Easterseals DuPage & Fox Valley Vision Clinic

By: Kristin Roemer, MS, OTR/L

The Importance of Vision

As a first grader, I got my first pair of eyeglasses at age 7. My school had an acuity screening, which showed that I could not see clearly from a certain distance. Getting glasses made seeing the board and all the materials within my classroom so much sharper and brighter. While many of us are familiar with the big “E” chart and understand the need for glasses for an acuity problem, we may not think as much about the other aspects of a person’s functional vision and how that impacts their participation in daily routines.

The Vision Clinic screening at Easterseals involves consultation with a developmental optometrist and an occupational therapist to screen for visual concerns and to discuss how these may be impacting a child’s participation in the classroom or at home. First and foremost, the developmental optometrist assesses the overall health of the eye structures and the need for a prescription. Two more areas, visual efficiency skills and visual processing skills, round out what makes up our vision.

Visual Efficiency Skills

Visual efficiency skills consist of three categories:

1. Oculomotor skills (or “eye tracking”):

• Fixation – the ability to maintain one’s gaze on a single image
• Smooth pursuits – the ability to keep one’s gaze on a moving image
• Saccades – quick movements between different visual targets

2. Accommodation (or “eye focusing”):

• The ability to sustain focus for an extended length of time
• The ability to change focus from far to near and back again

3. Binocularity: (also called eye teaming or coordination)

• Convergence and divergence: the ability of the eyes to move closer or farther and to keep a single image, not see double

Visual Efficiency Examples

If you think about your child sitting at their desk at school, each of these areas are put into play for them to be successful. Your child must use smooth pursuits to follow their teacher around the room and to follow along while reading. They must fixate and complete saccadic movements to look from one part of the board to another, such as when comparing two math equations. When they shift their gaze from up at the board back down to their desk, they are converging and diverging their eyes.

Keeping the information that they are looking at crisp and clear without “spacing out” and letting words get blurry involves their focusing system. When something about any of these systems is off, it can cause great difficulty in completing schoolwork. Even if a child is able to successfully hold each of these things together to complete a quick acuity screen, it may not show the bigger picture of how these skills have an impact on a full day in school or at home.

Visual Processing Skills

Visual processing skills refer to the brain’s ability to interpret visual information in different ways. These skills include:

• Visual discrimination – the ability to recognize details/differences among similar objects
• Form constancy – the ability to recognize an object in different contexts or in different sizes/colors/orientation
• Visual closure – the ability to visualize the whole picture when given a partial picture
• Visual figure-ground – the ability to perceive and locate an object in a busy visual field
• Visual-spatial relationships – the ability to perceive the position of objects in relation to each other and to oneself
• Visual memory – the ability to remember for immediate recall certain characteristics of an object
• Visual sequential memory – the ability to remember forms/characters in the correct order

Visual Processing Examples

Let’s imagine your child, now at home, is helping out with their chores and getting ready to get out the door. A child with a visual discrimination concern will have trouble matching up socks when they’re helping to sort laundry. When you ask your child to grab their homework off the messy kitchen counter, they may have difficulty locating it if they have poor figure ground skills. A child with form constancy problems may have trouble recognizing letters or words in different fonts or in different contexts, such as reading off a cereal box or from their assignment notebook. Let’s say you’ve asked your child with a visual closure problem to find their shoe, but they are unable to find it because it is partially obscured by a coat strewn halfway over it.

Maybe you show your middle schooler a neighbor’s address and ask them to drop off a letter down the street, but your child has difficulty with visual sequential memory and can’t remember the order of the house number. Your child, who is consistently clumsy, knocking over cups of water when reaching for the ketchup at the dinner table, may be having problems with visual-spatial relationships and be unable to adequately judge the distance between items. A child with visual memory difficulties may have poor reading comprehension, which can make for a frustrating situation when following a recipe or gathering up items from a list.

Vision Clinic Details and What to Expect

Who knew so much went into the way you take in information visually?! The occupational therapists on our team understand that the different sensory systems in our body affect how we navigate the environment and participate in various parts of daily life. If your OT feels that a developmental optometrist should be consulted to screen your child’s visual skills, they will first complete some screening activities themselves to grossly assess your child’s visual efficiency skills. If appropriate, they will also conduct some standardized assessments to get a baseline number for different visual processing skills. This information, along with identifying functional activities that may be difficult, is shared with the developmental optometrist before the clinic so the doctor can get a broader picture of how things have been going.

Our Vision Clinic typically takes place on the last Wednesday of the month. If possible, your child’s treating therapist will be present and able to share from her perspective how vision has impacted participation in therapy sessions based on what she has observed and in conversation with you. If s/he is not able to attend, she will touch base ahead of time with the OT running the clinic, who will then be able to share information and ask questions during the clinic. Information gathered from the screening will be shared informally with the treating therapist as well as a full report scanned into your child’s chart and emailed out for your records. In any case, if further consultation is needed with the optometrist, our therapists are able to contact their office and discuss strategies or action plans in more detail.

