Why Such a Secret?

Nearly every parent who has a child struggling to learn to read will have taken that child to an optometrist for a routine vision evaluation. In most cases they will have been told that their child’s vision is “just fine” after suitable adjustments have been made to correct acuity problems. Yet, in my opinion, the majority of children who continue to struggle are still suffering from undiagnosed vision problems. So the question becomes, why was something missed? What is it about these particular vision issues that makes it so difficult for parents to learn about them?

Business Considerations

I’ll try to answer that question without casting a shadow over your family optometrist. But first, consider that if your family physician detects something requiring surgery during your physical, he’ll readily refer you to a surgeon, knowing that you will return to him after the surgery and that you will probably be grateful that the problem was caught and handled.

But if your family optometrist decides to set up his practice to diagnose the sort of vision problems diagnosed routinely by developmental optometrists, he would find himself with two choices, neither necessarily favorable to his practice. If he diagnoses a problem, he either has to set up his practice to deal with that problem which is a huge business decision involving significant investments of time and money, or else he has to refer his patient, your child, to someone else who can deal with it, that is, to a vision therapy center. However, nearly all vision therapy centers are run by developmental optometrists that compete directly with your family optometrist for patients.

It would be wonderful if all family optometrists would decide to refer children who are experiencing reading problems to a developmental optometrist. However, in doing so they risk losing not only the referred patients, but entire families, to competing practices. So, frankly, most optometrists don’t make such referrals. And, to avoid being unethical in the sense of failing to tell you of certain findings from their testing, they normally don't perform the battery of tests that will uncover the deficits in visual skills that have profound effects on reading ability.

All of this is perfectly understandable, and fortunately some family optometrists do refer to a developmental optometrist for additional testing in certain cases. The only ones that I have no respect for are those who not only avoid doing the testing, but who take it a step further and actually discourage parents from investigating vision therapy by claiming that it’s controversial (which does make it controversial, all right) or that it doesn’t have sufficient research backing it up (which is far from true) and end up leaving the parent with the impression that their child’s vision is “fine.”

Dig Deeper

My recommendation is that before you assume that poorly developed visual skills are not the cause of your child’s reading struggles, you need to ask your family optometrist if he ever refers to a developmental optometrist with a vision therapy department. If the answer is no, or is evasive, or is disparaging of vision therapy, you can safely assume that your child’s vision still needs further evaluation before you stop investigating the vision angle. If his answer is yes, tell him that your child is struggling with reading and ask him who he refers to in your area, and whether he found anything in his testing of your child that had him thinking about making such a referral.

Differences in Testing

I’m often asked what developmental optometrists test for that is missed by the family optometrist. Some of the testing is the same, but the developmental optometrist will be more inclined to do further testing and is likely to prescribe vision therapy when indicated, whereas your family optometrist may mention that your child’s convergence ability is somewhat weak and suggest “pencil push ups” or some other home exercise. (Recent research demonstrates that vision therapy is effective and that pencil push ups are not. See the Convergence Insufficiency Study for more information.)

It’s also quite possible that your child actually did pass all the regular optometric testing with flying colors and still has a vision problem. The reason is that reading requires sustained effort. Your child might indeed be able to converge his eyes on the print and focus clearly for quite a long time, easily passing a standard convergence test. But reading even one page of print will take longer than the testing usually does. Have you noticed how your child seems to read easily and fluently sometimes? Have you also noticed that he starts to make mistakes, slow down, act tired or uncomfortable after two or three more pages? He’s telling you by his actions that he can’t sustain the effort visually.

A developmental optometrist will do all the standard vision testing and if a problem is detected in that testing and especially if you are concerned about a reading problem, it is likely that you will be told that your child should have a full developmental vision examination. This exam will probably run over an hour during which your child’s vision will be tested in several ways that are relevant to the reading process, as well as being relevant to many more processes in the daily life of a child. In addition, he will have to prove that he can sustain the effort when he’s taking these tests. Some children do fine for a while then gradually their performance starts to fall apart because they simply can’t sustain the effort. Reading absolutely requires the ability to not only exercise several vision competencies up close, but also to sustain those abilities for long periods of time.

If You Made Up Your Mind Before, Reconsider

The current situation is unfortunate, even intolerable, since parents end up being convinced that they’ve covered the vision issue when often vision is the issue. This situation will gradually change as more and more parents learn that vision therapy was the answer to their own child’s reading problem, or at least an important missing piece of the puzzle. I had one mother tell me that she was told by a developmental optometrist several years earlier that her child had a vision problem, but that she decided against pursuing vision therapy. She came back recently only because in the intervening time several other mothers in her area told her that vision therapy had helped their own children.

You need to realize that your child’s visual skills might not be in place even if you’ve been led to believe otherwise. Vision therapy is expensive, and it’s easy to take your family optometrist’s statement that he “finds no problems with your child’s vision” and to reinterpret him as saying “your child’s vision is fine.” Actually all he really said is that he didn’t find a problem during the testing he performed. It doesn’t mean that he did the tests that a developmental optometrist will recommend if he suspects a visual skills deficit.

Put all of this together, the possibility of losing business, the reluctance of some optometrists to acknowledge the effectiveness of vision therapy, the testing differences, and the fact that responsible parents have had their child's vision checked and have been reassured that the child's vision is "fine," and it's not surprising that, for many such parents, the very existence of a treatment that has helped many other children like their own remains a "secret" to them. Fortunately, that is slowly changing.