1996-2007, Optometrists Network

The Vision Screening of Academically & Behaviorally At-Risk Pupils

A Peer-Review Journal Article by:
Roger Johnson, Ph.D.
Derick Nottingham, M.S.
Randi Stratton, M.S.
Joel N. Zaba, O.D.

Journal of Behavioral Optometry
Volume 7/1996/Number 2/Page 39


The New York State Optometric Association Vision Screening Battery (NYSOA) was administered to 81 at-risk elementary, middle school, and high school students in order to rule out vision difficulties as contributing to academic difficulties and/or as to various determinations of attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), dyslexia or dyslexic, or oppositional-defiant behavior, etc. Thirty-three were classified as both academically and behaviorally at-risk. Ninety-seven percent of the students with behavioral problems failed at least one of the NYSOA subtests. A chi-square statistical analysis revealed that students who were academically at risk or behaviorally at risk scored significantly lower on the tracking, stereopsis, hyperopia, and color vision subtests. The results of this screening were also compared to several measures of academic achievement and subjective visual and academic assessment questionnaires.

Key Words

vision screening, attention deficit disorder, ADD, attention deficit hyperactivity disorder, ADHD, dyslexia, dyslexic, oppositional-defiant behavior, at-risk students, at risk students, problem behavior, disruptive behavior, hyperactivity, hyperactive, poor attention, reading problems, short attention span

Vast numbers of American school students are academically "at risk." Hundreds of publications in diverse academic fields have been written about students with unsatisfactory academic achievement. According to Donmoyer and Kos 1 700,000 students drop out of high school each year. Dropout rates for minority youth are twice that of white students. The vast majority of academically at-risk youth are from low socio-economic backgrounds and often display characteristics such as poor school attendance and anti-social behavior. Many at-risk students come from dysfunctional families characterized by substance abuse, psychotic disorder, and family violence.2 

Several types of school programs (supplemental, whole-school restructuring, therapy, intervention team approaches, and community/home/school partnership programs) have addressed the needs of at-risk students. Supplemental programs include pull out programs such as Chapter One reading programs and all-day kindergartens. Non-graded schools and site-based management are examples of whole-school restructuring programs. Therapy programs include effective education programs that attempt to apply humanistic Vision Screening of At-Risk Students, At Risk Studentspsychology to educational practices. Intervention teams comprised of teachers, administrators, guidance counselors, and school psychologists have focused on potential dropouts. Lastly, community/home/school partnerships enhance the self-esteem and cultural identity of at-risk students.1  Despite the implementation of these programs, the Education Commission of the States estimates that 30% of our nation's youth fail to acquire a sufficient education to obtain adequate employment.3 

None of these educational programs can be effective if students lack adequate vision. Although the school nurse tests most youngsters using a Snellen screening, few schools utilize a comprehensive vision screening program. Important visual skills such as tracking that are necessary for learning may not be measured. Undetected visual problems may lead to academic difficulties.

In spite of the importance of vision to the learning process, limited studies have screened special populations. Suchoff and Mozlin 4 noted significant visual problems among a population of inner city adolescents. Johnson and Zaba 5-6 found significant visual difficulties among illiterate adults and among at-risk college students. There is a need, however, to screen additional special populations, particularly inner city elementary, middle, and high school students who have been assigned to special alternative school settings for behavioral reasons.

Vision Screening of At-Risk Students, At Risk StudentsThis study has three purposes. The first purpose was to screen students who had been designated as academically at-risk, aged 8 to 18, in order to rule out vision difficulties as contributing to academic difficulties. The second purpose was to examine the prevalence visual difficulties among students with both academic and behavioral problems. Students who attended three alternative public school programs designed for students who were both academically and behaviorally at risk were compared with their counterparts who were only academically at risk, in order to determine whether behavioral status related to vision. A third purpose was to determine whether there was a significant relationship between passing the "Literacy Passport Exam"8 (a statewide exam that must be passed before being admitted to a regular high school program) and success on the NYSOA subtests.

Methods / Subjects

Thirty-three of 81 at-risk students who were selected for visual screening attended alternative school settings due to their behavioral problems, while 48 of the 81 attended traditional schools. One of the alternative school settings was on the elementary level, one on the middle school level, and one at the secondary level. Students who attended the alternative elementary or middle school had been assigned to these schools because of behavioral and/or social problems. Students chose to attend the secondary vocational school or have been assigned there because of behavior problems. The 81 students ranged in age from 8 to 18 with a median age of 14; 41 were males and 40 were females; 62 were African-American, while 19 were Caucasian. One of five individuals in this city is on public assistance with 60% of the city's students qualifying for free or reduced lunch. The median family income is less than $27,000 and seven in 10 students come from minority families. Approximately a million-and-one-half people live in this metropolitan area.

