Visual impairment and autism: Does social engagement hold the key?

Peter Hobson and Tony Lee

Tavistock Clinic and Institute of Child Health, UCL.

Autism

Autism involves:

• A profound impairment in interpersonal engagement

• Characteristic abnormalities in language

• A severe restriction in symbolic and flexible thinking

Someone else

ThingChild

Hobson (1993): The Relatedness Triangle

Are there autistic like features in congenitally blind children?Brown, R., Hobson, R.P., Lee, A., and Stevenson, J., (1997)

Journal of Child Psychology and Psychiatry, 38, 693-703

Participants:

24 congenitally blind children aged 3 and 9 years- Totally blind or minimal light perception from birth, no

identifiable neurological impairment- Selected from six schools in England- 15 with VIQ>70, 9 with VIQ<70

Upper ability were compared with 10 sighted children matched for age and IQ

Lower ability compared with 9 sighted children with autism, matched for age and IQ

Group of 24 children with congenital blindness: Scores on Childhood Autism Rating Scale

0

1

2

3

4

5

6

7

8

9

10

14 15 - 17 18 - 20 21 - 23 24 - 26 27 - 29 30 - 32 33 - 35 36 - 38 39 - 41

Total Score (excluding Item VII on visual responsiveness)

Num

ber

of p

artic

ipan

ts

Children with VI - IQ>70 Children with VI - IQ<70

Hobson, R.P., Lee, A., and Brown, R., (1999)Are there autistic like features in congenitally blind children?

Journal of Autism and Developmental Disorders, 29, 45-56.

Participants:

On the basis of a seeded cluster analysis of clinical features from the DSM-III-R, 9 congenitally blind children from the study were placed in the cluster with the children with autism

- All 9 children satisfied DSM-III-R criteria for autism- 4 boys and 5 girls, with diagnoses of congenital optic

atrophy (4), ROP (3), bilateral retinal dysplasia(1) and Leber’s amaurosis (1)

These participants were compared with a newly constituted group of 9 sighted children with autism (all male), matched according to age and VMA (verbal subtests of WISC or WIPPSI)

Hobson, R.P., Lee, A., and Brown, R., (1999)Are there autistic like features in congenitally blind children?

Journal of Autism and Developmental Disorders, 29, 45-56.

Chronological Age Verbal Mental Age

Meanyr;mo

SDmo

Rangeyr;mo

Meanyr;mo

SDmo

Rangeyr;mo

Non-sighted with autism

n = 9

6;06 16 5;00 - 8;10 4;02* 8 3;03 - 5;01

Sighted with autism

n = 9

7;08 17 5;02 - 9;06 4;08 11 2;11 - 5;07

Study 1

0

1

2

3

4

5

6

7

8

9

No

. par

tici

pan

ts w

ith

ab

no

rmal

ity

DSM-III-R: Impairments in Communication

Non-sighted participants Sighted participants with autism

Study 1: DSM-III-R clinical features among non-sighted and sighted children with autism

0

1

2

3

4

5

6

7

8

9N

o. p

arti

cip

ants

wit

h a

bn

orm

alit

y

DSM-III-R: Impairments in Reciprocal Social Interaction // Restricted Activities, Interest and Imagination

Non-sighted participants Sighted participants with autism

Study 1: DSM-III-R clinical features among non-sighted and sighted children with autism

Reversible autism among children with congenital blindness? A controlled follow-up study.

Hobson, R.P., & Lee, A. (2010). Journal of Child Psychology and Psychiatry, 51, 1235-1241.

* n = 8

Chronological Ageyears; months

Verbal mental ageyears; months

TIME 2 Mean SD Range Mean SD Range

Non-sighted with autismn = 9

15;00 1;01 13;06-16;04 10;00 2;01 6;06 - 13;07

Sighted with autismn = 7

15;07 1;09 13;03-17;09 10;07 2;03 8;00 - 13;07

Continue to meet DSM criteria

Fail to meet DSM criteria

Non sighted(n = 9)

1 8

Sighted (n = 7)

7 0

Fisher’s exact p = 0.01 (2-tail)

Diagnosis of autism at T2, according to DSM criteria

0

10

20

30

40

50

60

70

80

90

100

% p

arti

cip

ants

wit

h a

bn

orm

alit

y

DSM-III-R: Impairments in Communication

Non-sighted participants Sighted participants with autism

Study 2: DSM-III-R clinical features among non-sighted and sighted children with autism

0

10

20

30

40

50

60

70

80

90

100

% p

art

icip

an

ts w

ith

ab

no

rmali

ty

DSM-III-R: Impairments in Reciprocal Social Interaction // Restricted Activities, Interest and Imagination

Non-sighted participants Sighted participants with autism

Study 2: DSM-III-R clinical features among non-sighted and sighted children with autism

3 point + improvement

on CARS

< 3 point improvement on

CARS

Non-sighted 9 0

Sighted 1 6

Fisher’s exact p = 0.01 (2-tail)

CARS 1 vs CARS 2

Non-sighted Sighted

t 6.794 -0.078

df 8 6

p (2 tail) >0.001 0.940

Childhood Autism Rating Scale: T1 vs T2

VIQ1 vs VIQ 2

Non-sighted(note: n = 8)

Sighted(n = 7)

t = -2.495 t = -1.146

df 7 df 6

p < .05 ns (p < .3)

What happens to verbal ability?

Conclusions

• Autism is a syndrome• This syndrome is heterogeneous in

pathogenesis as well as aetiology• Congenitally blind children who fulfil the

diagnostic criteria for autism early in childhood may no longer satisfy those criteria 8 years later – and in this respect, there is a contrast with sighted children with autism

• What are the pros and cons to considering autism among VI children ‘autism-like’?

So…Visual impairment and autism: Does social engagement hold the key?

We are left with the possibility that -both in sighted children with autism -and for different reasons, visually impaired children who develop clinical features considered typical of autism

- ‘autism’ arises through impediments to interpersonal engagement vis-à-vis a shared, visually specified world.