorsaimedatachievingcontactwithorgainingproximitytotheattachment
figure.
Behaviorsdeployedinordertoremaininproximity/contactwiththeattachment
figure,regardlessofwhochildorcaregiverhadinitiatedcontact/proximity.
Behaviorsusedtorejectcontactwithorproximitytotheattachmentfigure,again
regardlessofwhohadinitiatedit.
Behaviorsaimedatavoidingtheattachmentfigure(Ainsworthetal.,1978).
Todeterminechildrensattachmentpatterns,observerscodeandscorethepresence,
intensityandpersistenceofeachofthefourbehaviors.Basedontheresultingscoreprofile
andthecodersoverallclinicalimpressionoftheinfant,thepatternofattachmentis
classified.Attachmentpatternsthusrefertoseveraldistinctivebehavioralstrategies
childrendemonstratetowardtheircaregiverswhenfacedwithapotentiallydangerous
situation,namelytheSSP.
Threepatternsandcorrespondingsubtypeswereidentified(Weinfieldetal.,2008).
InfantsclassifiedashavingasecureattachmentsubtypesB1throughB4clearly
demonstrateadesiretointeractandtobeintheproximityoftheirattachmentfigure,and
activelyattempttofulfillit.Whereastheymayormaynotbefriendlywiththestranger,
theyclearlyprefertobewiththeirattachmentfigure.Thechildrenmayormaynotbe
distresseduponseparation;ifdistressispresent,itseemsclearthatitisduetothe
attachmentfiguresabsenceandnotjustbecauseofbeingalone.Uponreunion,theygreet
theircaregiver,showapositiveemotionalresponse,andiftheyhadbeendistressedduring
separation,feelcomfortedandplayfairlyimmediately.Althoughallsecuresubtypesmeet
thiscriteria,theydifferinmoresubtleways.Forinstance,B1andB2showmoreavoidant
behaviorthantheothersubtypes,withB1showingthehighestamount;B2andB3arethe
mostcompetentinachievingproximity/contact,withB3beingthemostcompetent;B4
showsthemostresistantbehavior(seeappendix3foracomparisonofsecuresubtypes).
ChildrenclassifiedashavinganavoidantpatternsubtypesA1,A2tendto
avoidtheirattachmentfigureandshowlittleornotendencytointeractwithher.Theyalso
tendtoavoidthestrangerbutcanshowlessavoidancetowardher.Theseinfantsshowno
distressduringseparationoriftheydo,itisonlywhenleftalone.Uponreunion,theydonot
greettheattachmentfigure,oriftheydo,thegreetingisverytame.Theyeitherdonot
approachtheattachmentfigure,startbutdonotcompletetheapproach,oronlyapproach
aftermuchcoaxing.Iftheyarepickedupbythecaregiver,theydonotclingtoherordoso
onlybriefly;whenputdowntheydonotresistordosobutonlymomentarily.Avoidant
subtypesdifferinsubtleways,e.g.,A1showsmoreavoidantbehaviorthanA2(see
appendix4foracomparisonofavoidantsubtypes).
Infantsclassifiedashavingaresistant(alsocalledambivalent/anxious;subtypes:
C1,C2)showambivalentbehaviorsofanangryqualitytowardstheirattachmentfigures.
Theyseekcontactforinstancebyclingingtotheattachmentfigureorstrugglingagainsther
release,butalsoresistcontactbypushingawayfromher,kicking,and/orthrowingdown

 53

toysshegivesthem.Theyfailtousetheirattachmentfigureasasecurebasefor
exploration;theymaynotexploretheroom,ordosowithoutseemingtoenjoyit.They
showdistressduringseparation,andtendtorespondpositivelyuponreunion,butas
duringpreseparationthisisintermingledwithresistancebehavior.Resistantsubtypes
differinsubtleways,e.g.,C2showsamuchmorepassiveexploratorybehaviorthanC1(see
appendix5foracomparisonofresistantsubtypes).
Typesavoidantandresistantarebothlabeledinsecureattachmentpatterns,as
opposedtosecure.

Disorganization

InlaterSSPstudies,asmallgroupofinfantsattachmentpatternscouldnotbe
classified.Mainstudiedthesecasesandclassifiedthemwithinafourthcategory,whichshe
labeleddisorganized/disoriented(Main&Solomon,1986).Childrenclassifiedinthisgroup
show,inthepresenceofthecaregiver,contradictorybehaviorsandlackoforientationin
theenvironment.Uponreunionwiththeattachmentfiguretheydisplaybizarrebehaviors
suchas:dazedlook,freezingofallmovements,andstereotypes.Thisconflictingbehavioris
thoughttobearesultoftheinfantbeinginafrighteningsituation,whichhecannot
overcomebecausetheattachmentfigureisperceivedasfrighteningorisfrightenedherself,
andthusisasourceherselfoffearforthechild(Hesse&Main,2000;Main,1990).
Disorganizationisnotanattachmentpatternonitsownbutratheritreferstoa
disruptionintheinfantsattachmentpattern,whethersecure,avoidantorresistant.For
instance,achildwithasecurepatternwhohasnodisorganizationshowsbehaviorsthat
areallconsistentwithinthecriteriaforsecureattachment,andthereforetheirbehaviors
duringreunionwiththeattachmentfigurearepredictabletotheobserver.Incontrast,the
behaviorsofachildwithasecurepatternwhoalsoshowsdisorganizationarenotall
predictabletotheobserverbasedonhisattachmentpattern.Furthermore,thebehaviors
thatarenotpredictabledonotconstituteacoherentbehavioralsystem,givingthe
impressionthatthechildlacksabehavioralstrategytowardthecaregiveratthemoment.

Relationshiptocaregiversbehaviors

Howagiveninfantsattachmentbehaviordevelops,andthespecificpatternin
whichitbecomesorganized,isprincipallydeterminedbythehistoryofinteractionsthe
infanthaswithhisattachmentfigure.Thecaregiversresponsesdonotneedtobeofa
specificquality,forinstancewhethertheresponsesaresensitiveorinsensitivetothe
infantsneeds.Aslongasthesamecaregiverrespondstothechild,attachmentdevelops
(Bowlby,1980;Sroufe,1985).
Ainsworthetal.,(1971)foundrelationshipsbetweeninfantsattachmentpatterns
andtheirmothersbehaviorsathome.MothersofchildrenwhohadasecureB3attachment
scoredthehighestinsensitivity,definedasthedegreetowhichthemotherattendedtoand
interpretedthechildssignals;andwhenshedidntgivethechildwhathewanted,used
communicationratherthanrejecting,ignoringorinterferingwiththechildssignals.
Mothersofchildrenwhohadavoidantattachmentpatterndisplayedthemostavoidanceof
physicalcontactwiththeirinfants,andscoredhighestinrejection,definedasdifficulties

 54

integratingpositiveandnegativefeelingstowardsthechild.Mothersofchildrenwhohad
insecurepatternsA1andC1showedthemostinterferingbehavior,whichreferredto
issuesviewingthechildasaseparateperson,consideringhiswishes,andusingstrategies
toeasethetransitiontotimeswhenthemotherhadtointerferewiththechildswishes.
ThoseofinfantswithinsecurepatternsA2andC2scoredthehighestin
inaccessibility/ignoring,thatis,weretheleasttunedintotheirchildrensstate.
Researchhascontinuedtoprovideevidenceinsupportofarelationshipbetween
infantsattachmentpatternsandtheiraccumulatedexperiencesinteractingwith
caregivers.Ametaanalysisfoundamodestassociationbetweenattachmentand
sensitivityeffectsizer=.24and12outof65includedstudiesfullysupportedthe
association(vanIJzendoorn&SagiSchwartz,2008).Thestabilityovertimeofattachment
patternshasbeenrelatedtoenvironmentalchangesthatimpacttheattachmentfigures
qualityofcaregiving;forinstance,thebirthofasiblingwhichtaxesthemothers
availabilitytothefirstborn,orsocioeconomicalchangesthatcontributetoparental
depression(Thompson,2000).Disorganizationhasbeenassociatedtoparental
maltreatment,maternaldepression,andparentalpsychopathology(LyonsRuth,&
Jacobvitz,2008).Studieshavestartedtoconsidergeneenvironmentinteractionmodels;
forinstance,infantswhohavebothaDRD47repeatalleleandamotherwhoexperiences
unresolvedloss/traumashowa18.8foldincreaseintheriskofpresentingdisorganization,
comparedtopeerswithoutthesecombinedriskfactors(BakermansKranenburg&van
IJzendoorn,2007).

Relationshipwithotherdevelopmentalskills

Basedonobservationandteachersrating,preschoolagechildrenclassifiedas
insecurewereratedasmoredependentontheirteachersforhelpandattentionthanpeers
classifiedassecure.Thisdifferencewasfoundagainatages10and15years.Thereisalso
evidencethatpreschoolandelementaryschoolagechildrenwhowereclassifiedas
insecureordisorganizedshowedmorehostile/aggressivebehaviortowardparentsand
peers.Childrenclassifiedassecurewerecharacterizedassensitivetoothersemotional
cuesandabletoengageindyadicaffectregulationinwhichsocialpartnershelpregulate
eachothersemotionalstates(Weinfieldetal.,2008).
Evidencefromlongitudinaldatahasfoundthathavingaresistantpatternat12
monthsofagepredictedanxietydisordersininfancyandadolescenceafteraccountingfor
newborntemperamentandmaternalanxiety(Warren,Huston,Egeland,&Sroufe,1997).
Ametaanalysisofsevenstudiesfoundthatchildrenwhohadasecureattachment
weremorecompetentinthelanguagedomaine.g.,meanlengthofutterances,
comprehensionthanthosewhohadaninsecureone(vanIJzendoorn,Dijkstra,&Bus,
1995).Childrenwithahistoryofsecureattachmentarealsoreportedtodemonstratemore
competentsocialproblemsolvingskillsandtohaveamorepositiveselfconceptinboth
implicitandexplicittests,thanpeersclassifiedasinsecure(Thompson,2008).Butthere
arealsostudiesthathavenotfoundexpectedassociationsorhavenotreplicatedresults
frompreviousstudies(Thompson,2000).
Aclassificationofdisorganizedattachmentpatternshasbeenassociatedwith
severalnegativeoutcomesincludinginternalizingandexternalizingproblems,dissociative

 55

symptoms,issuesmanagingstress,andschoolunderachievement(vanIJzendoorn,
Schuengel,&BakermansKranenburg,1999;LyonsRuth,&Jacobvitz,2008).

Attachmentininfantswithvisualimpairments

Theliteratureinattachmenttendstoviewtheauditoryandvisualsystemsashaving
anespeciallyimportantroleininfantspreattachmentbehaviorsandthusinthebeginning
ofattachmentformation.However,Bowlbyalsoconsidersrelevantinfantsinnatebiasto
respondtotactileandkinaestheticstimuliarisingfromhumanarmsandbodies(Bowlby,
1982).
Researchhasexploredattachmentdevelopmentinchildrenwithvisual
impairments.Initialstudiesseemtohaveconsideredblindinfantsasameantoinvestigate
theroleofvisioninsightedchildrensemotionalbondingtotheircaregivers.Forinstance,
researchonblindchildrenwereusedasevidenceofhoweyetoeyecontactfacilitates
attachmentformationandthatvisionisnotaprerequisiteforsocialsmiling(Freedman,
1964;Robson,1967).
Fraiberg(1970,1977,1979)wentbeyondstudyingblindinfantsasanatural
experimenttostudytheroleofvision,reportingthealternativepathwaysthroughwhich
theseinfantsformedattachment.Thetenblindinfantssheobservedsmiledinresponseto
theirmothersvoicebythe4thweekoflife,whichwasconsistentwithreportsonsighted
peers.Shenotedhoweverthatsightedinfantssocialsmileinresponsetocaregiversface
werefairlyautomaticandconsistentlytriggered.Incontrast,blindchildrenssocialsmilein
responsetomothersvoicewasneitherautomaticnorregular,andrequiredlotsofvocal
stimulationfromher.Inaddition,whereasby611monthssightedchildrenwerereported
toshowregularandratherexclusivesmilestofamiliarfaces,blindchildreninthatsame
agerangedidnotsmileregularlyorexclusivelytofamiliarvoices.
Therelevanceofthehapticsystemforunderstandingattachmentdevelopmentin
blindchildrenishighlightedinseveralofFraibergsobservations.Themostconsistentway
toelicitasocialsmileinblindchildrenwasgrosstactileorkinestheticstimulation.Preisler
(1990)alsoreportedthatinthe3to6monthsageperiodthevisuallyimpairedinfantsshe
observedweremorelikelytosmilewhentheyparticipatedinbodytouchinggamesand
songs.InFraibergsstudyby58monthsblindinfantsdemonstratedapreferencefortheir
caregivers;theymorefrequentlymanuallyexploredparentsfacesthanthatofstrangers.
Infantsdislikedtouchingstrangersfacesandcalmeddownwhentheyreturnedto
exploringthatoftheirparents.
AnotherpreattachmentbehaviorreportedbyFraibergwasinfantsreachingfor
theircaregivers.Shenotedthatwhereas5montholdsightedinfantsextendhandsto
motherrelyingonhandeyecoordination,theblindchildrendidsobetween10and16
monthsofage.Shearguedthattheblindchild,lackingthevisualperceptionofcaregiver,
needstoachieveacertainlevelofobjectpermanencebeforehecanreachformotheron
hearinghervoice.Inarelatedreflection,Troster&Brambring(1992)notedthatcompared
tosightedpeers,blindinfantsshowedanxietywhenseparatedfromtheirmothersatlater
ages.Theyarguedhoweverthatthisdifferentialonsetdidnotneedtobeassessedasa
developmentaldelayinattachmentdevelopmentbutratherasanexpectedonsetina

 56

populationinwhichexperiencingseparationfrommotherrequiresamoreadvancedstage
intheunderstandingofobjectpermanencethaninsightedpeers.
Theseobservationscallattentiontohowvisualimpairmentsimpactontheinfants
cognitivedevelopmentcouldinfluenceattachmentformation.Theinternalworkingmodel
proposedbyBowlbyrequirestheinfantsrepresentationofthecaregiverashaving
permanence,thatis,asexistingindependentoftheiravailabilitytotheinfantscurrent
perception.Inarguingthis,BowlbyreferencesPiagetstheory(1952)onobject
permanencedevelopment.InPiagetsviewseveralearlyvisualdependingexperiencesare
crucial;infantsvisualperceptionofobjectsfromdifferentperspectives,experiencingthem
disappearingandreappearingindifferentlocationsinspace,andusingeyehand
coordinationtogainaccessandmanipulateobjectsinwaysthatexpandinfantsperception
ofthem.FollowingaPiagetiandevelopmentalframework,Bigelow(1986)concludedthat
comparedtosightedpeers,blindinfantsunderstandingofobjectpermanenceismore
cognitivelyconstructed.
Inthesecondhalfofthefirstyear,blindinfantsshoweddifferencesintheirvocal
responsestofamiliarversusunfamiliarpeople;theywouldengageinextendeddialogues
withtheirmothersbutnotwithstrangers.Alsoduringthatperiod,wheninthepresenceof
astrangerblindinfantsvocalizedtotheirmotherslessorceasedvocalizationsforseveral
minutesorlonger.Thisquietingreactiontostrangersresembledthestaringatstranger
thansightedinfantsshowpriortodemonstratingfullformedstrangeranxiety.Liketheir
sightedpeers,by715monthsblindchildrenshowedavoidanceofunfamiliarpeople.Blind
infantsshowedavoidanceofunfamiliarpeoplewhenthelatternotonlytalkedtothembut
alsoheldthem,thusprovidingthemwithhapticandperhapsalsoolfactorycues.
Fraibergreportedthatnotallindexesofstrangeravoidancefoundinsightedinfants
wereobservedintheblind;specificallysoberingandfrowningweretootameornon
existent.Instead,blindinfantsfearofstrangerswasevidentthroughtheirwhimpering,
crying,screaming,motorresistance,andseekingofmother.Between11and22monthsof
age,theblindinfantsstartedtoprotestwhenseparatedfromtheirmothers,anonsetthatis
about6monthslaterthaninsightedpeers.Usingadifferentmethodology,aparental
questionnaire,Daleetal.(2013)reportedthat32infantsbetweentheagesof10and44
monthswithvisualimpairmentsshowedattachmentbehaviorandreacteddifferentiallyto
strangers.Troster&Bambring(1992)usedasocioemotionaldevelopmentalscalethat
combinedparentalreportandobservationofinfantsintestsituations.Theirfindings
showedthat2outof59montholdblindinfantsand12outof1712montholdinfants
showedanavoidancereactionwhenastrangerpickedthemup.
Theimpactofvisualimpairmentsonattachmentcannotbeunderstoodbasedonly
ontheobservationofblindinfants,butrequiresconsiderationofhowtheseinfants
idiosyncraticbehaviorsinturnhaveaneffectontheirparentscaregivingbehavior.Preisler
(1990)forexamplereportedthatintheagerangeof3to6months,theblindandvisually
impairedinfantssheobservedreactedtomothersapproachbyincreasingtheirmotor
activitylegsandarmswavingandmakinglipandtonguemovements,butnotall
caregiversinterpretedthesebehaviorsassociallymeaningful.Fortheformationof
attachment,thecaregivermustrespondtotheinfantscues.Thelackofeyecontactand
visualattention,anotherpreattachmentbehaviorhasbeenfoundtoresultindecreased
visualattentionandvocalresponsivenessbythemother.Othercharacteristicsattributedto
theseinfantssuchasalimitedrangeoffacialexpressionsanddifficultiesmirroring

