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Learning Disabilities, Dyslexia, and Vision Sheryl M 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 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. Reading disability, or dyslexia, is the most common learning disabilities, vision, dyslexia, ophthalmology, eye learning disability. Itisareceptive language-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 phonics. 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, literacy 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 e818 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.pediatrics.org by on March 1, 2011 FROM THE AMERICAN ACADEMY OF PEDIATRICS 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 reading disability. 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
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