The American Academy of Pediatrics Takes Aim at Occupational Therapy

 I wasn’t entriely surprised to receive the item above in my inbox this morning.  The headline, Pediatricians doubt effectiveness of sensory integration therapy, smacks a bit of yellow journalism when you consider that the Reuters article on which it is based is titled Pediatricians raise caution on sensory-based therapy.  The issue here is a Policy Statement published online yesterday in Pediatrics, the official journal of the American Academy of Pediatrics, titled Sensory Integration Therapies for Children With Developmental and Behavioral Disorders.

In a nutshell, the recommendations of the Policy Statement are this:

1. At this time, pediatricians should not use sensory processing disorder as a diagnosis.  When these sensory symptoms are present, other developmental disorders – specifically autism, ADHD, developmental coordination disorder, and anxiety disorder – must be considered first, and be thoroughly evaluated by a developmental/behavioral pediatrician, child psychiatrist, or child psychologist.

2. Pediatricians should advice families about the limited data on the use of sensory-based therapies for childhood developmental and behavioral problems.

3. If the pediatrician is managing a child whose therapist is using sensory-based therapies, the pediatrician can play an important role in teaching families how to determine whether a therapy is effective.

4. Pediatricians should inform families that OT is a limited resource, particularly the number of sessions available through school and through insruance coverage.

We are familiar with these kinds of Policy Statements by the AAP, cloaked in a mantle of scientific concern, but usually with a hidden agenda.   Developmental and behavioral optometrists have been countering the AAP’s misrepresnetation of vision therapy for decades.  This policy statement has all of the same ingredients: OT is covered on a limited basis by third parties (as if the parent doesn’t have an option for paying privately!), it’s research base is questionable, and what it claims to treat is better treated elsewhere.  It even casts aspersion by citing a small study (involving four children on the autistic spectrum) cautioning that SI therapy by OTs can do more harm than good!  I say that none of this surprises me because I have heard directly from OTs during my seminars that pediatricians have been giving them a tough time.  I suspect that in the drive to establish primary care pediatrics as the child’s medical home, pediatricians have become more aggressive in cherry picking cost containment issues.  It’s expedient to point fingers at other professions, such as OT, rather than turning the magnifying lens inward.  The irrationality of the Policy Statement is evident in just one of its recommendations.  If one looks at the body of evidence in support of treatment for developmental coordination disorder (DCD), which the AAP is endorsing, it is clearly not better than sensory processing disorder (SPD) which it is disputing.

I am sure that we’ll be hearing from the AOTA about this.  In the interim, I’ll side with colleaguse such as Dr. Fortenbacher who advocate for collaboration between OTs and ODs on sensory integration therapy and vision therapy.  We would all do well to take this latest AAP policy statement with the grains of salt it deserves.  I know that most parents will.

“Doctor, I Think I’m Reading Better” – Part 6

I purposely changed the title, since Ruth has now begun to read again!  As noted in Part 5, we’re using the same tools that we have at our disposal to develop reading readiness skills.  Ruth’s background as a teacher successful in helping young children learn to read is fortuitous, and lends to her resolve in aiding her own rehabilitation.  We have begun to use yoked prisms, and Ruth now demonstrates improved awareness for tracking to the end of a line with or without the prisms.  Here’s a short clip of Ruth reading, and her re-acquired abilities within a few months’ time is astounding, given her inability to identify letters in print (yet alone words) at the outset.

Dr. Daniel Press has been instrumental in collaborating with me on Ruth’s program.  Most recently she has begun to demonstrate increased visual scanning ability in executing saccades toward the side of her field loss while keeping her head straight, effectively increasing her useful field of view.  The Neuro-Vision Rehabilitator (NVR) pictured below has been invaluable in providing Ruth feedback for when she is moving her head rather than her eyes.

To summarize, once letters can be identified again, successful rehabilitation of acquired alexia is linked more to saccadic therapy than to improvements in visual fields.  Although an Internet program is now available to help patients with this disorder, we agree with Dr. Susanne Schuett and colleagues that supervised, guided therapy of eye movement efficiency is essential because this is such a heterogeneous population.

