- Email: [email protected]
InfantSEE® as a portal to early intervention for autism spectrum disorders
IN PERSPECTIVE Leonard J. Press, O.D.
InfantSEEÒ as a portal to early intervention for autism spectrum disorders
E
arly intervention services are well established as essential in the public health effort to foster and guide normal childhood development.1 In a climate of diversity, normalcy is viewed more broadly as neurotypical development, with an increasingly wide range of children following patterns that are individualized and unique. Rather than unfolding along specific timelines or with specific behaviors, childhood development encompasses a variety of relative strengths and weaknesses. The essence of early intervention is the provision of assessment and therapeutic services to help infants and young children, from birth through age 3, develop to their full potential.2 The early intervention team traditionally has been composed of occupational therapists, physical therapists, and speech therapists. The rise of developmental and behavioral pediatrics has coincided with the emergence of these allied health care professionals who have taken the lead in clinical intervention.3 Children identified as being in need of services run the gamut from those with overt delays such as frank movement or communication disorders, to more subtle delays that may escape detection. Obvious candidates for early intervention services are children with cerebral palsy, articulation disorders, or legal blindness, as contrasted with those who are perceived to be late talkers or not particularly well coordinated. Aside from involvement through the Commission for the Blind and Visually Impaired, the ophthalmic professions have been largely invisible in early intervention services.
InfantSEEÒ and early visual development InfantSEEÒ is a public health program designed to ensure that eye and vision care becomes an integral part of infant wellness care to improve a child’s quality of life.4 Appreciable numbers of infants exhibit visual problems that escape detection. The major areas of dysfunction involve visual acuity differences between the 2 eyes stemming from refractive, strabismus, or disease origins. Public awareness has been heightened through reports of InfantSEEÒ providers detecting high bilateral ametropia and retinoblastoma, a life-threatening pediatric ocular tumor (http://www.cao.org/ CMS/default.asp?CMS_PageID=453). Assessment during the first year of life also detects potential problems that, if undetected, may lead to subsequent learning and developmental issues. Parents are encouraged to have their baby assessed initially through the InfantSEEÒ program between 6 months and 12 months of age. The functions probed during this assessment typically consist of visual acuity, visual fixation, ocular motility, binocular alignment and convergence, refractive status, and ocular health. The optometrist typically gains insight into the infant’s visual acuity by some type of preferential looking (PL) behavior. The ability to engage a child in looking toward the stimulus presented by the examiner is as much a skill set learned by the examiner as it is indicative of the infant’s level of vision development. Clinical tests exist for formal PL assessment, but informal examination is more frequently done in practice,
1529-1839/08/$ -see front matter Ó 2008 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2008.09.004
Leonard J. Press, O.D. particularly when there is no suspicion of disorder. A commonly used example is the Richman Face Dot Test, which uses contrast sensitivity in a forced choice testing procedure with test paddles having a ‘‘smile’’ face (see Figure 1). The results are converted into an approximate visual acuity based on the testing distance. Visual fixation, motilities, binocular function, and confrontation visual fields are probed with the use of finger puppets or other facelike targets (see Figure 2).
Eye contact and autism spectrum disorders One of the primary developmental disorders targeted for early intervention services is autism. One of the hallmark features of autism is gaze avoidance; inattention to faces, particularly the eye
628
In Perspective
Figure 1
Richman Face Dot paddles.
region, is one of the earliest and most consistent signs of autism.5 Klin et al.6 used infrared eye tracking technology to measure scan paths of individuals being screened for autism spectrum disorder (ASD) as they viewed movie clips involving social interactions.
Individuals with ASD focused much more intently and more frequently on the speaker’s mouth and rarely on the eyes. Strikingly, this one variable identified the ASD participants in this eye tracking study with 100% sensitivity and specificity.
There are many theories as to why young children who are on the spectrum of autistic disorders have difficulty attaining or maintaining eye contact. The most widespread school of thought stems from the work of Simon Baron-Cohen and his colleagues in the United Kingdom who posit a Theory of Mind that has most recently surfaced in the concept of mirror neurons in the brain.7 A key factor in Baron-Cohen’s model is the presence of an eye-direction detector (EDD), which allows infants to develop knowledge of where an adult is looking and engage in social interaction through shared emotion. The EDD appears to be localized neuroanatomically in the superior temporal sulcus and amygdala and synchronizes its actions with the orbito-frontal cortex.8 Irrespective of the details about EDD localization or function, it is clear that infants developing normally rely on information from eye contact to bootstrap other developing systems, and that children with autism typically remain in the stages exhibited by young infants.9
A unique opportunity for early intervention
Figure 2 aspx).
