Learning Disabilities, , and Vision Sheryl M. Handler, Walter M. Fierson and the Section on Ophthalmology and Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists Pediatrics 2011;127;e818-e856; originally published online Feb 28, 2011; DOI: 10.1542/peds.2010-3670

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/127/3/e818

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from www.pediatrics.org by on March 1, 2011 Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children Joint Technical Report—Learning Disabilities, Dyslexia, and Vision

Sheryl M. Handler, MD, Walter M. Fierson, MD, and the abstract SECTION ON OPHTHALMOLOGY AND COUNCIL ON CHILDREN WITH DISABILITIES, AMERICAN ACADEMY OF OPHTHALMOLOGY, Learning disabilities constitute a diverse group of disorders in which AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND children who generally possess at least average intelligence have STRABISMUS, AND AMERICAN ASSOCIATION OF CERTIFIED problems processing information or generating output. Their etiolo- ORTHOPTISTS gies are multifactorial and reflect genetic influences and dysfunction KEY WORDS of brain systems. disability, or dyslexia, is the most common learning disabilities, vision, dyslexia, ophthalmology, eye . Itisareceptive -based learning disability that examination, vision therapy is characterized by difficulties with decoding, fluent word recognition, ABBREVIATIONS ADHD—attention-deficit/hyperactivity disorder rapid automatic naming, and/or reading-comprehension skills. These dif- IDEA—Individuals With Disabilities Education Act ficulties typically result from a deficit in the phonologic component of ADA—Americans With Disabilities Act language that makes it difficult to use the alphabetic code to decode the IEP—individualized education plan EBM—evidence-based medicine written word. Early recognition and referral to qualified professionals for SSS—scotopic sensitivity syndrome evidence-based evaluations and treatments are necessary to achieve the This document is copyrighted and is property of the American best possible outcome. Because dyslexia is a language-based disorder, Academy of Pediatrics and its Board of Directors. All authors have treatment should be directed at this etiology. Remedial programs should filed conflict of interest statements with the American Academy of include specific instruction in decoding, fluency training, vocabulary, and Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of comprehension. Most programs include daily intensive individualized in- Pediatrics has neither solicited nor accepted any commercial struction that explicitly teaches phonemic awareness and the application involvement in the development of the content of this publication. of . Vision problems can interfere with the process of reading, but The guidance in this report does not indicate an exclusive course of children with dyslexia or related learning disabilities have the same visual treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. function and ocular health as children without such conditions. Currently, This technical report supports the joint policy statement from the there is inadequate scientific evidence to support the view that subtle eye American Academy of Pediatrics, American Academy of or visual problems cause or increase the severity of learning disabilities. Ophthalmology, American Academy of Pediatric Ophthalmology and Because they are difficult for the public to understand and for educators to Strabismus, and American Association of Certified Orthoptists titled “Learning Disabilities, Dyslexia, and Vision,” which is available at treat, learning disabilities have spawned a wide variety of scientifically www.aap.org (direct link: www.aappolicy.org/cgi/reprint/pediatrics; unsupported vision-based diagnostic and treatment procedures. Scien- 124/2/837.pdf) and www.aao.org(direct link: www.aao.org/about/ tific evidence does not support the claims that visual training, muscle policy/upload/Learning-Disabilities-Dyslexia-Vision-2009.pdf). exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual All technical reports from the American Academy of Pediatrics vision therapy, “training” glasses, prisms, and colored lenses and filters automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. are effective direct or indirect treatments for learning disabilities. There is no valid evidence that children who participate in vision therapy are more responsive to educational instruction than children who do not partici- pate. Pediatrics 2011;127:e818–e856

INTRODUCTION Reading is the complex process of extracting meaning from abstract www.pediatrics.org/cgi/doi/10.1542/peds.2010-3670 written symbols. In modern societies, reading is the most important doi:10.1542/peds.2010-3670 way to access information, and in today’s Western society, is a PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). prerequisite for success. In elementary school, a large amount of time Copyright © 2011 by the American Academy of Pediatrics and effort is devoted to the complicated process of learning to read. Because of the difficulties encountered in teaching some children to read, Congress mandated that the Eunice Kennedy Shriver National

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Institute of Child Health and Human De- angular gyrus immediately posterior proving perceptual and/or perceptual- velopment assemble a national panel to Wernicke’s area.4 Morgan,2,5 a gen- motor development, they were of educators and scientists to re- eral practitioner from England, pub- ineffective in improving academic per- search the optimal methods of teach- lished the first case of a child with formance.9–12 Although the use of per- ing children to read. The 2000 report of congenital word blindness in 1896. ceptual and perceptual-motor training the National Reading Panel, titled Subsequently, Hinshelwood turned his by educators persisted for a time, by Teaching Children to Read: An attention to both congenital and ac- the mid-1980s its use had waned Evidence-Based Assessment of the Sci- quired word blindness. He credited the considerably. entific Research Literature on Reading term “dyslexia” to Berlin.6 In 1917, he Attempts at improved understanding and Its Implications for Reading In- highlighted the potentially inherited of dyslexia led to the rejection of the 1 struction, linked research findings aspect of . Hinshel- visual theories. This process began with recommendations for specific ap- wood estimated that 1 in 1000 students with a series of related studies that proaches to teaching reading to all in elementary schools might have systematically evaluated traditional children. The panel concluded that word blindness and postulated that and widely accepted etiologic concep- existing evidence supported early the primary disability was in visual tualizations, such as Orton’s optical re- explicit instruction in phonemic memory for words and letters. He versibility theory,7 Hermann’s spatial awareness, phonics-based reading strongly advocated intensive, individu- confusion theory,13 and other theories programs, and guided oral reading to alized personal instruction.2,4 that implicated deficits in visual pro- improve fluency. Beginning in the 1920s, Orton,2,7,8 a neu- cesses, such as visualization, visual se- Learning disabilities may interfere ropsychiatrist, demonstrated a hered- quencing, and visual memory, as basic with children reaching their full poten- itary component for reading disabili- causes of reading difficulties.14,15 tial. The inability to read and compre- ties in children. His studies led to an Although Orton attributed dyslexia to hend is a major obstacle to learning expanded definition of reading disabil- visual dysfunction, he was the first to that may have long-term educational, ities that was much broader than Hin- advocate intensive phonics instruc- social, and economic implications. shelwood’s and included a graded se- tion, sound-blending, and multisen- Teaching children with reading diffi- ries of all degrees of severity of sory training.2,8 Orton’s work served as culties is a challenge for the student, disability. This more liberal definition the stimulus for Gillingham and Still- parents, and educators. Therefore, the increased the presumed prevalence to man,16 who also emphasized multisen- causes and treatment of reading dis- more than 10% of schoolchildren. IQ sory training. Subsequently, the Orton- orders have been the subject of con- testing revealed that these children Gillingham phonics techniques have siderable thought and study. scored near or above average. In 1925, served as the basis for many remedia- This report discusses how we learn to Orton attributed dyslexia to a problem tion programs. The International Dys- read, the phonologic model, the recog- in the visual system, which suggests lexia Society, formerly the Orton Dys- nition and treatment of reading diffi- that an apparent dysfunction from lexia Society, provides information and culties, visual function and reading, “mixed cerebral dominance” caused resources to professionals and par- the magnocellular deficit theory, col- problems in visual perception and ents regarding reading disabilities. ored lenses and overlays, vision ther- visual memory, characterized by per- apy, and the roles of the pediatrician ception of letters and words in Learning Disabilities and ophthalmologist. reverse. Learning disabilities constitute a di- BACKGROUND The theory that visual dysfunction verse group of disorders in which chil- caused dyslexia led to a proliferation dren who generally possess at least History of training programs developed for average intelligence have problems In 1877, Kussmal2,3 first described a visual-perceptual and/or visual-motor processing information or generating case of acquired word blindness in an disabilities. In the 1960s, those promi- output. Learning disabilities can affect adult alexic patient with a parietal lobe nent in developing and promoting neurocognitive processes and may lesion. Hinshelwood,2,4 an ophthalmol- these programs included Kephart, manifest as an imperfect ability to lis- ogist from Scotland, studied and de- Frostig, Getman, Barsch, Dorman, and ten, speak, read, spell, write, reason, scribed an adult with word blindness Delacato. Research into the programs concentrate, solve mathematical prob- in 1895. In 1903, an autopsy of this pa- revealed that, although these pro- lems, or organize information. Some tient revealed abnormalities in the left grams were sometimes effective in im- children may have associated difficul-

PEDIATRICS Volume 127, Number 3, March 2011 e819 Downloaded from www.pediatrics.org by on March 1, 2011 ties with motor coordination. Learning interactions, and motor function and as writing.28 People with dyslexia read difficulties can be associated with and may show inappropriate response to slowly, but not all people who read complicated by attention-deficit/hy- sensory information.23 slowly have dyslexia. peractivity disorder (ADHD),17,18 oppo- Dyslexia Approximately 80% of people with sitional defiant disorder, obsessive learning disabilities have dyslexia, compulsive disorder, anxiety, or de- Difficulties in reading are found in a which makes it the most common 19 pression. Problems in self-regulatory diverse group of conditions that in- learning disability.24,25,30–35 Depending behaviors, social perception, and so- clude dyslexia and secondary forms of on the definition chosen, the preva- cial interaction may exist with learning reading difficulties caused by visual or lence of reading disability is approxi- disabilities but do not, by themselves, hearing disorders, intellectual disabil- mately 5% to 20% of school-aged ity, experiential and/or instructional constitute a learning disability. Al- children in the United States.21,24,31,34 deficits, and other problems.14,24–26 though learning disabilities may occur Reading disabilities seem to affect Dyslexia is defined as a primary read- concomitantly with other disabilities males slightly more than females,36–38 ing disorder that is separate from (eg, sensory impairment, intellectual although schools identify boys with secondary forms.14,24–26 The terms disability, serious emotional distur- them twice as often as girls.22,31 Both “specific reading disability,” “reading bance) or with extrinsic influences (eg, environmental and genetic influences disability,” “reading disorder,” and cultural differences, insufficient or in- affect the expression of dyslexia.39 Dys- “dyslexia” are often used interchange- appropriate instruction), they are not lexia has been identified as having a ably in the literature.14 The term “dys- the result of those conditions or influ- strong genetic basis.14,24–26,30,31,40,41 Ap- lexia” is derived from Greek and ences.20 Results of recent studies sug- proximately 40% of siblings, children, means “difficulty with reading words.” gest that approximately 20% of the or parents of an affected person will Dyslexia is often unexpected in relation population has some degree of a learn- have dyslexia. Although dyslexia may to the child’s other cognitive abilities. ing disability.21 In 2007, 2.7 million be inherited, it may also exist in the It is a receptive language-based learn- public school students (5.5% of all absence of a family history. Results of ing disability that is characterized students in public schools) were iden- family and twin studies have sug- by difficulties with decoding, fluent tified as having learning disabilities gested that 50% of the problems in word recognition, and/or reading- and were eligible to receive educa- performance can be accounted for by comprehension skills. These difficul- tional assistance under the Individuals heritable factors; environmental influ- ties typically result from a deficit in the With Disabilities Education Act (IDEA).22 ences are greater in children with phonologic component of language lower IQ scores.42 Specific learning disabilities include that makes it difficult to use the alpha- dyslexia (reading disability), dys- betic code to decode the written word. Reading ability and reading disability graphia (writing disability), and dys- Secondary consequences may include occur along a continuum; reading dis- calculia (mathematics disability). Al- reduced reading experience that can ability is represented within the lower though not included in the Diagnostic impede growth of vocabulary, written tail of a normal bell-shaped distribu- and Statistical Manual of Mental Disor- expression, and background knowl- tion of reading ability.21 The lower tail ders, Fourth Edition, Text Revision23 as edge.27 A common misconception is is actually composed of reading diffi- a specific learning disability, nonver- that dyslexia is a problem of letter or culties from both primary dyslexia and bal learning disability comprises word reversals. Reversals of letters or secondary causes. Dyslexia is a life- difficulties with social interactions, in- words and mirror writing occur nor- long condition that varies in degrees of terpersonal skills, nonverbal problem- mally in early readers and writers. severity. Most children with reading solving, visuospatial skills, motor Children with dyslexia are not unusu- disabilities have relatively mild read- skills, reading comprehension, and ally prone to reversals. Although they ing disabilities, and a smaller number mathematics and often coexists with do occur, reversal of letters or words, of them have more severe reading dis- strengths in verbal skills and with flu- or mirror writing, is not included in the abilities.21,30 Because reading skills oc- ent and accurate reading.23 definition of dyslexia.14,28,29 People with cur on a continuum with no clear dis- spectrum disorder, although not a dyslexia may be very creative and tinction between typical readers and specific learning disability, certainly bright. In many cases, their high-level readers with dyslexia, some experts affects learning, because people with thinking is unaffected, and they may be assert that the term “dyslexia” should autism have difficulties with verbal gifted in mathematics, science, the be reserved for the 2% to 5% with the and nonverbal communication, social arts, or even in unexpected areas such most severe reading deficits.43

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Dyslexia occurs at all levels of intelli- atic for older children, who are ex- derstanding that segmented units of gence and is a persistent problem that pected to read increasingly sophisti- speech can be represented by printed does not represent a transient devel- cated texts.53 forms.55 Phonologic awareness is the opmental lag.* Children with poor oral Many children with reading disability basis for scaffolding written language language skills in kindergarten often are observed to grow ashamed as they onto oral language.55 become poor readers. Over time, good struggle with skills that their class- Phonemes are the speech sounds that readers and poor readers without in- mates master easily. This shame may enable us to tell 1 word from another. tervention tend to maintain their rela- cause a loss of motivation to learn to For example, “pet” and “bet” are distin- tive positions along the spectrum of read that can further compound the guished by the sounds of their initial reading ability. Children who get off to situation. Untreated or poorly treated consonant; thus, changing the “p” to a poor start in reading rarely catch up dyslexia may lead to frustration, low “b” changes the meaning of the word.56 on their own. A poor reader in 1st self-confidence, and poor self-esteem, Coarticulation is the merging and grade will almost invariably stay a which substantially increases the risk overlapping of sounds into a sound poor reader; more than 88% of these of developing psychological and emo- “bundle,” which makes oral communi- children display similar difficulties at 19,30 tional problems. cation much more efficient.55 To make the end of 4th grade.35,44,50 Seventy-four Approximately 15% of students with normal conversation possible, 8 to 10 percent of those children identified in reading disability also have ADHD, phonemes per second are strung to- 3rd grade as reading disabled will re- whereas approximately 35% of stu- gether and blended so thoroughly that main so in the 10th grade.30,34,43,51 Read- dents with disorders of attention also it is often impossible to separate them. ers with dyslexia must expend more have reading disability.19,24,30,54 How- A written word like “cat” has 3 letter- attention, concentration, and energy ever, the 2 disorders are distinct and sound units, although the ear hears on the task, which makes reading un- separable. only 1 sound, not 3, when the word pleasant, tiring, and difficult.39 Stu- “cat” is spoken aloud. dents who cannot read well read less. is a learning disability that Lost practice opportunities make it dif- affects writing abilities. Disorders of Oral has been ficult to acquire even average levels of written expression can manifest them- found to play a critical role in learning reading fluency. Both inaccurate read- selves as difficulty with and to read.1,35,57–59 Oral language acquisi- ing and diminished reading practice problems putting thoughts on paper. tion is preprogrammed into human de- cause slow growth of fluent word- The spelling deficits in dysgraphia may velopment; a drive for expression identification skills and vocabulary be oral and/or written. Dysgraphia can through organized vocalization seems growth. The vocabularies and concept also manifest itself as difficulty with innate to infant development, although knowledge of children who read less writing motor coordination or poor specific need to be ac- will plateau as their reading peers im- handwriting. Dysgraphia is the learn- quired. On the other hand, writing, an prove.52 The consequences of a slow ing disability that most frequently co- artificially designed use of abstract start in reading become monumental occurs with dyslexia because of their symbols to represent language, is an as they accumulate exponentially over directly related phonemic base. Decod- acquired skill.34 English uses an alpha- time.35 In the later grades, when chil- ing breaks the code receptively and en- betic system in which each letter is a dren switch from learning to read to coding (spelling) puts it back together symbol that is an abstract building reading to learn, reading-impaired expressively. block of that language’s phonemes children are prevented from fully ex- (sounds). English is a phonemically ploring science, history, literature, Phonologic Model complex language in which the 26 let- mathematics, and the wealth of infor- Currently, the most accepted model ters of the alphabet create 44 sounds mation that is presented in print. With for the acquisition of the ability to read or phonemes in approximately 70 let- interventions, people with dyslexia is the phonologic model. Phonologic ter combinations.32,33,60 The phonemic may learn to read accurately, but they awareness is the sensitivity to the complexity of a language corresponds have a persistent problem with flu- sound structure of oral speech and to the prevalence of dyslexia, which ency and continue to read slowly and phonemic awareness is the under- points to the linguistic origin of dyslex- not automatically throughout their standing that speech can be seg- ia.14,29 Manifestations of dyslexia are lives.39 The fluency deficit is problem- mented or broken into individual often worse in English because of the sounds that signal differences in greater number of inconsistencies *Refs 14, 20, 24–26, 28–31, 34, 35, and 44–49. meaning, whereas phonics is the un- and exceptions within the English lan-

