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The Autistic Spectrum



Vision & Autism
 
The following article was published in The Newsletter of Achievers Unlimited, Inc., Fields of Vision, Volume 1, Number 6 (March 1996). Permission to post on the ASW homepage was obtained. The information contained in this article is for your information and does not constitute endorsement by the Autism Society of Wisconsin.

Vision Development and Autism
At birth, the structure, size and growth of our eyes are almost complete. Once a baby is born, the eyes begin to learn how to function effectively with his body and brain. In order to function effectively, vision skills must automatically develop along with the baby’s motor and cognitive development. Up to 90% of individuals with autism lack the vision skills which determine how our eyes function. These skills have not developed automatically.
 
If an eye care professional can do the testing, we find most individuals with autism have 20/20 eyesight. Eyesight is the ability to see a certain size at a certain distance, momentarily. Vision, or the way our eyes function, is the ability to understand what we see, store the information, and retrieve what we know at a later time.
 
Vision is actually a set of skills and abilities including 20/20 eyesight, focusing, eye movement, two-eyed coordination and tracking. Vision skills can be taught.
 
Normal Vision Development
At birth, babies don’t see the world beyond their grasp. If you brush a newborn’s hand with your finger, the baby will grasp the finger. Eventually, the baby will begin to look at your finger after he grasps it. At this stage of development the tactile sense is directing the baby’s vision. This is the first step in training the visual system.
 
There are many steps in developing the visual system automatically. Soon, the baby can locate an object visually, reach for it and pick it up. By six months, the baby manipulates a toy with his hands, turning it around and around to allow his visual system to examine the toy from all angles. By 12 months, the child can glance at that toy from any direction and know that it is his toy.
 
As the visual system continues to develop it begins its lifelong task of directing the body and brain. The child learns to visualize his toy, making it possible to learn the word for that toy: “truck.” Language begins to develop, directed by the visual system. By 10 years of age, the goal of the visual system is integration: the ability to see an object, such as ice cream and know that it is cold without having to touch it.
 
Vision Development and Autism
Visual development is erratic in a child with autism. Eric, age 12, does not know that ice cream is cold without touching it. In Eric’s case, his tactile sense is still directing his body, brain and visual system. Eric’s world is confined to the objects he can see within his grasp. Eric does not see anything that he is not touching. Eric’s visual system is at the level of a newborn infant.
The goal of a developed visual system is to direct the body. Since Eric’s tactile sense is still directing his body, he does not move out in space very well. Yes, he can sit and walk and run, but Eric’s body never stops. He is constantly in motion, constantly running. Like a newborn, whose body moves without direction, Eric has not yet learned to stop and start his body. He doesn’t have body awareness. If we want Eric to stop running, we have to touch him on the shoulder. If we want Eric to sit in a chair, we have to direct him to the chair and press down on his shoulders. Jessica, age 8, has a visual system that has not learned from constancy. She can spend hours holding and looking at a plastic cup. We know that Jessica can say the word “cup.” However, if we give her a styrofoam cup, she cannot use the word “cup” to describe it. She has not visually integrated the information. We don’t know how much information she is receiving through her tactile sense.
 
Jessica’s visual system is in place, but it is on idle. Her vision is reflexive, rather than directive. Her visual system doesn’t help her survive in the real world.
 
Like some individuals with autism, Jessica has a photographic memory to compensate for the lack of visual development. As long as her environment remains the same, Jessica can function. If, however, the family sofa is moved to another part of the room, Jessica becomes agitated. She does not know this is the same sofa, because she is now seeing it from a different angle. Her ability to function in the family room setting is threatened. She cannot rely on her photographic memory. Jessica’s visual system is functioning at the level of a six month old infant.
 
Typical Visual Patterns Associated With Autism
Both Eric and Jessica have 20/20 eyesight, but they also have visual patterns that interfere with their ability to react and interact with their surrounding. These patterns include poor eye contact, looking through rather than at objects, using peripheral or central vision, and visually sweeping the room rather than looking at specific items in the room.
 
Splitting peripheral vision and central vision
Peripheral vision is using side vision. You can get the feeling of peripheral vision by putting your hand in front of your face and looking around your hand. Some individuals with autism shift from the extreme right to the extreme left, moving the head as the eyes shift. This results in picking up fragments of visual information, instead of the full picture.
 
Some individuals with autism switch from peripheral to central vision. Put your hand, once again, in front of your face. Separate your fingers in the center of your hand. Now switch from side to side or look at a detail in the center. The visual information is still fragmented.
 
Scanning
Scanning or darting is that constant shifting or sweeping motion. Again, put your hand in front of your face and continue to shift your eyes from one position to another. You may notice objects in the room jump at you, swim, blur, or double. The act of constantly scanning can lead to dizziness, headaches, nausea and disorientation.
 
Binocular problems
Seventy percent or more of individuals with autism do not automatically develop an efficient binocular (two-eyed) pattern. Think of the eyes as being two cameras. They need to point, focus, move exactly to avoid blur or double vision. When the two do not work exactly as a team, the individual experiences blur or double vision, or the brain conveniently suppresses vision partially or totally. Total suppression of an eye eliminates some visual confusion but does not allow information to get to both sides of the brain. Partial suppression leads to much confusion and visual stress making all visual tasks exhausting.
Poor visual attention
 
When the visual system is working correctly, the individual can see, understand what is seen, and remember what is seen with speed, accuracy, at any time and with little energy. An inefficient system makes controlling the eyes difficult. Shifting with exactness, and maintaining clear eyesight becomes exhausting. The physical effort is extensive, leaving little energy to understand, remember or use what was seen.
 
The Effects of Erratic Vision Development
These visual patterns are caused by the lack of vision development skills, such as eye-hand coordination, eye-foot coordination, eye movement control, convergence, difficulty with eye contact and eye-hand-foot-brain coordination. Vision skills impact a child’s ability to eat without spilling, walk without falling, and to be aware of their surrounding. Poorly developed vision skills will affect a child’s penmanship, reading, attention span and socialization skills.
 
Because vision development is erratic in an individual with autism, the visual system interferes with learning life skills and academics. An inefficient visual system causes the following:
 
Inability to pay attention (child doesn’t work at near for long because of blur or double vision); 
Vision is reflexive rather than directive (touch directs the visual system); 
Form constancy (cannot recognize an object from another angle, resulting in rigid behavior - don’t move your furniture around); 
Language delays (lack of visualization);
Lack of integration (knowing ice cream is cold without touching it);
Inability to move out in space very well (can’t see beyond his grasp);
 
Motor Development
Our visual system develops along with the body, not separate from the body. A child with autism has a visual system that develops erratically. This erratic development is caused by a compromised motor system.
 
Motor development is the sequential development of the body, brain and eyes as a coordinated unit. For example, a child needs to
    creep before he walks;
    walks before he runs;
    runs before he skips;
    skips before he jumps rope;
    jumps rope before playing baseball or football.
 
This sequential development occurs on many levels. In order for a child to learn to write, he must learn the following tasks:
    suck his fingers;
    observe his hands;
    grasp a rattle;
    eat finger foods;
    give a toy to another person;
    hold a crayon;
    scribble;
    watch his hand as he scribbles;
    color;
    and draw.
 
