Insights into Vision Therapy

Tiffani Lawton, RN is the Publisher of OUR Journey THRU Autism. OUR Journey THRU Autism is an online magazine featuring various professionals, experts and authors who work with children on the autism spectrum, ADHD and Sensory Processing Disorder. Tiffani leads the discussion with two amazing authors of EYEGAMES: Easy & Fun Visual Exercises.

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Rebecca Hutchins, OD, FCOVD

Rebecca obtained her Bachelors from Washington College and a Masters from American University. Having been nearsighted since the second grade, she noted that "close work" became an increasing challenge as she was preparing her Masters thesis.

After a visit with a behavioral optometrist and learning that her own eyes did not work well together she began a receiving vision therapy with much notable success. This propelled Rebecca to go back to optometry school, Pennsylvania College of Optometry, now called Salus University. With over 25 years of experience, Rebecca runs her practice in Behavioral Optometry in Longmont, CO. www.niwotvision.com

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Lois Hickman, MS, OTR, FAOTA

With over 30 years of experience in occupational therapy, Lois began her quest studying occupational therapy at Eastern Michigan University and Colorado State University. She became a member of Jean Ayers' faculty, grounded in sensory integrative theory. Lois creatively wove natural activities into her therapeutic sessions throughout her career. She created an outward bound camp experience for children with SPD, with trips to a local llama farm and to the Denver Zoo. She created hikes to goat farms and created yearly summer camps at Stonebridge Farms near Lyons, CO. She now operates JenLo Farms, offering "farm therapy" to address issues that are usually thought to be addressed in the clinic setting, without the feel of a clinic. www.peopletogether.org

Learn more about Lois Hickman....

Tiffani: There are varied views on the efficacy of Vision Therapy. Many pediatricians do not embrace the therapeutic value of this protocol. Can you discuss why this may be?

Rebecca: Pediatricians are trained to have an overview of the needs for health in infants and children; they don’t have training in the function, efficiency and comfort of how the visual system works, and most have not had experience with this realm. Many pediatricians and ophthalmologists appear to be uninformed or misinformed about the efficacy of optometric vision therapy, especially for convergence insufficiency, which has been demonstrated in a peer-reviewed, multi-site study, the CITT study.

Most eye care professionals do an excellent job of evaluating the health and refractive status of the eyes - the hardware. Behavioral O.D.'s are also interested in evaluating and treating the software - the way that the brain programs allow the eyes to work efficiently, binocularly and comfortably.

Tiffani: Can you briefly discuss the development of vision?

Rebecca: The criteria for visual development are light, attention and movement. A baby is drawn to light. Development is “doing”. The baby’s vision develops based on observing and responding to his/her own body’s movement, and the movement of people around the room. A baby needs to experience and integrate all the senses. An infant’s experience goes from mouth (putting everything in the mouth) to hand (touching everything) to vision. In adequate visual development, the child can “see” what something will feel like before it is touched.

At birth, the eye is not yet fully complete and the infant sees best at about 8-10”, so that the infant can see parents and others who interact with them, but much of the rest of the world is a blur. In the first few months, the eyes begin to work together (development of binocularity) and a child starts to work with eye-hand coordination.

By about 3 months, most children can follow moving objects and reach for them. To see an incredible view of vision development from birth onwards with amazing photos, secure a copy of the 1949 book, Vision and its Development in Infant and Child by Arnold Gesell.

Lois: It is important to pay attention to how, in the naturally evolving culture of childhood, the interaction between parent and child, and gradually, with other children, interactive play, movement, and song that children seek, correlate with the development of vision. Vision and visual perception expand outwardly and peripherally as children become more independent, moving and exploring, in their world.

Rebecca: Many of the children I see in elementary school, have not yet developed good tracking skills, yet are asked to learn to read; this is a problem And, as the name sensory integration implies, it is imperative that a child can sense and integrate all the senses to make sense of the world.

Tiffani: What are the signs of a visual perception impairment?

Rebecca:

1. An eye turn, head turn or tilt, covering or closing one eye even if only done when tired or under stress.

2. Frequent headaches or complaints of blurriness

3. A child who uses a finger or marker to read, or loses place when reading or frequently misreads small words

4. One who is clumsy, or has poor eye-hand or eye-body coordination

5. Complaints of seeing double, headaches, dizziness, or an unusual response to spinning (post rotary nystagmus as evaluated by an OT)

Lois: In evaluating and working with children in the clinic or in the school setting, I see them rubbing their eyes, shaking their head to give more vestibular-propriocptive input to ocular muscles, eyes following head movements rather than moving their eyes independently, squinting, and letter reversals past the age of about 7. There is poor visual/tactile integration. There is naturally a certain amount of postrotary nystagmus; if too prolonged, it indicates that the input is getting into the nervous system but isn't being organized. If too little, it could mean that it isn't getting in to organize other senses.

Tiffani: Can you define nystagmus? And,Is there a time frame, or a certain number seconds that is measured with regard to nystagmus?

