Supporting Joint Attention with Deaf and Hard-of-Hearing Babies and Toddlers

The issue

Visual experiences underlie learning and language development whether language is primarily visual (sign), vocal (speech) or a combination of the two.  Shared (or “joint”) visual experiences have special impact.  Vision is somewhat limited at birth—with a short focal distance, lack of sharpness, inability to see 3-dimentionally. Vision improves through the first months with experience and neural development promoting face-to-face exchanges.  But, when babies become more interested in objects, visual communication exchanges can become more challenging.  Especially when hearing is limited, how can visual attention for communication be facilitated?

What we know

Research shows higher parent sensitivity to early visual skills when they feel confident about their own and their babies’ communication potential.  During the early months, most caregivers respond to limited visual skills by leaning into focus and communicating in multisensory “bundles” of information—smiling broadly and tilting the head, vocalizing, touching, moving baby’s arms or legs.  Although sounds typically attract visual attention, “bundling” information means communication can be received even with limited hearing, something that occurs regardless of baby or parent hearing abilities. Shared eye contact, expressions of emotion, are frequent when baby is in a quiet, alert state (they look away when overstimulated).  Deaf mothers produce more positive facial expressions and more touching; hearing mothers provide more music-like vocal information.  But these differences are not defined simply by hearing status: parents can adjust to their own baby’s responses.

By 6 months, babies typically become fascinated with objects, often looking at them rather than the person trying to communicate. This natural development for hearing and for deaf/hard-of-hearing (DHH) babies creates special challenges for visually-based language input (speechreading, sign, gesture).  Before babies spontaneously look from object to communicator during an episode, caregivers can support joint attention by waiting for spontaneous looks up before communicating, moving hands and/or face so baby can see both them and the object, tapping/stroking baby’s arm or leg while moving object toward face—then signing or talking about it. It is important to follow the child’s lead by matching language input to the baby’s focus of attention:

Supported Attention:  Jake looks at the toy truck and leans forward, reaching to touch it.  Daddy moves the truck between him and Jake and signs “truck” just behind the toy. Daddy taps on Jake’s arm several times, signing and saying “d-u-m-p truck” near his own face when Jake looks up at him (Spencer & Koester, 2016, p. 193).

Such supported attention strategies can help build attention to sounds when children have enhanced hearing from cochlear implants or other devices. These typically lead to coordinated joint attention (CJA) episodes, with babies spontaneously switching visual attention between object and person.  CJAs predict language advances for hearing and DHH toddlers.  Without CJA, language input becomes more difficult and delays harder to address when mobility increases.

CJA example: Jaime has grabbed a doll from coffee table.  She looks up at her mother, back to the toy, then back to mother, holding it out to her.  Mother signs “no, that’s sister’s doll”(Spencer & Koester, p. 196).

What we don’t know

A few things we need to know: How do individual babies’ initial attention to people (and caregiver’s feelings of confidence) affect early interactions and attention development? How can touch be used in communication bundles to gently draw attention? How can speech and auditory information be integrated into communications for children with varied hearing abilities (across individuals and over time)?  How can we accommodate needs of children with limited vision as well as hearing or with other developmental challenges. What are some effective, naturalistic interventions for children with attention and language less advanced than expected for their age?


We have much research on group tendencies in visual attention development and parent strategies.  Systematic approaches to assessing individuals and dyads are needed, along with ways to support and measure progress.  Patterns of attention should be noted during infancy and modified input strategies explored so delays can be addressed before they increase. Delays in CJA call for renewing and reinforcing earlier supportive strategies. Bundling information across modalities and senses can be emphasized while recognizing that sensitivity and responses to sensory information may change over time.

Videos modelling successful attention episodes (at various developmental levels) can help caregivers and professionals assess and increase varied strategy use. Richer lists of supportive strategies should be developed and treated as menus from which to choose, not a “curriculum” for all.  Caregivers’ recognition of their child’s attention patterns—and their own abilities to encourage attention development—will promote overall positive attention and communicative exchanges.

Posted on April 2, 2018 by
Patricia Spencer
Bethesda, Maryland
bethesdapat {at}


Further reading