Which Visual Supports Work Best? an Examination of Visual Attention to Photograph and Cartoon Stimuli in Children with ASD.

Background: The use of visual supports is a common strategy for facilitating receptive language, enhancing communication, and increasing appropriate behaviors among children with autism spectrum disorder (ASD). At the same time, ASD is often accompanied by atypical visual attention to social stimuli. Specifically, several studies have documented an atypical tendency in ASD to look more at the mouth region of the face at the expense of the eye region of the face. To complicate matters, some researchers have argued that children with ASD demonstrate strengths when processing visual information from cartoons, whereas others have argued that photographic stimuli confer benefits.

Objectives: This study used eye tracking to assess children's visual attention when presented with Social Stories that employed either photographs or BoardMaker (BM) images. Social Stories were chosen (as were these two stimulus types) because they represent one of the most popular interventions in ASD and, hence, have great ecological validity. Our exploratory research questions were:

1) Is there a difference between TD children and children with ASD in how they attend to faces (i.e., eye region, mouth region, and background regions of a scene) in BM and photographic stimuli in the context of a Social Story?

2) Do group differences in visual attention to stimuli correlate with age, autism severity, executive function (attention shifting), intellectual functioning, or weak central coherence?

Methods: Nineteen TD children and 18 age- and gender-matched children with ASD participated. Children viewed two Social Stories (presented in counterbalanced order) on a eye tracking screen-capture monitor. The stories were identical with the exception that one used photographs and one used BM images. The BM and photograph stimuli were carefully controlled so that the images were as similar as possible with regard to semantic content, size, color, and orientation of people and objects. Each 'page' of the Social Story was presented for 4 seconds and the number of fixations and fixation time were assessed for eye, mouth, and 'other' (background) areas of interest.

Results: With one exception, we found no differences between groups when viewing images of faces. The exception involved one instance in which the image represented a person’s full body as well as a range of objects (i.e., the other scenes depicted only faces). For this more complex scene, an interaction was observed such that the TD and ASD groups were no different in their looking patterns in the BM condition but they were different in the photograph condition. Moreover, we found that in ASD, a shift toward more mouth-looking in the photograph condition was negatively associated with attention shifting and verbal IQ and that a shift toward more background-looking was negatively associated with attention shifting, age, and central coherence.

Conclusions: Children with ASD demonstrate typical visual attention patterns to both BM and photographic stimuli representing faces but children with ASD employ an atypical scanning strategy when presented with photographic stimuli representing more complex social scenes. Professionals should consider the potential benefits of simple, cartoon-like imagery when presenting complex images in the conduct of intervention.