A properly developed motor system allows the child to explore and inspect the world with his sense of touch, smell, taste, sight and hearing. Ideally, the child gradually becomes aware of his body and begins working to control the body’s action. As the child plays, his body’s movement becomes more relaxed and fluid, causing his mind, body and vision to develop.
 
Let’s say each of us is given 100 units of energy to use at birth. As a newborn, we use 100 units of energy to control our body. We learn how to such out fingers, roll over, grasp a rattle, eat finger foods. As we grow over the first few years, more and more units of energy are needed for developing our brains and visual system. By the time we are seven years old, we need 75 units of energy to control our visual system and allow our brains to function efficiently. Only 25 units of energy should be needed to control our body.
 
Healthy motor development allows a child to become aware of his body. A newborn’s first motor development stage a newborn involves fighting gravity. The sequential development is
 
    1) Body contact with floor
    2) Sitting
    3) Hand and knee
    4) Standing
    5) Walking, jumping, hopping, skipping
 
Between crawling and walking, a child learns to stop and start his body. When a child like Eric is unable to start and stop his body, we know something went wrong in his fight against gravity.
 
The goal of the motor system in fighting gravity is to develop posture. Correct posture allows our body to balance with a minimum of effort, so we don’t have to use the majority of our 100 units of energy to sit, stand or walk.
 
An additional bonus of good posture is the efficient use of addition energy we need for vision and fine motor activities. The muscles of the neck and trunk constantly adjust and hold the body in balanced relationship with gravitational forces. Many of these same muscles are also used in maintaining the body’s center of visual attention and for manual activities, such as writing.
 
We have all experienced situation in which we had to sit through a lecture, speech or church sermon when we needed to go to the bathroom. For a short period of time, our motor system is compromised. We need all our energy to control our body. We are unable to focus on that portion of the sermon, lecture or speech. Eric and Jessica have motor systems that are permanently compromised. They have poor vision skills, trouble paying attention, poor language skills, and learning difficulties because all of their energy is used up in an effort to control their bodies.
 
The Hazards of Ignoring Motor Development
Visual development is erratic in children with autism, because their motor system is compromised. Unfortunately, motor development, the most essential area in dealing with autism, is often neglected in pursuit of developing the child’s intellect.
Remember, motor development is the sequential development of the body, brain and eyes as a coordinated unit. A child’s intellectual development is often limited by an inefficient body and visual system.
 
Eric, who is constantly in motion, lacks body awareness. He has to be constantly watched to keep him from running into the street or any hazardous situation. He lacks the attention needed to learn the life skills needed for independence. His visual patterns prevent him from integrating what he sees, making a classroom setting out of the question.
 
Before we can teach Eric the vision skills he needs to pay attention, visualize, integrate information and move freely about, we must teach Eric’s body to start and stop. In Eric’s case it took six sessions.
 
Next, we try to get Eric’s eyes involved in some way with an activity. We’ll start by slowly rolling balls to him to see if his eyes can follow the ball. If that doesn’t work, we might try getting him to kick a ball or balloon. Our goal is to try to get Eric to use his eyes instead of his body.
 
If we cannot find a way to get Eric’s eyes to participate in an activity, we’ll look for another of his senses that is most adaptable to change. We start with the tactile sense. We’ll stand next to him and move his body for him. If we want him to kick a ball, we’ll move his leg when it’s time to kick, hoping that his eyes will eventually begin to participate.
 
We don’t know how much of a change we can make with Eric and Jessica. We don’t know how long it will take to make the changes. We do know, however, that any change improves the child’s quality of life. Once Eric could start and stop his body, the entire family benefited. The amount of stress involved with safeguarding Eric decreased. Dad and Eric now play catch for hours each week and have fun doing it.
 
Understand the visual components that accompany each stage of healthy motor development is the key to teaching vision skills that have not automatically developed in a child with autism. The next six issues of Fields of Vision will cover vision development by age groups: 0-3 years; preschool years; elementary school years; high school years; adulthood; mature adult years. Each issue will provide an overview of vision development for the particular age group and activities to teach skills your child may be lacking. Adults and senior will learn activities to ensure their vision is not limiting them in jobs, hobbies, sports, driving and independent living.
 
Fields of Vision is published six times per year by Achievers Unlimited of WI, Inc., 104 S. Main St., Suite 420 Fond du Lac, WI 54935,
Phone: 1-920-924-9898, toll-free: 1-866-924-9897
 
 
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Scientists Examine How a Disorder Makes Some See a Color-Coded World

 

By Lee Dye

 

March 28 Even as a child, the man called "WO" knew he saw the world quite differently than his friends.

 

Letters, numbers and words all had distinct colors.

He knew it, because he could see it with his own eyes. To him, a page of black print didn't look black at all. It was a symphony of color. The number "2" was bright orange, "5" was green, and so forth.

 

His young friends, no doubt, thought he was a bit nutty, but he had one close ally. His mother understood. She knew words had colors, because she, too, could see them. They weren't the same colors her son saw, but they were colors, nonetheless.

 

Both WO (as he is anonymously referred to in a recent study) and his mother had a condition known as synesthesia (rhymes with anesthesia), that causes some people to hear colors, feel sounds and taste shapes. Scientists have known about synesthesia for at least 300 years, but it wasn't taken all that seriously until recently. People who claimed to hear colors were dismissed as hallucinatory, or worse.

 

Condition Through the Ages

A decade ago Richard E. Cytowic, a neurologist, chronicled a number of case studies in a popular book, The Man Who Tasted Shapes, and scientists realized the time was ripe to reopen the case of synesthesia. New testing procedures, and new tools that could peer inside the brain, identifying areas that are active during various conditions, could allow them to see if there really was anything to all this.

 

And it turns out that there is. WO really does see the number 2 as bright orange, just as thousands of others around the world see it as blue, or yellow, or whatever. It is a concept that is quite difficult for the rest of us to grasp.

 

"It's like trying to describe color to someone who doesn't see color," says Thomas J. Palmieri, a Vanderbilt University psychologist and lead author of a study on WO that appears the March 19 issue of the Proceedings of the National Academy of Sciences.

 

In his earlier research, Cytowic documented a number of startling cases, including such well-known figures as Russian novelist Valdimir Nabokov, who as a child complained to his mother that the colors of the letters on his wooden alphabet blocks were all wrong. She knew, because she also saw letters as colors, and they clearly were not the same as those on the blocks.

 

The condition, which is genetically transmitted, seems especially prevalent among highly talented and gifted persons. The Russian composer Alexander Scriabin, who saw sounds as colors, even composed a symphony in 1910 that featured a colored light exhibit that he, no doubt, could see even without the lights. Other synesthetes, as they call themselves, include the poets Baudelaire and Rimbaud, painters Kandinsky and Klee, and the noted physicist Richard Feynman.

 

No one knows just how many people have the condition. Estimates range from one person out of every 300, to one out of every few thousand. The number is vague for obvious reasons. Some people learned early on not to talk about it out of fear of being regarded as odd. And those who have it tend to like it, so they don't feel a need to seek out medical help.

 

To take it away from them would be to deprive them of a special sense that may improve memory, and possibly stimulate creative instincts.

 

But do they really see, or hear, or feel what they claim to, or are they just fooling themselves?

 

Put to the Test

That is the question that Vanderbilt's Palmeri wanted to confront. He was in his office a couple of years ago, talking with colleagues and fellow psychologists Randolph Blake and Rene Marois, about a short item in a recent issue of the journal Nature. The item described some headway in the study of synesthesia, and it piqued their interest as students of the cognitive process.

