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.

How to Raise a Reader

Pamela Paul and Maria Russo

The authors have both been The New York Times children’s book editor and have extensive experience with children and reading. The book is not a manual and does not discuss teaching reading. Their motto is:

The book includes suggestions for engaging children in different types of reading, wonderful illustrations, and lists of suggested reading for children at different ages and stages of reading development. They respect that we are all different and have different interests. They encourage everyone to recognize that children do not all meet developmental milestones at the same time and that this should not be a problem in school or for anxious parents and grandparents. It is natural. Children need to be supported where they are in the learning process, not pushed to attain an artificial benchmark. It is also okay to go back and reread a book that is special. The authors endorse the Montessori philosophy of “Teach, don’t correct.”

The authors are concerned about children’s reading primarily for what reading can provide for children and can continue to provide as they become teens and adults, not just for the goals of doing well in school, getting into a good college, and making a lot of money. These are important, but there is much more to life which is often overlooked in our society. Without deeper meaning, we are more likely to struggle with anxiety, depression, drug use, and self-destructive thoughts. The authors emphasize that “we read a book out loud with a child, not to a child.” It is a shared experience and pleasure which is meant to be interrupted by laughter or discussion. They conclude the Introduction with the following statement by one of the authors:

I am more than okay with knowing that whatever life out there holds for them (her children), they will be more ready for it, having indulged in the stories held within books. They will understand story line and plot twists and happy endings. They will know about character development and underlying themes and sad endings as well. Through the novels they’ve read, they will know more about the stories they want to be part of, what kind of character they might be. They’ll be better prepared to read situations and to understand context and to search for meaning in the face of the seemingly incomprehensible. They will know how to break a story down to its essential elements and draw conclusions. They will be able to read people and situate themselves and others in the world. My hope is that they will seize on books as their own lifelines and share their stories with others.

The book caused me to reflect and make a list of what I feel is important about reading. Instead of posting my list, I hope that you take time to reflect, and perhaps write down, your list. Even though we can read quickly, reading facilitates stopping to think, which much of life does not allow. Reading (not just brief blurbs) facilitates living life more deeply with more connections, meaning, and appreciation.

For More:

The Enchanted Hour: Part 1

The Rights of the Reader: Part 1

Reading Comprehension

It is often reported in the history that a child is receiving remediation for poor reading comprehension without mentioning any other difficulties that the child has in reading. Problems with reading comprehension usually do not exist in isolation. Comprehension is the emergent when we read efficiently; when all of the components of the reading process are synchronized effortlessly. The first step in remediating comprehension should be to investigate the underlying processes. If the components of reading are not automatic, attention will have to be divided between the content and compensating for the deficits.

One way to probe comprehension is to assess a child’s understanding of a passage when it is read to them. This avoids the visual process (other than visualizing what is being read) as the information is received auditorily instead of visually. If listening comprehension is also poor, are there too many unknown words? Do they have challenges with receptive language? Is it a problem with attention? Are they not familiar with or not interested in the topic?

If listening comprehension is better than reading comprehension, are there words in the passage that are not in the child’s sight vocabulary? Assessing comprehension of a passage in which the child has to decode words is not valid. Decoding a word is an interruption in the flow of information. Attention has to be diverted from reading and, after decoding the word, shifted back to the uncompleted thought. How much this can interfere with understanding what is being read should not be underestimated.

Reading comprehension is highly dependent on background knowledge. Lack of background knowledge is one of the causes of what is known as “fourth grade dropout;” when some children start to fall behind and lose interest in reading due to a deficit of experience. When we are reading efficiently, we look to the next word to confirm that it is what we expect, not to discover what it is. Most of us do not comprehend well when we do “cold reading”; reading about something with which we are not familiar.

By fourth grade, many comprehension questions are inferential, not literal. The ability to answer these is dependent on the child’s stage of development and their personality. If they are a more literal thinker, they will have more difficulty judging how a person in a story is feeling or anticipating what may happen next.

Reading speed is a factor in reading comprehension. While the fluency of oral reading is often assessed, the speed of silent reading is rarely measured. Children who read more quickly tend to have better comprehension. While many factors are involved, being able to absorb the material faster than you can read it makes it difficult to keep your attention from wandering. Do you remember what it was like when the child whose turn it was to read out loud was a very slow reader?

