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Promoting healthy vision in students: progress and challenges in policy, programs, and research.

When vision is compromised, as is the case in 1 in 5 American children aged 1-I7 years, academic potential may also be compromised. (1-3) Uncorrected vision problems can worsen over time--some resulting in permanent vision loss--and may affect children's academic performance. (4) Early detection and treatment of vision problems is therefore essential in optimizing children's healthy development and educational progress. State and local policies and the capacity of school-based vision screening programs can influence detection and correction of the children's vision problems. Children from poor urban environments, in particular, have much to gain from preventive policies and programs, given their increased risk of vision problems and barriers to receiving preventive care and treatment.

Federal-, state-, and school-based prevention efforts continue to evolve to curb the wide-ranging impact of uncorrected vision in children. This article examines these efforts as well as other suggested strategies to increase the number of children with healthy vision. A research agenda that focused on determining the relationship between vision and educational outcomes is also discussed.

Vision Problems and Learning--A Preliminary Relationship Is Established

A developing child's visual sense consists of 2 interconnected systems: the visual system (eyes and eye muscles) and the perceptual system (brain). Both systems are needed for vision to occur. Children with uncorrected vision problems literally see the world differently than those with normal vision and may not reach their highest academic potential. Preliminary research has suggested a relationship between vision problems and academic achievement. For example, 2 separate British studies found that children with unstable binocular control made more reading errors when reading small print and more errors on a spelling test than students with normal vision. (5,6) In another study, significantly lower achievement scores were found among first through fifth graders with uncorrected hyperopia (farsightedness) whose refractive errors exceeded 1.25 diopters. (7) Similar findings in the UK showed impaired literacy skills among hyperopic 8-year-olds with larger refractive errors. (8)

Vision skills were significantly greater predictors of performance on specific standardized tests than race or socioeconomic status in a prospective study of elementary school children in the Oklahoma Public School System. (9) These findings should not be considered generalizable, however, given the small number of ethnic minorities represented in the study's sample. A New York City-based study examined associations between children's vision screening performance with class percentile for grades earned. Among these findings, the screening for farsightedness was significantly associated with placement in the bottom quartile of the class. (4) Of the 25 students given vision correction (predominantly prescription eyeglasses), 21 (84%) gained over 20 percentage points in their achievement test percentile rank. Limitations of this study include the fact that it was retrospective and had a small sample size and no control group. The author recommends that the findings warrant larger controlled studies to determine the relationship between academic performance and vision correction.

Vision Problems in Children--A Problem of Inequity

Children from poor urban areas, many of whom are ethnic minorities, experience more than twice the normal rate of vision problems. For instance, research findings shared at a Harvard Graduate School of Education conference found a 52% failure rate among at-risk high school students in New York City who underwent a vision screening test. (10) Another study found a 45% failure rate of Hispanic students screened in Tucson, AZ. (10)

Receiving follow-up care and treatment after failed vision screenings has also been extremely low among disadvantaged youth. For example, only 27% of at-risk students in a New York City study who were screened obtained the treatment they needed--despite the services being free. (11) Several barriers to obtaining a follow-up examination for their children were cited by low-income parents in an urban Illinois study: financial (cost and money concerns, no insurance coverage, and waiting for insurance), logistical (problems scheduling appointments and difficulty planning ahead), social/family (working adults/difficulty getting to appointments and parents having mental/physical disabilities), and perceptual barriers (vision problem not considered priority, belief that screening results were inaccurate/examination not needed, and mistrust of school nurse). (11)

Unusually high rates of vision problems have also been found among juvenile delinquents and among children in foster care. A study conducted with 132 juvenile offenders ranging from age 13 to 19 in Baltimore, MD, revealed that a staggering 98% of the subjects were diagnosed as having a vision problem. Almost 84% of the 351 foster children tested as part of a New York City study had visual problems. Of the children who were identified as those in need of vision care, the study's principal investigator and specialist in pediatric vision care surmised that 35% had vision problems that went undiagnosed by previous vision screenings, including those that would have been conducted at school. (12)

