Section A. Reading, Learning Disabilities, and Dyslexia

1. Reading

A. What is reading?

Reading is defined as the effort to get the meaning of something printed, written or embossed by using the eyes, or in the case of Braille, the fingertips, to interpret its characters or signs.¹

In today's society, reading serves as the major foundational skill for learning. The first few years of school are dedicated to teaching the difficult process of learning to read and write. Although speaking is a natural process, reading and writing are not natural nor easy for many students.^2,3,4

1. Role of oral language

Oral language is the foundation for reading. A child's vocabulary is a direct response to the amount of words that he or she hears.⁵ Exposure to a large number of words is necessary for high-quality oral language development, and strong oral language skills are a prerequisite for successful reading.⁶ The size of a child's vocabulary at the age of 3 is highly correlated to his or her spoken language ability, reading ability, and reading comprehension at the end of third grade. So, it is extremely important that parents talk to and read to their children from early infancy to develop strong language and literacy skills.

2. Phonological Model of Reading

Phonological awareness (also called auditory analysis) is the ability to hear, identify, and manipulate individual speech sounds. Phonological awareness (auditory analysis) is essential in learning to read. If children are not able to hear the individual sounds in speech, they will have difficulty rhyming words, blending sounds to make words, or segmenting words into sounds.

Individual sounds that are pronounced in a certain way by native speakers are referred to as phonemes. The phoneme is the smallest unit of speech that distinguishes one word from another.¹ Each language has a unique set of phonemes. The more phonemes inherent to a language, the higher the degree of difficulty to break down or decode the written word. Different combinations of phonemes produce all words in each language. English is a phonemically complex language in which the 26 letters of the alphabet create 44 sounds or phonemes. The 44 phonemes can be spelled in 74 ways and 23 of those letter combinations can make more than one sound. So, in English the relationship between letters and sounds is inconsistent (deep orthography), whereas in some other languages, the reader can look at a word and immediately know how to pronounce it (shallow orthography).

Spoken words are formed by combining one or more phonemes (sounds). These sounds create meaning. Phonemic awareness is the ability to hear, identify, blend, and break apart the individual sounds in words and to understand how changes in these sounds signal differences in meaning. Phonemic awareness is the phonological process that is most strongly associated with early word reading. A phonemically aware child is able to recognize that the difference in the sound of a word affects the meaning of that word. Developing phonemic awareness is a learned process, because phonemes are not separated in speech; they are co-articulated – spoken together – quickly, at 8 to 10 phonemes per second. Phonological and phonemic awareness are oral skills that must be in place before learning phonics.

Writing is an artificially designed use of abstract symbols to represent language. English uses an alphabetic system in which each letter is a symbol that is an abstract building block of the phonemes.

Phonics is an instructional approach that emphasizes the understanding of the relationship between the letters and the sounds that they make. The goal of learning phonics is to enable beginning readers to decode new written words by sounding them out and use that skill in reverse to spell or encode words. Early readers use phonics to sound out words, but they must eventually become proficient in reading larger units of print such as syllables, meaningful roots, suffixes (morphemes), and whole words at a fast pace.

3. 2000 National Reading Panel recommendations for teachers⁷

For a long time there has been a difference of opinion among teachers and other professional groups on the best ways to teach students to read. There has been a lot of frustration for parents of children struggling to read and the lack of effective remediation available for these problems. In 1997 Congress directed the creation of a “National Reading Panel” of experts to work together and establish formal recommendations.

After 3 years of site visits, literature review, and study the panel came up with the “Report of the National Reading Panel , Teaching Children to Read: An Evidence-Based Assessment of the Scientific Research Literature on Reading and its Implications for Reading Instruction.”

The report was the first of its kind because it outlined scientifically proven, evidence-based methods for the teaching of reading that can be used by teachers and parents in the education of their children. It is considered the most comprehensive and thorough report ever to be undertaken in American education.

2000 National Reading Panel Recommendations for Teaching Reading

• Phonemic awareness
• Phonics - explicitly and systematically taught
• Fluency training- via guided oral reading
• Vocabulary building
• Reading comprehension techniques

2. Learning Disabilities

A. What are learning disabilities?

Learning disabilities are lifelong conditions affecting the way the brain processes information, usually with hereditary antecedence. This difference in information processing impairs the ability to manage incoming and outgoing information. Learning disabilities are a reflection of DNA-based brain learning patterns inherited from parents or parents’ parents and not caused by brain injury or damage.⁴ Learning disabilities are more than learning differences; they are true obstacles to the learning process.

People with learning disabilities may have difficulty with the way they perceive, understand, remember, and/or communicate information. They affect an individual’s ability to read, write, or calculate at a level commensurate with his or her intellectual ability, educational exposure, and cultural influences.

B. Types of learning disabilities

Dyslexia - reading disability

Dysgraphia - writing disability (frequently co-occurs with dyslexia)
Includes problems with handwriting (fine-motor), spelling, copying, and/or organizing thoughts to put on paper (cognitive difficulty)

Dyscalculia - math disability
Includes problems with learning to count, estimate, remember math facts, solve arithmetic problems, grasp higher math concepts, and tell time, as well as visuo-spatial or other difficulties.

Dyspraxia - Developmental Coordination Disability - motor skill and coordination disability
Includes difficulties with planning and coordinating muscle movements, balance and posture, understanding visuo-spatial relationships, or oromotor coordination and speech.

Specific Language Impairment - delayed or disordered language development
It is a receptive and expressive language impairment. Most of these children will develop a reading disability.

C. Magnitude of the Problem

Figures provided by schools that indicate the number of children receiving special services for severe learning disabilities provide only a crude estimate of the actual problems.

According to US Department of Education statistics, (2000) 3% of children aged 6 to 21 years of age are receiving special services for learning disabilities. This is about 2.5 million students per annum in the United States.⁴

3. Dyslexia

A. What is dyslexia?

1. Definition of Dyslexia ⁸

The NICHD & The International Dyslexia Association definition of dyslexia is: “Dyslexia is characterized by difficulties with accurate and / or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.”

The U.K. Rose Report on Dyslexia (2009)⁹ described the following: “Dyslexia is a learning difficulty that primarily affects the skills involved in accurate and fluent word reading and spelling. Characteristic features of dyslexia are difficulties in phonological awareness, verbal memory, and verbal processing speed. Dyslexia occurs across the range of intellectual abilities. It is best thought of as a continuum, not a distinct category and there are no clear cut off points. Co-occurring difficulties may be seen in aspects of language, motor coordination, mental calculation, concentration and personal organization, but these are not themselves markers of dyslexia. A good indication of the severity and persistence of dyslexia can be determined by examining how the individual responds or has responded to well-founded intervention.

2. Epidemiology

a.The majority of currently available research for dyslexia relates to alphabetic writing systems, especially to European languages. However, substantial research is also available regarding dyslexia in Arabic, Chinese, and Hebrew, as well as other languages. The percentage of people is estimated to vary between countries, ranging from 1%-33% of the population, an average is between 3%-4% of the population. There are different definitions of dyslexia throughout the world, but despite these differences in writing systems, different populations suffer similarly from dyslexia. Dyslexia is not limited in converting letters to sound. Chinese dyslexics have difficulty extracting meaning from shapes and characters.⁴

b. Dyslexia is the most common learning disability, representing 80% of all learning disabilities.¹⁰

c. Dyslexia often runs in families; approximately 40% of siblings, children, or parents of an affected individual will have dyslexia.

d. Dyslexia is more common in children with speech and language delay or problem.

e. Dyslexia affects males slightly more than females, though schools identify boys at least twice as often as girls.^11,12

f. Dyslexia occurs at all levels of intelligence. Dyslexia reflects a very specific difficulty with reading and occurs in people with low, normal, and high IQs alike. Children with dyslexia process information differently. Slow reading and poor spelling are signs of dyslexia, not of low intelligence. Children with dyslexia are not “dumb” or “lazy” and they often work harder and longer than their peers. Children with dyslexia are often very bright, analytical, creative and gifted in other areas. Many people with dyslexia have an exceptional ability to reason and understand ideas and concepts. Because dyslexia is a “language-processing problem” unrelated to intelligence, it is often unexpected and may go undetected in an otherwise bright child.

g. Dyslexia represents the lower portion of a normal distribution of reading ability.¹³

h. Dyslexia can vary from mild to severe.¹³

i. Dyslexia is a lifelong condition — students do not “outgrow” dyslexia. Untreated, a poor reader in 1st grade will almost invariably stay a poor reader. Adults with dyslexia continue to read slowly and not automatically throughout life.¹⁴

3. Neurobiology^15,16

Dyslexia is a lifelong condition that is neurologic in origin. Our brains were originally designed to have the ability to speak, not read. Through experience with language, every child must adapt and rewire existing areas to develop the ability to read. But some people's brains do not reorganize in the typical pattern, creating dyslexia. Functional magnetic resonance imaging (fMRI) scans have found that this difference in "wiring" is present before these children start to read.

