Emily Stone, OTD

Emily specializes in vision therapy and working with kids with low vision. Emily gives practical activities for families. She also provides education for occupational therapists to use in their practice.

Transcript:

Bethany Darragh  

Today, on the podcast, we have Emily Stone. Hi, Emily!  Can you just start by telling us a little bit about yourself? 

Emily Stone   

I am a mom of three. This is an exciting year having  my oldest in high school, a middle schooler and an elementary schooler. So we're very busy at home, professionally, I have been an OT since 2003. I graduated with a bachelor's in OT, and then followed up with a Master's in Health Science, and then recently, just finished a post professional doctorate two years ago. And I have worked in everything from the NICU through assisted living places, home health schools, Pediatrics has been my most common placement, and for the past 10 years, I have been specializing in low vision and vision care.

Bethany Darragh  

I'm so curious about what got you into specializing in visual impairments and low vision. So if you could just tell us a little bit more about that journey, that'd be great. 

Emily Stone  

Well, actually, it started kind of happenstance, because I wanted to have a similar schedule as my kids. So my husband was working all hours, and I was working 10 hour days. And so it just so happened that a contract opened up with the North Carolina School for the Blind and Visually Impaired called the governor Morehead school. And so I took that with just the basic training that I got in OT school, and just really kind of fell in love with all of the different things that you can do to help people in that area, and started taking classes, and kind of went from there. 

Brennan Barber   

Emily, I assume you work with children that have both progressive vision loss and those who are also born visually impaired. Can you describe your approach, and maybe how you approach each of those categories differently.

Emily Stone   

So they have similar needs, but it's different because if you lose your vision early, like age three or four, it's much different than if you are born blind or if you are born premature and have retinopathy of prematurity, because you still have some experience with vision. So while the treatment approaches actually are fairly similar, as they get older, you might still be using the same types of assistive devices or assistive technology, the needs will be a little bit different. So someone who is congenitally blind may have more motor problems or spatial awareness problems that you're addressing in addition to the vision loss. And someone who has a progressive disease may start with a lot of vision and then gradually need more and more support as you go along, or they may have lost their vision completely early, but still have these memories and ability to use that as part of their daily experience.

Bethany Darragh  

So I know that you've developed a curriculum that is called the expanding horizons, expanded core curriculum, and I would love to hear a little bit more about that as and how you developed it, and kind of what it's for and who it's for. 

Emily Stone  

So it's actually two separate things. So I did this little project called expanding horizons in pediatric low vision education, and that's a website to provide information about the expanded core curriculum and. And the expanded core curriculum was actually developed in the 90s by, I think it was either the principal or maybe he called himself the President, I'm not sure, of Texas School for the Blind, and it includes nine areas that they determined students with a visual impairment need in addition to the standard academic curriculum. And so these include compensatory access, assistive technology, social skills, rec and leisure development, orientation and mobility, independent living skills, career development, sensory efficiency and self determination. So Expanding Horizons is a website that provides information about all of those areas, mainly for school based OTs, but parents and other people can use it as well. And then it breaks it down by age group, preschool, elementary, middle and high school, and gives ideas about how you would integrate those areas into a regular school day.

Bethany Darragh  

I really appreciate that explanation, because I didn't I had never heard of the expanded core curriculum before. I read your website, and I have really enjoyed diving into it, because I do have a number of children on my caseload right now who are blind, and I'm collaborating with the vision teacher a lot more, and it's been really helpful for me to think outside of my box, of using vision as part of the therapy, and having to think outside of that. So it's not something that I learned in OT school. Did you learn that in OT school or through your time at Governor Morehead or your doctoral program?

Emily Stone  

So I learned about it once I started working at Governor Morehead, and I had never heard of it either, and I don't think they teach it in OT school. Vision education in OT school is mainly focused on geriatrics, or, you know, age related vision loss, because that is predominantly what is what we see. There's a much lower number of individuals that are younger that have vision loss. But if you do have vision loss and you have to go to school, you need extra help, and so this is a great way to provide it. I did learn about the ECC, we can call it that for short, from the teachers of the visually impaired that I worked with, and I just felt like it was a really great way to support the students as an OT and I ended up kind of reframing all of my evaluations around that, because there really are no standardized kinds of tests that you can do. So it was a really great way to kind of frame what I did at that school to support the kids in the areas that they weren't their teachers couldn't meet.

