- How do children acquire skill in the use of their visual abilities?
- Why aren’t they getting the appropriate experiences at the right time?
- How do optometry and education complement each other in helping children with reading and learning problems?
- What percentages of school children have these problems?
- Now that the problem has been identified what will happen?/What is Vision Therapy?
- Within what kind of time frame should I expect to see change?
- How long until reading changes and what types of changes may I see?
- When will problems copying from the blackboard get better?
- Are timed tests a problem and if so, when should I expect this to cease being a problem?
We learn to use the visual process over time. They develop as a result of meaningful life experiences that children have prior to entering school and are thereby a product of the environment we grow up in. Visual skills and abilities are learned primarily through movement and interaction with our three-dimensional world.
A child with a limited set of experiences should not be expected to acquire skill merely as a result of surviving a certain number of years on this earth. Time alone does not cause development. Good development is the result of the appropriate meaningful experiences occurring at opportune times in a person’s life.
Learning how to fixate on an object, shift visual attention from one point in the visual array to another, precisely align both eyes with ease for sustained periods of time, and shift attention from distance to near and back again are all developed skills. A child who has not had appropriate life experiences in meaningful ways may come to school without these requisite skills.
A behavioral optometric evaluation can be compared to taking an inventory of these visual abilities and skills and finding which are present and which may not yet have emerged. The lack of the emergence of these visual abilities does not represent a physical or physiological or mental deficit. The vast majority of what we see in clinical practice are visual development problems.
There is no simple answer to this vital question. Parts of it will be found in many areas and blaming one exclusively will not lead to a resolution of the problem for large numbers of children. The following is a list of some of the potential culprits and a bit about what types of problems they may be causing.
- Not enough self-directed movement while young: In our modern fast-paced society, families seem to always be on the go. So we transfer our young child from the baby carrier to the car seat to the stroller and we move them around for much of the day, rather then having them exploring the world around them with their own visually directed mobility.
- Attention demands too short: So many of today’s television shows geared for children are so fast-paced that they seem to flit from one thing to another, barely giving the child the opportunity to learn to sustain attention.
- Too many pictures supplied rather than constructed by the child: When a child gets to listen to a reader who orates in an interesting manner, using descriptive prose, the child gets the chance to learn to make, modify and recall visualizations and visual imagery, which will become the basis for spelling and reading later in life. When a child is given a steady diet of graphics and cartoons they become passive viewers of “interesting” content but they don’t get the opportunity to develop the necessary mental imagery skills.
3. How do optometry and education complement each other in helping children with reading and learning problems?
The Toolbox Analogy
This analogy was beautifully written and provided by the Optometric Extension Foundation
Imagine that we have delivered to a plot of land all of the necessary raw materials needed to build a house. Piles of wood, nails, screws, drywall, cinder blocks, plumbing supplies, electrical supplies, cabinets, doors, windows, roofing materials, etc. are all present in abundance. The child brings to that work site each day their toolbox. The tools in that toolbox have been acquired over the years based on the life experiences that child has had. Some children enter the worksite with a rather complete set of tools to cover most needs, while others have only the essentials or may in fact be missing even a core or fundamental tool. Fundamental or required tools might be considered to be a hammer, a saw, a screwdriver or a tape measure.
In general, schools assume two things. The first is that most children enter with the set of tools that will carry them through their academic career and that the fundamental set of tools that a child brings to school is fairly set or immutable. The child is placed into a series of courses such as Carpentry 101, Plumbing 101, and Electrical Systems 101. In Carpentry 101 they may begin with the simple tasks of measuring and marking lumber to be cut to length, how to start, drive, and set a nail, and making a cross-cut saw cut safely, accurately, and square. To a child coming to the workplace with a basic framing hammer, a handheld crosscut saw, and a Stanley 25 foot tape-measure these beginning classes may come rather easily. To a child missing one or more of these basic tools, failure to achieve basic “educational” goals may become evident rather early on.
Generally in the education system a child comes to the attention of their teacher before testing for a problem is initiated. To qualify for services their performance must have fallen to a certain measurable amount.
Many resourceful and smart children who are missing fundamental tools may find ways to get the job done although they are not using the proper tool. They might find a rock to use as a hammer or they might use a monkey wrench to hammer in the nails. The job gets done but it takes longer, the job isn’t done as well and there may be some wear and tear on the child that would not have been present had the child used the proper tool for the job. However, the child, due to a lack of the appropriate developmental experiences is/was lacking the tool. This degree of compensating can often serve to mask the discovery of a missing fundamental tool for quite a while in a resourceful child.
Once the teacher realizes the child is having a problem, the school system will initiate a series of tests to identify the problems. Psychological educational testing often correctly identifies the general category of the problems, such as carpentry or plumbing but may fail to recognize that the lack of a tool may be the problem. Here is where a false assumption dooms the child to an intervention program that will actually work to embed the problem even more. How?