Why is therapy involving saccades toward the hemianopic field so crucial in Ruth’s case?   Think back to the apparent damage to the splenium of the corpus callosum documented in the radiology report.  Here is a labeled illustrative dissection, thankfully not Ruth’s.

The splenium of the corpus callosum is a thick neural bundle that interconnects occipital visual areas.  Several lines of evidence show that ischemic damage to the splenium leads to severe problems in visual integration across right and left hemi-fields.  However,  subcortical regions like the superior colliculi help compensate for the splenium.  Hence the importance of training saccades to bridge inter-hemispheric transfer.

Ruth’s improvement through vision therapy bolsters the argument that a significant component of reading resides in the visual aspect of orthography.   Specifically, rehabilitation of hemianopic dyslexia lends support to the importance of the visuo-spatial attention network in reading, as proposed by Vidyasagar and Pammer.  It also lends support to the observation that when attention is overloaded, children with developmental dyslexia exhibit a significant impairment in temporal order judgement in right as compared to left visual field.

“Doctor, I’m Having Trouble Reading” – Part 5

When we last left Ruth in Part 4 she had begun vision therapy for the reading difficulty she acquired due to damage in the left occipitotemporal region of her brain.  This had resulted in alexia sine agraphia, or hemianiopic dyslexia – a frequent and disabling functional impairment following brain injury.  As we noted in Part 2, disruption of the paraventricular white matter and the outflow of the corpus callosum impedes the visual information from accessing the angular gyrus in the language area.

I pulled the picture above from a gorgeous website of neuro images.  It is a diffusion spectrum MRI image of the human brain showing three dimensional grid structure of white matter tracts.  This cerebral architecture naturally supports functional spatio-temporal coherence,  and incremental rewiring with correlated adaptation of structure and function in cerebral plasticity.  In other words, the more we can restore Ruth’s functional abilities through therapy, the better her neurons that fire together will re-wire together.

Ruth has these intertwined problems:  alexia due in part to an inability to identify letters;  right homonymous hemianopia resulting in a reading scanpath into her blind field; and convergence insufficiency.  Our therapy approach has been in accordance with Schuett, who suggests that compensatory therapies to reorganize eye-movement control are superior to therapies aimed toward visual field restitution or restoration.  Our treatment protocol involved systematic and repetitive practice of specific eye movements for reading.

Here is a video of Ruth attempting the Test of Silent Word Reading Fluency (TOSWRF).  No spaces appear between the words (e.g., dimhowfigblue), and Ruth is asked to draw a line between the boundaries of as many words as possible (e.g., dim/how/fig/blue).  She comments that she can’t do it because she can’t say the name of the letters, even though she knows what the letters are.

 

 

As Ruth began to re-acquire letter recognition (see Part 4)  we were able to move toward higher level activities that promote reading, such as Michigan Letter and Word Tracking Workbooks, and using the TOSWRF as a training tool.  After spending considerable time the first month working on pencil and paper activities, we wanted to incorporate more elements of spatial vision into Ruth’s rehabilitation.   The Sanet Vision Integrator (SVI) was a helpful program, particularly in developing saccades, the eye movement function that is the platform for reading.

Convergence Insufficiency – A Bright Spot in Advocacy

Inadequately treated convergence insufficiency (CI) can consign an individual to a needless lifetime of struggle.  We’re beginning to highlight bright spots in the effort to promote awareness of this significantly overlooked condition.  Research has firmly established the importance of this condition, and although studies to date have primarily focused on children ages 9 to 18, the long-lasting impact of the condition is now being recognized.

Difficulties for individuals with ADHD in society are well-known, and the link between CI and ADHD has been established by ophthalmologic as well as optometric groups.  My colleague, Dr. Carole Hong and I have reviewed the implications of CI in childhood behavioral disorders.  What happens when CI is inadequately treated in childhood?  CI doesn’t go away by itself.  Patients who find it difficult if not impossible to overcome the symptoms often abandon any hope of a course of study or occupation that involves sustained reading or other forms of near work.

