EDUCATION & THERAPIES
Can Help Spectrum Children
Jeffrey Becker, OD, is the
director of vision services of the
Neurosensory Center of Eastern
Pennsylvania in Kingston. Dr.
Becker has been practicing as
a primary care optometrist and
specializing in vision rehabilitation
since 1983. He is a member of the
Neuro-Optometric Rehabilitation
Association, a Defeat Autism
Now! physician, and a Certified
Neurosensory Clinician. Becker
was also selected as one of
America’s top optometrists in 2007
by Consumers Research Council
of America out of Washington
D.C. Dr. Becker teaches vision
rehabilitation courses to students
pursuing doctoral level degrees at
Misericordia University.
 
Jeffrey Becker recently presented
at the Autism One 2009 Conference
held in Chicago. His lecture
was titled “Seeing Is Believing:
Sight, Vision and Autism.” In the
presentation, he discussed how
visual processing affects children on
the autism spectrum. In his 24 years
of clinical and research experience,
Dr. Becker has examined and
treated over 3,000 neurologically
impaired patients including children
and adults with autism spectrum
disorders.  perception, and vestibular inaccuracies.
 
Please visit:
www.keystonensc.com
76 THE AUTISM FILE | www.autismfile.com REPRINTED WITH PERMISSION © THE AUTISM FILE ISSUE 33 2009
with Visual Dysfunctions
By Jeffrey Becker, OD
DG, an 8-year-old boy, sat in my
examination chair after his
mother had completed all the appropriate
intake forms as recommended by the
Defeat Autism Now! protocol. She now
tried to control her son as he attempted
to touch the bright instruments in my
examination room. The paperwork
indicated that DG had been diagnosed
with autism spectrum disorder (ASD)
at 2 years old. He was in and out of
different programs and, at one time,
was labeled as dyslexic. The interview
proceeded typically, but his mother
was not quite sure why she was here
with her son, even though an observant
occupational therapist had suggested she
make an appointment with me. She said,
“I’ve had my son’s eyes checked before
school every year and he has always
had 20/20 vision.” My comprehensive
neurosensory examination, along with
the functional and developmental vision
examination, indicated that the other
eye care specialists were correct. DG did
have 20/20 visual acuity. But they had
apparently not assessed another aspect
of vision that is very important (Holmes,
et al., 2008). DG had significant eye
tracking and eye focusing problems,
reduced convergence, difficulty with depth
At this point, I explained to DG’s mother
the difference between sight (acuity)
and vision. Sight is the ability to see a
certain size object at a certain distance.
The standard means to assess acuity was
conceived by Herman Snellen in 1862.
Since that time, we have referred to
normal sight as 20/20. The top number
indicates the distance of the observer from
the acuity chart and the bottom number
the size of the letter being viewed. All
this really means is that a person can see
a certain size letter at a certain distance.
This terminology is, of course, important
for many aspects of our lives. But even
more important to our children with ASD,
like DG, is functional/behavioral vision.
Deficits with their visual systems can be
very disabling.
“Vision” refers to how the visual system
coordinates function between the two
eyes and the brain (Cohen, et al., 1988).
We ask questions like, “Do both eyes
perceive the same image at the same
time?” “Do both eyes move in unison?”
“Do both eyes have equal focusing
power?” “Do both eyes do all these visual
requirements easily, fluidly, and for an
extended length of time?” If the answer is
“no” to any one of these questions, then
a functional/behavioral vision problem
exists – one that can result in visual
“stimming” (e.g., a child waving his hands
back and forth in front of his eyes), poor
concentration, poor fine and/or gross
motor control, emotional outbursts, and
a preference for performing only certain
near point tasks, such as continuously
watching a hand-held video player at a
very close range or wanting to hold the
player at only one angle.
Children with ASD, like DG, appear more
likely to have visual functioning disorders
than the general population (Taub, 2007).
