Development and Psychopathology, 15 (2003), 259–275 Copyright 2003 Cambridge University Press Printed in the United States of America DOI: 10.1017.S0954579403000142
The development of joint attention in blind infants
ANN E. BIGELOW St. Francis Xavier University
Abstract There is little documentation of how and when joint attention emerges in blind infants because the study of this ability has been predominantly reliant on visual information. Ecological self-knowledge, which is necessary for joint attention, is impaired in blind infants and is evidenced by their reaching for objects on external cues, which also marks the beginning of their Stage 4 understanding of space and object. Entry into Stage 4 should occur before joint attention emerges in these infants. In a case study of two totally blind infants, the development of joint attention was longitudinally examined during Stage 4 in monthly sessions involving interactions with objects and familiar adults. The interactions were scored for behavior preliminary to joint attention, behavior liberally construed as joint attention, and behavior conservatively construed as joint attention. Behavior preliminary to joint attention occurred throughout Stage 4; behavior suggestive of joint attention by both liberal and conservative standards emerged initially in Stage 4 and became prevalent by mid to late Stage 4. The findings are discussed in terms of how they inform our thinking about the development of joint attention with respect to the importance of vision, cognition, social context, language, and early self-knowledge.
Although there has been theoretical speculation about joint attention in blind infants (Baron–Cohen, 1995; Hobson, 1990, 1993), the development of joint attention in these infants has not been documented. This lack of empirical investigation is due to the almost exclusive use of visual cues to determine the state of joint attention, as well as the rarity of blind infants without other handicaps. Joint attention is characterized by triadic exchanges that involve both the child’s and the partner’s awareness of the other’s mutual focus of at-
This research was aided by a Social and Behavioral Sciences Research Grant from the March of Dimes Birth Defects Foundation. Gratitude is expressed to the infants and mothers who participated in the study and to Donna MacDonald, Bernadette MacLellan, Oona Landry, Marie White, and Susan Birch, who were research assistants for the study. Address correspondence and reprint requests to: Ann E. Bigelow, Psychology Department, St. Francis Xavier University, P.O. Box 5000, Antigonish, Nova Scotia, B2G 2W5, Canada; E-mail:
[email protected].
tention to a third object or event. Its emergence indicates infants’ realization that their experience of objects can be shared with others. The study of joint attention in blind infants is important to understanding the development of these children, how they come to an awareness of a shared focus with another, and the obstacles they encounter in this process. Such a study also provides a unique context in which to examine assumptions about factors that influence the development of joint attention formed from the study of sighted infants. The Development of Joint Attention: The Importance of Vision Joint attention arises out of developments in infants’ social interactions on the one hand and their interactions with objects on the other. In sighted infants, these developments are highly dependent on vision. The ages from 3 to 5 months are called the most social time
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in infancy because infants’ interest in face to face interaction with others is at its height (Lamb, Morrison, & Malkin, 1987). Infants are visually fascinated by their partner, aware of the social contingencies the other provides (Bigelow, 1998; Hains & Muir, 1996), and sensitive to the mirroring of their own behavior in the partner’s facial, vocal, and body gestures (Gergely & Watson, 1996, 1999). After 5 months of age, infants’ interest in purely social interaction wanes in favor of interest in objects. Infants are visually attracted to objects and they actively reach for and manipulate these objects. In the second half of the first year, object and social play are combined with vision continuing to play a dominant role. Infants are able to visually share objects with others. At first, infants either engage in onlooking, where they passively watch their partner play with objects, or, if the infants are engaged with objects, they participate in supported joint attention, where their visual focus is on the objects and they show little awareness of the partner’s participation in the play even though it may depend on the partner’s scaffolding. Beginning around 9 months of age, infants more actively coordinate their visual attention to both the objects and the partner (Bakeman & Adamson, 1984). The prototype joint attention episode involves an infant and an adult playing with a toy and the infant looks from the toy to the adult’s face and back to the toy. Initially infants are simply checking to see if the partner is attending to the object they are manipulating. Later in coordinated joint attention, they can show or give the object to the partner as a means of more actively sharing their attention to the object with the partner (Adamson & Chance, 1998). Infants also are able to follow others’ directives to locate objects. From about 6 months of age, infants can use adults as social tools by following adults’ gazes to find interesting objects (Butterworth & Jarrett, 1991). In the use of adults as social tools, infants do not solicit adults’ help or attempt to engage them in their play with objects, yet infants can use adults’ acts as aids in locating or acquiring objects (Bates, Camaioni, & Volterra, 1975). By 9 to 12 months of age, infants can
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more reliably and flexibly locate objects within their visual field by following adults’ gazes and points (Butterworth, 1995). They use adult directives to find objects for mutual engagement. Toward the end of the first year, infants are able to direct others’ attention to objects of their own interest. Sustained joint attention emerges with infants’ attribution of intentionality to others (Tomasello, 1995). In particular, infants become aware of the effect of their signals to adults as instruments for operating on adults’ intentions. This awareness leads them to participate more actively in triadic interactions with adults and objects. Infants’ own gestures of pointing, showing objects, gazing, and accompanying affective expressions are used as directives for adult participation in object play. In their second year, infants begin to use symbols in their joint attention. Infants’ symbolic gestures and language, both comprehension and production, expand their communication with others about objects (Adamson & Chance, 1998). Eventually, such symbolinfused joint attention allows infants to move from a focus on the here and now to joint attention episodes that include multilayered temporal and spatial events.
