Oops! Page Not Found … Interview with Debbie Walhof, M.D. on Vision & Learning

In 2013, along with the pediatrician Dr. Debra Walhof, I co-authored an article titled: Could Vision Issues Be Contributing to Your Child’s Difficulty With Learning?  At the time Dr. Walhof was a parent advocate with the National Center for Learning Disabilities or NCLD.  But if you search for that paper now, all you’ll come up with is:

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However, I was pleased to discover that the article is still accessible as a PDF through the website WellChildVision.org.  But in case that site succumbs to the infamous 404 OOPS, and the article can no longer be found, I am reproducing it here in its entirety.

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Parents and educators often ask us questions about vision therapy and if it can be helpful for children with LD. While vision problems are not the cause of dyslexia or other learning disabilities, vision issues such as convergence insufficiency can certainly interfere with learning and contribute to difficulties with attention and behavior. And some practitioners report that convergence insufficiency may be more common in individuals with LD and ADHD.

We turned to a pediatrician, Debbie Walhof, MD, and an optometrist, Leonard Press, OD, to answer questions about vision therapy, convergence insufficiency, and what parents should know if they are considering vision therapy for their child.

 

What is Convergence Insufficiency (CI)? Is it related to dyslexia?

Our eyes are designed to work together to give us single, clear vision. Convergence Insufficiency (CI) is an eye coordination disorder, where the two eyes do not work together the way they are supposed to. As with any disorder, you can have a mild to severe case. The more severe the disorder, the more difficult it is for the eyes to work in ways that support effective reading. Some of the more common symptoms of CI are similar to those symptoms described by individuals with dyslexia or another reading disability when they describe what they “see” while reading, so it could be easy to confuse the two.

For example, CI can cause double vision or “ghosting” of print. Since children do not know how they are supposed to see, they rarely complain when they see double. Instead they struggle with reading, often avoiding it at every opportunity. They may be able to read aloud in a very broken, non-fluid manner, yet they don’t remember what they read.

Does CI occur more frequently in those with dyslexia than in the general population? What about in individuals who have ADHD and other disorders that impact learning, attention and behavior?

CI is estimated to occur at least three times more frequently in children diagnosed with ADHD as compared to the general population. Recent studies have established a link between CI and dyslexia, particularly regarding the negative impact of CI on the type of eye movements used when reading, called “saccades” in the professional literature.

Can CI be treated? Will curing CI cure (or help treat features of) dyslexia?

According to research funded by the National Eye Institute, part of the National Institutes of Health, not only is it possible to treat CI, but the treatment of choice is in-office optometric vision therapy combined with home reinforcement activities. While vision therapy is an optometric specialty service, the research was conducted as a multicenter study involving ophthalmologists and optometrists in a variety of academic settings across the United States.

First, it is important to understand that optometric vision therapy treats vision problems, not learning disorders. Having said that, when a vision disorder is at the root of a child’s difficulties with reading, we often see children excel once the vision problem is corrected. For children who have severe learning difficulties, vision therapy resolves the visual component to their challenges. Tutoring and other services often become more successful once the vision problem has been treated.

I’ve heard people say that vision therapy is a waste of time. Why would they say that, and what should I believe?

There are a variety of possible reasons why someone would say vision therapy is a waste of time. Typically it is because they are not up to date on the scientific literature supporting vision therapy. Or perhaps they know of a child who was engaged in vision therapy for many months and for whom there seemed to be little or no apparent benefit in terms of improved performance in school. Here are some important rules of thumb:

Vision therapy provides a highly specialized type of treatment for a very specific set of vision-related problems. Not every child is a candidate, and vision therapy alone may not result in better school success.

As with any therapeutic intervention, it must be implemented with fidelity. Professionals must use the right strategies over the proper period of time with clear goals and ongoing monitoring of progress, with adjustments made as needed.

Effective treatment for CI is clearly dependent not only on office-based treatment with a trained provider but also on the child’s commitment to regularly doing exercises at home.