When doing the intake form for DG, it
was noted that he disliked doing any near
point tasks. He preferred to run randomly
around the room and pick items up along
the way. He would briefly look at them
and then put them down quickly when he
saw another item to view and examine for
a very short period of time. This behavior
was repeated consistently. His mother
noted that she felt DG was very smart
because he could easily memorize songs
and verses. (My experience has been that
ASD children are very smart but are unable
to utilize their intelligence in a positive
manner that we all expect.) He would not
engage in eye contact and would attend
to objects out of the corners of his eyes.
Instead of moving his eyes, he turned his
head to see objects.
DG’s evaluation, which took more than
two hours, indicated visual functional
deficits that needed to be remedied
for DG to be able to visually function
in the world. This two-hour evaluation
includes evaluation with the Sensory
View® diagnostic system (NeuroSensory
Centers of America, 2009). This system
assists in the evaluation of myelin health,
eye movements, balance, proprioception,
and dynamic visual acuity. After these
tests are done, an additional evaluation
is done to assess depth perception, visual
suppressions, visual focusing, ocular
health, and the ability of the eyes to
work together. These tests, which are
done by an eye care specialist trained
in these procedures, need to be done
without the use of the phoropter, an
instrument normally utilized in routine eye
examinations.
THERAPY PROGRAM FOR DG:
Vision therapy is done in a sequential
manner that mirrors normal developmental
processes. This allows the child to most
readily relearn the visual skills that were
lost or to learn those that were never
developed. It is therefore necessary
to start with very easy tasks and work
towards more difficult tasks. The Piagetian
approach to development indicates that
this is the best way to remedy vision-
related problems.
Vision therapy can be done in an office
by a trained therapist, in an outpatient
rehabilitation center, or at home. Vision
rehabilitation to correct most oculomotor,
eye focusing, and eye deviation deficits
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Children with ASD, like DG, appear more likely to have visual
functioning disorders than the general population (Taub, 2007).
A patient with special 3-D goggles
to help with depth perception
typically continues for six to eight months
when done two or three times per week.
Treatment also requires home participation
for 30 to 45 minutes per day for five days
per week on an outpatient basis. This
does not mean that the rehabilitation
cannot be concluded earlier (or later)
than this prescribed time. Program length
is dependent on the child’s participation
level and attendance. Due to DG’s
particular needs, I began his therapy
program in my office. The eye movement
exercises I prescribed consisted of
computer-based therapy as well as hand-
held therapy techniques. Both techniques
have the same end result, but I have found
that the computer techniques seem to
work more quickly and the results are
more consistent in nature than those using
the hand-held therapies. The disadvantage
of the computer therapies is that many
children with ASD have difficulties sitting
at the computer for any length of time,
thus making the sessions more frustrating
for them. Therefore, we incorporated both
therapy techniques with DG.
The computer programs we have had
success with come from a company in
Gold Canyon, Arizona (HTS, 2009).
The programs can be tailored for each
child and his or her skill level. We can
incorporate therapies for all visual deficits,
including gross motor, fine motor,
vestibular, and focusing issues, into this
program. The computer programs allow
easy progression for each child and can be
modified when a child has difficulty with
certain tasks. I do this at least two times
per month but usually more frequently,
making sure that the child is meeting the
proper goals.
DG progressed very well through the
eye movement therapies and even seemed
to enjoy them. He was rewarded with
stars when he met the goals that we set
for him. He frequently came into the
therapy room and started to turn on the
computer before the therapist. This part
of the therapy, which may be the longest,
required 10 weeks to show significant
improvements.
Once we were able to achieve equal eye
movements (having both eyes function
so that each eye has the ability to move,
fixate, and track at the same time and
speed), attention was turned to the eye
focusing problems. We used multiple
techniques with DG. An accommodative
flipper is a hand-held device that has
equal and opposite powers in the lenses,
and this was used to control and improve
DG’s eye focusing. This technique was
incorporated into the eye movement
therapies because we knew that DG liked
doing these exercises, and adding the
flippers did not trigger any behavioral
problems. DG did not have any problems
Flipper and eye patch
77
 EDUCATION & THERAPIES
VISION REHABILITATION IS NOT SOMETHING THAT IS DONE TO A PATIENT OR
TO A PATIENT’S EYES. IT IS RE-EDUCATION AND RELEARNING OF VISUAL SKILLS
THAT A PATIENT HAS NEVER GAINED NOR LOST.
using the flipper and wanted to hold it
himself at times. He progressed with the
flippers and eye movement therapy at a
steady pace over a two-month period,
meeting all the goals set for him.