A hammerless child is labeled as “hammerless” or “hammer compromised.” The system then looks for special education materials that have been shown to be able to be mastered by those without hammers. The idea has been that the child who does not have a hammer should not be penalized for not having a hammer and we should not ask them to do things that require hammers. Therefore a program has been conceived and produced in, for and by the school, which addresses hammerless children’s needs.
The hammerless child will be given activities, which will not require them to use a hammer. Either they will now use screws and screw guns for everything or they will switch to learning to assemble prefab home kits. The child will advance through the rest of their courses but a fundamental tool and basic skill necessary to nearly any home building project will be missing, the ability to use a hammer. The false assumption was that once hammerless, forever hammerless.
The education system is not in the business of tools. They are in the business of tool usage. “Missing tool? Oh well you’ll just have to learn to accept your hammerless condition and arrange things differently so that you don’t encounter hammering demands in school life.” Real life then becomes another matter.
The key factor in behavioral vision care is that our assumption is that the presence of a missing tool is only evidence of not having had the appropriate meaningful experience to have developed or acquired that tool. We are in the business of identifying the missing tools and then putting together treatment protocol. The purpose of which is to provide the child with the necessary meaningful experiences to acquire the tool.
In essence, we take the child shopping. We know that hardware stores exist. We know the fundamental classes of tools. We know the order which people generally acquire tools. One would not start their saw collection with learning how to use a coping saw or a compound miter saw. One starts with a handheld crosscut saw and learns by cutting basic lumber to length. A rip saw may follow. Then a circular saw, jig saw, table saw, band saw, coping saw etc. each experience being built on the prior knowledge base all which came from the handheld crosscut saw. This process of tool acquisition and attaining fundamental competence in the use of the skill is the domain of optometric behavioral vision care. We turn over to the school system a child who now possesses the correct array of tools to perform the tasks required of them. When the school system moves on to fundamentals of balloon framing houses or the proper method of trussing up a floor the child will have the tools necessary to execute the demands of the class, understand the concepts, and to use the proper tools for the proper job.
Behavioral vision care optometrists do not teach carpentry, plumbing, or wiring. Behavioral vision care optometrists do not teach reading, writing or mathematics. Behavioral vision care optometrists do identify missing tools and take the child shopping to acquire and gain competency with the new tools. Then, and only then, will the school system find a child who is ready to be taught using conventional methods and who will achieve in a variety of educational settings and following a variety of teaching methods.
The answer to this question certainly depends on a number of variables, including what groups of children we are talking about and at which aspects of visual development we are looking. A study was done by the New York State Department of Education in conjunction with the New York State Optometric Association, in which they did testing on random samples of children in all socioecomic groups throughout New York State. It was found that around 23% of the general school population had visual development problems that were affecting learning in a significant way.
In this study, when you looked only at those children identified under public law 94-142 as needing extra help in school, the percentage climbed to 93%. In a study done in Baltimore with juvenile delinquents at the Hickey School in the late 1980’s, I found the number of these 14-18-year-old boys with visual development problems to be in the mid-90’s percentage wise. In another study in the late 1990’s in several Baltimore City public schools, it was found that over 80 percent of the children had primary visual development problems. Without the visual problems being addressed, simply reducing class size, getting better text books, finding better teachers, or changing the pay system to a merit system will not result in significant gains. The visual problems need to be addressed so that the children can then benefit from their education.
The primary method of treating a visual development problem is to arrange conditions to provide the person with the necessary meaningful experiences to acquire these needed skills and abilities. The method whereby this is done is called vision therapy.
During the early phase we will be building foundation skills and abilities, which may not translate immediately into observable changes in the classroom. These early changes will involve gross motor abilities along with acquiring the fundamental visual skills and abilities. The child may exhibit a decrease in symptoms such as headaches or blurred distance sight after doing close work.
Once the core skills are established, the therapy will focus on elaborating on those skills and abilities so the child can apply them to real life demands. These real life encounters may be similar but actually require slightly different skill sets than used earlier in therapy. The child will need to learn how to use these new skills by shifting from one application to another with ease.
The last phase of treatment has two major purposes. The first is to automate the newly acquired skills and abilities so that the new skills are simply called on when needed without any conscious thought. The second is to help the child generalize the new skills so that as life throws new challenges, they can immediately call on what they have learned and make the necessary adjustments, again almost without conscious awareness of having done so.
The time-frame for seeing change will vary with the degree of the problem, the age of the child, the intensity and regularity with which the home practice sessions are completed, and many other factors. Generally, by the eighth week of visual therapy changes are beginning to be noticed by all. At first, these may only be that the child is staying on task a bit longer or doesn’t have to be restarted on homework assignments so many times. Often the child is beginning to notice things in their environment, many of which may have been there all the time but are just being recognized.
