OTS 015: Beyond The Typical Vision Screening With Robert Constantine, OTR/L

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Welcome to the show notes for Episode 15 of the OT Schoolhouse Podcast.

In this episode, Abby interviews Robert Constantine of OTRobert.wordpress.com about how to assess and address concerns related to visual perception and visual-motor capabilities in our children. In this podcast, you will learn to identify some of the behaviors associated with vision problems and several helpful hints about how to tease out the reason for those behaviors. Robert provides simple steps that you can use tomorrow when you see your students. It is our pleasure to have such a great and knowledgeable guest. We have no doubt that you will thoroughly enjoy and benefit from hearing what Robert has to share.

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Links to Show References:

Robert's Website: https://otrobert.wordpress.com

On his website, Robert has a plethora of free resources and information relates to working with clients to demonstrate difficulties with visual perceptual and motor difficulties. Be sure to check it out and shoot him an email to say hello.

Robert's Reading List

Near the end of the episode, Robert referenced a reading list we would add to the show notes. Well, here it is! There's plenty to keep your reading list busy for a few weeks at least.

Robert on PESI:

If you enjoyed this podcast, you may enjoy hearing more from Robert in a formal training. PESI is a leading provider of continuing education in all formats. Visit PESI.com to see when Robert will be presenting the visual system in a city near you!

Freebies!

Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs.

Have any questions or comments about the podcast? Email Jayson at Jayson@otschoolhouse.com

Well,

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Episode Transcript

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Amazing Narrator   

Hello and welcome to the OT schoolhouse podcast. Your source for the latest school based occupational therapy tips, interviews and research now to get the conversation started, here are your hosts, Jayson and Abby. Class is officially in session. 

Jayson Davies   

Hello and welcome to the OT schoolhouse podcast. Episode number 15. And with us today, we have the birthday girl Abby Parana. 

Abby Parana   

Hello everybody. I am 34 years old today. 

Jayson Davies   

Do you like long walks on the beach? I do. Sounded like that's where you're going. Anyways, Happy Birthday Abby. I hope you're having a great day. Today is September 26 that we are recording this. And so everyone, please leave Abby some love on the Facebook page and wish you a happy birthday, even if it is a few days late. 

Abby Parana   

I had I also have to say, I have to give a shout out to my co worker, Gemma, she brought the most amazing cupcakes to work today, and I got to pick first. So just bragging about my birthday. 

Jayson Davies   

Well, Gemma is fantastic, awesome. So real quick, Hey, you want to tell them what we're doing in a few weeks.  

Abby Parana   

In a few weeks, we will be going to the Occupational Therapy Association of California conference in Pasadena. It is going to be a good time at per usual. 

Jayson Davies   

Yeah. In fact, we're actually going to be presenting session number 75 on Saturday afternoon. So if you're there, find us, say hi or come by session number 75 I think it's a 230 on Saturday afternoon. So yeah, that's going to be fun. We're looking forward to talking about social media and the influence online media, all online media, can have on school based ot practitioners. So swing on by. We would love to see you there. So let's jump into our interview today. Go ahead. Abby. 

Abby Parana   

Well, I had the opportunity to interview Robert Constantine. He is an occupational therapist with over 20 years of experience in the fields of visual and neurological rehab. He presently works for the pearl Nelson Child Development Center, where he focuses on the treatment of eye movement disorders in neurotypical and special needs children. He is also a member of the neuro optometric Rehabilitation Association, which brings together tools from optometry, occupational and physical therapy. If you're looking for show notes and a list of references, just head on over to Episode 15, where you'll find all that information.  

Jayson Davies   

And you can find those at ot schoolhouse.com, forward slash episode 15. And 

Abby Parana   

now let's jump into the interview. Thank you, Robert for joining me tonight on the podcast, how did you get into practicing vision rehab?  

Robert Constantine   

So I was working at an local inpatient rehab. Here I'm in Pensacola, Florida. I was working for West Florida rehab, where I had been the OT clinical specialist for TBI for about nine years. I had taken Mary Warren's vision course, which is a very good course if you're looking for a course on that and had a big interest in vision, I started looking for a new adventure, and found on Craigslist a an ad for an optometry practice that was looking for an occupational therapist, really. So there. OT, yeah. So their idea was they were going to offer low vision services at the optometry office. I would be doing, teaching eccentric viewing, Dr Katie spear and cars Carl spear were the owners of that practice at site. And son I worked here in Pensacola. And we were going to be doing, I would be teaching eccentric viewing, teaching patients to do, to use assistive devices, going out, doing some home modifications and those sort of things. So what actually happened was I started getting those TBI patients that were having eye movement problems. I started getting stroke patients with visual field cuts. I started one of our doctors, Dr Charles porch, who was with us at the time, was sending me a lot of kids that were having near vision focusing problems and eye movement problems that was was affecting their academic performance. Yeah. So I had to scramble about to figure out how to to do this job. And as if you've looked around for resources on this, they're kind of hard to find. So I learned a whole bunch real quick, not real quick, about seven or eight months, and it has been, it's been an amazing journey. Also got to do some sports vision training when I was there with with Dr don t, who's one of, sort of the founding fathers of performance vision training. So we got to do cool stuff with that. Worked with some NHRA drag racers, my brother and his buddies. We developed some glasses for that. And it was really, it's been an amazing adventure. A member of the neuro OT. To metric rehab Association, I did their clinical level one and level two training to to learn about better ways to treat those visual and vision related problems with stroke and TBI. So it's been a great adventure. It sounds crazy, but it's amazing what kids can do when they can see and that's why it's really become a passion for me, teaching other therapists, making other therapists aware of this, that this, this such a basic thing, like they can't see the words in front of them. How often we just sort of take that for granted a bit. 