Major Vision Problems in Children

The major eye problems that affect children--and those that are typically addressed by school vision screening programs--are strabismus, amblyopia, and refractive errors. Strabismus is misalignment of the eyes that causes 1 or both of the eyes to turn outward (wall eyes) or inward (crossed eyes) or turn up or down. If the condition is left untreated, the child may later experience a reduction of loss of vision in 1 eye. This vision problem is called amblyopia. (13)

Amblyopia, or "lazy eye," is reduced vision in an eye that has been insufficiently used during early childhood. Amblyopia usually occurs as a result of misaligned eyes (strabismus) or when I eye focuses better than the other. If the condition is not treated early enough, the stronger eye can suppress the image of the other eye, causing permanent vision loss in the weaker eye. If, however, strabismus and amblyopia are diagnosed and treated early, the effects of both can be minimal and, in some cases, totally correctable. (14,15)

The most common of eye problems and one of the most common chronic medical conditions in American children, refractive errors are not considered as loss of vision, rather as loss of visual acuity or sharpness. (2,16) Uncorrected refractive errors can cause eye strain, headaches, decreased vision, and amblyopia. (17) The most frequent treatment for children with poor visual acuity is the prescription of eyeglasses to be worn for near work (such as reading at one's desk), far work (seeing the chalkboard), of both. Seeing well in the classroom at near and far distance is included as part of a set of vision skills published by the American Optometric Association as important factors in children's ability to thrive at school.

School-Based Vision Screening Programs--Promises and Pitfalls

School-based vision screening programs are the most commonly used method to detect signs of vision problems in American children such as strabismus, amblyopia, and refractive errors. Vision screening programs are not used to diagnose but are widely considered as a critical step toward referral to an eye care professional. (2) Vision screening programs are often conducted quickly and at minimal cost by school nurses, trained laypeople, or volunteer professionals. The Snellen visual acuity test, a primary vision screening tool used in schools across the country for decades, has, however, been criticized for its narrow capacity to detect visual problems. Measuring levels of myopia (nearsightedness), the Snellen instrument can assess only 1 facet of children's overall vision status. Distance vision and tracking--skills that can impact on academic achievement--are rarely tested for. (18)

In a large longitudinal study, the predictive value of such traditional school-based screenings was shown to be high. The student cohort (N = 2938) was followed prospectively from kindergarten through grade 12 using school health records and eye care professional records to estimate incidence of school vision screening failures and follow-up rates. Findings showed that more than 85% of the students who received a referral for follow-up after a failed screening were confirmed to have a visual acuity problem that would require treatment. (16)

The efficacy of various technology-based commercially available vision screening tests in identifying the most common vision conditions in young children is currently being assessed through the multiphase Vision in Preschoolers Study funded by the National Institutes of Health. Phase I of the study determined the sensitivity and specificity of several screening tests (and certain combinations of these tests) for detecting 1 or more of the 3 major childhood vision problems: amblyopia, strabismus, and/or significant refractive error in 2500 Head Start preschoolers. (19) Phase II assessed whether pediatric nurses and lay screeners could accurately identify these common vision problems in approximately 1500 Head Start students using 4 of the screening tests. Similar accuracy rates were achieved by trained nurses and lay screeners: using handheld automated refractors, nurses correctly identified up to 68% of children with a common vision problem as compared with up to 62% of the children identified by lay screeners. In addition, over 80% of children with a vision disorder considered most severe were correctly identified by both the nurses and the lay screeners. (20) Given the controlled nature of the study, these preliminary results warrant additional research but seem to support autorefraction as a possible screening mechanism that nurses and laypeople can use to identify children in a preschool setting.

Federal and State Efforts to Detect and Treat Vision Problems in Children

As a timely reaction to the No Child Left Behind legislation, federal-, state-, and school-based policymakers have begun to reconsider policies and programs to ensure that children's vision does not impede healthy development and school performance.

On a national level, the US Department of Health and Human Services' Healthy People initiative is designed, in part, to assist states and schools in implementing plans to eliminate disparities in health status and utilization of prevention services. The initiative outlines several objectives that aim to promote healthy vision including:

* Reducing uncorrected visual impairment due to refractive errors.

* Reducing blindness and visual impairment in children and adolescents aged 17 years and younger.

* Increasing the proportion of preschool children who receive vision screening.

