The Science – Visual Factors a Primary Cause of Beginning Reader Failure

August is National Children’s Vision and Learning Month!

As promised I wanted to take the next few Science entries to highlight great research showing the correlation between vision and academic performance.

One thing that always amazes me is how just about every mom in America knows that their child needs to get their child’s teeth checked by a dentist before they enter school.  Yet, very few know that they they should get their child’s eyes checked by their eye doctor before those very first days learning how to read.  To which I always think, “How much learning do you do with your teeth.”

A great study named “Visual Factors – A Primary Cause of Failure in Beginning Reading” published in Optometry and Vision Development* looked to see if vision was something that impacted children’s ability to learn to read.  I think all of us can imagine that visual acuity or the ability to see clearly would impact a child’s ability to learn to read, which the study affirmed, but the study also found something else important.  Binocular function, or the ability to use the eyes together in tandem, was also a significant factor in impeding beginning reading.  And doesn’t that make sense?  If we cannot get the two eyes to point to the same place on a book, then a child will see doubling or overlapping of letters on the page.  Obviously, that could make an already difficult task of learning to read much more challenging.

So let’s think about the school screening or the vision check that pediatricians do.  We stand the child 20 ft from the letters on a wall and ask the child to cover an eye.  How much does that check how well the child can use both eyes up close for 5 hours a day at school?  Unfortunately, not very much.  Now, this is not to fault the dedicated school nurses and pediatricians.  Vision is not their specialty.

It does tell us however, that every child needs to have their vision checked before they enter school by their family eye doctor and every one to two years thereafter.  And it also tells us that every parent needs to know the warning signs of a vision problem that may need to be addressed by a developmental optometrist.

• Headaches, eye strain, or tired eyes with school work
• Slow or hesitant reading
• Skipping words or lines on a page when reading
• Words moving, doubling, or floating on the page
• Taking hours to do 20 minutes of schoolwork

August is National Children’s Vision and Learning Month!

Schedule a vision examination for your child TODAY!

To find a developmental optometrist near you, follow this link .

For more information on vision problems that affect school performance, learning, and reading please visit the COVD website at www.covd.org.

*Young B, Collier-Gary K, Schwing S. Visual factors – a primary cause of failure in beginning reading. J Optom Vis Devel 1994;25(Winter):276–88.

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Behavioral Vision 101

Today’s guest blogger is Dr. Steven Gallop.  Dr. Gallop practices in Broomall PA.  He is a prolific writer, with many published articles and several books!  Visit his website to learn more about developmental vision.  This article also appears here.

This is a photograph of a familiar object…… what is it?

Most people think of 20/20 when they hear the word vision.  Many eye doctors spend most of their time helping people see the 20/20 line on the eye chart.  Once it is determined that the eyes are healthy many eye doctors are interested in little else.  You may not realize this but 20/20 is nothing more than average eyesight.  It is the ability to see a certain size letter at a certain distance.  Some people can see better than 20/20, some cannot see 20/20 even with what are referred to as “corrective lenses.”

The lenses we know as corrective are really not corrective at all.  They are actually compensating lenses.  They do little more than mask an outward symptom – the inability to see clearly at some distance.  These compensating lenses often ignore any underlying reasons for the symptom they cover up.

There is much more to vision than just seeing clearly.  That is why I avoid the word vision and use visual process in most of my communications with people.  The visual process is a dynamic process that occurs in the brain, not in the eye.  The retina (the inner back surface of the eye, which processes light) is in fact part of the brain.  The visual process develops, and continues to do so throughout our lives.  The primary purpose of the visual process is to direct action.  The visual process is learned and therefore trainable at any age.  People can also experience visual difficulties at any age.  Behavioral optometrists are trained to analyze, diagnose and treat every type of functional visual problem.

So there should be much more to an eye exam that just trying to see smaller letters across the room.  Behavioral optometrists evaluate much more than that.  Behavioral optometrists evaluate the ability to smoothly and accurately track a moving target and how efficiently a person is able to shift their eyes from one target to another.  That is why what behavioral optometrists do is not an eye exam, but a visual evaluation.

