INTERVIEW WITH MELVIN
Melvin Kaplan, O.D. of Tarrytown, New York, is
one of the pioneers in the field of visual management training.
Dr. Kaplan has lectured extensively on visual training and has been
mentioned in two books, Rickie and Dancing in the Rain.
Dr. Kaplan is the Director of The Center for Visual Management (150
White Plains Road, Suite 410, Tarrytown, New York, 10591; Fax: 914-631-1004).
Dr. Stephen M. Edelson (SE) interviewed Dr. Kaplan (MK) on September
Let's start out with a basic and rather general question: What
is visual management training?
Vision Management Therapy is an individualized
program that measures, observes, and is designed to develop, improve,
remediate, and enhance visual performance. The ultimate goal is
to raise levels of performance which, in turn, affects behavior
and influences how one performs in social, academic, and vocational
Have you ever noticed anything unique or different about the vision
of autistic children versus the vision of other types of disabilities?
I do not view people with various disabilities
as different. I look at them as having different levels of visual
performance. Let us view visual performance on a bell curve with
the optimal performance at the peak. At one end of the curve are
people who are experiencing visual compression; and at the other
side are people who are experiencing visual disparity. The issue
is then: How far from optimal is the person? or What level is the
person at? One does not need to look at labels, whether it is autism,
a learning disability, or dyslexia, I do not want to become hung
up on labels because once you have a label then the community tells
you how the person should be treated. It has been said, "Labels
are for cans, not for people."
This reminds of a great article, "Labels
are for Cans, Not for Kids." The question is not of labels,
but of levels of performance. When we observe the level of performance
of autistic individuals, can we, through visual intervention of
lenses and therapy, raise the level of performance? What is the
difference between autism and learning or emotional problems? The
difference is a lower level of performance on the ladder of processing
information with a greater dysfunction in organization and orientation
shifts from the optimal.
Could you comment on why autistic children appear to rely heavily
on their peripheral vision?
I believe that this is a compensation. By turning
their head, they get a monocular view of the world. What happens
to be peripheral vision is simply a way to realign their focal or
visual system. This is probably a way to avoid a mismatch between
the right and left visual system which most likely fails to coordinate.
Research indicates that autistic individuals have between 21 and
50 percent greater amounts of strabismus as compared to "normal"
I once met someone who relied primarily on peripheral vision.
I asked him why he does not look at people directly, and he said
it was like looking through a "bowl of jelly."
I think this person may have difficulty thinking
and attending at the same time. This is a case of rivalry between
the two visual systems; they are competing and out of synch. That
is, if a person has difficulty handling bits of information, he/she
may look at the individual letters but not at the whole word. If
one is using just his/her identification portion of the visual system,
he/she will likely take a long time to process the information so
it will be difficult to attend while they are thinking.
In fact, for almost everybody, if you look at
them when they are thinking, their eyes tend to go up and to the
left. When people have a disability, and this happens in non-autistic
individuals as well, they cannot look at you when they are thinking;
or they cannot look at you when they are talking because they would
be unable to maintain the conversation. In other words, they cannot
process visual and auditory information simultaneously.
Could you comment on the idea that vision is a learned behavior?
The focal vision, which involves identification,
is not learned. There is a great deal of literature indicating that
blind people, whose vision later returns, such as through cornea
transplants, were able to identify letters because of their previous
experience. In contrast, the ambient system is learned. Using this
example, these individuals, can have much difficulty perceiving
depth, organizing space, and orienting themselves.
Literature has demonstrated that 'focal vision,'
which involves identification, can be learned through other sensory
systems, whereas the ambient visual system needs rehearsal. The
literature talks about people who have reclaimed vision after a
long period of lost sight. They are able to identify objects, but
they are unable to deal with the spatial organization of objects.
In your opinion, who would be a good candidate for visual management
training? Based on my conversations with you in the past, it seems
as though people who display many self-stimulatory behaviors, have
coordination problems, engage in toe walking, fail to reach out
to touch things, and/or have problems with eye contact. It seems
that many of these problems can be explained by improper depth perception.
You just mentioned expressive problems, but I
tend to look at these problems as receptive problems. Eighty percent
of the information we receive comes from the visual sensory system.
When we cannot obtain visual information from the environment due
to some kind of receptive problem, we then start to see changes
in performance or behavior. In fact, they spend so much energy trying
to find the information that they do not have time left to speak.
Let me answer the question of who is a good candidate
for visual management training. During the course of a non-verbal
evaluation, if the individual can demonstrate awareness to their
level performance and demonstrates that ambient lenses can make
a more positive change on their visual performance, then both the
patient and examiner will be highly motivated to a successful conclusion.
This means that through the lenses and visual management training,
they can reduce the symptoms that are characteristic of autism.
Do you believe there is a relationship between activity level
and the visual system?
I think most cases have to do with visual processing.
