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,

-focusing,

-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.

Copying

Copying projected material is a compound skill like riding a bike or driving a car. It does not become automatic until the subskills are mastered and integrated. If the goal of copying is to reinforce understanding, this only becomes possible once the child does not have to concentrate on the visual and mechanical processes that are required. Otherwise, the child’s attention and working memory are consumed by the low-level demands of the task and will not be available to attend to the content.

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All of us can think faster than we can write, but this is particularly true for young students who must stare to consciously guide their hand to make and space their letters and words. Handwriting Some students must also devote some of their attention to spelling.

Keeping their place is much more challenging when the material is at a distance than when it can be touched, and place-keepers can be used.

The length of the lines of what they are writing may not match the length of the lines of the projected material, which can also cause confusion.

If a person can write automatically, can spell the words being copied, and is familiar with the material, they will copy chunks at a time. But many students look back-and-forth for every word and some do it for every letter. Not only is this laborious, it causes visual fatigue and increases the opportunity for errors and loss of place.

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Curiously, the advent of modern technology has increased the amount of copying in many classrooms. While Smart Boards can enrich a classroom, copying from a clean chalkboard is more comfortable than copying from a Smart Board. Writing on a chalkboard will tend to be larger and better spaced. A clean board will not glare like a projection. Rooms do not have to be darkened, other than keeping glare off the board. White boards, which are more reflective with less contrast between the markers and the board, may have to be substituted since many classrooms no longer have chalkboards.

Some children are uncomfortable staring at illuminated screens and may not realize, as is true of other visual problems, that this is not the same for all their classmates. The effects of visual crowding also need to be considered.

Children need to apply themselves and persevere to learn and advance. But when tasks are too difficult, compensatory accommodations can reduce these barriers to learning.

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Visual Crowding

Raising Kids Who Read   

Vision and Mathematics

Have Smartphones Destroyed a Generation? by Jean M. Twenge

Sleights of Mind

 

By Stephen L. Machnik and Susana Martinez-Conde

With Sandra Blakeslee

This book, written by two specialists in visual neuroscience with the help of a science writer, uses magic and visual illusions to explain perception. The use of magic makes the book fun to read and it is fascinating to realize that magicians have had an empirical understanding of visual attention, perception and distraction for centuries. The following excerpts address some of the illusions that we have about how we function. Continue reading

Handwriting

Being able to write comfortably, quickly, and automatically is still an important skill in the digital age. Attending to the details of letters as we learn to form them also supports learning and remembering their names. Poor handwriting is a common, and logical, reason for children to be referred for an assessment of their vision.

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Learning to write is dependent on the development of the prerequisite visual and manual skills and their integration. Children struggle when they are asked to write before these skills are developed. They adopt immature pencil grips just to hold onto the pencil which makes the pencil more difficult to control. The index finger is the most dexterous and should guide the pencil with the thumb and middle finger in support. The hand and wrist must be relaxed so strokes can be made smoothly and the hand can process across the page. Since this is difficult, it is natural to get tense, but tension is inimical to the development and execution of efficient writing. Tension not only causes the hand to tire and ache, but the stress moves up the arm and changes the entire posture of the child.

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Copying shapes has been used for decades to assess child development. The ages when children can draw the basic shapes have not changed since Arnold Gesell started testing this in the 1930s. For example, most children do not make an adequate diamond until the age of seven (with a wide variation in when this is achieved) but we now expect all children to know all of their letters upon entering kindergarten. For comparison, one generation ago we expected children to know the 52 letters and their numbers by the end of their kindergarten experience. All children do not develop at the same rate and each child has areas which develop faster than others. It is not in a child’s best interest to assume that this can be ignored without consequences.

Development has not changed. It starts in utero. We learn to control large muscles and joints first and use feedback (hits and misses) from these movements to refine them and make them automatic. We make gross movements before we make fine movements. Smooth movements can only be made when we are relaxed. Movements are visually planned and guided until they become automatic which may take thousands of repetitions. Most children do not require guidance for this to happen. They just require opportunity.

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Writing needs to be developed at a mastery level before it doesn’t interfere with performance. Even then, we can think faster than we can write. The longer that it takes to write, the longer we have to hold what we want to write in working memory. Inefficient writing interferes with the expression of ideas. Working with children on the autism spectrum has increased our sensitivity to the importance of low-level skills such as eye movements and handwriting.

