Incorporating Behavior when treating this population because children Modifications, Strategies, with may have difficulty engaging in reciprocal conversation, have poor attention and Supports to Maximize due to sensory overstimulation, be resistant the Effectiveness of to change, or be non-verbal. This paper seeks Vision Therapy in the to compile effective behavior modifications, strategies, and supports used by other professionals, such as teachers, and physical, Disorder Population occupational, and behavioral therapists, that Jennifer Fisher, OD, FAAO may be incorporated into optometric vision Assistant Clinical Professor therapy to maximize visual outcomes for this UC Berkeley School of Optometry patient population. Berkeley, California

ARTICLE Tyler Phan, OD, FAAO Introduction Director of Vision Therapy The prevalence of autism spectrum disorder Union Community Health Center (ASD) has increased by almost double since SBH Health System, 2007 to 1 in every 50 American children ages Department of Ophthalmology 6-17.1 This increase has facilitated a need for a Bronx, New York specific approach in treating visual dysfunctions and visual processing disorders in this patient ABSTRACT population. Table 1 and 2 summarize common The prevalence of autism spectrum disorders visual deficits and common signs of visual has increased almost two-fold since 2007. problems in children with ASD. ASD is a This increase has facilitated a need for a new neurological disorder characterized by specific approach in vision therapy when treating characteristics, such as difficulties with social deficits in accommodation, binocularity, oculo­ interaction, communication, and repetitive, 2 motor, and visual processing in children with stereotyped behaviors. Patients with autism autism. The clinician may face challenges may have decreased eye contact, lack facial expression, and have difficulty developing Correspondence regarding this article should be emailed to relationships with others. They may also have Jennifer Fisher, OD, FAAO, at [email protected]. difficulty carrying a conversation, use repetitive, All statements­ are the authors’ personal opinions and may not reflect the opinions of the College of meaningless language, and are unable to Optometrists in Vision Development, Vision Development participate in imaginative play. Repetitive & Rehabilitation or any institu­tion or organization to which the authors may be affiliated. Permission to behaviors can include repetitive and obsessive use reprints of this article must be obtained from the interest to specific parts of an object.2 editor. Copyright 2019 College of Optometrists in Further research is needed to understand the Vision Development. VDR is indexed in the Directory of Open Access Journals. Online access is available at underlying mechanism for these behaviors. covd.org. https://doi.org/10.31707/VDR2019.5.4.p255. However, it is important for the clinician to be

Fisher J, Phan T. Incorporating Behavior Modifications, aware of these behaviors in order to effectively Strategies, and Supports to Maximize the Effectiveness treat this special population. of Vision Therapy in the Autism Spectrum Disorder Due to the difficulty with social interaction, Population. Vision Dev & Rehab 2019;5(4):255-67. communication, and repetitive behaviors, often children with ASD require an inter-professional Keywords: accommodations, autism, team of speech, occupational, physical, and autism spectrum disorder, behavior behavioral therapies to encourage meaningful modification, vision therapy communication and lessen anxiety in multiply-

255 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 stimulating settings. In conjunction with these Table 1 aforementioned therapies, vision therapy Common visual deficits in children with autism 3 should also be included to improve visual Reduced convergence Visuo-spatial processing deficits2 coordination, visual motor integration, and Photosensitivity2 visual information processing. Vision deficits Decreased processing of peripheral stimuli2 can contribute to reduced social interactions, Reduced visual closure perceptual ability2 as well as to academic difficulties. According Reduced sensory integration2 to a study by Milne et al. in 2009, there was an Reduced processing of faces and motion processing2 increased prevalence of reduced convergence in children with ASD.3 Children with autism Table 2 also have visuo-spatial processing deficits that Signs of visual problems in children with autism40 manifest as difficulty relating their own bodies Squints or closes an eye in space. In order to improve body awareness, Looks at objects sideways or with quick glances Sensitivity to light ASD patients rely on proprioceptive behaviors, Becomes confused at changes in flooring or on stairways such as toe walking and hand flapping near Pushes or rubs eyes 2 their faces. Other common vision deficits Has difficulty making eye contact in ASD patients include photosensitivity, Touches walls or tables while moving through space decreased processing of peripheral stimuli, Flaps hands, flicks objects in front of eyes reduced visual-closure perceptual ability, Stares at certain objects or patterns reduced sensory integration, and reduced processing of faces and motion processing.2 sentences while reading. AB also easily As optometrists, we have the ability to improve became confused with stairways and flooring, functional vision and enhance patients’ quality and she often looked at objects sideways with of life with lenses, prisms, and/or vision therapy. quick glances. AB was born very prematurely The clinician may face challenges when at 30 weeks with Caesarian Section, and she treating children with autism because they was born weighing 1 lb. 15 oz. She was in the may have difficulty engaging in reciprocal prenatal intensive care unit for three months conversation, have poor attention due to sensory after birth. Although she started walking on overstimulation, be resistant to change, or be time, she was delayed in speech development. non-verbal. Through other multi-disciplinary AB was diagnosed with mild, high functioning therapies, this article seeks to compile effective autism at two years of age. She received behavior modifications, strategies, and supports­ early intervention for occupational, speech, used by other professionals, such as teachers, and services since she was and physical, occupational, and behavioral two years old. She currently attends a special therapists. These modifications may be education school for children with ASD, and incorporated into optometric vision therapy in her mother reported that she was doing well in patients with ASD to more successfully improve school besides her difficulty with eye-tracking. vision functions and visually-guided activities. Upon entering the examination room, AB began to walk aimlessly in different directions, Case Report: Patient AB seemingly unaware of her surroundings. The AB is a 9-year-old female of Hispanic refractive analysis revealed emmetropia with descent, who presented for a comprehensive 20/20 visual acuity at distance and near OD, eye examination at University Eye Center. The OS, and OU. Pupils were round and reactive to chief complaints, reported by her mother, light without afferent pupillary defect. Anterior included bumping into objects, losing her segment and posterior segment ocular health place while reading, and needing to repeat with dilated fundus exam were unremarkable