Hyperactive individuals cannot locate things with their visual system
so they use their motor system to get to it. As a result, they are
always running into things because their world is 2-dimensional
rather than 3-dimensional. Things appear flat to them. They don't
visually 'feel' it. In addition, their space is limited so they
have to run and check on everything. When they go to a new room,
they have to know where the doors really are; they have to know
where all the light switches are. What they are really doing is
rehearsing so they can be in a room without having to think much
about it. That is why autistic individuals do not like new situations.
What about those individuals who are at the opposite end of the
continuum, those who are hypoactive?
Hypoactive children simply do not attend. They
are the ones who run away. This is no different than the child who
just says, "That's it, I quit; I'm not going to read."
And if you ask them a question, they will just say anything so that
you will leave them alone. These are the wallflowers. They just
do not want to play. They are the spectators and not the players.
Do you think this is the same as 'learned helplessness,' in which
the person learns to be helpless and simply gives up?
Yes. They give up and have other people do things
Can visual training affect stereotypic, self-stimulatory behavior?
behaviors appear to be inappropriate to us; but to the child,
they are appropriate and necessary. What these individuals are doing
is finding a way to interact with their world. For example, if a
child is flapping his arms, he wants to know where his body is located.
I should mention that people without autism exhibit these behaviors
as well. This is what people should understand. For example, many
people stick out their tongues when cutting a piece of bread. This
is a stim that is not considered inappropriate.
Does visual management training help people with strabismus or
Approximately three to four percent of the normal
population have strabismus; and based on our recent study, it appears
that 21 to 50 percent of the autistic population suffers from strabismus.
The question is: "Why is their such a relatively high percentage
of autistic individuals with strabismus?"
The answer to this question involves the ambient
system and a lack of coordination between the eyes. This may result
in amblyopia, strabismus, or the use of one eye for far viewing
and one eye for near viewing. These are all natural adaptations
to viewing the world singularly and enable interaction with the
world in a simplified or reduced fashion.
Some people have surgery to correct strabismus. This does not
seem to be a 'healthy' way to realign the eyes given that vision
also involves learning.
Surgery is the structural way to deal with strabismus.
The literature suggests that surgery is a cosmetic cure for strabismus,
but it is not a functional cure. I guess it depends on what you
are trying to accomplish. Many people are looking for a cosmetic
cure because they can still function moderately well. However, with
only a cosmetic cure, the eyes are not working as a team to create
depth perception. Depth can be accomplished with monocular cues,
but it is not as effective as with two eyes.
Unfortunately, the classical approach is a surgical
approach to strabismus. In my view, however, the question is not
one of eye structure but of performance. Case in point is the five
year old autistic male whose father, a physician, diagnosed him
with esotropia at two years old and was bedwetting. The condition
at age five, when I saw him, was alternating esotropia with little
change in performance. After a non-verbal examination, he was given
ambient lenses. Within one week of receiving the lenses, he stopped
bed-wetting, began to attend to objects above his head (previously,
he looked down), and was walking with greater facility. Two months
later his eyes were aligned.
Another problem which is common in autism and sometimes involves
surgery is toe walking. From my experience working with you, it
appears that, for many, toe walking may simply be due to a visual
Nothing is simple. There are many postural changes
that are due to visual management, one happens to be toeing in.
That is, autistic individuals may have a problem in orientation
in which they are not able to let go of the ground; as a result,
they become toe
walkers or they will place their toes inward as they walk. If
you can change their visual emphasis, they may not need so much
energy to manage it and could start to pay more visual attention
to themselves. When this happens, the toe walking stops; and they
become flat footed.
Dr. Richard Herman, an Orthopedic Surgeon, has
written that idiopathic scoliosis is probably due to a visual perceptual
problem. It has been my experience that posture changes can be elicited
through visual management training. For example, toeing in while
walking is a visual perceptual problem, the failure to be aware
of self and space simultaneously. The act of walking is a sequence
of landing on one's heels and pushing off with the toes. When the
visual system is dysfunctional, an individual holds his/her toes
longer to the ground; and the body moves with the appearance of
the toe turning in. I have seen a normal gait established in both
autistics and others who have been labeled as visually deprived.
What are some behaviors which may help a parent predict whether
visual management training will help their child?
One behavior is lack of eye contact. This is a
key issue. Another key issue is a postural shift in which they turn
their head to one side. A third behavior would be if the child walks
on his/her toes or if the child runs aimlessly. What visual management
goals are raising is the child's level of performance by reducing
the number of symptoms. When the number of symptoms is reduced,
the diagnosis disappears.
is a symptomatic-based spectrum disorder that displays obvious and
not so obvious visual characterization. Most professionals working
with autistic individuals would list poor visual attention, looking
from the side of the eye, and not making eye contact as obvious
visual characteristics. In my view, there are other visually-based
characteristics which are not usually considered. For example, rocking
from side to side usually is indicative of an orientation problem
and difficulty paying visual attention. Rocking forward and backward
allows one to create depth perception as does flicking the fingers
in front of the eyes. My advice to parents is to seek out a vision
professional who is also experienced with autistic individuals with
whom to share their concerns. This can lead to a judgment as to
whether or not visual management is an option for them.