Recent studies involving fMRIs in adults and children have shown that dyslexia occurs as a result of poor phonological processing at the level of the left parieto-temporal region during word analysis. In non-dyslexic patients, word form processing occurs in the left occipitotemporal region. Articulation and word analysis occur in Broca’s area in the left inferior frontal gyrus. The left parieto-temporal region involves the processing of phonemes in word analysis. The left occipito- temporal region is most active for times of skilled reading and “automatic rapid responding” also referred to as rapid automated naming (RAN) or verbal processing speed. An example of RAN is naming sets of colors, letters, digits, of about 50 items, timed.

fMRI studies have also shown that in dyslexic children cortical processing in these areas is deficient (when compared to non-dyslexic children) and that dyslexic children show activity in the right inferior frontal gyrus and other areas in the right cerebral cortex, during reading. These areas of increased activity are felt to be probable compensatory processes that occur in dyslexic children.

Forming letters with the lips or tongue is a common remediation technique for dyslexic persons. It is thought to be effective because it stimulates the left anterior cortical areas that are felt be involved in phoneme awareness and articulation.⁴

4. Dyslexia is not a vision based-disability

Dyslexia was identified by Oswahld Berkhan in 1881¹⁷ The term dyslexia was first used by an ophthalmologist from Stuttgart, Germany, Rudolph Berlin, in 1887 He used the term “dyslexia “to refer to “Particular Kind of word Blindness” in the case of a young boy who had a severe impairment in learning to read and write despite showing typical intelligence and physical abilities in all other respects. A similar scenario was published by Dr. W. Pringle Morgan in the British Medical Journal on November 7, 1896.¹⁷

It became commonplace to correlate dyslexia or “word blindness” with eye problems.

However, early on it became clear that reading and learning were a function of the brain and not the eye or the ocular motility apparatus.¹⁸ This was first and best described by an ophthalmologist of the Glasgow Eye Infirmary, Dr. James Hinshelwood. Dr. Hinshelwood published a case of “acquired alexia” in a highly educated 58-year-old man, a teacher of French and German, who suddenly woke up one morning unable to read his students’ papers. He was able to read numbers down to Jaeger 1 and had no problem with performing mathematics calculations. “There was no lowering of his visual acuity.”¹⁷ This report prompted other physicians to publish their studies including Edward Jackson of Denver, Colorado.¹⁸

It became clear that even though the problems were visual in nature, in most cases there was nothing wrong with the eyes.

Early anecdotal publications in the optometric literature in the 1950s reported a possible oculomotor deficit that disrupted the normal saccadic reading pattern. In contrast, many studies subsequently have demonstrated that ocular coordination and motility are normal in children with dyslexia.^19-22

Reading does not use smooth pursuit, it uses saccadic (jumping-type) eye movements that are short-duration and high-velocity. Reading uses both forward (rightward in English) saccades (85% of saccades) and backwards or regression (leftward in English) saccades (15% of saccades). Scanning a line of text requires both right and left saccades.

The saccade length is dependent on the ability to recognize letters, the length of the word before the saccade, and how well the text was understood. Experienced readers use longer saccades of approximately 2 degrees or 8 letters of average size print text.²³ Backwards saccades are used for verification and comprehension and increase with the difficulty of the text. They are also used to jump to the next line. Visual perception is suppressed during the saccade. Visual information is perceived during foveal fixations or pauses lasting approximately 200 msec, which constitute 90% of our reading time. The duration of a fixation varies with the difficulty of the text.

Both early readers and dyslexic readers use shorter forward saccades, more backwards saccades, and fixate for longer periods of time. The saccadic pattern progresses toward the adult pattern as typical readers or dyslexic readers improve their reading. Strong research has revealed that the eye movement differences found in dyslexic readers are secondary to difficulties with attention, decoding, and comprehension, not a cause of their reading problems. In summary, saccadic dysfunction is not a cause of dyslexia.

It is also critical to understand that eye movement problems are not related to dyslexia nor do they cause dyslexia. The vast majority of children who have dyslexia do not have any problem with “eye tracking” and the vast majority of patients with eye movement problems (nystagmus, Mobius Syndrome, cranial nerve palsies, or oculo-motor apraxia/saccadic initiation disorder) do not have dyslexia.

A child who skips words or lines, or who has difficulty with fluent reading may be thought to have a “tracking problem.” But “reading tracking” (fluent reading) has nothing to do with “eye tracking” (saccadic function). Children may lose their place while reading and skip words and lines because of language processing difficulties. These language processing difficulties cause them to struggle to decode a letter or word combination, have poor reading comprehension, or have difficulties with memory or attention. Difficulties with fluent reading are the result of dyslexia, not the cause of the reading problem.

People with dyslexia do not see things backwards. Difficulty maintaining proper directionality has been demonstrated to be a symptom, not a cause of reading disorders. Contrary to popular belief, the primary sign of dyslexia is not reversing letters, rather it is a difficulty sounding out words and, secondarily, having poor spelling.

Research has shown that vision problems do not cause dyslexia and vision problems are not more common in dyslexics.²⁴ Eye and vision problems including high refractive errors, poor vision, nystagmus, abnormal pursuits or saccadic eye movements, difficulties with "crossing the midline" of the visual field, CI, AI, strabismus, amblyopia, reduced stereopsis, binocular instability, or a magnocellular deficit do not cause or increase the severity of dyslexia. No consistent relationship has been demonstrated between visual perception and academic performance or reading ability. Dyslexia is no more frequent in children with significant eye movement disorders than in the general population.²⁵

Summary: Historically, dyslexia was thought to be a vision-based disorder. Vision problems can interfere with the process of reading; however, vision problems are not the cause of dyslexia. Although vision is important for seeing print, the brain must be able to interpret what it “sees” in order to read. Reviewing the last 50 years of scientific evidence has shown that differences in language processing in the brain are the cause of dyslexia. In conclusion, dyslexia is a neurobiologically based language problem, not a vision problem or a problem with intelligence.

5.  Dyslexia is a language-based disability

Reports of “word blindness” and dyslexia continued to be published, all with a similar clinical picture, namely; healthy patients with a normal eye and neurological examination, normal cognitive reasoning skills, and average or above average intelligence.

Samuel Orton was an American neurologist (1935) who noted that these patients had a common finding, namely none of them could break words down into their phonetic subsets. He felt that this was an inherited trait that involved the temporal lobe and was not associated with any brain damage or congenital defect. He felt it was a neurological problem. However, he felt that the best people to treat this condition were teachers. These teachers were trained in multisensory remediation techniques involving all of the 5 senses to help establish phonemic awareness by teaching the children how to sound out and identify words and how to spell them accurately along with practicing reading. The teacher he enlisted to promote these methods was his associate, Anna Gillingham and the methods they developed is called the Orton-Gillingham method of education. This method and updated modifications remain as the cornerstone of educational efforts for the remediation of dyslexia.²⁶

Dyslexia is a language processing disorder that causes difficulties with multiple language skills that leads to problems learning to read. Struggles with decoding typically result from a difficulty identifying the individual speech sounds within words, called a phonological deficit. It is often unexpected in children who otherwise possess the intelligence, motivation, and education necessary for accurate and fluent reading. The phonological deficit found in children with dyslexia makes it very difficult for them to learn and use phonics, because they have trouble associating the sound with a letter. These children typically have problems with speech perception²⁷ and have poor verbal short-term memory.

To decode a written word, the sounds must be broken apart. The goal of learning phonics is to enable beginning readers to decode new written words by sounding them out. Without phonics, children with dyslexia cannot break the alphabetic code to decode, or sound out, words and use that skill to spell or encode words. Poor spelling occurs because people with dyslexia have trouble recalling the sounds that the letters make and consequently have difficulty forming memories for spelling words.

