Vision: The Starting Point of Learning
By Robert Constantine, OTR/L
Introduction by Katherine J. Collmer, M.Ed., OTR/L
“We worry about what a child will become tomorrow, yet we forget he is someone today. “
September is an exciting time for me. School programs are starting to get into their groove, setting up a fresh palate upon which students, teachers, parents, and therapists can create new adventures, paint exciting ideas, and draw up plans for a positive literacy experience. And this is the month that I like to share resources designed to guide educational staff toward helping their students work on the developmental skills they need today for literacy – and handwriting – success. I have an exciting schedule of informative posts lined up for us.
Today I’m presenting a guest post about a developmental skill I feel is perhaps the most important aspect of learning: vision skills. Robert Constantine, OTR/L, has dedicated his work’s mission toward educating therapists, teachers, and parents about the visual system in the interest of improving client outcomes. He has developed a presence in both the occupational therapy and the vision field through his continuing education courses and his social media platforms. Thank you, Robert, for joining our team and sharing this informative post and resource about vision skills and the importance of vision exams.
Vision: The Starting Point of Learning
I am excited to do a guest blog for Handwriting with Katherine. I am Robert Constantine, an occupational therapist since 1997 (no comments please!). I have spent a lot of time as a neuro and brain injury specialist where I developed an interested in vision and its relationship to function and therapy outcomes. In 2012, I had the unique opportunity to work in an optometry office, where I learned about the importance of eye movements and near vision focusing in school.
During my work in the optometry office, I learned two things very quickly:
- Vision affects everything we do. It is our furthest reaching sense and it gives us the most information about our environment.
- Eye movements and near vision focusing problems are holding back too many kids!
Now, I am on a mission to talk to as many therapists, teachers, and parents as possible about vision and share what I have learned! Here are some of the basics…
What is an age-appropriate vision expectation?
Academic standards continue to ask more of our youngest students. Reading and writing expectations for kindergarten students are common throughout our school systems, even as therapists continue to argue that these academic standards may not even be age appropriate. These tasks place a heavy demand on a child’s near vision skills. It is actually normal for children between 3 and 6 to be farsighted (hyperopia) making near vision tasks more challenging during this young age.
The age appropriate visual system
Visual skills develop at their own pace. Skills like saccades and tracking are not yet fully developed in three- to five-year-old’s, making the “earlier is better” scholastic calendar challenging for every child. Many parents are not getting eye exams for their children before they enter school for the first time, mistaking vision screenings by pediatricians or school nurses as sufficient evidence that their little one’s eyes are ready for the challenge of school. Eye exams are vital links for uncovering the hidden visual problems of our students. These problems can be the root cause for difficulty with learning and handwriting mastery. When it comes to eye exams, there are three lessons that are important for us to learn:
Lesson one: The complete eye exam
Only an optometrist or ophthalmologist has the skills to perform a complete eye exam that insures a child’s eyes are ready for school. In a child, a dilation is always part of the complete eye exam, not just to get a good look at the back of the eye but also to help tell how hard the eyes are working to keep things clear. The skilled eye doctor has no problem getting an accurate glasses prescription on any child, even when they are not verbal or do not know their letters, by using a procedure called retinoscopy.
For the school-based therapist, when a vision related learning problem is suspected, the Vision Therapy doctor may be able to help. These specially trained doctors offer services to improve eye movements and near vision focusing that could be at the root of poor academic performance. The College of Optometrists in Vision Development’s website shares important information about the 17 vision skills that impact learning and a link to help you locate a board certified optometrist near you who is qualified in vision development, vision therapy, and vision rehabilitation skills.
Lesson two: Eye Exam Frequency
The American Optometric Association (AOA) recommends that infants receive their first eye exam around 6 months of age to determine if an infant is at risk for eye or vision disorders. This exam is considered so important that the AOA, in cooperation with Infantsee, a public health program, provides an initial eye exam at no charge, no matter the parents’ financial status or access to medical care, for infants between the ages of 6-12 months. After this first exam, the next recommended exam is at 3 years old, or on a schedule determined by the child’s optometrist. Starting at school age (age 5), all children should have an annual eye exam. Just as their bodies are changing, so too are their eyes growing and changing.
Lesson three: 20/20 is not enough
Good acuity does not mean good vision. Vision is a dynamic process that includes the 17 skills mentioned above, two of which are the important binocular vision skills needed for handwriting mastery: near vision focusing and the ability of the eyes to move together accurately. When these skills are not well developed, a child may get headaches, see double, and even have behaviors that look like ADHD. Every pediatric eye exam should include an assessment of these binocular vision skills.
