How common are learning-related vision problems? Are they becoming more prevalent?
Vision problems that interfere with learning include things like poor teamwork, difficulty focusing, inaccurate tracking, and visual processing problems that can interfere with attention to detail, memory, and sequencing. These problems have nothing to do with 20/20 eyesight, and are not associated with eye diseases. They occur in approximately 15 to 25% of the overall school-aged population, depending on which study you cite going back to mid 1980s. (The highest incidence I've found reported is in a long-term study of an urban school from 1993 to 1999. They found 53% of the children failed a functional vision evaluation, the children that failed had lower standardized test scores, and the children with the worst visual findings had the most improved test scores after treatment with glasses and vision therapy.)
Prevalence is higher in pediatric populations identified with learning or behavior problems: a majority of learning-disabled children (those in the resource room) have vision problems that can interfere with learning, and there's an even higher prevalence in the juvenile delinquent population.
Are there hallmark characteristics that children display that need vision therapy? When do sign/symptoms usually present?
Hallmark characteristics: in general, children with vision problems that get in the way of their school performance seem to be smart, but they struggle to do the work and get the grades. They don't seem to be living up to their potential, and may appear to avoid doing work (potentially being labeled as inattentive or lazy) or they may struggle inordinately (appearing to have a learning disability). Some parents describe their children as working very hard, but the effort isn't reflected in the quality of the work or the grade; there's a mismatch between effort and result.
How can a parent/teacher identify children whose vision restricts learning?
There are a lot of warning signs that parents and teachers can watch for during schoolwork or homework. Many of these are on the symptom checklist that we ask patients and parents to complete as part of their initial evaluation. When we do seminars, we start by talking about how the visual system is put together and what students are expected to do visually on a daily basis. Children that do not have well-developed skills experience visual stress (we have some pretty cool visual stress demos during the seminars), and the symptoms are the result of the poor skills and their response to deal with or avoid visual stress:
- postural things like covering one eye, head turning or tilting, changes in working distance, and shifting or wiggling in their seat (especially when the child is able to sit still to watch a movie or play a game)
- physical problems like watery eyes, eye rubbing, headaches or eye pain (and sometimes even tummy aches and dizziness) in the absence of health problems...
- and there's a wide range inattentive/avoidance behaviors that may actually be an adaptation to minimize the physical discomfort associated with visual problems
- reading problems like skipping words or lines, confusing similar words, repeatedly sounding out the same word, or difficulty remembering or understanding what they have read (a vision problem is likely involved if the child likes listening to stories but doesn't like reading)
- writing problems like poor sizing or spacing, misaligning their numbers during math problems, forgetting how to spell previously learned words, forgetting ideas while writing them down, or a general mismatch between how the child speaks compared to how they write
- difficulty copying for the board
- relatively more difficulty in math when trying to solve story problems
- tutoring, remediation, or occupational or speech therapy that has not been as effective as expected (vision problems can be a barrier to benefitting from other approaches)
- and the list goes on: clumsiness, distractibility, difficulty following directions, rushing to complete work...
Problems present when the academic demand exceeds the developmental level of the visual skills. For example, a bright child with developmental vision problems might be able to learn how to read, but problems can surface when they get to 3rd grade and are expected to read to learn. We've also seen some children that make it through elementary and middle school, but can't seem to handle the volume of work in high school. These older students are usually children that are especially gifted, and were able to achieve at a relatively high level in earlier grades, but were working especially hard in the presence of visual difficulties. We've also had college students and adult patients who realize that they've been working much harder than their peers. More mature patients usually recall symptoms of vision problems from childhood; some common ones are slow reading, or needing to study longer than their friends, or long-standing struggles with spelling.
What is the average length of treatment for vision therapy?
Average length of treatment – in our clinic, the majority of patients that we see are bright children who have a hard time showing how smart they are during school. Those children usually have 20/20 eyesight and healthy eyes, are in good health, and are eager to get better at reading and writing, but the visual problems are a huge barrier to their success. The average length of treatment for those children is approximately 6 to 8 months, with treatment sessions twice a week and a few minutes of daily "home support activities". (In general, children that attend twice a week develop much better visual skills than children that attend the same number of sessions at a frequency of once a week.) But there is no "magic number" of sessions, so visual skills are formally reassessed every 6 to 8 weeks. Coming to the office twice a week for several months is a really big deal for families, and we don't want anyone working longer than they need to, nor do we want someone stopping treatment before the new skills become new habits that are an integral part of their being.
