Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

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.****

75 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.

    ReplyDelete
    Replies
    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!

      Delete
    2. Do you have any update from Laura? My baby does the same so would be interested to know how she is getting on. Thanks

      Delete
    3. No, I'm sorry-- I'll post as soon as she comments--

      Delete
  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!!!!

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

      Delete
  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 :)

    ReplyDelete
    Replies
    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--:)

      Delete
  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!

    ReplyDelete
    Replies
    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.

      Delete
    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

      Delete
  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...

    ReplyDelete
    Replies
    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.

      Delete
  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.

    ReplyDelete
    Replies
    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.

      Delete
  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?

    ReplyDelete
    Replies
    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.

      Delete
  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?

    ReplyDelete
    Replies
    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.

      Delete
  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.

    ReplyDelete
    Replies
    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!

      Delete
  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

    ReplyDelete
  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.

    ReplyDelete
  12. Dear Jean,
    your advice about tummy time was so helpful. She hated to be on tummy, but every day it's getting better.

    Now she is 3 months 10 days and yes, she is much more responsive-looking at me as long as I want, smiles back to me, cooing a lot. Sometimes when I put toy in front of her she is reaching her arm and touching the toy.
    But still when I hold her up in my arms in upright position, rarely she will respond if somebody is standing just in front of her talking and smiling,hardly trying to be seen.
    hearing test is normal.
    thank you a lot

    ReplyDelete
    Replies
    1. She sounds as if she's doing very well. Could it be that when she's upright she just wants a chance to look around? The person in front of her may not seem very interesting if the light is behind them, anyway.

      Delete
  13. Hello Dr, Thanks for helping people. I sincerely thank you to help out people in this great manner.
    I also have twins ( 1B + 1G). My Girl is doing very fine by all God's grace but My son ( both 4 months as per birth but 4-5 weeks pre term) is not making good eye contact for long time. He looks upwards most of the time. Though he recognize and moves his hands, legs like her twin sister but make very little eye contact. When I show him mobile in active mode , he tracks that . My doctor ( Pedi) ask me to get the vision test done which we are doing tomorrow. He says ooh oha etc also when he is in need of milk. He was admitted at NICU for 7 days for pneumonia. We are very worried if this is normal or we should do something about it. Pleaseee help it here. I will keep you updated.
    Regards
    Shyam

    ReplyDelete
    Replies
    1. Dear Shyam, I think the vision test will have told you some important things, for example whether there is a problem related to gazing upward so much. At his age (effectively, 3 months), that is more important than the eye contact itself. Other than the possible vision or eye muscle problem, he sounds as if he is doing well. Don't forget that you need to think about him as younger than his chronological age. Let me know how the vision test went.

      Delete
  14. Hello Dr, Thanks for the reply. We got the vision test done and dr also did Retinopathy test due to preterm delivery. By all God's grace, there is no retina damage and everything seems fine. But Dr think that he has some number due to oval shape of eye lenses instead of circular. Though Doctor did not suggest anything right now but told us to get the eye tested after 3-6 months once again. What do you conclude from this sir?
    Also , I would like to mention one thing here that my boy has flat head shape from one side which is from birth. I have read that this will come in shape automatically with time. But do you think this could also be the reason that he doesn't make good eye contact as he may not feel comfortable due to its head shape.
    I again thank you from bottom of my heart for all your help.

    ReplyDelete
    Replies
    1. That's good, that there is no retina damage. Are you sure the shape the doctor mentioned was the lens alone and not the eyeball? But in either case his vision may be blurry because of it. It may improve, or he may need to wear eyeglasses later to make the image clear.

      As for the head shape, I don't think he is uncomfortable because of it, but you may want to try to make sure that he does not always lie with his head turned toward the flat side. If he sleeps or lies with his head in different positions it will help the head shape become rounder. Also, if he sleeps on his back, be sure you do a lot of "tummy time" with him lying on his tummy. This will also help him develop his chest and neck muscles and encourage him to lift his head and look around.

      Delete
  15. Hello Dr , Thanks for the reply once again. I am not very sure but Dr said its Lens shape.
    Thanks Dr for giving us tips on head shape and Tummy Time. We will definitely get him practice for this.
    At last , We need your blessing for my child and for us.
    Regards
    Shyam

    ReplyDelete
    Replies
    1. You certainly have all the blessings and good wishes I can give, for your dear babies and yourselves!