PEDIATRICS Volume 127, Number 3, March 2011 e821 Downloaded from www.pediatrics.org by on March 1, 2011 guage, but dyslexia is confined neither spelling (dysgraphia) because of im- rately is a necessary skill, reading to the United States nor to English perfectly stored representations of speed and fluency become critical fac- speakers.14 words, although not all children with tors in ensuring that children gain Learning to read and write is a com- poor spelling skills have dyslexia. comprehension. Fluency forms the plex process that requires active Children with more severe forms of bridge between decoding and compre- learning. Reading is more difficult than dyslexia may have a second deficit in hension.34 speaking, because children must be rapid automatic naming that causes Comprehension is impaired without aware of the sound structure in spo- slow naming of letters, numbers, and efficient automatic word-recognition ken language and then break the al- pictures, which creates a double defi- skills.55 If reading is slow and labored phabetic code to acquire the sound/ cit.14,31,66–69 Other children with severe because of decoding difficulties and symbol connection. Developing this forms of dyslexia may have problems requires a large portion of their avail- awareness is not automatic, because with their short-term able conscious attention, children do phonemes are not separated in or attention or an additional compre- not have enough attentional capacity speech. To decode a written word, the hension deficit.70 Some children with and cognitive energy to remember sounds must be broken apart. Unless reading difficulties also experience a what they have read, much less relate the child can convert the printed char- deficit in orthographic skills, which the ideas to their own background acters into the phonetic code, these are defined as difficulties with letter/ knowledge.32–34,64 Current theory main- letters remain a mystery of lines and number orientation recognition and tains that the deficit in lower-order circles that are devoid of linguistic memory, although these skills may im- phonologic linguistic decoding func- meaning.34 According to Moats61 and prove with development.14,71 tion blocks access to the usually intact the American Federation of Teachers, A child must first accurately decode a higher-order cognitive and linguistic teaching reading is rocket science! 15,24,25,30–35 word before it can be read fluently. Flu- functions. Thus, it is difficult Reading comprises decoding, fluency, ency is the ability to read connected to apply general intelligence and rea- and comprehension and requires ade- text with expression rapidly, smoothly, soning, vocabulary, and syntax to the quate memory and sustained atten- effortlessly, and automatically with lit- reading endeavor to obtain compre- tion. The foundation for reading is de- tle conscious attention to decoding. An hension.24,25,34 In some cases, however, coding. Decoding, or word attack, is inexperienced reader will use the pho- other children can show comprehen- the ability to sound out words. Poor netic method to sound out most words sion difficulties in the absence of word- decoding is the core characteristic of and consequently will read slowly. No recognition problems. Vocabulary ac- poor reading. Most people with dys- fluent reader uses phonics routinely. quisition in a child with dyslexia often lexia have a neurobiological deficit in Poor decoders are stuck on the task of may not keep pace with that of a child’s the processing of the sound structure trying to sound out words to make peers, because the less a child reads, of language, called a phonemic deficit, sense of the text.52 The next task for the the fewer the new words to which the which impairs decoding and prevents beginning reader is to move from the child is exposed. In addition to decod- word identification.† The ability to early phases of “sounding out” words ing deficiencies, inadequate vocabu- learn to decode print is determined to the more skilled phase in which lary, verbal reasoning, attention, mem- primarily by phonologic skills such as word recognition occurs almost in- ory, and limitations in background phonologic awareness, facility in al- stantly. Word recognition is the ability knowledge also can cause reading- phabetic mapping, name encoding and to read words without sounding them comprehension difficulties. Thus, any retrieval, and verbal memory.14 The out.52 Experienced readers use the or all of these problems can interfere reader with dyslexia experiences diffi- whole-word method and will quickly with the ultimate purpose of reading, culty in decoding and identifying 34 recognize most words as individual which is comprehension. words because of a specific impair- units. Average readers require 4 to 14 ment in the neural representation, exposures to a word before it becomes Neurobiology storage, retrieval, and coding of pho- a sight word,32,33 whereas students Dyslexia is currently believed to be nemes.‡ Children with dyslexia often with learning disabilities may need up neurobiological in origin, which means experience even more difficulty with to 40 exposures.33,72 Fluent reading re- that the problem is located physically quires automatic phonemic decoding in the brain. There is strong scientific †Refs 1, 14, 15, 20, 24–26, 30–35, 43, 46–49, 55, 60, 1,24,25,31–34,64 and 62–65. and word recognition. Al- evidence that supports the neurobio- ‡Refs 1, 24, 25, 31–34, 39, 46–49, and 64. though the ability to read words accu- logical basis for the phonologic-coding–

e822 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS deficit theory of dyslexia.§ Both ana- written words into spoken words. It is exposure to drugs or alcohol; infec- tomical and brain-imagery studies postulated that this abnormality is tions of the central nervous system; se- have revealed differences in the way causal, not a result of poor reading ex- vere head injuries; cognitive difficul- the brain of a person with dyslexia de- perience. Functional MRI studies have ties; or developmental delay.28 An early velops and functions. Neuroanatomi- also shown brain plasticity in that history of language difficulties such as cal changes, microarchitectural dis- the dyslexia-specific brain-activation delay or difficulty in developing speech tortion, and MRI findings in language- profile improves after successful and language, learning rhymes, or rec- related areas have been observed in evidence-based phonologic remedial ognizing letters and sound/symbol the brains of patients with dyslexia, in- intervention.48,80,85 connections, may be an early indica- cluding the absence of the normal White-matter abnormalities have also tion of dyslexia.14,24,34,35,58,62,81 Parents or asymmetry in the language areas of been detected in association with dys- teachers may detect early warning the brain and similar volume in the left lexia. In people with dyslexia, white- signs of learning difficulties in and right planum temporale; normally, matter organization seems to be preschool-aged children, and early the left planum temporale is larg- weaker in the left posterior brain re- evaluation and intervention should be er.86–88 Functional MRI and positron gion and seems to project too weakly considered. It is not in the child’s best emission tomography (PET) scans within the primary reading pathways interest to “wait and see” or hope that measure changes in metabolic activity of the linguistic left hemisphere and the child will “grow out of” his or her and blood flow during cognitive tasks too strongly between hemispheres.53 problems.91 in specific brain regions. In typical White-matter pathways of the brain readers, functional MRI and PET-scan However, in many cases, learning dis- may be characterized by diffusion ten- studies have shown that reading abilities are not discovered until chil- sor imaging that provides a quantita- takes place predominantly in left- dren experience academic difficulties tive index of the organization of large hemisphere sites including the infe- in elementary school.24,25,34,81 Many par- myelinated axons that constitute the rior frontal (Broca) area, which is as- long-range connections of brain net- ents who had noticed that their child sociated with articulation, naming, works. Young children are able to un- was exhibiting learning difficulties and silent reading; 2 areas in the pos- dergo diffusion tensor imaging. waited a year or more before acknowl- terior brain regions—the parietal edging that their child might have a Recent genetic-linkage studies have temporal region, which serves word problem and seeking assistance. In el- identified many loci at which analysis, and the left occipitotemporal ementary school, a child with reading dyslexia-related genes are encoded. area, which is involved in word-form disabilities may show difficulty with re- Four candidate genes have been im- and fluent reading; and the posterior membering words, reading, spelling, inferior temporal cortex, which is as- plicated in neural migration, axonal growth, and brain development.89 handwriting, or writing speed. Teach- sociated with lexical retrieval. Chil- ers are in a position to identify reading dren with dyslexia, on the other hand, These brain changes seem to cause problems before they progress signif- use different areas of the brain when phonologic and auditory processing 89 icantly. Early identification of children reading.࿣ People with dyslexia have abnormalities. in early grades who are showing de- demonstrated a dysfunction in the left- lays or difficulties should be a high pri- hemisphere posterior reading sys- RECOGNITION AND TREATMENT ority for elementary school teachers. tems and have shown compensatory Dyslexia is a disorder that affects peo- use of the inferior frontal gyri of both ple of all ages, but its symptom profile Teachers need to have a strong under- hemispheres and the right occipito- changes over time.81,90 Because dys- standing of the result of research in temporal word-form area.¶ These lexia is both familial and heritable, af- reading theory and practice to become studies have demonstrated that dys- fected younger siblings can often be well versed in reading development lexia is an abnormality in the word- identified earlier. A child should be ob- and assessment.33 At all grade levels, analysis pathways of the brain that in- served for early indications of dyslexia teachers must understand the course terferes with its ability to convert if he or she has a family history of and the role of instruction in optimiz- learning disabilities or has a history ing literacy development. After initial §Refs 14, 24, 25, 30–35, 39, 40, 43, 46, 48, 49, 66, and of other factors that may be predictive school interventions have been unsuc- 73–85. of learning disabilities including hear- cessful, evaluation for learning dis- ࿣Refs 14, 24, 25, 30, 31, 34, 39, 40, 46, 48, 49, 66, and 73–85. ing, language, or speech problems; abilities should be considered for all ¶Refs 24, 25, 30, 31, 34, 40, 46, 48, 49, 66, and 73–85. preterm birth; low birth weight; fetal children who present with school diffi-

PEDIATRICS Volume 127, Number 3, March 2011 e823 Downloaded from www.pediatrics.org by on March 1, 2011 culties, even if reading difficulty is not reading disabled after 2nd grade ent or automatic, which results in a the chief complaint.34 rarely catch up to their peers.43 Wait- slower reading rate.†† Although older Parents should read aloud to their chil- ing for failure decreases the chances children and adults can be taught to dren to help develop language skills of interventional success. Results of read, the time and expense of doing so beginning as early as 6 months of longitudinal studies have shown that is enormous.34 Poor comprehension age.92 Educational experts indicate when intervention is delayed until 3rd skills also persist and will impair the that reading aloud to children is the grade or 9 years of age (the average ability to learn in general. single most important activity for par- age at which these children receive Difficulties in early reading may be ents and caregivers to do to prepare services), then approximately 74% of caused by experiential and instruc- children to learn to read.33,35 Compre- these children will continue to have dif- tional deficits in addition to primary hensive beginning reading instruction ficulties learning to read through high dyslexia. Some children enter school is the best educational prevention for school.30,34,43,51 Gains are maintained with experiential deficits in oral lan- reading problems. for at least 1 or 2 years by approxi- guage skills and general knowledge as mately 50% of children after they re- 35 The best current approach to the prob- well as delayed phonologic skills. Ex- turn to the school’s standard curricu- lem of reading failure is to allocate re- periential risk factors include being lum. These children who retain their sources for prevention and early iden- raised in a high-poverty environment benefits improve from year to year, but tification. The beneficial effects of early or in a home in which English is the they do not further catch up to typical identification and intervention are ap- second language or having limited ex- readers.53 parent in many studies.35 In the ele- posure to oral or written language. It is mentary grades, reading screening Dyslexia is most often identified in the important to recognize these children, should be performed yearly and early primary grades, but it is not diagnosed differentiate them from children with in the school year. Assessments for dif- in some students until later during true dyslexia, and provide proper re- ficulties with alphabet recognition, middle or high school, when more mediation for them. phonemic awareness and rapid nam- complex reading and writing skills are The IDEA, Section 504 of the Rehabilita- ing in kindergarten,57,93 adding word required. In early elementary school, tion Act, and the Americans With Dis- identification fluency in 1st grade, and some children compensate by using abilities Act (ADA) define the rights of adding oral reading fluency in 2nd other strengths until the educational students with dyslexia and other spe- grade can predict many of those who demands increase and make the read- cific learning disabilities.95–98 The IDEA will have difficulty learning to read.# ing disability more evident. Reading defines a child with a disability as Prevention and early phonologic problems diagnosed in the 4th grade someone who has any of 13 disabling awareness intervention programs in or beyond may be secondary to poor conditions, including learning disabili- kindergarten through 2nd grade can word recognition, a combination of ties, and who need special education increase reading skills in many poor poor word recognition and poor com- and related services because of the readers to average reading levels. prehension skills, or solely attribut- disability. The IDEA guarantees each Torgesen reviewed many studies on able to poor comprehension skills. child a free, appropriate public educa- early intervention and found that when Late emerging reading disabilities of- tion tailored to his or her individual intervention began in the 1st grade, ten go undetected in schools. Approxi- needs and allows parents to request a the expected incidence of reading dis- mately 10% of children with dyslexia formal educational evaluation by the ability of 12% to 18% was reduced sub- have good word-reading skills but school district to determine if a child stantially to 1.6% to 6%.94 If reading- have poor listening and reading- has a disability and qualifies for spe- impaired children receive effective comprehension skills. Poor compre- cial education and related services. It phonologic training in kindergarten hension skills are often attributable to allows parental access to all meetings and 1st grade, they will have signifi- working-memory, semantic, and syn- and paperwork, transition planning, cantly fewer problems in learning to tactic difficulties. Deficits in phono- and related services. The IDEA also pro- read on grade level than do children logic coding continue to characterize vides funding for special education who are not identified or helped until readers with dyslexia even in adoles- services.96 People with a physical or 3rd grade.** Children identified as cence and adulthood.34 Older children mental impairment that substantially and adults may learn to read words restricts 1 or more major life activities #Refs 1, 14, 20, 24, 30, 32–35, 43, 55, 58, 60, 64, 65, accurately, but they will not be as flu- are eligible for services under Section and 93. **Refs 1, 14, 19, 32, 33, 35, 41, 43, 47, 54, 60, 64, 65, 88, 90, and 95. ††Refs 14, 24, 25, 34, 35, 39, 54, 60, and 65.

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504 of the Rehabilitation Act of 1973.97 rectly in an educational intervention on a discrepancy between IQ and read- This act protects the civil rights of stu- program when he or she first experi- ing achievement for a diagnosis of dys- dents with disabilities and attempts to ences academic difficulties. Struggling lexia has outlived its usefulness except remove barriers to allow them to par- learners are provided with interven- in limited circumstances.34,44,104 There ticipate freely. Students who do not tions at increasing levels of intensity is no single standardized test used to have 1 of the 13 included disabilities or to accelerate their rate of learning. make the diagnosis of dyslexia. Be- meet the severity criteria but still re- The individual student’s progress is cause the hallmark of dyslexia is the quire some assistance to be able to closely monitored to assess both the presence of a phonologic deficit in the participate fully in school may be a learning rate and level of perfor- context of relatively intact overall lan- candidate for a Section 504 plan. Some mance. Educational decisions about guage abilities, the diagnosis of dys- schools use Section 504 to support the intensity and duration of interven- lexia can be far more specific.34 Indica- learning-disabled students who need tions are based on the individual stu- tors of phonologic difficulties can be only accommodations. Children with dent’s response to instruction. Only detected by a child’s history, by obser- ADHD who do not need more compre- the children who do not show signifi- vation, and/or by specific tests. Fur- hensive special education support cant improvement with the first-tier thermore, dyslexia is not diagnosed also are frequently served under this group intervention program and the with testing in the areas of vision, law. The ADA protects people who have second-tier targeted intense individual sensory-motor skill, or auditory pro- a physical or mental impairment that intervention program will undergo a cessing, and it is not determined solely restricts 1 or more major life activities full diagnostic educational assess- by medical screening or psychologi- from discrimination. Because learning ment.14,100,101 The majority of these stu- cal/IQ testing alone.105 is considered such an activity under dents undergoing educational assess- A comprehensive evaluation is neces- the ADA, students served under the ment will likely be identified as reading sary to determine the appropriate di- IDEA also are covered by this law.99 disabled and qualify for special educa- agnosis for children who present with Congress recently passed the ADA tion services. Ideally, this approach reading weaknesses. Comprehensive Amendments Act of 2008, which be- will allow earlier and more effective evaluation in all areas of the suspect came effective in 2009. It expanded the identification and treatment than the disability should be conducted. Such list of major life activities to include traditional method in which the child evaluation is multifaceted and gener- reading, thinking, and concentrating.99 must show persistent poor academic ally involves interviews with the child As a result, more people with learning achievement for a few years before re- and family; questionnaires and rating disabilities are now able to satisfy the ferral, assessment, and remediation. A scales completed by parents, teach- definition of disability, gain access to “wait-to-fail” situation can occur when ers, and the student; social, develop- reasonable accommodations, and be an ability-achievement discrepancy mental, medical, and educational his- protected from discrimination. formula is used to determine if a stu- tories; observation of the child in the The latest revision of the IDEA, the fed- dent qualifies for a formal diagnostic classroom; and evaluation of test da- eral law that governs special educa- assessment for a learning disabili- ta.26 The testing can be conducted by tion, offers 2 approaches that can be ty.35,43,65,100,101 Thus, the student has suf- trained school or outside specialists. used in the young underachieving fered the academic and emotional The composition of testing by a school child.14 The first method is called the strains of failure for 2 to 3 years before psychologist varies according to state response-to-intervention (RTI) method potentially effective instruction can and school district. An evaluation by and is designed primarily for the ele- begin. a developmental/behavioral pediatri- mentary school grades. RTI is a multit- At all ages, dyslexia is a clinical diagno- cian, school psychologist, educational iered approach to the early identifica- sis.81 A formal evaluation is needed to psychologist, clinical psychologist with tion and support of students with discover whether a person has a learn- special training in learning assess- learning and behavior needs. The RTI ing disability. The assessment tech- ments, or neuropsychologist consists process begins with high-quality in- niques should be evidence based.102,103 of a battery of tests that will provide struction and screening of all children Although many schools still use a dis- information on a child’s overall abili- in kindergarten to identify any child crepancy formula to qualify students ties, particularly learning style, who exhibits the early signs of poten- for special education, there is an information-processing abilities, aca- tial reading difficulties. In the RTI emerging consensus among research- demic skills, and describing areas of method, the child will be placed di- ers and clinicians that the dependence strength and weakness. The assess-

