DOI: 10.1542/peds.2009-1445 2009;124;837-844; originally published online Jul 27, 2009; Pediatrics
Orthoptists Pediatric Ophthalmology and Strabismus and American Association of Certified
with Disabilities, American Academy of Ophthalmology, American Association for American Academy of Pediatrics, Section on Ophthalmology, Council on Children
Learning Disabilities, Dyslexia, and Vision
http://www.pediatrics.org/cgi/content/full/124/2/837located on the World Wide Web at:
The online version of this article, along with updated information and services, is
abstractLearning disabilities, including reading disabilities, are commonly di-agnosed in children. Their etiologies are multifactorial, reflecting ge-netic influences and dysfunction of brain systems. Learning disabilitiesare complex problems that require complex solutions. Early recogni-tion and referral to qualified educational professionals for evidence-based evaluations and treatments seem necessary to achieve the bestpossible outcome. Most experts believe that dyslexia is a language-based disorder. Vision problems can interfere with the process oflearning; however, vision problems are not the cause of primary dys-lexia or learning disabilities. Scientific evidence does not support theefficacy of eye exercises, behavioral vision therapy, or special tintedfilters or lenses for improving the long-term educational performancein these complex pediatric neurocognitive conditions. Diagnostic andtreatment approaches that lack scientific evidence of efficacy, includ-ing eye exercises, behavioral vision therapy, or special tinted filters orlenses, are not endorsed and should not be recommended. Pediatrics2009;124:837–844
BACKGROUND
Reading is the process of extracting meaning from written symboliccharacters. In elementary school, a large amount of time and effort isdevoted to the complicated task of learning to read. Because of thedifficulties that some children experience with learning to read, Con-gress mandated that the Eunice Kennedy Shriver National Institute ofChild Health and Human Development assemble a national panel ofeducators and scientists to review the literature to research the opti-mal methods of teaching children to read. The 2000 report of the Na-tional Reading Panel titled “Teaching Children to Read: An Evidence-Based Assessment of the Scientific Research Literature on Reading andIts Implications for Reading Instruction”1 linked research findings withrecommendations for specific approaches to teaching reading to allchildren.
Learning disabilities remain a concern for the children and familiesinvolved and for the public. The inability to read and comprehend is amajor obstacle to learning, which may have long-term educational,social, and economic consequences. Depending on the definition cho-sen, 5% to 17.5% of people in the United States have a learning disabil-ity, with an estimated 2.6 million children aged 6 to 11 years affected.2
Learning disabilities often prevent children from reaching their fullpotential. They may cause children to have difficulty learning to listen,
AMERICAN ACADEMY OF PEDIATRICS, SECTION ONOPHTHALMOLOGY, COUNCIL ON CHILDREN WITH DISABILITIESAMERICAN ACADEMY OF OPHTHALMOLOGYAMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY ANDSTRABISMUSAMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS
This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict-of-interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.
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doi:10.1542/peds.2009-1445
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speak, read, spell, write, reason, con-centrate, solve mathematical prob-lems, and organize information. Thesechildren may also have difficultymastering social skills or motor coor-dination. Learning difficulties are fre-quently associated with and compli-cated by attention-deficit/hyperactivitydisorder.2 Left untreated, learning dif-ficulties may lead to frustration, lowself-confidence, and poor self-esteemand substantially increase the risk ofdeveloping psychological and emo-tional problems.3
Approximately 80% of people withlearning disabilities have dyslexia.2,4–7
The terms “reading disability” and“dyslexia” are often used interchange-ably in the literature.8 Dyslexia is a pri-mary reading disorder and resultsfromawrittenword processing abnor-mality in the brain.2,4 It is characterizedby difficulties with accurate and/or flu-ent sight word recognition and by poorspelling and decoding abilities. Thesedifficulties are unexpected in relationto the child’s other cognitive skills.Dyslexia has been identified as havinga strong genetic basis.2,8,9 Recentgenetic-linkage studies have identifiedmany loci at which dyslexia-relatedgenes are encoded. Approximately40% of siblings, children, or parents ofan affected individual will have dys-lexia. Although dyslexia is often inher-ited, it may exist in the absence of afamily history. Dyslexia can be mild orsevere, occurs throughout the world,seems to affect boys more than girls,10
involves childrenwith all levels of intel-ligence, and can persist for a life-time.2,4,5,8,11,12 Dyslexia is identified insome people early in their lives but inothers is not diagnosed until muchlater, when more complex reading andwriting skills are required. People withdyslexia can be very bright and may begifted in math, science, the arts, oreven in unexpected areas such as writ-ing.12 Dyslexia should be separated
from other secondary forms of read-ing difficulties caused by visual orhearing disorders,mental retardation,and experiential or instructional defi-cits.2,8 Early reading difficulties may becaused by experiential and instruc-tional deficits.8 It is important to iden-tify and address such causes of sec-ondary reading difficulties.5,8
Oral language development has beenfound to play a critical role in learningto read.1 Unlike speaking, reading andwriting do not develop naturally andrequire active learning. Reading ismore difficult than speaking, becausechildren must be aware of the soundstructure in spoken language and thenbreak the alphabetic code to acquirethe sound/symbol connection.