      Delete
  16. Hello Doctor , This is Shyam again. Now We can see that our son have improved in making eye contact. He started tracking objects ( say Mobile) perfectly. He makes good eye contact when he is filled with mile and quite comfortable. He tracks the light , colorful toys etc very well. Only thing is that he is not so good in smiling as her twin sister is. though he smiles but we need to put an effort to get him smiled.
    What do you conclude Dr now ?
    Keep giving your good wishes also to my children.
    Thanking You & Regards

    ReplyDelete
    Replies
    1. I think the two babies simply have different personalities and temperaments. If you didn't have the little girl who smiles easily, you probably would never have worried about why the boy is less enthusiastic! It's hard not to compare babies to each other, but actually they each need to be understood in terms of their own patterns and developmental pathways.

      Delete
  17. Thank you for your reply!
    I think that when she is upright she is a little confused and doesn't show affections. maybe is overstimulated??
    But few days ago I noticed that when someone else is holding her up and I call her name she is trying to find me moving her head in my direction but can't see me. That makes me think about blurred vision???
    And again when she is lying on her back it's easier for her to find me. she is already blowing raspberries. smiles almost every time i smile and talk to her. gives me big smiles when i'm kissing her legs and tummy.

    ReplyDelete
    Replies
    1. She may be a bit overwhelmed if people are coming on too strongly. Does she avert her eyes, or look at her hands, or begin to drool or hiccup? If she does, she might need the interaction to be a little less intense.

      It may be that you are a little too far away for her to see, or the light may not be good enough, or it may be that her vision was also slightly affected by prematurity. Have you had her vision tested too?

      Delete
  18. Hello Jean Sir, I can see improvement in my child ( Twin son) now. His tracking ability is quite good especially mobile or Toy etc. Eye Contact is being improved but I guess due to minor vision issue it is not going so perfect. Due to which smile is not coming on his face all the time. Though he sense everything, babble etc. His shape of the head is also going good. His mother is giving him all lots of loves.
    Regards
    Shyam

    ReplyDelete
  19. This all sounds very good! Congratulations,parents of twins!

    ReplyDelete
  20. Hi Dr. Mercer,

    Two or three weeks ago, my 6 month old was making "ahh-goo" sounds and raspberries; however, he is now only making "mmmm" sounds - mostly when he is frustrated or tired. He has always been a smiley baby and has laughed with us quite a bit, but I've also noticed lately that it has become MUCH harder to get his attention, get him to make eye contact, and get him to smile. Our pedi says not to be concerned, especially because our son noticed her and made eye contact when she entered the room. She also says that his verbal skills have likely taken a backseat to his motor skills right now. He just cut his first two teeth and started sitting by himself yesterday, but he is still not himself. My main concern is with the drop off in eye contact, noises, and smiling. Can these things be caused by teething or hyper focus on learning a new skill, like sitting? He also seems to have a strong interest in feeling textures (with both his feet and hands) - is this normal? Do you think we should get a second opinion? Thanks in advance!

    ReplyDelete
    Replies
    1. This is a tricky question, and I can try to answer in terms of what I think is probably true, but honestly I don't know that anyone has looked into this systematically. The question is: do babies "work" on one thing at a time, so they reach a developmental plateau in one area (like communication) and then put their energies for a while into another one (like motor control)? It's my impression that they do, and especially that new skills are so fascinating to them that it's almost as if the skill is "doing the baby" rather than the other way around. I remember when one of my sons first sat by himself, I put him in his crib at night and he just bounced back up into a sitting position even though he was almost asleep -- finally I just stood back and watched, and he keeled over asleep, but with his legs still "sitting"! I do have the impression that they work on one thing for a while, then go back and pick up another skill where they temporarily left it, but I cannot give you chapter and verse on this and I doubt that your pediatrician can, either.

      Keep in mind that sitting opens up a whole new set of experiences, as he can look around without using his arms to keep his head up, can reach for and examine objects and bring them to his mouth. This is in many ways even more of a breakthrough than walking will be, so it's not surprising that he's focused on it.

      As for the feeling of textures, this is not only normal, but some people worry a lot about babies of this age who avoid such sensations.