Abby Parana   

You know? And that is a very good point, and that's why I really was super excited to have you come on the podcast, because I personally have seen this in my own practice and in working with schools, just noticing that students, oftentimes in OT were assessing students in school based practice, but Were not quite sure of, or quite getting the whole picture when we don't have that vision piece. And that was just an area that I know, I personally, have always kind of thought this kid is doing something, and I can't quite put my finger on what is happening here so, and I think it's vision related, but I'm not positive. So that was just, I was very glad that you were coming on the podcast. And so I guess, why do you feel that occupational therapists are well suited to provide interventions in this area, like, how do we tie it back to the functional skills of occupational therapy?  

Robert Constantine   

So when I first started working at the eye doctor's office, I was around doctors all the time. I was around optometrists. I was around vision therapy doctors. I was around sports vision doctors. I was around brilliant optometrists, and I was very intimidated by that. But what I found out was was those doctors are really good at vision, but they don't have that background in Kinesiology. They don't have that background in activity analysis, where we can look at something and go, how do we incorporate that? They don't get those courses in developmental spectrum in sequence. So they were very interested in how I took what I learned from them and put that together with ot that background for us is is makes us a little more effective, or at least as effective, as what they're doing in vision therapy. The other thing that tends to happen, and what I tell folks as I teach them so we already we get a kiddo who's having problems with visual motor integration, and we're going to look at his posture, and we're going to look at his scapula, and we're going to look at how he's holding the pencil, and we're going to do things to improve those things, but we're kind of leaving out the visual part of visual motor integration, yes, and I kind of think of it as sort of a three step process, where we first have to see and get accurate stimuli in we can then take and manipulate process that visual stimulus, and then we can act and produce a result on that. And we tend to focus much more quickly on the output part, on what is their you know, what is their grip, their posture, those things or we tend to go to while it looks like he's having a processing thing, when a lot of times, we find out, hey, he just can't see the thing you want him to copy. And so what I tell him is, they they draw wonky squares because they're seeing wonky squares. 

Abby Parana   

Yes, oh, that's exactly it. So I guess some of the assessments, like when I'm looking at a child in their classroom performance, some of the assessments we use, like the very VMI or the ravma, the wide range assessment of visual motor abilities, or even the bot I do pick up on. So what are some of in those assessments when we're looking at students, as you say, drawing wonky shapes, because they're possibly seeing wonky shapes, how can we better tease out or understand the vision part of visual motor integration, or, for instance, The bot with the tennis ball that that sub test or the fine precision fine motor integrate, actually, all of those sub tests require vision, right? 

Robert Constantine   

So, so all of and right? All of these things require and assume that you have best corrected visual acuity and that your eyes are moving well together things you can look for before you even start the assessment. Yes, so is this kiddo rubbing their eyes? Are they blinking a whole lot there? Those are signs that this this child is potentially having a having an accommodative problem. They're having problem with accommodation in their eyes. What did the teacher say? Hey, he's skipping lines when he's. Reading. He's reading words backwards, or he reads the first half of the sentence, pretty good, and then the second half, he sort of gets really creative. What's going on there, and what happens is, so their eyes stay focused for that first half of the sentence, they become fatigue and get blurry. So our buddy attempts to make up, or guess what? That the rest of that sentence is going on there? Oh, wow. You're gonna see things like head turns. I'm gonna try this eye and see if I can see out of this one. I'm gonna try that eye and see if I can see out of that one. Maybe those kiddos that Prop their head up and they cover up one eye when they're reading, yes. Okay, so their brain is figured out. Hey, I have a binocular vision problem. Here's the solution to that. I'm going to read without binocular vision, and I'm going to cover one eye. So those sort of behavioral things are very common, that inability to catch a ball, so as a as a ball comes toward us, our two eyes lock on that ball, and your brain gets cues from proprioception as your eyes converge, as the ball comes closer, and the visual flow on that ball, and they tell you to lift your hands up and catch the ball, right? So we know how our kids catch our kids hold their hands up and they turn away from the ball because they've been hit in the face with the ball a whole lot. Yeah. So they're hoping you aim for their hands. And this becomes sort of a reaction time test. How quick can I close my hands and catch the ball? Because their eyes aren't teaming. Well, their brain doesn't get that cue about now it's time to reach up and catch the ball. Those things are very common, those unexplained headaches, kids who have kids who kind of look like they have ADHD, but when you give them ADHD medication, it doesn't help. Okay, ADHD looks a little mild, but so, so those are all the things. And this is such a predictable pattern as behaviorally, as you see this, I was reading things as I read things on the internet. I hear, you know, oh, I have this kid, O who's been diagnosed with dyslexia and ADHD, but his medication isn't working, so immediately, that sends up a red flag for me. Hey, what's his eyes look like? Can he see up close? So those are going to be the common things you're going to find with kids that are having these sort of near vision focusing problems. Okay. 

