MANUSCRIPT SUBMISSION FOR COLLECTIVE VOLUME

Paper title: Shared intentionality in children with Autism Spectrum Disorder (ASD)

Authors: Asimenia Papoulidi1, Christina Papaeliou2, Stavroula Samartzi3

1
Panteion University of Social and Political Sciences
2
University of the Aegean
3
Panteion University of Social and Political Sciences

Contact author: Asimenia Papoulidi, Tritonos 60, Palaio Faliro, 175 61,
asimeniapap@gmail.com

Research fields

Physical development
Motor development
Cognitive development
Language development
√ Emotional development
√ Social development
Research methods
Applications (Family, School – Interventions, etc)

Age Phase
Prenatal phase – Neonatal phase – Infancy
√ Preschool years
Middle childhood
Adolescence
Young adulthood
Middle adulthood
Late adulthood
Lifespan development
2

Shared intentionality in children with Autism Spectrum Disorder (ASD)

Abstract

It is well documented that the ability and motivation to engage with others in collaborative,
activities with joint goals and shared intentions is the foundation of human uniqueness.
However, children with Autism Spectrum Disorder (ASD) show difficulties in sharing their
motives, intentions, and emotions with others about topics in the environment and manifest
low levels of engagement. The purpose of the present study was to compare the level of
intentionality and social engagement in ten children with ASD and ten Typically
Developing (TD) children, matched for mental age, during free play interactions with their
mothers. Children were video-recorded while playing with their mothers in a naturalistic
condition with toys provided by the researcher. For the microanalysis of the video
recordings the EUDICO Linguistic Annotator was used, which permits the analysis of joint
behaviors and captures subtle qualitative differences in social engagement. Results
indicated that children with ASD showed deficits in joint attention, exhibited no functional
play and employed less communicative gestures than their peers in the comparison group.
These differences between the two groups in their mode of communication led to the
emergence of two distinct patterns of engagement which depict the different level of
intentionality that these groups have in sharing their experiences during mother-child
interactions. These representative patterns of interaction can be used as a potential tool
for early identification of children at risk of ASD well before other behaviors become fully
manifested.

Key words: mother-child interaction, intentionality, intersubjectivity, Autism Spectrum Disorder

Introduction
Mother-child interaction has been seen as critical for child development, both cognitive
and emotional; for example evidence shows a link between such interaction and language
development (Feldman, 2007; Saint-Georges et al., 2013). Infants early on participate actively
in social interactions (Nagy, 2011; Trevarthen & Aitken, 2001) and learn to anticipate the
behavior of their communicative partner (Gallagher, 2008; Panksepp, 2011; Trevarthen, 2009;
Trevarthen & Reddy, 2007). A wealth of studies has shown that both mothers and infants adjust
the timing of their actions in order to achieve synchrony, which is defined as the dynamic and
reciprocal adaptation of the temporal structure of behaviors between interactive partners
(Leclère et al., 2014).
According to Schirmer, Meck and Penney (2016), interaction success depends on the
degree of temporal coordination between interaction partners. Contingent coordination in
mother-child interaction is achieved during the first months of life and is evident through
rhythmic patterns of behavior which consist of combinations of gestures, facial expressions and
vocalizations (Jaffe, Beebe, Feldstein, Crown, & Jasnow, 2001; Lester, Hoffman, & Brazelton
1985). During this coordinated interaction each partner reflects on the other’s affective states
and a matching of subjective experiences, which is called affect attunement, is achieved (Stern,
1985). Affect attunement is a particular kind of intersubjectivity exhibited during the first
months of life.
According to Trevarthen’s Theory of Intersubjectivity (2001, 2005), social engagement
is based on innate motives for moving and responding to the physical and social environment.
Intersubjectivity which is defined as the intuitive recognition and understanding of the impulses
and desires of another’s mind plays a significant role in the development of nonverbal,
intentional communication in human infants (Trevarthen, 1979). Early intersubjective skills
serve as a foundation for more advanced social cognitive skills as well as the development of
symbolic play (Cebula & Wishart, 2008; Meltzoff, 2007; Tager-Flusberg, Skwerer, & Joseph,
2006; Trevarthen & Aitken, 2001).
Infants gradually progress from primary intersubjectivity to secondary intersubjectivity
(Trevarthen, 1979). Primary intersubjectivity involves direct social attention and attunement
and is evident from birth. Secondary intersubjectivity appears around nine months of age and
refers to the intercoordination of self, other, and object based on the cooperative exchange of
behaviors (Hubley & Trevarthen, 1979; Trevarthen & Hubley, 1978). The most important
manifestation of secondary intersubjectivity is joint attention. Joint attention is the coordination
4