      One other thing about the reduction in smiling etc.: a 6-month-old is approaching the point in development where he will begin to be fearful as he never was before. He may presently be at the "wary" stage, where he is not afraid of things (like loud noises or new sights) but he is "wary" and checks things out seriously before he warms up to them. This stage comes before showing anxiety about separation from you, so don't be surprised if your cheerful, sociable baby gets more "difficult" in the near future.

      I don't think you need to worry about a second opinion right now, if ever. Just keep trying to follow his lead and encourage him in what he wants to do. That will be the best way of keeping communication going.

      Delete
    2. Thank you so much for your quick and reassuring response! I often feel overwhelmed with the abundance of opinions and information out there -- I just want to make sure I'm doing the best I can for my son. It really helped to have your advice!

      Delete
  21. Hi Doctor,
    Just like some of the others shared... I have been very concerned about my 6.5 month old daughter, who seems to be like Laura's baby. I have a set of boy/girl twins... My son is extremely intense and focused, ALWAYS smiling when he sees me and the second I smile, he does the same. He makes eye contact and holds the gaze and is just very aware and interactive, in general.
    However, my daughter at times will be smiley and laugh when I do raspberries or peek-a-boo. But sometimes when I hold her up on my lap, she will look everywhere else but in my eyes or in my direction. My son will be focused and she'll just be kind of "blah," staring off into space. She has a fixation on Mickey Mouse so will smile at other things or people (even SOME strangers), or songs. But the intermittent lack of eye contact and blah-ness that happens frequently just worry me. She's just in such contrast from her twin. Sometimes, I fear autism, like the other folks have shared... or some other mental/developmental issue. I'm hoping she's just more mellow - she smiles less, but also fusses less than her brother. Thanks for any additional input. All the best to you.

    ReplyDelete
    Replies
    1. Hi Juliette-- let me say once again that I never see any of these babies, so I can certainly not provide any kind of diagnosis! But my guess is that there is simply a temperamental difference between your twins, and if you didn't have the one lively twin you might well not notice that the other one is less lively. I would just suggest that you make sure that you give her as much attention as her twin, even though she doesn't seem to ask for it. Also, you may want to make sure that when you hold her up on your lap, your face is in the light, rather than having her see a shadowy head against a light background.

      Nobody can actually diagnose autism at this early age. I know it's useless to say not to worry, but keep in mind that girls are less likely to be autistic and that there are levels of autism that allow for good functioning. Also, if you have to have something else to do right now,you could have her vision and hearing checked, if that hasn't already been done. Best wishes!

      Delete
  22. Hello Doctor,
    I keep coming back to your blog post week after week. My son is 9 weeks old and was born two weeks premature. He rarely has a mutual gaze and when he does it's only for a few seconds usually. He especially does not like to look at me or his Dad when we are close up, which is weird because I thought they can see 8-12 inches away first before they can see farther away. This doesn't seem to be the case with him. He smiles sometimes but only at the wall...When the room is dark he stares off as if he can't see at all. I know it's early but I'm really worried. Any advice?

    ReplyDelete
  23. And also thank you for this blog post and for all the suggestions and advice you've given to parents on this post!

    ReplyDelete
    Replies
    1. Hi Candice-- so, your son is actually 7 weeks old, corrected age, and it's not surprising that he doesn't do much mutual gazing yet.

      If I were you, I'd be very careful about thinking that he "does not like to look at" you or his Dad.He doesn't do it, that's all! If he were an adult and didn't look at you, you might well conclude that he didn't like to look at you, but at this age all you know is that he does not, so please don't start telling yourself that he doesn't like to see you!

      It's true that infants can see 8-12 inches away before they can see at greater distances, but even then their vision is rather blurry compared to an adult's vision. He needs brighter light and higher contrast than you do, and he probably does not see much when the room is darkened.

      People used to call that smiling at the wall "smiling at the angels", which I think is charming-- all the same, what you want is a smile at you. I am thinking that you will probably see more of this in the next couple of weeks. You can try to get a bit more by "looming" at him-- move closer while opening your eyes and mouth wide, then back away while closing them, then repeat. At this age they often need a lot more of a social stimulus to get smiling than you would expect.

      If you are concerned that he actually does not see you, ask your pediatrician whether there was any problem associated with his preterm birth that might have caused some visual problems.