Lea Face Stimulus paddle (http://richmondproducts.com/253100%20LeaFaceStimulusPaddle.
As optometrists become progressively more involved in InfantSEEÒ, we are presented with the opportunity to monitor early childhood/infant development from a unique perspective. It is now well recognized that individuals with ASD have specific visual behaviors that are different from what the clinician will encounter with children with normal visual development, including: Avoidance of eye contact Aversion of gaze and gaze following Insensitivity to joint visual attention with another individual Difficulty integrating peripheral vision with central vision Paradoxical fixation and perseveration on one particular object of interest Our collective experience is that we can summarize these visual behaviors
In Perspective in ASD children by saying that they have ‘‘inverted’’ preferred looking patterns. In other words, they exhibit visual behaviors opposite to what one would expect to observe when examining neurotypical infants and toddlers. Young children normally tend to look at the examiner’s face rather than the target being presented. This makes collecting data more challenging but is an aspect of the examination resulting in unintended versions of ‘‘peek-a-boo’’ that make examining neurotypical infants so cute and enchanting. Inverted preferred looking patterns may be noted during routine InfantSEEÒ by the infant’s: Disinterest in the doctor’s face or expressions Disinterest in visual stimuli with faces, but attention to faceless targets Paradoxical response to the Richman Face Dot paddles (infant prefers to look toward paddle with the face less distinct or absent rather than toward the obvious ‘‘smile’’ face target) ‘‘Inverted’’ preferred looking patterns away from faces or face targets suggest, at an early age, that a child is at risk for emergent ASD behaviors. Clinicians who are comfortable with examining infants will note that the normal social context of the examination, in which the examiner and infant share joint attention, is lacking. InfantSEEÒ affords a unique opportunity to assess whether an infant’s visual behavior is typical, demonstrating the normal patterns of preferred looking toward facelike targets and eyes, or atypical. Why is documenting the looking pattern of infants toward faces an important optometric screening tool for ASD? First, it might help identify whether an infant’s visual behavior was normal before 12 months of age. Information from InfantSEEÒ assessments and subsequent examinations ultimately may help developmental pediatricians and pediatric neurologists decide if a child had been developing normally but is now experiencing regression or disintegrative disorder. Changes in behavior may
629 Eye contact is poor
Parent is aware
Parent is unaware
Discuss possibilities of early intervention (EI)
Consult with developmental pediatrician
, , , , , , ,
Eye contact improved
Monitor in 3–6 months Yoked prisms, lenses, and/or vision therapy
Decision tree when eye contact is poor during infant assessment.
have bearing on the timing or dosage of toddler vaccine administration and medical management of ASD.10 From an optometric standpoint, visual interventions are available in early childhood that can help guide visual development.11-13 Any interventions effective for children with ASD should be implemented as early as possible. A variety of behavior checklists and observation schedules have been recommended to assist in early detection.14 Most authorities now believe that subtle signs of ASD are present under 12 months of age, and eye tracking technology has been used experimentally to detect gaze patterns at progressively younger ages.15 Research will continue to inform clinical practice and contribute to clinically useful tools, including electrodiagnostic and brain imaging assessments.16 Yet, one of the observations that an optometrist can
Table 1
Eye contact still poor
Consult with developmental optometrist
Collaboration with occupational therapy and other EI services
Figure 3
Monitor in 1 month
make during an InfantSEEÒ assessment is whether that eye contact has begun to replace physical contact by 9 months of age.17 If eye contact is lacking to puppet faces, face targets, or the examiner’s face, the parent should be quizzed about how indicative this is of behavior at home and if this has been raised as a concern. Observations can be documented, and guidance can then be given to the family (see Figure 3). If the parent is unaware that the infant does not exhibit appropriate eye contact, the optometrist can reschedule the child for a visit in 1 month to see if the gaze aversion is consistent. In the interim, the parent can maintain an informal inventory of visually based social behaviors such as found in Table 1. If eye contact is improved, visual development should be monitored in 3 to 6 months and on a routine basis
Early sociovisual signs of autism spectrum disorders
Doesn’t keep eye contact or makes very little eye contact Doesn’t respond to parent’s smile or other facial expressions Doesn’t look at objects or events parents are looking at or pointing to Doesn’t point to objects or events to get parents to look at them Doesn’t bring objects to show to parents just to share interest Often does not have appropriate facial expressions Does not perceive what others might be thinking or feeling by looking at their facial expressions Adapted from https://aap.org/healthtopics/autism.cfm.
