by Sharon S. Lehman, M.D., FAAP, and
Kenneth W. Norwood Jr., M.D., FAAP
Many children with neurodevelopmental disabilities
such as cerebral palsy and spina bifida have deficits in
their senses, with vision impairment perhaps being the
most limiting to successful participation in life.
Several studies have found that vision care represents
one of the greatest unmet needs for children with special health care needs. In addition, infants and toddlers who are socially at risk with functional vision
difficulties make up one of the highest subgroups of
Examination of the eyes is a routine part of a well-child check. Thus, pediatricians are in a unique position to detect vision impairment in children with
neurodevelopmental disabilities and ensure that appropriate referrals and intervention occur and classroom
accommodations are made.
In January 2016, the Academy published a clinical
report and policy statement that provide guidance on
how to evaluate and when to refer children for full ophthalmologic evaluation (see resources). The documents,
issued along with the American Association of Certified
Orthoptists, the American Association for Pediatric
Ophthalmology and Strabismus, and the American
Academy of Ophthalmology, emphasize that ocular
problems can be the initial manifestation of systemic
or neurologic disease such as retinoblastoma or neuroblastoma in addition to identifying vision-threatening
Taking a history
Obtaining a history eliciting parental concerns and
family history is essential. As discussed in the policy,
identification of a family history of serious eye disorders such as retinoblastoma, childhood cataracts or
glaucoma, strabismus and amblyopia are indications
for evaluation by an ophthalmologist experienced in
the care of children. Parental concerns about vision also
are an indication for full ophthalmologic evaluation.
It is important to ask specifically about vision con-
cerns when obtaining a history about a child with
complex medical problems. The family may be more
focused on concerns about respiratory or neurologic
problems and forget to bring up vision issues, or they
may have a misconception that nothing can be done to
help their child use his or her vision more effectively.
Overcoming screening challenges
It is possible for pediatricians to screen children with
neurodevelopmental disabilities for vision problems,
but it may be challenging due to cognitive impairment,
processing delays, inability to cooperate, multiple sensory deficits and expressive language delay. The screening may need to be adjusted and may take more time,
for instance in children with cortical visual impairment
who display latency due to a delayed response because
of extra time needed for processing and responding to
the visual stimuli.
It is important to match the screening technique to
the developmental age of the child instead of chrono-
logic age. Interesting toys and charts with pictures or
symbols may be used for acuity testing. The rec-
ommended charts for younger children are those
with Lea symbols or HOTV (limited number
of symmetric letters). Providing the child with
matching cards can be helpful in obtaining co-
operation when testing acuity. Using critical line
testing instead of threshold line testing as dis-
cussed in the 2016 clinical report takes less time
and may be particularly helpful in children with
Instrument-based screening which identifies
refractive and structural risk factors for amblyopia
also can be used to screen a child who is nonverbal
or cannot cooperate for recognition acuity. This
technique is quick, and noncontact and distrac-
tion techniques can be used to obtain cooperation. It
requires less sustained attention from the child.
The physical exam of the eye looking at the alignment,
eyelid position and anterior and posterior aspect (red
reflex) also should be performed. If the recommended
vision screening cannot be performed or abnormalities
are found on physical examination, the child should be
referred for full ophthalmologic evaluation.
Pediatricians should have a low threshold for sending
a child with a neurodevelopmental disability for full
ophthalmologic evaluation if there are any concerns
about vision or if the child has a medical condition in
which there is a significant risk of ocular abnormalities
or visual conditions.
Complex neurodevelopmental disability is among
the conditions where evaluation by a pediatric ophthalmologist or eye care specialist appropriately trained
to treat pediatric patients is necessary because of the
risk of significant visual disability affecting the child’s
ability to learn and reach his or her potential.
Dr. Lehman is immediate past chair of the AAP
Section on Ophthalmology
Executive Committee. Dr.
Norwood is chair of the
AAP Council on Children
with Disabilities Executive
Dr. Lehman Dr. Norwood
by Cora C. Breuner, M.D., M.P.H., FAAP
It’s the end of a long week. You have a sports physical
to perform on a teen who has been your patient since
she was a baby. It should be a snap, right? Maybe.
Many screening tools are available to facilitate an
efficient and productive health care appointment, including HEEADSSS, CRAFFT and preparticipation
physical exam (see resources). Do these screens help
doctors streamline their interviews and tailor interventions to problems uncovered when screening?
The answer is a soft yes, but only when providers can
respond to positive answers to the screening questions
with appropriate referrals and/or interventions to help
address teens’ concerns in a healthy and proactive manner.
AAP Bright Futures recommends a strength-based
approach to screening and counseling around behaviors that lead to mortality and morbidity in adolescents. However, only 39% of adolescents received any
type of preventive counseling during ambulatory visits,
according to the National Ambulatory Medical Care
Survey and the National Hospital Ambulatory Medical
Care Survey. While 71% of teenagers reported at least
one potential health risk, only 37% of them reported
discussing any of these risks with their pediatrician or
primary care provider. For example, suicide is the third
leading cause of death in adolescents and young adults,
resulting in approximately 4,600 deaths per year. Clearly, screening for and counseling around these high-risk
behaviors need to be improved.
The HEEADSSS screen is one option, covering issues related to Home, Education/Employment, Eating,
Activities, Drugs, Sexuality, Suicide and Safety. When
a pediatrician uses the HEEADSSS screen, questions
that are easier to answer flow nicely from the beginning
of the interview into those that may be more difficult
to answer later on.
The order in which questions are asked may be
changed based on the greatest area of concern for the
adolescent; some teens have a tougher home environment than others, so home questions may be asked
later in the interview.
Importantly, it is unreasonable to expect an adolescent to discuss sensitive and personal information
unless confidentiality can be assured. Pediatricians
Screen children with neurodevelopmental disabilities for vision problems
The other ‘screen’ time: Make the most of adolescent health care visits
See Screening, page 13
• AAP clinical report Procedures for the Evaluation of
the Visual System by Pediatricians, http://pediatrics.
• AAP policy statement Visual System Assessment in
Infants, Children, and Young Adults by Pediatricians,