Recommendations and Additional Steps

Recommendations from the clinic may vary – the developmental optometrist may identify a few areas that need particular attention over the next few months. You will receive a list of activities to try at home, as well as toys and games that help promote visual development, and your therapist will also incorporate different activities into their therapy session. Sometimes, addressing these areas at home and in OT is all that a child needs to improve their visual skills adequately.

Other times, it may be recommended to go into the optometrist’s office for a more thorough evaluation. Some problems can be fixed with a pair of glasses (either performance lenses during tabletop tasks, glasses to address near or farsightedness, or specialty glasses with prisms), while others may require more intensive work in vision therapy. If this is the case, you will receive a packet of recommended providers in the area along with information about the typical vision therapy focus and progression. It is recommended that all children see an optometrist yearly to monitor vision development, regardless of suspected problems.

How to Get Started

If you feel that much of this information resonates for your child, ask your treating therapist about attending the Vision Clinic at Easterseals DuPage & Fox Valley. You can also contact our Clinic Coordinator, Christy Stringini, at 630-261-6216 or cstringini@eastersealsdfvr.org to facilitate this process. We look forward to *seeing* you!

Improve Children’s Handwriting

By: Laura Van Zandt, MS, OTR/L

There are many reasons children are referred to occupational therapy, but one of the most common, especially for school-age children, is because of difficulties with handwriting. Expectations for handwriting increase quickly between grades.

In most preschools, handwriting is done through more hands-on activities (think playing with play dough or using a paint brush). Then in kindergarten, children are expected to be able to write. By first and second grade, they are expected to write for longer periods of time with accuracy.

Many of the children we see as Occupational Therapists are able to write, but might have concerns with proximal stability (think core and shoulder strength), endurance, or have an inefficient grip on their writing instruments that may lead to messy handwriting. Other reasons might also be related to vision or sensory processing.

Below are a few tools for children to help their hands for strength, endurance, and grasp.

Some things to keep in mind when picking out writing tools for children:

• The smaller the writing instrument is, the more likely it is to encourage a tripod-like grasp (you may need to build up the handle to encourage)
• For kids with decreased grasp strength, drawing and coloring with markers or gel crayons may be easier and decrease frustration when presented with more challenging activities
• Work on a vertical surface whenever possible. It’s not only great for working on increasing upper extremity and core strength, it encourages wrist extension which is important for proper grasp on writing instruments

Squiggle pen

Who doesn’t remember this pen from their childhood!? The Squiggle Wiggle Writer is a vibrating pen that produces squiggly lines. It comes with 3 interchangeable pens which slide in and out of the tip of the pen (which is great for working on bilateral coordination). The vibration is great for providing children with sensory input while drawing or writing which helps with focus and attention.

Mechanical pencils

Picture by: www.raymondgeddes.com

I am a huge fan of using mechanical pencils with children because it helps them work on grading the pressure they use when writing. If you press too hard, the tip will break which gets frustrating after a few tries.

 

Twist and Write Pencil

This pencil was designed for a child’s hand. The Y design not only encourages a child to utilize a tripod grasp, but it also forces them to use less pressure allowing them to write for longer periods of time without tiring.

 

Small Pencils, Broken Crayons

 

I always have a collection of 1/2 pencils to use with the kids. The shorter a pencil, the more likely they are to use a proper grasp.

 

Beginning Writers

Crayola has launched a handful of new products meant just for little hands. These egg-shaped crayons are the perfect size and shape for your little artist. There are many benefits of children drawing at an early age including developing fine motor and grasping skills, encourages creativity and imagination, improves hand-eye coordination and bilateral coordination.

If you have an easel, I highly recommend having even the youngest of artists to use that because working on a vertical surface is great for kids of all ages. Working on a vertical surface helps increase core and upper extremity strength while encouraging proper wrist position, head and neck position, promotes bilateral coordination, and crossing midline skills.

Stylus

 

For a variety of reasons, kids spend more time on tablets these days. As with all things, as long as you don’t overdo it, working on the iPad can provide a lot of benefits. One of the things I recommend to all parents is that if they are going to let their kids use an iPad or other kind of tablet, be sure to have them use a stylus as much as possible to help develop fine motor and grasping skills. I think this is especially important if your child is doing any kind of handwriting or drawing apps. There are a lot of different stylus’ to choose.

 

Sidewalk Chalk or Small Chalk Pieces

One of my favorite outdoor activity is drawing with chalk.

 

Learning Without Tears Flip Crayons

Photo by: therapro.com

This is one great product. The crayons are already nice and small to encourage a tripod grasp and having a different color on each end encourages in-hand manipulation skills.