If possible symptoms of CI emerge during my child’s pediatric office visit, what should the pediatrician do?

The best thing your child’s pediatrician can do is review the symptom checklist that was used in CI studies funded by the National Eye Institute. If your child has many of these symptoms, it indicates that your child probably has an eye coordination problem and needs to have a binocular vision evaluation by a developmental optometrist or an optometrist who provides an in-office vision therapy program. Although optometrists and ophthalmologists can diagnose CI, you may want to choose a developmental optometrist for diagnosis who is also skilled in the therapeutic treatment for CI through vision therapy.

 

These studies found that children with CI reported that the following symptoms occurred “fairly often” or “always” while reading or doing close work:

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Other than “pencil push-ups,” what are some strategies used to treat CI?

 

“Pencil Push-ups” is an activity where a person holds a pencil at arms length in front of his or her face and keeps their eyes fixed on the tip as it is moved closer and closer to the face. Despite popularity of this activity, the study funded by the National Eye Institute found that doing “pencil push-ups” was no more effective than placebo therapy.

When working with children it is important that activities are designed to be engaging while teaching them how to use their eyes correctly. For example, tossing a bean bag back and forth might initially appear very simple, but if you put special lenses on the child to help the two eyes work together correctly, this simple game now becomes a therapeutic activity. There are also some very sophisticated computer programs specifically designed to be used with therapeutic lenses.

In addition, some parents are concerned as to whether or not their child can actually do what is needed to get through the therapy program. The activities are individualized for each child’s abilities. They start out very simple and become more demanding as the visual skills improve.

More clinically speaking, the procedures used in the landmark CI study included activities to help the eyes focus accurately through a variety of lens powers, and to team (work together) more accurately. Better integration of tracking, focusing, and eye teaming can be accomplished with something as simple as a Brock String (a 10 foot chord with three beads on it), or as complex as interactive computer activities with special binocular glasses. The optometrist selects the strategies best suited to the individual child.

Who does the treatment, and how long does it take?

While some doctors will provide vision therapy sessions personally and directly with their patients, many optometrists have vision therapists working with their patients under supervision of the doctor. The length of treatment can be as short as three to six months in uncomplicated cases, to much longer when other problems coexist with CI such as Cerebral Palsy or Traumatic Brain Injury.Make sure you understand the exact nature of your child’s vision problem.Ask the doctor how much continuing education they have attended and continue to attend on vision therapy. You want your child to see someone who is up to date on the latest research and technology.

 

Ask to see the vision therapy room. While a tremendous amount of equipment is not needed to treat CI, ask to be present during your child’s first therapy session to gain a sense of how treatment is conducted. If, after two- months, you do not see any incremental improvement despite attending weekly and getting home therapy done as instructed, you should reevaluate whether this is an appropriate therapy for your child and discuss this with the doctor.

Ask the doctor to download and share the Fact Sheets from the College of Optometrists in Vision Development that correspond to your child’s specific diagnosis. (They can be accessed through the member’s only section of the COVD.org website). These Fact Sheets explain the appropriate length of treatment.

Getting a second opinion is always beneficial, as long as you see a doctor who also provides an in-office program of optometric vision therapy. Ideally the doctor would also be a Fellow of the College of Optometrists in Vision Development, and therefore board certified in this field.

 

How can I find the right professional to treat CI? Will most Optometrists know what to do?

While all optometrists learn about vision therapy in optometry school, you want to find an optometrist who provides an in-office program of vision therapy. Most optometrists know how to diagnose CI, but it is important that you let them know the symptoms your child is reporting or the signs you are observing. If your child’s eye doctor says “everything is fine” yet your child continues to struggle with reading despite all best efforts to help, find your closest doctor certified in vision therapy at COVD.org and schedule an appointment.