How old does someone have to be for you to see them?
I'll examine children as young as a few days old. Visual teamwork, focusing, and tracking follow a developmental sequence, so if I see an 8 week-old infant or a 24-month-old toddler, they don't have to verbally interact much; I know what to look for to make sure they're at an age-appropriate level. Seeing children with these developmental problems is actually a lot of fun. We get to do a bunch of "eye experiments", and since there are no needles or scary things, it can seem like we're playing vision games while we try to figure out if the child's eyes are doing things that they should be doing.
What about non-verbal patients?
The testing for a child with speech delays or even autism can still be very playful, and for a child that may not be speaking much yet I have lots of alternative methods to obtain the pertinent clinical information.
Do you treat adults?
Adults with vision problems that interfere with reading, attention, or visual stamina usually require about two-thirds or even just half of the time to complete treatment. A lot of these people look like they've grown-up with and adapted to the problems they had in childhood; the problems don't go away with time, so adults make choices and figure out strategies to deal with them. We also treat adults with motion sickness (treatment usually completed in a couple months), or with head injuries and stroke (treatment can take over a year).
How and why does optometric vision therapy work?
When vision therapy is done well, it's like any well-designed course of academics, coaching, or therapy; it's about arranging conditions so that learning may occur. We assess a patient to see not only what is wrong and where they are starting, but how they are coping with their visual difficulties (what strategies have they developed to survive). And then we develop a personal treatment program that starts where they are, with conditions arranged such that they can learn new visual skills and integrate the skills into their daily life. Every moment of therapy is both diagnostic and therapeutic; the therapist presents an activity, observes how the patient performs, and adjusts the activity moment-by-moment.
Some numbers behind the how and why: our current understanding of human neurology reveals that approximately 70% of our brains are primarily involved in vision (not just 20/20 eyesight, but knowing where to look for tracking, focusing, and teaming, remembering what we've seen and where we saw it, linking up what we hear and what we visualize, guiding our hands along the page when writing or drawing, etc). And educational psychologists estimate that approximately 80 to 85% of classroom learning is visually-based; a "small" visual problem can actually be quite troublesome in the classroom. (There are a few very astute psychologists in the area that, when they see a child with a mismatch between verbal and non-verbal test scores, refer for care; the "non-verbal" could more appropriately be described as "visual".) Vision therapy allows a person to build the neuromuscular and perceptual mechanisms necessary for learning, and the new skills are repeatedly being applied in the classroom.
One warning for well-intentioned parents: if your teacher, tutor, or therapist has recommended an evaluation to check for vision problems that interfere with learning, you go to the eye doctor, and you are told that there is no problem because your child sees 20/20 and their eyes are healthy, the doctor didn't look for what you wanted them to look for. The kind of hidden vision problems that interfere with learning are not always detected at an eye exam, often because the doctor is especially well-trained at evaluating "eyes" but not at how the person is able to use their eyes.
What about colored overlays or colored filters and glasses with Chromagen lenses to help with reading?
These compensatory devices are great when they help, but do not remove the underlying visual problems causing the reading difficulty. And when they help, you can be pretty sure that there is a problem with visual coordination like teamwork, tracking, or focusing.
Another easy screening question to determine if vision problems are interfering with reading – does the child understand the story when they hear it but not when they read it? If so, then you know the child understands when words come in through the ears but not via the eyes, so you've ruled out a language-processing problem, and pointed to a problem with vision.
Some of the background for the connection between color and visual coordination problems comes from research conducted by one of my optometry school professors, Dr. Harold Solan. He delved into simultaneous and sequential visual processing, involving the relationship between peripheral and central visual pathways. This interplay plays a huge role in coordinating the two eyes as a team and directing 20/20 vision where we want to look, and the balance between the two pathways can be impacted by changing the color of the visual input.
Vision therapy seems overwhelming. How much of this can we do at home?