      So sorry I can't be more specific or reassuring, but remember that this first three months is what has been called 'exterogestation". The baby is still more like an unborn child than he is like an older one, and only further development can show you what his abilities really are.

      Delete
    2. Thank you very much for reply! It does mean a lot! And you're right, I shouldn't jump to the conclusion that he doesn't "like" to look at me. I've spoken to my pediatrician about all this and she says that right now she sees no reason to worry...maybe I'm just hyper-aware because I'm alone with my baby all day? It's just that I keep reading he should be interested in my face more than anything else and to me it seems like the opposite. He also rarely tracks objects, which I've read he should be doing. I will try the "looming" as I have not heard of that technique before...I've been doing full broadway numbers trying to get him to smile and pay attention to me (which perhaps is only laughable to me ;)
      Thanks again for your response and for this blog :)

      Delete
    3. Better stick to Little Theater at this point!

      Delete
  24. Hi jean.....i have a toddler of 18 months....she is very active and sociable she is always called by all a happy baby smiling laughing giggling around.. but when i hold her she hardly do any eye contact. but when she is far she does. she is still blabbering and trying to talk. But when i ask her to do something she gives no interest at times, sometime she does. she hardly say 2-3 words. her doctor said hold her close and try to talk her as much as you can. but she hardly stays at one place. is it something to worry about.

    ReplyDelete
    Replies
    1. Dear Varsha-- I don't want to say you "should worry" about this, but it's true that your little girl is a bit below average in her present language development. This may mean nothing, as many children develop in jumps and plateaus rather than just gradually day-by-day. She may show much more interest in speech soon.

      But at the same time, you don't want to be doing things that fail to support her language development. I would cut out all screen time of any kind. Reading and singing to her are good approaches. When she does use words, reply in a way that expands on them. (For example, she says "car", and you answer "yes, it's a big red car".) Don't use your cellphone around her unless you have to,because she needs to see that saying words is something people do together.

      I agree that talking a lot is important, but I would be afraid that holding this active child close would simply frustrate both of you. She may not seem to be paying attention while she is running around, but she probably is. Try to take advantage of whatever interests her-- for example, you could say that she's running, now she's stopping, etc.

      What are the kinds of things you ask her to do? Do you think she doesn't hear you, doesn't understand the words, or gets distracted?

      Delete
    2. Yes she understands the words and also does when i ask her to do something (For example, throw it in the trash or get me the spoon) but not always :) . And one more thing i forgot mention is she is always hooked to iPad. She love listening to rhymes...and now we literally have to hide it from her. And i am trying to talk to her more. Kindly help me know how do i interact with her so that her language development increase

      Delete
    3. If she does what you ask sometimes, then she must understand you at least sometimes, which is an excellent sign. there might be many reasons why she sometimes does not do things-- for example, something else might distract her.

      Do keep that iPad hidden. If she likes the nursery rhymes, you can say or sing them to her. Remember that understanding speech is not all about hearing, and it helps her to see your mouth and the way it moves to produce a sound.

      When you see that she's interested in something, try to build on that attention by talking to her about it. If she uses a word, reply to her and use the same word in your reply. If she babbles excitedly about something, talk to her about whatever is going on. Also, read aloud every day, for half an hour if you can manage it-- this is a good bedtime routine.

      I would bet that you are going to see some language advances quite soon!

      Delete
  25. Thank you so much for the advice.....i will definitely do what ever you have mentioned and let you know
    thanks again

    ReplyDelete
  26. Hi dr. I contacted you about 4 months ago concerning my son, then 9 months. He was born 3 weeks before term. I was really worried about his eye contact and how he did not respond to sounds. Now we finally found out he has a hearing loss of 60 db on left ear and 90 db on right ear. He is diagnosed with bor syndrome. The eye contact is much better, but still we have to work on that. Even now that we know he has a hearing loss, i still have the feeling that there is somthing more, still somthing wrong. He is really friendly with everyone, smiles to every human beeing he Sees, and also want to go to them. And i cant make him play with me, i can only hold hus focus for 1-5 minutts before he crawls off to somthing els. And we have a really hrad time feeding him, he only eats mashed food. He will close his mouth and turn his head if given enything not mashed. He has hearing aid now, and has had them for 2 months.
    Im so desperat now, are children with hearing loss somhow semilar to those with autism in symptoms?