The biggest stumbling block to therapy
(and this happened to DG) occurs when
a child falls ill with a cold or flu. This is
not an unusual circumstance and can
result in a setback in the therapy program
that lasts for several weeks until we can
get the child back into the program on a
regular basis. An important factor in all
therapies is consistency, including with
respect to therapy day, appointment
time, and therapist. Children with ASD, in
general, need consistency for any type of
activity to be willing to participate. Also,
having the same therapist, a quiet room,
and engagement in therapy on a one-on-
one basis is a must for children with ASD.
The third phase of DG’s therapy was
to address his convergence and depth
perception problems. Although they
are two separate processes, they can be
addressed together. The computer-based
therapy required DG to wear a special
pair of glasses that created a 3-D image.
Reluctant to wear them at first, our
therapist also donned a pair to persuade
DG to use them. DG wanted to imitate
the therapist so he then put on his pair of
special glasses and together they worked
on his convergence and depth perception
problems. At a rate of two sessions per
week, DG reached his goals in seven
weeks for both convergence and depth
perception.
NEXT STEPS:
Once DG’s visual skills progressed to
the point where he could perform fine
and gross motor tasks, one more focus
of therapy remained. This is called an
“integration phase” and helps with any
vestibular deficits the child with ASD
may have. Many children with ASD have
vestibular deficits, making it difficult
for the child to remain stationary or
78 THE AUTISM FILE | www.autismfile.com REPRINTED WITH PERMISSION © THE AUTISM FILE ISSUE 33 2009
maintain a vertical position. To get a
sense of this problem, recall the sensation
of having ridden a merry-go-round at
the playground. When it stopped, you
likely felt unbalanced, moving in an
uncontrolled manner and in various
directions. Children with ASD may move
in such ways on a regular basis. Many
of them have small, inaccurate eye
movements called nystagmus. If so, they
may feel as though the room is moving
around them, making the afferent
sensory information contradictory and
confusing. The result may be a child who
engages in seemingly senseless whole-
body movements or even drops to the
floor (Allison, et al., 2007; Trachtman,
2008).
The integration phase of therapy
teaches the body and brain to work
together, overcoming inappropriate
vestibular influences and enabling these
new skills to become natural. These
are learned activities and need to be
incorporated into the child’s daily routine
to embed them so the child can use them
with every waking moment. Integration
therapy is accomplished with balance
boards, trampolines, balance beams, ball
catching and rolling, and cognitive skills
training. In DG’s case, one of the tasks
that we had him perform was to count to
10 backwards, then call out the alphabet
at the same time as he engaged in balance
exercises and eye therapy programs.
We repeated all the therapies that
have been described while DG was doing
gross motor activities. By doing this, his
brain had to incorporate all the new skills
developed so that functioning could be
DG’s mother was completely
amazed by her son’s progress.
His eye contact improved, his
visual stimming significantly
decreased, and his school
performance accelerated.
smooth and coordinated. It can take up to
another eight to 12 weeks for this phase
of the therapy. Many children report it to
be the most enjoyable part of the program
because it involves movement. With DG, it
took five weeks and he was able to reach
all of his goals while engaging in gross
motor and cognitive skills.
FINAL OUTCOME:
DG’s mother was completely amazed
by her son’s progress. His eye contact
improved, his visual stimming significantly
decreased, and his school performance
accelerated. His teachers wanted to
know what his mother had done to get
him this far. He was a more pleasant
child according to what others told DG’s
mother. Most importantly, DG now knows
he can do these tasks and has improved
self-esteem.