English is a phonemically complex lan-guage in which the 26 letters of thealphabet create 44 sounds, or pho-nemes, in approximately 70 letter com-binations.6,7,13 The phonemic complex-ity of an alphabet-based languagecorresponds to the prevalence of dys-lexia, pointing to the linguistic origin ofdyslexia.8,14 Reading involves the inte-gration of multiple factors related to aperson’s experience, ability, and neu-rologic functioning. Most people withdyslexia have a neurobiological deficitin the processing of the sound struc-ture of language, called a phonemicdeficit,1,2,4–8,11,13,15 which exists despiterelatively intact overall language abili-ties.2,4–7 Children with more severeforms of dyslexia may have a seconddeficit in naming letters, numbers, andpictures, creating a double deficit,8,16
or they may have problems with theirattention or working memory.8 Otherchildren may have trouble orienting,recognizing, and remembering lettercombinations.8,17 This difficulty may bea neuromaturational delay that im-proves with development. Importantly,the definition of dyslexia does not in-clude reversal of letters or words or
mirror reading or writing, which arecommonly held misconceptions.8,12,14
Research has shown that most chil-dren and adults with reading disabili-ties experience a variety of problemswith language1,2,4–8,11,13 that stem fromaltered brain function.2,4,8,18–29 There issolid scientific evidence that supportsthe neurologic basis for the phonolog-ical coding deficit theory of readingdisabilities.2,4–8,18–29 Scientific researchusing functional MRI studies andpositron emission tomography scanshas shown that reading takes placepredominantly in left-hemispheresites including the inferior frontal, su-perior temporal, parietotemporal, andmiddle temporal-middle occipital gyriin typical readers. Children with dys-lexia, on the other hand, use differentareas of the brain when reading.2,4,18–29
People with dyslexia demonstrate adysfunction in the left-hemisphereposterior reading systems and showcompensatory use of the inferiorfrontal gyri of both hemispheres andthe right occipitotemporal area.2,4,18–29
People with dyslexia have an abnor-mality in the word-analysis pathwaysthat interferes with their ability to con-vert written words into spoken words.These dyslexia-specific brain abnor-malities have been shown to improveafter successful phonologically basedintervention.19,28,29
THE ROLE OF THE VISUAL SYSTEMAND THE EYES
Visual processing is a higher corticalfunction.8,30 Decoding and interpreta-tion of retinal images occur in thebrain after visual signals are transmit-ted from the eyes. Reading print in-volves adequate vision and the neuro-logic ability to identify what is seen.Although vision is fundamental forreading, the brain must interpret theincoming visual images. Historically,many theories have implicated defectsin the visual system as a cause of dys-
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lexia. We now know these theories tobe untrue. Improved understandingbegan with a series of related studiesthat systematically demonstrated thatdeficits in visual processes, such asvisualization, visual sequencing, vi-sual memory, visual perception, andperceptual-motor abilities, were notbasic causes of reading difficulties.8
Difficulties in maintaining proper di-rectionality have been demonstratedto be a symptom, not a cause, of read-ing disorders.8,30,31 Word reversals andskipping words, which are seen inreaders with dyslexia, have beenshown to result from linguistic defi-ciencies rather than visual or percep-tual disorders.8
Specific reading disability in a smallsubset of patients with dyslexia hasbeen attributed by some researchersto a deficit in the magnocellular visualsystem.32–35 The visual system com-prises 2 parallel systems: the magno-cellular system and the parvocellularsystem.32 The magnocellular systemresponds to high temporal frequencyand object movement, and the parvo-cellular system is sensitive to low-frequency and fine spatial details.32 Ithas been proposed that a magnocellu-lar system deficit produces a visualtrace of abnormal longevity that cre-ates a masking effect and causes vi-sual acuity blurring when reading con-nected text in some children withdyslexia.35 There are study results thatsupport this theory32–35 and others thatrefute it.36–44 Many researchers haveconcluded that magnocellular systemdeficits and associated visual tracepersistence are not a significant causeof specific reading disability.8,36–43 Atthe present, there is insufficient evi-dence to base any treatment on thispossible deficit.