PEDIATRICS Volume 127, Number 3, March 2011 e825 Downloaded from www.pediatrics.org by on March 1, 2011 ment may include information pro- therapy, and school-related records ment recommendations, accommoda- vided by parents; health and develop- (ie, Section 504 plans and individual- tions, and referral suggestions. mental history; knowledge of any ized education plans [IEPs]). Parents, After a comprehensive school evalua- previous medical conditions; behav- teachers, and treating professionals tion, a learning disability will be diag- ioral rating scales completed by par- are interviewed for their presenting nosed formally in some students. Un- ents, teachers, and, if appropriate, the concerns. Neuropsychologists assess der the IDEA, a “child with a disability” student; school observations; review intellect, memory, attention and con- is one who is eligible for special edu- of school records; evaluation of intel- centration, perceptual and sensory cation and related services. Eligibility lect, memory, attention, and concen- skills, executive skills, language, aca- for special education is determined by tration; perceptual and sensory skills; demic achievement, motor skills, the IEP team. The evaluation is neces- executive skills; language; academic social-emotional and behavioral com- sary for developing a proper treat- achievement; motor skills; social- ponents, regulatory capacities, adap- ment plan and should also identify the tive levels, and other neuropsycholog- emotional and behavioral compo- different instructional methods that ical phenomena to illuminate the nents; and adaptive levels. Such an are most beneficial at various stages neurocognitive underpinnings of spe- evaluation traditionally has included of reading development for each cific learning disabilities as well as critical underlying language skills that child.55,59,104 To outline the educational their subtypes. This information is crit- are closely linked to dyslexia, including goals and services that the student ical in identifying the specific deficits receptive-listening skills; expressive- needs to be successful, an IEP contract relative to the reading weaknesses as language skills; phonologic skills, in- is developed. The IEP will describe well as other comorbid variables cluding phonemic awareness and goals and objectives; outline what ser- that are also involved. These variables rapid naming of letters and names; vo- vices will be needed, including specific can include coexisting attention and cabulary; reading accuracy; fluency; remedial interventions, accommoda- concentration disorders, executive- and comprehension. A student’s ability tions, modifications, and which type of functioning weaknesses, and social- to read lists of words in isolation, as program would be best; and set guide- emotional factors (ie, anxiety, depression, well as words in context, should also lines to measure future educational be assessed. School assessments are and oppositional features). Such infor- mation helps to identify whether atten- progress. After there is agreement by usually performed to determine if a tional and/or emotional issues might the school professionals and parents, child qualifies for special education be contributing to or resulting from the services that the school system programs or therapies. These assess- learning difficulties.19 Because neuro- will provide are listed in the IEP. The IEP ments focus on achievement and the psychological evaluation is driven by contract must be signed by the school skills needed for academic success. an understanding of the brain systems professionals and parents before it If the focus of the studies is on educa- involved in different academic func- can be implemented. The IEP is re- tional issues as well as on a broader tions, it can illuminate learning disor- viewed on an annual basis and, if nec- assessment of brain function, the as- ders, allow predictions to be made essary, revised for the next school sessment is called a “neuropsycholog- about future difficulties a child may en- year. Addendum IEPs can be held if is- ical” evaluation. Neuropsychologists counter so that preemptive interven- sues in the initial IEP need to be with a special competency in the area tions can be initiated, and bring to light changed or modified during the school of pediatrics can perform extensive comorbid conditions that may not yet year. Every 3 years, the child will un- evaluations that can lead to a compre- have become apparent. The determi- dergo comprehensive reevaluation. Al- hensive understanding of the child’s nation of the underlying causes of the ternatively, parents may obtain an in- cognitive and emotional processes disorder and comorbid conditions will dependent educational evaluation. If and provide the gold standard for a clarify the types of interventions from parents obtain an independent educa- learning-disability evaluation. Neuro- which the child is most likely to benefit tional evaluation on their own and it psychologists can diagnose learning and will provide a road map on which meets the school’s criteria, those re- or behavior disorders caused by al- evidence-based interventions and ac- sults and recommendations must be tered brain function or development. commodations are based across considered by the IEP team. The IEP In addition to test data, the assess- home and school environments. Refer- team would still need to determine if ment also involves a review of the rel- ring professionals and parents are the disability and its severity qualify to evant medical, psychiatric, educa- provided with a detailed written report obtain special education and related tional, speech-language, occupational of test findings, the diagnosis, treat- services in school. Children with less

e826 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS severe disabilities who do not qualify present in these patients. Clinical psy- that it causes.24,30,33,34,55,60,63,81 The man- for school services may still benefit chologists or other mental health agement of dyslexia demands a life- from remediation and other therapies providers, including developmental/ span perspective; early on, the focus is outside of school at the parents’ behavioral and neurodevelopmental on remediation.34 Remedial interven- expense. pediatricians, can provide strategies tions should be aimed at the specific Many struggling students will not to help children better cope with social needs of the child and viewed as a dy- show severe enough difficulties on challenges that may be associated namic process. Because dyslexia is a evaluation to receive a diagnosis of a with learning disabilities. Psychia- language-based disorder, treatment learning disability and will not be eligi- trists, developmental/behavioral pedi- should be directed at this etiology.‡‡ ble for special education and related atricians, neurodevelopmental pedia- Reading instruction should be explic- services. These students still may need tricians, or general pediatricians with itly taught, which means that children targeted reading assistance to be able special expertise may prescribe medi- are not expected to infer key skills or 34 to participate fully in school and may cations or conduct therapy to improve knowledge. Students who are easily be a candidate for a Section 504 plan. comorbid psychological disorders. confused are more likely to be suc- The evaluation information may be Treatment for dyslexia consists of us- cessful when teachers demonstrate used to decide what educational ac- ing educational tools to enhance the and clearly explain what they need to learn.58 Most children with dyslexia commodations may be needed in a ability to read. Educational therapists need help from a teacher, tutor, or regular education program. In that or educators who have been specially therapist who has been specially case, a Section 504 plan will be written trained in learning disabilities develop trained in using a multisensory, struc- that describes the areas of difficulty and implement intervention plans for tured language approach. It is impor- and lists the accommodations that will children with learning disabilities and tant for these children to be taught by be provided in the regular classroom. dyslexia. An appropriate treatment a sequenced systematic and explicit plan will focus on strengthening the The diagnosis and treatment of a child method that involves several senses student’s weaknesses while using the who has learning disabilities depend (hearing, seeing, touching) at the strengths. Because many students on the ongoing, coordinated collabora- same time.107 Highly structured daily with learning disabilities receive most tion of a multidisciplinary team that intensive individualized instruction by of their instruction in general educa- may consist of educators, educational an educational therapist or skilled tion class, teachers need to be trained remediation specialists, special ser- teacher specially trained in explicitly on the instructional strategies essen- vices, psychologists, and physicians. teaching phonemic awareness and the tial to success for these students.22 Speech therapists can evaluate and application of phonics is the founda- Many children with dyslexia do well in treat underlying oral language difficul- tion for remedial programs.§§ In addi- small group instruction of matched ties often associated with dyslexia or tion, students with dyslexia often need students, whereas others need one-on- help students learn phonemic aware- a great deal of structured practice and ness. Physical and occupational thera- one help so that they can move for- immediate, corrective feedback to de- pists do not treat dyslexia but do treat ward at their own pace. The instruc- velop automatic word-recognition fine motor, gross motor, balance, pro- tion must be intensive enough and skills. Remedial programs should in- prioceptive, and sensory-processing continue long enough to have a posi- clude specific instruction in decoding, 105 disorders that may coexist in some tive effect that will endure. If a stu- fluency training, vocabulary, and com- children with learning disabilities.19 A dent with dyslexia has an outside aca- prehension.࿣࿣ The approach to learn- vision specialist for the visually im- demic therapist, the therapist should ing decoding begins with detailed in- paired may benefit children with dys- work closely with the child’s class- struction in phonemic awareness and lexia who have low vision. Physicians, room teachers. then progresses to sound-symbol as- including general pediatricians, devel- The critical elements for effective in- sociation (alphabetic principle), phon- opmental/behavioral pediatricians, tervention include individualization, ics, awareness of rhyme, and word family physicians, neurologists, oph- feedback and guidance, ongoing as- segmentation. Phonics is the system thalmologists, otolaryngologists, men- sessment, and regular ongoing prac- of instruction used to teach children tal health professionals, and other ap- tice.34 Remediation, educational ac- propriate medical specialists may commodation, and modification are ‡‡Refs 1, 14, 24, 25, 30–35, 43, 55, 60, 63–65, 81, and 106. assist in diagnosing and treating any used as techniques for overcoming §§Refs 1, 14, 24, 25, 30–35, 55, 60, and 63–65. associated health problems if they are dyslexia and the educational deficits ࿣࿣Refs 1, 14, 32–35, 43, 55, 60, 63–65, and 81.

PEDIATRICS Volume 127, Number 3, March 2011 e827 Downloaded from www.pediatrics.org by on March 1, 2011 the connection between letters and and tests, shortened or modified as- who avoid reading are most in need of sounds. Longitudinal data indicate that signments, help taking notes, lecture practice. Parents should help with systematic phonics instruction results notes, computers for writing, a sep- practice and reinforcement at home in more favorable outcomes for read- arate quiet room for taking tests, ex- with opportunities to check fluency ers with disabilities than does a tra assistance using computers, and comprehension via interactive context-emphasis (whole-language) spell checkers, a line guide, or tu- reading experiences. Reading practice approach.¶¶ Later, syllable instruc- tors. Reading can be bypassed by us- at home should be conducted in a sup- tion, morphology, memorization of ing tape recorders, recorded books, portive and nurturing environment sight words, spelling, syntax, and se- text-reading computer programs, with adequate opportunity for the mantics are taught.55 A child must first lecture tapes, taped tests, or other child to participate in other activities accurately decode a word before it can testing alternatives.24,25,34,47,81 in which he or she excels. As the child be read fluently, but accuracy does not Many good software programs cur- gets older, parents should help the spontaneously evolve into fluency. rently exist and are affordable. Text- child use recommended alternative Sight words need to be memorized, reading software programs provide learning strategies such as books on and speeded word-repetition drills an excellent opportunity for students tape or computers. should be performed. Daily fluency with dyslexia to keep up with reading Parents should provide ongoing feed- practice involves repeated guided oral assignments. They are also helpful back to remediating specialists and reading of a large amount of text at the with written examinations and hand- should be given the opportunity to ask child’s independent reading level. outs provided by the teacher. A porta- questions to maximize educational Practicing reading aloud makes feed- ble scanner can easily scan written outcomes. Parents need to serve as back possible. Fluency forms the material in the classroom and at the child’s advocate by speaking with bridge between decoding and compre- home and be used with these pro- the child’s teacher, pediatrician, and hension.34 Comprehension is gained grams. The text-reading rate can be other professionals; requesting an ed- through fluency training, vocabulary adjusted to assist with comprehen- ucational evaluation; and coordinating instruction, and active reading com- sion, and spaces can be created to remediation and other treatment. By prehension.34,35 Techniques that en- write notes in the text. Text-reading educating themselves in the areas of hance active reading comprehension software is also designed to be used learning disabilities, available ser- include prediction, summarization, vi- with writing software to allow a stu- vices, and state education rules and sualization, clarification, critical think- dent’s writing to be read aloud. The regulations, parents will increase ing, making inferences, and drawing software includes phonetic spelling their effectiveness as the child’s advo- conclusions.14,24,25,33–35,60,63,65 To further assistance and intelligent word- cate. Parents should work with educa- gain comprehension, these activities prediction features that can address tors to ensure that the school provides should be combined with other activi- the dysgraphia that often co-occurs the proper remediation and accommo- ties to improve language develop- with dyslexia. These programs should dations and should continue to moni- ment.24,25,32–34,55,60,63,64 The brain learns best by practice, and practice is the be a key component of an educational tor their child’s progress and advocate key to learning to read. plan, especially for older students. for their child when necessary. They provide relief, promote self- Schools can implement academic ac- The teaching of children with dyslexia esteem, and are fun to use. Ongoing commodations and modifications to and learning disabilities is a challenge appropriate reading remediation help students with dyslexia succeed. for educators and parents; however, should continue along with these com- Because people with dyslexia have a with proper remediations, educational pensatory techniques. persistent problem and continue to accommodations, and support, chil- read slowly throughout their life, it of- Parental participation in a child’s edu- dren with dyslexia and learning dis- ten becomes necessary to adapt the cation is of utmost importance but abilities can overcome obstacles to im- learning environment.24,25,34,81 Accom- may be more difficult if the parents are prove their reading and writing. modations allow access to higher-level functionally illiterate. The home is an Children with extreme deficits in basic thinking and reasoning strengths. Ex- ideal setting for practice and rein- reading skills or those with the double amples can include preferential forcement.34 Children should read deficit of phonologic and rapid auto- seating, extra time for assignments aloud to their parents using fun, easy- matic naming difficulties are much to-read books. Reading aloud will alert more difficult to remediate than chil- ¶¶Refs 1, 14, 30, 34, 60, 63, 65, 81, and 106. parents if a problem exists. Children dren with mild or moderate deficits.30

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The prognosis depends on the severity her for further evaluation if deemed ular, and visual disorders are identi- of the disability; specific patterns of appropriate.98,108 The physician should fied as early as possible.109 Periodic strengths and weaknesses of the indi- take a complete medical history, in- eye and vision screenings can identify vidual child; and the appropriateness, cluding determination of maternal most children who have reduced vi- amount, intensity, and timing of the in- drug or alcohol use, neonatal/birth sual acuity or other visual disorders. tervention.34 The instruction must be problems, genetic syndromes, and Vision screening with nonletter sym- intensive enough and continue long congenital anomalies. Additional med- bols may be necessary for testing chil- enough to have a positive effect that ical history should include detection of dren with dyslexia or other learning will endure.105 Early identification and medical problems (such as chronic or disabilities.110 treatment are the keys to helping chil- persistent otitis media, asthma, thy- Children who do not pass vision dren with dyslexia, because children 8 roid problems, or any chronic disease screening should be referred to an years and younger are more likely to that may have caused school absenc- ophthalmologist who has experience show improvement. es); neurologic problems (such as sei- with the care of children.109,110 In addi- A potential goal in the treatment of dys- zure disorder, head trauma, history of tion, the recommended routine pediat- lexia will be its prevention. Brain mea- central nervous system infection, or ric vision screenings are unlikely to sures, such as studies of longitudinal lead poisoning); developmental, be- disclose near-vision problems such as event-related potentials, have shown havioral, emotional, or psychiatric convergence insufficiency, accommo- impressive relations between brain re- problems (anxiety, depression, obses- dative insufficiency, and significant hy- sponses at infancy and later language sive compulsive disorder, or opposi- peropia. Children with suspected and reading success or failure. In the tional defiant disorder); ADHD; or learning disabilities in whom a vision future, a combination of behavioral autism spectrum disorder. Specific problem is suspected by the child, par- and brain measures, perhaps together questions on language acquisition and ents, physicians, or educators should with genetic and familial information, learning should include history of be seen by an ophthalmologist who may enhance the certainty with which speech delay, speech difficulties, or ar- has experience with the assessment dyslexia can be predicted and promote ticulation problems; difficulties in and treatment of children, because the possibility of preventive interven- learning letters or phonics; lack of some of these children may also have a tion that would allow many more chil- reading readiness; poor instruction; treatable visual problem that accom- dren to succeed at learning to read.53 overall academic achievement; and vi- panies or contributes to their primary sual difficulties. A family history of reading or learning dysfunction.110–113 ROLE OF THE PEDIATRICIAN AND speech and language problems, learn- Treatable ocular conditions can in- PRIMARY CARE PHYSICIAN ing disabilities, or functional illiteracy clude strabismus, amblyopia, con- Pediatricians and primary care physi- should also be noted. A social history vergence and/or focusing deficien- cians can serve a number of important should be taken, and alcohol use, drug cies, and refractive errors. Missing functions for children with dyslexia use, cultural differences, or poverty these problems could cause long- and their family members. Develop- for the child or the family should be term consequences from assigning mental screening as early as 30 to 48 noted. A complete physical examina- these patients to incorrect treat- months may identify language or tion to evaluate the child’s overall med- ment categories. learning concerns. During well-child ical and neurologic condition and a Pediatricians and primary care physi- visits, physicians should inquire about psychological, emotional, and behav- cians play an extremely important the child’s educational progress and ioral evaluation should be performed. function in acting as a medical home be vigilant in looking for early signs of An assessment of the child’s activity by helping parents decide whether fur- evolving learning disabilities. General level, attention span, alertness, coop- ther evaluations are needed and in co- pediatricians should not diagnose eration, and ability to communicate ordinating care for the child after a di- learning disabilities but may discuss should be noted. agnosis has been made.98,108 A child the possibility with parents.108 When a Primary sensory impairments should should receive medical and psycholog- child has suspected learning difficul- be ruled out by hearing and vision ical interventions as appropriate for ties, the pediatrician or family physi- screenings. For all children, primary diagnosed conditions.108 If the pediatri- cian should first assess the child for care physicians should perform hear- cian believes that the child has not re- medical problems that could affect the ing and vision screenings according to ceived a proper assessment at school, child’s ability to learn and refer him or national standards so that hearing, oc- then the pediatrician should refer the

