This article provides guidance for eye care professionals about treating patients with autism, and is written by eye care professionals who work with individuals on the autism spectrum.

Dr Paul Constable, City University, London
Mr Andrew Millington, Cardiff University
Mrs Pamela Anketell & Dr Julie-Anne Little, University of Ulster

Autism spectrum disorders (ASDs) affect 1 in 100 individuals in the United Kingdom and are characterised by impairments in:

  • communication – individuals may be non-verbal or use language in a repetitive or limited capacity
  • social imagination – individuals may have difficulty with interpreting abstract concepts and spontaneous actions
  • social interaction – individuals may have difficulty responding to another’s needs and interpreting gestures and emotions

Understanding individuals with an ASD can be challenging, and some advice on approaching a new patient with an ASD is given below. This information is primarily aimed at parents or carers of children with autism, but there is a section on treating adults with autism.

The diagnosis of an ASD may be made as early as the age of three years old if language is delayed, but in some children with Asperger syndrome the diagnosis may be made later when difficulties with social interaction amongst peers is evident.

Many children with poor language find visual aids and prompts useful in helping them to understand what will happen next and importantly when something will end. Therefore the aids that have been developed for ‘an eye-test’ use a pictorial narrative that can help the child understand what is required of them and what will happen.

The initial appointment

Parents may be unaware of the need for an eye-test for their child, owing to prioritising other difficulties that their child may face in relation to communication and social interaction. Many everyday tasks such as trying on new shoes, having a haircut or going to the cinema are difficult owing to the demands and needs of a child on the spectrum.

Parents will have devised strategies or key words or phrases that they use to calm down or gain the attention of the child. It is imperative that the practitioner involves and talks to the parent beforehand to learn what the child may like or dislike – for instance counting, shapes, lights, Nintendo characters, and so on.

Knowing when something will happen is important to a child with an ASD, for instance that the appointment will start at 10:00 and end at 10:25 promptly.

The first appointment may simply be to familiarise the child and allow them to explore the consulting room and feel comfortable in the place. This initial visit is important to gain the trust of the child, and their willingness to return again. It should be fun and non-invasive. It is best to see a child with an ASD when other children are not in the practice, as they may be sensitive to the crying of babies and they can have difficulties in ‘sharing’ any toys available in the practice with others.

Communicating with a child on the spectrum

Autism spectrum disorders affect the ability to communicate. Some children are entirely non-verbal or perhaps have just a handful of words, whilst others will talk on end about things like the Underground system or a television program, but little else.

The tips outlined below may ease the process of communication.

Always involve the parent in gaining the attention of the child, or assisting with the eye-test, and use simple one- to two-word instructions:

  • sitting
  • looking
  • what’s that?
  • eye open
  • again

The above list is used to highlight the limitations of language in many of these children when long sentences with complex parts such as this are difficult to understand:
‘Hello, sit up here for me on the big chair and look at that chart on the wall. I am just going to cover your eye and I want you to read the letters for me, OK?’

When you look at this statement which we might use for a child there are four instructions: ‘sit, look, cover and read’. This is too complex for most children with language difficulties. Therefore, break it down into simple one- or two-part instructions: ‘Sitting, sitting, good, now looking, looking, good, now one eye, again, what letter?’ may be an example of a sentence used with an individual with an ASD.

The following strategies can be helpful:

  • using the syntax ‘First X then Y’, because many speech therapists aim to develop this mode of thinking in line with communication: ‘First I speak, then you speak.’ A child with an ASD may be familiar with ‘First sitting then Looking’ or ‘First eye one then eye two.’
  • using an egg-timer or countdown clock to indicate how long they will be in the room
  • using ‘again’ to indicate that you want to repeat what we just did
  • using the parent as a model: ‘First mummy puts on glasses then Jack puts on glasses.’
  • turn-taking: if ‘we’ all do it then at some point it will be ‘my turn’ to look or read or put on the glasses.

Engaging in imaginative language such as ‘I wonder if I can see what you had for breakfast if I look in your eye’ will not be understood because of the complexity of the sentence, and the absurd notion that my breakfast would be in my eye.