Brennan Barber   

A lot of our I would say, you know, our listener base, or the market that we're serving is in pediatrics. And you mentioned that there's not a lot of vision deficits that tend to occur with pediatrics, but just out of curiosity, like, what are some of those deficits that you do see with pediatric patients, and what might some of those early indicators be?

Emily Stone  

That's a really great question, and I think we want to separate it into two areas. There's low vision and blindness. So that's one area, and there's a variety of reasons why, why a child might develop that, but then, which I think is probably a lot more common are just visual efficiency deficits. And what that means is that your visual acuity might be completely normal. You go through the school screener, you get 2020 you keep going, but you're having trouble reading perceptually. It's hard to line up math problems. And so what parents might notice is that kids are skipping words. They're skipping whole lines when they're reading. They have a hard time. They have to, like, put their finger on everything. And what that means is that maybe their eye their eye tracking movements going left to right, up and down, or their ability to make fast movements from one point to another is a little bit impaired, and then also the ability to focus far away and close up and shift back and forth like you're looking from the board to your paper or computer quickly. It may look fuzzy because your eyes can't focus quickly enough when you're shifting from far away to close up. So all of those things are actually very common with kids who have diagnoses like ADHD, autism. My daughter actually had that problem. She had a concussion, then afterwards, she needed not bifocals, but magnify, because it helped her be able to see up close better, because she couldn't refocus up close quickly enough. So those things are more vision therapy type activities. But it doesn't mean that you have a visual impairment per se. It's just exercises that you can do to improve that skill, to help with reading and other other areas.

Brennan Barber  

So those typically related to, like muscular development, or could it be the way in which the brain is perceiving the images that it's receiving, or both,

Emily Stone   

Or both, yes, so it's really a strong connection between the brain and how the muscles work. So when you're using your eyes, it's controlled by what you perceive. So it's this kind of loop, so you can do exercises and you're using eye muscles, but it's really you're training your brain how to recognize and perceive what you're looking at. So there's actually visual efficiency, which is what I was just describing. And there's also vision, visual perceptual skills, and that's the ability to really perceive different things in the environment and be able to see, for example, if you have a cluttered drawer and you need to find your keys, how do you get there? Can you separate and look amidst like different things to see what you need to I

Bethany Darragh  

We might get into the therapy weeds a little bit too deep here, but it's very much on my mind because I just completed a reevaluation on a student who it's been three years since our last reevaluation, and we've been working on functional skills in the classroom. So a lot of written expression and progress has been made on the legibility of his writing and the fluidity of his thoughts and all of these things. It looks like we've made a lot of progress, but when I went back to check his saccades and his pursuits, they are the same as they were three years ago, and they are not there at all. And I hadn't been doing anything specifically for saccades and pursuits, but I thought, Oh, we're just going to work on the function and this is going to come along, and it looks like he has completely circumvented, you know, just figured it out without it. Thoughts about that, and that kind of also leads me to vision therapy. I mean, that is a legit thing, and I feel like a lot of OTs can feel a little overwhelmed by going there. I mean, I did not do anything focused on that, and now I'm feeling like, Oh no, three years later, and there's been no change to his saccades and pursuits. So for the listeners, saccades are the ability for your eye to jump from one focal point to another point quickly, and pursuits are like a smooth tracking of a moving object. So go ahead, you can answer that,

Emily Stone  

Yeah. So I would again. I mean, we always get back to function. So if you can do everything, then I wouldn’t be so worried about that that's but that's my kind of personal, professional model. I'm not going to just make people do exercise to get a very smooth eye movement. What could happen, though, is that later on, as demands increase, he may have more trouble, because that's difficult. So there's pros and cons, but those are actually very, very easy to fix. So I had a little boy, and at the time, he was in third grade, and when I checked his pursuits, they were jumping all over the place. So you just have them follow your finger, like left to right, right to left, up and down. And you look at the eye and is it jerky, or is it smooth? And if it's jerky, that means that they have trouble focusing and doing that slow pursuit movement. The exercise is just to do that. So you're just having them follow left to right, right to left, back and forth, go up and down, go in a circle, do it like three or four times a day, 10 times, back and forth, super quick. They can do it themselves, and that usually will kind of clear that up pretty quickly. There's a lot of other visual efficiency skills that we kind of address an OT frequently, I think, through, you know, practicing copying things from near point and far point, and that's really addressing accommodation.  