As with any profession, you will find some practitioners who are more knowledgeable than others. Therefore it is vital that you ask how much experience the doctor has had with patients similar to your child. You can also ask to speak with some parents of children who have also had CI and reading difficulties, who went through their vision therapy program.

Vision therapy is expensive, and maybe not be (fully) covered by insurance. How can I decide which treatment approach is going to be both affordable and effective?

If your child has an eye coordination problem such as CI contributing to his or her challenges with reading, then it is important to fix the vision problem first. Over the years the majority of patients I have helped struggled for years trying all other treatment options before finding out their children had vision problems that were easily corrected.

Many of my patients have shared that they spent thousands, if not tens of thousands, trying to help their children with forms of treatment that proved inadequate prior to consulting me about optometric vision therapy.

To determine which treatment approach will be both affordable and effective, you can:

Make sure you understand the exact nature of your child’s vision problem.

Ask the doctor how much continuing education they have attended and continue to attend on vision therapy. You want your child to see someone who is up to date on the latest research and technology.

Ask to see the vision therapy room. While a tremendous amount of equipment is not needed to treat CI, ask to be present during your child’s first therapy session to gain a sense of how treatment is conducted. If, after two- months, you do not see any incremental improvement despite attending weekly and getting home therapy done as instructed, you should reevaluate whether this is an appropriate therapy for your child and discuss this with the doctor.

Ask the doctor to download and share the Fact Sheets from the College of Optometrists in Vision Development that correspond to your child’s specific diagnosis. (They can be accessed through the member’s only section of the COVD.org website). These Fact Sheets explain the appropriate length of treatment.

Getting a second opinion is always beneficial, as long as you see a doctor who also provides an in-office program of optometric vision therapy. Ideally the doctor would also be a Fellow of the College of Optometrists in Vision Development, and therefore board certified in this field.

 

Why do some doctors say vision therapy is controversial or that it lacks research?

Even though there is a wealth of optometric research which proves that vision therapy works, there are some in the medical (ophthalmology and pediatric) community who have the misimpression that there is insufficient evidence. The fact is that vision therapy is an optometric specialty and therefore the bulk of the research is in the optometric journals, not the medical journals. Vision therapy is not new; it has been around for 85 years!

In Summary

The bottom line is that NIH studies demonstrated that vision therapy is a valid treatment for CI. We know that many children, including those with learning disabilities, have CI so screening for CI in this population makes sense.

Healthy eyes and proper vision are essential ingredients for effective learning; reading, writing, spelling and math are all areas that could be affected by uncorrected problems with vision.

If your child is having trouble seeing, reading or writing, think about CI as a possible factor.

Parents should seek needed services from qualified professionals to discover and treat problems related to vision. The most qualified professionals to whom you should turn for expert guidance, evaluation or treatment are developmental optometrists who have completed fellowship training in this area.

Parents should be sure to include school personnel in their efforts to provide needed treatment and support for their children (for example, by identifying ways to support therapeutic progress during school activities) and should be sure that children are receiving the best quality academic instruction (in reading and in other areas) to maximize their opportunities for success.

If treatment is begun and no discernible improvement is seen within a few months despite doing everything as instructed, ask your child’s primary care physician to consult with the developmental optometrist.

For more information about healthy vision and dyslexia, see this informational sheet from the College of Optometrists in Vision Development: https://c.ymcdn.com/sites/www.covd.org/resource/resmgr/white_papers/7- _vision_and_dyslexia.pdf?hhSearchTerms=dyslexia

Debbie Walhof, MD is an Associate Clinical Professor at the University of California San Francisco and a practicing pediatrician with specialty training in the area of integrative medicine. She is also a Parent Advocate for NCLD. Leonard Press, OD is a board certified optometrist with specialty training in pediatrics and binocular vision. He has served as chief of the pediatric unit at the Eye Institute of the Pennsylvania College of Optometry and as Chief of the Vision Therapy Service at the State University of New York College of Optometry.

