Focusing on Hidden Vision Problems in Children

by Stanley A. Appelbaum, O.D., FCOVD | Reprinted from with Permission. June 2003

How can a child have 20/20 eyesight and still have a vision problem? If a child is having problems concentrating in school, is medication the only solution?

In my pediatric vision care practice, parents ask me questions like this almost every day. When children are having trouble concentrating at school, before considering medication, it’s always better to look for physiological causes. If a child takes a long time to do his homework because he cannot stay on-task, or if his teacher notices that he cannot stay focused on his schoolwork, he should be screened for developmental vision and sensory integration problems.

The pediatrician might recommend Ritalin, but may also suggest that Vision Therapy (VT) and Occupational Therapy (OT) be tried first. Many parents are reluctant to put their child on drugs and prefer to give OT & VT a try first.

Colin’s story is very typical of children seen at my practice.

Colin had 20/20 vision and always passed the school eye exams with no problems. “I really questioned what this was all about,” his mother said at the initial evaluation. After a few tests, I discovered that Colin had problems keeping close objects or written text in focus, which made his eyes tire easily. His mother said that because Colin’s eyes were tired, he would constantly look up from his work, making it appear that he had poor concentration.

After three months of eye therapy, his mother reported that Colin got his homework done much more quickly, and his teacher said that he is no longer having a concentration problem at school. “Everything is easier for him now than before eye therapy,” she said, adding that she is happy a solution was found that did not involve medication.

Many children have problems concentrating because they never learned to use their eyes properly. Babies are not born knowing how to focus; they have to learn. If, for some reason, children do not learn how to use their eyes properly, they can be taught, which is what vision therapy is all about. In an office vision therapy program, I work with patients who have a number of vision problems that involve more than just the ability to see. Testing includes many areas of vision to assess how a person takes in information and processes it. Treatment may include therapeutic, stress-reducing lenses, visual hygiene suggestions and procedures to be done at home, at school, with other professionals/therapists and at my office.

During more than 20 years as a board certified specialist in vision therapy, I have seen an explosion in the number of children being labeled ADD (Attention Deficit Disorder). Between 1990 and 1996, there was a 500 percent increase in the use of Ritalin. In an effort to educate parents about this trend, I hold frequent workshops called, “When ADD Doesn’t Add up.”

During a recent meeting, parents discussed the problems their children were having in school, which included problems with attention, headaches, reluctance to read, tears about homework and letter reversals. Some parents said that their children are overly active or have lost their desire to learn because school just seems too hard. Sometimes, medication such as Ritalin is needed to help children with attention issues, but many times, there is another factor that is not being addressed, such as eyesight or hearing problems. Sometimes, children exhibit undesirable behaviors in a reaction to certain foods.

Do we over-prescribe medicines because we see a behavioral trait? Mislabeling can result from categorizing a person based on assumptions not supported by thorough testing.

Many children don’t need glasses but still have vision problems. If it’s too much work to stay on-task, children will lose interest. Kids might not say they “see double.” They develop behavioral problems instead. Some children have problems focusing. Vision therapy specialists can measure a child’s ability to sustain focus. Focusing problems are significant, and they occur in over 20 percent of normal, healthy children.

When children do not move their eyes properly across the page, they lose their place, get discouraged and give up.

Some children do not process information properly once they receive it. They need to be taught how to make sense of what they see. In vision therapy, we can change a visual system’s response. This helps all the senses tie together, which is necessary for full functioning in our society.

Vision therapy can’t solve all problems, but it can help children build a visual function that most of us take for granted. Of course there will still be other reasons for attention drift. Some children need Ritalin. Some have auditory problems. Some have food allergies. And some have sensory integration and developmental vision problems. All of these children will benefit from a thorough evaluation of their symptoms.

Dr. Stanley A. Appelbaum has a family vision care practice in Bethesda & Annapolis, Maryland. Dr. Stanley A. Appelbaum, OD, FCOVD is a certified Fellow in the College of Optometrists in Vision Development. He is Board Certified in Vision Therapy & has been in private practice with his wife, Barbara Bassin, OTR/L, BCP for over 20 years in Bethesda & Annapolis, Maryland, combining Vision Therapy with Sensory Integration Therapy in the same office. He utilizes functional and developmental concepts in his approach to treating vision problems and enhancing vision skills & abilities. He lectures on topics related to infant vision development, visually- related learning difficulties, ADD/ADHD, Dyslexia, Strabismus, Amblyopia, the visual demands of computer use and sports vision. Stan has served on the Board of Sensory Integration International and has medical staff privileges at The Maryland Kessler Adventist Rehabilitation Hospital where he treats patients with visual problems associated with brain injury. For more information about Dr. Appelbaum’s practice, visit