For Therapists & Educators: A Free “Pointing to Request” Lesson Plan (ReThink Compatible)

This program outlines a strategy for teaching Pointing to Request, also called “protoimperative pointing”. Through the objectives, the client will begin to request items in view with a reach or unarticulated point, and progress to pointing with a gaze shift and observing response.

This program can run concurrently with the Joint Attention and Parallel Play program, a combination that should be strongly considered for children ages 1-5 years old who have not yet begun to indicate their choices or share enjoyment of an object or event with others. I’ve provided alternate responses for clients with physical limitations that prevent them from extending their arm and offer guidance for working with young children who do not (or do not yet) make eye contact. This instruction is best offered in 1:1 sessions in a home or clinic, ideally with an assisting adult to help the client stay successful. As always, individualize as needed for the learner and situation.

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Joint Attention with Autistic Children: A Respectful and Effective Framework

This program revolves around joint attention, social events that most people confirm with eye contact. But eye contact is a tricky subject. Years in this field have illustrated that providers address eye contact poorly and for superficial reasons. For this reason, among others, autistic adults are rightly frustrated by our failure to meet their needs with respect. To remedy this oversight as much as I am able, I have chosen to continue describing strategies that honor client preferences and prerogatives.

Regarding preferences, diminished eye contact is sometimes, but not necessarily, avoidance of eye contact. A client might decline to look toward another’s face or eyes because the information there has not yet been demonstrated to have value. If this client incidentally shares a glance with you, they don’t mind. In that case, we should help our client access and use this social information to effectively and independently navigate their situation. These are the clients for whom this program as-written is appropriate.

Critically, a client might also decline to make eye contact because they find it aversive or simply overwhelming in the context where we meet them. Some people don’t make eye contact. They have their reasons, and a skilled provider can amend their treatment to accommodate their declination. If active avoidance of eye contact is known or suspected, modify the program to accept approximations of eye contact (like visually orienting to the adult’s general direction) or consider modifications as would be offered to visually impaired clients.

Please keep in mind that the goal of this program is to strengthen the client’s requesting skills and their ability to direct another’s attention to their best advantage.

Program Goals:

Client will increase protoimperative pointing (using a reach or open-handed point toward an item to ask for it), and recognizable choice-making behaviors.

Objective 1:

Gestures to request in a minimal array with or without joint attention, with the interventionist across from them and the items between them.

Objective 1 targets:

Reaches with coordinated gaze for a preferred item held within reach
Reaches with coordinated gaze for a preferred item within reach, held in the mutual eye-line between the client and the adult
Reaches for a preferred item in an array of 2 against a neutral or non-preferred item

Objective 2:

Gestures to request in a minimal array and shifts their gaze to the face of the interventionist seated next to or across from them, who then delivers the item.

Objective 2 targets:

Reaches for a preferred item held just beyond arm’s length
Accepts an offered object from interventionist’s hand and looks from the item to the interventionist’s eyes when the interventionist briefly holds on to the item
Reaches for a preferred item held just out of reach and sustains reaching for up to 2s to access that item
Reaches for a preferred item held a few inches to the side of the BT’s face, and shifts their gaze from the item to the BT’s face to gain immediate access

Objective 3:

Gestures to request in a minimal array with a gaze-shift back to the communicative partner, who is looking at them and then looks at the item before delivering it to them.

Objective 4:

Gestures to request in a minimal array with a gaze shift back to the communicative partner and persists in pointing when the partner is looking away for a moment but then looks at them, follows their point to the item, and delivers the item.

Objective 5:

Gestures to request in large field or naturalistic setting with a gaze shift back to the communicative partner and persists in pointing when the partner is looking away for a moment but then looks at them. Communication partner then shifts their gaze to follow the client’s point to the item, and then delivers the item.