The Story of Vision Beyond Sight – A Different Approach? – Part 2

I posed the quasi-rhetorical question in Part 1 as to how effective we’ve been in getting the message across to the public than vision is more than 20/20.  Or more pointedly, that eyesight is not synonymous with vision.  Make no mistake about it:  Public Awareness Campaigns such as those engaged in by COVD have been effective.  But every time we see something widely circulated that addresses “good vision” only in terms of “good eyesight”, it’s a stark reminder that we can do better.

While I don’t have a film documentary trailer for you yet on the subject, here is a sneak preview of my Editorial in the upcoming issue of Vision Development & Rehabilitation that speaks to the matter at hand:

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Sofia is a 14 year-old girl who came to our practice accompanied by her mother. Clearly bright and articulate, she is a straight “A” student who reportedly works very hard to achieve her grades in school. But at what cost? She sees a psychiatrist for counseling, and has been on several different medications for ADD, all with side effects that significantly increase her anxiety. She takes three different psychotropic medications at bedtime to help her sleep.

When Sofia was eight years old, she began experiencing panic attacks. Her trigger seemed to be visual stimuli, and she developed a sensitivity to light. At that time she was diagnosed as having a sensory processing disorder (SPD) and received a year of occupational therapy services. OT for SPD can be very successful, but Sofia noted that although it was fun it didn’t seem to be of help in her case.

Shortly thereafter, Sofia’s mother took her for an eye examination and while she could read the 20/20 line with either eye she made the comment that “I just wish the letters on the chart would stop wobbling”. Mother asked the doctor if that was normal, and his response was “some kids report that but it’s nothing really to be concerned about”. As time went on, Sofia’s mother obtained Section 504 accommodations for her in school, but had this nagging feeling that they were missing something.

When I examined Sofia she confirmed that words move around on the page when she reads, and agreed that this instability of print results in countless additional hours of work for her over the course of the school year. Last year she began to experience more difficulty in copying from the board. Examination revealed 10 prism diopters of esophoria at distance and 2 prism diopters of esophoria at near, poor fusional reserves and classic pseudo aniso-myopia with stress cylinder against the rule.

We scheduled a return visit for a conference with Sofia and her parents to review my findings and recommendations. I noticed on her history sheet that Sofia’s hobbies included drawing, painting, and sculpting. So I asked her if she could create a representation to depict what the instability of print looked like to her. She seemed genuinely delighted that someone was taking the time to listen to her visual complaints, and her mother had that ambivalent look of relief but with a sadness tinged by the remorse of not uncovering this sooner.  Here is what Sofia emailed to me:

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A month prior to examining Sofia I evaluated a teenager by the name of Elizabeth whose mother is a former school teacher. After years of searching she was finally diagnosed as having a tick borne infection and had associated visual sequelae. She exhibits many of the signs and symptoms experience by individuals with acquired brain injury. Until the diagnosis was finally made, Elizabeth’s mother was accused by prior professionals as perpetuating Munchausen by Proxy. What enabled Elizabeth to go on was that her father is a psychiatrist, and he sensed that her issues were real and not imagined.

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Every day, in practices around the world, scenarios like this occur. A new dawn is emerging, however. Parents of children like Sofia and Elizabeth are taking matters into their own hands and serving as forceful advocates. They often discover the world of vision development and rehabilitation by word of mouth, and impels them to take on a mission so that other families do not have to struggle the way they did.

This advocacy network is growing on wide scale. Consider the efforts of individuals such as Patty Lemer, Robin and Jilian Benoit, Michele Chigas Hillman, Katie Johnson, Wendy Rosen, Sue Barry, Cavin Balaster, Susanna Zayarsky, and Debbie Walhof – just to name a handful. What do these individuals have in common? None are employed by practices offering vision development or rehabilitation services and therefore have no vested interest in advocacy other than a passion for promoting awareness of what we do.