 

Blake told his colleagues that another colleague, subsequently identified as WO, had the condition.

"We were really intrigued and started testing him," Palmeri says.

 

They wanted to learn two things: whether WO really saw what he thought he saw, and what part of the brain allowed him to do it. The first part of that question is the easier part. An answer to the second is still up for debate.

Since WO claimed that plain black letters and words appeared to him in vivid colors, the researchers devised a number of experiments to see if the perception claimed by WO was real.

 

They drew up a list of 100 common, one-syllable words, and asked WO to tell them the color of each word.

A month later they repeated the experiment. He got it right 97 percent of the time. The only time he missed was with the easily confused colors of off-white, beige and light brown. Other researchers have done the same experiment with similar results.

 

The Vanderbilt team then showed WO pages of black numbers. In one test, a few 5s were interspersed among 2s and he was asked to pick out the 5s. Since they stood out as a different color, he completed the task in a fraction of the time required for people without the condition.

 

Those and other tests led the researches to conclude that the condition was real.

 

Wires Crossed in the Brain?

Next, parts of the numbers were presented separately to each eye. WO didn't see the color with just part of the number. It took both parts to produce the color. So the color came only after his brain reassembled the parts.

"This strongly suggests," Palmeri says, "that his synesthetic associations take place at a central level of vision processing after information from the two eyes has been combined." Others have postulated that the condition occurs much earlier in the visual process.

 

Other researchers, including Vilayanur Ramachandran, director of the Brain and Perception Laboratory at the University of California, San Diego, believe the condition may result from "cross wiring" of the brain.

 

Ramachandran, a pioneer in the field of phantom limbs, in which persons claim to experience pain and other sensations in missing limbs, notes that the area of the brain that detects colors is adjacent to the area that handles letters and numbers.

 

Perhaps, he suggests, people like WO simply pick up information from one mental data stream and blend it into another. But whatever the cause, Ramachandran and graduate student Edward Hubbard have carried out studies similar to those at Vanderbilt and they have collected convincing evidence that the perceptions claimed by people with synesthesia are real.

 

Which brings us to this question: What, after all, is real? Green numbers are green because they occupy that specific region of the color spectrum. If someone sees a number that is painted in green, and perceives it as blue, is he seeing the real world?

 

To a physicist, maybe not. To a cognitive scientist, maybe so.

 

It doesn't really matter anymore to WO. He says parts of medical school were a breeze, thanks to his synesthesia. All those long words in biology and anatomy that are so hard to remember came easier to him, because if he forgot the letters, he could at least remember the colors.

Lee Dyes column appears weekly on ABCNEWS.com. A former science writer for the Los Angeles Times, he now lives in Juneau, Alaska.  

 

Source: http://www.abcnews.go.com/sections/scitech/DyeHard/dyehard.html

 

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Vision Therapy, Autism, and Sensory Integration
 
Vision Therapy and the Autistic Child.
Report from Sensory Integration Quarterly.
Vision Therapy and the Autistic Child
By Audrey Adams
 
I am the parent of an autistic child.
Too often, visual problems which would have been detected early in non-disabled children go undiagnosed and untreated for children with disabilities, perhaps because the visual examination would be difficult, or the child is not able to verbalize a problem, or the school's test showed "normal" 20/20 eyesight. Whatever the reason, all school aged children, including children with disabilities, should have a full visual examination.
 
The eye charts used by schools only measure clearness and sharpness of eyesight at a distance of 20 feet using a stationary target. However, these charts do not test for eye tracking, aim, teaming, depth perception or visual perceptual skills. In other words, a chart test will not measure the ability to see adequately at 20 inches (affects reading writing, math, etc.) visual efficiency in following an object or landscape in motion (affects all sports, PE, ball games, riding bicycle, etc.) or the ability to accurately judge distances and depth (affects balance, large motor coordination, perception of environment, etc).
 
If a child with autism/PDD is unable to read is uncooperative with close tasks, has illegible handwriting, or is disruptive in class, too often we assume these are "autistic" behaviors that must be modified behaviorally or taught with numerous repetitions. When these same characteristics are present in non-disabled children, most primary grade teachers would ask if the child has had a complete visual examination. My son's first, second, and third grade teacher all did and I regrettably ignored them until the fourth grade. Though he read and was disruptive, these regular education teachers all saw signs of possible vision problems: eye contact avoidance, blackboard visual avoidance, poor and uneven handwriting, inability to listen and look simultaneously, over use of peripheral vision, a stiff-legged walk and poking at the sides of his eyes.
 
Because some sensory dysfunction is present in all individuals with autism, and because vision problems are more common in individuals with sensory impairments, it would benefit parents of children with autism greatly to become more knowledgeable about vision impairments and possible remedies. Occupational therapists should also be interested in learning more about eye exercises and the improvement in motor skills when the "eye" is the culprit in "eye-hand" coordination difficulties.
 
My son, Kyle, had throwing and catching a ball on his IEP for about 6 years, because we knew improving coordination and reciprocal play was important. After all the time, he still was not able to catch even a beach ball. it simply bounced off his stomach and then he moved his arms, sometimes, but too late.
 
A vision examination two years ago revealed that Kyle had, among other things, significant convergence problems and could not focus on a fast moving object. His eyes were working independently, rather than together, so that he saw two pictures instead of one. In other words, he never accurately saw the ball as it moved, he only saw it after it stopped. Once the ball was still, he willingly retrieved it and brought it to you. We began doing the prescribed eye exercises at home for about 10 minutes a day; it seemed more like play than work. After three weeks, Kyle was catching tennis balls!
 
In addition to enabling Kyle to see moving objects, vision therapy has improved his reading efficiency and comfort, increased his depth perception and improved horizontal and vertical tracking (imperative for math and reading music.) these exercises also decreased Kyle's overuse of peripheral vision, reduced his gaze (and task) avoidance, and decrease eye poking and other physical signs of visual strain. Kyle also wears glasses with prisms lenses to slightly tilt his visual field upward, which helps him to look forward rather than down, as he tends to.
 
The bad news is that a lot of Kyle's early years were wasted (for example, as a human target, rather than a participant in ball games) because parents, educators and pediatricians alike were unaware of the limits of his vision. We accepted, and even ignored, many of Kyle's behavioral differences because those characteristics are known to be associated with autism. The good news is that many of this vision problems are correctable with methods that have been in use for over 40 years in the field of optometry. In fact, vision therapy has been around so long that it even appears in encyclopedias written in 1960.
 
Unfortunately, it seems almost unknown to those searching for answers for autism. Vision therapy does not cure autism, but it can significantly improve academic performance, personal comfort and security and participation in more typical, age-appropriate activities. in other words, enhance a person's quality of life.
 
When making an appointment for a vision examination, go straight to a developmental optometrists, not an ophthalmologist. While most optometrists do not offer therapy services, one with a developmental background is able to diagnose correctable vision problems and give a referral for therapy. Don't assume that your child can't be tested; a really good eye doctor can tell you a lot about the vision performance of even non-verbal individuals. If the optometrists tells you that your child is untestable, find one that is willing to try.
 