Given that only 1 in 3 children receives vision care services before age 6, the third objective has been set forth primarily as a means to detect and treat more cases of amblyopia in preschool-aged children. (21) This is due to the prevalence of amblyopia in American children, the subtlety of the signs that can often go undetected by parents, and the clear benefits of detection and treatment before age 5 in securing optimal vision for children with this condition.

States' responses toward promoting healthy vision in children are varied. A recent update of the Vision Council of America's 2005 report, Making the Grade: An Analysis of State and Federal Children's Vision Care Policy, revealed that 17 (now 16) states have no preventive policies requiring vision screening before entry into school or while in school (Table 1). (22) Of the 34 states that do require vision screening, 29 do not require a follow-up eye examination for students who rail the screening. While Medicaid and the State Children's Health Insurance Program reportedly provide insurance coverage for children's eye examinations and indicated follow-up care, we did not identify any published reports assessing the extent to which such resources are truly available and accessible and used by low-income families. If such resources are not readily available and accessible, this may further exacerbate inequities. Congressional leaders are proactively introducing legislation to address these policy gaps, according to the report. The "Vision Care for Kids Act of 2007," H.R. 507, was introduced in January 2007 and would include allocation of funds for states to use for follow-up care for children who have been identified by a prior vision screening or examination. Senator Christopher Bond (R-MO), a cosponsor of the bipartisan-supported bill, has spoken publicly about his own struggles with permanent vision loss due to undiagnosed and untreated amblyopia.

Individually, states have also gained ground by enacting their own children's vision laws. In 1999, Kentucky was the first state to require all children to receive a comprehensive eye examination before entering elementary school. Since then, 8 other states (Arkansas, Illinois, Massachusetts, Missouri, Ohio, Oklahoma, North Carolina, and Rhode Island) have enacted similar legislation to ensure that more children are receiving examinations from eye doctors. Additionally, new legislation passed in 2006 in Rhode Island, Oklahoma, and North Carolina requires a follow-up eye examination by an optometrist or ophthalmologist for those children who rail an initial screening before entering school. (23) This provision addresses the low as well as delayed compliance rate among children given optometric referrals after failed vision screenings. (10,16)

Largely unaddressed by most states, this low rate of follow-up is observed even when students are provided convenient care at low cost. Barriers cited by parents of students in need of vision care include their lack of time, financial resources, correct insurance coverage, and their children's refusal to wear eyeglasses. (24) In addition to parental and student factors, inadequate follow-up mechanisms in many school districts prevent children identified with a vision problem from receiving timely treatment. (2)

Improving Current Policies and Programs for Children's Vision

In order to improve children's visual outcomes, experts on vision and learning and policymakers alike have recommended modifying current school-based vision screening methods. Suggested alternative methods include screening for "visual function at near for reading and writing, rather than just their visual acuity at distance for looking at blackboards." (12) In a recent policy statement, the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology recommended that effective screening programs should include a mechanism to "inform parents of screening failures and attempt to ensure that proper follow-up care is received." (25) Historically, these mechanisms have not encouraged favorable follow-up rates. The chief investigators of the Baltimore Vision Screening Project have suggested that rates of follow-up care may be increased by strengthening parent and primary care provider education. (26) More specifically, education could be geared toward the importance of early intervention and the serious implications of vision screening failure such as potential vision loss. Educating teachers to increase their understanding and identify warning signs of vision problems in children has also been suggested. (2)

On a wider scale, it has been recommended that state governments develop minimum qualifications and provide ongoing, high-quality training for vision screeners. (2) Additionally, more states should require mandatory comprehensive vision examinations for preschoolers as is the case in Kentucky and other states. (2) Other states could follow the lead of states such as Arkansas, North Carolina, Massachusetts, Rhode Island, and Oklahoma and establish required follow-up eye examinations for children who have failed a prior vision screening.

DISCUSSION

It is clear that academic achievement is affected by many factors. It also seems clear that if children have difficulty seeing, it will be harder for them to learn in and outside of school. In particular, there is a pressing need to find ways to improve academic achievement among poor urban children, many of whom suffer from vision problems.

