Friday, October 30, 2009

How Hopscotch Helps Vision

One of the games I remember playing at recess was hopscotch. My school had a cement playground between the brick building and a twelve or fifteen foot high fence along the back yards of the neighboring houses. There was also a sand lot that did not belong to the school but which we were allowed to use during recess but no girls were welcome on that part of the playground in the early 1960s because the rough wild boys were always playing soccer or softball. And, of course, we were wearing dresses so that wasn't an option for us even if the boys would have tolerated our presence. Since boys have cooties, we didn't mind being excluded because who wants to get cooties. The girls tended to dominate the black-top part of the school yard. We also often played hopscotch - especially if someone remembered to ask the teacher for a piece of chalk from the black board to draw the board. It is too bad that recess is being marginalized because even a simple game of hopscotch relies on and improves the learning-related vision skills that make academic progress easier.

Even drawing the hopscotch board takes a combination of visual skills. First, using the visual perceptual skill of visual memory, the chalk artist checks the mental image of the board. Then, using visual spatial relations, another visual perceptual skill, and visual motor planning, the chalk artist arranges the lines - oops- don't forget to apply good visual motor integration so that the lines meet at good perpendicular corners and the numbers in the boxes are legible.

Applying visual attention and good saccadic eye movements, the kids scan the yard until they locate a rock that won't roll too much, is colored so that it contrasts with the pavement enough to find after tossing it, and is small and light weight enough to pitch.

Again, it takes good eye movements, visual attention, and the ability to team both eyes on a location in the distance as well as great visual motor integration to make an accurate throw so that the rock lands in the next box.

Next, the vestibular system has to coordinate with the visual system with good bilateral integration skills to hop through the board without stepping on any lines.

Finally, visual memory has to remain at work between turns so that the players can keep track of their next goal.

So, if anyone tries to take away your recess - try challenging them to a game of Hopscotch. And, please, post a comment to share what was your favorite recess activity when you were in grade school.

Thursday, October 29, 2009

What's So Good About Recess?

Recess, that endangered but kid's favorite part of the school day, could be key to a child's academic success. No, not because they need a break - but they do! And, not because it's fun - but it is! Recess is where the gross motor bilateral coordination building laterality & directionality eye movement visual perceptual and visual motor integration skills all get exercised on a daily basis without anyone realizing it. That's the problem. So many educators insist that the reason children are not making more consistent progress learning to read and write is because they don't spend enough time in the classroom that many (especially inner city) schools are doing away with recess. My next Eye Can Too! Read book will be about recess games that actually will make it easier for children to learn to read. These include hopscotch, jump rope, ball games, aiming/tossing games, running games, and clapping games. I'm going to provide the directions and then explain the learning-related visual skills involved as well as connect those to how they are critical to developing adequate reading and math skills. Want to help? Add a comment here or on FaceBook or Twitter about your favorite recess game when you were a kid. If there was a type of recess game that you just never were able to do well, let us know that also. And, more than anything, make sure that the children you know, love, and work with have plenty of opportunity to be outside playing the games that build the skills they need in the classroom.

Monday, October 26, 2009

For Teachers About Learning & Vision

Teachers should be the first line of intervention when one of their students has a learning-related vision problem since they get to see the children at work every day. When a student covers one eye or puts their head down so that only one eye points towards the text or paper, the teacher should recognize that this child needs to see an eye doctor to rule out amblyopia, or problems teaming the eyes to keep a word or other image single. When a student squints or complains of having a headache often during school - especially when asked to copy work from the board or smart-board to a piece of paper on their desk, the teacher should suggest that the student's parent make an eye appointment to make sure that the child knows how to accommodate i.e. switch their focus from near to far and back again efficiently. When a student cannot line up the digits in a math problem or appropriately space words on their paper, the teacher should first offer some practical hints but if these do not seem to help, it is time for a referral to an eye doctor to make sure that the child's eye movements and visual perceptual skills are developing on schedule. When a student makes frequent reversals when reading or writing - especially after the second grade, this may be a visual spatial delay in the skills of laterality and directionality. Finally, when a student has trouble in PE or on the playground catching or aiming balls or, in general, has under-performing gross motor skills, the root of the problem could the visual-motor-integration. While each of these symptoms can make success in school very difficult, all of them can be addressed by a few weeks or months of in-office vision therapy under the supervision of a developmental optometrist. No child should be left behind in school because of addressable learning-related vision problems.