Most of the families that come to us are already feeling overwhelmed just dealing with the consequences of the vision problems in their day to day life, and we don't want to add to the stress at home. Every patient in vision therapy is assigned activities to practice at home, thereby supporting the in-office program.
Vision therapy happens with a vision therapist, and our staff is highly trained to function as clinicians, constantly monitoring the patient and adjusting therapy activities such that conditions are provided for developing various visual skills. Initial training requires several months of coursework, including reading, discussion, and hands-on practice, and on-going staff training continues on a weekly basis.
We do not expect parents to take on this kind of training while they are coping with the challenges of trying to make sure their child completes a math page and studies the spelling list. Instead, as patients encounter various therapy tasks, things are assigned for home. At this point in a vision therapy session, parents watch the activity, and written instructions are reviewed and provided to take home. As skills improve by practicing at home, new activities in the office are introduced, and new activities are sent home.
My child's occupational therapist is concerned about vision. What should we do?
Many occupational therapists have training to look for vision problems that can interfere with success in OT. Take your child for testing with an eyecare professional that will look at functional vision, which is much more than just 20/20 eyesight and eye health.
You might have read this in other places on this site, but it's worth repeating: if your teacher, tutor, or therapist has recommended an evaluation to check for vision problems that interfere with learning, you go to the eye doctor, and you are told that there is no problem because your child sees 20/20 and their eyes are healthy, the doctor didn't look for what you wanted them to look for. The kind of hidden vision problems that interfere with learning are not always detected at an eye exam, often because the doctor is especially well-trained at evaluating "eyes" but not at how the person is able to use their eyes.
For patients that have been referred to The Developmental Vision Center by another healthcare provider, we make sure to communicate with that provider so that a patient's treatment plan takes into consideration everything that has been identified.
My child's occupational therapist said he can work on "the visual piece." Do we need to do vision therapy too?
That question can only be answered in a thorough visual evaluation. Some occupational therapists have studied visual rehabilitation, have learned how to work on basic eye movements, and can help people improve how they move their eyes. However, occupational therapists are not licensed or trained to use the testing and treatment tools available to licensed doctors of optometry, and visual problems can remain despite working on eye movements in the occupational therapy setting.
When another professional suspects vision problems, testing should be conducted to allow the patient and their family to figure out if vision therapy is needed. Since vision is a learned skill, when problems are identified, you can be pretty confident that they will get better with treatment.
For a child that might need both occupational and vision therapy, when vision testing is completed, findings are reviewed with the referring occupational therapist so that a patient's treatment plan encompasses everything that has been identified.
We've been told to take care of our child's other issues before vision. How do we know what to do first?
Once a child's vision has been assessed, any identified problems should be addressed as soon as possible. A small visual problem can actually present a huge barrier to success in treating other issues. In the past decade or so, neurologists have learned that over 70% of human neurology is primarily involved in vision. These neurological functions are for more than just identifying small letters on an eye chart, but also the brain connections that coordinate eye movements with hand and body movement; visual memory to recognize people, places, and words; interconnections between what we see and hear or touch; and neurological filters that we use to keep our attention on one thing while in the presence of various visual stimuli.When it comes to the classroom, effective visual function is even more crucial. Approximately 85% of classroom learning is related to vision.
We often see children who have spent several years working on other issues, like reading remediation, occupational therapy, speech therapy, and writing programs. One thing these various treatments have in common: in order for them to be successful, vision must be well developed. When a child has been working on other issues but not making progress as expected, vision problems may be the culprit.
We've been told that our child is not ready for vision testing. How old do they have to be?
Many well-intentioned professionals may recommend waiting to do vision testing, usually because they think the child will not be able to sit still and answer "which is better, one or two?" However, vision can be assessed from the moment a newborn opens her eyes, as long as the optometrist knows what to look for and how to look. Testing children does not have to involve forcing them to sit still and stare through a clunky machine. Instead, we use many hand-held instruments – and even things that look like toys – that allow for observations of a child's visual processes during various tasks. We are able to assess for nearsightedness, farsightedness, and astigmatism; teamwork between both eyes; control of eye tracking; focusing stamina and flexibility; eye health; and clarity of eyesight even with children that are not yet speaking. In general, if your child opens their eyes and looks, their visual system can be assessed.