Advocacy for the lifelong implications of improperly treated CI is championed by Helen Spencer, an attorney from Washington State.  Sometimes it takes someone from outside the system to point out how inadequately we address treatable conditions such as CI.  Ms. Spencer knows firsthand the frustrations that come about when patients are victimized by healthcare providers who make unfair and unwarranted value judgements about the significance of their condition.  I was reminded of Helen’s feelings as I came across a wonderful advocacy website, America’s Angel.  Among the many heartfelt experiences is one related by a mother who wrote the following letter to Dear Abby published on April 17, 2007:

Dear Abby: Please help me get the word out about a common condition that severely affects children’s ability to succeed in school because it inhibits reading, spelling and concentration.

My daughter, who was obviously bright, tested at first-grade reading level in fifth grade. She had undergone all the school testing for learning disabilities, plus two days of testing at a respected university hospital. None of these tests or specialists revealed what could be wrong with her.

My child’s self-esteem suffered. Her confidence faltered; she began acting out in school. At home she was a great kid, until it came time for schoolwork. Then the battles began. She thought she was dumb. She could read for only a very short time. She often begged me to read things to her. When working on spelling and assigned to rewrite the words she missed five times, she often recopied them wrong. We thought she just wasn’t trying.

After much research on the Internet, I came across a disorder called “Convergence Insufficiency Disorder.” This visual condition is the leading cause of eyestrain. Fortunately, we had the opportunity to have her tested at the Mayo Clinic, where her condition was confirmed, and she was successfully treated with vision therapy.

It was as though a miracle had occurred. After six months of treatment, my daughter is almost at her age-appropriate reading level. Her comprehension and retention have markedly increased, and her self-esteem and attitude about reading are much better.

Children with this condition will not benefit from tutoring, special education or extra help from teachers until the condition is diagnosed and treated. My child had 20/20 vision and still had this disorder. It’s not routinely checked with eye exams, and schools don’t test for it. I suspect that many children out there are undiagnosed or misdiagnosed and going untreated. The treatment for convergence insufficiency disorder is noninvasive, effective, and much of it can be done at home. Please help me get the word out so other families won’t have to go through what we experienced.

Angie W., Minnesota

 

 

The fact that Angie’s daughter was treated successfully for convergence insufficiency at the Mayo Clinic should come as no surprise.  Dr. Melissa Rice is an optometrist who was an integral part of the CITT study at the Clinic during the time that Angie’s daughter experienced her miraculous turnaround.  Dr. Rice has since moved to Washington State, where Helen Spencer continues her advocacy on behalf of CI awareness.

Brian Mohney, MD, is the Principal Investigator at Mayo Clinic for the CITT.  In a remarkable paper published in the journal Pediatrics, his research group reported that convergence insufficiency was associated with a significant  increase in the incidence of mental health disorders including ADHD, and the use of psychotropic medications, as compared to control subjects.

CI isn’t just an inconvenience.  It can seriously erode the quality of one’s life into adulthood.  For that reason, it deserves serious public health advocacy.  There are bright spots illuminating how we can better identify patients with CI and help them receive appropriate treatment.  We will continue to highlight their efforts.

Convergence Insufficiency a diagnosis that begins with “Bright Spots”

Why does the binocular vision related  medical diagnosis with a funny name,  known as Convergence Insufficiency (CI) (ICD-9-CM:378.83), a condition that has the potential to render a life time of struggle to over 20 million people in the US population alone,  have so  little public awareness? Why, even when this condition has been exhaustively researched through the National Eye Institute in multicenter, prospective, double-blind research and published in October 2008  in the American Medical Association’s Archives of Ophthalmology that spells out the effective modality of treatment, do so many eye doctors seem to pay little attention to identifying and properly treating the condition even when the related impact to the patient can mean a life of frustrating symptoms including eye fatigue, headaches, double vision at near, blurred vision and many more issues.