Once the in-office rehabilitation
program is completed, a reduction in
rehabilitation time is given to the child
and a phase-out program is begun for
several months. This is done to monitor
and maintain all visual skills that are
learned and to make sure the child has
adapted adequately to the new visual-
functioning environment.
As a final step, DG was given a
maintenance vision therapy program of
home exercises to follow and is checked
every three months in the office to
confirm that he has not regressed. The
home maintenance program can be a
computer-based program (HTS) or the
procedures that are outlined in the next
section. It is very important to do this
program with the understanding that
these visual skills have been learned and
can easily be unlearned if they are not
reinforced on a routine basis at home.
VISION REHABILITATION IS NOT
SOMETHING THAT IS DONE TO A
PATIENT OR TO A PATIENT’S EYES. IT IS
RE-EDUCATION AND RELEARNING OF
VISUAL SKILLS THAT A PATIENT HAS
NEVER GAINED NOR LOST.
 OCULOMOTOR, EYE FOCUSING, AND CONVERGENCE
PROCEDURES THAT CAN BE DONE AT HOME
Proper setup for tracking exercise
OCULOMOTOR EYE MOVEMENTS:
Visual Tracking
Visual skills emphasized are pursuit eye
movements, tracking skills, and eye-hand
coordination skills. Pursuit eye movement
and tracking skills are important for
effective near point tasks, eye contact,
and the development of good reading
skills. Eye-hand skills are important for
writing, eating, and the knowledge of
directionality and laterality.
Ball Rotations Procedure is a simple
but useful task used in the treatment of
oculomotor deficits.
The equipment needed is a ball with
letters written around the center of the
ball or a picture that your child may like,
a string, and a hook. Hang the ball (or
picture) from the ceiling and adjust the
height to his or her nose level.
Follow these procedures:
1. Place your child a comfortable distance
(approximately 3 to 4 feet) from the
hanging ball. This can be done lying down
or sitting up.
2. Bring the ball within one inch from
the child’s nose, and instruct the child to
follow the ball with just his or her eyes.
Let go of the ball.
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3. Observe your child’s ocular movements
as the ball swings in and out from his or
her face. This should last for one minute.
If your child wants to turn his or her head,
try to hold his or her head in place while
your child is moving his or her eyes.
4. After the ball is at rest, pull the ball to
the side of your child and let go so the
ball swings left to right and right to left
for one minute. Observe your child’s eye
movements laterally.
5. When the ball is at rest, begin by
throwing the ball in a circular motion
clockwise. Instruct your child to follow
the ball with his or her eyes for one
minute.
6. When the ball is at rest, begin
by throwing it in a circular motion
counterclockwise. Tell your child to follow
the ball with his or her eyes for one
minute.
7. Continue this daily for three minutes
several times per day. As you do this your
child will begin to improve his or her eye
movements.
EYE FOCUSING SKILLS:
The near/far chart is used for eye
focusing. Cut out pictures that your child
likes and put them on cardboard and
place them 6 to 10 feet away at standing
height. Make copies of these and shrink
them and place them on cardboard to be
held in front of the child about 12 inches
away.
Have your child look at the first picture
on the distance chart, and then have
him or her find the same picture on the
close chart. Continue repeating this and
increase the speed. This will allow his or
her eyes to quickly focus at distance and
near. Make a game of it and make sure
that the pictures are of interest to him
or her. Always change the pictures and
at times hold the close chart at different
rotations so that he or she still has to
recognize the picture even though it may
be oriented in a different position.
CONVERGENCE TRAINING:
Below you will find a useful procedure in
the treatment of many vision problems,
especially convergence insufficiency and
depth perception.
Obtain a piece of white string 10 feet
long, with three movable color beads
placed on it. (This is easily purchased at
any hobby or craft store.)
Normally, one end of the string is
placed on a distant object such as a
doorknob. Place one index finger over
the other end and hold it to the tip of
the nose. The first bead is placed at a
distance of 16 inches from the nose, the
second bead at 5 feet, and the last one at
about 9 feet.
