A diminished ability to socially interact with eye contact is recognized as a diagnostic marker for autism. A study published Nov. 6 in Nature reported that social engagement using eye contact starts at birth for all infants, but can start to decline as early as two months of age in children later identified with autism.

This prospective longitudinal study followed 36 male infants who were later diagnosed with autism spectrum disorders. The research headed by Dr. Warren Jones of Marcus Autism Center in Atlanta concluded:

"The timing of decline highlights a narrow developmental window and reveals the early derailment of processes that would otherwise have a key role in canalizing typical social development. Finally, the observation of this decline in eye fixation — rather than outright absence — offers a promising opportunity for early intervention that could build on the apparent preservation of mechanisms subserving reflexive initial orientation towards the eyes."

On the same topic, in an address to the American Public Health Association at the national meeting held in October in Boston, Dr. Glen Steele highlighted the need for early identification of visual dysfunction in infants and elaborated further on the visual functions known to be problematic in infants with autism. Steele was emphatic in his long-held belief that identification early of the ocular signs and symptoms of autism is essential.

Eye-care clinicians have the unique opportunity to recognize babies at risk for autism and provide guidance in the development of a management plan when the signs and symptoms are present. Autism experts agree with the need of early identification by eye-care specialists.

In an interview on CBS New York, autism expert Dr. Dominick Auciello of the Child Mind Institute commented, "The earlier you intervene, the more likely there is to be a benefit ... That may be helpful to promote social interaction, eye contact, interest in social interaction."

Programs that screen the vision in healthy infants as well as early vision exams to identify risks such as autism are important. CBS New York medical reporter Dr. Max Gomez went on to comment that his big takeaway from the study is the possibility that intervention before the full-blown disease develops might be able to slow or even stop autism.

But Gomez cautions that this eye-gaze determination is not something parents can do at home: "The technology used was sophisticated and the difference in gazes is so subtle that parents or pediatricians wouldn't be able to detect them."

The deficits in eye function are powerful in the diagnosis of autism. An October study in Autism looking at children between the ages of 18 and 60 months found that deficits in eye contact had a sensitivity of .89 and specificity of .91 in identifying autism.

Little is understood about the mechanism behind the avoidance of eye contact and its subsequent social cuing. One theory put forth is that there may be an abnormal percept of social threat triggered by direct eye contact. Processing of the known physiologic response of eye contact, heightened skin conductance and increased brain amygdala activity, may be too difficult in those with autism and eye avoidance is an adaptive strategy. The persistence of eye avoidance disrupts the development of vision cuing of social interactions such as expressions and gestures.

In his address to the APHA, Steele discussed early assessments of the visual system of infants, emphasizing the need of evaluations of all infants, not just those of those at risk for pathology. Steele has had an active role in a nonprofit organization that provides eye examinations for infants at no cost to the families.

The eye care optometric professionals involved in this program, InfantSee, are trained in the evaluation of eye fixation and eye tracking that are the necessary eye skills needed for normal social interactions and in particular eye contact.

Such programs advocating early eye health and function assessments will play an important role in the identification of infants at risk for autism, and it is hopeful that early diagnosis will translate to earlier and more effective interventions.