Sunday, July 17, 2011

Eye Contact With Babies: What, When, Why, and How

When I look at the statistics Blogspot gives me, I see that day after day, large numbers of people end up at this blog when they Google questions about babies and eye contact. Parents are obviously worried about this issue, and that fact is confirmed by the existence of quite a few websites that give instructions about how to get your child to make eye contact more often. But what are the facts about all this? Can you get your child to increase eye contact? Do you need to? Why are we concerned about this matter at all?

What is eye contact? The term “eye contact” might be better replaced by “mutual gaze”, because of course there is no real “contact” about this common human action. In mutual gaze, two people’s faces and eyes are aligned so that each set of eyes is gazing at the other set. This is often very brief, although it can also be maintained for seconds at a time. Mutual gaze may also be performed in a sequence of episodes, for example as two friends approach each other, joining and breaking gaze along the way, stop and briefly engage in mutual gaze, and finally avert their gazes slightly while talking. Prolonged mutual gaze may indicate deep emotional involvement-- but it can be either a loving look or a hostile or frightened stare, depending on the context and the rest of the facial expression. Mutual gaze has a terrific communicative power for human beings, but it can have more than one meaning.

When does eye contact happen? From birth, babies are interested in looking at faces and especially eyes, and do this so carefully that they can and do accurately imitate facial expressions in the early days of life. Nevertheless, most new parents find that it is quite difficult to get a sense of mutual gaze until some weeks have passed. At about 4 to 6 weeks, as babies begin to do what used to be called “taking notice”, they start to look more responsively at people who are looking at them-- especially if the adult does something attention-getting like opening eyes and mouth wide and “looming” closer to the baby’s face. Soon, the baby smiles in response to a smile, and maintains a mutual gaze with a friendly adult (familiar or unfamiliar). If the adult looks blank or “stares through” the baby, though, the latter will avert the gaze, appear uncomfortable, and begin to cry. The baby expects the adult to “manage” his or her gaze in a way that coordinates with the baby’s gaze.

By about 6 months, babies begin to look toward an adult’s face and eyes for “social referencing” purposes, not for eye contact in and of itself, but to get information from the facial expression and the direction of the adult’s gaze. This information guides the baby in understanding the environment and knowing whether unfamiliar things are worrisome, neutral, or pleasant. The baby continues to pay attention to the direction of people’s gazes and between 9 and 12 months begins to show “joint attention”-- using the gaze as a “pointer” to show someone else where to look, and following another person’s gaze to see an interesting sight. These are not examples of mutual gaze, but they are other forms of communication that may emerge from mutual gaze.

It can be hard for an inexperienced parent to know whether a baby makes eye contact soon enough, long enough, or often enough. Anyone who expects prolonged mutual gaze many times a day from the time of birth is bound to be disappointed and frightened. The earliest eye contact events are fleeting, and even at 2 months the baby may not pay much attention without a good deal of adult effort. Mutual gaze during breastfeeding is not likely until the child is old enough to pause in sucking and look around, or let go the nipple temporarily and move the head-- perhaps 5 or 6 months of age.

Why is eye contact important? Mutual gaze is an important form of communication that conveys information both to the baby (“hey, people are quite interesting and pleasing”) and to the adult caregiver (“oh, my baby’s looking at me-- this feels so good-- he thinks I’m important and interesting”). It may be the foundation of other uses of gaze and other gestures for communication.

Looking at whether young children engage in mutual gaze can be a helpful way of understanding whether their development is typical or whether they have certain special needs. One of the best-known aspects of autism is the infrequency of eye contact. Individuals with Asperger’s syndrome, a disorder related to autism, may say that they dislike being looked at and find mutual gaze very uncomfortable. Persons with Fragile X syndrome are also known for their poor use of the gaze in social communication.

When people avoid looking at other’s eyes, or when they are simply inattentive to gaze information, they can miss much other information too. If an adult uses a word a child does not know, for instance, the child can often make a good guess by watching the adult’s gaze, to see what he or she is looking at. When a child also has poor language development, as is common in autism, the combination of underdeveloped language and of lack of gaze communication can make for serious difficulties, the appearance of deliberate noncompliance, and frustration for both child and adult. These facts all suggest that if a child is really not using mutual gaze or other gaze information, helping him or her gain those skills would be a valuable achievement.

