Visual behavioursin neurodiversity

For those who don't know me, I'm a consultant ophthalmologist in Bradford. Um, my journey into the world of eye care began when I was 16 and I, um, was next-door neighbor to Andrew Tomkin. And, uh, when I was deciding what career to do, I really, really wanted to do optometry. And did some work experience with Andrew and Val. And then my parents had other ideas, and so off I went to do medicine. But I was going to be an optometrist. And, uh, so, yeah, fast forward 30 years and there I was in the School of Optometry in Bradford, signed to my parents. I got the chair in the middle of lockdown. So I remember when ringing my dad and saying, "Dad, I've got this job. I've got this job. I was right, I am an opto." So we're going to talk about, um, "Do you see what I see?" and visual behaviors in neurodiversity. I have no financial disclosures.

So, who am I? So, um, what I'm really interested in, and my sort of academic career has been in reaching the hard to reach, that group of patients who, um, are on the fringes, often don't receive eye care, and are difficult for us to deliver eye care to, and they have difficulty accessing it. More recently, that's become, uh, testing the untestable. Uh, it's a phrase that, um, an optometrist who did a masters with this used. A group of children who are traditionally, um, thought to be, uh, challenging in order for us to test, uh, that you can't get the information you want, and therefore they are untestable. And I just don't think that, that there has to be another way of doing that. I thought there has to be another way. So finding different ways of us adapting what we do in order to help them access eye care, rather than expecting that cohort of patients to do what we want, the way we want them to do it. That's then evolved into thinking differently. So, not what does this child see in terms of letters on a chart, but how does this child see? How does this person interact with their environment? How do they use their vision to do what they need to do? And what happens when this child leaves the clinic? So, it's all very well getting what we need in clinic. What actually happens afterwards? Because the children don't live in the clinic, they live in the world. How do they use the vision in their real world? So, it's not about vision, it's about learning. And if you hold that in your mind when you're seeing a child or an adult with learning disability in clinic, how does this person use their vision to interact with their world?

So, we think about these four elements. We think about communication. How does this person use their vision to communicate with people? That may be verbally or non-verbally. How do they use it to access literacy? By which I mean storytelling. So, this is not just about reading and writing. This is how do they interact with the world around them to learn things? How do they use their vision for independence? So, choosing their clothes, finding the food on their plate. How do they use their vision for mobility, getting around, wayfinding, map reading? How do they understand the place they're going, how they get there, and what it's like when they are there? And crucially, really, this has been the real game-changer in the last few years, is how does this person's vision interact with their behavior? So, how does their vision processing affect how that person is feeling? How they can keep sensory regulated? How they can keep their emotions under control, or how it is contributing to them having a dysregulation episode?

So, the classic scenario is that there's a child who is struggling for one other reason at school, and they're taken to an eye care specialist who says, "There's nothing wrong with his eyes or her eyes," which is true. There may be nothing wrong with the eyes, but that's not the full story. And so, we need to take a step back and stop thinking about how we perceive the world and think, "How is this child perceiving the world?" Because when we have a child in the classroom, what we're imagining is that child is sitting, seeing the backs of the heads of the children in front of them, and overlooking that and seeing the teacher standing at the board, or the whiteboard, or doing whatever it is to teach. That might not be what the child is seeing. What they might be seeing is a blue blob of something on the desk, and that is what is attracting their attention. That is what has got their focus for whatever reason. It might be just they find that interesting. Or it might be that they aren't really aware that what they're supposed to be looking at is the teacher over there. Or it may be that's just too much with all the other noise and chaos and other things that's going on. They need to just focus their attention on that little blue thing in front of them in order to keep their sensory regulation, in order to keep their emotional and behavioral regulation. So, we need to see the classroom, or see the environment, through the eyes of that individual.

