International Journal of Developmental Disabilities

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/yjdd20

The influence of picture book design on visual

attention of children with autism: a pilot study

Xiang Lian, Wilson Cheong Hin Hong, Xiaoshu Xu, Kolletar-Zhu Kimberly &
Zhi Wang

To cite this article: Xiang Lian, Wilson Cheong Hin Hong, Xiaoshu Xu, Kolletar-Zhu
Kimberly & Zhi Wang (2022): The influence of picture book design on visual attention of
children with autism: a pilot study, International Journal of Developmental Disabilities, DOI:
10.1080/20473869.2022.2033590

To link to this article: https://doi.org/10.1080/20473869.2022.2033590

Published online: 14 Feb 2022.

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The influence of picture book design on
visual attention of children with autism: a
pilot study
Xiang Lian1 , Wilson Cheong Hin Hong2 , Xiaoshu Xu3 , Kolletar-Zhu
Kimberly3 and Zhi Wang4
1
Quanzhou Preschool Education College, Quanzhou, China; 2Macao Institute for Tourism Studies, Macau,
China; 3School of Foreign Studies, Wenzhou University, Wenzhou, China; 4Faculty of Education, University of
Malaya, Kuala Lumpur, Malaysia

Taking 22 children with mild and moderate autism as subjects and using the TobiiX 120 eye-tracker to
record their eye movements in visual search of images in picture books, the characteristics of the process of
autistic children viewing picture books were explored. Two measures, fixation counts and gaze duration,
were used alongside attention heatmap, to explore the visual patterns among children with autism viewing
two types of researcher-made picture books and an ordinary picture book. Using a within-subject design, it
was found that children with autism could sustain longer gaze duration and have more fixation points on the
effective area of the picture book content when viewing researcher-made picture books than when viewing
the ordinary picture book, suggesting better visual attention to single-object and single-pattern picture books.
The study offers insights and support for related picture book reading and teaching in the future.
Keywords: picture book; story book; ASD; visual attention; eye-tracking; education

Introduction et al. 2004); in natural social situations, neural-typical

Visual behaviors and cognitive processing of babies look at people’s eyes first instead of mouths
children with autism from the age of three months (Haith et al. 1977). ASD
Autism, also known as autism spectrum disorder children, on the other hand, pay attention to the face
(ASD), is a pervasive developmental disorder that can and mouth twice as often as the nose, but 2.5 times less
be recognized before the age of three (Landa 2008). Its frequently than the eye area (Klin et al. 2003). In elec-
core disorders are language impairment, social difficul- trodermal experiments, while neural-typical children are
ties, and abnormal behaviors. According to incomplete found to display more neurological responses to people
statistics in China and abroad, the current incidence rate who look at them but a lower level of response to neu-
of autism is about 1/68, and social disorders are recog- tral objects such as a cup, ASD children produce a
nized as the primary area of intervention (Houghton similar level of response to both a human face and a
et al. 2013). Osterling et al. (2002) found that one-year- cup (Hirstein et al. 2001). The differences in these basic
old children with autism (hereafter ASD children) have processes eventually evolve into a problem of higher-
less eye contact with others than neural-typical children order processing in the brain. On the one hand, the
of the same age, or they rarely respond to other people's brains of ASD children pay similar attention to all stim-
calls to them. ASD children lack interest in human uli at the same time, causing a flood of information in
faces at 6 months, and lack directionality to human voi- the brain; on the other hand, they must actively aban-
ces at 24 months; they have significantly less response don some irrelevant information during post-processing,
to human voices than neuro-typical children (Klin et al. which becomes a bottleneck of information processing.
1992, Osterling and Dawson 1994). Magnetic resonance Functional neuroimaging studies have shown that when
imaging (MRI) results suggest that when facing familiar ASD children participate in social activities, their brains
or unfamiliar faces, ASD children do not activate the tend to rely on primary senses to process information,
same areas as typically developing children (Dawson and lack higher-order processing as that of ordinary
brains (Baron-Cohen et al. 1999, Casanova et al. 2002,
Correspondence to: Zhi Wang, Faculty of Education, University of
Malaya, Kuala Lumpur, Malaysia. Email: 17221470@siswa.um.edu.my Critchley et al. 2000, Pierce et al. 2001, Ring et al.

