Journal of Autism and Developmental Disorders (2021) 51:2578–2599

https://doi.org/10.1007/s10803-020-04731-w

ORIGINAL PAPER

Eye‑Tracking in Infants and Young Children at Risk for Autism

Spectrum Disorder: A Systematic Review of Visual Stimuli
in Experimental Paradigms
Ann M. Mastergeorge1 · Chanaka Kahathuduwa2 · Jessica Blume1

Published online: 4 October 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Eye-tracking represents a sensitive, direct measure of gaze allocation and goal-directed looking behaviors that correspond
to visual information processing. Clear definitions and standardization of research protocols to document the utility and fea-
sibility of these methods are warranted. This systematic review provides an account of stimuli dimensions and experimental
paradigms used in eye-tracking research for young children at risk for ASD published from 2005 through 2019. This review
identifies variability in eye-tracking protocols and heterogeneity of stimuli used for eye-tracking as factors that undermine the
value of eye-tracking as an objective, reliable screening tool. We underscore the importance of sharing eye-tracking stimuli
to enhance replicability of findings and more importantly the need to develop a bank of publicly available, validated stimuli.

Keywords  Eye-tracking · Screening · Gaze behavior · Infants · Young children

Eye-tracking represents a sensitive, direct measure of gaze
allocation and goal-directed looking behaviors that corre-
spond to information processing for a variety of visual stim-
uli (Elison et al. 2013; Gredebäck et al. 2010; Pierce et al.
2009). As such, over the past 10 years, eye-tracking research
has greatly expanded our understanding of both biological
and behavioral patterns of visual attention and gaze behav-
ior, especially in young children at risk for developmental
disorders including autism spectrum disorder (ASD; Falck-
Ytter et al. 2013a, b; Klin et al. 2009; Pierce et al. 2016). A
systematic review of both the content and context of studies
that have utilized eye-tracking could substantially improve
and advance the applications of eye-tracking as a reliable
assessment tool in infants and children at risk of being diag-
nosed with ASD.
* Ann M. Mastergeorge
ann.mastergeorge@ttu.edu
1
Department of Human Development and Family Sciences,
Texas Tech University, P.O. Box 41230, Lubbock,
TX 79409‑1230, USA
2
Department of Laboratory Sciences and Primary Care,
School of Medicine Department of Psychiatry, Texas
Tech University Health Sciences Center School of Health
Professions, Lubbock, TX, USA
Eye-tracking has several advantages as an assessment
tool for children with ASD. First, eye-tracking can be imple-
mented with very young infants (Elsabbagh et al. 2012; Gre-
debäck et al. 2010; Jones et al. 2008; Jones and Klin 2013),
possibly leading to earlier identification of gaze risk and
subsequent targeted interventions (Chawarska et al. 2013;
Elsabbagh et al. 2012; Jones and Klin 2013). However, not
all infants provide valid eye-tracking data (Aslin 2012).
Early risk identification has been a pivotal hallmark in ASD
intervention research in order to improve developmental out-
comes for young children at risk for ASD-associated delays
such as limited joint attention and social attention skills
(Davidovitch et al. 2018; Dawson et al. 2010; Janus et al.
2018; Zwaigenbaum et al. 2013). Particularly, Zwaigenbaum
et al. (2013) highlighted a growing evidence-base of ret-
rospective and prospective studies confirming differential
social attention patterns specific to ASD are often observ-
able by as early as 12 months of age. These authors sug-
gested eye-tracking as a promising experimental method for
identifying early markers of ASD during infancy, emphasiz-
ing the need for more published data based on infant popula-
tions. Second, eye-tracking provides quantitative data that
can be used potentially as biomarkers that indicate atypical
visual attention and possible information processing deficits
(Guillon et al. 2014; Klin et al. 2009; Pierce et al. 2016).
For example, Pierce et al. (2016) utilized eye-tracking to