So, the overall theme for this morning is this mismatch between the clinical signs that you are finding, which may be completely normal, and the visual symptoms, the reported symptoms that the parent or the teacher or the person themselves is saying to you, because often there is this big mismatch. And we're going to do that through talking about sensory channels, detecting the rhythm of vision, uh, two sensory, sensory processing and vision processing framework. And then, what happens next? Where do you begin as an eye health professional?

So, the question that I suppose I began with a number of years ago is, "Do children with neurodiversity have problems seeing?" And there's lots of literature out there. The difficulty with the medical literature, uh, certainly up to about five years ago, is most of the literature to do with vision and autism, because that's what it was mainly about. Oh, jumping forward, um, talks looked at a cohort of patients who could be enrolled in medical trials, which was broadly male, Asperger's, high-functioning autism, as it's called now. That is not the full spectrum of autism. So, a lot of the studies had very mismatched results, and you'll hear a bit about later. So, there's lots of controversy and studies contradicting one another. But what we did know is that atypical visual processing in early life may be the underlying cause of the social communication problems, which are the trademark, the hallmark of autism. That we classic sign of autism is somebody who is unable to make eye contact. And I'll show you a little video later as to why that might be. But that fits in with the theory of mind, which is, can you imagine what someone else might be feeling or thinking in this situation? And that is one of the kind of hallmarks which is said to be, um, different in those with autism.

The next question, really, is where is the overlap between all this stuff I'm going to talk about and CVI, cortical visual impairment, or vision in children who are premature, or children with cerebral palsy, or developmental delay, or even ocular visual impairment? I don't know. I think I know the answer. I don't know the answer to tell you. But what I do know is that there's more and more of us who are asking the question, "This child who's been diagnosed with autism, if the sole underlying issue with their symptoms is that they're unable to, uh, process vision in the same way that you are, or regulate their sensory information, is that CVI, or is it autism?" And the children who've got CVI, the way that that is expressed is in the child's ability to interact with people around them. Is, is that CVI, or is that, or? And actually, what matters more, having that label, or noticing it and doing something to help the child access learning, to climb, communication, literacy, independence, mobility, and behavior? And I think in the next 10 years, we're going to think about these things a little bit differently.

So, how do you describe some of this to a parent or a carer? Well, we start with, um, the point that some children with autism have difficulty regulating the flow of sensory information. So, what we see, hear, touch, taste, and smell. We have a sensory mixing desk in our brains that all the time is adjusting this. So, it's tuning out what's happening in the edge at the moment because you're looking at the slides or at me. It's, you're not hearing, or you might be hearing the rattle of that trolley in the corridor that you've turned down. You might be feeling the shoes on your feet. You're tuning all those things out because they're not important to you at the moment. You're focusing on the thing that's in front of you. Some people with autism can't do that. It's just all coming at them in one go at a time. So, instead of this lovely, idyllic mountain glade with trickling of information into this little pool, it feels different to them. So, they can become quickly overloaded. So, if we just talk about, uh, vision with movement, color, and light can overload your visual processing. But if you add in sound on top of that, and then you add in a change in temperature, or not being able to regulate your temperature, or then add in that you are nervous, or scared, or happy, or uncertain, or it can, the sensory regulation can just go off. And instead of your, um, what that turns into, what that can feel like for the person is a, a shutting down. So, all visual information just gets shut down, and so you go, the vision goes gray or black, or that they're able to focus their visual in only one very small section. And so, what they are looking at, like the child looking at the blue blu-tack, is not what you think that they should be or could be looking at. So, instead of your tinkly mountain glade, what you've actually got is Victoria Falls in the rainy season. You've got enormous amounts of sensory or visual information pouring in. I love this picture because it then the spray comes up and fogs what it is that you're trying to see or should be seeing. If that doesn't work for you, it's a sensory buckaroo. One thing, and your whole sensory system goes haywire.