# The British Society of Developmental Disabilities 2022

DOI 10.1080/20473869.2022.2033590 International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0 1
Xiang Lian et al. The influence of picture book design

1999, Schultz et al. 2000). If a newly born child relies auxiliary tool, picture books help to improve the social
on an overactive sensory processing system that is skills, communication skills, and imagination of ASD chil-
extremely low in screening ability, high-order cognitive dren (Tabernero and Calvo 2020). However, picture books
processes will be suppressed by the large number of stim- are different from other forms of illustrations in books.
uli in the surroundings (Belmonte and Yurgelun-Todd They focus on the continuity of the content of the picture
2003). Faced with such constraints, the brain adapts itself to convey a central message. After viewing or reading a
to the environment by being forced to reorganize itself picture book, children are likely to able to describe the
during its critical growth period (Johnson 2002). The basic pictures and form visual images in their mind (Hao 2006).
manifestation of the result of this adaptation is an abnor- Therefore, the content of picture books must be artistic,
mal ability for the brain to organize information and a contrastive, novel, and creative (Su 1987). However, pre-
cognitive style that is heavily dependent on low-level local vious studies have found that the content and style of the
processing (Frith and Happe 1994, Happe 1999), causing pictures will affect the visual attention of ASD children.
various interactive difficulties. On the one hand, related studies have found that the
physiological, emotional and intellectual functions of
Theory of Weak Central Coherence ASD children are improved after observing a certain color
Researchers suggest the root cause of the social barriers of light for a long time (Howlin 1996). Similarly, by using
of ASD children is their ‘Weak Central Coherence different colors of lenses, the text-reading speed of ASD
(WCC)’. According to the theory of WCC, ASD chil- children can be improved (Ludlow et al. 2006). Although
dren display a lack of global (i.e. integrated) percep- relevant studies have failed to prove that ASD children
tual-cognition processing, and are inclined to local (i.e. display a heterogeneous response to different colors.
detail-specific) processing (Happe and Frith 2006). That Hence, there are reasons to believe that ASD children
is, in information processing, attention is paid to proc- have a different preference for colors than typically devel-
essing details, and local areas are operated first. The oping children. Following this line of thought, the typic-
overall meaning or contextual meaning is often ignored. ally bright and colorful images of picture books may cast
As ASD children cannot pay attention to the whole of an indirect effect on ASD children’s sustained visual
an object but parts of it, they appear to lack sustained attention of the contents of picture books. On the other
attention and cannot establish social communication hand, research examining the visual search of ASD chil-
(Klinger and Dawson 1992, Lian 2018). In classroom dren mainly adjusts the difficulty of the tasks by increas-
teaching, ASD children often exhibit hyperactivity, ing or reducing the complexity of the distractors (such as
inattention, resistive behavior, and dependent behavior the number of distractors, the dimension of the back-
(Hodgdon 1995), since the oral information and the ground graphics, etc.) (O’Riordan and Plaisted 2001,
meaning of the text are symbolic information that is Schlooz and Hulstijn 2014). Other researchers found that
abstract and difficult to understand (Whalon and Hart the process of identifying the target stimulus from back-
2011). However, pictures and images are clear and ground distractors in ASD children is not only affected by
vivid, which can be used to present meaningful and organ- the complexity of the distractor, but also by the degree of
ized information to ASD children in order for them to confusion due to the similarity between the distractor and
acquire useful social information (Frith 2004, Grandin the target stimulus (Joseph et al. 2009). If the similarity
2006, Riviere 2002, Sigman and Cappas 2002). From the between the distractor and the target increases, the diffi-
perspective of educational support, using pictures to culty in completing the visual search task for autistic chil-
improve the reading materials for ASD children can dren will increase accordingly (O’Riordan et al. 2001).
enhance their reading and sustain viewing attention (Lian Therefore, if the picture elements of a picture book are
2016), thereby indirectly improving their social capacity. too complex, the sustained visual attention of ASD chil-
dren may likewise be affected. These are evidence to sug-
The design of picture books and visual gest that the presentation of image and text in typical
characteristics of ASD picture books does not meet the cognitive characteristics
Picture books originated from Europe and can be traced of autistic children, and it is necessary to redesign picture
back to the Middle Ages or before the 18th century (Lin books that are suitable for the cognitive characteristics of
2000). However, the modern form of picture books them (Gaffney and Wilkins 2016).
evolved from a genre of painting called Ukiyo-e in the Further, past studies have indicated that ASD’s cre-
Tokugawa shogunate period in Japan (Harris 2012). A ative and imaginative abilities are relatively unaffected
picture book is a book with pictures as the main body and (Hetzroni 2019, Roth 2020). Therefore, picture books for
text as a supplement, or a book with pictures only. ASD children should leave more room for imagination.
Previous studies have found that teaching with picture In view the above-mentioned findings, the authors have
books can help improve the academic performance of designed four picture books that integrate the cognitive
ASD children. Without pictures as an aid, academic per- characteristics of ASD children. Then, the authors com-
formance will decrease (Bryan and Gast 2000). As an pared the effect of the style of the researcher-designed

