There’s more to vision than just needing glasses
“But he already has glasses!” Even though we were separated by the phone, I could tell the mom thought I was crazy. Her son wears glasses daily, and I just recommended that she take him for a vision exam.
“But there’s more to vision than just needing glasses” I explained. “He needs a COMPLETE vision exam, so we can see what’s going on.”
Now the mom’s voice was exasperated. “What are you saying? The doctor did an incomplete exam?”
There are different kinds of eye care professionals and different models of treatment. Some doctors may only check the eye health and if the child needs glasses. Others also check eye movement and if the eyes work together.
Max was in the third grade. He was diagnosed with ADHD but his meds just weren’t working.
“He’s in reading extra help and math extra help—but they’re not helping!?”
Mom’s mood changed from angry to confused to sad.
“He’s starting to hate school. I don’t know what to do!”
Unfortunately, this is pretty common for children with undiagnosed vision deficits. The parents get them glasses, so they think they’ve crossed vision problems off the list.
But it’s just not true.
The most common vision problem (besides needing glasses) that school Occupational Therapy practitioners encounter is binocular vision deficits.
But there are a huge number of vision problems that may be impacting a child’s schoolwork. It’s really important that children have a complete eye exam. Not just finding out if they need glasses.
Understanding Visual Efficiency with Children
Binocular Vision Disorders — when a child’s two eyes aren’t working together as a team. This may include strabismus, convergence and divergence. Binocular vision issues are more common in children with with learning disabilities, developmental delays.
Ocular Motor (Eye Movement) Disorders — Eye movements include pursuits, saccades, and fixation.
- Pursuits — The reflex to follow a moving visual stimulus
- Saccades — A single eye movement from one thing to another, such as words in a sentence.
- Fixation — The ability to keep the eyes focused on a stationary object.
Accommodative Disorders are also called Focusing Disorders. Children who struggle with looking from near to far and back again are among 5 to 6 percent of the general pediatric population (Scheiman, 2104).
Sometimes it’s Not ADHD, it’s Vision.
Very often, children with vision difficulties display behaviors such as:
- avoiding work
- taking much longer to complete reading and writing assignments
- complaining of headaches
- difficulty focusing and paying attention
These are also common symptoms of Attention Deficit Disorder. So it’s sometimes hard to tell what exactly is going on with that student.
WHAT IS A COMPLETE EYE EXAM?
There are two models of vision:
The One Component Model of Vision:
- Checks the health of the eye and if the child needs glasses
The second, called the Three Component Model of Vision:
- Checks the health of the eye and if the child needs glasses
- Visual Information processing skills (aka visual perception)
- Checks the child’s visual efficiency
- Accommodation
- Binocular Vision
- Eye Movements
An annual eye exam done by an Optometrist may not include all three of these components. It depends on the doctor’s training. It can be difficult to find an optometrist who will do an exam looking for more than glasses. But for some children, it makes all the difference in the world.
After all, it’s awfully hard to learn if you can’t see what you’re looking at.
Max’s mom listened to me explain the different types of eye problems that a complete eye exam would rule out. “I had no idea that my doctor may not have looked at that!”
She laughed ruefully. “Half of me is mad… and the other half is hopeful!”
I knew what she meant. Of course, she didn’t WANT Max to have a vision deficit besides needing glasses. But on the other hand—what if there’s been a hidden problem all along?
It’s time to UNCOVER those hidden vision problems!
ARE YOU A SCHOOL OCCUPATIONAL THERAPIST?
School Occupational Therapy practitioners can screen and remediate many different vision deficits. It’s important to receive training so you feel competent.
Sign up for Vision 101 for School Occupational Therapy Practitioners, an AOTA-approved online training for school occupational therapy assistants and therapists.
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Our therapy department just completed our second workshop with Robert Constantine, and he mentioned you might have something to share soon. So I am really excited about your course!
Any information on Irlen syndrome and when to screen kids? Will the referral be to a developmental optometrist?
I have been screening my students with an assessment from the National Reading Styles Institute (NRSI.com) in Syracuse, NY for a number of years. It looks at the impact of colour when processing written script. Many of my kids would never get access to a specific Irlen evaluation for this. By using the NRSI screening kit [all have 19 colors to screen with and kits cost $25. -100 depending on the size of filament you wish for screening). I find 1-3 students/year (working part -time) who benefit from a coloured filter to “stop words moving on a page”, etc. Kids see what they do and think it is normal. I had a very academically angry child in grade 4 call home crying, and told her he was sorry he never told her that things moved on the page. A child with fetal alcohol syndrome suddenly focused well with the dark red glasses. IF we as OTs can do a 5 min screening as we are looking at the ocular motor skills, we could impact even more kids lives. I carry about 8 sets of coloured glasses (from colorglasses.com) with me, and loan them when I find issues. They cost about $16 US each. Some students go on for further evaluation, some get the coloured glasses. Some autistic children benefit from them who have refused to wear sunglasses or who struggle with visual stimulation in general -once they find a colour that feels right. 2 school staff have worn them following a concussion (blue is common for this but not always). Hope that helps.
Irlen syndrome, also called scotopic sensitivity syndrome, is the term used to describe the discomfort caused when someone has hyper-sensitive photoreceptors making the pattern the text on paper uncomfortable which causes headaches and difficulty reading. It is considered controversial as there has been inconsistent results attempting to objectively demonstrate and diagnose the condition. I have heard enough anecdotes to think this is something we need in our “toolbox” but things like uncorrected refractive state, binocular vision problems and dyslexia are all more common than Irlen syndrome and should be ruled out before an Irlen evaluation. That said, Irlen assessors are specifically trained and you can find one near you here. https://irlen.com/find-an-irlen-test-center/
There is a new systematic review on IS here too. https://pubmed.ncbi.nlm.nih.gov/30970133/
Irlen syndrome is not covered in our course.