Joint Attention in Blind Infants: Possible Mechanisms Despite the dominance of visual abilities in the attainment of joint attention, joint attention is assumed to occur in blind children. Baron–Cohen (1995) has given the most direct theoretical explanation of how joint attention might develop in blind children. He proposes that joint attention is a product of a Shared Attention Mechanism (SAM) that develops in normally sighted children from input acquired primarily through vision. Lack of vision hinders the development of the SAM, yet the SAM can use information from any modality to determine another’s focus of attention. In blind children, the SAM could function via touch or hearing, for example, the child could feel another’s hand on an object. Thus, joint attention is possible for blind
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children, but it is assumed they will acquire it later than sighted children. Hobson (1990, 1993) also hypothesized that blind children will have delays in, but not necessarily an absence of, joint attention. Unlike Baron–Cohen (1995), however, Hobson emphasized the importance of social experience in facilitating blind children’s ability to engage in joint attention. In drawing comparisons between blind children and autistic children, Hobson hypothesized that both have difficulty in understanding a shared focus with others, but autistic children are impaired in reacting to and identifying with the emotional attitudes of others whereas blind children have difficulties perceiving how others’ attention and emotional reactions are directed at objects and events in a shared world. If given appropriate social experience, blind children may find alternative routes to achieving coreference with others. His predictions were supported by Brown and colleagues’ (Brown, Hobson, Lee, & Stevenson, 1997) study of blind children with autistic-like features. The blind children did not necessarily show socioemotional impairments characteristic of autism, suggesting the features stemmed from other origins. The study concluded that some autistic-like features of blind children resulted from limitations in the ability to experience shared perspectives, indicating blindness can cause problems in coordinating subjective orientations or attention with others. The children presented with a range of severity in autistic-like features, suggestive of a continuum in mediating social experiences. Other theorists do not directly hypothesize about the development of joint attention in blind infants. Yet theoretical perspectives that speculate about the cognitive abilities that underlie joint attention are relevant to understanding how joint attention might evolve in blind infants. Some researchers (Adamson, Bakeman, & Smith, 1990; Nelson, 1979) suggest that joint attention is dependent upon infants’ cognitive development, particularly the development of causality and self-agency present in means–end understanding (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979). Tomasello and colleagues (Carpenter, Nagell, & Tomasello, 1998; Tomasello, 1995)
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propose that the importance of means–end understanding to joint attention is that it prepares the infant for an understanding of intentionality in others by providing the child with the experience of intentionality in self-behavior through formulating goals independent of actions and then pursuing them. Joint attention indicates that infants understand others as intentional agents, like themselves, whose attention to objects and events may be shared, followed, or directed. The cognitive abilities shown to be associated with joint attention in sighted infants, advancements in causality and self-agency, do not include the development of object permanence or spatial relations (Bates et al., 1979). The understanding of space and object is highly dependent on visual information, which allows infants to know where objects are in relation to self and others. For sighted infants, object search is stimulated by vision: seeing attractive objects, seeing their hands move, and sensing the control of that movement as a means of acquiring the objects. Sight allows children to observe the changing relation between themselves and their environment as they move through space. Their visual array provides information on the spatial relations among objects and self and how those relations change with self-movement (Rieser & Rider, 1991). In blind infants, however, the development of the understanding of space and object is closely tied to their development of causality and self-agency, that is, that they can effectively act on the environment with predictable outcomes (Bigelow, 1995). Blind children have a compromised ability to perceive the physical world and themselves in it. Knowledge of the spatial relations among objects and between self and objects is acquired primarily through sequential encounters with the objects. Spatial and event information that can be gleaned by sighted children in a single glance must be sequentially explored, synthesized, and reconstructed by blind children. Blind children have difficulty understanding that objects to reach for exist, that these objects have a permanence of their own that is independent of self, and that they can use their bodies to obtain and explore these ob-
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jects. This understanding is more cognitively constructed than it is for sighted children, and it is manifested initially in Stage 4 of the sensorimotor period when the infants begin to reach for objects on external cues (Bigelow, 1986; Fraiberg, 1977). This search for objects is an indication that blind infants have developed a sense that they can cause things to happen through their own actions. Thus, for blind infants a cognitive understanding of causality and self-agency, which is important to the development of joint attention, may be manifested through advancements in their understanding of space and object. Early Self-Knowledge: Relation to Joint Attention and Challenges for Blind Infants Joint attention is the initial indicator of the coordination of two forms of early selfknowledge: the interpersonal self and the ecological self (Neisser, 1991, 1993). Neisser proposes that prior to representation, infants acquire these forms of self-knowledge through perceptions of self in activity with the social and physical environment. Such perceptions allow awareness of the relation between self-actions and external changes. Vision is key to the acquisition of these early forms of self-knowledge. Other modalities can give information relevant to their formation, but not with the richness or dependability of vision (Neisser, 1991). The interpersonal self is concerned with the perception of the self in relation to others and is facilitated by behaviors such as mutual gaze and contingent responsiveness. The ecological self is concerned with the self in relation to the local physical environment. Knowledge of the layout of the environment seen from the perspective of the self and knowledge of how that relationship changes with movement through space positions the ecological self in the environment. In normal infants these two forms of perceptually based self-knowledge are operable by at least 4 months of age, if not earlier, as evidenced by their response to social contingency in face to face interactions (Bigelow, 1998; Bigelow, MacLean, & MacDonald, 1996; Hains & Muir, 1996; Muir & Hains, 1993; Murray & Trevarthen, 1985; Nadel, Carchon,
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Kervella, Marcelli, & Re´serbat–Plantey, 1999), their actions in response to movement-based information such as looming objects (Ball & Tronick, 1971), and posture adjustments to artificially created optic flow (Butterworth, 1990; Butterworth & Hicks, 1977; Lee & Aronson, 1974). Despite the early development of interpersonal and ecological self-knowledge, their coordination in normal infants occurs toward the end of the first year with the emergence of joint attention. With the coordination, infants are capable of attention to a person and an object at the same time, thus understanding that a specific person is attending simultaneously to them and to the object of their own focus. If infants are delayed or impaired in the development of either form of early self-knowledge, difficulties in joint attention should manifest. Interpersonal and ecological self-knowledge normally develop in harmony, and perceptions relevant to them can coexist in the same events. Yet the interpersonal and the ecological selves are distinct. They are based on different information, can be salient on different occasions, and are independently at risk for different pathologies. For example, autistic children are highly at risk for difficulties in interpersonal self-knowledge but not in ecological self-knowledge (Hobson, 1990; Loveland, 1993). They have difficulty acquiring concepts of others as people with their own subjective lives and have difficulty understanding themselves to be objects of others’ thoughts and feelings. Yet they have little trouble relating to objects and the physical environment. The problems autistic children have in engaging in joint attention (Baron– Cohen, Baldwin, & Crowson, 1997) may be, in part, a function of the discrepancies between their development of interpersonal and ecological self-knowledge. Blindness challenges the development of both forms of early self-knowledge (Bigelow, 1995). Yet for blind children, the primary pattern of disturbance in the development of the early sense of self is the reverse of that of autistic children. To be sure, blind children’s knowledge of their interpersonal self is hindered. Important avenues to the formation of the interpersonal self, such as mutual gaze and
