What can we do about child vision?

Every week brings in new children to my clinic; children who have hit a dead end with family doctors and paediatricians, as well as with the schools. I run a child vision development clinic, and we see children with apparent learning disabilities from all over Alberta and offer consultations on cases around the world.

Vision is most often misunderstood, partly because almost no one gets any formal training in how human vision is constructed, and even fewer study how vision works. It is much much more complicated than simply determining if there is ‘blur’ or not, and it clearly affects children’s global development. Vision concerns are easily the number one preventable cause of behaviour, development, and learning concerns, yet we as a Province barely pay lip service to it.

To wit: The Province sets aside funds each year for child eye exams. Even while eye exams are available to all parents, the best statistics we have suggest something like 1 in 4 kids ever has the benefit of a professional assessment of visual function and development status before it matters, before it’s too late. With all the other metrics we track for children, we ignore this arguably most important input to learning, with most physicians being unable tell parents about a child’s vision except that ‘the eyes look healthy, and they seem to be able to read a chart at 10 feet’. This is why discussion of even the basics – like whether the child is hyperopic, myopic, or has astigmatism – will never come up in discussions about whether to medicate. Other critical areas of concern such as vergence, accommodation (focusing), alignment, or the assessment of fine visumotor skills required for reading (saccades, pursuits, and fixation) are equally absent from the discussion, even though we will often measure the impacts of these through psychological assessment. Arguably, most people who read this have no idea if their children are nearsighted, farsighted, if they have astigmatism, and if these are significant in magnitude; most will simply report, ‘well, there doesn’t appear to be a problem’.

Nearly every child who comes through our doors has a similar story – they have some sort of significant primary or secondary visual dysfunction that is affecting learning, development, and behaviour. They all come to the clinic because parents have been told that the child has a developmental concern, that they need help at school and, most often, some sort of behaviour modifying medication. We use terms like DCD, ADHD, and ODD to describe what we see, but without understanding the child’s physical visual status, that is, how their visual system works and how it is taxed, these terms have no practical meaning in diagnosis or treatment.

In 2010, I presented serious concerns about one student in particular to a local school board through the superintendent and these concerns were also presented to the school principal. In the absence of formal training or policy around vision, the response was to ignore the problem, or more accurately, to fully reject it. As the teacher involved said: “The girl always complains about her vision, and besides, she’s from Eden Valley.” We know that children who complain about their vision are often the most severely impacted. We also know that Aboriginal communities often have high prevalence of significant visual disabilities. Needless to say, this ill-informed racist and bullying behaviour was and remains intolerable. And, while the school division and some of its key employees have continued to ignore the science I have presented, and threatened me personally and professionally, every year is a continuous stream of children who have been neglected because their physical disability is not recognized a ‘real’ or ‘significant’ by people who cannot tell hyperopia from myopia.

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We continue to allow thousands of children to struggle with the burden of vision dysfunction, and the costs to families and taxpayers is staggering. It’s a tragedy, a preventable modern day catastrophe, especially in light of increasing demands on computers/tablets, and decreasing physical training. So, in an environment where exams are covered by health care, but with so few parents using the service, the question becomes ‘What can we do to ensure kids’ vision needs are met?

What follows are brief notes on addressing visual disabilities. Most of these are administrative and would require minimal changes in budgeting at the Province.

It makes no sense to start attempting to manage learning and developmental concerns without first  understanding the basics of how a child’s senses are working. It’s reasonable to expect parents do not understand vision development, how to measure the different aspects of visual function, let alone how vision impacts upon behaviour, development, and learning. Visual disabilities are physical disabilities that often engender cognitive and emotional effects, and are therefore physical barriers to accessibility; we have a responsibility to address these concerns at the very least to meet the requirements of the Canadian Charter of Rights and Freedoms (various).

Professional Training – we can’t talk about what we don’t understand.

  1. All health and education faculties related to child development need to include in their curricula some basic elements around human vision function.
  2. Basic metrics on child vision should be required data for all child behavioural assessments.

Legislation – Sometimes some things are important enough that law is required to prevent damage to individuals.

  1. Legislation must be enacted to ensure all children have the benefit of a comprehensive vision assessment at an early age, and this should be approached with the same gravity as vaccination programs. Recent Bills in the Alberta Legislature are good examples.
  2. Children with need for glasses to assist with near and distance tasking should be given glasses.
  3. Children with significant visual dysfunction should have access to therapeutic help with professional visual rehabilitation doctors and therapists.

School Policy – as it stands, schools have at best only ad hoc and informal policies on vision, even while more children struggle with the visual demands of the classroom.

  1. Schools must work to ensure all children have been checked for visual functional concerns, including tracking rates of uptake to exams.
  2. Schools must implement programs to encourage and facilitate exams in a similar way to other critical health programs such as vaccination.
  3. There must be policies in place to prevent bullying around visual disabilities and to educate children around tolerance and understanding of these conditions.
  4. School employees should be forbidden from recommending medications for children with learning disabilities and behaviour concerns.

 

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