The Role of Accommodations in the Management of Visual Problems

Accommodations are modifications in the visual demands of a task with the intent of making the task easier. When visual problems are more severe, accommodations will be less effective or totally ineffective. The accommodations that I am going to address here are those that relate to the difficulties that students with healthy eyes have learning and while taking examinations.

The children who would receive that most benefit from accommodations are many children who have undiagnosed visual problems. These children have been able to cope with tracking, crowding, eye-hand coordination, focusing, and eye teaming problems, but school work could be easier for them and they could perform better if the print was bigger, the pages less crowded, they had frequent breaks, and they had more time to complete their work.

Children with diagnosed visual problems typically have more severe visual difficulties. While the above accommodations may still be appropriate, their effects will be limited.

This became personal for me lately due to the need for hip replacement surgery. Prior to the surgery and during the recovery, there were things that I just could not do regardless of accommodations. When I was able to “walk” with a walker and then for short distances with a walking stick, this was still far from walking automatically. I had to attend to walking. I was slow. There was little that I could think of other than walking due to the attention required and the associated discomfort. I fatigued quickly. Other parts of my body hurt from compensating. Student’s visual problems are no less incapacitating. I can look forward to putting this in my past. Without effective treatment, this will not happen for the children with significant visual problems.

A common example is a child who can keep their place much better when they point to each word with their finger. They cannot read without the finger and this can seem like a miracle, but it should not be equated with normal reading. It is similar to walking with a walker. It cannot be smooth. It takes longer. It is more tiresome. Attention is distracted from the reading material (comprehension) to the mechanics of reading. It is clumsy.

We will continue to recommend accommodations as appropriate. We don’t take crutches away from people who need them, but everyone who works with these children cannot forget that the effects of their problems have not been eliminated, even in the short-term.

Ironically, visual problems are less visible than many other problems. When I am walking with my walking stick, everyone knows that I have a problem and they do not expect me to function as if I did not have the problem. That can only happen when my problem is resolved. The same is also true for visual problems.

For More:



Eye-Hand Coordination

Visual Factors in Reading

Vision Therapy is Messy

In his book Messy: How to be Creative and Resilient in a Tidy-Minded World, Tim Harford provides examples of how extreme organization and structure, reduced diversity, and oversimplification makes things easier but constrain and compromise outcomes.

Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;

-eye alignment and movement,


-object perception, spatial perception, and guidance of movement

is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.

All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.

Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.

Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.

Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity.  The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits.  Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.

Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.

Curiosity and a Core Curriculum

We have a brand-new grandson. When he is awake he is constantly exploring; looking and reaching. He does not need to be taught the important things that he needs to be learning at this stage of his life. He just needs love, health, and opportunity.

As he grows, it is important that he keep that curiosity, not just for learning, but for joy and amazement. Young children are resilient. They do not quit. They keep trying as long as they are interested; as long as it is something that they want.

We all agree that there are things that children should learn to prepare for life and life’s responsibilities. How can this innate curiosity be wedded to this process? If they are not interested in learning arithmetic or how to read, is that due to them or to us?

Oliver Sacks was not an average person. His talents and accomplishments were many. He loved learning, libraries, and museums, but not school. His reading was deep and varied, but reading was not his primary method for learning. He experienced, he observed, he questioned, and he reflected. His is still just one experience from one person, but his words and thoughts are worth considering. The following are from Everything in its Place: First Loves and Last Tales which is a collection of his writings that were just published. They are on learning, on school, on the complexities of reading, and on the importance of nature – things for us to experience, question, and reflect on.

On the whole, I disliked school, sitting in class, receiving instruction; information seemed to go in one ear and out the other. I could not be passive – I had to be active, learn for myself, learn what I wanted, and in the way that suited me best. I was not a good pupil, but I was a good learner, and in the Willesden Library – and all the libraries that came later – I roamed the shelves and stacks, had the freedom to select whatever I wanted, to follow paths that fascinated me, to become myself.

Reading is a hugely complex task, one that calls upon many parts of the brain, but it is not a skill humans have acquired through evolution (unlike speech, which is largely hardwired). Reading is a relatively recent development, arising perhaps five thousand years ago, and it depends on a tiny area of the brain’s visual cortex. What we now call the visual word form area is part of the cortical region near the back of the left side of the brain that evolved to recognize basic shapes in nature but can be redeployed for the recognition of letters or words. This elementary shape or letter recognition is only the first step.

From this visual word form area, two-way connections must be made to many other parts of the brain, including those responsible for grammar, memories, associations, and feelings, so that letters and words acquire their particular meanings for us. We each form unique neural pathways associated with reading, and we each bring to the act of reading a unique combination not only of memory and experience, but of sensory modalities, too. Some people may “hear” the sounds of words as they read (I do, but only if I am reading for pleasure, not when I am reading for information); others may visualize them, consciously or not. Some may be acutely aware of the acoustic rhythms or emphases of a sentence; others are more aware of its look or its shape.