Development of joint attention
facial attunement, do not exist for blind children. Children born without vision have difficulty detecting patterns in social interactions. It is difficult for them to perceive what others are attending to and, therefore, to understand the emotional reactions of others (Brown et al., 1997; Hobson, 1993). Others also have difficulty assessing where blind children’s attention is focused; there is neither visual orienting nor pointing, and their facial expressions are more neutral. Nevertheless, for many blind children, their knowledge of their interpersonal selves can flourish if the actions of others are perceived by the children as contingent on their own behavior, a perception that is more difficult but possible without vision (Bigelow, 1995). Others’ tactile and vocal responses to the children’s actions allow the children to sense the effect of their behavior on the behavior of others. Interpersonal self-knowledge is attained as the children learn their actions can influence others in ways that become predictable. Blindness presents more pervasive impairments to ecological self-knowledge. Blind infants cannot readily perceive the physical layout of their environment, the objects in that environment, the spatial relations among the objects, or the spatial relation of self to the objects and the physical space. Sound cues do not initially convey to the infants an object’s location or sustained existence (Bigelow, 1986; Fraiberg, 1977). Reaching and locomotion are delayed because blind infants have difficulties understanding their position within the physical environment and to objects in it (Adelson & Fraiberg, 1974; Bigelow, 1986, 1992; Fraiberg, 1968). Such delays further impede the infants’ interaction with and exploration of the environment. Thus, blind infants’ have a compromised ability to acquire ecological self-knowledge. The initial indication of blind infants’ awareness of their ecological self is their reaching for objects on external cues. By their reaches they convey their awareness of self as existing in the physical world with objects, to which they can gain access through their own actions. Reaching for objects on external cues also marks the emergence of blind infants’ Stage 4 understanding of space and object within the senso-
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rimotor period (Bigelow, 1986; Fraiberg, 1977), although initially these reaches are limited to the space directly in front of infants or in front of an area of their body where they recently lost physical contact with the objects sought. By Stage 5 the search for objects has become autonomous from previous self-actions or current body positions and the task is one of sorting out where self is in the physical environment relative to key objects (or people) and, thus, what affordances are available (Bigelow, 1986). Knowing where one is in the physical environment, where objects are in relation to each other and to self, and how these relations change with self-movement are lifelong challenges for blind children (Bigelow, 1996; Lockman, Rieser, & Pick, 1981). Yet the reaching and search behavior of Stage 4 mark the beginning awareness of blind children’s ecological self-knowledge. In summary, joint attention depends on the coordinated use of interpersonally and ecologically generated self-knowledge. For sighted infants, these forms of self-knowledge are operable from their early months. For blind infants, interpersonal self-knowledge is at risk for delay, but sensitive parenting in which parents are vocally and tactually responsive to their children’s actions facilitates many blind infants’ ability to learn their interpersonal effectiveness in the social world. Blind infants’ ecological self-knowledge is more fundamentally challenged because blindness impairs infants’ spatial awareness and understanding of self in relation to the physical world. The formation of blind infants’ ecological selfknowledge is evidenced by their Stage 4 search for objects. Thus, it is predicted that blind infants’ development of joint attention, which depends on the presence of both interpersonal and ecological self-knowledge, must await their Stage 4 understanding of space and object. The present investigation is a longitudinal case study of two blind infants. The purpose of this investigation is (a) to document the emergence of joint attention in these infants by examining their behavior for acts suggestive of the infants’ awareness that they and their partner are focused on the same object or event, and (b) to test the prediction that
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joint attention emerges in blind infants after they acquire a Stage 4 ability to search for objects, which indicates their acquisition of ecological self-knowledge. Method Participants The children followed were two full-term male infants born totally blind with no mental or other sensory handicaps. Such infants are rare because most blind children become blind after birth, have some residual vision, or have additional handicaps. Past studies on totally blind children without other handicaps typically have been with single subjects or with a few children recruited over a period of years (e.g., Dunlea, 1984; Fraiberg, 1977; Landau & Gleitman, 1985). The infants were part of a longitudinal study on blind infants’ reaching and search behavior that documented their development of object permanence (Bigelow, 1986). The two infants were the only children in the original study whose development spanned the beginning of Stage 4 into Stage 5. The ages of the two children during their development of Stage 4 were 13–21 months (Infant 1) and 23–30 months (Infant 2). Infant 1 was in early Stage 4 on his initial session and was followed to entry of Stage 5. Infant 2 was seen at 17 and 20 months prior to his entry into Stage 4 and was followed through Stage 4 to entry of Stage 5. The difference in the chronological ages of the infants during this period of their cognitive development is not atypical of this population. Although blind children’s sequence of cognitive advancements is similar across children, the ages at which they achieve these advancements are affected by a number of factors, for example, age at diagnosis, availability of support services, time spent in hospitals, family socioeconomic status, and number of other children in the home (Bigelow, 1986, 1987, 1992). The two infants were diagnosed as blind in their early infancy, and support services were available to them from this early age. They were both from intact middle class families. The infants differed on
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a number of variables, including eye condition, time spent in hospitals, and number of other children in the home. Their eye conditions were congenital optic nerve hypoplasia (incomplete development of the optic nerve) and retinal dystrophy (nonfunctional retina). Their ordinal positions in their families were only child and second child in a family with two children. The time spent in hospitals varied from no time for one child to extended stays for the other. The children were residents of the maritime provinces of Canada. They were identified for participation in the study through contacts with medical centers in these provinces and the Canadian National Institute for the Blind. Object Search Tasks: Description and relation to stages of object permanence In monthly videotaped sessions in the infants’ homes, a familiar experimenter and the mothers presented the infants with sound and touch tasks involving objects.1 Below is a brief description of the tasks used until entry into Stage 5. Task 1. A toy was placed on the child’s body. On some trials the toy was a silent toy and on others it was a sounding toy. Task 2. A sounding toy was taken away from the child and held in front of the child where it was pulled away. The toy continued to sound. Task 3. A sounding toy was presented in a stationary position at chest level directly in front of the child, to the right, or to the left. Task 4. A sounding toy was moved slowly in a horizontal 180° arc around the child’s head. Task 5. The child was playing with a toy and it dropped on the floor. The toy was either
1
Hazardous driving conditions, the blind infants’ health, and vacations of the blind infants’ families resulted in intervals between sessions that were occasionally longer than 1 month.
