When an adult with a visual problem comes to the office they usually present with symptoms. When a child with visual problems comes to the office, they rarely report symptoms. This is true for children who have other issues which they readily make known. These children, however, frequently show signs that their vision is inadequate for the demands of the classroom. The most common sign is the one most easily overlooked; they avoid tasks that are visually difficult or uncomfortable. Since there are other reasons that a child may avoid these tasks, the possibility that the primary cause is visual may not be considered.
Taking a good history is critical, but it is difficult when children are young and when they have not experienced seeing any other way. It may also be that the change has developed gradually as the visual demands have increased. Adults who develop visual problems usually recognize the change. Open-ended questions such as “do your eyes bother you or do you have any problems seeing?” invariably result in a simple, impulsive response of “no”. But specific questions may cause them to answer an equally misleading “yes”. Fortunately, the history continues throughout the exam. Observations are often made during the evaluation that enable the doctor to predict what the child experiences. When this is confirmed, doctor-patient-parent communication is enhanced.
Children come into the office every week who have not complained but have visual problems that are affecting their ability to perform to their potential. The experience of a young lady who came into the office last week prompted me to share this information. She reported, in retrospect, that she has had visual problems that have made reading difficult since she started reading. She did well in school until her junior year when the reading demand increased and her grades plummeted. That summer, an occupational therapist helped her discover that her symptoms were reduced when she put a dark blue overlay on the print. Prior to this, she assumed that everyone saw print as she did – moving on the page – but that it did not impair their reading. While the overlay helps, she still has poor tracking and reads slowly. She is an excellent candidate to have her defective visual skills treated through optometric vision therapy, but she was leaving for college exactly two weeks after our appointment.
The reading demands of college, despite accommodations, are going to be a challenge. How different this story could have been if this problem was diagnosed and treated early in elementary school.
It is fortunate when children realize that they can read better when they use a finger or ruler under the print and are willing to do so, but this would not be necessary if they had adequate visual skills. And, no one can read efficiently when they must use props to help them keep their place. The act of reading should be subconscious. It should not waste attention that is required to process information, using that attention to keep our place or to move our finger under the words to see the print word-by-word. Some adaptations, like getting close to read or write, while a natural response, make the task more difficult, more stressful, and more fatiguing.
The Convergence Insufficiency Symptom Survey (CISS) was developed by a National Institutes of Health research team. Its scores correlate well with the presence of visual problems related to reading. Children who score 15 or above should have an examination which includes the evaluation of focusing, eye teaming, tracking, and visual information processing. I recommend the same for children who are receiving special assistance or accommodations in school, those children who are not performing to the expectations of their parents and teachers, and for any child whose parents’ intuition tells them that something is not right. Understandably, these populations have a high incidence of visual problems. We should not miss the children who are working hard to do adequate work who should be doing well with much less effort.
Vision screenings and most examinations do not assess these skills. Examinations for children typically assess their visual acuity at far and their eye health. You should find out before you schedule an appointment if the examination will include an assessment of these skills. You can look at the office’s website, contact their office, or find out if they are a member of the College of Optometrists in Vision Development (COVD) or the Optometric Extension Program Foundation (OEPF). You are more likely to find an optometrist who specializes in this area than an ophthalmologist.
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