 

Triangle Shapes

Triangle shapes are perfect to encourage the use of just your first three fingers.

Forbidden Tools

  

Who doesn’t like the power of doing something forbidden like writing on windows or in the bathtub! These special items from crayola are designed to encourage writing and creativity is a fun way but also keep mom and dad’s sanity with easier clean up!

For more information on occupational therapy services at Easterseals DuPage & Fox Valley, visit: http://www.easterseals.com/dfv/our-programs/medical-rehabilitation/occupational-therapy.html. 

Learning-Related Vision Problems

By: Carla D. Adams, OD, FCOVD

WHAT IS THE VISION TRIANGLE?
Some parents have received a notice that their child needs a complete eye examination.
Parents often take their child to an optometrist and anxiously watch as they are asked to distinguish between lenses. “Which is better -1 or 2?” While a routine exam is a good start it should not be the only test for many students. Since vision and learning are closely linked, problems with vision can often interfere with learning. A routine eye exam alone will not always detect all problems that could affect good vision and thus good learning. Parents should be aware of the vision triangle. There are three types of vision exams, two of which are beyond the routine exam performed by eye doctors. By understanding the vision triangle, it will help avoid frustrations. Parents are armed with options if their child should have academic problems related to how he or she interprets what is being taught, especially if the problems persists with eyeglass.

ROUTINE EYE EXAMS
The first part of the vision triangle is the routine eye exam (just like the example above). Routine eye exams can detect sight imperfections such as near-sighted, far-sighted and astigmatism. Routine exams can also detect more complex problems such as crossed-eyes and lazy eyes. These conditions are often diagnosed during routine eye exams and respond well to eyeglasses and contact lenses. However, if eyeglasses cured all learning related problems, then there would be an overabundance of “A” students. Clear vision or having 20/20 sight is only part of the vision triangle. Unfortunately, most optometrists and ophthalmologists do not proceed further.

FUNCTIONAL VISION
The second part of the vision triangle is centered on functional vision. To read smoothly, a child’s eyes must work well together. This is called binocularity. A depth perception test is one of several tests used to test this skill. Fine eye movements and focusing tests (accuracy, flexibility and stamina) should also be measured. There maybe deficits in this area if your child complains of reading problems such as eye strain, fluctuating vision that will not stay clear, words that float off the page or even headaches. Maybe you even suspect that one of your child’s eyes do not look straight. These types of deficits do not always respond well to eyeglasses or contact lenses which is why some students continue to have problems after a routine exam. Vision therapy is often a good approach to treating such problems. Typically, only a few eye doctors offer therapy. More will be discussed about vision therapy later.

PERCEPTUAL VISION
The third and final part of the vision triangle is perceptual visual testing. Visual perception involves not only the eyes but also the brain and how it interprets and organizes information. This type of disorder surfaces around the age of 6 when children first learn to read. You should consider perceptual problems if your child tends to avoid reading and writing. Children with perceptual problems may reverse letters, print poorly and have trouble learning. Eye glasses alone do not solve perceptual problems. A vision therapy consultation with a pediatric optometrist is advised when learning problems persist.

What is Vision Therapy (V.T.)?
Just as eyeglasses and contact lenses work well to treat sight imperfections (i.e., near sightedness, far sightedness, etc.), functional and perceptual problems are often best treated with vision therapy. It is a type of physical therapy for the eyes. The purpose is to resolve visual problems that interfere with reading and learning. V.T. helps children develop or improve visual skills, read with efficiency and changes how a child processes or
interprets visual information.

Vision therapy is a progressive program of vision exercises or procedures performed under an optometrist’s supervision. The therapy sessions are individualized for each child. The meeting sessions are conducted in-office, once a week.

Following is a list of symptoms that often respond well to vision therapy:

• Blurred or double vision
• Headaches or eye strain
• Crossed eyes or strabismus
• Avoidance or dislike of reading
• Short attention span when reading
• Turning or tilting head to favor one eye
• Rubbing the eyes
• Slow reading speed
• Difficulty remembering what is read
• Omitting or repeating works or confusing letters
• Poor eye-hand coordination
• Losing one’s place while reading or using finger as a guide

For more information regarding vision visit our website:
http://www.easterseals.com/dfv/our-programs/medical-rehabilitation/clinics.html

Editor’s Note:
Dr. Carla Adams is a Developmental Optometrist with a specialization in pediatrics and vision therapy.  Her training includes an emphasis on serving children with special needs.  Dr. Adams is successful in treating children struggling in the classroom as well as children with attention deficit, PDD and autism.  She is a partner of the Easter Seals DuPage & Fox Valley Jayne Shover Center in Elgin.  Learn more about her care via  www.optique-eyecare.com