Although a preliminary relationship between children's vision and academic performance has been established, further research to determine a causal relationship is needed. Moving forward, policy-relevant research agendas should include implementation and evaluation of innovative children's vision programs such as those that bring vision services to the schools. For instance, optometric screenings performed at school strengthen school-community partnerships and remove known barriers to children receiving vision care. Programs can also incorporate the help of school administrators and teachers in improving children's vision. This could be accomplished by educating school personnel about warning signs of possible vision problems in children (squinting, eyes turning inward or outward, and closing 1 eye to read). School health curricula could be adapted to include an eye health unit where local optometrists are brought in as guest educators. Taken a step further, programs can include teachers as active participants in monitoring and encouraging students who wear eyeglasses to wear them in the classroom, when appropriate.

Well-designed quantitative studies can assess whether children who should be wearing glasses actually wear them in the classroom. Establishing that children who need glasses wear them at school can serve as a preliminary and pivotal step toward determining if children who consistently wear glasses improve academically. To the extent that improving children's vision is associated with learning, policies can be revamped to help ensure that children who need glasses receive and wear them.

Meaningful policy and programmatic change in the area of children's vision are essential and more apparent than ever. Across the county, children--particularly those who are poor--are struggling to see the chalkboard, their books, and the world around them. Guided by research, we believe that feasible policy implementation can concretely address the achievement gap that exists among our nation's youth and support the goal of healthy vision for each child.

REFERENCES

(1.) Ganley, JP, Roberts J. Eye conditions and related need for medical care among persons 1-74 years of age: United States, 1971-1972. Vital Health Stat. 1983;11(228):1-69.

(2.) Ferebee A. Childhood Vision: Public Challenges & Opportunities: A Policy Brief. Washington, DC: The Center for Health and Healthcare in Schools, George Washington University; 2004. Available at: http://www.healthinschools.org/sh/visionfinal.pdf. Accessed October 2005.

(3.) Federal Interagency Forum on Child and Family Statistics. America's Children: Key National Indicators of Well-Being, 2007. Table POP1. Child population: number of children (in millions) ages 0-17 in the United States by age, 1950-2006, and projected 2007-2020. Washington, DC: US Government Printing Office; 2007. Available at: http://www.childstats.gov/americaschildren/ tables.asp. Accessed July 2007.

(4.) Krumholtz I. Results from a pediatric vision screening and its ability to predict academic performance. Optometry. 2000;71(7):426-430.

(5.) Cornelissen P, Bradley L, Fowler S, Stein J. What children see affects how they read. Dev Med Child Neurol. 1991;33:755-762.

(6.) Cornelissen P, Bradley L, Fowler S, Stein J. What children see affects how they spell. Dev Med Child Neurol. 1994;36:716-727.

(7.) Rosner J, Rosner J. The relationship between moderate hyperopia and academic achievement: how much plus is enough? J Am Optom Assoc. 1997;68(10):648-650.

(8.) Williams WR, Latif AH, Hannington L, Watkins DR. Hyperopia and educational attainment in a primary school cohort. Arch Dis Child. 2005;90(2):150-153.

(9.) Maples WC. A comparison of visual abilities, race and socioeconomic factors as predictors of academic achievement. J Behav Optom. 2001;12(3):60-65.

(10.) Gould MC, Gould, H. A clear vision for equity and opportunity. Phi Delta Kappan. 2003;85(4):324-328. Available at: http://www. pdkintl.org/kappan/k0312gou.htm. Accessed October 2005.

(11.) Kimel L. Lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. J Sch Nursing. 2006;22(3):156-162.

(12.) Harris P. The prevalence of visual conditions in a population of juvenile delinquents [OEPF Research Reports and Special Articles, Curriculum II]. 1989;61(4):1-10. Available at: http:// www.babousa.org/Juvenile%20Delinquents%20Paul%20Harris. pdf. Accessed November 2005.

(13.) Prevent Blindness America. The Vision Learning Center: Strabismus. Chicago, Ill: Prevent Blindness America; 2005. Available at: http://www.preventblindness.org/children/strabismusFAQ.html. Accessed January 2007.

(14.) Prevent Blindness America. The Vision Learning Center: Amblyopia (Lazy Eye). Chicago, Ill: Prevent Blindness America; 2005. Available at: http://www.preventblindness.org/children/amblyopiaFAQ.html. Accessed January 2007.

(15.) Prevent Blindness America. Vision Advocacy News: Groundbreaking Legislation Introduced to Help Save Children's Vision. Chicago, Ill: Prevent Blindness America; 2007. Available at: http://www. preventblindness.org/news/releases/011707_1.html. Accessed March 2007.