PEDIATRICS Volume 127, Number 3, March 2011 e829 Downloaded from www.pediatrics.org by on March 1, 2011 child for an outside independent edu- a complex disorder and that there are are normal in young children and are cational evaluation by an educational currently no quick cures. The American usually of no pathologic significance. psychologist, clinical psychologist with Academy of Pediatrics has information The average refraction of white chil- special training in learning assess- for families on what parents need to dren in the United States is nearly 2.00 ments, neuropsychologist, developmen- know about learning disabilities.114 diopters (D) of hyperopia in the first 5 tal/behavioral pediatrician, neurodevel- Pediatricians and primary care physi- years of life and then gradually de- opmental pediatrician, or neurologist cians should be familiar with the IDEA, creases into adolescence.115 (A diopter with appropriate expertise. Referral to Section 504 of the Rehabilitation Act, is the unit of measurement of the re- an educational psychologist for psycho- and the ADA, because these acts define fractive power of lenses equal to the educational assessment for the purpose the rights of students with dyslexia reciprocal of the focal length mea- of identifying special needs should be and other specific learning disabili- sured in meters.) Nonmyopic signifi- considered if the primary issue is the ties.95–97 The IDEA allows parents to re- cant refractive errors are present in child’s educational performance or quest a formal educational evaluation 10% of children younger than 12 years. learning problems. For patients with by the school district to determine eli- Children with uncorrected myopia will complex or long-standing educational gibility for special education.96 Infor- have reduced distance visual acuity problems that have been difficult to re- mation for pediatricians on this legis- and, thus, have difficulties with read- mediate, referral to a neuropsycholo- lation and its associated rights and ing the board at school but no difficulty gist, developmental/behavioral pediatri- procedures is available from the with near vision. Despite the condition, cian, neurodevelopmental pediatrician, American Academy of Pediatrics.98,108 children with myopia have been found or neurologist with appropriate exper- Physicians can refer parents of chil- to be average to above-average stu- tise should be considered for a more in- dren with learning disabilities to dents. Early optometric studies that depth evaluation of brain function to their state’s parent training and have indicated increased hyperopia in asses overall cognitive, emotional, and information center. These parent- children with reading difficulties are of behavioral functioning. A child should be directed centers provide informa- limited significance, because the stud- referred to a neuropsychologist for tion and technical assistance to par- ies did not have control groups and problems such as learning, attention, be- ents and professionals about family were generally unreliable because havior, socialization, or emotional con- and student rights and responsibili- they were performed without cyclople- trol; a disease or developmental prob- ties in special education. gia.116 Before diagnosis and treatment, lem that affects the brain; or a brain Physicians who have a strong role in children with uncorrected high hyper- injury from an accident or birth trauma. assisting school districts should rec- opia may be uninterested in books and Pediatricians and primary care physi- ommend only evidence-based treat- near tasks and secondarily experience cians should compile and provide a re- ments and accommodations. They difficulty starting to read, but they do source list of local specialists from should also discourage school dis- not have an increased likelihood of whom the child can obtain proper help tricts and parents from pursuing true dyslexia.115 There is no correlation and from whom the family members can treatments that are not evidence between reading performance and any learn to become advocates for the based, because they are likely to waste specific type of refractive error, includ- child.108 Pediatricians and primary care time and resources. ing hyperopia or a need for glasses.111 physicians should provide information and support to parents on learning dis- THE EYES AND VISION Amblyopia causes reduced visual acu- abilities and their treatment and should ity and susceptibility to the crowding dispel the myths surrounding these dis- Visual Acuity and Refraction phenomenon, a difficulty with distin- orders.111 When parents inquire about a Books for beginning readers usually guishing letters in close proximity to new technique or treatment concept, have very large print of approximately one another, but only in the amblyopic physicians should be ready to discuss 20/200 to 20/100 size. Good visual clar- eye/visual system. In children with am- the treatment and the current knowl- ity and resolution are necessary to dis- blyopia, fixation is usually performed edge about its efficacy.26 This discussion cern small print. There is no evidence with the fellow, nonamblyopic eye/vi- should include providing the parents that children with moderate myopia, sual system. In 1 study, microstrabis- with information regarding the lack of moderate hyperopia, or moderate mic amblyopia was associated with proven efficacy of vision therapy and astigmatism have any greater diffi- slower reading rates but not with dys- other “alternative treatments.”111 Par- culty in learning to read than do other lexia.117 Nystagmus, bilateral cata- ents need to be informed that dyslexia is children. Small amounts of hyperopia racts, and retinal or optic nerve prob-

e830 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS lems can interfere with visual acuity. over to the next fixation point. More let- dren with dyslexia often lose their Children with severe visual impair- ters are processed to the right of fixa- place while reading because they ment are able to learn to read with as- tion if the eye is scanning from left to struggle to decode a letter or word sistance from spectacle correction for right, as in English, and the opposite combination and/or lack attention or refractive errors and low-vision appli- would be true for reading a language comprehension, not because of a ances. In general, ocular disease does than is scanned from right to left. “tracking abnormality.” Children with not affect the ability of children to Early anecdotal publications in the op- saccadic disorders, Duane syndrome, learn to read. Furthermore, children tometric literature in the 1950s re- Moebius syndrome, and abnormal eye who are blind are able to learn to read ported a possible oculomotor deficit movements such as those with con- using Braille. Vision impairment, in it- that disrupted the normal saccadic genital motor nystagmus have shown 137 self, has not been shown to be a pre- reading pattern. In contrast, many the ability to learn to read fluently. 58 dictor of reading disability. studies subsequently have demon- Dyslexia is no more frequent in these children with significant eye- Saccades and Fixations strated that ocular coordination and motility are normal in children with movement disorders than in the gen- 137 The eye movements used in reading dyslexia.121–129 No difference was found eral population. Problems such as are not similar to a typewriter typing. between adults with dyslexia and con- nystagmus interfere with foveal fixa- Smooth pursuit or tracking eye move- trols on measures of saccadic accu- tion time, yet affected children have 136 ments are not used in reading. Read- racy and saccadic latency.130 Readers not shown an increased likelihood of ing uses saccades that are short- with dyslexia have shown saccadic eye dyslexia. Thus, dyslexia is not the re- duration, high-velocity, small jumping movements and fixations similar to sult of oculomotor deficits but, rather, eye movements. Reading uses both for- those of the beginning reader and have the result of more central processing 125 ward (rightward in English) saccades shown normal saccadic eye move- problems. (85% of saccades) and backward or ments when content is corrected for Accommodation regression (leftward in English) sac- ability.111,122 Improving reading has 118,119 cades (15% of saccades). Scan- been shown to change saccadic pat- Accommodation is the ability to focus ning a line of text in English involves a terns, but there is no evidence to sug- accurately at near and is necessary for sequence of rightward and leftward gest that saccadic training results in reading at near. Accommodative am- saccades. The saccade length depends better reading. Readers with dyslexia plitudes are maximal in childhood and on the ability to recognize letters, the have shown normal sequential sac- decrease naturally with age. The aver- difficulty of the text, and the length of cadic tracking in tasks other than age amplitude of accommodation in the word before the saccade. Experi- reading and oculomotor function- children younger than 10 years is 14 D, enced readers use longer saccades of ing.125 Simulated saccadic “abnormali- which corresponds with a near point approximately 2 degrees or 8 letters of ties” can be created by giving normal of accommodation of 2 to 3 in. Fifty per- 120 average-sized print text. Backward readers overly complex material or cent, or 7 D, is available for sustained saccades are used for verification and material in a new language.122 Results near activity; thus, young children can comprehension, increase with the dif- of 3 studies by Rayner et al131–133 were read comfortably at 6 in for a pro- ficulty of the text, and are also used to consistent with visual/linguistic- longed time. In the pediatric popula- jump to the next line. Early readers use control models of eye-movement con- tion, the incidence of accommodative 138,139 more backward saccades. Visual per- trol and inconsistent with visual/ insufficiency is low. If it is present, ception is suppressed during sac- oculomotor-control models. The symptoms can include discomfort or cades. Visual information is perceived saccadic patterns seen in readers with blurry or moving vision. Findings of ac- during foveal fixations, which consti- dyslexia appear not as a cause but as a commodative insufficiency may in- 111,118 tute 90% of our reading time. Fix- result of their reading disability.## De- clude decreased visual acuity at near, ations may last 45 to 450 milliseconds coding and comprehension difficul- a remote monocular near point, ac- and average 180 milliseconds. The du- ties, rather than a primary abnormal- commodative lag, and either esopho- ration of a fixation varies with the dif- ity of the oculomotor control systems, ria or exophoria. Decreased accommo- 118 ficulty of the text being read. When are responsible for slow reading, in- dation has been associated with fixated, the eye rests on a content word creased duration of fixations, and in- uncorrected high hyperopia, nonspe- and takes in a span of approximately 7 creased backward saccades.136 Chil- cific viral illness, local ocular trauma, to 9 letters to the right of fixation and 3 many medications, and functional to 4 letters to the left before it jumps ##Refs 14, 111, 112, 116, 118–128, and 134–136. problems.138 There is no proof that

PEDIATRICS Volume 127, Number 3, March 2011 e831 Downloaded from www.pediatrics.org by on March 1, 2011 there is a difference in accommodative proximately 3% to 5% of the popula- and exotropia), also has not been asso- ability between normal and abnormal tion. However, because of the ciated with dyslexia.116,148 readers.111 Difficulties in accommoda- differences in diagnostic criteria, tion do not interfere with decoding but some studies report the prevalence as can interfere with the child’s ability to being as low as 0.3% to 0.8%,142,143 Processing of visual input is a higher concentrate on print for a prolonged whereas a retrospective study of 8- to cortical function.14,15,111 Decoding and period of time.29 12-year-olds in which findings alone interpretation of retinal images occur in the brain after visual signals are The vergence system works to main- were used classified 51% of the chil- transmitted from the eyes. Although vi- tain fusion so that the eyes remain dren with possible convergence insuf- 144 sion is necessary for reading, it is the aligned on a visual target. Conver- ficiency. This classification system is brain that must perform the complex gence is the inward turning of the eyes obviously not valid, because it leads to classifying many normal children as function of interpreting the incoming and is used for near reading. Various abnormal. The disorder is much less visual images. Historically, many theo- authors define convergence insuffi- common in children younger than 10 ries have implicated the visual system ciency differently. The diagnosis of years. The incidence of ADHD was re- in the causation of dyslexia. The de- convergence insufficiency is based on ported in 1 study to be increased in mise of these theories began in the a remote near point of convergence or children with convergence insufficien- 1980s with a series of related studies difficulty in sustaining convergence cy,145 but additional analysis has re- that systematically evaluated deficits combined with asthenopic symptoms vealed that the reported incidence was in visual processes such as visualiza- (sensations of visual or ocular discom- actually average when compared with tion, visual sequencing, and visual fort) at near. The presence of 500 sec- large studies in which the prevalence memory as basic causes of reading dif- onds of arc of stereopsis is required. of ADHD was evaluated.17,18 Conver- ficulties.14,15 Visual theories of reading These findings should be accompanied gence amplitudes have not been corre- disability have become less and less by a low convergence fusional ampli- lated with reading comprehension.146 A popular, because only a few children tude, and/or a large exophoria or in- study of 735 children found no signifi- who are poor readers actually suffer termittent exotropia at near with a cant difference in school achievement from perceptual malfunctions. Robin- smaller exophoria, orthophoria, or for children who showed convergence son and Schwartz149 found no correla- esophoria at the distance. These latter insufficiency and those who did not.147 tion between visual-perceptual abili- findings alone do not constitute the di- Convergence insufficiency can inter- ties and reading ability. Larsen et al150 agnoses of convergence insufficiency, fere with a child’s ability to concen- found no differences in visual percep- because they may be present with trate on print for a prolonged period tion between normal and learning- good convergence.140,141 Of these find- of time but does not interfere with disabled children. Larsen and Ham- ings, the most important are the ability decoding.29 mill151 found no predictive relationship to obtain and maintain convergence. between standardized tests of visual The diagnosis of convergence insuffi- perception and reading ability in their ciency is relevant only if there are mul- True orthophoria—perfectly straight review of 60 studies. Morrison et al152 tiple findings accompanied by signifi- eyes—occurs rarely; most people found no perceptual deficits in chil- cant symptoms. Lack of sleep, illness, demonstrate a small asymptomatic dren with reading disabilities. In short, and anxiety are known to aggravate phoria, a latent deviation usually eso- visual skills do not reliably distinguish the problem. Older children, teenag- phoria or exophoria, that should be children who differ in reading abili- ers, and adults may become symptom- considered a normal variant. A study ty.*** In their review in 2004, Vellutino atic because of large amounts of de- of more than 3000 unselected students et al14 found no statistically significant manding near work and reading while revealed a near phoria in most chil- differences in the studies between fatigued. Patients typically present as dren. Several studies have investi- poor and normal readers on measures teenagers or young adults with gradu- gated the connection between reading evaluating visual recognition and vi- ally increasing complaints of discom- ability and the binocular and accom- sual recall of letters and words. Visual fort, eyestrain, headache, blurred vi- modative status of unselected chil- deficits of the types from the early lit- sion, or diplopia during extended dren. No causal relationship was found erature were found to be no more periods of studying. between normal variants and reading/ prevalent in poor readers than they 113 The prevalence of convergence insuf- writing difficulties. Manifest strabis- ***Refs 2, 9–12, 14, 15, 116, 119–128, 134, 135, 137, ficiency has been reported to be in ap- mus, known as tropias (eg, esotropia and 149–151.

e832 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS were in normal readers. In many stud- ROLE OF THE OPHTHALMOLOGIST lary dilation. Vision testing with nonlet- ies that compared poor and normal Because routine pediatric vision ter symbols may be necessary and readers, few significant differences screening is not designed to detect may be especially important for test- were found on measures of visual pro- problems with near vision, children ing children with dyslexia or other cessing ability when the influence of with suspected or diagnosed learning learning disabilities. The eye examina- verbal coding was controlled.14 Diffi- disabilities should undergo a compre- tion should place special importance culties in maintaining proper direc- hensive pediatric medical eye exami- on the detection of undiagnosed vision tionality have been demonstrated to be nation by an ophthalmologist who has impairment by assessing visual acu- a symptom, not a cause, of reading experience with the assessment and ity at the distance and near, signifi- disorders.14,15,111,122 Word reversals treatment of children, because some cant refractive errors, amblyopia, or and skipping words and lines were children may also have a treatable vi- strabismus. attributable to linguistic deficiencies sual problem along with their primary Strabismus, amblyopia, and refractive and not visual or perceptual reading or learning dysfunction.110–113,154 errors may require glasses, eye patch- disorders.14,15,59 The medical history should include de- ing, eye drops, convergence training, In summary, vision problems can in- tection of any medical condition that prisms, or eye muscle surgery in ac- terfere with the process of reading; could interfere with the child’s ability cordance with standard principles of 110,157,158 however, vision problems are not the to learn or a chronic medical illness treatment. In school-aged chil- dren without strabismus or amblyo- cause of dyslexia. Significant refrac- that could cause school absences or pia, correction of myopia should be tive errors can make reading more dif- difficulties concentrating or learning. considered approximately at Ϫ0.75 D ficult. Convergence insufficiency and The ocular history should include any eye or vision complaints that may or greater, astigmatism at 1.00 D to poor accommodation, both of which make it difficult for the child to concen- 1.50 D or greater, hyperopia atϩ4.00 D are uncommon in children, can inter- trate on reading for extended periods to ϩ4.50 D or greater, anisometropic fere with the physical act of reading of time. It is important for the ophthal- myopia at 2.00 D or greater, anisome- but not with decoding and word recog- mologist to recognize that healthy chil- tropic hyperopia at 1.50 D or greater, nition.29 Thus, treatment of these disor- dren often have visual complaints and anisometropic astigmatism at ders can make reading more comfort- from normal visual phenomena such 1.50 D to 2.00 D or greater.110,159 Myopia able and may allow reading for longer as physiologic diplopia and relaxation and astigmatism are fully corrected, periods of time but does not directly of accommodation.112,155 Also, most whereas high hyperopia is often un- improve decoding or comprehen- children (82%) who complain of eye- dercorrected by up to 50% but no more 29 sion. If reading impairment is attrib- strain and headaches have a normal than 3.00 D, depending on the clinical utable solely to a visual problem, im- eye examination, whereas children situation.110 These guidelines should provement in school performance with refractive error (78%), amblyopia be adjusted on the basis of the pa- should be observed once the problem (68%), or strabismus (58%) are free of tient’s visual needs and symptoms, 153 is corrected. Other than the need for eyestrain, which makes these com- such as asthenopia and reduced visual long-term optical correction, these plaints a poor marker of eye condi- acuity or lack of symptoms. Children problems generally do not require ex- tions in young children.156 with developmental delay or Down syn- tended treatment programs. The ophthalmologist should perform a drome often hypoaccommodate and Many children with reading disabili- complete dilated eye examination, in- may benefit from spectacle correction ties enjoy playing video games, includ- cluding cycloplegic refraction. Cyclo- at lower thresholds.159 ing handheld games, for prolonged pe- plegia with either 1% or 2% cyclopen- A careful external ocular examination riods. Playing video games requires tolate is necessary for accurate should be performed to determine if concentration, visual perception, vi- refraction in young children. The the child has problems such as dry sual processing, eye movements, and strength should be based on the eyes, blepharitis, or ocular allergies eye-hand coordination. Convergence child’s weight, iris coloration, and dila- that could cause eye irritation that can and accommodation are also required tion history. In eyes with heavily pig- secondarily interfere with his or her for handheld games. Thus, if visual def- mented irides, adjunctive agents such ability to concentrate and learn. Fi- icits were a major cause of reading as tropicamide and/or phenylephrine nally, a dilated retinal evaluation disabilities, these children would re- hydrochloride may be necessary to should be performed. Retinal or optic ject this vision-intensive play activity. achieve maximal cycloplegia and pupil- nerve problems can lead to strabis-

