Part II – The Limits of ‘VT’: Balancing Controversies
This is the first of two parts on ‘VT Controversies’. Simply put, for those who take the time to look at research and participate in clinic, there is no doubt of the role of vision in learning and the efficacy of VT to address vision related learning problems. This part is a general commentary, and Part IX goes into a great deal more detail about research and bias in medical reporting vis-à-vis VT.
The statement that ‘VT is controversial’ is in itself controversial. To say something is controversial is a general statement that can be applied to many clinical endeavours in both behavioural and medical practice, and so to say something is controversial is almost redundant. Here the controversy is more in the fact that VT, that is, visual neurorehabilitation, does have an important role to play in therapeutic practice but it is largely ignored by medicine – though slowly but surely, some researchers in ophthalmology are waking up to the science and clinical value of visual behavioural studies. (See this link for a very late admission from the AAO regarding ‘Convergence Insufficiency’, that is, the inability to cross the eyes inwards to read. Note also the very anti-optometry tone of the writing, including the lack of any references to professional optometric associations as contacts or in research. http://www.aapos.org/terms/conditions/108) The fact is, ‘VT’ fills a niche that answers the needs of many who can find no relief elsewhere, including through current standard allopathic means.
The shallow understanding of visual neurophysiology and physiological optics provided by general medical education, and the resulting denial of the benefits of visual neurorehabilitation by physicians, has a measurable and damaging effect in education and healthcare. The damage occurs when people are convinced, by no scientific or sound clinical means, that ‘the eyes’ are of little consequence in behaviour, health, and cognition. This has a tremendous ripple effect across other developmental professions that take their lead on human physiology from medicine, such as in education and psychology. Contributing to this problem is the recurring, but insubstantial, missives delivered by the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and the American Academy of Ophthalmology (AAO), neither of which has produced any original research in visual function in decades. Notably, the AAO and early 20th century ophthalmology did engage in discussions and some publication around the role of visual function in behaviour following observations and research in ‘orthoptics’ and the fledgling field of optometry. This interest was short-lived and visual neurorehabilitation took a back seat to the technology rich medical model of visual health. This focus shift did not erase the role of vision in behaviour, it simply took the spotlight off of it. (There are some horror stories around medical treatment of asthenopia in the mid-1800s that would also strongly discourage anyone from participating in any treatment for visual impediments to learning. )
In the end, children’s vision difficulties are largely ignored by professionals on the front lines, and by government officials who are never made aware of the great importance visual function has in, say, learning. Many examples also exist in medicine where visual functional problems underlie medical concerns such as headache and diplopia, but are ignored. The resulting costs to both education and healthcare are staggering compared to the modest cost of ensuring all children are checked early, then periodically afterwards through to the end of their education.
Ironically, the denial of the foundational role of vision in behaviour and learning for most stakeholders comes from a simple lack of experience and education in the domain. Generally speaking, when medical and behavioural professionals are exposed to the principles involved, they tend to take a more generous stance towards visual neurorehabilitation and learning therapy for children with apparent academic or behavioural difficulties. It is for this reason that even rudimentary courses in visual anatomy and function must be taught in professional programs that produce developmental specialists, including education, occupational therapy, psychology, general medicine and the relevant medical subspecialties.
Elsewhere, ‘VTODs’, that is, developmental optometrists, have also added fuel to the VT controversy fire by making untenable statements about the role and value of VT in addressing some issues, such as dyslexia. To some, dyslexia, that is, a neurodevelopmental abnormality that prevents children from integrating and assimilating grapheme-phoneme pairings, simply does not exist and any child diagnosed as ‘dyslexic’ simply hasn’t had the benefit of an appropriate visual developmental assessment and intervention. While much of what is called dyslexia can be shown to be visual dysfunction, this is often due to lax diagnostic standards, or diagnosis provided by untrained staff at the school. In my own experience, I have seen numerous children, for example, whose psychoeducational assessments suggest strong visual perceptual deficiencies, trouble with language, and reduced visual memory, all of which can combine to provide low aggregate scores for IQ. Most of theses children had never had a visual assessment and will often prove to have significant visual impediments to learning. This begs many questions around the value of such extensive and strenuous testing of children when the physiological basics are ignored. Scores, such as scores of visual information processing or language skills, are sure to be skewed against the child. Some rare ‘neurotypical’ children do in fact have some deep-seated neuro-integrative difficulties that present even when visual function is strong, this ‘dyslexia’ is quite different from reading trouble that stem from visual dysfunction.
VTODs can also be guilty of making promises to patients, but then being unable to follow through on these promises due to lack of training or proper equipment, or by not monitoring at-home practice sufficiently. Regardless of the reason for therapeutic failure, any treatment plan, whether in medicine or behavioural therapeutics, can and will persist. For some MDs in particular, there is sufficient evidence of a lack of efficacy if even one case falls short of therapeutic goals. The same standards, however, are not always applied to their own domains.
Because vision is the pinnacle of neurosensory development and the prime means of gleaning information from the environment, it only makes sense that it will have great influence on behaviour and comfort when it is functioning sub-optimally. In some cases, this means the patient will feel dizzy, see double, or experience wrenching headache. In other cases, it might well mean a child struggles so severely with near work that they are mistakenly diagnosed as having a reading or learning disorder, or even other psychiatric concerns with attention or emotional control. Checking vision through a comprehensive health and behavioural assessment is an economical, efficient, and quick means of ruling out a significant cause of many health and behavioural concerns.
A good example is described in the current trend of referring to neuroimaging to assist in diagnosis of reading and learning problems. This is predicated in part on the notion that such testing is ‘harmless’, and that it’s ‘better to be safe than sorry’. In fact, there are good reasons to avoid this practice, including psychological strain on children, and the unnecessary reinforcement of a pathology model vis-à-vis parents, children, and educators. Importantly, neuroimaging is also very expensive and will almost never lead to pragmatic gains in children’s personal and academic lives. If the concern is medico-legal, then the doctor in question should review essential neurological testing protocols before ordering testing that can run into the thousands of dollars. Better yet, a referral to a trained developmental optometrist with a decent visual fields analyser will surely produce the same assurances of health for well under $200 in an otherwise ‘neurotypical’ child.
The controversy behind VT is illusory, and based mostly in the lack of professional training in visual function, and perhaps some professional antagonism spurred in part by private medicine in the US. VTODs for their part must also remain aware of the limitations of visual neurorehabilitation and avoid making broad statements that detract from the tangible benefits of VT. There is a growing awareness around the critical and foundational role of vision in behaviour, and soon the only controversy will be in wondering why we never paid more attention to vision as a determinant of health and learning any sooner.