After 37 years of private practice providing vision therapy, it seemed unlikely that I would run into something that would completely change my practice. But I encountered this in working with gifted children.
Earlier, I had read Linda Silverman’s article, "Diagnosing and Treating Visual Perceptual Issues in Gifted Children" (Silverman, 2001) in the Journal of Optometric Vision Development. She described how she uses discrepancies in scores on IQ tests to determine if a gifted child needs an optometric examination. She provided a case study in which a highly gifted child with average scores on visually presented items significantly increased his performance, attaining scores in the gifted range, after two courses of vision therapy. She suggested that the goals for vision therapy should be extended beyond the goals for average children: vision therapy should be continued until the children’s visual speed and ease match their intellectual ability.
In 2014, I had the opportunity to work with gifted children and to learn firsthand the way that they differ from other cases. I had my first referral from The Helios School, a school for gifted children. Anne Beneventi, co-founder of the school, is affiliated with Linda Silverman. She is sensitized to visual processing issues in gifted children and to the benefits of vision therapy. I had excellent results with the first case. This led to a deluge of gifted patients. At the time of this writing, I have seen 207 gifted children. As I have worked with this special population, several patterns have become apparent.
The most consistent pattern I have seen with these gifted children is that their processing speed is significantly lower than their reasoning ability. This has been documented in studies of the gifted (Silverman, 2013; Wasserman, 2013). Psychologists have differences of opinions about the importance of processing speed. Some recommend using only measures of abstract reasoning to select gifted children to special programs and adapting the programs to the child’s processing speed weaknesses, such as allowing them extended time on standardized tests (Gilman, et al., 2013). Others assert that processing speed is extremely important to success in school and in life, and should definitely be considered in selecting students for gifted programs. "Processing speed and working memory, however, are important for success and for making one’s mark as gifted or eminent in many professions" (Pfeiffer, 2013, p. 66). In some state legislation regarding eligibility for gifted programs, and in many private schools for the gifted (e.g., The Nueva School), admission is based on Full Scale IQ scores, which are diminished by low processing speed.
As I saw more and more gifted children with the same pattern, all of whom were being helped by vision therapy, I began to see that there was a much deeper significance to the pattern and its treatment. The field of behavioral optometry was founded by a mathematical visionary, Dr. A. M. Skeffington. His conceptions were so abstract that they were not well understood. They required painstaking measurement and analysis, and gains could be made with most patients using simpler approaches. Over time, Skeffington’s methods were discarded. I discovered that while Skeffington’s work may not be applicable to the vast majority of vision therapy patients, his model has applicability for the gifted.
In the 1930s, Skeffington proposed a model through which the stress of near-point visual demands could alter visual function. This became known as the Skeffington Analytic Sequence. It was his premise that adaptations of these visual demands could start a series of what he termed “visual degenerations,” that were initially temporary (non-embedded), but could, without intervention, eventually become long-term (embedded). This is my simplified interpretation of his system.
For some individuals, poor development of processing speed may be a by-product of attempts to reduce the discomfort of having a visual system that delivers inconsistent visual input. Inconsistent visual input can cause a wide range of symptoms, including double vision, eye strain, blurred vision, headaches, nausea and motion sickness. These symptoms are often related to problems in which the two eyes receive dissimilar visual information: "binocular dysfunction."
The development of inattention to specific types of inconsistent visual input as a coping mechanism may result in increased comfort at the expense of reduced function. The coping mechanisms make the child asymptomatic, which make the issues difficult to detect, but lead to deeper issues if not corrected. For example, in an attempt to avoid these symptoms, children ignore information in their peripheral vision. Visual-spatial learners, who are able to understand the big picture cognitively may focus narrowly on central vision, unable to integrate the information from their peripheral vision. This asynchrony between cognitive and visual functioning (big picture thinkers narrowly focused) prevents them from being able to use their visual-spatial learning strengths efficiently.
The adaptations developed to cope with binocular dysfunction cause gifted children difficulties understanding the location of objects, leading them to lose their place easily. In the Coding subtest, they struggle to locate the code and then visually find and shift to the cell where they need to record the code. They may have difficulty identifying the abstract design in Symbol Search and determining if there is a matching design on the same line. All of this depresses processing speed.
The gifted have unusual discrepancies between their strengths and their weaknesses. Twice exceptional children—those who are both gifted and learning disabled—have extreme discrepancies between their strengths and weaknesses. The compensation strategies gifted children develop can lead to more serious issues if not remediated early. What begins as a functional adaptation to double vision or eye strain can actually degenerate into a structural adaptation of the brain with long-term consequences.
What is novel about this project is that it proposes a specific set of adaptations that the gifted appear to develop to reduce the discomfort and symptoms related to inconsistent visual input, which can result in reduced performance in Processing Speed. This adaptation has important implications. Elimination of inconsistent visual information removes the need for this adaptation and can result in significantly increased processing speed, without practicing activities similar to the tasks used to measure the Processing Speed Index on the IQ test. It is consistent with the model proposed over 80 years ago by Skeffington.