So, what does this look like? So, children who are able to describe it, um, or what you see in practice is children who have very short bursts of visual inattention. Their vision is not necessarily on all the time. They use vision on their own terms. So, many families have used this exact phrase to me that it's just become part of my lexicon. They use vision when they want, for what they want, which does not necessarily match with what you are wanting them to look at. So, many children, you're showing them flashcards, and they're looking, you know, they've seen it because they've looked in the opposite direction, and they're looking away. They are regulating the information for what they want to look at. And fluctuation in visual attention is really common. Sometimes vision is on, sometimes it's not. And that's when we come to look for this rhythm of vision. So, it's a bit like breathing. Some children will have their vision on all the time, like everyone else, and that's fine. But other children, they can use their, um, adjusting their sensory flow to help them look at something because they are interested in it, or it's new, or they think, "This is okay," and they're looking, and then they need a rest. And so they either zone out. They might, eyes might drift. Some children might light stare and look up at the ceiling, or you can just tell that they've zoned out. And they zone out. It's like they're breathing out. And then when they're ready, their vision comes back on again, and they attend, and they're interested, and they're engaged for as long as they can, and then they just breathe out again. And if you watch children, you can see this happening. And for some children, the breathe out is a second, and then they're back again. For some children, the breathe in is for a second, and then they're off again. So, watching and noticing when the child is able to use their vision is really important, particularly in a, a special school setting. So, we're trying to get a child to, um, attend to something. Not doing the tapping them on the shoulder. "Come on. Come on, Charlie. Do good looking. Do good looking. Are you looking? Are you looking?" All that's doing is piling more, more things on your buckaroo and making it more difficult for the child to see, not less difficult.

So, we've talked about sensory channels. We talked about this rhythm of vision that we see in some people with neurodiversity. So, we're going to talk about two processing frameworks. The first is by Dunn, and it's, um, uh, she was an occupational therapist, and what she describes is for all senses, but I'm going to talk about it in terms of vision. Vision gets left out a lot. It gets left out a lot. So, um, there's a, um, a set of reports called "Child of the North." It's eight, um, university settings in the North are campaigning with the government to improve outcomes for children in the North, not just those with special needs, but all children. And they wrote a report on autism, and they said the five senses are, uh, touch, taste, smell, hearing, and temperature. I said, "Temperature is not the fifth sense." Okay? Vision is the fifth sense. The regulation of vision is really important. And we talked about it's almost so big you can't see it. The problem with vision in some people with autism and ADHD is so big we cannot see it. And it's almost unthinkable how you, you know, you can imagine regulating sound by children wearing ear defenders. How, how do you regulate sensory information visually? It's a big, big thing that is overlooked, but that's fine. That's why we're here.

So, these four groups of children. So, I'm going to describe these children. You may have seen these children. You may have encountered them in clinic, or know friends or family that this is their child. So, the first group is sensory seekers. These children are interested. Their vision is on all the time. They have to touch everything. They are always on the move. They seem to lack focus. You are not worried about their vision. They like to see. Vision is a good thing, but it's on, on, on all the time. They might seek things because vision, they enjoy, and they enjoy blocking everything else out by using a vision trigger. So, the children who enjoy spinning wheels.

The second group are the vision avoiders. They dislike their vision. They find it overwhelming. They deliberately look away. They get stuck. If they find something that they find visually soothing, so it blocks all the other vision stuff out, they get stuck on it. So, a little boy in school that was a grill on the wall, an air vent, and he would just spend, and I mean all day, staring at this air vent. This is something that he could deal with. It helped him keep sensory regulated. He couldn't use his vision for anything else, or only for very, very brief periods. They seem to deliberately not hear you. Sounds like my brother. Um, they like specific colors. They like light gazing. They may be the flappers and chewers. They're doing something else to gain sensory, um, dopamine. So, they're sucking on their thumb, or they're gnawing on their finger, or they're rocking, or they're making sound to gain sensory information because they don't really like using their vision.

The third group are sensory sensitive. She says, but I think they're distracted by. They are overwhelmed by sensory stimulus. They cannot downregulate it like the group before. They react quite intently because it's just piling another thing on, another thing. One person described it as, "I can see too much." One little girl said to me, "My vision is too loud. My vision is too loud." They sometimes have to finish looking at everything before they can move on. One of the sort of obsessive, repeated behaviors that is a hallmark of autism, they have to see every word on the page. They might, in order to do this, do vision or sound. So, they have to switch their hearing off in order to see.

