A Clear Vision for Equity and Opportunity

Educators work very hard to help students solve the cognitive problems that impede their learning. Sometimes, the authors argue, it's the problems we can't "see" that need to be fixed first.

By Marge Christensen Gould and Herman Gould, O.D.

TWO OF THE most pressing issues in education today are the demands for improved academic performance and higher test scores and the mandate to close the achievement gaps between poor and middle-class students and minority and nonminority students. In response to these challenges, increased attention is being given to staff development that focuses on instructional methods, reading strategies, differentiated teaching and learning, test-taking strategies for students, and so on. However, before these approaches can begin to bring about improved student performance and close the achievement gaps, schools need to address a much more basic issue affecting learning for many students, especially those who live in poverty. This is the issue of undetected and uncorrected vision problems.

It is estimated that one out of four school-age children have undiagnosed vision problems significant enough to affect their performance in school and in life. Research shows that in at-risk populations, such as children born in poverty, this percentage is likely to be much higher.1

Since 70% of classroom learning depends on the visual system, students with uncorrected vision problems are at a tremendous disadvantage before they even enter the classroom.2 It seems obvious that if a student cannot see clearly, he or she is going to have a very difficult time reading, writing, and even participating in sports. Yet parents and educators almost always overlook vision problems as a possible roadblock to learning.

Vision Problems of Children in Poverty

In April 2001 the Harvard Graduate School of Education hosted a conference at which educators and optometrists shared their findings on the topic of "Visual Problems of Children in Poverty and Their Interference with Learning." Dr. Antonia Orfield, an optometrist at the Harvard University Health Services Eye Clinic and chief investigator of the Inner-City Vision and Learning Project at the Boston Mather School, discussed the high incidence of visual problems in urban poor children and reported that 53% of the children tested at the Mather School had vision problems that could hinder their ability to read.

School vision screenings typically check only for nearsightedness, which affects reading at a distance -- looking at chalkboards or whiteboards. Dr. Orfield recommended expanding the screenings to test for conditions that affect close-up (book) reading, such as farsightedness and problems with tracking.

Dr. Rochelle Mozlin, associate clinical professor of optometry at the College of Optometry, State University of New York, New York City, presented her research on vision problems of urban at-risk high school students. She tested students at two inner-city high schools, where 52% of the students failed the vision screening. She emphasized that treating the students proved to be difficult because parents and students generally did not follow up, even though there were several offers of free services. Only 17 of the 62 students (or 27%) identified as priority cases actually received the vision care they needed.

Dr. Robert Duckman, pediatric optometrist and professor of optometry at the SUNY College of Optometry, researched vision problems of children in foster care in New York City. He found that a staggering 83.5% of the 351 children he tested had vision problems.3

Vision Problems and Juvenile Delinquency

Several studies have linked uncorrected vision problems with juvenile delinquency. One rather alarming statistic is that in the population of all school-age students, 25% suffer from undiagnosed vision problems; however, among juvenile offenders, it is estimated that 70% have undiagnosed vision problems. If we understand that vision problems result in skill deficiencies, difficulty in reading and learning, and poor academic performance -- which, in turn, create feelings of failure, low self-esteem, and lack of interest in academics -- then the connection to delinquency becomes clear. In its study "Abandoned in the Back Row: New Lessons in Education and Delinquency Prevention," the Coalition for Juvenile Justice reported, "The biggest finding is that school failure is one of the earliest and best predictors for future delinquent and criminal behavior."4

In an earlier study titled "The Prevalence of Visual Conditions in a Population of Juvenile Delinquents," Dr. Paul Harris, an optometrist, reported that the population he and his colleagues tested had little, if any, contact with sustained near-vision demands. In other words, they were a population of nonreaders. Poor and nonreaders frequently exhibit poor academic performance; lack interpersonal problem-solving skills; demonstrate problem behaviors in school, such as aggressiveness and disobedience; and become delinquent.5

Working with At-Risk Students

According to the 2000 Census, 20% of U.S. children today live in poverty. In our home state of Arizona, that percentage is 33%. At the urban high school in Tucson, Arizona, where Marge works, nearly 70% of our students qualify for free or reduced-price lunches. Marge teaches and coordinates an innovative literacy and workplace-skills program for at-risk students, under the auspices of the Arizona Supreme Court and the Tucson Unified School District. The court's goal in sponsoring this program is to equip students with the skills that will prevent them from becoming involved with the criminal justice system.

Now in its 17th year, this student-centered and success-oriented program incorporates many elements of effective reform. These include real-world experiences in a professional workplace, the use of computers as central tools of instruction, differentiated teaching and learning, the pairing of students with adult mentors, a corps of wonderful volunteers who make possible a great deal of teacher/student interaction, and business and community partnerships that provide a wealth of resources.

The at-risk youths participating in the program include students reading at or below the fifth-grade level, students living on their own, students from dysfunctional families, special education students, English-language learners who are performing well below their English-speaking peers, students on probation, homeless students, dropouts returning to school, victims of abuse, and some teen parents. At least 85% of the students live in poverty. Although about 60% of them enter the program reading between six and 10 years below grade level, they gain an average of two grade levels per year. We have a 98% graduation rate, and approximately 60% of our graduates continue on to some form of higher education.