Short-duration, high-velocity, smalljumping eye movements called sac-cades are used for reading. Readerswith dyslexia characteristically have
saccadic eye movements and fixationssimilar to the beginning reader butshow normal saccadic eye movementswhen content is corrected for abil-ity.30,31 The saccadic patterns seen inreaders with dyslexia seem to be theresult, not the cause, of their readingdisability.30,31,45,46 Decoding and com-prehension failure, rather than a pri-mary abnormality of the oculomotorcontrol systems, is responsible forslow reading, increased duration offixations, and increased backwardsaccades.46 Children with dyslexia of-ten lose their place while reading be-cause they struggle to decode a letteror word combination and/or becauseof lack of comprehension, not becauseof a “tracking abnormality.” Improvingreading has been shown to changesaccadic patterns, but there has beenno evidence to suggest that saccadictraining results in better reading. Fi-nally, children with saccadic disordersdo not show an increased likelihood ofdyslexia.47 As indicated above, dyslexiais not correlated with eye or eye-movement abnormalities.8,30,31,45–59
Other conditions may affect reading.Convergence insufficiency and pooraccommodation, both of which are un-common in children, can interferewiththe physical act of reading but not withdecoding.14 Thus, treatment of thesedisorders can make reading morecomfortable and may allow readingfor longer periods of time but doesnot directly improve decoding orcomprehension.14
Numerous studies have shown thatchildren with dyslexia or related learn-ing disabilities have the same visualfunction and ocular health as childrenwithout such conditions.8,30,31,45,46,48–59
Specifically, subtle eye or visual prob-lems, including visual perceptual dis-orders, refractive error, abnormalfocusing, jerky eye movements, binoc-ular dysfunction, and misaligned orcrossed eyes, do not cause dys-
lexia.8,30,31,45,46,48–59 In summary, re-search has shown that most readingdisabilities are not caused by alteredvisual function.8,30,31,45,46,48–59
Many children with reading disabili-ties enjoy playing video games, includ-ing handheld games, for prolonged pe-riods. Playing video games requiresconcentration, visual perception, vi-sual processing, eye movements, andeye-hand coordination. Convergenceand accommodation are also requiredfor handheld games. Thus, if visual def-icits were a major cause of readingdisabilities, children with such disabil-ities would reject this vision-intensiveactivity.
EARLY DETECTION
A family history of learning disabilitiesshould keep parents, teachers, andphysicians alert to this possibility. Ahistory of delay or difficulty in develop-ing speech and language, learningrhymes, or recognizing letters andsound/symbol connections may be anearly indication of dyslexia.2,4,5,8 Par-ents or teachers may detect earlysigns of learning difficulties inpreschool-aged children; however, inmost cases, learning disabilities arenot discovered until children experi-ence academic difficulties in elemen-tary school.2,4 The child may havedifficulty with reading, spelling, hand-writing, remembering words, or per-forming mathematical computation.Because remediation is more effectiveduring the early years, prompt diagno-sis is important.1,2,4–8,13,15,60 The effectthat dyslexia has may be different foreach person and depends on the se-verity of the condition and the effec-tiveness and timeliness of instructionor remediation.