And the final group are the bystanders. These are a very passive group of children that can be overlooked. They are no trouble to anybody, but that doesn't mean they're using their vision effectively for learning. They may need things actually pointing out to them that you think they are looking at it, but they're not. They're just staring at the page. They'll notice when you show them. They almost like they need reminding that they've got vision. They will miss things because they're just keeping everything downgraded all the time. And their vision is probably more off than on. Now, autism is a spectrum. So, every child has their own patchwork quilt of this. And depending on where they are with their emotional regulation, or how they've been an hour ago compared to now, may change which of these that they are, um, sort of scenarios you can, or characteristics you're noticing. But a lot of children, there's one that is their go-to.

So, understanding that vision is different is important. So, that looks at the whole of vision. But actually, we notice that you can drill down even further and look at just the different bits of vision. So, I call these "vibes," visual behaviors. I don't really like the term behavior, but it's one that's used in the sensory world. So, we're calling them vibes. What vibe is this child showing to me? And there are four main groups.

So, the first group is the central processors. Children who prefer to use their central vision to see. And by central, I do mean just the very central five degrees. So, a child who's a central processor, if you ask them to look at this page and say, "Count how many people are on the page," they are seeing only a small section of the page at a time. Okay? So, they're not necessarily putting the full picture together. So, we look at this page and we say, "Oh, I can see four people." But if actually they're only able to use a small section at a time, they can't see the whole page as one. Visual acuity is normal. So, these children find moving objects very difficult to follow because as soon as it's moved out of that central area they're allowed to pay attention to, they've got to then go and find it. They won't necessarily see door frames because they can see what's on the over there and go and find it. But they will walk over their little brother or sister. They will step into something massive on the floor because they're just seeing that thing over there that they want. They might look clumsy, and they might find looking for someone in a crowd really difficult.

So, the second group are the off-center. So, this is going to sound the opposite of what I've just described. So, our central pathway, our acuity, our color vision is 3D, ultra TV, fabulous vision. The peripheral or off-center vision is more, um, tuned into light detection or night vision and our movement, and that's more like a black and white analog TV. I'm losing the number of people for whom that analogy works. I need to find a new one. So, we know this about vision. This isn't new. This is stuff we've known for ages and ages. So, if you are overwhelmed by lots of vision in the middle because that is so detailed, then that you might choose to use your off-center vision. And these are the children who will view objects from the side. They will turn. You have seen these children. It may be that by suppressing their center, what they're doing is reducing their sensitivity to light flicker. They might not be able to integrate both parts of their visual field together. So, they have an exotropia. Large numbers of children with autism have an exotropia, and indifferent to other exotropias. They drift when they're concentrating, and they're lined up when they're not. It's the opposite of what we usually see. So, they can be distracted by things. It's that they're off-center is their primary bit. They're distracted by things out there. It's really hard for them to use their central vision. They look at things from the side. They might not look for long. And they might prefer moving objects. They like things that move because they like using their off-center vision.

The third group are position processors. So, this is a group of children who find it difficult to know where they are in the world. Anyone who knows stuff about CVI, this is going to sound very familiar. So, they like stimulating the edges of their vision. They may do that to understand where they are in the world. They will trail their hand along a wall. That when they walk into a room, they have to build that room by touching it or exploring it. So, every time the child walks into a room, it may be as if they're feeling it or seeing it for the same time. They can't take it in. So, they are, we'll start the video. Thank you. So, they are building the room like you're building a Minecraft world. And that's exhausting. So, they're building this world around them, which is exhausting. That takes a lot of energy and time, and may make them feel emotionally dysregulated while they're doing it. It means if you move something in their world, it's really frustrating because they've got to rebuild their world again. If you take them somewhere new, if there's a lot going on, they can't build that world because they can't get to that bit of their vision because they are so overwhelmed by other sensory input. So, these are the children that when they, oh, when they walk into clinic, uh, they might walk with their hands slightly away from their side. Uh, that they may trail their hand along a wall. We've got a bit of a lag. Uh, they touch everything in your clinic room. They come in, and they have to touch everything. They have to just do a little tour of your room in order to understand the shape, the map of that room.