 57

caregiversfacialexpressionshavebeenassociatedwithalowerrateofresponsetothese
childrenssignalsbytheirsocialpartners,bothadultsandpeers(Rogers&Puchalski,1984
Troster&Brambring,1992;1984;Warren,1984).
Ifparentsofchildrenwithvisualimpairmentshavedifficultiesrecognizingtheir
infantscues,theconsolidationofattachmentandthepatterninwhichitbecomes
organizedcanbeimpacted.Ifacaregiverdoesnotrespondtoherinfantscues,thedyad
willnothavethehistoryofexchangesnecessaryforattachmentformation.Ifcaregiversto
agreaterdegreemisstheirvisuallyimpairedinfantscues,thesechildrenwillexperience
theirparentsaslesssensitivetotheirneeds,whichwillincreasethelikelihoodofthe
attachmentbeingorganizedasinsecure.Intermsofitsdevelopment,somepreattachment
behaviorslikereachingformothermayemergeatalateragethaninsightedinfants.
However,ifcaregiversmanagetorecognizetheirvisuallyimpairedinfants
idiosyncraticcues,attachmentformationwillnotfacethesamerisks.Developmental
interventioncanaidparentsinidentifyingtheirinfantssignalsandtorespondtothemin
waysthattheirchildrencanperceive.Forinstance,parentscanlearnthatawaytheir
infantsshowpreferenceforthemisbytactuallyexploringparentsfaces,andparentscan
continuetheinteractionbyprovidingtheirchildrentactilestimulation.Also,parentscan
learnaboutthebehaviorsevidenceshowsemergeatalaterageininfantswithvisual
impairments.Inthiswayparentsforinstancewillnotinterprettheirinfantslaterreachfor
themasasignofdevianceinattachmentdevelopment.Inlinewiththis,Fraiberg(1979)
reportedthatwhereasthe10blindinfantsshestudied,whoreceivedintervention,showed
attachmentbehaviorinthefirsttwoyearsoflifeinwayscomparablestosightedpeers,
olderblindchildrensheencounteredinherclinicalexperience,whohadnotreceived
intervention,didnotshowattachment.
ThereviewoftheliteraturefoundonestudythatappliedtheSSPtovisually
impairedinfantswhichhadasampleof27;14hadachronologicalagebetween12and48
monthsand13hadamentalagelowerthan48months,althoughwerechronologically
older.Infantshadanarrayofvisualimpairmentlevels;mosthadlowvision(71%),
followedbyalmostblindness(14%),blindness(11%),andnearnormalvision(4%).
Seventyninepercentofthesamplehadadditionaldisabilities.Theauthorsreported
modificationsoftheSSPprotocol:duringthesecondepisodethemotherwasallowedto
activelyinteractwiththechildinordertomediateforhimtheenvironmentwhereasin
thestandardprotocolthecaregiveristoldtorespondtothechildifheinitiatesbutnotto
activelyseekinteractionwithhim.Authorsalsoaddedaconsiderationtothe
disorganizationcodingprotocolinthattheydidnotconsidersignsofdisorganization
behaviorswhich,althoughatypicalinthegeneralpopulationofchildren,arewithinthe
normofinfantswithvisualimpairmentse.g.,repetitivemovementssuchasswinging.
Resultsshowedthat6infants,allofwhomhadadditionaldisabilities,weredeemednot
classifiableduetotheirlackofmovementandverysubtleornonexistentsignals.Twenty
fivepercentofthesamplecouldnotbeclassifiedbecausetheirmentalagewasassessedto
bebelow12monthsitseemsallthesecaseshadadditionaldisabilities.Teninfantswere
classifiedashavinginsecureattachmentpatterns,butthesubtypeswerenotspecified.
Therewasnomentionofsecurepatternsbeingfoundinthesample(Salvo,Falcetti,&
Caldironi,2001).
UsingtheAdultAttachmentInterviewwithblindadults,astudyexploredtheeffects
ofsightedmothersreportedhighfrequencyofmaternaldirectivenessandoverprotection

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towardtheircongenitallyblindinfants.Forinstance,Behl,Akers,Boyce,&Taylor(1996)
reportedthatmothersofchildrenwithvisualimpairmentsweremorephysicallyinvolved
withtheirchildren,usedmorecontrollingstrategies,andspokemoretothemthandidthe
mothersoffullysightedpeers.TheAdultAttachmentInterviewasksadultsquestions
regardingtheirearlyexperienceswiththeirattachmentfigures.Basedonthediscourse
characteristicsoftheadultsresponsese.g,coherence,lapsesinreasoningtheirmental
statesaboutattachmentareclassified.StudieshaveshownthattheSecureFree
autonomousstateofmindisaprotectivefactoragainstpsychopathologicalrisk,whereas
theotherthreeclassificationsaresignificantlycorrelatedtoclinicalstatus.Elevenofthe15
participantsreportedasignificantdegreeofdirectivenessandoverprotectionbytheir
mothers.However,theobtainedpercentageofSecure/Freeautonomousstatedofmind
wassimilarorevenhighercomparedtosomestudiestothatobservedinsighted
populationatlowpsychopathologicalrisk.Thestudysresultsdidnotfindthatmaternal
directivenessandoverprotectionnecessarilyhavenegativeconsequencesforpersonality
development.Thestudysblindadultsreportedexperiencingsuchmaternaldirectiveness
andoverprotectionasencouragingandfunctionaliftheywereaccompaniedbyan
affective,loving,andsupportiveattitude(Ardito,Adezanto,DellOsbel,Izard,&Veglia,
2004).

Study2aims

Thisstudyhastwomaingoals.
ThefirstgoalistoapplytheSSPinasampleofinfantswithvisualimpairments,
withoutadditionaldisabilities.
ThisstudyteststheapplicabilityoftheSSPinapopulationinfantswithvisual
impairmentsotherthantheonetheprocedurewasoriginallyappliedtosightedinfants.
Theliteraturereviewconductedforthisstudyrevealedonepublishedstudythatusedthe
SSPinasampleofinfantswithvisualimpairments,someofwhichhadadditional
disabilities(Salvo,Falcetti,&Caldironi,2001).Thisstudyssampleisdifferentinthatit
onlyincludevisuallyimpairedinfantswithoutadditionaldisabilities.Thereisalso
antecedentoftheSSPbeingappliedtopopulationsotherthanthesighted.Forinstance,a
metaanalysisof16studiesonattachmentinchildrenwithautismreportedonfourthat
usedtheSSP(Rutgers,BakermansKranenburg,vanIJzendoorn,&vanBerckelaerOnnes,
2004).
Onequestioniswhethertheprocedurecantriggerattachmentandexploratory
behaviorininfantswithvisualimpairments.TodothistheSSPpresentsthechildwith
informationaimedtotriggertheattachmentbehaviormothersabsencesandreturns,
strangerspresenceandtheexploratorybehaviortoysintheroom.Ifthisinformationis
notpresentedinawaythatisperceivablebyinfantswithvisualimpairments,theSSPwill
failtotriggerattachmentandexploratorybehavior,whichwouldimpedeitsuseasameans
toclassifythesechildrensattachmentpatternsanddisorganizationstatus.
AnotherquestioniswhethertheSSPcodingprotocolcouldleadtomisconstructions
ofthebehaviorsinfantswithvisualimpairmentsdisplaywhentheirattachmentsystemis
activated.Theseinfantsmaydemonstrateattachmentinwaysnotrecognizedinthecoding
guidelines.Forinstance,thechildmayattendtohisattachmentfigurebyloweringhisface

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inordertopickupauditorycuesfromher,whichcouldbewronglyconstruedas
avoidance.Inaddition,someoftheseinfantsbehaviorsaredevelopmentaladaptations
thatcanbemisunderstoodasabnormal.Forexample,thechildmayexhibitrepetitive
movementswhichtohimserveafunctione.g.,informationpickupbutwhichobservers
mightdeemasstereotypicalinsightedinfants,andthusbecodedasdisorganized.
Thesecondgoalofthestudyistoreportthedistributionofattachmentpatternsand
prevalenceofdisorganizedattachmentfoundinthesampleofinfantswithvisual
impairments,withoutadditionaldisabilities.
Onlyonepublishedstudywasfoundthatreportedthedistributionofattachment
patternsbasedontheSSP.MoreapplicationsoftheSSPonthispopulationareneeded.This
studywilladdressthisresearchneedinasamplethat,unliketheaforementionedstudy,
includesonlyinfantswithvisualimpairmentswithoutadditionaldisabilities.
Thedistributionofattachmentpatternsissusceptibletoculturalvariations;
consistentwithitsorigininhumanevolution,childrensattachmentbehaviorsmustadapt
totheenvironmenttheygrowinwithitsprevalentcaregivingpracticesandvaluedinfants
behaviors(vanIJzendoorn&SagiSchwartz,2008).Achildwithvisualimpairmentsmust
adapttoanenvironmentthatdiffersfromthatofsightedpeers.Hehasuniqueadaptive
needsforestablishinganemotionalbondwithhiscaregiverandlearningabouthis
environment.Thequestioniswhethertheseuniqueadaptiveneedsimpactthedistribution
ofattachmentpatternsininfantswithvisualimpairments.
Theseparticularadaptiveneedscouldpotentiallyhaveaneffectonthenormative
timesofattachmentdevelopmentininfantswithvisualimpairmentsandasaconsequence
ontheagesatwhichtheirattachmentsystemcanbeobservedwhentheyundergotheSSP.
Oneexampleofthislineofthinkingisthepreattachmentbehaviorofreachingforthe
caregiver.Fraibergnotedthatwhereas5montholdsightedinfantsextendhandstomother
relyingonhandeyecoordination,theblindchildrensheobserveddidsobetween10and
16monthsofage.Shearguedthattheblindchild,lackingthevisualperceptionofthe
caregiver,needstoachieveacertainlevelofobjectpermanencebeforehecanreachforhis
motheruponhearinghervoice.Therepresentationofthecaregiverashavingpermanence
ispartoftheinternalworkingmodelproposedbyBowlby.
Tofulfillitsgoals,thisstudyappliedtheSSPtoasampleof20infantswithvisual
impairments,withoutadditionaldisabilities.InstructionswereaddedtotheSSPprotocolto
maketherelevantinformationmoresalientandperceptibletoinfantswithvariousdegrees
ofvisualimpairments.
Theclassificationofattachmentanddisorganizationwasconductedbycoder1who
hasnoclinicalexperiencewithinfantswithvisualimpairmentsbutisacertifiedand
experiencedSSPcoder.ThereliabilitysamplewascodedbyatrainedSSPcoderwhohas6
yearsofclinicalexperiencewiththesechildren.Thediscrepanciesbetweenthetwocoders
willbediscussedinordertoexplorehowfamiliaritywiththepopulationimpactsthe
resultsobtainedfromtheSSP.

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2.2Methods

Participants

Thesame20infantsthatparticipatedinstudy1constitutestudy2ssample.As
reportedearlier,thesampleconsistedof20infantswithvisualimpairmentswithout
additionaldisabilities.Ofthese,10werefemalesand10weremales.Duetothelow
incidenceofthispopulationofinfants,theywererecruitedeitheraslongitudinal(N=7)or
crosssectionalsubjects(N=13),pertheircaregiverspreference.Forinfantsandtheir
caregiversdemographicinformationofinfants,refertothemethodsectionofstudy1.
Infantsagesatthetimeofassessmentweredividedintotwoagegroups,depending
onwhetherageswereclosesttoeither12months(age1)or18months(age2).Nine
infants(6females,3males)wereobservedatage1,averagefractionalageof1.05or1year,
18days(SD=0.11).Eighteeninfants(10females,8males)wereobservedatage2,average
fractionalageof1.61,or1year,7months,12days(SD=0.24).Seveninfants(6females,1
male)wereassessedatbothages.

Table2.1:Study2subjectsages.

Subject Age1N=9 Age2N=18

Number M=1.05SD=0.11 M=1.61SD=0.24
MinimumAge=0.9 MinimumAge=1.32
MaximumAge=1.27 MaximumAge=2.33
Years Months Days Years Months Days
1 0 11 23 1 6 21
2 0 10 25 1 4 29
3 2 3 29
4 1 0 5 1 6 1
5 1 3 8 1 6 21
6 1 0 9 1 6 20
7 1 6 14
8 1 0 10 1 6 1
9 1 5 1
10 1 2 13
11 1 0 2 1 6 10
12 1 9 11
13 2 0 10
14 1 7 13
15 1 9 19
16 1 6 4
17 1 0 2
18 1 6 5

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19 1 7 22
20 1 3 26

Procedures

StrangeSituationParadigm

Atotalof27StrangeSituationParadigm(SSP)wereconductedandvideorecorded
intheClinicalResearchCenterattheUCBerkeleySchoolofOptometry.Priortothestartof
theprocedure,theleadinvestigatorconductedabriefmeetingwiththecaregiverinaroom
adjacenttotheoneinwhichtheSSPwastolaterbeperformed.Inthismeeting,thelead
investigatorexplainedtheproceduretothecaregiver,gaveherinstructionsforeachofthe
SSPsepisodes,andansweredherquestions.ThecaregiverwasshowntheTV/VHSmonitor
onwhichtheywouldbeabletoviewaliveimageoftheirinfantinSSProomthroughoutthe
procedure,fromaspycameralocatedintheprotocolroom.Theinfantremainedwiththe
caregiverduringthisoverviewinterview.
TheSSPconsistsof8episodes,whichoccursequentially,backtoback,andtotalto
about20minutes(Table2.2).