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identify preferential looking at geometric vs. social images
as a predictive characteristic and biomarker of ASD in tod-
dlers. In their study, toddlers with ASD showed greater
fixation duration on dynamic geometric vs. dynamic social
images when compared to unaffected younger siblings of
ASD proband. Thus, this study suggested that particular
patterns in eye-tracking data could be used as valuable bio-
markers to discriminate between groups of young children
with and without ASD. Eye-tracking paradigms have been
successfully implemented in samples of children as young as
2 months later diagnosed with ASD (Jones and Klin 2013).
Third, eye-tracking is a highly objective, direct measure of
visual attention that is robust to biases associated with test
instruments that are commonly used to classify ASD and
determine response to intervention (Boraston and Blakemore
2007; Murias et al. 2018). For example, Murias et al. (2018)
examined the convergent validity of eye-tracking and tradi-
tional, indirect caregiver reports (i.e., responses to survey
instruments on behavior) of social communication in young
children with ASD. The authors reported a high degree of
agreement between the two methods in quantifying social
attention. However, given the objective nature of eye-track-
ing as compared to survey instruments that rely on subjec-
tive caregiver report (Boraston and Blakemore 2007), eye-
tracking could be considered a superior method, especially
for use as a screening tool and to examine the efficacy of
interventions in clinical trials. While eye-tracking has been
utilized to evaluate responsiveness to a variety of interven-
tion programs including visual-motor integration (Van Wyk
et al. 2012) and augmentative and alternative communica-
tion system training (Dube and Wilkinson 2014), eye-track-
ing paradigms are an especially practical tool for evaluating
social attention (van Rijn et al. 2018) and thus responsive-
ness to social-communication intervention programs as well.
Finally, eye-tracking provides researchers with opportunities
to examine complex visual scenes in a controlled manner
that mirrors real-life situations (Falck-Ytter et al. 2013a,
b). That is, participants are able to view objects, people,
and scenes, allowing the experimenters to recreate real-life
scenarios and study visual attention and gaze behavior in
such situations in a controlled environment. Taken together,
eye-tracking is a reliable technique that could be used to
study visual attention and gaze behavior even in very young
children with ASD, and also to differentiate children with
ASD from typically developing children at a very young age.
Eye-tracking studies conducted on children with or at risk
of being diagnosed with ASD primarily aim to establish evi-
dence of differential visual information processing and vis-
ual attention allocation in these target groups of children as
compared to typically developing children (e.g., Gharib et al.
2015; Key and Stone 2012a, b). Multiple eye-tracking gaze
behaviors that aim to differentiate children with ASD (or at
risk of developing ASD) from typically developing children
have been established to achieve this aim. For instance,
Jones et al. (2008) conducted an influential study in toddlers
with and without ASD to better understand attention to facial
features. This study was one of the first investigations of dif-
ferential visual fixation and preferential attention to specific
features of visual stimuli. Their results showed decreased
fixation to the eyes and increased fixation to the mouth of
an actress playing a game in toddlers with ASD, as com-
pared to toddlers with typical development and those with
delays not associated with autism. These results have been
corroborated (Jones and Klin 2013), further establishing a
connection between gaze allocation and preferential atten-
tion to a well-established characteristic of ASD, namely eye
contact and referential looking patterns. Of note, the afore-
mentioned studies as well as many others have focused on
differentiating individuals with ASD from neurotypical indi-
viduals rather than profiling ASD symptom severity. Com-
plex relationships between genetics, behavioral experiences,
and neurological development contribute to heterogeneity
in ASD and studies that use eye-tracking as a prognostic
indicator recognize the complications in findings attributable
to this heterogeneity (Bacon et al. 2020). Eye-tracking is
currently implemented to evaluate attention to social stimuli
with other, non-ASD samples of young children, including
children with Rett syndrome, Fragile X, Down Syndrome,
and Williams syndrome (D’Souza et al. 2020; Schwartzman
et al. 2015). While studies with different neurodevelopmen-
tal disorders have identified patterns similar to studies with
ASD samples such as reduced attention to faces, difficulty
with shifting attention, and reduced periods of social gaze,
most of this research has focused on adolescents and adults
(Crawford et al. 2016; Farzin et al. 2009; Hall et al. 2015)
and less has focused on younger populations and pivotal
issues related to looking and gaze patterns.
Referential looking and joint attention are two proximal
eye-tracking gaze behaviors that have been studied specifi-
cally in relation to ASD. Recent studies of elucidating gaze
patterns using dynamic stimuli corroborate evidence of sig-
nificant differences in fixation and eye movement between
objects and faces during initiating joint attention tasks,
unique to children with ASD (Billeci et al. 2016; Murias
et  al. 2018; Thorup et  al. 2016). Certain differences in
responsiveness to visual attention cues has also been linked
to high risk for ASD, with a notable reliance on both com-
posite eye and head cues rather than eye cues alone (Billeci
et al. 2016). Hence, eye-tracking is an effective method of
evaluating visual attention in a specific, quantitative man-
ner in order to better understand behavioral phenomena in
ASD. Eye-tracking technology is also a strong convergent
measure of social communication, yielding comprehensive
clinical intervention outcome data. Social communication
outcomes have been associated with visual attention to
social elements (i.e., an actor) unlike non-social elements
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2580
of a scene (i.e., toys), providing support for eye-tracking as a
valid assessment tool for identifying gaze behaviors of ASD
and response to intervention (Murias et al. 2018).
However, contrasting findings in recent studies question
the validity of use of eye-tracking as a potential early screen-
ing or diagnostic tool for ASD. Group differences in visual
attention in young, high risk children versus typically devel-
oping or low-risk children have indicated increased fixations
and fixation duration to objects or geometric images com-
pared to human faces and increased attention to non-salient
elements of larger social scenes (e.g., Billeci et al. 2016;
Chawarska et al. 2013; Pierce et al. 2016; Shic et al. 2011).
Later research, however, failed to confirm these previously
consistent findings and instead found absence of differences
between children with and without ASD (Campbell et al.
2014; Chawarska and Shic 2009). Suggested rationale for the
lack of differences in fixation duration include claims that
faces are not significantly different in observed patterns of
visual attention when compared to objects or other stimuli
components (Elsabbagh et al. 2013). However, these differ-
ences in results may instead reflect heterogeneity in the con-
tent and context of stimuli used in eye-tracking experiments
and also experimental preparation. Recent reviews of eye-
tracking methodology have also identified inconsistencies in
study results describing regions of facial fixation and orient-
ing to social stimuli that may be attributable to heterogeneity
in methodology and experimental preparation (Guillon et al.
2014; Papagiannopoulou et al. 2014). While eye-tracking is
an innovative and precise measurement method, reliable eye-
tracking systems are costly (Falck-Ytter et al. 2013a, b) and
measurement issues may arise regardless of the technology
quality. Further, analysis of eye-tracking data is not purely
objective; data quality can vary greatly across systems and
even participants, and researchers must evaluate data qual-
ity before specifying parameters for how data points will be
analyzed (Brunye et al. 2019; Orquin and Holmqvist 2018;
van Rijn et al. 2018). When combined with variations in
type of stimuli and setting, which can also influence eye-
tracking study results, eye-tracking does have limitations as
does any research measurement tool (Aslin 2012; Levantini
et al. 2020).
Clinical research in more traditional medical fields
emphasizes standardization of design, practice, and report-
ing methods in order to allow greater comparison across
research studies (e.g., Djulbegovic and Guyatt 2017; Hol-
mes et al. 2010). For example, Fischer and Milfont (2010)
argue that experimental control requires standardization of
research protocols that includes all aspects of the experi-
mental preparation, including set-up, stimuli, and meas-
urement. Therefore, clear definitions of research protocols
and features of eye-tracking studies (i.e., standardization) is
necessary to better understand findings and offer a strong
translational bridge from basic research to clinical utility in
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Journal of Autism and Developmental Disorders (2021) 51:2578–2599
distinguishing possible biomarkers and indicators of devel-
opmental risk. An established foundation of defined stim-
uli may strongly improve the field of eye-tracking in ASD
beyond simple descriptions of observed gaze differences
to more influential use of eye-tracking data for risk clas-
sification. Operational and categorical definition of stimuli
used in eye-tracking studies can assist previous and future
research endeavors in more efficient analyses of the state of
eye-tracking and ASD through improved consistency and
possible standardization of terms used to describe research
protocols. Classifying stimuli and components of eye-track-
ing studies are likely to offer additional clarity on context
with which to understand discrepancies and implications of
eye-tracking results for children at risk for ASD. In sum,
eye-tracking studies that utilize clearly defined stimuli with a
valid justification may support effective comparison, transla-
tion, and application of eye-tracking procedures and results.
Thus, discussion of the state of stimuli is a necessary step
in continuing to improve eye-tracking research by clarifying
methodology, establishing a general foundation for critical
analysis of experimental preparations and results, and allow-
ing for comparison across research groups and settings.
To date, no review, to our knowledge, has examined or
attempted to classify multiple dimensions of stimuli used in
eye-tracking studies with young children at risk for ASD.
Recent reviews have largely focused on social stimuli with-
out full comparison to non-social stimuli (i.e., Guillon et al.
2014; Papagiannopoulou et al. 2014) or clear definition and
comparison across additional stimuli dimensions and experi-
mental preparations. As such, in this systematic review, we
aim to provide an account of stimuli dimensions and experi-
mental paradigms used in eye-tracking research for young
children at risk for ASD. This systematic review specifi-
cally targets eye-tracking studies in children at risk for and
diagnosed with ASD published from 2005 through 2019.
The review sought to define common elements of visual
stimuli and descriptions of eye-tracking research protocols
and apply these definitions and descriptions to: (1) describe
reported use of eye-trackers and associated experimental
environments; (2) propose dimensional definitions for clas-
sification and comparison of stimuli; (3) identify patterns in
use of stimuli; and (4) provide recommendations for future
stimuli development, protocol design, and overall research.
Methods
Literature Search
This systematic review followed the Preferred Reporting
Items for Systematic Reviews and Meta-analyses Statement
(PRISMA; Moher et al. 2009) for conducting and report-
ing the findings. Three independent coders conducted the
Journal of Autism and Developmental Disorders (2021) 51:2578–2599 2581
original literature search with the objective of identifying
recent studies utilizing eye-tracking to study young children
at risk for and/or diagnosed with ASD. The coders searched
MEDLINE, Scopus, PsychINFO, and Web of Science data-
bases for journal article records published between 2005
and 2019 using specific keyword combinations across. The
following keywords were entered according to syntax guide-
lines of each database: (eye-tracking OR eye tracking) AND
(child OR children OR infant OR infants OR toddler OR
toddlers OR pre-school OR preschool OR pre-k OR prek
OR young OR early life) AND (autism OR autism spectrum
disorder OR autism spectrum disorders OR ASD OR autis-
tics) AND (risk OR at risk OR high risk OR diagnosed OR
screened). All identified records were pooled, and duplicates
were removed.
Following the original search, abstracts from identified
records were examined for pre-defined exclusion criteria: (a)
non-English language publication, (b) non-human study, and
(c) non-availability of full-text article. Full-text versions of
articles that passed the original search and exclusion screen-
ing were evaluated further for eligibility by two independent
research personnel (κ = .95). Included studies were required
to have all child participants falling within the age range of
0 to 8 years 11 months with at least one participant group
indicating a developmental status of at risk for autism, high
risk for autism, and/or showing signs of autism. The focus
of this study is on young children; while some reviews apply
an age cutoff of 5 or 6 years for young children (French and
Kennedy 2018), we extended our range to age eight in order
to encompass all ages as defined as part of early childhood
age ranges (World Health Organization 2020). Eligible stud-
ies also specified a research design with child participation
in an eye-tracking protocol.
Age range of participants, specific eye-tracker technology
(i.e., name and speed/Hz), and information regarding stimuli
were extracted from eligible records in order to describe and
characterize stimuli elements used in studies of eye-tracking
in young children at risk for ASD (See Table 1). Remaining
articles with questionable eligibility were discussed between
the two research personnel in order to make a decision on
inclusion or exclusion from the review. Final decisions were
confirmed with a senior researcher. Consensus coding was
also completed on all records to confirm agreement for char-
acterization of all stimuli elements.
Data Extraction
Studies that met eligibility were examined to extract data
regarding the following elements of interest: eye-tracking
hardware (i.e. eye-tracking technology, sampling rate, stimu-
lus presenting devices), eye-tracking environment (i.e. posi-
tioning of participants, distance to the stimulus presenting
device, lighting of the eye-tracking laboratory, presence or
absence of a caregiver and their position), and quantity and
characteristics of stimuli used.
Quantity of Stimuli
Stimulus quantity was defined as the number of distinct
visual stimuli presented to each participant during the eye-
tracking session. Specific finite values were used for each
study. Multiple presentations of the same stimulus were not
coded as multiple stimuli, as quantity reflected distinct, dif-
ferent stimuli used in each study.
Characteristics of Stimuli
Stimuli from each included study were also described
according to defined dimensions for (a) type, (b) form,
(c) design, and (d) participant exchange. These stimulus
dimensions were mutually exclusive, i.e., if a more complex
dimension was included in the stimuli set, the higher, more
complex dimension was coded and stimuli defined according
to that complex dimension (see Duchowski 2017 for discus-
sion of complexity in stimuli). Stimuli type described the
content of the stimuli and was coded as either social, the
more complex dimension, or non-social. Social stimuli were
defined as stimuli that presented visual images of human
faces and/or human characters displaying facial expressions
or emotions. Non-social stimuli were stimuli that lacked
human character images and included visuals of objects or
geometric figures (e. g., apples in Kaldy et al. 2011 and
clothing in Venker et al. 2019). Stimuli design referred to
the on-screen visual scene presentation of the stimuli as
either paired, the more complex dimension, or single. Paired
stimuli were defined as stimuli preparations that presented
two distinct images concurrently in a comparative manner
(e.g., visual paired comparison or joint attention compara-
tive presentation as described in Billeci et al. 2016 or Navab
et al. 2012).
Single stimuli were defined as visual images presented as
one complete scene without distinction, division, or com-
parison (e. g., photographs of faces in Guillon et al. 2015 or
pictures of landscapes, toys, faces, and animals in Ander-
son 2006). Stimuli form characterized stimuli according
to action or movement of the visual image and was coded
as dynamic, the more complex dimension, or static. These
dynamic stimuli were defined as visual images presented
in a video-based, moving action format. Static stimuli
included still visual images without accompanying video-
features, action, or movement. Participant exchange was the
final element defined for all stimuli and addressed meas-
ured participant interaction with the stimuli across active,
which was more complex, or passive dimensions. Active
exchange was defined as interaction in which the partici-
pant was prompted to respond to stimuli when presented
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Table 1  Characteristics of 95 studies that survived eligibility screening and their study aims
2582

