Vision Therapy is Messy

In his book Messy: How to be Creative and Resilient in a Tidy-Minded World, Tim Harford provides examples of how extreme organization and structure, reduced diversity, and oversimplification makes things easier but constrain and compromise outcomes.

Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;

-eye alignment and movement,


-object perception, spatial perception, and guidance of movement

is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.

All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.

Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.

Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.

Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity.  The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits.  Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.

Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.

Born on a Blue Day

By Daniel Tammet


Daniel Tammet is an autistic savant who became known by reciting 22,514 digits of pi without an error in five hours and nine minutes. In Born on a Blue Day he tries to explain what it was like growing up, what his experiences are now and how he perceives that he is different from people who are not on the autistic spectrum – which would be a challenge for any of us, even individuals who may be better at understanding other people than is someone with autism. Daniel is particularly interesting not only because of how he has managed his life and been able to describe it, but because, in addition to his Asperger’s, Daniel has synesthesia. As he describes how he processes objects, words, and numbers, you realize that this is an integral aspect of who Daniel is and his abilities as a savant. He sees numbers, sequences of numbers, calculations, and calendars as forms and colors. In the book he shares some hypotheses from research that we may all have some synesthtic traits which may be at the root of linguistic analogies.

His childhood is one of the most fascinating parts of the book. He was blessed with an exceptional family. But we also have to wonder about his ability to describe his experiences and feelings at such an early age – something which most of us could not do. Are they memories of memories which have been modified each time they have been recalled which is how memory seems to work for most of us? Around what is probably the time of puberty, which he does not mention, he makes a transition from being totally unaware of others (other than trying to avoid touching people and the confusion of dealing with people and crowds) to desiring relationships and feeling lonely. He does not say much about this transition other than sharing that it is an experience common to most individuals with Asperger’s syndrome.


He, like Temple Grandin (who has spoken at COVD) made great changes in his life through conscious effort. He discovered and accepted that he is homosexual and is able to be in a loving relationship. He has savant skills in languages as he has with numbers and has been able to use them to create a business he can operate from his home on the internet, which can be a more comfortable form of communication for many of those with Asperger’s than are face-to-face interactions. After gaining notoriety through his mnemonic feat, he was flown to California to be studied by Vilayanur Ramachandran (who has also presented to COVD). He also got to meet Kim Peek who inspired the Dustin Hoffman role in “Rain Man” and described his many savant abilities.

kim peek
Rain Man 2

This book is worth reading as it adds insights into how some of our patients may be processing and feeling. Daniel Tammet was born in 1979. Many of us were in practice already, but he was born in the dark ages of understanding autism. So much has been learned in this period of time which also demonstrates that we still have so much more to learn.

Growing Up with Sensory Issues:Insider Tips from a Woman with Autism

In a Different Key: The Story of Autism

A Full Life with Autism

NeuroTribes:The Legacy of Autism and the Future of Neurodiversity

Children’s Vision & Learning Month: Texas Mother Shares How She Put an End to Homework Battles

the curious incident of the dog in the night-time

Cover art

the curious incident of the dog in the night-time is a novel narrated in the first person by a 15-year-old boy with autism. The author, Mark Haddon, has worked with autistic individuals and expresses the feelings and thoughts that some autistic individuals may be experiencing. When the reader becomes absorbed in the book, the concept of a spectrum disorder starts to make sense. Most of us can identify with degrees of what the narrator is experiencing. It is important to recognize our similarities along with our differences and to keep in mind that understanding each other is a challenge in both directions. It is hard to believe how little literature was available on autism only a dozen years ago and how much our understanding, while far from complete, has expanded.

The narrator shares his insights. He has more understanding and tolerance than he had when he was younger, but is still easily overwhelmed. He knows his triggers and can usually avoid them in his controlled environment of home and school. He has learned ways to deduce the feelings and intentions of those he knows in routine situations. He avoids strangers, unfamiliar places, and over-stimulation. He has intellectualized ways to recognize when he does not understand someone’s intentions and bluntly asks what someone means, but he still often does not recognize when he doesn’t understand. This is particularly true with metaphors, colloquialisms, and most kinds of change. When he is overwhelmed, his systems break down readily.


Christopher is good at maths and physics, does not (cannot) lie, observes detail, and does not generalize. While his condition makes life difficult for him and for those around him, it is clear that he would not want to be someone different if it meant losing these special skills. We can see how he views his processes as superior. He is goal-oriented. He has plans for his future using his strengths and is ahead of most 15-year-olds in that area.