PEDIATRICS Volume 127, Number 3, March 2011 e833 Downloaded from www.pediatrics.org by on March 1, 2011 mus, amblyopia, reduced visual acuity, culties in concentrating on print for erally, children are reevaluated in the and, rarely, . prolonged periods of time. Symptom- office on a monthly basis.140,161 Inten- Emphasis should be placed on the eval- atic accommodative insufficiency with sive in-office vision therapy is effective uation of ocular alignment, binocular a near point of accommodation well but not required.161,163–165 Alternatively, function, stereopsis, accommodation, outside established norms can be for other patients, reading glasses and convergence. Ocular alignment is treated with reading glasses or bifo- with base-in prism or occlusion during assessed by using the corneal light cals; it must be emphasized, however, reading can be used to treat the symp- reflection, the binocular red-reflex that this condition is rare; hence, bifo- toms of diplopia but not the underlying (Bruckner) test, cover/uncover, and cals are rarely needed by children. convergence insufficiency.140 The treat- alternate-cover tests in primary gaze Treatment of accommodation difficul- ment of convergence insufficiency can with accommodative targets at dis- ties can make reading more comfort- help reading become more comfort- tance and near when feasible; cover able but does not improve decoding or able and may allow reading for longer testing is most important. If an ocular comprehension.29 periods of time, but this approach misalignment is detected, multiple The near point of convergence should does not directly improve decoding or measurements of the ocular deviation be tested by using an accommodative comprehension.29 using prisms in 1 or more fields of gaze target and measured with a ruler. In summary, the ophthalmologist at distance and/or at near is neces- Distance- and near-convergence am- should identify and treat any signifi- sary. Ocular versions and ductions plitudes can be measured by using a cant visual defect according to stan- should be evaluated. Stereoacuity can base-out horizontal prism bar or ro- dard principles of treatment.110,153,158,166 be evaluated with the random dot E, tary prism while the child is reading. If no ocular or visual disorder is found, Lang, or stereo fly test, whereas fusion Symptomatic convergence insuffi- the child needs no further vision treat- can be tested with the Worth 4-dot test ciency can cause discomfort, eye- ment. The ophthalmologist should not or Bagolini lenses. These tests can be strain, blurry vision, diplopia, and diagnose learning disabilities but performed at both near and distance headache, which can contribute to lim- should provide information on learn- when necessary. ited fluency by interfering with the ing disabilities and reinforce the need Near visual acuity should be assessed child’s ability to concentrate on print for additional medical, psychological, in the evaluation of accommodation. for a prolonged period of time. Symp- educational, or other appropriate eval- The monocular near point of accom- tomatic convergence insufficiency is a uation or services.153,167 The ophthal- modation can be measured by conven- treatable condition. To improve read- mologist, when necessary, should tional push-up technique using a ruler, ing comfort, it can be treated with compile and provide a resource list of Clark stick, or Costenbader accommo- near-point exercises, prism convergence local specialists to assist in obtaining dometer.160 Before cycloplegia, dy- exercises, or computer-based conver- proper help for the child.167 In addition, namic retinoscopy can provide a rapid gence exercises. Home computer- the ophthalmologist should dispel assessment of accommodative func- based convergence exercises are a myths surrounding these disorders tion and may be helpful in evaluating a newer method of treatment, and many and discuss the lack of proven efficacy child with high hyperopia, accommo- children enjoy using the computer pro- of vision therapy and other alternative dative lag, or possible accommodative gram. Over the years, orthoptic ther- treatments with the parents. The insufficiency. The accommodative fa- apy has been adapted into simple vi- American Academy of Ophthalmology cility can be assessed by alternately sual tasks that can be taught in the and American Academy of Pediatrics applying Ϫ2.00 and ϩ2.00 lenses office and conducted by the patient at have patient-education brochures for while the child reads monocularly. home. Near-point convergence exer- families on learning disabilities.114,168 Symptomatic accommodative infacility cises generally consists of push-up ex- may cause difficulty in shifting from ercises using an accommodative tar- SCIENTIFIC RESEARCH AND far to near and near to far. The accom- get of letters, numbers, or pictures; DISSEMINATION TO THE PUBLIC modative amplitude can be assessed push-up exercises with additional Science advances by a process of mod- by using increasing minus lenses base-out prisms; jump-to-near- ification. A continuous process of re- while the child reads monocularly. convergence exercises; stereogram search and testing needs to take place Symptomatic accommodative insuffi- convergence exercises; recession to show that a treatment has demon- ciency can cause blurry vision and dis- from a target; and maintaining conver- strable effect and benefits and to com- comfort, which can contribute to diffi- gence for 30 to 40 seconds.140,161,162 Gen- pare effectiveness between treat-

e834 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS ments. Over the last 50 years, progress scientific study reports. A positive as- posthoc subgroup analysis is per- in medicine has been based on con- certainment bias leads us to remem- formed; new statistically significant trolled studies. Evidence-based medi- ber only positive results and positive outcomes are introduced for publica- cine (EBM) categorizes different types studies. Positive studies are more tion; nonsignificant primary outcomes of clinical evidence and ranks them ac- likely to be published than are negative are omitted from reports; or statisti- cording to the strength of their free- studies because of publication bias. cally significant secondary outcomes dom from various biases. The “evi- Nonrandom sampling leads to difficul- are upgraded to primary end points.173 dence pyramid” ranks testimonials, ties generalizing the data. Selection Poorly conducted research may pro- anecdotes, case reports, and case bias includes self-selection, subject duce false-positive or false-negative studies as poor sources of scientific prescreening, and attrition. Manipula- results. Studies that do not control information. Alternative medicine tion of the data by rejection of “bad for the placebo effect may produce makes most of its claims by unsub- data” or “outliers” leads to biased false-positive results. Studies with stantiated testimonials. data. Preliminary positive results in controls and “no-treatment groups” EBM is the use of the most reliable cur- smaller studies often are not repeat- are necessary to evaluate the size of rent evidence to make treatment deci- able in larger randomized, placebo- the placebo effect. The placebo effect sions. The practice of EBM integrates controlled, double-blinded studies. A may be a large portion of the positive individual clinical expertise with the study with more preliminary support- responders. ing evidence is more plausible than best available external clinical evi- The public is largely uninformed about 169 one with weak or no previous support- dence from systematic research. the hallmarks of good research. The ing evidence. False-positive results are EBM is open to new evidence and re- finding of an association is not a find- more likely in clinical trials that exam- vised conclusions. To use EBM, the phy- ing of cause and effect. There should ine highly improbable hypotheses sician should investigate the medical be documented objectivity associated compared with hypotheses with a literature efficiently, read the method- with research, and, when possible, stronger basis in science.171,172 ology section to evaluate the quality of there should be replication. Good re- the evidence to determine the validity The Hawthorne effect may occur and search is rigorous and objective and of the study, and, lastly, evaluate the bias the research when the experi- requires peer review. Research find- results. The issue of validity speaks to mental subjects change their behavior ings should be tested and scrutinized the “truthfulness” of the information. as a result of being observed, not in from many angles by multiple, unre- Properly performed scientific studies response to any particular experimen- lated researchers. Ideally, a study of offer the possibility of validity. Critical tal manipulation. The multiplicity prob- efficacy compares a treatment with a appraisal is a systematic process used lem may occur when the more often a placebo or another treatment by using to identify the strengths and weak- hypothesis is tested, the more likely a a double-masked controlled trial and nesses of a research article to assess positive result will be obtained. Simi- well-defined protocol. Reports should the usefulness and validity of its find- larly, when a lot of data are collected describe enrollment procedures, eligi- ings. If the study is not valid, the data without a specific hypothesis in ad- bility criteria, clinical characteristics are not useful.170 The physician must vance, some pattern will likely be of the patients, methods for diagnosis, not take the conclusion seriously until found. An advanced hypothesis and ap- randomization method, definition of the appropriateness of the study de- propriate statistical methodologies to treatment, control conditions, and sign, methodology, and statistical control the probability of false-positive length of treatment. Standardized out- analysis have been critically evaluated. findings are essential for demonstrat- comes and appropriate statistical Thus, a physician cannot read the ing credible scientific findings. analyses should be used. Age-matched study abstract alone and be confident In poor research, the results or the control groups are important in of the conclusion. Serious scientific, conclusions may be skewed or biased learning-disability studies.112 Good methodologic, and statistical flaws to seem to be consistent with hypothe- baseline similarities of the population noted in some study reports that in- ses proposed. Confirmation bias oc- and the medical condition is necessary validated their conclusions are dis- curs when experiments are designed to compare like with like. All associ- cussed in “Controversial Theories to seek confirmatory evidence instead ated conditions or treatments should and Therapies.” of trying to disprove the hypothesis. be controlled. The comparison groups Many types of statistical bias or other Conclusions may be misleading or ar- must be the same except for the factor problems can be present in published tificially inflated when data-derived, that is being studied. Large-scale stud-

PEDIATRICS Volume 127, Number 3, March 2011 e835 Downloaded from www.pediatrics.org by on March 1, 2011 ies provide more reliable conclusions serve as scientific consumer advo- being commercially promoted be- by reducing the margin of error. The cates and help parents, teachers, and fore the research shows any support strongest evidence for therapeutic the community at large to evaluate for the proposed treatment; or there interventions is provided by carefully claims and insist on hard evidence re- is clear research evidence showing designed large-scale, randomized, garding diagnostic and therapeutic that the approach does not work, double-blinded, placebo-controlled tri- modalities. Although it is prudent to be yet the approach is still advertised als that involve good baseline similari- skeptical, especially with regard to commercially. ties of patient population and medical prematurely disseminated therapies, Kennedy et al180 stated that unvali- condition with an adequate follow-up it is important to also remain open- dated treatments often claim to be ef- time and low study participant attri- minded. Aggressive marketing, dra- fective against a range of disorders tion rate.170 matic presentations, loosely reviewed with different symptoms and etiolo- From a scientific perspective, “healthy journal articles, and fervent anecdotal gies. Worrall181 recommended that the skepticism” should be adopted by the reports of cure may convince school public be suspicious of any therapy research community174 and the public. personnel and parents that visual that claims to treat a large number of Scientists hesitate to accept research training is the answer. Levine warned illnesses. He stated that the chronic results unless they can demonstrate a that in such cases, the pediatrician nature of learning disabilities offers statistical probability of more than may be bypassed and considerable the ideal environment for fraud and 95% that the observations are not at- family and community resources may quackery. He noted that parents often tributable to chance. The research be diverted toward unsubstantiated abandon common sense in their quest community is willing to embrace a the- interventions. to help their struggling children and ory only when there is substantial Helveston177 stated that it has become become easy prey for therapists who convergent evidence from multiple traditional in medicine for new and un- promise a cure.181,182 Thus, the public sources. It often takes years to convince proven treatments to be evaluated un- must learn to carefully evaluate the in- the research community that a theory der a protocol by qualified investiga- formation received in the face of ag- has merit, but it frequently takes no time tors on patients who give informed gressive promotion. at all to convince the public. consent after the risks and benefits CONTROVERSIAL THEORIES AND The media now play a major role in have been explained. The work is often THERAPIES providing information or misinforma- performed at no charge, and results tion on new scientific developments to are reported for peer review. Only Magnocellular Deficit Theory when the aforementioned criteria are the public. They may report claims by a There is continuing interest in low- tiny minority and place them on equal met and it is shown that treatment is level impairments of the visual system footing with the majority opinion or re- effective is treatment customarily of- as an etiologic factor in dyslexia. The port claims before any research. Some fered on an unrestricted basis. Accord- visual system is composed of 2 parallel scientists report their claims directly ing to Helveston, the use of tinted systems: the magnocellular (large- to the media, which circumvents the lenses or filters and vision therapy for celled) (transient) system and the par- normal process of scientific review learning disabilities does not follow vocellular (small-celled) (sustained) and debate. Public health messages these standards. system.183 The magnocellular system are inadequate or distorted when jour- Silver178,179 has written many articles responds to high temporal frequency nalists ignore complexities or fail to on controversial therapies including and object movement, and the parvo- provide context.175 The result is that a vision therapy. He stated that a treat- cellular system is sensitive to low- large share of the science seen by the ment approach can be considered sus- frequency and fine spatial details.183 public is flawed because of minimal or pect if the approach is proposed to the The magnocellular component of the distorted scientific facts. This public public before any research results are visual system is important for timing information can influence the behavior available or preliminary research has visual events and controlling eye of clinicians and patients. Media hype not been replicated; the proposed ap- movements when reading.183,184 It is of the overstated findings of poorly de- proach goes beyond what research postulated that the magnocellular sys- signed research may change behavior data support; the approach is used in tem suppresses the parvocellular sys- and harm public welfare.176 an isolated way when a multimodal as- tem at the time of each saccade. This In 1984, Levine128 stated that pediatri- sessment and treatment approach is suppression terminates the activity in cians (and ophthalmologists) must needed; the treatment approach is the parvocellular system to prevent ac-

e836 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS tivity elicited during a fixation from lin- rapid changes of the stimulus. It was that have found no loss of contrast- gering into that from the next fixation. concluded that the temporal deficits sensitivity and other studies that have The magnocellular deficit theory of were attributable to a defective mag- found contrast-sensitivity reductions dyslexia proposes that without this nocellular visual pathway, because or other findings inconsistent with a suppression, the parvocellular activity this pathway preferentially responds magnocellular deficit.188–201 Thus, the from different fixations would be con- at higher temporal rates and lower evidence in support of the magnocellu- fused, which would result in a failure contrasts. This finding was not repro- lar theory is equivocal at best. Amitay to keep separate neural activity elic- duced in a larger study by Victor et et al191 found that although some (6 of ited during different fixations. Specific al,188 who concluded that it was un- 30) subject with dyslexia showed im- reading disability in a small subset of likely that a simple loss of magnocellu- paired magnocellular function, they patients with dyslexia has been attrib- lar function readily manifest in the vi- consistently showed impaired perfor- uted to a deficit in the magnocellular sual evoked potential is causally and mance in auditory and nonmagnocel- visual system.183–187 specifically related to dyslexia. Also in lular visual tasks. Amitay et al hypoth- In 1983, Breitmeyer183 proposed that opposition to Livingstone et al, May et esized that the magnocellular pathway reading disability is an expression of al189 found that the latency periods deficit is part of a more generalized the disruptive effects of a temporal were shortened under low spatial fre- deficit in fast temporal processing of processing deficit in the magnocellu- quency conditions. In 1993, Lehmkuhle visual, auditory, and perceptual in- lar system. Stein and Walsh184,187 sug- et al185 noted the lack of change in the formation. Hutzler et al129 suggested gested that this deficit in the inhibitory latency of the visual evoked potential that pathologic abnormality in the function of the magnocellular system in reading-disabled children com- magnocellular system may coexist produces a visual trace of abnormal pared with the increased latency noted with dyslexia but that it is not causal. longevity that creates masking effects in children without a reading disability Skoyles and Skottun202 calculated along with visual acuity problems by using low spatial frequency target that more people without dyslexia when reading connected text. This vi- and high-frequency flicker fields. Their have magnocellular deficits than sual trace could be responsible for conclusion was that it is possible that those with dyslexia, which chal- complaints of visual distortion and a defect in the magnocellular pathway lenges the view that dyslexia is the moving print in some people with dys- creates a timing disorder that pre- result of a magnocellular deficit. lexia. Selective disruption of the mag- cludes rapid and smooth integration of Many researchers have concluded nocellular pathway via the posterior detailed visual information necessary that magnocellular system deficits parietal cortex in certain people with for efficient reading. A letter to the ed- and associated visual trace persistence dyslexia could lead to deficiencies in itor from Victor190 interpreted the find- are not significant causes of specific read- visual processing, visuospatial atten- ings of Lehmkuhle et al as showing ing disability.14,188–190,192–203 tion, and abnormal binocular control. that the equalization of the responses Some study results involving tinted Reading errors have been attributed to of normal readers and reading- lenses, tinted filters, or occlusion instabilities in binocular vision that re- disabled subjects with the addition of seem to support the magnocellular sult from destabilization of binocular the flickering background reflects not theory,183–187,204 and others refute eye position. However, eye-movement only an increase in response latency in it.188–201,205 Iovino et al204 evaluated 60 recordings have shown that poor read- subjects with no reading disability but children with reading disability and co- ers and age-matched normal readers also a statistically insignificant short- morbid conditions involving mathematics have comparable stabilities in binocu- ening of response latency in reading- and ADHD in 1998. Reading accuracy, lar fixation. In another article, Stein disabled subjects. Victor further word-decoding rate, and reading com- and Walsh187 concluded that people stated that this finding defies a simple prehension were assessed by using with dyslexia may be unable to process interpretation in terms of a loss of the red, blue, and no overlay. Colored over- fast incoming sensory information ad- magnocellular input. lays did not differentially affect the equately in the phonological, visual, Most of the evidence supporting the reading performance of subjects with and motor systems. magnocellular theory comes from and without reading disabilities. How- In 1991, Livingstone et al186 found that contrast-sensitivity and functional MRI ever, blue transparencies significantly disabled readers had abnormally long studies on visual movement process- improved reading comprehension in visual evoked-potential latencies in ing.183–187 The studies supporting this all groups but reduced the reading conditions of low contrast or with theory are outnumbered by studies rate. The authors noted that these find-