Study Sample Mean age (range) Hardware ­specifications1 Study aims

size

13
(female)

Amso et al. (2014) 30 3.63 years SensoMotoric Instruments RED, model not Compared bottom-up and top-down attention
(12) (2–5 years) listed; sampling rate NR; 22-inch monitor with orienting to social stimuli between children with
child seated 70 cm from monitor ASD and neurotypical children
Anderson (2006) 24 48.85 months Applied Science Laboratory Model 504; sam- Contrasted the visual scanning patterns and pupil-
(2) (12–72 months) pling rate NR; 40.6 cm monitor with child lary responses of children with ASD and neuro-
secured in a car seat attached to a chair with eye typical children to landscape scenes versus faces
height adjusted to 123.5 cm from floor
Aresti-Bartoleme and Garcia-Zapirain (2015) 40 NR Tobii X1Light; 32 Hz; 21-inch touch screen Evaluated the social interactions between thera-
(NR) (3–8 years) device with 40 cm tactile pointer pists and children with ASD during a game using
eye-tracking technology
Bacon et al. (2018) 299 16.84 months Tobii T120; 120 Hz; 17-inch monitor with child Appraised differences in clinical phenotype
(82) (12–24 months) seated in parent’s lap 60 cm from monitor in a between early and late diagnosed toddlers with
dark room ASD
Bacon (2014) 52 10.15 months Tobii T120; 120 Hz; 17-inch monitor with infant Investigated early developmental trajectories
(23) (10–11 months) positioned in caregiver’s lap 60 cm from moni- and behavioral markers specific to late ASD
tor in dark room diagnosis
Barone et al. (2019) 45 37.86 months Tobii T60; 60 Hz; 17-inch monitor with infant Assessed word recognition accuracy of neurotypi-
(8) (21–61 months) seated in caregiver’s lap 60 cm from monitor cal preschoolers and preschoolers with ASD
across semantic categories
Bedford et al. (2012) 73 10.55 months Tobii 1750; 50 Hz; 17-inch monitor with infant Compared differences in gaze following behaviors
(NR) (7–13 months) seated on parent’s lap 50 cm, from monitor and attentional engagement between infants at
risk for ASD, low risk infants, and siblings of
children with ASD
Billeci et al. (2016) 32 26.05 months SensoMotoric Instruments, model not listed; Identified differences in visual patterns during
(5) (18–30 months) 120 Hz; 22-inch monitor with toddler seated on responding to joint attention and initiating joint
age-appropriate chair 50 cm from monitor attention tasks between toddlers with ASD and
typically developing toddlers
Bradshaw et al. (2019) 51 32.36 months SensoMotoric Instruments iView X-Version 2.8; Analyzed social preference and face scanning
(13) (18–48 months) 120 Hz; 22-inch monitor with child positioned eye-tracking behaviors as a biomarker tool to
in car seat 65 cm from monitor measure response to intervention for children
with ASD
Bradshaw et al. (2011) 42 37.5 SensoMotoric Instruments iView X RED; 60 Hz; Evaluated simple object, complex pattern, and
(12) months 20-inch monitor with child secured in car seat facial recognition skills of neurotypical children
(36–48 months) 75 cm away and children with ASD in a visual paired com-
parison paradigm
Braukmann et al. (2018) 52 10.15 months Tobii T120 or TX300; sampling frequency NR; Explored high and low ASD risk infants’ anticipa-
(23) (10–11 months) monitor size NR, child seated in infant chair or tory eye movements while viewing usual and
parent’s lap 65 cm from monitor unusual actions with everyday objects
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
 Table 1  (continued)
Study
Chawarska et al.(2016a)
Chawarska et al. (2016b)
Chawarska et al. (2013)
Chawarska et al. (2012)
Chita-Tegmark et al. (2015)
Congiu et al. (2016)
De Wit et al. (2008)
DeLaurentis (2008)
Dundas et al. (2012)
Elison et al. (2013)
13
Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)
169 20.5 months SensoMotoric Instruments iView X RED; 60 Hz; Assessed differences in the latent structure of
(37) (11–26 months) 24-inch monitor with toddler seated in a car spontaneous social attention between toddlers
seat in front of monitor in a dark and sound- with ASD and a control group
proof room
162 6.35 months SensoMotoric Instruments iView X RED; 60 Hz; Examined sex differences in social orienting of
(59) (6–12 months) 24-inch monitor with infant seated in a car infants with a high genetic risk for ASD
seat 75 cm in front of monitor in a dark and
soundproof room
84 6.27 months SensoMotoric Instruments iView X RED; 60 Hz; Analyzed associations between atypical spontane-
(30) (6 months) 24-inch monitor with infant seated in car seat ous social monitoring skills and later diagnosis
75 cm from monitor in a dark and soundproof of ASD
room
84 20.9 months SensoMotoric Instruments iView X RED; 60 Hz; Investigated social attention in varying contextual
(31) (13–25 months) 24-inch monitor with toddler positioned in car conditions across children with ASD, children
seat 75 cm from monitor in a dark and sound- with developmental delays, and neurotypical
proof room children
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
119 87.81 months Tobi T60; 60 Hz; infant seated in parent’s lap Measured differences in vocabulary knowledge and
(81) (18–36 months) 60 cm from monitor lexical processing speed between children at high
risk for ASD with no ASD outcome and low risk
controls
50 5.75 years Tobii T60; 60 Hz; 17-inch monitor with child Compared spontaneous gaze following between
(NR) (3–9 years) seated in adjustable height chair 65 cm from young children with ASD and typically develop-
monitor ing children
27 60.5 months (38–75 months) Tobii 1750; 50 Hz; 17-inch monitor with child Evaluated scanning patterns of neurotypical
(6) seated on a chair 60 cm from monitor in low children and children with ASD while viewing
light conditions positive and negative emotional expressions
151 7.23 months Tobii 1750; 50 Hz; 17-inch monitor with infant Determined gaze behavior and face processing
(NR) (6–12 months) seated in caregiver’s lap 60 cm from monitor skills as an early indicator of ASD in siblings of
children with ASD
74 9.55 months Tobii X120; 60 Hz; infant seated in a high chair Contrasted differences in amount of attention
(31) (6–11 months) 162 cm in front of a 69 × 91 cm projection allocated to left versus right half of face between
screen with guardian seated in chair behind infants at high risk of ASD and low risk
infant in a quiet and dark room
97 7.08 months Tobii 1750 and × 120; 50–60 Hz; no other setup Assessed predictive value of oculo-motor function-
(42) (6–8 months) information listed ing and visual orienting behaviors patterns at
7 months in later ASD diagnosis by identifying
neural correlates of observed oculo-motor func-
tioning and visual orienting behaviors
2583