Bethany Darragh   

Which his accommodation had improved, yeah, so that copying the board he was practicing. So that was an exciting Yes, yeah. So, I mean, when you think about, when you give that advice for that. Homework for a family with vision stuff, I know there's a lot of things online. Are you pro screen or away from a screen when it comes to working on vision, because I know there's a lot of screen based activities to work on that. Or would you rather than not do that?

Emily Stone  I think that it's okay. So we want to be able to transition from a screen to free space, but there are some really good programs online that you can use. And I would say, right now I'm actually working with an optometrist, and we use screens. So I do a combination. So for younger kids, I tend not to do those computer based activities or screen based activities. I do more games and things just but that's kind of an outpatient practice would be different from in the school, um, but I think it's all a balance, yeah.

Brennan Barber   

So little interesting anecdote. When my son was about four, we noticed that his one eye was starting to drift, and so he has cerebral palsy, and it would happen on occasion. And one of the things that I mean, we called a doctor, talked to his pediatrician, and they said that, honestly, it was probably just weak muscles that just need to develop still. So one of the bits of advice that we got was to use a screen a little bit more and have him focus on what he was watching, on whether it was a certain show or a game, just to strengthen those eye muscles. And it did work, and we haven't seen any recurrence of that since, but it was just interesting that the screen ended up being one of the devices that helped strengthen is, yeah, the muscles around his eyes, speaking of screens, I'm going to ask a very selfish question here, because my son does use an eye gaze AAC device, and I will say like one of the things I do worry about at times, or his eyes getting fatigued. Because he is a power user. He uses it all the I mean, we get the pop ups on the device itself. It's a Tobi DynaVox, and I'll say how many hours he's been on it on average during the course of the week, and it's usually pushing around 12. And yeah, I mean, during that time, he's not always actively using it, but it is on and in front of them. And just curious if you're aware of instances of strain or fatigue when it comes to using eye gaze devices.

Emily Stone  

So I will say I haven't worked with patients using eye gaze devices a lot, because most of the people I work with can’t.  For anybody using a computer or a screen, you know, at work, at school, whatever. Yeah, that can happen. And usually there's this rule, like the 20/20 rule. So for every 20 minutes, take a 20 second break. And a great way to do that is just to look off into the distance. Because when you're focusing on a point far away, your eyes have to relax to do that. So that might be hard for your son to remember to do

Brennan Barber  

20 seconds isn't bad, I think he can pull that

Emily Stone   

The other thing that is good for everybody, you know, and especially if you're on a computer or, you know, screen a lot, is just, they call it eye yoga, but you just close your eyes and then, like, look up and down, stretch your eyes left and right. You can rub, like, around the eye orbit, even use some like, massage. The optometrist that I work with says, Just get, like, an electric, a kid's electric toothbrush, and do some vibration around there if you are in discomfort. So if he's not complaining, you don't necessarily have to do that, but I would encourage breaks.

Bethany Darragh  

That's super helpful. So to get out of the therapy weeds a little bit, let's focus on parents. So what tips do you have for parents, especially with young children? How can they work on vision or work on senses that support vision? What do you recommend?