A word of caution here is prudent: If you are told that your child needs surgery to correct vision problems you MUST get a second (or even a third) opinion. A friend of mine has a non-disabled son who has had a "lazy eye" since he was a toddler. Over a period of several years, three different ophthalmologists told her that her son would need surgery to correct it. In the 4th grade his reading and other close work was suffering, prompting her to take him to yet another eye doctor, but this time to an optometrist. The optometrists told my friend, "DO NOT DO ANY SURGERY!" The surgery proposed corrects muscle problems; this is not a muscle problem, it's a brain problem. It is correctable with eye exercises your son can do at home." He referred them to a developmental optometrists for therapy. Four months of eye exercises corrected her son's vision problem. Reading, math, and sports are now much easier and enjoyable. A happier 10 year old, he exclaimed after one month of therapy, " Hey, Mom, the words don't jump all over the page anymore!" Interestingly , my friend had previously asked her son if he saw words moving, and he had replied, "No." He didn't know that what he saw was different than everyone else and was apparently expecting a larger movement, compared to what he typically saw.
 
Do you know the difference between an optometrists and an ophthalmologist? They are both "real" eye doctors. Their education differs in that ophthalmologists are trained in surgery. Optometrists are licensed to diagnose conditions that require surgery and ocular pathology but cannot operate. Some optometrists have additional training and certification in developmental optometry and prescribe and/or direct vision therapy programs, usually performed by a therapist. While most insurance companies will readily cover doctor visits, glasses and surgery, they do not always cover therapy. Is it any surprise that, generally, ophthalmologists are not interested in prescribing or learning about vision therapy?
 
My son is eleven and several questions continue to nag me. How many of the behavioral characteristics listed as diagnostic criteria for autism/PDD are symptoms of severe vision dysfunctions? Auditory dysfunctions? Tactile and vestibular dysfunctions? If my son could have seen, heard and felt as typical children do as a toddler, would he have had those characteristics that label him autistic? How much more could Kyle have learned in those formative years if we had addressed his sensory problems first?
 
If I could turn back the clock, I would do all sensory therapies FIRST and THEN behavioral therapies and interventions. I have done it backwards, not only wasting critical developmental years, but also not allowing Kyle to receive the full benefit of his behavioral therapies and educational instruction. He has spent his life trying to cope with and diminish his discomfort of sound and touch. He has worked diligently to make sense of what he sees that is not real, what he doesn't see that others do, and even trying to shut off his vision so that he may hear us better. All the while those of us with sensory systems intact say that he's in his own world. and he is, literally. Only HE can see, hear and feel his world as he does, but he did not ask it to be so.
 
(Note: Two developmental optometrists, Dr. Nancy Torgerson and Dr. Marcy Rose, wrote an article titled, " A behavioral Approach to Vision and Autism," that was published in the Journal of Optometric Vision Development Winter - 1994. Dr. Rose presented at the July '95 ASA National Conference and Dr. Torgerson presented at the March '96 ASW Best in The Northwest Conference.)
 
________________________________________________
Report from Sensory Integration Quarterly
Reprinted from Summer 1996 Issue with Permission
 
Letter from Mrs. Roxane Barricklow of West Harrison, IN, describing the positive response of her autistic son, Jimmy, to vision therapy:
 
Our family began vision therapy in April, 1994. It was recommended to us by our son's speech therapist and audiologist, along with other therapies. At that time our son was receiving many other therapies to help him deal with autism, including allergy medications, music therapy, auditory training (three times), speech therapy, sensory integration therapy, craniosacral therapy, and the medications Naltrexone, Trilafon, vitamin C, and a multivitamin. All of these therapies helped him in their own way, and doing them all frequently helped even more. We were leery of adding a new therapy that we did not understand, but followed the advice of a valued and trusted therapist. Our first visit was an eye-opener. We did nor believe that our 12 year old son would tolerate wearing the glasses because he is very touch sensitive. As soon as his eye exam was over and the doctor told Jimmy to pick himself out a pair of glasses, he did it! He tried glasses on and even looked in the mirror to see how he looked in them!
 
When the glasses came in we picked them up right away. Jimmy wore them out the door with no problem. On the way home we stopped at the park to walk on a trail. This was always a gambit because Jimmy had a strong fear of all animals, and if someone was walking their dog Jimmy would jump up on our backs to safety until the dog was gone out of sight. On this day a very large and mean looking dog passed us on the trail and Jimmy was not afraid. He simply looked at the dog as if, "Huh! So that is what a dog looks like. No big deal." He had only had his glasses for thirty minutes and already our lives were changed.
 
For the first few weeks he only wore his glasses for two to three hours per day and we did nor push the issue, since we wanted him to want to wear them. By the end of the third month he was wearing them 90% of the day. Ten months later he has them on when he comes down to breakfast and they are still on when he falls asleep at night.
 
The changes made in our home life were gradual but steady. Before vision therapy he spent long periods of time staring trance-like into space, even as he walked. Jimmy immediately began visually investigating his environment. He is now investigating his therapists' offices as though seeing them for the first time. He plays with his toys more appropriately instead of tapping them or making rows of them.
 
At age 13 Jimmy can now tie his own shoes. He is able to do this now because he has learned to "look" at what he is doing. He always puts his clothes on by himself, front-ways, and is very proud of this accomplishment. Before, dressing was hit-or-miss, with clothes put on backwards, or shoes on the wrong fret. Jimmy cares about his appearance now. After his shower he wants his hair blow-dried and styled, and wants to be told he looks handsome. He now washes himself and shampoos his own hair; drying himself when he is done. I believe this is because he now "looks" at what he is doing, something he could not seem to do before vision therapy.
 
All of his other therapies have benefited from vision therapy as well His progress in speech therapy has sky rocketed! He was basically non-verbal a year ago, and now uses speech to communicate. He makes eye contact while communicating with no trouble -- before now, eye contact was fleeting.
 
School is as different as night from day since vision therapy began. Jimmy has a longer attention span, follows instructions better, listens more closely and can sir for longer periods of time. Last year his time was spent doing sheltered workshop jobs, daily living skills, and he had lots of free time.
 
This year he has three or four five-minute breaks during his morning, with the rest filled with learning activities.
 
His classes are in the high school building this year and Jimmy has noticed that the kids there look and act different than the elementary kids did. Hr is trying very hard to be like the older kids. Socially, he is much happier. He wants to be in our company at home, instead of shut in his bedroom. He used to cry when told we were going out, but Jimmy loves outings in the community now, asking to go places every day. He wants to be a part of the world now. In stores, he pushes the shopping cart. If told he can pick a snack, he takes time and scans the shelves looking for what he likes, instead of blindly grabbing the first item. Stores used to give him panic attacks which sent him running for the nearest exit.
 
Our life together has definitely changed! Our son is still autistic, and in need of years more of his therapies, bur he now makes steady progress and is happy and proud of himself. He likes himself and wants to be an active part of his family, community and world.
 
Answers to Questions about Vision Therapy:
 
    Dr. Stanley A. Appelbaum, OD, FCOVD is a member of the Board of Directors of SII, and has been a developmental and behavioral optometrist in the Washington D.C. area for 22 yeares. Dr. Appelbaum's wife, Barbara S. Bassen, OTR/L,BCP is an Occupational Therapist trained and certified in using Sensory Integrative theory and therapy. She has added to Dr. Appelbaum's understanding about children with sensory integrative needs.
 