Table2.2:SummaryoftheStrangeSituationParadigmepisodes
*Episodeiscurtailedifthebabyishighlydistressed
Episode Participants Duration Behaviorhighlightedbyepisode
1 Mother,baby, 30sec Introductiontotheroombyexperimenter
experimenter approx.
2 Mother,baby 3min. Explorationofstrangeenvironmentwith
motherpresent
3 Stranger,mother, 3min. Responsetostrangerwithmotherpresent
baby
4 Stranger,baby 3min(*) Responsetoseparationwithstranger
present
5 Mother,baby Variable Responsetoreunionwiththemother
6 Baby 3min(*) Responsetoseparationwhenleftalone
7 Stranger,baby 3min(*) Responsetocontinuingseparation,andto
strangerafterleftalone
8 Mother,baby Variable Responsetosecondreunionwithmother

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GiventhattheSSPwasdesignedforfullysightedchildren,theleadinvestigator
addedinstructionstotheprotocolinordertofacilitateinfantsperceptionoftherelevant
aspectsoftheprocedure:entranceandexitofcaregiverandstranger,presenceoftoysin
theroom,andstrangersbidsforinteractionwiththeinfant.Specialconsiderationshave
beenusedwhentheSSPhasbeenappliedtoapopulationofchildrenotherthanthe
sighted.Instudieswithautisticchildren,codershaveconsideredchildrensownbaseline
behaviorpriortoseparationfromtheattachmentfigurewhendeterminingthepresence
andintensityofdisorganizedbehaviorsversusbehaviorsthatalthoughatypicalaretypical
inautism(Cappsetal.,1994;Naberetal.,2007).Whentestinginfantswithpervasive
developmentaldisorders,stereotypedbehaviorshavebeenexcludedfromthecodingof
disorganization(WillemsenSwinkles,BakermansKranenburg,Buitelaar,vanIJzendoorn,
&vanEngeland,2000).
Priortodatacollection,theseaccommodationswerediscussedwithattachment
researcherProf.AlanSoufre,UniversityofMinnesotaatMinneapolis.Adescriptionofthe
SSPepisodes(Ainsworthetal.1971)andtheaddedinstructionsusedinthisstudyare
describedbelow(Table2.3).

Table2.3:StrangeSituationParadigminstructions

Episode Instructions
1 Caregiverandinfantareintroducedtotheroombytheexperimenter.Then,the
experimenterleavesthemintheroom.
2 Thecaregiversitsinthechairandthebabyisallowedtoexplorethe
environment.Thecaregivercanhelpandcomfortthechild,asshedeems
appropriate.
Addedinstructionsforcaregiver:Youmayactivatetoys,helpthechildtouch
andhearthem,inordertomakesurethatyourchildhasnoticedthetoys.
Pleaseuseanymeansyounormallyusetohaveyourchildbeawareofthe
presenceoftoys.
3 Thestrangerenterstheroom.Forthefirstminuteoftheepisode,thestranger
sitsinherchairquietly.Forthesecondminute,shechatswiththecaregiver.
Forthethirdminute,thestrangerattemptstoplaywiththeinfant.
Addedinstructionsforstranger:Beforeenteringtheroomknockinthedoor,
onceintheroomsayhellotocaregiver.Makesuretomakenoisewithyour
stepsandwhenyousitsothattheinfanthasenoughcuestorealizethatyou
haveenteredtheroom.Wheninteractingwiththeinfant,talktothechild
beforeapproachingortouchinghim,sothatyouwarnhimofyourpresence.
Havetoysmakenoisetoalertchildoftheirpresence.Youmayalsobringtoys
tochildrenshandssothattheycantouchthetoys.
4 Thecaregiverleavestheroomandtheinfantstaysintheroomwiththe
stranger.Duringthisepisodethestrangercontinuestoattempttoplaywiththe
child.Thestrangercansitbackinthechairifthechildisfineplaying
independently.Ifthechildbecomesverydistressedandcannotbecomforted

 63

bythestranger,theepisodeiscurtailed.
Addedinstructionsforcaregiver:Letyourchildknowthatyouareleavingthe
roomasyouwouldregularlydo,youmaytalktoortouchyourchild.
5 Thecaregiverenterstheroom,pausingforamomentatthedoor.Thisgives
thebabytimetoapproachthecaregiver.Thecaregiversinstructionsareto
comfortthebabyandrenewthebabysinterestintoys.Meanwhile,the
strangerleavestheroom.
Addedinstructionsforcaregiver:Ifyouthinkyourchildtypicallyneedsyour
verbalgreetingmorethanonceforhimtonoticeandlocateyouintheroom,
youmayrepeatyourgreetingatthedoor.Ifyourchildseemstowantto
approachyouandyouknowthatheneedssoundcuestolocateyoucan,you
cancontinuetotalktoyourchildonceyouareinsidetheroom.Ifyourchildis
notyetindependentlymovinginspace,walkintotheroomandstandata
distancefromyourchildwherehecouldreachforyouwithextendedarms.
6 Thecaregiverleaves,andthebabystaysaloneintheroom.Iftheinfant
becomestoodistressed,thisepisodeiscurtailed.
Addedinstructionsforcaregiver:Letyourchildknowthatyouareleavingthe
roomasyouwouldregularlydo,youmaytalktoortouchyourchild.
7 Thestrangerenterstheroomandattemptstocomfortandplaywiththebaby.
Ifthechildistoodistressedthisepisodeiscurtailed.
AddedInstructionsforthestranger:Usethemeansthecaregiverusedtosignal
thatyouhavereturnedintotheroom.Also,ifchildisnotmobile,approachthe
childsothatyouareatadistancewherechildcanreachforyouwithextended
arms(justlikemomwasrecommendedtodo).
8 Thecaregiverreturns.Thecaregiversinstructionsaretocomfortandgetthe
babyreinterestedintoys.
Addedinstructionsforcaregiver:Ifyouthinkyourchildtypicallyneedsyour
verbalgreetingmorethanonceforhimtonoticeandlocateyouintheroom,
youmayrepeatyourgreetingatthedoor.Ifyourchildseemstowantto
approachyouandyouknowthatheneedssoundcuestolocateyoucan,you
cancontinuetotalktoyourchildonceyouareinsidetheroom.Ifyourchildis
notyetindependentlymovinginspace,walkintotheroomandstandata
distancefromyourchildwherehecouldreachforyouwithextendedarms.

Videorecordingsetting

Theprocedurewasadministeredina13by9.5footroomintheClinicalResearch
CenterattheUCBerkeleySchoolofOptometry.TheSSProomwasequippedwithtwo
videocamerasfordatarecordingandonewideanglespycameraforlivevideo
monitoringoftheSSProomactivityinanadjacentroom.Theroomwasextensivelychild
proofedandthecameraswerehiddenfromtheinfantsview.IntheSSProom,twochairs
wereplacedsidebysideonafloorrug,withasidetableholdingastackofmagazines
betweenthem.Thechairclosesttotheentrydoorwaslabeledparent.Acontaineroftoys
wasplacedinthecenteroftherug.Toyswerechosentakingintoconsiderationinfants

 64

absentorreducedvisualabilities,andthusincludedtoysthataffordedadiversityof
sensoryexperiences.Specifically:atoywith4finemotoroperatedpopupfigures;3
differentrattles;2babybooks(oneofthemhadtextures);3bellsofdifferentcolorand
sound;arollinggreencar;amusicalball;2cubeswithdifferenttexturesineachoftheir
sides;andseveralbigLegopieces(Figure2.1).

Figure2.1:ToysusedinStrangeSituationParadigm.

StrangeSituationParadigmsetting

Twohiddenvideocameras,onebytheroomsentrydoor,andasecondoneatthe
otherendoftheroom,capturedtheentirescenario.Videotapesfromthesecameraswere
usedtocodetheattachmentpattern.Theroomalsohadahiddenwirelessspycamera
whoseimagewasdisplayedandrecordedonaTV/VHSmonitorlocatedinanadjacent
room.ThespycameraallowedfortheleadinvestigatortoobservetheSSPasitwas
developing.Italsoallowedthecaregivertoseeherinfantwhenshewasoutsidetheroom.
Videotapesfromthiscamerawerenotusedincodingattachment.
Theroleofthestrangerwasperformedbyresearchassistantswhohadbeentrained
byleadinvestigator.Thistrainingincluded:
a.Theresearchassistantreviewedadetailedwrittenprotocolandmetwiththelead
investigatorfordiscussionandclarificationofanyquestions.
b.Theresearchassistantenactedthestrangersinstructionsintheroomwherethe
procedurewastotakeplaceandunderthesupervisionoftheleadinvestigator.
Duringepisode3,theleadinvestigatorknockedonthedooroncetosignaltothestranger
whentostarttoconversewiththecaregiver,andwhentostartinteractionwiththeinfant.

 65

Attheendofepisodes4and6,theinvestigatorknockedtwicetosignalthecaregiveritwas
timetosaygoodbyetoherinfantandleavetheroom.
WhenthecaregiverwasoutsidetheSSProom,sheremainedintheinterviewroom
andcouldseetheimagefromthespycameraandthusseeherinfantduringthetwo
separations.Iftheinfantbecametoodistressedduringanyofthetwoseparations,the
episodewascurtailedandthecaregiverwasinstructedtogobacktotheroom.

Codes

TheSSPvideoswerecodedusingprotocolsdevelopedfortheclassificationof
attachmentpatternssecure,ambivalent,avoidant,andfordisorganization(Ainsworthet
al.,1979;Main&Solomon,1986).

Attachmentpatterns:secure,avoidant,resistant

Theattachmentpatterni.e.,secure,avoidant,resistantisdeterminedbasedon
fourtypesofinfantsbehaviorduringthetworeunionswiththeattachmentfigure:contact
andproximityseeking,contactmaintenance,resistance,andavoidance.Thecodermust
determinealloftheinfantsbehaviorsthatcanbeclassifiedasoneofthosefourcategories,
andthenassignascorethatrepresentsalloftheobservedbehaviorsundereachtypeof
behavior.Thepossiblescoresrangefromalowestof1andahighestof7.Belowbehavioral
examplesofalowest,middleandhighestscoreareprovided(Ainsworthetal.,1979).

 66

Table2.4:SSPbehavioralcodesscoresexamples.

Score
Behavior 1 4 7
Contact/ Infantdoessignal Infantshowsdesire Infantachieves
Proximity desirefor forcontact/proximity physicalcontactsolely
Seeking contact/proximity(e.g., (e.g.,reachesfor basedonheractions
hedoesnotreachor caregivercrying)but (e.g.,walkingtoward
criesforcaregiver). hedoesnotachieve andclimbingonto
Infantacceptscontact contactonhisown caregiver),without
passivelye.g.,without andwaitsforthe neededcaregivers
clingingwhenthe caregivertopickhim assistance.Infant
caregiverpickshimup. up. maintainscontactfor
atleast15seconds.
Contact Childshowsnoprotest Infantisheldforless Duringcontactthat
Maintenance whencaregiverstops thanaminute,when lastsover2minutes,
contact. caregiverends infantactivelyand
contact,infant persistentlytriesto
proteststamely(e.g., remaininphysical
briefreach)butdoes contact(e.g.,clingsto
notactivelyattempts attachmentfigure,
toregaincontact. stronglyprotestsifput
downandclimbsback
oncaregiver).
Resistance Infantacceptscontact Isolatedresistant Atleasttwostrong
withoutanyprotest behaviorswithouta resistantbehaviors
towardthecaregiver. pervasiveangry suchas:repeated
mode,e.g.,infant hittingofcaregiver,
twicerejectstoygiven pushingawayand
bycaregiverwithout squirmingtogetdown
showinganyother whenpickedup.
angrybehavior
towardher.
Avoidance Infantdoesnotavoid Infantdoesnotgreet Infantdoesnot
caregiveruponher caregiverafterher respondtocaregivers
return(e.g.,infantturns returnforupto30 repeatedbidsfor
tolookatmom secondsbutthen interactionandinstead
immediatelyaftershe respondstomother focusesonplaying.
hearshervoice). outstretchedarmsby
reachingtowardher.

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Codingandscoringarebasedspecificallyonthechildrensbehaviorduringthetwo
reunionswiththeattachmentfigure.However,theinfantsbehaviorthroughoutallSSP
episodesinformsthecoding.Forinstance,indecidingbetweenambivalentsubtypesC1and
C2,thecoderconsidersthebehavioralexplorationoftheinfantinallepisodes(C2showsa
muchmorepassiveexplorationoftheenvironmentthanC1).

Disorganization

Thecodingprotocolfordisorganizationusedinthisstudywasobtainedfromthe
InstituteofChildDevelopmentoftheUniversityofMinneapolisatMinnesota.Itgroups
infantsbehaviorsinto7categories:
1. Sequentialdisplayofcontradictorybehaviorpatterns.Forinstance:thechildwas
highlydistressedduringseparation,cryingstronglybythedoorwithoutbeenable
toturnhisattentionelsewhere.Yet,immediatelyuponreuniontheinfantstops
crying,movesawayfromthecaregiver,andsharplyavertshergazefromher.Inthis
example,theinfantdisplaysstrongattachmentbehaviorimmediatelyfollowedby
strongavoidancebehavior.
2. Simultaneousdisplayofcontradictorybehaviorpattern.Forinstance,uponreunion
theinfantapproachestheattachmentfigurewithhisheadsharplyavertedfromher.
Inthisexamplethechilddisplaysproximityseekingandavoidancebehavioratthe
sametime.
3. Undirected,incomplete,andinterruptedmovementsandexpressions.Forexample:
infantcriesforanextensiveperiodoftimewithoutlooking,approachingor
signalinginanyotherwaytothecaregiver;childreachesforthecaregiverand
withdrawshandquicklybeforetouchingparent,withoutrationale;uponreunion
infantbeginstoapproachtheattachmentfigurebutfallsproneindepressed
(huddled)posture.
4. Stereotypes,asymmetricalmovements,mistimedmovements,andanomalous
postures.Forinstance:extendedbodyrocking;asymmetricalcreepingwhen
approachingcaregiveruponreunion;unpredictableboutsofactivity;childassumes
pronepostureformorethan20seconds,unlessinfantisclearlytired.
5. Freezing,whichconsistontheholdingofmovements,gesturesorpositionsina
posturethatinvolvesactiveresistancetogravity.Forexample,infantstandswith
armsheldoutwaisthighandtosides.Stilling,whichconsistsofthechildremaining
inarestingposturei.e.,itdoesnotinvolveactiveresistancetogravitywithoutany
clearfocusofattention.Slowedmovementsandexpressions;forexample:thechild
hasadazedfacialexpressionespeciallywhenunexpected,forexampleduring
contactseekingbehavior.
6. Directindicesofapprehensionregardingtheparent.Forinstance:uponreunion,the
childimmediatelyrespondstoparentsentrancebyjerkingbackwithfearful
expression.
7. Directindicesofdisorganizationordisorientation.Forexample:immediatelyupon
parentsreturn,thechildraiseshandstomouthwithaclearlywaryexpression.

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Thelistedexamplesofbehaviorsarenotexhaustive,thatis,theobservercancodea
behaviornotdescribedintheprotocolifitconceptuallymeetsthecriteriaofanytypeof
disorganizedbehavior.
TheinfantsbehaviorsthroughoutalloftheSSPsepisodesinformsthecoding
decisions;however,onlybehaviorsdisplayedwhentheattachmentfigureispresentinthe
roomcanbecodedasdisorganization.Forexample,whendeterminingiftheinfantshowsa
sequentialdisplayofcontradictorybehaviors,thecodermayhavetoconsiderthechilds
behaviorwhenthecaregiverwasnotintheroom.Ifachildwasextremelydistressed
duringseparation,didnotgetcomfortedbythecaregiver,remainedatthedoorcallingfor
hismother,andthenimmediatelyuponreunionshowsstrongavoidance,thiswouldcould
becodedasdisorganization.However,ifachildshowedthesameavoidantbehaviorupon
reunionbutpreviously,duringseparation,hadnotshowndistressandhadplayedwiththe
stranger,thiswouldnotbeconsidereddisorganization.
Eachcodercreatedawrittenrecordofthebehaviorscodedasdisorganized,
includingitsdescriptionandtimeofoccurrenceinthevideo.Eachofthesebehaviorswas
scoredinascalefromalowestof1andahighestof8.Theprotocolidentifiesbehaviors
thatthecodershouldconsiderstrongerindicatorsofdisorganization.Forinstance,
behaviorsthatoccurimmediatelyuponreunionwiththeattachmentfigurearestronger
indexesandreceiveahigherscore.
Ascoreof1wasgivenifwhatsuperficiallyseemeddisorganizationcouldbe
explainedinotherterms.Amiddlescoreof5wasgivenifnostrongindexeswereobserved
andtheonesobservedwerestrongenoughorcompletelylackinganalternative
explanation.Ascoreof8wasgivenwhenseveralstrongindicators,oroneverystrong
indicatorandseveralintenseexhibitionsofatleastoneotherindex,werepresent.