(16.) Yawn B, Lydick E, Epstein R, Jacobsen S. Is school vision screening effective? J Sch Health. 1996;66(5):171-175.

(17.) The American Association for Pediatric Ophthalmology and Strabismus. Policy Statement: Vision Screening for Infants and Children. San Francisco: American Association of Pediatric Ophthalmology and Strabismus; 1996. Available at: http:// www.aapos.org/displaycommon.cfm?an=1&subarticlenbr=54. Accessed November 2005.

(18.) Rothstein R. Class and Schools: Using Social, Economic, and Educational Reform to Close the Black-White Achievement Gap. New York, NY: Economic Policy Institute and Teachers College Press; 2004.

(19.) National Eye Institute, National Institutes of Health. Vision in Preschoolers Study Summary. 2006. Available at: http://www.nei. nih.gov/neitrials/viewStudyWeb.aspx?id=85. Accessed June 2007.

(20.) Vision in Preschoolers Study Group. Preschool vision screening tests administered by nurse screeners compared to lay screeners in the vision in preschoolers study. Invest Ophthalmal and Vis Sci. 2005;46:2639-2648.

(21.) Centers for Disease Control and Prevention. Visual impairment and use of eye-care services and protective eyewear among children--United States 2002. MMWR Morb Mortal Wkly Rep. 2005; 54(17):425-429. Available at: http://www.cdc.gov/mmwr/ preview/mmwrhtml/mm5417a2.htm. Accessed October 2005.

(22.) Vision Council of America. Making the Grade Update: An Analysis of State and Federal Children's Vision Care Policy. 2007. Available at: http://www.bettervisioninstitute.org/2007/Presentations/Making% 20the%20Grade%20Update%20copy.pdf. Accessed August 2007.

(23.) Vision Council of America. 20/20 Advocacy Action Alerts: The Smallest State Enacts a Really Big Law. 2005. Available at: http:// www.2020advocacy.com/s_2020/doc.asp?CID=790&DID=2529. Accessed November 2005.

(24.) Mark H, Mark T. Parental reasons for non-response following a referral in school vision screening. J Sch Health. 1999;69(1):35-38.

(25.) American Academy of Ophthalmology. Vision Screening for Infants and Children: A Joint Statement of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology. San Francisco, Calif: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/education/statements/ loader.cfm?url=/commonspot/security/getfile.cfm&PageID=15145. Accessed July 2005.

(26.) Preslan MW, Novak A. Baltimore vision screening project. Phase 2. Ophthalmology. 1998;105(1):151-153.

DANNA ETHAN, MA, MSW (a,b) CHARLES E. BASCH, PhD (c)

(a) Doctoral Candidate, Health Education, (dethan@earthlink.net), Department of Health and Behavior Studies, Teachers College, Columbia University, 525 W 120th St, 531A Thorndike Hall, New York, NY 10027.

(b) Instructor, Department of Health Education, Borough of Manhattan Community College, City University of New York, 199 Chambers St, New York, NY 10007.

(c) Professor, Health Education, (ceb35@columbia.edu), Department of Health and Behavior Studies, Teachers College, Columbia University, 525 W 120th St, 531A Thorndike Hall, New York, NY 10027.

Address correspondence to: Danna Ethan, Doctoral Candidate, Health Education, (dethan@earthlink.net), Department of Health and Behavior Studies, Teachers College, Columbia University, 525 W 120th St, 531A Thorndike Hall, New York, NY 10027.
Table 1. States With No Preventive Vision Care Requirements
for Children (N = 17) *

Alabama
Arizona
California
Idaho
Iowa
Mississippi
Missouri
Montana
Nevada
New Hampshire
New Mexico
North Dakota
Oregon
South Carolina
South Dakota
Wisconsin
Wyoming

* Based on recent update of the Vision Council's 2005 report. (22)
Missouri recently enacted a new law that requires comprehensive eye
examinations for children entering kindergarten of first grade.
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Title Annotation:General Article
Author:Ethan, Danna; Basch, Charles E.
Publication:Journal of School Health
Article Type:Report
Geographic Code:1USA
Date:Aug 1, 2008
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