Saturday, October 24, 2009

Hope for an amblyope

We have a new intern in our office, a fourth year optometry student who, as I am fond of saying to the therapy patients, is just a minute away from becoming an eye doctor. As I was introducing her to the various activities that we use in therapy, she disclosed that she is not binocular. In other words, she does not see in three dimensions because her eyes do not team properly together. She is also an amblyope. One eye has an acuity that is at least two lines on the Snellen Eye Chart worse the other eye. This is probably why she is not binocular - she opted to pay attention to the information coming into her brain from just one eye - actually, she did not do this on purpose, it just happened and therefore she does not experience double vision. You need two eyes to point to the same place in space AT THE SAME time in order to experience three-D vision. Since we deal with binocular dysfunctions a lot in VT (vision therapy), she and I began to talk about what her goals were for this rotation. Binocularity has been an abstract concept for her, not ever having experienced it and she hopes to understand it better. As I showed her patient histories that demonstrated how we can stimulate the emergence of binocularity in patients with similar conditions as her own, she became more and more intrigued with the possibility that she, like "Stereo Sue" Barry, could actually achieve a different visual outcome. That was last Monday. I only work on Mondays and Saturdays so when I saw her today she greeted me with the news that she is beginning to be able to do very simple binocular tasks. Later this morning, she was wearing a patch over her better eye to make the amblyopic eye work. I love when people unexpectedly gain hope for what they thought was a forever condition to change. I'll keep you posted.

Wednesday, October 21, 2009

Can't cross the midline - Rake my yard, please!

Children who cannot cross the midline have lots of problems in school. They don't easily form letters like X, V, W, M, N, or Z because these letters require them to draw a line that moves across a diagonal. These kids have trouble finishing worksheets where they have to connect a selection on the left side of the page by drawing a line to its match on the right side even when they can demonstrate mastery of the information orally or in other kinds of written assessments. Regular playground activities like skipping are also very difficult and the most delayed children may not be able to alternate their feet when climbing up or down a flight of stairs. These same children probably do not know their left from their right and may become confused about which side of a word or line of text to read first. By providing lots of gross motor experiences that require a child to cross their physical midline during a program of in-office vision therapy, we can often help them to form the neural pathways that allow them to understand where they are in space. Then we can assist them to apply that knowledge to directions outside of their body. So, it's fall. I spent much of the afternoon raking leaves. It is a perfect chore to give to a child who needs to learn to cross the midline. You hold the rake with both hands and sweep it across your body again and again. Of course, the satisfaction of creating a huge pile of crispy leaves to jump in and hide beneath provides most of the motivation needed. Even very small children can rake if you buy them rakes with shorter handles.

If you suspect that your child may have delays in the development of laterality & directionality, make an appointment for a comprehensive eye exam with a developmental optometrist who incorporated vision therapy into the practice. The doctor may decide to administer a series of normed tests to learn whether your child's visual perceptual skills are developing on schedule.

If you would like to have a set of original activities that assist children to grow in the development of the visual spatial skills of laterality & directionality, consider buying the Yellow Book of the Eye Can Too! Read e-book series by Lesley Barker

Tuesday, October 20, 2009

Before you Medicate, Investigate- ADHD & Vision

Clinical research has established that there is a link between a diagnosis of ADHD and certain vision deficits or delays in children. Many children with ADHD also test positive for a saccadic eye movement deficit. This means that they have difficulty moving their eyes efficiently and accurately from one fixed visual target to another as in going from one word or line to the next on a page of text. Many children with ADHD also test positive for a convergence insufficiency (CI). This means that they are unable to cross their eyes or team them appropriately and may experience words moving, blurring, or doubling on a page. They may get headaches when reading or they may, without ever being aware of it, suppress the vision in one eye. Many children with ADHD also test positive for accommodative infacility (AI) which means that they have trouble adjusting their focus when looking from a near image to a different image in the distance.