Codingprocedures

Afirstcoder,certifiedforthecodingofattachmentpatternsavoidant,secure,
ambivalentattachmentpatternsanddisorganizationbytheInstituteofChildDevelopment,
UniversityofMinneapolisatMinnesota,codedallofthecases.Forreliabilitypurposes,a
secondcoder(theleadinvestigator)coded30%oftheSSPvideos(N=8).Thesecondcoder
underwentSSPcodingtrainingattheUniversityofMinneapolisatMinnesota,andhad
clinicalexperienceworkingwithinfantswithvisualimpairmentswiththeBlindBabies
Foundation(www.blindbabies.org).Thefirstcoderdidnothaveanypriorexperiencewith
visuallyimpairedinfants.Bothcodersweremaskedtotheinfantsvisualstatus.
EachcoderwatchedthevideosfromthetwocamerasthatrecordedtheSSPas
manytimesashedeemednecessaryinordertoidentifyandassignascoretotheinfants
avoidance,contactandproximityseeking,resistance,contactmaintenance,and
disorganization.Additionally,thecoderskeptawrittenrecordofthebehaviorseachcoded
assignsofdisorganization,includingadescriptionofthebehaviorsandthetimetheywere
observedintheSSPvideo.
Novideosincludedinthereliabilitysamplewererecycled.Thatis,nonewerere
codedafterthecodersfirstattemptdidnotreachreliability.

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Dataanalysis

Reliabilityofcoders

Inordertomeasurereliabilityofthecoders,Cohenskappawascalculatedforthe
codessecurity/insecurity,andorganized/disorganized.Thebiasandprevalenceindexes
andmaximumkappawerecalculatedtocomplementtheinformationprovidedbythe
kappavalue.Lastly,theaccuracyofthecoderswascalculatedbasedonthecodesbase
ratesandtheobtainedkappa.

Distributionofattachmentpatterns

Inordertoexaminethedistributionofattachmentpatternsinthesample,
percentageswerecalculatedforeachtypeofattachmenti.e.,secure,insecureavoidant,
insecureambivalent.Thedistributionofdisorganizationinthesamplewasexaminedby
calculatingthepercentageofattachmentpatternsconsidereddisorganized,andthe
percentagedeemedorganized.
Itshouldbenotedthatinordertoexpandthecomparisonoftheattachment
classificationsfromacoderwithnoclinicalexperiencewithinfantswithvisual
impairmentsandanotherwithsuchclinicalexperience,thisstudyssecondcoderwill
continuetoclassifytheSSPsnotincludedinthereliabilitysamplereportedhere.Dueto
this,resultsarepresentedforthesampleasagroup,withoutidentifyingtheattachment
patternofindividualinfants.

2.3Results

Reliabilitystatistics

All 27 Strange Situation Paradigm (SSP) video recordings were coded by the first
coder.Thesecondcoder(leadinvestigator)coded30%ofthesample(N=8).
EachSSPcorrespondedtoaneventtowhichcodershadtoassigntwocodes:secure
orinsecure,anddisorganizedororganized.ThisallowedfortheuseoftheoriginalCohens
kappacalculationsinceitassumesthatcodersmakedecisionsaboutpredeterminedunits
andthatthenumberofdecisionsmadebyeachcoderisthesameasthenumberoftalliesin
thekappatable.(Bruckner&Yoder,2006;Bakeman&Quera,2011;Sim&Wright,2005;
Viera&Garrett,2005;YoderandSymons,2010).
ForsecurityofattachmenttheKappavaluewas1(Table2.5).Themaximumkappa
was1.Thevaluesofkapparangefrom1to1.Avalueof0signifiesthatcodersagreedatno
more or less than chance would allow for. Values below zero indicate agreement below
chancei.e., potential systematic disagreements between observers; positive values
representagreementabovechancewithavalueof1beingperfectagreement.
Thebiasindexwas0andtheprevalenceindexwas0.25.Thebaserateofthecode
securewas.63,andthatofinsecurewas0.38.Consideringthebaseratesandtheobtained

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kappa of 1 it was estimated that observers accuracy was above .99 (Bruckner & Yoder,
2006;Sim&Wright,2005).

Table2.5:Kapparesult,securityofattachment.
1Valueofkappa.
100%Agreement.
Numbersincellsrepresentattachmentpatternclassification.

Coder2
Secure Insecure Totals
Coder1 Secure 5 0 5
Insecure 0 3 3
Totals 5 3 8


For disorganization of attachment, the kappa value was .6 (Table 2.6). The
maximumkappawas.6.Thebiasindexwas0.13andtheprevalenceindexwas0.63.The
baserateofthecodeorganizedwas.8,andfordisorganizedwas.2.Consideringthebase
rates and the obtained kappa of .6, it was estimated that observers accuracy ranged
between0.9and0.95(Bruckner&Yoder,2006;Sim&Wright,2005).

Table2.6:Kapparesult,disorganizationofattachment.
0.6Valueofkappa.
78%Agreement.
Numbersincellsrepresentattachmentpatternclassification.

Coder2
Organized Disorganized Totals
Coder1 Organized 6 1 7
Disorganized 0 1 1
Totals 6 2 8

Attachmentpatterns

Inallbut1caseofthe18SSPcollectedatage2,thefirstcoderdeterminedthatan
attachmentpatterncouldbedeterminedfromtheobservedinfantsbehaviors.Inonecase
theattachmentpatternwasdeemednoncodable.Afterexcludingthatcasethemean
fractionalagewas1.62,or1year,7months,17days(SD=0.25).AllSSPcasescollectedat
age1weredeemedcodablebythefirstcoder.
Atage1thedistributionofattachmentpatternsshowsthat56%(N=5)ofthem
wereclassifiedassecure;oftheseoneinfanthadsubtypeB1,andfourhadsubtypeB2.

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Twentytwopercent(N=2)oftheinfantspatternswereclassifiedasinsecureavoidant
subtypeA2,and22%(N=2)ofthepatternswerecodedasinsecureambivalent;ofthese1
hadsubtypeC1and1hadsubtypeC2(seeFigure2.2).

AttachmentPatternDistributionatAge1

Avoidant
2 2

Secure

5 Resistant

Figure2.2:Attachmentpatternsdistributionatage1.
Coloredareasrepresentpercentages.
Valuesrepresentnumberofcases.

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Atage2ahigherpercentage,70%(N=12)ofthesamplesattachmentpatterns
wereclassifiedassecure.Ofthese,4childrenhadsubtypeB2,4hadsubtypeB4,3had
subtypeB3,and1hadsubtypeB1(seeTable2.7).Oftheinsecurepatterns,18%(N=3)
wereavoidant,2ofthemA2and1A1;and12%wereresistant(N=2),bothC1.

AttachmentPatternDistributionatAge2

2 3
Avoidant

Secure

12
Resistant

Figure2.3:Attachmentpatternsdistributionatage2.
Coloredareasrepresentpercentages.
Valuesrepresentnumberofcases.

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OftheseveninfantsthatunderwenttheSSPatbothages,fiveshowedthesame
attachmentpatternsatbothages,andtwoinfantschangedclassification.

Table2.7:Subjectsattachmentpatternsatages1and2.

Attachment Age1N=9 Age2N=17

Pattern M=1.05SD=0.11 M=1.62SD=0.25
MinimumAge=0.9 MinimumAge=1.32
MaximumAge=1.27 MaximumAge=2.33
Avoidant A1 0 1
A2 2 2
Secure B1 1 1
B2 4 4
B3 0 3
B4 0 4
Resistant C1 1 2
C2 1 0

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Disorganization

Atage1,7infantswerecodedasorganized,and2asdisorganized,representing
78%and22%ofthesamplerespectively(Figure2.4).Atage2,16weredeemedorganized,
and1wascodedasdisorganized,representing94%and6%ofthesamplerespectively
(Figure2.5).Ofthese,1childwascodedatbothages,meaningonechildwascodedas
disorganizedatage1andasorganizedatage2.

DisorganizedAttachmentatAge1

Organized

Disorganized
7

Figure2.4:Disorganizedattachmentpatternsatage1.
Coloredareasrepresentpercentages.
Valuesrepresentnumberofcases.

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DisorganizedAttachmentatAge2

Organized

Disorganized

16

Figure2.5:Disorganizedattachmentpatternsatage2.
Coloredareasrepresentpercentages.
Valuesrepresentnumberofcases.

2.4Discussion

ThisstudyprovidesevidencethattheStrangeSituationParadigm,withthe
additionalinstructionsasdescribedintheproceduressection,canbesuccessfullyapplied
toinfantswithvariouslevelsofvisualimpairments.Allbut1ofthe27SSPscollectedwere
deemedclassifiablebyacertifiedandexperiencedSSPfirstcoder.Notethatthiscoderdid
nothavepreviousexperiencewiththispopulation.Therefore,ifinfantswithvisual
impairmentsdisplayidiosyncraticbehaviorsduringtheSSP,anexperiencedcodercan
nonethelessinterpretthemwithrespecttotheprocedurescodingprotocol.Incontrast,in
astudybySalvoetal.(2001),18outof27SSPsweredeemedunclassifiable,allofwhich
seemtohavebeenwithinfantswhohadadditionaldisabilities.Thissharpdiscrepancy
betweenthetwostudiesinthenumberofinfantswhoseattachmentpatternscouldbe
classifiedhighlightsthedevelopmentaldifferencesthatcanbefoundbetweenvisually
impairedchildrenwithandwithoutadditionaldisabilities.
Regardingtheagesatwhichinfantswithvisualimpairmentsdeployattachment
behaviorduringtheSSPthatcoderscanclassify,thisstudyshowsthatall9infantstestedat
ameanageof1year,18dayshadpatternsthatwereclassifiable.Thissuggeststhatinfants
withvisualimpairmentscanconsolidateanattachmentsystemandorganizeitintoa

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patternbytheendofthefirstyearoflife.Ofthe18infantstestedatameanageof1year,7
months,17days,17hadpatternsthatwereclassifiable,andonly1wasdeemednon
classifiable.Duetoongoingdatacodingandtheneedtohavecoder2remainunbiased,itis
notpossibletoreportherethereasontheonecasecouldnotbeclassified.Possible
explanationsinclude:theattachmentsystemhasnotyetformed,theinfantdidnotperceive
theattachmentfiguresabsencesorreturnsduringtheSSP,orextremelyunusualbehaviors
onthepartofthechild.Theagesofthechildrenwhoseattachmentpatternswere
successfullyclassifiedrangedfrom10months,25daysto2years,3months,29days.This
informationcontributestotheunderstandingofnormativetimesforattachment
developmentinthispopulation.
Thesuccessfulrateofpatternsclassifiedinthisstudywastheproductofthe
applicationoftheSSPwiththeadditionalinstructionsdesignedtoincreasethelikelihood
thatrelevantinformationfortheactivationoftheattachmentandexplorationsystems
wouldbeperceivedbytheinfants.Theaddedinstructionsdifferedbetweenthisstudyand
thatofSalvoetal.(2001).Inbothinvestigations,parentswereinstructedtointroducethe
toysintheroomtotheirinfantsratherthanonlyberesponsiveafterinfantsbidsfor
interaction.Thepurposeofthismodificationinbothstudieswastoassurethrough
mothersmediationthattheinfantsnoticethepresenceoftoysintheroominformation
relevantforactivatingtheexploratorysystem.
Inaddition,thisstudyincludedotherspecialinstructions.Tohelpthechildnotice
theentranceofthestrangerinepisode3,shewastoknockonthedoorbeforeenteringthe
room,onceinsidesayhellotothecaregiverbutnotconversewithherfurtherandtake
noisystepsonherwaytothechair.Ofinterestatthatpointintheprocedureisthechilds
reactiontothestrangerspresencepriortoherinteractionwiththecaregiver,thatis,while
thestrangerremainsamoreambiguousstimuliforthechild.Iftheinfantdoesnotnotice
thestrangersentrancesuchbehavioralresponsesarenottested.Also,caregiverswereto
knockinthedoorbeforeenteringtheroomandwereallowedtocontinuetalkingtothe
childiftheyfeltheneededittolocatetheminspaceinordertomovetowardher,shouldhe
wanttodoso.Andbeforeleaving,caregiverswereinstructedtosaygoodbyetotheir
infantsastheywouldnormallydo.Althoughthisstudydidnothaveacontrolgroupof
infantswhichunderwenttheSSPwithoutadditionalinstructions,thesuccessfulrateof
classifiableattachmentpatternssuggeststhatthedescribedadaptationsareusefulandthat
futureresearchwiththispopulationwouldbenefitfromimplementingthem.
Oneaspectoftheprotocolthatwasnotmodifiedwasthedurationoftheinfants
separationsfromtheirattachmentfigures.Thisisrelevantsinceitisconceivablethat,
particularlyforinfantswhoroutinelyareseparatedfromtheircaregiverse.g.,in
daycarea3minuteseparationisnotstressfulenoughtoactivatetheattachmentsystem.
Fraiberg(1977)raisedarelatedpointwhensheobservedthatcomparedtoblindinfants,
sightedpeerscanbeaccustomedtomorefrequentperceptionofthecaregiverspresence.
Evenifthesightedchilddoesnotintentionallyturntolookatthecaregivertocheckonher
presence,andevenifthecaregiverremainssilent,shecanstillbepresentinthechilds
visualfield.Incomparison,ablindchildwhoisnotinphysicalcontactwiththecaregiver
reliesonthecaregiversvocalizationsandotherauditorycuesofherpresence,whichcan
bemoreintermittentthanwhatvisualperceptioncanafford.Ifblindinfantsare
accustomedtoamoreintermittentperceptionoftheircaregiverspresence,theymight
requirealongertimewithoutperceivingthecaregiverbeforedisplayingattachment

