An Overview of Vision in Special Health Needs Populations
Barbara Kotsamanidis-Burg, MSE
The term special needs is an umbrella underneath which an array of disabilities may lie. These disabilities may range in nature from developmental, behavioral or learning delays to neurodevelopmental conditions, such as autism or chromosomal disorders, such as Down Syndrome. This blog entry investigates the prevalence of special health needs conditions as well as the critical visual needs that should be on the forefront of diagnostic examinations and therapeutic processes.
Children with special health care needs often process sensory information and perceive their environment differently than a neurotypical child. Processing the right environmental cues, or equally important, the process of pruning synapses in an attempt to improve brain connections, can ultimately determine whether a child with special needs engages or suppresses their attention and participates in typical daily functions such as watching television, riding a bike or socializing with siblings and peers. Education and continued awareness of currently available statistics brings to light the significance of encouraging researchers and clinicians to more adequately identify, intervene and attempt to prevent the
impact of complicated visual conditions in these populations.
In a Pediatrics publication titled “Trends in the Prevalence of Developmental Disabilities in U.S. Children, 1997-2008”, the Center for Disease Control (CDC) and Health Resources and Services Administration (HRSA) report children in the United States with a developmental disability is as common as 1 in 6 children. Developmental disabilities included attention deficit hyperactivity disorder, autism, blindness, cerebral palsy, hearing loss, cognitive/learning disorders,
seizures, stuttering and other developmental delays.
The prevalence of any developmental disability in the 1997-2008 timeframe was 13.87%. Additionally, the prevalence of developmental delays between the 2006-2008 timeframe had increased to 17.1%--- meaning there were 1.8 million more children diagnosed with a developmental disability than had been diagnosed in the decade prior. These statistics brought the number of children with disabilities up to approximately 10 million between the same 2006-2008 period. A 17.1% increase was by in large due to the prevalence of ADHD and autism rising. Generally, there was a higher prevalence in the diagnosis of boys, as well as a higher prevalence for older children to be diagnosed. This would make sense as certain disorders, such as ADHD or learning disabilities are not usually screened for until the school aged years. Time trends for all disabilities showed small, but significant linear increases in prevalence every four years.
Next, to highlight the ocular epidemiology and role that vision plays:
Down Syndrome: Down Syndrome, the most common chromosomal disorder underneath the special needs umbrella is a genetic anomaly involving mutations of chromosome number 21. Currently, 1 in 691 babies are born with Down syndrome each year, and more than 400,000 individuals with Down Syndrome live in the United States (Woodhouse & Maino, 2012).
An astounding 80% of these children have significant ocular pathology. Refractive error is present in 70% of children with Down Syndrome, while strabismus has a prevalence of 45% and nystagmus 35%. Other pathological factors that should be taken into consideration when caring for a Down syndrome child include blepharitis, cataract and keratoconus.
Autism: Of the individual disorders, attention deficit disorders and autism are the two most rapidly growing conditions. Both having significant underlying visual anomalies. Autism is a neurodevelopmental disorder, characterized by problems in sensory processing, socialization and stereotypical behaviors. A surveillance study most recently conducted by The Center for Disease Control (CDC) tells us that the prevalence for ASD is 1 in 68 children. Boys are four times more likely to
develop autism—1 out of 42 boys are diagnosed on the spectrum compared to 1 in 189 girls.
In a 2013 publication by Black, et al, researchers found that 52% of individuals with ASD in the Greater Baltimore Medical Center had an ocular abnormality; specifically, 41% demonstrated strabismus, 27% significant refractive error, 11% with amblyopia and 7% showed anisometropia. Common delays and behaviors associated with visual deficits include inability to maintain eye contact or attention, perseveration to lights or spinning objects, “peripheral” side viewing (improper gaze characterized by looking out of the sides of one’s eyes). One of the most logical questions to ask ourselves is if a child is unable to ‘see’ in these various respects, how can we expect them to ‘attend' to the world around them?
Attention Deficit Hyperactivity Disorder: Attention deficit hyperactivity disorder is a neurological condition characterized by one’s inability to sustain attention and demonstrates hyperactivity and impulsivity. Finding statistical information on ADHD can be a challenge, as the number of children being diagnosed in the United States continues to climb. In a 2013 survey of parents, the CDC reports that of the 6.4 million children between the ages of 4 and 17, 11% have received an ADHD diagnosis.