THE ROLE OF EDUCATION
The educational system has the tripleresponsibility of early detection,evaluation, and treatment of chil-
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dren with learning disabilities. Ele-mentary school teachers are often thefirst to detect learning difficulties. As-sessments for difficulties with alpha-bet recognition in kindergarten anddifficulties with phonemic awarenessand rapid naming in kindergarten andfirst grade can predict many of thosewho will have difficulty learning toread.1,2,5–8,13,15 Because early readingdifficulties may be caused primarily byexperiential and instructional deficits,there are 2 approaches that can beused in the young underachievingchild.8 In the traditional approach, thechild would need to show significantunderachievement before referral, as-sessment, and remediation. In theresponse-to-intervention method, thechild will be placed directly in an edu-cational intervention program whenhe or she first experiences academicdifficulties. Only the children who donot show significant improvementwithboth the group-intervention first-tierprogram and second-tier targeted in-tensive individual intervention will un-dergo a full educational assess-ment.8,61,62 Ideally, the response-tointervention approach will allow ear-lier identification of learning disabili-ties than the “wait-to-fail” situationthat occurs when an ability achieve-ment discrepancy formula is used todetermine if a student qualifies for anevaluation of a learning disability.62
Because dyslexia is a language-baseddisorder, treatment should be di-rected at this etiology.1,2,4–8,13,15,60 Moststudents with dyslexia require highlystructured, intensive, individualized in-struction by a teacher or educationaltherapist whowas specially trained ex-plicitly in teaching the application ofphonics.1,2,4–8,13,15 Longitudinal data in-dicate that systematic phonics instruc-tion results in more favorable out-comes for readers with disabilitiesthan does a context-emphasis (whole-language) approach.1,4,8,13,15,60 The criti-
cal elements of effective interventioninclude individualization, feedback andguidance, ongoing assessment, andregular ongoing practice.4
Remediation programs should includespecific instruction in decoding, fluencytraining, vocabulary, and comprehen-sion.1,4–8,13,15 The approach to learningde-coding skills begins with explicit instruc-tion in recognizing spoken sounds(phonemic awareness), becomingaware of rhyme, learning the alphabeticcode, memorizing sight words, andstudying phonics and spelling.6–8 A childmust first accurately decode a word be-fore it can be read fluently.4,6–8 The homeis the ideal setting for practice and rein-forcement. Just as an athletemust prac-tice to optimize his or her skills, the childshould read aloud to a parent or tutoreachday topracticedecoding,memorizenew sight words, and develop greaterfluency by rereading of previously de-coded and memorized words.4 Fluencyforms the bridge between decoding andcomprehension.4,6–8 Comprehension isgained through fluency training, vocabu-lary instruction, and active reading com-prehension.4 Techniques that enhanceactive reading comprehension includeprediction, summarization, visualization,clarification, critical thinking, making in-ferences, and drawing conclusions.2,4,6–8,13
Because peoplewith dyslexia have a per-sistent problem and continue to haveslower reading throughout their lives,accommodationsandmodificationsmaybe necessary in addition to remedia-tion.2,4 Examples of accommodations in-clude extra time, shortened assign-ments, a separate quiet room for takingtests, testing alternatives, computers,spell checkers, tape recorders, lecturenotes, recorded books, and tutors.2,4,11
A MULTIDISCIPLINARY APPROACH
The diagnosis and treatment of learn-ing disabilities depend on the collab-oration of a team that may includeeducators; educational remediation
specialists; audiologists; speech, phys-ical, and occupational therapists;teachers for the visually impaired;psychologists; and physicians. Chil-dren with learning disabilitiesshould undergo assessments oftheir health, development, hearing,and vision and, when appropriate,medical and psychological interven-tions for associated and relatedtreatable conditions.63
A formal evidence-based evaluation isneeded to discoverwhether a child hasa learning disability. Educational psy-chologists and neuropsychologists di-agnose learning disabilities by per-forming appropriate testing as part ofan educational assessment of thechild’s abilities and disabilities. A for-mal assessment for learning disabili-ties should include evaluation of cogni-tion, memory functions, attention,intellectual ability, information pro-cessing, psycholinguistic processing,expressive and receptive languagefunction, academic skills, social-emotional development, and adaptivebehavioral functioning. These resultsare used to develop an individualizededucation plan (IEP), which includesevidence-based educational remedia-tions, accommodations, and modifica-tions.2,4,7,13 Educational therapists oreducators with specialized training inlearning disabilities play a key role bydesigning and implementing remedialprograms and monitoring the stu-dent’s progress.