Abby Parana   

that is very helpful, because that and you do have on your website, ot robert.wordpress.com, you that I loved the resource you have of it's a PDF of those things to look for. I think I read. It's like a checklist. It's the. 

Robert Constantine   

Is that the convergence insufficient?  

Abby Parana   

Yes, the conversion survey, yep. Okay, and I thought that that was a pretty good kind of reference tool for convergence insufficiency. Which brings me to because I'm not a vision specialist. You mentioned binocular vision convergence insufficiency. What are some other Would you mind defining those terms and maybe some other terms that you know we might be needing to know OTs. 

Robert Constantine   

So when you head to the eye doctor's office, the doctor plays a little better. Worse game is it A or B or one or two, and all optometry jokes are based on one or two, A or B, they're hilarious. So, so they're all based on that. So that's called a refraction. And what that refraction is doing is just adjusting for the fact that your eye is most likely not perfectly spherical, like a golf ball. So you get glasses, or you get contacts that helps to redirect the path the image in so it falls directly on your fovea, and you see nice and clear with those glasses don't influence or are those two eyes coordinated and working well together? Are the muscles in the eyes? Are they nice and balanced? Are they both equally strong and up to the task for what they're doing? So these eye movements are controlled by muscles, and they they behave like most other muscles, they fatigue. They can be imbalanced. So what happens with Well, let's talk about convergence insufficiency, because that's going to be the thing that's going to be the most common, depending on the study you look at, about 8% of kiddos, neurotypical kids are walking around with convergence insufficiency, with an eye movement problem. That's a lot a lot of kids.  

Abby Parana   

That is a lot of kids. 

Robert Constantine   

So convergence insufficiency is a problem with the near vision focusing system. So what's supposed to happen? As we see up close, our eyes should converge. Urge. They should move in towards the nose, nice and strong. They should stay there. At the same time, we have a lens in each eye. That lens is attached to muscles. The peripheral of that lens is attached to muscles in the eye. That muscle contracts and allows for that lens to focus. That part of the near vision system is called accommodation, okay, very closely at tied to that accommodation is going to be pupillary constriction. So as that child, as their as that lens is accommodating, we're going to see their pupil constrict as well. So as you bring something closer, you should see their pupils get nice and small as well. As their eyes move towards their nose with convergence insufficiency. There tends to be a lack of coordination or a muscle imbalance, particularly where the medial rectus muscles, the one closest to the nose, are too weak to overcome the lateral ones as they come in. So what you see as you assess this, as you bring a target towards a child's nose, rather than following that target all the way to their nose, you're going to see their eyes kind of they're going to separate, and one eye is not going to follow that in okay? And that's going to let you know, hey, this kid O, that's one of the diagnostic criteria that's called near point of convergence. As we assess that, I'll describe it, but it's better if you see it. And you can go to my blog, there's a video on how to do this. You're going to start with a target about 2430, inches away, and you tell your kid, O, tell me if you see two. And you're going to bring this target towards their nose and watch their eyes. And you want to see their eyes come all the way in, right until you get to their nose, and they stay there. And you're going to do this five times, you're going to do five trials with this. Okay, so normal is going to be within six centimeters after those five trials. And that's going to tell you, hey, this kiddo has a good, strong convergence system. The convergence is working well, and generally, one or the other doesn't go bad. If convergence is bad, the accommodation is bad and vice versa. Okay, so, but this is the quickest way to find those, to find those kids that are having near vision focusing problems, okay? 

Abby Parana   

And so this is going to impact in the classroom. This is going to impact their copying ability, their attention, their reading, and all of those. 

Robert Constantine   

So while those eyes are sort of weak up close as they go out to the board, their eyes are going to diverge and then come back in again and then diverge and then converge and diverge and converge. So this becomes really calisthenics, calisthenics for those eye muscles. This becomes a very aggressive eye exercise. And when it started off when our buddy couldn't see up close within going to that board and back, three or four times, he can't see the board or up close because His eyes are so fatigued, he's he's seeing double in both places. Generally, the kids don't know that they're not supposed to see that way. Oh, so they won't tell you. They won't tell you. The words are moving around on the page, or I see double up close. They might mention I I'm having trouble seeing the board. And then they go down to the to the hall, and they, they read the chart, and the the school nurse goes, he read the chart, he was fine. And most of the kids who come to see me are 2020. 

