By: Elizabeth Zeppernick, M.Ed., BCBA, LBA

It is common for individuals with Autism Spectrum Disorder (ASD) to lack eye contact and gaze which can hamper their ability to pick up on social cues.  These cues are critical for effective communication, academic success and help facilitate social interactions.  Eye contact provides a social connection, interest and can be a sign of respect.  Eye gaze is equally important in communication, ex: “Look at that dog over there!” or “Go get that basket.”  Existing research indicates that with systematic training, individuals with ASD can learn eye contact and gaze (Cook et al., 2017; Rapp et al., 2019; Conine, Vollmer, and Bolivar, 2020).

Researchers Lee, Tang & Xu (2022) recently published a study called “Improving Eye Contact and Gaze Following in Children with Autism Spectrum Disorder: Systematic Withdrawal of Stimulus Prompts and Tangible Reinforcers.”  This study, designed to teach eye contact and gaze, looked at two boys with ASD ages five and six years old and took place in an autism research center in China.  Both boys displayed symptoms typical of autism that ranged from mild to severe.  They lacked consistent eye contact, and did not dependently initiate or respond to social interactions.

This study used a sequential procedure to introduce and slowly fade the use of a reinforcing or preferred item or edible.  Unlike some other procedures used to address eye contact, no blocking or aversive punishments were implemented.  A preference assessment was completed to determine each participant's top-ranked edible and toy items. A baseline or pre-training measurement was taken to assess each child’s eye contact skills prior to any training.  

Phases of Eye Contact Training: 

1. Edible Prompt- Instructor verbally prompts, “Johnny, look at the teacher.” The instructor puts the edible in front of the participant’s eyes and then slowly shifts it to the instructor’s eyes.  

2. ½ Edible and ½ Finger Prompt- Instructor verbally prompts.  The edible is held in front of the participant’s eyes and moved halfway between the participant and instructor. The instructor then hides the edible in her palm, replacing it with a pointer finger stretched out.  The pointed finger then continues to the instructor’s eyes. 

3. Finger Prompt- Instructor verbally prompts.  The instructor only uses their pointer finger, moving it in front of the participant’s eyes toward their own eyes. 

4. No Prompt- Instructor verbally prompts, i.e. “Johnny, look at the teacher.” No additional prompts are given. 

Correct responses (defined as holding eye contact for at least five seconds) were rewarded with praise, the preferred edible and a token.  Incorrect responses were ignored. Progressing from each phase was contingent upon 90% accuracy across two separate sessions. With one training session occurring for each participant, each day for five days a week one participant completed or mastered the training in one and a half months and the other completed it in three months.  

A similar four phase system was used for teaching eye gaze. The eye gaze training was differentiated by moving the gaze first to the instructor’s eyes briefly and then to the target item on the table. 

Essentially, the procedure transferred the reinforcing quality of the preferred item with the human face, making the person not the object the rewarding point of contact.  The previous work of researchers Rapp et al. (2019) found that once it’s established, eye contact can improve and be sustained overtime by natural reinforcement, i.e. human faces and social praise rather than only edible rewards and tokens.

This study confirmed that using preferred items and a system of prompt fading was effective in establishing eye contact and gaze.  The two participants were able to acquire, maintain(when measured one month after the completion of the training) and generalize the skill to new settings and teachers. 

One benefit of this study is it demonstrated the model was successful in an instructional setting which had natural distractions of teachers and peers.  Training, the measurement of maintenance overtime and generalization to other instructors did not occur in a restrictive, isolated setting, making it more approachable for the average clinician working in a home or classroom environment. 

Sources: 

Conine, D. E., Vollmer, T. R., & Bolivar, H. A. (2020) Response to name in children with autism: Treatment, generalization and maintenance.  Journal of Applied Behavior Analysis,  53(2), 744-766. https://doi.org/10.1002/jaba.635

Cook, J. L., Rapp, J. T., Mann, K. R., McHugh, C., Burji, C., & Nuta, R. (2017).  A practitioner model for increasing eye contact in children with autism.  Behavior Modification, 41(3), 382-404. https://doi.org/10.1177/0145445516689323

Lee, G. T., Tang, Y. & Xu, S. (2022). Improving eye contact and gaze following in children with autism spectrum disorder: Systematic withdrawal of stimulus prompts and tangible reinforcers.  Behavior Modification, https://doi.org/10.1177/01454455211073741

Rapp,J. T., Cook, J. L., Nuta, R., Balagot, C., Crouchman, K., Jenkins, C., Karim, S., & Watters-Wybrow, C. (2019). Further evaluation of a practitioner model for increasing eye contact in children with autism. Behavior Modification, 43(3), 389-412. https://doi.org/10.1177/0145445518758595

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