Here is the issue in a nutshell. 

Vision, or something akin to it has evolved from some of the simplest creatures in the history of our planet, all the way up to what some consider the most highly evolved, most intelligent creatures in our planet’s history – dolphins, I mean human beings.  Different creatures have different types of eyes for different reasons.  Different types of eyes provide different types of advantages.  For example, flies have compound eyes to provide maximum awareness of their surroundings to avoid being swatted by creatures that have, to their way of thinking inferior, simple eyes.  However, I don’t think that, even if they were able to reach the gas pedal, their compound eyes would ever enable them to operate a motor vehicle.  Those compound eyes provide a very different visual experience from our simple eyes.  Other creatures, like lizards, have eyes on the sides of their heads to give them the ability to keep track of more of their surroundings.

Some creatures have their eyes stuck right on the front of their face, pointing straight ahead.  The greatest advantage provided by this set-up is the ability to judge space and depth with a great deal of precision.  This was initially helpful in tracking and catching moving prey.  Now it is also helpful for copying from the board, running without slamming into the door frame, hitting a baseball, shooting a basket, driving a car without hitting other cars, parallel parking and many other things we do every day.

It is much easier to gauge speed, direction of movement and distances with the type of visual equipment we humans have.  The visual process provides not only information, but is the guidance system we use to direct all of our actions.

Nowhere in creation have eyes evolved for the task of reading, nor for staring endlessly at a computer screen, iPad or smart phone.  There are two important factors that make these tasks stressful for a visual system that is designed as ours is.  First, these activities are two-dimensional.  Second, they involve very little movement other than a few fingers or thumbs flitting around a keyboard, or lips moving to read a few difficult passages.  For a visual system designed for action and three-dimensional seeing, the constant, prolonged encounter with a two-dimensional surface is like walking into a brick wall.  We are all happier to be able to walk around in any direction we would like.  Walking straight into a solid wall for hours on end, day after day would cause not only extreme boredom, but severe frustration, stress and fatigue.  This is similar to what is happening to our visual systems when we subject them to prolonged exposure to two-dimensional tasks.

Prolonged visual tasks without movement present a similarly undesirable situation.  It turns out our eyes are in constant motion.  If not for the fact of these constant microscopic eye movements, we would not see.  Period.  Experiments have been done that simulated a situation where the eyes were perfectly still.  They showed that if an image was projected to the exact same spot on the back of the eye it would fade from conscious awareness in a matter of seconds.  This constant wiggling of the eyes keeps this from happening.  The point here is that, from the bottom up, from input to output, the visual process is intimately involved with movement.  However, we are more concerned here with movement of the body.  Our visual systems are best suited to activities that involve our moving around in some way.

I hope you can see that the visual process is so much more than just sitting in a chair reading letters on a wall.  It is complex, elegant and pervasive in human behavior.  Don’t settle for an eye exam; have your visual process evaluated as soon as possible.  All children should receive a thorough visual evaluation before entering school because most visual problems go undetected without the input from a behavioral optometrist.

Even if you have 20/20 eyesight, were you able to “see” the cow in the photograph?  Vision is more than 20/20!

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The Splash – Elise Brisco, OD, FCOVD on “The Doctors”

There is no better way to make a splash than to be on a hit TV show.  One of our members, Elise Brisco, OD, FCOVD was featured on “The Doctors” a TV show on CBS that highlights medical issues.

I really appreciated the piece because Dr. Brisco was able to highlight some very key issues on vision.  First, she was able to point out how important it is for children to have more than a vision screening by their pediatrician before entering school.  Your child should have an eye examination as early as 6 months of age!  Many people are probably unaware of a nation-wide program called Infantsee.  This program offers an eye exam for children ages 6 months to a year at no charge by hundreds of participating optometrists throughout the nation.  You may ask, “What can you examine at that age? After all, a baby  can’t tell the doctor which is better, one or two.”  There are many important aspects of a child’s eye health and visual development that should be checked at this early age.  Many problems with your child’s vision could be avoided if diagnosis and intervention takes place early.