630 thereafter. However, if the infant still exhibits poor eye contact and exhibits other signs of ASD, collaboration with appropriate professionals and optometric services as indicated can be arranged. In doing so, the optometrist can make a valuable contribution to the potential need for early intervention. Genetic regulation of synaptic development in response to early-life environment may play a pivotal role in the pathogenesis of autism spectrum disorders.18 If so, optometrists performing InfantSEEÒ assessments have a unique public health obligation to identify crucial signs and symptoms of early autism development that signal the need for life-altering intervention services.19 As the first provider to clinically assess visual communication through preferred looking patterns, our opportunity to contribute to early child development is profound.
References 1. Ben Itzchak E, Lahat E, Burgin R, et al. Cognitive, behavior and intervention outcome in young children with autism. Res Dev Disabil 2008;29:447-58. 2. Ball J. Early intervention and autism: reallife questions, real life answers. Arlington, TX: Future Horizons, 2008.
In Perspective 3. Lytel J. Act early against autism: give your child a fighting chance from the start. New York: Perigee-Penguin, 2008. 4. Available at: www.infantsee.org. Last accessed July 14, 2008. 5. Schumann CM, Bauman MD, Machado CJ, et al. The social brain, amygdala, and autism. In: Moldin SO, Rubenstein JLR, editors. Understanding autism: From basic neuroscience to treatment. Boca Raton, FL: CRC Press–Taylor & Francis; 2006. 6. Klin A, Jones W, Schultz R, et al. Visual fixations patterns during viewing of naturalistic social situations as predictors of social competence in individuals with autism. Arch Gen Psychiatry 2002;59: 809-16. 7. Baron-Cohen S, Campbell R, KarmiloffSmith A, et al. Are children with autism blind to the mentalistic significance of the eyes? Br J Dev Psych 1995;13:379-98. 8. Baron-Cohen S. Mindblindness: an essay on autism and theory of mind. Cambridge MA: MIT Press, 1995. 9. Johnson MH, Farroni T. The neurodevelopmental origins of eye gaze perception. In: Flom R, Lee K, Muir D, editors. Gaze-following: its development and significance. Mahwah, NJ: Lawrence Erlbaum Associates; 2007. 10. Chez MG. Autism and its medical management: a guide for parents and professionals. Philadelphia: Jessica Kingsley Publishers, 2008. 11. Kaplan M. Seeing through new eyes: changing the lives of children with autism, Asperger syndrome, and other developmental disabilities through vision therapy. Philadelphia: Jessica Kingsley Publishers, 2006.
12. Schulman R. Optometry’s role in autism spectrum disorders. In: Lemer P, editor. Envisioning a bright future: interventions that work for children and adults with autism spectrum disorders. Santa Ana, CA: Optometric Extension Program Foundation; 2008. 13. Taub MB, Russell BS. Autistic spectrum disorders: a primer for the optometrist. Rev Optom 2007;144(5):82-91. 14. Yapko D. Understanding autism spectrum disorders: frequently asked questions. Philadelphia: Jessica Kingsley Publishers, 2003. 15. Pelphrey KA, Sasson NJ, Reznick JS, et al. Visual scanning of faces in autism. J Autism Dev Disord 2002;32:249-61. 16. Trachtman JN. Background and history of autism in relation to vision care. Optometry 2008;79:391-6. 17. Available at: http://www.infantsee.org/docu ments/InfantSEEBackgrounder.pdf. Last accessed July 14, 2008. 18. Sutcliffe JS. Insights into the pathogenesis of autism. Science 2008;321:208-9. 19. Jones W, Carr K, Klin A. Absence of preferential looking to the eyes of approaching adults predicts level of social disability in 2 year old toddlers with autism spectrum disorder. Arch Gen Psychiatry 2008;65:946-54.