Table 1  (continued)
Study
13
Elsabbagh et al. (2014)
Elsabbagh et al. (2013)
Falck et al. (2018)
Falck-Ytter et al. (2015)
Falck-Ytter et al. (2013a, b)
Falck-Ytter et al. (2012)
Falck-Ytter et al. (2010)
Franchini et al. (2017)
Frazier et al. (2016)
Fujisawa et al. (2014)
Gliga et al. (2015a)
Gliga et al. (2015b)
2584
Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)
104 NR Tobii system with no model listed; 50 Hz; Measured the predictive relationship of context-
(62) (6–15 months) 17-inch monitor with infant seated on parent’s dependent visual scanning patterns and later
lap 50–55 cm from screen communication and social skill patterns of
infants with and without familial risk of ASD
104 7.35 months Tobii system with no model listed; 50 Hz; Evaluated infants’ selective orientation to faces and
(62) (6–10 months) 17-inch monitor with infant seated in parent’s subsequent allocation of visual attention to non-
lap 50–55 cm from monitor social scene objects
47 10.24 months Tobii TX300; sampling rate NR; monitor size Identified differences between infants with high
(24) (9–12 months) NR; infant positioned in caregiver’s lap 60 cm and low ASD risk in visual orientation to audio-
from screen visual synchrony with biological motion
36 41.97 months Tobii T120; 60 Hz; 17-inch screen with child Analyzed gaze following patterns in typically
(12) (28–60 months) placed 60 cm in front of monitor developing, developmentally delayed, and ASD
3-year-olds and toddlers
24 41.9 months (3–4 years) Tobii T120; sampling rate NR; monitor size and Assessed visual orienting behaviors of children
(5) setup notes NR with ASD and neurotypical children in response
to displays of audiovisual synchrony and biologi-
cal motion
86 6 years Tobii T120; 60 Hz; 17-inch monitor with experi- Explored gaze patterns of children with ASD,
(NR) (5–7 years) menter seated behind child children with PDD_NOS, and neurotypical chil-
dren during point-gesture and spontaneous gaze
following tasks
30 5 years Tobii 1750; 50 Hz; 17-inch monitor with child Connected the social-emotional behavior and non-
(7) (4–5 years) seated in chair 60 cm from monitor with experi- verbal communication strengths of children with
menter and parent seated behind child ASD to patterns of attention allocation to actors’
eyes, mouth, and manual action cues
60 32.40 months Tobii T60XL and TX300; 60–300 Hz; 17-inch Compared the relationship between children
(17) (14–57 months) monitor with child seated on parent’s lap 60 cm with ASD’s joint attention and communication
from monitor behaviors and time spent viewing dynamic social
images
79 5.53 years SensoMotoric Instruments RED-m and RED 250; Developed an objective eye-tracking based meas-
(16) (3;0 to 8;11 years) 60–120 Hz; 19-inch monitor with child seated ure, the autism risk index
independently or in parent’s lap 65 cm from
screen with standard room lighting
73 54.6 months Gazefinder; 50 Hz; 19-inch monitor with child Examined the relationship between oxytocin levels
(35) (25–72 months) seated on parent’s lap 40 cm from monitor and visual attention for social information
109 NR Tobii T120; 120 Hz; infant seated on parent’s lap Evaluated associations between superior percep-
(50) (9–24 months) 60 cm from monitor tion, social interaction, and communication
symptoms, and autism symptoms
104 18.02 months Tobii 1750; 50 Hz; infant seated on parent’s lap Assessed visual foraging behaviors in siblings of
(55) (6–36 months) 60 cm from monitor children with ASD and controls
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
 Table 1  (continued)
Study Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)

Gliga et al. (2014) 133 38.68 months Tobii T120; 60 Hz; 17-inch monitor with child Characterized the association between mental state
(48) (33–52 months) seated independently on a chair placed 60 cm understanding for action prediction, as measured
from monitor through eye-gaze, and profiles of ASD
Groen et al. (2012) 69 3.4 years Tobii T120; 60 Hz; 17-inch monitor with child Correlated parents’ gaze patterns during non-social
(27) (1–7 years) positioned 70 cm from monitor and parent in movies with children’s gaze patterns and ASD
another room symptom severity
Guillon et al. (2015) 41 42.3 months (2–5 years) Tobii T120; 60 Hz; 17-inch monitor with child Analyzed face scanning patterns of preschoolers
(12) secured in car seat 60 cm from monitor and with ASD and neurotypical preschoolers using
light levels standardized fixation time measures and a novel complemen-
tary network analysis
Gyori et al. (2016) 20 61.54 months Eyefollower 2; 120 c/sec.; 22-inch monitor with Described data quality from an interactive social
(NR) (41–78 months) parent permitted to stay in the room game prototype
Hannigen et al. (2014) 128 9.22 months Tobii X120; 60 Hz; infant placed in high chair Identified discrepancies in facial expression
(57) (6–11 months) and seated 162 cm in front of projection screen production and perception at 2 points in infancy
and 81 cm in front of eye-tracker between infants with high risk for ASD and with
low risk
Journal of Autism and Developmental Disorders (2021) 51:2578–2599

He et al. (2019) 42 60.21 months SensoMotoric Instruments RED 250; 120 Hz; Characterized profiles of kindergarteners with mild
(8) (45–83 months) 22-inch monitor with child positioned or moderate ASD by facial emotion recognition
60–80 cm from monitor in a quiet and well-lit and intelligence profiles
room
Hendry et al. (2018) 143 21.86 months Tobii 120; 60 Hz; 17-inch monitor with infant Determined whether early differences in duration
(65) (9–36 months) seated in caregiver’s lap 50–55 cm from moni- of attention to visual stimuli is associated with
tor early differences in executive attention
Hosozawa et al. (2012) 66 3.64 years Tobii 1750; 120 Hz; 17-inch monitor with child Compared gaze behavior patterns of typically
(20) (2–5 years) seated 60 cm from monitor sitting indepen- developing children, children with ASD, and
dently or in parent’s lap children with specific language impairment
Johnels et al. (2014) 40 3 years Tobii T120; 60 Hz; 17-inch monitor with child Correlated proportion of time allocated to viewing
(9) (2–5 years) seated in chair 60 cm from monitor and experi- various facial regions to language comprehension
menter seated behind child profiles in children with ASD and neurotypical
children
Jones and Klin (2013) 110 NR ISCAN; 60 Hz; 20-inch monitor and infant posi- Defined periods and patterns of change in eye
(NR) (2–24 months) tioned in developmentally appropriate support fixations in the first 6 months of development
(i.e., bassinet or car seat) uniquely indicative of ASD
Jones et al. (2008) 66 2.1 years ISCAN; 60 Hz; 20-inch monitor with child Characterized preferential attention patterns of tod-
(20) (2–3 years) secured in car seat 30 cm from monitor with dlers with and without ASD to regions of social
caregiver in room stimuli
Kaldy et al. (2011) 34 29.6 months (21–35 months) Tobii T120; sampling rate NR; monitor size Assessed visual search skills of infants with and
(13) NR, child seated in caregiver’s lap 70 cm from without ASD
monitor with caregiver’s eyes closed

