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Cover Focus: Our Children's Vision Crisis 5 Ways You Can Help Millions of children stumble through school and
their key developmental years with vision problems. Why are we missing them? How can we save them? by John Murphy, Senior Editor Disruptive in class. In trouble with the law. "Nate," an inner city boy of 15, seemed to have a
behavior problem. And he looked mean. "But when you began to talk to him, you'd realize the meanness was just a cover-up for the frustration," explains optometrist Joel N. Zaba. Dr. Zaba found the frustration was the result
of Nate's vision problem, which went undetected in school because he had 20/20 distance acuity. Yet, the boy had a nearpoint convergence of 16 inches. He was seeing double close up. With the proper identification of his problem
and remedial training, Nate's grades improved. He got his act together and applied himself, snaring an athletic scholarship to Florida State University. Nate became a success story, but unfortunately many other children slip
through the cracks because of inadequate vision screening in schools and in pediatricians' offices. Not all get in trouble with the law, of course, but many children with vision problems stumble through school, suffer from poor
self-esteem and lack the skills necessary to compete among their peers. "Parents think this is an educational problem, not a vision problem," says Dr. Zaba, who practices in Norfolk, Va. "They don't realize that 80 percent of
what we learn is through the visual processing of information." This first article in this month's special report, "Our Children's Vision Crisis," looks at the scope of vision problems among children in the United States and how
our health-care and educational systems have missed them. Subsequent articles are " How Many Are Missed? • The Eye Care Council's See To Learn program has given
free vision assessments to more than 8,000 3-year-olds in its eight-year history, and determined that almost 14 percent had a vision problem. • Only 39 percent of 3-year-olds are screened for vision problems in private pediatric
practices. Among children who do get a vision test but fail it, half of their parents don't know this fact.1 • As many as 25 percent of 10-year-olds have vision problems significant enough to affect school performance, the Eye
Care Council says. That statistic increases to 30 percent of 15-year-olds. • In some underserved areas, the number of children who fall through the cracks is staggering. Optometrists volunteering through the Lions Club found
that 47 percent of children had vision problems in schools in West Los Angeles.2 The optometrists administered screenings that were more comprehensive than simple distance acuity. • Far too many children have no health
insurance. As recent as 1995, almost 14 percent of all children (9.8 million children) had no health insurance, according to the U.S. Census Bureau. • At-risk inner city children fare much worse than their peer group. In a study,
as many as 51 out of 59 at-risk inner city students in Norfolk, Va., failed at least one subtest of the New York State Optometric Vision Screening Battery.3 The authors, Dr. Zaba and Old Dominion University psychology professor
Roger A. Johnson, Ph.D., defined these students as those who were at-risk for dropping out—students who had repeated a grade, were in trouble with the law, been truant, or lacked family or community support. • Many
children with disabilities, who have a higher-than-normal incidence of visual problems, often don't get adequate vision testing. Studies have found:
—Significant refractive errors in 50 percent of children with cerebral palsy, along with a high incidence of strabismic and anisometropic amblyopia (15 percent) and visual field defects (11 percent).4 —Significant visual
problems in children with Down syndrome, including strabismus (57 percent), refractive errors of myopia (22.5 percent), hyperopia (20.9 percent) and astigmatism (22 percent).5 —Ocular anomalies interfering with good vision in
45.3 percent of 150 deaf children.6
• Many schools give tests infrequently. Although some schools administer annual vision screenings, others provide testing every other year. Some even test children as infrequently as every three years, says Carol F. Merritt,
O.D., of St. Louis, who is an advocate of annual screening. Two years can allow for a great amount of change in the development of a child. "Just like their shoe sizes change so rapidly, so do their eyes," she says. • School
screenings are inadequate. School vision screenings identify only one out of four children who have vision problems, reports the American Foundation for Visual Awareness (AFVA). So for every one child who's caught, there are three
others walking the halls or sitting at desks with some type of vision problem. Inadequate Screenings A main problem is that there are no national standards for vision screening for children. Vision screening guidelines for preschool children—who are at the prime age for detection of
ultimately detrimental visual problems—exist in only 34 states, but screening is voluntary in 19 of those states.8 A good vision screening could include tests for strabismus, amblyopia, refractive error, color vision and ocular
disease On an individual school basis, the screening itself or the way it is administered may be suspect. This author remembers standing in a line in second grade, memorizing the eye chart ahead of
time in order not to fail it. I'm not alone in this duplicity—school nurses are frequently aware of inherent problems in testing but do not get the tools or education to change them. Worse, students who have vision problems but
who pass a distance acuity test anyway are given a false reassurance that their vision is normal. "I feel like they're not screening as often and they're missing the kids that really need help," says Dr. Merritt. In May 1991 Dr.
