The Complexity of Vision and Visual Processing
This Week’s Topic
Occupational Therapist Maude Le Roux is back this week to discuss the visual system, vision, and visual processing, following up from our podcast on the vestibular system from a few months ago. The ‘I’ in the Developmental, Individual differences, Relationship-based (DIR) Model is for Individual differences, which includes the sensory processing profile of which vision is part. A lot of neurodivergent kids have different issues that come up around visual processing and visual spatial processing.
This Week’s Guest
Maude Le Roux is a DIR/Floortime Expert Training Leader. Maude has run her practice, A Total Approach, in Glen Mills, PA, just outside Philadelphia, for over 20 years and has also operated her own online academy for over three years now. She is one of our favourite Occupational Therapists and you can find many podcasts with her on this site if you search “Maude Le Roux” in the search box of this website.
The Visual System
Maude says that vision is a complex system that doesn’t develop in the womb. The systems are in place, but you only start seeing after birth–first in black and white, then in colour, and then the rest. In DIR/Floortime we are most concerned with is the visual-spatial piece. Many children on the spectrum struggle with visual and visual-spatial processing, including my son, who has been to Maude’s clinic many times for intensives, which we talk about in Season 2 of We chose play if you are interested in learning more.
In my son’s case, he absolutely loves watching things move. As a baby, he watched flags blowing in the wind wherever we went, he loved throwing pinecones and watching water move and has shown interest in dark and light–lately loving to turn off all of the lights. When he had severe brain inflammation at age 2, his visual cortex had severe brain damage. He seemed to look through us and as his inflammation calmed, we saw him start to focus. I spoke with an adult who had brain inflammation who said that afterwards, all he could see was black spots and I thought that that must have been what my son experienced as well.
When we talk about the visual system there are a number of professions involved, and they often don’t communicate with each other, Maude shares. There’s an Opthalmologist concerned with the medical medical condition of your eyes, i.e., the health and well-being of your eyes, an Optometrist who is checking visual acuity for 20/20 vision or not, and a Developmental Optometrist (sometimes called a Behavioural Optometrist) who checks how the eyes are moving together (i.e., the binocular fusion of the eyes), how you’re using your peripheral vision, and for depth perception, etc. Maude says that the ocular motor pieces are usually refined in typical development by the age of 5, but on the way, there’s several wonderful pieces that unfold, she explains.
In terms of the Developmental Capacities…
We use these pieces of our visual system’s development in play all the time, Maude says. And in DIR/Floortime, she explains, we are concerned with the emotional understanding of the body and how it connects to one’s cognitive skills, social skills, functional skills. The visual system is a huge driver of intrinsic curiosity of what’s going on around you. In the first and second Functional Emotional Developmental Capacities (FEDC 1 and 2), we’re developing object constancy. A mobile is hanging above the baby’s head, and is a certain shape, and the baby wants to reach out and touch it. It drives visual curiosity and puts perception between you and someone else, Maude continues.
In bonding with the mother, when the mother is cooing at the baby, the baby watches and moves their mouth as the mirror neurons are activated by the visual system as well as the auditory and tactile systems. It’s the emergence of self-identity, Maude says, and it’s the visual piece that drives the social engagement system, as Dr. Porges talks about, Maude explains. Parents often say to Maude that their child doesn’t make eye contact, but eye contact is driven by your social motivation and is a symptom of social engagement. There can also be something going on with the eyes, of course.
Maude explains that in DIR, we consider the child as a social engaging entity/being from birth. As a baby, I can look and discern what that object is and how it’s hiding from me, and how peek-a-boo is causing me to be visually excited as I take my vision away when I feel sympathetically aroused (i.e., the ebb and flow of seeing and hiding). It’s why peek-a-boo is such an important game, Maude says. From the driving of that visual system when I start crawling and doing more than one thing together, it’s the visual system that drives me to propel my body forward, she explains, as I want that red ball!
Challenges in the Development of Visual Spatial Processing
When we talked about my son wanting to throw something and see things fly through the air, that visual movement is part of that visual development, Maude explains. Part of developing visual spatial skill is moving your body after your vision but then using your vision in motion, she says. Flying mobiles and projections is exploring your space, Maude says.
Maude can focus on me on the screen and see her dog passing by on the side at the same time through her peripheral vision, but when kids play and are all over the place and can’t settle, they may be over-activating their peripheral vision system. Alternatively, there are kids who want to focus on something, so block out their peripheral vision to focus on central vision, using tunnel vision.
When kids don’t access their vestibular system very well, they can use their visual system to access movement for their body which increases their internal body awareness from an external source. When they flicker their hands in front of their face or watch the wheels on a car, they’re focusing on activating movement through vision. It doesn’t mean that they’re becoming a visual learner–it’s a misconception. It’s a maladaptive way to use their vision. Join them the Floortime way then withdraw them from using their vision in that way. They’re trying to accommodate for the vestibular system through the visual system, Maude says.