As a writer, I find gardens essential to the creative process; as a physician, I take my patients to gardens whenever possible. All of us have had the experience of wandering through a lush garden or a timeless desert, walking by a river or an ocean, or climbing a mountain and finding ourselves simultaneously calmed and reinvigorated, engaged in mind, refreshed in body and spirit. The importance of these physiological states on individual and community health is fundamental and wide-ranging. In forty years of medical practice, I have found only two types of non-pharmaceutical “therapy” to be vitally important for patients with chronic neurological diseases: music and gardens.

I cannot say exactly how nature exerts its calming and organizing effects on our brains, but I have seen in my patients the restorative and healing powers of nature and gardens, even for those who are deeply disabled neurologically. In many cases, gardens and nature are more powerful than any medication.

For More:

The Enchanted Hour

The Rights of the Reader

How Children Succeed: Grit, Curiosity, and the Hidden Power of Character

More Posts including Oliver Sacks:

Reflections on Change

Mapping the Wilds of Mortality and Fatherhood

Narrative Medicine

Memory Book

The River of Consciousness

The Mind’s Eye: Oliver Sacks

Understood Betsy

Dorothy Canfield Fisher

Understood Betsy is not a new book, but the themes are current and the messages and wisdom expressed are timeless. The book is worth reading for the story alone. Betsy is being raised by a doting aunt after her parents died and learned helplessness and fear are being nurtured by this fragile individual. Due to an illness in the family, she must be sent to relatives who live on a farm in Vermont. Betsy has been indoctrinated to understand that these relatives are not nice people and that this would be horrible for her. As soon as she arrives, her experiences appear to verify her expectations. She seems to be disregarded and expected to do things far beyond her abilities. Despite her expectations, she is surprised to discover that she has abilities she never knew that she had. She gradually experiences self-discovery through doing, by mastering useful skills while developing the confidence to face challenges and be responsible for herself and others. She starts to think for herself and model her decisions from what she has observed of her aunt in Vermont who she fears at first. She develops grit and the self-assurance necessary to be able to think of others and to care and help others.

The apparent clarity of explicit teaching can deceive us and cause us to forget the timeless power of stories to teach by example. I especially recommend this book to parents. It is a wonderful book to read aloud and share. It was written just over 100 years ago. Concerns about raising happy, competent children are not new. The world was also changing rapidly at that time as people were moving away from farms and nature due to industrialization, perhaps as dramatic a change to adapt to as those that we are currently experiencing. School was becoming industrialized instead of the interactive, personalized education of the one-room school house with a core message, continuity, and community. I enjoyed reading the book at least as much the second time.

More about reading:

The Enchanted Hour Part 1

Reader, Come Home

The Neural Basis of Reading

The Power of Play

David Elkind

This book addresses the concerns that many of us have about ignoring child development and the ranges of development within a grade level and even within individuals when educational standards are set. David Elkind reminds us that most children are enthusiastic learners in the appropriate circumstances but may be anxiously unsuccessful in other conditions.

He addresses the misconception of equating faster with better and approaches what children do and how they feel from the integrated perspectives of love, play, and work. I will touch on his primary message through the following excerpts.

Children’s play – their inborn disposition for learning, curiosity, imagination, and fantasy – is being silenced in the high-tech, commercialized world we have created. Toys, about which children once spun elaborate personal fables, now engender little more than habits of passive consumerism. The spontaneous pickup games that once filled neighborhoods have largely been replaced by organized team sports and computer games. Television sitcoms and movie CDs have all but eliminated the self-initiated dramatic play that once mimicked (and mocked) the adult world. Parents, anxious for their children to succeed in an increasingly competitive global economy, regard play as a luxury that the contemporary child cannot afford.

            The health consequences for children resulting from the disappearance of play are already apparent. At the first ever Surgeon General’s Conference on Children’s Mental Health in 2000, it was reported that “growing numbers of children are suffering needlessly because their emotional, behavioral and developmental needs are not being met by the very institutions that were explicitly created to take care of them.” Over 20 percent of the child population now suffers from these problems. Moreover, the surgeon general also suggests that two-thirds of the children in this country suffers at least one health problem. Thirteen percent of our children are obese. We have more than 2 million children on Ritalin and other ADHD medications. This may be the first generation of American children who are less healthy than their parents.

            Our increasingly test-driven curricula have all but eliminated creative and playful teaching practices.


            All too often children’s spontaneous active play has been transformed into passive audience participation.


            I now appreciate that silencing children’s play is as harmful to healthy development (if not more so) as hurrying them to grow up too fast too soon.

            Like other human potentials, imagination and fantasy can only be fully developed through practice. Yet the sheer number of toys owned by contemporary children weakens the power of playthings to engage children in dramatic thinking.