Let’s face it, the average American family is not normally going to find themselves engaged in a lively discussion about Convergence Insufficiency (CI)  around the dinner table.  Yet, for nearly 1 in 12 people (children and adults) this visual disorder can have the effect of “draining” the affected individual’s  attention and concentration for reading and other academically centered activities resulting in loss of confidence and labels of ADD/ADHD and reduced individual performance.

So, most would agree there exists a serious problem when a condition exists that takes such a heavy toll on the quality of so many human lives, yet there lacks a vigorous  public awareness outcry. Instead, the majority of those who suffer with Convergence Insufficiency must cope a list of common symptoms that have been identified by the CITT Investigation Group as:

• Headaches with reading or close work
• Loss of attention and concentration for reading or close work
• Words moving or doubling when reading or close work
• Eye fatigue and/or discomfort with reading or close work

So what are the answers for effective change? First, one way is to is to begin to look for ”Bright Spots”. Those examples of  good doctors around the US (and internationally) who do provide the proper diagnosis and treatment and set the standard of care for patient advocacy. They are already following  the evidence-based research and their patients are seeing the benefit of their decision to learn the necessary clinical skills and patient treatment protocols.

Second, another critically important way to bring about this change is for people to begin to talk about how they or someone they know have been affected by Convergence Insufficiency.  Public awareness will come when patients who have lived with CI and have found the help they needed with treatment, step up and tell their story of  how this has changed their lives. This can be done by blogging or social networking sites like Facebook, Twitter and now a site dedicated to vision advocacy…Sovoto.

As one example of a patient who found help is our patient Samantha who was diagnosed with Convergence Insufficiency by her primary care optometrist, Dr. Carrie Campbell.  Dr. Campbell who practices at Dr. Reed’s All Eyes in St. Joseph, Michigan is an excellent optometrist and an example of a “Bright Spot”. Dr. Campbell took the time to listen her patient, do the appropriate tests, arrive at the diagnosis and referred Samantha for the appropriate treatment…office-based optometric vision therapy. As a testimony to Samantha’s problem with CI here is her Story:

Helping more people find the help they need for Convergence Insufficiency (CI), and other vision conditions, is an ongoing vision advocacy mission for the VisionHelp Group. We welcome your helpful comments and suggestions.

Dan L. Fortenbacher, O.D., FCOVD

“Doctor, I’m Having Trouble Reading” – Part 4

Ruth has two concurrent problems, the first and more obvious one involving her inability to identify letters despite being able to write them, and the secondary issue of her right visual field defect.  The first step in rehabilitation would be to enable her to recognize letters and then words.  The second would be to help her track into her right field with more accuracy.

Ruth had one major advantage over other patients experiencing alexia sine agraphia: As a former schoolteacher she was experienced in helping young children learn to read.  She therefore put herself in the mindset of a child learning alphabet letters for the first time.  Initially she would point to the letter and draw it in the air.  She used her intact object recognition and naming skills to link the look of familiar objects with the first letter of the word.

Once Ruth had a better command of identifying individual letters, evidenced by her improved verbal reading of the Snellen Chart, we built her ability to blend words visually using the phonetic focus procedure.  Ruth then faced the next hurdle in being able to visually scan across a line in the presence of her right sided field defect.  This difficulty is what many authors refer to as hemianopic dyslexia.  The figure that you see here is a representation of the normal parafoveal preview that readers of English utilize.  The ability to be able to take in a window to the right of fixation is crucial in driving saccades along the line proceeding from left to right.  The figure is contained in a wonderful review paper:  Schuett  S, Heywood C A, Kentridge RW, Zihl J. The significance of visual information processing in reading: insights from hemianopic dyslexia.  Neuropsychologia 2008; 46:2445–2462.  A PDF of the paper can be found as item #67 here.