2 International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0

 Xiang Lian et al. The influence of picture book design

picture books with that of the traditional ones. institution in Quanzhou were recruited (see Table 1 for
Specifically, with the help of the eye-tracking technol- details). The identification of the degree of difficulties
ogy, the researchers tested the visual patterns of ASD of the subjects was based on the diagnostic results of
children when viewing traditional picture books and the Children Neuropsychological and Behavior Scale
researcher-made picture books. Measures of fixation (CNBS-R2016) which was developed by the Capital
counts and total fixation duration (also known as gaze Institute of Pediatrics of China. It is a diagnostic tool
duration) are used to test the effects of researcher-made widely used in maternal and child health hospitals,
picture books. They are two of the most widely adopted children’s hospitals across China and by researchers
measures to examine visual attention (Godfroid 2020, (Chen et al. 2021, Li et al. 2019, Luo et al. 2020, Yang
Susac et al. 2019). The connection between eye-tracking et al. 2021). The scale has been found to significantly
measures and attention is built upon the ‘eye-mind correlate with the Child Autism Rating Scale (CARS)
hypothesis’ (Just and Carpenter 1980), which assumes (Chen et al. 2021, Li et al. 2019) and has high reliabil-
that what is being looked at is what is being processed. ity and validity (Li and Lu 2008). According to the
There has been a growing body of research making use diagnostic report provided by the parents, the subjects
of the eye-tracking technology to understand the visual had an intelligent quotient of 55 to 69. As part of the
characteristics of autistic children and adolescents screening procedure, the primary researcher conducted
(Chevallier et al. 2015, Del Bianco et al. 2021, Falck- two rounds of interviews with the parents to evaluate
Ytter et al. 2013, Freeth et al. 2011, Hanley et al. 2015, the specific conditions and participatory suitability of
Sasson and Touchstone 2014). These studies assume a each ASD participant. The final selected participants
strong connection of the visual attention and cognitive had normal vision and were reported to be able to read
processing of ASD, just as neural-typical people. The picture books; no cases of color blindness or color
same convention has been followed in the current study. weakness were identified. The children’s parents were
Then, visual hotspot imaging maps (also known as heat- given adequate information as to the nature and process
maps), which is the most adopted integrated measure of of the experiment. Specifically, they were told the pur-
visual pattern (Godfroid 2020), is used to compare the pose of the experiment was to examine the visual atten-
viewing patterns of ordinary and researcher-made picture tion of ASD children when viewing different designs of
books among ASD children. The experiment provides picture books and that the results could inform ASD
insights into picture book development and its educa- teaching with visual aids; then, the whole process of the
tional support for ASD children. experiment was described and explained to the parents;
they were also introduced to the eye-tracking apparatus,
Research questions and hypotheses and were assured that it was a safe and unintrusive tool
The current pilot study attempts to answers one over-
and that there was no known harmful physical or men-
arching question: are there differences in sustained vis-
tal effects of this type of experiment on the participants;
ual attention and visual pattern between viewing
finally, they were informed of the researchers’ commit-
ordinary picture books and researcher-made picture
ment to participant anonymity and confidentiality; the
books among ASD children?
collected data would be used for academic purposes only
In view of the cognitive characteristics of ASD chil-
and they had the right to discontinue at any point of the
dren, who cannot efficiently filter out unnecessary
experiment and withdraw the data up to 14 days after the
stimulation, which impairs their ability to sustain atten-
experiment. The parents then signed the experiment con-
tion, the authors postulate the following hypotheses to
sent form prior to the start of the experiment.
be tested in the experiment:
The current pilot study takes on a within-subject
H1: Participants’ number of fixations on the ordinary picture experimental design, which can minimize the errors
book is significantly more than type 1 or type 2 researcher-
made picture books. caused by individual differences across different sets of
H2: Participants’ total fixation duration on the ordinary Table 1. Demographic information of the ASD subjects
picture book is significantly shorter than type 1 or type 2
researcher-made picture books. Subjects Sex Age IQ score Subjects Sex Age IQ score
H3: Hotspot imaging will show centralized and sustained A1 Male 4 65 A12 Male 5 62
visual attention towards the researcher-made picture books A2 Male 5 60 A13 Male 5 55
A3 Male 4 68 A14 Male 4 61
while dispersed and non-sustained visual attention towards
A4 Male 4 59 A15 Male 5 56
the ordinary picture book. A5 Female 4 66 A16 Male 6 66
A6 Male 4 68 A17 Male 4 60
A7 Male 5 60 A18 Male 4 69
Methods A8 Male 6 58 A19 Female 5 55
A9 Female 4 62 A20 Male 5 60
Research subjects A10 Male 4 59 A21 Male 6 65
Twenty-two children with mild and moderate autism A11 Male 5 60 A22 Male 4 68
who were 4-6 years old from a social rehabilitation