Starting with fluent movements and gradually making them more accurate and consistent is more effective than starting with intentional, stressful movements and trying to make them fluent and automatic. Throwing and hitting balls are good examples. We have to feel the movement and see the result for it to be refined. It is important for children to scribble freely before they attempt to refine their writing movements and what their movements produce. Unfortunately, many classrooms no longer have chalkboards which enable large movements with the drag of the chalk on the board providing important feedback to the large muscles and joints of the arm. White boards and markers are too slippery to provide that feedback. Movements refined by the large muscles and joints can then be transferred, with appropriate rehearsal, to the small muscles and joints of the hand and wrist. Another advantage of a chalkboard is that you can erase whatever you made and do it again. This is an integral part of learning, not mistakes to be avoided. Additionally, if your hand hurts from gripping the pencil to keep it from sliding out of your hand, that pain drowns out all other feedback and repetition will not make it better.

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For young children, making symbols and basic shapes is like copying complex forms for us. The shape has to be broken into components, the relationships between the components has to be assessed, the sequence of replication needs to be decided, and what is being placed on the paper and where needs to be monitored. Skill at copying forms correlates with performance in both reading and math due to this dependence on organization and attention to detail.

Some movements are easier than others. Manuscript writing is much more demanding than cursive for many children due to the precision required and the disjunctive movements involved. A capital “E” for example, requires 4 individual, precise lines in manuscript with the pencil placed accurately 4 times. It is one continuous line in cursive. Consequently, children often do better when they write with “modified italic” in which the letters are like those in cursive but they don’t have to be connected (and b and d are not mirror images).

Poor visual motor skills make writing more challenging and struggling with writing, in turn, produces eyestrain. When children struggle, they often hold their pencil so close to the point that they have to bend over to see the pencil point since their fingers are in the way. In that position, they often only see the point of their pencil with one eye and they are tense. To improve their posture, their grip on the pencil must change. It is natural to lean our head forward so it is parallel to the plane of our writing or reading. If the material is on a flat surface, leaning that far forward brings us too close to the material and in a stressful position. A slanted surface is more comfortable for both reading and writing because we tend to lean forward less. Everyone recognizes that we feel tense when we are anxious but we don’t always realize that we also feel anxious when we are tense.

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Because some children need to stare intently when they are writing, they experience more eyestrain from writing than they do from reading. This surprises adults because we don’t experience this unless we are doing something like lettering a sign. When we stare to concentrate, we see a smaller visual field. This makes it more difficult to write in straight lines, to keep our letters the same size, to put spaces between words, and to write numerals in columns.

Writing should reinforce our thinking, not interfere with it. What children write and what their writing looks like is part of their self-image. This important part of school – and life – deserves more understanding, patience, and informed guidance.

Copying

Visual Crowding

The Power of Handwriting

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The Wall Street Journal; April 5, 2016

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This article describes the differences in learning between college students who take notes using a computer and those who take notes by hand. Research studies from Princeton University, UCLA, the University of Nebraska, Harvard University, and Washington University in St. Louis all found that students could type lecture notes faster than they could write them. But they also found that the students who wrote their notes remembered more information about the lecture one week later than if they had typed their notes. (Note: this does not relate to copying notes verbatim as children are asked to do from the Smart Board. For many children, the components of this task are so difficult; looking back-and-forth, keeping their place, writing, and spelling, that they don’t have adequate working memory reserves to attend also to what they are writing.)

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The researchers’ explanation is that students have to think more about what they record when they are writing because they have to be more selective. When students type, they record almost everything stated by the lecturer. I also suggest that the motor involvement of writing also helps to embody information more than does tapping on keys and the engagement of writing may facilitate to later visualize what is on the page as can happen when writing – and forgetting – a shopping list.

Memory works through associations. If we record and read everything with an electronic device, we will not be able to attribute the material to a unique source, eliminating one of the clues that we use to retrieve what we are trying to remember. The speed and convenience of electronics are undeniable, but there is also value in retaining old technologies such as reading from hard copy and handwriting.

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The Hand : Frank R. Wilson

The following statement by the author is interesting, but it has to be considered that he interviewed a select group of people who were successful and how they became successful. It is a criticism of education which is not totally undeserved but which ignores all of those individuals for whom the system provided skills that it was intended to provide and also those individuals similar to those the author interviewed who were not so successful.

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Since the Industrial revolution, parents have expected that organized educational systems will tame and modernize their children and “prepare them for life”.  Such is the theory. But education – ritualized, formal education, at least – is not an all-purpose solution to the problem of inexperience and mental immaturity among the young. I was completely unprepared for the frequency with which I heard the people whom I interviewed either dismiss or actively denounce the time they had spent in school. Most of my interview subjects, although I never asked them directly, said quite forcefully that they had clarified their own thinking and their lives as a result of what they were doing with their hands. Not only were most of them essentially self-taught, but a few had engineered their personally unique repertoire of skills and experience in open retreat from painful experiences in a school system that had dictated the form and content of their education in order to prepare them for a life modeled on conventional norms of success.