However, it’s important to realize that increasing mutual gaze is not a way of increasing the child’s emotional attachment. Toddlers are more likely to engage in mutual gaze with people they are attached to, but increasing gaze episodes does not make them attached. Blind children become strongly attached to their familiar caregivers just as sighted children do; attachment is a very robust developmental phenomenon that involves hearing and touch as much as, or instead of, sight. Mutual gaze may have its strongest effect on adults, who are much influenced by the child’s gaze and feel a sense of emotional contact when exchanging gazes, so it’s possible that increasing mutual gaze can have an indirect effect on children through its influence on their caregivers. However, of course, blind parents also have strong emotional involvements with their children; they too can use other sources of communication to develop these intense relationships.

How to increase mutual gaze? I notice on several websites a variety of instructions for improving eye contact with children. These include wearing funny glasses (something like this was suggested by Nikolaas Tinbergen 40 years ago), playing games based on prolonging eye contact, and giving the child sweets while maintaining mutual gaze.

Whether these methods are a good idea depends in part on whether the child really does show too little eye contact for his age and situation. This is a point on which most parents need professional guidance. If the parent’s motivation comes from the belief that more eye contact would cause better attachment, and especially if the parent believes the child is poorly attached because he or she is disobedient, there is certainly little point in doing any of these things.

However, if the child is being treated for a developmental problem that is characterized by poor mutual gaze, the parent may already have received some training in rewarding eye contact or may at least be aware of how the behavior therapist works with this. An article that describes one method is to be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649838/ (Hall, S.S., Maynes, N.P., & Reiss, A.L. [2009]. Using percentile schedules to increase eye contact in children with Fragile X syndrome. Journal of Applied Behavior Analysis, 42, 171-176). Similar work can be done at home, but it needs to be carefully thought out beforehand.

**** Readers, if you accessed this post in a search for current work on eye contact and autism, please look at my post for Nov. 7, 2013, which discusses the Nature article by Warren Jones and Ami Klin.****

21 comments:

  1. Dear Dr. Thank you very much for these interesting articles. I'm an Italian mum of a toddler and a six month old baby girl. I'm really concerned about my second one who's very different from the first. I don't know whether it's a matter of temperament or a serious issue. My concerns are: 1. she gives me little eye contact when I'm close or I'm holding her (if I sit her on my lap in front of me she just looks in every direction but my face) 2. she used to smile a lot to faces until the fourth month, now it's more difficult to get her to smile 3. she does not respond her name most of the times and when she does she just gives me a glimpse and then goes back on what she's doing. 4.she does not always seem interested in people 5. she tends to look downwards. 6. she screams, goes "aaahh" and sometimes she cooes, I can hear some consonants but no babbling yet. There are some things that make me hope: 1. when I enter the room she smiles 2. she looks at my face for a longer time when I'm not too close 3. most of the times she enjoys "pick-a-boo" 4. she doesn't point to objects yet, but when I hold her, she reaches her arm out in the direction of the object she's interested in. 5. if her sister is around she is constantly looking at her moving. I mentioned my concerns to my ped but she said it's early to get worried. (according to what I have read, here in Italy we are far behind as far as intervention on children that show "red flags". Sorry for the long post, my questions are: Is there something I can do to work on her eye contact issue? Are there any signs i should notice in the next few months? should I take her to a specialist instead? thank you in advance. Hope you'll have time to answer my questions.

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    1. Dear Laura-- when a second baby seems a lot different from the first one, it's very hard not to think that the first was "right" and the second "wrong". But they may just be different. After all, the second child is really born into a different family than the first, because the second gets experienced parents and a lively and interesting sibling.

      About your concerns: although by 6 months she can see clearly at a much greater distance than she could at birth, it may still be much harder for her to look at a face that's near-- also,the face may be in shadow, or (because you're getting concerned) it may have a serious expression that is not attractive to a baby.

      Up until the fourth month, she was just smiling at a pattern. Now her smile is much more social and has to do with the whole interaction, not just a facial expression by itself.

      Six months is about the earliest you'd expect her to respond to her name, and if she's busy and interested in something she may not be easy to distract unless she's learned that someone calling her name is followed by fun. I wonder if she's non-distractible in general, speaking of temperament? This can be a great characteristic in older children and adults, but can be more problematic in infants and toddlers, who want what they want and are hard to distract from it when they can't have it.

