Learning and Behavioral Related Problems

It is estimated that 80 percent of what a child learns comes through the visual system, and that behavior is strongly influenced by vision. Dr. Press co-authored the Clinical Practice Guideline of the American Optometric Association on Care of the Patient with Learning Related Vision Problems. Download the Clinical Practice Guideline in its entirety.

A condensed version of this is available as a Quick Reference Guide.

Checklists of signs and symptoms involving visually based learning problems typically address performance problems.

These include a variety of difficulties in reading, writing, spelling, and math that may appear to be seemingly careless errors. The struggles that a child goes through include homework taking hours longer to complete than what the teacher expects when the work is assigned. It is understandable that this results in frustration and behavioral issues.

Behavioral problems can show up as avoidance

Sometimes a child simply gives up trying. That is why we keep the environment in our Vision & Learning Center is much like Liberty Science Center. Because our therapy is individualized and customized, we set conditions to help your child explore how he is interpreting what he sees. Unlike most educational settings, we focus on trusting what you see rather than worrying about right versus wrong answers.

As a child learns to modify what he sees through a variety of probes including lenses, prisms, filters, and computerized activities, he gains or re-gains confidence in his visual intellect. As an example, recognizing visual patterns and integrating them with corresponding sounds is crucial to word recognition and usage. This enables your child to develop the visual readiness skills necessary to be more fully responsive to educational interventions through school.

Dyslexia

What is Dyslexia?

Literally, dyslexia means difficulty reading words. As most clinical conditions, however, dyslexia exists on a continuum. There are two main forms of dyslexia, developmental dyslexia and acquired dyslexia. The acquired form typically occurs if you have trauma or bleeding in the brain that affects the pathways involved in reading. If someone can’t read at all, we call that alexia. If reading is possible but labored, we call that dyslexia. For more information about this form of dyslexia, see the information on Brain Injuries on this site.

Developmental dyslexia is the type of reading disorder that children face when they have difficulty in learning how to read. It may surprise you to learn that it was an ophthalmologist (eye surgeon) by the name of Hinshelwood who originally focused attention on developmental dyslexia in a series of papers written in the late 1800s and early 1900s. He understood that something was wrong with the communication between the visual centers of the brain and the language centers of the brain. Unfortunately contemporary ophthalmologists have distanced themselves from informed knowledge in the field, something we’ll address in the treatment section.

Most educators have shied away from using the term dyslexia, preferring instead to use terms such as specific reading disability.

Even today, in New Jersey, many parents are told that their child can’t be tested for dyslexia until age 10. Developmental dyslexia can be divided into three main subtypes:

  • Dysphonesia – the auditory or phonetic type in which there is a disability in associating symbols with sounds. Phonemic awareness is poor.
  • Dyseidesia – the visual type in which there are deficits in vision and memory of letters and word shapes limiting the ability to develop a sight word vocabulary. However they have the ability to acquire adequate phonetic skills.
  • Mixed type combining features of the dysphonetic and dyseidetic.

Lately attention has been focused on the idea that developmental dyslexia is different pattern in the wiring of the brain that predisposes people to have talents or gifts in areas other than reading. Two prominent physicians, Brock and Fernette Eide, have written a book about the potential benefits and advantages of developmental dyslexia.

There is a very important blog that the Doctors Eide have written, which puts the visual aspect of dyslexia into perspective. They write:

“While not all children or adults with dyslexia have visual processing problems, many–at least two-thirds in some studies–do. This makes sense from a neurological standpoint, because several of the structural neurological features associated with dyslexia appear to predispose to visual difficulties. For example, coordinated control of the movements of the two eyes requires sending signals over long distances in white matter tracts, as well as sharing information between the two hemispheres of the brain, and oversight, modulation, and coordination by the cerebellum. Deficiencies in white matter function, interhemispheric communication, and cerebellar function are each known to be more common in dyslexic than non-dyslexic individuals (especially in the pre-adult years). In addition, many dyslexic children are known to have difficulty with muscular coordination, especially for fine motor actions. Consequently, it should not be surprising that their visual movement functions, which are controlled by many of the same neural pathways, are also poorly coordinated.”