PEDIATRICS Volume 127, Number 3, March 2011 e837 Downloaded from www.pediatrics.org by on March 1, 2011 ings indicated that the magnocellular words, skipping words and lines, read- sual stress” and perceptual distor- deficit theory may need to be reexam- ing in dim light, shortened reading tions that seem to occur in people with ined. This result is important, because times, and avoidance of reading. Writ- SSS. Currently, the magnocellular dys- Breitmeyer, an author of the Iovino et ing problems can include slanted writ- function theory and cortical excitabil- al report, was also one of the authors ing, unequal spacing, misaligning ity are being considered. Although the who originally proposed the magnocel- numbers, and errors while copying. basis of SSS is unknown and the syn- lular deficit theory of dyslexia. Their al- General symptoms can include head- drome may not exist, interest in col- ternative hypothesis involved the fa- aches, nausea, fatigue, burning eyes, ored filters or overlays as a treatment cilitation of attention. At the present and tearing. The Irlen International for dyslexia persists and promotion time, there is insufficient evidence to Newsletter207 has reported that the continues. base any treatment on this possible Irlen syndrome should often be ex- Although Irlen and proponents of her 203 deficit. pected within the following clinical method routinely refer to SSS as composites: bipolar spectrum disor- Colored Lenses and Overlays though it were an accepted medical der, sensory integration disorder, syndrome, many experts question its At a national meeting in 1983, Irlen206 ADHD, anxiety disorders, school pho- validity.177,208,209 It is interesting that the proposed treatment with tinted lenses bia, cranial cerebral trauma, visual January 2006 Irlen International News- for a specific group of adults with dyslexia, tic disorders, reactive attach- letter stated that 1 reason that the reading problems, which she origi- ment disorders, , mood dis- problem of SSS escapes ophthalmolo- nally called the “scotopic sensitivity order spectrum, recurrent automobile gists is that ophthalmologists typically syndrome” (SSS) (now also called the accidents, excessive daytime fatigue, test under dim-light conditions.207 In Irlen syndrome or the Meares-Irlen and irritable bowel syndrome. 1990, Helveston177 stated that there is syndrome). Before any supporting re- The Irlen method uses colored lenses no evidence that SSS exists and also search, SSS was featured twice on the and filters to reduce the offending wave- that there is no basis to use the word television program 60 Minutes.Onthe lengths and correct these perceptual “scotopic,” because the photopic sys- program, it was stated that specially dysfunctions but does not treat children tem is used for reading. He also noted prescribed tinted lenses may be an ef- or adults with language deficiencies, that reports of successful treatment of fective method for the treatment of a dyslexia, specific learning disabilities, or reading disorders using tinted lenses variety of reading disorders, including attention deficit (Helen Irlen, MA., LMFT, are based on anecdotal information dyslexia.177 This national exposure led personal communication, July 17, 2007). and testimonials.177 For many, the to great interest in the treatment. The In addition to helping people read better, problem goes far beyond that of se- initial claims of Irlen were based on mantics. Hoyt209 and others have main- observations, students’ anecdotal ac- tinted lenses have been credited by mul- tained that SSS is not a recognized counts, and no formal experimenta- tiple Irlen International newsletters with medical syndrome and consists tion. Supporters of the Irlen syndrome helping those who suffer from light sen- contend that the syndrome affects, to sitivity, discomfort, and distortions asso- merely of a group of vague and non- some degree, 12% to 15% of the gen- ciated with a wide variety of different specific symptoms derived from anec- eral population and 45% of those with problems, including head injuries, con- dotal accounts. To this day, there are learning problems. People with this cussions, whiplash, perceptual prob- no clearly established criteria for SSS. syndrome are thought to suffer from lems, neurologic impairment, memory The only defining characteristic is a re- perceptual dysfunctions that cause vi- loss, language deficits, headaches (in- ported benefit of colored filters while 208 sual distortion, light sensitivity, visual cluding ), autoimmune disease, reading. stress, and visual fragmentation from fibromyalgia, , In 1990, the Journal of Learning Dis- sensitivities to particular wavelengths , , compli- abilities published 3 articles in a spe- of light not attributable to ocular con- cations from laser-assisted in situ kera- cial series on use of the Irlen tech- ditions. This syndrome is postulated to tomileusis (LASIK) and radial keratot- nique. A preface was written by interfere with overall attention, perfor- omy, depression, seasonal depression, Wiederholt,210 the editor in chief, who mance, fluency, and comprehension chronic anxiety, schizophrenia, multiple noted that the Irlen techniques had re- and create symptoms similar to learn- sclerosis, Asperger syndrome, and ceived extensive media coverage with- ing disabilities. Proposed reading others.207 out having data-based, experimentally problems can include slow reading A multitude of different models have controlled studies to validate either rate, poor comprehension, misreading been used to explain the apparent “vi- the syndrome or the treatment ap-

e838 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS proach. He stated that the consulting semiplacebo. He also noted that the groups. The improvement in some of editors who reviewed the studies for study only had a 50/50 chance of ob- the subjects in the placebo-filter publication noted significant scientific taining a statistically significant find- groups may have been attributable to and methodologic flaws that created a ing because of the small study size the placebo effect.209 The finding of re- significant controversy as to whether (which was actually the best of the 3 gression may have been attributable the studies should be published in the studies).176 Furthermore, no control to the unreliability or variability of the journal. He further stated that on the group was used,176,209 and 12 of the 44 reading assessments. Solan noted that basis of these 3 studies and the litera- subjects reported changes in remedial the improvement in reading was ture before 1990, the validity of the coaching, degree of assistance, or an equivocal211 and that the use of grade- Irlen technique still had not been alteration in the learning/supportive equivalent scores was mislead- established. environment. Hoyt209 and Solan211 ing.176,211 Solan also noted that there These 3 studies were then reviewed in noted that the study authors stated was no optometric pretesting.211 Most the journal by Parker,176 Solan,211 and that the participants had undergone importantly, this study was highly Hoyt.209 In their reviews of these 3 Irlen- optometric or ophthalmic examination flawed, because the children under- filter studies, Parker, Solan, and Hoyt within the year but did not provide the went biased selection.209,211 Dropping noted serious methodologic flaws. results. Because of the many weak- the 13 subjects in the study led Parker Parker concluded that the findings nesses in this study, the conclusion is to explain that using the same or sim- could not be considered statistically or not valid. ilar measures to define the treatment scientifically valid. Because firm con- The second study was by O’Connor et group and to assess the effects of clusions could not be drawn, Hoyt rec- al213 of 105 students from grades 2 to 6 treatment is “criterion contamina- ommended a long-term (over 1-year) who were reading below grade level. tion.”176 On the basis of examination of prospective multicenter trial with Students who displayed definite the methodology of this study, the con- carefully constructed control groups scotopic symptoms using the Irlen Dif- clusion is not valid. of children with learning disabilities ferential Perceptual Schedule and dis- The third study, by Blaskey et al,214 in- who have an ophthalmic or optometric played marked improvement in read- cluded 40 participants from the ages examination at the study’s onset and at ing performance with a particular of 9 to 51 years who were self-referred least yearly thereafter. colored overlay were classified as for a study on Irlen treatment. Thirty- The first article in the series was by scotopic. Students who did not show eight of these participants were found Robinson and Conway,212 who studied scotopic signs were classified as to have optometric problems. The poor readers with symptoms of nonscotopic. Thirteen subjects were study then included only subjects who scotopic sensitivity. For the first 3 dropped from the study, because al- tested positive for both SSS symptoms months, the study subjects used an “in- though they had scotopic complaints, and vision problems. Thirty of the 38 termediate” set of lenses based on the they did not show any preference for originally chose to participate, but only student’s first preference, then fol- color and showed no symptomatic or 22 completed the study. The subjects lowed by use of “optimum” lenses for reading improvement with the colored were assigned to an Irlen-treatment, the next 9 months. Optimum color overlays. Ninety-two children contin- vision-therapy, or control group. The lenses were identified after a 2-hour ued in the 1-week study.213 The article’s subjects underwent pretreatment and diagnostic procedure that involved up conclusion stated that reading rate, posttreatment optometric and reading to 130 colors. The use of the intermedi- accuracy, and comprehension were tests. The Irlen-treatment group used ate colors was expected to act as a significantly improved when the Irlen lenses for 2 weeks and placebo “semiplacebo.” The authors concluded scotopic children read with the pre- lenses for 2 weeks, in random order. that comprehension and accuracy but ferred colored overlay. In his review, Three of 11 in the Irlen-treatment not reading rate improved using the Parker noted that the study was very group preferred the placebo filter. optimum color lenses.212 In his review short, and the subjects were divided Subjects in the Irlen-filter group noted of the study, Parker stated that the use into small groups, randomly and in an a reduction in SSS symptoms, but no of age scores was a major flaw, the idiosyncratic manner.176 The small reading improvement or change in op- improvement in all reading measures group size diminished the study’s sta- tometric testing results was noted. seemed developmental, and the treat- tistical significance.176 Reading mea- Three of 11 in the vision-therapy group ment with the optimum lenses seemed sures varied between improvement, dropped out. The remaining subjects to have no greater effect than the no change, and regression in 4 of 5 in the vision-therapy group showed a

PEDIATRICS Volume 127, Number 3, March 2011 e839 Downloaded from www.pediatrics.org by on March 1, 2011 reduction in SSS symptoms and im- provement in variable subskill areas of affected by either the prescribed or provement in optometric testing but reading. One study showed initial pos- placebo filters. improvement on only 1 of 4 reading itive gains in reading that were not The study by Robinson and Foreman219 subtests. Five of the 8 control subjects sustained at retesting. Another study in 1999 also highlighted the need for dropped out. The remaining control claimed that the positive effects may proper control procedures. This study group was too small to be of any signif- have been confounded with other re- measured the effect of Irlen filters on icance, but it was stated that they medial interventions given at the same reading performance as well as stu- showed no change in vision status or time. In many studies with positive re- dents’ perception of their academic symptoms or on any of the reading sults, the effect of heightened expecta- ability. The study included a control measures. Authors of past studies tions cannot be eliminated because of group (no SSS and no filter) and 3 ex- have remarked that the symptoms of the lack of a control group. Robinson perimental groups (placebo, blue, and SSS seem similar to convergence in- also noted that some studies with pos- precision filters). All 4 groups showed sufficiency.209,211,213 This group with itive results were unable to be dupli- increased accuracy and reading com- Irlen symptoms showed a high per- cated. Many studies found no signifi- prehension, and the 3 experimental centage of convergence and accom- cant improvement in reading when groups, including the placebo group, modative dysfunction, which chal- using colored filters. Robinson con- demonstrated significantly more im- lenges the claim that the symptoms of cluded in his review that improved provement than the controls. Sub- SSS are not attributable to vision ab- print clarity may make the learning of jects also perceived an improvement normalities.211,213 This finding high- word-attack skills more effective but in their SSS symptoms regardless of lighted the need for a formal definition will not teach such skills and must be whether they were wearing placebo of SSS. The main flaws in this study accompanied by reading instruction tints, blue tints, or prescribed were that multiple treatments were when needed.208,216 tints.219 This study revealed a likely given to the Irlen-treatment group and Menacker et al217 performed a cohort placebo effect not only on subjective the unacceptably large loss of sub- study (the results of which were pub- symptoms but on actual reading jects. Parker176 challenged the statis- lished in 1993) using 6 different col- performance.208,219 tics in the study and stated that the ored lenses, 1 neutral-density lens, In 2002, Bouldoukian et al220 reported probability of finding a statistically sig- and an empty spectacle frame and on subjects who experienced SSS nificant result when none existed was showed no reading-performance symptoms while reading and con- unacceptably high, which invalided the change or preferred tint among dis- cluded that colored overlays improved study. abled readers. reading speed. However, the results Serious methodologic flaws have con- In 1994, Wilkins et al218 conducted also revealed that greater than one- tinued to be noted in subsequent SSS the first double-masked placebo- third of the subjects preferred the con- studies. In 1991, Evans and Drasdo215 controlled study to test the effect of trol filter and, overall, the subjects criticized the literature for having no colored filters on symptoms of SSS were not significantly more likely to sound theoretical basis for SSS and for and reading performance.218 Subjects prefer their colored overlay than the the unscientific testing of precision who experienced headaches or eye control filter. tints. Robinson216 reviewed the litera- strain in addition to reading difficul- Spafford et al221 found that contrast re- ture concerning tinted lenses and ties were chosen. Both the precision- duction, but not lens color, permitted filters up to 1993. He reported that au- tint and placebo-control groups poor readers to be diagnostically dif- thors of some studies that used anec- showed a reduction in symptoms of ferentiated from proficient readers. dotal comments and questionnaires SSS, but a larger effect occurred in the Lightstone et al222 stated that the reported improvements in symptoms group that used prescribed colored fil- choice of color must be child-specific of visual distortion. Although those ters. Although the contribution of pla- and requires trial and error. Multiple survey studies have produced a high cebo effects was not entirely ruled out, different methods have been used to rate of positive anecdotal comments, this study’s results suggested that select the lens or filter color.218,223–225 they have not been supported by signif- some of the effects of colored lenses Color selection has shown consider- icant gains of reading achievement in may not be entirely attributable to pla- able variability224 and poor test-retest controlled studies. The few noncon- cebo. Although symptoms were re- consistency.226 Also, the tint selected trolled studies that he reviewed duced in this study, reading rate, accu- needed to be changed in up to 25% of showed evidence of inconsistent im- racy, and comprehension were not subjects within 1 year in a study by

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Stone.227 In a study by Croyle, the blue lection, small sample size, biased in- colored filters and lenses may be inef- background provided improvement in terpretation, heightened expectations, fective, except that they act as a pla- the reading rate in low-contrast condi- combination with traditional remedia- cebo. In 1999, Evans237 explained that tions, whereas the blue background tion techniques, and insufficient con- treating visual problems or perceptual had a slight deteriorative effect under trol for the placebo effect to support symptoms will likely alleviate only the high-contrast conditions.228 Solan et the assertion.††† Some studies have “visual component” of reading prob- al229 found that comprehension of poor claimed to detect some improvement lems and will not impact the phono- readers was improved by using blue in a few patients in 1 reading subskill logic deficits underlying most cases of filters, whereas Christenson et al230 but not in other areas. However, im- reading disabilities. Thus, even propo- found no significant difference in read- provements in reading subskills do not nents of precision tints have main- ing comprehension or reading rate necessarily translate into improve- tained that although an improvement when using blue filters. Iovino et al205 ments in reading. Overall, study re- in print clarity may facilitate the pro- found that blue transparencies signif- sults have been inconsistent208,216,223,232; cess of learning to read, it is not icantly improved reading comprehen- many studies have shown that colored enough to lead to spontaneous im- sion but reduced reading rate. In a overlays and filters are ineffec- provements in word-recognition skills study of yellow filters by Ray et al,231 the tive,205,214,217,233–235 but a few studies and other complex elements of read- conclusion stated that there was im- have reported partial positive re- ing; therefore, remediation for under- provement in accommodation, conver- sults.212,213,218,222,224,231 Many unreported lying reading problems will still be gence, and reading rates, but deeper studies have shown no effect of col- required.208 Rooney238 advised the edu- analysis of the statistics revealed a ored filters on measures of either cation community not to embrace SSS question of significance. reading performance or SSS symp- and its treatment for learning disabili- toms. Also, many of the studies cited as Among the numerous criticisms of ties and dyslexia. proof of Irlen-lens efficiency actually Irlen’s treatment is the argument that With nothing but a small amount of an- have been found to be inconclusive af- precision tints are highly susceptible ecdotal evidence, CBS reported Irlen’s ter deeper analysis. Not only are some to placebo effects. By relying on anec- claims to the public and circumvented findings less meaningful than they first dotal accounts or experiments that the normal process of scientific review appear, the large variability in the lack adequate placebo controls, inter- and debate. Despite the continued lack methodology, techniques, and largely pretations of findings are speculative of definitive evidence of its effective- negative results does not support the at best. Controlling for placebo effects ness, colored lenses and filters con- effectiveness of tinted lenses and requires, among other things, the in- tinue to be promoted. Since 1990, tinted filters in these patients.‡‡‡ clusion of placebo filters of similar the medical community has recom- color to precision tints but outside the Contrary to the broad claims of many mended that Irlen promoters design effective range of chromaticity. Such Irlen-treatment proponents that the and perform rigorous prospective, filters have been successfully pro- syndrome is highly prevalent in the masked, controlled scientific studies duced but have rarely been imple- reading-disabled population, the effi- to document the effectiveness of their mented in Irlen-lens research. Many cacy, if any, of this approach seems to method. Scientifically, the burden of be limited to a small subgroup of chil- studies include control groups, but proof is on the developers and promot- dren with reading problems. The posi- they are typically composed of chil- ers of the Irlen method to provide tive evidence for the effects of colored dren who use no filters during testing strong evidence to show that their di- overlays and filters on reading perfor- and who report no symptoms of SSS. agnosis is valid and their treatments mance is limited. Worrall et al182 noted Although this is a form of control, it are beneficial. Contrary to usual scien- that the studies indicated that fewer does not adequately control for the tific practice, 1 Irlen center director than 5% of readers who experience possibility of placebo effects.208 Re- stated that it is equally the responsibil- discomfort benefit from a change in sults are inconclusive when placebo ity of others to carry out this validation contrast, brightness, or color on the filters are not implemented.208 research.177 page beyond what would be expected More recent published studies advo- from a placebo treatment alone. Thus, cating the use of these therapies to Behavioral Optometry treat reading difficulties have contin- Skeffington was the director of educa- †††Refs 111, 166, 176, 208, 209, and 215. ued to have serious flaws in their ‡‡‡Refs 14, 111, 112, 177, 178, 205, 208, 209, 211, tion of the Optometric Extension Pro- methods, including biased sample se- 214, 215, 217, 223, and 233–236. gram from 1928 to 1976.239 The Skeffin-