It is often overlooked that reading is a complex visual task requiring the coordination of many visual skills to function accurately, quickly, and without conscious attention to enable comprehension to emerge. Focusing, eye teaming, tracking across the page, and stamina are all crucial. Not being confused by the size and spacing of print and the volume of information on the page is critical. (Visual Crowding)

Some children have not developed the ability to understand what they are reading if they do not hear it at the same time; out loud, not just in their heads. They may continue to prefer to read orally. As reading becomes increasingly efficient, they will not even need to subvocalize the words. This is an example of automaticity; when the brain does not have to work so hard.

If all of these components of reading are not investigated, and treated if necessary, intervention to improve comprehension is likely to be frustrating. The visual skills involved can only be assessed by an optometrist who provides care in this area. There are tests to assess focusing ability, eye teaming, eye movements, visual stamina, visual crowding, and the speed of visual processing. Assuming that these skills are functional because a child’s eyes are healthy and they can read small print on a chart across the room with each eye can be misleading with serious consequences for a child’s reading and learning.

Lastly, if a child does not do a good job of writing about what they have read, it is not certain that they did not understand. The problem may be in retelling, not recalling. There are organizational skills required in retelling, especially in writing, that are not required to understand. 

For more:

Assessment of Silent Reading Efficiency

Reading as a Perceptual Skill


Children Do Not Learn All They Need to Know in Kindergarten

As I was writing about the joys of summer for children, including learning experiences that can only be learned outside school, an opinion piece appeared in the August 6, 2019 issue of the Wall Street Journal entitled, “Toddlers Don’t Have to go to School”. Its placement next to a review of the book, The Intelligence Trap reinforced the article’s message.

The review begins, “Every year brings more books about how stupid we are. Apparently, humans are impulsive, gullible, and prone to making all sorts of bad decisions.” The “Toddlers” article reads, “Researchers at the University of Virginia discovered that 31% of kindergarten teachers in 1998 agreed that children should learn to read in kindergarten. By 2010 that number had risen to 80%.” This is not because 2 ½ times more children were now developmentally ready to read at age five. It was due to a policy change that became more accepted over those 12 years. It was also due to the replacement of older teachers with younger teachers who have less developmental background.

A policy in high schools where we grew up outside NYC provided me with experience of how this happens. There were no competitive sports for girls because sports were not healthy for young women. Women were not competitive. We believed it. Who would believe this today?

Kerry McDonald, who wrote the opinion piece in the WSJ, advocates homeschooling without a curriculum in her book Unschooled. Study is guided by the interests of the child. Her information that can be applied to children who attend school, both in and out of the classroom, is more practical.

The uneven readiness of children of the same age placed in the same grade is one of the biggest challenges that has faced education since primary schools are no longer one-room schoolhouses. (Understood Betsy) Accelerating the curriculum exacerbates this problem. The following statement from Kerry McDonald is telling. “Last fall, Harvard researchers published findings in the New England Journal of Medicine showing that in states with a September 1 cutoff for kindergarten enrollment, children who were born in August were 30% more likely to be diagnosed with attention-deficit/hyperactivity disorders than peers who were born in September.” Steven Levitt has written about this in the book Freakonomics using the example of ice hockey players. “The evidence in the literature overwhelmingly supports the basic point — that across many activities, you can identify long-term effects of essentially arbitrary age cutoffs early in life.” If a child who would have been ready to read at 8 or 9, is labeled as reading disabled at 5 or 6, it changes their lives, perhaps forever.

Unschooled reminds us that school is not the only place where children learn. There are many things that are learned better outside of school, in ways that are meaningful and can be more naturally applied. This is not a criticism of school. School cannot substitute for free play, experience, family, travel, or a child following their curiosities. Imaginative teachers work to make learning relevant which occurs naturally with experiences that are not constrained by the classroom. The teacher tries to interest all the children on the same topic at the same time for prolonged periods of time. Learning is more passive in school with less movement. Explicit instruction is not easily assimilated. School is taught in subjects so that math and reading tend to be silos, not methods of investigation and understanding.

Because some children start to read early and have a head start, it should not be assumed that having other children struggling to read at the same age will give them the same head start. Allowing them to read when they are ready and have a positive attitude about reading will prevent wasted time and effort and cause much less frustration. This time can be used to bring other learning back which was minimized due to the extra time spent on reading.

Schools are trying, but children are being pressured which does not enhance learning. Their free play and time outdoors have been reduced. We have higher rates of anxiety, depression, and suicide than other comparable countries and our academic achievement is not better despite the money spent and sending children to school earlier.  We can do better. Other countries are doing better. We can learn from what they are doing.