Trouble with sounding out words (decoding words) and inaccurate word recognition are the primary difficulties. Many children with dyslexia also have trouble with "Rapid Automatized Naming," leading to a "double deficit."

These challenges can result in problems with reading fluency, comprehension, spelling, and writing. Students with dyslexia must expend more attention, concentration, and energy on the task, which makes reading unpleasant, tiring, and difficult. Because children with dyslexia tend to read less, they often have reduced growth in their vocabulary and background knowledge. Another predictor of dyslexia is poor vocabulary.

Children with dyslexia often have trouble with reading comprehension because of slow and inaccurate decoding. Most have average comprehension when listening. But, comprehension is not a marker of dyslexia, as it is currently defined. Approximately 10% of children with reading disabilities show decreased comprehension in the absence of decoding or word recognition problems.

6. Associated disabilities and problems

There are a number of associated conditions that may occur with dyslexia. Some of these conditions include:

a.  Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common mental health disorder of childhood, its incidence is nearly 10%. Children with ADHD may demonstrate inattention, distractibility, hyperactivity, impulsivity, and delayed executive functions. Similarly to dyslexia, some people have mild ADHD and others have more severe attention regulation difficulties. It is a separate condition from dyslexia, but the combination of ADHD, especially the inattentive type, and dyslexia is frequent. Approximately 20% to 40% of people with dyslexia also have ADHD and vice versa.²⁸

ADHD is not a learning disability, but especially the inattentive type can interfere with learning and can profoundly affect academic achievement. Many children with ADHD have language problems and difficulties with word reading. Sometimes, the symptoms of ADHD are difficult to distinguish from a learning disability. Psycho-educational testing is very important in identifying the presence or absence of these two conditions. Accurate identification requires proper history, testing, and knowledgeable analysis.^29,30

Children with ADHD have impaired executive functioning. Executive functions consist of several mental skills that help the brain organize and act on information. These skills enable people to plan, organize, remember things, prioritize, pay attention and get started on tasks. They also help people use information and experiences from the past to solve current problems. Children with imperfect executive functioning have difficulty with any task that requires planning, organization, memory, time management, and flexible thinking. Children with learning disabilities typically have problems with one or more executive skill.³⁰

Treatment of ADHD includes medications, behavioral modification, or a combination of the two. Enhanced attention may contribute to improvement in the child’s reading and overall performance in school.³⁰

b.  Auditory processing disorder - Auditory processing disorder is an oral language disorder. It is a condition that affects the brain’s ability to process auditory information. It is considered a “listening disability.”

Below are important terms concerning auditory processing:

Auditory processing refers to how the brain perceives and interprets sound information.

Auditory Analysis (also called phonological awareness) - the ability to identify, blend, separate, and manipulate sounds in words. This skill is vital for reading.

Auditory Sequencing - the ability to remember the order of sounds and words

Auditory Memory - the ability to remember and retain auditory information
 
Auditory Comprehension - the ability to follow directions, understand conversation and stories.

There is research that suggests that auditory processing deficiency could be the primary deficiency in dyslexia.²⁷ Reading may be affected by auditory processing difficulties, because these difficulties undermine the development of phonological and phonemic awareness required for decoding. Reading is a language skill that requires accurate phonemic awareness (to be able to break down words into individual sounds) and then phonics (to recognize the sounds in print). In addition to weak phonological awareness skills and decoding difficulties, these children may have impaired auditory, and secondarily, reading comprehension. These children may also struggle with articulation, vocabulary, grammar, and syntax, further impairing reading ability.³⁰

A child who has auditory processing difficulties may have difficulty listening in class, causing a struggle to maintain attention. These symptoms may cause these children to be diagnosed with inattentive ADHD. Therefore, it is important to include psychoeducational evaluation, to detect auditory processing problems, in the evaluation of children with suspected attention problems.^30,31

c. Specific Language Impairment (SLI) is delayed or disordered oral language development that is not due to an underlying condition (such as hearing loss). Spoken language may be immature and receptive language ability may also be impaired. A high percentage of these children will have problems learning to read.

d. Dysgraphia or writing disability is the learning disability most frequently associated with dyslexia. Many of these children have poor fine motor skills. Children with dysgraphia may experience difficulties with handwriting, drawing, or copying. The Helveston Dyslexia Screen emphasizes the relationship between fine motor skills and dyslexia by having children copy letters and draw a bike.³²

But dysgraphia is more than poor handwriting. Many of these children have problems encoding language leading to difficulties with spelling, organizing sentences and paragraphs, and putting their thoughts on paper.

e. Dyscalculia or math disability is the disability associated with difficulties learning to count, estimate, remember math facts, solve arithmetic problems, grasp higher math concepts, and tell time, as well as visuo-spatial difficulties or other issues. Some children with dyslexia also have dyscalculia.²⁶

But other children with dyslexia have good math computational skills yet may experience difficulties with math word problems because of the language component associated with math word problems.

f. Dyspraxia or Developmental Coordination Disorder (DCD) is the disability associated difficulties with planning and coordinating gross or fine muscle movements, understanding visuo-spatial relationships, or oromotor coordination. These children may have trouble planning, completing, or automatizing motor skills. This may make balance, posture, sports, handwriting, or speech difficult.

g. Right-Left confusion - This is a common finding in dyslexic persons and it continues throughout life. Using memory schemes or strict protocol applications involving laterality may be helpful.²⁶

h. Psychological and emotional problems - Untreated or poorly treated dyslexia may lead to frustration, low self-confidence, and poor self-esteem. This substantially increases the risk of developing psychological and emotional problems such as anxiety, depression, or aggression. Dyslexia may also be associated with Oppositional Defiant Disorder (ODD) and Obsessive-Compulsive Disorder (OCD).

Parents should be sympathetic to the stress that their child is experiencing and should provide encouragement and emotional support. Additionally, parents and teachers should be aware that dyslexic children might be teased or bullied by others, further ostracizing them and exacerbating these issues. If any of these problems are suspected it is important to seek evaluation and treatment from your pediatrician, family physician, or mental health professional. Counseling, cognitive therapy, and/or medications may be very helpful.

7. Risk Factors for Dyslexia³⁰

• Family history of dyslexia 
• Fetal exposure to drugs or alcohol 
• Birth problems, premature birth, or low birth weight 
• Neurologic problems
• Hearing or speech problems 
• Exposure to toxins (lead) 
• Severe head injuries 
• Other chronic health problems 

If there is a family history of reading disability, a child’s early language development and performance in pre-school and elementary school should be carefully monitored and problems addressed. While signs of dyslexia are typically more noticeable once a child begins school, there are some early indicators that parents and teachers might observe even in pre-school.

8. Signs of Possible Dyslexia³⁰

Pre-School Children:

• Developmental delays
• Hearing, language or speech problems
• Difficulty learning the names of colors, shapes, letters, and numbers
• Difficulty with rhymes
• Mispronouncing or mixing up words
• Searching for words
• Difficulty with memory
• Difficulty learning right from left

Early Elementary School Students:

• Difficulty learning the names of the letters 
• Trouble connecting letters to their sounds 
• Confusing or substituting words 
• Difficulty decoding (sounding out) single words 
• Making consistent errors 
• Using the pictures in the book to “read” 
• Not reading at the expected grade level 
• Slow reading 
• Dislike of reading 
• Reversals of letters or words after 2nd grade 
• Trouble with reading comprehension 
• Trouble copying 
• Poor or erratic spelling
• Frustration with schoolwork and homework
• Schoolwork and homework takes a much longer time than expected 
• Reluctance to go to school 
• Problems with attention 

Older Students:

• Reading below grade level 
• Slow reading 
• Numerous reading errors 
• Avoidance of reading – especially out loud 
• Persistent difficulty decoding/sounding out new words 
• Persistent difficulty with sight word recognition 
• Difficulty understanding prefixes, suffixes, and root words 
• Difficulty with non-literal language (jokes, idioms, poetry, proverbs, slang) 
• Trouble with reading comprehension 
• Poor or erratic spelling 
• Difficulty learning a foreign language 
• Poor recall of facts 
• Trouble with math, especially word problems 
• Difficulty with writing 
• Difficulty with planning, organizing and time management 
• Difficulty telling time 

It is important to note that these signs and symptoms are indicators and not proof of dyslexia. The only way to diagnose dyslexia is through appropriate comprehensive testing.