Rebecca: Nystagmus is an involuntary, repetitive movement of the eyes; it can be congenital, (from birth), situational, as in the post-rotary, and may be caused by poor acuity, as in Albinism, where the retina doesn't have enough pigment to be a good screen, in this case it is a "searching" nystagmus.

Lois: Postrotary nystagmus is the fast back and forth movement of the eyes that occurs after spinning, as the eyes try to focus and find stability. A rule of thumb is that you see about 10 seconds of postrotary nystagmus. If much more or none at all, this could indicate a problem. Of course, any generalization is a problem! Other behaviors need to be considered as well.

Tiffani: Are vision problems common in individuals with autism? Why?

Rebecca: There may be several types of vision problems in individuals with autism; I will address only one. Many individuals with autism do not feel comfortable with central or focal vision. They are more comfortable with “ambient” vision and may look out of the corner of their eyes, or refuse to make eye contact. A excellent resource for information on this topic is the book by Dr. Melvin Kaplan, Seeing through New Eyes: Changing the Lives of Children with Autism, Asperger Syndrome and Other Developmental Disabilities through Vision Therapy. Dr. Kaplan initiated the use of yoked prisms (lenses used over both eyes which move the image either up, down, right or left) with his population of special needs clients. He uses yoked prisms, which he calls ambient lenses, frequently with an individual with autism to evaluate the lenses’ ability to create changes in posture, attention and/or mood.

Lois: Children with autism are often uncomfortable and defensive in their environment, and may behave defensively or avoid interaction. The response of a person who is stressed or fearful is to use peripheral vision, the vision that reacts to danger in the environment. They may actually experience direct eye contact as painful.

Tiffani: Is this considered convergence insufficiency?

Rebecca: Not exactly. Convergence Insufficiency (CI) is a common binocular problem where there is a tendency for the eyes to turn out and not be able to aim together (be binocular) at near. The person may see double or ignore or suppress one eye. CI is present in 5% of school age children, and in my experience, is definitely found in the population with autism, possibly connected with the tendency not to be comfortable with focal vision. The CITT study, funded by NEI, part of NIH, determined that in-office optometric vision therapy is the most effective way to treat convergence insufficiency. I see many children with CI who are thought to be ADD and/or dyslexic, which may be a co-morbid situation, but may be related to the convergence issue.

Tiffani: Can this issue be addressed through vision therapy?

Rebecca: Absolutely, as stated, the CITT study determined that in-office optometric vision therapy was more effective than home-based activities or prism glasses for convergence insufficiency.

Tiffani: When my son was a tot, he would be able to make direct eye contact but have to look away. He was able to tell me that it hurt his eyes to sustain eye contact. However, over the years, this seems to have caught up as he is able to sustain eye contact for longer periods.

Lois: Many of the activities that are done in the occupational therapy setting can provide the functional play that encourages convergence and takes it into the real world.

Rebecca: There can be SO many reasons to avoid eye contact. The poetic "eyes are windows to the soul" may have some real truth in it. My sister is a professor in college and she noted that one of her students with autism built a little wall around him with backpack, etc., and seemed to feel more comfortable.

Lois: I have worked with children with autism who could only accept direct eye contact if through a gauzy material curtain.

Tiffani: Ladies, What are your thoughts on integrating vision therapy into the current educational dynamics?

Rebecca: I think that we need to be open and observant to each, individual child. I encourage as much integration of senses, movement and flexibility in teaching as possible to meet individual children’s needs and learning styles. With this population, it is extremely important to start with child’s interest. I confer with teachers of visually impaired, special education teachers, and classroom teachers to inform about visual needs and accommodations.

Lois: The occupational therapist is a vital member of the educational team, advising on environmental adaptations, optimal ways to relate to the child, and ways to support the teacher and paraprofessionals.

Tiffani: In your book, you discuss light being a culprit in lack of sleep. Can you elaborate on this?

Rebecca: Oh, yes, I love to talk about light! Light is necessary for vision. We rarely consider the quality of light, and sunlight and artificial light are not the same. This is why Lois and I emphasize the need for outdoor play every day. There is a separate pathway from the retina that does not go to visual areas of the brain, but to the hypothalamus.

Blue light, traveling on this pathway, blocks development of melatonin in the pineal. Melatonin is a hormone that prepares the body and brain for sleep. Computers and TV emanate lots of blue light; using them the last 2 hours before bed may interrupt sleep. In addition, I stress to parents that light from screens, whether TV or computer, is hard on the eyes for long periods of time, so limiting “screen time” is an excellent idea, for this and many other reasons

See Jane Healy: Endangered Minds

Tiffani: A lot of parents supplement with melatonin. But certain simple modifications can be made to help foster the development of melatonin.

Rebecca: My understanding, talking with someone from the Light Research Institute of RPI, is that natural melatonin is preferable to synthetic, but I have seen no studies on this. There ARE studies on the use of blue-blocking glasses that safely protect the production of melatonin in night-workers who are exposed to light. I use the FL41 lens for my clients who want to safeguard their melatonin production and still use TV or computer. This tint is also helpful for migraines and blepharospasm (blinking).

Stay tuned for the next hub discussing some activities for vision therapy.