Vision problems and ADHD…why “rational management” should be as simple as glaucoma

In the October 15, 2016 edition of Review of Optometry  there is a feature article entitled, Controversies in Glaucoma Management written by Bruce Onofrey, OD, clinical professor at the University of Houston. Dr Onofrey begins with the following, “The rational management of ocular disease is simple. First, know the disease. Get acquainted with the pathophysiology…Second, know the patient. Consider the risk factors for, and the consequences of the disease as well as the the patient individual considerations for drug therapy. Finally, know the drug. Get familiar with the pharmacology of the many therapies available.”

Just one day prior to the above publication, on October 14, 2016 it was my pleasure to  present  along with our resident, Dr. Mark Takesuye, to the 3rd year graduate students at the Michigan College of Optometry at Ferris State University. Our lecture, entitled, Understanding ADHD and the role of Optometry was delivered as part of the Developmental Vision course taught by professor, Dr. Sarah Hinkley. I began with a question to the audience, “In your future career as optometrists, raise your hand if you see yourself diagnosing and treating glaucoma?” The response was unanimous, 100%, every hand was raised. Then I asked, “how many of you anticipate diagnosing and managing vision problems linked with ADHD, such as convergence insufficiency?” The response was much less about 20%. Now to be fair, this is what I expected given the early phase in these students training, but at the same time it mirrors a pattern that does exist in optometry overall about certain types of  developmental vision problems and their significance to the patient.

In the eye care arena, If you are an optometrist, glaucoma is a condition that gets a lot of attention from our earliest ocular disease courses as well as almost every general optometry conference where there are a multitude of continuing education courses dedicated to glaucoma. After all, glaucoma is an important healthcare issue and because if undetected and/or untreated, can lead to blindness. Fortunately, the good news is glaucoma in children and young adults is rare. Studies show that the prevalence of glaucoma in children (under age 20 yrs old) to be .0023% or about 2 in 100,000 individuals. In older adults (over 40) there is a greater prevalence but still uncommon at about 1.86%.

But, the topic of our lecture to the students at MCO was not glaucoma. Rather our lecture was about the vision problems that are common and known to exist frequently in children that can also lead to ADHD behaviors. Furthermore, there are too many children who have been diagnosed with ADHD and unnecessarily treated with stimulant medications when there is an undetected vision problem that, once identified and properly treated, will significantly reduce ADHD behaviors and improve the quality of that child’s life. Therefore, the purpose of this lecture was to provide a basic understanding for ADHD and  to show our future doctors how  specific types of developmental vision problems can and often lead to symptoms that can be mistaken for ADHD. Most important we wanted to demonstrate the  important role we in Optometry have for our patients through optometric  evaluation and management of these vision conditions including treatment considerations involving vision therapy.

Attention Deficit Hyperactivity Disorder (ADHD) is coined a  neurodevelopmental or neurobehavioral condition. It is the most commonly studied and diagnosed psychiatric disorder in children and adolescents. The American Psychiatric Association estimates ADHD occurs in about 5% of children when diagnosed via the DSM-V criteria. However, the CDC surveys estimate that approximately 11% of children 4-17 years of age (6.4 million) have been diagnosed with ADHD as of 2011. In some states the number diagnosed is nearly 20%!

How is ADHD diagnosed? Those with ADHD show a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development.  Medicine’s primary diagnostic criteria relies on a symptom profile from family and non-family members, ex: Connor’s Rating Scale

In the pediatric medicine arena, ADHD is one diagnoses that captures the spotlight. However unlike glaucoma that is rare in children ADHD is much more common in children. Even using the DSM-V criteria of 5% the incidence would be reason to have concern. But, considering that the CDC estimates that diagnosis of ADHD is diagnosed and stimulant medication prescribed 1 in 10 children on average in the US and in some states as much as 1 in 5 children and predominantly on a symptom checklist, begs the question…what if the child diagnosed with ADHD has another cause for their behaviors? Are we overmedicating millions of children with potentially dangerous stimulant drugs when there is another explanation involving a vision problem?