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The enthusiasm of advocates is infectious. Consider the story of Hayley Barber, competing in the Miss America contest this year. She uses her platform of “Sight for Young Eyes” to encourage eye examinations at a young age and raise funds to provide vision therapy for children with low vision. Ms. Barber helped pen a bill requiring comprehensive eye exams before kindergarten, and has been advocating for this bill to be passed by the Alabama legislature. Her platform has now expanded to include an interactive visual curriculum for the Boys & Girls Clubs of America.

A measure of the worth of what we do is the extent to which others promote our services. By nurturing these advocacy networks through social media, we help key individuals connect the dots. They will ultimately coalesce into a grass roots international movement, complementing the public awareness efforts of COVD.

 

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.

 

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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.

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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.

NCLD on Visual Scanning in Dyslexia & ADHD

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You may recall an interview on vision and LD that I did awhile back with the pediatrician, Dr. Debbie Walhof, posted on the NCLD website.  I received an interesting email this evening from NCLD with the subject line “See What Your Child Sees”.  I was hoping it had something to do with vision.  Sure enough, here’s what the body of the message reads:

“Ever wonder what your child face on a daily basis?  Everyday tasks like scanning letters or numbers can be maddening for people with learning and attention issues, like LD and ADHD.  We’ve put together a few exercises to help you better understand what your child sees.”

Take a look at the examples provided in this piece written by the NCLD editorial team.  They all relate to visual scanning or visual search.  The first one asks you to find the two Bs in this array:

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The second one asks you to find the letter N in this array:

Letter N

The third one asks you to find the number 1 in this array:

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We’ve alluded to visual search and serial scanning as key readiness skills for reading in this blog before.  Aside from the workbooks mentioned, or visual scanning worksheets in open source such as here, there are computer programs we use regularly in vision therapy for these purposes.  Examples include home therapy procedures in Vision Builder available through OEPF, and the in-office procedures in CPT from Dr. Sidney Groffman.

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Myths About Myths, or Meta-Myths

The Gomer Pyle Award of the Day goes to this video, from the NCLD, which does a textbook job of framing a mis-statement about vision and dyslexia.  Take a look at the 50 second mark of the video:

Done as an on-the-street-interview of selected New Yorkers in True/False answer format, the interviewer poses the statement: “Poor Vision is a Type of Dyslexia”.  The woman chooses “False” and the interviewer comments: “You are absolutely right.  Poor vision on its own isn’t a type of dyslexia.”

Uh … yeh, but who ever asserted that poor vision on its own is a type of dyslexia?  Although we’ve heard this meta-myth elsewhere, at this point in time it does come as a bit of a surprise.

…. reason being, the NCLD itself ran a nice article by a developmental pediatrician not long ago indicating the role that vision plays in learning which is factual and to the point (see here).

Guess in this instance, the left hand doesn’t know what the right hand is doing at NCLD.  Hmm … is that a sign of dyslexia?  Shame of it is, there are alot of really good informational pieces on the NCLD website.  This just isn’t one of them, and it serves to perpetuate the myth that vision has little if anything to do with reading and learning difficulties.  In addition to re-reading Dr. Walhof’s fine piece, the NCLD editorial team should take a look at this new Position Paper on Optometric Care of the Struggling Student from the American Academy of Optometry.  Is it any wonder why the public continues to be con-fused?

The Distraction Addiction vs. Contemplative Computing

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Alex Soojung-Kim Pang is a science writer who has penned a very enjoyable read about the challenges of modern technology in terms of attention, and how to manage the potential for addiction to distraction.  In addition to being a talented writer, he also has a smooth voice for presentation, and in the following YouTube video does a nice job of presenting the background of what would become his just-released book, in which he coins the zen-like phrase contemplative computing.