So, the final group, again, where there's a lot of overlap with what I'm describing and CVI, cortical visual impairment, is the single-channel processors. It's one thing at once. They get overwhelmed by lots of sensory information. It just makes their central computer shut down. "I've got too many tabs open. I can't do this. I'm just going to freeze." So, these children describe visual blackouts. Or, if they're not verbal, you may see that they, at times, they just can't seem to see anything. They have really short visual attention. Visual fatigue is a big, big issue. They can't see and hear at the same time. They may choose to use tactile processing of objects. They prefer to touch things to understand them rather than look at them. So, that's a description of a range of visual behaviors, vibes, that we see in some children with autism and ADHD.

Before we move on, there's two, three other things that are really important vision stuff for you to know about that can begin to explain why somebody may be struggling with their vision. The first is saccades. One of the first things that was ever documented about vision in autism was that 50% of people with autism were known to have hypermetric inaccurate saccades. So, moving your eyes accurately along the page to read is very, very difficult. Very difficult. So, a child learning to read normally, in the size of text in the learning reading book, would move along a couple of words at a time. So, "Once upon a time, there was..." they can begin to build a story. But if you have inaccurate saccades, and your eyes just land upon some words, well, then this might be what you're reading: "Upon a was a big a castle the hill." How do you, how do you understand that story when actually the words that your eyes are landing on are not in the order that we think we should? We'll come to later why kids seem to be able to read and then suddenly don't read. But this inaccurate saccades is really, really common.

The second thing is, uh, knowing what something, imagining what something looks like if it doesn't look like it does now. So, a t-shirt looks like a t-shirt in the middle. That's what the child's expecting. But if it's folded up, it doesn't look that shape. Can you do that translational piece to understand with your visual memory and visual processing that that is still a t-shirt on the left-hand side, even though it doesn't look like the one in the middle? And if it's at the end of a PE lesson and it's all jumbled up, can you work out that that's a t-shirt? Can you find your clothes because they don't look like clothes when they are jumbled up or folded in the same way they do when they are on hangers?

And the final thing, which is so key, and I think is one of the least recognized parts of why children with autism struggle with so many things, is facial recognition. There is a huge problem with understanding faces for people, some people with autism. So, this is the mum of a child who is, uh, pre-verbal. He's age three, and he's very active, and his vision is fine, says Mum. But Mum's gonna, we'll play the video to tell you what happens when he goes to the park. >> He will go up to, um, sometimes complete strangers, take their hand, and try and walk off with them. He also has a delayed reaction trying to recognize familiar people. So, if I have a friend that looks fairly similar to me, he will study our faces for a few seconds to determine which one is Mum and which one isn't. Um, so it can be quite tricky when he does this with a complete stranger because he will just try and walk off with them. So, she goes to the park, and when he's ready to go home, he'll just walk up to somebody that looks a bit like Mum in terms of body shape and take their hand. It's a bit terrifying, isn't it? So, if you're in a classroom, you know who the teacher is because they're the grown-up. But if you've got more than one grown-up in the classroom, how do you know which is the teacher? How do you understand if that person opposite you is cross, or happy, or or sad, or frustrated, if you don't see faces? So, we go back to the very first part of my talk: that lack of eye contact in early years is thought to be a precursor for autism. Although you're not looking at faces because they don't mean anything to you. So, that you don't understand emotions because you don't know what they look like on somebody's face. It's really, really common. But people with autism don't know that everyone else can understand faces. So, how do you, you can't say, "I don't understand someone's face," because you don't know that other people can. So, I bang on about this all the time. Well, more at home than I thought I did, because, um, my daughter was watching a Korean TV show called "Attorney Woo." And "Attorney Woo" is about, um, an autistic young lady who was, didn't speak until she was eight. And then they fast forward in the first episode, and she's this hotshot attorney, and she's been taken on by this firm who do not know what to do with her, but she's brilliant at, um, winning court cases. So, in the clip we're going to show, she's been sent a new outfit by her dad, and she's going to do, um, a video call with him to tell him how pleased she is, and she's, um, looking to work out how she should make her face to be happy. So, we'll play the clip. So, he sent her all these photos of him with different emotions written underneath, "What emotion this is. This is the emotion I want. I'm just gonna practice looking like that in the mirror because I don't know how to make my face look happy because I don't see it in other people's faces. So, I need to look and work out how to do that." So, um, after the conversation of, "I thought you were doing your economics homework," um, I said to my daughter, "Well, that's brilliant because that's, that's quite fascinating that that is now understood by whoever wrote that show understands that this very, very intelligent woman has had difficulty getting on in life because she hasn't understood how people are, but they found a fix for it."

