’t “EYE” Read Why Can Todd Goldblum, MD
Why Can’t “EYE” Read Todd Goldblum, MD Pediatric Ophthalmology Family and Children’s Eye Center of NM Sheryl Handler Pediatric Ophthalmology Financial Disclosure I have NO financial interest in any of the material presented Sheryl Handler Pediatric Ophthalmology “ The more you read, the more things you will know. The more that you know, the more places you will go” (Dr Seuss) Sheryl Handler Pediatric Ophthalmology Learning to Read Most children spend the first few years of school learning to read Then they need reading to learn Sheryl Handler Pediatric Ophthalmology “The act of reading a text is like playing music and listening to it at the same time” Margaret Atwood (2002), “Negotiating with the Dead” Sheryl Handler Pediatric Ophthalmology Learning to Read According to a leading reading researcher, Dr. Louisa Moats: “Teaching reading IS rocket science” Sheryl Handler Pediatric Ophthalmology Early Speech and Language Milestones Smile Imitate speech sounds Monosyllabic babbling Polysyllabic babbling Comprehends individual words Mama / Dada correct use First word (other than above) Two word combination Vocabulary 50(+) words 1-2 months 4-6 months 4-8 months 5-9 months 6-10 months 7-12 months 9-14 months 16-22 months 16-24 months Delay in meeting these milestones may indicate, among other problems, a future learning disability Sheryl Handler Pediatric Ophthalmology Language Development Sequence Understanding Speaking Reading Writing Sheryl Handler Pediatric Ophthalmology Oral Language Sheryl Handler Pediatric Ophthalmology Oral Language The development of oral language is an ongoing natural process – pre-programmed into human development Oral language is the foundation for reading The number of words in a child’s vocabulary is an indicator of his “linguistic health” It is extremely important for parents to begin talking to their child in infancy Sheryl Handler Pediatric Ophthalmology Exposure to Oral Language Hart & Risley –30 Million Word Difference in 4 years Talkative parents 2153 words/hour 11.2 million words/year Moderately talkative parents 1250 words/hour 6.5 million words/year Minimally talkative parents 616 words/hour 3.2 million words/year Sheryl Handler Pediatric Ophthalmology Exposure to Oral Language Hart & Risley (1995) Expressive language practice is linked to receptive language experience 30 Million Word Difference in 4 years Toddlers’ talkativeness stops growing when it matches the level of their parents’ talkativeness Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Oral Language Oral language is the foundation for reading Oral language is broken up into phonemes Sounds signaling differences of meaning English is a phonemically complex language 44 Phonemes (sounds) in 70 letter combinations Sheryl Handler Pediatric Ophthalmology Oral Language Phonemes - sounds signaling differences of meaning 44 Phonemes in English Cannot break letters into phonemes “Pet” & “Bet” are distinguished by the sounds of their initial consonants Semantics – meaning of words, combining words into phrases and sentences Syntax - Use of language to communicate needs, get information – grammatical structure Pragmatics - use of language for functional communication – connected sentences Sheryl Handler Pediatric Ophthalmology How We Read - Language Oral language is pre-programmed into human brain development Reading is not pre-programmed Reading is the complex process of extracting meaning from written symbolic characters Sheryl Handler Pediatric Ophthalmology What is Reading? A complex process of extracting meaning from written symbolic characters Sheryl Handler Pediatric Ophthalmology Reading Reading is more difficult than speaking Children must understand the connection between the sounds of spoken language Then utilize the corresponding alphabetic code to acquire the sound/symbol connection Sheryl Handler Pediatric Ophthalmology Reading Learning to read is a sequential process; each new skills builds on mastering the previously learned skills Decoding written symbols Converting the symbols to sound Converting the symbols to meaning Progressively increasing fluency Building comprehension skills Storing cumulative information in memory Sheryl Handler Pediatric Ophthalmology The Basics of Reading Fixation >>Visual Processing >> Decoding >>Fluency>> Comprehension >>Retention = Success ! Sheryl Handler Pediatric Ophthalmology The History of Reading Spoken communication has been an evolutionary “gift” for 6 million years Written communication has been around only 6000 years……no time for the brain to evolve ! Sheryl Handler Pediatric Ophthalmology The History Of Reading Spoken words are the symbols of mental experience Written words are the symbols of spoken words Aristotle On Interpretation 2000 BC--Phoenician alphabet contained consonants only Sheryl Handler Sumerian Logographs - circa 4000 BC Pediatric Ophthalmology Written Language Written language is artificial Writing is the use of abstract symbols to represent language Writing Systems Ideographic – symbol represents an idea Logographic – symbol represents an object/word Alphabetic – symbol represents an abstract building block of that language’s phonemes Written language must be actively learned Sheryl Handler Pediatric Ophthalmology Ideographic Sheryl Handler Pediatric Ophthalmology Logographic Sheryl Handler Pediatric Ophthalmology Alphabetic Sheryl Handler Pediatric Ophthalmology Alphabetic Sheryl Handler Pediatric Ophthalmology Written Language English uses Alphabetic system – symbols represent an abstract building block of that language’s phonemes Sheryl Handler Pediatric Ophthalmology Object Constancy Object constancy is the understanding that objects continue to exist even when they cannot be seen, heard, or touched And that objects are the same even when they are moved Peek-a-boo game Usually fully ingrained by 24 months Sheryl Handler Pediatric Ophthalmology This is the same dog in different directions “Object Constancy” 30 Sheryl Handler Pediatric Ophthalmology How We Read - Language Orthographic Perception b This is nearly the same shape turned d p in different directions – creating 5 unique letters & 2 numbers q g 9 6 ?? New Concept ?? “Incomplete Object Constancy ??” Unless the child can convert these symbols into the phonetic code - they are just lines and circles devoid of linguistic meaning Sheryl Handler Pediatric Ophthalmology How we Read - Language Important terminology Phonological awareness is the ability to hear individual sounds, manipulate them and remember the order