Believe or not, 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 enhancing eye contact; That making eye contact ‘hurt them’. Consequently, many clinicians now refrain from 'teaching eye contact'.

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Naturally, as clinicians, we always need to be sensitive to any pain and discomfort resulting from what we do, and such indications always require adjustments on our part. After all, our job as teachers is to ensure that children are happy and engaged in learning. This goes without saying. And while we can't deny the reports of persons  being 'hurt', we need to ask, "Have all children with autism whose eye contact increased as a function of direct intervention been subjected to pain producing practices?" Surely not.

 

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 the practical considerations for doing so, vast amounts of anecdotal evidence and scientific evidence that 'pain' is not a necessary or natural outcome of meeting the gaze of others for children with autism.

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A little context

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Many years ago, (and perhaps still), a particular exercise called “look at me” was common in EIBI practice. Children were asked to sustain eye contact for increasingly longer periods of time….5 secs, 10 secs… the longer the better. Of course, sustained eye contact is uncomfortable for most of us and there are few instances in our social practice where it occurs... so not only did such efforts not match what is done in our social practice but, such efforts were carried to absurd lengths. Additionally, 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, likely resulted(s) in discomfort, and, if this practice is still included in intervention programs, it should be excised.

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However, efforts to establish eye contact (gaze) should not be. It is possible to enhance eye contact without discomfort. It is possible to increase (frequency) of eye contact with joy and fun. Moreover, abandoning efforts to enhance eye contact is to forgo offering children the benefits of ‘eye contact’.

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But wait. There are other voices who give other reasons for not addressing 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 means. We could ask a similar question about persons with diabetes. Does intervention , i.e., taking insulin or other medications to manage sugar levels make them 'not diabetic'? Of course not. And, is someone who is dyslexic no longer dyslexic after intervention makes reading easier? What is clear to me and my colleagues is that the goal of intervention for persons with autism should only be to assist in ways so that navigating the world is easier. Enhancing eye contact is one of those ways. Let's explore this.

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Benefits of eye contact

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For purposes of intervention, it's useful to consider what it means 'to have 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, both when combined with words or gesture and without. Having such 'technique' enlarges and enhances communication abilities and is a part of our communication practice. It enhances social acuity and awareness. It is a part of our social practice; a part of our way of being social. It is socially relevant.

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‘Eye contact’ is involved when 'checking-in' with others, 'checking back' with others, 'checking others out'. Eye contact is often manifest when obtaining or soliciting approval, acknowledgement or agreement. It is often used when soliciting feedback, or to invite a response. It is included exclusively or partly in our efforts to secure attention and assurances of attention, when directing others or taking direction. It is used when we wish to convey appeals for assistance, to implore, to convey uncertainty and confusion, it is employed for emphasis/ or to stress a point. There are many things we do in our communication practice, which includes eye contact technique.

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It is possible, by using basic shaping procedures, that eye contact can be developed and encouraged so that eventually it is used within communication and linguistic practices for different purposes. Eye contact as a technique does not always need to be taught directly, but we have found that getting children into the habit of meeting the gaze of others, under highly contrived situations, may lead to the development of 'technique' that is a part of children's routine communication practices.

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Establishing early eye contact/ early ‘habit’

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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. At its most basic, intervention is about getting children to pay attention to us so that we become relevant 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, is a social enterprise. Eye contact is a fundamental part of that.

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When we begin, we establish eye contact by first offering regular 'free' access to goodies… as part of a simple shaping process in which 'eye contact' is encouraged. The goodies (reinforcers) we select 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 so to not create severe 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 look to the item in our hand, try something else. We call these items ‘eye catchers’. We want ‘eye catchers’.

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Once 'eye catchers' are identified, and children have come to expect delivery when the item is shown, we change the game a bit. Once the 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.)

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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 before them. It's simple for the child 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. It is manifest so that 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 were discomfort, we would see greater gaze avoidance, not more. It is our job as instructors to be on the lookout for such indications and to make adjustments when we see it. This goes for any child when teaching anything.

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Additionally, research shows that children on the spectrum are not emotionally 'dis-regulated' in their responses to mutual gaze (Nuske, Vivanti and Dissanayake, 2015). Anecdotally, I can say that in 30+ years of practice, I’ve seen, that as eye contact increases children are more happily engaged in more efficient learning. Moreover, it’s easy to implement this simple procedure, both for parents and teachers.

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Once the routine of prompting the child’s gaze to meet yours is established, begin to wait to see if their eyes come up on their own. They usually do. If so … reinforce… and if a child enjoys other things, 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 should be thinned over time particularly as eye gaze begins to occur more spontaneously, i.e. more habitually.

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Moving ahead:

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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:

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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

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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’ 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, and out of practical considerations, 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.

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The eye contact springboard:

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​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 (see ABA Mini-Manual Level One: Tracking exercises) and teaching children to use a point 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. Additionally, 'deixic insistence' baked into teaching practices supports efforts to secure social awareness (See ABA Mini-Manuals Level One and Level Two for countless exercises which stress this critical dimension of intervention).

 

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...this is supported anecdotally and in the literature. Integrating eye contact into communication/social practice increases communication efficiencies and adds to the number of tools and related techniques in a child's communication toolbox.