In fact,  we have a large body of clinical research published in optometry, medicine, neuroscience in the United States and internationally (some of the most notable summarized here) to show that there is a direct connection between specific vision problems and ADHD behaviors. These vision disorders are known as: convergence insufficiency,  accommodative disorder,  oculomotor dysfunction and delays in visual processing (visual perception).  The prevalence of these conditions are significant. Convergence insufficiency and accommodative disorders tend to occur together and are 5-10% in children. Oculomotor dysfunction as high as 22%  Visual Information processing problems occur in about 15-20%

If we  in Optometry have the professional responsibility to diagnose and manage glaucoma a condition that is rare in children, shouldn’t the same be said for developmental vision problems that can mimic or exacerbate ADHD which have a significantly high prevalence in children?

If the rational management of a serious vision problem is to “know the disease, understand the patient’s needs and know the treatments, both drug treatments and other therapies”, how long will it take before optometry and all of healthcare considers the same for the vision problems found with ADHD?

However, in spite of the best efforts by many of our optometric organizations, The American Optometric Association which has published Clinical Practice Guidelines for Optometrists (Care of the patient with Learning Related Vision Problems and Care of the patient with Accommodative and Vergence Dysfunction), The American Academy of Optometry (position paper on vision and learning), The College of Optometrists in Vision Development which offers Board Certification, continuing education for doctors and has a plethora of materials on these diagnosis and much more, and the Optometric Extension Program which also provides continuing education and many resources, too many children with vision problems linked to their ADHD are unfortunately being overlooked. Could this be one of the primary reasons why the CDC estimates for diagnosed ADHD are so over the top out of sync with what the American Psychiatric Association?

Consider the facts: ADHD is a neurodevelopmental/behavioral disorder  and medicine’s “best practice” for diagnosing ADHD is based on a symptom profile with a high frequency of certain behaviors.

Since there are many other medical diagnoses that can mimic and/or increase  ADHD behaviors and since  vision problems have been proven to be significant, optometrists and all healthcare providers should rule out vision problems such as convergence insufficiency, accommodative dysfunction, oculomotor dysfunction and delays in visual information processing as possible causes first before beginning medication.

While there can be a role for medication for some with ADHD, the important message for doctors is to know how to first diagnose and treat when vision problems co-exist with ADHD.

The time has come to end the senseless struggle for those children who have vision-based ADHD behaviors and apply a rational management of these vision problems just as simply as identifying and treating glaucoma. 

Dan L. Fortenbacher, O.D., FCOVD

Vincent Monastra, Ph.D. on Vision & ADHD

One of the country’s leading authorities on ADHD, Dr. Vincent Monastra holds a Ph.D. in clinical psychology and is the Director of the FPI Attention Disorders Clinic in Endicott, NY.

I became aware of Dr. Monastra’s perspective on undetected and untreated vision problems compounding ADHD issues through our optometric colleague, Dr. Gary Williams, who has collaborated with him.

At the 8:13 mark of the following video, Dr. Monastra relates his approach.  He notes that another kind of problem that isn’t picked up on routine evaluation, or even lab work done by a physician, are visual problems.  When he first began doing EEG studies, he noted that certain children had significant problems maintaining focus and fixation with their eyes, which is a prerequisite for obtaining recordings without artifacts.  At first he was puzzled as to why it was so hard for these children to keep their eyes focused.  It was at that point that he sought out developmental optometrists who could conduct a comprehensive evaluation of visual tracking and convergence.  He found that 20-25% of the ADHD population had visual issues contributing to signs and symptoms of ADHD, and there’s no medication that’s going to take that away.

Why is there a lack of vision for children with ADHD when there is so much evidence?

If you are a parent whose child struggles to concentrate and read and the task of homework is a family battle, there can be an immediate assumption that he or she has ADHD. According to the World Health Organization in 2013,  ADHD affects about  39 million people and is defined  as a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (e.g., attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness.

In school-aged individuals inattention symptoms often result in poor school performance and yet too often these ADHD behaviors are assumed to be due to a defective ADHD brain that needs psychostimulant medication to normalize. Click here to see the surprising truth about the history of psychostimulants for ADHD.

However, when there is over 50 years of  scientific evidence published in optometry, medicine and neuroscience in the US and internationally that shows a direct connection between developmental vision problems having a causative relationship to ADHD, why is there not a public health outcry to insist that all children be tested for vision-related problems to rule out certain forms of visual problems before placing them on psychostimulant medications? Click here to see a sample of 7 of the best research papers from medical, neuroscience and optometry journals, US and International from 20 years ago to less than 6 months ago that show the vision and ADHD connection.