of the sound Phonemes are the small units of sound in words that signal differences in meaning (“bat” vs “cat”) Phonemic awareness is the ability to hear the individual sounds in words and knowing that these sounds signal differences in meaning Phonics is the understanding that segmented units of speech can be represented by printed letters Sheryl Handler Pediatric Ophthalmology How we Read Comprised of Perception Decoding Fluency Comprehension Requires Sheryl Handler Adequate vision Adequate memory Ability to sustain attention Absence of these do not equal dyslexia Pediatric Ophthalmology Decoding Phonemes: spoken word can be segmented into different sounds Phonics: puts those sounds into printed forms Sheryl Handler Phoneme Example /A/ a (table) /a/ a (flat) /r/ r (road), wr (wrong) /s/ s (say), c (cent) /u/ u (thumb), a (about), e (loaded), o (wagon) Pediatric Ophthalmology Decoding 44 phonemes in English language Then need to blend the phonemes to form word Sheryl Handler Phoneme Word /f/ /o/ /n/ /e/ /m/ phoneme Pediatric Ophthalmology Decoding Hebrew letter Phoneme Hebrew word Phonemes English translation ל /l/ לא /lo/ no מ /m/ מה /ma/ what ו,ב /v/ נבל /nevel/ harp Sheryl Handler Pediatric Ophthalmology What Does it Feel Like to be Dyslexic? Decoding & Working Memory A/a = А/a В/в = V/v г/г = G/g Д/д = D/d Е/е = E/e И/и = I/i К/к = K/k М/м = M/m Н/н = N/n • • • • • • • • О/о = O/o П/п = P/p P/p = R/r C/c = S/s Т/т = T/t Y/у = U/u or W/w Х/х = H/h Э/э = E/e п э н Пэн Декодинг путс хэви дэмандс он уоркинг мэмори, уэн нот аутоматик Sheryl Handler Pediatric Ophthalmology What Does it Feel Like to be Dyslexic? Decoding & Working Memory Пэн = Pen п э Декодинг путс хэви дэмандс он н уоркинг мэмори, уэн нот аутоматик = Decoding puts heavy demands on working memory, when not automatic Sheryl Handler Pediatric Ophthalmology What Does it Feel Like to be Dyslexic? Decoding & Working Memory יש לך עיניים יפות Sheryl Handler What Does it Feel Like to be Dyslexic? .gnidaer era yeht tahw dneherpmoc ot elbanu era yeht taht gnimusnoc emit dna suoirobal os signidoced fo ssecorp eht nerdlihc emos roF Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology For some children the process of decoding is so laborious and time consuming that they are unable to comprehend what they are reading. What Does it Feel Like to be Dyslexic? What Does it Feel Like to be Dyslexic? For some children the process of decoding is so laborious and time consuming that they are unable to comprehend what they are reading. Sheryl Handler Pediatric Ophthalmology The Complexity of the Mind Believe it or not, you can read this… Sheryl Handler Pediatric Ophthalmology The Complexity of the Mind I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdgnieg. The phaonmneal pweor of the hmuan mnid. Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, teh olny iprmoatnt tihng is that the frist and lsat ltteer be in the rghit pclae. Yaeh and I awlyas thought slpeling was ipmorantt! Sheryl Handler Pediatric Ophthalmology How We Read - Language Fluency Ability to read connected text with expression rapidly, smoothly, effortlessly, and automatically with little conscious attention to the mechanics of reading such as decoding Sheryl Handler Pediatric Ophthalmology How We Read - Language Fluency Children must become accurate readers before they can become fluent readers Sheryl Handler Pediatric Ophthalmology How We Read - Language Fluency - Sight words Sight words include any word that readers have practiced reading sufficiently often to be read automatically from memory Sight words are read as whole units with no pauses between sounds Sight of the word activates its pronunciation and meaning in memory immediately without any sounding out or blending required Sheryl Handler Pediatric Ophthalmology What Does it Feel Like to be Dyslexic? Fluency It isn't as if the are difficult to or understand, but the make you between words, which your reading is less words identify spaces pause means fluent. Sometimes you can identify words and comprehend them, but, if the processes don't come together smoothly reading will be labored & non-fluent Sheryl Handler Pediatric Ophthalmology How We Read - Language Comprehension– Higher Order Linguistic Function General Intelligence Reasoning Vocabulary Pragmatics Syntax - grammar Comprehension – Other Factors Attention Memory Knowledge Cultural influences Sheryl Handler Pediatric Ophthalmology What Does it Feel Like to be Dyslexic? Comprehension The Montillation of Traxoline It is very important that you learn about traxoline. Traxoline is a new form of zionter. It is montilled in Ceristanna. The Ceristannians gristeriate large amounts of fevon and then bracter it to quasel traxoline. Traxoline may well be one of our most lukized snezlaus in the future because of our zionter lescelidge. Attributed to Judy Lanier Sheryl Handler Pediatric Ophthalmology How We Read - Comprehension The Montillation of Traxoline What is traxoline ? Where is it montilled ? Why will it be one of our most lukized snezlaus in the future ? Sheryl Handler Pediatric Ophthalmology How We Read – Visual Functions Visual acuity Accommodation Convergence Saccades Fixations Sheryl Handler Pediatric Ophthalmology How We Read – Vision Print characteristics Kindergarten books 1st grade books 3rd grade books Paperback books Average Print Size 20/200 20/100 20/70 20/50 As children begin to read faster the print size and spacing becomes much smaller over a few years and many children including good readers don’t like it Slightly larger print and spacing helps all readers but especially those who are having reading difficulties Sheryl Handler Pediatric Ophthalmology How We Read - Accommodation Sheryl Handler Pediatric Ophthalmology How We Read - Accommodation Accommodation (Focusing) Children under the age of 10 have tremendous power to focus at near Half is available for sustained use Under the age of 10 the near point of focusing is 1 inch from the nose This is why young children often hold books closely especially when they are concentrating – because they can!! Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology How we Read – Accommodation Problems Accommodative Insufficiency Decreased focusing ability at near EXTREMELY RARE in children Due to: Uncorrected refractive error, medications, illness, eye trauma Treatment Reading glasses Near fusion exercises Sheryl Handler Pediatric Ophthalmology How We Read - Vergence Vergence The ability to keep the eyes aligned on a visual target to maintain fusion (binocular interaction) Convergence Turning the eyes inward Is needed for near reading Sheryl Handler Pediatric Ophthalmology Convergence Sheryl Handler Pediatric Ophthalmology How We Read - Vergence Problems Convergence Insufficiency Unable to fully converge eyes at near Frequently over-diagnosed in children! Recommend getting 2nd opinion if CI diagnosed Much less common in children Most people have NO symptoms Symptomatic CI Is treatable Does NOT cause dyslexia Sheryl Handler Pediatric Ophthalmology How We Read - Vergence Problems Symptomatic Convergence Insufficiency Treatment will make reading more comfortable But does NOT improve decoding or comprehension directly Patching one eye in CI relieves symptoms but does NOT improve decoding or comprehension Sheryl Handler Pediatric Ophthalmology How We Read - Fixation Fixation Visual information is perceived during foveal fixation Short words are read with 1 fixation Longer words with 2 fixations 90% of our reading time are fixations Duration of fixation 45-450 millisec (average 180 milliseconds) Sheryl Handler Pediatric Ophthalmology How We Read - Problems with Fixation Nystagmus – movements shortens fixation time and reduces vision Foveal Scar – reduces visual acuity and necessitates use of non-foveal retina Foveal Hypoplasia – legal blindness which necessitates use of non-foveal retina and may also be associated with nystagmus Pediatric Ophthalmology Saccades Rapid eye movements Bring images seen in periphery to center Pediatric Ophthalmology How We Read - Saccades Saccades - small jumping eye movements Forward saccades - 85% of saccades Adult saccade average distance is 2 degrees (eight letters) Saccade length is dependent on the ability to recognize letters, the difficulty of the text and the length of the word prior to the saccade Backwards saccades - 15% of saccades Half the distance of forward saccades Increase with difficulty of the text Used for verification & comprehension Used to jump to the next line Sheryl Handler Pediatric Ophthalmology Physiologic Saccadic Movement for Adult Reading Sheryl Handler Pediatric Ophthalmology LINE OF SIGHT Saccadic eye movements were recorded while reading 2 pages of a 2 column newspaper Sheryl Handler 67 Pediatric Ophthalmology How We Read – Saccades & Fixation Child/early or dyslexic reader Saccades - 1/2 length More backwards saccades Fixates - 2 times as long and twice as often Dyslexic readers show saccadic eye movements and fixations similar to the beginning reader Dyslexic readers show normal saccadic function when not reading Sheryl Handler Pediatric Ophthalmology How We Read NOT involved in reading Smooth Pursuit (“TRACKING”) Vestibular System Sheryl Handler Pediatric Ophthalmology Smooth Pursuit (TRACKING) Extremely slow eye movements Helps keep the image of a moving target on the fovea (retina) AKA: “tracking” Very inefficient and rarely used Pediatric Ophthalmology Eye tracking is NOT used for reading Sheryl Handler Pediatric Ophthalmology Vestibular Holds images on the retina during head rotation or movements Inner ear sends signal to brain Pediatric Ophthalmology How We Read – Visual Functions Children with reduced vision often are good readers Accommodation deficits require reading glasses Symptomatic convergence insufficiency is extremely rare in young children Children with inability to make saccades can be good readers Children with nystagmus (jiggling eyes) can be good readers Sheryl Handler Pediatric Ophthalmology Difficulties in Early Reading Initial difficulty in learning to read occurs in nearly 40% of students in the U.S. It may have a number of different causes: Deficits in oral language Lack of background knowledge Inadequate instruction Insufficient reading practice Reading disability = Dyslexia Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Learning Disabilities Are common problems 5 – 20% of the U.S. population has a learning disability depending on the definition chosen 2.6 million children aged 6 – 11 years in the U.S. are affected Sheryl Handler Pediatric Ophthalmology Learning Disabilities Arise from neurological differences in brain structure and function Affect the brain’s ability to store, process or communicate information Do not arise from malfunctions in the visual system Sheryl Handler Pediatric Ophthalmology Learning Disabilities LDs may cause difficulty in learning to: Read Listen Speak Spell Write Reason Solve mathematical calculations Organize information Sheryl Handler Pediatric Ophthalmology Specific Learning Disabilities Dyslexia Reading disability Dysgraphia Writing disability Often found in addition to dyslexia Dyscalculia Mathematics disability Sheryl Handler Pediatric Ophthalmology Dyslexia-A Language-Based Learning Disorder International Dyslexia Association Dyslexia is a specific learning disability that is neurological in origin. It is characterized by difficulties in accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Sheryl Handler Pediatric Ophthalmology Dyslexia Dyslexia is the most common learning disability 80% of all learning disabilities 20% of children in the U.S. have some degree of dyslexia But only 5% of children with dyslexia have been diagnosed Sheryl Handler Pediatric Ophthalmology Dyslexia Dyslexia runs in families 40% affected sibling 40 % affected parent Multiple genes are suspected Sheryl Handler Pediatric Ophthalmology Dyslexia - Shaywitz Dyslexia is not related to intelligence Dyslexia occurs at all levels of intelligence Children with dyslexia are not “dumb” or “lazy” their brains just process information differently They are often very bright, analytic, creative and gifted in other areas Sheryl Handler Pediatric Ophthalmology Dyslexia - Shaywitz Dyslexia can vary from mild to severe Reading disability represents the lower tail of a normal distribution of reading ability Sheryl Handler Pediatric Ophthalmology Dyslexia - Shaywitz Dyslexia does not represent a transient developmental lag Dyslexia is a life-long condition A child doesn’t just “grow out of it” Sheryl Handler Pediatric Ophthalmology Dyslexia Associated Problems ADHD in 20 – 40% & vice versa Spoken language difficulties Dysgraphia (writing disabilities) Difficulties learning a foreign language Math word-problem difficulties Motor coordination difficulties Anxiety Depression Sheryl Handler Pediatric Ophthalmology Brain Regions Involved In Reading Healthy readers use both ! Sheryl Handler Pediatric Ophthalmology When is the Phonological Pathway Used? Used for “regular words” Can is a regular word – the c, a, and n are pronounced in the regular way Not used for “irregular