Finally, I really appreciated how Dr. Brisco discussed her specialty as a developmental optometrist.  She discussed her role in identifying problems with vision development so crucial to good performance in school and sports.  These skills include the ability to track with the eyes, focus the eyes appropriately, and interpret our complex visual world.  Children with problems with vision development often complain of headaches at the end of the school day,  skipping words and lines when they read, reversing letters and words, or taking longer than average to complete assignments in school.  If a child struggles with vision, he or she will struggle in school.  So, make sure your child receives an eye exam before age 1, at 3 years old, and before they enter kindergarten.  After that, if vision is developing on schedule, children should be seen every one to two years as directed by their eye doctor.  To find a developmental optometrist near you, please click on the “locate a doctor” icon on the COVD website, http://www.covd.org or you can follow the link here.

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A Message Worth Repeating

Vision is more than 20/20!  A recent article in AOL Health reminds me that this is a message worth repeating.  The article tells the story of Andrew, a 2nd grader struggling in school.  After a series of professional evaluations, his mother knew that he was NOT learning disabled, but no one was able to identify the problem.  A vision screening confirmed that he had “perfect eyesight,” 20/20, so it wasn’t a vision problem……… or was it?  Only when Andrew’s mother sought the services of a developmental optometrist, Dr. Kimberly Walker, was a vision problem diagnosed and the wheels set in motion to help Andrew succeed.

Clarity of vision is only one of the visual skills children require to succeed in an academic environment.  But 20/20 has little impact on a child’s ability to function with comfort and efficiency.  This requires other visual skills– eye movements, focusing, and eye teaming.  Here is how I often explain this concept to parents: Suppose your child has 10 energy units to complete a homework assignment involving reading a chapter and then applying this new knowledge by writing a short essay.  The average student uses 2 energy units to coordinate their eyes, focus them without fatigue, and move them accurately through the pages of text.  That leaves 8 energy units to comprehend what is being read and consider what is important for completing the essay.  Your child, on the other hand, requires 7 or 8 energy units to coordinate, focus and move the eyes through the text.  With only 2 or 3 energy units remaining, comprehension is going to suffer and this will be  reflected in the written assignment.

Through the work of a developmental optometrist, Andrew has recovered those energy units and is on his way.  Thanks to Andrew and his mom for sharing their story.  Hopefully more children will be more successful when they discover that vision is more than 20/20!

Be sure to read Dr. Walker’s guest post about  divergence excess strabismus!

 

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It Takes A Village

“It Takes a Village.”  That is the title of the book, written by Hillary Rodham Clinton in 1996, when she was the First Lady.  This title refers to an African proverb, “It takes a village to raise a child.” How appropriate to introduce this post from Dr. Leonard Press.  This post also appears on VisionHelp Blog.  Dr. Press has been building a strong village to support the needs of the children (and grown-ups) he serves.  He knows he can’t do it alone.  The more we interact with like-minded professionals, the more we will learn about how to help our patients.

I’ve had a fabulous time, twice over the past two weeks,  giving a day long seminar to occupational therapists, physical therapists and speech-language pathologists.  Our field has been blessed with colleagues who do a marvelous job of this, in particular Drs. Appelbaum, Hellerstein, Hillier and Scheiman.  Although I’ve been asked to put seminars like this together before, I’ve shied away due to time constraints.

Venturing first up the Hudson River along the Palisades Parkway to do the seminar in Spring Valley, and then down the New Jersey Turnpike for a gathering in Princeton, I had a blast.  One of the best things about having an interactive seminar with “the big three” therapies of OT, PT and Speech,  the ones who are part and parcel of early intervention services, is that they get it.  There’s no need to  convince any of the attendees of the importance of VT, only to work out a framework in which they can feel comfortable collaborating.

