“Is it a vision problem?”

Does this child have a visually-based problem?

Our children present with a vast array of problems affecting their development and academics. Sensory problems, trauma, autism, behavior, ADHD and the list goes on. Our children get assessed by OTs, and PTs, neurologists, neuropsychologists, and pediatricians. But did they have an eye-exam? A complete eye exam? Only 40% of children have had their eyes examined by an eye doctor. (1) That leaves all of those children potentially walking around with vision problems affecting their academic and developmental development. Meanwhile, we attempt to teach them catch a ball or write the alphabet or button a button.

“Does he need an eye exam?”

YES!!! Every child, regardless of academic performance or other diagnosis, needs a complete eye exam with a binocular vision assessment and cycloplegic dilation, even if the child has never complained about their vision.  Many times, when a child is assessed with the Convergence Insufficiency Symptom Survey, they learn that they are not supposed to see “words moving” on the page or see double when they read. They had symptoms and were not even aware. Most children with ocular motor or near vision problems will read letters on a chart without difficulty. 20/20 means only that each eye has good acuity. It does not tell us how well the eyes are working together or how hard the eyes are working to make a 20/20 acuity. Only a complete eye exam with binocular assessment and cycloplegic dilation can give the whole picture.

“Is this is visually-based problem?”

There are many signs a child is having a visual-based problem.

  • Eye rubbing
  • unexplained headaches
  • poor handwriting
  • poor reading skills that do not improve with tutoring
  • head turning or tilting when reading
  • closing one eye while reading
  • poor visual motor integration that does not improve practice
  • poor balance or motion sensitivity
  • Diagnosed ADHD that does not respond to medication
  • unable to catch a ball
  • letter reversals
  • visual perceptual problems
  • spacing and size problems during handwriting tasks
  • fine motor delays
  • poor depth perception

These problems maybe mis-diagnosed as things like dyslexia or ADHD and even be treated as such without success for many years.

“Who do I send them to, to make sure they a complete eye exam?”

A good place to start is College of Optometrists in Visual Development. These doctor specialize in the assessment and treatment of eye movement disorders and near vision focusing problems that could be affecting academic performance. You can your local COVD doctor with the search tool on the site. One might also look for an optometrist that specializes in pediatrics or binocular vision.

When an appointment is made, be specific about symptoms and ask for a “binocular vision assessment”.

Every child

Every child needs a complete eye exam. Parents may have many reasons to not get this dome, but you cannot teach a child read or write, or catch a ball that cannot see.

Learn More

Learn more about this subject in a live course presented by Robert.  Its now available as a webinar too!! Hosted by PESI Education

1.Children’s Vision Screening and Intervention. (n.d.). Retrieved from https://nationalcenter.preventblindness.org/childrens-vision-screening-and-intervention

Letter Reversals

Letter reversals are frequently an area of concern for parents as their child begins to learn writing and reading. Reversals are often viewed as a sign of dyslexia and are surrounded by myth. Here are the facts on letter reversals

  • Letter reversals are common and appropriate until a child reaches 7 or 8 years old (second grade).
  • After the age of 7-8, the children who continue to have reversals are the children that are having difficulty with reading(1)
  • Learning letters is the first time a child learns that an item becomes a different thing based on the way it is facing. A cup from seen from one side or the other is still a cup but a “b” seen the other way (“d”) is not the same thing.
  • Visual spatial and left/right body awareness correlated with children having letter reversal problems suggesting that addressing left/right awareness would improve letter reversals (2)
  • Working memory deficits, also found in dyslexia, were found in children with letter reversals, so addressing working memory may improve letter reversals. (3)
  • Children with ADHD tend to have more reversals, possibly related to difficulty in an inability to to suppress the more natural left-right flow of making most letters.

Treatment Ideas

Having the child the pull letters from a bag and identify the letters without looking at them has been a great activity (suggested by Dr. Charles Boulet) and correlated well with children having difficulty with this task that have reversal problems.

Dr. Kenneth Lane OD, FCOVD’s book , Developing Ocular Motor and Visual Perceptual Skills: An Activity Workbook, has an excellent discussion of letter reversals as well as treatment techniques. Presenting p-q-d-b chart and having the child touch “p” and “b”  with right and q and d with the left has proven to be very challenging. This activity include a component of eye0hand cooridnation and saccade accuracy that will further improve binocular vision and saccade accuracy.

The Optomteric Extension Program offers Recognition of Reversals Workbook, also by Dr, Lane (a great bookstore!!). This workbook has more activities for reversals and its only $20.

Calm the panic!!

In a few cases, letter reversals after the age of 7-8 can indicate dyslexia, but there are many other reasons a child may have reversals.

Learn More

About the Author

Learn more about this subject in a live course presented by Robert.  Its now available as a webinar too!! Hosted by PESI Education

 

References

  1. Terepocki, M., Kruk, R. S., & Willows, D. M. (n.d.). The incidence and nature of letter orientation errors in reading disability. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/15493319
  2. McMonnies, C. W. (1992, October). Visuo-spatial discrimination and mirror image letter reversals in reading. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/1430744
  3. Brooks, A. D., Berninger, V. W., & Abbott, R. D. (n.d.). Letter naming and letter writing reversals in children with dyslexia: momentary inefficiency in the phonological and orthographic loops of working memory. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/21978009
  4. Levy, F., & Young, D. (n.d.). Letter Reversals, Default Mode, and Childhood ADHD. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26794673

Equipment for Vision Rehabilitation

“What tools do I need to perform basic vision rehab interventions in my clinic?”

