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EDUCATION AND TREATMENT OF CHILDREN Vol. 36, No. 2, 2013
Pages 139-159
Teaching Eye Contact to Children with Autism:
A Conceptual Analysis and Single Case Study
Vincent J. Carbone
Leigh O’Brien
Emily J. Sweeney-Kerwin
Kristin M. Albert
Carbone Clinic
Abstract
Eye contact occurs very early in development and serves many functions for
the young child. It has been implicated in the development of social, cogni-
tive, and language skills. A substantial number of children with autism fail to
develop this important skill and therefore experimenters with both develop-
mental and behavior analytic perspectives have researched methods to teach
-
dition the response of the communication partner as a reinforcer for social
behavior and thereby arrange the conditions under which typical children
develop social responses. The purpose of this case study was to extend the
analysis of typical development of social skills to the teaching of eye contact
as a language pragmatic skill to a child with autism. Data from a single case
study of a child with autism are provided.
: Eye Contact, Social Skills, Mands, Extinction, Autism, Motivating
Operations
It has been suggested that eye contact, sometimes referred to as
(eye) gaze behavior or eye-to-face gaze (Mirenda, Donnellan, &
Yoder, 1983) serves an important social function for young children
even before vocal responding begins to develop (Stern, 1985). In early
development, eye contact serves to regulate face-to-face social inter-
social interactions (Tiegerman & Primavera, 1984). Later, eye contact
-
We would like to thank the parents of the participant who took part in this study and
the instructors who conducted the sessions.
Correspondence concerning this article should be addressed to Vincent J. Carbone,
drvjc@
aol.com.
CARBONE, et al.
al and an object of interest (Arnold, Semple, Beale, & Fletcher-Flinn,
acquisition (Podrouzek & Furrow, 1988).
particularly in dyadic (i.e., eye-to-face) and triadic eye gaze (i.e., joint
-
tal delays and of Autism Spectrum Disorder in particular (Baron-Co-
various social functions eye contact may serve, failure to emit this im-
autism. In addition, there are possible educational concerns associ-
-
gested that the diversity of prelinguistic pragmatic skills exhibited
vocabulary acquisition (Kleinke, 1986) and it has also been suggested
children with autism due to the relationship between eye contact and
in eye contact, the development of eye contact responses in children
behavior analytic principles and procedures on eye contact responses
have been investigated.
Early behavior analytic investigations targeted eye contact re-
-
was that if children with autism failed to orient toward the instruc-
behavioral interventions to increase eye contact with children with
autism, there have been increasing concerns regarding the function-
results of studies investigating eye contact as a prerequisite skill for
141
TEACHING EYE CONTACT
eye contact responses has some possible disadvantages. First, some
children may resist the use of physical prompts and consequently
emit interfering behaviors. Second, the use of prompts to teach eye
contact requires an additional instructional step related to prompt
consuming to fade, resulting in slower skill acquisition.
-
havior analytic studies targeting eye contact have departed from the
rigid instructional models of earlier research and instead targeted eye
contact within social contexts through various social-interactive strat-
egies (Tiegerman & Primavera, 1984). An array of procedures, includ-
ing peer modeling, peer implemented pivotal response training, role
playing, contingent imitation, time delay, and naturalistic behavior
-
est increases in a variety of social behaviors, including eye contact and
-
Although the results of these more recent behavior analytic
studies have demonstrated moderately improved generalization over
earlier studies, they did not present an analysis of eye contact that
these studies did not include an analysis of the possible role of social
and motivational variables implicated in the learning of eye contact
responses by typical children. In other words, within these studies,
social consequences were not conditioned as reinforcers but instead
the eye contact responses were strengthened by “extrinsic” reinforc-
ers in the form of the presentation of tangibles, social praise, or edible
cited this as a limitation within their studies on gaze shift when teach-
The procedure employed in the current case study was designed
with consideration of the limitations of previous behavior analytic re-
the lack of generality and potential problems associated with vocal
and physical prompting of eye contact responses used in a number of
previous studies, the procedures implemented in this case study were
designed to induce the eye contact response in the same manner that
typical children acquire this important response in a number of ways.
