An Open Letter to the Editor of Contemporary Pediatrics

You may recall that on August 28 we blogged about an article published by a pediatric ophthalmologist in the online magazine, Contemporary Pediatrics.  For reference, here is a link to the article.

 

Debra Walhof, M.D., a pediatrician with whom I’ve collaborated before (see here), called my attention to this article and asked what I thought of it.  The more we discussed it the more concerned we became that the article reflects a narrow viewpoint of dyslexia, and certainly not the essence of what pediatricians need to know to be the best advocates for their patients.  Dr. Walhof sought the opinion of a pediatric colleague, Dr. Carina Quezada, and I checked with a developmental optometry colleague, Dr. Gabrielle Marshall.  We all had the same reaction, which culminated in our Open Letter to the Editor of Contemporary Pediatrics which was sent today.  We have reproduced the letter below, which you have our permission to quote or circulate.

 

We are writing to express concern about the article in the August 1, 2016 issue of Contemporary Pediatrics titled Dyslexia: What you need to know. The content is represented as dispelling myths and helping to coordinate care, enabling pediatricians to support children with dyslexia in school and in daily life. We applaud this intent. Dyslexia is a subject that has unfortunately been misunderstood in our culture and in our education system. Pediatricians as well as teachers are perfectly situated in a child’s life to identify and support a Dyslexic child and their family as well as to dispel cultural myths.

This article regrettably perpetuates the traditional pathologizing of Dyslexia and contributes nothing new to the discussion. The biggest paradigm shift concerning the Dyslexic individual in recent years is the understanding that as they make up as much of 20% of the population, and that they in fact have a brain variant as opposed to a brain pathology. Thus, defining the individual solely on their educational weaknesses with language, while not stressing their multifaceted unique strengths and recognizing that differing teaching styles play a role in educational difficulties or successes is perpetuating an antiquated model of pathology. Although there is some mention of supporting a child’s strengths, the substance of the article is a highly selective review that adds to the mythology surrounding a complex subject rather than lending clarity.

As one example of a more productive approach, The Dyslexic Advantage (or dyslexicadvantage.org website) by two noted physicians, Drs. Brock and Fernette Eide, is an updated and groundbreaking resource that looks at the individual in context and shifts the paradigm to one that views the individual’s relative strengths and weaknesses. It enables approaches that capitalize on visual, language, or cognitive foundations. They elaborate the role of the child’s ability for reasoning, or MIND strengths that surpass the strengths of language- based learners. These MIND factors are the strengths that pediatricians can see in their offices when interacting with the child, and can use as red flags as well as to alert parents that their child might have varying educational needs.

Pediatricians can be encouraged by approaches as championed by Dean Bragonier of NoticeAbility, who is forging experiential curricula that teach middle- school Dyslexic children thru a MIND based approach. Rather than traditional classroom lectures, students learn via hands-on practice in disciplines including entrepreneurship, architecture, engineering, and the narrative arts. Because Dyslexic individuals learn to read with reading instruction that differs from language based learners, it is time to stop jamming square pegs down round holes.

The bottom line is that each Dyslexic child is unique, and that different things work for different kids. That is why this article does a disservice in summarily dismissing visual factors in dyslexia. Though we might generalize that Dyslexics are visual learners and vision is strength, a subset will have conditions such as convergence insufficiency that hampers progress. The distinction that the author makes that the inability to focus on letters on the page will affect concentration but not decoding is a very narrow approach to reading comprehension and fluency.

 

The article characterizes reading disabilities in general and Dyslexia in particular as solely a language based problem, thereby minimizing the role of vision in reading. This runs counter to contemporary research on the neural basis of reading (1) and leads to sweeping statements such as “vision-related approaches are misdirected in theory”, and “the erroneous concept that dyslexia is a vision-based disorder”. These are opinions designed primarily to dissuade pediatricians and parents from exploring treatments such as optometric vision therapy. Perhaps because the author is an ophthalmologist with limited education regarding developmental/behavioral optometry and its evidence based studies, this is understandable.

Articles with this agenda advance position statements that have been amply rebutted owing to their misrepresentations.(2) Conversely policy statements addressing the positive role of vision in dyslexia are conveniently omitted.(3) Cloaked in a mantle of scientific concern, the misrepresentation of clinical science of which pediatricians should be made aware is most apparent in the following paragraph:

“Children diagnosed with symptomatic convergence insufficiency are usually prescribed convergence eye exercises to be performed at home. These exercises usually result in improved reading comfort within a few weeks. In-office exercises with at-home reinforcement are considered if a child continues to show signs and symptoms of convergence insufficiency.”

Evidence based medicine does not support this recommendation. In fact a gold standard randomized clinical trial, the Convergence Insufficiency Treatment Trial (CITT) conclusively demonstrated that exercises prescribed for home use without in-office therapy is no better than placebo therapy.(5) If home alone therapy is being advocated, both the pediatrician and parent should be advised that a placebo approach to convergence insufficiency is being prescribed for the child.

 

Contemporary pediatrics has acknowledged that in certain domains a Developmental/Behavioral Pediatrician has more specialized knowledge, training and experience in rendering expert opinions. From a medical perspective regarding Dyslexia, the role of the Pediatric Ophthalmologist or Primary Care Optometrist in this field is limited as compared to Developmental/Behavioral Optometrists with post-graduate training and certification that encompasses visual function and its relationship to learning.

In summary, Dyslexic individuals’ brains are different than language based learners’ brains.(5) These individuals require different teaching methods to acquire a mastery of reading and often thrive in project based educational systems that support their MIND strengths. Early identification is key to ensuring that the child is put in an educational environment that promotes his or her strengths as well as supports his or her weaknesses. Pediatricians and Early Childhood Educators should be aware of the red flags signaling weaknesses as well as key strengths. (6). Parents should be knowledgeable about hereditary and environmental components in conjunction with the red flags so they can collaborate with those who can be of assistance. Visual conditions such as convergence Insufficiency should be adequately treated based on evidence based medicine in any population that is having difficulties learning to read or reading to learn, and should be addressed by trained professionals with expertise in these areas. And most importantly, perhaps with continued dispelling of cultural myths this bright population of Dyslexics will cease to appear disabled to the greater culture.

Debra Walhof, M.D., FAAP

Carina Quezada, M.D., FAAP

Leonard J. Press, O.D., FAAO, FCOVD

Gabrielle W. Marshall, O.D., FCOVD

 

REFERENCES

1. The Neural Basis of Reading. PL Cornelissen, PC Hansen, L Kringelbach, and K Pugh, eds. New York: Oxford University Press. 2010.

2. Bowan MD. Learning disabilities, dyslexia, and vision: a subject review – a rebuttal, literature review, and commentary. Optometry 2002;73(9):553-75.

3. Vision, Learning, and Dyslexia: A Joint Organizational Policy Statement. American Academy of Optometry and American Optometric Association. Optom Vis Sci 1997;74(10):868-70.

4. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126(10):1336-49.

5. Visual Aspects of Dyslexia. J. Stein and Z. Kapoula, eds. Oxford University Press 2012.

6. Johnson K. Red Flags for Elementary Teachers: Vision and Neurodevelopmental Issues that Interfere with Reading and What To Do About them. Tendrill Press 2014.