The first thing one needs is information. Understanding and Managing Vision Deficits-A Guide for Occupational Therapists would be a wise investment. Dr. Scheiman’s book explains assessing and treating basic binocular vision defects making the subject approachable for therapists. He also teaches a course by the same name that would be a good start.

Vyne Education also offers a course Vision Rehabilitation for Pediatrics-Seeing the Whole the Picture, taught by this author also introduces basic assessment and treating of eye movement disorders.

The Convergence Insufficiency Treatment Trial Manual’s Chapter 8 explains the in-clinic activities used in the CITT and would also be a worth while read.

You will need an optometrist

This may be the hardest thing to find. While the complete binocular vision assessment is the standard of care, frequently this assessment is neglected. Find the optometrist in your community that consistently performs these assessments and you will most likely find a partner. COVD and NORA doctors may be most receptive to working with a physical or occupational therapist that is training in binocular vision disorders.

The optometrist diagnosis is as important as the diagnosis a therapist would get before starting rehab on a shoulder. While we can perform basic testing on a shoulder, some results would indicate further assessment by the orthopedist. Same rules would apply concerning eye movements except that even poor tracking could be caused by a lack of visual acuity requiring glasses (or more accurate glasses).  Always insist that a child have a current eye exam before working on eye movement or even skills like visual motor integration or visual perception. Performance of these tasks requires best corrected visual acuity.

What about Equipment?

The Worth 4 dot   would be a wise first investment. With models starting at about $20, it it also very cost effective and gives great first clues to a eye movement problem.

Marsden Balls offer an easy to use moving target that requires good fixation to read letters. The handy therapist could probably make one on their own.

The Hart Chart is simple way to strengthen accommodation. Do it on a balance board and add in the challenge of balance.

The brock string is a must and its cousin the barrel card can be used to strengthen convergence.  Have the patient make their own brock string becomes a great fine motor activity too.

The Developmental Eye Movement Test is quick to give assessment that gives good data to reading ability and accuracy.

 

Prism and Lenses

The rules governing the use of prism and lenses vary greatly from state to state with the interpretation of the rules varying. Because of this, the author has chosen not to openly recommend these tools. They would generally require being under the supervision of an optometrist or ophthalmologist for there use and purchase.  They also require training to understand the appropriate therapeutic use of these tools.

Be a therapist!

The near-far axis is generally referred to as the Z-axis. When we turn our midline crossing tasks into the Z axis, we are now working the near far visual system.  Check out a previous post here. Be creative and have fun.

Learn More

Learn more about this subject in a live course presented by Robert.  Its now available as a webinar too!! Hosted by PESI Education

About the Author

 

 

 

Vision Resources for Occupational Therapist

Vision Rehab Resources for Occupational Therapists

It has been my pleasure to share information with OT students, PTs, SLPs and anyone else that will listen. It is my belief that information should be free and accessible to all. It is very exciting working in a unique OT area where there is so much to share.

Where can an occupational therapist learn more about vision rehab??

My first course was Mary Warren’s Vision Processing Impairment . This teaches the basics of eye movement assessment, visual field treatment and puts it in a nice functional context. It was a great course that got me much more aware of the visual problems neurological patients face and how to fix them.

If Mary Warren is the OT reaching towards optometry, Mitchell Scheiman is the optometrist reaching out to OTs. His courses and books are specifically teaching OD skills to OTs. I refer to this book frequently and it needs to be on more OT’s shelves.

Dr Scheiman also teaches a two day course for therapists that discusses the mechanics of vision the first day and interventions on the second. He is also on the faculty of Salus University’s post professional OTD program in Vision Rehabilitation.

There is also the course that I teach for PESI Education on assessment and treatment of binocular vision disorders.

Vision Rehab articles that are important for OT’s

Here are some of my favorite journal articles.

The Convergence Insufficiency Trial is important. It proves that that in-office treatment of convergence insufficiency works.

A systematic review of what works for treating visual field defects.   

The website of the Neuro Optometric Rehab Association is a great resource for information on treating the visual problems of stroke TBI and concussion.

For the EI therapists, here is a nice piece on the development of the visual system in infants.

The Journal of Behavioral Optometry and Optometry and Visual Performance are located at the Optometry Extension Program Foundation website. Complete article are available. There is a great bookstore too!

Vision Rehab and Occupational Therapy websites

Eyecanlearn.com has great activities.

Hartchartdecoding has a fun saccade activity.

Michigan Tracking is a tracking/Saccades task.

Learning Works for Kids is a great website that has search engine to find apps that address specific skills a for specific ages .

LittleBearSees.org offers great information about cortical visual impairment for therapists and parents alike.

Who cares about eyes anyway?

As one discovers more about vision it becomes obvious that as OTs we must be evaluating vision better. Eye movement accuracy affects balance, academic performance and overall development and it can be improved.

Visual processing, balance, gross motor development and reading cannot be successfully treated while a child has poor eye movements! It is like testing for sensation while a patient has gloves on.

Learn More

Learn more about this subject in a live course presented by Robert.  Its now available as a webinar too!! Hosted by PESI Education

About the Author