256 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 Table 3. Patient AB’s post VT comparison Examination Testing Pre-Vision Therapy Post-Vision Therapy Symptoms 1. Loss of place while reading 1. No longer loses her place 2. Re-reading lines 2. No longer re-reads 3. Bumping into surroundings 3. Only occasionally bumps into surroundings Distance and Near VA 20/20 OD/OS/OU Stable Distance Cover Test Ortho Ortho Near Cover Test 8XP Ortho Near Point of Convergence 5”/recovery 7” 3”/recovery 4” Pursuits Several fixation losses, unable to follow No re-fixations, no head movements, accommo­dative target or fixation light. smooth and accurate Saccades Profound inaccuracy, with severe head No more re-fixations, no head movements, movements, 50-60% undershoots in all gazes about 10-20% undershoots in all gazes Developmental Eye Movement Test (DEM) • Vertical 1st%ile 15th%ile • Horizontal 1st%ile 15th%ile • Error 15th%ile 35th%ile • Ratio 15th%ile 35th%ile Vergence Ranges • Distance Base In X/18/6 X/8/4 • Distance BO X/28/6 X/12/10 • Near Base In X/30/12 X/6/2 • Near Base Out X/24/6 X/35/25 for each eye. Binocular findings were adequate, verbal directions. When focused on a particular and stereo-acuity at near was normal at 30 activity, she experienced difficulty transitioning seconds of arc. The pertinent examination to a new activity. She was easily distracted with findings are summarized in Table 3. environmental noise and was easily frustrated Pursuit eye movement testing revealed pro­ when multiple sensory components were added, found fixation losses and an inability to follow such as the board and metronome. one cycle of a moving target. Her saccades Explaining activities required multiple forms of were also grossly inaccurate, and she was visual demonstrations. Though AB experienced unable to complete a single cycle of fixating significant challenges with sensory issues, between two targets without many re-fixations transitioning, and comprehension, with the and head movements. The Developmental application of visual supports, accommodations, Eye Movement (DEM) testA also demonstrated and behavior modifications to vision therapy difficulties with horizontal eye movements. AB as described in this article, AB was able to had little ability to control her eye movements read more efficiently after 25 sessions of vision and was diagnosed with severe deficits of therapy, and her oculomotor skills improved to saccades. within age appropriate levels. In-office vision therapy was recommended with an estimate of 20 sessions consisting of Interdisciplinary Behavior Modifications, weekly 45-minute in-office sessions combined Strategies, and Supports to Implement with daily home activities. The goal of vision During In-office Vision Therapy therapy was to improve oculomotor control and 1. Challenge: Difficulty transitioning improve visual spatial awareness. Though AB between activities. was light-hearted and eager to play, challenges Strategy: Implement activity schedules in vision therapy included frustration when and/or , gradually change changing between activities, hypersensitivity to activities, and offer choices. sensory stimulation, and difficulty understanding

257 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 Psychologists have studied how people with views of 50 professionals in a general hospital ASD often show strong reaction to changes, and a community child health service were which may be due to atypical development analyzed through a brief questionnaire about for change-detection among children with the child’s understanding and compliance. autism.4 Because of this resistance to change, All professionals felt that the visual symbols children with autism may struggle with helped increase understanding of the verbal transitions, which may lead to behaviors such explanation. They reported that the visual as aggression, tantrums, and non-compliance. symbols reinforce what has been said for those Their further difficulty with socialization may with poor auditory memory.13 cause them to be unable to communicate Social stories, used by parents, therapists, their frustration with change. and other professionals, are narrative activity Teachers have researched behavior modifi­ schedules that identify concerns and develop cations to improve this change, and provide a story to support a desired outcome. These support for every change within a schedule. help children with challenges in verbal These include choice-making, incorporating communication and social interactions and preferred activities, reinforcement, and visual will help them predict what will happen in support systems.5 Teachers provide choices social situations.14 Children with ASD can amongst different positive behaviors, which review the social story before the vision improves compliance.6 In addition, special therapy sessions and thus, be more at ease education teachers use activity schedules, which by having a predictable outcome. Unlike an combines photographs, images, or drawings activity schedule, social stories require specific in a sequential format to provide structure for elements and structure, such as descriptive, the child.5 This allows children with autism to perspective, affirmative, and directive text.15 anticipate change throughout the day. Recent Descriptive statements tell the story specifically. research studies since 2000 have shown how Perspective sentences relate feelings and teachers use activity schedules to successfully opinions. Directive sentences provide behavior help children progress easily between steps in choices, while affirmative statements highlight an activity and improve compliance.7,8,9,10,11,12 what is shared.5 Further studies are needed to However, most of the research are either case confirm the effectiveness of social stories. reports or represent a small sample size. Further Developmental optometrists can incorpor­ randomized controlled studies are needed to ate techniques researched by psycholo­­ verify the effectiveness of activity schedules. gists, teachers, and other professionals­ into Activity schedules may be created using a child’s optometric vision therapy. Giving children tablet. ChoiceworksB and Brill Routines-Visual with autism a choice between activities on the TimerC are examples of Apple and Android schedule can help children feel more at ease apps to implement in the therapy room and with the activity. Additionally, having a consistent to incorporate into the children’s given tablet therapist is also important to minimize change from their special education schools. to the patient. Finally, visual schedules of vision Through a survey conducted by Vaz,13 it therapy techniques can be implemented by has been shown how visual symbols can clarify using technology already used in the classroom procedures, re-assuring children with ASD that (see Table 4 for an example). the procedures will not proceed indefinitely. 2. Challenge: Difficulty understanding Professionals in a hospital setting instructed verbal instructions. 20 children with learning disabilities and ASD Strategy: Use visual stimuli when by using 150 visual symbols of the hospital giving instructions. setting, such as “doctor” and “hospital”. The

