1996-2007, Optometrists Network

Comments on Attention Deficit Disorder (or Attention Deficit Hyperactivity Disorder) and Vision Therapy

by Donald J. Getz, O.D., FCOVD, FAAO

Children with undetected vision problems are sometimes inaccurately diagnosed as having ADD (attention deficit disorder) or ADHD (attention deficit hyperactivity disorder, attention deficit hyperactive disorder, ADD/ADHD, ADD-ADHD, AD(H)D) or LD/ADD, LD. Before labeling a child as having ADD or ADHD, evaluate them for developmental problems.In the last two decades, the diagnoses of attention deficit disorder or attention deficit hyperactivity disorder have become very popular (some would say epidemic). Before labeling a child as having attention deficit disorder or attention deficit hyperactivity disorder, it would be wise to evaluate them for developmental problems such as problems with visual development, motor development and/or auditory development.

Q.   Can discipline and behavior problems in the classroom (such as those associated with attention deficit disorder) be related to problems with visual development?

A.   It is the feeling of most authorities on the subject that there is a very positive correlation between the two kinds of problems. Furthermore, it is felt that a cause and effect relationship exists between visual problems and school behavior problems.

When vision is difficult and requires greater effort than normal, the child will usually exhibit an avoidance reaction to near point work, and thus will appear not to be trying or daydreaming.

The child with an undetected visual problem is often accused of having a short attention span and is often told he could do better if he tried harder. However, the child soon learns that no matter how hard he tries, success is not possible. Consequently, he soon gives up academically and must find other ways to occupy his time. Unfortunately, most of his alternatives are not socially acceptable in a large classroom.

Human nature also dictates that what the child does not do well, he would rather not do. Therefore, he will look for things which he can do well and these, also, might be socially unacceptable in the classroom.

The answer does not lie in stricter discipline and regimentation of these children, but rather in making a stronger attempt to detect and correct the underlying visual problems with the proper lenses and/or vision therapy.

Q.   What are the clues that I should look for in a child that might indicate a possible need for vision therapy?

A.   Besides the more obvious clues of blurred vision, discomfort, double vision, words running together, etc., I feel a deeper probe in the history might elicit some of the following signs:

  1. Reversals when reading (i.e., "was" for "saw", "on" for "no", etc.)
  2. Reversals when writing (b for d, p for q, etc.)
  3. Transposition of letters and numbers (12 for 21, etc.)
  4. Loss of place when reading, line to line and word to word.
  5. Use of finger to maintain place
  6. Holding book too close
  7. Distorted posture when reading or writing
  8. Omitting small words
  9. Confusing small words
  10. Short attention span
  11. Daydreaming in class
  12. Poor handwriting
  13. Clumsiness on playground or at home

In addition to the specific items mentioned above, I believe the single most important clue is performance that is not up to potential. Any child whose verbal ability surpasses his ability to learn visually should be suspected of a vision problem.

Additional signposts, which alert me to a possible vision problem, are statements from parents and teachers such as "he is lazy," "he does not try," "he could do better if he exerted more effort," and other such statements. It is obvious that various kinds of vision problems could cause these types of observations.

It is vital that a complete case history be obtained so that any vision problems uncovered can be related directly to both the child and the parental observations. A vision problem standing alone can only be of academic interest. But if that problem can be related to observable behavior, then it takes on significance and can, in turn, be related to lowered academic performance.

Q.   What are the vision skills necessary for classroom achievement which can be provided through vision therapy?

A.   It has been estimated that 75 to 90 percent of all learning in the classroom comes to the student either wholly or partially via the visual pathways, the child cannot develop to his fullest potential.

There are numerous learned skills that the child must develop in order to achieve in the classroom.

The most obvious skill is that the child must already have learned to coordinate his two eyes together. If he has difficulty in this area, he might be perceiving overlapping images or -- if he is not perceiving in this manner -- he is using an abnormal amount of effort to overcome the coordination problem, thus reducing performance.