Here is what we covered:

seminar-visual-processing-and-therapy-oct-2010

I’m happy to share this information, though it isn’t as much the facts that makes the seminar special as it is the interaction.  In contrast with some professions who don’t grasp the science and substance of optometric vision therapy, those in attendance at these seminars grasped the concepts almost intuitively.  Ideas about the balance between structure and function, between reductionist disease models and holistic developmental models, and between the senses and the senseless resonated with each of the attendees.

My seminars are highly interactive, and though the PowerPoint slides in the hyperlink above will give you a feel for what we covered, it really is the interaction that is priceless.  Though I’m referring principally to hands-on workshop demonstrations, a subject that comes up frequently is how best to advise parents to obtain a consult with a developmental optometrist.  To steer clear of school system and health care politics, I suggest that therapists simply guide parents to the wealth of information at http://www.covd.org, http://www.oep.org, http://www.aoa.org and http://www.visionhelp.com.

Build it, and they will come.  Interact, and they will process the facts – with the public as the ultimate beneficiaries.

- Leonard J. Press, O.D., FCOVD, FAAO

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“His Eyes Are Fine”

Today’s guest blogger is Dr. Leonard Press, from Fairlawn NJ.  This post also appears on  The VisionHelp Blog.

I saw a young boy as a patient in the office this morning who is almost five years of age.  His history is amazing, and suffice it to say that he had a rough start in life.  In the NICU for the first six days after birth, neonatologists recognized that he had severe motor weaknesses.  He doesn’t really fit into any pattern of a known syndrome, and currently bears the diagnostic entity of “neuromuscular problems of unknown origin”.  Sociable and articulate, he’s been talking since 9 months of age, and has received significant amounts of occupational and physical therapy.  As the early intervention period came to a close at age three, someone decided it would be a good time for him to have an eye examination.  His parents took him to an ophthalmologist, and here is a copy of the report sent to his other physician providers:

OPHTHALMOLOGY – Minimalist Repor t 2010

Now that’s what I call “ophthalmo-minimalism”.  20/20 visual acuity.  Eye exam normal.  See you in two years, and don’t let the door hit you on the way out.

As was the case with this young man, we get many referrals from OTs and PTs who understand how the eyes are interconnected with the rest of the body’s motor systems.  Both the OT and PT recognized that this child had difficulty with copying, switching focus from near to far, and with visual motor testing relative to gross motor testing.  They suggested to mom that her son be examined by a developmental optometrist, and impressed upon her that although “his eyes are fine”, that’s not where the visual system begins or ends.  And when mom brought in her son’s report from the ophthalmologist, I was reminded of the extent to which we miss more by not looking than by not seeing.

So we looked deeper into Jonathan’s visual system, as closely as one can look without peering directly into the rest of his brain.  He showed a low amount of hyperopia on manifest retinoscopy but +2.50-0.75 cx 180 OU after just 15 minutes of one drop of  1% cylopentolate having been instilled.  His Keystone Visual Skills showed a high dergee of binocular instability, with eso at distance compatible with latent hyperopia, and exo at near compatible with accommodative stress and lag.  He also exhibited a small but significant variable vertical drift, compatible with his overall motor history, and his strereopsis was reduced.  The WACS (Wachs Analysis of Cognitive Structures) Test showed that his visual cognition was substantially lagging behind his superior verbal intellect and reasoning skills.

I’ll be meeting with his parents on Monday to gain a bigger picture, and will stay in touch with his developmental pediatrician, physical therapist, and occupational therapist.  Though I haven’t decided as yet what course of action we’ll take, I do know one thing for sure.  His eyes may be fine, but his vision isn’t “normal”.