For this reason, the ideal procedure for Ruth to master is Michigan Letter Tracking (MLT).  In the beginning phases Ruth needed only to keep track of the letters by circling them in alphabetic sequence.  We then want her to say the alphabet letters as she circles them to reinforce letter naming ability.  As she picks up speed in doing this, she is becoming more skilled in Rapid Automatized Naming (RAN).  She then proceeded to Michigan Word Tracking.  Take a look at Ruth’s body position as she performs MLT, proceeding along the line from left to right.  She starts out fine in her unrestricted field on the left side, but as she tracks to the right she has to re-position herself to double-check that she hasn’t missed something toward the right margin.

“Doctor, I’m Having Some Trouble Reading” – Part 3

To review, there is evidence for a Visual Word Form Area localized to the left occipito-temporal region of the brain that is responsible for recognizing letters and words. This is represented by the region of green within the white square with its epicenter in yellow, and is supplied by the left posterior cerebral artery – the area in which our patient, Ruth, evidently suffered an infarct according to her MRI report.  This image, along with the one below, is from Stanislas Dehaene’s Unite de Neuroimagerie Cognitive.

 

The figure below is a 3-D representation of the transcallosal fiber tract connecting ventral visual areas (red cluster) to the Visual Word Form Area (green cluster).

Ruth’s inability to read, but her preserved ability to write, is a disconnection in communication between her two hemispheres that she has experienced due to infarctions within her left posterior cerebral artery (PCA).  This includes the left aspect of the splenium of her corpus callosum, supplied by the posterior pericallosal artery as derived from her PCA.

Ruth may also have a form of memory loss specific to letters.  She was cognitively sharp with auditory and verbal skills, and her naming of objects and numbers was not impacted.  Her radiology report indicates posterior medial left temporal lobe, involving a portion of the left hippocampal formation showing abnormal restricted diffusion, impacted by infarction.  There is also a chronic zone of infraction within the right frontal lobe, a likely sequel of a prior ischemic event.

Ruth’s blood workup was entirely normal and her friend, Nancy, was helpful in pinpointing that the only substantive change Ruth seemed to be experiencing was this inability to read.  There was nothing of medical concern that required further attention, per internal medicine and neurology.  We offered to refer Ruth for a neuropsych work-up but Nancy, a long-standing patient in our office, encouraged us to do whatever we thought might be helpful in rehabilitating Ruth rather than pursuing more elaborate diagnostic labeling.  She trusted us implicitly, and therefore so did Ruth.

“Doctor, I’m Having Some Trouble Reading” – Part 2

In Part 1 we introduced you to Ruth and her conundrum in trying to read.  She has a condition known as Alexia Sine Agraphia, popularized by Oliver Sacks, and chronicled by Howard Engel in his book, The Man Who Forgot How To Read.  Ruth has become a member of a club that she had no interest in joining.  As a retired school teacher who specialized in teaching children how to read, her condition was not debilitating to her career as it was for Howard Engel, the Canadian mystery novel writer.  How did Ruth wind up with this condition?  The narrative of her MRI report on February 2, 2012 provides the clues.  Here are the key findings:

“Multifocal areas of abnormal restricted diffusion are evident within the left posterior cerebral artery territory, consistent with multifocal acute/early subacute infarctions involving the left paramedian occipital lobe, posterior medial left temporal lobe, involving a portion of the left hippocampal formation, and also involving the left aspect of the splenium of the corupus callosum, which is supplied typically by the posterior pericallosal artery derived from the posterior cerebral artery”.

Wow!  No one does run-on sentences like dictating radiologists, but you can get the gist of the problem as we take another look at the textbook photo we introduced in Part 1.

The large arrow in the right occipital lobe shows that the flow of information is intact on that side.  However, disruption of the paraventricular white matter and the outflow of the corpus callosum (C.C.) impedes the visual information (small arrow) from accessing the angular gyrus in the language area.  As you go back and re-read the radiologist’s narrative, think of the evidence pointing toward the existence of a visual word form area in the posterior part of the left midfusiform gyrus in the occipitotemporal region of the brain, as championed by Dehaene.  While the most common cause of alexia sine agraphia is a posterior cerebral artery distribution stroke, it has also been reported in association with intracerebral hemorrhages, A-V malformations, tumors, encephalitis, and even migraine.  As if we needed it, yet another reminder of just how fra-gile we are.