This is a 42% increase when compared to an evaluation conducted in 2003.
In a 2007 publication in Eye, Gronlund et al investigated ocular and visual functions in 42 children with the following results: 29% of the participants demonstrated heterophoria, 26% subnormal stereovision, 24% abnormal convergence patterns, 24% showed >1.00D astigmatism, 21% signs of visual perceptual problems. Further, this study found no significant differences in ophthalmologic findings when comparing participants receiving stimulant medication versus those who were not, indicating true biological components unaffected by medicinal side effects.
Again, issues pertaining to healthcare, treatment planning and educational concerns arise. As we see in Gronlund’s study, medication does not influence, nor does it treat what may potentially be a visual impairment, and not necessarily “ADHD.”
The road to remediation first starts with a comprehensive examination and it is critical that exams be conducted as early as possible. In the American Optometric Association’s second edition guideline manual (2010), Scheiman et al instituted an optometric practice guideline for the pediatric eye and vision examination, calling for the examiner to set forth the following goals.
- Develop an appropriate timetable for eye and vision examinations for pediatric patients
- Select appropriate examination procedures for all pediatric patients
- Examine the eye health and visual status of pediatric patients effectively
- Minimize or avoid the adverse effects of eye and vision problems in children through early identification, education, treatment and prevention
- Inform and educate patients, parents/caregivers and other health care providers about the importance and frequency of pediatric eye and vision examinations
Once a thorough examination has been implemented, it is your vision examiner’s responsibility to outline treatment options, albeit lenses for near-sighted, far-sighted, astigmatism; prismatic lenses, or evidence based approaches to visual therapy.
Though no single profession claims to treat all symptoms, optometry does carry a large position in the visual rehabilitation of special needs individuals. It is well known that 80% of our learning is experienced through vision, and although we may take it for granted, a special needs child with visual impairments cannot. A multidisciplinary approach, or co-managed care, fosters collaboration with other specialties, including psychophysiology, cognitive and perceptual neuroscience, occupational, physical and speech therapies, as well as the behavioral sciences. In order to elevate the child’s potential, all systems must work together.
Boyle CA, Boulet S, Schieve L, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Visser S, Kogan MD.
Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011. 127 (6): 1033-1043.
Gronlund MA, Aring E, Hellstrom A. Visual function and ocular features in children and adolescents with attention deficit disorder,
with and without treatment with stimulants. Eye (Lond). 2007; 21 (4): 494-502.
Black K, McCarus C, Collins ML, Jensen A. Ocular manifestations of autism in ophthalmology. Strabismus. 2013; 21 (2): 98-102.
Taniai H, Nishiyama T, Miyahci T, Imaeda M, Sumi S. Genetic influences on the board spectrum of autism:
Study of proband-ascertained twins. Am J Med Genet B Neuropschiatr Genet. 2008: 147B (6): 844-849.
Ozonoff S, Young GS, Carter A, Messinger D, Yirmiya N, Zwaigenbaum L, Bryson S, Carver LJ, Constantino JN, Dobkins K, Hutman T, Iverson JM, Landa R, Rogers SJ, Sigman M, Stone WL. Recurrence risk for autism spectrum disorders: A baby siblings research consortium study. Pediatrics. 2011; 128: 488-495.
Coulter R. Visual diagnosis and care of the patient with special needs. 2012; 69-84.
Woodhouse J, Maino D. Visual diagnosis and care of the patient with special needs. 2012; 31-47.
Scheiman M, Amos C, Ciner E, Tootle W, Moore B, Rouse M. Optometric clinical practice guideline. Pediatric eye and vision examination. American Optometric Association 2010.
My Child Had a Formal Psychological/ Educational Evaluation…
What Should I Do Next?
You may have read every parenting book, blog, or posts from your local mom’s boards for every difficulty your child might have, but chances are your child only represents a small portion of what is being presented to you. With this being said, when your child undergoes any psychological or educational evaluation, whether it be in a school, clinic, or private practice setting it is your job to ask questions related to your child.
Most importantly, ask questions beyond what the data or general “norms” suggest.