sight words” = Words that cannot be “sounded out” Yacht” or “eye” are examples These words must be memorized and are often called “irregular sight words” Direct Pathway is used Sheryl Handler Pediatric Ophthalmology Dyslexia – Neurobiologic Pathology Brain Research – FMRI & PET scans have made an “invisible” diagnosis “visible” The brain of people with dyslexia are “wired” differently even before they start to read Children with dyslexia use a different area of the brain for processing written words, compared to typical readers This alternative pathway has trouble retrieving the sounds in spoken words making it difficult to read Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Dyslexia – Neurobiologic Pathology Normal Readers Dyslexic Readers Inferior Frontal (Broca’s Region) Left Left & Right Left Parieto-temporal Yes Decreased Left Occipito-temporal Yes Decreased Left Posterior-inferior temporal Yes Decreased Right Occipto-temporal No Yes The dyslexic pattern improves after effective phonological remediation Sheryl Handler Pediatric Ophthalmology Dyslexia – Phonologic Deficit The primary problem or “core deficit” for most children with dyslexia is: A phonological deficit causes weak decoding skills leading to labored reading and secondary difficulties with spelling Sheryl Handler Pediatric Ophthalmology Decoding Difficulties Dyslexia - SE Shaywitz Scientific American.1996;275(5):98-104 available at: http://dyslexia.yale.edu/Dyslexia_articleintro.html Sheryl Handler Pediatric Ophthalmology Spelling Difficulties Sheryl Handler Pediatric Ophthalmology Dyslexia is a Language-Based Problem Dyslexia is a language-based problem Phonologic coding, analysis, and word identification deficit Verbal memory deficit Not a vision-based problem Sheryl Handler Pediatric Ophthalmology Dyslexia – Not a Vision-Based Disorder MYTH: Dyslexia is caused by the eyes FACT: The scientific evidence does not show that subtle eye or visual problems including abnormal focusing, jerky eye movements, misaligned or crossed eyes cause or increase the severity of dyslexia Sheryl Handler Pediatric Ophthalmology Dyslexia – Not a Vision-Based Disorder MYTH: Dyslexia is caused by a vision problem FACT: No specific vision problem causes dyslexia No relationship between visual function & academic performance or reading ability has been shown Children with LDs do not have more visual problems than children without LDs Visual problems may co-exist with dyslexia but are present with the same incidence as in the general population Sheryl Handler Pediatric Ophthalmology Dyslexia – Not a Vision Based Problem People with dyslexia do NOT see things backwards Difficulties in maintaining proper directionality have been demonstrated to be a symptom, not a cause, of reading disorders Word reversals and skipping words and lines are due to linguistic deficiencies and not visual or perceptual disorders Sheryl Handler Pediatric Ophthalmology Dyslexia – Not a Vision-Based Disorder If deficiencies in motor and visual-motor development or defects in eye movements caused perceptual impairment reading problems one would be at a loss to explain why: So many children with cerebral palsy, strabismus, amblyopia, nystagmus become good readers So many children with dyslexia play video games Sheryl Handler Pediatric Ophthalmology Can’t Read Because of a “Tracking” Problem ??? Sheryl Handler Pediatric Ophthalmology Dyslexia is a Language-Based Problem Contrary to popular belief The primary sign of dyslexia is not reversing letters Rather it is a difficulty interpreting the sound components of our language Sheryl Handler Pediatric Ophthalmology Dyslexia is NOT Caused by a “Tracking Problem” Children with dyslexia often skip words or lines when reading Some people call this word and line skipping a “tracking problem” Fluent reading is not based on “eye tracking” Sheryl Handler Pediatric Ophthalmology Dyslexia is NOT Caused by a “Tracking Problem” Fluent reading or “reading tracking” has nothing to do with “eye tracking” = either ocular smooth pursuit or horizontal saccades Fluent reading has to do with decoding abilities, comprehension, memory and attention ! “Tracking problems” are over-diagnosed! Sheryl Handler Pediatric Ophthalmology Dyslexia Risk Factors Family history of dyslexia Fetal exposure to drugs or alcohol Prematurity or birth problems Infections of the central nervous system Exposure to toxins (lead) Severe head injuries Other neurological problems Sheryl Handler Pediatric Ophthalmology Possible Early Indications of Dyslexia History of: Family history Speech delay Difficulty with rhymes Confusing words that sound alike Delay in learning letters Delay in learning phonics Sheryl Handler Pediatric Ophthalmology Dyslexia - Common Signs Significance of the signs are age dependent If a student has several signs that persist -he/she should undergo testing Difficulty remembering the names of the letters Difficulty remembering the sounds of the letters Reversing letters and words Reading words incorrectly - guessing Adding, dropping, changing words & skipping lines Slow reading in adolescents & adults Sheryl Handler Pediatric Ophthalmology Dyslexia – Other Signs Trouble with reading comprehension Trouble spelling Frustration with schoolwork and homework Not wanting to go to school Problems with attention Sheryl Handler Pediatric Ophthalmology Possible Indications of Dyslexia May be overlooked because the child has been labeled as a: Slow learner Underachiever Lazy Problem child By the time a child may be found to have dyslexia he/she may have labeled himself/herself as stupid and have damaged self-esteem Sheryl Handler Pediatric Ophthalmology Dyslexia – Secondary Consequences The ripple effect = secondary problems caused by dyslexia The extra amount of work expended by dyslexic readers combined with the frustration of failing to achieve meaningful comprehension makes reading unpleasant, tiring & unrewarding Sheryl Handler Pediatric Ophthalmology Dyslexia – Secondary Consequences Students who cannot read well tend to read less and this negatively impacts their: Reading fluency Vocabulary Comprehension Concept knowledge Sheryl Handler Pediatric Ophthalmology Dyslexia – Secondary Consequences Can damage self-esteem Cause emotional problems Withdrawal Anxiety Depression Aggression Children may be teased or bullied by others Sheryl Handler Pediatric Ophthalmology Teacher Knowledge & Preparation Many teachers receive only a cursory introduction to reading instruction and often have not been exposed to the latest research Currently, the