Audiologists can identify hearing prob-lems. Speech therapists can evaluateand treat underlying oral language dif-ficulties often associated with dyslexiaand help students learn phonologicalawareness. Physical and occupationaltherapists do not treat dyslexia but dotreat fine and gross motor difficultiesor sensory problems that may be asso-ciated with learning disabilities. Chil-dren with low vision and learning dis-abilities may benefit from having a
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teacher of the visually impaired. Psy-chiatrists, psychologists, neurologists,and specialty-trained pediatricianscan diagnose associated comorbidconditions. Psychiatrists, clinical psy-chologists, licensed clinical socialworkers, or licensed mental healthcounselors can provide strategies tohelp children adapt to their disabilitiesand provide therapy to address con-current psychological disorders. Psy-chiatrists, neurologists, or specialty-trained pediatricians may prescribemedications. The role of other physi-cians will be elaborated in a later sec-tion of this statement.
THE ROLE OF PARENTS
Parental participation in a child’s edu-cation is of utmost importance. Fami-lies with a history of dyslexia shouldobserve their children for early lan-guage difficulties. Reading to theirpreschool-aged child and having theirchild read to them as soon as he or sheis able allows parents to detect earlysigns of learning difficulties. Parentsshould collaborate with early elemen-tary school teachers to monitor theirchild for academic struggles. Parentsneed to serve as the child’s advocate,speaking with the child’s teacher, pe-diatrician, and other professionals; re-questing an educational evaluation;and coordinating remediation andother treatment. By educating them-selves in the areas of learning disabil-ities, available services, and state edu-cation rules and regulations, parentswill increase their effectiveness as thechild’s advocate. After a child has beendiagnosed with a learning disability,an individualized educational plan or aSection 504 plan may be created. Par-ents should work with educators to en-sure that the school provides theproper remediation and accommoda-tions. Children with dyslexia shouldread aloud to their parents frequently.Parents should help with practice andreinforcement at home in a supportive
and nurturing environment with ade-quate opportunity for their child toparticipate in activities in which he orshe excels. As the child gets older, par-ents should help their child use recom-mended alternative learning strate-gies such as books on tape orcomputers. Parents should continue tomonitor their child’s progress and ad-vocate for their child when necessary.
Because of the complex nature oflearning disabilities, including dys-lexia, there are no simple remedies.Teaching children with dyslexia andlearning disabilities can be a challengefor educators and parents. Withproper remediation, accommodations,and support, children with dyslexiaand learning disabilities can succeed.
