Vision Blindness Part 2 – What we don’t see.

What We Don’t See Affects How Things Appear

(See Part 1 here.) Sharry came in with her daughter Sam, a socially awkward but friendly and intelligent 9 year-old, who is struggling in Gr 4. “The pediatrician said her eyes were ok”, she proclaimed, “but we wanted you to have a look since we heard you were good with kids with learning problems.” I have learned that when the pediatrician tells the parents ‘vision is fine’, they still don’t know much about the child’s vision.

Sharry told me the story of how Sam was a good reader, but had trouble sitting still for the required periods, and that this was identified as a problem in the classroom. The teacher had taken to isolating Sam at lunch hour, inside the school and away from her friends, in order ‘to help her learn to focus’. When her classroom inattention was unmoved by verbal prompts, her teacher would sit Sam beside her, at the front of the class, so she could keep Sam on task. When I met Sam, she had already had a ‘learning assessment’ that lasted two days, was working with an OT, had had extensive medical testing and brain imaging, had been offered pills… and was also quite intelligent and feeling about 6-inches tall.

It was clear that Sam was exhibiting common behaviour for children with significant visual impediments. The findings only confirmed what was already obvious, just from observing Sam and how she managed the clinic environment. Even the parents and teachers attested to how she had trouble in sports catching balls, absolutely hates to ride her bike even though she can, has emotional outbursts, gets frustrated, is clumsy, and has bad handwriting. The current model for assessment and intervention fully disregards visual function beyond a usually rough measure of visual acuity and a check of eye health, and so none of Sam’s caregivers were remotely aware of the details of Sam’s vision.

Sam, not surprisingly, was significantly farsighted with astigmatism in the right eye, enough to need to work through it with effort, but not enough to make her blind to the text she was expected to read. Compound Hyperopic Astigmatism (CHA) at this level (+2.00-1.00×180) is especially difficult for kids because their eyes have the muscle power to produce the necessary optical correction, but they feel it as strain and pain. In addition, because Sam could read the distant shape chart, she was considered fine. Because she had not been tested properly, it turned out the left eye was legally visually impaired with a prescription that was three times as high as the right’s (+3.50-3.00×180) –  and where the eye could not focus on its own, nor see anything with reasonable clarity. So, the right eye was hard to work with, but he could see to read. The left eye was nearly of no use at all in a classroom. The extreme left prescription, combined with the great difference between left and right prescriptions (anisometropia) creates a whole new set of problems in spatial perception, and therefore fine and gross motor control, balance, and coordination. Sam had no binocular depth perception, and would also likely see the world as quite distorted. Sam had great difficulty with the fine motor skills required for reading and computer work. With all the pain and visual anomalies she was dealing with, there’s little wonder her motor skills and coordination were affected, and that she feels the need to ‘flee’ the near work environment several times in the day.

The diagnosis must fit the observations, and vision-related disorders will manifest as many specific concerns; those with no professional training in vision assessment will take one of the common diagnostic paths outlined for this purpose in the DSM-V (which itself still does not recognize significant visual dysfunction), but will never consider where vision could be a root cause, or a part of the solution. That is not in Alberta, not currently. For lack of knowledge, the true problem often goes unseen and unmanaged leading to great costs and risks. To the behavioural vision specialist, the refraction is a key element with great potential impact on the child and is tracked over time, under different conditions, and at different distances. The refraction is not the only thing to be considered, but it remains a element that causes kids to struggle with learning and development, and so it should be required knowledge for anyone managing the child’s health and learning. At least that.

Field Distortions: How what we believe affects what we will believe.

A recent report indicated how teacher bias and behaviour is determined in no small part by the terms we use to describe children’s ‘conditions’:

Does the dyslexia label disable teachers? – British Psychological Society

“…the label ‘dyslexia’ evoked responses that suggested it was seen as a fixed disability, and that the teachers believed their ability to help children with ‘dyslexia was unlikely to develop over time.

By contrast, the teachers who had been asked about ‘reading difficulties’ were less likely to see the children’s problems as permanent; were also more likely to believe that they would be able to help them, and that their skills developed with experience.”

In other words, what teachers are told about a child’s condition shapes their approach to instruction as well as their willingness to even try to help. The same remains for family doctors, pediatricians, psychologists, and educators: We all tend to see what we know, and rarely look outside our own fences to find alternate perspectives. Vision scientists will attest to the fact that the neo-traditional classroom (text-based, computer-based) is detrimental to a child’s visual development, which requires gross and fine motor input, movement, interaction with moving targets in space, and exposure to wide open spaces. Rather than scolding and isolating the child for his behaviour, Sam’s teacher would have gotten farther faster with a referral to vision assessment rather than a fishing trip for drugs. The rigid commitment to one way of viewing the child, as a robot, essentially, is the field distortion: We can no longer see what is before us in any accurate way. Addressing basic needs first should always remain the first step.

The modern learning paradigm requires strong visual function, but this is especially so given the over-emphasis on computers, and that most of the instruction is text-based, so requiring a higher degree of fine visuomotor control and optimal accommodative and vergence. At the same time, the child who does have a challenging visual functional profile will struggle and this will be expressed in myriad ways, some of which are outlined in these posts. Still, vision, the most important sense for learning in modern classrooms, remains largely ignored by health and education.

It is not sufficient to say that vision ‘doesn’t matter’, indeed it is foolhardy to do so and represents a great misunderstanding of how humans ‘work’ and how children develop. Likewise, it is unacceptable and clinically dishonest to refer to non-vision professionals’ assessment of vision when making decisions in the child’s interest. As the visual demands of classroom learning increase, and there is less room for whole child development, we should not be surprised to see increases of so-called learning disabilities and child behaviour concerns, or the precipitous rise in prescribing drugs to manage learning problems. Vision requires greater attention:  The technician in me says it makes sense to address the machine first, and see if the software glitches resolve themselves: 99.0% of the time, they do. In the end, all children need comprehensive vision examinations, and the rudiments of these should be on their medical and psychology reports and considered before any other intervention is put on the table.