PEDIATRICS Volume 127, Number 3, March 2011 e841 Downloaded from www.pediatrics.org by on March 1, 2011 gton near-point stress model is the A recent model of vision, consider- sion training. Behavioral optometrists basis for much of behavioral optome- ably different than the traditional believe that training lenses help the vi- try.240 His theories were derived exclu- optometric model, proposed by sual system develop and mature nor- sively from his and his collaborators’ Scheiman247 divides evaluation and mally. Skeffington240 stated that they (Harmon and Renshaw) clinical experi- treatment into 3 categories: (1) vi- are best prescribed preventively be- ence and never independently refer- sual acuity, refraction, and eye fore a visual problem is identified. Hen- eed or formally debated outside the health disorders; (2) visual efficiency drickson stated that every child would Optometric Extension Program.239 skills of accommodation, binocular- benefit from the use of “learning Skeffington’s model states that binoc- ity, and ocular motility; and (3) visual glasses” in the classroom.258 It has ular anomalies and refractive errors information-processing skills of vi- been argued that treatment of accom- are not primary conditions but prod- sual discrimination, visual closure, modative dysfunctions with low- ucts of underlying near-point stress. visual memory, visualization, visual- power reading lenses will eliminate The model states that near-work motor integration, and figure-ground secondary problems and their asso- stress causes underaccommodation perception. ciated symptoms and thereby im- and overconvergence. Esophoria usu- The optometric literature has impli- prove reading efficacy.259,260 Although ally develops, but sometimes exopho- cated accommodative spasm, accom- they do not provide best-distance vi- ria or myopia develops from the modative insufficiency, ill-sustained sual acuity, they are used to teach stress. The model further states that accommodation, accommodative iner- the eyes to relearn distance-vision this esophoria is best treated preven- tia, and binocular dysfunction as be- skills that have atrophied. They gen- tively. Harmon’s theories concern ing linked with reading disor- erally have a power of ϩ0.50 to reading posture. ders.111,113,116,247–250 The authors of most ϩ1.00 D, and some incorporate bifo- Skeffington recommends an examina- of these studies claim that patients ex- cals or prisms. Practitioners have tion using 21 procedures for every pa- perience visual symptoms that lead to followed several highly variable tient in a standard sequence.241 The re- degradation in reading perfor- methods to establish the dioptric 261,262 sults of each test are then noted to be mance.249–252 Accommodative disor- value of the near correction. higher or lower than an “expected” val- ders are implicated in causing print Greenspan253 showed improvement in ue.242 The “expected value” is an “ideal blurring, daydreaming, decreased at- pencil-and-paper visual tasks and value,” not a norm.242 The Optometric tention span, increased heart and re- reading posture with the low-plus Extension Program “expected value” spiratory rate, and poor posture.253–256 lenses. Keller and Amos263 critically re- for ocular alignment at near for chil- Grisham et al257 reported an increased viewed Greenspan’s data and found dren is 6 prism diopters of exophoria. incidence of various symptoms in the effect of the developmental lenses Most people free from ocular symp- slower readers but could not show a to be insignificant. Keller and Amos toms have small amounts of latent significant difference in reading ability also noted that if there is an effect, it strabismus (esophorias or exopho- between readers with normal and ab- would imply some unique property of rias) that should be considered physi- normal binocular function. There is no the ϩ0.50 D lens regardless of the pa- ologic. Ophthalmologic and optometric proof of cause and effect between de- tients’ refractive error. A study by clinical studies have shown that the av- creased binocular function and symp- Barry and Cochran264 compared plano erage near ocular alignment is ap- toms or between symptoms and poor (no power) and ϩ0.50 D lenses near proximately 1 prism diopter of exopho- reading. Other studies have been un- prescriptions in young adults and ria.243–246 Using diagnostic criteria that able to find an increase in the inci- found no significant difference in vi- are not valid such as the developmen- dence of binocular disorders in chil- sual performance. Wildsoet and Foo265 tal optometric “expected values” will dren with reading difficulties or an compared 13 children who wore lead to misdiagnosis of many condi- association between motility disor- plano lenses and low-power (ϩ0.50 to tions. Many children with typical latent ders and reading ability.124,126,127 ϩ1.00 D) training lenses for 6 to 15 strabismus have been labeled by de- months and found no significant differ- velopmental optometrists as abnor- Training Glasses ence in reading comprehension. mal and diagnosed with near-point “Training” or “developmental” lenses Beauchamp266 discussed the issue of stress and a “relative esophoria” if are low-plus power glasses to be used overprescription of spectacles in his they show physiologic lower values of for reading to relieve stress. They are review of vision training in 1986. The exophoria than their “expected value.” frequently used in conjunction with vi- justification and benefit for routine in-

e842 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS tegration of costly spectacles into the ing the person to be more responsive ate and effective. In 1974, Keogh269 program is unsupported and often not to educational instruction.”268 A vision- stated that the research on vision the- discussed. Beauchamp stated that spec- therapy program consists of in-office ory was sparse, fragmented, and, for tacles are provided to the vast majority and at-home exercises performed over the most part, methodologically of children undergoing optometric vi- weeks to months and may include flawed, and that the professional liter- sion training despite the demonstrably training glasses. ature was characterized more by opin- low incidence of ocular motility or re- Developmental optometrists divide vi- ion than evidence. The 1974 review 124,126,127,266,267 124 fractive deficits. Blika sion therapy into 2 broad categories: concluded with the observation that found that one third of children in his classic orthoptic techniques and be- there was a lack of substantive and study had unnecessary glasses, and havioral or perceptual vision therapy. comprehensive evidence on which to many had improper prescriptions. Orthoptic techniques are used to cor- make decisions about program effects Olitsky and Nelson111 stated that there rect accommodative and convergence and called for research to specify child is no proof that there is a difference in dysfunctions as well as heterophorias and program characteristics that con- accommodative ability between nor- and refractive errors that might be re- tribute to intervention outcomes. mal and abnormal readers and that sponsible for asthenopic symptoms Keogh stated that, in the 10 years after there was no correlation between (eye fatigue and discomfort often ag- her first review, behavioral optome- reading performance and any specific gravated by close work). In behavioral trists continued to offer and expand vi- type of refractive error, including hy- vision therapy, eye-movement and eye- sion training to learning- and reading- peropia or a need for glasses. Olitsky hand coordination training techniques disabled pupils, which led to her and Nelson noted that the very low are used to improve learning efficiency second review. She noted in her 1985 power of the reading glasses or bifo- by improving visual processing skills. review that the necessary and suffi- cals that are often prescribed throws These visual processing skills include cient components of vision training further doubt on their usefulness in a visual-spatial orientation skills, visual are unspecified and, thus, untested. child who often shows large ampli- discrimination, visual closure, visual Keogh and Pelland267 stated that after tudes of accommodative ability.111 In a memory, and visual-motor integration. detailed review of more than 35 pro- critical review of the behavioral op- Behavioral vision therapists claim to gram descriptions, there was not a tometric literature before 2000 for improve the efficiency of eye move- single prototypic program model, the UK College of Optometrists, Jen- ments to improve scanning and locat- which led to the comment that there nings239 declared that the literature ing. Behavioral vision therapy is based were almost as many training pro- revealed no convincing experimental on the premise that differences in chil- grams as there were vision trainers. evidence of any benefits from a low- dren’s visual-perceptual-motor abili- They noted that the variation in vision- plus prescription. ties exist and that these perceptual- training programs was so great that it motor abilities influence cognitive and was extraordinarily difficult to draw Vision Therapy adaptive skills such as reading, writ- inferences about the effectiveness Vision therapy is an attempt to correct ing, and motor activities used in activ- of the procedures. Furthermore, it or improve ocular, visual processing, ities of daily living. It has been recom- seemed paradoxical that vision train- and visual-perceptual disorders. A mended to improve visual skills and ing was being recommended and used task force representing the College of processing in the belief that they will for a broad range of problems includ- Optometrists in Vision Development, improve learning disabilities, includ- ing preventive treatment. the American Optometric Association, ing speech and language disorders, Keogh and Pelland also noted that the and the American Academy of Optome- and nonverbal learning disorders.112 nature of the relationship between vi- try formulated the following policy sion, reading, and learning problems statement: “Optometric intervention Vision-Therapy Literature Review continues to be a troublesome theoret- for people with learning related vision Two major reviews of the vision- ical question that has not been well an- problems consists of lenses, prisms, training literature were undertaken by swered by optometrists involved in vi- and vision therapy. Vision therapy Keogh, a professor of special educa- sion training. Although much of the does not directly treat learning disabil- tion, in 1974 and again in 1985 with Pel- research basis for behavioral optome- ities or dyslexia. Vision therapy is a land267,269 to answer the questions of trists’ interpretation was completed treatment to improve visual efficiency what optometric vision training is and before 1975, in general, optometrists and visual processing, thereby allow- for whom vision training is appropri- accept a link between poor reading

PEDIATRICS Volume 127, Number 3, March 2011 e843 Downloaded from www.pediatrics.org by on March 1, 2011 and convergence inefficiencies, far- children when compared with those in nosed with learning disabilities by sightedness, and near and distance control groups.116 Levine,128 in his com- using different criteria and may have phorias. Thus, many optometrists ar- mentary on their article, remarked on been misdiagnosed or may have had gue in favor of vision therapy for prob- the poor methodology in the reviewed additional conditions that confounded lems of convergence, accommodation, studies, researchers having a vested the findings. Furthermore, during a ocular motility, and binocular fusion. interest, narrow interpretation of the course of vision therapy, children were Keogh and Pelland reported that most findings, and an initial preconception simultaneously receiving continued of the reviewed studies did not meet that a factor in isolation causes read- and even enhanced instruction in a rigorous research standards. In most ing disability. He recommended prop- standard or remedial educational set- of the reported studies the data were erly designing research on the use of ting and undergoing natural matura- ambiguous with equivocal findings so vision training for learning disabilities. tional changes. The results of subse- that the importance of visual efficacy In 1987, Beauchamp and Kosmorsky122 quent studies have been inconsistent was undeterminable. They declared extensively reviewed the interdiscipli- and have failed to reproduce many of that to focus on a single aspect of nary literature for the history of dys- these findings. The American Academy learning problems and to interpret an lexia and its relationship to neuropa- of Ophthalmology recommended that association or relationship as if it has thology and eye movements. They appropriately designed and method- causal implications goes beyond the concluded that eye movements are not ologically rigorous scientific studies evidence.267 the controlling factor in dyslexia or with a team approach using multidis- Keogh and Pelland stated that if visual learning disabilities but are secondary ciplinary educational specialists be processing problems are not the to the comprehension difficulties. In conducted to assess the effectiveness cause of many reading problems, vi- addition, they concluded that ap- of vision therapy.112 sion training to improve visual effi- proaches designed to improve visual The Institute for Clinical Systems Im- ciency is not the treatment of choice. perception by training are misdi- provement technology assessment re- They found little definitive evidence for rected, because visual-perceptual port on vision therapy was published the effectiveness of vision therapy problems do not underlie dyslexia. in 2003.270 The Institute for Clinical Sys- even when the results were aggre- Their literature review revealed that tems Improvement reports are de- gated across studies and concluded visual-perceptual training seems to be signed to assist clinicians by providing that using this treatment would lead to ineffective and that controlled evi- a scientific assessment, thorough wasteful and ineffective intervention dence for treatment efficacy has been search, review, and analysis of medi- efforts. They concluded that it is imper- found to be conceptually flawed, scant, cal literature of the safety and efficacy ative that vision-training research re- and contradictory. of medical technologies. The reports ceive systematic and rigorous testing Complementary Therapy Assessment: classify and grade references by their and that the research be reported for Vision Therapy for Learning Disabili- level of evidence. Two ophthalmolo- review in a broader scientific arena.267 ties was published in 2001 by the Amer- gists and 2 optometrists were in- In 1984, Metzger and Werner116 re- ican Academy of Ophthalmology.112 cluded on the panel on the topic of vi- viewed the ophthalmologic, optomet- This report reviewed the literature on sion therapy. Their conclusions were ric, and psychological literature on the vision therapy for reading disabilities that the studies of vision therapy are use of visual training for reading dis- and concluded that there seems to be predominantly poor-quality case se- abilities. They found that refractive ab- no consistent scientific evidence that ries that provided inadequate scien- normalities, ocular motor abnormali- supports behavioral vision therapy, or- tific evidence to enable a conclusion to ties, and perceptual capabilities did thoptic vision therapy, or colored over- be reached about the efficacy of vision not differ between reading-disabled lays and lenses as effective treatments therapy for patients with learning dis- children and those with no reading dis- for learning disabilities. No well- abilities, amblyopia, strabismus, con- ability. In their review, they noted sig- performed randomized controlled tri- vergence insufficiency, or accommo- nificant flaws in experimental method- als (level I evidence) were found in the dative disorders. The committee ology that supports the visually based literature. The vision-therapy studies encouraged masked, randomized, con- hypotheses. They also found that have shown an absence of a standard trolled trials of vision therapy for these visual-motor-perceptual training pro- definition of the techniques that con- potential uses. They recommended grams produced no further improve- stitute vision therapy. Children in- that these trials include clearly de- ment in reading ability for affected cluded in the studies had been diag- fined patient populations, control

e844 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS groups, clearly defined treatment pro- Treatment Group published data from domized clinical trial comparing grams, relevant outcome measures, a small, masked, placebo-controlled, home-based pencil push-up exercises, and adequate patient follow-up to de- multicenter, randomized clinical trial home computer vergence therapy, termine if any observed benefits are that showed that patients treated with office-based orthoptic vision therapy maintained.270 office-based vision therapy improved with home reinforcement, and office- Rawstron et al271 published a literature more than those treated with mini- based placebo therapy with home rein- review of eye exercises in 2005. The re- mally intensive home-based pencil forcement in 221 children in a 12-week view concluded that the results of push-up exercises or placebo.165 The study. Symptomatic improvement was small controlled trials and many case study used both findings and a symp- noted in 43% of the home-based pencil reports support the use of eye exer- tom score. Eight of the 15 patients, or push-up exercises group, 33% of the home cises in the treatment of convergence 53% of the patients treated with computer vergence therapy group, 75% of insufficiency but that there is no clear office-based vision therapy, were con- the office-based vision therapy with home scientific evidence published in the lit- sidered symptomatically “cured.”165 reinforcement group, and 35% of the erature to support the use of eye exer- Kushner,161 in his accompanying edito- office-based placebo therapy with home cises in the remainder of the areas re- rial, surveyed 20 pediatric ophthalmol- reinforcement group. The Convergence In- viewed, including learning disabilities ogists and 15 orthoptists who treat sufficiency Treatment Group study showed and dyslexia. convergence insufficiency. His survey better improvement with intensive office- A 2005 Association for Research in Vi- revealed that most pediatric ophthal- based vergence/accommodative and sion and Ophthalmology abstract by mologists and orthoptists do not use home reinforcement therapy compared optometrists Sampson et al272 dis- unmonitored home treatment with withlessintensivehometreatmentsorpla- cussed a randomized, masked, and pencil push-ups. Generally, orthoptic cebo. Wallace,164 in his accompanying edi- controlled study of 96 suboptimally therapy prescribed by pediatric oph- torial, noted that neither home-based achieving children who showed visual thalmologists and orthoptists consists treatment group used in this study was an information-processing delay and nor- of push-up exercises using an accom- ideal comparison group, because fewer mal auditory/verbal language develop- modative target of letters, numbers, or actual hours of treatment were received, ment. The experimental group under- pictures; push-up exercises with addi- and the home therapy was less intensive. went a visual training program tional base-out prisms; jump-to-near- Granet,273 a site principle investigator for designed to be typical of programs convergence exercises; stereogram the study, wrote a letter to the editor con- used in pediatric optometric practice. convergence exercises; and recession cerning the methodology of the study. He The control group received a placebo from a target. The exercises are per- stated that the difference between treat- program that provided similar formed at home, and the children are ment groups could have easily been af- amounts of individual time with the reevaluated in the office on a monthly fected if the time in true treatment had children. Diagnostic educational test- basis. Kushner retrospectively re- been equalized. ing took place before the study, at the viewed his last 20 patients with conver- Another major criticism of the 2 stud- conclusion, and 6 months after the gence insufficiency treated with these ies is the definition of convergence in- completion of the programs. Both orthoptic techniques. Sixteen of his 20 sufficiency. The criteria for study inclu- groups made significantly greater patients (80%) reported complete res- sion was a near exophoria at least 4 postintervention progress on most olution of symptoms and were objec- prism diopters greater than at far, a variables compared with that ex- tively “cured” using the same criteria receded near point of convergence, in- pected had no intervention occurred. as in the study.160 The Convergence In- sufficient positive fusional vergence at Results for the entire group showed no sufficiency Treatment Group study near or minimum positive fusional ver- significant between-group differences showed that convergence insufficiency gence, and a minimum symptom for all educational tests. Thus, results can be improved with in-office vision score. Using these diagnostic criteria for the entire group did not provide ev- therapy, but the accompanying edito- may overestimate convergence insuffi- idence to support efficacy of the visual rial revealed that properly prescribed ciency. Although the convergence- training program under investigation, and monitored home treatment is also insufficiency symptom survey has un- which suggests that a placebo effect very effective.161,165 dergone validation,274 many of the was responsible for much of the dem- The Convergence Insufficiency Treat- symptoms in their symptom-scoring onstrated improvement. ment Group163 published a larger sec- system are too vague and repetitive. In 2005, the Convergence Insufficiency ond study in 2008, which was a ran- Two examples are: (1) Do your eyes