142 CARBONE, et al.
First, eye contact responses were induced through the implementation
of extinction for previously acquired requests. Although extinction is
is to induce response variability (Lerman & Iwata, 1996). When ex-
tinction of a high probability response occurs, but the environmental
arrangement is such that a motivating operation (MO) is still present
(Michael, 1993), novel or previously reinforced less probable mem-
bers of a response class may be induced. The responses induced by
extinction may be aberrant behavior such as aggression, self-injury, or
property destruction (Lerman & Iwata, 1996). However, a number of
studies have demonstrated that extinction also induced appropriate,
adaptive behaviors that were then increased through the arrangement
-
-
training, was used in this case study. Mundy, Sigman, Ungerer, Sher-
man (1986) reported that children with autism fail to make eye con-
a characteristic consequence and is therefore under the control of rel-
evant conditions of deprivation and aversion” (pp. 35-36). This is one
usually accompanies this type of verbal behavior (Podrouzek & Fur-
-
ever, that children with autism often fail to emit these important social
responses while manding (Podrouzek & Furrow, 1988). A study by
-
signed to increase mand responses may also increase collateral social
-
-
be an appropriate condition in which to begin targeting eye contact
responses.
Finally, the procedure described and employed in this case
previous researchers concerning the use of “extrinsic” reinforcement
to establish and maintain eye contact responses. Preliminary work
143
TEACHING EYE CONTACT
-
use of “extrinsic” reinforcement. As one phase of establishing joint
-
smiling and nodding of an adult, as reinforcement. In this phase of
training, children with autism sat across a table from an adult and
were only allowed to take preferred items when the adult was smil-
-
ding were not occurring were blocked by the adult. The researchers
asserted that these procedures established adult smiling and nodding
as conditioned reinforcement for the eye contact responses that pro-
duced them. In other words, the results of this experiment suggested
that the children’s looking responses were ultimately increased by the
-
rent case study was derived from a functional analysis of the environ-
mental variables that may account for the acquisition of eye contact
responses for typical individuals.
There were two purposes of the current case study. First, this
case study was designed to extend the literature on teaching social
autism. Second, this case study evaluated an extension to a child with
autism of a teaching procedure derived from an analysis of the moti-
vational and discriminative variables responsible for the acquisition
of eye contact responses in typical children.
Method
Participant
The participant, Jake, was a 3-year-old boy with a primary diag-
nosis of autism. Jake’s vocal mand repertoire was multiply controlled
in that mands occurred under the control of both a relevant motivat-
ing operation and the presence of preferred items which served a
discriminative function. Prior to the beginning of the study, data on
month period. According to these data, at the time of this study, Jake
of about one mand per min during a 3 hr instructional session. An As-
sessment of Basic Language and Learning Skills (ABLLS, Partington
& Sundberg, 1998) conducted approximately 3 months prior to be-
ginning this study indicated that Jake exhibited limited tact, listener,
-
144 CARBONE, et al.
ing, crying, and whining. Sequence analysis data were collected on
occurrences of problem behavior and allowed for the tentative identi-
a problem behavior and its putative evocative or antecedent stimulus.
Based on the sequence analysis data collected, it appeared the major
functions of Jake’s interfering problem behavior were socially medi-
ated positive reinforcement and socially mediated negative reinforce-
ment The sequence analysis data also revealed that problem behavior
hr session. Prior to the onset of this study, behavior reduction pro-
cedures were implemented that consisted of teaching procedures to
reduce the value of escape from instructional tasks as a reinforcer,
extinction for problem behavior, and reinforcement for vocal mands.
After 3 months of intervention, Jake’s interfering problem behavior
was reduced to an average rate of one episode of problem behavior
per 3 hr session by the beginning of this study.