of attention between social partners and objects in order to share an experience (Bakeman &
Adamson, 1984).
Around the same age, infants begin to act intentionally in order to influence the behavior
of their communicative partner (Bates, 1976; McLean, 1990). They exhibit a new readiness to
tune in with the intentions and interests of a partner in joint exploration and use of objects.
Infants gradually progress from preintentional communication, which entails acts directed to
either a communication partner or object with no indication of joint attention, to intentional
communication, which includes acts clearly directed toward a communication partner (Crais &
Ogletree, 2016). These skills are described under the term “shared intentionality” which refers
to collaborative interactions in which participants share psychological states with one another
(Tomasello & Carpenter, 2007). The capacity to share intention with others is unique to human
social cognition and makes human social skills very different from those of other animal species
(Tomasello, 1999). The transition from preintentional to intentional communication is a major
milestone for all children and is critical to the development of higher-level communication
skills (Brady, Marquis, Fleming, & McLean, 2004; Tomasello, Carpenter, & Liszkowski,
2007).
However, for many children with developmental disabilities this critical transition to
intentional communication is delayed or does not happen at all. This seems to be the case for
children with Autism Spectrum Disorder. ASD is a neurodevelopmental disorder characterized
by social and communicative deficits as well as restricted and repetitive behaviors (APA, 2013).
In particular, children with ASD show deficits in communicative abilities and difficulties in
sharing their motives, intentions, and emotions with others about topics in the environment
(Papoulidi, Papaeliou, Samartzi, 2017; Trevarthen & Delafield-Butt, 2013).
Children with ASD show impairment in contingent interactions and mutual
coordination with their communicative partner (Macintosh & Dissanayake, 2006) that may
stem from their severe difficulties in creating expectancies and predicting the behavior of others
(Sinha et al., 2014). In their seminal study, Trevarthen and Daniel (2005) examined home
videos of 11-month-old twin infants with Rett syndrome, one of whom was diagnosed with
ASD at the age of two years. Their research focused on rhythmic behavior and synchrony during
the interaction of the twin girls with their father. Results demonstrated that the infant who later
developed ASD showed little eye contact, incoherent engagement of mutual attention, absence
of co-regulation, weak emotional expression and lack of anticipation, making the interaction
asynchronous. Moreover, a series of prospective studies with high-risk infants (siblings of
children with ASD) has detected differences in early social engagement, weaker synchrony in
infant-led interactions and stronger tendency toward inactivity (Rozga et al., 2011; Wan et al.,
2012; Yirmiya et al., 2006).
Impairment in joint attention is among the earliest signs of the disorder (Charman, 2003;
Dawson et al., 2004; Jones & Carr, 2004) and constitutes a key diagnostic criterion. In addition,
numerous studies have shown that children with ASD present deficits in multiple
communicative gestures (Iverson et al., 2018; Watson, Crais, Baranek, Dykstra, & Wilson,
2013). The lack of motivation in social engagement is also revealed in play activities. Although
children with ASD may play with objects functionally, this play tends to be less frequent,
elaborated, varied and integrated than that of TD children (Christensen et al., 2010; Williams,
Reddy, & Costall, 2001). They also show particular difficulties in symbolic play (Dominguez,
Ziviani, & Rodger, 2006; Stanley & Konstantareas, 2007; Thiemann-Bourque et al., 2012;
Warreyn, Roeyers, & De Groote, 2005). Unsurprisingly, children with ASD prefer solitary
actions and simple manipulation of objects (Elison et al., 2014). In most cases, they do not show
any interest in sharing their experiences with others and they do not engage in social
interactions.
The aim of the present study is to compare the level of intentionality and social
engagement in ten children with ASD and ten typically developing children, matched for mental
age, during free play interactions with their mothers by employing a microanalytic approach.
The following hypotheses were raised. Compared to TD children, children with ASD
would present:
1. deficits in gaze coordination with their mother
2. difficulties attuning their affect to that with their communicative partner
3. a different pattern of interaction with their mothers, which would reveal their limited
intentionality to share their experiences with her.

Method
The current study constitutes part of a larger-scale project, the BabyAffect, which
studied affective and behavioral modeling of early childhood lexicalizations and
communicative functions with application to ASD and language delay detection. Τhe method
followed in the present study, which is described below, was also applied in the BabyAffect
project.

Recruitment and participants

6

The participants of the present study were ten children with Autism Spectrum Disorder
(9 males), aged between 29 and 81 months (M = 55.1, SD = 21.03) and ten typically developing
children (8 males), aged between 9 and 30 months (M = 16.9, SD = 5.82) (F = 33.23, p < .001).
The male/female ratio of the sample depicts the overrepresentation of males with ASD, which
is well known in the literature (Halladay et al., 2015; Wijngaarden-Cremers et al., 2014).
Participants were recruited from pediatric clinics, daycare centers, developmental pediatric
clinics, private psychological centers and special schools (non random sampling). Typically
developing children were mainly recruited through the social network of the researchers. All
participants came from Greek-speaking families and were matched for visuospatial, fine motor,
and linguistic abilities on the raw scores of the Mullen Scales of Early Learning (1995). This
test is administered in infants and preschool children from birth to 68 months and is commonly
used in studies of infants and young preschoolers with developmental disorders (Klein-Tasman,
Mervis, Lord, & Phillips, 2007). Table 1 presents the raw scores of participants on the four
subscales that were assessed (visual reception, fine motor, receptive and expressive language).

Table1
Performance on Mullen Scales of Early Learning
ASD TD F p
Visual reception
Mean 20.9 21.6 0.07 .782
Range 14 - 29 12 - 35
Sd 4.22 6.63
Fine motor
Mean 20.8 20.2 0.04 .832
Range 14 - 28 13 - 38
Sd 5.51 6.84
Receptive language
Mean 15.6 19.5 1.82 .193
Range 6 - 23 10 - 33
Sd 5.29 7.42
Expressive language
Mean 17.2 16.2 0.15 .699
Range 8 - 29 13 - 29
Sd 6.54 4.68

Procedure
Parents were informed of the procedure of the study and were asked to sign a consent
form. During the first visit, a questionnaire for demographic and medical information was
administered to parents. Even though, mothers and fathers in the two groups did not differ
significantly in age (F = 0.14, p = .708 and F = 0.02, p = .883 respectively), significant
differences were observed in parents’ education. In particular, the majority of mothers in the
ASD group had graduated from High School, while the majority of mothers in the TD group
had a University degree (χ2 = 13.24, p = .004). The same holds for fathers as well (χ2 = 14.00,
p = .007).
Videorecordings took place in children’s homes. Home environment was considered
more appropriate for obtaining representative samples of the children’s spontaneous behavior
than the unfamiliar laboratory environment (Papaeliou, Minadakis, & Cavouras, 2002). Each
session lasted approximately 35 minutes and was video recorded using a high quality camera,
mounted on a tripod. According to the relevant literature, this is a common duration for video
recordings, which provides adequate data and has been extensively used in previous work,
including children with ASD (Iverson & Fagan, 2004; Iverson & Wozniak, 2007). Mothers
were asked to play with their child, as they would normally do, trying to introduce to the child
all the toys provided by the researcher.

