Seeing the Future – Children's Vision Report (2014) by Marshall B. Ketchum University

Seeing the Future Childrenâ&#x20AC;&#x2122;s Vision Report Orange County, California 2014

Prepared by: Morris Berman, O.D., M.S. Lynn Lowell, O.D.

When you consider that vision is responsible for about 80% of what a child learns, it becomes apparent that if we maximize a child’s ability to see clearly and comfortably, then we have gone a long way toward maximizing that child’s potential. The sooner we uncover and correct vision problems, the better start children will have in school. And we can do just that through vision screenings and comprehensive eye exams. However, not all children are receiving the care that is accessible to them, resulting in a gap between a child’s potential and his or her performance in school. What we present to you is a report on the state of children’s vision in Orange County. In this inaugural report, we take a look at the data regarding our children right here in Orange County, as well as the impact vision problems may have on a child’s ability to learn. We discuss the barriers that are preventing our children from receiving the vision care they need and some steps already taken in the United States, California and in Orange County to make pediatric vision care more accessible. We also suggest further measures we must continue to take in order to address this crucial need. All members of the Orange County community share in the responsibility for providing intervention when a child is unable to learn effectively due to poor vision. As involved members of this community, Marshall B. Ketchum University is committed to addressing the unmet need for vision care for children through our school screening programs, our mobile eye care van, "Eye Force One," and comprehensive vision exams at our Southern California College of Optometry. I now invite you to consider the following report and challenge you to join us in making sure that every child in Orange County is vision ready to learn and succeed. Together, we can make a difference in the future of each of these children.

Kevin Alexander, O.D., Ph.D. University President

Marshall B. Ketchum University | Southern California College of Optometry

TABLE OF CONTENTS A look at children in Orange County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Importance of eye health to childrenâ&#x20AC;&#x2122;s education . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Recommended care for childrenâ&#x20AC;&#x2122;s vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Overcoming barriers to children receiving care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Marshall B. Ketchum University | Southern California College of Optometry

A Look At Children In Orange County

In 2012, the recorded population in Orange County, California was 3,071,933, ranking it the third most populous county in the state, after Los Angeles and San Diego Counties.

Orange County at a Glance • 34 incorporated cities

• 947.98 square miles area of land and water The population growth of Orange County has been explosive and this has resulted in the land being • 6th most populous county in the United States transformed from industrial farm use to suburban development with independent cities, industry and • 2nd most densely populated county in the state the supporting infrastructure, including school of California districts, colleges and research universities. The attraction of Orange County has resulted in a major population increase that reflects ethnic diversity. The population is projected to increase to 3,198,279 by 2020 and reach 3,286,100 by the year 2030. During this period, the ethnic diversity is projected to show increases in Hispanics (38.6%) and Asians (19.4%) with a decrease in Whites (36.7%) by the year 2030.

Race/Ethnicity Distribution of Orange County 2.80% 1.60%

43.30%

18.00% White Hispanic Asian

34.30%

African American Other Above statistics obtained from the 2013 Orange County Community Health Profile1

Marshall B. Ketchum University | Southern California College of Optometry

Children in Orange County The distribution by age group in Orange County includes 724,976 (23.6%) of the population below age 17 years in 2012, which is projected to decrease slightly to 22% by the year 2030. The decrease is associated with a 15% decline in the birth rate over the past 10 years. It is anticipated that the school age population will remain relatively stable over the

next 20 years and these projections are important from an educational planning perspective. By contrast, the county population of seniors (65+ years), which was 12.3% in 2012, will increase to 20.4% by the year 2030. This change can be attributed to longevity as a result of improved health care and healthier living habits.

Above statistics obtained from the 2013 Orange County Community Health Profile15

K-12 Public School Enrollment According to the California Department of Education's Data Reporting Office, 500,487 students (K-12) were enrolled in Orange County public schools in 2013-14.2 For Orange County, public school enrollment rose sharply each year from 1996 through 2004, then slightly decreased through 2007 and has been relatively level over the past seven years. Orange County is composed of 28 school districts. Santa Ana Unified is the largest public school district in Orange County with 57,499 students enrolled, followed by Capistrano Unified (53,833 students), Garden Grove Unified (46,936 students), Anaheim Union High (31,889 students) and Irvine Unified School District (30,123 students). The smallest school district in Orange County is Savanna Elementary School District (2,433 students).3

Marshall B. Ketchum University | Southern California College of Optometry

Orange County Public School Enrollment Trend 520,000

K-12 Enrollment

500,000 480,000 460,000 440,000 420,000

2013-14

2012-13

2011-12

2010-11

2009-10

2008-09

2007-08

2006-07

2005-06

2004-05

2003-04

2002-03

2001-02

2000-01

1999-00

1998-99

1997-98

1996-97

400,000

School Year Above statistics obtained from the California Department of Education, Data Reporting Office2

