Pilot Study Finds Behavioral Training Can Improve ‘Social Gaze’ Skills in Boys with Fragile X

Poor “social gaze” skills, or an inability to make and hold eye contact during a social interaction, is a common problem for fragile X syndrome patients but can be improved with  standard behavioral training, according to the results of a proof-of-concept study.

The study, “Improving social gaze behavior in fragile X syndrome using a behavioral skills training approach: a proof of concept study,” was published  in the Journal of Neurodevelopmental Disorders.

The eyes are important in social interactions, as people use their eyes to both perceive information and to signal their intentions. The ability to engage in appropriate social gaze behavior with others is considered crucial to socialization and communication, and of importance in language development, emotional recognition, and general learning.

People with fragile X are known to be particularly prone to difficulties in socializing with others, which the study notes may be attributed to impaired social gaze behavior and especially to eye gaze avoidance.  This genetic disease is marked by impaired intellectual functioning, and a likelihood of  autistic-like behaviors that can include social avoidance, poor communication skills, and repetitive behaviors.

Behavioral interventions to improve social gaze have not been evaluated for these patients.

Researchers at  Palo Alto University and Stanford University School of Medicine, in California, designed a Phase 1/2 clinical trial (NCT02616796) to assess a two- to three-day training program on patients’ behavioral and social skills.

Twenty boys with fragile X, ages 8 to 18 years, were randomized to receive a type of behavioral training called discrete trial instruction (DTI), at either a more or a less intense level, plus relaxation training to relieve stress. The training took place over four consecutive days.

On day one, a female examiner administered a social challenge to evaluate the boys’ baseline levels of social gaze behavior; on days two and three, a trained therapist conducted behavioral training trials; on day four, a different female examiner administered a social challenge to evaluate social gaze behavior and physiological arousal. Intense DTI sessions consisted of 320 DTI trials conducted in eight, 1-hour sessions; 160 DTI trials over four, 1-hour time blocks were given in less intense sessions.

During DTI, participants sat in a chair facing the therapist, while engaging in a series of discrete trials. Examples are “look while listening” (“I’m going to tell you about something … remember to look at my eyes while I talk to you”), where the therapist would tell a story or provide information; and “look while speaking,” where the therapist asked participant questions about things they liked (“I want you to tell me about … remember to look at my eyes while you talk to me”).

The boys were also encouraged to ask questions, and, social challenges consisted of engaging in a conversation with the therapist.  Social gaze was reinforced with praise, tokens, and access to leisure materials. Relaxation training preceded DTI sessions.

Researchers wanted to understand to what extent the use of DTI plus relaxation result in longer and better social gaze in fragile X boys, and if more intensive training  would  result in greater improvements.

Social gaze behavior was measured using an eye tracker. Physiological stress was recorded by monitoring the boys’ heart rate.

Over the course of treatment, social gaze duration improved significantly for six of the 10 boys who received the more intense training, and for three of the 10 who underwent less intense trials.

Boys receiving more intense (called high-dose in the study) training also showed greater improvement in social challenges compared to those in the other group.

“These results suggest that appropriate social gaze behavior can be successfully taught to boys with [fragile X] using a standardized behavioral skills training approach,” the researchers wrote.

“Although further research will be needed to determine whether these gains in social gaze can be generalized and maintained over time, overall, these data suggest that professionals should not be deterred from providing much needed target interventions for children with [fragile X],” they added.