The program's exceptional success in improving students' academic performance began to attract national attention about six years ago. Over 1,200 educators from across the U.S. have visited our classroom. As a result, Marge has written three books and a case study and established a nonprofit organization (Educational ReadSources, Inc.) to train educators to create similar programs at their sites across the country.

Marge constantly researches best practices, new methods, and tools to improve her students' reading and writing skills and their academic performance in general. After learning about the relationship between vision problems and learning difficulties, Marge wanted to investigate her students' visual performance and compare it to the results of the previously mentioned studies. She discovered that a very large percentage of her students either had never had an eye examination or had not had one in the last two years. Working together as educator and optometrist, we were able to implement a vision and learning project for Marge's students.

Vision and Learning Project

In 2001 we conducted a vision screening to determine the visual status of 100 at-risk students in Marge's program. The study also included 124 other students at the school who, like most of Marge's students, were eligible for free or reduced-price lunches, had very poor literacy skills, and had failed one or more classes.

Through Educational ReadSources, we obtained a $10,000 grant from the Pearle Vision Foundation and were able to refer the students who failed the vision screening for comprehensive eye examinations and glasses at little or no cost to them.

The goal of this project was to remove a major roadblock to learning and thus avoid perpetuating a cycle of failure for these students. With their vision problems corrected, they would experience much less frustration and be relieved of any physical discomfort (headaches, blurred vision, eye fatigue) that may have troubled them previously. Then their academic performance would improve, their self-esteem would be elevated, and the likelihood of their becoming delinquents would decrease.

Since most poor and nonreaders pass the distant eye-chart test with ease, we chose to use a computerized objective instrument called an auto-refractor. It produces readings that are not in terms of visual acuity, such as 20/20, but rather indicate the amount of nearsightedness, farsightedness, and astigmatism. The testing procedure takes less than a minute per eye and does not require drops or an air puff. The student looks into the instrument and an objective measurement is taken.

Of the 224 students Dr. Gould screened using the auto-refractor, 101 (or 45%) failed the test, that is, had readings exceeding the expected value. Thus our findings are similar to those of Orfield and Mozlin.

Vision and the Education Gap

The majority of Marge's students are Hispanics, and so, not surprisingly, the largest percentage of students referred for eye exams from our vision screening were Hispanics. In exploring additional ways to help these students to raise their levels of achievement, we looked to an organization that is heavily committed to increasing higher education attainment among Hispanics, the Hispanic Scholarship Fund. The Fund's Hispanic Education Study, conducted by the RAND Corporation, confirmed that our work with these students could have far-reaching effects. A significant education gap exists between Hispanics and non-Hispanic whites, and, as the report makes clear, the situation "will not improve without aggressive action." We learned that "it is also estimated that the share of Hispanics among high school dropouts will double by 2010, reaching 32%. Hispanics are projected to be the only ethnic group to experience an increase in the number of high school dropouts between 2000 and 2010."6 To the extent that our work eliminates the negative effects on Hispanic students' academic performance caused by undiagnosed and untreated vision problems, we hope that it can help to reduce the incidence of failure among these young people.

Another Challenge -- Compliance

A few months after initiating our vision screening project, we learned firsthand what we had read in the articles from the Harvard conference: screening students for uncorrected vision problems and referring them for eye examinations and glasses is the easy part. We encountered the poverty mentality regarding health care -- you don't go to a doctor until there is a serious or painful problem. Thus our most challenging task was getting students and parents living in poverty to follow through with the eye examinations and glasses, even if it would cost them little or nothing.

Many of the students had never had a comprehensive eye examination, and explaining to them and their parents the importance of taking care of their eyes, making the appointment for the eye examination, and then keeping the appointment was a crucial part of the project. Dr. Gould met one-on-one with the students who failed the vision screening to explain their results and personally give them a letter addressed to their parents (in English or Spanish), along with a voucher for a comprehensive eye examination and glasses, if needed.

About half of Marge's students who failed the vision screening took the vouchers and parent letters home and made appointments for their eye examinations. The other half either procrastinated or ignored the eye exam altogether, and it took a collaborative effort of teachers, mentors, volunteers, and staff members from our school's Family Resource and Wellness Center to finally get them to follow through. Five of the students refused to make the appointments, as they didn't want to wear glasses. Three of those students' parents refused to have their children's eyes examined.

Once they had the eye exams and got their glasses, only about half of the students would regularly wear their glasses. Thus we began reminding them to wear their glasses if they needed them for reading or for seeing the whiteboard, complimenting them when they wore their glasses, and giving them encouragement to keep wearing them. They responded well to comments such as, "Those glasses are really cool. You look like a college student with them." Once several students started wearing their glasses, others were less hesitant to wear theirs.