Leonard J. Press, O.D., FCOVD, FAAO

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Children Vision Problems and why some doctors don’t tell you… Answers found with Cats who Succeed

In my private practice that specializes in vision therapy, the majority (about 70%) of our patients find their way to my care from a direct referral from another doctor or rehabilitation professional. Yet there are a significant number of patients, (often children) who are referred by a parent of a past patient who recognizes behaviors in a child that looks like what their own child struggled with before coming to see us for vision therapy.

This represents about a third of our practice that come to us directly because of a parent, teacher or friend who saw behaviors or recognized the problems described by the other parent. That means many children somewhat serendipitously find their way to our care because of a thoughtful  ”goodwill ambassador” past patient or friend.

This group of patients are typically the kids with vision related learning problems. There can be a variety of clinically presenting conditions but some of the more common diagnoses are convergence insufficiency, accommodative dysfunction or oculomotor dysfunction or a combination of all three.They may also have a visual processing problem resulting in letter reversals, difficulty with visual memory and/or hand-eye coordination.

When a child has a vision related learning problem, it is also interesting to note that the diagnosis is typically very obvious as I will demonstrate to the parent directly their child’s trouble with the sample visual test  and then let the parent see for themselves usually how effortless the test is if they have normal abilities. Once we establish the diagnosis and determine that this child has a vision problem that can be effectively treated, there is typically a three part response by the child’s parents.

First there is a sense of relief that finally  a visual explanation has been found that answers why their child has struggled and it is not because their child was “not smart enough” or “not trying hard enough” and they are not ”bad parents”.

Second  there is a feeling of hope for their child’s future because the solution I present just makes sense. We provide the “best practice” delivery of care, doctor supervised office-based vision therapy that is a proven and effective treatment and I have a solid track record of 30 years experience in this specialty.

Thirdly the parents then experience a momentary feeling of regret and disappointment (sometimes anger) that their previous eye care professional who saw their child did not not recognize the problem in the first place. As a result of overlooking their child’s vision problem their child had to deal with often years of frustration and emotional side effects. It is this group of parents who will ask me, ”Dr. Fortenbacher, why did our child’s previous eye doctor not tell us about this problem with our child’s vision?” Often I can not honestly say why with certainty, but try to emphasize the positive, we can leave the past behind and move forward now to solve the problem.

However now I’m pleased to have a better response to this question. Thanks to my friend and colleague, Dr. Leonard Press who has written 3 wonderful articles on The VisionHelp Blog there is now an answer to  the proverbial question, “Why did our other eye doctor not tell us about this problem?” The answer can be found in CATS WHO SUCCEED.

CATS WHO SUCCEED – Part 1

CATS WHO SUCCEED – Part 2

CATS WHO SUCCEED – Part 3

Dan L. Fortenbacher, O.D., FCOVD

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Physicians Pay Attention To ADHD On College Campuses

Can’t study. Can’t focus. Can’t remember what I was supposed to do next. I’ve got to do this. No, I’ve got to do that. What was I doing?

In college, students with attention deficit/hyperactive disorder face an array of challenges-long days and nights of classes, studying and activities, all of which require increasing amounts of concentration….

Comments: No where does this article mention vision problems as a source for the behaviors of ADHD…for instance:

Academic Behaviors in Children with Convergence Insufficiency with and without Parent-Reported ADHD.
Rouse M, Borsting E, Mitchell GL, Kulp MT, Scheiman M, Amster D, Coulter R, Fecho G, Gallaway M; The CITT Study Group.Optom Vis Sci. 2009 Sep 7.

Oculomotor performance identifies underlying cognitive deficits in attention-deficit/hyperactivity disorder. Loe IM, Feldman HM, Yasui E, Luna B. J Am Acad Child Adolesc Psychiatry. 2009 Apr;48(4):431-40.

The relationship between convergence insufficiency and ADHD.Granet DB, Gomi CF, Ventura R, Miller-Scholte A. Strabismus. 2005 Dec;13(4):163-8.

Nearpoint phorias after nearwork predict ADHD symptoms in college students.Wilmer JB, Buchanan GM.Optom Vis Sci. 2009 Aug;86(8):971-8.

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