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.

Your Inner Fish

Neil Shubin

            Neil Shubin is a paleontologist whose team discovered fossils in 2004 of an animal which is a transition between a fish and a land-living animal. How we have evolved is fascinating and much more than a curiosity. He uses examples from living animals, fossils, and DNA to show how we are all related and how that information can be used to help understand our health problems and is being used to develop new treatments. The links are fascinating. How can it not be fascinating when we realize that all of our cells have the same genetic code and our cells differentiate and develop into thousands of kinds of cells which link to become our organs through communicating with each other and turning genes on and off. It is, as Neil Shubin states, like a pile of bricks being able to build a house by themselves. Mutations have enabled evolution but are also the cause of cancers. Did you know…

            Our sense of smell allows us to discriminate among five thousand to ten thousand odors. Some people can detect the odor molecules in a green bell pepper at a concentration of less that one part per trillion. That is like picking out one grain of sand from a mile-long beach…. Fully three percent of our entire genome is devoted to genes for detecting different odors…. Our large number of odor genes makes sense – mammals are highly specialized smelling animals….  But when geneticists looked at the structure of human genes in more detail, they found a big surprise: fully three hundred of these three thousand genes are rendered completely functionless by mutations…. Why have so many of our odor genes been knocked out? The answer was found by comparing genes among different primates. Primates that developed color vision tend to have large numbers of knocked-out smell genes. The conclusion is clear. We humans are part of a lineage that has traded smell for sight. We now rely on vision more than smell, and this is reflected in our genome.

            If we look around the animal world, we can assess whether animals are specialized for daylight or night by looking at the percentage of each type of light-sensing cell in their eyes. In humans these cells make up about 70 percent of all the sensory cells in our body. That is a clear statement about how important vision is to us.

            The whole system we use to perceive position and acceleration (our vestibular system) is connected to our eye muscles via connections in our brain. The motion of our eyes is controlled by six small muscles attached to the side walls of the eyeball. The muscles contract to move the eye up, down, left, and right. We can move our eyes voluntarily by contracting these muscles each time we decide to look in a new direction; but some of the most fascinating properties of these muscles is related to their involuntary action. They move our eyes all the time, without our even thinking about it. To appreciate the sensitivity of this eye-muscle link, move your head back and forth while looking at the page. Keep your eye fixed in one place as you move your head. What happened during this experiment? Your eyes stayed fixed on a single point while your head moved. This motion is so commonplace that we take it for granted, but it is incredibly complex. Each of the six muscles in both eyes is responding to the movement of the head. Sensors in your head record the direction and velocity of your head’s movement. These signals are carried to the brain, which then sends out signals telling your eye muscles to fire. This system can misfire, and misfires have much to tell us about our general well-being. This is one of the many things that our ambient visual system does subconsciously. This system can be disrupted from drinking too much alcohol. It can also be disrupted when the connections and timing are disturbed by a head injury and is often the most debilitating problem in post-concussion syndrome. So few things in life are simple.

For More:

Plasticity in Sensory Systems

The Body: A Guide for Occupants

Vision, Body Schema, and Clumsiness

Optometric Vision Therapy

Our body image is how we see ourselves. Our body schema is our subconscious sense of our body and how it relates to the space immediately around us. Movement is necessary to develop vision and body schema and to integrate them which enables us to move effectively. Our conscious brain has difficulty accepting that most of what we do is subconscious. Even when our movements are consciously ordered, not reflexive, the implementation is largely subconscious. Our conscious mind and focal vision are the strategists which make the overall plan while the subconscious mind, body, and ambient vision direct the tactics. It is now thought that learning does not take place solely in the brain but also in the body.

Focal vision is conscious: seeing objects, colors and symbols; recognizing what we see despite differences in size, distance, and position. Ambient vision is as complex as focal vision but is subconscious. It monitors where we are and where things are around us. It assists our balance. It directs eye movements to obtain information with phenomenal speed and precision. It helps us simultaneously process the movement of multiple objects around us. It enables us to navigate while our conscious mind is occupied. It stabilizes the images of what we are moving past so we perceive that it is our body that is moving and not our surroundings. Ambient vision is faster than focal vision and is able to multitask to accomplish all that it does.  We are unaware of its existence until there is a problem.

Most of us develop adequate ambient visual skills and, if we don’t, we probably don’t realize it. We are who we are. We may become carsick easily, be clumsy, have difficulty tracking across a page to read, perceive movement that is not there, not coordinate our two eyes well, be uncomfortable in busy places, and be easily overstimulated compared with others, but we adapt and compensate. Unless the deficits are extreme, it also goes unnoticed by others. But these problems are obvious when they develop suddenly such as after a head injury and may be extreme.

It is intriguing to watch vision and body schema develop in infants. We have an infant grandson who just started sitting in a highchair. Being able to sit expands what he can do with his hands and vision. He can pick up food and start to get it into his mouth. Sometimes he can control letting go of things to accomplish the all-important milestone of dropping objects and watching them fall to the floor. This is the beginning of thousands of experiences of trying and developing.

