There is a controversy within the ABA treatment community about whether we should ‘teach’ eye contact to children with ASD. Opposing voices, those which insist intervention should not include efforts to enhance eye contact, are informed by reports from adult persons with autism who as children received “ABA”, and who recall uncomfortable or painful experiences during exercises that were employed for 'teaching' eye contact; That making eye contact ‘hurt them’. Consequently, many clinicians now refrain from 'teaching' eye contact.
Naturally, as clinicians, we always need to be sensitive to discomfort resulting from what we do, and such indications always require adjustments on our part. And while we can't deny the experiences of those persons who report 'pain' with eye contact, we need to ask, "Have all children with autism whose eye contact increased as a function of intervention been subjected to pain producing practices?" Surely not.
In fact, there is research which shows that children on the spectrum are not emotionally dis-regulated in their responses to mutual gaze (Nuske, Vivanti and Dissanayake, 2015). In 28 years of practice, I’ve seen this anecdotally. Additionally, I've seen that as eye contact increases, children become more engaged in more efficient learning.
So how do we navigate this? On the one hand, there are persons with autism saying "No to eye contact". On the other, there are practical reasons for doing so and evidence that 'pain' is not a necessary or natural outcome of meeting the gaze of others for children with autism.
A little context
Many years ago, (and perhaps still), a particular exercise called “look at me” was common in early behavioral Intervention practice. Children were asked to sustain eye contact for increasingly longer periods of time….5 secs, 10 secs… the longer the better. There were accompanying efforts to ‘prompt’ eye contact by forcing children's heads up, hoping that the child would look at the instructor’s eyes. It is safe to say, this iteration of the “Look at me” exercise, resulted(s) in discomfort on all levels. It is a senseless 'program' and insisting on prolonged eye contact would leave anyone feeling uncomfortable. Moreover, doing so does not resemble the way eye contact is normally manifest and used. If this 'program' is still included in intervention programs, it should rightly be excised.
However, efforts to establish eye contact should not be. It is possible to enhance eye contact without discomfort. It is possible to increase eye contact with joy and fun. Moreover, abandoning efforts to enhance eye contact is to forgo offering children the benefits of ‘eye contact’.
But wait. There are other voices who give other reasons for not encouraging eye contact in children with autism. Doing so, they argue, is to try to make persons with autism, or autistic persons, non-autistic. I'm not sure what this even means. What is clear to me and my colleagues is that the goal of intervention should only be to assist in ways so that persons who struggle to navigate in the world are able to do so more easily. Enhancing eye contact is one of those things. Let's explore this.
Benefits of eye contact
For purposes of intervention, it useful to consider what we are talking about when we talk about 'eye contact' . To ‘have eye contact’ is to acquire a 'technique’; a technique that is part of the way, or a way in which we communicate...verbally and non-verbally. Having such 'technique' enhances one's abilities in communication. It enhances social acuity and awareness. It is a part of our social practice; a part of our way of being social.
‘Eye contact’ is involved when checking-in with others, checking back with others, checking others out (Think Larry David). Eye contact is often manifest when obtaining or soliciting approval or acknowledgement or agreement. It is often used when soliciting feedback, or to invite a response. It is included in our efforts to secure attention and assurances of attention, and is included when directing others or taking direction. It is used when we wish to convey appeals for assistance, to implore, to convey uncertainty and confusion and, it is employed for emphasis or to stress a point. There are many things we do which includes eye contact, with or without words.
It is possible, by using basic shaping procedures, that eye contact can be developed so that it is eventually used within communication and linguistic practices... to different effect… so that children acquire a technique. Eye contact as a technique does not always need to be taught directly, but we have found that by getting children into the habit of meeting the gaze of others, under highly contrived situations, assists in the development of 'technique' that is a part of our communication practices.
Establishing early eye contact/ early ‘habit’
In our clinical practice, when intervention begins… even for children who had been involved in intervention for many years, we first establish eye contact as a part of developing early readiness skills. A significant part of intervention should be about getting children to pay attention to us so that we become relevant to them and so that we can teach efficiently and effectively. At its most basic, intervention is about getting children to pay attention to us so they learn through us and enjoy being with us. After all, learning, particularly for young children is a social enterprise. Eye contact is a fundamental part of that.
When we begin intervention, we work to establish eye contact. First, we offer regular 'free' access to goodies…in the service (at least in part) of what has become known as"pairing", but more specifically as part of a simple shaping process in which 'eye contact' is eventually encouraged.