Race/Ethnicity Distribution of Orange County Total Student Enrollment 0.40% 1.50%

Hispanic or Latino White

17.30%

Asian, Pacific Islander, or Filipino Black or African American American Indian or Alaskan Native

3.30%

48.70% 28.80%

Other (Multi-racial or Other Race and Ethnicity)

Above statistics obtained from the Report on the Conditions of Children in Orange County, 20144

Marshall B. Ketchum University | Southern California College of Optometry

Looking specifically at the Santa Ana Unified School District, 47.8% of the students are English Learners, 88.1% are a part of the Free/Reduced Meal Program, 96.6% of the students are minorities and the largest ethnic group is Hispanic or Latino.3

Profile of Children in Orange County 2010-2014 • Approx. 24% of the population is children • 6.9% of children are uninsured • 18% of children are living in poverty • 50% of students are a part of the Free/ Reduced Meal Program

Prevalence of Vision Problems in Preschool and School-aged Children

• 7.3% High school dropout rate • 2.46% Juvenile arrests

Source: Report on the Conditions of Children in Orange County, 20144

Nationwide, vision disorders are a common pediatric health problem affecting both preschool (ages 3 to 5 years old) and school-aged children (ages 6 to 18 years old). Some of the major visual conditions affecting children include strabismus (eye turn), amblyopia (lazy eye) and significant refractive error including: hyperopia (far-sightedness), myopia (nearsightedness) and astigmatism.

Riverside and Los Angeles Counties was investigated in a series of studies, the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS). These studies showed the below percentages of visual conditions for preschoolaged children (ages 36 to 59 months).5,6,7,8,9 For the purpose of this report, significant hyperopia was considered +3.00 D and higher, since hyperopia of 3.00 D and upwards was found to be a risk factor for esotropia in the Risk Factors Associated with Specifically looking at Southern California, the Childhood Strabismus study conducted by the prevalence of these visual conditions in children ages MEPEDS group.10 6 to 72 months from 4 racial/ethnic groups in the

Marshall B. Ketchum University | Southern California College of Optometry

1.81% 2.68% 2.05% 1.33% 2.05%

Amblyopia (Any Type)

3.04% 3.27% 4.27% 4.01% 3.50%

Strabismus (Any Type)

7.51% 5.73% 9.91%

4.81% 1.67% 4.11% 1.39% 3.07%

9.26%

Astigmatism (>1.50 D)

Hyperopia (+3 to +5 D)

Myopia (-1 to -4 D)

5.72% 9.72% 10.52%

10%

10.83% 13.12%

15%

14.05%

Percentage of Significant Refractive Error, Strabismus and Amblyopia in Preschool Children in Riverside and Los Angeles Counties:

African-American Hispanic Asian Non-Hispanic White Total

Equivalent studies were performed by The Baltimore Pediatric Eye Disease Group. Interestingly, the prevalence of refractive error, strabismus and amblyopia was similar in Baltimore, Maryland.11,12

From these studies, one could infer that nationwide the percentage of preschool children with potential vision problems is at minimum 13.59% based on hyperopic and myopic refractive error alone.

Number of Estimated Children under 18 years old with Vision Problems in the United States 50,000,000 45,000,000 9,268,399

40,000,000

Number of Children

35,000,000 30,000,000 25,000,000 20,000,000

2,781,532

15,000,000 10,000,000

37,073,596 TOTAL

19,868,088 TOTAL

4,161,047

16,644,188 TOTAL

5,000,000

Approximate Number of Children with Vision Problems 2013 U.S. Census Population Estimates

0 Under 5 years

5 to 13 years

14 to 17 years

Age of Children

In regards to school-aged children, it is estimated that nearly 25% have these same visual conditions.13,14,15,16,17 According to the U.S. Census in 2013, there are 73,585,872 children in the United States under the age of 18 with 19,868,088 under 5 years old.18 Extrapolating this data further with an estimation of 14% of preschool children and 25% of school-aged children having vision problems, that is approximately 2.8 million preschool children and 13.4 million school-aged children with vision problems here in the United States. 8

Marshall B. Ketchum University | Southern California College of Optometry

Children with Vision Problems in Orange County Estimating that 14% of preschool children5-12 and 25% of school-aged children13-17 have vision problems, the following data can be extrapolated based on the US Census 2013 populations estimate.19 â&#x20AC;˘ Orange County Population: 3,114,363 -- Persons under 5 years old: 6.1% -- Persons under 18 years old: 23.3% -- Persons between 5 and 18 years old: 17.2% Altogether there are approximately 160,000 children in Orange County estimated to have vision problems.