I discovered that the difficulties gifted children have on the Coding and Symbol Search subtests, which comprise the Processing Speed Index of the Wechsler IQ scales, could be ameliorated with 20 – 30 sessions of a specific kind of vision therapy, based on Skeffington’s model. The therapy could even be accomplished in an intensive program with several sessions per week, or even per day. No home program is needed. Vision therapy improved scores on the Processing Speed Index for a few patients who had re-tests during the first fourth or half of therapy. In these individuals, large gains were also found in Verbal Comprehension and Visual Spatial Indexes of the Wechsler Intelligence Scale in Children, Fifth Edition (WISC-V), and sometimes in the Working Memory Index as well. However, Coding and Symbol Search were still relatively low compared with the other Index scores. In individuals who were retested on the WISC-V six months to a year after the completion of therapy, Processing Speed scores were more consistent with scores for Verbal Comprehension and Fluid Reasoning—the indexes that are the best measures of abstract reasoning (Gc and Gf in CHC theory).
This finding alone could increase the opportunity for gifted children to gain acceptance into schools and special programs for the gifted. Of much greater significance, vision therapy has the potential to prevent embedded, long-term visual issues that are much harder to ameliorate. Processing speed problems begin as a temporary issue, amenable to a short program of vision therapy. Untreated, however, they can become embedded, which can cause much more far-reaching deficits, lowering scores in the Visual Spatial Index (e.g., Block Design), Working Memory Index, and Verbal Comprehension Index. So much energy is consumed by the brain’s adaptations to confusing visual input that it puts too much stress on working memory and interferes with comprehension. This eventual outcome can be prevented. Embedded visual degenerations affect intelligence, performance in school and success in life.
My goal is to put forth the basic model of Low Visual Processing Syndrome in the Gifted to psychologists, educators and parents, so that others will know that processing speed issues, and even working memory issues, respond to vision therapy. I would like to help other optometrists become aware that their early education on Skeffington’s Analytic Sequence has applicability to the gifted population. I would like my colleagues to understand that twice exceptional children have a different operating system and they need a different program of optometric vision therapy for optimal improvement. This can result in a much more rapid, intuitive understanding of the treatment/enhancement process.
Skeffington offered a mathematically logical plan to explain how changes in visual function take place at different levels. It explains why some functions are easy to train and some functions need other tactics to enact change. It appears that a similar “degeneration pathway” takes place with intelligence. It follows logically that certain factors would respond well to direct training, while others need a very different approach. This pathway explains the pattern of improvement that Linda Silverman and Lynn Hellerstein presented in cases reported at the College of Optometrists in Vision Development annual meeting (Hellerstein & Silverman, 2017). It also explains reasons why vision therapy often did not impact Processing Speed and Working Memory to the same extent in the cases presented. Vision affects verbal comprehension and visual-spatial skills in different processes than it affects processing speed or working memory. Different strategies are required.
The major concept I would like to present to optometrists is that a degenerative pathway exists by which the individual’s adaptations can eventually impact processing speed, working memory, and verbal comprehension. In children who followed this pathway, a treatment process could improve function in these areas. My first goal is to establish that such a pathway exists and is common. This involves establishing a Low Visual Processing Speed Syndrome in the Gifted. I would like psychologists, educators and optometrists to learn how to identify these children through a list of signs and symptoms. Psychologist Linda Silverman interprets IQ test protocols to determine the need for vision therapy. Anne Beneventi, Qualitative Assessor, uses observations and information about the child’s weaknesses, such as not developing an interest in reading commensurate with their abilities. I use a system of correlations of visual scores for related functions.
No one has proposed a comprehensive model for the visual assessment and treatment of gifted children. This is what I propose to do with the remainder of my career. I want to educate the top specialists in vision therapy in this model for reversing Low Visual Processing Speed Syndrome in the Gifted. Once they are convinced of the need to re-examine Skeffington’s model and embrace its applicability to the special population of gifted learners, I believe that gifted children all over the world will benefit.
To do this involves educating psychologists first—particularly psychologists of the gifted. Psychologists have the measurement tools to determine the deficits and to document the improvement. Few optometrists understand IQ tests. Both professions need to improve our understanding of gifted children with visual processing deficits who can show marked improvement with intervention. And both professions need to be aware of the risks of not identifying and treating these issues.
Gilman, B.J., Lovecky, D.V., Kearney, K., Peters, D. B., Wasserman, J. D., Silverman, L. K., et al. Critical issues in the identification of gifted students with co-existing disabilities. SAGE Publications, 2013 (September 29). [https://sgo.sagepub.com/content/3/3/2158244013505855.full].
Pfeiffer, S. I. (2015). Essentials of gifted assessment. Hoboken, NJ: John Wiley & Sons.
Rimm, S., Gilman, B. J., & Silverman, L. K. (2008). Non-traditional applications of traditional testing. In J. VanTassel-Baska (Ed.), Alternative assessments with gifted and talented students (pp. 175-202). Waco, TX: Prufrock Press.
Schmitt, E. P. (2006). The Skeffington perspective of the behavioral model of optometric data anaylsis and vision care. Author House. (ISBN 1-4259-1054-8)
Silverman, L. K. (2001). Diagnosing and treating visual perceptual issues in gifted children. Journal of Optometric Vision Development, 32, 153-176.
Silverman, L. K. (2013). Giftedness 101. New York: Springer.
Silverman, L. K. & Hellerstein, L. F. (2017, April). The impact of vision therapy on IQ. College of Optometrists in Vision Development 47th Annual Meeting, Jacksonville, FL.
Manas, Leo. (1958) Visual Analysis: Chicago, Illinois: The Prefessional Press, Inc.
Wasserman, J. D. (2013). Identification of gifted learners: Traditional assessment models. In C. S. Neville, M. M. Piechowski, & S. S. Tolan (Eds.), Off the charts: Asynchrony and the gifted child (pp. 292-346). Unionville, NY: Royal Fireworks Press.