So, what is the science underpinning these observations? How is it that I'm not just making all this up? Well, as I said before, there is tons and tons in the medical literature about this, but the majority of it talks about a very small cohort of people. What we do know is the eye and the brain have a common embryological origin, and so it shouldn't be a surprise that vision is a, is a problem when there is a neurodevelopmental problem, and that neurotransmitter pathways are atypical in ADHD and autism. We know that the dopamine merging, the inhibitory pathways are implicated. So, you are difficulty. Dopamine is your, um, your happiness, your reward hormone. How it excites the brain. How do you keep that under regulation? And if you can't keep that under regulation, then all your senses, or your emotions are out of control, or could be out of control. We know that it's also involved. Dopamine is also involved in color and contrast and spatial processing, and saccadic inhibition and control. You have these burst on, burst off cells that make your eyes move and stop, move and stop, move and stop. And so, if there's a neurotransmitter problem, well, then you're not going to be able to make them move and stop when you want. And it may also be responsible for an accommodation lag. So, um, this study, um, looked just at people with autism, and it only looked, as many of studies, if you go and look about autism and vision, it just looks at, um, traditional eye things. So, uh, it looks at a refraction, or strabismus, or amblyopia. And it found that it's very high rates, more than the background population, but most commonly in children with a dual diagnosis. So, if you have autism and Down's, autism and cerebral palsy, autism and, uh, premature, but this, of course, doesn't tell the full story. We're not, I mean, I'm a bit interested in squint, but that's not what is making the child not function well in, in real life.

So, there's this fabulous paper that, um, I heard at a conference a few weeks ago that was like, "Excellent. This is what I've been looking for but not able to find." Electrodiagnostic findings on people with autism. They mirror what I've been describing about this center and off-center, and that dark-adapted B-waves is reduced in some, but not all, individuals with autism. So, depending on your electrodiagnostic findings, I'll bet that will mirror which vibes it is that you are showing. And what we know about photoreceptors is that if one is triggered, well, then the rim around the edge are inhibited. That's how your vision works. But actually, if you're not able to do that inhibition, then actually all your photoreceptors, receptors being triggered at the same time just causes this overwhelm. And so, so difficult to deal with from a vision point of view, may explain why some people with autism describe glare that we can't see, um, halos of light that we can't see, things that we can't see that is normal for them. They don't know that's not how the rest of the world is seeing things.

So, this paper, um, looked at, uh, is a meta-analysis of dozens and dozens of papers and showed contradictory findings. So, some papers felt that, uh, uh, color discrimination was, um, enhanced in ch, some people with autism, and some papers found that it was diminished. And again, depending whether you were testing an on-center or an off-center person, you would get different results. And then this paper just looked specifically at ADHD and said, "Is it that the, um, a vision problem causes you to have symptoms of ADHD?" Um, and they found that not really, but visual problems in early life can mimic ADHD. So, the way that you're able to use your vision for concentration, the amount of fluctuation you have in visual attention, which can look like ADHD.