Dr. Appelbaum, what is developmental, or behavioral optometry?
 
Developmental, or behavioral optometry is a specialty within the field of optometry. We have a certifying organization called the College of Optometrists in Vision Development (COVD). This organization certifies specialists in vision therapy development.
 
A number of books have been written about it (vision therapy). It looks at how an individual processes visual information. A routine eye exam looks at eye sight and health -- a behavioral optometrist looks at those things, but also how the individual processes information: whether or nor the eyes work together as a team, focusing problems, eye movement problems, or whether there is a problem integrating vision with other sensory modalities. Vision therapy is not new. It started in the early 1920's. Our "Jean Ayres figures" are Dr. A.M. Skeffington and the late Dr. Jerry Getman, (who worked with Dr. Ayres). Dr. Getman's book, "How to Develop Your Child's Intelligence," can be purchased from the Optometric Extension program Foundation, in Santa Ana, CA. The PAVE group can help you find the book in your area.
 
Is there a basic pattern that vision therapists use when they prescribe vision therapy for children?  If I were to have therapy at your center in Maryland, then go to a vision therapist here in my town, would your basic approaches be the same?
 
If you go to an optometrist who is a Fellow of the College of Optometrists in Vision Development it is like going to a SIPT-certified OT. They would have similar training. But there is not one program for vision therapy. Instead, there are many different diagnoses - oculomotor problems, strabismus, amblyopia - many kinds of programs. Each patient receives a treatment strategy designed for her/him, to help them gain their own oculomotor control.
 
In your optometric practice (or anyone else's) approximately what percentage of the clients you see need vision therapy?
 
In a general practice, of family vision care, it turns out that about 20% of all of the patients seen have vision problems that can't be solved by any therapy other than vision therapy. In my practice here in Bethesda, I get a high number of referrals from other professionals who have already identified the patient as having a vision problems, so my percentages are higher.
 
What should we look for when choosing a vision therapist?
 
When choosing an eye doctor it's est to get someone who is Board Certified in Vision Therapy. The initials FCOVD (Fellow of the College of Optometrists in Vision Development) will follow her or his name. Also, you want to be sure that, during the exam, the doctor makes a series of near-point tests. No eye drops can be used for that procedure. There is a list from the COVD of those people who have passed oral and written exams demonstrating competence in vision therapy. (1-800-PAVE-988 is a national group of parents, Parents Active in Vision Education, who staff this number, and will give you a list of developmental or behavioral optometrists in your area, as well as information about symptoms).
 
 
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VISION THERAPY: A BENEFICIAL INTERVENTION FOR DEVELOPMENTAL DISABILITIES
 
Written by Sally Brockett, M.S., Educational Consultant
Innovative Developments for Educational Achievements, Inc.
North Haven, CT 06473-2342
 
Just as language and motor skills are achieved through a sequence of developmental stages, vision must also follow a progression of development. An infant is not born with the visual abilities that he will need in order to function successfully in his world. These abilities must develop through a variety of experiences across a period of time. At any point during this process, the visual development may be hindered, altered or completely stopped, sometimes by injury, illness, emotional trauma, lack of appropriate stimulation, or other unidentified causes. When language and/or motor skill development is interrupted, parents and teachers seek to identify the problem and intervene with therapy or training activities designed to assist the child in overcoming the delay. A similar approach is available to parents of children (or to adults) who have inadequately developed visual abilities.
 
Distorted Input. When we speak of vision, we are referring to the ability of the brain to organize and interpret the information seen so it becomes understandable or meaningful. Even individuals with good eyesight (20/20 acuity), can have undiagnosed vision problems that make it difficult to correctly comprehend the visual message. If sensory input, whether it is visual, tactile, auditory, etc., is received in a distorted or faulty manner, the behaviors that are based on that input are likely to be distorted. Many of the behaviors characteristic of autism, and many behavior problems associated with learning disabilities, may include attempts to manage in spite of a visual system, and other systems that fail to provide understandable, reliable information.
 
Vision Therapy. Since vision development follows predictable stages, it is a process that can respond to training if disruptions occur. Vision training is available through Behavioral (developmental or functional) Optometrists who have received postdoctoral training in this specific field. Unlike the correction of refractive problems (near and farsightedness, and focusing problems), which may only require the use of a specific prescriptive lens, vision therapy is a process of retraining the visual perceptual system so it functions with optimal efficiency. The process follows a sequence of steps aimed at improving the visual system. Therefore, it is a procedure with therapy activities prescribed by the vision therapist which are carried out in the office, and frequently reinforced with home activities.
 
Identifying the Problem. Vision dysfunctions often go unrecognized or misdiagnosed because people do not understand how vision relates to behavior and can affect the overall performance of the individual. In addition, many people develop ways to compensate for their visual difficulties, which masks the fundamental cause of the problem. So how does a parent know if their child has a problem with visual development? Since dysfunctions in the visual system can lead to a variety of behavior, learning, social, work and health problems, the parent and/or teacher should consider this as a possibility for any individual with developmental disabilities.
 
There are also many observable clues that can indicate visual difficulties, including:
 
Symptoms:
    * Eyes that cross or turn, even a little bit.
    * Tilting, turning the head, covering or closing an eye in order to use only one eye.
    * Looking at things out of the corner or side of the eyes.
    * Blinking, grimacing, squinting and other compensating behaviors.
    * Visual stimulation behaviors: finger flicking; obsession with spinning, patterns, or other visual effects; sighting along linear objects (counter edges, telephone wires).
    * Short attention span, avoidance of close work and activities.
    * Low frustration level, irritability, emotional immaturity.
    * Headaches, dizziness, nausea, car sickness and light sensitivity.
 
Obtaining an Evaluation. Parents interested in a functional or developmental visual evaluation for their child can locate a Behavioral Optometrist through the College of Optometrists for Vision Development, (619) 425-6191, or the Optometric Extension Program, (714) 250-8070. Informative books, such as The Suddenly Successful Student, Your Child's Vision, and 20/20 Is Not Enough are also available through these sources. These books cite many of the research studies that document the efficacy of vision therapy. A comprehensive evaluation should take between 45-60 minutes and typically costs between $100 to $250 for the initial visit. In the evaluation, the doctor should be interested in the child's symptoms, general physical health, developmental history and specific visual demands. In addition, the doctor should examine not only the clarity of eyesight and health of the eyes, but eye movements, skills, focusing ability, depth perception and binocularity (eyes working together as a team).
 
What to Expect. The optometrist should discuss the results of the evaluation and recommend treatment in the form of lens, prisms or visual therapy. Therapy sessions are usually between 30 - 60 minutes, depending on the person's attention span, and range in cost from $65 to $120 depending on the time spent.
 
Many health insurance companies include this type of vision care in their coverage. Therapy with young children, highly distractible people, or autistic individuals is usually done on an individual basis. A closely monitored program is essential in order to evaluate progress and make adjustments as changes occur.
 
Vision evaluations and therapy provided by Behavioral Optometrists should, at some point, include the use of developmental lenses. This may include prisms to help achieve better visual alignment and processing, and/or red/green filters (anaglyphs) and polaroid filters during the individual sessions.
 