 

On his blog Pang notes that both his wife and son are dyslexic, and this explains Pang’s short but informative view about the visual nature of reading in his book.  This complements the information we recently blogged about from pediatrician Debbie Walhof, M.D., and also serves as an antidote to the biased information promulgated by AAPOS and the IDA that paints vision – and therefore visual interventions, as essentially irrelevant to dyslexia.  It is evident that the latest AAPOS attack on vision therapy, fronted by the IDA, will conflate vision as necessary but not sufficient, with vision as a byproduct of reading.  

From Pang’s book:

“Let’s take a look at something you’re doing right now:  reading.  Reading has the virtue of being both very familiar and very complex and multilayered.  By deconstructing it, we can see more clearly how cognitive functions that we develop with years of practice, formal techniques that we consciously learn and apply, and the physical nature of the printed page all work together … First, observe something really basic:  You’re reading letters … You’re aware of reading words and lines of text, but what you don’t realize is that your eyes aren’t moving evenly across letters and spaces; rather, they’re focusing on groups of letters for a couple of tenths of a second, performing these saccadic jumps, without your awareness.  Your visual system learned to move your eyes like this, and when you were quite young, your brain learned to take these individual frames and convert them into a smooth picture of your visual reality.”

Reading, in essence, is a form of contemplative computing that goes well beyond phonology.  To suggest otherwise turns out to be a distraction to which (for whatever reasons) some persons and organizations are addicted.

National Center for Learning Disabilities Addresses Vision Therapy

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Wonderful to see the interview in which Dr. Debbie Walhof and I participated, Could Vision Issues Be Contributing to Your Child’s Difficulty With Learning?  The article is a very timely one, particularly for the back-to-school season that is almost upon us.  But it should be recommended reading for pediatricians, educators, and parents year-round.

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Let me tell you a little bit more about Debbie Walhof, M.D., as noted on the NCLD website.  First and foremost, she is a parent and believes that all children need to be in an environment that helps them blossom and be the best they can be. Her son Jack is 13 years old and has Dyslexia. It is a journey for him, their family and those involved in his education. In her words, “the field of education just likes the field of healthcare needs to undergo a paradigm shift: a shift that supports multiple styles of learning.”

Debbie is also a Pediatrician who specializes in Integrative Medicine. During the past 20 years, she has been involved in hospital-based, clinic-based, academia and community-based projects. Her work focused primarily on multi-cultural and underserved populations who present as “at risk” across many developmental and behavioral domains. Debbie also completed an Associate Fellowship of Integrative Medicine under the leadership of Dr. Andrew Weil. Her philosophy has always been to tweak the environment not the child, especially when it comes to the area of learning differences. She currently works as a Pediatrician at Kaiser Permanente in Santa Rosa, California.

If you look around on the NCLD website, you’ll find an article about VT by an educator, Dr. Sheldon Horowitz.  There are a variety of comments under that piece, pointing out its inaccuracies.  To help mitigate this, Dr. Horowitz amended his information to include a link to the new piece about vision therapy.  He notes:  “While vision problems are not the cause of dyslexia or other learning disabilities, vision issues such as convergence insufficiency can certainly interfere with learning and contribute to difficulties with attention and behavior. Behavioral optometrists are the ones who offer this therapy, with treatments involving in-office visits and exercises to do at home, and often, the prescription of low-power lenses.”  Kudos to Dr. Horowitz for working toward a more balanced view of optometric vision therapy.

What I would suggest now is that you you encourage parents of children to go to the new interview with Dr. Walhof, and add comments regarding their positive experiences with VT.  It is important for NCLD, pediatricians, and other parents to know about the many positive experiences that we collectively share.  Lastly, share this link in your social media!

NOTE ADDED JULY 29, 2020: The NCLD website was revamped, and the article that Dr. Walhof and I co-authored was removed.  However, the complete text of the original article is available here.

Pediatricians Supportive of Optometric Vision Therapy

Pat Wyman is a learning specialist who understands the applicability and value of optometric vision therapy to learning.  In a blog piece posted on her site yesterday, she quotes experts who note that vision therapy is a missing link for struggling readers.   Readers are advised to consult doctors who are members either of COVD  or OEP.