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behavior.Troster&Brambring(1992)comparedthereactionsofsightedandblindinfants
totheirmothersdeparture,noticingthatwhileprotestwasfrequentlyobservedin12
montholdsightedchildren,itwasseeninnoneofthe59monthand6ofthe17monthold
blindinfantstheystudied.
Theclassificationof26outofthe27testedinfantsatteststothesuccessful
activationoftheirattachmentsystems.Evenincasesinwhichtherewasnoclearindication
uponthecaregiversdepartureastowhetherthechildsapparentlackofreactionwasdue
tothewayhisattachmentsystemwasorganizedortonotnoticingherexit,infants
displayedattachmentbehavioruponreunion.Oneofthemostseverallyvisuallyimpaired
infantsinthisstudydidnotreacttohermotherleavingtheroom,eventhoughshe
approachedthechildandsaidgoodbyebeforeexiting.Afterabout2seconds,thechild
turnedhisupperbodyandextendedhisarmstowardthechairmomhadbeenpreviously
sittingon.Whenheobtainednoresponse,heinsistedforsometime,addingvocalizations.
Eventuallythechilddesistedandinsteadofgoingbacktoplayingashehaddoneprior,he
startedtorockhisbodybackandforth.Inthiscase,eventhoughtheinfantdidnotshow
distresswhenmomlefttheroom,afterenoughtimepassedduringwhichhehadno
evidenceofthemotherspresencedespitehisattemptstoregaincontactwithherby
performingactionsthatwouldhavetriggeredmothersbehaviorifshewouldhavebeen
present,thechildsplayingbehaviorloweredinquality.Adecreaseinthecomplexityof
playafterseparationfromthecaregiverisrecognizedintheSSPcodingprotocolasasignal
ofdistress.Thusthethreesecondsseparationwasenoughinthiscasefortheinfantto
perceivehismothersabsence.
Thequestionthatstillremains,however,iswhethera3secondseparationaffords
thevisuallyimpairedchildthesamelevelofstressasitdoestosightedpeers.Theamount
ofstresscanhaveanimpactinthedeploymentofattachment,asBowlby(1980)posited.
Theconditionsthatleadtothecessationofattachmentbehaviorsvarydependingonhow
arousedwastheattachmentsystem;themorearoused,themorephysicalcontactand
reassurancewillberequiredfromtheattachmentfigure.
Studieswithsightedchildrenarereportedtofindmostpatternsofattachmenttobe
securealthoughnumbersvaryconsiderablyacrosssampleswithinapopulationwith
upto40%reportedasinsecure.Areviewof1,584SSPofUSchildrenshowedthat67%
qualifiedassecure,21%asavoidant,and12%asresistant(vanIJzendoorn&Sagi
Schwartz,2008).Thisdistributioniscomparablewiththisstudysfindings;atbothages
tested,themajorityofthepatternswerecodedassecureandinsecurepatterns
representedupto44%ofthesample.Atage1,56%(N=5)wereclassifiedassecure,and
44%asinsecure(N=4).Atage2,70%(N=12)ofthepatternswereclassifiedassecure,
and29.41%asinsecure.Ofthe7infantsthatunderwenttheSSPatbothages,5showedthe
sameattachmentpatternatbothtestingtimes,and2twoinfantschangedclassification.
Intermsofthesecurepatternssubtypesdistribution,thisstudyfoundthatthemost
representedwereB2(N=4)atage1,andB2(N=4),B3(N=4),andB4(N=3)atage2.B1
wastheleastrepresentedatbothages(N=1).ThehigherprevalenceofB2andB3isinline
withfindingsfromstudieswithsightedchildren,whichinitiallyreportedB3ashavingthe
highestfrequency,whereasmorecontemporaryonesreportsubtypeB2asthemost
represented(A.Sroufe,personalcommunication,February,2014).Ofallattachment
patternssecureandinsecuresubtypesB2andB3infantsshowthehighestabilityto
accomplishcontact/proximitytothecaregiver.Thefactthatmostinfantsateachagetested

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wereclassifiedasB2andB3,suggeststhatinfantswithvisualimpairmentscanactivelyand
successfullydeployproximityseekingbehaviors.
Oftheinsecurepatterns,avoidantandambivalentwereclosetoequallyrepresented
atage2N=3and2respectivelyandequallyrepresentedatage1eachtypeN=2.
Oftheinsecureavoidantsubtypes,A1wastheleastrepresentedN=0atage1,
andN=1atage2.Atbothages2patternswereclassifiedasA2.Ofallsecureandinsecure
patterns,infantsclassifiedasA1showthemostavoidanceofthecaregiver.Aquestion
regardingtheapplicationoftheSSPtoinfantswithvisualimpairmentswaswhetherthey
wouldnoticewhentheircaregiversreturnedtotheroom.Ifthisstudysinfantshad
difficultiesnoticingmothersreturn,moreavoidantbehaviorscouldhavebeencoded.
Behaviorscodedasavoidantareanartifactiftheyarecausedbytheinfantfailingto
perceivetheirattachmentfigureduringreunion,whichcouldleadtomorepatternsbeen
classifiedasavoidant.Thisdoesnotseemtobethecaseinthisstudy.
Oftheinsecureambivalentsubtypesthemostrepresentedacrossages1and2was
C12outof2atage1;1outof2atage2.
Instudieswithsightedchildren,thepercentageofattachmentpatternsclassifiedas
disorganizedvariesaccordingtothesampleofinfantstested.Ametaanalysisfoundthatin
middleclass,nonclinicalgroupsthepercentagewas14%,whereasinlowsocioeconomic
samplesthepercentagewas24%(LyonsRuth&Jacobvitz,2008).Inthisstudyatage1,2
outof9infantswerecodedasdisorganized(22%);atage21outof17werecodedas
disorganized(N=6%).Onechildclassifiedasdisorganizedatage1wasatage2classified
asorganized.
Thecodingofthereliabilitysample30%oftheSSPvideos,N=8allowedfor
comparisonbetweentheclassificationsgivenbytwocodersthatdifferedintheir
experiencewiththepopulationofvisuallyimpairedchildren.Nodifferenceincodingwas
foundregardingsecurityofattachmentascoderswerereliableinalleightcases.
Discrepanciesexistedintwocasesregardingthecodingofdisorganization.Inone
case,coder1whodidnthaveexperiencewithpopulationcodedtheattachmentas
disorganized,whereascoder2whohadclinicalexperienceworkingwiththeseinfants
considereditasorganized.Thediscrepancycouldbeduetocodersdifferent
interpretationsofanidiosyncraticbehaviorinthispopulation.Bothcodersnotedthattwo
timesafterhavingbeenplayingcontentedlywithtoys,thechildstartedtocry,and
continuedtodosowithoutturninghisfaceorbodytotheattachmentfigure.Bothcoders
alsoconsideredthisabehaviorthatcouldbeconsideredunderthecategoryofseemingly
undirectedmovementsandexpressions.Underthiscategory,thecodingprotocollistsas
anexampletimeswhenthechildcriesextensivelyinthecaregiverspresencewithoutany
moveorlooktowardher.
Thediscrepancybetweenthecoderswasinthescoretheygavetothebehaviors.
Coder1gaveitascoreof7,whichasthehighestpossiblescoremandatesaclassificationof
disorganization.Thesecondcodergavethesebehaviorsacodeof4.5,whichleftittothe
codertodeterminewhetheritwasenoughevidencetowarrantaclassificationof
disorganization.Coder2consideredthefollowingfactors.First,thecodingprotocolstates
thatthisbehaviorisnotnecessarilydisorganizedifthecaregiverisalreadynearbyand
attentive.Thecoderdeemedthistobethecase,sincethechildwasplayingnearthe
caregiver;whenthechildcried,thecaregiverseveraltimestalkedtohim,making
commentsthatreflectedthechildsapparentemotionalstatus,e.g.,dontbemad,itsOK.

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Eventhoughthechildcontinuedcrying,heseemedtoattendtothecaregiversspeech,at
timesvocalizedhimselftowhichhismotherreplied,andeventuallystoppedcrying.The
childdidturnhisfacetotheattachmentfigureatothertimesduringtheSSP,thusthiswas
abehavioravailabletohim.Itispossiblethattheconditionsunderwhichvisuallyimpaired
infantsareimpelledtoturntheirfacesorbodiestowardtheircaregiversaresomewhat
differentsothatevenincontextsofdistress,theperceptionofthecaregiverscaringvoice
issufficientreassuranceforthem.Additionally,thiswastheonlybehaviorthechild
demonstratedthatwarrantedtheconsiderationofaDclassification.
Inthesecondcase,thecodersdisagreementdidnotseemrelatedtoidiosyncratic
behaviorsshownbyvisuallyimpairedinfants.Thediscrepancyhadtodowiththescoring
ofbehaviorsinwhichthechildshowedrapidchangesinaffect,specificallyfrombeing
seeminglycontenttoveryupset.Whereascoder2consideredtheseeventsenough
evidenceofdisorganization,coder1consideredthattheywerenotlackinginrationality
andcouldbeexplainedastantrumsduetothechildsfrustrationwithtoys.
Ofsignificanceisthatthisstudysresultsarefromasamplethatincludedanarrayof
visuallevels,withvisualacuityreductionsfromnormrangingfromverymildtosevereand
roughly67%beingbelowthecontrastsensitivitynormandtherestabovethenorm.This
suggeststhatthisstudysfindingsoftheapplicabilityoftheSSPwithaddedinstructions
andtheobservationofaformedattachmentsystemintheagestestedinthisstudyarenot
restrictedtoaparticularlevelofvisualimpairment.

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Study3

Exploringtherelationshipbetweenjointengagement
andattachmentininfantswithvisualimpairments

3.1Background

Theoreticalrelationbetweenattachmentandjointengagement

AsexplainedinStudy2,theattachmentsystemisrelatedtotheexplorationsystem
ofaninfant.Theattachmentfigureactsasasecurebasetowhomthechildcanreturnand
reconnectwiththroughdistantmeansinbetweenhisventuresintotheenvironment.In
thisway,thechildisreassuredthatasourceofprotectionisavailableandresponsiveto
hisneedsshouldhegetintoathreateningsituation.Thissenseofsecurityhelpshimmove
awayfromthecaregiverssideandlearnabouttheenvironmentbeyondhismost
immediatesurroundings.Fromthisperspective,theexistenceofanattachmentfigure,and
withinthat,howmuchthechildcanuseherasasecurebase,willhaveconsequencesinthe
amountandcharacteristicsofthechildsexplorations.
Becauseofthisrelationship,theinitialcodingoftheStrangeSituationParadigm
includedthechildsexploratorybehaviorintheroom.(ForadescriptionoftheSSP
protocol,seetheMethodssectionofStudy2.)However,resultsshowedthatthese
exploratorybehaviorsdidnotsignificantlydifferentiatebetweenthepatternsof
attachmentthatemergedfromtheapplicationoftheprocedure.Consequently,themost
currentSSPcodingprotocoldoesnotincludeadimensionforexploratorybehavior
(Ainsworthetal.,1978).However,thedescriptionofthepatternsandtheirsubtypesdo
considerhowexploratorybehaviordiffersbetweenthem.Forinstance,duringreunion,
subtypesecureB3ischaracterizedasbeingabletoreturntoplayandexplorationafter
beingcomfortedbytheattachmentfigure,whereasB4hasamoredifficulttimereturning
toexplorationandmayremainplayingwhileonthecaregiverslapandnotexplorethe
room.
Toparticipateinjointengagement,thechildmustattendtothesocialpartnerandto
theenvironmentwheretheobjectoreventofsharedinterestresides.Besidestheirrelation
toexplorationoftheenvironment,attachmentpatternsalsodifferonhowinfantsdeploy
attentiontotheircaregivers.Disorganizationofattachmentdisruptsinfantsattentionto
bothcaregiverandenvironment.Thisbegsthequestionastowhetherandhowattachment
relatestojointengagement.

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Thereisevidencethatachildrensabilitytouselocomotiontoexploretheir
surroundingsincreasestheiropportunitiestosharetheiremotionswiththeircaregivers
acrossadistanceinreferencetothenewobjectsandeventstheyencounterintheirdistant
explorations(Camposetal.,2000).Ifduetoinsecureattachment,thechildventuresless
intotheenvironment,thedyadwillhavefeweropportunitiestocalleachothersattention
toanexternalfocus,andthelatterwillbelimitedtowhatthedyadcanperceivewhile
stationary.
Attendingtoanexternalfocusofattentionhoweverisnotenough,forinstanceeven
ifthechilddoesagreatdealofexploration.Ifthenatureofhisemotionalbondtothe
caregiverissothathetendstoignoreher,thedyadsparticipationinjointengagementcan
alsobereduced.Thefrequencyandintensityofthechildsavoidanceoftheattachment
figureisoneofthebehavioraldimensionscodedintheSSPandwhichdifferentiates
betweenattachmentpatterns.
Anotherdimensionreferstothechildsattemptstoachievecontact/proximitywith
thecaregiver.Contactcanbeestablishedphysicallyandalsoacrossadistance,forexample
byinitiatingjointengagement;callingthecaregiversattentiontoanobjecttoshareitorto
requesthelpwithit.Childrencandifferonthestrategiestheydeploytoachieve
contact/proximity,includingtheiruseofjointengagement.Contactmaintenance,another
behaviorcodedintheSSP,referstohowmuchtheinfantactivelyremainsincontactafter
thishasbeenestablished,regardlesswhetherhimorthecaregiverinitiatedit.Ifcontact
hasbeeninitiatedbyajointattentionbid,forinstance,bythecaregiverofferingatoytothe
child,thelengthofthesharedfocuswillvarydependingonhowactiveisthechild
maintainingcontact.Childrenwithlowerlevelsofcontact/proximityseekingbehaviorare
likelytoengageinshorterepisodesofjointengagement.
Toconsiderhowdifferentattachmentpatternscouldrelatetojointengagement
patternsinwhichsecurityiscompromisedseemslikeagoodstartingpoint.Children
classifiedasavoidantdonotovertlypayattentiontotheattachmentfigure,evenwhileshe
repeatedlyattemptstointeractwithhim.ThischaracteristicisvisiblethroughouttheSSP
andnotonlyuponreunion.Insomecasesthesechildrenmayevenbelessavoidantofthe
strangerthanofthecaregiver.Achildwhodoesnotovertlypayattentiontothecaregiver
seemslesslikelytoinitiatejointengagementortorespondtotheattachmentfiguresbids
forit.Avoidantinfantsarethoughttobepayingattentioncovertlytothecaregiverwiththe
purposeofavoidingher.Thisattentionaldemandisthoughttotaxtheirattentionresources
tothedetrimenttotheattentiontheypaytoobjectsintheenvironment.Intheorythen,
highavoidancewouldintervenewithachildsattentiontoexternalfociandwithhis
initiationofandresponsivenesstojointengagementbids.
Childrenclassifiedasresistantshowmixedfeelingstowardtheattachmentfigure,
evidencedbybehaviorthatalternatesbetweenseekingcontact/proximityand
subsequentlyrejectingit.Ifthecontactestablishedwiththecaregiverincludedanexternal
focusofattentione.g.,collaborativeplaywithtoythechildstendencytorejectcontact
wouldresultinshorterjointengagementepisodes.SubtypeC1ischaracterizedbystriking
passivityintheirexplorationoftheenvironment;thelesstheinfantencountersobjectsin
theenvironment,thefeweropportunitiesthedyadwillhavetoattendtothesameexternal
focusandthemorejointengagementwilldependonthecaregiversinitiation.
Whichevertheattachmentpattern,disorganizationofitwillalterthechildsability
toorienthisattentiontothecurrentstateofaffairs,includinghisabilitytoattendtoboth

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caregiverandenvironment.Characteristicofdisorganizationistheassessmentthatthe
childsbehaviorseemsrationaltotheobserverifheassumesthatthechildfearsthe
attachmentfigure.Fearingwhathisattachmentsystemidentifiesasthesourceof
protectionandthetargetoftheproximitygoal,hisbehavioralstrategycollapses.Also
characteristicofdisorganizedbehaviorsarelackofrationality,unpredictability,
incongruenceanddisorientation.Achildwhoseattentionandbehaviorhasbrokendown
presumablyisinapsychologicalstatelessconducivetosharingattentiononanexternal
focuswithhiscaregiver.
Individualdifferenceshavebeenreportedinchildrensjointengagementskills,both
withinapopulationandamongdiverseones.Onepossiblefactorforthesedifferencesis
infantsearlysocioemotionalexperienceswiththeircaregivers(Claussen,Mundy,Mallik,
andWilloughby,2002;Mundy,Kasari,&Sigman,1992;Raver&Leadbeater,1995).The
studyofthisideacanshedlightintotheprocessesinvolvedinthereportedconnections
betweenattachmentandinfantscognitiveandemotionaloutcomes(seeStudy2).Since
studieshavealsofoundassociationsbetweenjointengagementandbetteremotionaland
cognitiveskills(seeStudy1),itisplausiblethatearlierimpactsofattachmentinjoint
engagementmediatetherelationshipbetweenattachmentanddevelopmentaloutcomesat
laterages(Claussenatal.,2002;Roggmanetal.,1998).
Onehypothesisisthatinfantsparticipationinjointattentionisinfluencedbyhow
rewardingtheyhaveexperiencedittobe(Claussenetal.,2002).Presumably,acaregiver
thatislesssensitivetothechildssignalswillbemorelikelytomissorignorehisbids,orto
respondtotheminawaythatislessthanoptimale.g.,mistimedresponses,engagement
shorterthanwhatisdesiredbythechild.Thechildthenwillassociatenegativeemotionsto
hisattemptsatsharingattention,anddecreasehismotivationtopursuethem.Andvice
versa,achildwhointeractswithacaregiverthatisresponsivetohisattemptstoshare
attention,willassociatethemwithrewardingevents,andbemoremotivatedtoengagein
suchinteractions.
Theputativeimpactofearlycaregiverchildexperiencescanbeproposednotonly
forcoordinatedbutalsosupportedjointengagement,particularlyconsideringtheactive
rolethecaregivermustplayinthelatter.Init,thesharednatureoftheengagementwith
theobjectisprimarilycarriedbythecaregiver,andunlikeincoordinatedjointengagement
thechildsattentionmayremainmostlyontheexternalfocuswithoutovertly
acknowledgingthecaregiversroleinthesharedactivity.Presumably,acaregiverwhois
lesssensitivetothechildsneedsandsignalswillbelesslikelytoinitiatejointengagement,
toinitiatelessfrequently,orinwaysthatarelessintunewiththechilde.g.,whenthe
childsinternalstateisnotoptimaltoshareattention.