Data analysis and annotation

A microanalytic approach was considered the best method in order to study the
interaction of the dyad since it permits the analysis of joint behaviors and captures subtle
qualitative differences in social engagement. For the microanalysis of the video recordings the
EUDICO Linguistic Annotator (ELAN) was used. ELAN is a professional tool for the creation
of complex annotations on video and audio resources, developed at the Max Planck Institute
for Psycholinguistics (Hellwig, 2014).
A coding system which was based on previous schemes (Laing et al., 2002; Papaeliou
& Trevarthen, 2006; Papaeliou et al., 2015) was designed and included the following axes: gaze
direction, action on object, action on partner and emotion (see Appendix). The coding system
was intended to be concise and not redundant and to describe overt behaviors (The BabyAffect
Team, 2014). Behaviors were coded on a split second basis. Milliseconds was the unit of
analysis that was considered most appropriate for the present data. At an initial level, behaviors
were coded separately for the mother and the child on a frame-by-frame basis and then their
behaviors were combined in order to assess the interaction of the dyad in terms of shared
intentionality. According to the literature there are three levels of intentionality (Crais &
Ogletree, 2016; Iverson & Wozniak, 2016; Meadows, Elias, & Bain, 2000; Yoder, McCathren,
Warren, & Watson, 2001). Non-intentional communication is evident in acts with complete
absence of intent, directed neither to a person nor to an object (i.e. different focus of attention,
solitary actions). Pre-intentional communication entails acts directed to either a communication
8

partner or object with no indication of joint attention between communication partner and
object, (i.e. parallel looking: partners are looking at the same object without though
communicating about it). Intentional communication includes acts clearly directed toward a
communication partner that carry intent for interaction (i.e. joint attention, functional play).
Joint attention is achieved through the use of alternating gaze (looking back and forth between
the partner and an object) and/or communicative gestures (pointing, showing, offering).
Functional play refers to conventional use of objects according to their function (Bigelow,
MacLean, & Proctor, 2004). The innovation of the current research lies on the grouping of the
separate behaviors observed in mothers and children into the above-mentioned categories of
intentionality. It also demonstrates the way these categories are alternated during the interaction
which produces a distinct rhythmical pattern for each group of participants. Inter-rater and intra-
rater reliability was calculated for three ASD children and three TD children (30% of the
sample) for each behavior category and was found to be very high. For inter-rater reliability
Cohen’s kappa ranged from .77 to .87 and for intra-rater reliability kappa ranged from .78 to
.91.

Results
Interaction initiation
A chi-square test was performed to examine the relation between initiation of interaction
and group category. The relation between these variables was statistically significant, χ2 (1, N
= 20) = 5.05, p = .025. Overall, compared to TD children, children with ASD were less likely
to commence an interaction and engage their mother in their actions. In particular, only two out
of 10 children with ASD initiated the interaction. In all other cases, it was the mother who
initiated the interaction and attempted to engage the child in order to play together and share
their experiences.

Gaze direction of the dyad

An independent samples t-test was performed to examine between group differences in
relation to gaze coordination of mother-child dyad. Results indicated that ASD dyads spent
significantly more time looking at different objects/directions, compared to TD dyads. In
addition, the duration of alternating gaze was significantly shorter for the ASD group in relation
to the TD group. Alternating gaze between the partner and an object signifies an attempt for
joint attention. As it is presented in Table 2, no significant differences were found between
groups in the amount of time spent in either eye contact or parallel looking.
 It is be clarified that since duration (dependent variable) does not follow normal
distribution, data were transformed in order to conform to normality. Among the different types
of transformations used to transform skewed data to conform to normality, the log
transformation was selected as the most appropriate to the data of the present study (Field,
2013).

Table 2
Mean time of gaze direction of the dyad
Mean duration SD t p
(msec)
Eye contact 0.09 .927
ASD 1.60 3.40
TD 1.47 3.10
Parallel looking 0.77 .449
ASD 9.62 1.53
TD 8.73 3.32
Alternating gaze - 5.76 <.001*
ASD 0.99 3.13
TD 9.33 3.33
Different focus of attention 3.94 .002*
ASD 10.07 0.44
TD 8.48 1.19
*p < .05.

Affect of the Dyad

Examining the emotional state of partners (see Appendix for behavioral variables that
serve as criteria of emotional state), it was observed that in most cases both mothers and
children retained a neutral affect during the play session in both ASD and TD groups. Assessing
the degree to which each member of the dyad manages to attune to the affect of the other, it
was noteworthy that children in the ASD group did not exhibit positive affect at all, whereas
TD children did not exhibit negative affect at all. Therefore, statistical analysis could not be run
for those categories. Although emotional states signifying lack of affect attunement lasted
longer in the ASD group, no statistically significant differences were found (Table 3).

Table 3
Mean duration of attuned vs. non attuned affect of the dyad
Mean duration SD t p
(msec)
Affect attunement -1.00 .327
ASD 9.81 3.57
TD 10.99 0.91
Lack of affect attunement 1.01 .325
10

ASD 6.14 5.33

TD 3.80 4.96
*p < .05.
Type of action
An independent sample t-test was conducted in order to examine whether there were
any differences between the groups of the ASD and TD children in relation to the type of action
(communicative gestures, exploratory play, functional play) they usually performed during the
play interaction. Results showed that the mean duration of communicative gestures was
significantly less for children with ASD than TD children. It was also noteworthy, that children
with ASD did not display functional play at all, while it was highly produced by TD children.
In relation to exploratory play, there were no significant differences between the groups (Table
4).

Table 4
Between group differences in type of action performed by children
Mean duration SD t p
(msec)
Exploratory play 1.36 .190
ASD 8.01 4.41
TD 5.26 4.59
Communicative gestures -3.85 .001*
ASD 2.30 3.72
TD 8.11 2.97
*p < .05.
With regards to mothers, an independent samples t-test indicated that there was a
significant difference in the time they spent in exploratory play. In particular, mothers of
children with ASD used this type of play much longer than mothers of TD children. It was also
observed that mothers in the ASD group displayed more functional play than mothers in the
TD group, while the second group performed more communicative gestures than the first.
However, as it is presented in Table 5, these differences were not statistically significant.

Table 5
Between group differences in type of action performed by mothers
Mean duration SD t p
(msec)
Exploratory play 2.21 .045*
ASD 4.45 4.71
TD 0.75 2.39
Communicative gestures -0.80 .432
ASD 4.71 4.12
TD 6.23 4.30
 Functional play 0.89 .387
ASD 8.23 3.03
TD 6.67 4.65

*p < .05.