Abby Parana   

Okay, yeah, that was my next question. Because when I was reading on your website, which has a ton of amazing information, I was up late reading through it, because I just my brain kept going. I read that only about 40% of children have their eyes actually examined by an eye doctor, and that possibly even with 2020 vision, their eye exam may not include things like this, absolutely 

Robert Constantine   

so um, so that 2020 means that that image falls perfectly on euphovia And you see, you see clearly without any blur. Okay? It does not talk about any of those dynamic processes that we talked about as we're seeing near vision, as we're doing saccades across the paper. So that 2020, means, yes, that static error has been corrected for, but it doesn't affect the movement of the eyes at all. 2020 as the the eye doctors tell you, 2020 is not enough, 

Abby Parana   

right? And, yeah. And so when we're talking about saccades, would you mind just kind of elaborating a little bit on saccades and reading and how all of that kind of works, right? 

Robert Constantine   

So a saccade is going to be a very small, very fast movement. So this was saccades originally, sort of developed evolutionarily. So we could, we could they respond to changes in the peripheral as we were out hiking, hunting in the woods, if there was a bear off to the side of the trail, the bear would move, and our eyes would very quickly pop over there and go, Hey, look out there. To bear. So as we, as we evolved and we started to read, these very short, fast movements are now how we go about reading. So it's going to be a series of fixations and saccades that allow us to read accurately. So it becomes a coordination thing. So are those two eyes coordinating correctly. It's, it's pretty easy to improve those with some with some basic exercises and things, but saccades are very important. Saccades are also how we define visual space. So Okay, as you, as you walk into a room, you're with your nice still head, your eyes very quickly pop around the room, and you set up a nice spatial map of the room where you can close your eyes and find things in the room. Our kid, OTs, with inaccurate saccades, with excessive head movement during those saccades, don't get an accurate spatial map. So what happens is, we send them to find their shoes after our treatment session, and they tell you, I can't find my shoes. So this is another thing, though, saccades are very important about defining those that that spatial sort of defining the size of the universe, right? 

Abby Parana   

And that, you know, that makes a whole lot of sense, because, well, it i when I've been working in OT when you have the kids that are very inattentive, and then in the classroom you they kind of almost seem really unaware of things in their environment. They run into kids they have no concept, really, of their body position in relation to other objects in the room? Would those be sort of behaviors? I know there's sensory processing involved with that, but also this seems like it would play a big role too. 

Robert Constantine   

Yeah, I see where a lot of times the kids with eye movement problems in general tend to be a little clumsy, and part of that is there is a lack of awareness of you know, if I if I close my eyes, I know I have stuff over to my right. If I fall to my right, I'm going to trip over things that lack of that spatial map can affect that. But they also because those eyes don't work well. So there, they should focus on the edge of a step as they're walking towards the step, and again on that convergence, should send a signal that says, now it's time to step up over the step. When their eyes don't work well together, they don't get that signal for now it's time to step over the step. So they trip over the edge of the step. So all of those movements are affecting those functional things, but Right? They're not getting a good spatial map, so they don't know where the Buddy is, so they bump into him, or they can't find their book bag, or they trip over a desk, or whatever, 

Abby Parana   

right? Oh, that just I had not even thought of it that way, because I think, and I think the way, or why these are just such light bulb moments for me is because we give assessments such as the sensory processing measure for the sensory profile, and they and we do that kind of assuming, again, that these skills are all intact, and that when we're looking at the behaviors related to sensory processing, we're not really or at least when I've done it, I've not considered these other deficit area or possible areas of need. Well, 

Robert Constantine   

it's crazy. We get kids in our practice who have had early intervention, PT, OT, speech, neuropsych evaluations, ABA, all of these services. And so we just sort of assume, well, of course he can see at some point, someone took him to the eye doctor, someone he's wearing glasses, so that means his vision is good. So we tend to to just sort of take it for granted, and and I love the light bulb moments as I as I present my course around, I'll I talk, and I look out over the folks, and you'll see, I'll say something, and you can almost see that little light bulb go off on top of their head. They're like, Oh, that's why that kiddo is doing that. So it's, it's, it's really cool to do that, but it's, we just sort of take it for granted. We get 75% of our information about the universe around us from vision, right? We're not even asking, Hey, have you had an eye exam? And so that's, you know, we need to, we need to step up on that as therapists, but we need to be able the next part of that is, is we need to have optometrists behind us. We need to have eye doctors behind us who are going to do that complete eye exam, who are going to make sure that these things are appropriately assessed. And sometimes that's not always easy to find, right? 

Abby Parana   

And I guess that was kind of one of my questions, and I'm not sure if you can answer it, but how can us at school? They. Based OTs, kind of refer kids for those more comprehensive. 