Every word must be directed at exactly what you want the child to do, with no ambiguity or demands on the child to imagine or have to interpret the meaning. A useful anecdote here is the story of a child with ASD playing pool and being instructed to put the ball in the pocket. Naturally, the boy picked up the ball and put the ball in his trouser pocket.

It takes time for a child with language difficulties to respond to a statement or question. You must ask a question and then leave time (20-30 seconds) for the question to be understood and a response given. Be patient, repetitive and calm.

Echolalia is a term to describe the repeating of a phrase or sound and is typical in children with ASD. If the child has echolalia then they will repeat the last part of any phrase heard. Therefore, turn the question around and see if the response remains the same because the child is just repeating the last thing that they have heard, or if it changes. Here is an example of echolalia.

Practitioner: Better first or second?
Child: Second.
Practitioner: Better second or first?
Child: First.

Don’t forget to say how long it will be and stick to the time: two minutes means two minutes!

The examination - what should I do?

What can be achieved in the eye examination will be dependent on many factors and it may be the case that on the first visit, little clinical can be ‘achieved’ beyond the child becoming familiar with the room, and with you. This is as important as a measure of acuity, though, given that you might well be seeing the child for years to come.

One measure of vision may be ‘visually curious’. If the child is given a toy, do they explore the features with their eyes, or dismiss it because they have difficulty seeing the features of the toy?

Parents will understand that you may not be able to do a full examination. With children for whom a visit to the hairdresser is difficult, the parent may cut one side of their hair while they sleep and the other side the next night. They will understand if it is not possible to do ophthalmoscopy and a full binocular vision assessment in just one visit. What the parents want is to know that their child can ‘see’ and if any further investigations are possible then that is a bonus.

Suggested minimum tests and tips:

  • Vision: Use sunglasses with one lens tinted to occlude the right and left eyes. Use turn-taking to change the pair of glasses: ‘First me, then you.’
  • Binocular vision: pupil reflexes – are the eyes straight?
       Twenty dioptre base out test
       Cover test ’First eye one then eye two’ looking here
       Stereopsis
       Eye movements – the child may follow mum’s hands or a favourite toy
  • Colour Vision: Ishihara plates, maybe what number? Where are red spots?
  • Ophthalmoscopy: Use monocular indirect and a dim light
  • Refraction: A cycloplegic refraction may be clinically necessary. However the parent, and where possible the child, should understand the reason clearly. The blur and glare induced may cause significant stress and parents need to be aware of this. These side-effects tap into the core difficulties children with an ASD encounter – a lack of understanding of things that are strange (blur) and when something will end (concept of time). An explanation of why it is important to do cycloplegia might be lost on the child because of difficulties with language and extracting meaning from language.

Mohindra retinoscopy, or retinoscopy with a +2.00D lens and an estimation of any error, may be all that can be achieved. Binocular auto-refractors are advantageous but not readily accessible. The subjective refraction may or may not be possible owing to resistance to putting on trial frames or understanding what is required and when this is the case repeated visits for retinoscopy (with cycloplegia if required) may be all that is possible.

Remember, you may not be able to do ‘the best’ eye examination on a child with an autism spectrum disorder, and to do as much as is possible to reassure yourself and the parents that the vision is good may be in some cases all that is possible. Naturally referrals should be made if the practitioner feels that there is a clinical need that the practitioner or practice may not be able to meet.

Adults on the spectrum

Autism is a lifelong condition and many of the issues surrounding communicating to facilitate the eye-test with an adult will be similar. In general, communication and repetitive behaviours become less of a problem over time, but they may still manifest if an individual is stressed by a new and uncertain situation. In order to accommodate an individual on the spectrum the following guidance is suggested:

  • take time to wait for a response
  • use direct and simple language
  • see the individual at a quiet time of the day
  • allow extra time for the consultation or do parts of the examination over several visits
  • explain in advance what will happen during each procedure
  • above all else, be patient and understanding of the difficulties an adult may still face in following and understanding instructions

 

Dr Paul Constable, City University, London
Mr Andrew Millington, Cardiff University
Mrs Pamela Anketell & Dr Julie-Anne Little, University of Ulster

First published: November 2012