Patterns of intentional interaction

Having examined independently the type of action each partner performs during the
interaction, it was then time to combine their behaviors and investigate how the dyad interacted
during the play episode. For this purpose, the behaviors of both partners were taken into account
simultaneously. This study explored the temporal succession of their behaviors as well as the
level of intentionality that each behavior revealed. More specifically, three levels of
intentionality (non-intentional, pre-intentional, intentional) were assumed and each behavior
was then categorized into one of them.
The following patterns emerged for each group. Figure 1 and 2 depict the temporal
succession of behaviors during the interaction of 10 ASD children and 10 TD children with
their mothers, respectively. As it was depicted graphically, the differences between the groups
in their intentionality for interaction were distinct. In the ASD group, non-intentional
communication prevailed and there were only scarce periods of pre-intentional communication
which were shorter in duration. By contrast, in the TD group intentional communication was
the dominant category and there were shorter periods of pre-intentional and non-intentional
communication.

Figure 1. Intentionality pattern for children with ASD

12

Figure 2. Intentionality pattern for TD children

Non-intentional
Pre-intentional
Intentional
An independent samples t-test indicated that there were significant differences between
the groups in relation to non-intentional and intentional communication (Table 6). More
specifically, the duration of non-intentional communication was statistically significantly
longer in the ASD group. Marked differences between the groups were also observed in relation
to intentional communication, since it was almost absent from the ASD group, with the
exception of one child, while it dominated in the pattern of interaction of the TD group. No
significant differences between the groups were found in pre-intentional communication.

Table 6
Between group differences in levels of intentionality
Mean duration SD t p
(msec)
Non-intentional communication 3.65 .002*
ASD 10.70 0.78
TD 9.09 1.15
Pre-intentional communication 1.23 .231
ASD 9.01 1.10
TD 7.38 4.00
Intentional communication -9.30 <.001*
ASD 0.99 3.13
TD 10.64 0.96
*p < .05

Discussion
 The purpose of the present study was to compare the level of intentionality of ten
children with ASD and ten TD children, matched for mental age, during free play interactions.
As evidenced in the literature, infants are socially responsive from soon after birth and their
motive for sharing a narrative is clearly demonstrated by their ability to imitate the expressive
movements of their partner and collaborate in turn-taking sequences (Kugiumutzakis &
Trevarthen, 2015; Trevarthen & Delafield-Butt, 2013). The emergence of intentional
communication around the end of the first year of life is widely recognized as a basic milestone
in the infant’s development.
Shared intentionality drives human cooperation. This unique human ability allows
people not only to understand that others act intentionally but also to share common goals.
Humans are from a very early age motivated to share their goals and communicate about the
coordinated strategies necessary to achieve them (McClung, Placì, Bangerter, Clément, &
Bshary, 2017). However, this is not universal; children with ASD have particular difficulties in
shared intentionality which accounts for the social-cognitive impairments they display
(Tomasello, Carpenter, Call, Behne, & Moll, 2005).
Several neurodevelopmental disorders that impair the individual’s social functioning
are manifested in reduced eye contact or atypical gaze behavior and may be detected in early
infancy (Niedźwiecka, Ramotowska, & Tomalski, 2017; Yirmiya et al., 2006). According to
the findings of the present study, children with ASD made much fewer gaze alternations than
TD children, a finding which was also reported in the retrospective study of Clifford and
Dissanayke (2008). Using eye tracking technology, Thorup et al. (2018) found that reduced
alternating gaze during social interaction in infancy is associated with elevated symptoms of
ASD in toddlerhood. Similarly, prospective studies focusing on initiating joint attention have
reported fewer gaze alternations in 14 month-old infants who later received an ASD diagnosis
(Landa, Holman, & Garrett-Mayer, 2007; Macari et al., 2012).
Gaze alternation which indicates intentional communication is impaired in children with
ASD. This deficit in intentionality is also confirmed by the long time these children spent
focusing their attention on a different object than the one indicated by the mother. This finding
is consistent with reports that many children with ASD are less likely to orient socially
(Dawson, Meltzoff, Osterling, Rinaldi, & Brown, 1998) and more likely to ignore the social
aspects of a communicative context (Adamson, Deckner, & Bakeman, 2010). These results
support the view that the social difficulties associated with ASD are in part due to lowered
levels of motivation to engage with people (Carr, 2007; Dawson et al., 2004).
14

Moreover, it is well established that children with ASD gesture at a lower rate than TD
children (Shumway & Wetherby, 2009) and demonstrate an atypical developmental trajectory
for gesturing (Paparella, Goods, Freeman, & Kasari, 2011). Τhe social communicative gestures,
such as pointing, showing and offering, were the most affected (Barbaro & Dissanayake, 2013;
Werner & Dawson, 2005; Wetherby et al., 2004). The findings of the present study confirmed
that children with ASD produced significantly less communicative gestures than TD children.
According to Manwaring, Stevens, Mowdood and Lackey (2018), not all types of deictic
gestures are equally impaired in toddlers with ASD. These researchers suggest that reduced
pointing in the second year is a marker for delay, but that reduced showing may be a more
specific marker of ASD, at least until closer to 2 years of age.
In relation to exploratory play no marked differences were found between the groups in
the present sample. This finding is also confirmed by other studies (Baranek et al., 2005; Wilson
et al., 2017) but comes in contrast to findings showing that children with ASD spend more time
in exploratory play than TD children (Bentenuto, De Falco, & Venuti, 2016; Dominguez et al.,
2006).
Furthermore, in accordance with other work (Jarrold, Boucher, & Smith, 1993;
Williams et al., 2001) the present study showed that children with ASD show severe difficulties
in producing functional play. In particular, none of the ASD participants in the present sample
played functionally with the toys. A recent study conducted by Wilson et al. (2017), presented
the low frequency of high level play behaviors exhibited by infants in natural contexts,
especially by infants with ASD and other developmental disorders (DD). Their findings
demonstrated that functional play acts were exhibited by 41% of the TD group, but only by
13% of the DD group and 9% of the ASD group. However, it should also be noted that there
are other studies that do not report differences between the groups in functional play (Barοn-
Cohen, 1987; Dominguez et al., 2006; Libby, Powell, Messer, & Jordan, 1998). Discrepancies
in findings may be attributed to the definition of functional play, the specific nature of the play
setting, the structure of the coding system and the time interval method of analysis which was
employed.