      You say she doesn't seem interested in people, but she's watching her sister all the time? I'm not sure what you mean here.

      Tending to look downwards-- is she sitting alone, or propped up? Looking down can be part of balancing as a baby develops sitting skills. What is she looking at? Is it her hands or her body?

      No babbling: this is a tricky one. It's been demonstrated clearly that first-born and later-born children tend to have different characteristic patterns of early speech, but I've never come across anything about pre-speech development. Not long ago, I was concerned about a baby in my own family who did not babble, even when alone in his crib. He really produced very few sounds but seemed to hear, and at 16 months began to produce words. I don't know what the story is here, but all you can do is to be sure that her hearing is intact and that she hears speech directed toward her.

      Don't expect here to gaze for a long time at your face. The important issue is that she communicates with other people-- which she does by smiling when she sees you and by playing peek-a-boo (and I want to tell you that she is quite young to be able to do this!). She also reaches in the direction of something that interests her, which you probably respond to. I would not expect her to be able to point yet or to be able to move her index finger independently of the others at will.

      In the next few months (but not weeks!), I think you will see "joint attention" develop. In this, she will look at something interesting, then look back at another person, then back at the interesting object, until she gets her partner to look too and share the interesting sight. To do this, she will use her gaze to "point" just as adults do. You will also see her begin to look at your face for information when she encounters something strange and possibly scary.

      I know there's no point in telling you not to worry (but keep in mind that she won't much like to look at a worried face!). I agree that it's too early for even the most specialized specialist to detect problems.

      Keep on playing peek-a-boo, that's one of the best things you can do!

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  2. thank you very much for your reply! (maybe my translation of peek-a-boo is wrong... I hide my face behind my hands or an object and then I show it and say "cip!" and smile.... Rebecca usually smiles back..) I'll keep you updated.... thank you!!!!

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    1. Yes, that's peek-a-boo, and she's doing well if she does that at 6 months!

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  3. Your article really gave me hope..i am a mother of a toddler and a seven months baby and my baby is similar to Laura's baby and I was worrying like hell because each time I Google I end up with autism :(
    We are Egyptians and we don't have early intervention program for autism here. I was alot worried until I found this article and your reply to Laura :)

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    1. Dear Anon-- I wonder whether you got worried because the first and second babies are so different? Any two babies are very different, but somehow we're surprised when our own are different from each other!

      Best of luck, and remember that the best thing you can do for any baby's development is to be responsive and playful. That's really all that any early behavioral intervention does, anyway--:)

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  4. Jean, your article also giving me a lot of hopes! My situation is exactly like Laura. My little one is 6 months now. He keeps looking at other things (especially my clothes with cartoons) when I held her close to my lap. He doesn't really smile to strangers but he laugh out loud playing with his brother and sister. He hasn't been babbling yet but will have conversation with us using aahhh. He screams when excited too. And hr lives blowing rasberries. He loves peek a boo too since young. What worries me also is he likes to stick out his tougue, rolling it or sometimes going back and forth. I hope he's teething else it's really scary as it shouldn't be for a 6th month baby. He response to name sometimes but not all the time. Sometimes even totally ignore me which really scary. Yes, and my first one is a super quick learner and active!

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    1. If he likes blowing raspberries, he probably likes tongue play too. Totally ignoring you sometimes may just mean that he's not easily distracted from what he's paying attention to-- which would be good-- but of course this is just a guess on my part.

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    2. Yes, he likes to play with his tongue! He started of blowing bubbles then move to blowing rasberries and that's where the tongue thingy is getting worst. Luckily he does make eye contact, smiles and 'talk' to me when im breastfeeding. And you are right, he won't be happy seeing my worried face and I should play more with him for more stimulation. Thanks for your comment. Really appreciate it

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  5. Hi there, Jean - excellent information, thanks.
    Quick question. We have 7-month-old twins. They're both very friendly, sociable girls but avoid eye contact while being held. They'll look and smile at you if you someone else is holding them but very rarely when you're holding them yourself. I'm pretty sure it's not a problem but wouldn't mind a little reassurance...

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    1. They sound like they're doing fine!

