Report from Sensory Integration Quarterly.

Vision Therapy and the Autistic Child

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

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 chldren? 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 pracice (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).