If vision and body schema have not developed adequately, they have the potential to be improved through therapy. A surprising degree of plasticity remains even into old age. Just trying harder tends to reinforce inefficient behaviors, not foster change. The visual system can be incrementally modified through optometric vision therapy; an individualized sequence of activities. The new or modified skill must then be practiced with attentive repetition to become automatic. Effective attention is subconscious as is effective vision. Forced attention (concentration) is much less effective.

Attentive repetition is difficult to achieve in the infant and young child. When possible, carefully chosen games which rely on the developing visual skill are employed which stimulate engagement. Success in the game is dependent on improving the deficient visual skills. Games may also reduce the rehearsal required to become automatic because the skill is developing implicitly. The roles of the therapist and doctor are critical. They plan and modify the sequence of activities for each patient based on the diagnosis and progress. Knowledge and experience are critical, but the success of care is equally dependent on empathy and support as in all of the healing arts. Being scientific and evidence-based does not reduce the importance of the personal connections.

Most change has to be done consciously at first and then practiced until it becomes automatic. The actions are consciously directed, but all action is too intricate to be consciously controlled. The conditions need to be arranged to facilitate the subconscious creation of new patterns. Trying to guide a ball instead of looking at a target and throwing it naturally is a good example.

The role of personality in development and in therapy cannot be ignored. Some children are more adventurous. Some are less flexible and less resilient. Mindsets can change dramatically as a child becomes empowered through growth, but some are still resistant to change. This is influenced by a history of failures, but it can also be their inherent temperament.      

Some of the brightest and most determined patients can be the most challenging. Their intelligence and determination have enabled them to find ways to compensate. It can be difficult to get them to stop overthinking to enable their subconscious to guide the development of automaticity. A dog which loses a leg can soon learn to run effectively on three legs. Having minimal consciousness may be an asset in this circumstance.

The success of vision therapy is dependent on a team effort and dedication. Appointments need to be kept and reinforcement activities need to be practiced at home to foster automaticity. Temporary accommodations may be necessary in school to relieve the visual load.

Helping develop vision is natural. Our species would not survive without it and it does not usually require professional guidance. It is a primary reason for the importance of play. Further development of visual skills is critical for athletes, dancers, artists, TSA workers, those in law enforcement, and all children who are learning to read. However, this is not the same as rehabilitating visual dysfunctions. Doctors and therapists who have been certified by the College of Optometrists in Vision Development have demonstrated their knowledge and clinical skills in vision development and vision therapy.

For More:

The Brains Sense of Movement

Vision Therapy Changes in the Brain

Action in Perception

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

Jennifer McIlwee Myers


There hasn’t been a book that I have reviewed for the blog which I have enjoyed reading as much as this book. The author, now in her 40s, tells her own story augmented by decades of research and experience and does it in an engaging and endearing way. Since we all process the information from our senses differently, we all have some sensory issues, but “SPD happens when a person’s brain does not make good enough sense of sensory input for that person to complete the tasks of daily life without serious impediment.” p. 27 The book reads like a good historical novel which gives you the feel of the situation while you are absorbing more history than you realize….

Then there’s the fight-or-flight reflex thing: Like a lot of people with SPD, my tactile and visual responses are set up so I get into that all-out-fight-or-flight, adrenaline-addled, ready-to-rip-out-a-tiger’s throat mental state quickly and effectively in totally inappropriate situations. p. 12

The vital information I got from learning about SPD gave me real power over my own life. It provided a basic tool for me to learn to be more emotionally resilient and generally functional. The second thing I learned when I started reading everything I could find on SPD was that my brain was not always an accurate source of information. In fact, no human brain really is. pp. 13 – 14


Stress makes behaving sanely difficult. p. 14

The only path to success is through roughly five zillion failures, and the only way to stop having bad patches is to give up and stop growing. You can’t protect anyone, not even yourself, from everything. p. 20

So perfect eyesight doesn’t guarantee that a person will understand or remember visual information very well. And it doesn’t guarantee having a “sense” of color or distance. p. 22


Heck, the ordinary senses of where our bodies are and how we are moving are vastly different from person to person. p. 22

There’s a ton of work to be done just to have a shot at using your eyes to coordinate what you’re doing with your hands. p. 23


Thing is, my crafting skills did not have to be so very poor. It’s possible for a child with a poor muscle sense to grow and stretch that sense and develop better and better skills. But because I was embarrassed by anyone seeing how clumsy and awkward I was at art skills (and physical skills), I avoided the very activities that might have helped me. p. 45

Some children can almost immediately take advantage of the improved sight that comes with having glasses that give them clear vision, but some kids with SPD have a really hard time adapting to suddenly being able to see so much more than before. If a kid has had years of bad hand-eye coordination because he is terribly farsighted, the process of getting eyes and hands synced up can take time and may require help from an OT or behavioral optometrist. p. 55