majority of teachers have not been sufficiently prepared to prevent reading problems and they are not aware of the signs of dyslexia Which leads to delays in assessments & interventions Sheryl Handler Pediatric Ophthalmology Teacher Knowledge & Preparation Educators need to be trained on: Language structure Reading theory Reading development Reading problems The early signs of possible dyslexia Reading assessment Sheryl Handler Pediatric Ophthalmology Teacher Knowledge & Preparation In many states the teachers who have been trained in science-based reading intervention programs are improving reading scores Sheryl Handler Pediatric Ophthalmology Role of Education Early recognition and intervention is a cost effective solution to improving reading skills Delaying identification and intervention is “penny-wise but dollar-foolish” financially for schools Sheryl Handler Pediatric Ophthalmology Role of Education - Screening Early detection of reading difficulties by yearly reading screening K – Alphabet recognition, phonemic awareness & rapid naming 1st – Add word identification fluency 2nd – Add oral reading fluency Sheryl Handler Pediatric Ophthalmology Role of Education 2 approaches can be utilized in the young underachieving child Persistently poor academic achievement prior to referral & assessment – 2 years behind Response To Intervention (RTI) method Screening allows earlier identification of LDs than the “wait to fail” approach Child is directly placed in an educational intervention program when difficulties arise Only children who do not show significant improvement with both the group intervention & 2nd tier targeted intensive individual intervention will undergo a full educational assessment Sheryl Handler Pediatric Ophthalmology Multidisciplinary Approach The diagnosis and treatment depends on the collaboration of a team Making the correct diagnosis in children with reading weaknesses is important before a therapeutic regimen can be prescribed Evaluation for attention (ADHD) and other problems is very important Sheryl Handler Pediatric Ophthalmology Multidisciplinary Approach Comprehensive Medical & Psychological Evaluation & Treatment Team Primary Care Physician Developmental Pediatrician Pediatric Ophthalmologist Pediatric Otolaryngologist Pediatric Psychiatrist Pediatric Neurologist Pediatric Psychologist Educational Psychologist Neuropsychologist Sheryl Handler Pediatric Ophthalmology Multidisciplinary Approach Special Services Team & more Educational Therapy Speech Therapy Occupational Therapy Physical Therapy Educational Legal Advocate Schools specializing in Learning Disabilities Sheryl Handler Pediatric Ophthalmology Multidisciplinary Approach Formal Assessment for Learning Disabilities Cognition Intellectual ability Information processing Psycho-linguistic processing Academic skills Social-emotional development Adaptive components Sheryl Handler Pediatric Ophthalmology Multidisciplinary Approach Formal Assessment for Reading Disabilities Receptive listening skills Receptive written language skills Expressive oral language skills Expressive written language skills Phonologic skills – including phonemic awareness Sheryl Handler Pediatric Ophthalmology Multidisciplinary Approach Formal Assessment for Reading Disabilities Alphabet knowledge Rapid naming of letters and pictures Vocabulary Reading accuracy Fluency Comprehension Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia Federal Laws : Individuals with Disabilities Education Act (IDEA) & (IDEIA) Section 504 of the Rehabilitation Act of 1973 (504) Americans with Disabilities Act (ADA) 2008 ADA Amendments Act (ADAAA) No Child Left Behind (NCLB) Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia Federal Laws : Under (IDEA) & (IDEIA) – a “child with a disability” is one who is eligible for special education & related services IDEA guarantees a “free and appropriate” public education Provides funding for special education & services In the least restrictive environment possible Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia The I.E.P. team determines eligibility for special education Need to have 1 or more of 13 disabilities (including specific learning disability) AND need special education because of the disability If your child is eligible - an IEP plan will be written Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia An I.E.P. Plan will include: Student’s educational needs Specific learning goals Different instructional methods Treatments necessary In addition to remedial education, accommodations and modifications may be included Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia Generally only students with severe dyslexia will qualify for an IEP Many struggling students with a learning disability will not show severe enough difficulties on evaluation to be qualified as “learning disabled” as defined by IDEA and will not be eligible for special education and related services Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia 504 plans are used to provide a child equal access to education If dyslexia has been shown to “substantially limit” a student’s learning And if he/she still needs targeted reading or other assistance to be able to fully participate in school he/she may be a candidate for a 504 plan Accommodations or other assistance may be provided Sheryl Handler Pediatric Ophthalmology Role of Education – Remediation Dyslexic children who receive effective phonological training in K & 1st grade 10 – 25% will continue to show problems in learning to read Vs. children not identified until 3rd grade 74% will continue to show problems through high school Sheryl Handler Pediatric Ophthalmology Role of Education – Remediation Intensive treatment 90 minutes in regular classroom 60 minutes extra instruction Sufficient duration Individual or small group instruction Individualized multi-sensory (visual, auditory, tactile) reading and language program by a high quality instructor Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment The spoken code must be understood before children can progress to the written code In Kindergarten both phonologic and phonemic awareness should be taught before instruction on the alphabet and phonics begins Otherwise, the phonics instruction will not make sense to the dyslexic child Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment Decoding Training Phonology and Phonological Awareness Rhyme & Alliteration Exaggerating sounds Segmenting words Blending words Separating words into syllables Separating syllables into phonemes Sound-Symbol Association – Alphabetics Sight words - memorize Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment Phonics – Learning about and using different sound and letter combinations to decode words Letter-sound relationship Vowel sounds Complex letter-sound patterns (ex. sh-, -ng, -dge, -ight) Rules (ex. silent e rule) Spelling Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment Fluency Training Practice, practice, practice!! Just as an athlete must practice to optimize his or her skills, a child should read aloud each day to practice decoding, memorize new sight words Greater fluency is developed by re-reading previously decoded and memorized words Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment Fluency Training Guided oral reading Paired reading Repeated reading Vocabulary Training Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment Comprehension Training – Active reading Prior to reading Purpose for reading Predictions During reading Who, what, where, when, and why Visualization and predictions After reading Retell the sequence of events Summarization and drawing conclusions Other activities to improve language development Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment Accommodations & Modifications can include Extra time Separate quiet room Testing alternatives – oral instead of written tests Preferential seating Computers Spell checkers Recorded books Computer assisted reading programs Lecture notes Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment The accommodation of extra time Allows the student to show what he/she knows It is more important to show what he/she knows than how fast he/she can show it Decreases stress and anxiety As an adult, life is not a timed test – it matters how you do the job Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment What can be done in the classroom? Explicit instruction in phonologic awareness, basic print concepts, & knowledge of letter sounds Sequenced phonics instruction Do not encourage students to sound out irregular words such as: the, of, come, some, have, said, was, one, two, you, be, by etc. Use multisensory learning – hearing, seeing & touching Integrate listening, speaking, reading & writing Sheryl Handler Pediatric Ophthalmology Overcoming Dyslexia - Treatment What can be done in the classroom? Work with student in groups of 2 - 5 Student paired reading & repeated reading Allow students to preview reading assignments Allow students to preview vocabulary – give definitions and pictures Give tests orally Allow extra time Sheryl Handler Pediatric Ophthalmology Dyslexia – The Whole Child We need to look at the “whole child” not only at their weaknesses It is a disservice to the child to concentrate on only their weaknesses We must stop viewing these children as “broken” Even though the child has difficulty reading it does not mean that he/she has difficulty thinking Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Dyslexia – “The Gift” Frequent strengths of children with dyslexia “Out-of-the-box thinking” Bright, analytic, creative & gifted in other areas High ability to reason and understand concepts, excellent at solving problems in a novel fashion **Necessary for the 21st Century ** Sheryl Handler Pediatric Ophthalmology Dyslexia – “The Gift” Children with dyslexia often have many strengths Everyone succeeds on their strengths NOT on their weaknesses Children need time to concentrate on their strengths Long list of entrepreneurs, inventors, scientists, actors, doctors, lawyers, and other professionals Sheryl Handler Pediatric Ophthalmology Famous People with Dyslexia Sheryl Handler Pediatric Ophthalmology Examining the Evidence Sheryl Handler Pediatric Ophthalmology Levels of Evidence in Medicine Sheryl Handler Pediatric Ophthalmology Dr. Hokum’s Cure for the Common Cold 100,000 patients treated with Cold-B-Gon 100% cure rate! Proves it’s effective, right? • What about the control group?? Sheryl Handler Pediatric Ophthalmology Dr. Hokum’s Cure for Cancer of the Elbow Sheryl Handler Treated 100 patients with Eye of Newt (and standard chemotherapy/radiation) 96% cure rate Proves Eye of Newt works, right? What about the control group? Was it the Eye of Newt that helped them? Pediatric Ophthalmology Controversial Theories and Treatments Key points: The more things that a theory explains, the more likely it is to be false Public dissemination of “fact” needs to be validated The results of small studies are likely to be disproved in larger studies Studies without matched controls have a high false positive error Sheryl Handler Pediatric Ophthalmology Controversial Treatments - Silver The treatment is proposed to the public prior to research or before preliminary research has been replicated The treatment is commercially pushed before the research shows any support or evidence shows that it does not work The treatment proposed goes beyond what research data supports Am J Dis Child. 1986 Oct;140(10):1045-52 Sheryl Handler Pediatric Ophthalmology Questions to ask in assessing the claims of dyslexia trials: Where’s the control group? • How were “reading disorders” diagnosed? • Were the subjects receiving other intervention (such as reading instruction) while receiving vision therapy? • Do the investigators have a financial interest? • Sheryl Handler Pediatric Ophthalmology Controversies ? Sheryl Handler Pediatric Ophthalmology Controversies ? Sheryl Handler Pediatric Ophthalmology “Scotopic Sensitivity Syndrome” Scotopic Sensitivity Syndrome = SSS = Irlen Syndrome = Mears-Irlen Syndrome Not an actual medical syndrome Current supporters claim that it may be due to “Magnocellular Dysfunction” “Hypersensitive photoreceptors” “Cortical Excitability” Supporters relate that SSS affects: 12-15% of the general population 45% with learning disabilities Sheryl Handler Pediatric Ophthalmology Irlen Lenses Sheryl Handler 160 Pediatric Ophthalmology Tinted Lenses / Filters Helen Irlen proposed using colored lenses in certain types of dyslexics (1983) Irlen’s initial claims were based on observations, anecdotal accounts of adults and no formal experimentation Prior to any supporting research SSS was featured twice on the television program 60 Minutes This national exposure led to great interest in the treatment Sheryl Handler Pediatric Ophthalmology Tinted Lenses / Filters Treatment with tinted lenses are used because of presumed perceptual dysfunction causing visual distortion & sensitivity to particular wavelengths of light; now called “visual stress“ Lenses are now being used to treat a variety of non-ocular