Screening Procedures

One of the researchers, assisted by local volunteers screened the students, using the New York State Optometric Association Vision Screening Battery (NYSOA).7  The NYSOA (1983) includes the following nine tests:

  1. Tracking: the ability to move the eyes across a sheet of paper
  2. Fusion: the ability to use both eyes together at the same time
  3. Acuity-Distance: visual acuity (sharpness, clearness) at 20 feet distance
  4. Stereopis: binocular depth perception
  5. Acuity-Near: near visual acuity for a short distance (specifically, the reading distance)
  6. Convergence: the ability of the eyes to move and work as a team
  7. Hyperopia: a refractive condition that makes it difficult to focus, especially at near viewing distances
  8. Color Vision: the ability to differentiate colors
  9. Visual Motor Integration: the ability to transform images from a vertical to a horizontal plane

The Fusion subtest was not included in the data analysis. A student data sheet containing various demographic data and test scores was completed on each student. In addition, each student completed a student appraisal form that contained attitudinal questions concerning the student's school and reading, and questions concerning whether he or she had seen an eye doctor or had ever worn glasses. Lastly, teachers completed a teacher appraisal form and a checklist of visual problems (see Appendices 1 and 2). The teacher appraisal form asked teachers to agree or disagree with a series of statements concerning student achievement in relation to peer ability, individual ability, referrals to the school nurse, etc. A modified checklist of possible visual problems was utilized for teacher observations.


Table 1 depicts the number and percentages of subjects that failed NYSOA subtests. Eighty-five percent of the subjects failed one or more of the visual tests, with more subjects failing the Tracking subtest (37%) than any other subtest. As can be seen from Table 1, a significant number of subjects failed Visual Acuity-Far, Visual Acuity-Near, Stereopsis, and Visual Motor Integration.

Number and Percent of Subjects
Failing NYSOA Subtests


Subtests Number Percentages
Tracking 30 37
Visual Acuity - Far 28 35
Stereopsis 23 28
Visual Acuity - Near 25 31
Convergence 0 0
Hyperopia 3 4
Color Vision 3 4
Visual Motor Integration 23 29
Failed at least one subtest 69 85

Table 2 portrays the failure rate on the NYSOA subtest of 33 academically and behaviorally at-risk students who attended alternative schools compared with students who were academically but not behaviorally at risk and attended traditional schools. Fifty-two percent of the alternative students failed the Tracking subtests, while only 27% of the traditional students failed Tracking. In addition, more alternative students than traditional students failed Visual Acuity-Far, Visual Acuity-Near, Hyperopia, Stereopsis, Color Vision and Visual Motor Integration. Furthermore, 97% of the alternative students failed at least one subtest.


The Percentage of Failure at At-Risk Alternativly vs. Traditionally School-Based Students on the NYSOA
Alternative N = 33
Traditional N = 48

Subtest Alternative Traditional
Tracking 52b 27
Visual Acuity - Far 42 29
Stereopsis 51a 13
Visual Acuity - Near 33 29
Convergence 0 0
Hyperopia 9b 0
Color Vision 9b 0
Visual Motor Integration 39 21
Failed at least one subtest 97b 77
a indicates p<.01
b indicates p<.05

A chi-square analysis determined the statistical significance of failure rates of students who attended alternative schools vs. traditional schools on the NYSOA sub-tests. This analysis indicated the greater failure rate of the alternative students was at the .01 level of significance for the Stereopsis subtest and at the .05 level for the Tracking, Hyperopia, and Color Vision subtests. The greater number of alternative students failing one or more subtests was at the .05 level of significance. Furthermore, a chi-square statistical analysis determined that the failure rates on the Reading portion of the "Literacy Passport Exam" for students who attended alternative schools were significantly higher (.05) than for their counterparts who attended traditional schools.

Vision Screening of At-Risk Students, At Risk Students On the other hand, no significant relationship was found between failing one or more of the NYSOA subtests and the Writing (essay) and Math sections of the "Literacy Passport Exam" nor failing the NYSOA subtests and current language and math grades. In addition, no significant relationship was found between failing one or more of the NYSOA subtests and dropping out of school nor being absent from school.


The most significant finding of this research was the 85% failure rate on one or more tests among these at-risk students. Moreover, they experienced significant failures on Tracking (37%), Visual Acuity-Far (35%), Stereopsis (28%), Visual Acuity-Near (31%), and on Visual Motor Integration (29%) subtests. Tracking, Visual Acuity-Near, and Visual Motor Integration are very important tests because they detect visual problems at the reading distance of 13 to 16 inches, a distance at which most school learning experiences occur.

Tracking is particularly important in learning to read. Since reading incorporates language acquisitions, the visual verbal process, and tracking, if one lacks the ability to efficiently move one's eyes across a page of print, this is likely to interfere with one's reading development. Thus, passing the reading scale of the "Literacy Passport Exam" is likely to be difficult. Therefore, the significant relationship between failing the reading scale of the "Literacy Passport Exam" and tracking as well as measures of near point vision such as Visual Acuity-Near (31%), Visual Motor Integration (29%), and Stereopsis (28%), lends credence to Johnson and Zaba's (footnotes 5 and 6) earlier studies. These found a significant relationship between failure on various NYSOA subtests and academic failure among illiterate adults and college freshmen.