Research

Studieshaveprovidedmixedresultsonthequestionofarelationshipbetweenjoint
engagementandattachment,bothintermsofhowandwhichspecificpatternshavean
impact,andhowglobalorspecificistheinfluenceonjointengagement.Somestudiesfind
significantresultsbasedonsecuritystatus,whileothersnotedifferencesbutdonotreach
significance.Somestudiesreporteffectsintheoverallfrequencyofjointengagementand

 83

othersfoundnarrowerconnections,suchuseffectsfoundinchildrensabilitytoinitiate
jointengagementbutnottorespondtoasocialpartnersbidsforit.
AttachmentresearcherMaryMain(1983)studiedtherelationshipbetweeninfants
attachmentpatternsandtheirplaybehavior.Althoughshedidnotspecificallymeasure
jointengagement,shereportedthatcomparedtochildrenwhoatage12monthswere
classifiedasinsecure,thosecodedassecurewhentestedatage21monthssignificantly
moreoftenrespondedtoanexperimentersbidforinteractionbyplayfullythrowingaball
backtohimwhilelookingattheexperimenter.Thisbehaviorcouldberegardedas
respondingtoasocialpartnersbidforjointengagement.
Otherstudieshavealsoreportedanassociationbetweensecurityofattachmentand
jointengagement.Infantscodedashavingasecurepatternatage12monthssignificantly
morefrequentlyinitiatedtoyexchangeswiththeirmothersat14months,comparedto
thosewithinsecureattachment.Motherinfantcoorientationtotoyswassignificantlyless
frequentincasesofavoidantattachmentpatternscomparedtosecure(Roggman,Langlois,
&HubbsTait,1987).Motherssensitivityscoreswheninfantswere6monthsolda
behavioralmeasurementassociatedwithsecureattachmenthasbeenreportedtopredict
theirchildrensabilitytoshareattentionwithanexperimenterat9monthsofage(Gaffan,
Martins,Healy,&Murray,2009).
Astudythatcompared2yearoldtypicallydevelopinginfantsandpeersfrom
severalclinicalgroupsautismspectrumdisorder,mentalretardation,languagedelay,
pervasivedevelopmentaldisordernonotherwisespecifiedfoundthattherelationship
betweenattachmentandjointattentionvarieddependingonwhichgroupofinfantswere
considered(Naberetal.,2007).Authorsdifferentiatedbetweenbasicjointattentionskills
towhichtheyattributedanonsetbetween6and12monthse.g.,pointingoutobjectsto
others,checkingothersgazedirectiontowardsobjects;andassociativejointattention
whichencompassedlateremergingbehaviorse.g.,followpointing,lookingintheeye
directionofthesocialpartnertoverifyherbehavior.
Consideringallchildreninthesample,withtypicalandatypicaldevelopment,those
whohadasecureattachmenthadasignificantlyhigherfrequencyperminuteofbothbasic
andassociatedjointattention,thanpeerswithinsecurepatterns.Thisrelationship,
however,wasnotfoundwithintheclinicalgroups.Authorshypothesizedthismightbe
relatedtothelowercognitiveabilitiesinchildrenintheclinicalgroups,whichmayimpose
limitstothedevelopmentofjointattentionandoverridethepositiveinfluenceofsecurity
ofattachment.Theauthorsalsonotedthatthesmallnumberofsecureattachmentinthe
clinicalgroupsmighthaveimpacteditsfoundlackofasignificantrelationshiptojoint
attention.
Againwhenconsideringallchildreninthesample,thosewithdisorganized
attachmentshowedasignificantlyhigherfrequencyofbasicandassociatedjointattention,
thanpeerswithorganizedpatterns.Whenconsideringonlytheclinicalgroupsandonly
thosewithautisticspectrumdisorder,thosewithsecureattachmentshowedasignificantly
higherfrequencyofbasicjointattention,buttherewasnosignificantdifferencefor
associatedjointengagement.Inchildrenwithautisticspectrumdisorderhowever,after
controllingforageanddevelopmentallevel,securityanddisorganizationofattachmentdid
notcontributetothepredictionofjointattentionbeyondthevarianceexplainedbythe
numberofautisticsymptoms.

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Arelationshipbetweensecurityofattachmentandjointattentionhasalsobeen
reportedwithindisorganizedpatterns.Inonestudyoftheattachmentpatternsof15
childrenwithautism,40%werecodedassecureand100%asdisorganized.Jointattention
wasmeasuredinstructuredplayinteractionswithinwhichthesocialpartnermotheror
experimenterusedprompts.Jointattentionwascodedonlywhenchildrenengagedinit
withthepurposeofsharinganexperience,butnotwhenrequestingthesocialpartnerfor
assistancewiththeobject.Thelattertypeofinteractionwasinsteadcodedasrequesting,
butstillinvolvedthechildsuseofgaze,pointingandshowingtodirectthesocialpartners
attentiontotheobject.Comparedtopeerswithdisorganizedinsecureattachment,those
withdisorganizedsecurepatternsshowedasignificantlyhigherfrequencyofrequesting
behaviorwithbothmotherandexperimenter.Theyalsoshowedasignificantlyhigher
responsetotheexperimentersbidsforjointattention(butnottomother).Nosignificant
differencewasfoundbasedonsecuritystatusforinfantsfrequencyinitiatingjoint
attention.However,theauthorsnotethatthiscouldbeduetotheverylowfrequencyof
initiatingbehaviorsinallobservedchildren(Cappsetal.,1994).
Anegativerelationshipbetweendisorganizationandjointattentionwasalso
reportedinastudywhosesampleincludedmothersfromtwoculturalbackgrounds
EuroAmericanandCentralAmerican.Theyweretaskedwithteachingtheirinfantsthree
actionsinvolvinganobject.Inbothculturalgroups,childrenclassifiedashaving
disorganizedattachmentspentlesstimewiththeirmotherssharingattentionthanthose
classifiedassecure,butthisdifferencewasonlysignificantfortheCentralAmericandyads.
Whereasinthisgroup,infantswithinsecureandinsecurepatternsspentsimilaramounts
oftimeinjointattention,intheEuroAmericangroupinfantsclassifiedasinsecurespenta
relativelyhigheramountoftimeinit.Itshouldbenotedthatthestudydefinedjoint
attentionastimeswhenchildandmotherdirectedtheirattentiontotheteachingobject,
butitisnotclearwhetheranindexsuchasinfantsgazeswitchwasrequiredforitscoding
(Scholmerich,Lamb,Leyendecker,&Fracasso,1997).
Arelationshipbetweendisorganizationofattachmentandspecificjointattention
skillswasfoundinalongitudinalstudyofinfantsatriskfordevelopmentalbehavioral
morbidityi.e.,cocaineexposed.Jointattentionwasmeasuredwheninfantswere12and
18monthsoldusingastructuredprotocolthatincludedpromptstotriggerjointattention.
Twentyeightoutofthe56infantshadadisorganizedattachmentpattern.Theseinfants,
comparedtothosewhohadanorganizedattachmentpatternshowedasignificantlylower
frequencyofactionstoinitiatejointattentionbymakingeyecontact,showingatoy,and
pointingat18monthsofagebutnotat12.Theyalsodisplayedasignificantlylower
frequencyofactionsaimedatrequestingfromthesocialpartneraidtoobtainorreactivate
anobject.Incontrast,nosignificantdifferencewasfoundinthefrequencyinfants
respondedtotheexperimentersbidsforjointattentione.g.,turningtolookinthe
directionofhispointingbetweenchildrenwithdisorganizationandthosewithoutit.The
relationshipbetweendisorganizationandjointattentionwasfoundevenaftertakinginto
accountinfantsexpressivevocabularyscores,whichauthorsusedasanindexofinfants
mentalrepresentationskills.Atrendanalysisshowedthatatage18months,infantswith
bothinsecureattachmentpatternshadlowermeanresultsforinitiatingjointattention
comparedtosecureones.Althoughnotsignificant,infantswithasecureattachment
respondedtoahigherpercentageoftheexperimenterbidsforjointattentionthanthose
withinsecureattachmentpatterns(Claussenetal.,2002).

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Arelatedlineofresearchhaslookedintotherelationshipbetweenattachmentand
infantstheoryofmind.ThisinquirymakessensegiventhatBowlbysconceptualizationof
theattachmentworkingmodelsdevelopmentincludedthechildsabilitytorepresentthe
caregiversgoalsandtodifferentiatethemtheinfantsowngoals(Bowlby,1982).As
reviewedinStudy1,insomeperspectivesjointattentionisthoughttoinvolveabeginning
understandingonthepartofthechildofothersashavingmentalstates,althoughnotas
complexastheunderstandinginvolvedininfantstheoryofmindbyage4years.For
instance,unliketheunderstandingoffalsebeliefusedinparadigmstoassesstheoryof
mindjointattentiondoesnotrequirethechildtodifferentiatebetweenhisownand
othersbeliefsaboutasharedsituation.Alsoaspreviouslyreviewed,evidencehasshowna
positivecorrelationbetweenhigherjointattentionandsuccessfulcompletionoffalsebelief
tasks.Onehypothesisisthatinfantsfirststartlearningaboutmentalstatesinearlysocial
experiencesinwhichcaregiverscommunicateunderstandingoftheirinfantsmentalstates.
Forinstance,giveninteractionsinwhichcaregiversreflectthechildrensemotion,infants
associaterepresentationsoftheirselfexperienceoftheemotionandoftheircaregivers
reactionstotheinfantsaffectivedisplayandeventuallylabeltheseaffectiveself
experiencesasemotionsordesires.Evidenceinsupportofarelationshipbetween
attachmentandtheoryofmindshowsthatahigherpercentageinfantswithsecure
attachmentcomparedtoinsecurepassfalsebelieftestse.g.,82versus46%respectively
(Fonagy&Target,1997).SeeTable3.1forasummaryofthefindings.

 86

Table3.1:Findingsontherelationshipbetweenattachmentandjointengagement.
(*)AgeM=25.7monthsSD=6.Measurementstookplacebetween20and30monthsofage.

Attachment
Author Population Variable Finding
Securev/s
Main, Typical Insecureat Significantlyhigherresponsetoexperimenters
1983 N=40 12months bidsat21months
Roggman Typical Securev/s Significantlymorefrequenttoyexchangewith
etal., N=37 Insecureat momat14months
1987 12months
Gaffanet Typical Mother Predictssharingattentionwithexperimenterat9
al.,2009 N=59 Sensitivity months
at6months
Scholmeri Typical Disorganized Significantlylesstimeinjointattentionat4,8,12
chetal., N=69 v/sSecure months(onlyinCenterAmericandyads,notin
1997 at13months EuropeanAmerican
Cappset Autism Disorganized Significantlyhigherrequestingandrespondingto
al.,1994 N=15 Securev/s bids.Nosignificantdifferenceinitiating.
MentalageM= Disorganized
24.1SD=9.9 Insecure
Claussen Atrisk(cocaine Disorganized Significantlylowerinitiationsofsharingand
etal., exposed) v/s requestingat18butnot12months.Nosignificant
2002 N=56 Organized differencesinresponsestoexperimenter'sbids
at15months forjointattention.
Naberet Typical& Securev/s Inwholesample:significantlyhigherfrequencyof
al.,2007 clinicalgroups insecure jointattention.Noeffectinclinicalgroups.
N=78(*)

Organized Inwholesample,onlyclinicalgroups,onlyautism:
v/s significantlyhigherfrequencyofjointattention.
disorganized


Study3aims

Thisstudyexploredtherelationshipbetweenattachmentpatternsandjoint
engagementinasampleofinfantswithvariouslevelsofvisualimpairments.Forthis
purpose,eighteeninfantswithvisualimpairmentswerevideorecordedduring30minute
freeplayswiththeircaregiver.Thesevideoswerecodedforjointengagementand
percentageswerecalculatedofthetimeinfantsandcaregiversparticipatedinit.Infants
attachmentpatternswereclassifiedbasedontheirperformanceintheSSP.Dataanalysis
comparedpercentagesinjointengagementbetweensecureandinsecureattachment
patterns.

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Toourknowledgethisisaquestionthathasnotbeeninvestigatedinthis
population.Asshowedbythereviewoftheliterature,therelationshipbetweenattachment
andjointengagementcandifferdependingonthepopulationstudied.Thus,researching
thisinvisuallyimpairedinfantscanservetoexpandtheunderstandingofthesechildrens
developmentandalsotodeepentheknowledgeofthewaysattachmentandjoint
engagementrelate.
Unlikepreviousresearchthatfocusedonjointattention,whichinBakeman&
Adamsonsterminology(1984,2014)islabeledcoordinatedjointengagement,thisstudy
lookedattherelationshipbetweenattachmentandjointengagementwithout
differentiatingbetweensupportedandcoordinatedtypes.Inthisway,thisstudyexpanded
thequestiontotherelationshipbetweenattachmentpatternsandinfantscoordinationof
attentiontobothsocialpartnerandexternalfocusofmutualinterest,whetherornotthe
childovertlyacknowledgedthecaregiversroleinthesharedactivity.AsreviewedinStudy
1,aftertheemergenceofcoordinatedjointengagement,passivejointengagement
continuestooccuranddoesnotdecreaseinthepercentageoftimeitoccurs.Theoretically
neitheroneisconsideredasqualitativelybetter,andbothhavebeenassociatedwith
positiveoutcomesindevelopment.Thus,itisrelevanttoincludesupportedjoint
engagementwhenresearchingtheconnectionsbetweenattachmentandinfantsabilityto
shareanexternalfocusofattention.
Itisalsointerestinggivenevidencethatattachmentselectivelyrelatestoinfants
initiationsofjointengagementbutnotresponsestoinitiationsbysocialpartners.Initiating
jointengagementrequiresamoreactiveroleonthepartofthechildthanrespondingtoa
bidforit.Thisbegsthequestionwhetheraneffectofattachmentpatternwouldstillbe
observedwhensupportedjointengagementisincluded,giventhatitrequireslessactive
participationfromthechildthancoordinatedjointengagementandisalwaysinitiatedand
sustainedbythecaregiversactions.