PEDIATRICS Volume 127, Number 3, March 2011 e845 Downloaded from www.pediatrics.org by on March 1, 2011 hurt when reading or doing close Ͼtherapy studies for the UK College of gence insufficiency seemed to have work? and (2) Do your eyes ever feel Optometrists. His report on the evalu- some benefits but that further large- sore when reading or doing close ation of the theory and practice of be- scale controlled trials that used work? Also, many of the symptoms havioral optometry was published in proper controls were needed. He re- used in the symptom score are non- 2000. In his review he noted that many ported that vision therapy cannot cur- specific. Two examples are: (1) Do you studies showed methodologic and sta- rently be considered as an evidence- read slowly? and (2) Do you have trou- tistical weaknesses. He commented based treatment for reading or ble remembering what you have read? that careful study design is essential, learning disorders. He declared that Using this symptom survey, many peo- because with training and practice, the large majority of behavioral man- ple without convergence insufficiency perceptual judgments improve. This agement techniques were to be con- may have a symptom score that quali- improvement would be greatest if the sidered unproven until more rigorous fies them for the study. Finally, the use patient is encouraged and reinforced. trials were undertaken. His report con- of symptoms in children may be unre- He also questioned whether improve- cluded that the continued absence of liable. In a separate study, complaints ment on the training task would trans- rigorous scientific evidence from well- such as eyestrain and headaches have fer to routine activities. He concluded designed trials to support behavioral been found to be poor markers of eye that the merits of vision therapy are management approaches, and the conditions in young children.156 extremely difficult to assess and that paucity of controlled trials in particu- The apparent superiority of office- there is a lack of controlled studies to lar, represented a major challenge to based orthoptic vision therapy over support behavioral management the credibility of the theory and prac- home-based exercises in these 2 strategies. Jennings’ conclusion was tice of behavioral optometry. Barrett’s studies is not as strong as it first that behavioral optometric therapies final conclusion was that these ap- seemed. This problem was noted in the do not satisfy evidence-based scrutiny. proaches were not evidence-based 276 editorials161,164 that accompanied both On behalf of the UK College of Optome- and could not be advocated. the 2005 and 2008 convergence- trists, Barrett276 in 2009 reviewed stud- A 2009 article in Optician Online com- insufficiency treatment studies and ies of vision therapy published since mented on Barrett’s study. The clinical also in a letter to the editor by Gra- the Jennings report in 2000. Barrett editor of Optician Online stated that al- net.273 The major weakness of these remarked that the theory and practice though some practitioners may be studies was that the study groups of behavioral optometry remain con- convinced from their own experience were not appropriately chosen to pro- troversial, especially when considered of the effectiveness of behavioral op- vide a proper comparison. Treatment from the perspective of the traditional tometry, the lack of sound evidence- with minimally intensive pencil push- optometrist. This is because many of based research supporting this stance ups is not representative of the stan- the patients that behavioral optome- will always leave it open to the criti- dard of care and, thus, does not pro- trists are treating would not exhibit cism that all it does is pay attention to vide the appropriate comparison. The any abnormality under clinical assess- a perceived problem and thereby influ- comparison group should consist of ment using traditional optometric ap- ence its expression. The editor con- the home exercise methods that are proaches. Barrett reviewed evidence tended that it seemed less than ethical frequently prescribed by pediatric in 10 categories: accommodative/ to charge for such interventions under ophthalmologists or orthoptists and vergence disorders; underachieving a cloak of clinical practice until good should be for the same number of child; prisms for near binocular disor- evidence for the techniques exists.277 hours and intensity as the in-office vi- ders and for producing postural sion therapy. Sethi,275 in his letter to change; near-point stress and low-plus Summary on Vision Therapy the editor, noted that sustained con- prescriptions; low-plus lenses at near- Some optometrists attribute reading vergence should have been stressed in to-slow myopia progression; therapy disabilities or a portion of them to 1 or performing the home pencil push-up to reduce myopia; therapy of amblyo- more subtle ocular or visual abnor- exercises. Methodologically, the 2008 pia and strabismus; training central malities. The basic tenet of their hy- study is weakened, because it included and peripheral awareness and synton- pothesis is that children with reading 2 different variables and compared dif- ics; sports vision therapy; and neuro- disorders have an increased incidence ferent treatments and 2 different in- logic disorders and neurorehabilita- of vision abnormalities. The College of tensities of treatment. tion after trauma/stroke. Barrett Optometrists in Vision Development Jennings239 reviewed behavioral vision- found that vision therapy for conver- estimates that more than 60% of prob-

e846 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS lem learners have undiagnosed vision is important to have adequate eyesight tions. Many of the references used to problems that contribute to their diffi- and ocular motility to read with the support the claims in these articles do culties. This claim has not been scien- greatest efficiency, subtle or severe not relate directly to the topic. Often, a tifically established. Many children eye defects do not cause decoding or variety of criteria have been used in without vision problems have been la- comprehension difficulties. diagnosing subjects included in the beled as abnormal, because typical Because visual problems do not underlie study, and a variety of treatment pro- physiologic latent strabismus is not dyslexia, approaches designed to im- grams have been used within a study. taken into account. Optometrists also prove visual function by training are mis- In addition, the investigator often has a claim that visual dysfunction in chil- directed.122,128,137,153,266,267 Optometric vi- vested interest in the outcome of the dren impairs their ability to respond to sion training is based on the premise study. Many of the studies that support the specific instruction intended to that reading is primarily a visual task. vision therapy use small numbers, and remedy the disability. However, the as- Many authors in the optometric litera- they typically rely on case studies, self- sociation of binocular and other vision ture proclaim the usefulness of vision reports, anecdotal information, and anomalies with learning disabilities, therapy for reading and learning disabil- testimonials. Studies have been poorly as well as the significance of any asso- ities. Proponents of vision therapy claim designed, failed to “mask” the investi- ciation, has not been scientifically that treatment of these visual abnormal- gator, and used inadequate or poor demonstrated. Thus, the nature of the ities will help children with learning dis- controls so that bias and placebo ef- relationship between vision problems abilities be more responsive to educa- fects may have confounded the re- and reading and learning problems tional instruction, but this hypothesis sults.### In general, these research continues to be a troublesome theoret- has not been proven scientifically. Also, methods and references show poor 62,112,270,271 ical question that has not been an- many of the abnormalities that are said scientific validation. swered adequately by optometrists in- to cause problems with reading are un- Scientific evidence does not support 267 volved in vision training. Currently, defined and unspecified, which makes the claims that visual training, muscle there is inadequate scientific evidence evaluation of the claims of successful exercises, ocular pursuit-and-tracking to support the view that subtle eye or treatment difficult to analyze. It is even exercises, behavioral/perceptual vi- visual problems, including abnormal more difficult to determine any possible sion therapy, training glasses, prisms, focusing, jerky eye movements, mis- benefit of vision therapy when used and colored lenses and filters are ef- aligned or crossed eyes, visual-motor “preventively.” fective direct or indirect treatments dysfunction, binocular dysfunction, Over the last 35 years, many reviews of for learning disabilities.**** There is perceptual dysfunctions, or hypotheti- the literature that optometry uses to no valid evidence that children who cal difficulties with laterality or “trou- support vision therapy have been per- participate in vision therapy are more ble crossing the midline” of the visual formed. Reviews of the vision-therapy responsive to educational instruction field, cause or increase the severity of literature revealing a lack of scientific than children who do not partici- learning disabilities.§§§ Statistically, support have been performed by re- pate.†††† The reported benefits of vi- children with dyslexia or related learn- searchers in reading and education, sion therapy, including nonspecific ing disabilities have the same visual pediatricians, and ophthalmologists. gains in reading ability, can often be function and ocular health as children Many of the detailed reviews that sci- explained by the placebo effect, in- without such conditions.࿣࿣࿣ Visual entifically questioned the credibility of creased time and attention given to problems may coexist with dyslexia the theory and practice of vision ther- students who are poor readers, matu- but seem to be present with the same apy have been performed recently by ration changes, or the traditional edu- incidence as in the population in gen- optometrists.181,182,239,270,276 Detailed re- cational remedial techniques with eral; furthermore, no consistent rela- view of the vision-therapy literature which they are usually combined.‡‡‡‡ tionship between visual function and has revealed significant weaknesses, academic performance and reading because most of the information has ###Refs 111–113, 116, 122, 128, 136, 153, 166, 178, ability has been shown.¶¶¶ Although it 239, 266, 267, 270, 271, and 276. been of poor statistical and scientific ****Refs 14, 24–26, 29, 31, 34, 39, 44, 82, 111–113, quality. Many claims supporting vision 116, 122, 128, 136, 152, 153, 166, 178, 205, 208, 214, §§§Refs 14, 26, 111–113, 116, 119–128, 134–138, therapy are old or found in newslet- 233–235, 239, 266, 267, 270–272, and 276. 154, and 266. ††††Refs 14, 24, 29, 34, 111–113, 116, 122, 128, 136, ࿣࿣࿣Refs 2, 9–12, 14, 15, 111–113, 116, 119–128, 134– ters, flyers, books without research, or 152, 153, 166, 178, 239, 266, 267, 270–272, 276, and 137, 149–151, 153, 166, 178, 239, 266, 267, 270, and nonedited or loosely reviewed publica- 278. 276. ‡‡‡‡Refs 111–113, 116, 136, 239, 266, 267, 270, and ¶¶¶Refs 118–121, 123, 124, 126, 127, 134, 135, and 149–151. 278.

PEDIATRICS Volume 127, Number 3, March 2011 e847 Downloaded from www.pediatrics.org by on March 1, 2011 Other than convergence-insufficiency ture review will ensure that the best commodations, and which type of pro- treatment, the optometric claims that evidence is disseminated and poor- gram would be best and should set vision therapy improves visual effi- quality studies are subject to proper guidelines for measuring future edu- ciency cannot be substantiated. Treat- scrutiny. cational progress. ment of convergence insufficiency The remedial program should be individ- helps the reader maintain visual effort MANAGEMENT SUMMARY ualized. Remedial programs should in- for prolonged reading, but treatment Parents should read aloud to their chil- clude specific instruction in decoding, of convergence insufficiency by any dren to help develop language skills. If fluency training, vocabulary, and com- method is not a treatment for dyslexia. early warning signs of learning difficul- prehension.¶¶¶¶ Most programs in- These ineffective, controversial ties are detected in preschool-aged chil- clude daily intensive individualized in- methods of treatment may give par- dren by parents or teachers or during struction to explicitly teach phonemic ents and teachers a false sense of developmental surveillance or screen- awareness and the application of security that a child’s reading diffi- ing, the primary care provider should re- phonics.#### Later, syllable instruc- culties are being addressed, may fer the child for early evaluation and in- tion, morphology, memorization of waste family and/or school time and tervention. Cost-effective prevention, sight words, spelling, syntax, and se- resources, and may delay proper in- early identification, and early phonologic mantics are taught.55 Comprehension struction or remediation. awareness intervention programs in is gained through fluency training, Because they are difficult for the public kindergarten through 2nd grade should vocabulary instruction, and active to understand and for educators to be encouraged. Early identification of reading comprehension.34,35 Practice- treat, learning disabilities have spawned children who show delays or difficulties reading aloud at home is essential. Be- a wide variety of scientifically unsup- should be a high priority for elementary cause people with dyslexia have a persis- ported vision-based diagnostic and school teachers. Evaluation for learning tent problem and continue to read slowly treatment procedures.§§§§ Despite the disabilities should be considered for all throughout their life, it often becomes continued lack of definitive evidence of children who present with school diffi- necessary to adapt the learning environ- its effectiveness, vision training for im- culties, even if reading difficulty is not ment.24,25,34,81 Schools can implement ac- proving visual efficiency and visual the chief complaint.34 A child with sus- ademic accommodations and modifica- processing has been widely used, at pected learning disabilities should be tions to help students with dyslexia great cost, over the last half-century in placed into remediation and be referred succeed. many thousands of children with as early as possible for educational Children with learning disabilities and learning disabilities and also as a evaluation. possible visual problems suspected by “preventive treatment.” During these A multidisciplinary team consisting of their parents, teachers, or physician years, the medical and educational educators, educational remediation should be seen by an ophthalmologist communities have recommended de- specialists, special service profession- who has experience with the assess- signing and performing rigorous pro- als, psychologists, and pediatric spe- ment and treatment of children, because spective, masked, controlled scientific cialists in neurodevelopmental disabil- some of these children may also have a studies to document the effectiveness treatable visual problem along with their of vision therapy. The burden of proof ities or developmental and behavioral pediatrics should be called on to diag- primary reading or learning dysfunc- is on the promoters of vision therapy tion.110–113,154 Treatable ocular condi- nose and treat suspected learning dis- to provide strong evidence to show tions include strabismus, amblyopia, abilities in children. Making the cor- that their testing methods are valid, convergence and/or focusing deficien- rect diagnosis of the specific type of that an association exists between vi- cies, and refractive errors. The oph- learning disability along with any co- sual dysfunction and learning disabili- thalmologist should identify and treat morbid conditions is of paramount im- ties, and that their treatments are ben- any significant visual defect according portance before any therapeutic regi- eficial. Outcome studies documenting to standard principles of treat- men can be prescribed.167 To outline effective results using EBM are neces- ment.110,113,153,166 The primary care pedia- the educational goals and services sary before vision therapy can be rec- trician and ophthalmologist should not that the student needs to be success- ommended. Continuing critical litera- diagnose learning disabilities but should ful, an IEP contract should be devel- provide information on learning disabili- oped. The IEP should describe what §§§§Refs 12, 14, 24, 111–113, 116, 122, 128, 136, 152, 166, 177, 178, 205, 208, 209, 211, 214, 215, 217, 223, services will be needed, including spe- ¶¶¶¶Refs 1, 14, 32–35, 43, 55, 60, 63–65, and 81. 233–236, 239, 266, 267, 270–272, 276, and 278. cific remedial interventions and ac- ####Refs 1, 14, 24, 25, 30–35, 55, 60, and 63–65.

e848 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS ties and reinforce the need for additional the alphabetic code. Because of our ru- SECTION ON OPHTHALMOLOGY medical, psychological, educational, or dimentary knowledge of learning dis- EXECUTIVE COMMITTEE, 2010–2011 other appropriate evaluation or serv- abilities, including dyslexia, there cur- James B. Ruben, MD, Chairperson David B. Granet, MD, Chairperson-Elect ices.167 In addition, the primary care pe- rently are no simple remedies. Richard J. Blocker, MD diatrician and ophthalmologist should Because dyslexia is a language-based Geoffrey E. Bradford, MD discuss the lack of proven efficacy of vi- disorder, treatment should be di- Daniel J. Karr, MD sion therapy and other alternative treat- Gregg T. Lueder, MD, Immediate Past rected at this etiology.***** The prog- Chairperson ments with the parents. Finally, the pub- nosis depends on the severity of the Sharon S. Lehman, MD lic must learn to carefully evaluate the disability, the specific patterns of Sebastian J. Troia, MD information that they receive in the face strengths and weaknesses, and the ap- of aggressive promotion. LIAISONS propriateness, amount, intensity, and Kyle A. Arnoldi, CO – American Association of timing of the intervention. Early recog- Certified Orthoptists CONCLUSIONS nition and individualized, interdiscipli- Christie L. Morse, MD – American Academy of Underachievement is not synonymous Ophthalmology nary management strategies are the Michael R. Redmond, MD – American 279 with specific learning disability. Learn- keys to helping children with dyslexia. Association for Pediatric Ophthalmology ing disabilities arise from neurologic dif- Early intervention with intense, explicit and Strabismus ferences in brain structure and function instruction is critical for helping stu- George S. Ellis, Jr, MD – American Academy of Ophthalmology Council that affect the brain’s ability to store, dents ameliorate the lifelong conse- process, or communicate information. quences of poor reading. STAFF The consensus of educators, psycholo- Jennifer G. Riefe, MEd Visual problems do not cause dyslexia. gists, and medical specialists is that chil- Scientific evidence does not support the COUNCIL ON CHILDREN WITH dren who exhibit signs of learning dis- efficacy of eye exercises, behavioral/per- DISABILITIES EXECUTIVE COMMITTEE, abilities should be referred as early as ceptual vision therapy, training glasses, 2010–2011 possible for educational, psychological, or special tinted filters or lenses in im- Nancy A. Murphy, MD, Chairperson neuropsychological, and/or medical di- Richard C. Adams, MD agnostic assessments, because the ben- proving the long-term educational per- Robert T. Burke, MD, MPH eficial effects of early identification and formance in these complex pediatric Sandra L. Friedman, MD neurocognitive conditions. Recommen- Miriam A. Kalichman, MD intervention are apparent in many stud- Susan E. Levy, MD ies. Children diagnosed with learning dations for multidisciplinary evalua- Gregory S. Liptak, MD, MPH disabilities should receive appropriate tion and management must be based Douglas McNeal, MD on evidence of proven effectiveness Kenneth W. Norwood Jr, MD support and individualized evidence- Renee M. Turchi, MD, MPH based educational interventions com- demonstrated by objective scientific Susan E. Wiley, MD bined with psychological, medical, and methodology.106,112,239,270,276 It is impor- PRIMARY REVIEWER visual treatments as needed. tant that any therapy for learning Paul H. Lipkin, MD – Immediate Past Reading difficulties constitute a di- disabilities be scientifically estab- Chairperson, Council on Children With verse group of problems that include lished to be valid before it can be Disabilities Executive Committee recommended for treatment.106 Be- dyslexia and secondary forms of read- LIAISONS cause vision therapy is not evidence ing difficulties caused by visual or Carolyn Bridgemohan, MD – Section on hearing disorders, intellectual disabil- based, it cannot be advocated. Developmental and Behavioral Pediatrics ity, experiential and/or instructional Georgina Peacock, MD, MPH – Centers for Disease Control and Prevention 14,24–26 LEAD AUTHORS deficits, and other problems. Bonnie Strickland, PhD – Maternal and Child Sheryl M. Handler, MD – American Academy of Missing these problems could cause Health Bureau Ophthalmology and Learning Disabilities long-term consequences from assign- Nora Wells, MSEd – Family Voices Subcommittee, AAP Section on Max Wiznitzer, MD – Section on Neurology ing these patients to incorrect treat- Ophthalmology ment categories. Dyslexia is a primary Walter M. Fierson, MD – Chairperson, Learning STAFF receptive language-based reading dis- Disabilities Subcommittee, AAP Section on Stephanie Mucha Skipper, MPH Ophthalmology order secondary to a neurobiological deficit in the processing of the sound OTHER RESOURCES structure of language called a phone- *****Refs 1, 14, 24, 25, 30–35, 55, 60, 63–65, 81, and International Dyslexia Association: mic deficit that makes it difficult to use 106. www.interdys.org

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e856 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 Learning Disabilities, Dyslexia, and Vision Sheryl M. Handler, Walter M. Fierson and the Section on Ophthalmology and Council on Children with Disabilities, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists Pediatrics 2011;127;e818-e856; originally published online Feb 28, 2011; DOI: 10.1542/peds.2010-3670 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/127/3/e818 References This article cites 216 articles, 62 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/127/3/e818#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Ophthalmology http://www.pediatrics.org/cgi/collection/ophthalmology Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml

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