Marshall B. Ketchum University | Southern California College of Optometry

Number of Estimated Children under 18 years old with Vision Problems in Orange County, CA 800,000

Number of Children

700,000 600,000

133,917

500,000 400,000 300,000 200,000

26,596

100,000

189,976 TOTAL

535,670 TOTAL

Approximate Number of Children with Vision Problems 2013 U.S. Census Population Estimates for Orange County, CA

0 5 to 13 years

14 to 17 years

Age of Children

Marshall B. Ketchum University | Southern California College of Optometry

Importance of Eye Health To Childrenâ&#x20AC;&#x2122;s Education Vision's Effect on Learning The topic of vision and learning is currently of great interest and an area in which more clinical research is needed. It is estimated that 1 in 4-5 school-aged children have visual problems.20,21,22 Uncorrected refractive error, specifically hyperopia, has been shown to adversely affect standardized measures of literacy,23 reading abilities,24 standardized reading test scores22 and the percentile ranking on such tests as the Iowa Test of Basic Skills.25

Additionally, uncorrected hyperopia was investigated in 4-7 year olds and showed to adversely affect these childrenâ&#x20AC;&#x2122;s emergent literacy skills including letter and word recognition as well as vocabulary.26 With uncorrected hyperopia, distant objects need to be brought into focus by the visual system in order to be seen clearly and near objects (such as words on a page) require even more focusing to be seen clearly, so this excess physical work of the visual system may be the reason for these findings.

Marshall B. Ketchum University | Southern California College of Optometry

Vision is more than 20/20 Vision is an all-encompassing term. When most people hear the word vision, they generally just think of one aspect of the visual system – eyesight. Eyesight is how well a person can see on the eye chart, i.e. 20/20. Vision, however, is composed of not only the central vision (eyesight) and side vision (peripheral vision), but also such visual skills as how the eyes work together as a team (binocular vision system) and how a person interprets, analyzes and remembers the information obtained visually (visual information processing/ visual perception). Visual perceptual skills also include how well a person can coordinate the various sensory systems with vision, i.e. eye-hand coordination (also known as visual motor integration). The visual system is a complex neuro-muscular system, meaning it is a neurological system since the brain contains the visual pathway in which vision is processed.27 Additionally the visual system has a muscular component with each eye containing seven muscles (including the iris which controls the focusing system). These muscles need to be well coordinated between the two eyes and are responsible for visual efficiency skills including: visual teaming system (3D vision/depth perception/binocular vision), visual tracking system (moving both eyes in the same direction at the same time, i.e. moving the eyes left to right when reading) and visual focusing system (maintaining clear vision, similar to how a lens in a camera can bring a picture into focus). Convergence Insufficiency is a well-studied and common visual teaming disorder in which the eyes have difficulty coordinating for near point activities • Visual tracking • Visual spatial skills such as reading a book or working on the computer. • Visual teaming • Visual analysis skills • Visual focusing • Visual motor integration This condition is typically associated with the following symptoms with reading: headaches, blurred vision, double vision, sleepiness, trouble concentrating, the appearance of words moving on a page and decreased comprehension after short periods of reading.28,29,30,31,32,33,34,35,36,37 Visual Efficiency Skills

Visual Perceptual Skills

Below are some demonstrations of the visual efficiency disorders:

Visual Teaming problems such as a Convergence Insufficiency can lead to double vision which appears as shadowy or blurry vison while reading. Visual Tracking consist of problems continually one's place a difficult time since the eyes are having

moving

losing

while reading

smoothly.

across the page

Marshall B. Ketchum University | Southern California College of Optometry

Visual efficiency skills have been associated with reading and spelling ability.38,39 Along with poor teaming skills discussed previously, inefficient visual tracking or focusing skills have been suggested as a risk factor for decreased reading ability.40,41,42 Additionally there have been associations with visual perceptual skills and reading, math, spelling, writing and standardized test scores.43,44,45,46 Difficulty with reading can have multiple causes; therefore treatment is best with a multidisciplinary approach. If vision problems including refractive error, strabismus, amblyopia, visual efficiency or visual perceptual deficits are contributing to difficulty with reading, then eye care professionals can address these deficits with glasses and/or vision therapy.

Societal Impact of Uncorrected Vision Problems The article Vision and the Achievement Gap Among Urban Minority Youth focuses on the academic implications of uncorrected vision problems. The article states that â&#x20AC;&#x153;vision problems cannot be overcome by simply trying harder, but need to be addressed with timely and appropriate treatment. A likely outcome for children demoralized by ongoing struggle coupled with lack of academic success is disengagement from school."47 Studies have shown that vision problems have been seen in up to 74% of juvenile offenders.48,49 Nationwide it has been shown that 40% to 67% of children identified with a vision problem from a school-based vision screening do not obtain the recommended professional eye care. 50,51,52,53 Comprehensive eye examinations are needed to address uncorrected visual conditions. Marshall B. Ketchum University | Southern California College of Optometry