Corresponding author: Leonard J. Press, O.D. The Vision & Learning Center 17-10 Fair Lawn Avenue Fair Lawn, New Jersey 07410 [email protected]
InfantSEEÒ as a portal to early intervention for autism spectrum disorders
E
arly intervention services are well established as essential in the public health effort to foster and guide normal childhood development.1 In a climate of diversity, normalcy is viewed more broadly as neurotypical development, with an increasingly wide range of children following patterns that are individualized and unique. Rather than unfolding along specific timelines or with specific behaviors, childhood development encompasses a variety of relative strengths and weaknesses. The essence of early intervention is the provision of assessment and therapeutic services to help infants and young children, from birth through age 3, develop to their full potential.2 The early intervention team traditionally has been composed of occupational therapists, physical therapists, and speech therapists. The rise of developmental and behavioral pediatrics has coincided with the emergence of these allied health care professionals who have taken the lead in clinical intervention.3 Children identified as being in need of services run the gamut from those with overt delays such as frank movement or communication disorders, to more subtle delays that may escape detection. Obvious candidates for early intervention services are children with cerebral palsy, articulation disorders, or legal blindness, as contrasted with those who are perceived to be late talkers or not particularly well coordinated. Aside from involvement through the Commission for the Blind and Visually Impaired, the ophthalmic professions have been largely invisible in early intervention services.
InfantSEEÒ and early visual development InfantSEEÒ is a public health program designed to ensure that eye and vision care becomes an integral part of infant wellness care to improve a child’s quality of life.4 Appreciable numbers of infants exhibit visual problems that escape detection. The major areas of dysfunction involve visual acuity differences between the 2 eyes stemming from refractive, strabismus, or disease origins. Public awareness has been heightened through reports of InfantSEEÒ providers detecting high bilateral ametropia and retinoblastoma, a life-threatening pediatric ocular tumor (http://www.cao.org/ CMS/default.asp?CMS_PageID=453). Assessment during the first year of life also detects potential problems that, if undetected, may lead to subsequent learning and developmental issues. Parents are encouraged to have their baby assessed initially through the InfantSEEÒ program between 6 months and 12 months of age. The functions probed during this assessment typically consist of visual acuity, visual fixation, ocular motility, binocular alignment and convergence, refractive status, and ocular health. The optometrist typically gains insight into the infant’s visual acuity by some type of preferential looking (PL) behavior. The ability to engage a child in looking toward the stimulus presented by the examiner is as much a skill set learned by the examiner as it is indicative of the infant’s level of vision development. Clinical tests exist for formal PL assessment, but informal examination is more frequently done in practice,
1529-1839/08/$ -see front matter Ó 2008 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2008.09.004
Leonard J. Press, O.D. particularly when there is no suspicion of disorder. A commonly used example is the Richman Face Dot Test, which uses contrast sensitivity in a forced choice testing procedure with test paddles having a ‘‘smile’’ face (see Figure 1). The results are converted into an approximate visual acuity based on the testing distance. Visual fixation, motilities, binocular function, and confrontation visual fields are probed with the use of finger puppets or other facelike targets (see Figure 2).
Eye contact and autism spectrum disorders One of the primary developmental disorders targeted for early intervention services is autism. One of the hallmark features of autism is gaze avoidance; inattention to faces, particularly the eye
628
In Perspective
Figure 1
Richman Face Dot paddles.
region, is one of the earliest and most consistent signs of autism.5 Klin et al.6 used infrared eye tracking technology to measure scan paths of individuals being screened for autism spectrum disorder (ASD) as they viewed movie clips involving social interactions.
Individuals with ASD focused much more intently and more frequently on the speaker’s mouth and rarely on the eyes. Strikingly, this one variable identified the ASD participants in this eye tracking study with 100% sensitivity and specificity.
There are many theories as to why young children who are on the spectrum of autistic disorders have difficulty attaining or maintaining eye contact. The most widespread school of thought stems from the work of Simon Baron-Cohen and his colleagues in the United Kingdom who posit a Theory of Mind that has most recently surfaced in the concept of mirror neurons in the brain.7 A key factor in Baron-Cohen’s model is the presence of an eye-direction detector (EDD), which allows infants to develop knowledge of where an adult is looking and engage in social interaction through shared emotion. The EDD appears to be localized neuroanatomically in the superior temporal sulcus and amygdala and synchronizes its actions with the orbito-frontal cortex.8 Irrespective of the details about EDD localization or function, it is clear that infants developing normally rely on information from eye contact to bootstrap other developing systems, and that children with autism typically remain in the stages exhibited by young infants.9
A unique opportunity for early intervention
Figure 2 aspx).
