Racheli’s mom asked to speak with me privately before we started the exam. “She’s so smart, I just don’t understand what could be wrong. Her handwriting is atrocious, she hates to read out loud, and the constant pressure to do better is causing her to hate school. When she learns Parshah on Friday and just has to listen in class and then answer the questions at the Shabbos table, she does beautifully; she even knows more than her older sister! She can add and manipulate numbers in her head but when it comes to taking a test at school, the grades just don’t reflect what she actually knows. She had a vision screening at the pediatrician and she was 20/20 in both eyes. No one in the family wears glasses and Racheli has never complained about her eyes. The school recommended that before we have her tested for learning disabilities we should have her eyes checked more carefully.”
Racheli was indeed 20/20 in both eyes for distance. For reading, however, she could only read 20/25 (one line off “normal”) and it hurt her eyes to sustain her focus. Upon further discussion she told me she would get headaches every day at about six p.m. when she came home from school but did not have headaches on the weekend. Her eye tracking was good, as were her eye teaming skills. As suspected, her accommodative (focusing) skills were abnormal. In the real world this translates into not being able to quickly change focus from the blackboard to the desk as well the inability to read for long periods of time. I recommended a pair of reading glasses to use for sustained close work with a six-week follow up. We also discussed vision therapy as an option with a colleague of mine in the next town.
Later in the week a young man named Kevin (not his real name) came in for a routine checkup. He’s a third grader in the local public school and his mom said he’s doing fine in school. He doesn’t like to read, preferring instead to play ball outside with his friends. Interestingly, the objective results of his visual efficiency skills were the same as Racheli’s; the notable difference between them is Kevin’s lack of symptoms.
There are myriad reasons why Racheli is struggling and Kevin is not, and it is beyond the purview of this article to delve into all of them. One factor is the length of Racheli’s school day compared with Kevin’s. Racheli has one to two hours more per day of visual demands. For a child with a visual deficit, it’s that much longer that her overtaxed visual system has to keep up. Perhaps it could be done for shorter periods of time, but the longer day exacerbates her symptoms. Add to that the demands of a dual curriculum and on the simplest level we can see why Racheli is not progressing.
I just saw Racheli for her follow-up appointment and had a chance to speak to her alone while her mother was in the waiting room. The girl’s smile was bright and her body language more confident. Happily she told me her headaches were gone and her grades were up. When her mom stepped in she reaffirmed Racheli’s comments and we set up a progress check around report-card time to ensure that any further issues could be promptly addressed.
Many, though not all, children will have this optimal outcome. As mentioned, a child with a visual problem can also have ADD/ADHD or a learning disability – or all three. That being said, a very wise professor once taught me to “never underestimate the power of a pair of glasses.”