For more:

The Rights of the Reader: Part 1

Reading Instruction in Kindergarten

Raising Kids who Read

Reading as a Perceptual Skill

The difference between spoken language and written language is vision. Most of us learn to speak, develop adequate auditory processing, and learn the rules of our language implicitly. Spoken language is symbolic, but most children easily and rapidly absorb the symbolism because it is immediately useful and it is part of our genetic endowment. Reading is not part of our genetic endowment. It requires explicit instruction to learn letters and letter/sound relationships which do not have immediate utility. Reading requires years of practice and places extraordinary perceptual demands on the visual system. As the symbolism of algebra overwhelms some children, especially if it is presented too early, the symbolism of letters, their subtle differences, their orientation specificity, and their sequencing within words can be overwhelming. This is also exacerbated when children are pushed to read before they are perceptually ready.

Tests of visual perception which require a child to copy shapes have been accepted as an important part of a learning-related evaluation for over 50 years. They continue to be used because the ability of a child to copy shapes is predictive of their progress in reading and in math, recognizing that the predictive ability of any single test is limited. Since the differences of these tasks is great on the surface, this connection may seem surprising, but the ability to copy, read, and do math are all dependent on some of the same foundational skills; attention to detail, perseverance, patience, breaking a problem down and putting it back together, and working memory. They all involve symbols. Tasks designed to develop perceptual skills have been found to be salutary, especially when implemented early when children are still in the early stages of reading and math.

We received a video this week of our two-month-old grandson sitting in a tub of sudsy water. His lower body cannot be seen. He suddenly raises a leg and sees what appears to be his toes – and then they disappear. From this stage of perceptual immaturity, we anticipate that he will be speaking in two years and learning his letters and numerals in three or four. The development and processing that these feats represent are astounding and, to our amazement, are accomplished by almost every child. The processing of visual symbols that is necessary to read is contrary to a child’s prior perceptual learning. Young children readily learn many different categories and perceptual constancy. They know, for example, that a wide variety of different looking and different sized animals are “dogs” and that it is the same dog whether it is standing or sitting and whether we see it from the front or the back. These rules change with letters which must have a specified orientation and a precise sequence to become a word. (see Reversals)

Visual perception, eye movements, and visual span must integrate many times a second to enable reading. Early readers see individual letters in the order in which their eyes aim at them and construct words from these pieces as if the letters were presented individually. It takes years for children to see whole words as we do. The word-length effect is an example of this. Accomplished readers read words of different lengths in approximately the same time. The time to recognize words for early readers is proportional to how many letters are in the word. If their eyes do not process the letters in the correct spatial order, they will be confused and skip the word or guess based on the first letter which is the easiest letter to find.

Some children are more prone than others to interference from the surrounding letters and words, which is known as visual crowding. The auditory system is also vulnerable to crowding. Auditory crowding causes sequential sounds to run together so they cannot be discriminated. Children may have difficulty with both visual and auditory crowding. Written words may overlap and spoken words may overlap as they do when we are listening to another language.  (see Visual Crowding)

We can only see a very small area clearly with each fixation (about 5 degrees which is the equivalent of 5 letters). We believe that we can see more because our eyes are constantly moving and our brains make a composite picture of the individual snapshots. Reading is visually discontinuous but is sensed as continuous when the visual system is working efficiently. Our eyes move 4 times a second when we are reading. During that ¼ second:

-we move our eyes to the target that has been selected by a shift in our visual attention

-we take in what we can see in that fixation in 1/10 second

-we integrate this information with prior information from the preceding text and from our experience

-we use this to predict the word that is most likely to come next

-we shift our attention to the next target

-our eyes make the next saccade and start the process all over

This happens four times a second and the visual system must erase the image from the prior fixation so it does not overlap with the next fixation. Vision must also be suppressed during the eye movement or the page will appear smeared. Not everyone is fortunate to have the visual agility, timing, and stamina to sustain this rapid process over extended periods of time. The conscious mind is much too slow to orchestrate this. It also does not have the bandwidth to perform all of these tasks and attend to the information that is encoded in the print on the page. 

Since we cannot move our eyes faster than four times a second, to be able to read faster, we need to be able to take in information from adjacent letters that cannot be seen clearly. This bottom-up process (from eyes to brain) is assisted by the top-down process of predicting what is coming next. This breaks down if our perception is disrupted by crowding. It also breaks down and creates noise in the signals received by the brain if the eyes are not aligned within a fraction of a millimeter.

Unless we are the rare individual with eidetic imagery, we do not store what we are reading as pages of words. Most of what we read is stored as visualizations and associations.