Conclusions
The pattern of intentional communication exhibited by children with ASD during
interaction with their mother may reveal deficits in innate motives for intersubjective
communication, which constitute a core characteristic of the disorder (Trevarthen & Daniel,
2005). According to Fuchs (2015), ASD is a paradigmatic disorder of intersubjectivity. Several
research projects have shown that deficits in intersubjective behaviors are the best way to
discriminate children with ASD from those with typical development during the first year of
life (Muratori & Maestro, 2007). The representative patterns of interaction that were revealed
in the present study may be used as a potential tool for early identification of children at risk of
ASD well before other behaviors become fully manifested.

Acknowledgements
This research is supported by the State Scholarships Foundation (IKY) under the
“Granting Scholarships for Postgraduate Studies of the second-cycle (PhD)” Action of the
operational programme “Development of Human Resources, Education and Lifelong Learning”
cofunded by the European Social Fund (NSRF 2014-2020) and the project “BabyAffect” which
was implemented under the “ARISTEIA II” Action of the operational programme “Education
and Lifelong Learning” and was cofunded by the European Social Fund (ESF) and National
Resources (NSRF 2007-2013).
16

References

Adamson, L. B., Deckner, D. F., & Bakeman, R. (2010). Early interests and joint engagement
in typical development, autism, and Down syndrome. Journal of Autism and
Developmental Disorders, 40, 665-676
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders, (5th ed.). Arlington, VA, USA: American Psychiatric Association.
Bakeman, R., & Adamson, L. B. (1984). Coordinating attention to people and objects in
mother-infant and peer-infant interaction. Child Development, 55, 1278-1289.
Baranek, G. T., Barnett, C. R., Adams, E. M., Wolcott, N. A., Watson, L. R., & Crais, E. R.
(2005). Object play in infants with autism: Methodological issues in retrospective video
analysis. American Journal of Occupational Therapy, 59, 20-30.
Barbaro, J., & Dissanayake, C. (2013). Early markers of autism spectrum disorders in infants
and toddlers prospectively identified in the social communication and attention study.
Autism, 17, 64-86.
Baron-Cohen, S. (1987). Autism and symbolic play. British Journal of Developmental
Psychology, 5, 139-148.
Bates, E. (1976). Language and context. New York: Academic Press.
Bentenuto, A., De Falco, S., & Venuti, P. (2016). Mother-Child Play: A Comparison of Autism
Spectrum Disorder, Down Syndrome, and Typical Development. Frontiers in
psychology, 7, 1829. doi:10.3389/fpsyg.2016.01829
Bigelow, A. E., MacLean, K., & Proctor, J. (2004). The role of joint attention in the
development of infants’ play with objects. Developmental Science, 7(5) 518-526.
Brady, N., Marquis, J., Fleming, K., & McLean, L. (2004). Prelinguistic predictors of language
growth in children with developmental disabilities. Journal of Speech Language and
Hearing Research, 47, 663-677.
Carr, E. G. (2007). Social skills that are not always social and problems that are not always
problems. Research and Practice for Persons with Severe Disabilities, 32, 110-111.
Cebula, K. R., & Wishart, J. G. (2008). Social cognition in children with Down syndrome.
International Review of Research in Mental Retardation, 35, 43-86. doi:10.1016/S0074-
7750(07)35002-7
Charman, T. (2003). Why is joint attention a pivotal skill in autism?. Philosophical transactions
of the Royal Society of London. Series B, Biological sciences, 358(1430), 315-24.
Christensen, L., Hutman, T., Rozga, A., Young, G. S., Ozonoff, S., Rogers, S. J., … Sigman,
M. (2010). Play and developmental outcomes in infant siblings of children with autism.
Journal of Autism and Developmental Disorders, 40, 946-957.

Clifford, S., & Dissanayake, C. (2008). The early development of joint attention in infants with
autistic disorder using home video observations and parental interview. Journal of
Autism and Developmental Disorders 38, 791-805. doi: 10.1007/s10803‐007‐0444‐7
Crais, E., & Ogletree, B. T. (2016). Prelinguistic communication development. In Prelinguistic
and Minimally Verbal Communicators on the Autism Spectrum (pp. 9-32). Springer
Singapore. doi:10.1007/978-981-10-0713-2_2

Dawson, G., Meltzoff, A., Osterling, J., Rinaldi, J., & Brown, E. (1998). Children with autism
fail to orient to naturally occurring social stimuli, Journal of Autism and Developmental
Disorders, 28, 479-485.
Dawson, G., Toth, K., Abbott, R., Osterling, J., Munson, J., Estes, A., & Liaw, J. (2004). Early
social attention impairments in autism: Social orienting, joint attention, and attention to
distress. Developmental Psychology, 40, 2, 271-283.
Dominguez, A., Ziviani, J., & Rodger, S. (2006). Play behaviors and play object preferences of
young children with autistic disorder in a clinical play environment. Autism 10, 53-69.
Elison, J. T., Wolff, J. J., Reznick, J. S., Botteron, K. N., Estes, A. M., Gu, H., . . . Piven, J.
(2014). Repetitive behavior in 12-month-olds later classified with autism spectrum
disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 53(11),
1216-1224.