    ReplyDelete
  27. Dear ramz-- this sounds as if there are many challenges for your little boy and for yourself. To answer your last question first, yes, there are resemblances between hearing-impaired and autistic children at this early age. Without the hearing test that your son had, it can be hard to tell them apart.

    The hearing loss you mention is a pretty severe one. I am wondering whether you have learned sign language and are using it with him. If you haven't started this, it would be a good idea. Is there a school for the deaf near you? If so,they may be able to help you plan for how you are going to support his good development.

    You may need some help to follow his lead and use his interests to expand on your play together. On youtube, there are some excellent videos on "Floor time" that may give you some ideas about how to do this. However, he may not be mature enough to play for more than 5 minutes at a time, and if you can't use speech with him it's difficult for you to help him organize his play. Using sign could be very helpful here.

    As for eating, it would be good if he could start on some lumpy or chewy food. Can you offer him something liked cooked carrots or peas to finger-feed to himself? He should be able to do this by now, and if he can't, you may need to work with a physical therapist to help him develop skills in using his hands.

    Because he has the BOR diagnosis, I am thinking that you will have a lot of medical help, and the doctors should be able to suggest other services for you.

    Finally, I wonder whether you are getting the kind of support you need yourself. I'm sure you're uncertain about what the future holds and feel a lot of anxiety about your child. Has anyone suggested counseling from a specialist who understands these genetic or similar problems? I understand that you are very worried, but when you say you are desperate, I think you may need more help than you are getting.

    ReplyDelete
  28. Thank you so much.
    We have started on the sign language now, it 's hard to learn, but we have a great plan for that i norway. We have a total of 35 weeks at sign language school.
    I will try the food you suggested, and contact his physical therapist about work ing on his hands. He does put food in his mouth , but he gags and spit out.
    There are no specialist on BOR in Norway, there are specialist on each symptome.
    I will also try the floor time with him.
    Thank u again for talking time to answear me.

    ReplyDelete
  29. I just want to say that is amazing and rare in this day and age to get such wonderful and personal responses from a professional. Reading the above has been very helpful to me.

    I would like to add my own experience and if you have anything to add it would be so very much appreciated!
    My little guy is 7 months and is similar in many ways to the above children. All his developmental milestones are great in many ways - his gross motor is ahead, he is already army crawling and pulls up to stand. He smiles and babbles and loves everyone. He is super affectionate, and he laughs at silly things his brothers do. But he really struggles to maintain eye contact with me. He wants to look at everything else around him! He will smile at me across the room and gets really excited when I come into the room when he is awake in his crib after a nap. He is my 6th child (yes 6th!) and I understand all babies are different even within a family. My worry is that I know how important that "shared attention" milestone is as we have two children with very high functioning autism (they are my baby's half siblings) and I keep watching and waiting for it and its not there. He stares at unusual things but doesn't check my face for my reaction. Should I be expecting that at 7 months? The only time I have seen it so far is once at the doctor's office, he looked up at me then back at her during his exam. I honestly didn't know to even look for this with his older sibs so I may just be hyper aware and overthinking it, but it is causing some anxiety for me so I would love to get more information. Thank you!

    ReplyDelete
  30. one more thing...he does not yet respond to his name. He will look at us if we make funny sounds to get his attention, but simply calling his name gets no response if he is busy playing with something. Reason for concern?

    ReplyDelete
    Replies
    1. I'm so glad to hear that this is helpful to someone.It's certainly very interesting to me to read what people share!

      I think that what you're looking for is not joint attention, but social referencing. In joint attention, the child tries to get you to look at something interesting that he sees, and I wouldn't expect that to happen until 10-12 months.

      Social referencing means noticing that something unusual is happening and looking at the adult's face to see whether he or she looks scared or happy. If the adult looks scared, the child looks serious and wary and backs off-- if the adult looks happy, the child goes ahead and approaches the strange person or thing. Social referencing comes earlier than joint attention, but I wouldn't expect it to happen until the child has begun to be scared of strange people or things. At 7 months he might begin to be wary and give strangers or unusual things a serious look (maybe this is what you called staring at things), but then to warm up to them. At 8-10 months you typically get fear of strange people, sudden moves, or loud noises beginning. But until that happens,he won't check out your face to see if you're scared, because he isn't.

      I think that what you saw him do at the pediatrician's office was neither one of these, but just looking at the differences between your faces as she handled him in ways that you usually do.