Accommodation and ‘Visual Learners’
In almost every single child who has come as a ‘visual learner’ to Maude’s clinic, they have found a visual deficit. As soon as one system tries to accommodate another system, it’s maladaptive and not using the system the way it was designed. As soon as you have to put in an accommodation for vision and movement, you’re not helping either system, Maude says. When there’s an imbalance and one system is accommodating for another, there exists that need for kids to move and vision can be one way that they try because the vestibular system needs input.
Vision and Praxis
Then, if your body has praxis issues, you’re not utilizing your vestibular system in the most productive way. Praxis issues are when your brain has to tell your body how to move in a certain sequence for a certain purpose in a certain time, such as when you put on your pants. You first have to put this foot into the right leg, then put in your left leg. I described how my son’s pants are always crooked after he pulls up his pants and Maude said this gets in to the somatosensory system, which is yet a different topic!
Praxis includes motor planning where you figure out how do I get from this place to that place, or how do I follow along with the jumping jacks my classmates are doing? When you can’t, you compensate, Maude explains. You can model by looking at and trying to imitate someone, which is using your vision to tell your body how to move. This is not using the information from within your body and where the vestibular system comes in. Many of our kids have trouble organizing their vestibular system in a good, coordinated way. They use their visual system to take in the information with visual movement so their vestibular system can be fed. It’s not the only reason, but can be the reason, Maude says.
The VOR Reflex
Another piece that connects to this discussion, Maude says, is the ‘VOR reflex’, or the Vestibuar Ocular Reflex. It’s made for getting the vision system working with the vestibular system, she says, and you can test for it. If it’s not in place, that’s why the visual spatial is challenged. I gave an example of visual spatial awareness from when I scraped the side of my car in back from turning too sharply next to a cement pillar in an underground parking garage. Maude says that if the 2 eyes are not working together in an ocular motor way, you can lose depth perception.
There can be a lack of the visual spatial awareness where the central and peripheral vision aren’t gelling together at that moment, but it could also be that you may not have known that someone is suppressing an eye; many will not see it if they don’t know to look for it. But if our kids can’t judge distance, you’ll see that they’re scared to walk down stairs or jump into a pool. They’re hesitant. They don’t want to do ladders that have openings in between. It’s about a depth perception challenge.
Why is it this way?
Maude says that we don’t really know the origin of sensory integration issues. There is speculation that it was birth complications, in utero, various waves in the air, diet with preservatives, or genetics. There are predispositions from genomes from parents. Epigenetics can turn on the gene that was suppressed in parents or grandparents. We do know that developmental delay in the sensory areas exists all over the world and is not in a certain population or gender. There is so much pseudoscience that has been disproven, but so much that is still unknown. We need a lot of research, Maude says.
How do we fix it?
Maude suggests surrounding yourself with people you can trust and who will tell you what they know and what they don’t know to figure out what is true for your child. Maude has a bias towards sensory integration but as she learned more about trauma, she saw a trauma lens with sensory integration issues in many clients as well. She says a Developmental Optometrist can be very helpful, like the one who gave my son vision exercises to help his two eyes work together. She reminds us again that the ocular, visual system is really firmly adapted by the age of 5, which means there’s a layer of development that precedes the final acquisition of the visual system.
Maude starts with a sensory integration evaluation and first works on the vestibular system and how it contributes and adapts and integrates the other systems. Only after that, she’ll go to optometry. She tells the optometrists to hang on and once she sends her clients to them, they’ll look like gold when they’re doing the vision exercises with them! You need the VOR to use the vestibular system in a balanced way first so the visual system will have a place to hold on to, Maude explains.
If you prepare the body, the vision will follow.
Maude uses sensory integration therapy, typically starting with great success with sound therapy that has both air and bone conduction (i.e., ‘pure vestibular glory’, Maude says). Once the child can find the vestibular system they’re so much more available for what’s out there and the visual space can develop, Maude explains. This is why she never works on the vision system first in therapy. First, work on the vestibular system and the somatosensory system (i.e., tactile/touch) and the auditory system as these systems are developed early in the womb. Get the body in a place where awareness is there, then you can use your body in space, she reiterates.
Back to the Developmental Capacities
Visual spatial comes in to play in the third and fourth Functional Emotional Developmental Capacities (FEDCs)–especially in FEDC 4–as you develop praxis, figuring out what to do, rolling/catching a ball, etc., Maude says. I added walking around the coffee table banging their hand on it–my favourite cute stage that little toddlers go through. Maude explains that here, they are exploring their little world and when they’re banging their hand, they’re listening to the sound in the background, and when they’re cruising towards that thing Mommy said not to touch it’s their visual system driving that piece, making them move.
That’s where we want that integration, Maude says: crawling to walking into praxis and getting the visual spatial system to do the work. And the important piece that Maude doesn’t hear people talking about enough is what Dr. Stanley Greenspan said: You only conquer the fourth Functional Emotional Developmental Capacity if you get 60 or more ideas in a session; it’s where we build stories, have representational thinking, having a beginning, a middle, and an end to a story. It depends on how we’re visualizing from what our visual memory has buried from all our visual experiences and now we can conjure up if we’re going to be a witch that we’ll need a hat, or something that looks like a hat.