Physicians, teachers, and parents, need to learn the signs and symptoms of possible dyslexia. Surprisingly, educators may have many of the same misconceptions about dyslexia as the general public. Importantly, many teachers do not know that dyslexia is a learning disability that affects language, and that phonemic awareness is impaired more than any other ability. Many teachers incorrectly look for letter and word reversals to identify dyslexia when they should be looking for problems sounding out words and spelling.

9. Early detection of dyslexia³⁰

Dyslexia is most often identified in the primary grades, but in some children it may not be identified until middle or high school, when more complex reading and writing skills are required. In early elementary school, some of these children can compensate by using other strengths until the educational demands increase, making the reading disability more evident. Many of these children have tried to hide their reading difficulties and have relied on their very strong memory, background knowledge, and other strengths. Unfortunately, these “late emerging” reading disabilities often go undetected by schools.

Teachers are in a position to identify reading problems before they worsen significantly. School and state policies that delay identification and intervention are a financially “penny-wise but dollar-foolish” approach for schools and devastating for the students.

Reading screening tests should be performed on all students in the early elementary grades. These tests are used to locate poorly performing students who may be “at risk” for reading difficulties, before they turn into reading failures. In the elementary grades, screening assessments should ideally be performed early in the school year, repeated mid-year and at the end of the school year. These assessments can predict many of those who will have difficulty learning to read. Children who are found to be “at risk” for reading difficulties can be given extra assistance in an intervention program, which can lead to improved reading performance.

Reading Screening Assessment Components³⁰

Pre-kindergarten and Kindergarten Assessments:

• Names of the letters and numbers 
• Sounds associated with the letters
• Rapid naming of objects 

Kindergarten and 1st Grade add:

• Reading of one-syllable words
• Spelling 

2nd grade and beyond add:

• Decoding of new words
• Reading fluency
• Comprehension

10. Evaluation for Dyslexia³⁰

Dyslexia is a clinical diagnosis that requires formal testing. The Individuals with Disabilities Education Act allows parents to request evaluation for "Specific Learning Disability" at their local public school (even if their child attends private school); alternatively the testing can be conducted privately outside of school.

Testing should be used to make the correct diagnosis of the specific type of learning disability and comorbid conditions in order to prescribe the proper therapeutic regimen. Comprehensive evaluation of the causes of a child’s reading difficulty can be performed by clinical or educational psychologists, neuropsychologists or developmental pediatricians, with familiarity with dyslexia and its evaluation and assessment. These clinicians can also determine whether there are comorbid conditions, such as ADHD or other psychological issues, which might also interfere with a child's reading. Assessment limited to answering the question of whether the child has dyslexia can be performed by many reading/dyslexia specialists, educational therapists, or speech-language pathologists, again assuming they are properly trained in dyslexia and its assessment.

Family history and personal history are important components in the evaluation. There is no single standardized test to identify dyslexia. The group of tests that are selected by the evaluator will vary according to the age of the individual and the presenting problems.

Most children with dyslexia demonstrate evidence of a phonologic deficit and may also show problems with rapid naming, or other deficits.

Once testing is performed, a learning profile will be developed by the psychologist. This will give the parents and the teachers an objective description of the child’s learning strengths and weaknesses. A formal Individual Educational Plan (IEP) can be developed by the school system.

11. Early Intervention³⁰

The importance of early intervention cannot be stressed enough. Like amblyopia treatment, the earlier treatment begins the better the chance for a successful long-term outcome. Teachers are in a position to identify reading problems before they worsen significantly. So, it is extremely important that teachers understand dyslexia and its early signs.

Students whose dyslexia is identified and addressed in kindergarten and 1st grade have approximately a 90% chance of improving to grade level. At-risk kindergarten students can often be helped with 30 minutes of intervention a day, while intervention takes much longer for older students. Children identified after 3rd grade have only a 26% likelihood of improving to grade level. It is important to identify and treat children before they leave 3rd grade to have the best chance at academic success, however, it is never too late.

12. Education and the U.S. Law³⁰

Important federal laws protect students’ rights and provide for special instruction and services. The Individuals with Disabilities Education Act (IDEA), the Individuals with Disabilities Education Improvement Act (IDEIA), Section 504 of the Rehabilitation Act, the Americans with Disabilities Act (ADA) and the Americans with Disabilities Act Amendments Act (ADAAA) define Specific Learning Disabilities and the rights of students with them. (If you would like more information on this topic see A Parent's Guide to Dyslexia by AAPOS - available at www.AAPOS.org.)

13. Treatment of dyslexia³⁰

In educational terms dyslexia is a "disability," in medical terms it is a "disorder," but it is really not a disease, it is a condition. Dyslexia is a condition which can be treated and improved but it cannot be cured.

Knowledgeable and skilled teachers are essential for the instruction of children with dyslexia. Until recently, most college programs that train elementary education teachers have given minimal courses in language structure, reading theory, reading development, signs of dyslexia, and methods of teaching students with dyslexia. In 2010 the International Dyslexia Association developed a guide for colleges to prepare and certify the professional development of those who teach reading called "The Knowledge and Practice Standards for Teachers of Reading."

Some college programs for elementary education teachers are now beginning to incorporate this training. Teachers who understand reading development, and the signs of dyslexia, can assist in early identification. Educational therapists or educators who have been specially trained in reading disabilities can develop and implement intervention plans for children with dyslexia.

a. Remediations³⁰

Since dyslexia is a language-based disorder, th e educational treatment should target language development. Children with dyslexia need language explained in patterns that are logical, explicit, systematic, and multisensory. Remediation needs to be tailored to address individual student skill deficits that were detected on the educational evaluation.

Programs for children with dyslexia should be individualized, structured, intensive multi-sensory instruction with daily practice with a specially trained reading teacher or an educational therapist. These programs must continue long enough to have a lasting positive effect. Multisensory learning involves the use of visual, auditory, kinesthetic, and tactile pathways simultaneously, in order to enhance memory and learning of written language.

Children with dyslexia require more intensive instruction. They should have the full 90 minutes of language instruction in the regular classroom plus 60 minutes of extra instruction. These programs must continue long enough to have a lasting positive effect, a minimum of 2 years.

These children need to start with explicit training in phonemic awareness and then instruction in the direct connection between sounds and letters (phonics). The International Dyslexia Association calls programs that include explicit, systematic, multi-sensory, and evidence-based instruction in the reading skills and the structure of language the "Structured Literacy Approach."

Training in the Reading Skills:

• Phonemic awareness
• Phonics
• Fluency Training (including daily practice reading aloud)
• Vocabulary Building
  Comprehension Techniques
  Plus: Writing and Spelling

Instruction in the Structure of Language:

• Morphology (analysis of word parts)
• Syntax (grammar)
• Semantics (analysis of meaning)
• Pragmatics (interpretation of language in social contexts).

b. Accommodations³⁰

For early elementary school children with dyslexia, remediations are very important, while accommodations become increasingly important for students in middle school and beyond. Because people with dyslexia continue to read more slowly than others throughout life, accommodations can allow access to higher-level thinking and reasoning skills for learning and testing.

Accommodations change the manner or setting in which information is presented or the manner in which students respond. Accommodations may be instructional in nature, or adaptations to the testing process or environment.

Important Accommodations Include:

• Extra time
• Computers or other technology
• Recorded books
• Text-reading software
• Note-takers
• Spell-checkers
• Testing alternatives (eg, verbal testing)
• Special quiet room for testing
• Preferential seating

c. Modifications³⁰

Modifications actually change the curriculum by changing or reducing instruction or testing. They generally decrease learning expectations. Parents need to understand that if modifications are below grade level standards, the child may be at risk for not meeting graduation requirements, and may interfere with obtaining a high school diploma.

Section B. Primer for the Ophthalmologist

1. Ophthalmic History and Evaluation of the Patient With Reading Difficulties

A. Who should have an eye examination?

Edward Jackson, an American ophthalmologist from Denver, Colorado, and one of the formative figures of the American Academy of Ophthalmology and Otolaryngology, used the word alexia in his textbook “Diseases of the Eye” to describe a condition that was previously called in the English and European literature “Congenital Word Blindness.” Dr. Jackson stated that “Alexia was a medical condition that almost always had its original presentation with and was subsequently diagnosed by an ophthalmologist.”¹⁸

Now, over 100 years later, children and adults with dyslexia (the term that is now preferred) almost always start their journey with a visit to the eye doctor, who is not uncommonly a pediatric or general ophthalmologist.