Recommended Care for Children's Vision Much like a well-baby visit, the American Optometric Association recommends that a child should have their first comprehensive eye exam within the first year of life. Science has shown that the visual system has a critical phase of development during childhood; therefore, the earlier a vision problem is detected and treated through a comprehensive eye exam, the more likely the treatment will be successful and benefit the child. Comprehensive eye examinations differ from a vision screening since an exam not only determines how clearly a child sees, but also evaluates eye movement and eye coordination, as well as the health of the eyes. A vision screening does not substitute for an examination. Additionally, passing a vision screening does not mean that there are no vision problems, since a vision screening is limited and does not test all elements of vision. Children with special needs and those children who are unable to be tested at a vision screening should be referred for professional eye care.54 With school-aged children, it has been stated that as much as 80% of the learning a child does in school occurs through their eyes. This is why it is important that children have their eyes examined before they enter school, to make sure their eyes are ready for the rigors of school. Common symptoms that may indicate that a child has a vision problem that is interfering with reading and learning may include losing place or skipping words when reading, difficulty with copying tasks, blurred vision, double vision and slow reading. Research such as the Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children has shown that problems with eye coordination are common in students and can be improved with such treatments as vision therapy.28 Overall, early detection and treatment of eye health and vision problems for children should be a major public health goal.

Marshall B. Ketchum University | Southern California College of Optometry

Children’s Vision Examinations and Screenings The American Public Health Association and the American Optometric Association recommend routine eye examinations at suggested intervals. However, the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus recommend that while children who fail vision screenings should have a follow-up eye exam, routine eye examinations for children with no abnormal symptoms have no medical benefit.55 The Optometric Clinical Practice Guidelines set forth by the American Optometric Association recommend comprehensive pediatric eye exams at the following intervals: 6 months of age, 3 years of age, 5 years of age and then every 2 years thereafter if there are no risk factors for visual problems. If there are risk factors for vision problems then annual comprehensive eye exams are recommended.56

The 19th Annual Report on the Conditions of Children in Orange County (2013) gives attention to children’s vision. The report describes factors that contribute to children’s vision issues, the need for early vision screenings and the impact of children’s vision issues. The conclusion reached in this report is that “vision screening(s) are an efficient and cost-effective method to identify children with visual impairment or eye conditions that are likely to lead to visual impairment so that a referral can be made to an appropriate eye care professional for further evaluation and treatment.”57 The Children and Families Commission of Orange County also issued a report in 2013 that details the initiatives related to promoting health, education and support systems to provide the development of young children. While stating that vision screenings can detect the most common vision problems, the issue is that only approximately 40% of the preschool-age group in California has received a vision screening.58

Marshall B. Ketchum University | Southern California College of Optometry

Estimated Prevalence of Vision Screening for Preschool Children in Orange County, 2012

117,586 60%

77,092 40%

Do receive vision screening Do not receive vision screening

Above statistics obtained from The Children and Families Commission of Orange County58

Currently the Children and Families Commission of Orange County is working with several partners to help increase access to vision screenings for preschool children, along with a triage system for those children identified with vision problems to receive professional eye care from an optometrist or ophthalmologist.

Marshall B. Ketchum University | Southern California College of Optometry

School Vision Screening and Exam Requirements in the United States The requirements for vision care differs state by state. A majority of the states require school vision screenings for various grades. Only a few states either have: no requirements, eye exam requirements or eye exam and vision screening requirements (see below).59

School Vision Screening and Exam Requirements in the United States ME

WA VT

OR ID

SD WY

VA NC

AR MS

RI CT

KY TN

NH MA NJ

LA FL

Vision Screening Required

Eye Exam Required Eye Exam and Vision Screening Required No Vision Screening or Exam Requirements HI

No Requirements, Eye Exam Allowed

The above map illustrates the disparity in state requirements for childrenâ&#x20AC;&#x2122;s vision in school. The state of Nebraska requires eye exams prior to entering school. Additionally Illinois, Kentucky and Missouri require eye exams and vision screening for children. California falls within the majority of states which require a vision screening only.

Marshall B. Ketchum University | Southern California College of Optometry

2014 California School Requirements for Children’s Vision:

Vision Screening only • Frequency - Upon initial enrollment in public elementary school. Every three years thereafter until child completes the eighth grade. • Procedures - Visual acuity; color vision (males only) upon entering first grade; gross external evaluation of eyes. • Requirements - Waived if child shows proof of receiving professional eye care. If a student fails the school’s vision screening, the school district must advise the parents or guardians on corrective actions; however, the state does not require parents to report back to the school district as to whether the child actually received follow-up care.

A report by the California Senate Office of Research states that California’s vision screening requirements for children are not designed to identify all eye and vision problems.61 The state requires routine vision screenings for school-age children, but not for infants or preschool-age children. California does not require certain local entities to identify and assess children, including infants and preschool-age children, for vision impairments to determine if a child qualifies for special education services. In addition, no consensus was found among eye and vision care professionals regarding the appropriate testing for children. For example, there is no agreement as to whether preschool-age children should receive a routine eye examination before starting school.