Development of joint attention
a silent toy or a sounding toy that continued to sound in its dropped position. Task 6. A sounding toy was placed in front of the child and covered. The toy continued to sound from under the covering. Task 7. A sounding toy was presented in a stationary position above the child’s head or below the child’s waist at the midline, to the right, or to the left. Task 8. A silent toy was taken away from the child and held in front of the child where it was pulled away. Task 9. A sounding toy was pulled away from the child at chest level directly in front of the child and moved in a horizontal arc to one side where it remained stationary. The toy continued to sound throughout the procedure. A task trial was judged to be successful if the children reached directly to the toy without any scanning or groping movements on their first response to the trial presentation. An attempt was made to present each task (in each of its positions, if multiple positions were indicated, and with both sounding and silent toys, if both types of toys were indicated) for a minimum of three trails in each session. But because this was not always possible, a criterion for mastery of a given task was adopted in which 50% or more of the trials were successful on two successive sessions. The first session then became the mastery session. In assessing what the mastery of the tasks demonstrates about the development of object permanence in blind children, two approaches were taken: (a) the underlying cognitive abilities that the standard visual object permanence tasks demonstrate were examined and matched to similar underlying abilities in the Object Search Tasks, and (b) the performance of sighted children, whose level of object permanence was known, was examined on tasks similar to the Object Search Tasks. Such approaches suggest that Task 1 was a Stage 3 task, Tasks 2 through 7 were Stage 4 tasks, Task 8 was a transitional task, and Task 9 was
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a Stage 5 task (see Bigelow, 1986, for a full rationale). Procedure The two blind infants’ monthly videotapes to the entry of Stage 5 were examined for behaviors relevant to the emergence of joint attention. The Object Search Tasks provided the infants with much opportunity for adult and object involvement. In addition, new behaviors that the infants acquired since the last session, particularly new social behaviors or play activities, and naturally occurring episodes, which typically included social interactions and object play, were videotaped on each session. Joint attention was defined as involvement of the child with an object and a social partner in which the child is aware of the partner’s sharing in the attention to the object of mutual interest. The selection of the behaviors related to joint attention was determined by examination of the behaviors the infants demonstrated and a categorization of actions that incorporated nonvisual abilities suggestive of joint attention. Behaviors relevant to joint attention: Description and rationale. The behaviors selected as relevant to joint attention in blind infants were divided into three categories: those preliminary to joint attention, those that might be liberally construed as joint attention, and those that were more conservatively suggestive of joint attention. Table 1 describes the behaviors in these three categories. Preliminary behaviors to joint attention included the use of adults as social tools and acts by the infants that could be construed as communicative gestures about objects. In the use of adults’ bodies to acquire objects (P1), the blind infants use adults as social tools to locate desired objects. In sighted infants, the use of adults as social tools to find objects precedes behaviors indicative of sustained joint attention (Bates et al., 1975; Tomasello, 1995), yet the use of adults as social tools does not necessarily lead to joint attention. Autistic children, who are typically delayed
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Table 1. Behaviors relevant to joint attention in blind infants Preliminary Behaviors P1: P2: P3:
The child uses an adult’s body to find objects. (The child tactually scans the adult’s body to the hand that may hold an object.) The child performs instrumental acts that may be interpreted as gestures concerning objects. (The child discards an object after fleeting contact or resists having an object taken away.) The child performs self-stimulating behavior that may be interpreted as gestures concerning objects. (The child shakes his head in a back and forth fashion.) Liberally Construed Joint Attention Behaviors
L1: L2: L3: L4:
The child spontaneously labels an object with which he is engaged. The child spontaneously labels an object with which he is not engaged or labels acts to be done to objects (verbal acts that could be construed as requests). The child uses an adult’s words to find or manipulate objects. (The child uses an adult’s verbal directions to locate objects or to aid his manipulation of objects.) The child acts on an object at the request of an adult. (The child changes the way he is engaged with an object at an adult’s request.) Conservatively Construed Joint Attention Behaviors
C1: C2: C3: C4:
The child repeatedly gives an object to an adult and then takes it again or repeatedly retrieves an object that an adult positions. (The context is gamelike in that the object is a tool for interaction rather than the primary focus of the child.) At the request of an adult, the child labels an object with which he is engaged. (The context is gamelike; the adult presents objects to the child and the child identifies them, typically with several objects presented in succession.) An object is incorporated into an established adult–child game. (The object is a noticeable addition from the child’s perspective.) The child cooperates with an adult in the manipulation of an object. (The context involves the child’s awareness of the adult’s actions on the object with which the child is engaged.)
or impaired in the establishment of joint attention, can use others to manipulate objects in ways they cannot, such as grasping an adult’s hand and pulling it to a door knob to open the door. The second and third preliminary behaviors, instrumental acts (P2) and self-stimulating behavior (P3), are gestures concerning objects that the adults often interpreted as communicative in that they adjusted their scaffolding in response. It is questionable whether these behaviors were intentionally communicative, although they may have evolved into being so. The liberally construed joint attention behaviors all involved the comprehension or production of language. As such, they could be interpreted as acts of symbol-infused joint attention, which is a late acquired form of joint attention in which the child’s language, either comprehension or production, or symbolic gestures affect the way in which the