Robert Constantine   

So the magic words are a binocular vision exam. Okay, that was what my question. That's the magic words. The magic words are binocular vision exam. I know a lot of times with the school based OTs, you can't say your child needs a binocular vision exam or an eye exam, because then the school system becomes financially burdened with that, as I understand it. So what I have is a sheet of reading tips, and it's things like, so your Hey, your kiddo. Is your child having trouble reading? Is he holding the reading material at 20 centimeters away. Is he reading in a well lit area? Is he sitting upright and showing good posture while he's reading? Has he had a binocular vision assessment eye movements can affect reading performance. So this becomes a way where it's not, it's it's more a tip sheet for reading, and it doesn't say take your child to a binocular vision exam, but it does give some folks some words to use that they can google and find those folks out. The most reliable source is COVID doctors, the doctors who are doing vision therapy, okay? They have had special training to so all all optometrists and ophthalmologists know how to do a binocular vision exam. Okay? It is the standard of care for a pediatric eye exam. For both of those professions. Okay, do a binocular vision exam a psycho plegic. Dilation, which is a specialized dilation and and to to refract using a technique called retinoscopy, as opposed to better worse. They use this very objective way of doing that with our kids. So they all know how to do this. They all know this is the this is a thing. They all learned it in school. They all learned how they all had to do it in order to pass their boards, so they will know that this is a thing. Now, whether they feel comfortable doing it or not, is going to be something else. Oh, so some of the optometrists kind of like, if I had to treat an extensor tendon repair, okay, so I would be like, Oh, I remember those words being together, but yeah, I don't really want to treat an extensor tendon repair, right? So there's going to be some doctors that are more comfortable with it than others, the vision therapy doctors, the covd doctors. And Codd is the College of optometrists and visual development. These are the doctors that offer vision therapy. Okay, they're going to be the most reliable source, but a lot of times these doctors are cash only, and so that's going to limit access. There's also a lot of communities, even here in Pensacola, where I'm at, we don't have a COPD doctor, and there's a lot of communities that don't have access to a VT doctor at all. Yeah, what I will tell the therapist is, so the optometrists, they want to work with us, because we have all the kids that have the eye movement problems and need glasses. So the opportunities there to talk with some docs and go, Hey, I need someone to do this. I need someone that can reliably do this. And you may have to call up and and kiss a couple of frogs before you find the prince. But I think in those in those rural communities, in those communities that don't have a vision therapy doctor, you're going to find a doc who is interested in doing this, who wants to do this assessment. I think sometimes they don't do it because they don't have a way to treat it. If they're not, apparently. So. So a lot of times in the community, as well as I go around and teach someone knows who, who the good Doc is. And a lot of times in my class, someone will say, Oh, you got to send them to this, to this person over here. They do a great job. They're they're pretty reliable. They take all the the the insurances and that sort of thing. 

Abby Parana   

Okay, that makes a lot of sense, and it's important, it seems, to get these kind of vision issues diagnosed, so then we can come up with better accommodations and strategies for the classroom. Which leads me to my kind of next question. When we're talking about I often get parents and teachers and psychologists and just staff in general mentioning dyslexia, and how does that differ from what you're talking about with the movement of the eyes? What? And it's my understanding, has to do with auditory processing. A bit it has. 

Robert Constantine   

It has a it's a phonological problem. So I work a lot. I talk a lot with the folks at the Read, Write Learning Center. Here, and they have offices in Daphne, Alabama, in Montgomery, Alabama and Mobile, Alabama. But they also can do dyslexia assessment and treatment over Skype. So if you do not have, and I haven't been to any city yet in America where they say, we have great dyslexia resources here, and you can get an assessment, here's the people you go to, so read, write, Learning Center, com, they can help you out with that. So all of the kids who come to see me are typically have the signs of that you typically think of as dyslexia. They have letter reversals. They may be flipping whole words was, become saw, that they're generally not very good readers. Okay, so over the six years I've worked with the with these kiddos, after we've cleaned up their eye movements, I've had, I've have had 14 children who have tested positive for dyslexia. So what happens with dyslexia is it's a it's a problem of encoding and decoding phonetics. Okay, and I'll tell you some of the things that I see with in those kids. As you have them write the alphabet, they consistently leave out the same letters. Oh, and I had two, I had two kiddos that left out the whole middle of the alphabet from j to q1. Of them was in fifth grade, and I cued him after writing the uppercase alphabet. Hey, hey, my dude, you left out the whole middle of the alphabet. And he did the same thing. So you see that very hard time learning the letters. I had another young lady that was five, and she was very closely watching my mouth as I was saying letters, B, C, D, V, trying to figure out what letter I was saying. So you're going to see that. You're going to see kids with dyslexia. They're going to have a hard time phonetically spelling words. Okay. So their, their command of how phonetics works is is not very good. So if you tell them, hey, take a guess at how you spell that. A lot of times, their go to strategy is, I stick an E on the end of the word. Okay, so they, they don't have good, good enough command of those phonetics in order to be able to do that. So this is a highly specialized area. There's 150 different types of dyslexia. It is, it's fascinating. It is, like I said, those 14 other kids that I saw had binocular vision problems, and they had dyslexia underneath that. Okay, so you can have both. We absolutely when we cleaned up the binocular vision problems, what we saw was I had one young lady who actually became a very proficient reader. She was reading above her age, her grade level, wow, but she couldn't she couldn't spell her words. She could orally spell them. She could verbally take her spelling test and do fine when it came time to translate that sound into symbols, that's when she had the problem and she would fail her spelling tests. Okay, so there we're looking at that encoding of sounds or decoding of sounds, is the word, is the reading part of that, and those are going to be more typical of the of children with dyslexia, again, though they can have both of these and and Hunter OST, the director of the readwrite Learning Center, recently sent me a child over who said, you know, I don't think this kiddo has has dyslexia. I think he's got that eye movement thing that you do. So we're finishing up with him, and it's really interesting, his sister had the same thing. He's 12, and his sister, as well, had convergence problems. Oh, wow, I've had, I've had, now 15 or 16 sets of siblings. So I won't say this runs in the family, right, but it certainly tends to cluster up. I went, I went, two out of three on, on one of one of the OTs kids here, two of her three kids out. So it'll tend to sort of run in the family a little bit. I see Dyslexia as well. It's going to have a genetic component to it as well. Okay, so, so those are going to be the things you're looking for. Is it tends to look like a visual problem. And again, I was able to take them to a certain point with reading, right? But it's going to come back to that difficulty encoding and decoding, those phonetics, those sounds, okay? 

