9/13/2016 Autism is a complex and common developmental disorder that includes problems with social interaction and communication, and ranges from mild to disabling in severity Glen T. Steele, OD, FCOVD FAAO What is the incidence of autism? Pre 2010 – 1 in 1500 with autism Appreciable numbers of infants exhibit visual CDC 2012 – 1 in 150 children in the US has problems that escape detection Press LJ. InfantSEE as a portal to early intervention for autism spectrum autism or an autism spectrum disorder, such as disorders. Optometry 2008;79:627-630. Asperger’s syndrome CDC 2013 – 1 in 88 The absence of eye contact, unresponsiveness to facial gestures, and/or difficulty in sharing joint Latest – 1 in 68 visual attention are signs of abnormal or atypical Incidence - variable visual development Cause - multifactorial Press LJ, Richman J. The role of the optometrist in early detection of autism spectrum disorders. Optom Vis Devel 2009;40(3):141-149. Start with a careful history Does anyone in the family have issues? Especially in the presence of difficulty Place particular emphasis on eye movement and control - includes interest in parent, staff and doctor AND objects in the room as you test Carefully evaluate looking behavior Carefully evaluate refraction 1 9/13/2016 The best way to induce anxiety in children with Retinoscopy is a significant resource for autism is to prompt them to look at you determining how the child is really looking – look also at pupil size and change in this process When children on the spectrum are trying to listen to what you are saying, prompting them Binocular function - if binocular function is to look at your eyes will make them anxious present, the chances improve for having a and interfere with them being able to listen to foundation for "looking" you. Pupillary reflexes – speed and quantity of “I can see you or I can hear you. Which do you movement want?” Blink reflexes – link with fixation There are three primary reasons for this: Some children use peripheral vision to view Many children have auditory processing things. For them, direct vision is too intense problems. Research has shown that people on and overwhelming, so they look with their the spectrum often look at your mouth. This peripheral vision. When they are “looking” at would make sense if they need to look at your you, they will appear to be looking away from mouth to better understand what you are you because they cannot maintain eye contact. saying. Many adults on the spectrum have indicated that they become overwhelmed by the intensity of looking directly into your eyes. It feels very intimidating, very scary. Therefore - forcing a child to look at you is not Like most all of us, looking at someone is much increasing their understanding, but often easier when we do it under our own volition. It inhibiting it. It totally overwhelms and is intimidating when someone prompts us to distracts them. look at them. Same goes for all communication. We have found that children with ASD will look at you more frequently when indirectly invited to, not told to. 2 9/13/2016 Use the following tips during examination and Use less words and more nonverbal language you find the child looking at you more often: when communicating. Use more animated ◦ When talking to the child, position yourself so facial expressions, and exaggerated gestures to you are in front of him and at eye level. communicate. This invites the child to ◦ When your face is in his field of vision, it will get reference your face to obtain the information his attention better. This does not mean “in their needed. face” which would intimidate them. Just in their Use words to augment your nonverbal field of vision so it makes it easier for them to language; while conveying most of information reference you. nonverbally. I animate my facial expressions which draws their attention. When the child stops referencing you, try For many young children their eyes follow pausing briefly until his attention returns. their hands. If they feel safe with my touch, Often the break in the interaction invites the bring their hands up to the sides of your face child to check back with you to repair the which automatically brings a soft gaze. Do this breakdown. in moments of sharing positive emotion so the child references the positive gaze. This helps encode positive associations with gazing at your face. The worst time to demand eye contact is when Invite facial referencing, you are angry and scolding. Very intimidating ◦ Do not demand eye contact and encoding strong negative associations with ◦ Definitely do not grab and turn their face to you. looking. ◦ Facial referencing is glancing at the face for information or to share a positive moment, not necessarily eye contact. 