child and the adult engage each other with objects (Adamson & Chance, 1998). However, in the absence of appropriate visual cues, these behaviors are ambiguous as joint attention behaviors. The spontaneous naming of objects by sighted children is not necessarily an act of sharing with another about an object; for example, children label objects when alone. Yet if the naming is accompanied by gaze shifting between the object and the partner, such naming may be seen as communicating with a partner about an object. When blind children are in the company of an adult and they label an object they find or are manipulating (L1), are the children identifying the object for self or sharing their discovery with another? Verbal labels for actions, which could be construed as requests for adults’ actions on objects of the children’s focus, or the children’s labels for objects they are not currently manipulating, which could be con-
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strued as requests for the objects (L2), more clearly involve the children’s awareness of the adult partner. However, such requests may be imperatives rather than declaratives; that is, the labels may be designed to get the adult to do something rather than to direct the adult’s attention to an object or activity of common interest. The blind infants’ use of adults’ verbal instructions to find or manipulate objects (L3) and their actions on objects at adults’ requests (L4) may be behaviors indicating the infants’ awareness of the adults’ attention to objects of the infants’ own focus. Yet such actions may be analogous to passive or supported joint attention episodes (Bakeman & Adamson, 1984), in which the children use the adults’ behavior as a form of verbal scaffolding for their own actions on objects but do not truly attend to the adults when engaged with the objects. Conservatively construed joint attention behaviors were judged to be less questionable indicators of joint attention in that the children’s actions more clearly indicated their awareness of the adults’ role in their mutual interaction with objects, although here, too, some ambiguity in interpretation remains. Characteristic of these behaviors is the gamelike context in which they occurred. The children engaged in social interaction with their adult partner, and an object was an integral part of the interaction. In C1 there is a repeated giving and taking of an object. Giving an object is a primary way young blind children show or share an object with another (Bigelow, 1988). In sighted children, the offering of objects to others and the giving and taking of objects are examples of coordinated joint attention (Adamson & Chance, 1998). C1 also includes the retrieving of objects where the goal is to find objects that the adult has positioned rather than to play with the objects themselves. C2 involves a naming game: the adult presents an object to the child and requests a label, the child feels the object and responds, and then a new object is presented. Such an object naming activity in sighted children constitutes symbol-infused joint attention (Adamson, Bakeman, & Decker, 2001; Adamson & Chance, 1998). In C3 an object is added to a familiar adult–child routine in a
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way that is obvious to the child. In C4 there is adult–child cooperation in the manipulation of an object and the child clearly indicates awareness of the adult’s role in the play. The videotapes of the monthly sessions (mean length, 26 min; SD, 7.2 min) were scored for incidents of each of the behaviors in each minute of the session. For reliability, a second scorer, who was blind to the purpose of the study, independently scored four of the videotaped sessions of each infant. Kappas, calculated on judgments of occurrence and nonoccurrence of each of the behaviors in each minute of the sessions, were .99 for P1, .97 for P2, .88 for P3, 1.00 for L1, .95 for L2, .98 for L3, .97 for L4, .77 for C1, .98 for C2, 1.00 for C3, and .94 for C4. Results and Discussion Performance of the behaviors relevant to joint attention Table 2 shows the proportion of time each infant engaged in the behaviors relevant to joint attention on each session, their ages on each session, and their ages of entry into Stages 4 and 5 based on their performance on the Object Search Tasks. The data were converted to proportions (number of minutes in which the behavior occurred divided by the total number of minutes in the videotaped session) so that the data were comparable across sessions. The infants demonstrated, by a number of different behaviors that overlapped in timing, an emerging ability suggestive of joint attention. They demonstrated behaviors preliminary to joint attention throughout the sessions, but behaviors suggestive of joint attention by both liberal and conservative standards occurred subsequent to the infants’ entry into Stage 4 and became more prevalent by mid to late Stage 4. Thus, support was found for the prediction that joint attention in blind infants must await their development of ecological self-knowledge, which is evidenced by their Stage 4 search for objects. Preliminary behaviors. Like sighted infants (Bates et al., 1975), the blind infants used others as social tools before they more actively
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Table 2. Proportion of time the infants engaged in behaviors relevant to joint attention and their ages on each session, at entry into Stages 4 and 5, and at mastery of each of the Object Search Tasks (T) Infant 1 (Age in Months) 13 Behavior Relevant to Joint Attention
14
15
16
17
18
19
a
Stage 4 T: 1, 2, 3, 4, 5
Preliminary P1 P2 P3 Liberally construed L1 L2 L3 L4 Conservatively construed C1 C2 C3 C4
T: 6
.06 .42 .33
.10 .05 .05
21 Stage 5 T: 9
T: 7, 8
0 .33 0
.07 .33 0
0 0 0
0 0 .57
0 .09 .06
0
.04 .04 0 0
.44 .16 0 .03
.65 .40 0 .05
.09 0 0 0
.09 .22 0 .25
0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0
.57 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
.20
.10 .10
.25 0 .15
Infant 2 (Age in Months)
Behavior Relevant to Joint Attention Preliminary P1 P2 P3 Liberally construed L1 L2 L3 L4 Conservatively construed C1 C2 C3 C4 a
17
20
T:
1
23
24
25
26
27
Stage 4 T: 2, 3, 4 T: 5 T: 6, 7
28
29
T: 8
.21 0 .33 .21 0 0
.12 .32 0
.18 .61 0
.07 .44 0
0 .21 .73 .29 .05 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0
0 0
0 0 0 0
0 0 0 0
0 0 0 .08
0 0 .06 0
30 Stage 5 T: 9
.10 .26 .52 .26 .06 0
.20 .20 .20
0
0 0 0 0 0 0 .05 .12 .06 .29 0 .15 .13 0
0 0 0 .27
0 0 0
0 0 0
0 0 0 .07
.15
.11
.32 .06 .06 0 0 0 0 .03 0 .09 0 .13 .19
Infant 1 met the criteria for Stage 4 on his first session.
engaged in joint attention behaviors. In the infants’ use of the adults’ bodies to find desired objects (P1), they found the adult’s arm and felt down the arm to the hand that held the toy. If they found the adult’s leg first, they tactually scanned the body for the arm and
felt down the arm to the hand for the toy. The blind infants’ physical use of adults’ bodies as tools to find objects held by these adults illustrates the infants’ facile understanding of the schema of the human body and their ability to use that schema as a means to an end.