      I'm not sure whether you mean he doesn't respond to his name at all, or just doesn't notice it when he's paying attention to something else. If it's the latter, that isn't very surprising or different from what all of us do from infancy on up. If he really doesn't respond to his name ever, even when there's very little background noise, you might want to have his hearing tested.

      As for the eye contact, I wonder whether you're expecting him to do this more than they really do (even though with 5 others I guess you'd know!). You make it sound as if he sees your face better at a distance. It could be that when you're close your face is in shadow. Also, it sounds like there are plenty of other interesting things for him to be looking at.

      He sounds terrific to me. Just as a footnote, I wonder whether with lots of other kids in the house he doesn't depend on you to socialize the way a single baby would, so he doesn't look at you as much as you might expect. Not only are all the children in a family different,as you say, but in fact if you think about it you'll realize that except for twins no two children are born into "the same family", because the family changes with each child as well as with other events.

      Delete
    2. Thank you so much for your response. Yes, I guess I am looking for social referencing. And it makes sense that would not appear until he starts needing that reassurance as a result of his own fears of strangers, etc. I know when to expect that milestone (usually not before 8 months). I have a background in early childhood ed in addition to all my mothering experience so I have a good handle on a lot of the developmental milestones, but the joint attention and social referencing, mutual gaze, etc are "newer" ones to look for that I just don't quite understand yet! Thank you for clarifying which is which.

      I think he hears perfectly fine. I can get his attention with my voice, but if he is playing with something and I simply say his name, he doesn't look at me yet. I think he just doesn't respond to his name being spoken when he has other more interesting things that are holding his attention. I guess with all I have read about kids on the spectrum that if he doesn't immediately look at me when I call his name that is supposedly a red flag...but I don't know that any kids immediately respond to their parents when they are interested in something! I think it is confusing to separate normal development and potential concerning early "red flags" for autism.

      He seems very interested in people in general and when someone else is holding him, he is more likely to interact with me using eye contact. He will make it when I change his diaper and sing songs to him. But if I try to hold him in my lap and play with him, he tends to look everywhere other than my face. There IS a lot to look at around here and I think you are right, he has multiple care givers and helping hands so he doesn't need my attention as much as another baby would. I notice when I am holding him and someone is interacting with him he makes appropriate eye contact. I will have to see how this is affected by light in the room. I do a lot of his feedings in a chair with its back to the window meaning my face would be in shadow, whereas I change his diaper in an area where the light is on the side and so he can more clearly see my face and he does make more eye contact there.

      Delete
    3. I think this "red flag" stuff is very scary to people because nobody mentions the range of ages within which it's typical to see various behaviors begin. Behaviors that are seen in older autistic kids, like saying "you" for "me", flapping hands when excited, and toe-walking, are all characteristic of typically-developing younger children. Autism involves developmental delays as well as other things, so "autistic" behavior is seen in non-delayed younger children who will stop doing it after a while. (Actually,people used to talk about the first three months as a period of "normal autism", but we seem to have lost the idea that being unresponsive can be perfectly normal for some ages and situations.)

      Delete
  31. Hello Dr. Mercer,
    I am a first time mother of an almost 5 month old (4 months, 3 weeks). I have some concerns and would appreciate your advice!
    My son seems to go through a personality change when he is lying down and when he is sitting up. Lying down, he laughs at songs, squeels with delight at peekaboo and can stare at me for minutes at a time - even likes to reach out and touch my face (same goes for when he is resting on my knees). When we hold him, there is no way of getting him to look at the person holding him. He will look and smile at other people around the room, but not intently (like babies "should"?), just fleetingly and never the one holding him. And I mean never - I have even used a toy that he can track in front of us and his eyes will drop as soon as it nears my head. At a distance, he's also fine (smiles at both of our reflexions in the mirror and at other people), although I have only heard him laugh three times when he wasn't on his back. People have commented on the fact that he is a "serious" baby and doesnt make eye contact- which stresses me out!
    Also, my baby rarely cries. He can be left alone in a room up to 10-15 minutes before he starts fussing and even then it's fussing, not really crying - sometimes he does an upset squeel (which I also don't like). Of course, he does cry SOMETIMES, but I think only when he is in pain or wakes up in a place that is not our home.
    We checked his eyes and they are fine (although dr said he could tell already that he would need glasses when he is in elementary school).
    What are your thoughts, please? Yes I am worried about early signs of autism, but the "red flags" seem situational. I understand he is too young for a diagnosis and that you can't say anything specific without seeing him but I would appreciate your thoughts based on your experience, and advice or a reference on how to improve his eye contact in different positions (I don't think I can do anything else about the other things I am concerned about).
    Thank you in advance!

