Vision Mechanic: Fundamentals – Preface

From the upcoming book intended to assist therapists of all backgrounds to open their eyes to human vision. Knowing how vision works helps to avoid common pitfalls in education and in therapy, it also helps us to accelerate treatment and care by attending to core principles first.

This preface offers a sense of where the book is going. The following post will offer more insight into the general structure of the book.

I look forward to getting this out soon enough and will keep readers updated here.

Warm wishes,

Dr. B

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Vision Mechanic: Fundamentals 

Preface

The title of this book has seen an evolution in time from its roots when I’d begun working in rural communities in Southern Alberta around 2010. Borne of sheer frustration at what I’d later call vision blindness in the broader psychology, education, and medical communities, and from the stark neglect of children I was seeing in some communities in particular – the draft title was in my mind appropriately edgy: ‘Nearsighted White Kids’. This edgy title was no doubt conceived to capture a reader’s attention, and there will be no apologies for that: Human vision is easily one of the most important yet most widely disregarded factors in child development and pediatrics today – and the cost to children, families, and governments is great. 

The provocative title ‘Nearsighted White Kids’ itself reflects two core principles. First, that certain visual functional profiles (or ‘schemata’, another concept to be described later) are better suited to school work regardless of age. A simple example is that a moderately nearsighted child is much more likely to succeed in academic worlds where fluid and effortless near vision is in high demand; hyperopic, or farsighted, children are at a distinct disadvantage in the neo-traditional or eClassroom, all else being equal, because they bear a greater physiological burden – it’s physically harder for the farsighted child to study near targets. A corollary of this is that children with significant visual impediments will most often be misdiagnosed, and this leads to unnecessary and often risky treatments – common examples include offering ADHD medication or brain imaging to explore behavioural concerns in pediatric patients who are simply struggling with  astigmatism, hyperopia, or convergence insufficiency (all these and more to be described in these pages). Secondly, with respect to ‘White Kids’, it is well-documented that unhelpful visual profiles are not evenly distributed across ethnicities. This is not to say that if a person is of X descent, they will necessarily have Y refractive state (the glasses prescription), nor does it mean that if the child is Caucasian they will have better eyes or vision. The fact remains that the distribution of these ‘unhelpful visual profiles’ is notable and impacts upon social and academic outcomes in some communities and populations more than others: Asian children are more likely to be nearsighted than not, children in some Indigenous populations show high prevalence of significant astigmatism, and hyperopia is relatively more common among children of Western European descent. Also, with regards to ethnic bias, in all societies and without exception, social support structures, including systems of health, policing, and education, will all have an inherited bias towards the descendants of and adherents to the cultural and social standards established by the systems’ founding fathers and mothers. Those who are not of similar descent or who have not assimilated into the dominant social-cultural paradigm will struggle to fit in, or find there is no place for them at all if the systems are too rigid. For many, the collision of difficult visual schemata and social-cultural bias create a preventable perfect storm that wreaks havoc over lifetimes and generations. In my world in southern Alberta and across Canada, it’s the White Kids who have set the rules since colonisation began in full force during the 16th Century, and this has continued for the most part violently through systemic social, cultural, and racial genocide and bias. While the bias of the White Kids (euro-centric, primarily of Christian descent) pervades our modern approach to governance, health, and education, Vision Blindness is equally common among different communities and cultures, as are the effects of ignoring visual impediments to learning and development – we are all afflicted with Vision Blindness until our eyes are opened. 

Long before I was a vision rehabilitation doctor, I had finished degrees in neuropsychology and education and spent some years teaching sciences. In my second year of teaching I was honoured with a ‘Teacher of The Year’ award – I was a good teacher and loved the work. My science background included studies in human psychology, psychiatry, neurobiology and  perception. Still, after all that training I can speak personally to the fact that we, adults, even teachers, are given very little to work with in our training when it comes to understanding human vision, how it works, how it fails us, and how this shapes our lives and interferes with them as well. It’s the most important part of who we are and what we do on a daily basis and we are virtually blind to it. I was. 

It’s hard, for example, to find a general practice family MD who can offer a functional comparison between hyperopia (farsightedness) and myopia (nearsightedness) – how each one affects a child’s learning, development, and behavior – let alone give you the numbers for their pediatric patients – who has what and how much of it. Don’t bother trying to add astigmatism, anisometropia, aniseikonia, or amblyopia to the discussion – all common issues related to refractive state (often called Refractive Error, or RE, and yes, you’ll learn all about these and more in the chapters to follow). Try it, the next time you encounter a family GP (general practice doctor/MD), ask if they track their pediatric or adult refractive errors. They just don’t, but they should, and you’ll learn some of the why here in these pages. The same applies to teachers, therapists, and counsellors of all stripes: They need to not only note visual functional status of their clients, but to also pay close attention to it – pushing a child with visual impediments to read and write is like having him ride a bike on flat tires, or with a broken leg. In the same way, offering psychological or motor testing in the blind vis-à-vis a child’s visual functional status is common, but severely impacts on outcomes, burden, and testing validity: We cannot know if a child’s performance is affected by vision until we actually look, measure, and understand it in the same way a mechanic understands how a vehicle is running by looking at all the subsystems and how these coordinate to provide an effortless, responsive, and reliable machine.  