Why does my doctor say vision therapy doesn't work?
Not all doctors are created equal. There are decades of research supporting the effectiveness of vision therapy for vision problems that interfere with reading, writing, and attention. But some doctors are not aware of these studies. If you're interested in reading the research, the College of Optometrists in Vision Development has compiled summaries of over 400 articles here. And if you're especially eager to spread the word about the latest advancements in vision treatment, please fill out the online form to let us know who you doctor is, and we will contact them.
Why doesn't every optometrist provide vision therapy?
I often ask myself the same question. Most optometry school programs emphasize diagnosis and treatment of eye diseases instead of functional vision problems, although disease occurs in 1 to 4% of the U.S. population, while functional problems have a prevalence rate of 15 to 25%. After graduating from optometry school, the amount of time and money required to learn about this specialty can be daunting. And the amount of time required to evaluate patients does not fit into the modern medicine's model of efficiency. But as more people are becoming aware of these vision problems, doctors are responding and starting to offer vision therapy in their offices. There is also a groundswell of young optometry students eager to provide care to this under-served segment of patients. And there are many excellent optometrists that will test for functional vision problems and refer to another optometrist for treatment.
The school says my child needs more practice with reading and writing. Should we work with a tutor first?
Many families that we see have tried extra practice, like working with a reading specialist in school, hiring private tutors, or visiting learning specialists. These professionals have well-designed programs to help children learn to read and write. If vision problems are present, the well-designed programs do not work as well as expected, and often lead to more frustration.
What about video games?
Many parents report discrepancies in performance during video games compared to school tasks. Some children will sit still and play a game for hours, but won't tolerate reading or writing for 20 minutes. Video games are a very different visual task than reading and writing, and a child's good attention with video games is an indicator of how well they should be able to pay attention to reading and writing. And if good attention is displayed with some tasks but not with others, there probably is not an underlying problem like ADD or ADHD.
My child has really good eye-hand coordination with video games. So why is their writing so messy?
The visual demand of a video game is very different from that of writing. With video games, the player uses thumbs and fingers to repeatedly mash on the same few buttons over and over. When one level of the game becomes challenging, the player repeats it and repeats it until they become successful, mashing the same buttons in a slightly different sequence.
When writing, those same fingers much be controlled in a much more mature fashion, creating the patterns of 26 lowercase letters, 26 uppercase letters, 10 digits, and various punctuation marks and math symbols. And each writing task is different from another, requiring unique combinations of those numerous letter and number patterns. Many children do not have the control or integration of vision and fingers for writing.
At the risk of sounding facetious, video games do not provide the visual environment to build skills for academic success; if they did, we would have a nation full of geniuses, right?
How can you tell if vision problems might be interfering with writing?
If a child can verbally express an idea, but struggles to write the same idea, there might be a vision problem. There could also be a problem with hand control, what occupational therapists call "fine motor" skills. Does your child draw well, but struggle to write ideas? The fine motor skills are being applied to drawing, but writing letters, words, and ideas is a far more complicated visual task than just drawing pictures.
What about dysgraphia?
Many children with these vision problems may be identified with dysgraphia. For example, if the eyes do not move well, how are they supposed to monitor where the hand is moving when writing? When the vision problems are overcome and the child is giving the opportunity to apply the new visual skills to writing, the dysgraphic behavior can disappear. When we work on writing skills, our clinical goal is not just neat writing, but good spelling while writing a sequence of ideas.
What does vision have to do with spelling? Isn't spelling a language thing?
Yes, spelling is a language thing, but it is a visual language. When writing, we need to make it look right. English is a totally unfair language: the letters and sounds sometimes match up and sometimes they do not. Children with vision problems often lean on a strategy of spelling words the way they sound, for example /because/ becomes /bikuz/, or /what/ is /wut/.
In some cases, children remember that a word has an extra letter that doesn't make a sound, but they still don't recall how the word is supposed to look, so /train/ becomes /trane/. Sometimes children can recall the letter sequences long enough to write the words correctly on a spelling test, but misspell the same words when using them in a story a few days later. Sometimes the vision problem is so severe that the spelling words practiced during homework are forgotten the next day during the test.