What Are Explicit Visual Teaching Methods and What Can We Learn from Eye-tracking Research?

Studies involving the visual pathway in ASD offer a window into a better understanding of how the brain processes visual information, and how arousal affects the ability to attend to cues in the environment.

Parents and providers are quite familiar with the recommendation that we should use visual supports when working with children with ASD. We often hear that using a visual schedule or picture cards can help children better communicate. Why do these intervention methods work and how are they most effective for improving social communication? How can we take the use of visual schedules, visual supports, and video modeling, all considered evidence-based practices^1,2, and apply them across the age span and levels of ability? As a clinical scientist using visual supports in practice for many years, I was interested in understanding why these interventions work.  What changes occur when methods focused on visual attention integrate modalities to support social communication? Eye-tracking is a great way to examine these questions.  

Eye-Tracking: A Non-Invasive Way to “See What the Person with ASD Sees”

Eye-tracking helps us understand the interplay between what a person is visually attending to and what specific areas of stimuli attract and hold attention. This technology can examine skills such as joint attention, following gestures, and tracking exchanges between communication partners. We can examine features of stimuli which impact visual attention such as faces, social context, and preferred vs. non-preferred objects. Eye-tracking systems use infrared cameras to track subtle shifts in eye-gaze by measuring changes in the pupil and the point of gaze. This method of measurement is used with a computer monitor and in natural contexts using mobile technology and eye-tracking glasses.

Eye-tracking studies tell us that individuals with ASD may prefer objects over faces, attend to the mouth more than eyes, attend more to contexts with one person versus two, and attend to video more than static photos. Research using this technology is relatively new and is evolving every day. We are just beginning to understand nuances about the visual system and social cognition in ASD in relationship to development using this method. Although studies vary in specific outcomes, it is clear diminished visual attention is an underlying issue impacting the “building blocks” for language. Reduced visual attention in infancy has a cascade effect much later in development, impacting skills such as inference and perspective taking, which rely on an interpretation of non-verbal cues and context.  Pupillary changes captured using eye-tracking also tell us about how efficiently a person is regulating arousal. We know, for example, that the visual system in ASD involves latency in the pupillary light reflex (how long it takes the pupil to change in response to light),  which can indicate signs of arousal associated with symptoms of anxiety.^3,4  This test documents pupil response patterns which reflect the body’s “fight or flight” response. Atypical arousal, eye gaze avoidance, and diminished attention to salient cues compound the social deficits.

Visual Teaching Methods—An Intervention Approach or a Different Way of Thinking About Intervention?

It’s clear the eyes may be the “window to the soul” as we learn more about ASD and how best to tap into the visual modality in treatment. We can use eye-tracking to objectively document changes in visual attention as a result of intervention. Researchers have identified changes in brain activity in early development as a result of visually based interventions.⁵ Attention to faces is diminished early in development in children with ASD⁶ and diminished visual attention to social scenes and a speaker’s mouth at the same time have been shown to differentiate subtypes of ASD by language ability.⁷ In a study examining salient cues such as a caregiver speaking, vs. attention to non-social cues such as toys, toddlers with ASD showed reduced attention to the scene and face together, and attended better when the stimulus included the speaker alone.⁸ This research tells us there may be “competing” signals based on context. Reduced joint attention and visual attention to salient cues early in development may persist into later development, and when left untreated, diminished visual attention impacts every aspect of social communication. 

Can We Change Visual Attention Through Explicit Teaching?

We are conducting a study exploring outcomes of intervention methods which incorporate visual supports such as mnemonics (visual symbols/cues), schedules, and video modeling paired with positive behavioral supports to measure a change in visual attention to salient vs. non-salient nonverbal cues. We call these explicit visual teaching methods (VTM). VTM rely on evidence-based practices using specific, versus embedded instruction to promote social communication. Speech-language pathologists are very good at teaching skills such as greetings, staying on topic, and taking turns in a conversation. We sometimes forget to explicitly teach how to “read” non-verbal messages, which in social contexts may cause anxiety for many on the autism spectrum, especially in older kids⁹. The caveat of “less is more” rings true here in that focused visual attention, as opposed to immersing kids in conversation, appears to have a positive impact on visual attention. We begin explicitly, then we expand to dialogue and reflection as skills begin to improve.