    ReplyDelete
  32. Dear Unknown-- so many people have asked similar questions about distant and near faces that I've just done a whole post about it: http://childmyths.blogspot.com/2014/07/infant-eye-contact-and-visual.html.

    I am assuming that your baby is sleeping supine, as most do nowadays. There is reason to think that this sleeping position slows down aspects of motor control that are encouraged by prone sleeping or lots of "tummy time". This could mean that the effort of staying upright is taking a lot of his energy when he is not lying down. Be sure you do plenty of tummy time, even though he might seem not to like it at first. This will not make any difference developmentally in the long run, but it might make him more able to respond now and thus make you feel better.

    As for being left alone for a bit without crying, my guess would be that he has a mild temperament with a positive mood. In addition, he is not old enough to feel afraid when left alone. The squeal may just be practicing making different sounds, which he's getting old enough to do.

    People should SHUT UP and not comment on whether a baby makes eye contact with them! Tell them he's busy thinking about his investments and planning his college applications. Or if you dare, say "I guess he doesn't like you!"

    ReplyDelete
    Replies
    1. Your response just made my day! Thank you, so much Dr. Mercer. I have just read your other blog and it was enlightening to me. Having zero medical background or child rearing education, I was even wondering if some neurological wiring was getting disconnected in my baby's brain when he was held up. Your explanation makes much more sense and puts me at ease. My baby is still shakey when he is being held up, so now I see he really needs his concentration for that and I notice him turn towards who is holding him as soon as he get's a little bit of distance (held at full arm's length, for example) which can explain it is more comfortable for his current vision.
      This new mom business can be scary and your blog is a wonderful source for us. Much better than a bunch of moms trying to figure things out on our own or using another mom's individual experiences to "assess" our own babies. Thank you for giving us access to your expertise! Jessica

      Delete
  33. Hello dr.

    My son is seven weeks old ( eight weeks on the 7th two months on the 12th) and the last two days he seems to have lost his interest in any eye contact or face gazing which last week he was doing all the time. His smiles have been less frequent as well these last two days and I am beginning to worry because these are things he had been doing and suddenly stopped. His temperment is normal though he has been sleeping a bit more often. If it continues I plan to mention it at his two month physical but do you have any thoughts in the mean time? Is it normal for a baby to seem to temporarily loose a skill they seemed to have mastered or should I worry at this sudden change?

    ReplyDelete
    Replies
    1. Infants and children can lose interest in doing things they've mastered-- they don't lose the skill, but just stop doing things when there are more interesting and challenging options. I don't know whether that's what's happening in your case, but with the extra sleeping it sounds as if he is going through some kind of organizational change. This kind of change is one of the many reasons for the variability and unpredictability of infant behavior. We can't expect infants to act the same all the time, but I know it's worrying to see the apparent loss of something we thought was important and valuable. He is at a transitional time in terms of being able to use his eyes together, so that may be what he's dealing with right now. (I did a post on this kind of change a couple of days ago.)

      Do you mean that his temperature is normal, rather than his temperament?

      My guess is that there's nothing to worry about, but I know that won't stop you! I hope your doctor can reassure you.

      Delete
  34. Hi Dr my name is Martha, i have a 6 and half months daughter, she had her 6 month apppitment yesterday and her pediatrician is concern her head is not growing, she is bellow the average on the chart so they going to run some tests. As everybody else im concern that she is a little behind, she is a happy baby always smiling when i make sounds or call het name but she doesnt make eye contact for a long time, she looks at me smile and turn her head. She doesnt reach for toys or passes them like she should. She always sucking her fingers and grabbing her hands, she also pulls my hair and necklace or earrings ( not sure if that count as reaching) she also makes a lot of sounds and imitates when i make a sound. Any advice will be appreciated, thanks

    ReplyDelete
    Replies
    1. Dear Anonymous-- I am sorry to hear to hear that your daughter is not doing as well as she might, but she sounds like a lively and happy little person. The most important thing for you to do is to follow up on what your pediatrician
      wants you to do. It's possible that the head growth will catch up, because growth is not exactly the same as the average every month. However, if her head growth is delayed, it's essential to find out why this is and to see if treatment is possible. She might "outgrow" the problem, but you can't count on that, so please do everything the pediatrician suggests, and if he or she does not seem to be actively working on this, find a medical specialist to help you. That's all the advice I can give, I'm afraid. I hope this all goes well in the near future.

