Incorporating Behavior when treating this population because children Modifications, Strategies, with autism 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, Autism Spectrum 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 state ments 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 institu tion 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 sup ports early intervention for occupational, speech, used by other professionals, such as teachers, and physical therapy 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, accommo dative 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 balance 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,