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
Hobson (1993): The Relatedness Triangle
Someone else
Child
Thing
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
10
9
Number of participants
8
7
6
5
4
3
2
1
0
14
15 - 17
18 - 20
21 - 23
24 - 26
27 - 29
30 - 32
33 - 35
Total Score (excluding ItemVII on visual responsiveness)
Children with VI - IQ>70
Children with VI - IQ<70
36 - 38
39 - 41
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
Mean
yr;mo
SD
mo
Range
yr;mo
Mean
yr;mo
SD
mo
Range
yr;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: DSM-III-R clinical features among non-sighted and sighted
children with autism
Study 1
No. participants with abnormality
9
8
7
6
5
4
3
2
1
N
A
bs
e
nt
Co
on
m
ve
m
rb
al
C
om
m
Sp
ee
ch
Pr
od
n
Im
m
ed
Ec
ho
D
el
ay
ed
Ec
ho
Id
io
sy
n
W
or
Pe
ds
rs
Pr
on
ou
ns
Sp
at
ia
lt
er
Te
m
m
s
po
ra
lt
er
m
s
In
to
na
tio
n
Co
nv
er
sa
tio
n
0
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
9
No. participants with abnormality
8
7
6
5
4
3
2
1
eo
ty
pi
es
ss
to
ch
an
ge
Ro
ut
in
es
Se
ns
Se
ek
Re
st
ric
tI
nt
N
o
Im
ag
in
ist
re
St
er
in
Pl
ay
nd
s
Im
ag
Fr
ie
Im
ita
tio
n
co
k
Se
e
D
A
w
ar
e
of
ot
he
r
s
m
fo
rt
0
DSM-III-R: Impairments in Reciprocal Social Interaction // Restricted
Activities, Interest and Imagination
Non-sighted participants
Sighted participants 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.
Chronological Age
years; months
Verbal mental age
years; months
TIME 2
Mean
SD
Range
Mean
SD
Range
Non-sighted with
autism
n=9
15;00
1;01
13;06-16;04
10;00
2;01
6;06 - 13;07
Sighted * n = 8
with autism
n=7
15;07
1;09
13;03-17;09
10;07
2;03
8;00 - 13;07
Diagnosis of autism at T2, according to DSM criteria
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)
Study 2: DSM-III-R clinical features among non-sighted and
sighted children with autism
100
% participants with abnormality
90
80
70
60
50
40
30
20
10
N
A
bs
e
nt
Co
on
m
ve
m
rb
al
C
om
m
Sp
ee
ch
Pr
od
n
Im
m
ed
Ec
ho
D
el
ay
ed
Ec
Id
ho
io
sy
n
W
or
Pe
ds
rs
Pr
on
ou
ns
Sp
at
ia
lt
er
Te
m
m
s
po
ra
lt
er
m
s
In
to
na
tio
n
Co
nv
er
sa
tio
n
0
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
100
% participants with abnormality
90
80
70
60
50
40
30
20
10
eo
ty
pi
es
ss
to
ch
an
ge
Ro
ut
in
es
Se
ns
Se
ek
Re
st
ric
tI
nt
N
o
Im
ag
in
ist
re
St
er
in
Pl
ay
nd
s
Im
ag
Fr
ie
Im
ita
tio
n
co
k
Se
e
D
A
w
ar
e
of
ot
he
r
s
m
fo
rt
0
DSM-III-R: Impairments in Reciprocal Social Interaction // Restricted
Activities, Interest and Imagination
Non-sighted participants
Sighted participants with autism
Childhood Autism Rating Scale: T1 vs T2
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
What happens to verbal ability?
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)
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.