Many at-risk students may not be aware that they have a visual problem. Instead, they may simply believe that they have a reading or learning problem. This self-perceived learning problem along with undetected visual problems is likely to frustrate many of these students. In spite of working hard at their studies, these children may be unable to keep up with their classmates. Unless students with these undetected visual problems are properly diagnosed and treated, they may become behavioral problems. Provisions for alternative schools may need to be made. Thus, the 97% failure rate of the academically and behaviorally at-risk population in the present study is understandable.

In an at-risk population a general or modified academic and behavioral appraisal of the student's performance is usually not sufficient. Even though teacher observations of student behavior are very important, these observations alone will not always detect visual difficulties. Therefore, with at-risk populations, it is essential that classroom teachers work closely with visual care professionals, community volunteers, and organizations in order that each pupil receive a comprehensive vision screening and appropriate follow-up care.


The authors are most appreciative of the contributions of Dr. Katherine Devine and Phi Delta Kappa for funding this research.


Appendix 1

Teacher's Checklist

Subject/Grade Level           
Please indicate which behaviors exhibited by this student you have observed:

  • Loses place often during reading.
  • Needs finger when reading across page.
  • Turn head when reading across page.
  • Omits "small" words.
  • Rereads or skips lines.
  • Displays short attention span while reading or copying.
  • Reverses letters and/or words in writing or copying.
  • Tilts head excessively while working at desk.
  • Writes with very irregular letter size and spacing.
  • Misaligns both horizontal and vertical series of numbers.
  • Complains of seeing double.
  • Rubs one or both eyes after short periods of visual activity.
  • Blinks excessively at desk tasks and/or reading, but not elsewhere.
  • Appears clumsy, uncoordinated.
  • Displays overactive behavior in class.
  • Displays lethargic behavior in class.



Appendix 2

Phi Delta Kappa
Teacher Appraisal Form

Student's Name                
Teacher's Name                

Thank you for participating in this study of the impact of poor visual performance on scholastic performance. We need your professional opinion about your student's progress to complete our initial evaluation. While we realize that your student's judgements must necessarily be subjective, we appreciate your thoughtful response. Please take a moment to complete this questionnaire.

Please indicate your degree with each statement by circling the correct letter:

Neutral Strongly
1. This student achieves at a level commensurate with his or her ability 1    2 3 4    5
2. This student achieves at a level commensurate with most of my other students 1    2 3 4    5
3. This student's achievement has improved during the course of this study 1    2 3 4    5
4. This student's behavior is commensurate with that of my other students 1    2 3 4    5
5. This student's behavior has improved during the course of this study 1    2 3 4    5
6. This student's self esteem is commensurate with that of my other students 1    2 3 4    5
7. This student's self esteem has improved during the course of this study 1    2 3 4    5
8. This student's referrals to the nurse are commensurate with those of my other students 1    2 3 4    5


Appendix 3

Phi Delta Kappa
Student Appraisal Form

Please answer the following questions:

Yes No

1. Compared to other students in your class, are you a good student?

2. Compared to other students in your class, are you a good reader?

3. What are you best at in school?

4. What do you like best about school?

5. How much do you like school?

6. Has a doctor ever examined your eyes?
If so, when?

7. Do you wear glasses or contact lenses now?

8. Have you ever worn glasses or contact lenses before?
If so, why did you stop wearing them:

Lost     Broken     Don't need     Other



1  Donmoyer R. Kos. At-risk students: portraits, policies, programs, and practices. Albany, NY: State University of New York Press, 1993.
2  Swanson M. At-risk students in elementary education: effective schools for disadvantaged learners. Springfield, IL; Charles C. Thomas Publishers, 1991.
3  Education Commission of the States. Securing our future: the report of the national forum for youth at-risk. Denver, CO, 1988.
4  Suchoff IB, Mozlin R. Vision screening of an adolescent inner city population: a high rate of failure and low compliance on a follow-up care. Journal of the American Optometric Association, 1991; 62(8): 13-18.
5  Johnson R., Zaba J. Examining the link between vision and literacy. Journal of Behavioral Optometry, 1994; 5(2): 41-43.
6  Johnson R., Zaba J. Vision screening of at-risk college students. Journal of Behavioral Optometry, 1995; 6(3): 62-65.
7  Cohen A., Lieberman S., Stolzberg M., Ritty J. The NYSOA vision screening battery -- a total approach. Journal of the American Optometric Association, 1983; 54: 979-84.
8  Virginia Department of Education. Literacy Passport Exam, 1988.


Corresponding author:

Roger A. Johnson, Ph.D.
Old Dominion University
Darden College of Education
Norfolk, VA 23529-0161

Date accepted for publication:
July 26, 1995


The URL of this page is: http://www.add-adhd.org/at_risk_at-risk_students.html