When the child looks at the first bead,
he or she should see one bead with two
short strings leading toward it and two
longer strings leaving it. On the two
strings which leave the bead there will be
– to the child’s perception – two beads at
the 5-foot distance and two more beads
at the 9-foot distance. Next, have him or
her look at the second bead and again the
subject should see two strings entering
the bead and two strings leaving it,
making a large “X.” At this position there
will now be two beads – to the child’s
A patient displaying proper setup for
convergence training
79
 EDUCATION & THERAPIES
Setting up a convergence string
perception – ahead of (at the 16-inch
distance) and two behind – to the child’s
perception – (at the 9-foot distance) the
single bead at 5 feet. Finally, look at the
bead furthest from the nose. The child
should notice the two strings making a
“V” toward the bead and crossing exactly
at the bead. The beads at the 16-inch
and 5-foot distances will appear to be
double. The doorknob or whatever object
the string was tied to may also appear
doubled if there is adequate separation
between it and the last bead.
NOTE: If only one string is seen, the
subject is suppressing one eye, which
means that the brain is not responding
to that image coming from the eye. If
this is the case, the child has to do a lot
of spontaneous blinking to relieve this
situation. If the strings seem to cross in
front of the beads, this is referred to as
an “over convergence” and the child will
tend to perceive things being closer than
they really are. If the strings seem to
cross behind the beads, this is referred to
as an “under convergence” and the child
Almost all individuals are born with the potential for good
eyesight. But vision, the ability to understand and perceive
what is seen, is developed and learned.
80 THE AUTISM FILE | www.autismfile.com REPRINTED WITH PERMISSION © THE AUTISM FILE ISSUE 33 2009
What a patient is supposed to see looking at
the first bead if the eyes are lined up
will tend to perceive objects being farther
away than they actually are.
The object of this training device is
to be able to have the child see the
strings cross exactly at the bead he or
she is looking at without suppression at
any distance. Everything in front of and
behind this bead should be doubled. If
not, have the child find some spot on the
string where it is possible to achieve the
proper image (strings crossing exactly
at the bead). Many times this is a closer
bead for those with over-convergence
posture and a farther bead for an under-
convergence posture. From this point he
or she will slowly slide the bead closer
or farther away, maintaining proper
alignment and fusion. The goal is to
expand the range from this point until
normal fixation can be obtained at all
distances.
The next goal is to be able to jump
quickly from one bead to another,
achieving proper fixation each time.
The position and separations of the
beads should be varied during this part
of the training. Once this has been
Almost all individuals are born with
the potential for good eyesight. But
vision, the ability to understand and
perceive what is seen, is developed
and learned. As our children grow,
we tend to believe that their visual
abilities develop accordingly. New
findings and research indicate that
this is not always the case, and 25
percent of children in a classroom may
have undiagnosed visual skills deficits
that affect the learning process. In
addition to these undiagnosed visual
deficits, neurosensory disorders can
also linger in this same population.
How are vision and sight related?
Both require concurrent development
in order to work effectively. If one
is not in unison with the other, then
parents and teachers may start to
notice learning difficulties. In many
instances this can then lead to
reduced reading skills, poor behavior,
and deficits in gross motor control.
Visual and neurosensory disorders
can disrupt eye functions such as
tracking, depth perception, peripheral
vision, binocularity, maintaining
attention, and visualization.
Signs of vision and neurosensory
disorders in children related to the
eyes:
 Holds head at extreme angles to
read or write
 Poor posture when sitting at a
desk
 Rubs eyes frequently when doing
near point tasks
 Writing tends to wander above or
below the lines
 Omits small words when reading
 Misaligns digits in columns of
numbers
 Can’t describe what he or she has
just read
 Loses place while reading
 Can better understand a story
when read to versus reading
by self
 Avoids near work
 Behavioral problems
accomplished, the next goal is to be able Finally, this training technique can
to look away from the beads at a distant be used while the child is on a balance References
object and then look back at them and board, balance beam, or trampoline, Allison, C.L., Gabriel, H., Schlange, D., &
regain fusion. Alternate beads after each incorporating all sensory systems Frederickson, S. (2007). An optometric approach
to patients with sensory integration dysfunction.
distance glance. at once. Optometry 78(12), 644-651.