Seing
Jake was enrolled at a private clinic that provided one-to-one
educational services to individuals with autism and other develop-
mental disabilities. Instruction and treatment was guided by the prin-
ciples of applied behavior analysis (ABA) and incorporated Skinner’s
of two classrooms and one activity room. Approximately nine other
children were receiving intensive one-to-one instruction simultane-
wide variety of items and activities were available to students. Exam-
ples include gross motor activities (e.g., trampoline, bikes, basketball
-
demic activities (e.g., books, workbooks, computers), and toys (e.g.,
-
sions consisted of one-on-one intensive teaching in the form of DTT
interspersed with natural environment teaching. Mand training was
-
vironment was enriched with items such as food, toys, and activities
that had previously been demonstrated to serve as reinforcers in that
the delivery of these items following behavior produced an increase
in the frequency of that behavior. Access to these items was manipu-
lated so as to contrive MOs and arrange opportunities to teach mand
responses.
-
line and treatment conditions. All instructors were supervised by a
145
TEACHING EYE CONTACT
children with autism. Three of the four instructors held bachelor’s de-
language pathologist. The instructors had been employed at the clinic
for an average of 12 months (range, 2-18 months). All instructors un-
derwent a 2-week, competency-based training program upon being
hired at the clinic where this research was conducted. Following the
initial training period, monthly checks for treatment integrity were
conducted.
Response Denition & Dependent Variable
head and eyes so as to make direct contact with the eyes of the person
from whom he was manding immediately prior to or simultaneous
eye contact was not established in order to promote natural and func-
tional response topographies. Eye contact responses of any duration
one-word vocal mand that was immediately preceded or accompa-
the production of a vocal mand that was not immediately preceded or
accompanied by an eye contact response. The dependent measure in
this study was the percentage of mands accompanied by eye contact
during a 3 hr session.
Response Recording
Jake’s instructors also served as the data recorders throughout
the study. An instructor was seated in close proximity (no more than
sheet on a clip board. Trial-by-trial data on the frequency of mand re-
the entire 3 hr session. In addition, the occurrence of an eye contact
response was recorded by circling a “yes” on a data sheet when the
vocal mand was immediately preceded or accompanied by eye con-
tact. Mands that were not preceded or accompanied by eye contact
were recorded by circling a “no.” The percentage of mand trials ac-
companied by eye contact was determined by dividing the number of
trials with eye contact by the number of mand trials with eye contact
plus the number of trials without eye contact and converting the ratio
to a percentage.
146 CARBONE, et al.
Instructors manipulated various environmental stimuli and con-
ditions so as to increase the value of items and activities as reinforc-
ers and contrive opportunities for Jake to mand. The number of trials
or opportunities to mand was not predetermined but instead based
on the reinforcing value of stimuli within the environment and the
Interobserver Agreement
All sessions were videotaped to allow for measurements of in-
terobserver agreement (IOA). Either the second or third author of this
session and recorded data independent of the instructors for the pur-
poses of assessing IOA. The data records of the second observer were
then compared to those of the instructor and an agreement between
the instructor and second observer was scored when both observers
recorded a response as either correct or incorrect. A disagreement was
scored when the instructor recorded a correct response and the sec-
ond observer recorded an incorrect response, or vice versa. IOA was
calculated by dividing the number of agreements by agreements plus
disagreements and converting the ratio to a percentage. IOA was cal-
culated as 89% during baseline and 92% during treatment.
Design and Procedures
An AB design was used in this case study. This type of design
does not allow one to suggest there is a functional relation between the
dependent and independent variables. It may instead demonstrate a
correlation between the independent and dependent variables.
General procedures. The items and activities used as reinforcers
to the items. Examples of these behaviors included looking at, reach-
ing for, guiding the instructor to, or requesting an item or activity.
Whenever Jake demonstrated possible motivation for an item, the in-
structor waited for up to 5 s for Jake to emit a vocal one-word mand.
If Jake continued to demonstrate possible motivation for the item but
did not emit a vocal mand within 5 s the instructor provided a vo-
mand responses under the control of an MO and the presence of the
reinforcing item and consequently vocal prompting of mand respons-
es rarely occurred during this study.
