Dr. Nathan Flax received the Skeffington Award in 1982. He is an author, educator and advocate, especially when the issue is childrens’ vision. Dr. Flax is a Professor Emeritus at SUNY State College of Optometry, where he served as Chief of the Vision Therapy Service for many years. He also maintained a private practice in Garden City, NY (that’s on Long Island). He has published and lectured extensively on a wide range of topics related to vision development and vision therapy. Dr. Flax is now enjoying the life of a retired optometrist in Arizona.
Understanding the relationship between vision and learning begins by acknowledging that both are very complex processes. Rather than considering vision and learning each as one specific skill, Dr. Flax’s writings on this topic emphasize a task analysis approach. He writes, “It is illogical to assume that all aspects of visual function would relate to all aspects of the learning process.” By first considering the specific learning task, then the potential contribution of specific visual functions can be analyzed.
When a parent reports, “my child is doing poorly in school” or “he/she has a reading problem,” what does this mean? The case history is essential to determine the nature and extent of the learning problem. Only then can the doctor begin to consider which if any visual functions may be implicated. If the primary problem is reading, then the first distinction that should be made is between learning to read vs. reading to learn. These two tasks require very different visual skills.
Learning to read is more dependent upon recognition and recall of visual symbols. The child must be able to understand how a visual symbol represents a sound (auditory-visual integration) in order to sound out words (phonetic analysis). Visual-motor integration comes into play when the child begins to write the letters of the alphabet and then words and sentences. Understanding the directional aspect of visual stimuli is also critical. Otherwise, the letters b and d are equivalent and the child will confuse these letters when reading and writing which leads to a “reversals” problem. The visual skills that are more related to the ability to sustain attention are usually less significant. The teacher usually engages the students in a particular learning activity for a short amount of time before moving to another activity. Text at both distant and near activities is typically quite large. Using this task analysis approach, learning to read places less demands on precise accommodation (focusing) and binocularity (eye teaming) but great demand on visual perceptual/processing skills.
Reading to learn places far greater emphasis on the ability to sustain visual attention. The emphasis shifts to speed and comprehension. Binocular vision (eye teaming) and accommodative (eye focusing) skills increase in the potential contribution to reading disorders as the reading demand shifts toward the capacity to sustain reading for longer periods of time. Many children enter school and make great progress in learning to read. When they enter 3rd or 4th grade, they begin to have difficulties and their grades drop. As the size of the print decreases and the time spent reading increases, deficient visual skills begin to interfere with academic performance. Oculomotor (eye movement) accuracy is necessary to read without skipping words or rereading. Copying from the board accurately also requires oculomotor control and accuracy. Reading comprehension difficulties may result if eye movements are not fluid enough to facilitate the proper sequencing of information being obtained from the page. Accommodative (eye focusing) and binocular (eye teaming) disorders both show a strong relationship to time. The more time required to complete an assignment, the more the child’s efficiency (or willingness to participate) declines. These children often complain of intermittent blur or even double vision, but sometimes they do not complain because they assume this is normal! They also avoid reading because of the associated discomfort. If these children remain undetected, they may learn to compensate by reading very slowly in order to gain any degree of comprehension. They often run into serious difficulty on standardized tests, because they cannot function well with time constraints. They often think of themselves as slow readers and don’t realize that their visual systems are to blame.
This task analysis also helps to understand expectations when therapy is implemented. If the problem is reading to learn, reading performance often improves as soon as the visual skills are enhanced and no longer a roadblock to reading comprehension. If the problem is learning to read, the child may need instructional support or tutoring. The child will be able to respond to reading instruction once the visual perceptual skills have been put in place.
This task analysis also helps to understand expectations when therapy is implemented. If the problem is reading to learn, reading performance often improves as soon as the visual skills are enhanced and no longer a roadblock to reading comprehension. If the problem is learning to read, the child may need instructional support or tutoring, in addition to VT. The child will be able to respond more favorably to reading instruction once the visual perceptual skills have been put in place.
Dr. Flax has provided the developmental optometrist with this roadmap to help direct appropriate diagnosis and treatment for children with learning related visual problems. The best map is in the book by Scheiman and Rouse, titled Optometric Management of Learning-Related Vision Problems. Dr. Flax’s chapter on the Relationship between Vision and Learning – General Issues is well worth reading.