Lea Face Stimulus paddle (http://richmondproducts.com/253100%20LeaFaceStimulusPaddle.
As optometrists become progressively more involved in InfantSEEÒ, we are presented with the opportunity to monitor early childhood/infant development from a unique perspective. It is now well recognized that individuals with ASD have specific visual behaviors that are different from what the clinician will encounter with children with normal visual development, including: Avoidance of eye contact Aversion of gaze and gaze following Insensitivity to joint visual attention with another individual Difficulty integrating peripheral vision with central vision Paradoxical fixation and perseveration on one particular object of interest Our collective experience is that we can summarize these visual behaviors
In Perspective in ASD children by saying that they have ‘‘inverted’’ preferred looking patterns. In other words, they exhibit visual behaviors opposite to what one would expect to observe when examining neurotypical infants and toddlers. Young children normally tend to look at the examiner’s face rather than the target being presented. This makes collecting data more challenging but is an aspect of the examination resulting in unintended versions of ‘‘peek-a-boo’’ that make examining neurotypical infants so cute and enchanting. Inverted preferred looking patterns may be noted during routine InfantSEEÒ by the infant’s: Disinterest in the doctor’s face or expressions Disinterest in visual stimuli with faces, but attention to faceless targets Paradoxical response to the Richman Face Dot paddles (infant prefers to look toward paddle with the face less distinct or absent rather than toward the obvious ‘‘smile’’ face target) ‘‘Inverted’’ preferred looking patterns away from faces or face targets suggest, at an early age, that a child is at risk for emergent ASD behaviors. Clinicians who are comfortable with examining infants will note that the normal social context of the examination, in which the examiner and infant share joint attention, is lacking. InfantSEEÒ affords a unique opportunity to assess whether an infant’s visual behavior is typical, demonstrating the normal patterns of preferred looking toward facelike targets and eyes, or atypical. Why is documenting the looking pattern of infants toward faces an important optometric screening tool for ASD? First, it might help identify whether an infant’s visual behavior was normal before 12 months of age. Information from InfantSEEÒ assessments and subsequent examinations ultimately may help developmental pediatricians and pediatric neurologists decide if a child had been developing normally but is now experiencing regression or disintegrative disorder. Changes in behavior may
629 Eye contact is poor
Parent is aware
Parent is unaware
Discuss possibilities of early intervention (EI)
Consult with developmental pediatrician
, , , , , , ,
Eye contact improved
Monitor in 3–6 months Yoked prisms, lenses, and/or vision therapy
Decision tree when eye contact is poor during infant assessment.
have bearing on the timing or dosage of toddler vaccine administration and medical management of ASD.10 From an optometric standpoint, visual interventions are available in early childhood that can help guide visual development.11-13 Any interventions effective for children with ASD should be implemented as early as possible. A variety of behavior checklists and observation schedules have been recommended to assist in early detection.14 Most authorities now believe that subtle signs of ASD are present under 12 months of age, and eye tracking technology has been used experimentally to detect gaze patterns at progressively younger ages.15 Research will continue to inform clinical practice and contribute to clinically useful tools, including electrodiagnostic and brain imaging assessments.16 Yet, one of the observations that an optometrist can
Table 1
Eye contact still poor
Consult with developmental optometrist
Collaboration with occupational therapy and other EI services
Figure 3
Monitor in 1 month
make during an InfantSEEÒ assessment is whether that eye contact has begun to replace physical contact by 9 months of age.17 If eye contact is lacking to puppet faces, face targets, or the examiner’s face, the parent should be quizzed about how indicative this is of behavior at home and if this has been raised as a concern. Observations can be documented, and guidance can then be given to the family (see Figure 3). If the parent is unaware that the infant does not exhibit appropriate eye contact, the optometrist can reschedule the child for a visit in 1 month to see if the gaze aversion is consistent. In the interim, the parent can maintain an informal inventory of visually based social behaviors such as found in Table 1. If eye contact is improved, visual development should be monitored in 3 to 6 months and on a routine basis
Early sociovisual signs of autism spectrum disorders
Doesn’t keep eye contact or makes very little eye contact Doesn’t respond to parent’s smile or other facial expressions Doesn’t look at objects or events parents are looking at or pointing to Doesn’t point to objects or events to get parents to look at them Doesn’t bring objects to show to parents just to share interest Often does not have appropriate facial expressions Does not perceive what others might be thinking or feeling by looking at their facial expressions Adapted from https://aap.org/healthtopics/autism.cfm.