Who should have an eye examination? Any child who ....

1. Is experiencing difficulty in school
2. Is experiencing difficulty with reading
3. Is experiencing eye or visual complaints especially if during reading
4. Has a reading problem that teachers or caregivers suspect might be due to an eye or visual problem
5. Has been diagnosed with dyslexia, other LD, or ADHD
6. Does not pass vision screening
7. Has had vision therapy, reading glasses, or tinted lenses/overlays recommended

The ophthalmologic exam frequently precedes the diagnostic evaluation of phonological processing or psycho-educational testing, which is performed by a licensed educational psychologist with knowledge of the different batteries available for testing all ranges of educationally challenged children.

Ophthalmologists are often the first professional evaluating the child, which places them in a unique position to evaluate and treat the child, dispel the myths (See part B2), give the family proper information, and help them get on the right track. (See part B3) Thus, it is important that pediatric ophthalmologists be well informed on the subject of dyslexia and be on the dyslexia evaluation team.

Some children may have a treatable vision problem in addition to their primary learning problem; it may be masquerading as ADHD or a learning difficulty. Vision problems occur in 5% – 10% of early elementary students and up to 25% of high school students. Although vision and eye problems may cause trouble seeing the printed word, they rarely result in difficulty learning to read.

The ophthalmologist should identify and treat any significant visual defect according to standard principles of treatment. Treatable conditions include refractive errors, strabismus, amblyopia, CI, AI, dry eyes, blepharitis, allergic conjunctivitis and others. Many of these conditions can be treated with corrective eyeglasses and generally will show benefit very quickly. Glasses, however, do not treat reading disorders or dyslexia.³⁰

It is the purpose of this section to describe the clinical work up of the patient suspected of having learning differences or dyslexia, from an ophthalmologist perspective. The ophthalmologist’s role is to exclude any visual or neuro-visual problem that may be contributing to a person’s inability to read fluently.

B. Ophthalmic history

It is important to ask questions that are not leading and for the ophthalmologist to recognize that children with dyslexia whose eyes are normal may present with visual symptoms. Also, it is important to understand that healthy children often have visual complaints from normal visual phenomena, such as physiologic diplopia and relaxation of accommodation.³³ In addition most children complaining of eyestrain and headaches have a normal eye examination, whereas most children with refractive error, amblyopia, or strabismus were free of eyestrain, making these complaints a poor marker of eye conditions.³⁴

The ocular history should include any eye or vision complaints that may make it difficult for the child to concentrate on reading for extended periods of time. Also, ask about the child's use of computers, laptops, hand held devices, and video games. Be sure to determine if the child experiences similar problems while using these devices. It is difficult to think that a near vision abnormality would be of much significance if these children play on these devices for many hours.

The interview is associated with a detailed history:

Educational History:

1. Does your child have any problems with speech?
2. Does your child have problems sounding out words?
3. Does your child have problems reading?
4. Has your child had specialized reading testing?
5. Has your child been diagnosed as having a reading problem?
6. Is your child in a special reading program, or has your child had tutoring, special help, IEP, or repeated a grade?
7. Does your child have problems with concentrating or has your child been diagnosed with ADHD?
8. Does any family member have reading difficulties?
9. Did any family member repeat a grade?

Ocular History:

1. Do you have blurry vision?
2. Do you have headaches?
3. Do your eyes get tired?
4. Do words move on the page when you read?
5. Do you have problems with burning eyes, itchy eyes, or tearing?
6. Do you use a computer, laptop, or phone, or play video games?
7. If you experience visual problems while you read, do you experience any visual problems when using these devices?

C. Eye functions necessary to read and how to test them

1. Visual Acuity

Visual acuity should be tested with and without the glasses at distance and near. When possible use Snellen letters or the ETDRS (Early Treatment of Diabetic Retinopathy) pyramid letters. For younger children, letter or figure matching should be done at distance (minimum ten feet) and near. The values need to be recorded. Look for squinting at distance and near and look for alternate closing of the eyes.²⁶

2.  Cycloplegic Refraction

All patients need to have a manifest and full cycloplegic refraction, using cyclopentolate, with good dilation of the pupils.

3.  Accommodation

There are many different ways to measure accommodation. All methods have their inaccuracies. All accommodative testing should be done prior to cycloplegia.

a. Near Point of Accommodation (NPA)

The near point of accommodation can be measured with the patient's refractive error corrected, by the conventional push-up technique using a ruler, the Royal Air Force Rule, or Prince Rule. If using the Prince rule, small print should be placed on the target clip and the target slowly advanced from 40 cm to the point of blur or nonrecognition of the small letters on the target. This distance is measured and compared directly with the chronological age on the Prince Rule. If the age is more than 10 years beyond the chronologic age for the patient, then the patient is diagnosed with accommodative insufficiency.²⁶

b. Dynamic retinoscopy can provide a rapid assessment of accommodative function and may be helpful in evaluating a child with high hyperopia, accommodative lag, or accommodative insufficiency.

c. The accommodative amplitude can be assessed by using increasing minus lenses in the phoropter while reading at near.

d. The accommodative facility can be assessed by alternately applying –1.50D and +1.50D lenses in the phoropter (using the 3.00D coarse adjustment) while the child reads at near.

Accommodative Insufficiency

Symptomatic accommodative insufficiency is an exceedingly uncommon condition in children. It can cause blurring and discomfort at near, which can contribute to difficulties in concentrating on print for prolonged periods of time. It is typically associated with uncorrected high hyperopia, occasionally secondary to medications or anxiety, or rarely a primary condition. Symptomatic accommodative insufficiency with a near point of accommodation well outside established norms can be treated with reading glasses or bifocals when indicated. Importantly, children with developmental delay or Down syndrome often hypoaccommodate and may benefit from spectacle correction at lower thresholds of hyperopia. Treatment of accommodation difficulties can make reading more comfortable but does not improve decoding or comprehension.³⁵

4. Convergence

All convergence testing should be done prior to cycloplegia.

a. Near Point of Convergence (NPC)

The near point of convergence should be tested using an accommodative target and measured with a ruler.

b. Convergence Amplitudes

Distance and near convergence amplitudes can be measured by using a base-out horizontal prism bar or rotary prism while the child is reading.

Convergence Insufficiency (CI)

CI is defined differently from profession to profession and from country to country. Depending on the definition chosen, the prevalence of CI varies greatly. It is more common than accommodative insufficiency, but it is still uncommon in early elementary school children, who are learning to read. Patients typically present as teenagers or young adults during extended periods of studying.³⁵

The diagnosis of convergence insufficiency is based on a remote near point of convergence or difficulty in sustaining convergence, combined with asthenopic symptoms (sensations of visual or ocular discomfort) at near. The presence of 500 seconds of arc of stereopsis is required. These findings should be accompanied by a low convergence fusional amplitude, and/or a large exophoria or intermittent exotropia at near with a smaller exophoria, orthophoria, or esophoria at distance. These latter findings alone do not constitute the diagnosis of convergence insufficiency, as they may be present with good convergence. Of these findings, the most important is the ability to obtain and maintain convergence.³⁵

CI is often asymptomatic. The diagnosis of convergence insufficiency is relevant only if there are multiple findings accompanied by significant symptoms. Symptomatic CI can cause discomfort, eyestrain, blurry vision, jumpy vision, moving print, diplopia, and headache.

CI can interfere with a child’s ability to concentrate while reading print. Because of this behavior in the classroom, CI may be confused with ADHD or dyslexia. Therefore, it is important that ophthalmologists be familiar with CI and its testing to make the correct diagnosis.

Symptomatic CI is a treatable condition. It can be treated with home, computer, or office-based orthoptic exercises. Adequate sleep and rest breaks while reading may also be helpful. Alternatively, for other patients, reading glasses with base-in prism or occlusion during reading can be used to treat the symptoms of diplopia but not the underlying CI.