Events in the book put him in situations which overwhelm him and you are taken through what he is experiencing and his stages of coping until he is totally overwhelmed on a couple of different occasions. He describes his contacts with different people, how he feels about them, and why.


The book is narrated in a stream-of consciousness and frequently digresses as Christopher is distracted. While this makes for strange reading, it uses the ability of a novel to express how someone feels.

How much can we generalize about those with autistic spectrum disorder? People with autism are individuals, but this book expresses traits in a way which helps us feel what it may be like and not just intellectualize about the condition. The book is short and can be read in a few hours. It is a wonderful example of how humanism needs to be mixed with science for us to really understand.

Growing Up with Sensory Issues:Insider Tips from a Woman with Autism

In a Different Key: The Story of Autism

A Full Life with Autism

In a Different Key: The Story of Autism

John Donvan & Caren Zucker

I wrote about the book NeuroTribes recently and recommended it for anyone who enjoys interesting stories, well-written. While In a Different Key is similar, it contains even more stories – 46 chapters – and the writing may be even better. John Donvan and Caren Zucker are a talented, well-informed team. In a Different Key reminds me of The Making of the Atomic Bomb by Richard Rhodes which tells the story about our growing understanding of the atom interwoven with the stories of the scientists, their families, and the times. Seeing the change in understanding over time is much more meaningful than just being exposed to the current understanding without knowing how it evolved. Equally important is understanding that this evolution was the product of people, their lives, and their interactions, not by names in a book. The emergence of our understanding of autism, autistics, their families, and societies’ reactions is at least as interesting a story. It is an example of how change takes place. These changes did not take place in isolation and parallel changes in society’s view of the roles of women, race, religions, nationality, age, and sexual orientation. In the authors’ words…

That is probably autism’s single certainty: that the story is far from over. The mystery remains complex. Attempts to investigate its nature continue to bring new questions to the surface. The boundary lines set by professionals can, and should be expected to, move yet again.

In that uncertainty lies much of the explanation for why, over a span of eighty years, the story of autism has been so uniquely riven with division and dispute. The concept’s inherent elusiveness, the vagueness in how it has been described, and the variety in how it presents itself – to a degree that hints at infinity – has meant that anyone could say anything about autism, and eventually probably would. This effect was seen repeatedly, in the latching on to the word “autism” by all manner of theories, therapies, claims, interpretations, and controversies – from the scientific to the social to the legal to the nearly religious.



While only some of this helped shed light on what autism is, all of it served as a mirror for the societies that recognized autism as something real. Not everything revealed in that mirror was flattering; not the blaming that autism inspired, or the vituperation, or the exploitation, or the grandstanding, or the outright and sometimes willful neglect of the vulnerable.

 At the same time, however, that mirror showed how, in the search for treatments and services, for recognition and understanding, some good and admirable qualities came into play over the decades, on the part of many people. They demonstrated talents for organization, self-sacrifice, the expansion of knowledge through solid science, and for channeling love into pure, inexhaustible energy. This was most true of parental love. To be sure, that love could run awry at times, and be fierce to a fault, but it was one element in the whole long saga that was always, unquestionably, pure.


Indeed, the fact is that even with all the contentiousness attached to the word “autism”, the momentum pushing all the argument has also, over time, pushed all the societies that have tried to deal with autism in the most commendable direction, which is toward ever greater recognition of the dignity of individuals who are different by virtue of fitting the label in some way. It is this interpretation of autism that has come to be shared by the bitterest foes and the most casual bystanders: that having autism – being autistic – represents but one more wrinkle in the fabric of humanity, and that no one among us is living a life “unwrinkled”.


A Full Life with Autism

Chantal Sicile-Kira and Jeremy Sicile-Kira

This new book, which was written by a mother and son team, focuses on the challenges of people on the autism spectrum as they move into adulthood. I recommend it for families who are facing that challenge or who will soon have the challenges of that transition. What I found to be most interesting from our perspective is a very insightful explanation by Jeremy of the differences in his visual perception before and after optometric vision therapy. It is now recognized that many of the behaviors of those with autism which seem so strange to neurotypicals are a consequence of faulty ocular motor skills and visual processing. Ocular motor skills may be deficient in people who do not have other motor difficulties, but they are more common in those individuals with poor coordination. Accurate visual processing is dependent on accurate input, a prerequisite of which is skilled and automatic ocular motor skills. These sensations are integrated with input from other senses and prior visual experiences. Handling this volume of stimulation and integrating it is often a problem for those with autism. These skills can be developed as they must be for neurotypicals but may need extra guidance and rehearsal.