THE ROLE OF THE PHYSICIAN
Physicians, including pediatricians,family physicians, otolaryngologists,neurologists, ophthalmologists, men-tal health professionals, and other rel-evant medical specialists, may partici-pate in the comprehensive care ofchildren with learning disabilities in-cluding dyslexia. Pediatricians shouldnot diagnose learning disabilities63 butshould inquire about the child’s educa-tional progress and be vigilant in look-ing for early signs of evolving learningdisabilities.63 When a child has sus-pected learning difficulties, the pedia-trician or family physician should firstassess the child for medical problemsthat could affect the child’s ability tolearn and refer him or her for furtherevaluation if deemed appropriate.63,64
Pediatricians and family physicianshave an extremely important functionin acting as a medical home by helpingparents decide whether further evalu-ations are needed and in coordinatingcare for the child after a diagnosis hasbeen made.63,64 Primary care physi-cians who have a strong role in assist-ing school districts should only recom-mend evidence-based treatments and
accommodations. Pediatricians andfamily physicians should provide infor-mation and support to parents onlearning disabilities and their treat-ment and should dispel the myths sur-rounding these disorders.30 Thisshould include discussion regardingthe lack of efficacy of vision therapyand other “alternative treatments”with the parents.30 Parents need to beinformed that dyslexia is a complexdisorder and that there are no quickcures. The American Academy of Pedi-atrics has information for families onwhat parents need to know aboutlearning disabilities.65 The primarycare physician should compile andprovide a resource list of local special-ists from whom the child can obtainproper help and from whom the familymembers can learn to become advo-cates for the child.63
The Individuals With Disabilities Educa-tion Act, Section 504 of the Rehabilita-tion Act, and the Americans With Dis-abilities Act define the rights ofstudents with dyslexia and other spe-cific learning disabilities.66,67 Theseacts allow parents to request a formaleducational evaluation by the schooldistrict to determine eligibility for spe-cial education and related services. In-formation for pediatricians on this leg-islation and its associated rights andprocedures is available from theAmerican Academy of Pediatrics.63,64
Physicians can refer parents of chil-dren with learning disabilities to theirstate’s parent training and informa-tion center. These parent-directed cen-ters provide information and technicalassistance to parents and professionalsregarding family and student rights andresponsibilities in special education.
For all children, primary care physi-cians should perform hearing and vi-sion screenings according to nationalstandards68 so that hearing, ocular,and visual disorders are identified asearly as possible. Periodic eye and vi-
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sion screenings can identify childrenwho have reduced visual acuity orother visual disorders. Vision screen-ing with nonletter symbolsmay be nec-essary for testing children with dys-lexia or other learning disabilities.
Children who do not pass visionscreening should be referred to anophthalmologist with experience in thecare of children.68 In addition, the rec-ommended routine pediatric visionscreenings are unlikely to disclosenear-vision problems such as conver-gence insufficiency, accommodativeinsufficiency, and significant hyper-opia. Children with suspected learningdisabilities in whom a vision problemis suspected by the child, parents, phy-sicians, or educators should be seenby an ophthalmologist with experiencein the assessment and treatment ofchildren, because some of these chil-dren may also have a treatable visualproblem that accompanies or contrib-utes to their primary reading or learn-ing dysfunction.30,45,58 Treatable ocularconditions can include strabismus,amblyopia, convergence and/or focus-ing deficiencies, and refractive errors.Missing these problems could causelong-term consequences from assign-ing these patients to incorrect treat-ment categories.
The ophthalmologist should identifyand treat any significant visual defectaccording to standard principles oftreatment.69,70 Strabismus, amblyopia,and refractive errors may requireglasses, eye patching, eye drops, oreye-muscle surgery. Symptomatic con-vergence insufficiency can be treatedwith near-point exercises, prism-convergence exercises, or computer-based convergence exercises. Most ofthese exercises can be performed athome, and extensive in-office visiontherapy is usually not required.71–73 Al-ternatively, for other patients, readingglasses with base-in prism73 or minus-lenses can be used as treatment.