13
2585

Table 1  (continued)
Study
13
Keemink et al. (2019)
Key and Stone (2012a)
Key and Stone (2012b)
Kleberg et al. (2019)
Klin et al. (2009)
Kou et al. (2019)
Krogh-Jespersen et al. (2018)
Merin et al. (2007)
Murias et al. (2018)
Navab et al. (2012)
2586
Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)
162 9.56 months (6–12 months) Eyelink 1000 + ; 500 Hz; 20-inch monitor with Explored face scanning and social interaction
(83) child fastened in car seat attached to chair, behavior patterns of neurotypical infants and
positioned 60 cm from monitor in a room with infants at risk for ASD within a gaze-contingent
dim lighting eye-tracking paradigm
35 8.96 months Tobii X50; sampling rate NR; 19-inch monitor Analyzed differences in visual processing of facial
(12) (8–10 months) with infant seated in parent’s lap 20 inches from features between infants at average or high risk
monitor in a dark, sound-attenuated room for ASD and determined whether the aforemen-
tioned differences are associated with social and
communication skills
35 9.11 months Tobii X50; sampling rate NR; monitor size NR; Measured whether infant siblings of children
(13) (8–10 months) infant seated in parent’s lap 20 inches from with ASD differentially process familiar and
monitor novel faces compared to typical infants based on
associations between infant sensitivity to face
familiarity and infants’ social and communica-
tion behaviors
99 10.18 months Tobii 1750 or Tobii TX300; 50–120 Hz; 17–23 Contrasted the visual attention of neurotypical
(53) (9–11 months) inch monitor with child seated in parent’s lap infants and high-ASD risk infants to emotionally
60 cm from monitor expressive faces
76 2.1 years (1.4.–2.7 years) ISCAN; 60 Hz; 20-inch monitor, child secured Compared visual orientation to displays of biologi-
(NR) in a car seat 30 inches from monitor with car- cal motion among toddlers with and without
egiver in room ASD
66 3.92 years (2–7 years) Tobii TX300; 60 Hz; 23-inch monitor with child Investigated the efficacy of using three different
(15) seated alone or in caregiver’s lap visual preference paradigms as a biomarker for
ASD risk
75 24.67 months Tobii T120; 60 Hz; 17-inch monitor with child Described variation in predictive reasoning skills
(25) (14–36 months) positioned in parent’s lap 60 cm from screen between toddlers with ASD and typically devel-
oping infants
55 5.99 months Tobii ET-17, sampling rate NR; monitor size NR; Examined differences in visual fixation patterns
(24) (5–7 months) parent seated in a room adjacent to infant with during a live sound and image modified Still
infant on a researcher’s lap Face paradigm between infants with a sibling
diagnosed with ASD and a comparison group
25 53.6 months Tobii TX300; 120 Hz; child seated in parent’s lap Evaluated the relationship between eye-tracking
(4) (27–71 months) with standard room lighting and volume responses and caregiver-reported social com-
munication behaviors as outcomes measures for
ASD clinical trials
40 NR Tobii 1750; 50 Hz; 17-inch monitor with infant Determined consistency of responsive joint
(17) (17–19 months) seated on parent’s lap 65 cm from monitor attention assessment findings with eye-tracking
measures and the Early Social Communication
Scales (ESCS)
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
 Table 1  (continued)
Study Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)

Nele et al. (2015) 59 5.24 months Tobii T60, 60 Hz; 17-inch monitor with infant Analyzed differences in face processing between
(19) (4–6 months) seated on parent’s lap 60 cm from monitor in a infants at high risk for ASD and low risk
dimly lit room
Noris et al. (2012) 20 4.3 years (1.2–8.8 years) WearCam; 25 Hz; child wore head mounted Assessed attention to social partner’s face and
(2) camera while interacting with experimenter and proximal environmental elements in a naturalistic
caregiver remained seated behind child play task in children with and without ASD
Nuske et al. (2015) 42 4.1 years Tobii T120; 60 Hz; 34 cm monitor with child Contrasted visual attention and pupil dilation
(6) (2–5 years) seated in a chair 60 cm from monitor and light- patterns in response to mutual and averted social
ing standardized gaze between children with ASD and neurotypi-
cal children
Nuske et al. (2014) 44 4.2 years Tobii T120; 60 Hz; 34 cm monitor and child Differentiated pupillary reactions of children
(7) (2–5 years) positioned in a chair 60 cm from monitor with with and without ASD in response to emotional
standardized lighting expressions from familiar versus nonfamiliar
faces
Nyström et al. (2019) 112 10.4 months (10–18 months) Tobii TX300; 120 Hz; no monitor used, infant Investigated initiating joint attention and respond-
(58) seated in parent’s lap 200 cm from adult experi- ing to joint attention behaviors of infants at high
Journal of Autism and Developmental Disorders (2021) 51:2578–2599

menter seated at table across from parent and low risk of ASD with live eye-tracking
Nyström et al. (2017) 78 10.41 months Tobii TX300; 120 Hz; infant seated in parent’s Identified differences in response to others’ direct
(44) (9–11 months) lap 200 cm from a test leader seated with eye gaze between infants at high risk for ASD and a
tracker placed between test leader and infant control group
Nyström et al. 2015 44 10.24 months Tobii 1750; 50 Hz; infant positioned in car seat Compared pupillary light reflex responses between
(23) (9–11 months) supported posteriorly by parent in a room with infants with an older sibling with autism and
ambient light level of 0.9 lx matched controls
Parikh et al. 2017 73 7.64 months Tobii T60; 60 Hz; 17-inch screen with infant Measured longitudinal gaze patterns of infants and
(32) (3–24 months) placed in high chair 65 cm from monitor and toddlers related to language development and
parent seated in adjacent chair facing opposite joint attention skills
direction of monitor
Parsons et al. (2019) 124 14.93 months Tobii T120; 60 Hz; monitor size NR; child seated Examined associations between gaze following
(56) (13–16 months) in parent’s lap 60 cm from monitor and attention allocation behaviors during a word
learning task with later verbal skills and ASD
symptom severity
Pierce et al. (2016) 334 24.17 months Tobii T120; 120 Hz; 17-inch monitor Analyzed potential of unusual patterns of visual
(113) (10–49 months) preference as an early biomarker of ASD or
subtype of ASD
Pierce et al. (2011) 110 24.93 months Tobii T120; 120 Hz; 17-inch screen with toddler Assessed whether toddlers with ASD demon-
(30) (14–42 months) seated on parent’s lap 60 cm from monitor and strate a visual preference for dynamic geometric
room lights turned off images over social images and whether visual
fixation patterns correctly result in a toddler’s
classification as ASD