conditions: headaches, trauma, language deficits, autoimmune disease, & depression Sheryl Handler Pediatric Ophthalmology Tinted Lenses / Filters Color Color selection methods in the different studies are highly variable Many methods are used: Yellow filters Blue filters Irlen Method – patient selection Wilkins Precision Tint Method using the “Intuitive Colorimeter” ChromaGen Method Sheryl Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Tinted Lenses / Filters Color Woerz’s study - poor test-retest reliability on color selection Stone’s study - 25% needed their color changed within a year Henderson’s study – 38% chose a different color 2 weeks later Sheryl Handler Pediatric Ophthalmology Tinted Lenses / Filters 1990: Parker, Solan, Hoyt’s review of 3 studies using tinted lenses noted serious methodological flaws – making the studies’ conclusions invalid 1993: Menacker’s cohort study showed no improvement or preferred tint among disabled readers Robinson - Literature Review 1993: Multiple studies showed methodologic flaws Sheryl Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Tinted Lenses / Filters Hyatt, Stephenson & Carter – 2009 Review of 3 Controversial Practices Including Tinted Lenses Reviewed 17 Studies on Tinted Lenses Filters from 1988-2003 Conclusion: failed to demonstrate the efficacy of the tinted lenses Sheryl Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Tinted Lenses / Filters Ritchie, Della Sala & McIntosh– 2011 Placebo controlled study Irlen diagnostician diagnosed Irlen Syndrome in 47/61 below-average readers Irlen Syndrome children were evaluated with an overlay of prescribed color, overlay of non-prescribed color and no overlay in random order Irlen colored overlays showed no immediate effect on reading in children with reading difficulties even among those diagnosed with Irlen Syndrome Sheryl Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Tinted Lenses/Filters JM Fletcher & D Currie 2011 – Review Conclusions: Many current studies find: Inconsistent evidence for small and questionably clinically significant increases in reading rate Little evidence of measurable effects on accuracy or comprehension Little evidence of specific improvement in children with reading disabilities Sheryl Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Tinted Lenses / Filters Handler & Fierson - 2011 Learning Disabilities, Dyslexia and Vision Joint AAP, AAO, AAPOS & AACO Technical Report Published studies contain serious flaws Many of the studies cited as proof actually have been found to be inconclusive Colored filters and lenses may be ineffective except that they act as a placebo The evidence does not support the effectiveness of tinted lenses & filters in patients with dyslexia Sheryl SherylHandler Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Tinted Lenses/Filters LM Henderson, N Tsogka, MJ Snowling - 2013 “Visual stress”: Questions the value of using colored overlays as a tool to identify visual stress Questions the value of using a questionnaire to identify visual stress Symptoms can be attributed to visual problems or dyslexia itself Sheryl Handler Pediatric Ophthalmology Tinted Lenses/Filters LM Henderson, N Tsogka, MJ Snowling - 2013 Results and Conclusions: Both the dyslexic and control groups read jumbled text faster with a colored overlay than without Reading connected text was not improved by colored overlays Comprehension was not improved by colored overlays Questions the value of using colored overlays for the remediation of reading difficulties associated with dyslexia Sheryl Handler Pediatric Ophthalmology כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. כל עוד בלבב פנימה נפש יהודי הומיה ולפאתי מזרח קדימה עין לציון צופיה. עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים עוד לא אבדה תקוותנו התקווה בת שנות אלפיים להיות עם חופשי בארצנו ארץ ציון וירושלים Pediatric Ophthalmology Sheryl Handler Vision Therapy (Vision Training = VT) Vision therapy (VT) is a term used by optometrists Optometrists define VT as an attempt to develop or improve visual skills and abilities; improve visual comfort, ease, and efficiency; and change visual processing or processing of visual info An optometric VT program consists of an individualized progressive program of vision procedures performed under supervision in-office and supplemented with procedures performed at home between office visits Sheryl Handler Pediatric Ophthalmology Vision Therapy (Vision Training = VT) Therapy is generally conducted once or twice weekly in-office for 30 – 60 minutes over a period of weeks to years In addition to exercises, lenses (“training glasses”), prisms, filters, patches, electronic targets, specialized instruments, or balance boards may be used Sheryl Handler Pediatric Ophthalmology Vision Therapy (Vision Training = VT) Orthoptic techniques are used to change specific visual functions Convergence Accommodation Ocular motility Binocular fusion capability Behavioral vision therapy is used to improve visual efficiency Improve scanning Improve locating Sheryl Handler Pediatric Ophthalmology Vision Therapy (Vision Training = VT) Behavioral VT treats visual processing & perception defs Visual spatial orientation skills Bilateral integration Laterality & directionality Visual analysis skills Visual discrimination Visual figure-ground discrimination Visual closure Visual memory & visualization Visual-motor integration Eye-hand coordination Auditory-visual integration Visual-verbal integration Sheryl Handler Pediatric Ophthalmology Training Techniques - Ocular Motility Space Fixator and Rotating Pegboard Sheryl Handler Marsden Ball Pediatric Ophthalmology Training Techniques - Bilateral Integration Jumping Jacks + metronome Windshield wipers Angels in the snow Balance board Chalkboard circles Slap-tap Bean bag toss Sheryl Handler Balance board Chalkboard circles Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Optometric Use of Training Glasses Skeffington’s Nearpoint Stress Model The model predicts that a relatively lowpowered lens is often all that is required to permit equilibration of accommodation and convergence Developmental optometrists believe that relatively low-power plus lenses are surprising effective in permitting more efficient reading Developmental optometrists believe their methods foster optimal development and minimize stress on the visual system Sheryl Handler Pediatric Ophthalmology Sheryl Handler Pediatric Ophthalmology Vision Therapy (Vision Training = VT) Vision therapy has a 35% placebo rate (in the convergence insufficiency treatment