Indeed,  if the majority of these ADHD behaviors are triggered with visual tasks, might there be a vision connection to ADHD? And if there is, what targeted treatment can be done to help the patient overcome this disorder without the need for drugs?

To explore this patient health issue, developmental and rehabilitation optometrists and vision therapists from around Michigan, Illinois and Indiana met for the Annual Michigan Vision Therapy Study Group on January 22-23, 2016 and this year conducted at the Michigan College of Optometry at Ferris State University. The theme of the meeting was dedicated to the Role of Vision and Attention.

Because this is  a prevailing patient issue for not only our practice but for optometric vision therapy offices worldwide, our lecture addressed Understanding ADHD and the research connection of treatable vision problems in ADHD and using advanced VT techniques for targeting ADHD behaviors. Click here for an abridged version with featured content.

To be clear, the behaviors found with ADHD are often due to multiple factors. As a result the best approach to ADHD should involve a multidisciplinary approach, including developmental optometry for effective management. But, how long will it take before the role  of vision development is considered to be a priority in the assessment a child with ADHD? Only time will tell…but only with knowledge and understanding comes empathy and action.

Please join with us and be a part of the VisionHelp mission to help end the senseless struggle. Vision based ADHD behaviors can be effectively treated but only if properly identified and treated. You can help “sustain the focus” for children when you share this post with others. Thank you!

Dan L. Fortenbacher, O.D., FCOVD

Hyperopia/ADHD: You Make The Call – Part 2

Two very good responses so far to the case in Part 1, both very reasonable approaches in light of the information I presented.  Dr. Dominick Maino wrote:

I’d give him the dry with the cyl and up to a +2.00 add. Once he adjusts to the specs…I’d increase the +. May also recommend VT depending upon how the vision system responds to the specs.

Dr. Charles Boulet wrote:  “What the child needs is an adequate Rx for full-time wear, and perhaps we can discuss what the Rx ought to be. Since this sort of Rx also wreaks havoc on accommodation and vergence, I would advise general VT to ensure these are normalized.”

A little more background about Brayden.  He is a very intelligent child, but also “all over the place” in the vernacular.  He was inquisitive about everything going on during the examination, almost to a fault.  (Can curiosity ever be “unhealthy”?) Although terribly apprehensive about the drops I put in his eyes, he was endlessly fascinated by the blur.

When repeating auto-refraction under cycloplegia, encouraging Brayden to keep his eye as steady as he could on the beautiful hot air balloon at the end of the road, I told him what a great job he was doing and that I could see exactly where his eye was looking.  He  ran around to my side and was disappointed that he couldn’t see his eye on the screen.  I pulled out my “eye phone” and told him that if he held his head and eye steady on the balloon, I could take a picture of what his eye looked like, and that pleased him considerably.

What I didn’t share in Part 1, in the report from the OT, is that Brayden’s diet centers heavily on fast food items.  We know that nutritional factors can play a significant role in development, and I will mention in a tactful way to his parents.

So I’m in full agreement with Drs. Maino & Boulet that we need to Rx something for Brayden, but what?  There is a strong school of thought as Dr. Maino notes that we can Rx the manifest finding and make up the difference in latent hyperopia on cycloplegia in the add value.  Might there be reservations in prescribing a multifocal Rx to a child who is easily distracted?

Brayden’s parents will be returning for a conference next week, and I will lay out both Rx options.  The good news here is that I really don’t think one is right and one is wrong – there is wiggle room.  I’m leaning toward full time wear of the single vision Rx, but I have a week to change my mind.  I also believe vision therapy is indicated, and that we can help Brayden improve his visual focus and binocular control which will in term aid his overall control of attention.  One could make an argument for incorporating prism in his Rx, as seems to be quite in vogue these days, yoked or otherwise, but the “KISS” principle seems reasonable in nudging the obvious accommodative/vergence issue with plus lenses and to respect that the WR cylinder isn’t going to disappear and might be additive to the mild bilaterally amblyogenic hyperopia.  So I won’t incorporate prism at this point, but I still have the week to change my mind.  But if the conference were done “chairside”, and I had to Rx on the spot, it would be single vision manifest, no add, and no prism — get the Rx first, and then begin VT, with the proviso that indications for an add and/or prism will be revisited during each progress evaluation.