My brother underwent vision therapy that made a huge difference. For a long time, he had to wear special glasses that had partially blacked-out lenses to permanently train his eyes to look forward correctly. But the initial therapy made a huge difference in his behavior quite quickly. He stopped his pugilistic habits and became much easier to deal with in a lot of situations. p. 56

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In other words, a kid who has poor fine-motor skills won’t get far in improving them if he can’t be gradually led into activities that give him some upper-body strength and better posture. This is an area in which you have to look at the entire person, because just finding and implementing ways to improve fine-motor skills won’t work if the other parts of the body aren’t able to support that hand. p. 86

Active play engages more muscle groups than sit-ups or calisthenics. p. 93


Kids who have a sensory discrimination disorder that affects their vision (aka muddled up sight) can get into a lot of social trouble since people’s facial features, facial expressions, and body language are all assumed to be open books for sighted folk. p. 109

If someone says, “Look at the tree next to X,” unless both the tree and X are fairly isolated in my visual field, my chance of finding either one is pretty slim. p. 111

There are many tasks that we do without ever thinking about what we are actually doing with the vast amount of visual data involved. I can’t imagine what it is like for a child with very iffy visual processing to go to the grocery store right after the floor plan has been entirely reorganized. p. 113

Think about what this would mean to a child: If you can’t make sense of the visual information in comic books, how much of the visual information are you missing in your day-to-day life? How much social communication is purely visual, and how often do the real intended meanings of words hinge on visual clues like facial expressions and body language? p. 114


With a stranger in the room, he couldn’t generalize his abilities. p. 122 (We are all susceptible to the total load at the time which includes present and past stresses. This is why one of the goals of vision therapy is to make visual abilities automatic; less likely to fail to be generalized.)

Kids develop through play. Not just motor skills, not just imagination or problem solving, but whole-kid development. Children need play. It’s the most serious and important work of childhood. p. 124


Developing and improving sensory processing is a lot like developing any skill that involves coordinating your brain and nervous system with the rest of the body. This means going with activities that are not too far from what the child can already do. It’s called “scaling” (or, sometimes, “scaffolding”), and it’s a vital concept. p. 129

I learned more in the classrooms of teachers who knew that they didn’t understand me than in the classrooms of teachers who thought they did. That matters. p. 190


You can influence a child very positively with well thought-out rules and consequences. It’s a behaviorally approach, and the thing about behavioral approaches is that they can work really well when they are realistic. p. 190

Kids do need to have a realistic idea of how their own negative behaviors (or lack of behavior) can hurt them. For both long-term and short-term independence, kids need that clear cause-and-effect process to be part of their lives. p. 197

Powerful emotional states are, by nature, hard to manage. Sensory processing can be stronger and more urgent than any kind of logic… You can’t talk someone out of what their senses assure them is real. p. 200


What children need to know is that their brains can become stronger and better…. Not only that, but making mistakes and having them corrected actually makes you smarter. p. 209

In a Different Key: The Story of Autism

A Full Life with Autism

NeuroTribes:The Legacy of Autism and the Future of Neurodiversity

Autism, Parenting, and Rage

Autism and the Self

The Autism Revolution, Part One   The Autism Revolution, Part Two

Book review: Finding Kansas

Autism Solutions by Ricki G. Robinson, M.D., M.P.H.

Sensory Processing Challenges: Effective Clinical Work with Kids & Teens

Lindsey Biel, MA, OTR/L


Perhaps the most significant change in understanding children’s behavior is the increased acceptance and understanding of Sensory Processing Disorders (SPS) and their effects on behavior and learning. While we need to be vigilant to not enable behaviors which children can control with self-regulation, self-regulation is very difficult for children with significant SPD. As is true of Attention Deficit Disorder, research is causing a decrease in the number of people who are denying this constellation of problems and their influence. The recognition of these problems in people who have experienced head trauma and the realization that many of the behaviors we associate with autism are really due to problems in sensory processing, have accelerated this acceptance.

In her new book, Lindsey Biel gives helpful examples of children with these problems, how they can be diagnosed, the accommodations which can help them function, and how their sensory processing can be normalized. Ms. Biel has many insights from working with challenged children and from her relationships with other professions including developmental optometry. We had Ms. Biel present at the College of Optometrists in Vision Development when she brought out her first book, Raising a Sensory Smart Child. Sensory Processing Challenges includes questionnaires to help parents and other professionals decide when a referral to occupational therapy is indicated. Due to her work with optometrists, Ms. Biel has an excellent understanding of vision and devotes many pages to the influence of vision problems and who should evaluate them. Many children have more than one condition and will need intervention from more than one profession to address their issues. I recommend this book for any parent who has a child with learning or behavior problems and for those professionals who work with these children.