            The complexity of electronic technology changes the child’s intellectual engagement with these toys. The mechanics of soapbox cars and windup toys are easy for children to understand. Toys with embedded microcontrollers, in contrast, work as if by magic.


            Parents who talk, play with, or sing to their young infants or toddlers give them much more than any DVD or television program ever could. The most important stimulus to healthy growth and development for infants and young children is affectionate human interaction.

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            Parental angst leads to the overprotection, overscheduling, and overprogramming of contemporary children. It originates in pressures unique to contemporary family life…. Hyperparenting gets in the way of seeing our children as separate individuals and from supporting the healthy ways in which they are different from us.

            I have been working with children and families for almost fifty years, and children still develop in the same way and at the same pace.

            I have serious doubts that infants and toddlers learn anything beneficial from a computer program. Any possible benefits are more than offset by what the experience does to their inclination for self-directed learning.

            It is only after children have attained the age of reason that they can learn verbal rules – the basis of formal instruction. A summary of European research on early childhood education submitted to the British House of Commons is representative of the research on this issue:

Comparisons with other countries suggest that there is no benefit to starting formal instruction before the age of six. The majority of other European countries admit children to school at six or seven following a three year period of pre-school education which focuses on social and physical development. Yet standards of literacy and numeracy are generally higher in those countries than in the U. S., despite our earlier starting age.

            But it is not until the age of reason that they can break the phonics code and understand that letters are in fact units. To truly appreciate phonics the child has to understand that one and the same letter can be sounded in different ways and that different letters are sounded in the same way.

            A child’s verbal facility often gives a false impression of their level of mental development.

            We see many similarities between patterns of behavior bringing about successful socio-dramatic play experiences and patterns of behavior required for successful integration into the school situation. For example, problem solving in most school subjects requires a great deal of make-believe: visualizing how the Eskimos live, reading stories, imaging a story and writing it down, solving arithmetic problems and determining what will come next. History, geography, and literature are all make believe. All of these are conceptual constructions never directly experienced by the child.

Thinking Goes to School:Piaget’s Theory in Practice

Hans G. Furth and Harry Wachs

There has always been a temptation to ignore the influence of child development. Development takes time; not everyone develops at the same rate; and all areas may not develop on the same schedule within one individual. There is an increased temptation to ignore development when there is pressure to push students to meet short-term academic goals. Technology can delude us into believing that developmental constraints can be circumvented due to the easy and interesting access to data that technology can provide, but there is no substitute for interactions with real objects, real activities, and real exchanges with other people to stimulate thinking and problem-solving and to develop visual skills, language, balance, inhibition, and social skills. Since only so much can be squeezed into the school day, an increased pressure on academics is also associated with a decreased emphasis on the areas of development reported on The Other Side of the Report Card.


Thinking Goes to School was written in 1974. We had Dr. Harry Wachs come to Owego 35 years ago to present a seminar to teachers on child development and on vision and learning. There was more interest in the development of learning readiness at that time as many schools were using the McGuinness/Hammondsport program. In that program, children worked through a series of visual and auditory activities designed to support the development of essential perceptual processing prior to formal instruction in reading and math. With all children doing the same program, regardless of their level of development, the results were diluted and the program was gradually discontinued. The purpose of the curriculum was to free students from having their performance handicapped by the need to focus on low-level skills as explained in the excerpt below on typing. The distinction between learning facts and learning how to think and problem-solve was central to Piaget’s understanding of development. In presenting their curriculum, Furth and Wachs wrote the following.


“Our belief that the majority of kindergarten children are not ready for formalized academics is reflected by the lack of scheduled academic activities.”

“Piaget’s theory erases the traditional distinction between activities of the mind and activities of the body. Movement and thinking are interdependent.”


“As adults we may forget the complexity of what appear to be, on the surface, simple movements, yet the majority of us do tend to be somewhat clumsy when mastering a new physical task. Our performance may fall short of our expectations when we are beginners. For example, merely memorizing the keyboard of a typewriter will not lead to fluent typing. The typist must also learn the finger movements. Until he does this, his movements will be slow, planned, and deliberate. His attention will be divided between what he is doing and how he is doing it. After he has mastered the movement thinking control, he is free to concentrate exclusively on the material being typed. Similar problems are faced by the child when he is first given a pencil and asked to write.”


“While we recognize the educational value of directed classroom teaching and instructional television programs, we know that all children are not equally ready to benefit from the same situation at the same time. In addition, physical participation in activities is necessary for the child’s healthy intellectual development; passive observation is not enough.”


Reading Instruction in Kindergarten

Reclaiming Childhood:Letting Children Be Children in Our Achievement Oriented Society

Let Them Eat Dirt

Balanced and Barefoot

The Happy Kid Handbook