13
2587

Table 1  (continued)
Study
13
Righi et al. (2018)
Rutherford et al. (2015)
Sasson and Touchstone (2014)
Sasson et al. (2011)
Sekigawa-Hosozawa et al. (2017)
Senju et al. (2010)
Shi et al. (2015)
Shic et al. (2019)
Shic et al. (2014)
Shic et al. (2011)
Shic et al. (2008)
Smith et al. (2019)
2588
Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)
77 4.26 years SensoMotoric Instruments RED500; 60 Hz; Appraised consistencies between typically
(20) (1.09–8.98 years) 19-inch monitor with child seated 70 cm from developing children and children with ASD in
screen processing of audio-visual synchrony
62 7.5 months Tobii 60x; 60 Hz.; 52 cm. monitor with child Described differences in facial feature scanning
(28) (3–12 months) seated in car seat 60 cm from screen in a well- between infants at high and low risk for ASD
lit room
30 43.1 months (2–5 years) Tobii T60 XL; 60 Hz; 24-inch monitor with child Analyzed visual exploration and perseveration
(2) seated in parent or teacher’s lap 60 cm from trends while children with and without ASD
monitor view picture arrays
22 41.4 months (2–5 years) Tobii 1750; 50 Hz; 17-inch monitor with child Contrasted visual attention preference, prioritiza-
(2) seated 60 cm from monitor tion, and duration patterns of children with and
without ASD in response to faces presented with
objects related to and unrelated to circumscribed
interests
47 28.36 weeks Tobii X120; 50 Hz; monitor size NR, described Evaluated viewing behaviors of very preterm
(26) (27–29 weeks) stimuli and design as consistent with previous children that reflect social difficulties
studies
29 7.6 years Tobii 2150; sampling rate NR; 20-inch monitor Identified differences in action anticipation and
(9) (6–9 years) with child seated 50 cm from monitor false belief attribution between children with and
without ASD
33 59.2 months EyeLink 1000; 500 Hz; 60 cm monitor with child Discerned variations in visual preference to
(7) (3–8 years) seated in chair or parent’s lap 60 cm from moni- dynamic geometric versus social images from
tor and room lights turned off children with ASD and neurotypical children
97 22.36 months iView X RED; 60 Hz; 24-inch monitor with child Characterized patterns of visual attention to faces
(29) (18–26 months) positioned in a car seat in a dark soundproof in the context of direct gaze and speech produc-
room 65 cm from monitor tion observed with neurotypical toddlers and
toddlers with ASD
99 6.32 months SensoMotoric Instruments iView X RED; 60 Hz.; Compared eye gaze patterns of high and low ASD
(NR) (5–7 months) 24-inch monitor with child placed in a car seat risk infants in response to faces in a variety of
75 cm from screen conditions
78 19.9 months (16–24 months) SensoMotoric Instruments, model NR; 60 Hz; Differentiated social activity monitoring patterns
(24) monitor size NR, toddler secured in car seat of toddlers with ASD, toddlers with developmen-
placed 75 cm from monitor in a dark room with tal delay, and neurotypical toddlers
caregiver standing 6 feet behind toddler
51 35 months (19–49 months) SensoMotoric Instruments, model NR; 60 Hz; Examined trends in fine and gross visual attention
(NR) monitor size ranged from 20–24 inches, child to static faces demonstrated by children with and
positioned 75 cm from monitor without ASD
59 27.36 months Tobii T120; 60 Hz; 17-inch monitor, caregiver Assessed attentional set-shifting behavior of neuro-
(18) (15–37 months) holding child in lap 65 cm from monitor with typical toddlers and toddlers with ASD within a
eyes closed or wearing blacked-out sunglasses visual search task
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
 Table 1  (continued)
Study
Tenenbaum et al. (2014)
Tenenbaum et al. (2017)
Thorup et al. (2016)
Thorup et al. (2018)
Trembath et al. (2015)
Vargas-Cuentas et al. (2017)
Venker et al. (2019)
Vernetti et al. (2018)
Vivanti & Dissanayake (2014)
Vivanti et al. (2014)
Wagner et al. (2016)
Wagner et al. (2018)
13
Sample Mean age (range) Hardware ­specifications1 Study aims
size
(female)
38 2.65 years SensoMotoric Instruments RED500; 60 Hz; Identified associations of early word learning and
(7) (2–5 years) 19-inch monitor with child seated on a car- language abilities with patterns of attention in
egiver’s lap or chair 70 cm in front of screen children with ASD, language delays, and typical
development
38 33.52 months SensoMotoric Instruments RED500; 60 Hz; Investigated the potential of facilitating word learn-
(10) (18–72 months) 19-inch monitor with child seated on caregiv- ing by directing attention to relevant areas of
er’s lap 70 cm from monitor visual scenes
64 10.26 months Tobii TX300; 120 Hz; infant seated on caregiv- Analyzed gaze following behaviors of infants at
(32) (9-11 months) er’s lap 200 cm from experimenter risk for ASD specific to information conveyed by
eyes, head movements, or a combination
67 10.43 months Tobi TX300; 120 Hz; infant seated in parent’s lap Evaluated infant gaze behavior while interacting
(35) (9–11 months) 200 cm from experimenter seated at a low table live with an adult in an initiating joint attention
in between two remote controlled lamps eliciting task
61 47.9 months (30–60 months) Tobii T120; 120 Hz; monitor size NR, child Compared visual attention during an instructional
(18) seated 60 cm from monitor video with and without picture cues among
children with ASD, children with developmental
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
delays, and neurotypical children
31 3.75 years Tablet-camera system designed for study; 60 Hz; Determined consistency of an eye-tracking
(16) (2–6 years) child seated in caregiver’s lap 30 cm from tablet algorithm accurately assessing gaze preferences
screen at a 90-degree angle associated with ASD
51 30.8 months (24–36 months) Tobii X2-60; 60 Hz; 55-inch monitor with tod- Examined data loss and patterns of results with
(11) dler positioned in caregiver’s lap while wearing manual gaze coding versus automatic eye-track-
opaque sunglasses ing for toddler participants with ASD
118 26.48 months Tobii T120; 60 Hz; 17-inch monitor with child Compared toddlers’ reward related behaviors
(52) (25–57 months) seated in caregiver’s lap 60 cm from monitor attributable to variations of social video stimuli
50 45 months (21–72 months) Tobii 1750; 60 Hz; monitor size NR, child seated Classified differences in preschoolers’ imitation
(15) 60 cm from monitor and visual attention behaviors in direct gaze and
averted gaze conditions
48 45.4 months (32–58 months) Tobii 1750; 60 Hz; monitor size NR, child posi- Assessed how children with and without ASD
(14) tioned in chair 60 away from monitor allocate visual attention to incomplete demon-
strations of an action with overt versus neutral
signals of goal-directedness
49 9.22 months Tobii T60; 60 Hz; 17-inch monitor with infant Measured autonomic responses and visual scan-
(19) (8–10 months) seated on caregiver’s lap 60 cm from monitor ning behaviors of infants at risk for ASD with
and room light limited to a small lamp behind a social stimuli
black curtain
77 6.35 months Tobii T60; 60 Hz; 17-inch monitor with infant Identified differences in eye tracking to familiar
(33) (5–7 months) seated on caregiver’s lap 60 cm from monitor in and unfamiliar faces between infants at high risk
a dark room for ASD and controls
2589


Table 1  (continued)
2590

Study Sample Mean age (range) Hardware ­specifications1 Study aims

size

13
(female)

Wagner et al. (2019) 111 NR Tobii T60; 60 Hz; 17-inch monitor with infant Investigated attentional disengagement patterns of
(43) (6–12 months) positioned in caregiver’s lap in a dimly lit room neurotypical infants and infants at high risk for
60 cm from monitor ASD during presentation of emotional faces with
a peripheral distractor
Wass et al. (2015) 94 7.6 months (6–9 months) Tobii 1750; 50 Hz; monitor size NR, infant seated Compared fixation duration of infants at high and
(58) in mother’s lap low risk for ASD while observing static images
Yamashiro et al. (2019) 58 NR SensoMotoric Instruments RED-m; 60–120 Hz; Characterized preferential looking patterns
(27) (6–18 months) 29 cm by 47 cm monitor with child seated in observed from neurotypical infants and infants
a highchair 60 cm from monitor in a sound later diagnosed with ASD with human and non-
attenuated room human primate faces
Young et al. (2009) 58 NR Tobii ET-17; 30 Hz; parent in adjacent room with Evaluated associations between gaze behavior and
(26) (6–24 months) live video and sound display on monitor affect from 6–24 months in order to compare
developmental trajectories
Zantinge et al. (2017) 73 4.69 years Tobii T120; 120 Hz; child seated in adjustable Compared social attention toward faces and
(10) (3–7 years) height chair at table 6 cm from monitor changes in affective arousal between young chil-
dren with ASD and a control group

NR indicates this item was not reported in the reviewed study

1
 Eye-tracker model, sampling frequency, monitor size and set-up are listed in order
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
Journal of Autism and Developmental Disorders (2021) 51:2578–2599 2591
and preparations in which participant responses to prompts
or engagement with the stimuli were documented. Passive
exchange was coded for stimuli in which the participant was
simply observing the visual images in a free viewing manner
without requirements of direct engagement or measured par-
ticipant responses. All stimuli, as described in the methods
of included studies, received quantity values and dimension
codes, with agreement and consensus of the authors. These
values and codes were used to more clearly and consistently
define the state of stimuli used in eye-tracking studies of
young children at risk for ASD.
Results
Outcomes of Database Search
Results of the initial database search and subsequent screen-
ing are summarized in a PRISMA flow chart (See Fig. 1).
All of the included studies were published from 2005
through 2019 and used eye-tracking protocols with children
ages 0 to 8 years 11 months, at risk for or diagnosed with
ASD. The initial database search with MEDLINE, Sco-
pus, PsychINFO, and Web of Science yielded 286 records
Fig. 1  PRISMA flow chart of
publication selection for the sys-
tematic review
matching key word criteria. An additional 128 records were
identified following the initial database search when look-
ing at the table of contents of a recently published textbook
edition and identifying a related meta-analysis. A total of
163 duplicate records were removed, and the remaining 251
articles were further screened. Due to failure to screening
criteria, 14 articles were removed; 237 articles were assessed
for eligibility. An additional 142 articles were excluded due
to failure to meet full inclusion criteria. Thus, 95 articles
were included in the systematic review.
Eye‑Tracking Hardware
Reported eye-tracker devices and technology was more con-
sistent among the reviewed studies, with a majority of stud-
ies utilizing Tobii systems. Types of eye-trackers used in the
reviewed studies included: Tobii X1Light (Aresti-Bartoleme
and Garcia-Zapirain 2015), Tobii 1750 (Bedford et al. 2012),
Tobii T60 (Nele et al. 2015), Tobii X120 (Sekigawa-Hoso-
zawa et al. 2017), Tobii TX300 (Thorup et al. 2018), Tobii
ET-17 (Young et al. 2009), and SensoMotoric Instruments
IView X RED (Righi et al. 2018). Therefore, a majority of
the reviewed studies remained consistent in terms of the uti-
lized eye-tracker technology.
13