The good news is that all three of these visual diagnoses can be addressed with a program of in-office vision therapy under the supervision of a developmental optometrist. So, if your child has been diagnosed or if you are being encouraged to obtain a diagnosis of ADHD, don't stop there. Arrange an appointment for your child to receive a comprehensive eye exam by a developmental optometrist who incorporates vision therapy into their practice. If the eye doctor finds that your child has any of these visual problems, follow through with the program of vision therapy. To find a developmental optometrist in your area, plug your zip code into the search box at

You can read more about this in: Borsting, Eric; Michael Rouse, and Ray Chu. Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study. "Optometry", Volume 76. Number 10. October 2005

Saturday, October 17, 2009

Learn to Be the Boss of Your Own Eyes

A first grader came to his 15th in-office session of vision therapy today. His parents brought him to the developmental optometrist in the first place because they noticed one eye shifting in whenever he got tired. They feared he would be teased for having crossed eyes and wanted to try to avoid surgery. Not only did the doctor concur that he has a strabismus- an eye turn, she discovered that he did not use both eyes as a team. Like many other children, he suppressed the vision in one eye to avoid seeing two images when his eyes were not aligned at the same time on the same visual image in space. This unconscious strategy made him unaware of any visual problem. He had good grades, was a good athlete, and had no intrinsic use for coming to see me every week. It has taken all sorts of monocular, and binocular activities disguised as games to coax him to begin to experience binocularity. Last week it started to make sense TO HIM. I asked him to watch a bead approaching his nose on a long string (the Brock String - magic to many patients but key to learning to use two eyes together). Whenever the bead got within about six inches of his nose, his left eye swooped in towards his nose and he reported seeing two balls. Had his eyes continued to be teamed on the in-coming bead it would have remained single. Finally he was able to connect the feeling of that eye moving in with the sensation of double vision. "You need to be the boss of your own eye," I suggested, "but it keeps saying: 'I don't have to obey you - I can do anything I want.'" That apparently was enough motivation to make the child take charge. Today I could push the bead within two inches of his nose without the eye wigging out and he could switch between that bead and another bead about eight feet away on the same string without any problems at all except that it made him very tired. By next week he should be able to do more repetitions without fatiguing. As long as he is the boss of his own eyes, he will make them mind. Of course, this activity correlates with the ability to read for extended periods of time without fatigue, double vision, headaches, or the words wiggling on the page. It also solves the cosmetic problem that his parents were so (justifiably) worried about.  I can't wait for his re-evaluation appointment with the doctor who will be thrilled at the emerging binocularity and independent control of his eye movements both when using one eye and two.

Wednesday, October 14, 2009

Your Child Can't Keep Their Eye on the Ball?

Just because a child has difficulty aiming and catching a ball does not necessarily mean that they are not athletic. It might mean that they need to see a developmental optometrist for a comprehensive eye exam. Children with poor ocular motility skills do not know how to control their eye muscles. The same kids who can't catch may also move their heads from side to side across a page when reading instead of moving just their eyes. This may result in frequent losses of place or skipping little words and lines of text. Why is this? Because each eye is equipped with six muscles that serve to coordinate to physically point the eye towards a visual target when used efficiently. However, children who don't know how to make automatic voluntary eye movements may have difficulty tracking the flight of the ball (and finding their place in a book.) Children can also have a visual-motor mismatch that makes it hard for them to discern where something is in space. This can impair a child's visual-motor integration skills- not just in sports, but in handwriting and other fine motor skills as well. Every child should receive an annual eye exam and if your child exhibits any of these problems, ask about a comprehensive evaluation of their binocular skills when you talk to the doctor. These problems are routinely addressed with just a few weeks of in-office vision therapy.

By the way, the activities in the Purple Book of my Eye Can Too! Read series of e-books all can be used as an addition to a program of in-office vision therapy to improve a child's eye movement skills. Written for homeschooled families, these activities are easy to do and appropriate for elementary school children.