3.2Methods

Participants

Thesame20infantsthatparticipatedinstudies1and2constitutedthisstudys
sample.Asreportedearlier,thesampleconsistedof20infantswithvisualimpairments
withoutadditionaldisabilities.Ofthese,10werefemalesand10weremales.Duetothe
lowincidenceofthispopulationofinfants,theywererecruitedeitheraslongitudinal(N=
7)orcrosssectionalsubjects(N=13),pertheircaregiverspreference.Forinfantsand
theircaregiversdemographicinformation,pleaserefertoStudy1.

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Procedures

StrangeSituationParadigm

Thesame27SSPreportedinstudy2areusedinthisstudy.Asreportedearlier,
infantsagesatthetimeofassessmentweredividedintotwoagegroups,dependingon
whetherageswereclosesttoeither12months(age1)or18months(age2).Nineinfants
(6females,3males)wereobservedatage1,averageof1year,18days(SD=1month,12
days).Eighteeninfants(10females,8males)wereobservedatage2,withanaverageof1
year,7months,12days(SD=2months,23days).Seveninfants(6females,1male)were
assessedatbothages.

Homevisits

HomevisitswerescheduledtheclosestpossibletothetimeoftheSSP
measurement.Duetoschedulingissues,twoinfantsatage1werevideotapedathome
morethan2weeksfromthedateoftheirSSP.Foreachofthesechildren,weincludedone
homevisitbeforeandoneaftertheirSSP.Thetotalnumberofhomevisitsreportedinthis
studyisthus29.TheagemeanandSDatage1wascalculatedtwice,onetimewiththe
homevisitinwhichthesetwoinfantshadayoungeragethanatSSP(youngerage1),and
asecondtimewiththehomevisitinwhichtheyhadanolderage(olderage1).InTable
3.2forsubjects1and6agesamongparenthesiscorrespondtothehomevisitaftertheSSP,
andagesnotwithinparenthesiscorrespondtothehomevisitdonebeforetheirSSP.
Ninechildrenweretestedatage1.Youngerage1smeanwasfractionalageof1.03
or1year,12days(SD=0.13),andforolderage1was1.08or1year,28days(SD=0.11).
Eighteenchildrenweretestedatage2;themeanwas1.62or1year,7months,15days(SD
=0.23).ThesamesevenchildrenwerethatunderwenttheSSPatages1and2were
observedathomeatbothages.

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Table3.2:Study3subjectsagesathomevisits.
()=ageathomevisitdoneafterSSP

Subject Age1N=9
Number YoungerM=1.03SD=0.13 Age2N=18
OlderM=1.08SD=0.11 M=1.62SD=0.23
Years Months Days Years Months Days
1 0 10 27 1 6 25
(1) (1) (25)

2 0 10 29 1 5 1
3 2 3 8
4 1 0 12 1 5 26
5 1 2 28 1 6 9
6 0 11 9 1 6 4
(1) (1) (4)
7 1 6 7
8 1 0 1 1 6 0
9 1 5 9
10 1 2 26
11 0 11 23 1 6 3
12 1 9 18
13 2 0 5
14 1 7 26
15 1 9 28
16 1 6 23
17 1 0 10
18 1 6 22
19 1 8 16
20 1 4 11


Excludingthetwoinfantswhosehomevisitswerenotwithin2weeksoftheirSSP,
themeandifferenceindaysbetweenhomevisitandSSP1was8.6days(SD=2.8).
Includingthoseinfants,thefollowingresultsareobtained:Ifweincludeforbothchildren
thehomevisitsthattookplacebeforetheSSP,weobtainameanof12.89days(SD=8.95);
ifweinsteadincludethehomevisitsthattookplaceaftertheSSP,wehaveameanof16.44
days(SD=18.44)
Atage2,2infantshomevisitshappenedatleast17daysfromtheSSP.Excluding
thesetwoinfants,theaveragedifferencebetweenmeasurementswas8.67(SD=5.29).If
weincludethesetwoinfantstheaveragedifferenceis10.29(SD=6.77).

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DataAnalysis

Inordertodetermineiftherewasasignificantdifferenceinthepercentageoftime
injointengagementbetweenchildrenwhoseattachmentpatternswereclassifiedassecure
versusthosecodedasinsecureavoidantandambivalentgroupedtogether,twotailed
ttestwithWelchscorrectiontodegreesoffreedomwereperformed.Comparisonswere
performedseparatelyfortoys1and2atbothages1and2.Allcalculationsweredonewith
theRStatisticalpackage(TheRFoundationforStatisticalComputing,Vienna,Austria).

3.3Results

Relationshipbetweenjointengagementandsecurityofattachmentat
age1

Toys1

Consideringeitheryoungerage1andyoungerage2,therewasnosignificant
differenceinthepercentageofjointengagementbetweeninfantswhohadsecureversus
insecureattachmentpatterns.TheresultsfromthetwotailedttestwithWelchs
correctiontodegreesoffreedomwereforage1younger=t(3.81)=0.17,p=0.876;forage
1older=t(3.97)=0.27,p=0.800(Table3.3).

Toys2

Aswithtoys1,allcomparisonswerenotsignificant.Theresultsfromthetwotailed
ttestwithWelchscorrectiontodegreesoffreedomwereforage1younger=t(4.06)=
2.06,p=0.11;forage1older=t(4.69)=1.11p=0.321(table3.3).

Relationshipbetweenjointengagementandsecurityofattachmentat
age2

Toys1

Therelationshipbetweenthepercentageoftimeinfantsparticipatedinjoint
engagementandthesecuritystatusoftheirattachmentpatternwasnotsignificant.The
resultofthetwotailedttestwithWelchscorrectiontodegreesoffreedomwas=t(6.90)=
0.94,p=0.38(Table3.3).

Toys2

Aswithtoys1,therewasnosignificantdifferenceinthepercentageoftimeinfants
withasecureversusinsecureattachmentpatternspendinjointengagement.Theresultof

 91

thetwotailedttestwithWelchscorrectiontodegreesoffreedomwas=t(5.11)=0.32,p
=0.761(Table3.3).

Table3.3:Twotailedttests(Welchscorrectiontodegreesoffreedom)resultsfor
comparisonofpercentageoftimeinjointengagementatages1and2.

PercentageofTimeinJoint
SSP1Younger Engagement.Mean(SD)
M=1.03SD=0.13 teststatistic pvalue
Secure Insecure
N=5 N=4

Toys1 31.56(9.37) 29.53(22.86) t(3.81)=0.17 0.876
Toys2 42.89(9.69) 19.90(22.56) t(4.06)=2.06 0.11
SSP1Older Secure Insecure teststatistic pvalue
M=1.08SD=0.11 N=5 N=4

Toys1 26.19(10.28) 29.53(22.86) t(3.97)=0.27 0.800
Toys2 32.84(12.37) 19.90(20.56) t(4.69)=1.11 0.321
SSP2 Secure Insecure teststatistic pvalue
M=1.62SD=0.23 N=12 N=5

Toys1 42.39(22.89) 38.19(23.09) t(6.90)=0.94 0.38
Toys2 37.19(18.23) 42.11(32.17) t(5.11)=0.32 0.761

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3.4Discussion

Thisstudydidnotfindasignificantdifferenceinthepercentageoftimeinjoint
engagementbetweeninfantswithsecureandinsecureattachmentpatterns.Previous
findingsregardingtherelationshipbetweensecurityofattachmentandjointengagement
havebeenmixed,withsomeobservingsignificanteffects(Naberetal.,2007),others
noticingdifferencesthatdonotreachsignificance(Claussenetal.,2002),andevenothers
reportingthattheeffectvariesdependingonculturalbackground(Scholmerichetal.,
1997).
Ofnote,severalofthepreviousstudiesthatfoundarelationshipbetween
attachmentandjointengagementmeasuredjointengagementatalateragethantheoneat
whichtheyassessedinfantsattachmentpatternsrangingbetween2and11monthslater.
IntheClaussenetal.(2002)study,forinstance,infantsattachmentpatternswereassessed
atage15months.Therelationshipbetweendisorganizationandasignificantlylower
numberofinitiationsofjointattentiononlyoccurredwheninfantsweretestedatage18
monthsbutnotat12months.
Inthisstudy,forthemajorityofcases(N=22;85%)thejointengagement
measurementtookplaceameanof8.6daysaftertheSSP.Intheremainingfourcasesthe
jointengagementmeasurementtookplacemorethan2weeksfromtheSSP.Thisstudy
thushadasmallerlapseoftimebetweenmeasurementsthanpreviousstudiesthathave
reportedrelationshipsbetweenattachmentandjointengagement.Ininfancy,development
canbeacceleratedinshortperiodsoftimeandthusdifferencesintimeoftestingbetween
studiesorinthesubjectswithinastudycanimpacttheresults.
Attachmentbehavioristhoughttobeobservableatage12months,unlessthereis
socialdeprivation.Jointengagementemergesbetween9to12months,butitdoesnot
becomeconsolidateduntilmonthslater,atabout18monthsofageoronward.Giventhis
differenceintheageofconsolidationofbothdevelopmentalbehaviors,itispossiblethat
thetimeoftestingofjointengagementhasanimpactonastudiesabilitytofinda
significantrelationshipwithattachment.Onepossibilityisthattheeffectsofattachmenton
jointengagementarenotclearlyobservableuntilchildrenhavecommencedtoparticipate
injointengagementmorereadilyandroutinely.Andifso,futurestudieswithvisually
impairedinfantsneedtoconsiderthequestionofwhatthenormativetimeforthe
consolidationofjointengagementinthispopulationmightbe,amatterthatisatopicof
researchandnotyetestablished.
TheSSPresultsfromthisstudyssampleshowedthat3outof17testedinfantshad
disorganizedattachmentpatterns.Thisfrequencywasnotlargeenoughtotestwhether
therewasasignificantdifferenceinthepercentageoftimeinjointengagementbetween
infantswithorganizedanddisorganizedattachmentpatterns.Previousstudieshadfound
significantdifferencesbetweenorganizedversusdisorganizedpatternsaswellasbetween
disorganizedversussecure.Thisstudycouldnotcontributenewresultstothislineof
findings.Basedonthefrequencyofdisorganizedattachmentfoundinthisresearch,future
studiesthataimtopursuethisinquiryininfantswithvisualimpairmentsshouldplanon
largersamplesizesthantheoneusedinthisstudy.
Thelackofarelationshipfoundinthisstudydoesnotprecludefurtherresearchon
thequestionoftherelationshipbetweenjointengagementandattachmentpatternsin

 93

infantswithvisualimpairments.Althoughnotallstudiesseemtoclearlyreportthecriteria
bywhichtheycodedjointattention,severalofthemrequestedinfantsgazeswitch
betweenthesocialpartnerandtheobjectofsharedinterest.Thiscorrespondsto
coordinatedjointengagement,whichwasnotcodedseparatelyfromsupportedjoint
engagementinthisstudy.Furthermore,preliminaryanalysisofthisstudysvideosseemsto
indicatethatdyadsspentalargerproportionoftimewithinsupportedratherthan
coordinatedjointengagement.Itispossiblethatiftherewasaneffectofattachmentin
infantspercentageoftimeincoordinatedjointengagementitcouldhavebeenwashedout
byalackofeffectwithpercentageoftimeinsupportedjointengagement.
Insomepreviousstudies,thecodingwasfurtherspecifiedtodiscreteattention
sharingskills,withsignificantfindingsreportedforsomeandnotothers.Forinstance,
Claussenetal.(2002)reportedaneffectininitiatingjointattentionbutnotinresponding
tobidsforit.Thisstudyhoweverdidnotcodeforsuchbehavioraldimensions.
Futureanalysisofthisstudysdatawillcontinuetoexploretherelationshipofjoint
engagementandattachmentbyreviewingthealreadyidentifiedjointengagementepisodes
andcodingseparatelythosethataresupportedandthosethatarecoordinated.Thiswill
allowforanalysisbetweenthesamplesattachmentpatternsandeachtypeofjoint
engagementseparately.

 94

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Appendixes

Appendix1

JointEngagementCodingProtocol

Thiscodingprotocolisadaptedfrom:Adamson,L.B.,Bakeman,R.,Russell,C.L,&
Deckner,D.F.(1998;rev10/2000).CodingSymbolInfusedEngagementStates.Technical
Report9.Developmentallaboratory.DepartmentofPsychology.GeorgiaStateUniversity.
Thisschemesegmentsthechildsactivityintodistinctandmutuallyexclusive
periods.Theseperiodscharacterizedifferentwaysthechildmightbeengagedwithobjects
and/orpeople.Thecoderstaskistodeterminethesustainedfocusofthechildsinterest
inpeopleandobjectsandthentocodethechildsengagementstate.

Class:EngagementState

Code:JointEngagement

Jointengagementoccurswhenthechildactivelyengageswiththesameobjector
eventthatthepartnerisattendingto.Thetermjointiskeytotheseitems.Itreferstoa
sharedtopic.Thus,forachildtobeconsideredinjointengagement,heorshemustbe
attendingtothesameobjectoreventasthecaregiver.Jointengagementmayalsooccur
whenthetopicisinthehereandnoworwhenitispartiallyorfullypresentthrough
symbols.InAdamson,Bakeman,Russell,&Decknersprotocol(2000)jointengagement
neededtolastatleast3seconds.Inthisprotocolhoweverthereisnominimumlength
requiredtocodeastateasjointengagement.
Achildcannotbeinastateofjointengagementifthepartnerisnotinvolved.Itmay
behelpfultothinkofjointengagementastriadicsinceitinvolvesthechild,asharedobject,
andapartner.Thepartnersparticipationisusuallyevidencedbyactivemanipulationof
theobjectalthoughitmayalsobeconveyedbycommunicativeactsthatarerelatedtothe
sharedevent.Theremaybetimeswhenachildisseekingjointengagementbutthepartner
isnotengagedwithasharedobject.Therearealsotimeswhenacaregiverismerely
narratingthechildsactions(backgroundchatter)andnotactivelyengagedinashared
activity.Insuchinstances,thechildisnotinastateofjointengagement.
Thechildmustindeedbeactivelyinvolvedwithasharedtopicthatfocuseson
objectsandeventsoverandabovethesocialinteractionperse.Jointengagementisnot
creditedwhenthecaregiverandchildengageindyadicplay(e.g.,agameofpeekaboo)
thatdoesnotincludeasharedfocusotherthantheirmutualactivity.Whenthereappears

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tobeatopicbeyondthesocialinteraction,besurethatthereareclearindicationsthatthe
childisengagedwiththesharedtopic.
Partnersmayactinwaysthatmakeitappearthatthechildissharinganobjectoran
eventevenwhenthechildsattentioniselsewhere.Theymayalsoattractattentionsothat
thechildwatchestheirdisplayordemonstrationwithoutfullyengagingwithit.Adamson
etal.,protocol(2000)consideredthatinsuchcasesthechildisconsideredinastateof
nonjointengagement.Inthisprotocolhowever,ifthecaregiverintentionallycallsthe
childsattentiontotheobjectandthechildswitcheshisattentionfromitspreviousfocusto
theobject,thisiscodedasjointengagement.Inotherwords,forthisscenariotobecoded
asjointengagement,thechilddoesnotneedtomanipulatetheobject.Butifthechildonhis
ownswitcheshisattentiontothecaregiversengagementwiththeobject,withoutthe
caregiverhavinghadcalledthechildsattentiontoit,thisshouldbecodedasnonjoint
engagement.
Alsobecarefulnottoassumethatachildisjointlyengagedwiththetopicofa
partnersspeechandgesturesiftheonlyindicationoftheirinvolvementisthattheyseem
tobelisteningtothepartner.Itisimportantthattherebeclearindicationsthatthechildis
engagedwiththesamespecifictopiconwhichthepartnerisfocused.
Jointengagementdoesnotrequirethecaregiversengagementwiththeobjectto
changetheactionthechildisperformingontheobject.Ratherithastoinfluencethechilds
experiencewiththeobject.Influencingthechildsexperiencewiththeobjectcanconsist
on:
a. Thecaregiverdrawingthechildsattentiontotheobject,forexample:thechild
ismouthingarattle,momshakesabowlwithcubesinfrontofchild,thechild
reachesforthebowl,grabsitandbringsittohermouth.
b. Thecaregiverjoiningthechildinasharedactivitywiththeobject,afterthe
childwasalreadyengagedwiththeobject.Forexample,thechildismovinga
toycarbackandforth.Momcomesinandstartshittingthecarwithatoy
truck.Thischangestheexperiencethechildishavingwiththeobjectandchild
andmomareparticipatinginasharedactivitywithit.Yetthechilddoesnot
changehisactionontheobject.
c. Thecaregiverinfluencingtheactionthechildisperformingontheobject.For
example:thechildismouthingaring,themotherdemonstrateshowtoplace
theringinastack,thechildstopsmouthingtheringandputsitonthestack.
Anepisodeofjointengagementcaninvolveoneormoreofthesescenarios.