 

Hyperopia/ADHD: You Make The Call

Those of you who are optometrists reading this will recall your student days when a clinical instructor presented a topic by saying: “I just had a case like this come in to my office yesterday …”  Well as coincidence would have it (as David Cook might add, or not …) I had a 5 year-old in the office this afternoon who exemplified the two most recent blog topics, hyperopia/literacy and ADHD.  A little background first, and you can cobble together the essentials from three key passages I’ve extracted from the referring OT’s nine page report:

Some key findings (all unaided):

VA: OD = 20/40- and OS = 20/40- at distance and near

Randot Forms:  Correct >/= 250 seconds of arc

Keystone Visual Skills: Distance fusion with esophoria/ Near diplopia high esophoria

Cheiroscopic Tracing significant eso shift

 

Manifest Open View Autorefractor Distance and Near:

Closed View Autorefractor 1% Cyclpentolate after 15 minutes:

Best Visual Acuities With Tentative Rx:

Manifest (“Dry”) OD: +1.75-1.00 cx 180 = 20/30-  and OS: +1.25-1.00 cx 180 = 20/30-

Cycloplegic (“Wet”) OD and OS +2.50 – 1.50 cx 180 = 20/25-

One more tidbit.  Brayden has an older brother who has accommodative esotropia.  The same pediatric ophthalmologist who Rxed glasses for his brother (single vision) saw Brayden 5 months ago, and said that everything was fine, and no Rx or other intervention was necessary at that time.

What’s your call?

 

Does ADHD Exist? (Redux)

On a recent post on the Doc-L Listserv, Dr. Tod Davis recommended a book by Richard Saul, a pediatric neurologist based in North Suburban Chicago, entitled: “ADHD Does Not Exist“.  We blogged about this two years ago, but it is worth re-visiting.  When you listen to Dr. Saul interviewed about this, he qualifies the title by stating that the symptoms attributed to ADHD are very real, but often attributable to other causes rather than to ADHD as a unique disease entity.  He also acknowledges that there is a small subset of these children who really do need medication to orient their attention – but that’s only about 5% of the children who are actually taking medication once the underlying causes have been properly tested for and addressed.

At the 6 minute mark of this interview, the host asks Dr. Saul for the other conditions that can causes symptoms, and he replies beginning with the most common misdiagnoses, which are vision and hearing problems.  The host replies, “Well that just seems painfully obvious, Dr. Saul … If you have vision or hearing problems, you’re not going to be engaged.”

I like the way his chapter on Vision Problems (in which he includes binocular vision problems) begins with The Big Point as follows:

“Problems related to vision among the most overlooked explanations for attention-deficit/hyperactivity symptoms.  Children (and adults) who struggle to see normally are likely to demonstrate short attention span and distractability that may be mistaken as symptoms of ADHD.  Steps taken to address the vision problem should resolve the attention/hyperactivity symptoms.”

Our VisionHelp colleague Dr. Carole Hong and I addressed this in detail, in an article published in 2009, but it is always welcome news to see this concept in print from a pediatric neurologist.

More On ADHD and Vergence

Last September, our colleague Dr. Dan Fortenbacher blogged eloquently about why all children with ADD/ADHD or adverse academic behaviors should have a a binocular vision evaluation.  A research article published in PLOS One last month, Attention-Related Eye Vergence Measured in Children with Attention Deficit Hyperactivity Disorder by Puig and colleagues in Barcelona, bolsters this position.

The nature of the study has some resemblance to the T.O.V.A. (Test of Variables of Attention) in that computerized stimuli were used with the subjects pressing a button to indicate their response.  In this story, the experimental setup has the advantage of monitoring vergence angle and eye positions with minimal apparatus – an important consideration for children whose attention is easily drawn away from the task.  While fixating a center cross, subjects indicated covert attention to face targets, with their gaze monitored objectively by a Tobii Eye Tracker built into the computer so that nothing distracting was on their face or in front of their eyes.  The authors had previously published about successful use of this methodology in studying attention and vergence in adults.  This study compared children diagnosed with ADHD to a control group of children who did not have that diagnosis.

From the current article, here is a schematic of the vergence and task design.

The authors report that they observed a strong modulation in the angle of vergence and a difference between the cue conditions in the control group. However in the ADHD group a weak modulation in the angle of vergence was observed and no difference between the cue conditions was detected.