Continue reading

NeuroTribes:The Legacy of Autism and the Future of Neurodiversity


At the recommendation of a colleague and friend, I purchased NeuroTribes and In a Different Key: The Story of Autism at the same time and then spent months looking at them on my shelf. Would I ever read two large, dry books on the same subject? Finally, trusting the recommendation, I started to read NeuroTribes and was pleased to find out how wrong my assumption was.

NeuroTribes goes from one interesting, well-told story to another. Most people who enjoy history and good stories will enjoy reading the book even if they are not interested in autism. The stories involve human struggle. They involve divisiveness within the medical community which make us wonder what is accepted now that will be recognized as misguided in the future. The book contains an interesting chapter on the history of psychiatry and the strategic series of revisions to the Diagnostic and Statistical Manual of Mental Disorders which saved the profession. It is about people deceiving themselves and deceiving others, sometimes intentionally, and the consequences of this deception. It is about inadequate research trumpeted as dogma. It is about a generation of mothers of children with autism being incorrectly blamed for causing the condition and being told that they secretly hated their children. They were called “Refrigerator Mothers” and were subjected to psychotherapy while their children were institutionalized at the recommendation of their physicians. This inevitably halted their progress despite claims to the contrary. But the book is also about the power of people working together to change decades-old assumptions and the progress which has been made due to these efforts.

Rain Man 2

There is an entire chapter about the making of the movie “Rain Man”; all of the obstacles that had to be overcome; and some very interesting information about Dustin Hoffman. The book is about the change in the definition of autism from being a psychiatric condition to a disability and from being rare to probably being the single largest group in the world classified as disabled. It presents the unique abilities of many people who are on the autism spectrum; demonstrating that their traits are beneficial in many occupations and that they have made critical contributions in science and technology. Technology is facilitating communication for those with autism and enabling them to be a part of a community. Steve Silberman explains how neurotypicals have as much difficulty understanding the perceptions and processing of those on the autism spectrum as those on the spectrum have difficulty understanding why neurotypicals are so distractible, obsessively social, and deficient in attention to detail and routine. Why do neurotypicals prefer a world which is unpredictable and chaotic, perpetually turned up too loud, and full of people who have little respect for personal space? P. 471


The concept of neurodiversity is that conditions such as autism, dyslexia, and attention-deficit/hyperactivity disorder should be regarded as naturally occurring cognitive variations with distinctive strengths that have contributed to the evolution of technology and culture rather than mere checklists of deficits and dysfunctions. P. 16 Attention can be improved; most people with dyslexia can learn to read; and most people with autism learn and adapt which is not the same as curing autism. While there are still reasons to research epigenetic factors which may be involved in the expression of genes for autistic traits, most people now agree that the primary goal of research should be to find out how to help people with autism and their families live happier, healthier, more productive and more secure lives.


NeuroTribes reminds us that eugenics was a movement that was very popular in the United States. After it was adopted by Hitler and turned into ethnic cleansing and the horror of what was done became known, movements developed in the United States to end ethnic, religious, and racial discrimination. Despite our ideals, our track record has not been admirable over the years at assimilating ethnic groups, religions, races, and those with disabilities. After years of decreasing crime rates, we are in a time of increasing anger, violence, and restrictions on respectful freedom of expression. Perhaps awareness of how this population has been misunderstood and how our misunderstanding has led to inappropriate treatment will be seen as an example. The book makes it clear that this is not easy or simple.



Eliezer J. Sternberg

I recommend this book to those who are fascinated by the brain, particularly as it relates to our sense of self. Sternberg’s approach is through the many aberrations that can occur in our brains from disease, injury, and stress. For those who are well-versed in these conditions, there will be some repetition, but he also includes less familiar conditions such as sleep paralysis which can have fascinating effects. Sternberg reminds us, with statements such as “our visual system is designed for survival”, that traits which we may see as flaws developed in the system over millions of years in response to challenges for survival.

Vision is often oversimplified as sight because we don’t appreciate all that our vision is doing for us when it is working correctly and automatically. One way to appreciate the complexity of vision is to consider vision without sight which Sternberg does as he discusses the visual skills and the use of the visual areas of the brain by the blind.

We are amazingly complex which causes one to wonder how so many of us do as well as we do.