International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0 3

Xiang Lian et al. The influence of picture book design

participants, yielding a higher statistical power screen. He/she was then told again that he/she would be
(Charness et al. 2012). Eye-tracking experiments are looking at some picture books on the screen, but they
susceptible to individual differences and therefore a had to stare at a small ball first. The small ball was dis-
within-subject design is recommended over between- played as the viewing target of a 9-point calibration to
subject comparisons (Godfroid 2020). calibrate the subject’s fixation and eye movements. The
researcher guided the subject in a pleasant tone to stare
Picture book materials at the ball until the ball on the screen broke, which sig-
One set of ordinary picture books, with a title ‘David, naled the end of the calibration, and the experiment
don’t!’, and four sets of researcher-made picture books, could be started. At the beginning of the experiment,
with titles ‘Knot’, ‘Bubble’, ‘Rainbow’ and ‘Dragon four practice pictures were given one at a time as a
Fruit’ were used in the experiment. The rationales for warm-up. Each picture (i.e. page) was displayed for 5 s
choosing ‘David, don’t’ are: (1) It contains all the com- before the next page appeared automatically. The prac-
mon elements of a typical picture book, including char- tice trials were immediately followed by one of the pic-
acters, a story line, text and contrastive colors; (2) The ture book types. Similarly, each page was displayed
book is relatively simple in its theme and design, with separately for 5 s. The three types of picture books
only one repeated idea (i.e. David, don’t), and there is appeared in rotated sequence to achieve counterbalance.
only one character on each page. These allow for more During the viewing of the picture books, the researcher
meaningful comparison between the different types of did not provide any support, but allowed the subject to
picture books used in this study. The first eight pages view the pictures of the picture books independently.
of ‘David, don’t’ were chosen to maintain the intended The experiment ends once the subject finishes viewing
storyline or logical flow of the picture book. On the all 24 experimental pages. The whole process was over-
other hand, the researcher-made picture books ‘Knot’ watched by the researcher and at least one of the sub-
and ‘Bubble’ mainly focus on lines, while ‘Rainbow’ ject’s parents. There was no talking between or among
and ‘Dragon Fruit’ mainly focus on colors, emphasizing the subject, the researcher and the parent(s) during the
the entirety of the image with strong colors. The experimental trials.
researcher-made picture books contain one single
theme, either line patterns or color patterns. They do Research tools
not focus on story and plot, and do not emphasize the The TobiiX 120 eye-tracker was used for visual track-
knowledge and logic of the contents. Each book con- ing; a 17-inch display with a resolution of 1366
768
sists of four pages of images. All picture books were pixels was used. The distance between the eyes of the
scanned in the computer and trimmed to the size subjects and the eye-tracker was approximately 45 cm,
of 1080
768. while monitor to eye approximately 60 cm. A sampling
Type 1 research-made picture books, ‘Knot’ and rate of 30fps and head free-to-move mode were chosen.
‘Bubble’, present objects in the form of gradual pro- As the subjects in the current experiment are all young
gression, from part to whole, gradually showing the children, the use of a head-stabilizer such as chin-rest is
whole of things. Type 2, ‘Rainbow’ and ‘Dragon Fruit’, impractical. The Tobii Studio 3.4 was used to specify the
takes colors as the theme and displays colors on the area of interest and to generate the eye-tracking data. The
entire picture. The area of interest (AOI), from which data were subsequently analyzed using SPSS 24.0.
eye-tracking data can be extracted (Godfroid 2020),
was specified to cover the whole image of each picture Results
book page. The sequence of display of the picture
books were decided by means of a Latin-square design H1: Participants’ number of fixations on the ordinary picture
to ensure the books have equal chances of early or book is significantly more than type 1 or type 2 researcher-
made picture books.
late appearance.
Table 2 shows the differences in the mean values of the
Research process number of fixations among the ordinary, type 1 (pro-
The experiment was conducted in a quiet laboratory gression) and type 2 (color) researcher-made picture
room to minimize all potential disturbance or distrac- books. A one-way repeated measure analysis of vari-
tion. The primary researcher, together with an assistant, ance (ANOVA) was conducted to evaluate the null
who were responsible for conducting the experiment hypothesis that there are no differences among the par-
first asked individual subjects to sit down on a comfort- ticipants’ (N ¼ 22) number of fixations on the three
able chair to read a regular picture book to ease their types of picture books. The results of the ANOVA indi-
emotions. Meanwhile, the subject was told that they cated a significant difference related to the types of pic-
would read some similar pictures on the computer ture books (Wilks’ Lambda ¼ .241, F(2, 20) ¼ 31.55, p
screen. After a few minutes of rest, the researcher asked < .001, g2 ¼ .76). Hence, the null hypothesis
the subject to sit on another chair facing the computer is rejected.