The treatment of asthenopic symptoms, accommodative difficulties or symptomatic CI can help reading become more comfortable and may allow reading for longer periods of time, but treatment of these visual problems does not directly improve decoding or comprehension and will not treat dyslexia or ADHD, if present.

5. Ocular Alignment, Stereopsis, Saccades, and Fixation

Ocular alignment at the distance and near, ductions and versions, and stereopsis should be evaluated to determine whether the child is experiencing symptoms from a phoria, intermittent tropia, tropia, or limitation of gaze.

Saccadic dysfunction is not a cause of dyslexia and there is no evidence that saccadic function significantly affects reading performance. (See Section A3a4)

6.  Slit Lamp, Confrontational Visual Fields, and Dilated Retinal Evaluations

A careful external ocular examination should be performed to determine whether the child has problems that cause eye irritation that could secondarily interfere with the ability to concentrate and learn. These problems include: dry eyes, blepharitis, or ocular allergies. Confrontational visual fields should be performed to detect visual field deficits. Finally, a dilated retinal evaluation should be performed to detect retinal or optic nerve problems.

Section C. Controversial Vision Theories and Therapies

A. Behavioral Optometry

1. Theory:

Arthur Marten Skeffington (1890 – 1976) is credited as the father of Behavioral Optometry. He co-founded the Optometric Extension Program and was its director from 1928 – 1976.

His theories are based on clinical experience only and form the basis of the practices of behavioral optometry. His theories were never independently refereed or formally debated by non-behavioral optometrists.

Behavioral optometrists describe visual efficiency and visual processing skills as being linked to reading disorders. Those advocating vision therapy claim that more than 60% of slow readers have undiagnosed vision problems as the basis of their reading difficulties.

However, the majority of studies have shown that eye and visual problems do not cause or increase the severity of dyslexia. Moreover, it has been shown that children with dyslexia, statistically, have the same visual function and ocular health as normal readers.¹

Current behavioral optometric evaluation grades eye health: Visual acuity and refraction; visual efficiency: eye movement, accommodation, teaming; visual information processing: spatial orientation, visual processing.

2. Testing:

a. Optometric Eye Movement Testing

Subjective evaluation of saccades and pursuits (despite multiple studies that show increased saccades and pursuits are due to poor comprehension and are due to dyslexia, not a cause)

• NSUCO test—patients asked to glance back and forth at colored balls on sticks
• No consistent procedures for oculomotor testing, poor reliability, low inter-observer agreement ²
• Developmental Eye Movement Test (DEM)
• Accuracy is related to attention³
• Not an eye movement test, doesn’t correlate with saccadic movements, and is not an appropriate assessment tool and is related to reading performance and NOT to eye movements⁴
• Visagraph I & II—computer monitored eye movement (Other similar device is the ReadAlyzer)
• Documents reading eye movements but there is no “normal” baseline for comparison⁵

Conclusions: Eye movement testing have no validity as being currently used; there is no valid reason in grading saccades in dyslexia; these eye movement test do not accurately assess eye movements.

b. Visual Information Processing

• Tests for deficits in visual spatial orientation
• Bilateral integration—“chalkboard circles”
• Directional Concepts—Reversals test, Piaget left-right
• Visual Analysis—visual discrimination, figure ground, figure closure,
• Visual motor performance—grooved pegboard tests

Conclusion: all information is anecdotal and tests have not been validated.

3. Low-plus Lenses

Skeffington proposed the unproven “near-point stress” theory which suggests that the reading and near- vision demands of society, in the 1920s, was at odds with the evolutionary development of the visual system. It does not take into account that since the beginning of modern humans, long prior to the 1920s, we have utilized our near vision for a variety of tasks such as tool making, pottery, basket weaving, cooking, art, and clothing making, as well as writing development. He suggested that near work in modern culture creates a biologic stress response. It is this stress that creates binocular difficulties and refractive errors. He believed that using low-plus “training” readers (+.50), will “help the visual system develop and mature normally.”

Subsequent studies: 

• Barry & Cochran^6 - plano vs +.50- no significant difference in visual performance
• Wildsoe& Foo⁷ - plano vs+.50 to +1.00- No significant difference in reading comprehension
• UK College of Optometry (Jennings 2000), in a review of all the behavioral  optometric literature⁸—no evidence of any benefit from low plus training  glasses and therefore these glasses are NOT a covered benefit by the NHS in  the UK 

4. Vision Therapy (Vision Training = VT)

Designed to improve visual skills, improve visual comfort, ease and efficiency and change visual processing (although this effect has never been documented). Felt to improve visual perception. 

• Typical program:
• Performed in office with at home supplementation
• Once or twice weekly for 30-60 minutes for 1-2 yrs (cost in some cities can range as high as $17,000/year)
• Consists of training glasses, prisms, filters, electronic targets, balance boards
• Exercises designed to improve ocular motility—monocular and binocular Saccades
• Eye movement—Marsden Ball, Space fixator and pegboard
• Vergence training—pencil push ups. Brock string, Vectographic targets, Aperture-Rule
• Accommodation Targets—near far “Rock,” flippers, Aperture Rule
• Bilateral integration—Jumping jacks with metronome, “angels in the snow,” balance board, “slap-tap,” bean bag toss
• Visual Motor Integration—Geoboard

 Studies: 

1. UCLA 1975 & 1985 Department of Special Education, Keough, et al.,^9,10 - Found little evidence for VT effectiveness even in aggregated studies. Found it paradoxical that VT was being used for a broad range of problems.
2. AAO Statement 2001¹¹—Alternative Technology Assessment - Vision Therapy - During courses of VT, most patients were receiving other instruction, as well. “No consistent scientific evidence supports VT as an effective treatment for learning disabilities.”
3. Institute of Clinical Systems Improvement Assessment Report on VT - 2003: majority of studies were of poor quality and there was “inadequate scientific evidence about the efficacy of VT for patients with learning disabilities.”
4. Rawstron., et al., review of VT studies, 2005¹² - Same conclusion reached as above
5. UK College of Optometrists, AJ Jennings, et al[8]., 2000 & BT Barrett, et al.,2009¹³ - Lack of controlled studies to support behavioral management strategies—and is not a covered by NHS in UK.
6. Joint Policy Statement 2009¹⁴ and Technical Report 2011¹⁵—AAP, AAO, AAPOS and AACO - no evidence to support VT or tinted lenses to treat dyslexia and VT has not been shown to improve a child’s responsiveness to educational therapy
7. Fletcher, a neuropsychologist and Currie, an optometrist in 2011¹⁶ reviewed the optometric literature. Their conclusions follow:.routine screening for "vision-related learning problems" is not warranted and would not be expected to have a major impact on the reading performance of children and adults with well-defined reading disabilities. It may be that vision efficiency interventions (for example treatment of CI) make a person more comfortable with reading. However, there is little evaluation of whether even the experience of more comfort carries over to the classroom or is a sustained practice. Referral for color overlays, tinted lenses, eye tracking, and visual information processing interventions are not supported by research.

 Interventions tend to be effective for what is actually trained and pervasive effects outside the domain of intervention are rarely apparent. If the goal is improved reading or math, teach reading and math, and prioritize resources in the domain of interest.

Conclusion: Vision Therapy Studies Summary--

Poor quality, inadequate numbers, inadequate control groups, anecdotal information, failure to mask the investigators and frequently a direct interest by the investigators in the results

B. The Magnocellular Deficit Theory and Tinted Lenses

1. Magnocellular Deficit TheoryVisual system is divided into 2 parallel systems, the magnocellular (large-cell/ transient) system and the parvocellular (small-cell/ sustained) system. The magnocellular responds more to lower contrast, high frequency and movement (“the where”). The parvocellular is more sensitive to low-frequency and fine details (“the what”).

It is thought that the magnocellular system is responsible for controlling visual input during saccades. This system suppresses the parvocellular input so your brain does not perceive the motion. A deficit in this suppression is at the basis of dyslexia in this theory; there is a blurring effect that results in dyslexia.