Neocortex size is a reliable predictor of group size because intelligence is mainly social intelligence; the more people there are to keep track of, the greater the complexity of relationships to be kept in mind and orchestrated, and the more time which must be spent maintaining coalitions.

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This faculty of searching for the object is slowly acquired in the child: and, in truth, the motions of the eye are made perfect, like those of the hand, in slow degrees. In both organs there is a compound operation: the impression on the nerve of sense is accompanied with an effort of the will, to accommodate the muscular action to it. This is a statement by Charles Bell who was a contemporary of Charles Darwin.

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This mode of learning may be common to many forms of acquisition: there will be good days and bad days, with wild and largely unforeseen fluctuations in performance any time a new skill is being learned or an old one is being modified. This seems to be the natural mode of progression in a motor skill. (It may also account for a strong aversion among teachers and students to the analysis of both success and failure, not to mention a strong propensity toward superstitions about study. An actress once said this to me: “You do something very well, try to figure it out, and it goes away. That makes you believe that you shouldn’t think about what you’re doing. Analyzing success just leads to mistakes.)

You will never be able to throw accurately enough to hit a target unless your own internal clock, which controls the timing of the muscle activity, is perfectly calibrated. Based on what we have learned about the normal behavior of babies less than a year old, that clock is not set or calibrated until the head is under control. And when that time comes, the setting and calibration is organized through active movement, including the catching games the child plays. Simple repetition does improve some aspects of performance, but much more is required for expert performance. The development of any high-level skill requires intelligent rehearsal: repetition according to a well-designed plan. Developing a physical skill is primarily a mental activity.

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juggling

From a professional juggler: The eyes have to stay in practice, too. When I stop for one or two days, there’s no problem with my body, my arms are okay, but my eyes have got to get used to seeing all of it again. The eye thing is very, very important.

We need to question the premise that intelligence is a purely mental phenomenon, that the mind can be educated without the participation of the body.

Parents today tend to be concerned, if not obsessed, with getting a child moving in a certain desired direction as soon as possible. If getting ahead is the new purpose of American life, getting your child ahead of the rest of the kids is its sacramental corollary: the right toys, the right preschool activities, so many hours of this, so many hours of that, somehow beating the timetable of the public school system. In David we see an earlier educational model, one rooted in life’s immediate circumstances, very rich in rewards for self-reliance and invention. David grew up where “farm work: was an open-ended , loosely structured plan providing real-life demands (and real hardships) that produced many branchings, many unexpected experiences, many opportunities for a young child to explore and pursue interests on the basis of native curiosity. Is the model outmoded?

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hands

Handedness is uniquely human, ranking with speech and tool use as a distinctive behavioral trait of Homo sapiens. We still know essentially nothing about the history of our special trait or its neurological foundations.

There is a logical division of labor between the two hands. The left hand knows that the right hand is planning and the right hand knows what the left hand just did.

Writing is a complex act because engaged along with forearm and hand muscles, whose job is a sustained contraction, are muscles that must contract and relax over and over again. The solution the brain adopts for overcoming the complexity of these muscular tasks is to automatize them – to create simple micrometric  movements, memorize them, and repeat them without variation. Once the movement is learned, very little sensory monitoring is necessary.

The same brain injuries which affect people who communicate through speech affect the communication of those who use sign.

The following is from Moshe Feldenkrais who was a physicist and antimissile defense scientist. Feldenkrais taught us to look for what isn’t there. A big problem is when the teaching is done independent of the child’s subjective reality. Somebody walks into the room to teach something without taking into account in a real way the students who are there. You’re not connecting with anything that matters to them. Our understanding is that in this way we connect to their brain. There needs to be a revolution in comprehending what works in learning. “Teaching and learning are two independent processes, and usually they do not correlate.” And what do they learn? They learn that it’s hard. You know, we learn everything, we don’t just learn what we’re supposed to learn, or what the teacher believes is being taught.

Perception is not something that goes on inside a processor running inside the brain. There is not, and cannot be, anything called perception – including any kind of visual or visuomotor perception – just as there is not and cannot be anything called intelligence, independent of the behavior of the entire organism, or of its entire and exclusive personal history of interactions with the world.

All students learn best and most quickly when self-interest orients and drives the search for information, understanding, and skill.

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Teachers need to look at their own understanding of ordinary things which they teach to try to remember what it was like before, when they didn’t know these things. It is very difficult because the memory of not knowing has been wiped out.