I’d be remiss if I didn’t finish this New Year’s Day trilogy without addressing a baby elephant in the room of this discussion, and that is the similarity between some of the psychosocial sequelae of institutional deprivation and Autism Spectrum Disorder (ASD). It is noteworthy that strabismus has been reported to occur more frequently in ASD (see Kaplan et al, Ikeda et al, and most recently by Black et al). Though that hasn’t been my clinical experience, I respect these reports. What about other features of ASD?
Let’s return to the book that has now brought this groundbreaking research to a public stage. On p. 139 Nelson, Fox and Zeanah write: “Romanian adoptees displayed deficits in executive function measures as well as in theory of mind, with the effects strongest among those who had experienced more than six months of institutional deprivation. As a further link the proposed institutional syndrome, deficits in both domains were associated with quasi-autism, disinhibited attachment, and inattention/overactivity.” This is where eyes meet brains. There are commonalities between the mind-blindess of autism, resulting in psychosocial impairments, and gradients of visual impairment. R. Peter Hobson was among the first to recognize that congenitally blind infants exhibit many autistic stereotypies and that the underlying commonality was a restriction in certain forms of perceptually dependent social experience.
Nelson, Fox and Zeanah comment on these stereotypies (p. 216): “One of the striking images to an observer visiting an institution in Romania is the sight of many children rocking back and forth while sitting or on all fours, turning their heads from side to side, or repeatedly bringing their hand to their face, often slapping themselves. Stereotypies are defined as repetitive, invariant movements with no obvious goal or function. They seem to occur when individuals receive diminished or atypical sensory input … It is important to note that other conditions limiting sensory input such as visual impairment or autism are also accompanied by stereotypies. In these cases, the deprivation is a result of of lack of visual stimuli or an inability to accommodate social stimulation – a condition known as disorder-induced deprivation. Typically developing children, particularly when they are young and particularly when they are excited, may occasionally exhibit stereotypies such as hand flapping, but these behaviors are transient and fairly readily distinguished from the more pervasive and intense stereotypies associated with deprivation.
The connection between deprivation, visual impairment, and quasi-autism was touched upon by Lea Hyvarinen. Lea is one of the few pediatric ophthalmologists who understands deprivation in the context of vision and brain development as we are addressing it. (This is one of the reasons she was an invited lecturer at the Annual Meeting of the College of Optometrists in Vision Development in 2012). She address some of these commonalities in the context of communication on her website, through the Heidi Expressions testing and training protocol.
There are two identical cards of each expression and a third where Heidi has a bow. If a child does not see the difference in the expression she is likely to match two cards where Heidi has the bow as the similar ones. In such a case we can direct the child’s attention to the form of the mouth and discuss what Heidi might be expressing with her mouth (smile, frown, or neutral) or eyes (tears together with frown) in the different pictures.
Regardless of the causes of deprivation, and their deleterious effects on brain development, the struggle for recovery challenges us to make full use of our knowledge about visual development.