Supporting evidence of this comes from fMRIs on movement processing. However, the number of studies supporting this theory are far outnumbered by the fMRI studies that show no loss of contrast sensitivity (which would be expected).^17-22 Evidence in support of the “magnocellular theory of visual blur” is questionable, at best. It has actually been found that more people WITHOUT dyslexia have a magnocellular deficit than those with dyslexia.²³ It may be associated with a form of attention deficit, but other authors dispute this.²⁴

2 Irlen/Wilkins/ChromaGen lenses

a. Irlen Lenses

In 1983, Helen Irlen, MA, a school psychologist, proposed that certain types of dyslexics could be helped by the use of colored lenses. Her findings were based on observational, anecdotal accounts of 6 adults. Prior to any supporting research, her results were featured twice on 60 minutes, and many other TV shows, which led to widespread public interest.

Different color overlays are used to treat a condition referred to as Scotopic Sensitivity Syndrome (SSS), which results in “visual stress.” People with this condition are said to have visual distortions to particular wavelengths of light resulting in moving or blurred print, sensitivity to color, pattern glare, eye strain, tearing, and headache. The Irlen method uses colored lenses or overlays in an attempt to reduce the offending wavelengths to correct "perceptual dysfunctions." The overlays can be placed over reading material or tints put into glasses. Irlen claimed that tinted glasses resulted in instantaneous improvement in reading performance and comprehension.

Per the Irlen informational brochure “… a simple method can change the lives of children and adults with LD, ADHD, TBI [traumatic brain injury], dyslexia, autism, headaches, medical conditions, and much more” including, but not limited to multiple autoimmune diseases, fibromyalgia, depression, and other conditions.

It is important to understand that SSS is not a recognized medical syndrome and there are no clearly established criteria for making the diagnosis; the only defining characteristic is the reported benefit of the colored filters themselves.

In studies there have been poor test-retest reliability on color selection;²⁵ 25% wanted a color change in a year, and in Henderson’s study, patients wanted a color change in 2 weeks.

In a 2011 article by Ritchie et al,²⁶ an Irlen diagnostician diagnosed Irlen syndrome in 77% of poor readers in the study. The study found no evidence for any immediate benefit of the Irlen overlays as measured by the reading-rate test or the global reading measure. Their conclusion was that Irlen colored overlays do not have any demonstrable immediate effect on reading in children with reading difficulties.

b. Wilkins

Wilkins “Intuitive Colorimeter” lenses— (Scotopic Sensitivity Syndrome-SSS) symptoms were decreased equally in both the placebo and tint groups.

Reading rate, accuracy, and comprehension were not affected in either the placebo or the lens group.²⁷

c. ChromaGen glasses

Originally designed to help color discrimination for patients with true color deficiency—some subjects said it also helps with reading.

Proprietary lens system—the colors are combined so the lenses appear a neutral grey. Biased selection in original cohort due to media interest and grey lenses could not be masked from placebo clear lenses.^28,29

Conclusions: Deficits in the magnocellular system do not appear to be a significant cause of dyslexia. There is no evidence that Irlen, Wilkins, or Chromagen filters/lenses improve reading comprehension or speed.^26,30-33 However, some colors/tinted lenses may make some children more comfortable with print, but this effect is frequently transient.

Section D. Discussing Dyslexia With Families, Teachers, Physicians, and Other Professionals

A. Discussing learning disabilities and dyslexia with parents

The ophthalmologist needs to convey to the parents:

1. What dyslexia is, and what it's not;

2. Why their child should be evaluated for dyslexia; and

3. A plan of action: what they should do to help their child get tested/treated after they leave your office; 

. . . and this all needs be done in 10 minutes or less, because the waiting room is full!

 To become well versed in this topic, the ophthalmologist should review Section A parts 1-3 (Reading, Learning Disabilities, and Dyslexia) of this POWER Center document for a useful introduction to the topic. In addition, a very readable and useful resource is Dr. Sheryl Handler's 33-page A Parent's Guide to Dyslexia (Reading Disability), which is available from the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), at www.aapos.org. The entire booklet is extremely useful, but pages 3-8 will allow the ophthalmologist to become familiar very quickly with the language of reading disorders, the key features of dyslexia, and the neurobiological basis of this disorder. It is not all one needs to know, but it is a good solid start, and will serve as a good foundation for your further reading regarding dyslexia. The joint AAP, AAO, AAPOS, ACCO Technical Report on Learning Disabilities, Dyslexia, and Vision¹ is extremely comprehensive and reviews the literature and the shorter Policy Statement of the same name.²

1. What is dyslexia (and what is it not)? Section A (Reading, Learning Disabilities, and Dyslexia) of this document addresses this question in detail. Various definitions of dyslexia exist, but the common theme is that dyslexia is reading difficulty despite adequate intelligence, instruction, and exposure. It is a neurobiologically based language problem, not a vision problem, and not an intelligence problem.

Key features of dyslexia: (source: IDA Dyslexia Handbook: What Every Should Know, The International Dyslexia Association 2014)

a. Problems with oral language, including subtle difficulties such as mispronouncing words, difficulty learning the alphabet, and difficulty with rhyming. In taking a history from the patient's parent, the ophthalmologist should listen for evidence that the child may have these problems, and also ask whether the child's speech was delayed and whether the child has received speech therapy. An early clue: difficulty learning nursery rhymes.

b. Problems with reading. Most people with dyslexia have trouble “sounding out” words. Most are choppy readers, not smooth (“fluent”) readers. Reading aloud is difficult for most people with dyslexia.

c. Problems with written language. Spelling is a challenge for most people with dyslexia.

d. Associated conditions, including ADHD, though ADHD and dyslexia are distinct conditions.

e. Dyslexia cannot be cured (ie, kids do not “grow out of it”), but it can almost always be helped with appropriate remediation—and the earlier the better.

Note that not all children with dyslexia have all of the features of dyslexia, but most have more than one. Conversely, children with one of the features of dyslexia listed above do not necessarily have dyslexia. Evaluation by a trained professional (see below) is required to determine whether a child has dyslexia.

2. Why should this child be evaluated for dyslexia?

a. A teacher or parent has already observed that the child is struggling with reading.

b. The child has symptoms while reading (headaches, words move around on the page, blurry near vision) which do not occur with other near tasks, such as math or video games, and which are not explained by the eye examination findings

c. The child performs significantly better in math than in reading

In addition, even if the child or parent does not offer a complaint of reading difficulty (ie, even if the chief complaint for today's visit is completely unrelated to reading), the ophthalmologist should ask about the child's reading performance if the child presents with:

• non-organic visual blur (especially at near)
• a first degree relative who struggles with reading
• a history of speech delay/speech therapy
• a history of vision therapy, reading glasses, or tinted lenses/overlays to help with reading

Also consider asking about reading performance if the child is home schooled. (Many families choose to home school for religious or social reasons completely unrelated to any academic difficulty, and indeed many home-schooled children outperform their traditionally schooled peers academically--but it is not uncommon for parents to choose to home school a child if they feel the school is not meeting the needs of their child who is struggling with reading.)

3. How to ask about reading when reading difficulty is not the chief complaint

a. Include a question about reading difficulty on the history form, so that this information can be gathered regardless of what the child came to the office for today. One way to put the question on the form: “Does your child have difficulty with reading, or other learning difficulties? (Y/N) If yes, please explain.” If the question is not answered on the form, always follow up on it: in many cases when this question is left blank, it turns out that it's really a “Yes.”

b. In taking the history, consider simply asking, “How's school going for Johnny?” There will be a range of answers, from “Top of his class” to “Not so good.” Regardless, follow up with, “And how's he doing in reading?” If the answer is “He's an excellent reader” or something similar which really does not hint at any difficulty with reading, there is no need to ask anything further; just proceed with the normal exam. That takes about 10 seconds.

But if the answer suggests any doubt about how well he's doing in reading, ask, “Which is easier for him, math or reading?” (“Which is easier” is more positive than “which is harder,” and provides the same information without embarrassing the patient or parent.) If the answer suggests that there is difficulty with reading, or that reading is more difficult than math, ask, “How does he do with phonics ('sounding out' words)?” And “Does anyone in the family struggle with reading?”

The answers to these questions will help guide the recommendation of dyslexia evaluation for this child, even though he did not present with an overt complaint of reading difficulty.

4. Giving the parents a plan of action

a. General

The ophthalmologist may give this child a world-class eye examination and may determine definitively that there is nothing about his eyes that would cause or contribute to any reading difficulty the child may be having. But if the encounter is ended with, “Mrs. Jones, Johnny's eyes are fine, and I can tell you with absolute certainty that they are not the cause of his reading difficulty. Have a nice day!,” this does the patient and the parent a disservice, because the parents are still left to wonder, “So what do I do now?”