Emily Stone  

So let's dive back into more of the low vision, vision impairment area, because this is where I see kids falling behind. And I think one of the most important things that parents can do, even if their child is not talking, their infant, one/two year old, tell them everything that you're doing. I mean not you may not be able to do that all day long, but describe what you're doing, let them feel the tools that you're using. Because with vision, as children, we learn incidentally by watching what's going on around us, and if we can't do that, we can't learn what things are. So I'll give you a quick example. I was in helping with the middle school class, and there was maybe six or eight kids in there, and it was cooking class, so we were learning about how to make grilled cheese sandwiches. And I would say more than half of those kids didn't know what a spatula was, because no one had ever handed them a spatula and said, This is what I use to flip a grilled cheese sandwich or a hamburger or a pancake. So letting them feel things, so they know what it feels like. Telling them what it's used for is really, really important. And then the other thing is to help develop problem solving skills, because that's the other thing. We tend to teach explicitly, do this, and then do this, and then do this, and then when you get into a situation where you have to. Figure something out. They're sitting there waiting for something to happen or for someone to tell them what to do, and they've done a lot of research. And people who develop problem solving skills to be able to use assistive technology and adaptive equipment are the kids who eventually graduate from high school and get a job and hold a job, so that's very important. And then just moving and helping your kids explore their environment, getting as much, I think, movement and information through their muscles and joints so they can develop good body awareness and spatial awareness is also a big recommendation, because when you can't see you're not you tend not to explore and use your body in the same way as someone who is curious because of something that they see.

Brennan Barber  

Is that considered the proprioception system, the ability to kind of sense where you are in space. 

Emily Stone  

Proprioception is when you can tell what your body is doing. So if you close your eyes and you're sitting down, you know you're sitting down because the weight of your body is in the chair, and you can feel it. And it also helps you know where you are in space compared to something else. So when we have vision, we can see those things, and we have depth perception, but it's interesting, and this might be going into the weeds a little bit too much also, but there's a part in your brain called the superior colliculus, and that's where information from the vestibular system, which is your sense of movement, The proprio sense, proprioceptive system, which is your body awareness and your peripheral spatial awareness. They all go to that one spot, and they talk to each other, and then they kind of integrate, and then they send messages to your visual cortex, and then they talk back and forth. And that's how you can be able to function in the environment around you and know where things are and how fast things are coming at you, and how to climb up a lot on the playground and all that sort of stuff. 

Brennan Barber  

It's something obviously we've experienced too. That's why I ask, is with my son being a wheelchair, we've had instances where, like laying on his back, he gets the sense of falling, so we got to kind of adjust him and make him feel a little more secure in his space. And I was more or less curious if those same effects, because he does not have any visual impairments, but if, if those similar symptoms existed with with children that did so,

Emily Stone  

Yeah, it's actually really common. And some adults that I see who develop, they come in, they come in with complaints of dizziness, but it's really a combination of visual efficiency problems and just the way that it's working together in the brain. 

Bethany Darragh  

Emily, as we kind of close out, we'll ask one more question before we close. And if you could just talk a little bit more about how to involve family members and caregivers in this therapy plan involving vision & low vision.

Emily Stone   

Well, I think especially with children and as OTs, we want to develop client centered plans of care, the parents and caregivers are part of that plan. So what I like to do is a lot of coaching, so when they bring a concern to me, you know, education is important, and coaching them so that they can help their child at home. And I think one of the things that's important for caregivers and parents to remember is that you can't be scared to let your child be independent so they may fail, but that's okay, as long as they're as they're safe, let them try again. And one example that I have from one of my previous students is making a video of her doing this task at school, and then we sent it to her grandma. And so then her grandma could see that she could actually do it, and then when? So at the governor Morehead school, it's residential, so she was there all week, and then went home on the weekends. So when she went home on the weekend, she was able to do that task with her grandma, and she knew that she would be able to do it. And actually, they used the video as kind of a support because the student couldn't always remember all of the steps, so she had been learning how to fold a shirt using a folding clothing folding board, and so she listened to the steps and she did it. And so then she kept help fold clothes over the weekend, and that was a big step for everyone, because her grandma didn't think it was something that she should make her do, because she didn't want her to have to do chores on the weekend, when she's home from school, but it was actually a very positive experience, because the student felt independent and felt like she was helping. My grandma felt she didn't have to fold all the clothes, so that was great, and she could really see how well her granddaughter could do. So that was exciting. 

Bethany Darragh   

Emily, thank you so much for coming onto the podcast, I've learned so much, and I can't wait to use some of the stuff in my practice.