Feldman, R. (2007). Mother-infant synchrony and the development of moral orientation in

childhood and adolescence: Direct and indirect mechanisms of developmental
continuity. American Journal of Orthopsychiatry, 77, 582-597.
Field, A. (2013). Discovering statistics using IBM SPSS Statistics: and sex and drugs and rock
'n' roll (4th ed.). Sage, London.
Fuchs, T. (2015). Pathologies of intersubjectivity in autism and schizophrenia. Journal of
Consciousness Studies, 22, 191-214.
Gallagher, S. (2008). Direct perception in the intersubjective context. Consciousness and
Cognition, 17(2), 535-543.
Halladay, A. K., Bishop, S., Constantino, J. N., Daniels, A. M., Koenig, K., Palmer, K., …
Szatmari, P. (2015). Sex and gender differences in autism spectrum disorder:
18

Summarizing evidence gaps and identifying emerging areas of priority. Molecular

Autism, 6, 36. doi:10.1186/s13229-015-0019-y
Hellwig, B. (2014). User Guide for ELAN, Linguistic Annotator, version 4.8.0. The Language
Archive, MPI for Psycholinguistics, Nijmegen, The Netherlands.
Hubley, P., & Trevarthen, C. (1979). Sharing a task in infancy. In I. C. Uzgiris (Ed.), Social
interaction during infancy (pp. 38-52). San Francisco, CA, USA: Jossey-Bass.
Iverson, J. M., & Fagan, M. K. (2004). Infant vocal-motor coordination: Precursor to the
gesture-peech system? Child Development, 75(4), 1053-1066.
Iverson, J. M., & Wozniak, R. H. (2007). Variation in vocal-motor development in infant
siblings of children with autism. Journal of Autism and Developmental Disorders,
37(1), 158-170.
Iverson, J. M., & Wozniak, R. H. (2016). Transitions to Intentional and Symbolic
Communication in Typical Development and in Autism Spectrum Disorder. In
Prelinguistic and Minimally Verbal Communicators on the Autism Spectrum (pp. 9-32).
Springer Singapore. doi:10.1007/978-981-10-0713-2_2

Iverson, J. M., Northrup, J. B., Leezenbaum, N. B., Parladé, M. V., Koterba, E. A., & West, K.
L. (2018). Early Gesture and Vocabulary Development in Infant Siblings of Children
with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 48,
55-71. doi:10.1007/s10803-017-3297-8
Jaffe, J., Beebe, B., Feldstein, S., Crown, C., & Jasnow, M. (2001). Rhythms of dialogue in
infancy: Coordinated timing in development. Monographs of the Society for Research
in Child Development, 66(2), i-viii, 1-132. doi:10.2307/3181589
Jarrold, C., Boucher, J., & Smith, P. (1993). Symbolic play in autism: A review. Journal of
Autism and Developmental Disorders, 23(2), 281-307.
Jones, E. A., & Carr, E. G. (2004). Joint attention in children with autism: Theory and
intervention. Focus on Autism and Developmental Disabilities, 19(1), 13-26.
doi:10.1177/10883576040190010301
Klein-Tasman, B. P., Mervis, C. B., Lord, C. E., & Phillips, K. D. (2007). Socio-communicative
deficits in young children with Williams syndrome: Performance on the Autism
Diagnostic Observation Schedule. Child Neuropsychology, 13(5), 444-467.
Kugiumutzakis, G., & Trevarthen, C. (2015). Neonatal Imitation. In James D. Wright (editor-
in-chief), International Encyclopedia of the Social and Behavioral Sciences, (2nd
edition, Vol 16, pp. 481-488). Oxford: Elsevier.
Laing, E., Butterworth, G., Ansari, D., Gsödl, M., Longhi, E., Panagiotaki, G., Paterson, S., &
Karmiloff-Smith, A. (2002). Atypical development of language and social
communication in toddlers with Williams syndrome. Developmental Science, 5, 233-
246.
Landa, R. J., Holman, K. C., & Garrett-Mayer, E. (2007). Social and communication
development in toddler with early and later diagnosis of autism spectrum disorders.
Archives of General Psychiatry, 64(7), 853-864.
Leclère, C., Viaux, S., Avril, M., Achard, C., Chetouani, M., Missonnier, S., & Cohen, D.
(2014). Why synchrony matters during mother-child interactions: A systematic review.
PLoS. ONE, 9(12), e113571.
Lester, B. M., Hoffman, J., & Brazelton, T. B. (1985). The rhythmic structure of mother-infant
interaction in term and preterm infants. Child Development, 56, 15-27.
Libby, S., Powell, S., Messer, D., & Jordan, R. (1998). Spontaneous play in children with
autism: A reappraisal. Journal of Autism and Developmental Disorders, 28(6), 487-497.
Macari, S. L., Campbell, D., Gengoux, G. W., Saulnier, C. A., Klin, A. J., & Chawarska, K.
(2012). Predicting developmental status from 12 to 24 months in infants at risk for
autism spectrum disorder: A preliminary report. Journal of Autism and Developmental
Disorders, 42(12), 2636-2647.
Macintosh, K., & Dissanayake, C. (2006). A comparative study of the spontaneous social
interactions of children with high-functioning autism and children with Asperger’s
disorder. Autism, 10, 199-220.
Manwaring, S. S., Stevens, A. L., Mowdood, A., & Lackey, M. (2018). A scoping review of
deictic gesture use in toddlers with or at-risk for autism spectrum disorder. Autism &
Developmental Language Impairments, 3, 1-27.
McClung, J. S., Placì, S., Bangerter, A., Clément, F., & Bshary, R. (2017). The language of
cooperation: shared intentionality drives variation in helping as a function of group
membership. Proceedings Biological sciences, 284(1863), 20171682.
doi:10.1098/rspb.2017.1682

McLean, L. (1990). Communication development in the first two years of life: A transactional
process. Zero to Three, 11(1), 13-19.
Meadows, D., Elias, G., & Bain, J. (2000). Mothers' ability to identify infants' communicative
acts consistently. Journal of Child Language, 27(2), 393-406.
20

