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Committee on Children With Disabilities, American Academy of Pediatrics (AAP) and American Academy of Ophthalmology (AAO), American Association for Pediatric Ophthalmology and Strabismus (AAPOS)
Learning disabilities are common conditions in pediatric patients. The etiology of these difficulties is multifactorial, reflecting genetic influences and abnormalities of brain structure and function. Early recognition and referral to qualified educational professionals is critical for the best possible outcome. Visual problems are rarely responsible for learning difficulties. No scientific evidence exists for the efficacy of eye exercises ("vision therapy") or the use of special tinted lenses in the remediation of these complex pediatric developmental and neurologic conditions.
BACKGROUND
Learning disabilities have become an increasing personal and public concern. Among the spectrum of issues of concern in learning disabilities, the inability to read and comprehend is a major obstacle to learning and may have long-term educational, social, and economic implications. Family concern for the welfare of children with dyslexia and learning disabilities has led to a proliferation of diagnostic and remedial treatment procedures, many of which are controversial or without clear scientific evidence of efficacy. Many educators, psychologists, and medical specialists concur that individuals who have learning disabilities should: 1) receive early comprehensive educational, psychological, and medical assessment; 2) receive educational remediation combined with appropriate psychological and medical treatment; and 3) avoid remedies involving eye exercises, filters, tinted lenses, or other optical devices that have no known scientific proof of efficacy.
EVALUATION AND MANAGEMENT
Reading involves the integration of multiple factors related to an individual's experience, ability, and neurologic functioning. Research has shown that the majority of children and adults with reading difficulties experience a variety of problems with language1-3 that stem from altered brain function and that such difficulties are not caused by altered visual function.4-7 In addition, a variety of secondary emotional and environmental factors may have a detrimental effect on the learning process in such children.
Role of the Eyes
Decoding of retinal images occurs in the brain after
visual signals are transmitted from the eye via the visual pathways. Some vision
care practitioners incorrectly attribute reading difficulties to one or more
subtle ocular or visual abnormalities. Although the eyes are obviously necessary
for vision, the brain performs the complex function of interpreting visual
images. Currently, no scientific evidence supports the view that correction of
subtle visual defects can alter the brain's processing of visual stimuli.
Statistically, children with dyslexia or related learning disabilities have the
same ocular health as children without such conditions.10-12
Controversies
Eye defects, subtle or severe, do not cause the patient
to experience reversal of letters, words, or numbers. No scientific evidence
supports claims that the academic abilities of children with learning
disabilities can be improved with treatments that are based on 1) visual
training, including muscle exercises, ocular pursuit, tracking exercises, or
"training" glasses (with or without bifocals or prisms),13-15 2) neurologic
organizational training (laterality training, crawling, balance board,
perceptual training),16-18 or 3) colored lenses.18-20 These more controversial
methods of treatment may give parents and teachers a false sense of security
that a child's reading difficulties are being addressed, which may delay proper
instruction or remediation. The expense of these methods is unwarranted, and
they cannot be substituted for appropriate educational measures. Claims of
improved reading and learning after visual training, neurologic organization
training, or use of colored lenses, are almost always based on poorly controlled
studies that typically rely on anecdotal information. These methods are without
scientific validation.21 Their reported benefits can be explained by the
traditional educational remedial techniques with which they are usually
combined.
Early Detection
Pediatricians, other primary care physicians, and
educational specialists may use screening techniques to detect learning
disabilities in preschool-aged children, but in many cases, the learning
disability is discovered after the child experiences academic difficulties.
Learning disabilities can include dyslexia, problems with memory and language,
and difficulty with mathematic computation. These difficulties are often
complicated by attention deficit disorders. A family history of learning
disabilities is common in such conditions. Children who are considered to be at
risk for or suspected of having these conditions by their physician should be
evaluated for more detailed study by educational and/or psychological
specialists.
Role of the Physician
Ocular defects in young children should be
identified as early as possible, and when they are correctable, they should be
managed by an ophthalmologist who is experienced in the care of children.22
Treatable ocular conditions among others include refractive errors, focusing
deficiencies, eye muscle imbalances, and motor fusion deficiencies. When
children have learning problems that are suspected to be associated with visual
defects, the ophthalmologist may be consulted by the primary care pediatrician.
If no ocular defect is found, the child needs no further vision care or
treatment and should be referred for medical and appropriate special educational
evaluation and services. Pediatricians have an important role in coordination of
care between the family and other health care services provided by
ophthalmologists, optometrists, and other health care professionals who may
become involved in the treatment plan.
Multidisciplinary Approach
The management of a child who has learning
disabilities requires a multidisciplinary approach for diagnosis and treatment
that involves educators, psychologists, and physicians. Basic scientific and
clinical research into the role of the brain's structure and function in
learning disabilities has demonstrated a neural basis of dyslexia and other
specific learning disabilities and not the result of an ocular disorder
alone.4-6
The Role of Education
The teaching of children, adolescents, and
adults with dyslexia and learning disabilities is a challenge for educators.
Skilled educators use standardized educational diagnostic evaluations and
professional judgment to design and monitor individualized remedial programs.
Psychologists may help with educational diagnosis and classification.
Physicians, including pediatricians, otolaryngologists, neurologists,
ophthalmologists, mental health professionals and other appropriate medical
specialists, may assist in treating the health problems of these patients.