Can you describe how you assess an individual?
Basically, we do two different assessments. We
perform a conventional eye examination to see whether or not there
is a refractive error, meaning whether or not the person is nearsighted
or farsighted. In other words, how well they identify things; however,
20/20 is not always enough.
A visual assessment of an autistic individual
requires investigation for "sight" glasses to see if the
individual needs a compensating lens for identification of objects
in his/her environment. Taking into mind that measurements of autistic
individuals is difficult at best and lacks a verbal response, I
have designed a non-verbal performance test to see if ambient lenses
(performance lenses) can 'Jump Start" visual information processing.
I refer you to a recent research paper of mine, "Postural Orientation
Modifications in Autism in Response to Ambient Lenses" which
appeared in Child Psychiatry and Human Development, Volume
27, Winter, 1996.
How soon do you see changes in these individuals?
There are certain areas in which we see changes
almost immediately, such as posture, eye contact, and attention.
It usually takes two months before the subject displays behavioral
changes to the care-giver.
Paraphrasing Dr. A. M. Skeffington, he once said
'the fastest way to change a person is through a lens.' Basically,
lenses transform light which then changes the electrical activity
of the central nervous system. In contrast, drugs also affect the
nervous system, but it takes five times as long since it involves
Could you describe a couple of recent patients of yours?
Well, I had a very interesting patient who had
a history of speaking and then stopped talking. I believe she was
verbal until she had the DPT shots and then lost her ability to
speak due to seizures.
We tried a series of non-verbal tasks and nothing happened. Since
I was unable to direct her visual system, I decided to disrupt it.
After I placed disruptive lenses on her, she then stood up in front
of the mirror and began to dance and talk. This was a really exciting
experience for me. I performed an evaluation on her three months
later, and she was still doing extremely well. She was verbal and
acting very appropriate.
Another example is a four year old patient with
label. When he came to see me, we performed a battery of non-verbal
tests. Overall, the child was physically fine and behaved very appropriate,
but he did not have language. He was visually involved, and I felt
that he was simply delayed. I told the parents that I did not consider
him a PDD case, and that he may be suffering from visual deprivation.
After three months in my program, the child had language and was
starting to function well. The family brought the child to his neurologist
six months later, and the neurologist said that the child did not
have PDD anymore. He couldn't understand it.
Have you ever seen a case in which a person did not respond at
all to visual management training?
I have rarely seen a case who did not respond
to at least some degree of visual integration training.
So the changes range from mild to dramatic?
Yes. Let me tell you about another case we recently
had. This was a six-year-old child whom we literally had to pull
off the walls. The child was strabismic, one eye was turned inward.
He entered my office screaming and was uncooperative. We finally
got some lenses on him, and he responded very well. Six months later
this child was completely verbal and was doing well in school. His
eyes appeared straightened. The child went back to the neurologist
who nearly fainted when she saw him. She could not believe that
this was the same person.
How long does the program last?
It varies depending on the specific needs of
a person. If the person has a visual learning problem, the program
usually requires approximately six months of therapy. If a person
has a visually-related emotional problem, the program requires about
one year of therapy, depending on his or her level of dysfunction.
In a person with panic disorder or bi-polar disorder for example,
the program takes about one year to complete.
What about a person with autism?
I do not have a timeline when it comes to people
with autism. We can get very positive results within a year's time.
With some people, we feel that more enrichment is possible and so
the program takes longer than a year. But within a year's time,
we have been very successful with vision as well as language development
and more appropriate behavior.
Autism, as you know, is a spectrum disorder, as
such, we give degrees to levels of performance as well as visual
involvement. In the study I did with you at Gateway in Ladner, B.C.,
we showed marked improvement in the behavioral characteristics of
autistic children within two months. The time frame depends on the
individual. As a rule, most visual systems display higher levels
of performance within a year.
If you would like to contact Dr. Melvin Kaplan,
write to: The Center for Visual Management, 150 White Plains Road,
Suite 410, Tarrytown, New York, 10591 (Fax: 914-631-1004).
Copyright The purpose of this copyright is to
protect your right to make free copies of this paper for your friends
and colleagues, to prevent publishers from using it for commercial
advantage, and to prevent ill-meaning people from altering the meaning
of the document by changing or removing a few paragraphs.
Reproduction kindly allowed by www.autism.org
Visit their site for more useful resources.
to read a fact sheet on Tunnel vision & Autism Spectrum Disorders
Click here for the full
range of Asperger's and autism fact sheets at www.autism-help.org