In discussing the clinical relevance of their findings, the authors note that because attention related vergence differs between controls and children with ADHD, evaluation of vergence during an attention task may be useful for the development of an observer independent tool for the diagnosis of ADHD.  They write:  “Furthermore, for people with binocular deficits, vision therapy increases the eyes’ convergence ability with eye-focusing exercises. Typically, these exercises include simple ‘pencil pushups’, computer vision therapy, or glasses with built-in prisms. It will be interesting to examine whether attention related vergence can be improved by vision therapy that employs purposed designed visual tests.”

Although Puig and colleagues are apparently not familiar with the breadth of vision therapy for CI beyond pencil pushups, computer vision therapy, or prism glasses, as employed for example in the CITT, their research supports a burgeoning worldwide interest in the interrelationships between vergence and ADHD.  This takes us to the doorstep of the CITT-ART, the design of which was recently introduced in Vision Development and Rehabilitation.  From a variety of angles, including performance in school, bringing attention to the interrelationships between vergence and ADHD stands to convert alot of sad and neutral faces to happy faces.

 

Why all children with ADD/ADHD or adverse academic behaviors should have a binocular vision examination

This article was written to provide parents with authoritative information, based on scholarly research, about a relatively common vision problem  that often causes ADD-like behaviors and adverse academic performance. In addition, this post will emphasize the importance of finding a primary care optometrist (as well as specialty trained optometrists) who can perform the vision tests, diagnose and properly manage the condition to end the senseless struggle. So let’s begin…

When you look into the eyes of your child, you see two beautiful eyes looking back.  And if your child struggles with reading fluency, poor attention and concentration behaviors and/or if homework is a battle, you have probably looked them square in the eyes and thought – WHY?  Why does my child struggle so hard? It can be frustrating and emotionally upsetting for you, your child and your entire family.

So, you begin looking for answers and after trips to the pediatrician, you are told it’s all because of ADD/ADHD, Attention Deficit Disorder and your child is prescribed Ritalin or other psychostimulant medication. The regimen of taking the pills begins, but there often are side effects to the medication so you go back to the doctor and try a different drug or adjust the dosage. Your child’s attention improves because of the psychoactive process of the drug. But too often the adverse academic problems still persist and naturally you’re concerned about the long term consequences of giving your child psychostimulant drugs. So now what do you do?! Is there some other rational explanation for their problems besides the need to take drugs to concentrate? You look again into your child eyes and wonder, could it be their eyes!?

 

 

 

The answer to this question is yes! The scientific literature from the National Institutes of Health (NIH), National Eye Institute research shows the existence of a specific and recognizable vision problem that is directly linked to ADD/ADHD and academic problems. The condition, known as Convergence Insufficiency (CI), is a disorder of binocular eye coordination while looking at near. Convergence Insufficiency (CI) occurs in 1 in 20 children. Furthermore, while CI is easily recognizable with a binocular vision evaluation, it can be easily overlooked if the eye doctor does not run the necessary binocular vision tests to detect the condition. But wait, aren’t all eye doctors trained to do these tests?  Yes, all primary care optometrists in the US and Canada are taught how to test binocular vision.

However,  it’s important to know that not all eye doctors, optometrists or ophthalmologists, take the time to routinely evaluate a patient’s binocular vision unless they have sufficient reason to suspect a problem in this area.  So what can a parent  do to make sure their child’s eye doctor is very aware of these concerns and performs a binocular vision evaluation?

Here are 3 easy steps you can do:

1. First, begin with clearly informing the doctor about your concerns. The VisionHelp Group recommends all primary eye care offices have the patient complete the Vision and Learning Checklist  shown here. You can print it out, complete the 10 questions and give to your child’s eye doctor.
2. Second, let your doctor know you are aware of the research by handing him/her a printed copy of the NIH paper entitled: Academic Behaviors in Children with Convergence Insufficiency with and without Parent-Reported ADHD
3. Third, let your doctor know you are interested in a binocular vision evaluation to rule out Convergence Insufficiency.

Even more important, if your child is diagnosed with Convergence Insufficiency, the research shows how office-based optometric therapy will result in Improvement in Academic Behaviors Following Successful Treatment of Convergence Insufficiency

As a Past President of the College of Optometrists in Vision Development (COVD), I’m a strong proponent of seeking out a doctor who is in the process of, or has completed their Board Certification in Developmental Vision and Rehabilitation – FCOVD. This is especially true from the treatment side of binocular vision problems. But, if your primary care eye doctor is proactive, referring their patients with Convergence Insufficiency for the best care, then they will usually know who are the best doctors in your area/region providing vision therapy.

