Behavioural evidence of atypical joint attention behaviours is striking in its presence in preschool development. Items measuring behaviours of joint attention are central to the early, preschool detection of children affected by autism, or at risk of autism [10]. This study aimed at constructing a questionnaire called EJAQ for JA skills in young Egyptian children to be used as an early detector of the presence of autistic behaviours in high-risk children in order to guide plans for early intervention. It is a parent or caregiver report questionnaire for assessment of joint attention in Arabic-speaking children, taking in consideration social, cultural and language considerations appropriate to Egyptian society. The questionnaire consisted of 44 items covering 5 domains of joint attention behaviours. It was evaluated by three phoniatricians before the presentation of the questionnaire to the pilot study group. After application of the pilot study on 10 children, two questions were modified after the pilot study to be easily understood by the parent.
The advantage of the ability to use the questionnaire for the assessment of joint attention is the flexibility it affords when assessing difficult populations. Children with autism, particularly those more impacted by the disorder, often have difficulty sitting and attending for extended period of time. Highly structured assessments, like the Early Social Communication Scales (ESCS), may be difficult for some of these children to complete. As research in autism moves towards identifying early indicators, appropriate assessment must be developed and altered to address their developmental appropriateness. In the cases of highly impacted children and infants, these children may not be able to sufficiently display their full range of abilities within traditional structured assessment.
In the present study after application of EJAQ Questionnaire on the TD children, the results have shown that the core or basic joint attention abilities, namely eye gaze and facial expressions, are acquired early at 30 months of age; while other abilities, RJA, IJA, and coordinated joint attention, continue to grow. This finding coincides with previous researches [11,12,13]. It was drawn from the fact that there was no significant difference in eye gaze and facial expressions between the three age subgroups of TD children in the questionnaire results. As the age limit of the first subgroup I-A is 30 months, then it is expected that these abilities are well developed by this age. On the other hand, RJA, IJA, and coordinated joint attention are expected to continue to grow until the age of 54 months which is the age limit of the subgroup I-C, as there was significant difference in these abilities between the three subgroups.
After applying EJAQ Questionnaire on autistic children, they showed lower performance than TD children in all domains of joint attention (eye gaze, RJA, IJA, coordinated joint attention and facial expressions). This result is in line with previous studies [14,15,16]. In the present study, autism is more prevalent in males (73%) than in females (27%) which concurs with previous studies reporting higher prevalence of ASD among males [17,18,19]. In the autistic group, the mean of initiating JA was lower than the mean of responding to JA which coincides with the research by Gangi et al. [20].
Most of the present tests measure joint attention as a part of social communication assessment scales such as Early Social Communication Scales (ESCS) [21], Communication and Symbolic Behaviour Scales (CSBS) [22] and Social Communication Assessment for Toddlers with Autism (SCATA) [23]. Social communication questionnaire (SCQ) [24] is also a parent report questionnaire for screening of autism. Its items include questions referring to reciprocal social interaction, language and communication, and repetitive stereotyped patterns of behaviour. Unlike all these scales, EJAQ is a specific questionnaire which assesses joint attention behaviours in details.
ESCS [21] is the most commonly used test for assessment of joint attention. It is a videotaped structured observation measure that requires between 15 to 25 min to administer. It provides measures of individual differences in nonverbal communication skills that typically emerge in children between 8 and 30 months of age. A set of 25 semi-structured eliciting situations were developed to encourage interaction between an adult tester and the child. While the ESCS is an effective and validated measure, it does have limitations. The assessment requires a controlled setting, with assessors trained in the standardized administration. This can place high demands on both the child and the assessor. Very young children or children with attention difficulties may have difficulty expressing their full capabilities in such a structured setting. While standardized administration is the strength of the ESCS, it may also make it difficult for professionals outside of research institutions to effectively administer. In EJAQ, on the other hand, behavioural requests were excluded as they do not represent joint attention skills, while social interaction behaviours were included in coordinated joint engagement. Eye gaze and facial expressions were also included as they are very important in the development of joint attention.
Although this questionnaire appears to be similar in structure to the childhood joint attention rating scale(C-JARS) [25], there are discrepancies. The EJAQ assesses the 5 domains of joint attention that include eye gaze, responding to JA, initiating JA, coordinated JA and facial expressions and is applied on the preschool period to be an early screening tool of autism. On the other hand, C-JARS is done for older verbal children and during adolescence and it assesses responding to JA, initiating JA and joint action.
EJAQ Questionnaire displayed high sensitivity and high specificity for diagnostic identification of autistic children. This was the case for both males and females with autism. The joint attention skills differed strikingly in individuals of autism compared to TD children. Reliability and validity test results showed that EJAQ is a valid and highly reliable questionnaire that reflects joint attention abilities in developing Egyptian Arabic children between 18 and 54 months.