4 International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0

 Xiang Lian et al. The influence of picture book design

Table 2. Descriptive statistics of the number of fixations Hotspot imaging is a visualization tool that uses vari-
of the ordinary, type 1 and type 2 picture books.
ous colors to indicate the density of fixations (Godfroid
Mean Std. Deviation N 2020). In the current study, warmer colors (e.g. red,
Ordinary 107.00 18.17 22 orange) are used to denote high fixation density, mean-
Type 1 self-made 62.00 19.28 22
Type 2 self-made 62.59 16.70 22 ing a high visual attention. By visualizing fixation dur-
ation, it is found that all ASD children (N ¼ 22) tend to
pay attention to multiple elements of the picture book
Pairwise comparisons suggest the number of fixa-
content when they participate in the viewing process of
tions on the ordinary picture book is significantly dif-
the picture book ‘David, don’t’ (as illustrated in Figure
ferent from both type 1 (p < .001) and type 2 (p <
1). Generally speaking, the heatmaps show that partici-
.001) researcher-made picture books. However, there is
pants’ eyes pay attention to a number of elements and
no significant difference between the two types of
typically do not focus on a specific knowledge element.
researcher-made picture books.
In addition, the trajectory of the eye movements
H2: Participants’ total fixation duration on the ordinary
presents a scattered distribution, with viewing activities
picture book is significantly shorter than type 1 or type 2
researcher-made picture books. happening all over the pictures. However, a strong ten-
dency to focus on human faces was observed, which is
It is hypothesized that more sustained attention in
similar to previous findings that autistic children pay
the form of longer fixation duration would be observed
attention to human faces nearly as much as non-autistic
in type 1 (progression) and type 2 (color) than the
ones (Van Der Geest et al. 2002). As expected, words
ordinary picture book. Descriptive statistics do indicate
are not always fixated, while other objects in the pic-
shorter total fixation duration (in ms) of the ordinary
tures are viewed occasionally.
book. The mean differences among the three types are
The first type of picture books made by the
shown in Table 3. However, ANOVA fails to reject the
researcher is a researcher-made picture book presented
null hypothesis that there are no differences in total fix-
in a gradual manner. The content of one of the picture
ation duration among the participants’ (N ¼ 22) viewing
book presents the sequence of things as a clue, namely,
of the three types of picture books (Wilks’ Lambda ¼
.769, F(2, 20) ¼ 3, p > .05, g2¼.231). the process of tying a ‘Chinese knot’. Different from
To further analyze the difference between the ordin- the ordinary picture book, during the viewing process,
ary and researcher-made picture books, the authors all autistic participants (N ¼ 22) viewing type 1
combined the results of the total fixation duration of researcher-made book display a concentrated viewing
type 1 and type 2 picture books by averaging the view trajectory (as shown in Figure 2), which conforms with
time of both types in each participant. Then, the newly the shape of the knot and has a prolonged focus in the
combined variable of total fixation duration (in ms) of center of the ‘Chinese knot’ itself. All in all, the eye
the researcher-made picture books (M ¼ 3546.41, SD ¼ movement shows a tendency to concentrate, centralize
811.46) is compared against the ordinary picture book and look for clues.
(M ¼ 3154.49, SD ¼ 613.38) using a paired samples T- The second type of picture book made by the
test. A statistical significant difference of 391.92 was researcher has colors as themes. One of them shows
found (t(21) ¼ 2.39, p ¼ .026). that a kitten knocks over the paint, and the paint is scat-
Taken together, although it cannot be verified that tered on the ground, forming different patterns. The pat-
ASD children fixated on the ordinary picture books sig- terns are being enlarged and presented over the entire
nificantly shorter than either type of the researcher- picture. During the viewing process of autistic children,
made books individually. The total fixation duration of prolonged visual attention appears in the central area of
the ordinary picture books is still significantly shorter the picture (N ¼ 22), and overall viewing follows the
than that of the researcher-made books on the whole. patterns of the colors. The eye movement process
H3: Hotspot imaging will show centralized and sustained
reflects higher focused attention and centralized view-
visual attention towards the researcher-made picture books ing of the content of the picture book (Figure 3) in all
while dispersed and non-sustained visual attention towards participants.
the ordinary picture book.
To sum up the results, H1 and H3 have been verified
by means of repeated measure ANOVA and the analy-
ses of the hotspot imaging respectively. Although H2
Table 3. Descriptive statistics of the total fixation dur- has not been fully supported statistically, an observable
ation of the ordinary, type 1 and type 2 picture books. increase in fixation duration has been noted, and a sig-
Mean (ms) Std. Deviation (ms) N nificant difference was found between the ordinary and
Ordinary 3154.49 613.38 22 researcher-made picture books on the whole. Figure 4
Type 1 self-made 3453.55 709.33 22 illustrates how the types of picture books interact with
Type 2 self-made 3639.26 909.44 22
the visual measures.