Tostartanewjointengagementeventthecoderneedsmoreevidencethanto
continuecodingonethathadalreadystarted.Jointengagementcanconsistofparentand
childactivelyparticipatinginaturntakingsequence.Forinstance,thesharedactivitycan
involvethatcaregiverandchildtaketurnsmanipulatingtheobjectwhiletheother
observes.Insuchsettingchildandcaregivermayattimesbeengagedwithouttouchingthe
object,forinstancewhenoneobservestheothersaction.Thismayseemasasequenceof
nonjointengagementevents(e.g.,childfocusesonobject,childfocusesoncaregiver,and
soon)butinsteadisanepisodeofjointengagementwithturns.Bemindfulthatsome
childrenandsomeactivitiesmayrequireparticipantstotaketurnslongerthan3secondsIf
theeventisnotpartofthesharedactivityanditlastsatleast3secondscodeasaseparate
nonjointengagementevent.

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Jointengagementwithtwinsibling:twinsintentionalitytoengageinjoint
engagementneedsstrongerevidencethanfromcaregiver.Forinstance,sometimesthe
caregiverintentionallyattemptstocallthechildsattentiontotheobjectbyplacingitinthe
fieldofviewofthechild,notlookingortalkingtothechildatthemoment.Thissame
behavioralonefromatwinsiblingwouldnotbeenoughevidence.
Alwaysrememberthatweareinterestedintheinfantsjointengagement.When
choosingwhentobeginandendcodingforinfantsjointengagement,decisionsshouldbe
basedontheinfantsbehavior.Iftheinfantwatchesmombangonadrumandthenchild
bangsondrum,andthenmombangsagainbutchildwalkedawayrightafterhisturn,stop
codingwhenthechildabandonstheactivity,notwhenmomfinishesherturn.However,
theremayberareinstanceswhenitisthechildwhotriestoelicitengagement,butthe
adultdoesnotreciprocate.Thisshouldnotbecodedasanengagementstate.
Jointengagementexamples:
Caregiverandchildtaketurnsrollingaball.
Theparentandchildfaceapuzzleonthefloor,andtaketurnsputtingpieces
together.
Theparentdemonstratesthewayatoyworksandthenthechildimmediately
imitatesheractionontheobject.
Thechildplacesajarinmomsopenhand,waitsforherhandtoopenthejar.
Theparentplacesadollinchildshands,thechildyellsandpushesthedollaway.
Thechild,seatedonmomslap,activelylooksatthebookwhileitisreadstohim.
Themotherdanglesbeadsinfrontofthechildwhilespeakingwithaheightened
affect,seeminglyinattempttoelicitaresponsefromthechild.Thechildresponds
bylaughing.
Thechildislabelingobjectsofsharedinvolvement,and/ormimickingthewordsof
thecaregiverwithregardtoanobject.
Thechildbangshishandontothesametoythatthemotherismanipulatingand
thenorientshisfacetothecaregiver,repeatedly.
Thechildholdsupatoyplane,showsittothemother,andthenmovesitthrough
theairwhilethemotheracknowledgestheirsharedfocusbylaughingandsaying
zoom.

Jointengagementnonexamples:
Thechildsitsinthemomslapwhilethemomreadsabooktohim,butthechildis
playingwithanothertoy.
Thechildlooksatcaregiverlookingatabook.Thecaregiverisonlyfocusedonthe
book.

RulesforBeginningCodeJointEngagement

Startcodewhenchildsexperiencewiththeobjectseemsclearlyinfluencedbythe
caregiversengagementwiththeobject.
Ifthecaregiveractivelycallschildsattentiontotheobject(e.g.,shakingitinfrontof
him,verballycallingattentiontoit,placingitnearthechildsothatshecanperceiveit),and

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thenthechildswitcheshisattentiontoit,codeasjointengagement.Begincodingwhenthe
childstartstoswitchherattentiontowardtheobject.But,ifthecaregivermakestoy
availabletochildaspartofherhousekeeping(e.g.,takingtoysoutofbagbutwithout
tryingtoengagechildwiththem),codeasnonjointengagement.
Ifthechildisalreadyattendingoractingontheobject,andthecaregiverinfluences
thechildsengagementwithit,startcodingjointengagementwhenthechildsengagement
withtheobjectstartstochange.Forinstance:
Thechildisonlyobservingtheobjectbutnotmanipulatingit,thecaregiver
demonstratestothechildhowtomanipulatetheobject,startcodingwhencaregiver
startsdemonstration.
Thechildismanipulatingtheobject,thecaregiverdemonstratestothechilda
differentwaytousetheobject,startcodingjointengagementwhencaregiverstarts
demonstration.
Ifthejointattentionepisodeisstartedbytheinfant,startcodingatthebeginningof
thefirstindexshownbythechild,forinstance:startwhenchildbeginsgivingtoytothe
caregiver.Butifthechildsattentiontotheobjectbeforecallingcaregiversattentiontoit
lastslessthan3seconds,includeitinthejointengagementevent.Insuchcasestartcoding
fromthetimethechildstartstoattendtotheobject.
Ifthecaregiverwasplayingwiththetoywithoutintendingtocallthechild's
attentionandthechildonhisownstartsobservingheractionswiththeobject:ifthe
caregivernoticesandtheactsinawaythatinfluencesthechild'sexperienceofthepiano
(e.g.,teachesthechildhowtoplaythepiano);startcodingjointengagementsincethe
caregiverchangesheraction.

RulesforEndingCodeJointEngagement

Stopcodingjointengagementwhenthechildstartstoattendonlytoobjectand
momstopsscaffoldingchildsengagementwithit.But,ifthecaregivercontinuesto
scaffold,andthusinfluencethechildsengagementwiththeobject,continuecodingasjoint
engagement.
Ifthechildattemptstostopthecaregiverfromengaginghimwithanobject(e.g.,
pushingitaway,vocallyprotesting),stopcodingjointengagementwhenchildendsthe
action.
Ifthejointengagementepisodeinvolvesturns,forinstancecaregiverandchildtake
turnsmanipulatingtheobjectwhiletheotherobserves,stopcodingatthefirstturnthe
childstartstoonlyfocusontheobject,evenifthecaregivercontinuesattendingtothe
childsactionwiththeobject.
Ifthecaregiverintentionallycalledthechild'sattentiontotheobject;theinfant
switchedhisattentionfromitspreviousfocustotheobject;andthecaregiverisnolonger
influencingthechild'sexperiencewiththeobject(e.g.,caregiverisonlyobserving,
narratingwhatthechildisdoing,holdingtheobjectasatablecoulddo),stopcodingjoint
engagementoncethecaregiverisnolongerinfluencingthechild'sexperiencewiththe
object.Forexample:themotherhasatoypianoonherlap,thechildisstartingtocrawl
away,thecaregiveractivatesthepianotryingtoengagethechildwithit,thentheinfant
turnsinthedirectionofthetoypiano.Stopcodingoncechildsattentionisonthepianoand
thecaregiverisnolongeractingonit.Inthisscenariothecaregiverinfluencesthechild's

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experiencewiththeobjectbycallinghisattentiontoitbutnotafterwards.But,ifthe
mothercontinuesplayingthepianoasthechildcrawlstowardit,continuecodinguntilthe
caregiverisnolongerplayingwiththepiano.Inthiscase,jointengagementcontinues
becausethecaregiverremainsinfluencingthechild'sexperiencewiththeobject.

Code:NonJointEngagement

Thiscodereferstostates(lastingatleast3seconds)inwhichthechildshowsanyof
thefollowing:
Noapparentengagementwithaspecificperson,object,orsymbols.Thechildmay
beunoccupied,maybescanningtheenvironmentasthoughsearchingforsomethingwith
whichtobeengaged,ormaybeflittingbetweenfociwithoutcommittingtoany.Include
segmentsinwhichthechildisinvolvedwithfoodasfoodandnotasanobject(e.g.,
munchingonacookiewhilelookingaround).Alsoincludesegmentswhenthechildis
cryingorhavingatantrumandisnotfocusedonanyparticularobjectorperson.
Attentiontothecaregiversactivity.Thechildsobservationofthecaregivers
activitycanoccurthroughanysensorychannel,notonlyvision.Thecaregiverdidnotcall
thechildsattentiontoheractivity.
Engagementinobjectplay,exploringorplayingwithobject(s)byhimself.The
partnermayattempttoengagethechildduringobjectplay,butthechildignoresher.
Enngagementwithanotherpersononly.Forexamples:thecaregiverticklesthe
childandthechildappearstobereactingtothepartnersactivity.
Thechildsseemstoonlyfocusonherownbodymovement,whetherwholebodyor
partsofit.

Nonjointengagementexamples:
Thecaregiverissinging,childlistenstoher.
Thechildwatchesparentputbeadsintoacup.Thecaregiverdidnotcallthechilds
attentiontoheraction.
Thechildfeelswithherhandshowthecaregiverispressingontoy.Thecaregiver
didnotcallthechildsattentiontoheraction.
Thechildisplayingwithbeadswhiletheparentnarrateshisactions.
Thechildengagesinsolitaryplaywithaslinkyandsaysslinky.
Childshakesheadandthisisnotacommunicationalgesturetothecaregiver.
Childliftsahandandplacesitinfrontofhiseyesandstartswaivingit.

Nonjointengagementnonexamples:
Thechildisplayingwithbeads,andfollowingtheparentsdirectionswhattodo
withthem.
Thechildattendstotheparentwhoisreadingabook,andscratchesonthepagethe
parenthadjustscratched.

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Appendix2

Demographicsurvey

1.Whatisyourrelationshiptothechild?Areyouhis/her(chooseone)
1.BiologicalMother 5.BiologicalFather 9.Other(pleaseexplain)
2.AdoptiveMother 6.AdoptiveFather __________________________________
3.FosterMother 7.FosterFather
4.Stepmother 8.Stepfather

2.Inwhichmonthandyearwereyouborn?Month:________Year:__________

3.Whatisthehighestlevelofeducationyouhavecompleted?
1.Noformalschooling
2.Primaryschool
3.Middleschool
4.Somehighschool
5.HighSchoolDiploma/GED
6.Morethanhighschool(e.g.,technicalschool,vocationalschool,certification,some
college,associatedegrees)
7.Bachelorsdegree
8.MastersDegree
9.Doctorate(JD,MD,PhD)

4.Whatisyourethnicorracialbackground?
1.AfricanAmerican
2.Asian
3.Hispanic
4.NativeAmerican
5.White
6.Other,pleaseexplain:_________________________________________________________________
7.Morethanonerace,pleaseexplain:______________________________________________________

5.Whatisyourchildsethnicorracialbackground?
1.AfricanAmerican
2.Asian
3.Hispanic
4.NativeAmerican
5.White
6.Other,pleaseexplain:_________________________________________________________________
7.Morethanonerace,pleaseexplain:______________________________________________________

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6.Whatlanguage(s)is/arespokenatyourhome?Pleaseexplain:
__________________________________
______________________________________________________________________________________

7.Pleaseestimateyourtotalfamilyincomeforthe12monthspriortothedateyouentered
ourstudy.Thinkaboutyourcombinedfamilyincomefromallsources,includingjobsand
selfemploymentforyouandotheradultswhocontributetohouseholdexpenses,aswellas
moneyfromothersourceslikewelfare,disabilitybenefits,andchildsupport.Whatisyour
bestguessforthisamount?
1.Lessthanorequalto$5,000
2.$5,00010,000
3.$10,00115,000
4.$15,00120,000
5.$20,00125,000
6.$25,00130,000
7.$30,00135,000
8.$35,00140,000
9.$40,00145,000
10.$45,00150,000
11.$50,00155,000
12.$55,00160,000
13.$60,00165,000
14.$65,00170,000
15.$70,00175,000
16.$75,00180,000
17.$80,00185,000
18.$85,00190,000
19.$90,00195,000
20.Morethan$95,001

8.Atthetimethatyouenteredourstudy,howmanypeoplewerelivinginyourhome?
Pleaseprovideanumberfor:
1. Adultrelatives(includingyourself):_________
2. Adultnonrelatives:_________
3. Siblingsofyourchildwhoisparticipatinginourstudy:_________
4. Otherminorrelatives(excludingyourchildren):_________
5. Minornonrelatives:_________

9.Atthetimeyouenteredourstudywereyoureceivinganytypeofassistancefrom
governmentprograms?Examplesofsuchprogramsinclude:WIC,FoodStamps,Childcare
subsidy/voucher,Welfare,Publichousing/Section8/housingvouchers,SocialSecurity
IncomeorSSI,Unemploymentbenefits,PublicHealthInsurancesuchasMedical,
Medicaid,HealthyFamilies.
1. Yes
2. No

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Appendix3

Comparisonofsecureattachmentpatternssubtypes

B1 B2 B3 B4
Smiles, shows interest Greets, approaches Responds to return Clear desire for
in caregiver, but does caregiver, seems to although may cry proximity not only
not especially seeks want contact, but less rather than smile. during separation.
proximity.Interest in than B3. Does not Very clear desire to Entirely preoccupied
maintaining contact seek as much across- be in proximity with with caregiver even
with caregiver across distance interaction mother, actively with her present.
distance upon reunion. as B1. approaches her. Little exploration.
Upon reunion,
shows greeting
mixed with contact-
resisting behavior.
Does not specially Tends to accept Actively seeks Actively seeks to
seek contact with contact if picked up, physical contact with maintain physical
mother. If picked up, but does not cling or mother. If contact contact by clinging
does not cling or resist release as established, tends to and resisting release.
protest release. strongly as B3. cling, and strongly
resists release.
Little or no distress Little or no distress May or may not be Clearly disturbed in
during separation. during separation. distressed. More separation episodes.
active in seeking
contact and resisting
release than B1 and
B2.

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Appendix4

Comparisonofavoidantattachmentpatternssubtypes

A1
No greeting upon reunion, or just
look/smile.
Does not approach, the approach is
abortive, or only after much coaxing.
Avoids caregiver throughout reunion.
If picked up does not cling, does not resist
being put down, may squirm to be put
down.
A2
Mixed response upon reunion; greeting
and avoidance.
Upon reunion, tendency to approach
intermingled with marked avoidance
Mixed feeling when picked up (turn face
away, cling only momentarily, squirms
to be put down). If put down, may resist
momentarily.

Appendix5

Comparisonofresistantattachmentpatternssubtypes

C1
Tends to respond positively upon
reunion (reaching, mote active
approach).
Highly ambivalent: seeks contact but
also shows angry contact-resisting
behavior.
Distressed during separation.
May explore pre-separation but does so Passivity, striking inability to use mother as
less enthusiastically than A or B.
Exploration shows anxiety and/or anger.
C2
Unable to actively achieve
proximity/interaction even pre separation.
Abortive approach attempts. More likely to
signal than to actively approach.
No active seeking of contact, if established
fails to maintain it.
May or may not be highly distressed.
a secure base.