Baseline. In the baseline condition, all vocal mands were immedi-
ately followed by the delivery of the item or activity requested regard-
less of the occurrence of an eye contact response. The consequences
-
TEACHING EYE CONTACT
ties, consumption of food items, or until Jake initiated another trial by
-
a mand response at the end of the consequence period, the instructor
manipulated environmental stimuli so as to contrive an MO for some
stimulus and arranged an opportunity for Jake to mand again. Fol-
lowing all vocal mands with or without eye contact the instructor re-
sponded conversationally (e.g., “Yeah, let’s play with the dinosaurs”)
but did not make explicit statements or provide praise for the mand
response or eye contact.
Extinction and dierential reinforcement during mand training. If
Jake manded for an item or activity and eye contact occurred immedi-
ately prior to or simultaneous with the vocal mand, the item or activi-
ty requested was delivered immediately. Consequences took the form
instructor manipulated environmental stimuli so as to contrive an
MO for some stimulus and arranged an opportunity for Jake to mand
again.
by eye contact, extinction was implemented by withholding the rein-
-
tion of the extinction period, the reinforcer continued to be withheld.
The extinction period continued until a vocal mand was immediately
preceded or accompanied by an eye contact response. Only vocal
mands immediately preceded or accompanied by eye contact resulted
in reinforcement. For correct responses that occurred only after extinc-
tion was implemented the magnitude of the reinforcer was decreased
regardless of the amount of time that had passed (e.g., 1 s between an
incorrect or correct response, versus 2 min between an incorrect and
correct response). Magnitude was manipulated for items and activi-
ties by providing shorter durations of access and was manipulated for
food by providing smaller portions of the item.
Results
The percentage of vocal mands accompanied by eye contact
reinforcement condition is displayed in Figure 1. Across both condi-
148 CARBONE, et al.
the long-standing level of responding observed clinically prior to
percentage of mands accompanied by eye contact increased to about
reinforcement contingency for incorrect responses. A notable and rel-
atively immediate increase in eye contact responses occurred begin-
28 showed some variability, the majority of data points were above
55%. The mean percentage of mands accompanied by eye contact dur-
-
-
line level. Moreover, the mean percentage of mands accompanied by
eye contact responses for the last 15 sessions of the treatment condi-
contact was relatively stable.
Figure 1. The percentage of mands accompanied by eye contact per session
during baseline and treatment conditions for Jake.
-10
0
10
20
30
40
50
60
70
80
90
100
0 5 10 15 20 25 30 35 40
Sessions
Percentage of Mands Accompanied by Eye Contact
Baseline Extinction and Differential Reinforcement during Mand Training
149
TEACHING EYE CONTACT
Discussion
The purpose of the current case study was to extend the litera-
-
sponses, to children with autism. Furthermore, this case study sought
an analysis of the motivational and discriminative variables respon-
sible for the acquisition of eye contact responses for typical children.
The data from this single case study showed that, compared to base-
line, the percentage of eye contact responses was substantially higher
after the implementation of the treatment method. These results sug-
in increasing eye contact for some children with autism. In addition,
pragmatic skills by demonstrating that it may be possible to induce
eye contact responses through extinction for previously reinforced
& Lee, 1996).
analytic research, response prompts are frequently implemented to
supplement the control for the response and ensure that the behavior
contacts the reinforcer.
In this situation, a vocal or physical prompt may have been
implemented to produce the eye contact response as demonstrated
-
ated with response prompts, all previously reinforced mands were
placed on extinction during the treatment condition to take advan-
tage of response variability induced by extinction. Early on in the
treatment condition, Jake continuously manded for items or activi-
-
ment session, however, response variability increased and eye contact
responses accompanied the vocal mand and were selected through
reinforcement. Future research should examine the extent to which
procedures that promote extinction induced response variability are
or near-zero baseline levels of eye contact responses. Jake’s baseline
level of responding was relatively low suggesting that this procedure
suspected reinforcer for the eye contact response was the sight of the
eyes or face of the listener, since the response increased in frequency
following this consequence. What follows is an analysis of how the
CARBONE, et al.