Also quoted is a pediatrician, Dr. Erin, who learned to read at age four,  but encountered reading problems in first grade.  Though I don’t know if Dr. Erin was formally diagnosed with hyperlexia,  we are seeing more and more children in our practices who acquire word recognition abilities at an early age, but then encounter difficulty with comprehension or fluency during early elementary school years.

 “I don’t know what would have happened if my reading problems were not solved by vision therapy,” exclaimed Dr. Erin.  She goes 0n to say that if the eye doctor had not discovered what the teacher could not, “I could have gone on in school thinking I was not intelligent because I had so many reading problems“.

Another pediatrician who “gets it” is Debbie Walhof, MD.  Debbie is a product of Dr. Andrew Weil’s Integrative Medicine Program, and I’ve blogged about this previously in the context of Integrative Pediatrics.  In the course of an interview with the National Center for Learning Disabilities, Debbie fields a question and gives a straightforward response:

Chris P.:

I need help understanding whether I should consider “vision therapy” for my child. I’m not sure what it is and how it might be helpful for my child. My child’s pediatrician as much as said that eye training is nonsense. What do you think?

Debbie Walhof, M.D.:

I think you are right to ask about vision training before making up your mind whether it is right for your child. Some parents have wondered aloud that their child was evaluated by a behavioral optometrist, engaged in many weeks of vision therapy without any apparent benefit. Others parents have been neutral about the benefit (not sure, but it didn’t do any harm) and many others say that it made a huge difference. My advice about vision therapy can be applied to pretty much every type of “specialty” approach to treatment. Be an informed consumer and do your homework!

Think of the fable of the two blind men who approach an elephant from different directions. The one who discovers the trunk describes the animal very differently than the one who finds the tail, than the one who finds the leg, the tusk, etc. None of them “see” that what they found is just one part of the same, bigger animal.

I believe that all learning disabilities are multifaceted and that LD manifests itself in unique ways in each individual. I don’t believe one approach or practitioner holds all the answers. With regard to vision therapy, I have seen some amazing results in some children, and minimal in others. I believe, for some children, it is a modality worth exploring with a skilled practitioner.

If you decide to explore any multifaceted, multi-modality approach for your child, be very clear about the goals of treatment and pay careful attention to the unique characteristics of your child. How can you know whether vision therapy is right for your child? I believe that the answer lies in the workup. Starting vision therapy without a full workup or comprehensive consultation is an invitation for poor success. Everyone chooses their tests for evaluation based on the information they want to gather, which is usually based on the comprehensiveness of their treatment. It all has to do with the evaluation and preparation for therapy. You must have other testing that dives deeper into the reason for the convergence insufficiency or tracking issue. Any office that wants to start VT without a workup, consult or both is asking for a low success rate. You want to work with a Behavioral Optometrist who is experienced and skilled in Vision Therapy.

Even within Behavioral Optometrists’ offices there are differences here. I think the best way to know if it’s right is to ask about success rates and compliance rates. How does the program work? How do you measure success? Is it goal-based or number of sessions-based? Talk with former patients who have completed their program. It’s very important to think of the VT as a specialty service. It’s not primary care, and it warrants some research.

You can feel the gears turning here.  Dr. Walhof notes that vision therapy has to be considered in the framework of a larger context because it is a multifaceted problem, and that message is consistent with the COVD white paper on the role of the optometrist in a multidisciplinary framework.  For some children, though clearly not all, it is a modality worth pursuing with a skilled practitioner.

The issue is no longer whether vision therapy “works”.  The issue is whether a differential diagnosis has been determined that establishes:

a) a child has a condition or conditions that can benefit from vision therapy

b) the child has the support structure necessary for vision therapy to be beneficial at this time

c) goals that can be measured during progress evaluations.

 

– Leonard J. Press, O.D., FCOVD, FAAO