Visual Perceptual Skills and Child Development

When we think about vision, most of us think about how clearly a child can see. But eyesight is only the delivery system. What happens after the image arrives at the brain is a separate set of abilities, and those are what clinicians call visual perceptual skills.

Your brain takes in far more visual information than it can use. It has to sort, compare, store and interpret before any of it means anything. When that sorting is slower or less accurate than it should be for a child’s age, a student with 20/20 eyesight can still find schoolwork harder than it looks from the outside.

Key takeaways

• Visual perceptual skills are what the brain does with what the eyes send it. They are separate from eyesight, and separate again from eye teaming, focusing and tracking.
• Clinicians usually describe seven of them, because that is how the standardized test is built.
• Perceptual and visual-motor scores are consistently and measurably related to reading, math and handwriting in school-age children (Kulp, 1999; Hopkins et al., 2019). These are correlations, not proof of cause.
• Vision problems do not cause dyslexia, and perceptual training is not a treatment for a learning disability. We say that plainly.
• If schoolwork does not match the effort your child puts in, a comprehensive developmental vision evaluation tells you whether vision and visual processing are part of the picture.

The seven visual perceptual skills

Each of these works with the others. A weakness in one rarely shows up on its own, which is why we test the whole set rather than a single skill.

1. Visual discrimination

The ability to notice similarities and differences in shape, size, color, pattern and detail.

• Difficulty finding and correcting errors in schoolwork.
• Confusing words that look alike.

2. Visual memory

The ability to hold the details of a visual image in short-term memory.

• Difficulty remembering sight words.
• Inconsistent use of upper- and lower-case letters.
• Slow, letter-by-letter copying.

3. Visual-spatial relations

The ability to perceive where an object sits in space in relation to oneself and to other objects.

• Difficulty telling apart b, d, p and q.
• Handwriting that is crooked, unevenly sized or poorly spaced.
• Trouble remembering left from right.

4. Visual form constancy

The ability to recognize that a form is the same even when its size, position, orientation or font changes.

• Difficulty recognizing a familiar word in a new font, size or place on the page.
• Slower mastery of the alphabet and of numbers.

5. Visual sequential memory

The ability to remember a series of forms in the correct order.

• Difficulty copying from the board.
• Weak spelling.
• Trouble following multi-step instructions.

6. Visual figure-ground

The ability to find and identify a target in a busy visual field without being pulled off task by everything around it.

• Overwhelmed by a page with a lot of print or graphics.
• Difficulty keeping attention on one task.
• Difficulty scanning text to find a specific piece of information.

7. Visual closure

The ability to fill in missing information and recognize an object as complete.

• Weaker reading comprehension.
• Confusing words with similar beginnings or endings.
• Difficulty making inferences and drawing conclusions.

How these skills develop

Perception is built on experience. Babies and toddlers use vision to explore, to learn shapes, and to recognize faces and objects. School readiness depends on recognizing letters, numbers and symbols. Drawing, cutting, building and catching all require vision to guide the hands.

The visual system itself is still maturing while this is happening. Depth perception is the clearest example we can put a number on: in 4,355 normally sighted children tested on a widely used preschool stereo test, average stereoacuity sharpened from about 100 arcseconds at age 3 to 60 by age 5 and 40 by age 7 (Birch et al., 2008). Because vision is still developing through the early school years, this is exactly the window in which an uncorrected or unnoticed problem matters most.

Clear, comfortable vision is part of the foundation. In 492 four- and five-year-olds, children with uncorrected moderate farsightedness scored 4.3 points lower on a test of early literacy than children who did not need a correction (VIP-HIP Study Group, 2016). That is not a perceptual skill deficit, but it shows how much the input side matters while these abilities are forming.

This is also why a passed school screening should not close the question. The AOA’s pediatric guideline reports that acuity testing alone missed 75.5% of children who turned out to have binocular or eye-movement problems on a complete examination, and recommends a comprehensive exam before first grade and annually after (AOA, 2017).

Why these skills matter at school

Reading is not a smooth glide across the page. The eyes jump, land, hold still long enough to take in a few letters, then jump again, and the pattern of those jumps reflects what the brain is doing with the words (Rayner, 1998). Perception is the work done between the landings.

The measured relationships are real. In 191 children in kindergarten through third grade, performance on the Beery visual-motor integration test was significantly related to teacher ratings of reading, math and writing (all p = 0.0001), and to spelling among the second and third graders who were rated on it (p = 0.0118). When the author partly controlled for cognitive ability, the math and writing relationships still held among second-graders of average ability (p = 0.007 and p = 0.001); the paper reports no such controlled analysis for reading or spelling (Kulp, 1999).