      When you say they avoid eye contact, do you mean they look at something else? Anything in particular? Or is it that when things are too close or not well illuminated, it's not so easy for them to see? It does take a while for babies to be able to see clearly when things are near them, although I would think your girls were past that point, unless there's some vision problem that's not obvious yet-- beyond just the fact that children usually stay a bit far-sighted until closer to school age. Of course, I'm not really sure what position and distance you have in mind when you say you're holding them.

      I'm assuming that as twins they were born a bit pre-term. Don't forget that when you think about what they "should" be doing, you need to use their corrected age, counting from 40 weeks gestational age, not from their actual birthdate.

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  6. I guess they're usually around 8-12 inches away from our faces. One of them has just started (yesterday) to look at me a little when I hold her. But not the other one so far. They just look around at whatever takes their fancy. They were 7 weeks prem but, according to our ped, they have caught up now.

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    1. It's hard to tell how the vision develops without special techniques, though, so that may not be as "caught up" as the rest. But really, I don't think you need to be worried about autism, if that's what's concerning you.

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  7. Hi,
    My son is 9 monts,born 3 weeks before term. When he was 3 monts we tought he could not hear,but at the hospital they took som tests an said everything is normal. I doesent sit on his own,does not turn his head when there are sounds behind him,and there is no babbeling only aaaah oooh. When ond back he males some eye contact, but not when we hold him up. When i search the internet only thing that comes up is autism. What do think about that?

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    1. I think you're right to be concerned about these problems. Autism would not explain why he doesn't sit up. What does your pediatrician say? Can you have the baby examined by a pediatric neurologist?

      I'm very sorry you are seeing these difficulties, and I hope you will be able to get a clear diagnosis soon.

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  8. Hi. Thank you for responding. When he was 6 months he started fysiotherapy beacuse he could not lift his head when on back. Now he is in a crawling position but dont crawl. The childcare center i see has never mentiond enything wrong with him;only thing is they feel he is a bit weak. When others hold him,he will look into my eyes. And when playing with him, he will smile when we make funny noises.he also can look at the tv for houres and nit get disturb or look up when i go behind or in front off him.I just feel somthing is wrong,but everyone in my family think he just normal.ill call my doctor on monday and get an appointment. Im so scared that somthings wrong with him. What are your first thougts about him?

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    1. I'm sorry, I can't really speculate since I have never seen him. I'm glad you are following up with your doctor. It's true that some babies are slower to develop than others and then catch up, but if he will need any kind of early intervention, now would be a good time to find out. He may be hypotonic (have muscles that are too weak or relaxed) and he can be helped with that.

      I would not have him looking at the TV for hours-- in fact, not at all would be better at his age.

      Please do let me know what happens.

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  9. Dear Dr,
    Thank you very much for your article. I'm Vietnamese. My little baby is now 5 month old and is exactly the same as Laura's baby. I am so much worried about her. Have you got any update info about Laura's baby? I try to contact Laura but impossible. Do you have any contact point to her. If yes, can you share with me. I'm so worried now. Thank you so much.

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    1. Dear Pucca-- I'm so sorry, I have no way to contact Laura. If she reads this,she can send me her contact information to give to you-- I can do that backchannel, without publishing it here, if you do the same.( I mean, if you write a comment here, it does not get posted unless I make that decision, but I will receive it on my e-mail.) Please read carefully what I wrote to Laura. You may not need to worry so much!

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  10. Dear Dr,
    I`m mother of a toddler and 10 weeks baby girl.
    I`m concerned about my little baby. When she is lying on her back she is making eye contact for few seconds and staring in my face, returns to my smile and makes sounds goo, ahh..she is tracking toys, but when i hold her up she is not responding to her name, she is looking anything but faces.. nobody can gets her attention. Is it too early or we should make some tests?
    thank you

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  11. My guess is that when you hold her upright she sees a lot of interesting things to look at-- things that are hard to see when she is on her back. Are you being sure to give her a lot of tummy time, so she can look around by herself a bit?

    I do think it's much too early to test for autism. Here is an article that might be helpful to you if you can get it:

    Sheinkopf, S.J. (2014). Autism in infancy: Advances and implications for clinical practice. Brown University Child and Adolescent Behavior Letter, Vol. 30 (3), pp. 1, 4-5.

    This author points out that early signs of autism are subtle, and even after 12 months there should be caution about the diagnosis.

    Your baby is still very young and I would bet that she will become much more responsive in the next month or so.

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