procedures within this case study may have achieved the important
outcome of conditioning the eye gaze of the communication partner
as a reinforcer and therefore increased the eye contact responses. As
previously described, a number of behavior analytic methods have
that includes consideration of all relevant motivational and discrimi-
-
-
vironment and an object of interest, presumably serving to direct the
Following frequent exposure to the variables that control the mand response,
a behavioral chain occurs:
Italicized Words = Stimuli Bold Wor ds = Standard Print Words =
Behavioral Variables Effects of Behavioral Variables
Child wants something & needs Listener’s action to receive it -- but Listener is not looking
Conditioned Transitive Motivating Operation
Sight of Listener’s face and eyes (acts as a)
Reinforcer for the Looking Response & S
D
for the Mand
Conditions the sight of Listen er’s face and eyes as a Reinforcer
& evokes looking for face and eyes of Listener
Mand Response is evoked
Child Mands
Delivery of the item acts as Reinforcer for Mand
Figure 2. Description of the behavioral variables that evoke the eye contact
response and select and maintain it by reinforcement in the form of social at-
tention of a communication partner.
151
TEACHING EYE CONTACT
This environmental arrangement establishes the value of adult-at-
tending stimuli (i.e., the adult orienting toward the interesting event)
as reinforcers and evokes behavior that produces those reinforcers,
as reinforcers due to a history of adult reactions to the interesting
event leading to greater access to reinforcement. In addition, Dube et
stimuli correlated with the availability of reinforcement in the form
of event-related and adult-mediated consequences for event-related
behavior.
-
vironmental arrangement that includes an interesting event as an
MO and the context of a familiar adult’s presence implicates more
-
engender other stimuli with reinforcing value (Michael, 1993) and oc-
curs when one already existing MO combines with an environmental
context in which access to some relevant reinforcer is blocked or inter-
-
esting event and the context includes the presence of a familiar adult
-
-
tact behavior by the child in this case study. Figure 2 provides a dia-
gram of the possible behavioral variables implicated in establishing
eye contact responses for typical children. Similar to the interesting
case study environmental variables were manipulated to contrive an
MO for an item, activity, or food item. The programmed contingen-
cies were then arranged such that access to the reinforcer was denied
or blocked when an eye contact response did not occur. This environ-
mental arrangement may have acted as a CMO-T that momentarily
established the value of the sight of the eyes or face of a listener as a
reinforcer and evoked eye contact behavior. In the analysis of joint at-
-
esting event is analogous to the stimulus condition acting as a CMO-T
and evoking eye gaze shift in this case study. Under the conditions of
the CMO-T in this study, the sight of the eyes or face of the communi-
cative partner may have served not only as the reinforcer for the eye
contact response but also as a discriminative stimulus for the mand
152 CARBONE, et al.
-
contact, consistent with the principles of behavior analysis derived
-
nation for the acquisition of eye contact responses in typically devel-
oping children and provides a reasonable basis from which to derive
teaching methods for children with autism. The value of proposing
conditioning of social consequences as reinforcers is vitally important
-
tentially fruitful line of research for others to follow.
In order to validate the interpretative analysis of eye contact of-
fered here and provide evidence of the reinforcing and discriminative
function of the sight of the eyes or face of the listener, two revisions
to the procedures described should be considered. First, in this study
the listener was always looking at Jake and eye contact responses of-
ten occurred simultaneously with the mand response. Consequently,
both the sight of the listener’s eyes or face and the delivery of the man-
ded stimulus often, but not always, occurred simultaneously. This ar-
controlling variables for the two responses and might lead some to
conclude that this was merely a two-component mand response (i.e.,
eye contact response and vocal mand). In order to more clearly distin-
and face and the item that was ultimately delivered as a reinforcer,
future studies should include a condition in which the listener’s face
or body is turned away from the child and some response (e.g., po-
sitioning his body in front of the listener, tapping the listener on the
shoulder) must occur to produce sight of the eyes of the listener. The
additional responses required to produce the eye contact would pro-
-
er’s eye gaze. For example, a listener may sit with her face turned from
the child and require that the child taps the listener on the shoulder
or moves his body to be in line with the listener’s face prior to making
eye contact. The occurrence of these responses would provide further
-
eyes and face compared to the reinforcing value of the item ultimately
delivered for the mand.