Visualization is a pre-cursor to ideation
When your child can’t come up with a next idea, Maude explains, it’s because they don’t know sequence–they can’t come up with a 2nd or 3rd step; that could be true. But if they can’t visualize, it may be a level different from sequencing. Visualization is when my mind goes alive with abstract thinking, and it’s a very necessary step for Theory of Mind, perspective taking, and understanding that you may have a different thought than I have. We have our eyes that need to coordinate with our vestibular system so that visual spatial supports our visual memory to retrieve that to use our own ideas in play to support our own visualization, Maude says.
When your child reads, for instance, that the blond girl stood at the green bus stop waiting for the red bus on a cold and wintery day, you might be picturing a blond girl with long or short hair, maybe with a coat on. Your imagination can flesh out the picture. That’s an example of why we need visualization at FEDC 4. Where are the child’s own ideas? Are they coming from a lack of sequencing or a lack of visualization? A lack of visual space, or that they didn’t explore objects enough as a baby because their touch system was too defensive, so they never built a memory from that exploration?
A crucial piece of DIR work is in play with symbolic thinking and the whole pretend play action, Maude asserts. I mentioned how Dr. Gil Tippy talks about the goal of Floortime being the real work that Maude just talked about: where you can take one thing, then a second piece, and make a third product in your mind. He says that it’s very easy to go through the first three capacities, but it’s in that fourth capacity where you get the long chains of back-and-forth communication, along with all the other pieces we discussed.
I gave Maude the example of my son playing that I shared with Dr. Gil Tippy, who said that clearly he was doing imaginary play. He was enacting what he’s memorized from his video game. That’s the start of imaginary play, for sure, but he’s not yet coming up with his own ideas. When you get more abstract that’s where you get into the fifth developmental capacity. Dr. Tippy would inspire that by asking something like, “What? Why would Bowser throw someone into the lava? I would never do something like that!” to make him wonder what Mom’s thinking about and to inspire his thinking.
Dr. John Carpente , whom I’m presenting with at the 2022 International ICDL DIR/Floortime Conference next week, also watched the video and commented that my son seems to have many compartmentalized ideas but they’re not joined together into a story. He suggested that when a character falls into the lava, I could say things like, “Aow! Does that hurt? Does he need to see a doctor?! Where is the doctor’s office? I wonder if it’s open or closed?” Mike Fields also commented, after recording our recent podcast, that everything has to do with praxis. It might be difficult to image what to do next.
Maude says it’s the fourth capacity coming together. There are many pieces to it. There’s his vestibular system and how he can’t sit still, and how he finds it hard to pay attention. His vision impacts that. It takes a team, Maude offers. Yes, it can be sequencing, praxis, vision, vestibular, and maybe his attempts to bridge it. Maybe it’s relaxing to use his cognitive skill of re-enacting his memory. Bridging ideas is not always so easy, she says. Sometimes we need to support their parasympathetic system–their calm system–to help them to just stay in that abstract in their mind, Maude suggests.
You want them to be able to go there to the abstract, then do a reality check with them by saying, “Wait a minute…wait a minute…” to pull them out of that and he might ignore it and look at you. Then, let him play again. Then, bring him back to reality again, she says. Show him there’s another piece that might be just as fun that he can’t see! When you bring Cinderella (for example) into his story and he starts to see the fun in that too, that’s when you’ve got them, Maude shares. And, she adds, you can put all the pieces together and stay in the pretend. It’s all through play. It’s play-based.
Maude will often become the character so when he throws a character into the ‘lava’ she would say, “Aow! THAT HURT! I’m hurt!” Then my son would have to think that he can’t go on to the fun of playing because Mom is hurt! Maude says we are switching them out of that built sequence, however you can deflect them from it–whether you bring in a new piece to the story or counter them verbally by saying, “Wait a minute… I’m confused!“
Building on interests
Maude said that she loves hearing kids say, “I’m confused” the way she says it in their play, with affect. If we build on the things they are interested in and build on the ideation they’re interested in, it’s like gold explodes in front of you, she shares. She then shared a funny story: Maude’s DIR therapist was playing with a 3-year-old problem solving at the fourth capacity, where Maude says we use “How?” questions to work on praxis and ideation such as, “How are we going to do this?” with your hands on your hips. The 3-year-old said to the therapist, “Google it!“
Do not forfeit pretend, abstract, ideational play for learning material that doesn’t have an abstract value to the child.
This week’s PRACTICE TIP:
This week let’s again look at our child’s behaviour with a lens of curiosity about their sensory processing.
For example: Does your child watch thing move a lot such as flags, their fingers in front of their face, leaves on the trees, or moving water? Do they have a hard time coming up with new and novel ideas of their own? Do they struggle with praxis and knowing what to do next?
Thank you to Maude Le Roux for enlightening us about the vestibular system and the importance of its functioning for functional emotional development. I hope that you learned something valuable and will share it on Facebook or Twitter and feel free to share relevant experiences, questions, or comments in the Comments section below.
Until next time, here’s to choosing play and experiencing joy everyday!