Literature review
Background and history of autism in relation to vision care

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Abstract

Although autism existed before 1943, it was Leo Kanner who is credited with the first detailed description of autistic behavior. Before Kanner's report, the behavior was generally known as childhood schizophrenia. He noted that the outstanding common feature of all the children was certain parental personalities, like obsessiveness and lack of warm-heartedness. Concurrent with Kanner's report and observations were those of Asperger in 1944. However, Asperger's report, in a German-language journal, was not brought to the forefront until the 1980s. The children described by Asperger had milder forms of behavior disorders than those described by Kanner, with the resulting diagnosis of autism broadened and blurred. The main features of the new autistic spectrum included a triad of developmental deficiencies: recognition, communication, and understanding. Regardless of whose research is read, autistic behavior is considered peculiar and difficult to treat. Early treatments included LSD, tranquilizers, and developmental remediation. A later treatment, which proved to be the most successful, is applied behavior analysis (ABA), an outgrowth of B.F. Skinner's conditioning research. The etiology of autism remains a puzzle to scientists, with the most likely hypothesis being a central nervous system dysfunction. With regard to vision, people with autism tend to have abnormal electroretinograms, deficient evoked visual potentials, and atypical opticokinetic nystagmus. Other than a higher than expected incidence of strabismus and oculomotor deficiencies, refractive and binocular vision status of people with autism have been reported to be within normal ranges. Accordingly, the most useful tests for a patient with the diagnosis of autism are those for oculomotor function, opticokinetic nystagmus, and strabismus. The optometrist, thereby, becomes a member of the team helping to diagnose and treat the visual sequelae of autism.

Section snippets

Incidence

Because the criteria for diagnosis of autism are often varied, so are the rates of the incidence of autism as reported by Wing.7 The range cited is from 1.2 to 16 per 10,000 in the United States, Europe, and Japan, and for the “autistic spectrum” as high as 47 per 10,000. A more current study reports that the recent changing criteria can result in an increase up to 28.8-fold8 or an incidence of 1 in 150.

Etiology

As with the variability in the diagnosis and incidence of autism, there is also a wide variety of proposed etiologies. Perhaps the best way to illustrate this point is to take the proposed theories of one noted autism researcher and his coworkers. Edward Ritvo has been a distinguished and well-recognized researcher for more than 2 decades. The fact that he and his coworkers have failed to identify a definitive etiology of autism emphasizes and illustrates the elusive nature of the etiology.

Synesthesia

The uncommon and unusual phenomena of synesthesia may be defined as one sensory input being responded to by a different sense. For example, “seeing” a sound or “hearing” a color.31 Although synesthesia was first recorded in the Old Testament32 in the description of the Revelation at Mt. Sinai, more than 3,200 years ago, articles cite it as recently reported within the last 200 years.33 Cytowic34 states that 15% of people with autism experience synesthesia compared with 1% of the general

Vision disorders

Scharre and Creedon52 measured visual acuity (using Teller Visual Acuity Cards), refractive error, binocular vision, and oculomotor status of people with autism. Binocular visual acuity ranged from 20/15 to 20/1600 with a mode of 20/80. Refractive error ranged from −4.25 to +3.25 diopters (D) with a median of plano. Astigmatism ranged from 0.25 to 3.25 with a mode of 1.50 D. Twenty-one percent of the children (7 of 34) were found to be strabismic, the majority having intermittent exotropia,

Treatment

Kanner3 recommended a special school for the children that he examined and described. The primary treatments for autism in subsequent years were pharmacologic in nature including LSD56, 57and major tranquilizers.58, 59

The major breakthrough in the treatment of people with autism was the application of behavior modification, known as ABA—applied behavior analysis.60, 61 ABA is an outgrowth of B.F. Skinner's reinforcement and conditioning research with animals.62 Briefly, according to ABA, the

Conclusion

While reviewing the literature pertaining to autism for the last 60 years, it seems that there are many unanswered questions. In particular, the factors that remain uncertain are etiology, diagnosis, and prevention.

A probable hypothesis is that autistic behavior is caused by a central nervous system dysfunction. This dysfunction involves the sensory systems, i.e., vestibular, auditory, and visual, and may explain the high incidence of synesthesia and irregular EEGs, ERGs VEPs, and OKN in

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    Copyright © 2008 American Optometric Association. Published by Elsevier U.S.A. All rights reserved.