In addition, he must have learned accurate, smooth versional eye movements and quick, accurate saccadic movements so that he can point his eyes where he will with a minimum of effort.

Focusing ability must be adequately developed so that it can be maintained over extended periods of time. Also, accommodative flexibility must be present so that attention can be shifted quickly, smoothly and effortlessly from book to chalkboard and back to book.

Form perception must be developed so that he can make the many fine discriminations necessary to distinguish one letter from another and one word from another.

Span of perception must be wide enough so that he can read in terms of ideas rather than letter-by-letter or word-by-word.

The left-to-right directionality pattern must be firmly established so that eye movements are carried out in the conventional direction for the English language.

Visualization is one of the most important visual skills, and it is vital for reading, spelling, and particularly, abstract thinking.

In brief, these are some of the visual skills needed for success in school. But I would like to emphasize that since all of these skills are learned, it is possible to train them to a more highly skilled degree.

Q.   What is the importance of directionality and laterality and how can be these functions be trained?

A.   The left to right direction pattern of the English language is a convention of our culture. As you know, some languages are read right to left and some are read in a vertical top to bottom direction.

This left to right directionality must become a habit, unconsciously used as a movement pattern in large movements, in small activities and in eye movements.

Many reading problems are rooted in the failure to develop a good habitual movement pattern and most poor readers have faulty movement patterns.

These directionality problems can be uncovered by observing the direction of his pencil strokes by observing the pattern in which the child arranges his work, and by observations during his oral reading. A child with directionality problems often reverses words and may attack words from the right end rather than the left.

With regard to laterality, it is important that a child be aware of his own right and left sides, because this is a vital prerequisite of projecting left and right out into space. A child lacking in firm laterality often reverses words when reading and writes letters and numbers in a backwards direction.

In teaching a child the difference between left and right, it is important to first make him aware that he has a left and right side and these must be teamed together in order to achieve bilaterality. This can be accomplished with such activities as balance boards, walking rails, trampolines, etc.

Then it becomes important that a child be able to label "right" and "left" on himself and then later out in space. This can be accomplished with such activities as "Angels in the Snow," "Simon Says," jump board activities with right and left directions, eye fixations, catching with right and left hands, doll and stick figure play, etc.

...a cause and effect relationship exists between visual problems and schol behavior problems...In developing the left to right pattern, the training is first started with large muscle, wide scan activities such as connecting dots on a chalkboard, and making various right to left as well as left to right patterns on a chalkboard. Thus, he learns the difference between the movement patterns. This graduates to small muscle, small scan activities with paper and pencil. Both of these are accompanied by eye movement training since the eyes are used to direct all of these activities. Visual tracking procedures are then used to reinforce the skill so that the end result is good laterality and firmly entrenched left to right direction patterns.

Q.   What is meant by the statement: "Vision is learned?"

A.   A child learns a visual skill or ability just as he learns to walk and to talk. Unfortunately, he doesn't have the opportunity to mimic his parents and siblings as he does in learning to walk and to talk. By the same token, a parent cannot observe how his child's visual skills are developing as he can in observing his child learning to walk and talk.

We can watch the child learn to roll over, lift his head, sit up, crawl, creep, stand, walk, etc., but learning to see is a process that goes on, generally, without assistance or even informed awareness.

The child who is learning vision:

  • must learn his own center,
  • must learn to team the two halves of his body,
  • must learn where he is in relation to other visually observable stimulae,
  • must learn to move against gravity and to operate in a gravitationally controlled environment.

It is possible that some parents restrain their children in limiting the full range of activity through the restricting use of playpens and walkers. By so doing, they prevent adequate range of movement and the normal development patterns found necessary during this period through crawling and creeping activities.

Later, children are given scooters and wagons which they invariably learn to push with a particular foot and leg. This contributes to shortening the leg on that side and hence a change takes place in the pelvic height that distorts the body balance.

Children who don't creep long enough or who are restricted in the physical exploration of their environment, frequently head into life with a physically produced disability. This may handicap them throughout life and never show in the usual routine physical or eye examination.