It was a much greater challenge to get the screened students who were not in Marge's classes to follow through with their eye exams. Toward the end of the school year, the director and staff of the Family Resource and Wellness Center contacted these students' parents, explained to them -- in Spanish if necessary -- that vision problems pose an obstacle to learning and reading, and emphasized the importance of vision care and the value of this opportunity for their children to obtain an eye examination and glasses at very minimal cost. After receiving parent permission, the Wellness Center staff made appointments for eye examinations for the students and then drove them to the optical center in groups of five or six. After the exams, they took the students out to lunch, so that the entire experience was a positive one.

Eye on the Future

On 27 March 2002, we attended a lecture presented by Dr. Robert Snyder and the late Dr. Jorge Rodriguez of the Department of Ophthalmology at the University of Arizona, who had conducted a three-year study on 4,774 Hispanics in Tucson and Nogales, Arizona, to determine the prevalence and causes of eye diseases among Mexican Americans. The study, called Proyecto VER (Project Vision, Evaluation, and Research -- the Spanish word ver means "to see"), found that uncorrected vision problems in this population were strongly associated with less than 13 years of education, a low acculturation index, lack of insurance coverage, and not having seen an eye-care provider in the past two years. Furthermore, the study found that Hispanics over the age of 40 are more likely than other ethnic groups to have undiagnosed diabetic retinopathy and glaucoma.7

The findings and conclusions of Proyecto VER underscore the importance of vision screening projects not only for Hispanic students but for all students, especially those living in poverty. We hope that we can teach these students to value their vision and learn to take care of their own eyes as well as encourage their families to do so. Once they incorporate this new belief system into their mindset, it will benefit not only themselves, but future generations.

Expanding the Project

Our vision screening project has attracted the attention of some local and state education and health-care leaders who feel that it is a very worthwhile and important endeavor. We are exploring with them the possibility of expanding the project to include additional schools. We have had numerous offers of help from individuals in the community, and any expansion would be a large collaborative effort of the public and private sectors working together to improve education for young people.

A Vision for Equity and Opportunity

Our public schools now have the most diverse student population in U.S. history. This diversity, which has made our nation so great, also requires that we do things differently in education in order to meet the needs of all students. There are many proposals now before various state legislatures to mandate comprehensive vision screenings for all students before they enter kindergarten. This is not enough. Schools need to provide comprehensive vision screenings that include checking for conditions that affect reading and learning, and these should be repeated every two years.

Will this be a huge task? Of course it will be, but the alternative -- ignoring the fact that many students may be struggling because they cannot see the printed materials they are supposed to learn or cannot see the board -- is unacceptable. Most vision problems, if left uncorrected, will only worsen. Consequently, the longer we wait to take action on this important issue, the more frustrated students will become, the more their self-esteem will be eroded, and the more their academic performance will suffer.

There is no guarantee that once a student's uncorrected vision problem is corrected, his or her grades will immediately improve. However, if the student has a vision problem that interferes with the ability to read or to learn, it will certainly hinder the student's performance. Removing this roadblock will at least give the student a fighting chance to achieve his or her potential. We owe our students that much. Besides, our nation cannot afford to squander the abilities of bright, capable young people.

This is a good opportunity to initiate collaborative efforts between the public and private sectors to make a real difference for these students. The most eloquent argument for undertaking such projects comes from the students themselves:

Thank you for the voucher to get my glasses -- they work great! Now I can see what I need to see in class and can read easier too. They also make me feel more businesslike, and they make me feel like I want to do work.

* * *

I had difficulties with my eyes since I was a little girl. My glasses have helped me a lot. I see better, my eyes don't get so tired since I got my glasses, and I don't get headaches anymore like I used to.

* * *

Thank you for helping me get glasses. It is nice to be able to see without squinting and holding things two inches from my face. Now when I read, my head does not hurt.

* * *

Thank you very much for your grant so I can get myself a pair of glasses. My eyes were very bad because I am nearsighted. I cannot see far enough to look at the whiteboard. My eyes get really tired when I try to look at the board. Sometimes I can even see my teacher very blurry. Now that I have a pair of glasses I can see very well in class, and it does help me to get my work done faster.

We can make a significant and realistic contribution toward closing the achievement gap. All it takes is commitment and a vision of equity and opportunity for all students.

2. Ibid.

3. Kathleen Gillespie, "How Vision Impacts Literacy: An Educational Problem That Can Be Solved," HGSE News, 17 April 2001, available at http://gseweb.harvard.edu/news/features/vision04172001.html.

4. Angela Townsend, "Poor Students, Drop-Outs Likely to Graduate to Jail, Report Says," Cleveland Plain Dealer, 7 December 2001.

5. Paul Harris, O.D., "The Prevalence of Visual Conditions in a Population of Juvenile Delinquents," Optometric Extension Program Curriculum II, January 1989, pp. 1-24.

6. The HSF RAND Report can be downloaded at www.hsf.net.

7. Beatriz Muñoz et al., "Blindness, Visual Impairment and the Problem of Uncorrected Refractive Error in a Mexican-American Population: Proyecto VER," Investigative Ophthalmology and Visual Science, vol. 43, 2002, pp. 608-14, available at www.iovs.org/cgi/content/abstract/43/3/608.

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