Abby Parana   

That helps me tremendously, because that was that's kind of one of those areas where you think you know what it is or what it looks like, but you're only really you know. As OTs, we look a lot at the writing and and sometimes I think we're missing certain components, or if the child's not making progress, it's good to kind of you. Just look at what it is the actual deficit areas are, or the areas of need for the child, which so when you're working with children, oftentimes in school based practice, we're not given the same level of we don't give the same level of services and supports for the children, as one would in a medical setting. So with these types of difficulties, I guess, how often do you see the kids in the clinic, and how, what's the duration of sessions? And sort of, how do you monitor, measure progress for these kids? 

Robert Constantine   

So for me, all of my kids are coming with a vision problem. Two thirds of them, it is a diagnosed vision problem. Okay, so you already know, so I already know that they're coming with that that said, I see my kids twice a week for an hour. Okay? The convergence insufficiency treatment trial, which gave us the the symptom survey we talked about earlier in that trial, they used a protocol that consisted of 12 visits, okay, and that would that that protocol was 75% effective. I tend to see kids, neurotypical kids, I can generally correct their convergence and near vision eye movement problems in eight to 10 visits. Wow. That's so the Wow. No, it comes along very quickly. Okay, so what I found is, if I can do those eight to 10 visits twice a week, or I can do those eight to 10 visits once a week, and it still takes eight to 10 visits. Okay, so unlike looking for that elbow. Because, again, what we're going to be doing is exercises that are just going to strengthen muscles. That's all this that's happening here. So as we as we stop and think about an elbow that's weak, we do have to stop, and we have to grab some theraband and do some exercises to strengthen that elbow. Our eyes, as we strengthen those muscles, they're up there all the time attempting to figure out the best possible strategy. As we strengthen those muscles, the eyes are going to practice those strategies as best they can. So I tend not to, you know, if I get from from zero to four on this visit, when I come back for the next visit, we don't start at zero. Again, we start at four, okay, go from four to eight, and then on the next visit, we might go from six to 10. So we tend to jump and make cops very, very quickly, okay, so even in if you're just getting a half an hour a week, even making simple modifications, we we love midline crossing tasks, right? So what if we take midline crossing tasks and we turn them near far and we put them in the Z axis, and now, rather than a midline crossing task, we're now working near farping, that near far near vision system. But even in those half hour sessions you guys are getting once a week, within three or four sessions, you're going to see some improvement there. Okay, make sure you're holding their their little head still. That's a big one. I used to get a lot of questions on that. So what we're supposed to see with the with the still head is by by 10 years old, we should see a still head that decline should start to happen beginning at five years old. Okay, so some that that head movement is going to decrease until 10 years old, and then we shouldn't see that anymore as we're assessing eye movements. Our kids, our 10 year olds, all have excessive head movements. That's because there are 10 year olds. They've been referred because that, that head movement separation is very much tied to vestibular development, yeah, it's tied to pro proprioceptive development. It's tied to overall brain development. So where we're getting referred to kiddo who's having trouble with body awareness, who's having trouble with balance, yeah, those other systems are not developed. We're going to find the ocular motor system is not developed. Along with that. And you may pick that up as rough CAES as lousy tracking, and you're going to see that with excessive head movement, because all those systems rely upon one another in order to get stronger as they develop, right? 