258 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 Table 4. Here is an example of Patient AB’s social story. Photograph Story Text Patient AB walking into the eye center There are a lot of students in the waiting room. It is okay to feel this way. Patient AB can choose to greet the other vision therapy students. Patient AB reviewing the schedule of the day There are going to be 3 activities. Patient AB gets to choose which one she wants to do first. First, we will play with the Marsden Ball Patient AB will try to catch the butterfly flying around. It is okay if she sometimes misses the butterfly. Playing with the Vectogram Patient AB will try to make the into one clown with her eyes so that she can paint the clown’s face. Playing with the Brock String Patient AB will try to make each bead one and pretend like she’s an elephant eating peanuts Then, we will show your mom what you It is okay for your eyes to feel tired afterwards. Patient AB are going to play with at home! will explain to her mom which one is her favorite. It is time to leave Say bye.

Children with ASD often struggle with greater weight loss (p<0.014).18 With the compre­ hending­­ verbal instructions, and help of visual assistance, such as delineation have difficulty with receptive and expressive of playing fields, posters, pictures, and language.3 Compared to auditory information, demonstration of difficulty levels, children children with ASD respond more favorably to succeeded more and demonstrated greater visual information. Thus, special education improvements in physical activity, possibly teachers minimize giving solely auditory due to greater understanding. In a small instructions.16 sample study, educators also showed how A case-controlled study with 16 boys with picture-activity schedules greater improved ASD, conducted by Molloy et al. in 2003, fine and gross motor skill performances, showed the importance of visual cues in compared to traditional verbal descriptions maintaining balance. When compared with and demonstration.17 This provides further neurologically normal controls, children with evidence on the importance of incorporating ASD had significantly (p<0.05) more difficulty visual instructions with verbal instructions maintaining an upright posture when visual when explaining each vision therapy activity. cues were eliminated.17 This demonstrates the In the vision therapy room, as discussed need for treating patients with autism who have previously, activity schedules, visual schedules, difficulty with binocular and visual information- and social stories can be integrated. A processing deficits with in-office vision therapy. compilation of activity schedules for commonly Improving visual efficiency in these patients can used activities can be implemented. Further­ improve visual-vestibular interaction, and, in more, to improve efficiency when giving turn, reduce “clumsiness”, which is sometimes instructions, short videos can be used, as described as a feature of ASD.13 However, well as taking actual pictures of each activity. randomized controlled studies are still needed Additionally, vision therapists can also to confirm the significance of visual stimuli on demonstrate or model the activity to perform postural control in children with ASD. to provide visual support. Many offices have Similar to Social Stories and Activity used white boards with Velcro attachments to Schedules, in a non-randomized controlled improve flow of demonstrating visual schedules. study with 33 children with ASD aged 13-16 Figure 1 is an examination of a Visual Schedule years, visual stimuli were shown to enhance used with the Brill Routines – Visual Timer.C productivity in a physical education program 3. Challenge: Difficulty with hyper- or and enable children with autism to achieve hypo- sensitivity to sensory stimulation.