International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0 5

Xiang Lian et al. The influence of picture book design

Figure 1. Heatmap patterns and original pictures of ‘David, don’t’.

Figure 2. Heatmaps of the researcher-made picture book and the original pictures indicating gradual progression (i.e. pic-
ture book ‘Knot’).

Figure 3. Heatmaps of the researcher-made picture book and the original pictures showing colors as the theme (i.e. picture
book ‘Rainbow’).

6 International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0

 Xiang Lian et al. The influence of picture book design

Figure 4. Means of the total number of fixations and total fixation duration among the three types of picture books.

Discussion sure where to look at and therefore constantly shift their

An apparent positive effect on visual attention has been attention to different objects on a page. This thought
found in the two types of researcher-made picture seems to be further verified as we examine the dis-
books. ASD children are noted for their lack of capabil- carded data, such as the total length of saccades and
ity to filter information, which results in short and blinking (in ms)—Ordinary (M ¼ 358.4, SD ¼ 142.55),
jumpy attention (Happe 1999, Klinger and Dawson Type 1 (M ¼ 245.82, SD ¼ 138.1), Type 2
1992, Lian 2018). In this study, the ordinary picture (M ¼ 199.99, SD ¼ 128.87). Saccade/blink to gaze dur-
books received more fixations but shorter fixation dur- ation proportion is at 11.23% when reading ordinary
ation, which suggests participants’ average fixations are picture books, much higher than that of Type 1 (7.12%)
relatively short. On the other hand, when viewing the and Type 2 (5.48%). Although no hypothesis was pro-
researcher-made picture books, especially the type 2 posed in relation to saccades/blinks and thus inferential
color picture books, the average fixation points are lon- analysis was not conducted, subjects on average seem
ger, indicative of sufficient visual attention and infor- to display a lot more skipping, attention shifting, or
mation processing (i.e. genuine reading) (Godfroid searching behaviors when reading the ordinary picture
2020). However, in terms of the comparative effects of books, which echoes with existing findings that ASD
the gradual-progression and the color-theme picture children produce highly frequent saccades when looking
book styles, no statistically significant difference can be at objects or people (Kemner et al. 1998, Pensiero et al.
found. It is worth noting that fixation duration and fix- 2009), a sign taken as an inadequate ability to suppress
ation counts have been widely documented to be highly the urge to visually search around. The two proposed
correlated (e.g. Cornelissen et al. 2016, George et al. types of picture books seem to be able to alleviate this
2011, Godfroid 2020, Raptis et al. 2016) for the simple urge. However, relatively little is understood about the
reason that more fixations will add up to longer total relationship between saccades/eye-blinks and visual
viewing time. However, ASD children might have felt attention (Bruny
e and Gardony 2017, Remington 1980),
constantly distracted by the non-target elements (Joseph which is the main reason why this part of the data was
et al. 2009, O’Riordan and Plaisted 2001, Schlooz and not used in the main analysis. All in all, results suggest
Hulstijn 2014) as they viewed ordinary picture books, a a much more concentrated visual attention in both the
large amount of their viewing time was lost due to rapid gradual-progression and the color-theme picture books.
non-processing eye movements, which resulted in a
strange phenomenon of increased fixations but reduced The impact of stimulus presentation time on
viewing time. research results
Further, hotspot imaging suggests the viewing pat- In this study, 5 s is used as the unit of picture book dis-
terns of the ordinary picture books are very different play and at every 5 s, the screen will switch to the next
from the researcher-made picture books, while both page. Previous studies believed that the presentation
types of researcher-made picture books show similar speed of the stimulus material has an impact on the
patterns. Combining the shorter average fixations with processing efficiency of the screen content (Manning
the scattered focuses across the whole picture in the et al. 2017). That is, with longer intervals, the total
ordinary book, it is suspected that ASD children are not number of fixation points and the average gaze duration