Finally, if this information was helpful to you, your child or grandchild, please help us touch more lives and end the senseless struggle by sharing this post. Thank you!

Dan L. Fortenbacher, O.D., FCOVD

ADD/ADHD…the vision connection and the drug-free treatment of choice

Why do some health care plans cover a life-time supply of psycho-stimulant medication for ADD/ADHD but deny patients coverage for the vision development and rehabilitative therapy that will correct the cause of the ADD-like behaviors rendering the patient medication free?

Let’s get right to the point. There are 2 highly recognized diagnoses of the visual system that routinely result in ADD/ADHD behaviors.

The first is known as Convergence Insufficiency

The second is known as Accommodative Disorder

Dr. Press and I have written about both of these visual entities extensively on the VisionHelp Blog and for more information just click on the “linked” words above.

Furthermore, there is sufficient clinical trial research to show that both of these conditions are successfully treated with office-based vision therapy as outlined in the links.

So why write a post that is a rehash of what has been written before? Like many of my posts, this one was inspired by a patient. The scenario presented to me last Friday. One of our patients, a 13 year old girl with a serious convergence insufficiency in conjunction with an accommodative disorder and struggling with classic ADD-like behaviors plus headaches and fatigue with reading. Her PCP diagnosed her with ADHD and tried a variety of medications but nearly all, especially the stimulant medications gave her many negative side effects and did not address her visual dysfunctions.  Yet, her health insurance is saying “yes” to the drugs but “no” to treating the sensory motor dysfunction of her visual system with vision therapy!

Why would a health insurance policy cover the patient with ADD/ADHD medications but to deny treatment for the very thing that is causing the ADD/ADHD behaviors- Convergence Insufficiency and Accommodative Disorder? Well possibly it is because they just do not have the current research and therefore the facts are needed to set the record straight.

To this I’m responding on behalf of our patient with an appeal that will include the research that provides substantial evidence for supporting this patient’s treatment. But, knowing that if this is happening to our patient, it is also happening to others around the country, I’m providing the following peer reviewed scholarly research papers in this post to help others who may be experiencing the same problem. Here are 3 papers to provide the research documentation to support the necessary treatment.

Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency

Accommodative Insufficiency Is the Primary Source of Symptoms in Children Diagnosed With Convergence Insufficiency

Academic Behaviors in Children with Convergence Insufficiency with and without Parent-Reported ADHD

Yes, it is important to recognize that not all ADD/ADHD is caused by a visual problem, and with that understanding, there clearly can be a place for psychostimulant medications for those individuals with a biochemical cause for their symptoms. However, it is absolutely critical to the health and well being of those with a visual problem such as convergence insufficiency and/or accommodative disorder not to be mistaken for ADD/ADHD and obtain the proper “drug-free” office-based vision therapy treatment to correct the underlying cause of the problem.

Dan L. Fortenbacher, O.D., FCOVD

NCLD on Visual Scanning in Dyslexia & ADHD

You may recall an interview on vision and LD that I did awhile back with the pediatrician, Dr. Debbie Walhof, posted on the NCLD website.  I received an interesting email this evening from NCLD with the subject line “See What Your Child Sees”.  I was hoping it had something to do with vision.  Sure enough, here’s what the body of the message reads:

“Ever wonder what your child face on a daily basis?  Everyday tasks like scanning letters or numbers can be maddening for people with learning and attention issues, like LD and ADHD.  We’ve put together a few exercises to help you better understand what your child sees.”

Take a look at the examples provided in this piece written by the NCLD editorial team.  They all relate to visual scanning or visual search.  The first one asks you to find the two Bs in this array:

The second one asks you to find the letter N in this array:

The third one asks you to find the number 1 in this array:

We’ve alluded to visual search and serial scanning as key readiness skills for reading in this blog before.  Aside from the workbooks mentioned, or visual scanning worksheets in open source such as here, there are computer programs we use regularly in vision therapy for these purposes.  Examples include home therapy procedures in Vision Builder available through OEPF, and the in-office procedures in CPT from Dr. Sidney Groffman.