Meltzoff, A. N. (2007). The 'like me' framework for recognizing and becoming an intentional
agent. Acta Psychologica, 124(1), 26-43.
Mullen, E. M. (1995). The Mullen Scales of Early Learning: AGS Edition. Circle Pines, MN,
USA: American Guidance Service.
Muratori, F., & Maestro, S. (2007). Autism as a downstream effect of primary difficulties in
intersubjectivity interacting with abnormal development of brain connectivity.
International Journal for Dialogical Science, 2(1), 93-118.
Nagy, E. (2011). The newborn infant: A missing stage in developmental psychology. Infant and
Child Development, 20, 3-19.
Niedźwiecka, A., Ramotowska, S., & Tomalski, P. (2017). Mutual gaze during early mother-
infant interactions promotes attention control development. Child Development.
doi:10.1111/cdev.12830 [Epub ahead of print].
Panksepp, J. (2011). Cross-species affective neuroscience decoding of the primal affective
experiences of humans and related animals. PLoS ONE 6, e21236.
Papaeliou, C. F., Minadakis, G., & Cavouras, D. (2002). Acoustic patterns of infant
vocalizations expressing emotions and communicative functions. Journal of Speech,
Language, and Hearing Research, 45(2), 311-317. doi:10.1044/1092-4388(2002/024)
Papaeliou, C., & Trevarthen, C. (2006). Pre‐linguistic pitch patterns expressing
‘communication’ and ‘apprehension’. Journal of Child Language, 33, 163-178.
Papaeliou, C., Samartzi, S., Christodoulou, E., Koumnaki, M., Sakellaki, K., Vrettopoulou, M.,
& Papoulidi, A. (2015). Speech gesture combination in Autism Spectrum Disorders.
Presentation at the 10th International Conference on Child and Adolescent
Psychopathology, London, United Kingdom.
Paparella, T., Goods, K. S., Freeman, S., & Kasari, C. (2011). The emergence of nonverbal
joint attention and requesting skills in young children with autism. Journal of
communication disorders, 44(6), 569-583.
Papoulidi, A., Papaeliou, C. F., & Samartzi, S. (2017). Rhythm in Interactions between Children
with Autism Spectrum Disorder and Their Mothers. Timing & Time Perception, 5(1),
5-34. doi:10.1163/22134468-00002082
Rozga, A., Hutman, T., Young, G. S., Rogers, S. J., Ozonoff, S., Dapretto, M., & Sigman, M.
(2011). Behavioral profiles of affected and unaffected siblings of children with autism:
Contribution of measures of mother–infant interaction and nonverbal communication.
Journal of Autism and Developmental Disorders, 41, 287-301.
Saint-Georges, C., Chetouani, M., Cassel, R., Apicella, F., Mahdhaoui, A., Muratori, F., Laznik,
M. C., & Cohen, D. (2013). Motherese in interaction: at the cross-road of emotion and
cognition? (A systematic review). PLoS ONE 8(10), e78103.
doi:10.1371/journal.pone.0078103
Schirmer, A., Meck, W. H., & Penney, T. B. (2016). The socio-temporal brain: Connecting
people in time. Trends in cognitive sciences, 20, 760-772.
Shumway, S., & Wetherby, A. (2009). Communicative acts of children with autism spectrum
disorders in the second year of life. Journal of Speech, Language, and Hearing
Research, 52, 1139-1156.
Sinha, P., Kjelgaard, M. M., Gandhi, T. K., Tsourides, K., Cardinaux, A. L., Pantazis, D.,
Diamond, S. P., & Held, R. M. (2014). Autism as a disorder of prediction. Proceedings
of the National Academy of Sciences USA, 111(42), 15220-15225.
doi:10.1073/pnas.1416797111
Stanley, G. C., & Konstantareas, M. M. (2007). Symbolic play in children with autism spectrum
disorder. Journal of Autism & Developmental Disorders, 37(7), 1215-1223.
Stern, D. N. (1985). The interpersonal world of the infant. New York, NY, USA: Basic Books.
Tager-Flusberg, H., Skwerer D. P., & Joseph, R. M. (2006). Model syndromes for investigating
social cognitive and affective neuroscience: a comparison of autism and Williams
syndrome. Social Cognitive and Affective Neuroscience, 1(3), 175-182.
The BabyAffect Team (2014). Report on dense audiovisual data collection from TD and ASD
children (deliverable). Retrieved from:
https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxi
YWJ5YWZmZWN0cHJvamVjdHxneDo2NjIzZWM4YTU4ZDY0NzI0
Thiemann-Bourque, K. S., Brady, N. C., & Fleming, K. (2012). Symbolic play of preschoolers
with severe communication impairments with autism and other developmental delays:
More similarities than differences. Journal of Autism and Developmental Disorders, 42,
863-873.
Thorup, E., Nyström, P., Gredebäck, G., Bölte, S., Falck-Ytter, T., & EASE Team Affiliations.
(2018). Reduced Alternating Gaze During Social Interaction in Infancy is Associated
with Elevated Symptoms of Autism in Toddlerhood. Journal of Abnormal Child
Psychology, 46(7), 1547-1561. doi:10.1007/s10802-017-0388-0
Tomasello, M. (1999). The cultural origins of human cognition. Cambridge, MA: Harvard
University Press.
22