Because remediation may be more effective during the early years, prompt
diagnosis is paramount.20,21 Educators with specialty training in learning
disabilities play a key role in providing help for the learning disabled or
dyslexic child or adult.
RECOMMENDATIONS
1. For all children, clinicians should perform vision screening according to national standards.8,9
2. Any child who cannot pass the recommended vision screening test should be referred to an ophthalmologist who has experience in the care of children.
3. Children with educational problems and normal vision screening should be referred for educational diagnostic evaluation and appropriate special educational evaluation and services.
4. Diagnostic and treatment approaches that lack objective, scientifically-established efficacy should not be used.
SUMMARY
Reading difficulties and learning disabilities are complex
problems that have no simple solutions. The American Academy of Pediatrics and
the American Academy of Ophthalmology, American Association for Pediatric
Ophthalmology and Strabismus strongly support the need for early diagnosis and
educational remediation. There is no known visual cause for these learning
disabilities and no known effective visual treatment.23,24 Recommendations for
multidisciplinary evaluation and management must be based on evidence of proven
effectiveness demonstrated by objective scientific methodology.23-24 It is
important that any therapy for learning disabilities be scientifically
established to be valid before it can be recommended for treatment.
COMMITTEE ON CHILDREN WITH DISABILITIES, 1998-1999
Philip R. Ziring,
MD, Chairperson
Dana Brazdziunas, MD
W. Carl Cooley, MD
Theodore A.
Kastner, MD
Marian E. Kummer, MD
Lilliam Gonzalez de Pijem, MD
Richard D. Quint, MD, MPH
Elizabeth S. Ruppert, MD
Adrian D.
Sandler, MD
LIAISON REPRESENTATIVES
William Anderson
Social Security Administration
Polly Arango
Family Voices
Paul Burgan, MD, PhD
Social Security Administration
Connie Garner, RN, MSN, EdD
United States Department of Education
Merle McPherson, MD
Maternal and Child Health Bureau
Marshalyn Yeargin-Allsopp, MD
Centers for Disease Control and
Prevention
SECTION LIAISONS
Chris P. Johnson, MEd, MD
Section on Children With Disabilities
Lani S. M. Wheeler, MD
Section on School Health
REFERENCES
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2. Vellutino FR. Dyslexia. Sci Am. 1987;256:34-41
3. Council on Scientific Affairs. Dyslexia. JAMA. 1989;261:2236-2239
4. Petersen SE, Fox PT, Posner MI, Mintum M, Raichle ME. Positron emission tomographic studies of the cortical anatomy of single-word processing. Nature. 1988;331:585-589
5. Galaburda A. Ordinary and extraordinary brain development: anatomical variation in developmental dyslexia. Ann Dyslexia. 1989;39:67-80
6. Hynd GW, Semrud-Clikerman M, Lorys AR, Novey ES, Eliopulos D. Brain morphology in developmental dyslexia and attention deficit disorder/hyperactivity. Arch Neurol. 1990;47:919-926
7. Metzger RL, Werner DB. Use of visual training for reading disabilities: a review. Pediatrics. 1984;73:824-829
8. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine and Section on Ophthalmology. Eye examination and vision screening in infants, children, and young adults. Pediatrics. 1996;98:153-157
9. American Academy of Ophthalmology and American Association for Pediatric Ophthalmology and Strabismus. Vision Screening for Infants and Children. 1996
10. Golberg HK, Drash PW. The disabled reader. J Pediatr Ophthalmol. 1968;5:11-24
11. Helveston EM, Weber JC, Miller K, et al. Visual function and academic performance. Am J Ophthalmol. 1985;99:346-355
12. Levine MD. Reading disability: do the eyes have it? Pediatrics. 1984;73:869-870
13. Keogh B, Pelland M. Vision training revisited. J Learn Disabil. 1985;18:228-236
14. Beauchamp GR. Optometric vision training. Pediatrics. 1986;77:121-124
15. Cohen HJ, Birch HG, Taft LT. Some considerations for evaluating the Doman-Delacato "patterning method." Pediatrics. 1970;45:302-314
16. Kavale K, Mattson PD. One jumped off the balance beam: meta-analysis of perceptual-motor training. J Learn Disabil. 1983;16:165-173
17. Black JL, Collins DWK, DeRoach JN, et al. A detailed study of sequential saccadic eye movements for normal and poor reading children. Percept Mot Skills. 1984;59:423-434
18. Solan HA. An appraisal of the Irlen technique of correcting reading disorders using tinted overlays and tinted lenses. J Learn Disabil. 1990;23:621-623
19. Hoyt CS. Irlen lenses and reading difficulties. J Learn Disabil. 1990;23:624-626
20. Sedun AA. Dyslexia at New York Times: (mis)understanding of parallel vision processing. Arch Ophthalmol. 1992;110:933-934
21. Bradley L. Rhyme recognition and reading and spelling in young children. In: Masland RL, Masland MW, eds. Preschool Prevention of Reading Failure. Parkton, MD: York Press; 1988:143-162
22. Ogden S, Hindman S, Turner SD. Multisensory programs in the public schools: a brighter future for LD children. Ann Dyslexia. 1989;39:247-267
23. Romanchuk KG. Skepticism about Irlen filters to treat learning disabilities. CMAJ. 1995;153:397
24. Silver LB. Controversial therapies. J Child Neurol. 1995;10(suppl 1):S96-S100
Pediatrics Volume 102, Number 5 November 1998, pp 1217-1219
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.