5 Signs Your Child May Need Vision Therapy

The school nurse checks the eye chart, the pediatrician asks whether your child can see the board, and everyone moves on. But the eye chart measures one thing: how sharply each eye sees a letter 20 feet away. It says nothing about whether the two eyes work together, focus quickly, or track smoothly across a line of print.

Those are the skills vision therapy addresses. Here are the five signs we ask parents about most often at Vision & Learning Center, what the research says about each, and what to do next.

Key takeaways

Each point below is a short summary of a section further down, where the study behind it is cited in full.

• A child can have 20/20 eyesight and still have a treatable problem with eye teaming, focusing or tracking.
• Convergence insufficiency (CI) is the best-studied of these problems: about 13% of fifth- and sixth-graders in a US school-based study met a high-suspect or definite classification for it (Rouse et al., 1999).
• Office-based vision therapy relieved CI symptoms better than placebo in the 2008 CITT trial (CITT Study Group, 2008), though the later, larger CITT-ART trial found symptom scores improved about as much with placebo (CITT-ART, 2019) and no reading-score benefit at all (CITT-ART, 2019).
• Pediatric and ophthalmology groups and optometric groups disagree about vision therapy and learning. We explain both positions below.
• The signs on this list are reasons to get a developmental vision evaluation, not a diagnosis.

Sign 1: Reading is a struggle even though they “see fine”

Losing their place, skipping lines, re-reading, complaining that words move or blur, avoiding books. These are the complaints we hear most.

Several are classic symptoms of convergence insufficiency, in which the eyes struggle to turn inward and hold together at reading distance. CI is common. In a school-based study of 453 fifth- and sixth-graders, about 13% met a high-suspect or definite CI classification, and most children with all three signs of CI also had trouble focusing (Rouse et al., 1999). On the Convergence Insufficiency Symptom Survey, the validated questionnaire researchers use to measure these complaints, children with CI averaged 30.8 versus 8.4 for children with normal binocular vision, and a score of 16 or more separated the groups with 96% sensitivity (Borsting et al., 2003).

A few honest cautions. Most reading difficulty is not a vision problem: in a cohort of 5,822 British children, four out of five with severe reading impairment had normal ophthalmic function, and reading was not associated with convergence or focusing measures, although poor depth perception was somewhat more common (Creavin et al., 2015). One small clinical study did find these skills weaker in children with dyslexia: comparing 29 children with dyslexia and 33 typical readers, focusing deficits turned up in 55% versus 9% and eye-tracking deficits in 62% versus 15%, with a deficit in at least one area of visual function in 79% versus 33%. The authors called the cause and the clinical relevance of those findings uncertain (Raghuram et al., 2018). And treating CI has not been shown to raise reading scores: in the CITT-ART trial of 310 children, 16 weeks of office-based therapy improved reading comprehension by 3.7 points versus 3.8 with placebo therapy (CITT-ART Investigator Group, 2019).

Our clinical perspective is that therapy earns its place differently here: not by teaching reading, but by making near work more comfortable for a child whose eyes ache or blur when they try, which is the outcome the 2008 CITT trial actually measured (CITT Study Group, 2008). Our post on reading struggles and vision goes deeper.

Sign 2: Headaches or tired eyes after school or homework

Headaches late in the school day, eyes that feel tired, sore or “pulling,” a child who needs a break after 10 minutes of homework. Distance vision can be perfect while the near-focusing and eye-teaming systems work overtime, and the two usually fail together: among the 221 children in the Convergence Insufficiency Treatment Trial (CITT), 74% also had a focusing problem (Scheiman et al., 2011).

This is where the evidence for vision therapy is strongest, with one caveat. In CITT, 73% of children in office-based therapy were successful or improved after 12 weeks, versus 35% with placebo therapy and 33 to 43% with home programs (CITT Study Group, 2008), and a Cochrane review of 12 trials agreed (Scheiman et al., 2020). In the later, larger CITT-ART trial, however, eye-teaming measures improved more with therapy while symptom scores improved similarly in the therapy and placebo groups (CITT-ART Investigator Group, 2019). We share both results with families.

Persistent headaches also deserve your pediatrician’s attention; see our headaches page for the visual patterns we look for.

Sign 3: Poor hand-eye coordination

Trouble catching a ball, slow or messy handwriting, difficulty with puzzles, scissors or copying from the board. Some of this is normal variation, and some is a motor question for a pediatrician or occupational therapist. But depth perception plays a part. In a study of 143 people aged 10 to 30, those with no measurable stereopsis (the fine depth perception that comes from two eyes working together) performed significantly worse on pegboard and bead-threading tasks than those with normal stereopsis, with reduced stereopsis falling in between (O’Connor et al., 2010).

