Visual Impediments to Learning and Development – Putting the Pieces Together

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(The goal of VisionMechanic.net is to provide science-based clinically relevant resources about humans, for humans. All humans. This series highlighting International Vision and Learning Month (August) is more focused on those humans who are in formal learning programs, most notably, younger humans. If you yourself are a learner, or if you teach them, guide them, care for them or provide therapy for them, then this series will be of interest to you.)

The fact is that we don’t look at vision, not seriously, and most kids who struggle with Visual Impediments to Learning and Development fall through the cracks

It’s reasonable to acknowledge that the lack of attention to vision in a meaningful way constitutes an abrogation of the basic rights of these children.

To understand how vision affects learning and development we first need a foundation in some basics, and that’s what was covered in earlier posts in this series. Importantly:

  1. Vision is more than simply just eyesight, and so measuring vision means more than simply using an eye chart.
  2. Using eye charts alone as ‘tests of vision’ is a problematic pursuit, even discriminatory: It most often fails the children who don’t need help and leaves out those who really do need help.
  3. Refractive States (nearsighted, farsighted, astigmatism) are common causes of reading and behaviour problems in the classroom. Most people are unaware of their own refractive states, most doctors don’t ask about refractive state before prescribing medications for unwanted behaviours.
  4. Blur is important in driving accommodation (the focusing reflex), and if an image cannot be made clear (for instance in the case of farsightedness or astigmatism) the eye’s focusing system will continue to struggle to try to make it as clear as possible. This is felt as eye strain (asthenopia, of which there are different kinds).
  5. There are different kinds of ‘blur’ including differences in image sizing (so ‘ghosting’ of images, a condition called aniseikonia), differences in refractive state between the eyes (one eye a little nearsighted, the other very nearsighted – one example of a condition known as anisometropia).
  6. Muscle movements are also very complicated. Our eye muscle movements offer us a sort of short-hand, or quick way of gathering a lot of information in a very short time with minimal effort.
  7. Impaired or restrictive muscle movements can and will result in impediments to learning and development such as reading disorders.
  8. Most Visual Impediments to Learning and Development (VILD) are detectable early and can even be used to predict who will succeed and fail in school with a fair degree of accuracy.
  9. VILD may be addressed often through simple therapeutic means at a relatively low cost.

Studies abound in the world of research in how vision function affects the three pillars of childhood: Development, Behaviour, and Learning. The fact that most child development professionals are unfamiliar with the basics of vision science is a problem for education and health budgets, and for families. The saying goes that if your only tool is a hammer, then everything will look like a nail is applicable, but so is this related notion: If you don’t know what a screw is, you will also likely ruin it trying to pound it in with that hammer.

A growing number of researchers are paying attention to the basics of human vision in child learning and development, including in psychiatry…

A growing number of researchers are paying attention to the basics of human vision in child learning and development, including in psychiatry such as this work from the Journal of Attention Disorders from 2018: The Underestimated Role of Refractive Error (Hyperopia, Myopia, and Astigmatism) and Strabismus in Children With ADHD or this one from Dr. Patrick Quaid in Medical Ophthalmology from 2013. Two papers of hundreds pointing to what should otherwise be obvious – obvious but for the simple fact that we, as a population of adults and developmental professionals, simply do not have a common background in the basics of human vision.

In my own case, I was trained in neuro-psychology and neural science, then in educational psychology and instruction – this included work in designing standardized testing, curriculum design. My students saw good success and were well supported – it was a relatively affluent community with a healthy tax base. At no point did I ever consider that vision could ever be a problem for my students – some had glasses, that was it. I later learned, during studies in human visual function in my optometric studies, that I had been in fact blind to the very intricate and important details of how we work as visual beings, and more importantly, how it shapes who and what we become.

I later learned … that I had been in fact blind to the very intricate and important details of how we work as visual beings, and more importantly, how it shapes who and what we become.

Even in that well-supported classroom with the best technology available, there were likely 1 in every 4 kids that struggled with a visual impediment of some kind, something about how their their eyes struggle to focus on near targets or to align properly, or to track lines of text. My own clinical experience, corroborated by studies in similar populations, shows extremes in some populations, namely First Nations communities where up to 50% of children in one survey showed enough astigmatism to interfere with reading and cause strain when dealing with text and computers. What makes matters worse is that these communities are the most poorly supported on visual function – even though they might have the very best computer technology on the Planet (which ironically is often especially toxic for those affected with visual impediments).

With vision, the impediments themselves can cause anything from mild blur and difficulty finding focus, to extreme discomfort and disability. The sad truth is even the extreme cases are most often missed and there is a price to be paid.

Vision is at the root of how we behave – our core inputs to life: If we struggle with simply perceiving something, if looking at something is painful, arduous, tedious, we will resist, fight it, and our performance will take a hit. With vision, the impediments themselves can cause anything from mild blur and difficulty finding focus, to extreme discomfort and disability. The sad truth is even the extreme cases are most often missed and there is a price to be paid.

It is still surprising to find medical and psychological clinics that make no reference to actual visual function in a meaningful way – like even considering the basic refractive state, for example.

In moderate and extreme cases, VILD are mis-labelled as anything from ADHD to dyslexia to even autism and other emotional disorders. Still, vision is not even on the radar for public health, or in pediatric clinics where medications are a common catch-all for therapists who want to try something and where the testing seems driven to justify use of medications. It is still surprising to find medical and psychological clinics that make no reference to actual visual function in a meaningful way – like even considering the basic refractive state, for example. There are reasons for this, not least of which is the DSM-V makes no requirement to note or assess visual function – so by default, vision cannot have anything to do with what is observed. This blind spot is dangerous and costly.

The fact is that we don’t look at vision, not seriously, and most kids who struggle with Visual Impediments to Learning and Development fall through the cracks: This includes kids who succeed in spite of real physical disabilities rooted in poor visual function – so study might be unnecessarily painful, for example, or reading belaboured, but for treatable reasons. Mostly kids who have significant visual impediments will see improved function (reading, athletics, comfort) and emotional balance when they are not bothered by the core element to learning, what most people take for granted – clear, fluid, effortless visual function.

For the price of one psychoeducational testing series with a report, the going rate is somewhere in the neighborhood of $7000 – per child. Most mild to moderate visual impediments to learning and development can be managed over the school life for less than $3k, including glasses and training. This provides a path to a solution, rather that a shot in the dark as to what the problem might be. Testing results always improve when vision is addressed first, and this makes perfect sense. Still, most psychological testing and medicating is done in the blind when it comes to vision.

…it makes no rational sense to use a vision-centric testing battery on a child whose visual functional status is unknown.

We all have reason to pay attention to VILD because it costs, all of us. The ones who suffer most are those who struggle in pain, or through needless testing and treatment only to find no solace because the hammer does not work on the screw. The worst part of this story is certainly the lost opportunities of these affected and labelled children who are forced to endure needless testing and treatment. Likewise, it makes no rational sense to use a vision-centric testing battery on a child whose visual functional status is unknown.

It’s reasonable to acknowledge that the lack of attention to vision in a meaningful way constitutes an abrogation of the basic rights of these children. With this in mind, and the consideration of additional costs to taxpayers and families of not treating basic vision issues, it’s time we reconsider our approach to dealing with learning and behaviour concerns from a nuts and bolts perspective first, with vision as a primary concern.

In an upcoming post in this series, we’ll have a look at how instructional design and health policy can be used to prevent harm from unmanaged visual impediments, and ultimately save millions annually.

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