2592
However, substantial variability of the eye-tracker param-
eters and stimulus presenting hardware was observed among
the reviewed studies (see Table 1 for a description of eye-
tracker information for each study and related study aims).
First, despite the use of Tobii systems in most studies, the
sampling rate varied across studies. Sampling rates ranged
between reported 30 Hz (Young et al. 2009) and 500 Hz
(Keemink et al. 2019; Stagg et al. 2014), with the majority
of studies reporting a sampling rate of 60 Hz (e.g., Nele
et al. 2015; Parikh et al. 2017; Righi et al. 2018). Of the 95
reviewed studies, nine did not specifically report sampling
rates. Second, reported monitor sizes ranged from 34 cm
(e.g., Nuske et al. 2015) to 55 (e.g., Venker et al. 2019)
inches, although some studies used a projection screen for
presentation of stimulus items (Dundas et al. 2012; Han-
nigen et al. 2014). From the 95 studies reviewed, 24 did not
report the monitor or screen size used for stimulus presen-
tation. For studies that reported participant distance from
the monitor displaying stimuli, a range of 40 (e.g., Aresti-
Bartoleme and Garcia-Zapirain 2015) to 162 (e.g., Hannigen
et al. 2014) cm was noted. Sixteen studies did not report
participant distance from monitors or eye-trackers. Taken
together, while eye-tracker technology used in most of the
reviewed studies was consistent, heterogeneity as well as
insufficient reporting of eye-tracker parameters and stimulus
presenting hardware were found to limit the ability to com-
pare and contrast findings of multiple studies.
Eye‑Tracking Environments
The environments in which eye-tracking was performed also
varied across the reviewed studies. Some studies provided
little to no detail regarding participant positioning (Falck-
Ytter et al. 2015; Gliga et al. 2015a, b; Pierce et al. 2016;
Young et al. 2009). For those studies with eye-tracker set up
or experimental arrangement details, variability was noted
in the level and nature of child only versus child-caregiver
positioning. Many studies reported infant participants were
seated in a caregiver’s lap (Bedford et al. 2012; Delaurentis
2008; Elsabbagh et al. 2014; Gliga et al. 2015a, b; Hendry
et al. 2018; Key and Stone 2012a, b; Murias et al. 2018;
Vargas-Cuentas et al. 2017) while some studies reported
infant participants were seated in a car seat (Chawarska et al.
2016a, b; Chawarska et al. 2013; Nyström et al. 2015) or a
high chair (Dundas et al. 2012; Hannigen et al. 2014; Yama-
shiro et al. 2019). Some variation in child positioning is to
be anticipated given the age of participants and general com-
fort of the children and caregivers with the research setting.
Variability in positioning, however, should be considered
and arrangement specified more clearly given the potential
implications of the experimental set-up on calibration, con-
fidence with data collection of child versus caregiver gaze
13
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
behavior, and potential distractibility and salience of car-
egivers in relation to experimental stimuli.
Continuing the demonstration of variability and limited
information, discussion of general environmental context
was often not reported or vaguely reported. Of the 95 stud-
ies, 19 reported that eye-tracking data collection occurred in
a dark or dimly lit room (Chawarska et al. 2016a, b; Dundas
et al. 2012; Key and Stone 2012a, b; Nele et al. 2015; Pierce
et al. 2011; Wagner et al. 2018). Murias et al. (2018), as
well as Frazier et al. (2016), reported using standardized
room lighting; however, this review shows that standard-
ized may not necessarily be clearly established. Only one
study described precise levels of ambient light during the
eye-tracking session (Nyström et al. 2015). Sixty-eight stud-
ies failed to describe lighting context in any detail. Caregiver
presence and positioning was described to some extent in 55
studies, with the child sitting on a caregiver’s lap or the car-
egiver being located in another room for live video feedback
interactions (Dundas et al. 2012; Nyström et al. 2015; Parikh
et al. 2017). Thirty-seven studies provided no description
of caregiver position in relation to the child participant and
eye-tracking arrangement. As with positioning variability,
inconsistencies with lighting and presence of caregivers may
alter the quality and quantity of eye-tracking data collected
with each child within studies and between studies. Taken
together, although variability in experimental arrangement
(e.g., monitor size and distance from monitor/stimulus dis-
play) may be anticipated, inadequate reporting of the stimu-
lus presenting setup was a major concern that is likely to
limit aggregation and cumulative interpretation of quantita-
tive outcomes of the reviewed studies.
Eye‑Tracking Stimuli
Our systematic review of current eye-tracking studies
revealed notable heterogeneity in stimuli quantity and
dimensional qualities. Stimuli quantity used in each of the
reviewed studies ranged from 1 to 58, representing a posi-
tively skewed distribution with a median of 8 [IQR 8] and a
mean of 10.383 (see Fig. 2 for a box-whisker plot of stimuli
quantities). This distribution per se was a strong indicator of
heterogeneity of eye-tracking study protocols.
Heterogeneity of stimuli in terms of dimensional descrip-
tors (i.e., type, form, design, and participant exchange)
among the reviewed studies was a notable concern (see
Fig. 3 for an overview of the proportional distributions of
each dimensional classification). On categorization of the
studies based on the content type of used stimuli as social
(i.e. inclusion of human characters or faces) versus non-
social (i.e. objects, geometric figures, or other non-human
images), 85 of the 95 reviewed studies were observed to
have used social stimuli or a combination of social and non-
social stimuli, while the remaining 10 studies exclusively
Journal of Autism and Developmental Disorders (2021) 51:2578–2599 2593

Fig. 2  Stimuli quantity distribu-

60
tion in reviewed research studies

50
40
Stimulus Quantity

30
20
10
0

A Type B Design C Form D Participant Exchange

11% 12%
31% 28%

69% 72% 88%

89%

Social Non-Social Dynamic Static Paired Single Active Passive

Fig. 3  Distribution of categorical stimuli dimensions. Stimuli were
independently coded according to dimension then confirmed through
consensus coding. Dimensions were defined as follows: a Stimuli
Type. Social: stimuli presented visuals of human faces and/or human
characters displaying facial expressions or emotions; Non-social: lack
of human character elements, stimuli presented visuals of objects
and/or geometric figures; b Stimuli Design. Dynamic: stimuli pre-
sented visuals in a video-based, moving action format; Static: stimuli
presented still images without video-features, action, or movement; c
Stimuli Form. Single: stimuli were presented as one complete image;
Paired: stimuli presented two distinct visual images in a comparative
manner; d Participant Exchange. Passive: the participant was pre-
sented with the stimuli in a free viewing, observational manner with-
out requirement for direct engagement or response; Active: the partic-
ipant was prompted to respond to stimuli to continue session/viewing
and responses were documented