For additonal information, please refer to the Eide Neurolearning Blog.

For additonal information, check out our Dyslexia and Vision Blog and Vision and Reading Blog.

Signs of Dyslexia

As previously noted, dyslexia exists on a continuum. Let’s start first with an example of a child with a severe form of dyslexia. Before any patient begins vision therapy in our office, we have them complete a survey form asking three basic questions. If they’re unable to read the question, we read it to them. Here is what Jason, a second grader who had been tutored unsuccessfully for two years, wrote on his survey form:

Question 1: Why Do You Think You Are Here?

  • Jason wrote: To helmp me reed To wake wy rite Eay stonogr

Question 2: What Are Your Goals?

  • Jason wrote: Not to yoos wy fuingr to reed to wake wy rite eay stogr

Question 3: Do You Have Any Idea How This Will Help You In School?

  • Jason wrote: Thith will huelp me To see my pagus Klere

What do you notice? Jason shows features of dyslexia that are classic in terms of letter transpositions, reversals, and inversions. Look how Jason flips the “m” for a “w”. Letters are often out of sequence. He has a poor concept of word spacing, capitalization, and grammar. He has features of a mixed type of dyslexia, poor in phonemic awareness and in both sight word recognition and expression. Both encoding and decoding of words are challenging. How words are formed are a mystery to him and he’s inconsistent in how he guesses words should look even when he’s trying to spell phonetically.

Old school says that dyslexics simply reverse things

It is old school to say that dyslexics simply reverse things, but reversals remain one sign that many dyslexics share in common most notably confusion of “b” and “d”. There can also be reversals of numbers, like a 3 backwards. There can be transposition of number sequences, like “21” instead of “12”, just like there are letter transpositions, like “was” instead of “saw”. Additionally, there can be substitutions of similar looking words like “these” and “there”.

Signs of the visual form of dyslexia include problems in sequencing or placing things in the right order. Words are frequently misspelled and reading fluency is limited by both poor sight word recognition or vocabulary, and difficulty in following the flow of print while reading. This is thought to be related to poor visual sequential memory.

Visual Processing and Visual Efficiency

These are all issues in what we call visual processing or perception. Think of this as the software of the visual parts of the brain. But don’t forget that software is only as good as the hardware that runs it. Therefore, any consideration of visual dyslexia is incomplete until you know how the eyes are working in concert with the brain. This is what we call visual efficiency, and involves focusing, tracking, and eye teaming. This is crucial in making sure that print is coming in clear, single, and stable. It is more of a factor once someone knows how to read but is having difficulty doing so. Signs of visual inefficiency include print wiggling, shimmering, ghosting, blurring, or doubling. This often results in fatigue, headaches, or loss of place when reading.

Our Treatment

The majority of patients who come to us with reading difficulties have already had a variety of interventions with varying degrees of success. Typically someone, such as an educator or occupational therapist, feels that there is a missing link between a child’s intelligence and the response to prior interventions. Treatment therefore begins with an understanding of what has been tried before, and what resulted.

We always conduct a conference with the patient or parents to review our findings from the evaluation. If our evaluation shows that problems in visual efficiency or visual processing can account for key signs or symptoms that a patient is exhibiting, we customize a treatment plan. This may consist of a prescription for lenses or prisms, or active optometric vision therapy. Targeted interventions include focusing, eye teaming and tracking, as well as visual perception.

Visual Crowding is a significant factor in visual dyslexia

Visual crowding is a significant factor in visual dyslexia and is a form of visual sensory overload. Therapy to address this includes computerized as well as non-computerized activities. Guided reading programs using a moving window help to balance reading speed with comprehension with the goal to attain improved fluency. When appropriate, we make recommendations for Section 504 accommodations that include enlarged print size, which helps to reduce crowding, but does not get at the source of the problem which is within the visual brain.