trial) That means that 1/3 people will have a positive result to VT based on the placebo response There is no evidence to support using VT for dyslexia Because visual problems do not underlie dyslexia, approaches designed to improve visual function by training are misdirected Sheryl Handler Pediatric Ophthalmology Vision Therapy (Vision Training = VT) American Academy of Optometry American Optometric Association Policy Statement 1997 “Vision therapy does not directly treat learning disabilities or dyslexia” “Vision therapy is a treatment to improve visual efficiency and visual processing, thereby allowing the person to be more responsive to educational instruction.” Sheryl Handler Pediatric Ophthalmology Review of Optometric Vision Therapy Studies Vision Therapy Studies – Poor Quality Poor planning of study Inadequate numbers Inadequate control group Anecdotal information Failure to “mask” the investigator Investigator with a vested interest in the result Old studies Many of the findings have not been reproducible in subsequent studies Sheryl Handler Pediatric Ophthalmology Review of Optometric Vision Therapy Studies L Kirkeby – 2012 Percentage of Quality Scores for Vision Therapy Articles 2.6 2.6 23.1 53.85 Excellent Good Moderate Poor Invalid 17.95 Percentage of Quality Scores for all Vision Therapy Articles Reviewed Sheryl Handler Pediatric Ophthalmology Review of Optometric Vision Therapy Studies L Kirkeby – 2012 Review of 567 VT Studies Only 41 of these studies were primary research on VT Only 5 studies were on reading &/or attention !! No study on reading &/or attention was classified as excellent or good Only 2 were classified as moderate Sheryl Handler Pediatric Ophthalmology Review of Optometric Vision Therapy Studies L Kirkeby – 2012 Review of 567 VT Studies Shelley-Trembly examined 77 students using the VT “reading plus program” combined with guided reading and word memory therapy Found improvement in comprehension & word knowledge but not decoding compared to the control group Sheryl Handler Pediatric Ophthalmology Review of Optometric Vision Therapy Studies L Kirkeby – 2012 Review of 567 VT Studies Solan examined 31 reading disabled students 1st group had 12 sessions of eye movement therapy (VT) combined with guided reading therapy followed by comprehension therapy vs 2nd group reversed order Both groups improved equally The group that had comprehension therapy first had the same improvement in eye movement skills as the VT group Sheryl Handler Pediatric Ophthalmology See the dramatic effect of this revolutionary new treatment Sheryl Handler 195 Pediatric Ophthalmology IF A STUDY DOES NOT ADHERE TO PROPER SCIENTIFIC RIGOR, YOU CAN MAKE IT SHOW ANYTHING YOU WANT! Sheryl Handler Pediatric Ophthalmology Retracted autism study an 'elaborate fraud,' British journal finds Sheryl Handler Pediatric Ophthalmology Vision Therapy Summary Therapy overlaps different areas Occupational Therapy Educational Therapy & Special Education Education psychology Not evidence based treatment Except Convergence Insufficiency Sheryl Handler Pediatric Ophthalmology Financial Disclosure for Irlen and VT advocates: They have a HUGE financial interest What are the costs associated with a visual exam and therapy? A Behavioral Vision Exam and Perceptual testing completed by a Behavioral Optometrist to determine visual deficiencies runs between $500-$800 dollars. Vision Therapy plans are a lot like braces in regards to cost and setting appropriate programs based on findings from the exam. Once an exam has been completed, and the full extent of the visual system challenges is determined, a therapy plan is detailed by the Behavioral Optometrist. Based on the patients needs the therapy plan can last anywhere from 3 months to a year or more. These programs cost on average $2500$8000 and include all therapy, re-evaluations with the doctor to evaluate progress and equipment used during therapy. Sheryl Handler Pediatric Ophthalmology Joint Policy Statement 2009 Joint Technical Report 2011 Learning Disabilities, Dyslexia, and Vision American Academy of Pediatrics American Academy of Ophthalmology American Association for Pediatric Ophthalmology & Strabismus American Association of Orthoptists Sheryl Handler Pediatric Ophthalmology Joint Policy Statement & Technical Report Currently, there is inadequate scientific evidence to support the view that subtle eye or visual problems cause learning disabilities Or that correction of subtle eye or visual defects by visual therapy is effective direct or indirect treatment of learning disabilities Sheryl Handler Pediatric Ophthalmology Joint Policy Statement & Technical Report Children who exhibit signs of LDs should be referred as early in the process for educational, psychological, neuropsychological, and/ medical diagnostic assessment Sheryl Handler Pediatric Ophthalmology Joint Policy Statement & Technical Report Primary Care Physicians should perform eye & vision screening Children who fail screening or those with suspected visual problems should be referred to an ophthalmologist experienced in children’s care Sheryl Handler Pediatric Ophthalmology Joint Policy Statement & Technical Report Ophthalmologists should identify & treat any significant ocular or visual disorder Diagnostic & treatment approaches for dyslexia that lack scientific evidence of efficacy such as behavioral vision therapy, eye muscle exercises, or colored filters & lenses are not endorsed or recommended Sheryl Handler Pediatric Ophthalmology Joint Policy Statement & Technical Report Children with LDs should receive appropriate support and individualized evidence-based educational interventions combined with psychological and medical treatments as needed Sheryl Handler Pediatric Ophthalmology AMERICAN ACADEMY OF PEDIATRICS “Ineffective, controversial methods of treatment such as vision therapy may give parents and teachers a false sense of security that a child’s learning difficulties are being addressed, may waste family and/or school resources and may delay proper instruction or remediation.” Sheryl Handler Pediatric Ophthalmology Resources Education and Information on Learning Disabilities International Dyslexia Association www.interdys.org Learning Disabilities On-Line www.ldonline.com National Center for Learning Disabilities www.ncld.org Schwab www.greatschools.org/LD.topic?content=1541 Mel Levine, M.D. www.allkindsofminds.org CHADD www.chadd.org “Overcoming Dyslexia” – Sally Shaywitz, M.D. Sheryl Handler Pediatric Ophthalmology
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