      Delete
  35. Hello Dr,

    As mentioned in last post , what if Child ( 7 month Old) is not started up sitting. though he is very lovely child and smiles ( laugh) a lot , response good when called by names or sound. He makes good eye contact when lying on the bed but not much when in the sitting position. He cries only when he needs milk , rest of the time he is very good boy and doesn't trouble for any thing. Is everything normal in this case and it is just delay in Normal growth. We are very positive about him and loves to play him a lot but still feel sometimes little concern. what do you say doctor?

    ReplyDelete
  36. Can he sit with support, for example on your knee with your hands on his hips? If he can do that, it would suggest that he is just a little behind in motor development. If he cannot sit in that way either, you should have a specialist check him.

    What happens when you try to put him in the sitting position? Does he lean forward for a few seconds as if he is trying to balance? That would be the beginning of sitting.

    Has he been sleeping on his back or on his tummy? Babies who sleep on their backs are often somewhat delayed in motor development in comparison to the norms you will find published.

    Are you seeing other developments like reaching for objects? Is he beginning to hold a bottle to feed himself or to pick things up by scooping with the side of his hand? Those would be achievements that would tell you that most of his development is normal.

    Do you have a pediatrician you can discuss this with? I would like to see you have some peace of mind if he is really doing well, or if ,there is a problem, to know that you are finding help.

    ReplyDelete
  37. Hi Doctor, Yes he can sit very much with his support from hand for 50-60 second before he lean forward. Also to my surprise, he sleeps on his tummy on his own and prefers to that way but we do change his position time to time. He reaches objects also like toy, mobile, watch etc. he doesn't hold for the bottle right now but he is cares for the other objects.
    We thank you for help and need your blessing for my child too.
    Regards
    Rohit

    ReplyDelete
    Replies
    1. My guess is that this is only a slight delay, but please ask your pediatrician! Also, be sure that you talk to the baby a lot, even though he is quiet and "good". He still needs it even if he isn't asking for it in an obvious way.

      You have my very best wishes for good development and a happy family!

      Delete
  38. Hi Dr, I just stumbled on this article. I have been very concerned about my 9 month old daughter. I work with babies and so I am unfortunately always comparing my daughter to them. My daughter has never been good with eye contact. She looks at me occasionally but it's not often. When I sit her in my lap she will turn her head just to avoid looking at me. Some of the children I work with will stare at me and explore my face, my daughter has never done that. My other concern is her response to us calling her name. There are times when I can call her name 20 times and she won't look in my direction or show any sort of response. She has turned to her name a few times but I can't tell if it's her reacting to a sound or actually responding to her name. I also feel that she doesn't follow with her gaze if I point to something or look to something. On a positive note, she has always been smiley and laughs when we tickle her or play peek-a-boo. She has babbled for quite a while and says ba ba ba, da da da, and recently ma ma ma. She rolled very late but once that happened she picked up crawling and pulling to stand soon after (started crawling the day after she turned 8 months). She has also recently been following me if I leave the room and will try to climb into my lap when I'm on the floor with her. She has always been a snuggler and loves to be held and cuddle when she's sleepy. Do you think I should be concerned about the eye contact and response to her name?

    ReplyDelete
    Replies
    1. Although she seems to be right on the right page in a lot of ways, I can see why you feel concerned. Have her hearing and vision been checked? I think that should be the first step in trying to understand what's going on.

      I'm sure that like everyone else you are worried about autism, but it really cannot be diagnosed this early, and many young children who seem to have autistic-like behaviors lose them later on anyway. However, you can get information about vision and hearing now, and when you have that you may have a better idea about how to proceed-- or, it's possible that you may not, but it's worth trying to find out how she is seeing and hearing the world, which could explain what seems to be her unresponsiveness.

      Delete