In civilized progressive society, we offer physical accommodations to virtually anyone we can identify who is at a disadvantage. Still, in an increasingly digital-centric world, it remains a modern tragedy that we are blind to the 1 in 4 children with significant Visual Impediments to Learning and Development (VILD). If a vehicle is not running well, we will find a reliable and knowledgeable mechanic and address the one or many concerns in the various subsystems of the vehicle. Vision is like the vehicle in that we can break it down into subsystems and test these, document them and measure them, and then finally address the weak points so that the human child might be unencumbered visually while being forced to endure endless hours of visual-intensive instruction. As a visual being, visual encumbrances can have pervasive, profound and lasting effects. As complex as it is, vision in its perfected form is the pinnacle of evolved human behavior. It is the last of the senses to mature and is the core of our being in terms of cognitive process, how we think and how we move. Not surprisingly, there are many possible weak links in vision development and these impact on how the child functions, their behavioural limits, and on the outcomes and limits of our attempts to intervene. This book attempts to put the mechanic’s tools into your hands to start to identify and address the 1 in 4 children in your care that are struggling in part or in whole due to visual dysfunction. 

Some years ago, I was discussing the premise of this book with a former professor, Dr. JK. The thesis of that book is fundamentally unchanged in the one you’re now reading – that most people who matter in a child’s life have no idea what vision is, how it works, and the extent to which that matters. Importantly, some children are more affected than others by visual impediments and this carries a great cost. I’d mentioned the ironic and provocative title ‘Nearsighted White Kids’ to him, more as a dark joke – I was thinking of something less offensive and less noticeable like “Vision Blindness: An Introduction to Human Vision and Why What We Don’t See Matters.” His response was immediate to the point of reflexive: “What!? Nearsighted White kids are the least affected, they have the greatest advantage in our schools – easy near sight and they fit right in.” Then he caught on to the irony, and the message. “Exactly.”, I’d replied. Years later, after witnessing serial abuses in local schools and communities, after having been attacked for speaking out about it, I’d come to grow fond of the biting and provocative title and felt the tone was an important part of the story in that it offers a voice to the frustrated many clients who know me or one of my colleagues, most often through tragedy, and who have had their eyes opened to vision. 

As preparation for submission of the final manuscript to the publisher, I’d run a few ideas past my most trusted colleagues relating to the look of the cover, and the title. The response was predictably filled with love and caution – that the title might offend or put people off to the point of disregarding the message. I’d advised them that the risk of offense, the edginess of the title, was part of the point – that we should all feel a little uneasy about the facts in front of us, right before our very eyes – that unchecked visual dysfunction and the uneven ethnic distribution of visual impediments does damage, more so for vulnerable populations. In the end, I relented and have included one section in this current version with the original name. 

The book speaks for itself – it is fully science-based and factual, and steeped in my own clinical experience and that of many others from a number of vision-related fields in medicine, research, and related therapeutic. It goes beyond the science of human visual function to consider sociology, psychology, and economics as well. The first three sections serve as a decent introduction to some of the more important clinical elements, so the science of vision. The last section is much more personal and reflects some of the driving winds behind my own passion, a passion shared by many of my colleagues. The title of this last section remains Nearsighted White Kids, partly to maintain the same imperative of the original manuscript that arose out of neglect and abuses witnessed in local schools and communities, partly to honour those families, known and unknown, that still struggle with inadequate vision care and ineffective treatment trials and whose children are barrelling forward through public schooling regardless. If anyone should be offended, in the end, it is the individuals, families and children who have been neglected by education, psychiatric and medical practices that are so modern that they are blind to the very obvious, the very simple. Finally, the essays are personal, from the countless encounters with families where that light goes on when people finally open their eyes to their own vision blindness. As I’ve heard so many times in my clinic, “Why didn’t anyone ever tell me this?”. To that I say, somewhat reflexively: “Exactly.” There is need for greater knowledge and understanding about vision among the people that decide how you and your children will spend health and education dollars, the doctors, teachers, administrators and psychologists, pediatricians and psychometricians that mold our lives through diagnoses and treatment. 

I hope, dear reader, that you can forgive the provocative tone of the title of the last section and keep reading. If I’ve done my job, the pages will turn easily until that point and your knowledge will broaden. Just maybe, you’ll lose yourself for a while and when you wake up, your eyes, too, will be widely opened to your own vision blindness. Just like mine did some years ago, and like a growing number of others. 

The book should be viewed as a technical resource for therapists, and everyone else working in child development and in rehabilitation generally: Vision is central to our being, and those who address human health and development need to know about it, period, full stop. This book is intended primarily for the therapist’s ears and eyes, sensibilities and expectations: There is first a foundation in the science but only deep enough to get us on track, then a view to how this applies in the real world, and finally what can be done about things that don’t work so well and are causing problems. Teachers, doctors, psychologists, parents and many others will hopefully find the book ultimately readable and relevant; it includes the best pearls I would want to share as a teacher of new clinical professionals, all those things I wish were a standard part of curriculum everywhere child development and brain injury are discussed – all the things I wish I’d been taught as a teacher and student of psychology. 

CB

PS – Final Note: Since starting this manuscript for final production, I had the pleasure of meeting Mr. Robert Constantine, OT, from Florida. Robert goes by “The VisionRehab OT” in the United States where he teaches and practices, as well as online on Facebook and at VisionRehabOT.com. His specialty, not surprisingly, has been working with visual dysfunction for brain injury cases and with children who struggle with vision-related learning and behaviour concerns. Robert admitted one day, paying me a high compliment in the process, that he had ‘borrowed’ many of my writings and ideas over time, to expand his knowledge and practice, and to help educate others. Late in 2019 Robert and I committed to collaborating on a few major projects, and this led ultimately to a vision rehabilitation training event in Calgary, Alberta, and two coincident media projects: The ‘Vision Mechanic’ channel on YouTube, and a major web project, visionmechanic.net. Readers can follow, share, and extend their knowledge by visiting these two resources. 

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