What You Can Do When Learning and Attention Problems are Due to a Vision Problem

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By: Carole L. Hong, OD, FCOVD


Photo Credit: Belinda Hankins Miller

According to the College of Optometrist in Vision Development, while learning occurs through a number of complex and interrelated processes, vision plays a key role. What can you do to help your clients after you have performed a vision screening or referred them for a developmental vision examination as part of your interdisciplinary evaluation? In this article you will find some simple strategies and accommodations that you can suggest or implemented when visual problems are suspected, detected or being treated.

To rule out a learning-related vision problem, the first step is a developmental vision examination. This is often performed after a comprehensive vision and eye health examination has ruled out any pathology or visual acuity problems. Annual eye examinations are important between 6-12 months of age, three years, five years and once every year while in school. When a learning-related vision problem is identified, treatment may include prescription glasses or contact lenses, prisms and/or office-based optometric vision therapy.

First and foremost, vision is the ability to derive meaning from the world, and to guide the intelligent movement of the body. It used to be thought that having 20/20 eyesight, and having healthy eyes, was sufficient to be visually prepared for success in this world. But what we know today is that the visual skills necessary for learning go far beyond the ability to see 20/20 and having healthy eyes.

There are 17 visual skills necessary for reading and learning success and they can be separated into seven main categories. A link to a complete list of visual skills can be found on the website for the College of Optometrists in Vision Development at www.covd.org.

Following is a list of the seven main categories along with the signs and symptoms, suspected causes, and accommodations which can be made until the underlying vision problems are resolved:

  1. 20/20 Visual Acuity: Clarity of sight at far and at near distances.
    • Signs and Symptoms: complains of blurred vision, rubs eyes frequently or squints, headaches, abnormal working distance when reading
    • Suspected Causes: need for glasses (nearsightedness, farsightedness or astigmatism), ocular disease, amblyopia or lazy eye or underlying focusing or eye teaming problems
    • Accommodations: Make sure glasses are worn as specified, reduce distance to see (i.e., sit close to the board), enlarge font, minimize near/far copying, have good lighting and encourage proper posture and optimal working distance. Research on human ergonomics has determined that the optimal visual distance for reading and other close work is the Harmon Distance or “Elbow Distance”. This distance is measured by placing a closed fist at the eyes. The point at the end of the elbow represents the closest distance a person should be from their near work.
  2. Eye Teaming: To coordinate and sustain the use of the two eyes together effectively at far and near distances. This is vital for tracking and maintaining single clear vision.
    • Signs and Symptoms: Closes or covers an eye, tilts head, double vision, words move on the page, motion sickness, rubs eyes, excessive blinking, only able to read for a short time, reduced reading comprehension, close working distance, avoidance of near work, decreased depth perception, poor eye-hand coordination or poor handwriting
    • Suspected Causes: Significantly different prescriptions required for each eye, amblyopia (lazy eye), convergence insufficiency (eyes drift apart) or convergence excess (eyes tend to over-cross), strabismus (eye turn), head injury, tumor (rare)
    • Accommodations: Frequent breaks, 20/20/20 rule (for 20 seconds, every 20 minutes, look 20 feet away), provide extra time to complete tasks that require prolonged near visual attention, break up assignments into smaller components, allow the student to do palming (putting palms of hands over closed eyes) when tired, after reading, or during tests. Provide him/her 30 seconds to 1 minute to do this.
  3. Focusing: Rapid automatic focus adjustments, essential for sustained reading or copying from the board. The eyes must have adequate focusing ability, flexibility, accuracy, and stamina in order to visually inspect, scan, and maintain attention for the length of time required to do schoolwork.
    • Signs and Symptoms:Holds things very close, eyes tearing, blurred vision at near or when going from near to far, poor reading comprehension, fatigue or tired eyes, easily distracted, headaches when reading, excessive time copying from the board or to complete assignments, day dreaming, avoiding close work, reduced comprehension or slow reading speed
    • Suspected Causes: undetected or excessive farsightedness, visual stress, eye teaming problems, certain medications
    • Accommodations: The same as for visual acuity problems noted above.
  4. Tracking: To quickly and accurately move both eyes from place to place as well as smoothly follow a moving object.
    • Signs and Symptoms: Moves head side to side when reading, frequently loses place when reading, writing or copying, skips or rereads words/lines, uses finger to keep place, poor reading comprehension, tired eyes, short attention span, difficulty with sports (hitting, catching, etc.)
    • Suspected Causes: poor eye-teaming or binocularity, poor development of eye movement control as related to an underdeveloped vestibular system, balance and core muscle strength
    • Accommodations: Using a finger, marker or line guide to help keep one’s place when reading, use graph paper for math problems, give more time on tests/assignments that involve reading or aligning columns, listen to books on tape, allow more time or minimize copying assignments, provide assistance with scantron answer sheets, enlarge print and/or have fewer items or words each page
    • Additional Treatment: Be sure to consult with an occupational therapist for additional evaluation and/or treatment.
  5. Visual Analysis: Visual discrimination of size, shape and form, used to identify, sort, organize, store and recall visually presented information. It is the ability to take in maximum visual information in the shortest amount of time, remember it and apply it later
    • Signs and Symptoms: Mistakes words with similar beginnings, difficulty recognizing or writing letters, numbers, words, or simple shapes and forms, over-generalizes and confuses minor likes and differences, can’t distinguish the main idea from insignificant details, trouble learning basic math concepts of size, magnitude, and position, traces or touches figures, hyper- or hypo-active, distractible, problems concentrating, poor comprehension, poor speller, poor recall of visually presented material
    • Suspected Causes: Inadequate visual skills development may lead to faulty information storage and retrieval
    • Accommodations: Provide multi-sensory support from auditory and tactile (hands on learning) systems, reduce confusion by limiting information on each page
    • Additional Treatment: Be sure to consult with an educational specialist and an occupational therapist for simultaneous guidance, evaluation and/or treatment.
  6. Visual Spatial (Laterality and Directionality): Skills we use to understand directional concepts that organize our visual space.
    • Symptoms: Trouble learning right and left, reverses letters, numbers and words when writing or copying, trouble writing and remembering letters and numbers, lack of coordination and balance, clumsy, difficulty with activities involving rhythm, does not cross the midline when doing tasks (switches objects from hand to hand), does not use nondominant hand for support when writing or copying, rotates body when writing or copying
    • Suspected Causes: weak knowledge/understanding of rights and lefts on self, poor bilateral integration, poor visualization skills
    • Accommodations: Again, provide auditory and tactile systems, give cues to spatial coordinates, use or learn cursive writing because it is more difficult to reverse letters than with printing
    • Additional Treatment: Be sure to consult with an educational specialist and an occupational therapist for simultaneous guidance, evaluation and/or treatment.
  7. Visual Motor Integration: To process and reproduce visual mages by writing or drawing
    • Symptoms: Sloppy handwriting and drawing, can’t stay on lines, poor copying skills, can respond orally but not in writing, needs extra time to complete tasks.
    • Suspected Causes: faulty visual input or visual analysis, weak fine motor or gross motor skills
    • Additional Treatment: Be sure to consult with an occupational therapist for evaluation and/or treatment if not already in place.

