Managing Editor's Note: Dr. Schulman treats my daughter Bella. Bella's eyes were not tracking, and you could see each eye "wander" as she lost focus. After a long exam by a top pediatric opthalmologist, her ocular health was pronounced, "intact." Mind you, this doc spent over two hours with Bella. He was really interested in her health and we chatted amiably. I'd go back to him in a second for opthalmological care. (Heck, he even drives a Prius!) He said that Bella's vision problem was neurological, not muscular. So while he sent us off, we still had a real eye problem. We went to Dr. Schulman, who created a pair of glasses that have helped Bella noticeably. The moral of the story is that even the best docs in the medical field are often unable to help a child on the spectrum. We require specialists within specialties. Isn't that special? She was kind enough to prepare this post for our readers. Enjoy. Kim
By Randy Schulman, MS, OD, FCOVD
Many of the behavioral characteristics of those falling within the autism spectrum involve the visual system. Poor eye contact, staring at lights or spinning objects, looking askance, side viewing and general difficulties attending are often symptoms of visual dysfunction. Thus, any individual with a diagnosis of autism, PDD, learning disability, speech-language delay, sensory integration dysfunction, Asperger syndrome, non-verbal learning disability or with psychological problems should most certainly undergo a thorough examination by a developmental optometrist.
The earlier families of children with autism undergo a visual examination and begin visual intervention, the faster the improvement and the longer lasting the gains and overall chances for success. The American Optometric Association (AOA) recommends that all children undergo visual exams by six months of age. If parents complied with this guideline, optometrists would certainly note many visual problems in these young, yet undiagnosed children. For those with autism spectrum diagnoses, an immediate developmental exam is essential. After age four, a child may make adaptations which further embed the visual problems. For example, an eye turn out becomes an eye turn in or a suppression becomes firmly established by a large angle head turn or tilt.
Children with autism spectrum disorders (ASD) have motor, sensory, language and social-emotional delays that affect visual processing. Likewise visual problems affect cognitive, speech-language, social-emotional and perceptual development. Specifically, delays in oculomotor function, focusing, and binocular abilities can affect gross and fine motor abilities and language acquisition. Sensory problems result when vision does not coordinate with the vestibular and proprioceptive systems properly, or if there is poor synchronization between the central and peripheral visual systems. Poor visual awareness and poor eye contact negatively affects socialization and poor visualization can hinder the development of skills for imaginative play.
What is important is that the time period from age 18 months to four years of age, when autism is usually diagnosed, is an extremely important window of development for vision, as well as language, socialization and other crucial areas.
During this very critical time frame, vision should begin to dominate the movement system, to coordinate the proprioceptive, vestibular and tactile systems. As vision combines with the other senses, central or focal vision should emerge. If there is faulty information processing in any of the primitive sensory systems, visual dysfunction is inevitable. These patients then still need to touch and move to experience their environment because their visual systems are so inefficient. Some of their stimulatory behaviors such as flapping and side looking, may actually serve the purpose of allowing them to interact with their world, and tell the brain where the body is in space.
Most individuals on the less severe end of the spectrum, generally show more subtle, but very significant visual processing problems. Patients with attention deficits and learning disabilities are often very attracted to external, highly charged visual stimulation. They love to play video games and are generally highly skilled with computers. These traits lead to the misunderstanding by well-meaning adults that vision is an area of strength. Often it is these kids who are then labeled “visual learners” because they learn best when they can touch and see the materials. The real crime is that this misunderstanding about vision often prevents them from seeing any eye doctor, let alone one who can make a profound difference in their functioning. Optometrists must enlighten educators and parents about vision as a developmental process that must work with other systems in a coordinated manner. Just because the visual system is “strong” does not necessarily mean that it is operating in an efficient manner.
The literature supports that a very high percentage of children with autism spectrum disorders demonstrate eye movement disorders and a high incidence of strabismus. Many children with autism also have many competing stressors on their bodies during the critical second year of life. Inadequate or inappropriate sensory stimulation and health problems, ranging from food allergies to ear infections and asthma can all wreck havoc with vision development. Whether the health or the vision issues come first, visual concerns are real, and parents and professionals must pay attention to them. Even when health issues subside, and behavior, attention, and even eye contact improve, underlying visual delays often remain, and optometric intervention is necessary. Those with autism spectrum disorders simply have gaps in sensory, motor and visual areas so enormous that they cannot be closed without therapy.