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2594
used non-social stimuli. For example, stimuli in the study
from Chawarska et al. (2016a, b) featured a woman demon-
strating a variety of verbal and nonverbal social engagement
cues, whereas Chita-Tegmark et al. (2015) study used digi-
tized photographs of simple nouns like a dog, bird, and cof-
fee. Even though a majority of studies seem to have utilized
social stimuli, stimulus type is a potential confounder of the
outcomes and is likely to affect comparability of evidence
coming from various studies.
Categorization of studies based on form into dynamic (i.e.
video clips with motion) versus static (i.e. still images) also
revealed considerable heterogeneity as indicated in Fig. 3.
For instance, Congiu et al. (2016) presented stimuli of a
woman hiding an object in a cup and shuffling cups (i.e.
dynamic stimuli). Nele et al. (2015), presented alternating
images of two female adult faces or two objects (i.e. static
stimuli only). Collectively, 66 of 95 studies used dynamic
stimuli or a combination of dynamic and static stimuli, while
the remaining twenty studies used only static stimuli. Thus,
form of stimuli was also a major source of heterogeneity.
Design of stimuli and participant exchange were also
observed as contributors to heterogeneity of stimuli. On
classification of studies based on design into paired (i.e. two
images shown on screen simultaneously in a comparative
manner) versus single (i.e. presentation of a single stimulus
at a given time), 27 of the 95 studies utilized paired stimuli
(e.g. Wagner et al. (2018) and the remaining 68 studies used
single stimuli (e.g. Gliga et al. (2015a). When the reviewed
articles were classified based on participant exchange (i.e.
requirement of responses by participants during the eye-
tracking session) into active and passive categories, 11 of
the 95 reviewed studies were found to have used active
stimuli, with the remaining 84 studies using passive stimuli.
For example, Merin et al. (2007) presented infants with an
adapted Still Face paradigm and coded the infants’ behavio-
ral responses immediately following the eye-tracking expo-
sure, whereas, Hendry et al. (2018) expected participants to
simply to observe stimuli, which automatically transitioned
after 15 s unless sustained collection of eye-tracking data
occurred longer than 5 s. Therefore, stimulus design and
participant exchange were also contributing to heterogene-
ity of stimuli.
Discussion
Eye-tracking is an objective screening tool that has shown
rapid growth over the past decades as an indicator for early
gaze patterns that follow both typical and atypical location
and fixation patterns. However, several recent studies have
failed to replicate the previous findings, questioning the
validity of use of eye-tracking to classify young children
with at risk gaze patterns. In this systematic review, we
13
Journal of Autism and Developmental Disorders (2021) 51:2578–2599
examined the recent eye-tracking literature to explore the
experimental paradigms and dimensions of stimuli used to
study young children at risk for ASD with the aim of iden-
tifying factors contributing to the poor replicability of eye-
tracking findings in relation to at risk gaze patterns. Further,
in our extensive review of literature, we identified substantial
variability of hardware and experimental settings, quantita-
tive and qualitative heterogeneity of stimuli, and limitations
in reporting experimental protocols as major contributors to
the observed limited replicability of eye-tracking findings.
While variability of eye-tracker hardware and minor
variations in participant positioning are unavoidable, our
synthesis of literature suggested substantial variability in
experimental settings in the reviewed studies. For instance,
it was clear that level of lighting in the experimental settings,
the positions of participants and the presence of the caregiv-
ers varied across the minority of studies that reported such
details. All of these factors could significantly influence the
attention as well as behavior of a child and hence are likely
to affect outcomes of eye-tracking experiments (Triesch
et al. 2007; Zhu et al. 2002; Zhu and Ji 2005). A majority of
authors did not report the specific details of the experimental
setting, limiting the ability to qualitatively synthesize and
compare the results of the studies. Similarly, the reliability
of experiments on vision and visual attention also depend on
the visual angles and intensity of the presented stimuli (Tsal
1983) Yet, due to poor reporting it was almost impossible
to determine the visual angles or the optical intensity of the
presented stimuli in almost all studies that were reviewed.
In fact, in a recent meta-regression analysis, it was observed
that poor design and reporting quality of studies is signifi-
cantly, yet negatively associate with ASD vs. control group
differences in eye-tracking studies, suggesting that on aver-
age, poorly designed studies and studies that inadequately
report protocols seem to over-estimate the ASD vs. control
group differences (Frazier et al. 2017). Taken together, there
seems to be a lack of consensus regarding the experimen-
tal protocols that need to be followed when studying young
children, especially for the risk of ASD. More importantly,
the discipline appears to lack guidelines on reporting such
experimental details. Such widely accepted protocols and
guidelines have contributed to rapid growth of many other
experimental disciplines that study visual attention (e.g.
Calibration Standard Committee of the International Soci-
ety for Clinical Electrophysiology of Vision (ISCEV; Brigell
et al. 1998). As such, we emphasize the imperative need to
establish guidelines on setting up and reporting eye-tracking
experiments. The establishment of these guidelines is likely
to contribute elimination of the heterogeneity in results of
eye-tracking experiments that are due to variability in the
experimental settings.
An even greater concern that is likely to contribute to
poor replicability of eye-tracking findings is the substantial
Journal of Autism and Developmental Disorders (2021) 51:2578–2599 2595
heterogeneity of the quality of stimuli. A comparison of the
eye-tracking patterns observed in studies that used hetero-
geneous types of stimuli will invariably be a ‘comparison
of apples and oranges’. For instance, the neurophysiological
processes that regulate visual attention to images of faces
(i.e. social stimuli) differs from the regulation of attention
to objects (i.e. non-social stimuli). Similarly, a greater num-
ber of saccades are expected when observing a video (i.e. a
dynamic stimulus) as opposed to a still image (i.e. a static
stimulus). Therefore, it seems almost impossible to directly
compare the results of most eye-tracking studies given the
vast heterogeneity of stimuli characteristics. This is further
evident by the significant heterogeneity observed for ASD
vs. neurotypical control group comparisons for eye-tracking
outcomes (Frazier et al. 2017).
One potential contributor to this heterogeneity is the lack
of publicly available stimuli for use in eye-tracking studies.
There is an emerging trend, as common in the field of behav-
ioral sciences, of researchers to complete follow-up stud-
ies and to repeat their own protocols with or without minor
modifications to stimuli (e.g., Elison et al. 2013; Sekigawa-
Hosozawa et al. 2017). Multiple studies examined in the our
systematic review incorporated replications of their stimuli;
however, all except one of the studies (Frazier et al. 2016)
did not provide access to the complete set of stimuli for
critical analysis or repeated use across independent research
groups (Billeci et al. 2016; Falck-Ytter et al. 2015; Hendry
et al. 2018; Sekigawa-Hosozawa et al. 2017; Tenenbaum
et al. 2014, 2017; Wagner et al. 2018). Sharing stimuli for
public use will increase the feasibility of replication and
will contribute to breaking the vicious cycle of performing
variations of the same experiment without confirmation of
the generated knowledge. Furthermore, sharing stimuli will
foster the development of new research groups, particularly
from institutes with limited resources, to meaningfully con-
tribute to the literature by building on the work of previous
researchers and their research paradigms.
Another important concern in the eye-tracking litera-
ture was the lack of validated stimuli. Without empirical
validation, researchers cannot be certain that stimuli in eye-
tracking tasks accurately target proposed skills or behaviors
across research settings and developmental groups (Wood
et al. 2006). To ensure construct validity, eye-tracking stim-
uli should ideally be validated for cultural contexts, age and
gender. Further, response to designated stimuli may vary
given a child’s cognitive level, communicative and compre-
hension skills, attentional abilities and/or severity of ASD
and thus, these participant factors should also be considered
when describing data variability. However, none of the 95
reviewed studies described and/or cited validation studies of
stimuli. Although eye-tracking is an objective and accurate
measurement of visual attention, there is a clear need for
standardized and empirically validated stimuli in order to
better understand and define patterns of gaze fixation and
saccades as they apply to and describe children at develop-
mental risk. Taken together, our systematic review empha-
sizes the unmet need of a bank of publicly available, vali-
dated stimuli and stimulus paradigms for use in eye-tracking
experiments. Adoption of a stimulus classification system,
such as the binarized classification system presented in this
review is likely to enhance the usefulness of the stimulus
bank by guiding the researchers to replicate experiments
using same types of stimuli and make comparisons between
studies that utilized the same types of stimuli.
In conclusion, our systematic review identifies variabil-
ity in eye-tracking methodology and more importantly the
heterogeneity of stimuli used for eye-tracking as major fac-
tors that undermine the value of eye-tracking to be used as
an objective, reliable screening tool to be used for young
children with developmental risk factors. Our review also
highlights poor and inadequate reporting as a contributor
that limits the substantive growth of the eye-tracking lit-
erature. While additional factors contributing to conflicting
study results include variations in sample characteristics,
low sample sizes, inconsistent definition of areas of inter-
est, and poor analytic methods, we highlight stimuli and
experimental design descriptions as a starting point for
strengthening eye-tracking study transparency, validity, and
replicability. As such, we emphasize the critical necessity to
establish consistent guidelines for developing and describing
eye-tracking experiments and protocols. Furthermore, we
underscore the importance of sharing eye-tracking stimuli
to enhance replicability of findings and more importantly
the need to develop a bank of publicly available, validated
stimuli.
Author contribution  AMM conceptualized and wrote the majority
of this manuscript. CK provided substantial feedback, organized the
Table and wrote some portions of the manuscript. JP contributed to
the Table contents, contributed to the writing and substantial editing
of the manuscript.
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