From a developmental viewpoint, a child must first learn to team the two halves of his body together before he can team his two eyes together. Also, from a developmental standpoint, a child must first learn to control his large gross muscles before he can control the fine muscles of his eyes. Consequently, when we find a problem in bilaterality, we find a problem in binocularity and visual perception.

Therefore, apparatus such as balance boards, walk rails, jump boards and such activities as crawling and creeping constitute an integral part of a developmental visual training practice.

Q.   What are the postural distortions associated with visual problems?

A.   We are aware of the more obvious postural distortions that can be observed in many patients entering our offices. When a patient tilts his head laterally, we frequently find astigmatism at an oblique axis. Likewise, when we see a patient with his head inclined backwards leading with his chin, we frequently discover that he is a myope [has myopia or nearsightedness]. When a patient has his head rotated to one side, he may well be found to be an anismetrope.

However, in this article we are primarily concerned with the problems associated with binocularity [two-eyed vision, eye teaming], and there are many postural distortions typically exhibited by a child with inadequate binocularity.

If a child does not possess good binocularity, or if he cannot maintain binocularity over a period of time, he will attempt to make compensations so that he doesn't have to use the two eyes together. The easiest way to do this is to adjust his posture so that one eye is taken out of the act.

One way to accomplish this is by rotating the head so that one eye is blocked by the bridge of the nose; another way is by putting the head down so that one eye is covered by an arm. Still another way is by holding a hand over one eye, or by bring the head down so that one hand covers an eye. All of these compensations can produce postural warps which, if continued for some time, can cause other problems.

A child who has difficulty in binocularity usually becomes a head mover rather than an eye mover. He will move his head as he looks at successive words with a reluctant stress on head, neck and shoulder muscles.

There are also environmental conditions that can create visual and postural problems. In an experiment with over 6,000 children conducted at the University of Texas, it was found that the minimum of stress occurs when the reading or writing material is parallel to the plane of the face.

In some of today's so-called modern classrooms, most reading and writing materials are placed on a flat desk. In order to achieve the parallel, minimum stress position, the child must bend over. This often brings his eyes within just three to four inches of his task.

The focusing and converging effort for this close distance is at least five times greater than that required for a usual working distance and this increased effort usually lowers performance. Therefore, it becomes important that we realize the direct interrelationship that exists between vision and posture.

Q.   Is there a relationship between faulty eye teaming and poor reading?

A.   I feel that there is an absolute direct relationship between the child's ability to team his two eyes together and his ability to learn to read successfully.

A child is born with two eyes, but he must learn to team those eyes together. Most children learn to do this quite well, but there are others who do not adequately develop this skill.

I would like to discuss the problem that a child who has developed an exophoria might encounter during the task of reading. There has been some controversy over the definition of exophoria. Some define exophoria as a tendency of the eyes to deviate outwards. Others define exophoria as that visual situation where the eyes converge beyond the plane of regard for accommodation.

Regardless of the definition for exophoria, the same situation exists during the act of reading. The visual demand while reading is for the eyes to point inward at the printed page. Since the relaxed posture for the exophore is for the eyes to go outward, it means that he must use an excessive amount of energy and effort just to keep the eyes pointing at the reading distance. Many university studies have shown that the greater the amount of effort involved in the reading process, the lower the comprehension and thus the lower the performance.

Eye movement photography show that when the saccadic eye movements are made during the act of reading, and each time fixation is broken as the child moves from word to word, an exophore's eyes will move outward and then move in to regain fixation. Consequently, the eyes will often regain binocularity two or three words over rather than on the next word. Therefore, it is not uncommon for him to make up the intervening words to make the sentence make sense. Typically, then, we have a reader who substitutes little words, confuses little words, and doesn't understand what he is reading.