As parents interview the provider of their choice, questions should be asked and answered regarding this type of lens. When this type of lens is used, parents should be aware that it is a lens to help direct more efficient visual processing and this lens must be monitored by the optometrist every three to four weeks. If the optometrist is not seeing the child regularly, this is a red flag for parent concern. Lenses are the tool used by Behavioral Optometry to produce postural and processing changes. If lenses are not used in vision therapy, parents should ask questions about the procedure.
 
How Will My Child Respond? Frequently, parents express concern that their child will not accept wearing glasses, particularly if the child is tactilely defensive or very resistant to change. Some individuals with visual problems generally adjust quickly to wearing glasses once they see the difference and how the glasses help them. A behavioral plan following learning principles such as desensitization, positive reinforcement, shaping, etc. can be implemented for those who have difficulty accepting new glasses. Many parents report that their child shows interest in glasses, frequently taking glasses off other people to try on themselves. This may be an indication that the child is seeking to find a solution to his vision problem!
 
Vision therapy may correct or improve visual functioning conditions which will otherwise continue to interfere with appropriate development and learning. Sometimes the changes occur quickly and dramatically; more often, the individual will make gradual progress, with spurts of more rapid growth mixed with short periods of regression, typical of normal developmental progression. A great many parents have reported positive results with vision therapy.
 
 
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Autism in the Visually Impaired Child
 
Terese Pawletko, Ph.D. & Lorraine Rocissano, Ph.D.
Psychology Department
Maryland School for the Blind
 
AER/DENVER, July 18, 2000
 
Their behaviors (e.g., stereotypies, rituals; restrictions in play) seen as:
    * indicative of emotional disturbance
    * associated with sensory deprivation (e.g., turn inward for stimulation)
    * related to mother-child attachment (e.g., in incubators longer; lack of eye contact so hard to read cues; maternal depression further limiting her involvement with child)
 
Non-Autistic and Autistic Rubella - Distinctions noted by Chess et al.
Non-autistic rubella children with sensory defects:
   1. Are very alert to their surroundings through their other senses
   2. Exhibit appropriate responsiveness - "Some are shy, some slow to warm up, some perhaps wary; but one is impressed by their readiness to respond to appropriately selected and carefully timed overtures."
 
Rubella children with autism and sensory defects
   1. Do not explore with alternative senses
   2. Maintain distance from people that is not explained by the sensory deficits nor by degree of retardation
   3. Their affective behaviors do not resemble those of the same mental age.
 
Caveats in Diagnosing
   1. Autism is a developmental disability, not parent induced, not induced by blindness
   2. It is a syndrome; no one symptom yields a diagnosis.
   3. Autism is a spectrum disorder, with a wide range of functional levels, and behavioral presentations.
   4. While symptoms show improvement over time, the individual remains autistic. Autism is a lifelong disorder and for most individuals some level of support may be required.
 
Note: the following sections were depicted as "icebergs." They detail the key diagnostic features of autism using an iceberg approach - the behaviors one might observe on the surface, and the processing difficulties that might account for them.
 
Problems with Socialization
YOU SEE:
    * Fails to or has difficulty engaging in reciprocal interactions
    * Treats others as though they were objects
    * Seems uninterested in peers
 
What you do not see:
    * Problems shifting attention
    * Unable to process social information effectively
    * Difficulty processing complex stimuli due to difficulties telling figure from ground, and problems making very rapid shifts of attention
    * Cannot process multiple sensory stimuli simultaneously
 
Implications for Parents and Educators
   1. Recognize that the social world is more complex and less predictable for an individual with autism, and therefore more stress producing.
   2. Do not assume that simple exposure to peers will result in the acquisition of social skills.
   3. A child cannot be pushed to acquire social skills. Begin with something short, structured, teacher directed, and success oriented.
 
Problems in Language
YOU SEE:
    * Seems very verbal but can't follow instructions
    * Poor receptive language
    * Echolalia (Echolalia is a positive sign in that it shows that the child is at least discriminating among phonemes, sequencing sounds, using working memory)
    * Pronoun reversal
    * Non-verbal
 
What you do not see:
    * May use words expressively which they don't really understand (receptive language lower than expressive)
    * Difficulties discriminating language sounds - poor central auditory processing
    * Difficulties with sequencing phonemes and words
    * Can't break the linguistic code
 
Implications
   1. Check out whether child understands what he/she is saying (e.g., "what does that mean?")
   2. Use controlled language (e.g., short, concrete phrases with time between statements to allow for processing)
   3. If student has vision, try to provide some information visually; if not, provide information tactually.
 
Problems in Communication
YOU SEE:
    * Perseverates on one topic
    * Shows no interest in other people's topics
    * Too close or too far when talking
    * Says something unrelated to the conversation
    * May become angry when he hears certain words
 
What you do not see:
    * Can't apply rules in context
    * Problems with impulse control
    * Inability to take the perspective of another, as well as problems shifting attention
 
Implications
   1. Direct instruction in the actual setting is key.
   2. Identify clear, concrete rules that the child needs to follow in specific situations.
   3. Social stories can be helpful in providing a child with a script to follow.
 
Perseverative or Narrowly Focused Interests
YOU SEE:
    * Need for sameness, predictability
    * Motor stereotypies
    * Focuses on parts of objects in play (e.g., wheels, spins everything, flips handle of basket repeatedly)
    * Age appropriate pretend play not observed
    * Restricted and perseverative interest (e.g., elevators, Xerox machines, CD titles)
 
What you do not see:
    * Difficulty getting meaning from environment due to all cognitive processing deficits
    * Repetitive events are easier to understand and make sense of than multifaceted input
    * Repetitive behavior may be experienced as soothing
Implications
   1. Recognize that the routines and self-stimulatory behavior are the things that the child understands best and may serve as a "life-preserver" for the child. It is the child's retreat to his comfort zone.
   2. The child's reliance on such behaviors will tend to increase in times of stress and anxiety (e.g., transition, lack of clear expectation, challenges). Ask yourself "why is the child engaging in this now?"
   3. Identify a time when the child can engage in his self- stimulatory behavior; tighten up the structure, schedule, routine to decrease anxiety and increase non-verbal information.
 
Hypo- and Hyper-Sensory Systems
YOU SEE:
    * Over-reacts to certain noises (e.g., fire-alarms, vacuum cleaner, fan motor)
    * Finds certain tactile experiences aversive (e.g., certain foods, texture of clothing, soft furry objects, being touched)
    * Often finds warm temperatures aversive
    * May not react to bumping head, falling down, etc.
    * Stops listening to instructions when asked to open book
What you do not see:
    * Has poor regulation of auditory system (e.g., at times may find raindrops sounding like gunshots, other times not a problem; visceral panic regulation to sudden loud sounds like fire alarm - heart and respiration rate do not return to normal for several hours)
    * Can only process one sensory input at a time
    * Brains process temperature, texture, multi-sensory things differently
 
Implications
   1. Be alert to how the sensory environment may be impacting on your student.
   2. Try to keep the environment as low key as possible (e.g., visually clear, sound absorbing materials, no extraneous noise or conversation; balance lighting needs for children's visual impairment with those of arousal).
   3. Be aware of possible multi-sensory input issues and adjust instruction accordingly.
 
 
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Interview with Melvin Kaplan, O.D.
 