I say this because although we psychologists are trained to look at how a child’s behaviors present throughout the testing and account for them along with their abilities and skills, visual processing and behavioral observations are often overlooked during these most informative times. Unfortunately, this does not happen on any negligent behalf of the psychologist, but more so because psychologists are not trained to detect visual processing issues beyond what the scores present.
It is usually the parent who asks the psychologist “have you ever heard of vision therapy?" and "do you think my child needs this?” Visual processing difficulties can present in many ways across testing. If you are a parent who has had your child tested before or is going to in the future you will likely hear/see the abbreviated terms of the testing materials used. Some of the most frequently used tests are the WISC-V, WPPSI, WJ-IV, Bender-Gestalt II, GORT-5, GSRT, and the WIAT-III which assess cognitive abilities, visual motor integration, and academic achievement (reading, writing and math). Across each of these measures your child may present with below average scores--- your provider will spend some time discussing this and if your child presents as average it is likely he/she will move on during any type of feedback unless you stop them. Nonetheless, you should inquire about what the processes of your child’s work looked like. By asking these questions you will know whether or not you should turn to vision therapy or consult further about your child’s visual processing.
Here are some suggestions I would recommend asking the evaluator:
During testing did my child...
Work closely to the page
Have difficulty copying items (i.e. reversals or exerting excessive energy)
Seem to slow down or spend more time re-reading parts of larger passages
Write words that exhibited letter reversals
Fatigue during reading tasks
Exhibit lip biting or excessive mouth movements during reading
Express complaints when approaching reading/writing tasks
Skip lines when reading aloud
Read the words accurately, but exhibit minimal comprehension
Write sentences with poor spacing or ‘floating’ letters off the line
Not attend to the mathematical sign changes
Exhibit minimal organization across tasks, both spatially and/or verbally
Have difficulty following multi-step directions
Have difficulty self-monitoring during tasks
Have a short attention span for particular tasks
Exhibit dysfluency across timed tasks
These questions are important to ask because they are all signs of visually related difficulties that can be causing your child to exert additional effort or strain of the eyes, which often go unrecognized. Regardless of your child’s performance on these measures, it is by understanding his/her behaviors throughout the testing that will enable you to detect visual processing difficulties and a need for vision therapy. Remember, you are your child’s best expert witness!
My First Day at The Center for
Dr Nadia Kalantarova
What I experienced on day one at The Center for
Visual Management was not your typical eye exam---
I would say it's more about testing how ready and
able one's vision is for life skills. Our vision being our
dominant sense is not only used to see things clearly,
but also makes us aware of our surroundings, allows
us to switch our attention instantaneously when a threat is perceived, allows us to follow our kids around on the playground, scan papers at work, look at our phone while constantly switching our visual attention to other people and things around the room. All tasks that sound simple and basic but require an intricate system of focusing the lens, tracking moving objects, and having the two eyes work together.
The Center for Visual Management tests beyond what the average optometrist/ophthalmologist does. We treat not only the eyes but the visual system as part of the whole body. Seeing a young boy from Thailand being examined, Dr. Alami, a collegue of mine at The Center evaluated the child not only in the exam chair but out of it as well, making the exam more realistic and relevant to his everyday use of vision. She tested his visual acuity (20/20 vision) but also how ready and able his visual system is for school and being able to track and focus properly for reading. In addition testing how his eyes function in real life, like his ability to track a ball in 3-D space, balance while watching TV, follow a moving object, etc was conducted. Many of these tasks seem simple or primitive but for children and adults with binocular vision disorders, these tasks are all but easy or automatic. However, there is a solution called vision therapy that can be targeted to getting children's visual system ready for school so they can use more energy on comprehension, giving athletes those extra few seconds to react by having more precision and accuracy, or even alleviating many visual symptoms for developmentally delayed and autistic children to allow them more freed up energy to focus , or interact socially. I am excited to join The Center and now be a part of this journey with my patients!
How would I know if my nonverbal child needs a vision evaluation?
-Larah Alami, OD FAAO
One of the easiest and most immediate changes that can be seen with ambient prism lenses is watching toe-walking children suddenly demonstrate an instinctive ability to walk flat–footed. Doctors and parents alike notice a big difference just by watching the child walking throughout the testing area. We have many success stories of improvements in all sorts of areas such as toe-walking, stimming, grazing the walls, tantrums, increased expressive language, reading comprehension, and much more!
