1. Is it a Learning Disability or Vision Problem? The Eye M.D.’s role in screening and treating children to support school and life success Joint Policy Statement 2009 AAP, AAO, AAPOS, AACO Sheryl Handler, M.D. Pediatric Ophthalmology

2. Financial Disclosure The author acknowledges no financial interest

3. Learning Disabilities Are common problems 5 – 17.5 % of the U.S. population has a learning disability 2.6 million children aged 6 – 11 years in the U.S. are affected

4. Learning Disabilities Arise from neurological differences in brain structure and function Affect the brain’s ability to store, process or communicate information

5. Learning Disabilities LDs may cause difficulty in learning to: –Read –Listen –Speak –Spell –Write –Reason –Solve mathematical calculations –Organize information

6. Dyslexia (Reading Disability) Most common learning disability 80% of all learning disabilities Family history –40% affected sibling –40% affected parent

7. Dyslexia - Definition Dyslexia is a specific learning disability that is neurological in origin It is characterized by difficulties with decoding, accurate and/or fluent word recognition, and/or comprehension

8. Dyslexia – Cognitive Basis Brain processing disorder Language-based learning disorder –Phonologic decoding, analysis, and word identification deficit –Verbal memory deficit Not a vision based disorder

9. Dyslexia – Early Detection Possible early indications of dyslexia: –Speech delay –Difficulty with rhymes –Confusing words that sound alike –Delay in learning letters –Delay in learning phonics

10. Dyslexia – Common Signs Significance of signs is age dependent: Difficulty remembering the names of the letters Difficulty remembering the sounds of the letters Reading words incorrectly – guessing Reversing letters and words – (past 3 rd grade) Skipping words or lines Slow reading in adolescents & adults

11. Dyslexia – Visual Function 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

12. Dyslexia – Visual Function Children with dyslexia have the same ocular health, ocular coordination, motility, and visual processing as children without dyslexia

13. Vision Therapy No evidence that children who participate in vision therapy are more responsive to educational instruction No evidence that vision training is a necessary primary or adjunctive therapy in learning disabilities

14. Vision Therapy Parents can be reassured that the scientific evidence shows vision therapy does not benefit children with learning disabilities, saving valuable time and resources

15. Tinted Lenses The scientific evidence does not support the use of tinted lenses & filters in patients with learning disabilities

16. Role of Education Early detection - screening Evaluation Treatment –Remediation –Accommodations & Modifications Vision screening

17. Role of Education - Remediation Dyslexic children who receive effective phonological training in K & 1 st grade will have fewer problems in learning to read than children not identified until 3 rd grade

18. Role of Parents Read to their children Children should read to their parents as soon as they are able Monitor children for language difficulties Educate themselves on learning disabilities Advocate for the child

19. Role of the PCP (Medical Home) Determine if medical, neurological, or behavioral problems exist Perform complete medical history and physical examination Perform vision and hearing screening Refer to ophthalmologist if vision screening is failed or vision problem is suspected PCP’s do not diagnose learning disabilities

20. Role of the PCP (Medical Home) Referral to appropriate educational evaluation, medical, psychological, and other services Coordinate care between the family and other health care services Dispel myths surrounding learning disabilities Encourage family to become the child’s advocate

21. Role of the Ophthalmologist Perform comprehensive eye examination Detection & treatment of vision problems as some children may also have a treatable visual problem along with their primary reading or learning dysfunction Ophthalmologists do not diagnose learning disabilities

22. Role of the Ophthalmologist Treatable ocular conditions include: –Refractive errors Hyperopia Myopia Astigmatism –Amblyopia –Strabismus –Convergence and/or focusing deficiencies

23. Role of the Ophthalmologist Treatments include: –Glasses –Eye patching –Eye drops –Prisms –Eye muscle surgery –Convergence training

24. Role of the Ophthalmologist Assist with referral to appropriate educational evaluation, medical, psychological, and other services Distribute information on learning disabilities Discuss the lack of efficacy of vision therapy and other alternative treatments

25. Recommendations Children who exhibit signs of LDs should be referred as early in the process for diagnostic assessment Children with LDs should receive individualized evidence-based educational interventions combined with psychological and medical treatments as needed

26. Recommendations PCPs 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

27. Recommendations PCPs should only recommend evidence- based treatments & accommodations to school districts Families of children with suspected LDs should receive information about state & local parent support programs

28. Recommendations 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

29. Resources: The Policy Statement is available at: http://www.aao.org/about/policy/upload/ Learning-Disabilities-Dyslexia-Vision- 2009.pdf More information about vision therapy for learning disabilities is available at: http://www.aao.org/eyecare/treatment/ alternative-therapies/vision-therapies- learning-disabilities.cfm

30. Resources: International Dyslexia Association: www.interdys.org National Center for Learning Disabilities: www.ncld.org Learning Disabilities On Line: http://www.ldonline.org Interdisciplinary Council on Developmental and Learning Disorders: www.icdl.com Great Schools Inc/Schwab Learning: www.schwablearning.org All Kinds of Minds: www.allkindsofminds.org