International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0 7

Xiang Lian et al. The influence of picture book design

of the picture book content will increase for ASD chil- ability. As an example, Wang et al. (2019) used picture
dren. Therefore, in subsequent research, researchers book with emotional themes to intervene with the emo-
will continue to pay attention to the effect of the ratio tional understanding of ASD children. During the
of the presentation time of the picture book content to experiment, visual cues and behavior guidance were
the interval time on the reading. used to strengthen children’s understanding of emo-
In terms of the fixation points in the content of pic- tional themes. Although the intervention effect is satis-
ture books, the total number of fixation points of ASD factory, it is difficult to explain whether the content of
children on the content of ordinary picture books is the picture book played a decisive role, rather than the
higher than that of researcher-made picture books. The effect of the auxiliary means. At the same time, the pur-
main reason is that ordinary picture books have more pose of Wang’s research is not to establish reading
content elements and the ASD children are passively behavior or develop effective picture books, but to use
attracted by the multiple elements of ordinary picture the contents of picture books as an intervention method.
books, while researcher-made picture books contain sin- Contrarily, the design of the picture book style in the
gle elements, which is less likely to cause confusion to current study is based on the consideration of the cogni-
the visual perception of ASD children and induce visual tive characteristics of ASD children. The purpose is to
revisits to different stimuli. improve the quality of picture book reading, enhance
In terms of the time allowed for viewing, if the the visual attention capability of ASD children, and
viewing of each page of the picture books was change the traditional mechanized teaching mode of
increased, the total viewing time of the 24 pictures will picture books to improve the ability of ASD children to
increase. In view of the higher requirements for the read and think independently.
attention span of ASD children, the control of viewing On the one hand, the gradual design of the first type
time is vital. If ASD children cannot perform continu- of picture book highlights the presentation of the con-
ous viewing, it will have a more serious implication on tents part by part according to the composition relation-
the research results. In this study, the average gaze dur- ship of things, which will help ASD children to obtain
ation of researcher-made picture books was longer than effective information. This study found that there are
that of ordinary picture books within the specified time significant differences in autistic children’s fixation
range. It is argued that the longer the average gaze time and the number of fixation points on the content
time, the better the quality and effect of picture book of picture books compared with traditional picture
reading, and the more effective it is for picture book books. The two researcher-made picture books ‘Knot’
education and teaching for ASD children. and ‘Bubble’ mainly focus on lines and adopt a gradual
All in all, for ASD children, both the average fix- design method to present the real object from part to
ation time and the number of fixation points have an the whole, and finally the picture presents the whole
impact on the reading outcome and reading quality of object. During the experiment, ASD children pay more
picture books. Therefore, increasing autistic children’s attention to the components of the object, and can con-
average gaze time and the number of fixation points on tinue to pay attention to the target area for a long time.
the contents of picture books will likely to improve the Previous studies have suggested that when ASD chil-
effectiveness of picture book reading for ASD children, dren recognize objects, they are likely to divide things
which is conducive to the development of picture book into parts for processing, unlike non-autistic children,
education and teaching. who view the objects in entirety first (Zhai 2008). The
findings of this research are consistent with those of
The impact of different picture book styles on previous related studies.
the research results On the other hand, existing studies on color percep-
Previous studies on picture book reading of autistic tion of ASD children have found that they have exces-
children have used traditional picture books for the sive compulsive behaviors for certain colors, including
materials. The results of these studies suggest that pic- accepting and rejecting behaviors (Zhang and Lin
ture book reading with auxiliary strategies such as vis- 1992); In the teaching process, colors may help ASD
ual cues can help improve the emotional problems and children to adjust their emotions; colored lenses can
gaze levels of ASD children (Jin 2010). However, the also help ASD children to improve reading efficiency
research process requires the use of auxiliary methods, (Ludlow et al. 2006). Subsequent research further found
and the research results fail to explain which types of that ASD children have preferences over certain colors.
picture books have a supporting effect on the visual Green, blue, red, purple, orange and yellow appear to
attention of ASD children. These studies limit them- be the order of preference (Cao et al. 2012). In this
selves to the understanding and providing support to aid research, the two researcher-made picture books
comprehension of the content of the picture books, but ‘Rainbow’ and ‘Dragon Fruit’ both use colors as the
lack investigations into and special support for autistic main content of the picture book, and the content of the
children's divergent thinking and autonomous thinking pictures constructed by color is enlarged and presented