259 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 identities and locations of objects, and the speed of movement. We have a “comfort range” for each of these senses. For individuals with ASD, there is a reduced “comfort range”20 leading to sensory disturbances, which include hyper- and hypo- sensitivities. These sensitivities may be due to differences in how these stimuli are processed in the brain. A more sensitive child may show withdrawal behaviors when being touched, avoid textures, and have poor coordination when there is too much activity in the environment. Hypo-sensitive children can be under-responsive to visual and auditory stimuli, as well as pain. This may mean that they place themselves in dangerous situations as they do not understand or interpret warning signs clearly. These characteristics can lead to poor organization and behavioral problems. Furthermore, in a study conducted by Hilton et al., those with atypical sensory responsiveness and social impairments seem to be strongly related.21 Children with hyper- responsiveness to tactile stimuli were more likely to develop stereotypical behaviors, such as repetitive verbalizations, inflexible behaviors, and inattention.21 Thus, identifying and treating sensory integration disorders can greatly impact a child with ASD’s social characteristics. Occupational therapists and psychologists have researched methods to improve sensory integration in children with ASD. In more than 80 studies, improving sensory integration has shown to be effective in some aspects, though some with limitations.22 During occupational Figure 1: Example of Brill Routines-Visual TimerC therapy, the therapist will slowly introduce vestibular, proprioceptive, and tactile stimuli Strategy: First, allow sensory supports, while the patient is in motion.23 Sensory- second, slowly emphasize sensory integration therapy (SIT) with occupational integration to improve compliance and therapists can improve both organizational motor planning. speed and smooth pursuit.24 In order to identify patients with sensory Children with ASD have difficulty integrating processing disorders, a questionnaire was visual, tactile, and auditory stimuli.19,20 Our developed by Robertson et al., which included senses provide important information about questions like: “Do you find yourself fascinated ourselves and our environments, such as the by small particles?”, “Do you notice that you

260 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 have hurt yourself but did not feel any pain?”, therapy can improve attention and compliance, and “Do you react very strongly when you hear as well as improve motor planning and their an unexpected noise?”20 This questionnaire social function. Allowing for sensory supports can easily be implemented early in therapy to and motor breaks in therapy can also improve identify hyper- and hypo-sensitivities.25 compliance for more sensory stimulating Because children with autism may manifest activities, such as walking in different patterns sensory difficulties in many different facets, in with a metronome, monocular accommodative vision therapy, developmental optometrists rock with magazine saccades, and binocular should consult with the patient’s occupational activities on a balance board. Another method therapist on how the patient modulates to improve sensory integration is providing sensory information.26 Sensory items provided a visual schedule, as discussed previously, by occupational therapists include chew toys, which can allow unpleasant sensory stimuli such as chewable jewelry, weighted sensory to be more predictable, making them more lap pads, slant boards, swings, and hammocks. tolerable. Patients should be encouraged to use these 4. Challenge: Poor compliance with sensory supports in the beginning of therapy. therapy and homework, poor reciprocal In order to improve sensory integration into communication. vision therapy, activities should begin with Strategy: Positive reinforcement and gross motor skills, such as incorporating extinction (withdrawal of reinforcement), bilaterality while drawing on a chalkboard and Discrete Trial Therapy. (Chalkboard circles) to provide a strong motor foundation.19 Therapy should also first begin in Reinforcement strategies have been a quiet environment free of clutter. In addition, shown by behavioral therapists to improve regulating the patient’s sensory system at the social skills, language, and academic tasks. beginning of therapy prepares the patient to In a case series with three children with move to a more sensory challenging activity and autism, positive reinforcement has been environment.21 This could mean incorporating shown to improve working memory, or the rhythmic motor demands, such as bunting a ability to “keep information online” while ball repetitively before incorporating bilateral simultaneously processing it.28 Behavioral integration. Additionally, tactile defenses can therapists implement positive reinforcement be modulated by engaging in symbolic play, through Applied Behavior Analysis (ABA).29 such as pretending to be a butterfly, pirate, or ABA has shown to increase functional and princess.21 cognitive skills in children with autism. As therapy advances, more sensory input Special education teachers have shown how can be added, such as a balance board, implementing ABA in the classroom can bilateral integration, and a metronome for decrease challenging behaviors and increase auditory integration. Oftentimes, vertical yoked socially significant replacement behavior. prisms are used to create an image shift, Moreover, the frequency of reinforcement can which requires a motor response to the be systematically decreased, in order to more sensory mismatch in space. Thus, yoked closely mimic a natural environment.30 prism can improve visual spatial awareness in There are many dimensions to ABA training, patients with ASD. Incorporating yoked prism which vary based on the 1) degree of structure in therapy can facilitate and improve sensory in the curriculum, 2) depth of the curriculum, motor integration.27 and 3) decisions regarding maintenance, Incorporating facets of sensory integration modification, and control.31 Discrete trial therapy therapy from occupational therapists into vision (DTT) is one technique used within an ABA

261 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 program, which includes a structured method of includes 1) a list of target behaviors, 2) tokens presenting stimuli in small steps in a controlled or points for achieving behaviors, 3) and a list setting. ABA emphasizes repetition for rapid of backup reinforcement items (see Figure 2).25 attainment of rote skills in the beginning, and An example of a token economy implemented then contextualizing what was learned into daily in therapy is encouraging eye exercises for living skills once the initial skills are mastered.30 tokens, and achieving 10 tokens can lead to Reinforcements can include food, toys, praise, a sticker or a small snack. Special education sensory stimulation (vibration, music, strobe), teachers have shown how the inclusion of and tokens, and allowing children to choose token economy improved the effectiveness the form of reinforcement also enhances of learning, partly because students are given effectiveness. Studies have shown that multiple a choice for their behaviors.31 Optometrists reinforcements can be effective, and Leaf et al. can also implement DTT by breaking each also demonstrated that verbal feedback alone vision therapy technique into small finite might be a form of social reinforcement that steps and reinforcing specific responses. might be effective.29 Once compliance and therapy effectiveness Though optometrists may not always have been achieved, optometrists can spread be able to implement a highly structured out the amount of tokens given (i.e. needing ABA program during in-office vision therapy, to achieve a greater quantity of favorable incorporating certain aspects of ABA can behaviors before receiving a token), and allow vision therapy to be more efficacious for transition physical reinforcements into more children with autism. Positive reinforcement verbal feedbacks. Through implementing seems to have a beneficial effect on learning positive reinforcements, choice making, and new tasks for children with autism, such as finite goals, developmental optometrists can working memory and social skills, which effectively im­prove compliance and success in optometrists can translate into the therapy vision therapy. room. Positive reinforcement also allows for 5. Challenge: Reduced motor planning better compliance in therapy and a more ability, increased restlessness, and structured setting, which helps children with clumsiness during therapy. autism cope with transitions. As developmental Strategy: Incorporate rhythmic optometrists, a token economy devel­oped movement then incorporate bilateral from ABA can be implemented to decrease integration activities. challenging behaviors. A token economy