Marshall B. Ketchum University | Southern California College of Optometry

Overcoming Barriers to Children Receiving Care Although there have been improvements in access to care through changes in public policy to include benefits for pediatric eye care, still only about one-third of children have received an eye examination, or at minimum, a vision screening before entering school.62 According to Prevent Blindness, 27% of parents believe their children are too young to experience a problem with their vision and therefore do not take them for a comprehensive eye exam. Additionally, a little over 50% of people state they do not know the difference between a vision screening and a vision exam.63

Children's Vision Examinations and Screenings: What's the Difference? A vision screening is typically one to two tests to assess how well a person can see on an eye chart (visual acuity). It is most often performed by a school nurse or a technician in a pediatrician’s office, and not a trained eye care professional. It may include color vision testing, most often tested in males, to evaluate for any color vision deficits. With advancements in technology, some vision screenings are now also including photoscreening, which can provide an automated estimation of a person’s refractive error, as well as a comparison of the two eyes. Based on this information and age-based normative values for refractive error, the photoscreener will indicate if the person passed or failed the vision screening. Although a vision screening can identify a possible vision problem, it does not typically evaluate the health of the eyes, so it can give parents a false sense of security about their child’s vision and eye health. Additionally, a vision problem cannot be diagnosed or treated by a vision screening and if a vision problem is noted then a referral for a comprehensive eye exam is still needed. According to the American Optometric Association: Ready For School: Understanding the difference between vision screenings and vision examinations, it takes 18 months for a child who has been identified with a vision problem via a school screening to go to the optometrist or ophthalmologist for evaluation and treatment.

A comprehensive eye examination includes: • Eye health • Peripheral vision • Refractive error / necessity of glasses • Visual skills: -- Eye tracking -- Eye teaming -- Eye focusing

Marshall B. Ketchum University | Southern California College of Optometry

Current Public Policy on Vision Care The Patient Protection and Affordable Care Act implemented in late 2013 began the major reorganization of the health care insurance system. The ACA has impacted children’s care by preventing a health plan from limiting or denying benefits or denying coverage for children below 19 years old based on a preexisting medical condition. In addition, the ACA removes co-payments for preventative services including vaccinations. A comprehensive Policy Brief by the Children and Families Commission of Orange County (2013) details access to health care benefits and services available to children in Orange County. The report is linked to the 2012 American Academy of Pediatrics Policy emphasizing the importance of access to comprehensive health care benefits for all children. The commission’s report covers children’s insurance statistics, community clinics utilization, school district services and prevention services.

Highlights of the Report:

• In 2013 most children under age 18 years old had health insurance coverage (92%) and the percentage of insured children has risen in recent years. • The percentage of uninsured children under age 18 in 2013 was 8.2% and this number decreased by 2% between 2009 and 2011. • The ACA provides increased eligibility for uninsured children and families to Medi-Cal based on lowering eligibility households and new poverty standards. • Undocumented children and immigrant children who have lived in the U.S. for less than 5 years do not qualify for public coverage. • Community clinics serve an increasing number of children in Orange County, accounting for approximately 12% of the population of children aged 19 years old or younger. This equates to 96,000 children. • The utilization of community clinics is increasing due to an increase in growth of these facilities together with a rise in the number of children accessing these health services. There were 50 community clinic sites in 2011.

Marshall B. Ketchum University | Southern California College of Optometry

Affordable Care Act With the passage of the Affordable Care Act, comprehensive pediatric eye examinations are now an Essential Health Benefit. These recent changes provide comprehensive eye care coverage for children less than 19 years of age and provision of glasses, if needed, that is covered through private or public health insurance plans.65 The Essential Health Benefits consist of 10 benefits outlined in the ACA which all health plans that sell in the new health insurance marketplaces must adhere to in order to comply with the law. The pediatric vision benefit is one of the 10 essential benefits laid out by the ACA. The pediatric vision benefit will be a yearly eye exam with a glasses/materials benefit for every patient under the age of 19 years old. Under the federal law, patients can directly access their vision benefits without having to first fail a vision screening. Also, under the law, an individual is not required to pay directly for essential benefits, but is required to purchase coverage through a health plan which meets acceptable coverage levels to satisfy the individual mandate.

Health Insurance Coverage and Access to Care In 2011, 82.7% of Orange County residents were estimated to be covered by some form of health insurance, as determined by the U.S. Census Bureau.66 Insured individuals are more likely to access health care which could lead to better overall health than those who are uninsured. Children whose families have health coverage are more likely to receive medical and health care as well as utilize preventative health services. Access to health care services is financed through an array of health insurance options for most and private pay options for some who lack access to these resources. The insurance options include employer-based health plans, private plans or subsidized low-cost or free publically subsidized programs for families based on income levels. There are currently several publically subsidized health insurance programs in California with the primary coverage provided by Medi-Cal and the Child Health and Disability Prevention Program. Other programs include: Access for Infants and Mothers (AIM), California Childrenâ&#x20AC;&#x2122;s Services (CCS), California Kids (CalKids) and Kaiser-Permanente's Child Health Plan. Children who were formerly enrolled in the Healthy Families Program (HFP) have transitioned to Medi-Cal with the elimination of HFP in 2012/13.

