Helping children with vision related learning problems is often recognized as a multidisciplinary collaboration. This weekÛªs post comes from Advance for Occupational Therapists where the topic is particularly relevant as children begin back to school.
Taking on Vision Advocacy in Schools
By Paula Jarrard, OT/L
Occupational therapists working in our nation’s schools engage in multiple roles to serve children ages 3-21. The occupational therapist is responsible for evaluating and implementing goals related to occupational performance and participation in self-care, motor-performance and sensory-responsiveness domains. For every identified student to participate and learn in the least restrictive setting, an individualized educational plan is designed by a team including parents, general and special education teachers, social worker, educational psychologist, physical and occupational therapists and speech language pathologists.
A sensory-impaired student may also be referred for evaluation to a vision or hearing impairment specialist in the school system. However, given these encompassing assessments, the issue of “vision” may not be adequately addressed by any team members within the school setting.
Students typically may be screened by the school nurse’s office using a Snellen chart, which assesses whether the child can identify letters of 3/8-inch height at a distance of twenty feet. However, only 5 percent of children are identified as having problems with distant vision.1
Statistics from Prevent Blindness America report that vision disorders are the number one handicapping condition for children and that one in four school-age children have vision problems.
We can no longer ignore the need to address the impact of vision in school performance.2 The Vision Council of America reports that as of July 2006, 33 states mandate vision screenings for children, but 29 do not require follow-up for failed screenings. “Since nearly two-thirds of children who fail vision screenings do not comply with recommended treatment, many children enter school with uncorrected vision problems.”3
Implications for the Child
The importance of vision cannot be understated. About 80 percent of learning in the first 12 years occurs through vision.1 Research shows a significant relationship between undetected vision problems and reading, learning and behavioral difficulties.4
Furthermore, those children with developmental disabilities have a higher incidence of learning-related vision anomalies than that found in the general population.5 Certainly visual deficits may impact children’s occupational performance at home, school and play. With higher demands placed on students in this information-technology age, and with the transition in curriculum from “learning to read” to “reading to learn” typically occurring in the fourth grade, the ability to learn efficiently is dependent on optimal vision.6
If a child succeeds in passing the Snellen, the “myth” of perfect 20/20 sight does not take into account all performance factors needed for optimal vision.2 Near acuity required for reading, depth perception, peripheral vision, ability to focus, eye teaming and ocular health are necessary components to evaluate.
Is the OT Eval Valid?
In evaluation of referred children, occupational therapists in the school setting may perform visual-motor integration, visual-perceptual skill and developmental eye-movement testing. These results contribute to an overall picture of the child, and data may be utilized to set goals to improve occupational performance.
Warren, Bouska et al, and Gianutsos all express concerns over “little systematic consideration of a patient’s visual profile in occupational therapy” and stress the need to have vision fully assessed by an eye professional before embarking on evaluation and treatment. “Ignoring visual deficits is likely to result in invalid assessment, faulty clinical reasoning, and, ultimately, ineffective treatment.”7
From the pragmatic viewpoint of a school OT, parent follow-through on a recommended comprehensive eye examination may not occur, but the OT is mandated by legal requirements to complete the evaluation within a certain number of days after referral.
What to Do
The College of Optometrists in Vision Development advocates that a vision problem should be considered and ruled out if a child struggles with academics, behavior or sports. In the school arena, a teacher, parent or observant therapist may note physical and performance signs of possible visual problems including squinting; closing or covering one eye; eye turning in or out; dislike and/or avoidance of close work; short attention span; placing a book close to the eyes; losing one’s place or using a finger to read; complaint of headaches; turning or tilting the head to one side; difficulty copying from the blackboard; or poor handwriting. Many of these signs are voiced during the teacher interview as part of a school OT evaluation!
But, did anyone think to ask the child if he can see the blackboard or read the letters on the page? The child may not even be aware that he cannot see because he has always seen this way or it is a result of a gradual change.
An OT may quickly screen for vision by having the child perform far and near copy. Let the child read numbers or letters, first with both eyes, then covering one eye at a time. Other screening assessments, such as the Visual Skills Appraisal (Richards, 1984), may require more training and time than is available in fast-paced school practice. Based on this cursory screen, observation of performance in the classroom and interview of the teacher, best practice may recommend that it would be helpful to determine the presence of any vision problems with a referral to an eye professional.
Working with Optometry
Children would be best served by counseling the parent to inquire if the optometrist performs a comprehensive exam including testing of binocularity, accommodation, color and stereo vision, and eye movements. Some eye care professionals may not perform this extensive service, but all areas are critical for optimal visual performance.
A child that passes a comprehensive eye examination may still have problems in the area of visual information processing, impacting the ability to read and write.
The occupational therapist routinely evaluates visual perception and visual motor integration skills using various standardized assessments including:
- the Developmental Test of Visual Perception, 2nd ed. (DVPT-II) (Hammill, Pearson and Voress, 1993),
- the Test of Visual-Perceptual Skills Revised (TVPS-R) (Gardner, 1996), and
- the Developmental Test of Visual-Motor Integration, 5th ed. (VMI) (Beery, 1997). These assessments yield valuable data.A study reported by the Harvard University Graduate School of Education showed that vision perception and eye movement abilities are strong predictors of academic scores.2 Studies by Beery and Benbow, Hanft, and Marsh support that handwriting readiness occurs with the ability to copy the first nine figures in the VMI test predictor of handwriting ability.8However, an assessment of vision-information processing may still be indicated to fully evaluate the child with referral to a specialist in this area, often in a behavioral optometric practice, who may recommend treatment.
What better voice for advocating for vision in the schools than the OT, who understands the dynamic relationship between vision and occupation? Best practice dictates forming a collaborative relationship with the parent, teacher and optometrist to reinforce compliance with the prescribed glasses-wearing schedule, even though the child may report he does not need to wear them “because I can see okay.”
Scheiman emphasizes that “in cases such as hyperopia, binocular vision, and accommodative disorders and amblyopia, poor compliance with the doctor’s instructions can lead to decreased functional performance and lack of progress in treatment.”7 When one considers that lack of follow-through for treatment of amblyopia at a critical time of development may result in permanent loss of vision in one eye, OTs are in a unique position to ensure treatment is followed at school if needed.
The OT may fulfill a role as educator to teachers and parents to support classroom environment modifications for optimal vision with consideration of positioning, lighting, contrasted materials and promotion of periodic breaks to rest eyes.
Don W. Lyon, OD, chief of binocular vision/pediatric clinic services at Indiana University, promotes collaboration between optometry and occupational therapy.
“By working together through the referral process and open communication, both professions have a unique opportunity to ensure that vision problems do not negatively impact the educational potential of any child,” he said. “We can do this by fully evaluating the visual system with comprehensive eye examinations by the optometrist and a visual skills assessment by the occupational therapist.”
Please take note of these alarming statistics published by COVD:2
- The American Optometric Association reports that 60 percent of students identified as problem learners have undetected vision problems.
- A study by Roger Johnson, PhD, showed that 70 percent of juvenile offenders had undetected and untreated vision problems.These gaps in priority illustrate the need to bring vision to the forefront. OTs taking on the role of vision advocate could positively impact the occupational performance of all students!References available at www.advanceweb.com/OT or upon request.
Paula Jarrard, OTR/L, is currently educational consultant for the vision information processing clinic at Indiana University School of Optometry in Bloomington, IN. She has several years’ experience as a school occupational therapist.