Melvin Kaplan, O. D. of Tarrytown, New York, is one of the pioneers in the field of visual management training. Dr. Kaplan has lectured extensively on visual training and has been mentioned in two books, Rickie and Dancing in the Rain. Dr. Kaplan is the Director of The Center for Visual Management (150 White Plains Road, Suite 410, Tarrytown, New York, 10591; Fax: 914-631-1004). Dr. Stephen M. Edelson (SE) interviewed Dr. Kaplan (MK) on September 17, 1996.
 
SE: Let's start out with a basic and rather general question: What is visual management training?
 
MK: Vision Management Therapy is an individualized program that measures, observes, and is designed to develop, improve, remediate, and enhance visual performance. The ultimate goal is to raise levels of performance which, in turn, affects behavior and influences how one performs in social, academic, and vocational surroundings.
 
SE: Have you ever noticed anything unique or different about the vision of autistic children versus the vision of other types of disabilities?
 
MK: I do not view people with various disabilities as different. I look at them as having different levels of visual performance. Let us view visual performance on a bell curve with the optimal performance at the peak. At one end of the curve are people who are experiencing visual compression; and at the other side are people who are experiencing visual disparity. The issue is then: How far from optimal is the person? or What level is the person at? One does not need to look at labels, whether it is autism, a learning disability, or dyslexia, I do not want to become hung up on labels because once you have a label then the community tells you how the person should be treated. It has been said, "Labels are for cans, not for people."
 
This reminds of a great article, "Labels are for Cans, Not for Kids." The question is not of labels, but of levels of performance.
 
When we observe the level of performance of autistic individuals, can we, through visual intervention of lenses and therapy, raise the level of performance? What is the difference between autism and learning or emotional problems? The difference is a lower level of performance on the ladder of processing information with a greater dysfunction in organization and orientation shifts from the optimal.
 
SE: Could you comment on why autistic children appear to rely heavily on their peripheral vision?
 
MK: I believe that this is a compensation. By turning their head, they get a monocular view of the world. What happens to be peripheral vision is simply a way to realign their focal or visual system. This is probably a way to avoid a mismatch between the right and left visual system which most likely fails to coordinate. Research indicates that autistic individuals have between 21 and 50 percent greater amounts of strabismus as compared to "normal" individuals.
 
SE: I once met someone who relied primarily on peripheral vision. I asked him why he does not look at people directly, and he said it was like looking through a "bowl of jelly."
MK: I think this person may have difficulty thinking and attending at the same time. This is a case of rivalry between the two visual systems; they are competing and out of synch. That is, if a person has difficulty handling bits of information, he/she may look at the individual letters but not at the whole word. If one is using just his/her identification portion of the visual system, he/she will likely take a long time to process the information so it will be difficult to attend while they are thinking. In fact, for almost everybody, if you look at them when they are thinking, their eyes tend to go up and to the left. When people have a disability, and this happens in non-autistic individuals as well, they cannot look at you when they are thinking; or they cannot look at you when they are talking because they would be unable to maintain the conversation. In other words, they cannot process visual and auditory information simultaneously.
 
SE: Could you comment on the idea that vision is a learned behavior?
 
MK: The focal vision, which involves identification, is not learned. There is a great deal of literature indicating that blind people, whose vision later returns, such as through cornea transplants, were able to identify letters because of their previous experience. In contrast, the ambient system is learned. Using this example, these individuals, can have much difficulty perceiving depth, organizing space, and orienting themselves.
 
Literature has demonstrated that 'focal vision,' which involves identification, can be learned through other sensory systems, whereas the ambient visual system needs rehearsal. The literature talks about people who have reclaimed vision after a long period of lost sight. They are able to identify objects, but they are unable to deal with the spatial organization of objects.
 
SE: In your opinion, who would be a good candidate for visual management training? Based on my conversations with you in the past, it seems as though people who display many self-stimulatory behaviors, have coordination problems, engage in toe walking, fail to reach out to touch things, and/or have problems with eye contact. It seems that many of these problems can be explained by improper depth perception.
 
MK: You just mentioned expressive problems, but I tend to look at these problems as receptive problems. Eighty percent of the information we receive comes from the visual sensory system. When we cannot obtain visual information from the environment due to some kind of receptive problem, we then start to see changes in performance or behavior. In fact, they spend so much energy trying to find the information that they do not have time left to speak.
 
Let me answer the question of who is a good candidate for visual management training. During the course of a non-verbal evaluation, if the individual can demonstrate awareness to their level performance and demonstrates that ambient lenses can make a more positive change on their visual performance, then both the patient and examiner will be highly motivated to a successful conclusion. This means that through the lenses and visual management training, they can reduce the symptoms that are characteristic of autism.
 
SE: Do you believe there is a relationship between activity level and the visual system?
 
MK: I think most cases have to do with visual processing. Hyperactive individuals cannot locate things with their visual system so they use their motor system to get to it. As a result, they are always running into things because their world is 2-dimensional rather than 3-dimensional. Things appear flat to them. They don't visually 'feel' it. In addition, their space is limited so they have to run and check on everything. When they go to a new room, they have to know where the doors really are; they have to know where all the light switches are. What they are really doing is rehearsing so they can be in a room without having to think much about it. That is why autistic individuals do not like new situations.
 
SE: What about those individuals who are at the opposite end of the continuum, those who are hypoactive?
 
MK: Hypoactive children simply do not attend. They are the ones who run away. This is no different than the child who just says, "That's it, I quit; I'm not going to read." And if you ask them a question, they will just say anything so that you will leave them alone. These are the wallflowers. They just do not want to play. They are the spectators and not the players.
 
SE: Do you think this is the same as 'learned helplessness,' in which the person learns to be helpless and simply gives up?
 
MK: Yes. They give up and have other people do things for them.
 
SE: Can visual training affect stereotypic, self-stimulatory behavior?
 
MK: Self-stimulatory behaviors appear to be inappropriate to us; but to the child, they are appropriate and necessary. What these individuals are doing is finding a way to interact with their world. For example, if a child is flapping his arms, he wants to know where his body is located. I should mention that people without autism exhibit these behaviors as well. This is what people should understand. For example, many people stick out their tongues when cutting a piece of bread. This is a stim that is not considered inappropriate.
 
SE: Does visual management training help people with strabismus or cross-eyedness?
 
MK: Approximately three to four percent of the normal population have strabismus; and based on our recent study, it appears that 21 to 50 percent of the autistic population suffers from strabismus. The question is: "Why is their such a relatively high percentage of autistic individuals with strabismus?"
The answer to this question involves the ambient system and a lack of coordination between the eyes. This may result in amblyopia, strabismus, or the use of one eye for far viewing and one eye for near viewing. These are all natural adaptations to viewing the world singularly and enable interaction with the world in a simplified or reduced fashion.
 
SE: Some people have surgery to correct strabismus. This does not seem to be a 'healthy' way to realign the eyes given that vision also involves learning.
 
MK: Surgery is the structural way to deal with strabismus. The literature suggests that surgery is a cosmetic cure for strabismus, but it is not a functional cure. I guess it depends on what you are trying to accomplish. Many people are looking for a cosmetic cure because they can still function moderately well.
 