What are some of the most common visual problems in autistic spectrum populations?
A large number of spectrum children have a developmental history of delays in spatial orientation and spatial organization. Spatial orientation disorders are delays in processing information concerning posture, balance, and bodily movements. A child with such delays in orientation will often overcompensate with excessive body movements to know ‘where’ they are in space. This causes them to over focus on self, interfering with information processing of spatial information, which can result in anxiety and reduced processing skills and time.
Spatial organization, however, is one’s ability to organize information between self and their environment; this includes objects related to other objects and space and to self simultaneously.
As a result of spatial organization deficits, we frequently see issues with the eyes working together or focusing appropriately. Deficient binocular skills very often result in discomfort of the eyes, headaches, double or blurred vision, or fatigue. The excess effort expended in coordinating the eyes may interfere with the ability to make eye contact. This is one reason we see a high prevalence of ‘peripheral’ side viewing, flapping one’s hands in front of their eyes, or even pulling or pushing one’s lids.
Accommodative, or focusing skills refer to one's ability to focus clearly on near objects as well as to sustain this focus for an extended period of time. Deficient accommodative skills may result in rapid fatigue, or difficulty in shifting between persons or objects near and far.
After analyzing data from 100 cases evaluated by our office, including verbal and nonverbal spectrum cases, 36 individuals demonstrated convergence insufficiency (a problem with the two eyes coming in and remaining focused up close); 6 individuals demonstrated convergence excess (the eyes staying in too long and having trouble focusing outward). 28 individuals demonstrated exotropia, which is an eye turn outward and 13 showed esotropia, an eye turning inward). The remaining 17 received no diagnosis. So to summarize, 83 of the 100 individuals examined were found to have a visual anomaly inhibiting proper development or learning.
What are the signs? How can a parent suspect their child should have a vision examination?
Does this consider verbal and nonverbal populations?
Whether your child is verbal or has limited language there are many signs that could indicate a vision issue is warranted. It could be something as simple as excessive blinking, squinting, or frequently closing one eye. Or it could be something more complex. For example, observations of peripheral viewing, also referred to as “side viewing” might be something a parent or teacher might notice. Peripheral viewing tendencies arise when misinformation of visual stimulus is present and can often be a mechanism to suppress double vision. Or, there might be issues of balance and transport, such as postural warps, toe-walking, grazing of walls while walking and challenges with steps and stairs. In our model, this is a delay in the question of “where am I in space?” Oral impulses, such as placement of hand and other objects in the mouth, are also common in spectrum individuals with visual and proprioceptive delays.
According to the American Optometric Association, all children should receive examinations at 6 months, 3 years and again before the first grade. This recommendation is urged even when children may appear asymptomatic. While we expect all children to receive thorough evaluations at these milestones, we especially warrant parents whose children are symptomatic or are nonverbal/have limited communication skills to follow this trajectory, since they are unable to communicate blurry or disordered vision to their caretakers.
What is involved in the examination process?
At The Center for Visual Management, our examination is comprised of a few simple pre-tests if the child is able to undergo these tests. The doctor then splits the evaluations into two parts. First, we attempt a comprehensive eye exam in a traditional exam room. We discuss the child's history, and then attempt to check visual acuity, refractive status, eye turns or any muscular abnormalities, depth perception, binocularity, and eye health. While child participation is ideal for collecting visual status information, it's not necessary for the doctor to determine certain aspects of the exam, such as eye turn or refractive status. There are other very successful ways of extrapolating this information.
Next, we will all move to a larger, more open area that is designed much like a room you might see at a physical or occupational therapy office. There we complete a sensorimotor examination comprised of several activities. The Kaplan Nonverbal Battery was designed by our center’s founder, Dr. Melvin Kaplan years ago, and requires pre-prism lens and post-prism lens responses to specific tasks of visual attention, posture and disposition. By observing the child and allowing them to move through these tasks, simulating real-life day to day activities, we will be looking for increases in eye contact and conjugate eye movements, improved attention and interest in surroundings, more relaxed attention in visual-vestibular and visual-motor tasks, and any significant improvement in depth perception.