Token Economy Children with autism may have 1. Brock String 2. Letter Chart 3. Ball and 4. Fusion 5. motor deficiencies in addition to social Loop Pictures and com­munication de­ficiencies such Token as deficiencies in walking, coordination, symmetry, and movement initiation.18 Move­ment therapy can strengthen these deficits, improve sensory

GOAL integra­tion, and enhance social and REACHED: cognitive learning. Movement therapy SNACK focuses on increasing vestibular and REWARD proprioceptive stimulation­ to increase Figure 2: Example of a Vision Therapy Token Economy. Patient AB will body awareness,­ increase attention, and receive 1 “token” for each procedure. When each box is complete, she behavior regulation. Repetition and gets a SNACK! routine of sequences, such as yoga

262 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019

therapy, increases the child’s motor planning Children with ASD have difficulty relating to ability, which improves balance and coordin­ others as well as emotions to actions. Another ation.32 Additionally, improving motor skills theory used in behavioral therapy is cognitive may allow children with autism to engage behavioral therapy (CBT), which seeks to with other normally developing children with promote “retrievable memories of adaptive more ease, which can result in improved social responses”, which can override and suppress interaction, self-confidence, and motivation.18 memories of maladaptive responses. Individuals In a study conducted by Askay et al., physical in CBT learn skills to modify their thoughts activity improved strength, walking, and and beliefs, as well as develop problem- running in children with ASD, which, in solving strategies.34 In order to promote turn, decreased maladaptive behaviors. An deep processing of new concepts, behavioral observational study by See et al. involved therapists incorporate Socratic questions, or 41 children and found that music and questions that incorporate hints of the correct movement therapies are beneficial. Positive answer. In this way, children will put the accurate impact was evident in regards to behavioral answers in their own words, which could then problems, such as restlessness, temper convert the task into memory and, thus, be tantrums, and inattention (p<0.001). Rhythmic incorporated into their everyday lives. In a songs alongside movement helped develop randomized controlled study with 70 children auditory-motor coordination and improve diagnosed with high functioning ASD, CBT body awareness.33 significantly improved social communication Developmental optometrists can incorpor­ skills and decreased anxiety (p<0.04). The ate movement in vision therapy not only to program comprised of three main sections: improve motor planning, but also to improve part one emphasizes recognizing different social communication, cognition, and reduce emotions, part two focuses on management maladaptive behaviors. Allowing for motor techniques, and part three focuses on breaks, as discussed above, vision therapy problem-solving strategies, using the STAR should begin with rhythmic movements, such (STOP, THINK, ACT, and REFLECT) strategy. as stomping in place before incorporating CBT addresses the cognitive deficiencies that bilateral integration and left-right awareness may cause communication, behavioral, and activities. Examples of incorporating movement emotional difficulties.35 with vision therapy include incorporating gross In vision therapy, optometrists can imple­ motor activities, such as tossing a bean bag, ment CBT during more difficult procedures that jumping in different directions corresponding require visualization and cognitive thinking, to arrows, as well as incorporating movement such as visual perceptual training. Socratic alongside common therapy procedures, such questions can be asked during binocular as using a bead and string while walking in a training to promote awareness and control straight line, or balance beam while reading a of convergence and divergence. During letter chart. vectogram procedures, questions such as, what 6. Challenge: Anxiety, poor attention, and do you think your eyes are doing? If the image inability to generalize learned ideas. seems to come closer to you, what could that Strategy: Incorporate problem solving mean about how you are controlling your eyes? techniques, repeated practice, and During difficult procedures, the STAR strategy abstract reasoning influenced by can be implemented to lessen frustrations and cognitive behavioral therapy. improve communication with the therapist.