Treating convergence insufficiencycan make reading more comfortablebut does not improve the decoding orunderstanding of reading.14 If no ocu-lar or visual disorder is found, thechild needs no further vision assess-ment ormanagement. The ophthalmol-ogist should not diagnose learningdisabilities but should provide infor-mation on learning disabilities and re-inforce the need for additional medi-cal, psychological, educational, orother appropriate evaluation or ser-vices. In addition, the ophthalmologistshould discuss the lack of efficacy ofvision therapy and other “alternativetreatments” with the parents. TheAmerican Academy of Ophthalmologyhas a patient-education brochure forfamilies titled “Learning Disabilities.”74
The ophthalmologist, when necessary,should compile and provide a re-source list of local specialists who canhelp obtain proper help for the child.69
CONTROVERSIES
Because they are difficult for the pub-lic to understand and for educatorsto treat, learning disabilities havespawned a wide variety of controver-sial and scientifically unsupported al-ternative treatments, including visiontherapy.* Scientific evidence of effec-tiveness should be the basis for treat-ment recommendations.4,45,60 Treat-ments that have inadequate scientificproof of efficacy should be discour-aged. Ineffective, controversial meth-ods of treatment such as vision ther-apy may give parents and teachers afalse sense of security that a child’slearning difficulties are being ad-dressed, may waste family and/orschool resources, and may delayproper instruction or remediation.45
Currently, there is inadequate scien-tific evidence to support the view thatsubtle eye or visual problems, includ-ing abnormal focusing, jerky eyemove-
ments, misaligned or crossed eyes,binocular dysfunction, visual-motordysfunction, visual perceptual difficul-ties, or hypothetical difficulties withlaterality or “trouble crossing the mid-line” of the visual field, cause learningdisabilities.8,30,31,45,46,48–59 Statistically,children with dyslexia or related learn-ing disabilities have the same visualfunction and ocular health as childrenwithout such conditions.8,30,31,45,46,48–59
Because visual problems do not under-lie dyslexia, approaches designed toimprove visual function by trainingare misdirected.31,47,56,57,69,78 Otherthan convergence-insufficiency treat-ment,70–73,79,81,95,96 scientific evidencedoes not support the assumption thatvision therapy is capable of correctingsubtle visual defects,† nor does itprove eye exercises or behavioral vi-sion therapy to be effective direct orindirect treatments for learning dis-abilities.‡ Detailed review of the litera-ture supporting vision therapy revealsthat most of the information is poorlyvalidated, because it relies on anec-dotes, poorly designed studies, andpoorly controlled or uncontrolled stud-ies.§ Their reported benefits can oftenbe explained by the placebo effect orby the traditional educational reme-dial techniques with which they areusually combined.30,45,46,55,57,58,78,79 Thereis currently no evidence that childrenwho participate in vision therapy aremore responsive to educational in-struction than are children who do notparticipate.� Thus, current evidence isof poor scientific quality and does notprovide adequate scientific evidencethat vision training is a necessary pri-mary or adjunctive therapy.¶
Tinted lenses and filters have beensuggested to treat visual perceptualdysfunctions that lead to visual distor-tion caused by sensitivities to particu-lar wavelengths of light but not to treatlanguage-based dyslexia.97 Scrutiny ofpublished study results that advocatedthe use of these therapies to treat dys-lexia have shown serious flaws in theirmethods and have not been sufficientlywell controlled to support this asser-tion.30,70,84,85,88 There have also beenmany inconsistencies in the re-sults,89,98,99 with some studies showingsome partial positive results100–106
and others showing negative re-sults.84,86,90–94 The method used to se-lect the lens or filter color has beenhighly variable,89,104,106 the color selec-tion has also shown considerable vari-ability,104 and the test-retest consis-tency has been poor.107 Many of thestudies that have been cited as proofof Irlen-lens efficiency have actuallybeen inconclusive after deeper analy-sis. The evidence does not support theeffectiveness of tinted lenses andtinted filters in these patients becauseof the weaknesses in methodology andstatistics, variability in techniques inthe trials, and the largely negativeresults.8,30,45,70,76,83–94,107
RECOMMENDATIONS
1. Children who exhibit signs of learn-ing disabilities should be referredas early in the process as possiblefor educational, psychological, neu-ropsychological, and/or medical di-agnostic assessments.
2. Children with learning disabilitiesshould receive appropriate supportand individualized evidence-basededucational interventions com-bined with psychological and medi-cal treatments as needed.
3. Families of children with suspectedlearning disabilities should receiveinformation about state and localparent support programs.
4. Pediatricians and family physiciansshould perform periodic eye and vi-sion screening for all children ac-cording to national standards andrefer those who do not pass screen-ing to ophthalmologists who are ex-perienced in the care of children.
5. Children with a suspected or diag-nosed learning disability in whichvision is felt to play a role by par-ents, the child, educators, or phy-sicians should be referred to anophthalmologist with experiencein the care of children, becauseroutine pediatric vision screeningis not designed to detect near-vision problems.
6. Ophthalmologists should identifyand treat any significant ocular orvisual disorder found to be present.
7. Primary care physicians shouldonly recommend evidence-basedtreatments and accommodationsto school districts.
8. Diagnostic and treatment ap-proaches for dyslexia that lack sci-entific evidence of efficacy such asbehavioral vision therapy, eye-muscle exercises, or colored filtersand lenses are not endorsed orrecommended.