Preparing your child for an appointment
In preparing your child for an appointment with our office, we offer the following advice:
· If your child is tactile defensive, we first suggest going to a dollar store and buying a cheap pair of children's sunglasses. Pop out the lenses and for a few minutes each day leading up to the appointment, try having your child practice wearing the glasses at home. By becoming better acclimated to the feel of the frame on their face, the evaluation process can sometimes go more smoothly in the office.
· We also encourage you to share as much information about the doctors and our office as you can with your child. Explain to them that in addition to having their eyes checked, there will be other fun activities, involving televisions, balance boards, balloons, balls, slinky’s, puzzles, etc. Therapeutic glasses will be used to see if we can improve performance based tasks, like balancing on one foot or catching ball. Definitely let your child know that he or she will not be receiving any shots in our office! It is for the child's comfort that we also choose not to wear white coats in the office, and there is no noise or heavy fragrances in the office either.
· A video tour of our facility is available on some of our social media pages, including Facebook and YouTube. Having a sense of our facility and how non-threatening it is also very helpful to children. You can find our CVM video tour here: https://www.youtube.com/watch?v=EtwGGD711PU
· Most importantly, if you or your child have any specific concerns, please do not hesitate to contact our office. We make every attempt at accommodating each individual's needs.
An estimated 1 in 4 children
have a vision problem that if left untreated
impacts their development, learning and/or behaviors
Visual, DEVELOPMENTAL & EDUCATIONAL Services for your entire family
The Word of the Week: Executive Functioning
Madison Lee, MS
Executive functioning is a term frequently used within schools and amongst providers as executive functioning can impact a child’s most important job, to perform well in school and with their peers. Most often, when I speak with parents and I bring up executive functioning, they have heard of the term, but are confused as to what it exactly means. It isn’t the easiest concept to understand and covers such a large area of skills.
Executive functioning is a term that describes goal directed behavior, which is executed through mechanisms of initiating, planning, verbal reasoning, problem solving, sequencing, inhibiting impulses, and being cognitively flexible¹. These skills begin developing in infancy and continue to develop through adolescence². Well-developed executive functioning skills allow individuals to engage in daily activities independently, yet when there are deficits in any of the aforementioned areas, behaviors such as irritability, rigidity, impulsivity, and the inability to shift attention are observed³. It is likely that the first time you will hear of executive functioning, if you haven’t already, will be when your child enters school.
In school, executive functioning deficits manifest in many ways, such as:
-forgetting to turn in homework
-not writing down homework
-losing papers or throwing papers in a backpack
-disorganized desk space
-missing words in written texts or disorganized writing
-the inability to follow through with multi-step instructions
-disorganized speech output
-emotional arousals or shutdowns when there is a change in schedule
-only seeing/understanding situations in black and white or one particular way (concretely)
-acting before thinking
Upon reading this list, you might think that your child engages in a number of these behaviors, but has a different diagnosis such as Autism or ADHD, or maybe no diagnosis. It is important to know that this can be possible as children with such diagnoses also exhibit poor executive functioning skills to a certain degree as a similar part of the brain is affected, and children who are not identified should be thoroughly evaluated.
It is often that when a child has difficulty with any of the tasks mentioned, it impinges on their ability to achieve to their full potential and engage with peers as they truly intend. In turn, when these difficulties are overlooked and not addressed, he/she might be reprimanded more frequently and become discouraged more quickly. Renowned neuropsychologist Russel A. Barkley4 states “the issue is not ignorance or a lack of knowledge of a skill; the problems are with the skill’s timing and execution at key points of performance and with the self-motivation needed to sustain the performance.” In other words, helping your child through these challenges appropriately and fostering self-motivation is key to maintaining their highest functioning.
With all of this being said, assessing for executive functioning deficits is challenging. Your child’s school psychologist, private psychologist, or neuropsychologist can assess for executive functioning deficits. Either of the professionals will usually conduct a full psychological battery inclusive of several domains: cognitive, achievement, social-emotional, and attention/executive functioning.