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Throughout the sessions the infants acted on objects in ways that adults interpreted as communication of desire or dislike for particular objects. From their first session the infants resisted having some toys taken from them, whereas they discarded other toys after fleeting contact (P2). These acts may have been part of a series of behaviors associated with arousal due to the stimulation and, at times, frustration of the tasks. Upon finding a desired toy or when there were attempts to take such a toy from them, the infants’ physical activity typically increased; they often flapped their limbs, shaking or pulling on the toy in their grasp. After unsuccessful attempts at trying to search for objects or after having objects repeatedly taken from them, they would often disengage from the activity, frequently by rolling over face down on the floor. Usually this action was not accompanied by fussing or it would terminate the infants’ fussing. Such behavior suggests that the infants were modulating the level of their stimulation through self-action, much like sighted infants do by gazing away from interactions when their arousal level is about to become or becomes overwhelming (Brazelton, Koslowski, & Main, 1974; Stern, 1974, 1985). Both infants engaged in headshaking (P3), but only the mother of Infant 1, with or without awareness, attempted to train this action into a communicative gesture meaning “no.” Her training was not effective until late in the sequence of sessions. In the child’s first session the mother interpreted his headshakes as negative responses to her questions about objects. However, in this session the infant’s headshakes were more often not accompanied by the mother’s questions (7 out of 27 headshakes were accompanied by questions; discrete headshakes were separated from each other by at least 3 s). In instances where they were accompanied by questions, the questions were as likely to come after the onset of his headshakes as before (4 of the 7 questions accompanying headshakes came after the onset of the headshakes). It was not until the infant was 18 months old that more of the infant’s headshakes followed the mother’s questions than preceded them (9 of the 10 questions accompanying headshakes came before the on-
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set of the headshakes), but even at this age there were more headshakes that occurred without questions to accompany them than in response to questions (10 out of 22 headshakes were accompanied by questions). For young blind children, self-produced actions on the self, like head shaking, may be comforting in their predictability compared to the relative unpredictability of acts and sensory input from the external world. This may underlie blind children’s proneness to autistic-like behaviors (Brown et al., 1997). Such self-stimulating behavior is reduced as blind children gain more mastery over their environment (Warren, 1984). Liberally construed joint attention behaviors. The close parallel in timing between the emergence of liberally construed and conservatively construed episodes of joint attention suggests that the behaviors in these two categories may be similarly indicative of joint attention, despite differences in the ambiguity of their interpretation as joint attention behaviors. The infants differed in their language production, which affected their respective ability to engage in liberally construed joint attention behaviors. Infant 1, who participated in an early language study (Bigelow, 1987), acquired a 50-word vocabulary between 14 and 19 months of age.2 Infant 2, who did not participate in the early language study, did not say any words in the sessions examined. Infant 1’s first spontaneous label of an object he was manipulating (L1) was “bell,” which he said while playing with a bell and again while playing with a rattle. In the following sessions he spontaneously labeled objects while he was playing with them (e.g., “playdough”), although “bell” was the most common label, which he used to refer to both bells and rattles. The infant’s spontaneous la-
2
By the end of Stage 4, Infant 1 was combining words that related objects to self and other, for example, “give [to] Mommy.” Problems with joint attention may be related to difficulties in perspective taking that are reflected in blind children’s early language, such as reversals of I/ you pronouns (Andersen, Dunlea, & Kekelis, 1984; Dunlea, 1984). However, neither infant was using first or second person pronouns by the end of the sessions examined.
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bels for objects with which he was playing may have been simply his verbal categorization of the objects he could identity rather than an effort to engage others with the objects. Infant 1’s mother first interpreted his words as requests for objects with which he was not currently engaged (L2) when he said “bell” while listening to a music box and later when he said “bell” while playing with a rattle just after he had been playing with a bell. It is possible that “bell” in this context was not a request but rather an overgeneralized label for sounding objects. At 21 months he said “off” while touching the knob at the end of his ring toy, which the mother then unscrewed so that he could remove the rings. This appeared to be more clearly a request, yet such an utterance alone may simply indicate the child’s understanding that others are agents of action (Mundy, Sigman, & Kasari, 1993), that is, the child needed the adult to perform a functional act but was not sharing his experience of the object with another person. Both infants followed adults’ verbal instructions to find or manipulate objects (L3) and acted on objects at adults’ requests (L4), indicating the infants’ comprehension of their partners’ language concerning objects. The adults’ instructions that aided the infants’ search for objects typically used the child’s body as a reference point (e.g., “it’s beside you,” “down by your toes”), suggesting the adults’ awareness of the infants’ body-oriented understanding of space. The adults’ instructions also facilitated the infants’ attempts to manipulate objects (e.g., “push down,” “pull it by the heel”). The infants’ actions done to objects at the request of an adult were varied. For example, Infant 2 was given a comb and asked to comb his hair, which he attempted to do, and he hugged a stuffed animal at his mother’s request; both infants handed toys to adults at their request by extending the arm with the toy in the adult’s direction and releasing the toy to the adult’s hand. These actions indicate that the infants were aware of the adults’ attention to the objects the infants were manipulating. In following adults’ verbal directives, however, the infants may be using the adults’ language as support for their
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own activities with objects and may not be focused on the adults as partners in the interactions. Conservatively construed joint attention behaviors. The conservatively construed joint attention episodes were generally lively, playlike interactions in which both child and adult played an active role. For Infant 1, the initial instance of conservatively construed joint attention behavior was an extended episode of retrieving objects that an adult positioned (C1), where the focus was on finding the objects rather than playing with them. His mother positioned a toy that sounded as she jiggled it; he reached out and jiggled it to produce the sound but did not take it; she placed the toy in a new position within his reach and jiggled it; he found it, jiggled it, withdrew his hand, and waited for the next positioning. This was repeated several times in succession. In the following months the mother and child engaged in interactions where the mother would hand the child an object and request its label (C2), the child would feel the object and respond, then another object would be given. The context was much like a guessing game in which the mother and child were active partners and the objects were central features in the interaction. An early instance of conservatively construed joint attention for Infant 2 involved an addition of an object to a familiar game in which the mother moved her hand repeatedly over the child’s mouth while he produced vowel sounds, thereby making interesting sound variations. By adding a bowl to this game (C3), the child made echoing sounds as the mother moved the bowl back and forth over his mouth while he vocalized. The child held on to the bowl while the mother moved it and his vocalizations turned to giggles. In episodes of adult–child cooperation in manipulating a toy, the child must indicate an awareness of the adult’s role (C4). For example, Infant 2 and his mother played with a toy that produced sound when a string was pulled; the child pulled the string while the mother pulled back on the toy. After a few such joint efforts, the mother stopped doing her part.