By incorporating a cognitive-behavioral treatment approach (CBT) to acknowledge social communication challenges, kids with ASD can use what they learned with the VTM approach to reflect on social communication.  We introduce visual cues in an explicit manner providing repetition and practice with focused visual attention. We use static photos and markers for children to identify features of the face as “parts”,  much like they might identify parts of an object. We do this first, knowing visual attention is improved when we reduce the complexity of stimuli.  We then move toward an advanced interpretation of cues in relation to body language and social context, from single person contexts to more than one person and multiple objects. We strive to improve efficiency integrating social information that typically comes into the brain in a very dynamic, fast-paced fashion. Our goal is to slow the input down and build from the “bottom up”.

Attention to Salient vs. Non-Salient Cues—A Hierarchy of Skill

This experimental VTM intervention capitalizes on building from a hierarchy of skills.  In social groups, these skills are often taught “in the moment”, vs. teaching skills based on a hierarchy of difficulty related to visual attention.  For example, when looking at an image involving kids the same age engaged in an interaction, instead of focusing on a triad of eyes, facial expression, and body proximity, the child with ASD may focus on the fire alarm hanging on the wall in the background. Think about how many cues are missed when non-salient stimuli “compete” for visual attention! We decided to tackle this dilemma as an intervention concept providing explicit instruction toward these interactions, first in static photos with hands-on practice, then progressing to dynamic practice using iPads and video modeling. The hierarchy includes emotion recognition, identifying shared referents, following a line of regard, reading body proximity and cues, and forming inference.  Our goal is to incrementally build skills using this VTM approach as the foundation for building advanced social language “expertise”.

Future Directions for Examining VTM and Outcomes

Neuroscience tells us the brain is “under-connected” in ASD—regions supporting connections between hearing, seeing, motor planning, and understanding language are not efficiently integrating signals. This is partly why we see children with ASD struggle to learn verbal speech, process auditory information, and they may have delayed motor skills. Explicit VTM relies on the provider thinking about the neural systems affected, then pairing stimuli to link the auditory, visual, and motor pathways. Whereas the examples above apply to children with higher level language skills, thinking this way to address early intervention helps children acquire verbal speech and language by strengthening neural processes through pairing objects (visual) with words (auditory).  This approach also facilitates augmentative alternative communication (AAC) for children who are non-verbal by increasing visual attention and discrimination¹⁰. This focus on explicit use of visual teaching capitalizes on a “less is more” philosophy.

Eye-tracking gives us the tool to examine treatment outcomes objectively at varying stages of development and may help bolster evidence-based practices in relation to technology. While still experimental, VTM integrates well with behavioral intervention but aren’t necessarily new. They are a new way of “looking” at visual attention skills in relation to treatment—-pardon the pun!

For more on eye-tracking research methods, See Spectrum Wiki.

Georgina Lynch is an Assistant Professor in the Department of Speech and Hearing Sciences in the Elson S. Floyd College of Medicine at Washington State University. She holds a bachelor’s degree in psychology, a master’s degree in communication disorders, and an interdisciplinary Ph.D. in neuroscience/psychology. She is a licensed speech-language pathologist, holding national certification by the American Speech-Language-Hearing Association, and has assessed and treated ASD for the past twenty years. Her clinical research program focuses on the visual pathway and identifying biomarkers using pupillometry to examine its potential to support screening practices. Dr. Lynch’s work also involves developing innovative interventions using technology.  She and her team use eye-tracking to measure outcomes related to social language treatment and to develop tools to support commonly used intervention practices.  Her work has been presented nationally and her scholarship includes publications for peer-reviewed journals, edited books, and professional associations. In clinical practice, Dr. Lynch has extensive experience as a learning specialist with the public-school system, developing intervention programs for kids with ASD from preschool to adolescence. She developed systems-based training which included inter-professional teams of psychologists, SLP’s, OT/PT’s, and special educators. Dr. Lynch has also provided treatment and consultation in the clinic setting to support intensive programs for individuals with significant communication needs involving the use of AAC and she has collaborated with BCBAs to create individualized plans. Community partnerships support her research program at WSU, which include active engagement with the Northwest Autism Center, an advocacy and clinical service delivery organization in Washington State.

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