 

“Doctor, I’m Having Some Trouble Reading”

Got an email from Oliver Sacks’ office this week about the BBC Documentary, Imagine, that will be playing in the UK this weekend.  I cited it when it was broadcast originally last summer, though it appears they’ve disabled video links to the program.  Here’s a photo of Sue Barry watching a 3D film together with Imagine’s producer, Alan Yentob.  The series is based on Sacks’s book The Mind’s Eye, which included the story of Stereo Sue, but its title – The Man Who Forgot How to Read – is a story that belongs to Howard Engel.  I’ve covered Engel’s story before in a three-part series on The Visuality of Reading.  In short, Sacks relates how Engel lost his ability to read when he suffered an occipital lobe lesion, though leaving his ability to write intact – a condition termed alexia sine agraphia.  That’s alexia [inability to read] sine [without] agraphia [inability to write].

Your occipital lobe, in the back of the brain, is the hub for much visual information.  Here’s a nice MRI photo taken from a neuro-ophthalmology textbook showing classic localization of a left occipital lobe lesion in a patient who has alexia sine agraphia.  Because the disturbance occurs in the left region of the occipital lobe, it classically results in loss of visual field on the patient’s right side.  Loss of this nature is referred to as homonymous, and the “anopia” or absence of seeing is classified according to whether it involves half of the field (hemianopia) or a sector (quadrantanopia).

Ruth, a 68 year-old retired reading teacher, came to see me earlier this year.  She was referred by a friend who swore by (not at) our practice, and her initial impression was that she needed a change in her glasses because she was having trouble reading.  We conduct an automated visual field screening on every patient above age 17, and occasionally you’ll see diagnostic fields that alert you to the possibility that something is deeply wrong, well beyond the need for a change in glasses.  Ruth came in to my exam room and when I asked her to read the Snellen Chart she was stymied in identifying the letters verbally.  The “blur” that she thought was related to her eyes was clearly occurring somewhere deeper in her brain.

We referred Ruth for a neurology work-up and an MRI, but in the interim conducted a 24-2 SITA Standard Threshold Visual Field Test.  As you can see from the above, Ruth essentially had a right homonymous field loss, the top photo being the plot of the R eye and the bottom of the L eye.  Though there appears to be some sparing of field on the right side, her Pattern Deviation graph makes the functional effect more obvious, again the top is the R eye and bottom is the L eye.

We probed further.  Sure enough, Ruth could write but she had no idea what letters she had written.  She had Alexia Sine Agraphia.  Now what?

The Autism Revolution – Part 3

As you can see by the billboard on your left, Polly Tommey isn’t shy.  The outspoken mother of a 15 year old boy on the autistic spectrum, Ms. Tommey has become a tenacious critic and fierce advocate  within the Autism community in the UK.  Her campaigns have engendered their fair share of controversy and her unwavering support of Dr. Andrew Wakefield’s position on vaccines has alienated her from some factions within the public health sector.  Nevertheless Ms. Tommey interviews well and the quarterly magazine of which she is Editor-in-Chief, The Autism File, now boasts a readership of 50,000 internationally.

I was therefore pleased to see that one of the cover stories of the June-July 2012 issue of The Autism File positions Vision Therapy as a breakthrough treatment.  Our colleague, Dr. Neil Margolis in Illinois, is the author of the article and sent me an advance copy of the magazine.  You can either subscribe to the mag, or pick it up in retail outlets such as Barnes & Noble.  Dr. Margolis offers some nice tips for evaluation as well as therapy.  He covers ocular motor, visual processing, visual spatial judgment and central & peripheral vision.  It’s an important contribution to The Autism Revolution.