In 155 second- through fourth-graders, the visual memory subtest of the TVPS predicted below-average word decoding, math and overall achievement after controlling for age and verbal ability (Kulp et al., 2002). Breaking the Beery into parts showed that its visual perception and motor coordination scores were each related to Stanford math and reading scores while age and verbal school ability were partly controlled; in a fuller model that also accounted for the VMI itself and the other subtest, only visual perception stayed significantly related to math. Those authors concluded that visual perceptual ability should be assessed in children with poor math or reading achievement (Sortor & Kulp, 2003). In a larger Australian sample of 222 second-graders, visual-motor integration and horizontal eye-movement timing were the visual measures most associated with reading and math, explaining roughly 29% and 24% of the variation in scores (Hopkins et al., 2019).

The limit is important. Every one of those studies is correlational. Children who score better on perceptual tests tend to do better at school; none of this shows that the perceptual score is what caused the difference, or that raising the score raises the grade. Read what vision does and does not do for learning for the full picture.

Handwriting, math layout and coordination

Handwriting is where perceptual skills become most visible, because the output is right there on the page. A review of handwriting development lists visual-motor integration, visual perception, fine motor control, motor planning and sustained attention among its building blocks, notes that handwriting difficulty affects an estimated 10 to 30% of school-age children, and reports that it does not tend to resolve on its own without intervention (Feder & Majnemer, 2007).

When researchers compared 49 children with handwriting difficulties against 27 controls, the children who struggled scored lower on accommodative facility, directionality, visual-motor integration, and on visual discrimination, spatial relations, form constancy, sequential memory, figure-ground and closure (Leung et al., 2014). That is essentially the whole list in this article, plus focusing.

Coordination outside the classroom draws on the same system. Depth perception is a good example: in 143 people aged 10 to 30, pegboard and bead-threading performance tracked with stereoacuity, and those with normal stereo vision did best on every task (O’Connor et al., 2010). If handwriting or math layout is your main concern, our page on handwriting and math goes into how we look at it, and these two posts go deeper on the writing side: why handwriting may not be improving and spelling struggles.

How we test visual perceptual skills

Perceptual testing is standardized and age-normed, so your child’s result is compared with children of the same age rather than judged by impression.

• Test of Visual Perceptual Skills (TVPS). Covers the seven areas above with no motor demand, so a child’s score is not held down by pencil control. This is the instrument used in the visual memory and achievement research cited above.
• Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery VMI). A copying task, with supplemental subtests that separate the visual perception part from the motor coordination part. That separation is what let researchers test each component against achievement scores (Sortor & Kulp, 2003).
• The rest of the exam. Eye health, refraction, focusing (accommodation), eye teaming (binocular vision) and eye movements. Perceptual scores are only interpretable once we know the input is clear and comfortable.

What the evidence does and does not support

We would rather you have the whole picture than a flattering half of it.

The 2009 joint statement from the American Academy of Pediatrics, the American Academy of Ophthalmology, AAPOS and AACO holds 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). The accompanying technical report adds that children with dyslexia have the same visual function and ocular health as other children, and that evidence-based reading instruction is what works (Handler & Fierson, 2011). The optometric position differs in emphasis: vision problems can and often do interfere with learning, and optometric care aims to improve visual function as one part of multidisciplinary care (AAO/AOA, 1997).

The data sit between those positions. In 5822 children, four of every five with severe reading impairment had entirely normal ophthalmic function (Creavin et al., 2015). And in the largest trial of its kind, office-based vision therapy for convergence insufficiency improved reading comprehension by 3.7 points against 3.8 points for placebo therapy (CITT-ART, 2019). Treating a vision problem is not a reading intervention.

Studies of perceptual training itself are small. One program raised TVPS-3 scores and improved handwriting quality in students with dyslexia, but the study included 20 children in total and was not a randomized controlled trial (Fusco et al., 2015). Promising is the right word; proven is not.

Our clinical perspective at Vision & Learning Center, offered as ours rather than as settled science: perceptual testing tells us how a child takes in and organizes visual information, and that is useful for a teacher, a tutor and an occupational therapist as well as for us. When we also find a focusing, eye teaming or tracking problem, treating it — the work of our learning-related vision care — removes an obstacle so good instruction can do its work. It does not replace that instruction.

What parents can do

• Say what you actually see. “He rereads the same line” and “she copies four words then loses her place” are more useful to us than a label.
• Ask the school for the reading and math instruction picture first, including any screening for a language-based learning difference.
• Keep the near-work environment sane: good light, a reasonable working distance, and breaks before fatigue sets in.
• Do not stop at the screening. Screenings check eyesight; they were never designed to check focusing, eye teaming, tracking or perception.
• Trust the pattern you are noticing. Parents are usually right that something does not add up, even when they cannot name it.

If reading, writing, math or coordination is harder for your child than the effort they put in can explain, a comprehensive developmental vision evaluation will tell you clearly whether vision and visual processing belong in the conversation. Schedule an evaluation at our Boynton Beach or Boca Raton office and we will give you a straight answer either way.