A major visual development step is the ability to track and fixate with eyes only. In cases where this was not present, I see this emerging by the 10-week progress evaluation. The visual therapy begins in free space with real physical objects and moves to working in the two-dimensional plane of paper or a blackboard at about this time. Since visual development follows this course one of the early signs of change is often in sports. The child with emerging spatial competency is more aware of where they are in space in relation to others and to objects and as a result of this they interact with these things more accurately and more consistently.
Reading is a complex process that is dependent on many visual abilities as well as a host of other skills. Much of the early emphasis in the visual therapy programs is aimed at the fundamental visual abilities. These foundational skills are necessary to build on, but often do not have an immediate effect on improving reading performance. Early on, the major effects might be that the child can stay on task for a longer period of time before tiring.
A major developmental hurdle is learning to move the eyes only when shifting visual attention from one place in space to another. Once this has been achieved we often see renewed interest in near tasks that involve sustained use of vision for deriving meaning. The fact that the child can now do this kind of task often helps them feel better about themselves, and early changes in reading may not be directly from the actual visual therapy, but indirectly from the changes in the child’s self-image and feeling that they are not dumb, that a real problem had been found and that it is being addressed.
As the therapy progresses we often see a pick up in the fluency of reading at their current instructional level. Mechanically we see the child begin to take in a larger perceptual chunk, resulting in them not needing to stop so many times with their eyes per unit of text. Because less effort is needed to keep their place, to keep the print clear, and to plan where to go next, as well as keeping both eyes directed accurately so that their inputs are complementary, more of the child is left to learn from the experience.
Over time we see a consolidation of gains at a level of reading material followed by a non-linear jump to a new demand level. When that happens there is a short period of time when the mechanics seem to make a downturn. This is because it takes more thought, reflection and some conscious effort to decode new words and to find the appropriate meaning in more complex contexts at the new level. Over time this too becomes consolidated, with a commensurate period of time of improvement in the mechanics again. This continues cyclically during the course of treatment as well as continuing for many months after treatment has been completed. This can also be seen in normally developing readers at the appropriate developmental time.
To recap, we first often see improvements that are more secondary to attitude differences than to actual treatment effects. Once the “eye movement free of the rest of the body” target has been achieved there is often a new ability to sustain near centered visual attention, which can be seen in renewed interest in close work. Then begins a cycle of change; beginning with improved mechanics at the current demand level and followed by a jump in the demand level that can be understood. During the early part of the jump to the new level the mechanics typically suffer for a finite period of time.
Difficulties in copying from the blackboard come in two flavors. The first is problems secondary to clarity problems. A child who is nearsighted sitting in the back of the room without glasses or contact lenses may not be able to see the letters and differentiate them well and therefore may make lots of mistakes or copy the wrong thing entirely. Generally no amount of treatment will address this. Some form of eyewear, glasses or contacts, are needed to address this problem.
The second and more common problem affecting copying from the blackboard is the problem with fixation and tracking already noted. The child may be incapable of remembering where they were as they shift from one place to another. So when they return to the blackboard after writing down the last portion seen, they may be unable to relocate where they were. This ability to leave a mental marker from the last fixation point is taught in therapy and often comes in between the 8th and 10th week of treatment and certainly should be present by the 16th week. So problems related to fixation and tracking respond to treatment rather quickly. In the meantime it might be helpful to give a child with this type of problem a copy of their assignments so that they can have it at their desk and they are not penalized for making copying mistakes.
Many children with learning related visual problems fall apart when put in timed situations. The added pressure of having to work fast may be the straw that breaks the camel’s back, causing many of these children to “melt down”. During the first 8-10 weeks we are working to build fundamental visual abilities. From that point on, although more skill building and elaboration are being done, we shift emphasis to being able to multitask and to perform under pressure.
This aspect of treatment is aided by the use of a stop watch. A number of activities are timed and emphasis on some activities is shifted away from perfection to speed. Some errors are accepted in order to get the child moving. Once moving, then the emphasis shifts back to increased accuracy and then back to faster speeds. These cycles are built into many of the visual therapy activities all the way to using guided reading in the last 8-10 weeks of treatment. Here a moving window flies over text to be read about 20-30 words per minute faster than the speed at which the child is currently reading. These sessions of being pulled over text a bit faster than is comfortable pay great dividends. It also reduces the number of regressions in text (going back to the left within a line of text to reread a section) because the window only moves forward and does not allow for regressions to be of any help when reading.
So the bottom line here is that many of these children have trouble with completing work on time and when time pressures are added they may crumble. However, vision therapy specifically targets this and most children make very quick changes here. Generally from 4-6 months into treatment timing issues are no longer a concern.