The three primary educational interventions to address word recognition and reading readiness in dyslexia are Orton-Gillingham, Wilson, and Lindamood-Bell. Our treatment incorporates principles involved in each of these approaches, based on technologies such as PACE and Master the Code. Rather than being rooted to a particular method, we evaluate each child individually to customize an approach likely to result in the best outcome for visually based reading problems.

The Vision & Learning Center

The first step in helping an individual with dyslexia is understanding that we work in a multidisciplinary framework. Rarely, if ever, are we the first professionals consulted when someone has significant reading disability. That’s good news and bad news.

The good news is that we don’t have to guess as other interventions often have been tried first. Most patients who have been diagnosed with dyslexia, or suspected of having dyslexia, have already tried a number of different educational interventions. It is helpful for us to review what has been tried already and what the response to intervention has been.

Before recommending visual intervention for dyslexia, we carefully look at how the eyes are taking in information when reading and compare that to how the visual areas in the brain are working together with language areas in the brain. That helps us to decide whether visual interventions are likely to be helpful and, if so, the areas in which to concentrate.

Specialized eye movement sensors help us measure precisely what a patient’s eyes are doing while reading.

We can tell how many stops per line you are making, how many times your eyes back-track to re-read, and your visual speed while tracking.

The Dyslexia Screener helps us identify whether the reading disability stems more from dyseidetic or visual origins as compared to dysphonetic or auditory/phonic origins. We also administer the Test of Silent Word Reading Fluency (TOSWRF) in addition to other tests that help us pinpoint where visual processing deficits occur that compound dyslexia.

Elsewhere on our site you’ll find information about dyslexia and about reading.

The first step in helping an individual with dyslexia is understanding that we work in a multidisciplinary framework. Rarely if ever are we the first professionals consulted when someone has significant reading disability. That’s good news and bad news.

The good news is that we don’t have to guess is other interventions should be tried first.

Most patients who have been diagnosed with dyslexia, or suspected of having dyslexia, have already tried a number of different educational interventions. It is helpful for us to review what has been tried already, and what the response to intervention has been.

Before recommending visual intervention for dyslexia, we carefully look at how the eyes are taking in information when reading, and compare that to how the visual areas in the brain are working together with language areas in the brain. That helps us to decide whether visual interventions are likely to be helpful and, ir so, the areas in which to concentrate.

Specialized eye movement sensors help us measure precisely what your eyes are doing while you’re reading.

We can tell how many stops per line you are making, how many times your eyes back-track to re-read, and your visual speed while tracking.

The Dyslexia Screener helps us identify whether the reading disability stems more from dyseidetic or visual origins as compared to dysphonetic or auditory/phonic origins. We also administer the Test of Silent Word Reading Fluency (TOSWRF) in addition to other tests that help us pinpoint where visual processing deficits occur that compound dyslexia.

A conference is held after we complete our evaluation to review the results and to make recommendations for intervention if indicated.

Visual Processing Disorders

What is Visual Processing?

Our visual system functions through interconnected pieces. What occurs in the eye is considered to be the hardware component of vision and what occurs in the brain is considered to be the software component. This is a bit simplistic because in humans at least 10 to 15% of the information regarding what we see is passed on to the visual centers of the brain from sources other than the eyes. We refer to this as subcortical vision, and it includes pivotal centers for balance and movement.

It is widely recognized now that in sensory systems the distinction between what occurs in the brain and what occurs through the end organ is crucial. When we speak of a child with auditory processing problems, no one says “Oh, do you mean she needs a hearing aid?” It is understood by ENTs, audiologists, speech-language pathologists, and educators that how the brain processes incoming sound is quite distinct from the condition of the ears, and they must work in concert.