So, way back at the beginning, what is the, let's take this out of the clinic. What are we going to do for this cohort of children? Or for central processors? You need simple layout of text. So, cover up. A lot of this sounds very familiar to children with ocular visual impairment, doesn't it? You may need directing to different parts of the page. There are two columns of spellings that you need to learn, not just one. You need to teach visual search. You can zone spaces out. So, um, you can have drawers with things in so they know which drawer they're looking for, so they're not having to search in every place, and using audio or tactile queuing. So, Lego bricks along a wall which helps you know where you're going.

If you're an off-center processor, you may need larger text than you think. Your acuity, if you're doing it for a few seconds in a quiet, calm place, may be normal, but that's not what you're using most of the time. Think where you are in the, where they need to be positioned in a room. Limit movement and distraction. I mean, that's impossible in a special school. Um, and allow the person to move into a room before other people so they can sit where it works for them.

If you're a position processor, you might find it really difficult to stand in line. You might not be able to judge personal space. You might stand too close to people. You can't, we've talked about you can't understand the room layout. So, you may need to arrive places early. You may find yourself going with your hands out towards someone in order to judge where you need to be.

And single-channel processes. And this is really what we're aiming for in all schools, where we're, we're aiming high, we're trying to get in with, um, SENCO and Ofsted to say, "You need to change what you think a special school classroom should look like," because what you're judging the schools by is a poor sensory environment for the children. So, a clutter-free zone, nothing on the walls, plain walls, plain flooring, not flashy lighting. Turn the big screen off. Less, less, less. Um, practical things, having cutlery in a spacer so you know where the knives, the forks, the spoons are. Um, turning the radio and the TV off when you're trying to eat. Large print, plain background, speak and then show.

So, one of the major reasons that I've encountered these children find their way into my clinic, or find their way into community practice, is that this child is suddenly not seeing. So, that's the story. This child's doing absolutely fine, and they're suddenly not seeing. Why are they not seeing? Well, this, um, lovely set of videos is from my colleague Daniel Davies, who's a visual impairment teacher in Salford. Um, and he describes, he thinks that primary school child. So, primary school is like a lovely little meadow. The child is tottering through in this lovely little world with some little bunnies somewhere, and it's all lovely. And you get to high school, and you hit a mountain, and you do not understand. The cliff face is absolutely huge, and it's such a different environment, and you suddenly can't see. So, you then have to develop a whole new set of skills and strategies to climb up the mountain, or hack your way through it, so you can keep moving and learning.

So, why is that? Well, when you are learning to read, the size of text you are being asked to read is very large. I'm going to show my age again. The second one, "The box was by Chip's bed. Something was glowing inside. What's inside the box? The magic key. The magic key's inside the box." Um, so the text, you've got more text, it's smaller. Then you've got mainly text with line drawings. And then you move on to Harry Potter, and there's basically no line drawings. It's all really close together. You can't see because everything has got more complicated. Your saccades need to be more accurate. The amount of the page that you can see at a time may just be beyond what you are able to do. You've not stopped being able to read. What's happened is your visual burden has gone up, and your visual strategies have stayed the same. So, you think about the layout of a school. A primary school, broadly on one level, a single corridor. You go in a whole tribe of you to and from the same places all the time, one teacher, you know everyone, you've known them for 10 years, everyone looks the same. And you move to secondary school. Multiple floors, multiple buildings, different teacher all the time. You are moving about all the time. The teacher over there calls your name and tells you to stop doing something. You don't know who that teacher is. You can't recognize them. You can't see which of the adults it is that's just said that. So, you're looking in the wrong direction. So, then you're told off for being rude. It's a big, big problem. There's a huge, huge jump between what your vision needs to do in primary school and what you can adapt to, and the gulf in secondary school.