Abby Parana   

And that sort of leads me right into my next kind of set of questions, I guess, or next topic area would be, I work in a program, one of the programs I provide support for, has a many children with autism, and oftentimes we're looking at sensory processing difficulties with that population related to self regulation. But also what I noticed is it's kind of what came first, the chicken or the egg, kind of situation where they're having trouble with self regulation, but they're also not processing things in their environment. And we see a lot of seeking movement, vestibular proprioceptive movement, and then. And I often have found as well, the coordination of their body movements in relation to what they're seeing in the environment, or their response to stimuli in the environment, can be clumsy. So what is your background? I guess, how does vision and autism, how do these skills go to 

Robert Constantine   

there has been, I just recently updated my my presentation concerning autism, because there's been several studies late 2017 early 2018 that are showing, showing some interesting things. Yeah, so, so the first thing with our kids with autism is they're going to have a higher rate of accommodative problems. They're going to have more trouble seeing up close than than the neurotypical population. So what that means is that eye exam for them is going to be very important. Okay, so it's sort of worst case scenario for the parents, because they need that psychoplegic dilation, which is going to help assess that near vision system better, okay? And so the parents know, you know, my my kiddo is going to have a meltdown when we try to do this, but they have a higher rate of problems seeing up close. And so now we think about handwriting. We think about those visual motor integrations problems, those fine motor deficit threatening and those sort of things, right? So those sort of things there, this sort of gazing at things in the peripheral, yes. Okay, so that is another way of squinting. That's another way of attempting to squint. It is also there they're shown so let's see. So we actually have two visual systems. We have we have two things happening in our brain with vision. We have this central, the central visual field, and then we have our peripheral visual field. So that peripheral visual field is called a magnocellular tract, and it's, it's very much involved in balance. It's involved in gait. The easiest way to describe this magnocellular track, so if you're taking a hike in the woods and the trail goes uphill, your magnocellular track sees the the tilt of the trail change, and it automatically adjusts your posture and gait so you can continue to walk up the hill. Okay, okay, so what we're finding in kids with autism is a decreased integration of connections between the cerebellum and this magnocellular tract, okay, and so they are thinking this could be part of why we see things first, those fine motor problems, why we're seeing problems with increased toe walking in children, yes, with with autism as well. Another study, and I think we're going to have the list of resources up on your website. Yeah, all of the articles are out there, and I encourage you to go read them up, because they're they're absolutely fascinating. If you want to be an eyeball nerd, you got to go to the source. So go read the resources. So some of the so they're finding this lack of integration between those two pathways. What they found was the the children with autism did not make that postural shift in response to a visual change, so their brain sees the trail go uphill, it does not adjust their gait to help them walk up that hill without difficulty. So pretty consistently this this was coming back to a lack of connections into and out of the cerebellum, and a lack of integration between the cerebellum and this magnocellular postural tract couple that with difficulty seeing up close, with a higher rate of seeing up close, and suddenly maybe some of these gazes off to the side, this toe walking. One of the other things that was suggested was, our kids with autism have a very narrow attentional visual field. Okay, so this isn't it doesn't mean they have poor peripheral vision. It means, rather than seeing a whole forest, they only see a tree at a time, okay? And so they were suggesting that this small, central attentional field, they were having difficulty getting all the sensory input into there as they're looking at your face and you're giving instructions and your mouth is moving, they're attempting to process that auditory information, it becomes overwhelming, so they look away and they lose eye contact. Okay, so there was some things that were tried with that, and sometimes it's effective and sometimes it's not, but you may see some of those, some of that eye eye contact behavior as well. You may find that some of the eye doctors are trying some things to help with that as well. So it sounds like, 

Abby Parana   

sorry to interrupt. It just sounds like it's. A somewhat of a newer research area like this is kind of an emerging area of research, as far as the children with autism that population. 

Robert Constantine   

Well, what happened was, as we lost Asperger's, we lost pervasive developmental disorder, and all of that became ASD, we now had a much broader population to look at, okay, and several of the studies that I read talked about how earlier studies showed things differently. OT, studies on ocular motor problems in kids with autism, half of them say yes, they have a higher rate of ocular motor problems, and the other half say no, they have a regular rate of OT motor problems. That just means we need to check that out as well. But because of this redefinition of autism, we're finding some different data, and they're finding some different trends as well. 

Abby Parana   

Okay, that, I mean, that's certainly an area that I'm very interested in as well. So I know we've touched on so many topics, and I am very grateful for this podcast, opportunity to speak with you. I just know right now my wheels are turning in my head of different ways that I'm going to be able to my students, and so I know I will probably be visiting your site more often, but also I know that you offer continuing education courses through pesi. Is that right? P, E, S, I?  