263 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 7. Challenge: Poor ability to relate to based refers to the importance of providing therapist and develop meaningful play. affect-based interactions with the child to Strategy: Incorporate techniques of facilitate learning. Incorporation of meaningful Symbolic Play (Development Individual- play, including incorporating emotions, will Differences-Relationship-Based Model maximize the patient’s understanding and “”). also promote better communication with others.31 In the earliest stages, occupational The Developmental Individual-Differences therapists, speech and language pathologists, Relationship Based (DIR) model is developed teachers, and other professionals first try to by Greenspan and Wieder in the 1980s to establish a two-way communication. Later, provide a clinical model for therapeutic “Floortime” activities are integrated into each intervention in children with ASD.36 The model specific therapeutic profession. Controlled is used by interdisciplinary professionals to research supporting “Floortime” is limited, but emphasize the importance of emotional, affect- preliminary research shows a positive outcome. based experiences within a relationship, which A pilot study by Solomon et al. in 2007, found children with ASD may lack.37 The DIR model that nearly half of the children (45.5%) made also addresses the differences in how children significant emotional developmental progress with ASD engage, relate, and communicate (using the Functional Emotional Assessment with their environment.38 Children with ASD Scale created by Greenspan et al. in 2001) and also often develop spontaneous behaviors, reported a 90% approval rating from parents.39 including wandering aimlessly without In vision therapy, the DIR Model can be purpose, lining up toys, habitually placing incorporated to better understand the patients’ toys at eye level, and demanding to play with emotional developmental levels and to better the same toys over and over. Serena Wieder, connect with patients and facilitate progress a child psychologist, found good results in in vision therapy. The therapist must first therapy with these children by matching the understand how a child responds to auditory patient’s developmental level and interacting or tactile stimuli, challenging motor tasks, and with the child in ways that were meaningful to language, gestures, and facial expressions. and enjoyable.36 In this way, meaningful play Then, the therapist can modify the task to meet through the use of “Floortime” interactions the child at his or her developmental level, can be encouraged. “Floortime” interactions such as changing equipment use, instructions, occur when the therapist follows the patient’s and the pace of the procedure. In order to lead, and at the same time supporting their add affect and connect with patients, the emotional and intellectual abilities. therapist can add a simple story to procedures, First, by using the “developmental” aspect for example, the therapist can pretend the of the DIR model the therapist can understand Marsden ball represents a swimming fish, and the emotional developmental capacity of the the patient will try to catch the fish with the child in how he or she engages and relates to loop, which represents a net. Affect can be others, in order to show intentional behavior, added by establishing the purpose of catching to communicate needs, and to stay calm and the fish, how it makes the child feel, and the regulated. The therapist must also understand difficulty of the task. Affect can also be added how the child processes sensory information, via nonverbal communication, such as facial such as vision, sound, touch, balance, and motor expressions and gestures. See Table 5 for movements, which is the Individual-Differences a summary of challenges and strategies to aspect of the model. Finally, Relationship- incorporate into optometric vision therapy.

264 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 Patient AB: Post-Vision Therapy with Table 5: Summary of challenges and strategies to incor­ Behavior Modifications por­ate into optometric vision therapy. At the conclusion of therapy, patient AB Challenges Strategies showed progress in many areas and her mother 1. Difficulty • Implement activity schedules and/or social stories was thrilled with the dramatic transformation transitioning • Gradually change activities between • Offer choices at the end of therapy. The clinical findings after activities completion of vision therapy are summarized in Table 3. There were marked improvements in 2. Difficulty • Use visual stimuli when giving instructions understanding Example: Short videos, pictures of each activity or ocular motility control. Pursuit eye movements verbal vision therapists can demonstrate or model the also showed profound improvement. She was instructions activity to be performed. able to follow a target for 5 cycles, and initiated 3. Difficulty with • Allow sensory supports and slowly emphasize saccadic eye movements with only moderate hyper- or hypo- sensory integration to improve compliance and undershoot. The horizontal component of the sensitivity motor planning to sensory Example: As therapy advances add balance board, DEM test was significantly improved, and she stimulation. bilateral integration, and a metronome for auditory performed within age norms. These findings integration. Vertical yoked prisms to create an image correlated well with the symptomatic changes shift, requiring a motor response to the sensory mismatch in space. that her mother reports at school. Patient AB no longer has difficulty with keeping her place 4. Poor compliance • Positive reinforcement, extinction and Discrete Trial with therapy Therapy while reading, and she did not bump into and homework, Example: Token economy for positive reinforcement. objects as frequently. poor reciprocal Break each vision therapy technique into small finite communication steps and reinforce specific responses Conclusion 5. Reduced motor • Incorporate rhythmic movement With the help of a plethora of multi- planning ability, • Incorporate bilateral integration activities dis­ciplin­ary clinical practice models to increased Example: Incorporate gross motor activities, such as restlessness, tossing a bean bag, jumping in different directions improve the emotional, communicative, and and clumsiness corresponding to arrows motor development of children with ASD, during therapy Incorporate movement alongside common therapy procedures, such as using a bead and string while optometrists can improve the effectiveness walking in a straight line, or balance beam while of vision therapy to promote better visual reading a letter chart. comfort in these patients’ daily lives. 6. Anxiety, poor • Incorporate problem solving techniques, repeated Compared to the non-neurologically-impaired attention, practice, and abstract reasoning child, the child with ASD may present with and inability Example: Socratic questions during vectogram many challenges, including lack of social and to generalize procedures. What do you think your eyes are doing? learned ideas If the image seems to come closer to you, what could emotional reciprocity, sensory disorganization, that mean about how you are controlling your eyes? as well as resistance to change. Eye care 7. Poor ability • Incorporate techniques of Symbolic Play professionals have an opportunity to become to relate to Example: Matching patient’s developmental level an integral part to the growing need in therapist and interacting in ways that are meaningful and improving ASD children’s developmental level and develop enjoyable. Therapist follows the patient’s lead, while meaningful play supporting their emotional and intellectual abilities. and, thus, maximize their daily function. Vision Therapist must understand how a child responds to therapy not only can improve their academic auditory or tactile stimuli, challenging motor tasks, function, but also, with the help of these and to language, gestures, and facial expressions. Then, therapist can modify the task to meet the child multi-disciplinary modifications, strategies, at his or her developmental level. and supports can improve their emotional and social functions. More controlled research is with ASD. However, with an effective treatment needed to outline the effectiveness of vision plan that meets the child’s developmental therapy in this population, as well as take into level, those with ASD can benefit significantly account low- versus high- functioning children from vision therapy.