Merritt was featured in a Review of Optometry article, "Can Anyone Solve the Black Vision Crisis?" She says that on the whole the availability and quality of vision screening for minorities and children in poorer areas has gotten
worse, not better, since the time of that article. She eventually had to close her office in the economically depressed town of Jennings, Mo., and transfer her practice to her other office in a more middle-class neighborhood.
Dr. Merritt concedes there's no national standard for who should administer a screening—in many cases it's a certified school nurse, in other cases it's a technician, certainly in a few it's the teacher. Rarely is it an
optometrist or ophthalmologist. For instance, she ran a clinic in East St. Louis, Ill., for the University of Missouri–St. Louis. The state of Illinois certifies technicians to perform audiological and vision screenings, but
because of a bureaucratic snafu, Dr. Merritt and her optometric colleagues—and apparently any other doctor in Illinois—may not take the instructional class to be certified. They couldn't be reimbursed to screen children in the Head
Start program, so they ended up doing them for free anyway. But it's kids from poorer families who need vision care the most. Mike Smith, executive director of the American Foundation for Vision Awareness, also located in St.
Louis, says that he's aware of schools in economically depressed neighborhoods that don't even have school nurses to provide vision screening. "We know that kids who grow up in poverty are at high risk for all kinds of health
problems, so they're at high risk for vision problems as well," he says. To promote better vision care in poorer neighborhoods, Dr. Merritt had made herself available and communicated with the school nurses in the schools near
her office. But, she says, the nurses are not testing vision often enough, in part because of the backlog of work, including their daily cases as well as immunizations and other duties. Like everything else, it seems, the problem
often boils down to money. Funding for large-scale, more comprehensive in-school vision screenings by optometrists has been cut steadily since its peak during the push for public health initiatives in the 1960s and 1970s, observes
Dr. Zaba. Furthermore, services such as nursing, health education, physical fitness and music programs are being trimmed if not eliminated in many schools. Long- and Short-term Effects • School performance. Visual motor integration (eye-hand coordination)—a widely overlooked element of learning—is tied to academic
performance in children.9 If a child has trouble writing what he sees, he'll eventually have trouble with his grades. • Parents think screening equals an exam. When parents receive a note saying their child
received a vision test at school and everything was OK, they may postpone or ignore scheduling a comprehensive eye exam for their child, Dr. Merritt explains. • Continued/permanent dysfunction. A condition such as strabismus, in
the form of accommodative esotropia, typically develops at toddler age. But the longer it's left unidentified and untreated, the more unlikely a functional or cosmetic cure will work, according to information from the Preschool
Children's Vision Study Group. • Delinquency. To say that a child's vision problems would lead him to a life of crime would be a gross simplification. Nevertheless, visual problems could put a child on a downward spiral,
according to Dr. Zaba. Visual problems can impede learning, depriving the child of adequate educational standing and intellectual capability to succeed in life. Also, visual problems cause frustration and lead to disruptive acting
out in class. That can descend into delinquent behavior and branding as a "bad kid." Such labels may become self-fulfilling. What Can Be Done? But on an individual basis, there are many things you as an eye doctor can do to ameliorate this situation, from communicating personally with your local school's nurse to volunteering your time to give screenings to
"The most important thing: If you're not looking and testing for these problems, you need to," Dr. Zaba advises. "It's the same way when a new drug comes out and you take a course to learn how to treat a particular type of disease. Spend time to learn to be aware of these conditions and how to evaluate them. Or refer these patients if you don't want to treat them." 1. Wasserman RC, Croft CA, Brotherton SE.
Preschool vision screening in pediatric practice: A study from the pediatric research in office settings (PROS) network. Pediatrics 1992 May;89(5 Pt 1):834-8. |
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The problem of insufficient vision assessment for children isn't going to fix itself. Here are a few ways your know-how and goodwill can help.
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Suggested Components of a Preschool Vision Screening Program • Designed to detect children at risk for the following disorders: strabismus, amblyopia, significant refractive error, color vision deficits, ocular disease. • Uses
age-appropriate tests, each of which has been validated, compared with norms, and shown to be reliable for detection of the targeted disorders when used by screening personnel. • Includes parent education concerning vision
disorders, screening and the importance of follow-up. • Has a clearly written manual, which includes the following: —State regulations or laws governing vision screening. Ciner EB et al. A Survey of Vision Screening Policy of Preschool Children in the United States. Surv Ophthalmol 1999;43(5):445-57.top |
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Vision Screening in Four Big City School Districts
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