Autism, Vision Disorders, and Developmental Optometry
There is a complex interplay between autism and vision that has yet to be fully explored. A relatively recent study reveals that ophthalmologic pathology was found in 40% of patients with autism or a related disorder with 29% having significant refractive errors, 21% demonstrating strabismus, and 10% having amblyopia. However, most studies have focused on treating visual acuity alone, ignoring the more complex neuro-visual processes that can be the root cause of strabismus, amblyopia, and convergence insufficiency—which are also found to have a higher prevalence in the autism spectrum disorder (ASD) population.
As Dr. Susan Daniel, an expert in developmental optometry and parent of a child with autism notes,
"What is often poorly understood is that 70% to 90% of kids with autism have associated problems with visual processing. Significantly underdeveloped visual processing contributes to many other social, academic and communication problems, including some of the behaviors that we associate with autism. A common problem, for example, is misperception of where the body is in space, or of the body’s midline. That causes posture problems and behaviors such as toe walking, spinning and discoordination. Failure to maintain eye contact — often considered a classic autism behavior — is also closely tied to visual processing. The child may see double or have difficulty maintaining fixation. Failure to develop these basic visual skills contributes to problems with facial recognition and identification of others’ emotions."
-Susan Daniel, OD, International President of the Neuro-Optometric Rehabilitation Association (NORA), Daniel & Davis Optometry
Developmental optometry, or vision therapy, continues to develop as the best means of treating the vision processing problems that lie at the core of challenges people with autism have to face.
Why Do People with Autism Have More Vision Problems?
The root causes of autism are not well understood as of yet, so this question cannot be fully addressed. However, the increased incidence rate of visual processing problems among people known to have ASD suggests a strong connection. The big question is whether vision problems are caused by autism, or whether vision is one of the root causes of autism. Innovative scientists at the Marcus Autism Center in Atlanta, GA, observed that infants who would later be diagnosed with ASD display a decline in eye contact as young as 2-6 months of age, currently the earliest known indicator of autism. However, despite the correlation between vision and ASD, many questions remain unanswered by the current research.
Can Autistic Patients Fixate? Can Vision Therapy Work?
There is a tendency for professionals to assume that children with autism cannot improve on their abilities to fixate. This is unfortunate since it means that appropriate further interventions aren’t taken. Instead, a developmental optometrist will delve into the causes, “Why are they not looking?”
For example, the problem with fixation could be caused by a sensory overload, which would lead the vision therapy team to seek to balance the sensory input so that it’s not overwhelming. This might be accomplished with therapeutic lenses before vision therapy even begins.
The fact is that most children with autism spectrum disorders are interested and do look at certain things—for example, video or words scrolling on a page—so success is often a matter of building on the visual stimuli that capture interest.
There are numerous ways to treat an autistic patient, and the developmental optometrist will always start with articulating the goal. Such goals are generally related to acquiring or improving on day-to-day functioning. This could mean improving their ability to learn, physical coordination, or other such skills that depend on neuro-visual functionality.
A developmental optometrist will begin with a comprehensive vision therapy assessment in order to understand the baseline skill set and identify what skills can be improved.
How Is Vision Therapy Done For People with Autism?
Once vision integration problems are pinpointed, they can be effectively treated with vision therapy. Screening for vision problems—or autism for that matter—requires looking at how a child or adult uses their vision and establishing the gaps in functional skills. Vision therapy can be profoundly important to improving the ability to track, learn, and coordinate their bodies with the world. As a first step the developmental optometrist performs a vision therapy assessment to closely examine basic fixation. If the patient cannot fixate at all, that is where the therapy begins. The exercises would gradually train the patient to fixate for progressively longer periods, which can drastically improve overall vision and function by enabling the patient to continually learn more from their environment. Once a patient with autism can look and fixate, the vision therapist or developmental optometrist can then work with the patient to build up more visual-motor skills in a similar manner to any other vision therapy patient.
Like any vision therapy assessment, the practitioner will look at the health of eye movements and diagnose any binocular vision dysfunctions, as well as some of the more complex issues that are common in autistic patients, which can enable a patient to achieve better coordination and balance. In some cases of severe disability, patients begin the process with such poor fixation skills that ascertaining the correct refractive prescription is difficult. Vision therapy can successfully build the patient’s focus enough to overcome this and diagnose the correct prescription.
As Dr. Daniel again notes,
“Vision is learned, and therefore can be taught. Visual fixation, eye focusing, and eye teaming are all visual skills that are needed for alternative communication systems, such as with a letter board, PECS, or assistive technology device. Social interactions, academics, motor coordination and sensory processing all rely on developed visual skills. Lenses, prisms, filters, and prescribed therapeutic activities can make a huge difference in the development of these crucial skills.”
How Is Vision Therapy for Patients with Autism Different?
Typically, the vision therapy process, which is customized to the individual patient in any case, has to be slowed down with autistic patients, particularly as their sensory systems are easily overloaded. Patients with autism tend to accomplish less than a neurotypical patient during each session, and thus typically require a longer timetable for treatment, sometimes involving occasional breaks from therapy altogether.
As Dr. Takeia Locke, an Atlanta-based developmental optometrist specializing in Vision Therapy for Autism puts it,
“If you get to a point where the cognitive ability limits what you need to do in the therapy room, sometimes you will have them take a little bit of a break and have them focus. For example, I will occasionally recommend more behavior therapy. When the system gets overloaded, the behavior that the child may display can limit what we can do in the therapy room, which requires added stimulation that patient isn’t able to handle at the moment. That doesn’t mean the patient doesn’t get invited back to therapy, but because sometimes they will need multiple therapies, we will start and then pause and then start again.”
-Takeia Locke, OD, FCOVD, Family Eye Care
An Interdisciplinary Approach to Treating Autism
Like any therapeutic or rehabilitative therapy, the best results are achieved through a comprehensive and multi-disciplinary approach with a number of different specialists. With respect to autism spectrum disorders, a developmental optometrist will often work with behavioral and occupational therapists for treatment of fine motor issues. Beyond this, the patient can usually benefit from complementary therapies that provide a calming break, such as music or animal therapy. Some vision therapy clinics incorporate elements of the latter into their treatment regimen as well, in order to provide those therapeutic breaks within the vision therapy process. Care must be taken to tone things down when the patient is in danger of being overstimulated, and accommodations must be made for unpredictable behavioral responses in the moment.
Autism is a complex spectrum disorder, and that typically means a compounding of visual function, balance, and coordination problems. Parents and professionals alike have been resigned to the fact that these difficulties are inherent to autism and, as such, there isn’t much that can be done if a patient with autism won’t fixate or has severe convergence insufficiency issues. However, vision therapy done properly under the supervision of a developmental optometrist can improve critical neuro-visual skills in patients with autism. These deficits, which can be improved by vision therapy, are closely interwoven into the array of challenges faced by patients with autism. Therefore, vision therapy should be an integral part of any interdisciplinary approach to improving integration, functionality, and quality of life for patients.