Monday, October 12, 2009

Strategies to Develop Visual Memory Skills

Today, after eight weeks of seeing me for in-office vision therapy, the optometrist discharged a high school sophomore patient previously diagnosed with a delay in the development of the perceptual skill called visual memory. She attends an elite parochial school with high standards and hard tests. Because it has been so difficult for her to remember what she studies, she has struggled with both her grades and her self image. Last week I introduced tangram puzzles as a way to help her discover meaningful strategies to remember complex material. This week she reported that it was the most significant activity of all the ones we did in therapy because it helped her approach her homework differently. Instead of becoming overwhelmed at the many individual words or concepts she had to remember, she began looking for and sorting the work into chunks and patterns that made sense. Even remembering the verb conjugations in her Spanish 2 class became so much easier.

Here is the sequence we came up with to remember a block design so that, without looking at the model, it is easy to rebuild it from memory:
  • Start with a simple block design that you want to remember
  • Build it 
  • Analyze it by making associations and by dividing the larger design into manageable chunks
  • See if you can close your eyes and see the design in your mind
  • Practice referring to the mental image and drawing or assembling it on paper or in space
  • Do something else for a while
  • After several minutes, hours, or days, see if you can still access, refer to, build, and use the visual image stored in your mind
Shameless self-promotion: For home-schoolers (and vision therapy patients who need home therapy activities), I created the Green Book of the Eye Can Too! Read e-book series. All the activities require the use of visual perceptual skills to accomplish academic activities - I indicate the expected grade level for each activity as well as tips for parents to observe while their children attempt the tasks.

Thursday, October 1, 2009

Eye Movements & a Struggling Adult Reader Who Has an MBA

I recently did a very simple eye movement activity with a friend who reads very slowly. It has always been a problem for her from the time she was in elementary school. In fact, she chose her high school and college courses to avoid reading so she became good at math and ended up with an MBA in finance. It remains agonizingly difficult for her to find the energy to tackle reading even a few pages. When she reads aloud, she lacks fluency, obviously struggling to keep her place while decoding the words and trying to process their meaning. So, I suggested that she might have some basic eye movement deficits. Now, I am not an eye doctor. Nor do I play one on TV but I am a skilled observer of a person's eye movements because of the work I do as a vision therapist. I asked my friend to cover one eye and to follow my pen as it moved in a slow arc in front of her eyes, up, down, across, and circling in toward her face. Then she covered the other eye and we repeated the activity. She had no problem making smooth eye movements to track the moving pen so her ocular pursuits look fine. She could even maintain a conversation while doing this activity. Next, one eye at a time again, I asked my friend to look at one pen and then, on my signal, jump her eye to another. She could not keep her fixation on the first object, nor could she accurately locate the second. When she visits a developmental optometrist for a thorough eye exam, I predict that she will receive a diagnosis of saccadic deficits. This is the result of poor control of the six muscles in each eye and can be addressed through a program of vision therapy. (In fact, just as a side note, the Purple Book of the Eye Can Too! Read series of e-books that I wrote has a lot of activities that rely on and can improve these eye movement skills). Next I asked my friend to use two eyes and focus on the #2 written on the side of a pencil that I was holding about a yard away from her face so that the eraser was facing up. I asked her to keep the #2 single and clear and to tell me if it got blurry or doubled. Slowly I pushed the pencil towards her face watching her eyes to make sure that they were converging. They did get closer and closer to her nose which is appropriate. However, when the pencil was about a foot away, my friend said, "That hurts!" She did not look away right then but I could see the stress that she was under. I repeated the activity and she repeated her report of discomfort at about the same place. So, when she visits the developmental optometrist she will likely receive another diagnosis related to her eye teaming skills.She should have been able to track that pencil in to three inches or nearer to her nose without pain, blur, or double vision. No wonder reading has been so difficult in spite of her willingness to tolerate significant discomfort in order to succeed. No matter your age, if you have difficulty reading, see whether there is a visual issue that can be resolved with a few eye exercises. Locate a developmental optometrist by going to and plugging in your zip code. Make an appointment and see what the doctor discovers.