Robert Constantine   

So what's happening right now is, at the end of the month, I'm going to be in Northern California, I'm going to be starting in Reno and I'll be in Sacramento, San Jose, Walnut Creek. I skipped somewhere. Anyway, I'll be in Northern California at the end of the month, starting on September 24 that course is through vine. Okay? V, Y, N, E, the course is called vision, vision rehabilitation for pediatrics. Okay, seeing the whole picture, so you can go over to vines website, and they have where you can get registered to see those. There's also a digital seminar where you can go in and watch that as a webinar. Oh, very good. So that's there. So that's my last tour with the vine name. So pessi is a is a larger continuing education provider, okay? And they bought vine. So what's happening is my course is changing names and it's changing sponsors, but the course material wise is going to be the same thing. So you can go to pesi.com Okay? And the new title of the course is called assessing and treating the visual system in children and a lesson and adolescents. So it's kind of a longer name. You can actually go to pass E, P, E, S, i.com and just search for my last name if you want Constantine, C, O, N, S, T, A N, T, I N, E, and by searching for my name, it's going to pull up those courses. So I'm going to be in in Wichita, in Overland Park, Kansas, in St Louis in October, and then in November, I'm going back out west to Phoenix, Albuquerque, Colorado Springs, Denver and Fort Collins. So I will be spending a lot of time out west in the next couple months, and I am looking forward to that. I I've been all over the place. It's interesting. Therapists are all the same. Doesn't matter if it's in if it's in Manhattan, if it's in Grand Rapids, if it's in Iowa, we're all sort of the same. Interestingly quirky sort of folks. Isn't that true? It is. We're all, yeah, we're all the same sort of folks. We're all griped about the same we're all irritated about the same thing. One more thing on the course, on November 21 that's a fun day. Yeah, of course, is going to be done live. Oh, that was my if you're hanging out at the house on November I'm sorry, November 12. So the house on a Monday, November the 12th, and you can watch this live. And we'll go into how to assess for eye movement problems, standardized testing, all of those sort of things, the research that supports everything that I do. And then in the afternoon, we talk about treatment, and I show you some videos of what I do in the clinic.  

Abby Parana   

That's fantastic, because I know that I can't get up to northern California by the end of the month because I'm in Southern California. So I'm super bummed that you're not going to be in Southern California at the end of the month, but if you ever are, I will be signing up for your class. 

Robert Constantine   

I was there. I was in San Diego, LA area, I guess, three tours ago and and so part of what we're hoping for with the change to pessi. Pessi is a mighty marketing machine, so hopefully, if I end up back in Southern California, you're gonna get emails. And things in your mailbox and all kind of stuff to make sure everybody knows I'm there. You can always go to I have a Facebook group as well. It's called Vision rehab OT, and you can always go to vision rehab OT, and I post where I'm going next. I post cheesy eyeball jokes and all sort of vision related things. And you never know 2019 I'm gonna I'm waiting on where I'm going in February and March in 2019 I haven't heard back yet. Could be doing an adult course, if you're doing some things so that could be happening in 2019. 

Abby Parana   

Well, sounds like you're a busy man. I appreciate it. Yeah, I appreciate you taking the time to record this podcast, and I know I personally have found a lot of your videos very interesting, and a lot of good tools and tricks that we can be trying to practice and help these kids out. And I just now I know kind of a couple of the key phrases to throw out there. The binocular vision exam was just, it's one of those things where that's a very specific phrase that I know. Well, I'm sure if a parent takes that to an optometrist or eye doctor, they're going to get something out of that. 

Robert Constantine   

Hopefully they're going to get the thing that they need to get. Yes, and that's and the key, like I said, they they are aware that this is the standard of care, and to some extent, it's done, it's done one way or the other, but it needs to be the doctor I work with here in Pensacola, Dr Mark obenchain, OBS OTs does this complete eye exam on every person under 18 years old, and so he will frequently find problems that have been overlooked for years. I had a I had a level one ot student who came in and saw me, and as I was explaining how we assess this, I said, So, do you get headaches at night? Yeah, I get migraines sometimes. Yeah, she had convergence insufficiency. 24 years old, working on her master's in OT doing her level one. Wow, it's out there. It's all over the place. Looks like 

Abby Parana   

she was. It must have been a Devine intervention that her level one field work was with you.  

Robert Constantine   

Yeah, It happens a lot. It happens a lot. Where the folks who come to my class go, You know what? I think I have this? Yeah, it looks like you do. So it happens?  

Abby Parana   

Well, I know I will be looking at things no pun intended.  

Robert Constantine   

Quite. Puns are great. We all love puns. That's true. Anyone who's been to my class knows that I am the punniest guy around. 

Abby Parana   

Well, I can tell you, it has been a real pleasure talking to you about this. So thank you so much, and hopefully we can talk about it again at some point, maybe even get even more in depth. 

Robert Constantine   

absolutely, I'm always here to help.  

Abby Parana   

Awesome. Thank you, Robert. Thank you special. Thank you to Robert Constantine for the interview, and thank you all for listening. We'll see you next time.  

Amazing Narrator   

Thank you for listening to the OT school house podcast for more ways to help you and your students succeed right now, head on

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