Depending on the depth of the vision problem, vision treatment can be as simple as wearing lenses to a program of both lenses and optometric vision therapy. The above list is provided to give you steps you can take to help your clients while optometric treatment is in progress. Collaborating with an Optometrist that provides developmental vision care can make all the difference. You can find a doctor at www.covd.org.

One final note, as everyone is preparing for back to school, it’s important to mention that August is National Children’s Vision and Learning Month. Many parents assume that a vision screening replaces an eye exam. Please tell the parent’s of your clients to put vision on their school-readiness checklist, especially if they have any of the symptoms noted here. Vision problems are among the top five most overlooked conditions that contribute to learning difficulties. If a child can’t see properly, school and daily things in life can seem nearly impossible.

Featured Author and Organization: Carole L. Hong, OD, FCOVD and the College of Optometrists in Vision Development (COVD)

About the Author:  Dr. Hong is residency trained and board certified in vision development and has been practicing for over 20 years in San Carlos, California. She often collaborates with OT’s, PT’s and SLP’s and provides excellence in children and adult vision care. Her practice has an emphasis on vision and learning; as well as, treatment of vision problems of those with special needs, strabismus (eye turns) or amblyopia (lazy eye,) head injury and stroke. She is an adjunct professor at SUNY State College of Optometry and Vice President of the College of Optometrist in Vision Development (COVD). She can be reached at (650) 593-1661 or [email protected]

About COVD:  The College of Optometrists in Vision Development (COVD) is an international, non-profit optometric membership organization that provides education, evaluation and board certification programs in behavioral and developmental vision care, vision therapy and visual rehabilitation. The organization is comprised of doctors of optometry, vision therapists and other vision specialists. For more information on learning-related vision problems, vision therapy and COVD, please visit http://www.covd.org or call 888.268.3770.

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