The Therapist’s Role
Just as visual skills begin to develop early on, an assessment of those skills should begin during those same years. The early intervention therapist is in the unique position to teach new parents about the importance of their child’s vision and the importance of eye exams. But many EI therapists have a difficult time finding the information they need to share with their parents. I have put together a group of tools for the early intervention therapist that includes a narrated power point discussing the development of vision from birth to 5 years old. It includes information to share with parents about eye exam frequency, an informational webpage on childhood vision pathologies with hyperlinks to explore the causes and prognosis of the most common problems, and a helpful glossary of vision related terms and more. This kit is a valuable collection of tools that can improve any therapist’s basic understanding of the visual system.
For school-based therapists, vision problems may be linked to many of your students’ handwriting and reading challenges. As you observe and assess their handwritten work, some initial symptoms of vision-related problems may appear as:
• poor letter spacing,
• “floating” letters that sit above or below the lines,
• different sized letters
• letter reversals
• poor far-near copying skills
Vision motor integration and visual perception problems that are uncovered during a handwriting assessment are, as the name implies, vision-related concerns. It is important to make sure the child completing these assessments has had an eye exam, as undiagnosed vision problems can affect the results.
I have some help for the school-based therapist, too. A vision toolkit for pediatric therapists with a narrated power point full of videos of treatment ideas, a narrated power point on my recipe for reversals, and lots more. There are also some easy strategies that can be employed during an initial assessment that can help you form a basic understanding of your students’ vision skills:
ASSESS EYE MOVEMENTS: Checking the tracking and saccade accuracy of your students will give you an idea of how well their eyes are working. A quick check of near point of convergence can tell you if they are seeing double when working up close.
HAVE A LOOK AT THEIR GLASSES. Are they dirty (yes…they are)? Do they slide down their nose when looking down to write? If so, they are losing the benefit of the glasses as the lenses are not in front of the eyes when they look up, causing possible copying errors.
ASK YOUR STUDENTS WHICH HAND IS THEIR LEFT AND WHICH IS RIGHT. Poor left-right awareness is frequently associated with letter reversals. Those children with laterization problems may also delay picking a dominant hand.
As therapists, we are also responsible for sharing the importance of vision with our teachers and parents. Every child needs an eye exam every year.
My Vision Platforms
My passion for spreading the word about vision has grown into the development of educational platforms where professionals can access resources easily and in a venue that is easy for them to use.
• I have a webpage at Vision Rehab OT where I share my blog, books, and wide array of courses.
• My Facebook group can be found at Vision Rehab OT .
• And for you visual learners, check out my YouTube Channel: Vision Rehab OT .
But that’s not all. I also conduct three live continuing education courses for PESI :
• Visual Rehab After Neurological Events: Seeing the World Through New Eyes – All about assessing vision skills and treating vision problems associated with stroke, TBI, and concussion.
• Innovative Vision Rehab Strategies for PTs, OTs, & SLPs: Don’t Let Vision Limit Your Patient’s Progress – For all of the therapists treating adult patients with eyes! This is about understanding vision and how it is affecting your patient outcomes.
• Vision Techniques for Eye Movement Disorders Associated with Autism, ADHD, Dyslexia & Other Neurological Disorders: Hands-on Assessments and Treatments for Children and Adolescents – The pediatric course that I started presenting nearly three years ago. Its updated and lots of fun!!
You can always email me at firstname.lastname@example.org with that “I have this one kid…” question. I like those challenges.
Thanks, Handwriting with Katherine, for helping me spread the word about the importance of vision.
Robert Constantine graduated from University of Alabama in Birmingham in 1997. He developed an interest in vision while working as the clinical specialist in brain injury for the West Florida Rehabilitation Institute, in Pensacola, Florida. He had an opportunity to work at an optometry office where he learned the techniques used in optometry to improve near vision focusing and ocular motor problems that affect academic performance. He continues to provide vision rehab services to both children and adults at the Pearl Nelson Center, working closely with several optometrists in his community. He has completed training in sports vision and was a member of the High-Performance Vision Associates, working with a team of optometrists assessing the visual skills of elite athletes. He has developed drag racing specific glasses in use by many NHRA drivers. He is also a member of the Neuro Optometric Rehab Association, having attended clinical level 1 and 2 trainings. Robert has lectured on binocular vision assessment and treatment for several years to thousands of therapists and teachers.
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