Methods

Data Settings:

Collection Type: Opportunity Based
Mastery criteria: 100% of 3 trials across 4 sessions
Maintenance criteria: 100% of 2 trials across 5 sessions
Trigger Maintenance For Mastered Targets: Yes
Maintenance Schedule: Weekly
Automatic Phase Change Line: Yes

Note—

True mastery and maintenance of this skill requires its functional, independent use in the natural environment, in the presence of a caregiver prepared to respond to it adequately to support the skill’s continued use.

Exercise:

Observe the client at the beginning of each activity or session to determine their preferences or motivations.

To occasion a reach with a coordinated gaze, sit across from the learner so you can see each other’s faces. Hold the item between your eyes and their eyes, so if they look at the item they will also briefly make eye contact with you. Sit far enough back that the learner needs to sustain the reach for a moment before you put it in their hand. As soon as they bring their hand up to the item while looking at it, deliver the item. Label the item if possible but do not ask them to repeat you to access it.

To occasion a reach to a preferred item in an array, set out the item or items you know the learner doesn’t want (like a damp piece of paper towel or a bar of soap), and set out the preferred item so it is in view but out of reach. Make a gestural offer to all the items and deliver any item the learner reaches for.

Generalize by:

Increasing the distance between the learner and the item
Increasing the expectation to include a gaze shift from the item back to the interventionist’s face
Embedding choice making into routine structured preference assessments
Offering more-preferred items against somewhat-preferred items

Error correction:

This program relies on contextual support for errorless learning. Physical prompts and “errors” should be minimal.
If the client leaves the instructional context rather than reaching for the item, establish momentum by placing the item first right in front of them and progressively increasing the item’s distance from them
If the learner does not reach for the item (putatively) preferred item, provide the requested distractor item anyway. Observe their interaction with the distractor item. If they indicate a preference for the distractor, consider using that as the preferred item instead.
If the learner does not look back to you from the item, try to get into their eye-line and gain incidental eye contact before releasing the item.

Supplies:

Client’s preferred items or items needed for preferred activities, possibly a few neutral or unwanted items to serve as distractors.

Troubleshooting:

Do not require index-finger isolation for a conventional “point” for this program. The most recent evidence suggests articulated canonical pointing and open-handed and unarticulated pointing have distinct grammatical functions.
Try to offer the learner things they didn’t have before starting the program rather than interrupting their access to items they already had. Make it an “I want that” and not an “I want that back” as much as possible.
Interrupting access too frequently can trigger problem behavior. Don’t rush this program.

Alternate responses to reaching—

Motioning toward the desired item with their head
Leaning their shoulder toward the desired item
Sustained gaze at the desired item with or without behaviors to gain the caregiver’s attention, like banging on the surface of a table or vocalizing

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References:

Holly Rayson, James J. Bonaiuto, Pier F. Ferrari, Bhismadev Chakrabarti, Lynne Murray. (2019), Building blocks of joint attention: Early sensitivity to having one’s own gaze followed. Developmental Cognitive Neuroscience, Volume 37. ISSN 1878-9293, https://doi.org/10.1016/j.dcn.2019.100631.

Taylor, B.A. and Hoch, H. (2008), Teaching children with autism to respond to and initiate bids for joint attention. Journal of Applied Behavior Analysis, 41: 377-391. https://doi.org/10.1901/jaba.2008.41-377

Salo VC, Rowe ML, Reeb-Sutherland B. Exploring Infant Gesture and Joint Attention as Related Constructs and asPredictors of Later Language. Infancy. 2018 May-Jun;23(3):432-452. doi: 10.1111/infa.12229. Epub 2018 Feb 6. PMID: 29725273; PMCID: PMC5927593. https://pmc.ncbi.nlm.nih.gov/articles/PMC5927593/

Gabouer A, Bortfeld H. Revisiting how we operationalize joint attention. Infant Behav Dev. 2021 May;63:101566. doi: 10.1016/j.infbeh.2021.101566. Epub 2021 Apr 21. PMID: 33894632; PMCID: PMC8172475. https://pmc.ncbi.nlm.nih.gov/articles/PMC8172475/