Autism and vision
We work with autistic patients, mostly children, at our Vancouver eye clinic. As parents and autism care providers know, vision based behaviors are characteristic of autism.
Here are a few examples:
- Poor eye contact,
- staring at lights or spinning objects,
- looking askance,
- side viewing,
- general difficulties giving attention to visual stimuli,
- Squints or closes an eye,
- Stares at certain objects or patterns,
- Looks through hands,
- Flaps hands, flicks objects in front of eyes,
- Looks at objects sideways or with quick glances,
- Shows sensitivity to light (photophobia),
- Becomes confused at changes in flooring or on stairways,
- Pushes or rubs eyes,
- Has difficulty making eye contact,
- Widens eyes or squints when asked to look,
- Bumps into objects,
- Is fascinated by lights and shadows, and
- Touches walls or tables while moving through space.
People often assume that most autism spectrum behaviors are caused by the disorder. But they could be caused by underlying and treatable vision problems.
For example, they could be caused by poor fixation, accommodation, or eye teaming abilities (binocular vision dysfunctions).These behaviors are often symptoms of visual dysfunction and these dysfunctions are often present in people with no autism spectrum disorder. Therefore, anyone with a diagnosis of the following conditions should have a thorough examination by a developmental optometrist:
- learning disability,
- speech-language delay,
- sensory integration dysfunction,
- Asperger syndrome,
- non-verbal learning disability, and
- psychological problems.
Visual examinations and treatment for visual dysfunctions are better when they are undertaken early. That is because the younger the patient, the faster and longer lasting the improvement in the patient and the higher the changes of treatment success.
When to see a developmental optometrist
The American Optometric Association (AOA) recommends that all children undergo visual exams by six months of age. If parents complied with this guideline, optometrists would likely discover visual problems in many young children who have not yet been diagnosed with autism. In fact, the signs of autism are often first encountered in an optometrists chair because the disorder has so many pronounced visual manifestations. For children who have been diagnosed with an autism spectrum disorder it is necessary to obtain a developmental optometrist examination as soon as possible.
Why the urgency? After age four, a child may make adaptations which embed visual problems, making them much more difficult to correct. For example, an eye turn out (also called strabismus or exotropia) becomes an eye turn in (esotropia) or a suppression (when one eye does not work) becomes almost fixed by a large angle head turn or tilt. An eye that turns out is much easier to treat than an eye that turns in.
How do visual problems fit within autism spectrum disorder?
Children with autism spectrum disorders (ASD) have motor, sensory, language and social-emotional delays that affect visual processing. But it goes both ways. Visual problems affect cognitive, speech-language, social-emotional and perceptual development.
For example, developmental delays in oculomotor function, focusing, and binocular abilities can affect gross and fine motor abilities and language acquisition. Sensory problems are often caused when vision does not coordinate properly with the vestibular and proprioceptive systems (the proprioceptive system senses the relative position of neighboring parts of the body). Poor visual awareness and poor eye contact is bad for socialization and poor visualization impairs the development of imaginative play.
What is the critical age?
The ages of 18 months to four years of age is the important period. This is the time when autism is usually diagnosed, and it is an important time of development for vision, language, socialization and other critical areas.
During this period, vision normally begins to dominate the movement system and coordinate the sensory systems (proprioceptive, vestibular and tactile). As vision combines with the other senses, central or focal vision normally emerges. If there is faulty information processing in any of the primitive sensory systems, visual dysfunction will result. Patients like this need to touch and move to experience their environment because their visual systems don't work well. Some of typical autism behaviors like flapping and side looking, might be their way of interacting the world to tell their brain where the body is in space.
The literature supports that a very high percentage of children with autism spectrum disorders have eye movement disorders and strabismus. Many kids with autism spectrum disorders have large gaps in their sensory, motor and visual development that cannot be fixed without therapy.
Developmental vision examination for autistic patients
A vision examination with a behavioral or developmental optometrist like Dr. M.K. Randhawa (visit www.oep.org or www.covd.org to find a developmental optometrist near you), looks at eye health and refraction and determine whether corrective lenses are needed. But importantly, the developmental optometric examination tests the visual skills of the patient and determines whether the visual system is functionally performing. Dr. Randhawa typically assess:
- acuity -the ability to see clearly,
- accommodation, or the ability to focus clearly,
- pursuits, fixations and saccades - the ability to move the eyes appropriately, and
- binocular or eye teaming ability.
- whether there is an eye turn (strabismus),
- whether there is a lazy eye (amblyopia),
- visual motor integration - how the eyes direct the hands and the body,
- visual auditory integration - how the visual system interacts with auditory commands,
- visual perception or processing or how the brain understands what is being seen. For example, Dr. Randhawa will determine if the patient can picture in his head what he is seeing, recall what is being seen or differentiate the figure from the ground.
Autism and vision consultation
Dr. Randhawa explains each aspect of the exam, discussing the child’s skills in focusing, eye teaming, visual motor and visual perceptual abilities. She will also discuss treatment options in terms of lenses and prisms, how they create changes in the light energy coming into the eye, and how they allow the brain to organize visual information in a different, hopefully easier, way. In most cases, in addition to lenses and prisms, vision therapy is appropriate.
Vision therapy, like occupational or speech therapy, is a tool to teach the one of the body's systems how to work - it this case it is the visual system. Most children with autism spectrum disorders require one-on-one, in-office therapy plus a home program to reinforce the work done in the office. The frequency and duration of therapy must be determined on a case-by-case basis. Dr. Randhawa may also make also refer the patient to other health professionals whose interventions may be required.