Some ways to help a child with true executive functioning difficulties in school are: use of graphic organizers and/or planning pages, checklists (school work or self-regulation), behavior reinforcement plans, providing structured routines, teaching perspective taking, use of rehearsal strategies, having the teacher check in for understanding, setting time limits, desk reminders for a targeted problem and use of a social story (for younger children)
1. Chan, R. C., Shum, D., Toulopoulou, T., & Chen, E. Y. (2008). Assessment of executive functions: Review of instruments and identification of critical issues. Archives of Clinical Neuropsychology, 23(2), 201-216. doi:10.1016/j.acn.2007.08.010
2. Diamond, A. (1990). Developmental Time Course in Human Infants and Infant Monkeys, and the Neural Bases of, Inhibitory Control in Reaching. Annals of the New York Academy of Sciences, 608(1), 637-676. doi:10.1111/j.1749-6632.1990.tb48913.x
3. Lezak, M.D., Howieson, D.B., Bigler, E.D., Tranel, D. (2004). Neuropsychological assessment (4th ed.). New York, NY: Oxford University Press.
4. Barkley, R. A. (2012). Executive functions: What they are, how they work, and why they evolved. New York: Guilford Press.
Before We Can Teach, We Have to Learn
Barbara Kotsamanidis-Burg, MSE
First and foremost, I’d like to extend my best wishes for your children as they
commence into the next academic school year. This is the time of year that for
many can be filled with uncertainties, questions and plenty of stomach jitters.
Just remember, the doctors and I are here to help in any way we can and if
needed, can help advise you with helpful transitioning techniques.
I’ve spent the last fifteen years of my professional life learning from the children
I have served, CONSTANTLY evaluating how our sessions went. Is there
anything I could have done differently? What cues did I receive from the child?
My background in educational psychology has made me a better vision therapist,
and becoming skilled in my trade, I feel has helped me tremendously as a parent
to two (very) active children. My secret is as simple as applying what I have learned clinically into our home life. As I watch all of my 50+ children develop (those inside the office and at home) physically, visually, socially and emotionally, I routinely go back to those three fundamental questions--- how did our day go? What could I/we have done differently? What cues did the children provide us—meaning their educators, therapists and parents alike.
Remember, this academic year, as well as your child’s journey within it, will be cyclical. That’s what development is! It’s a dynamic process through which they, and we, evolve. It’s filled with happiness and excitement, as well as uncertainty and lessons to be learned. At the end of each day’s journey, let us appreciate what we have and the potential in the road ahead!
All my best,
FOSTERING Clinical EXPERTISE, RESEARCH & EDUCATION
The Fundamental Difference between Vision Screenings
and Comprehensive Eye Examinations
Barbara Kotsamanidis-Burg, MSE
I recently asked a close friend if she’d like to bring her four year old daughter into the office for an eye examination. “That’s okay” she said, “there’s an upcoming screening at her school.” Her response nearly caused me to fall off my chair. After shaking my head in disbelief several times, I quickly came to realize that perhaps those of us in vision care must not be communicating the difference between vision screenings and comprehensive exams effectively. This inspired me to create our very first blog post.
A vision screening, frequently performed by pediatricians or school nurses usually includes the use of the big “E,” also known as the Snellen chart. How well a child can interpret this chart at a twenty foot distance then determines whether that child will be referred to a vision care provider for further examination. In some cases, a prescription for clearer eyesight (20/20 vision) will be administered and the vision screening, at least to these children’s parents, will have been considered a success.
However, these same vision screenings are usually not exploring
eye health, assessment of eye focusing, eye teaming and
eye movements, including abnormalities that may exist in
the muscles. They more than likely are not examining
peripheral vision, depth perception or color vision, either.
Because children are completely unaware that seeing
words jump around on a page, or even seeing those words
split into two is abnormal, they frequently go on to live
with the disorder until either someone makes them aware
that there are treatments to resolve their issues OR they
continue living with poor visual function and
not knowing any differently.
Although the eyes are an extension of the brain (and quite literally the only part of the brain that we visibly see), visual issues are wildly undetected and I feel it is our responsibility to effectively communicate and advocate on behalf of those living with visual disturbances. Vision screenings are a good start, however, comprehensive examinations, performed by a licensed optometrist or ophthalmologist must become a yearly gold standard of care.
On behalf of The Center for Visual Management, the doctors and I look forward to periodically posting on our “CVM Visionary Blog.” Please feel free to share this and future posts with your child’s pediatricians, ancillary therapists or school administrators or educators—your willingness to share may very well save a child’s sight.