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The child then swung the toy at her several times and began to fuss. He became reengaged with the toy only when she resumed her part of the interaction. Thus, he appeared to be aware of the necessity of his mother’s participation. As Ross and Lollis (1987) found with sighted children, infants may appear more focused on their own actions with an object than on the partners’ actions until the partners stop doing their part. Then the infants often behave in ways that indicate they are very aware of the adults’ participation and demand the partners’ reengagement. A striking feature of the conservatively construed joint attention episodes was that in all instances they were initiated by adults. There were no episodes in which the infants instigated the interactions by attempting to direct the adults’ attention to new activities. Children with disabilities can present with specific problems in joint attention that reflect the particular ways their disability impacts on factors important to joint attention; for example, deaf children at the end of their second year have virtually no symbol-infused joint attention, although they do not show deficits in other forms of joint attention (Prezbindowski, Adamson, & Lederberg, 1998). Blindness impairs the ability to detect the focus of others’ attention and the spatial relations among self, object, and other, making the initiation of joint attention difficult. Blind infants are particularly dependent on others to present the physical and social affordances available because they cannot easily predict these affordances themselves. As blind children begin to use language more effectively to engage others and to inquire about and discuss objects, they can more easily initiate joint attention. It is possible that Infant 1’s spontaneous labels of objects in the liberally construed joint attention episodes were early attempts to do so. However, blind infants’ dependency on others for instigating joint attention does not indicate passivity in their involvement in joint attention. Once joint attention episodes were begun, the blind infants participated actively in the maintenance of the episodes and used directives to adults for their continued participation in object play. As noted by Urwin (1979), blind children can prompt and exert control
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over their parents’ actions once routines are underway, but initiating routines depends on the children having physical contact with objects and parents putting themselves at their children’s disposal. Contributions of the findings from blind infants to the study of joint attention The examination of the emergence of joint attention in blind infants both affirms and challenges our thinking about factors important to joint attention. Specifically, the findings contribute to the understanding of the role of vision, early self-knowledge, cognition, social context, and language in the acquisition of joint attention. The delay and difficulty blind infants have in attaining joint attention affirms the importance of vision in the establishment of joint attention, yet indicates vision is not necessary for joint attention to occur. Blind children must rely on subtle and indirect cues for deciphering where objects are and where the attention of others is directed. To coordinate the spatial placement of objects in relation to themselves and others, blind children depend on tactile and kinesthetic information and memory, sound changes, air currents, and echolocation (Millar, 1988), as well as the verbal comments of others. To interpret others’ attentional focus, blind children depend primarily on auditory and tactile information. Blind infants’ reliance on such nonvisual cues for the information that is necessary for joint attention taxes their abilities beyond those of sighted peers but does not prevent the attainment of joint attention. The support for the prediction that blind infants’ acquisition of ecological self-knowledge would occur prior to joint attention indicates that the early forms of self-knowledge may act as control parameters to the development of joint attention. Difficulties in either ecological or interpersonal self-knowledge can result in delays or impairments in joint attention. The findings indicate that difficulties in ecological self-knowledge delay blind infants’ development of joint attention, yet difficulties in the social–emotional realm may further impede their attainment of joint attention. If blind
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infants lack adults who respond sensitively to them or when other social–emotional problems prevail, they will be at increased risk, not only for autistic-like behaviors (Brown et al., 1997), which suggest difficulties with interpersonal self-knowledge, but also for delays in searching for objects on external cues that are substantially beyond those of blind infants in more sensitive family or social environments (Fraiberg, 1977). Such extended delays in searching for objects indicate increased difficulties with ecological selfknowledge. Joint attention requires the prior acquisition of early understandings of the self in the social realm with others and in the physical world with objects. The findings reveal parallels in the relation between joint attention abilities and cognitive functioning in blind and sighted children, which suggest that cognition is important to the development of joint attention. For sighted infants, sustained joint attention emerges toward the end of the first year (Adamson, 1995). This timing corresponds to mid to late Stage 4 of the sensorimotor period (Flavell, 1963), which is when the blind infants also showed prevalent behaviors suggestive of joint attention. For sighted infants, developments in causality and self-agency, as demonstrated in means–end understanding, are associated with joint attention (Bates et al., 1979). In blind infants, the development of causality and self-agency may be manifested by their development of object permanence; reaching for objects in response to external cues indicates blind infants’ emerging awareness that they can cause things to happen through their own actions. Thus, for both blind and sighted infants, a similar level of cognitive mastery involving the understanding of themselves as causal agents may be important to the attainment of joint attention, although such mastery may be acquired through different means and manifested through different abilities. Cognitive abilities alone, however, may not in themselves be sufficient for the establishment of new skills (Fisher & Silvern, 1985). Their significance to the development of joint attention may be that they allow for new understandings of self in the context of others and objects by opening the possibilities for the co-
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ordination of interpersonal and ecological self-knowledge. A rich social context structured by adults facilitated blind infants’ ability to interpret the perceptual cues necessary for joint attention to occur and affirms the importance of the role of adults in mediating infants’ ability to coreference objects with others. Blind infants are particularly dependent on adults for providing the social context, as evidenced by the finding that, in all instances, the blind infants’ playlike conservatively construed episodes of joint attention were initiated by adults. Adult scaffolding of the social and physical environment presents blind infants with the affordances available to them and facilitates their discovery that their experience with objects can be shared. Such is also the case for sighted children. Adults control many of the variables that must coincide to enable infants to participate in joint attention (Carpenter et al., 1998). Although blind infants may be more reliant than sighted infants on the social initiative of others, the social context in which infants engage in joint attention influences their ability to interpret whatever perceptual information is available to them. Language expanded the ability of blind infants to engage in joint attention, which affirms the facilitating relation between joint attention and language yet highlights the bidirectionality of that relation. The comprehension of language aids blind children’s ability to detect the attention of others, and the production of language is perhaps blind children’s most powerful tool in directing others’ attention to objects of the children’s own focus. Although studies of symbol-infused joint attention (Adamson et al., 2001; Adamson & Chance, 1998) acknowledge the transformational nature of language to joint attention, in many studies with sighted infants, the examination of the relation between joint attention and language has focused primarily on the ways in which joint attention facilitates language development (Smith, Adamson, & Bakeman, 1988; Tomasello & Todd, 1983) and has ignored, with few exceptions (Carpenter et al., 1998), the ways in which the reverse is also true. Mothers’ speech to infants during periods of joint attention, but not outside periods