265 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 Source List 12. Dettmer S, Simpson RL, Myles BS, and Ganz JB. The use of visual supports to facilitate transitions of students with A. Bernell VTP 4016 N Home Street Mishawaka, IN 46545 autism. Focus Autism Other Dev Disabl 2000;15:163-9. 800-348-2225. https://www.bernell.com B. Choiceworks. Computer Software. Apple App Store. 4.4.1. 13. Vaz I. Visual symbols in healthcare settings for children Bee Visual LLC. 2012-2014. https://apple.co/2RnM0CF with learning disabilities and Autism Spectrum Disorder. C. Brili Routines-Visual Timer. Computer Software. Apple Br J Nurs 2013;22:156-9. App Store. 2.0.9. Brili GmbH, Inc. 2019. https://apple. 14. Briody J, McGarry K. Using social stories to ease co/2YRHJZM children’s transitions. Young Children 2005;60:38-42. 15. Gray C. The New Social Story Book: Illustrated Edition, References 2nd ed. Arlington, TX: Future Horizons Inc.; 2000. 1. Blumberg SJ, Bramlett MD, Kogan MD, et al. Changes in 16. Liu T, Breslin CM. The effect of a picture activity schedule prevalence of parent-reported autism spectrum disorder on performance of the MABC-2 for children with autism in school-aged U.S. children: 2007 to 2011-2012. National spectrum disorder. Res Q Exerc Sport. 2013;84:206-12. health statistics reports; no 65. Hyattsville, MD: National 17. Molloy CA, Dietrich KN, Bhattacharya A. Postural stability Center for Health Statistics, 2013. in children with Autism Spectrum Disorder. J Autism Dev 2. Coulter RA. Understanding the visual symptoms of Disord. 2003;33(6):643-52 individuals with Autism Spectrum Disorder (ASD). 18. Aksay E. Effects of physical activity programs with visual Optom Vis Dev 2009;40(3):164-75. stimuli on physical development of children with Autism 3. Milne E, Griffiths E, et al. Vision in children and Spectrum Disorder. J Educ Psychol 2014;5(1)34-43. adolescents with Autistic Spectrum Disorder: Evidence 19. Case-Smith J, Bryan T. The effects of occupational therapy for Reduced Convergence. J Autism Dev Disord with sensory integration emphasis on preschool-age 2009;39: 965-75. Web. children with Autism. Am J Occup Ther 1999;53(5):489-497. 4. Simmons DR, Robertson AE, McKay LS, Toal E, McAleer 20. Robertson AE, Simmons DR. The relationship between P, Pollick Fe. Vision in Autism Spectrum Disorders. Vision sensory sensitivity and autistic traits in the general Res 2009;49.22:2705-39. population. J Autism Dev Disord 2013; 43:775-84. 5. Banda DR, Grimmett E, Hart, SL. Helping students 21. Hilton CL, Harper JD, Kueker RH, Lang AR, Abbacchi with Autism Spectrum Disorders in general education AM, Todorow A, LaVesser PD. Sensory responsiveness classrooms manage transitions issues. Teach Escep as a predictor of social severity in children with high Child 2009;41:16-21. functioning Autism Spectrum Disorders. J Autism Dev 6. Coulter RA, Bade A, Tea, Y, Fecho G, Amster D, Jenewein Disord 2010;(40)-937-45. E, Rodena J, Lyons K, Mitchell GL, Quint N, Dunbar S, 22. Shaaf RC, Millder LJ. Occupational therapy using a sensory Ricamato M, Trocchio J, Kabat B, Garcia C, Radik I. Eye integrative approach for children with developmental examination testability in children with Autism and in disabilities. Ment Retard Dev Disabil Res Rev 2005;11:143-8. Typical Peers. Optom Vis Dev 2014;92:31-43. 23. Allison CL, Gabriel H, Schlange D, Frerickson S. An 7. Dauphin M, Kinney EM, and Stromer R. Using video- optometric approach to patients with sensory integration enhanced activity schedules and matrix training to teach dysfunction. Optometry 2007;78:644-651. sociodramatic play to a child with autism. J Posit Behav 24. Horowitz LJ, Oosterveld WJ, Adrichem R. Effectiveness Interv 2004;6:238-50. of sensory integration therapy on smooth pursuits and 8. Morrison RS, Sainato DM, Benchaban D, and Endo organization time in children. Padiatrie und Grenzgebiete S. Increasing play skills of children with autism using 1993;31:331-44. activity schedules and correspondence training. J Early 25. Robertson AE, Simmons DR. The relationship between Interv 2002;25:58-72. sensory sensitivity and autistic traits in the general 9. Bryan LC and Gast DL. Teaching on-task and on- population. J Autism Dev Disord 2013; 43:775-84. schedule behaviors to high-functioning children with 26. Coulter RA, Tea Y, Weider S. Thinking goes back to school: autism via picture activity schedules. J Autism Dev providing better vision therapy to patients with autism Disord 2000;30:553-67. spectrum disorder. Optom Vis Perf 2014;2(5):211-9. 10. Dooley P, Wilczenski FL, and Torem C. Using an activity 27. Eubank TF, Ooi TL. Improving visually guided action schedule to smooth school transitions. J Posit Behav and perception through use of prisms. Optometry Interv 2001;3:57-61. 2001;72:217-27. 11. Massey NG and Wheeler JJ. Acquisition and 28. Baltruschat L, Hasselhorn M, Tarbox J, Dixon DR, generalization of activity schedules and their effects Najdowski AC, Mullins RD, Gould ER. Further analysis on task management in a young child with autism in an of the effects of positive reinforcement on working inclusive pre-school classroom. Education and Training memory in children with autism. Res Autism Spectr in Mental Retardation and Developmental Disabilities Disord 2011;5:855-63. 2000;35:326-35.