630 thereafter. However, if the infant still exhibits poor eye contact and exhibits other signs of ASD, collaboration with appropriate professionals and optometric services as indicated can be arranged. In doing so, the optometrist can make a valuable contribution to the potential need for early intervention. Genetic regulation of synaptic development in response to early-life environment may play a pivotal role in the pathogenesis of autism spectrum disorders.18 If so, optometrists performing InfantSEEÒ assessments have a unique public health obligation to identify crucial signs and symptoms of early autism development that signal the need for life-altering intervention services.19 As the first provider to clinically assess visual communication through preferred looking patterns, our opportunity to contribute to early child development is profound.
References 1. Ben Itzchak E, Lahat E, Burgin R, et al. Cognitive, behavior and intervention outcome in young children with autism. Res Dev Disabil 2008;29:447-58. 2. Ball J. Early intervention and autism: reallife questions, real life answers. Arlington, TX: Future Horizons, 2008.
In Perspective 3. Lytel J. Act early against autism: give your child a fighting chance from the start. New York: Perigee-Penguin, 2008. 4. Available at: www.infantsee.org. Last accessed July 14, 2008. 5. Schumann CM, Bauman MD, Machado CJ, et al. The social brain, amygdala, and autism. In: Moldin SO, Rubenstein JLR, editors. Understanding autism: From basic neuroscience to treatment. Boca Raton, FL: CRC Press–Taylor & Francis; 2006. 6. Klin A, Jones W, Schultz R, et al. Visual fixations patterns during viewing of naturalistic social situations as predictors of social competence in individuals with autism. Arch Gen Psychiatry 2002;59: 809-16. 7. Baron-Cohen S, Campbell R, KarmiloffSmith A, et al. Are children with autism blind to the mentalistic significance of the eyes? Br J Dev Psych 1995;13:379-98. 8. Baron-Cohen S. Mindblindness: an essay on autism and theory of mind. Cambridge MA: MIT Press, 1995. 9. Johnson MH, Farroni T. The neurodevelopmental origins of eye gaze perception. In: Flom R, Lee K, Muir D, editors. Gaze-following: its development and significance. Mahwah, NJ: Lawrence Erlbaum Associates; 2007. 10. Chez MG. Autism and its medical management: a guide for parents and professionals. Philadelphia: Jessica Kingsley Publishers, 2008. 11. Kaplan M. Seeing through new eyes: changing the lives of children with autism, Asperger syndrome, and other developmental disabilities through vision therapy. Philadelphia: Jessica Kingsley Publishers, 2006.
12. Schulman R. Optometry’s role in autism spectrum disorders. In: Lemer P, editor. Envisioning a bright future: interventions that work for children and adults with autism spectrum disorders. Santa Ana, CA: Optometric Extension Program Foundation; 2008. 13. Taub MB, Russell BS. Autistic spectrum disorders: a primer for the optometrist. Rev Optom 2007;144(5):82-91. 14. Yapko D. Understanding autism spectrum disorders: frequently asked questions. Philadelphia: Jessica Kingsley Publishers, 2003. 15. Pelphrey KA, Sasson NJ, Reznick JS, et al. Visual scanning of faces in autism. J Autism Dev Disord 2002;32:249-61. 16. Trachtman JN. Background and history of autism in relation to vision care. Optometry 2008;79:391-6. 17. Available at: http://www.infantsee.org/docu ments/InfantSEEBackgrounder.pdf. Last accessed July 14, 2008. 18. Sutcliffe JS. Insights into the pathogenesis of autism. Science 2008;321:208-9. 19. Jones W, Carr K, Klin A. Absence of preferential looking to the eyes of approaching adults predicts level of social disability in 2 year old toddlers with autism spectrum disorder. Arch Gen Psychiatry 2008;65:946-54.
Corresponding author: Leonard J. Press, O.D. The Vision & Learning Center 17-10 Fair Lawn Avenue Fair Lawn, New Jersey 07410 [email protected]