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Students with Persistent Problems -
The Visual Connection

by Dr. Leonard J. Press, OD, FAAO
School Nurse News, September 2000

As everyone becomes familiar with the new school year routine, students with persistent problems will begin to emerge, those children who seem to appear on a regular basis complaining of headaches, dizziness, nausea, and various other recurring symptoms. What's wrong with these children?

It may surprise you to find out that many of these children actually have vision problems at the root of their difficulties. According to the National PTA, "It is estimated that more than ten million children (ages 0-10) suffer from vision problems that may cause them to fail in school."

Don't be lulled into thinking that because a child sees an eye chart across the room clearly that he or she has perfect vision. "20/20" is simply the ability to see at 20 feet what a person should be able to see on an eye chart at 20 feet.

To help in understanding some of the visual skills required for school work, think about the classroom environment. A child sits at a desk, writes, alternately reads from a textbook and from the chalkboard, and usually follows the teacher's movements around the room while listening to the lesson. Some of the visual skills required in the classroom are:

  • Distance vision: being able to see the board

  • Near vision: being able to see the words in a book

  • Focusing flexibility: being able to maintain clear vision while shifting focus from a distant object to a near one

  • Tracking/eye movement skills: being able to aim both eyes accurately and move smoothly across a line of print or from object to object with ease

  • Eye-hand coordination: being able to use the eyes to guide the hands

  • Eye teaming: being able to coordinate the two eyes together so that they are precisely directed at the same object at the same time

  • Eye focusing: maintaining, for long periods of time, completely clear vision while looking at near or distant objects
Students who have eye teaming, tracking and focusing deficiencies often have complaints of dizziness, nausea, headaches, and/or red, burning and itchy eyes. They usually occur after the student is required to maintain visual concentration. For example, doing a reading lesson is enough to stress a student's visual system when it is deficient in any of the above skills and may cause fatigue, restlessness and difficulty paying attention.

A study at the University of California in San Diego has recently pointed toward a link between Attention Deficit Hyperactivity Disorder (ADHD) and vision problems. One of the concerns raised by this study is that the vision problem causes symptoms that could easily be mistaken for ADHD.

Children lacking these visual skills may not report symptoms even though they may tire easily, see double or have "ghost images" at times while reading for long periods. Their school work may be poor, or they may not be reaching their full potential. It is not uncommon for these children to have difficulty with reading, or paying attention, or even to exhibit behavioral problems. Since these are also symptoms of ADHD it is easy to understand how one could be mistaken for the other.

Table 1:

Students with Persistent Problems - Checklist

Do you see the same children at the same time, with the same symptoms day after day? If yes, do they:
  • Complain of headaches, pain around the eyes, dizziness or nausea?

  • Complain of itching or burning of their eyes and possibly excessive tearing?

  • Look tired, with red, irritated eyes?

  • Have red eyes with debris in the corners or on the lashes?

  • Have allergies?

  • Have these complaints after classes such as reading, social studies or science?
These are signs of possible vision problems requiring further evaluation

"We have shown that children with convergence insufficiency (difficulty focusing both eyes at a target and getting a clear single image) are three times as likely to be diagnosed as having ADHD as children without this visual disorder," according to David B. Granet, MD, a UCSD School of Medicine professor of Ophthalmology and Pediatrics and also Director of the UCSD Ratner Children's Eye Center. One of the possible reasons for this connection given by Dr. Granet is that sometimes these vision problems are being misdiagnosed as ADHD. Convergence insufficiency "makes it more difficult to concentrate on reading, which is also one of the ways doctors diagnose ADHD," Dr. Granet commented.

This new research appears to support what developmental optometrists have been saying for a long time. There are numerous optometric studies showing a close connection between vision and learning. In fact, some studies have shown that a significant percentage of children with learning disabilities have some type of learning-related vision problem.

Maria Lymberis, MD, Treasurer of the American Psychiatric Association and Clinical Professor of Psychiatry at University of California Los Angeles, is quoted in Health A to Z (a medical news Web site) as saying, "I'd bet that most psychiatrists and pediatricians are not that familiar with convergence insufficiency and maybe the best thing that comes out of this (Dr. Granet's study) is that those experts dealing with ADHD will be more aware of this."

Table 2:

Sample Vision Screening Form

Student Name: ______________________
Date: _________ Grade: ______________
School: _________ Teacher: ___________

Please check appropriate items and return to the school registered nurse for review and determination of action to be taken.

APPEARANCE: Do the eyes look normal?
  • Eyes turn in or out

  • Crusty or red eyelids

  • Different size pupils or eyes

  • Swelling of eyelids

  • Conjunctivitis (pink eye)

  • Drooping lids

  • Other: _________________________

BEHAVIOR: Teacher/Parent Observation
  • Tilts head, covers or closes one eye for critical seeing

  • Difficulty in keeping place while reading - a "finger" reader

  • Disinterested in activities involving critical seeing

  • Excessive stumbling, awkwardness or daydreaming

  • Holds printed materials in unusual position

  • Other: _________________________

COMPLAINTS: Child's Statements
  • Eyes hurt or blur while reading

  • Headaches when reading

  • Words move or jump about when reading

  • Double Vision

  • Eye problem following blow to head

  • Can't see the chalkboard

  • Other: _________________________
This screening is taken from "Guidelines for School Vision Screening Programs" which is printed and distributed by the Colorado Department of Health Community Nursing Section.

Children with convergence insufficiency will start out satisfactorily, but after a short period of working up close will find it difficult to continue reading due to the amount of difficulty with their vision. Their tendency to look away will make them appear to be disinterested, or have a poor attention span. These same children will appear more interested when they are being read to, or listening. They will then be labeled "attention deficit," or "lazy" when they're simply limited based on their visual abilities.

The idea of vision problems interfering with school performance is also gaining momentum in other areas. The National PTA voiced concern that "the relationship between poorly developed visual skills and poor academic performance is not widely held among students, parents, teachers, administrators and public health officials" and actually passed a resolution stating that the "National PTA, through its constituent organizations, provide information to educate members, educators, administrators, public health officials and the public at large about learning related visual problems."

When you find you have a child appearing with the same symptoms around the same time of day, find out what the child was doing in the classroom. Was it a reading assignment or some other visual task that could be challenging the child's visual system? If so, when you speak with the child's parents, you should recommend the child's vision be evaluated by an optometrist who provides specialized testing for all the visual skills required for learning, specifically, eye movement control, focusing near to far, sustaining clear focus, eye teaming ability, depth perception, visual motor integration, form perception, and visual memory.

In addition to the above, you could also have the teacher fill out a symptom checklist to give you more information as to what is occurring in the classroom (see Table 1). If the teacher is willing, it is possible some adjustments that will generate relief could be made to the child's program. For example, if the child has difficulty reading for long periods of time, perhaps the teacher could have the child take a visual break every few minutes and have the child look out the window, or to the far back of the classroom, and then go back to reading.

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