Presentation of Vision Problems
Children on the autism spectrum typically bring a number of unusual visual behaviors or concerns to the eye doctor.
Squints or closes an eye
Stares at certain objects or patterns
Looks through hands
Flaps hands, flicks objects in front of eyes
Looks at objects sideways or with quick glances
Shows sensitivity to light (photophobia)
Becomes confused at changes in flooring or on stairways
Pushes or rubs eyes
Has difficulty making eye contact
Widens eyes or squints when asked to look
Bumps into objects
Is fascinated by lights and shadows
Touches walls or tables while moving through space
Parents, teachers, and other professionals assume that most behaviors seen in autism spectrum disorders are simply a result of the disorder, not a by-product of vision problems. They are astonished to learn that poor eye contact, repetitive stimulatory behaviors, and practically every other behavioral symptom, could be caused by poor fixation, accommodation, or eye teaming abilities.
A vision examination with a behavioral optometrist, such as can be found on www.oep.org or www.covd.org, will determine not only the eye health and refraction or whether they require a compensatory prescription, but also the visual skills of an individual with autism and how they are functionally performing. The examination will assess acuity, or ability to see clearly, accommodation, or the ability to focus clearly, pursuits, fixations and saccades, the ability to move the eyes appropriately, and binocular or eye teaming ability. She will also determine whether there is an eye turn or lazy eye and assess higher-level visual functions such as visual motor integration, or how the eyes direct the hands and the body, visual auditory integration, or how the visual system interacts with auditory commands, and most importantly, visual perception or processing or how the brain understands what is being seen. For example, she will determine if the individual can picture in his head what he is seeing, recall what is being seen or differentiate the figure from the ground.
The optometrist will explain each aspect of the exam, discussing the child’s skills in focusing, eye teaming, visual motor and visual perceptual abilities. She will also discuss treatment options in terms of lenses and prisms, how they create changes in the light energy coming into the eye, and how they allow the brain to organize visual information in a different, hopefully easier, fashion. In the majority of the cases, in addition to lenses and prisms, vision therapy is appropriate. Vision therapy, like occupational or speech therapy, is a tool to teach the visual system how to work. Most children with autism spectrum disorders require one-on-one, in-office therapy plus a home program to reinforce the work done in the office. The frequency and duration of therapy must be determined on a case-by-case basis. The optometrist may also make a referral to adjunct professionals whose interventions are also indicated.
1 Streff, JW. Optometric care for a child manifesting qualities of autism. J Am Optom Assoc 1979; 46-592-7.
2 Scharre JE, Creedon MP. Assessment of visual function in autistic children. Optom vision Sci. 1992;69:433-439.
4 Kaplan, Edelson
5 Ratner Eye Center (www.add-adhd.org)
6 Another study (COVD white paper on ADHD)
7 Harvard (COVD vision and dyslexia)
8 Beth Israel (COVD vision and dyslexia)
9 “Vision, Learning and Dyslexia” (To order a copy call COVD’s Fax on Demand at 800-365-2219 and ask for document #0040 or go to www.aoanet.org)
12 Out-of Sync Child
15 Shankman, A. Behavioral Optometry’s Birthright-Skeffingon’s Four Circles. J Optom Vision Dev. 1993;24:29-30.
16 Schulman, R. Optometry’s Role in the Treatment of Autism. JOVD. 1994; 25: 259-268.
17 Kavner R. Your Child’s Vision: A Parents Guide to Seeing, Growing, and Developing. New York: Simon and Schuster, Inc.; 1985.
18 Williams D. Somebody Somewhere. New York: Times Books; 1994.
Dr. Schulman graduated cum laude from the University of Pennsylvania where she received her degree in psychology. She graduated with both her Doctor degree and a Masters degree in Vision Science from the State University of New York, State College of Optometry. She received her Fellowship in the College of Optometry for Vision Development and is an Associate member of the Optometric Extension Program. She has lectured extensively on such topics as vision in the classroom, vision and aging, and visual difficulties in the developmentally delayed, and has published on vision and autism. She is fully licensed to diagnose and treat eye disease and specializes in vision therapy, pediatrics, learning disabilities and preventative vision care for all ages. You can reach Dr. Schulman at her practices in Fairfield County, CT:
139 Main Street
Norwalk, CT 06851
Total Learning and Therapy Center
5893 Main Street
Trumbull, CT 06611