3 9/13/2016 If the child is relaxed and feels safe with you, he will be more likely to reference your face. If you demand it he will be scared to look at you. Relating is about feeling safe and accepted, not instructed. And how does this involve optometry? Autism : Prompting Eye Contact – Bill Nason Autism Specialist, limited license psychologist, author, speaker Dec 19, 2015 Autism Discussion Page on the Core Challenges of Autism. - Routine young child exams with more careful If a child has does not develop appropriate eye attention to specifics we address with every tracking ability, there is a greater chance that patient they will not develop appropriate binocular ◦ History function and refractive testing will show ◦ Ocular Motility – special attention here fluctuations ◦ Binocular Function Don’t assume this is just a child who has not ◦ Refraction developed an ability to “pay attention.” ◦ Visual Acuity Paying attention is VERY important from the ◦ Eye Health – especially pupil responses earliest of ages Pupillary Reflex Blink Reflex Gaze Following Attention Oculomotor Function Choice of fixation object These are all tests optometrists do every day in practice 4 9/13/2016 Seeing what a child is interested in can give Abstract: …We found that participants with clues to what they're able to recognize -- ASDs showed significantly longer PLR latency, different shapes or sounds, for example. smaller constriction amplitude and lower A researcher might show a child two images constriction velocity than children with typical side by side and see which one they look at for development. longer. Measuring the size of a baby's pupils could do the same without needing a Abnormal Transient Pupillary Light Reflex in Individuals with Autism Spectrum comparison. Disorders Xiaofei Fan Æ Judith H. Miles Æ Nicole Takahashi Æ Gang Yao J Autism Dev Disord (2009) 39:1499–1508 Perspectives on Psychological Science – Jan 2012 …have shown that children and young adults Pupil size related to accommodation with autism have prolonged latency and less If pupil does not decrease, it can be assumed constriction of their pupils in reaction to light. that the child is not really looking Pupillary Reflex Differences Distinguish Autism From Typical Development Daniel M. Keller, PhD 9th Annual International Meeting for Autism Research (IMFAR): Abstract 109.004. Presented May 20, 2010 Moreover, typical toddlers inhibited their blinking earlier than toddlers with ASD, indicating active anticipation of the unfolding of those events. These findings indicate that measures of blink inhibition ….. are useful quantifiers of atypical processing of social affective signals in toddlers with ASD. Inhibition of eye blinking reveals subjective perceptions of stimulus salience Sarah Shultza, Ami Klin, and Warren Jones, Edited by Riitta Hari, Aalto University School of Science and Technology, Espoo, Finland, and approved November 1, 2011 www.pnas.org/cgi/doi/10.1073/pnas.1109304108 5 9/13/2016 When we are looking more intently at something, blink rate decreases or stops Watch blink rate Conclusions: Infrequent self-initiated socially Conclusion: This study suggests that a broader directed gaze may be an early marker of later autism phenotype, which includes an atypical social and communication delays. response to direct gaze, is manifest early in infancy. Social and non-social visual attention patterns and associative learning in infants at risk for autism Neural Correlates of Eye Gaze Processing in the Infant Broader Autism Phenotype A.N. Bhat, J.C. Galloway, R.J. Landa Mayada Elsabbagh, Agnes Volein, Gergely Csibra, Karla Holmboe, Holly Garwood, Leslie Tucker, Sanya Krljes, Simon Baron-Cohen, Patrick Bolton, Tony Charman, Gillian Baird, and Mark H. Johnson BIOL PSYCHIATRY 2009;65:31–38 These findings suggest that although gaze Eye contact is crucial in achieving social behavior at 6 months may not provide early communication. Deviant patterns of eye markers for autism as initially conceived, gaze contact behavior are found in individuals with to the mouth in particular may be useful in autism, who suffer from severe social and predicting individual differences in language communicative deficits. … development. The results revealed that children with autism were no better at detecting direct gaze than at Gaze behavior and affect at 6 months: predicting clinical outcomes and language development in typically developing infants and infants at risk for autism Gregory detecting averted gaze, which is unlike normal S. Young, Noah Merin, Sally J. Rogers and Sally Ozonoff children. Developmental Science 12:5 (2009), pp 798–814 6 9/13/2016 This suggests that whereas typically Active gaze following by 12 months