266 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019 29. Leaf JB, Dale S, Kassardjian A, Tsuji KH, Taubman M, McEachin JJ, Leaf, RB, Oppenheim-Leaf ML. Comparing AUTHOR BIOGRAPHY: Different Classes of Reinforcement to Increase Expressive Jennifer Fisher, OD, FAAO Language for Individuals with Autism. Educ Train Autism Berkeley, California Dev Disabil 2014;49:533-46. Dr. Jennifer Fisher completed her 30. Hahs AD, Miller S. ABA in the special education Doctorate of Optometry and Bachelor’s classroom: promoting on-task behavior in an individual in Integrative Biology at UC Berkeley. She with autism. Education 2014;4:95-102. graduated from UC Berkeley School of 31. Jensen VK, Sinclair LV. Treatment of autism in young Optometry and completed a residency in children: behavioral intervention and Applied Behavior Vision Therapy and Vision Rehabilitation Analysis. Infants and Young Children 2002:42-9. at the State University of New York College of Optometry. She is a Fellow of the American Academy of Optometry 32. Kenny M. Integrated Movement Therapy: Yoga-Based Therapy as a viable and effective intervention for autism and a member of the College of Optometrists in Vision spectrum and related disorders. Int J Yoga Therap Development. During her residency, she worked extensively 2002;12:71-9. with children on the autism spectrum and with special needs. Dr. Fisher currently works as an Assistant Clinical Professor at 33. See, CM. The use of music and movement therapy to the Binocular Vision clinic at UC Berkeley. modify behavior of children with autism. Partanika J Soc Sci & Hum 2012;20:1103-16. 34. Sung M, Ooi Y, Goh T. Effects of Cognitive-Behavioral AUTHOR BIOGRAPHY: Therapy on Anxiety in Children with Autism Spectrum Tyler Phan, OD, FAAO Disorders: A Randomized Controlled Trial: Child Bronx, New York Psychiatry Hum Dev 2011;42:634–49. Dr. Tyler Phan is the Director of Vision 35. Wood J. Brief Report: effects of cognitive behavioral Therapy at Union Community Health therapy on parent-reported Autism symptoms in school- age children with high-functioning Autism. J Autism Dev Center where he founded the clinic’s Disord 2009;39(11):1608-12. vision therapy and neuro-optometric rehabilitation program. He is also a 36. Greenspan, S, Wieder S. Engaging autism: using the Staff Optometrist in the Department of floortime approach to help children relate, communicate, Ophthalmology at SBH Health System in Bronx, New York. and think. Cambridge, MA: Da Capo Press, Lifelong Books, 2006. He is a Fellow of the American Academy of Optometry and a member of the College of Optometrists in Vision Development. 37. Coulter RA, Tea Y, Weider S. Thinking goes back to school: providing better vision therapy to patients with autism Dr. Phan graduated from the University of California Los spectrum disorder. Optom Vis Perf 2014;2(5):211-9. Angeles (UCLA) with a Bachelor of Science in Psychobiology 38. Azimi Green MD, Wachs H, Dee M. Successful optometric and received his Doctor of Optometry from Western vision therapy with patients on the autistic spectrum: University of Health Sciences College of Optometry. He engaging patients with visual- cognitive therapy. Optom completed a residency in Neuro-Optometric Rehabilitation Vis Perf 2014;2(5):235-9. and Vision Therapy at The State University of New York College of Optometry. 39. Solomon R, Necheles J, Ferch C, and Bruckman D. Pilot Study of a parent training program for young children with autism: The PLAY project home consultation program. Autism 2007;11:205-24. 40. Lemer P, et al. Envisioning a bright future: interventions that work for children and adults with Autism Spectrum Disorders, 2008.

267 Vision Development & Rehabilitation Volume 5, Issue 4 • December 2019