8 International Journal of Developmental Disabilities 2022 VOL. 0 NO. 0

 Xiang Lian et al. The influence of picture book design

as the whole picture. In terms of duration and area of typical picture books with some proposed ones, the
attention, ASD children show more interest in the con- comparison should be deemed valid and necessary.
tents of the two researcher-made picture books Third, the choice of research subjects lacks contrast.
‘Rainbow’ and ‘Dragon Fruit’ by displaying longer and Typically-developed children, children with Down syn-
denser fixation at the center of the color patterns. The drome and children with severe autism are not considered
results of this study are consistent with previous studies as research subjects. The results and conclusions are
on the effect of colors on the visual perception of ASD solely based on children with mild to moderate level aut-
children, which provide evidence that colors have a cer- ism. However, this is only a pilot study and that within-
tain effect on the visual perception of ASD children. subject comparisons are known for better statistical power
Thus far, based on the characteristics of the than between-subject comparisons (Charness et al. 2012),
researcher-made picture books, which do not contain which is an especially true in eye-tracking experiments
characters and words, and are presented with objective (Godfroid 2020). Nonetheless, the current study has laid
items, the researchers argue that the significantly better the foundation for further comparative analysis among dif-
attention found in the researcher-made picture books ferent groups of children.
are caused by the fact that the design of the picture Finally, the style and content of researcher-made pic-
books caters to the cognitive characteristics of ASD ture books need to be continuously enriched.
children. Previous studies have found that when ASD Meanwhile, with evidence from the research findings,
children participate in reading, they will deliberately focus needs to shift to education and teaching. For
pay attention to the face and body of the characters in example, the development of picture books of interest
the content of the picture book (Chita-Tegmark 2016). needs to be considered in combination with picture
Zhao (2016) also found in research that when back- book education and teaching for ASD children. Case
ground information is weak, ASD children pay attention studies of picture book teaching for ASD children can
to characters for a longer period of time and can under- be one future research direction.
stand their images and mental states. Therefore, the As a conclusion, it is observed during the research
researcher's self-made picture book style highlights the process, ASD children can sustain better visual atten-
main elements of the story content, reduces the number tion to the content of researcher-made picture books.
of irrelevant elements and the interference of irrelevant Results indicate the areas and points of attention on the
stimuli, which subsequently increases the sustained designed ones are quite different from those of ordinary
attention time and visits of ASD children. picture books. However, there are still a number of
shortcomings in the research process mainly in the
Limitations and recommendations to materials used and participants recruited. The research
future research process, materials and participants are recommended to
This research has provided preliminary evidence that be enriched in future research. It is hoped that the
special design and special arrangement of the content of results of the study can provide reference for the devel-
the picture books may stimulate sustained attention and opment and teaching of picture books for
increase the effective viewing area of the autistic chil- ASD children.
dren, and that it provides a reference for picture book
teaching and development for ASD children. However, Disclosure statement
there are a number of limitations in the implementation No potential conflict of interest was reported by
of this research. First of all, this study only selected the authors.
two researcher-made picture book styles. More import-
antly, only limited contents and pages were provided, ORCID
which makes it difficult to conclude with confidence Xiang Lian http://orcid.org/0000-0002-1807-4054
the effectiveness of each style of picture book. Future Wilson Cheong Hin Hong http://orcid.org/0000-
research can create more variety of picture book styles 0002-9858-2015
with more pages and improved presentation of contents. Xiaoshu Xu http://orcid.org/0000-0002-0667-4511
Secondly, regarding data selection, the areas that Kolletar-Zhu Kimberly http://orcid.org/0000-0002-
ASD children tend to pay attention to during the view- 5347-9575
ing process have not been expounded on, as data are
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