When the eyes are not teaming well, the brain gets a less reliable sense of where things are in space, and the hands follow the eyes. See our handwriting and math page for the visual-motor side.

Sign 4: Difficulty concentrating on close work

A child who fidgets or “just won’t focus” during reading and homework, yet concentrates fine on things they enjoy at a distance, presents a puzzle. Many CI symptoms (losing concentration, re-reading, slow work, avoiding near tasks) overlap with attention symptoms, and the overlap shows up in the data. In one pediatric ophthalmology practice, 9.8% of 266 patients with CI carried an ADHD diagnosis, which the authors describe as about three times the 1.8 to 3.3% ADHD rate they cite for the general US population, and a records review found CI in 15.9% of patients with ADHD (Granet et al., 2005). In the CITT population, parents reported ADHD in 16% of children with symptomatic CI versus 6% with normal binocular vision, and children with CI but no ADHD still showed more academic behavior problems (Rouse et al., 2009). Nationally, ADHD was reported in 15.6% of children with a vision problem not correctable with glasses or contact lenses versus 8.3% of children with normal vision (DeCarlo et al., 2016).

These are associations, not causes. Vision therapy does not treat ADHD, and a vision problem does not rule ADHD out. The narrower point: when the trouble concentrating is concentrated on near work, examine the eyes before the behavior is explained away. More in vision problems vs. ADHD and on our vision and ADD/ADHD page.

Sign 5: Rubbing eyes, squinting, tilting the head or covering one eye

Children rarely announce that they see double or that the print swims. In our experience they assume everyone sees the way they do, and they compensate: rubbing, squinting, closing or covering one eye, tilting the head, holding books very close, sitting sideways to the page.

These behaviors can also point to uncorrected refractive error, allergies or dry eye, which is why an exam, not a guess, should sort them out. Farsightedness in particular hides behind a good distance chart: in a study of 492 preschoolers, children with moderate uncorrected hyperopia scored lower on an early-literacy test than children with normal refraction, with the largest deficits when near acuity or depth perception was also reduced (Kulp et al., 2016).

Why a school screening or a routine exam can miss these

School and pediatrician screenings do one job well: catching amblyopia (“lazy eye”) and its risk factors, including strabismus and significant refractive error, early. The US Preventive Services Task Force recommends screening at least once between ages 3 and 5 for exactly that purpose (USPSTF, 2017). None of that is a test of eye teaming, focusing or tracking, and even a routine eye exam may cover only acuity, eye health and a prescription unless binocular testing is asked for.

More on the screening gap in what school vision screenings miss, and on what the eye chart itself does and does not measure in can a child have 20/20 vision and still struggle with reading?, which is our main article on that question.

What the professional bodies say, and where we stand

Parents deserve to know that this is a debated area. The American Academy of Pediatrics, the American Academy of Ophthalmology and allied groups hold that dyslexia is a language-based disorder, that vision problems can interfere with learning but do not cause dyslexia, and that eye exercises, behavioral vision therapy and tinted lenses are not supported as treatments for learning disabilities (AAP et al., 2009; reaffirmed 2014). The American Optometric Association and the American Academy of Optometry hold that vision problems can and often do interfere with learning, that people at risk should be evaluated by an optometrist, and that optometric care is one part of a multidisciplinary approach (AAOpt & AOA, 1997).

Our clinical perspective at Vision & Learning Center: vision therapy is not a treatment for dyslexia or ADHD, and we do not present it as one. It treats specific, measurable problems with eye teaming, focusing and tracking that make near work uncomfortable, and whether treating them helps a particular child learn is a question we work through with the child’s teacher, tutor and pediatrician rather than a promise. Our pillar article, Vision and Learning, lays out the full evidence picture, and we compare the two positions side by side in can a child have 20/20 vision and still struggle with reading?.

What to do next

Do not try to diagnose from a list, including this one. Instead:

1. Run the checklist. Our symptom checklist turns these signs into questions you can bring to any eye doctor.
2. Ask for binocular testing. A developmental vision evaluation measures convergence, accommodation, eye movements, depth perception and visual processing, the skills that screenings skip.
3. Loop in the school. Share the results with your child’s teacher or reading specialist so vision care, instruction and any other therapy work together.

If several of these signs sound like your child, the next step is simple and low-risk: a comprehensive developmental vision evaluation at our Boynton Beach or Boca Raton office. Schedule an evaluation and we will tell you plainly what we find, and what we do not.