The second consideration involves a thorough demonstration
that the listener’s eyes or face acquired discriminative control over
153
TEACHING EYE CONTACT
stimulus as:
A stimulus condition that (1) alters the current or momentary
frequency of a type of behavior (2) because of a historical rela-
tion between the presence/absence of that stimulus condition
and the dierential availability
that type of behavior (p. 59).
In order to support the contention that the sight of the listener’s eyes
and face were discriminative for mands responses, it is necessary to
show that in the absence of those stimuli, or the S-delta condition,
mand responses occurred at a lower frequency relative to the frequen-
cy of responses in the presence of the eyes and face of the listener.
To demonstrate empirically the discriminative control of the listener’s
eyes and face, future research should include a condition in which the
listener is turned away from the child but when the child emits re-
sponses that have typically produced the sight of the listener’s eyes or
face as a form of reinforcement (e.g., tapping the listener on the shoul-
der, moving to be in line with listener’s face, gaze shifting), the lis-
tener does not turn to look at the child. According to the interpretative
sight of the listener’s eyes and face (e.g., tapping the listener’s shoul-
der) would be put on extinction and gradually decrease. Second, if
the sight of the listener’s eyes and face had become discriminative for
the availability of reinforcement for mand responses, the frequency of
mands for reinforcing items and activities would also decrease. The
decrease in mand responses under this condition would suggest that
the absence of the listener’s eyes and face served as an S-delta condi-
tion and would therefore suppress the mand response. The inclusion
in this paper.
The need for a more thorough experimental analysis notwith-
standing, the results of this research and the interpretative analysis
training for children with autism. Teaching topographically appropri-
ate social responses to children with autism by delivering reinforcers
that have not selected and maintained the same responses in typically
-
rally occurring stimuli are not conditioned as reinforcers, the respons-
154 CARBONE, et al.
programmed “extrinsic” reinforcer is high and therefore limit the gen-
erality of the response. In addition, what may appear to be appropri-
ate social responses, based upon their form, may be functionally un-
actually be nothing more than mands for the “extrinsic” reinforcer
that have been programmed by the experimenter. Consequently, a to-
the practice of teaching topographically correct responses without re-
gard for the relevant controlling variables produces only “mechanistic
In this case study, it is suspected that the sight of the listener’s
eyes and face were conditioned as reinforcers within the context of
manding for preferred items and activities. This is one of many condi-
tions in which eye contact responses occur for nondisabled children.
However, if in fact social consequences can be conditioned as reinforc-
ers, as is suspected in this case, the implications for functional out-
comes for children with autism using these and similar procedures is
vast. The eye contact response targeted here is one step in a progres-
sion of increasingly complex social interactions that require further
area of social skills instruction in children with autism.
The data reported in this case study show a substantial change
following implementation of the treatment method and should there-
fore encourage other authors to pursue an experimental analysis of
the procedures reported in this paper. Perhaps more importantly,
-
quences as reinforcement for eye contact responses, addresses a criti-
cal issue in autism research and treatment. This account is a valuable
extension to the available literature on teaching social pragmatic skills
to children with autism and provides researchers with numerous op-
portunities for future empirical work.
There are some limitations of this case study and additional re-
search is needed, however, to support this conceptual analysis. The
case study data of only one participant reported here provide only
-
ed but do not demonstrate a functional relation or allow for conclusive
-
tal investigations across multiple participants with rigorous research
designs and measures of treatment integrity are necessary to demon-
155
TEACHING EYE CONTACT
strate a functional relation between the independent and dependent
should investigate the extent to which eye contact responses estab-
lished under the conditions described within this case study are main-
tained over time and generalized across stimulus conditions. Some
cogent, conceptually systematic, and amenable to experimentation.
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