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of joint attention, has been associated with advances in infants’ early vocabulary (Tomasello & Farrar, 1986). The facilitating effect of adults’ speech within episodes of joint attention is particularly operative when adults’ speech is about the objects of the infants’ current attentional focus rather than about objects to which the adults want to direct the infants’ focus. The same process operates with blind infants. Blind children’s early words label their close perceptual experiences of touch, taste, and smell (Bigelow, 1987). Referents to distal objects, the experiences of others, or events the children have not participated in, all of which might be perceived with interest by sighted children, are rare in blind children. The close perceptual experiences encompass their primary attentional focus and are the experiences that parents of blind children typically talk about when attempting to engage with their infants (Kekelis & Andersen, 1984); thus, the parental speech to blind infants tends to follow the infants’ attentional focus. Yet for blind infants, the facilitating relation between joint attention and language is bidirectional. Although joint attention facilitates language development, it also is facilitated by the infants’ use of language. This is true for sighted infants as well, despite the unidirectional focus much of the research has taken. The ways in which language enhances joint attention may be particularly important to blind infants, whose avenues for communicating their attentional focus and engaging with objects are more limited than for sighted infants, yet for all infants the relation between language and joint attention is beneficial in both directions. In summary, the study of joint attention in blind infants informs our thinking about several factors relevant to the attainment of joint attention. The blind infants’ delay in acquiring joint attention affirms the importance of vision for this development, but it also indicates that vision is not essential for joint attention to occur. The other modalities allow infants to detect when self and other are focused on the same object, although these modalities do not do so as readily or directly as vision. The support for the prediction that blind infants would acquire ecological self-knowledge prior to joint attention affirms early self-knowledge
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as a prerequisite for joint attention. Problems in early perceptually based self-knowledge hinder the development of joint attention. That the blind infants initially demonstrated joint attention after entry into Stage 4 of the sensorimotor period suggests that certain cognitive abilities may be important for the attainment of joint attention. The critical cognitive advancements may be in causality and self-agency, which for blind infants are manifested in their understanding of space and object. These cognitive advancements may allow for the coordination of early forms self-knowledge. This coordination is enhanced by a rich social context in which adults play a major role in enabling infants to interpret the available perceptual cues. Blind infants’ reliance on language, both comprehension and production, in many of their joint attention episodes highlights the importance of language as a social pragmatic tool that facilitates children’s ability to engage in joint attention. Thus, the study of the emergence of joint attention in blind infants extends our understanding of factors influencing joint attention and suggests fruitful avenues for further exploration of this triadic relationship between self, other, and object. Limitations There are a number of limitations to this examination of the development of joint attention in blind infants. First, the investigation was based on a case study of only two infants. The development of these infants may not be representative of blind children; indeed, the infants’ total blindness from birth and their lack of mental or other sensory handicaps make them exceptional in the population of blind children, most of whom are adventitiously blind or have multiple handicaps. Yet the exclusivity and totality of the infants’ blindness allows for investigation of the effects of lack of vision on the attainment of joint attention, which may be useful to the understanding of the importance of vision per se to this development and of the role blindness plays in joint attention difficulties shown by children in the more diverse blind population. Second, the data were taken from videotapes that were not made to document joint atten-
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tion and, thus, the behaviors shown may not demonstrate the full abilities of the infants to engage in interactions with objects and others. Third, it is difficult to identify when blind children are aware that they and their partners are attending to the same objects; thus, the behaviors relevant to joint attention are ambiguous. This ambiguity is present to some degree in each of the three categories of scored behaviors. Fourth, the behaviors judged to be associated with joint attention were chosen after examining the behaviors the infants demonstrated. Such a post hoc analysis has
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obvious methodological limitations. Fifth, the investigation did not include a comparison sample of sighted children. Although much is known about sighted children’s development of joint attention (Adamson, 1995), relying on such prior knowledge for comparison is problematic given the uniqueness of the present paradigm. These limitations necessitate caution in interpreting the findings. Nevertheless, the information provided by the examination may give direction to the heretofore speculation of how and when blind infants come to engage in joint attention.
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275 to perturbations in adult facial, vocal, tactile, and contingent stimulation during face-to-face interactions. In B. de Boysson–Bardies, S. de Schoenen, P. Jusczyk, P. McNeilage, & J. Morton (Eds.), Developmental neurocognition: Speech and face processing in the first year of life (pp. 171–185). Dordrecht: Kluwer. Mundy, P., Sigman, M., & Kasari, C. (1993). The theory of mind and joint-attention deficits in autism. In S. Baron–Cohen, H. Tager–Flusberg, & D. J. Cohen (Eds.), Understanding other minds: Perspectives from autism (pp. 181–203). Oxford: Oxford University Press. Murray, L., & Trevarthen, C. (1985). Emotional regulation of interactions between two-month-olds and their mothers. In T. M. Field & N. A. Fox (Eds.), Social perception in infants (pp. 177–197). Norwood, NJ: Ablex. Nadel, J., Carchon, I., Kervella, C., Marcelli, D., & Re´serbat–Plantey, D. (1999). Expectancies for social contingency in 2-month-olds. Developmental Science, 2, 164–173. Neisser, U. (1991). Two perceptually given aspects of the self and their development. Developmental Review, 11, 197–209. Neisser, U. (1993). The self perceived. In U. Neisser (Ed.), The perceived self: Ecological and interpersonal sources of self-knowledge (pp. 3–21). Cambridge: Cambridge University Press. Nelson, K. (1979). The role of language in infant development. In M. H. Bornstein & W. Kessen (Eds.), Psychological development from infancy: Image to intention (pp. 307–337). Hillsdale, NJ: Erlbaum. Prezbindowski, A. K., Adamson, L. B., & Lederberg, A. R. (1998). Joint attention in deaf and hearing 22 month-old children and their hearing mothers. Journal of Applied Developmental Psychology, 19, 377–387. Rieser, J. J., & Rider, E. A. (1991). Young children’s spatial orientation with respect to multiple targets when walking without vision. Developmental Psychology, 27, 97–107. Ross, H. S., & Lollis, S. P. (1987). Communication within infant social games. Developmental Psychology, 23, 241–248. Smith, C. B., Adamson, L. B., & Bakeman, R. (1988). Interactional predictions of early language. First Language, 8, 143–156. Stern, D. N. (1974). Mother and infant at play: The dyadic interaction involving facial, vocal, and gaze behaviors. In M. Lewis & L. A. Rosenblum (Eds.), The effect of the infant on its caregiver (pp. 187–213). New York: Wiley. Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. New York: Basic Books. Tomasello, M. (1995). Joint attention as social cognition. In C. Moore & P. J. Dunham (Eds.), Joint attention: Its origins and role in development (pp. 103–130). Hillsdale, NJ: Erlbaum. Tomasello, M., & Farrar, M. J. (1986). Joint attention and early language. Child Development, 57, 1454–1463. Tomasello, M., & Todd, J. (1983). Joint attention and lexical acquisition style. First Language, 4, 197–212. Urwin, C. (1979). Preverbal communication and early language development in blind children. Papers and Reports on Child Language Development, 17, 119–127. Warren, D. H. (1984). Blindness and early childhood development (Rev. ed.). New York: American Foundation for the Blind.