The goodies (reinforcers) selected are those we are able to keep in our hands, (candies are especially good because they ‘disappear’ once eaten and thus they don’t need to be removed, thereby avoiding side-effects of ‘removal’). If candies aren’t preferred, care must be taken when removing the things that had been offered (Greg Hanley offers guidance on how to manage this well) so to not create unhappiness.
When we begin, we display the item as it lays in our hands. If children's eyes track to the item in our hand, it gives us some assurance that it will likely serve as a reinforcer. If children do not track to the item in our hand, try something else. We call these items ‘eye catchers’. We want ‘eye catchers’.
Once 'eye catchers' are identified, and children have come to expect delivery when the item is shown, we change the game a bit...we raise the stakes. Once a child looks at the item in our hand, we track it to our eyes (between our eyes to be precise). As we track it up, we look to see that the child's eyes come up with it to meet ours... and if so, the child receives the item. Eye contact needs only to be momentary, a glance, but delivery of the R+ needs to be immediate. As eyes meet, children begin to also see our smiles and our excitement with them. If children do not track up as we raise the item to our eyes, switch the item until tracking to eyes occurs. (If no tracking occurs, it is usually an indication that the item is not ‘strong’ enough to serve as a reinforcer.)
In this way it is possible to begin to establish a basic routine… 'when you look at me something terrific will happen' thus establishing a ‘habit’ of looking at the person in front of them. It's a simple process and it’s free of discomfort. How do we know this? We know this because we recognize discomfort in others because it is manifest behaviorally; we see it. When we see it, we use the terms “discomfort” or “pain”. It is that simple. Children are not adept at hiding their discomfort. Additionally, if there was discomfort, we would see greater gaze avoidance, not more.
Once this basic routine is established of prompting the child’s gaze to meet yours, we begin to wait to see if children's eyes come up on their own. They usually do. If so … we reinforce… and if a child enjoys other things, we include them as well, e.g., pats on backs, noodle arms, kisses, tickles etc. If you are getting eye contact, but not smiles and laughter, work harder to ensure maximum happiness. If eyes don’t come up on their own… use a 'quick prompt’; show the item in your hand, track and reinforce or try showing the reinforcer but withhold reinforcement for a bit and see if eyes come up without tracking. Don’t assume it will happen without reinforcement... Good happiness producing reinforcement! Naturally, schedules of reinforcement can be thinned over time particularly as eye gaze begins to occur more spontaneously.
Moving ahead:
With this basic routine in place, begin to teach new things and establish a ‘response package’ that looks like this:
Look at teacher>listen>respond>look at teacher again>reinforce.
For example:
Establish eye contact > present instruction (e.g., give me the car) > child offers a car- just when the child offers the car, prompt for eye contact (bring reinforcer to between eyes > deliver reinforcer
This routine works on several levels. First it assures instructors that they have a good reinforcer. We have found that diminution of eye contact suggests the need to switch items used for reinforcement. This sometimes is needed on a moment-to-moment basis… so don’t become complacent with your selection of reinforcers. Simply because a child accepts something doesn’t mean it is a reinforcer… We see a strong correlation between ‘tracking’ of the reinforcer to our eyes and effective reinforcer selection. Second, this ‘response package’ rules out questions of ‘inattention’ when teaching. If eyes drift, we restart and reassess our reinforcers. Over time, the 'routine' will need to be relaxed...but bear in mind the need to continue to reinforce eye gaze... not necessarily by calling attention to it of course... but just because you adore the little person in front of you.
The eye contact springboard:
These early eye contact 'habits’ serve as a springboard that allows for greater success with other exercises which call for eye contact. Foundational exercises such as following a point and teaching children to use a point (joint attention) will more likely be successful if these eye gaze habits are established. Pragmatics during requests, calling someone's name or delivery of items are more easily shaped as children are accustomed to looking up and responding to the ‘tracking prompt’. We can contrive exercises with ‘programmed uncertainty’ or ‘ambiguity’ so that children need to look back to us in order to obtain clarification on what to do or how to proceed. Such exercises may be found in Early Intervention for Children with ASD: Considerations (Lund and Schnee, 2018) and perhaps in other common intervention guides.
To summarize:
It is important that children meet our gaze. Establishing eye contact should be fun filled. It is important to know that this can be accomplished without creating distress or discomfort in children. Integrating eye contact into communication practices increases communication efficiencies and adds to the number of tools and related techniques in a child's communication toolbox.