Thousands of children continue to struggle with learning

Yet somehow we persist with a very antiquated notion that if the condition of the eyes is normal, everything is fine with vision. This one misconception results in a false sense of security that allows thousands of children to continue to struggle with learning. Much as ENTs do not proclaim that all aspects of hearing must be fine if the ears are normal, eye doctors should not conclude that all aspects of vision must be fine if the eyes are normal.

Early Intervention

All eye doctors agree that the earlier a visual problem is detected and treated, the better the chances are of vision developing normal vision. Where we differ is what we define as “normal” vision. Regarding strabismus, for example, the emphasis of many doctors is to insure that the eyes look straight by three years of age. Regarding amblyopia, the emphasis of many doctors is to insure that eyesight is similar in both eyes by age seven. As we’ve learned, however, there is no magic age limit beyond which vision can no longer be improved. Research is continually pushing this window of opportunity wide open.

More importantly, there are many aspects of vision development that extend beyond straight and sharp eyes. Normal development of the visual brain is as important as normal development of the eyes. There are many distinct areas of the visual brain that operate in parallel, and vision is a learned process. Developmental optometrists are adept at evaluating the visual system in its entirely so that infants and toddlers can receive the benefits of early intervention. This adds to awareness of the opportunities for early intervention through occupational therapy, physical therapy, and speech therapy services.

Is your Child Developing Appropriate Vision Function?

If you know that your child has an eye disease that requires treatment by an M.D., by all means go to a pediatric ophthalmologist. They are superb in the application of a wide variety of surgeries and treatment of diseases. But if you have a concern over whether or not your child is developing appropriate visual function in the context of sensory processing or visual behavior, you want the opinion of a developmental optometrist. It really is that simple.

Evaluation and Treatment

There are two complementary forms of evaluation for visual processing; clinical observations and standardized testing. A patient’s observation begins from the moment they enter our office, extending to the way they are able to interact with our doctors and staff. Therapists in our office are carefully selected so that they are sensitive to children who have special needs.

When patients are old enough and cognitively ready, we use a variety of standardized visual processing tests. The goal of these tests is to generate a score in terms of a percentile rank. This allows us to compare the performance of your child on the test to other children who are his age level. A key test that we use for preschoolers is the Wachs Analysis of Cognitive Structures. Dr. Harry Wachs is a world-renowned developmental optometrist who worked in conjunction with Dr. Stanley Greenspan, developer of the floor-time model for children (what is this?) with autism spectrum disorder, developmental delays, and learning disabilities.

During school-aged years, our battery of tests include other standardized instruments that cluster into visual perception or processing without motor involvement versus tests that incorporate movement. In movement categories we differentiate gross-motor from fine-motor, or eye-body coordination from eye-hand coordination.

Individualized Treatment and Therapy Provided

When treatment is indicated, we carefully weigh which activities and in what time frame a patient will receive the most benefit. The length of treatment, and the balance between home therapy and office therapy is individualized for each child. All therapy in our office is done on a one-to-one basis so that each patient receives the undivided attention of the therapist. Our therapists work closely with our doctors who guide programming and monitor progress on a regular basis.

The environment in our office is much like Liberty Science Center. Our patients’ performance on the visual processing evaluation helps us pinpoint the areas of greatest need. While we celebrate each patient’s individuality, we set conditions to help explore how each individual interprets visual space, visual sequencing, laterality and directionality, visual memory, and other components of visual processing including auditory-visual integration.

Visual processing is a key aspect of your child’s readiness for learning in general and reading in particular.

Our role at PressVision at Family Eyecare Associates is not to provide alternative teaching methods. Rather, it’s to help develop the readiness skills necessary to be more fully responsive to educational interventions.

We have a strong tradition of collaborating with occupational therapists, particularly those therapists who have a solid background and experience in sensory integration. OT (occupational therapy) and VT (vision therapy) are not a substitute for one another, but rather complement each other.