However, with only a cosmetic cure, the eyes are not working as a team to create depth perception. Depth can be accomplished with monocular cues, but it is not as effective as with two eyes.
Unfortunately, the classical approach is a surgical approach to strabismus. In my view, however, the question is not one of eye structure but of performance. Case in point is the five year old autistic male whose father, a physician, diagnosed him with esotropia at two years old and was bedwetting. The condition at age five, when I saw him, was alternating esotropia with little change in performance. After a non-verbal examination, he was given ambient lenses. Within one week of receiving the lenses, he stopped bed-wetting, began to attend to objects above his head (previously, he looked down), and was walking with greater facility. Two months later his eyes were aligned.
 
SE: Another problem which is common in autism and sometimes involves surgery is toe walking. From my experience working with you, it appears that, for many, toe walking may simply be due to a visual dysfunction.
 
MK: Nothing is simple. There are many postural changes that are due to visual management, one happens to be toeing in. That is, autistic individuals may have a problem in orientation in which they are not able to let go of the ground; as a result, they become toe walkers or they will place their toes inward as they walk. If you can change their visual emphasis, they may not need so much energy to manage it and could start to pay more visual attention to themselves. When this happens, the toe walking stops; and they become flat footed.
 
Dr. Richard Herman, an Orthopedic Surgeon, has written that idiopathic scoliosis is probably due to a visual perceptual problem. It has been my experience that posture changes can be elicited through visual management training. For example, toeing in while walking is a visual perceptual problem, the failure to be aware of self and space simultaneously. The act of walking is a sequence of landing on one's heels and pushing off with the toes. When the visual system is dysfunctional, an individual holds his/her toes longer to the ground; and the body moves with the appearance of the toe turning in. I have seen a normal gait established in both autistics and others who have been labeled as visually deprived.
 
SE: What are some behaviors which may help a parent predict whether visual management training will help their child?
 
MK: One behavior is lack of eye contact. This is a key issue. Another key issue is a postural shift in which they turn their head to one side. A third behavior would be if the child walks on his/her toes or if the child runs aimlessly. What visual management goals are raising is the child's level of performance by reducing the number of symptoms. When the number of symptoms is reduced, the diagnosis disappears.
 
Autism is a symptomatic-based spectrum disorder that displays obvious and not so obvious visual characterization. Most professionals working with autistic individuals would list poor visual attention, looking from the side of the eye, and not making eye contact as obvious visual characteristics. In my view, there are other visually-based characteristics which are not usually considered. For example, rocking from side to side usually is indicative of an orientation problem and difficulty paying visual attention. Rocking forward and backward allows one to create depth perception as does flicking the fingers in front of the eyes. My advice to parents is to seek out a vision professional who is also experienced with autistic individuals with whom to share their concerns. This can lead to a judgment as to whether or not visual management is an option for them.
 
SE: Can you describe how you assess an individual?
 
MK: Basically, we do two different assessments. We perform a conventional eye examination to see whether or not there is a refractive error, meaning whether or not the person is nearsighted or farsighted. In other words, how well they identify things; however, 20/20 is not always enough.
 
A visual assessment of an autistic individual requires investigation for "sight" glasses to see if the individual needs a compensating lens for identification of objects in his/her environment. Taking into mind that measurements of autistic individuals is difficult at best and lacks a verbal response, I have designed a non-verbal performance test to see if ambient lenses (performance lenses) can 'Jump Start" visual information processing. I refer you to a recent research paper of mine, "Postural Orientation Modifications in Autism in Response to Ambient Lenses" which appeared in Child Psychiatry and Human Development, Volume 27, Winter, 1996.
 
SE: How soon do you see changes in these individuals?
 
MK: There are certain areas in which we see changes almost immediately, such as posture, eye contact, and attention. It usually takes two months before the subject displays behavioral changes to the care-giver.
 
Paraphrasing Dr. A. M. Skeffington, he once said 'the fastest way to change a person is through a lens.' Basically, lenses transform light which then changes the electrical activity of the central nervous system. In contrast, drugs also affect the nervous system, but it takes five times as long since it involves chemical changes.
 
SE: Could you describe a couple of recent patients of yours?
 
MK: Well, I had a very interesting patient who had a history of speaking and then stopped talking. I believe she was verbal until she had the DPT shots and then lost her ability to speak due to seizures. We tried a series of non-verbal tasks and nothing happened. Since I was unable to direct her visual system, I decided to disrupt it. After I placed disruptive lenses on her, she then stood up in front of the mirror and began to dance and talk. This was a really exciting experience for me. I performed an evaluation on her three months later, and she was still doing extremely well. She was verbal and acting very appropriate.
 
Another example is a four year old patient with a PDD label. When he came to see me, we performed a battery of non-verbal tests. Overall, the child was physically fine and behaved very appropriate, but he did not have language. He was visually involved, and I felt that he was simply delayed. I told the parents that I did not consider him a PDD case, and that he may be suffering from visual deprivation. After three months in my program, the child had language and was starting to function well. The family brought the child to his neurologist six months later, and the neurologist said that the child did not have PDD anymore. He couldn't understand it.
 
SE: Have you ever seen a case in which a person did not respond at all to visual management training?
 
MK: I have rarely seen a case who did not respond to at least some degree of visual integration training.
 
SE: So the changes range from mild to dramatic?
 
MK: Yes. Let me tell you about another case we recently had. This was a six year old child whom we literally had to pull off the walls. The child was strabismic, one eye was turned inward. He entered my office screaming and was uncooperative. We finally got some lenses on him, and he responded very well. Six months later this child was completely verbal and was doing well in school. His eyes appeared straightened. The child went back to the neurologist who nearly fainted when she saw him. She could not believe that this was the same person.
 
SE: How long does the program last?
 
MK: It varies depending on the specific needs of a person. If the person has a visual learning problem, the program usually requires approximately six months of therapy. If a person has a visually-related emotional problem, the program requires about one year of therapy, depending on his or her level of dysfunction. In a person with panic disorder or bi-polar disorder for example, the program takes about one year to complete.
 
SE: What about a person with autism?
 
MK: I do not have a timeline when it comes to people with autism. We can get very positive results within a year's time. With some people, we feel that more enrichment is possible and so the program takes longer than a year. But within a year's time, we have been very successful with vision as well as language development and more appropriate behavior.
 
Autism, as you know, is a spectrum disorder, as such, we give degrees to levels of performance as well as visual involvement. In the study I did with you at Gateway in Ladner, B.C., we showed marked improvement in the behavioral characteristics of autistic children within two months. The time frame depends on the individual. As a rule, most visual systems display higher levels of performance within a year.
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If you would like to contact Dr. Melvin Kaplan, write to: The Center for Visual Management, 150 White Plains Road, Suite 410, Tarrytown, New York, 10591 (Fax: 914-631-1004).

Source:  http://www.autism.org/interview/kaplan.html

If you would like to visit Dr. Kaplan's site, click here.

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HELPFUL LINKS:

BBB Autism - Vision Therapy

Choosing an eye doctor.

Cook Vision Therapy Center - Vision Therapy for those with Autism and Asperger's Disorder.

Geneva Centre for Autism empowers individuals with autism spectrum disorders, and their families, to fully participate in their communities.

Sanford Reid Cohen (Maryland area) - Drs. Ely and Cohen provide routine and preventive vision care, vision rehabilitation, and vision therapy. Our patients include children and adults with learning-related vision problems, attention deficit disorders, reading problems, pervasive developmental disorders, autism spectrum and more.

Vision Therapy and the Autistic Child

Vision Care

Vision Therapy Stories;Find a Doctor.