So, here's a student that Daniel has, um, mocked up based on a real student. So, he was asked to see this child because there was functional visual loss. So, she was saying she'd lost all vision in her left eye. Her right eye was amblyopic. So, she's saying, "I've lost all vision in my good eye." So, she was diagnosed, um, ASC, so they call it Autistic Spectrum Condition in schools. Um, in the previous school, in primary school, she was top of the class. If you want to do any research in education at the moment, the thing you need to write on the research application form is that this project is going to improve attendance. They're not interested in outcomes. They're interested in attendance. And the good thing about attendance is it's really easy to count. They're either child's there or not. The school has digital records, and it doesn't matter whether the child, what their initial attainment was in terms of educational progress, because you've got to be in school if you're going to learn. So, attendance had dropped to 8%. So, this is an intelligent, compliant little girl, little girl, not a stroppy teenager. And so, Daniel sat with her and said, "Okay, let's talk about two subjects. One that you find okay, and one that you don't." So, he's asking things like, "So, do you find it comfortable reading from the whiteboard, or do you find it challenging?" And she would say, "Oh, I find that very challenging." And then, um, "Tell me about what it's like listening to instructions and watching the teacher at the same time. Is that comfortable, or very challenging?" And she'd say, "Oh, I find that very challenging." And so, for a comfortable subject, he went through about, um, 10 of these. She, uh, which is English, which she really enjoyed. This is what it looked like. It doesn't matter, you can't read the detail, but what you can see is there's a number of things that she found comfortable, and a couple she found quite challenging. And then when you talked, so that's what the shape of her path was, but when you talked about her challenging subject, which, by the way, is always a language, it's French for this girl, this is what it looked like. This is the mountain wallop. She's hit the mountain. She cannot do this. She just cannot learn. In the French classroom, there's too many things that are different or new, or she's required to use her vision for it. She can't do it. Being an audio learner, she just cannot do it. And she gets overwhelmed, and her vision shuts down, and that's the end. And she goes to school every day thinking, "I'm going to feel like this in a classroom. It is terrifying. I do not want to go to school."

So, the overall summary, really, then, to take away is that kids don't do weird things for no reason. There is a reason this child is doing something unusual, showing an unusual visual behavior. Our job is to unpick it. My vision is not like your vision. So, we, um, we know, we are know that children with neurodiversity are going to behave differently, or feel differently, or, um, their development is different. Why would we think their vision outlies that? Why do we think that their vision is, is normal? It's normal for them, but it's not the same vision that we've got. So, we need to start from a blank sheet of paper and build up a profile of that child's vision. There's a questionnaire to do with vibes that is underway. Version one was okay, but it needed improving. Um, so version two is on its way, but it's things like, we're asking parents, um, how, you know, is this statement true? So, "They tilt their head sometimes when looking at me or a toy, or when they're moving around, like side-eyeing." Side-eyeing is a phrase that parents use to me. "It takes time to become familiar with new places." "They're uncertain when entering a space they've not been in before." "They find it difficult if changes are made to familiar spaces." So, there's a range of statements that a parent will say, "Oh yeah, I've noticed that," or "No, I haven't." Those children at some stage will need to have an acuity check, but actually, this is for schools, teachers, parents. There will be an associated, okay, so if you're noticing this, this might be the reason why. I wonder if this is the reason why. What you could try is this. And the whole thing is aimed at helping children remain more emotionally regulated in order to be able to access their vision in a way that works for them, which means they can then learn. Uh, there's a little QR code if you want. This is all in, in progress. Uh, but I'm hopeful by the end of the year we'll have, next year we'll have the data so we can work out what we do with it. By the way, the plan is not for all children with neurodiversity to revert into an eye clinic. Right? The whole point of all this is to stop that happening because the majority of the time there isn't an organic cause. It's a sensory cause. That's not to say we don't want to miss the children who have got an eye cause, but it is, it is different to the other developmental problems. Lovely. That's all I've got to say. I'm happy to answer any questions.