Children with perceptual problems which make it difficult to process print have no way of knowing that how they perceive differs from how others perceive. Astute observers who are working with them may notice behaviors which make them suspect that they have visual problems and refer them for evaluation and appropriate care if indicated. Some people recognize as adults that they have a processing problem and seek care at that time. Patients whose visual processing is affected by a head injury know that they have a problem because reading is not as it was before. Insights from this population have enhanced our understanding of developmental aberrations.  

In the book Range, David Epstein states that narrow specialists are needed with deep understanding, but they need to be teamed with others who have a broader perspective. Some specialists are convinced that all reading problems have the same cause. Scientists and professionals with greater range understand that it should be expected that problems in complex systems such as reading most likely have multiple causes.  A restricted perspective keeps many children from receiving the help that they need to perform to their cognitive potential.

For more:

Assessment of Silent Reading Efficiency

New JAMA Research Shows Reading Problems Linked to Treatable Vision Problems

Prediction and Prevention of Reading Failure

The Neural Basis of Reading

Visual Perception and Who We Are

The Rights of the Reader: Part 5

Daniel Pennac

…a continuation from The Rights of the Reader: Part 4 (See Part 1 Here).

The following is how Daniel Pennac expresses his concern for the over-scheduled lives of children. This was written in 1992. It hasn’t gotten better.

She won’t have a moment to herself.

No time to dream.

No chance of being bored.

But being bored is great.

A long stretch of boredom… and all kinds of creativity are possible.

He goes on to write:

Schools everywhere have always confined themselves to making students learn techniques and write essays, while proscribing reading for pleasure. It seems to be established in perpetuity, in every part of the world, that enjoyment has no part to play in the curriculum, and that knowledge can only be the fruit of suffering.

There’s a case to me made for this.

And no shortage of supporting arguments.

Schools can’t be about pleasure, with all the freedom that implies. They’re knowledge factories and require effort. The subjects taught are tools of consciousness, and it’s the teachers’ job to initiate their students in those subjects. You can’t expect them to promote education for education’s sake when every aspect of school life – timetables, marks, exams, ratings, courses, subject choices, departments – reinforces competitiveness and is dictated by the job market.

If a student occasionally comes across a teacher who’s genuinely enthusiastic about pure mathematics and teaches it like one of the fine arts, it’s down to luck, not the brilliance of the school. That teacher’s enthusiasm inspires a love of their subject and turns effort into pleasure.

Human beings will always have the capacity to inspire a love of life, even when life takes the form of quadratic equations, but enthusiasm has never been part of the curriculum.

It’s all about duty.

Life is elsewhere.

You learn to read at school.

But to love reading….

My personal experience is that there are more enthusiastic teachers here than David Pennac has found in France, despite the pressures on them. In the U. S., as in France, most of these decisions are made at the state or Federal level and imposed from above, where the children and students may become obscured by the political goals. In closing…

Curiosity is awakened, not forced.

For More:

The Enchanted Hour

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

How to Raise and Adult

Nurture Shock: New Thinking About Children

The Rights of the Reader: Part 4

Daniel Pennac

A continuation from The Rights of the Reader: Part 3

Reading is the scourge of childhood and almost the only occupation we know to prescribe…. A child is hardly interested in perfecting the instrument with which we torture him, but make that instrument serve his pleasures and he will soon apply himself, in spite of you…

A great to-do is made of finding the best methods for learning to read. We devise bureaux and cards, we turn the child’s bedroom into a printing press…. What a pity! A far surer method, and the one that always gets forgotten, is the desire to read. Give the child that desire, and leave your bureaux right there….any method will work from then on.

To capture his interest; that’s the great motive, and the only one that leads surely and far…

I will just add this word as an important maxim: which is that, ordinarily, we obtain most surely and quickly that which we’re in no hurry to obtain.

This is from Jeans-Jacques Rosseau. It reminds us that the adult obsession with “knowing how to read” is nothing new. Nor are foolish teaching methods that operate counter to the desire to learn. Our children will become good readers (we must recognize, despite the author’s  optimism, that there are exceptions) if the adults around them nourish their enthusiasm. If we stimulate their desire to learn before making them recite out loud; if we support them in their efforts instead of trying to catch them out; if we give up whole evenings instead of trying to save time; if we make the present come alive without threatening them with the future; if we refuse to make a pleasure into a chore but nurture it instead…. And their reading will get better and better the more they enjoy the experience.

For more:

The Enchanted Hour

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

How to Raise and Adult

17Nurture Shock: New Thinking About Children