Marshall B. Ketchum University | Southern California College of Optometry

Next Steps Call to Action for

Increased Vision Care in Orange County Together, we have a prime opportunity to increase children’s vision care in Orange County. By identifying and addressing barriers to preschool and school-aged children's access to vision care, we can shorten the time it takes for a child who is identified with a visual problem in a screening to receiving proper eye care. Achieving the goal of ensuring vision readiness for all school children in Orange County will take the cooperation of all stakeholders – families, teachers, health professionals and legislators. Below are recommended actions that focus on current children’s vision intervention methods (screenings and comprehensive eye care), shortcomings within the vision care system, barriers to accessing vision care and funding available for the provision of vision services.

EDUCATE 1. Work with all school districts in Orange County to inform teachers and families about the importance of good visual skills for successful learning, and how to be aware of signs and symptoms in children that suggest a visual problem is present. 2. Develop and promote a “vision awareness” program to educate families and teachers on the value that good vision care plays in learning. 3. Communicate to families and teachers the available resources for vision care in Orange County. These resources should include vision care funding (both public and private) and a list of eye care professionals with expertise in pediatrics and children’s vision care. 4. Educate other health care professionals about the Essential Health Benefits. Continued on next page

Marshall B. Ketchum University | Southern California College of Optometry

PROVIDE 5. Offer transportation access for school districts to obtain vision care for their students (with parent or guardian consent) to local centers and private offices that provide childrenâ&#x20AC;&#x2122;s vision services. 6. Provide access to comprehensive vision services in community-based clinics and remote locations through innovative funding mechanisms and provide transportation access as needed. 7. Increase efforts to provide children with access to eye care through private insurance, public insurance or foundations that are able to assist those who do not qualify for insurance. 8. Expand pediatric vision care services in Federally Qualified Health Centers in low income areas.

ADVOCATE 9. Address the barriers to comprehensive eye care that are preventing children from receiving the recommended follow up care. These barriers include health care policy legislation, funding, transportation, accountability and communication. 10. Advocate for insurance reimbursement where vision therapy services are recommended for children.

GUIDE 11. Ensure that children receive vision care as part of a required health evaluation. 12. Improve vision screening protocols and guidelines that will enable non-eye care professionals to provide consistent screenings and optimize referrals for comprehensive eye exams when problems are detected. 13. When screenings are performed, require a parent or guardian to provide a confirmation that a follow up comprehensive eye examination occurred within 3 months. Marshall B. Ketchum University | Southern California College of Optometry

References OC Health Care Agency. Orange County Community Health Profile 2013. Available at https://media.ocgov.com/civicax/ filebank/blobdload.aspx?BlobID=32217.

California Department of Education, Data Reporting Office. Available at http://dq.cde.ca.gov/dataquest.

Ed-Data. Available at http://www.ed-data.k12.ca.us/App_Resx/EdDataClassic/fsTwoPanel.aspx?#!bottom=/_layouts/ EdDataClassic/fiscal/MC-Results.asp.

OC Health Care Agency. The 20th Annual Report on the Conditions of Children in Orange County. Available at http:// ochealthinfo.com/civicax/filebank/blobdload.aspx?BlobID=396021.

Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months the multi-ethnic pediatric eye disease study. Ophthalmology, 2008 Jul;115(7):1229-1236.

Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of myopia and hyperopia in 6- to 72-month-old African American and Hispanic children: the multi-ethnic pediatric eye disease study. Ophthalmology, 2010 Jan;117(1):140-147.

Fozailoff A, Tarczy-Hornoch K, Cotter S, Wen G, et al. Prevalence of astigmatism in 6- to 72-month-old African American and Hispanic children: the Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology, 2011 Feb;118(2):284-93.

McKean-Cowdin R, Cotter S, Tarczy-Hornoch K, Wen G, et al. Prevalence of amblyopia or strabismus in Asian and NonHispanic White preschool children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology, 2013 Oct;120(10):2117-24.

Wen G, Tarczy-Hornoch K, McKean-Cowdin R, Cotter S, et al. Prevalence of myopia, hyperopia, and astigmatism in NonHispanic White and Asian children: Multi-Ethnic Pediatric Eye Disease Study. Ophthalmology, 2013 Oct;120(10):2109-16.

Cotter S, Varma R, Tarczy-Hornoch K, McKean-Cowdin R, et al. Risk Factors Associated with Childhood Strabismus. Ophthalmology, 2011;118:2251â&#x20AC;&#x201C;2261.