SUMMARY
Dyslexia and learning disabilities arecomplex problems that have no simplesolutions. The most widely acceptedview is that dyslexia is a language-based disorder. The American Acad-emy of Pediatrics, the American Acad-emy of Ophthalmology, the AmericanAssociation for Pediatric Ophthalmol-ogy and Strabismus, and the AmericanAssociation of Certified Orthoptistsstrongly support the need for early di-agnosis and educational intervention.
Recommendations for multidisci-plinary evaluation and managementmust be based on evidence of proveneffectiveness that is demonstrated by
objective scientificmethodology.4,45,60 Itis important that any therapy for learn-ing disabilities be scientifically estab-lished to be valid before it can be rec-ommended for treatment.60
Currently, there is no adequate scien-tific evidence to support the view thatsubtle eye or visual problems causelearning disabilities.8,30,31,45,46,48–59 Fur-thermore, the evidence does not sup-port the concept that vision therapy ortinted lenses or filters are effective, di-rectly or indirectly, in the treatment oflearning disabilities.# Thus, the claimthat vision therapy improves visual ef-ficiency cannot be substantiated. Diag-nostic and treatment approaches thatlack scientific evidence of efficacy arenot endorsed or recommended.
With early recognition and individual-ized, interdisciplinary managementstrategies, children with learning dis-abilities can enjoy successful aca-demic experiences.
SECTION ON OPHTHALMOLOGYEXECUTIVE COMMITTEE, 2008–2009Gregg T. Lueder, MD, FAAP, ChairpersonJames B. Ruben, MD, FAAPRichard J. Blocker, MD, FAAPDavid B. Granet, MD, FAAPDaniel J. Karr, MD, FAAPSharon S. Lehman, MD, FAAPSebastian J. Troia, MD, FAAPGeorge S. Ellis Jr, MD, FAAP
LIAISONSChristie L. Morse, MD, FAAP – AmericanAcademy of OphthalmologyMichael X. Repka, MD, FAAP – AmericanAssociation for Pediatric Ophthalmologyand StrabismusKyle Arnoldi, CO – American Association ofCertified Orthoptists
CONTRIBUTORS*Sheryl Handler, MD – American Academy ofOphthalmology*Walter M. Fierson, MD, FAAP – FormerChairperson
COUNCIL ON CHILDREN WITHDISABILITIES EXECUTIVE COMMITTEE,2008–2009Nancy A. Murphy, MD, FAAP, ChairpersonRobert Burke, MD, MPH, FAAPLarry W. Desch, MD, FAAPJohn C. Duby, MD, FAAPEllen Roy Elias, MD, FAAPSusan E. Levy, MD, FAAP
Gregory S. Liptak, MD, FAAPDouglas McNeal, MD, FAAPScott M. Myers, MD, FAAPKenneth W. Norwood Jr, MD, FAAPPaul J. Sagerman, MD, FAAP
EX-OFFICIO CHAIRPERSON (PRIMARYREVIEWER)Paul H. Lipkin, MD, FAAP
STAFFStephanie Mucha Skipper, MPH,
*Lead author
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OTHER RESOURCES
International Dyslexia Association: www.interdys.org
National Center for Learning Disabilities: www.ncld.org
Learning Disabilities OnLine: 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
Children and Adults With Attention Deficit/Hyperactivity Disorder: www.chadd.org
National Center for the Study of Adult Learning and Literacy: www.ncsall.net
Parent Advocacy Coalition for Educational Rights Center: www.pacer.org
Parental Information and Resource Centers: www.ed.gov/programs/pirc/index.html
Family Voices: www.familyvoices.org
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DOI: 10.1542/peds.2009-1445 2009;124;837-844; originally published online Jul 27, 2009; Pediatrics
Orthoptists Pediatric Ophthalmology and Strabismus and American Association of Certified
with Disabilities, American Academy of Ophthalmology, American Association for American Academy of Pediatrics, Section on Ophthalmology, Council on Children
Learning Disabilities, Dyslexia, and Vision
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