Cohen, A. H., Lowe, S.E., Steele, G.T., Suchoff,
HOW TO FIND A QUALIFIED EYE CARE SPECIALIST I.B., Gottlieb, D.D., & Trevorrow, T.L. (1988). The
efficacy of optometric vision therapy, Journal
of the American Optometric Association, 59(2),
To locate a neuro-developmental optometrist in your area, log onto 95-105.
www.nora.cc (Neuro-Optometric Rehabilitation Association). Holmes, J., Rice, M., Karlsson, V., Nielsen, B.,
When making an appointment, ask the following questions: Sease, J., & Shevlin, T. (2008). The best treatment
determined for childhood eye problem. Archives
1. H ow frequently does the doctor examine children with autism spectrum of Ophthalmology, 126(10) 1336-1349.
disorders? HTS Inc. (2009). 6788 S. Kings Ranch Rd., Gold
Canyon, AZ 85118.
2. Does the doctor do functional vision testing, not just acuity testing? NeuroSensory Centers of America. (2009). 300
3. Does the doctor prescribe vision therapy, and who carries out the therapy? Beardsley Road, Austin, TX 78746
Taub, M.B., & Russell, R. (2007). Autism spectrum
4. How long is the examination process with the doctor? (It should last at least disorders: A primer for the optometrist. Review of
90 minutes to get a good understanding of the child’s deficits.) Optometry. 144(5). 82-91
5. Will the doctor write and correspond with the school and/or other Trachtman, J.N. (2008). Background and history
of autism in relation to vision care, Optometry,
professionals? 79(7), 391-396.

ERRATA
Going back and forth in the editorial process, words get switched around, sentences get changed
and, occasionally, an error results. This was the case with the article from Dr. Nancy Mullan,
which was printed in the July edition (issue #32). We are reprinting the paragraphs below, which
emphasize the need to be cautious about high glycemic index foods.

Excerpted from “The Importance of Nutritional Treatment” by Nancy Mullan, MD

Diet is foundational. A symptom which
is being caused by a food or a substance
the patient is ingesting will not resolve
until that substance is removed. The
foods chosen should have nutritional
value, be organic, be free of chemicals,
additives, preservatives, and other
pollutants, and be eaten in the least
processed form possible. Double
handfuls of nutritional supplements
can be negated by poor food choice or
quality. High glycemic index foods should
be avoided as blood sugar fluctuations
are a common cause of psychiatric
symptoms of all varieties, especially in
the bipolar individual.
Thyroid and adrenal functions
potentiate each other. If adrenal
gland function is low, there is strain
on the thyroid. If appropriate thyroid
support gives the patient symptoms,
the adrenal gland must be treated
first, and the thyroid addressed
again later. The adrenal glands are
the body’s first line of defense
against stress. They produce cortisol,
a stress hormone with important
functions. Adrenal stressors include
chemical toxins, allergies, infections
and psychological stress, among
other things. High glycemic index
foods, foods that increase blood
sugar levels rapidly and then let
them drop, are a stressor to the
adrenal glands. Cortisol is the
hormone which must be secreted
to prevent that blood sugar drop.
Patients with hypoglycemia are not
able to produce enough cortisol
quickly enough to keep their blood
sugar levels steady. Patients with
postural hypotension, dizziness
upon coming to an upright position
quickly, are experiencing a blood
pressure drop that indicates that
their adrenal function is impaired.
Adrenal hormones regulate blood
pressure also.

We apologize for any confusion this may have caused. If you would like a corrected .pdf file of this article e-mailed to you, please e-mail
Teri at teri@autismfile.com.
Also in the July 2009 edition, concerning the article titled “Are Federal Research Dollars Being Spent Wisely?” the lead author should
have been listed as Theresa Wrangham, with Vicky Debold, PhD, RN, as contributing author.

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