Friedman D, Repka M, Katz J, Giordano L, et al. Prevalence of amblyopia and strabismus in White and African American children aged 6 through 71 months: The Baltimore Pediatric Eye Disease Study. Ophthalmology, 2009 Nov;116(11):2128-34.

Giordano L, Friedman D, Repka M, Katz J, et al. Prevalence of Refractive Error among Preschool Children in an Urban Population: The Baltimore Pediatric Eye Disease Study. Ophthalmology, 2009 Apr;116(4):739-46.

Roberts J. Eye examination findings among youths age 12-17 years, United States. Vital and health statistics, Series 11, No. 155, DHEW Publication (HRA) 76-1637, Rockville, MD, November 1975. 13

Peters HB. Vision care of children in a comprehensive health program. J Am Optom Assoc 1966; 37(12):1113-1118.

Bloom B. Use of selected preventive care procedures United States, 1982. Vital and health statistics, Series 10, No. 157, DHHS Publication (PHS) 86-1585, Hyattsville, MD, September 1986.

Prevent Blindness America. Seeing is achieving. Schaumburg, IL, 1996.

Ferebee A. Childhood vision: public challenges and opportunities. A policy brief. Washington, DC: Center for Health and Health Care in Schools, School of Public Health, George Washington University Medical Center; 2004.

United States Census Bureau. Available at http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?src=bkmk.

United States Census Bureau. Available at http://quickfacts.census.gov/qfd/states/06/06059.html.

Zaba JN, Johnson RA, Reynolds WT. Vision examinations for all children entering public school: the new Kentucky law. Optometry. 2003;74:149-158

Marshall B. Ketchum University | Southern California College of Optometry

Pizzarello L, Tilp M, Tiezzi L, Vaughn R, McCarthy J. A new school-based program to provide eyeglasses: childsight. J Am Assoc Pediatr Ophthalmol Strabismus. 1998;2:372-373.

Krumholtz I. Results from a pediatric vision screening and its ability to predict academic performance. Optometry. 2000;71:426-430.

Williams WR, Latif AHA, Hannington L, Watkins DR. Hyperopia and educational attainment in a primary school cohort. Arch Dis Child. 2005;90:150-153.

Williams SM, Sanderson GF, Share, DL, Silva PA. Refractive error, IQ and reading ability: a longitudinal study from age seven to 11. Dev Med Child Neurol. 1988;30:735-742.

Rosner J, Rosner J. The relationship between moderate hyperopia and academic achievement: how much plus is enough? J Am Optom Assoc. 1997;68:648-650.

Shankar S, Evans MA, Bobier WR. Hyperopia and emergent literacy of young children: pilot study. Optom Vision Sci. 2007;84:1031-1038.

The Primary Visual Cortex. Available at http://hubel.med.harvard.edu/book/ch4.pdf.

Convergence Insufficiency Treatment Trial Study Group. Randomized Clinical Trial of Treatments for Symptomatic Convergence Insufficiency in Children. Arch Ophthalmol. 2008 Oct;126(10):1336-49.

Daum KM. Convergence insufficiency. Am J Optom Physiol Opt. 1984;61(1):16-22.

Cooper J, Duckman R. Convergence insufficiency: incidence, diagnosis, and treatment. J Am Optom Assoc. 1978;49(6):673-680.

Kent PR, Steeve JH. Convergence insufficiency: incidence among military personnel and relief by orthoptic methods. Mil Surg. 1953;112(3):202-205.

Poynter HL, Schor C, Haynes HM, Hirsch J. Oculomotor functions in reading disability. Am J Optom Physiol Opt. 1982;59(2):116-127.

Mazow ML. The convergence insufficiency syndrome. J Pediatr Ophthalmol. 1971;8:243-244.

Duke-Elder S, Wybar K. Ocular motility and strabismus. In: Duke-Elder S, ed. System of Ophthalmology. St Louis, MO: Mosby; 1973. 34

Pickwell LD, Hampshire R. The significance of inadequate convergence. Ophthalmic Physiol Opt. 1981;1(1):13-18.

Borsting E, Rouse MW, Deland PN, et al. Association of symptoms and convergenceand accommodative insufficiency in school-age children. Optometry. 2003;74(1):25-34.

Borsting EJ, Rouse MW, Mitchell GL, et al. Validity and reliability of the revised convergence insufficiency symptom survey in children aged 9-18 years. Optom Vis Sci. 2003;80(12):832-838.

Cornelissen P, Bradley L, Fowler S, Stein J. What children see affects how they read. Dev Med Child Neurol. 1991;33:755762.

Cornelissen P, Bradley L, Fowler S, Stein J. What children see affects how they spell. Dev Med Child Neurol. 1994;36:716727.

Powers M, Grisham D, Riles P. Saccadic tracking skills of poor readers in high school. Optometry. 2008;79:228-234.