Tomasello, M., & Carpenter, M. (2007). Shared intentionality. Developmental Science, 10(1),
121-125. doi:10.1111/j.1467-7687.2007.00573.x
Tomasello, M., Carpenter, M., & Liszkowski, U. (2007). A new look at infant pointing. Child
Development, 78(3), 705-722.
Tomasello, M., Carpenter, M., Call, J., Behne, T., & Moll, H. (2005). Understanding and
sharing intentions: The origins of cultural cognition. Behavioral and Brain
Sciences, 28(5), 675-691. doi:10.1017/S0140525X05000129
Trevarthen, C. (1979). Communication and cooperation in early infancy: A description of
primary intersubjectivity. In M. Bullowa (Ed.), Before speech: The beginning of
interpersonal communication (pp. 321-347). New York: NY, USA Cambridge
University Press.
Trevarthen, C. (2001). Intrinsic motives for companionship in understanding: Their origin,
development and significance for infant mental health. Infant Mental Health Journal,
22(1-2), 95-131.
Trevarthen, C. (2005). Action and emotion in development of the human self, its sociability and
cultural intelligence: Why infants have feelings like ours. In J. Nadel & D. Muir (Eds.),
Emotional Development (pp. 61-91). Oxford, UK: Oxford University Press.
Trevarthen, C. (2009). The intersubjective psychobiology of human meaning: Learning of
culture depends on interest for co-operative practical work-and affection for the joyful
art of good company. Psychoanalytic Dialogues, 19, 507-518.
doi:10.1080/10481880903231894
Trevarthen, C., & Aitken, K. J. (2001). Infant intersubjectivity: Research, theory, and clinical
applications. Journal of Child Psychology and Psychiatry, 42(1), 3-48.
Trevarthen, C., & Daniel, S. (2005). Disorganized rhythm and synchrony: Early signs of autism
and Rett syndrome. Brain & Development 27, S25-S34.
Trevarthen, C., & Delafield-Butt, J. T. (2013). Autism as a developmental disorder in
intentional movement and affective engagement. Frontiers in Integrative Neuroscience,
7, 49. doi: 10.3389/fnint.2013.00049
Trevarthen, C., & Hubley, P. (1978). Secondary intersubjectivity: Confidence, confiding and
acts of meaning in the first year. In A. Lock (Ed.), Action, gesture and symbol: The
emergence of language (pp. 183-229). London, UK: Academic Press.
Trevarthen, C., & Reddy, V. (2007). Consciousness in infants. In M. Velman & S. Schneider
(Eds.), A companion to consciousness (pp. 41-57). Oxford, UK: Blackwells.
Wan, M. W., Green, J., Elsabbagh, M., Johnson, M. H., Charman, T., Plummer, F., & The
BASIS Team. (2012). Parent-infant interaction in infant siblings at risk of autism.
Research in Developmental Disabilities, 33(3), 924-932.
doi:10.1016/j.ridd.2011.12.011
Warreyn, P., Roeyers, H., & De Groote, I. (2005). Early social communicative behaviors of
preschoolers with autism spectrum disorder during interaction with their mothers.
Autism, 9, 342-361.
Watson, L. R., Crais, E. R., Baranek, G. T., Dykstra, J. R., & Wilson, K. P. (2013).
Communicative gesture use in infants with and without autism: a retrospective home
video study. American Journal of Speech-Language Pathology, 22(1), 25-39.
doi:10.1044/1058-0360(2012/11-0145
Werner, E., & Dawson, G. (2005). Validation of the phenomenon of autistic regression using
home videotapes. Archives of General Psychiatry 62(8), 889-895.
Wetherby, A. M., Woods, J., Allen, L., Cleary, J., Dickinson, H., & Lord, C. (2004). Early
indicators of autism spectrum disorders in the second year of life. Journal of Autism and
Developmental Disorders, 34(5), 473-493.
Wijngaarden-Cremers, P. J. M., Van Eeten, E., Groen, W. B., Van Deurzen, P. A., Oosterling,
I., & Van der Gaag, R. J. (2014). Gender and age differences in the core triad of
impairments in autism spectrum disorders: a systematic review and meta-analysis.
Journal of Autism and Developmental Disorders, 44, 627-635.
Williams, E., Reddy, V., & Costall, A. (2001). Taking a closer look at functional play in
children with autism. Journal of Autism and Developmental Disorders, 31, 67-77.
Wilson, K. P., Carter, M. W., Wiener, H. L., DeRamus, M. L., Bulluck, J. C., Watson, L. R.,
Crais, E. R., & Baranek, G. T. (2017). Object play in infants with autism spectrum
disorder: A longitudinal retrospective video analysis. Autism & Developmental
Language Impairments, 2, 1-12.
Yirmiya, N., Gamliel, I., Pilowsky, T., Feldman, R., Baron-Cohen, S., & Sigman, M. (2006).
The development of siblings of children with autism at 4 and 14 months: Social
engagement, communication, and cognition. Journal of Child Psychology and
Psychiatry, 47, 511-523.
Yoder, P. J., McCathren, R. B., Warren, S. F., & Watson, A. L. (2001). Important distinctions
in measuring maternal responses to communication in prelinguistic children with
24

disabilities. Communication Disorders Quarterly, 22(3), 135-147.

doi:10.1177/152574010102200303
 APPENDIX: CODING SCHEME

Gaze direction
Looking at Partner’s eyes/face Gaze clearly directed to partner’s face
Looking at Partner’s hands or body Gaze directed to partner’s hands or body
Looking at object Partner focuses attention on one object from those
provided by the researcher.
Looking around Partner does not focus attention on anything in
particular.
Fixing gaze while listening to a sound Partner fixates gaze while listening to a sound
Blank stare/still face Partner looks without focusing
Action on object

Pointing Extending index finger towards a topic in the

environment
Showing Holding out an object to the Partner but does not give it
to her
Offering Holding out an object to the Partner and gives it to her
Holding an object / Inspecting an object Attempting to modify the orientation of an object
Exploring Mouthing, banging, bouncing, swinging, rolling,
shaking, pushing or pulling an object. These actions are
not conventional.
Relational use of objects in non-conventional e.g. putting nesting cups in line
manner
Functional play Manipulating objects in ways that are
socially and functionally intended (e.g. rolling a ball,
pushing-pulling a car, taking a piece out of a puzzle)
Combinatorial functional play Using two or more objects in conventional way (e.g.
stirring spoon in cup, putting pieces of puzzle together)
Cooperative functional play Using an object that is related to Partner’s object in a
conventional way, so as to achieve a goal with Partner
(e.g. Mother opens a box and Child puts something in
it)
Symbolic play Involves pretense or complex play actions that
incorporate items, attributes, or contexts not actually
present, or the substitution of objects
Action on partner
Touches other’s body One of the partners touches the other’s body while
interacting
Imposes action One of the partners clearly imposes an action to the
other
Pushes or pulls towards One of the partners pulls towards or pushes away the
other
Moving away from other One of the partners moves away from the other
Moving towards other One of the partners moves towards the other
Emotions
Positive Happy face, bright eyes, elongated mouth, stretched lips
Negative Furrowed brow, wrinkles around the eyes and the nose,
tight lips, mouth either open or closed, corners of the
mouth slightly downward or pulled downward
Neutral Absence of positive or negative facial expressions