Human nature being what it is, the child would rather not do anything that is difficult to do. ...the child with an undetected visual problem is often accused of having a short attention span.Thus, we observe an avoidance reaction in which the child would rather look out the window or talk to his neighbor than have to concentrate on the difficult visual task of reading. He often is labeled as having a short attention span, "not trying," having a behavioral problem, or being just plain dumb. We often observe this type of child who gives up and develops a strong dislike for school. It is possible that there is nothing else wrong with him other than an undetected visual problem.

An exophoric child often will make compensations in an attempt to minimize the effect of the problems. It usually is helpful for him to use his finger when reading to prevent the loss of place associated with a break in fixation. Unfortunately, too many educators have been taught not to let a child use his finger when reading. Fortunately, however, modern educational training teaches that when a child uses his finger, he is displaying to the teacher that he has a visual problem in teaming the two eyes together and that he is unable to read successfully without the finger.

Children will also distort their posture in an attempt to eliminate one eye during the act of reading. Many will cover one eye with a hand, or put their head down on their arm so that one eye is covered. Others will rotate their arm so that one eye is covered. Others will rotate their heads in such a manner so that the bridge of their nose will act as a shield between one eye and the printed page. Therefore, the observation of these postural distortions should alert the observer to the possibility of the existence of an eye teaming problem.

Q.   What is the relationship between crossed dominancy and academic failure?

A.   This is a question which has generated a great deal of controversy. There are some "authorities" who have claimed that cross dominancy is the leading cause of all reading failures. There are still other "authorities" who claim that there is zero relationship between cross dominancy and reading failures. This controversy, however, has had the beneficial effect of pointing out the relationship of visual skills to academic success.

A large part of the controversy has been created by a failure to define terms, especially what is meant by the dominant eye. Various tests have been designed to determine the so-called "dominant" eye. Many of these tests merely determine which is the dominant eye for "sighting." The dominant eye for sighting may or may not be the same eye which is dominant during the process of reading. It is even less likely to be the same eye if the sighting tests are done at a distant object rather than an object located at the reading distance and position of the particular child.

Most of the studies that I have read show that a larger proportion of cross dominant children exist in a population of under-achieving children than in a normal population. I feel, however, that a mistake has been made in drawing a cause-effect conclusion from this information. It has been assumed by many that the cross dominancy was the cause of the reading problem. It is felt by most authorities in optometry today that the cross dominancy is not the cause of the reading problem but, rather, just another symptom of the neurological disorganization which is at the root of the reading problem.

detect and correct the underlying visual problems with vision therapyIt has been my observation that most children who are cross dominant display a right to left visual direction pattern. It is this directionality problem which, I feel, has the more direct relationship to the reading problem. Therefore, vision therapy, which is directed towards establishment of a firmly established left to right direction pattern will produce more positive results in a shorter length of time.

Q.   Will children grow out of perceptual motor problems?

A.   The answer to that question is "frequently, yes," but whether or not a child will grow out of perceptual-motor problems must be related to the environmental demands on and opportunities open to the child.

Most of the perceptual-motor skills which are prerequisite for academic success are skills which are developmental in nature. In other words, they are learned skills. Since children learn at different rates, it can be assumed that these skills will be mastered at different chronological ages.

The problem to the child is created by the culturally imposed task of being required to learn to read at a definite chronological age. Some children are ready to learn to read at this age and other are not.

The child who has not developed the necessary perceptual motor skills may eventually develop these skills if left to his own devices. However, at the time he develops the skills, he might be hopelessly behind the rest of his class. It is also possible that he may never be exposed to the cultural experiences which would lead to the natural development of the perceptual-motor skills in question, in which case, unless he received therapy to develop these skills, he has no way of growing out of the problem. In addition, he might develop such negative attitudes towards education, based on his personal failures, that his natural desire to learn might be nullified.

It is the goal of optometric vision therapy to provide the child with these necessary perceptual-motor skills at the time he most needs them so that he will be able to meet the demands of the culture at the time that they are imposed on him.

© 2000 Donald J. Getz, O.D., FCOVD, FAAO


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