Kulp MT, Schmidt PP. Effect of oculomotor and other visual skills on reading performance: a literature review. Optom Vision Sci. 1996;73:283-292.

Marshall B. Ketchum University | Southern California College of Optometry

Kulp MT, Schmidt PP. The relation of clinical saccadic eye movement testing to reading in kindergartners and first graders. Optom Vision Sci. 1997;74:37-42.

Kulp MT. Relationship between visual motor integration skill and academic performance in kindergarten through third grade. Optom Vision Sci. 1999;76:159-163.

Kulp MT, Edwards KE, Mitchell GL. Is visual memory predictive of below-average academic achievement in second through fourth graders? Optom Vision Sci. 2002;79:431-434. 44

Goldstand S, Koslowe KC, Parush S. Vision, visual-information processing, and academic performance among seventhgrade schoolchildren: a more significant relationship than we thought? Am J Occup Ther. 2005;59:377-389.

Bull R, Espy KA, Wiebe SA. Short-term memory, working memory, and executive functioning in preschoolers: longitudinal predictors of mathematical achievement at age 7 years. Dev Neuropsychol. 2008;33:205-228.

Basch C. Vision and the Achievement Gap Among Urban Minority Youth. Jnl of School Health October 2011, Vol 81, No. 10.

Zaba JN. Childrenâ&#x20AC;&#x2122;s vision care in the 21st century and its impact on education, literacy, social issues and the workplace: A call to action. J Behav Optom. 2011;22(2):39-41.

Barber A, Johnson R, ed. Behavioral aspects of vision care. Santa Ana, CA: Optometric Extension Program, 2002;42:1-7.

Donohue S, Johnson T, Leonard-Martin T. Screening for amblyogenic factors using a volunteer lay network and the MTI Photoscreener. Ophthalmol 2000;107:1637-44.

Preslan M., Novak A., Baltimore Vision Screening Project; Ophthalmol 1998; 105: 150-53.

Smith N. Eye advice unused by 45% of parents. Little Rock: Arkansas Democrat Gazette; September 5, 2007:11,15.

Texas Dept. of State Health Services Annual Vision Screening Report. Austin:Oct. 25, 2007.

Cotter S, Cyert L, Miller J, Quinn G. Vision screening for children 36 to <72 months: recommended practices. Optom Vis Sci. 2015 Jan;92(1):6-16.

American Academy of Ophthalmology. Joint Policy Statement. Vision Screening for Infants and Children. Available at http:// one.aao.org/Assets/902411d9-f839-4c9f-b5eb-8822f7c097a7/635209988330700000/vision-screening-for-infants-andchildren-2013.

American Optometric Association. Optometric Clinical Practice Guidelines. Available at http://www.aoa.org/documents/ optometrists/CPG-2.pdf. 56

OC Health Care Agency. 19th Annual Conditions of Children Report, 2013. Available at http://www1.ochca.com/ ochealthinfo.com/docs/occp/report2013/pdf/02_Good/ChildrensVision33.pdf.

Children and Families Commission of Orange County. Fifteen Years and Moving Forward. Available at http://www. occhildrenandfamilies.com/images/pdf/15YearBrchr.pdf.

Prevent Blindness 2013. Available at http://www.starpupils.org/pba/content/school.

Legislative Counsel. State of California. Available at www.leginfo.ca.gov.

California Senate Office of Research. Available at http://sor.govoffice3.com/vertical.

The Need for Comprehensive Vision Examination of Preschool and School-age Children. Available at http://www.aoa.org/ optometrists/education-and-training/clinical-care/the-need-for-comprehensive-vision-examination-of-preschool-and-schoolage-children?sso=y.

Marshall B. Ketchum University | Southern California College of Optometry

Prevent Blindness. Our Vision for Children’s Vision: A national call to action for the advancement of children’s vision and eye health. Available at http://documents.preventblindness.org/publichealth/OurVisionforChildren_2010.pdf.

Supporting Children’s Health in Orange County. Policy Brief. Children and Families Commission of Orange County. L. Zimskind and A. Mastuianni. September 1, 2013.

Infant and Children’s Vision and Eye Care Guidelines. California Optometric Association White Paper October, 2013, Scott Daley, O.D.

Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report - United States, 2011. MMWR 2011; 60 (Suppl.): 1-113.

Acknowledgments

Marshall B. Ketchum University supports the ongoing endeavor of the Southern California College of Optometry to report on the state of children's vision in Orange County, California. The University thanks the following individuals for their contributions to this report:

Contributors Ray Chu, O.D., M.S. Kristine Huang, O.D., M.P.H. John Nishimoto, O.D., M.B.A. Michele Whitecavage Pat Yoshinaga, O.D., M.P.H.

Design Matthew Dennehy Chris Fuentes Katie Santos-Coy

Marshall B. Ketchum University | Southern California College of Optometry

2575 Yorba Linda Boulevard, Fullerton, CA 92831 ketchum.edu