Johnny's mom is determined to help her child. The vision therapist is right down the street, and he is telling her that he can help. He is offering her hope and a plan. The ophthalmologist must do the same by providing specific guidance regarding where to go and whom to see to get proper evaluation of Johnny's reading problem, and evidence-based remediation to give him the best chance of success. This can be life-changing for the child and indeed the whole family: in many cases they've known for some time that there was a problem, and no one has really taken an interest—until now.

The ophthalmologist should do some research to find out what individuals or institutions are good in the specific city or area of the practice, and then share that information with the child’s mother so she has specific options from which to choose. Also, information regarding dyslexia should be provided to the parent, so she can educate herself. Below are specific recommendations regarding how to find good dyslexia evaluation and remediation in the area of the practice, and suggestions regarding what information you might consider giving parents to inform themselves regarding dyslexia.

b. Discussing vision therapy and tinted lenses

If the patient is a struggling reader, there's a good chance that a well-intentioned friend or teacher may have already mentioned to the parent that vision therapy and/or tinted lenses or overlays (“Irlen filters”) may be helpful. Review Section B2 of this document (Controversial Therapies) for details regarding why the evidence does not support these remedies as being appropriate or effective for treating dyslexia.

To summarize the argument briefly for the patient's parents, consider saying, “The bottom line is that dyslexia is a language problem, not a vision problem, and that's why vision-oriented remedies such as reading glasses, tinted overlays, or 'vision therapy' are not the answer. The answer lies on the language path, not on the vision path. Going down the vision path not only wastes your money, it also wastes valuable time, because it delays your child getting the language-based help he really needs.”

Please note: you can, and should, be clear and unequivocal in stating that vision therapy and tinted overlays are not the answer, without casting aspersions on any practitioner or group of practitioners who do not share your view.

c. Creating an informed, savvy consumer: the ophthalmologist's role

The ophthalmologist is not going to diagnose or treat the patient's dyslexia directly, but instead will begin to educate the parent regarding dyslexia, and give her resources so that she can further inform herself  regarding this condition, and you will make specific recommendations regarding how and where to get help. With help, she will be able to navigate the sometimes murky waters of learning disabilities, know which “remedies” are valid and which are not, and get her child the help he needs.

d. How to find effective, evidence-based evaluation and remediation in the patient’s area

First, be aware that it is unlikely that your patient's teacher is adequately trained to do this—and many, if not most, schools do not have anyone on staff equipped to do this, so help should be sought outside the school system.

The patient needs an evaluation by an appropriately trained clinician to see why he is struggling with reading, and then he needs evidence-based remediation. Note that the best person to conduct the evaluation may not be, and often is not, the same as the best person to do the remediation.

1. Educational Evaluation:

Comprehensive evaluation of the causes of a child’s reading difficulty can be performed by a clinical psychologist, neuropsychologist, or developmental pediatrician, assuming that the clinician conducting the evaluation is properly trained in dyslexia and its assessment. These clinicians are able to determine not only whether the child has dyslexia, but also whether there may be other factors (such as ADHD or other psychological issues, for example) that might interfere with the child’s reading. Assessment limited to answering the question of whether the child has dyslexia can be performed by some reading/dyslexia specialists, educational therapists, or speech-language pathologists, again assuming they are properly trained in dyslexia and its assessment.

Unless there is other reliable guidance regarding who in the area is good at evaluating struggling readers, it may be necessary to call the local clinical pediatric psychologist(s), neuropsychologist(s), and developmental pediatrician(s) and essentially interview them. It is necessary to know which one(s) have an interest in dyslexia, and which ones understand that dyslexia is fundamentally a language issue, not an issue of visual function or “processing.”

Likewise, if looking for a reading specialist, educational therapist, or speech-language pathologist to make the assessment of whether the child has dyslexia, you need to verify that they have appropriate training in dyslexia and its assessment. Look for someone accredited by one of the organizations recognized by the International Dyslexia Association as providing proper training:

• Academic Language Therapy Association (ALTA) www.altaread.org
• Alliance for Accreditation and Certification of Multisensory Structured Language Educators (www.allianceaccreditation.org)
• International Multisensory Structured Language Education Council (IMSLEC) www.imslec.org
• National Institute of Learning Development (NILD) www.nild.org
• Academy of Orton-Gillingham Practitioners and Educators www.ortonacademy.org

2. Remediation:

Dyslexia remediation can be thought of as a 3-legged stool, with the legs representing the elements which, working together, have been shown to be most effective (source: Sandie Barrie Blackley, Lexercise.com blog post):

• a structured language methodology;
• a clinician who knows language structure and how to teach it; and
• customized, dedicated daily practice.

If any of these legs is absent or weak, the stool will topple: the dyslexia remediation will be ineffective--or at least much less effective than it could, and should, be.

Note that neuropsychologists, clinical or educational psychologists, and developmental pediatricians very seldom provide dyslexia remediation. Reading specialists, educational therapists, and some speech-language pathologists do. Use the list of IDA-approved organizations above to find one of these clinicians with proper training to provide dyslexia remediation.

In addition, the IDA has begun accrediting literacy training programs in colleges in the United States, recognizing those that meet IDA standards. Nine colleges and universities were accredited in the IDA's first round of accreditation in 2012. A list of those institutions is available from the IDA (https://dyslexiaida.org/). Look for a teacher or clinician who has been trained in one of those programs.

A quick way to find a qualified person is to contact the state branch of the International Dyslexia Association (each state has one; they are listed at IDA's website, https://dyslexiaida.org/). Note that the person who is best for evaluation may not be best for remediation, and vice versa. Educational therapists can be located by contacting the Association of Educational Therapists (www.aetonline.org).

Note that there are local differences regarding who may be best equipped to provide dyslexia evaluation/remediation. To evaluate a struggling reader, in some communities the local neuropsychologist may be the best choice and in others the developmental pediatrician may be better, for example. And regarding remediation, in some communities a reading specialist associated with the school system may be the best choice, but in others, it may be a speech-language pathologist or an educational therapist. An ophthalmologist can do patients a great service by taking the time to find out who is good for evaluation and remediation in their area. The patients' parents can help: it is useful to talk with the parent after they've seen a particular clinician for evaluation or remediation, and see if what they were told sounds correct. Or, better yet, the ophthalmologist can talk with the clinician directly. In this way, the ophthalmologist can build a list of names of trusted people to send their patients to for evaluation and remediation.

For those who live in an area where there is not someone good locally, be aware that evidence-based remediation is available remotely—for example, by Lexercise (www.lexercise.com). And the Verticy Learning home curriculum (www.verticylearning.org) provides an optional “advisory teaching service” or one-on-one tutoring online.

A partial list of resources for parents seeking tutoring help:

• Association of Educational Therapists www.aetonline.org
• Children's Dyslexia Centers (free tutoring) www.childrensdyslexiacenters.org
• Decoding Dyslexia (your state's initials—NJ for example) www.decodingdyslexianj.org
• Lexercise (online tutoring) www.lexercise.com
• Proactive Parent www.proactiveparent.com
• Teacher Help for Parents www.teacherhelpforparents.com
• Verticy (home program with online tutoring) www.verticylearning.org

For a full list of resources, please consult the AAPOS Resource List referred to above, available for purchase by AAPOS members and non-members at www.aapos.org.

Note that for many families the cost of dyslexia evaluation and remediation is an insurmountable barrier. The Scottish Rite Masons and Massachusetts General Hospital have created The Children's Dyslexia Centers (www.childrensdyslexiacenters.org) to serve children who have been identified as having dyslexia but who cannot afford tutoring.

e. So—how can this be put together for a parent in the short time the ophthalmologist has available?

1. Stick to what an ophthalmologist knows. As an expert in ophthalmology, not in dyslexia, it is appropriate to emphasize that a diagnosis is for other professionals to make: “I can say whether his eyes are causing or contributing to any reading difficulty he may be having, and based on today's examination, they are not. So if he's struggling with reading, it's not because of his eyes, his vision, or his visual function.”

2. Briefly convey to the parent basic information about dyslexia, in plain English: “Dyslexia is a language problem, not a vision problem. It is not about switching letters around (though some people with dyslexia do that), and it is not about intelligence: Kids with dyslexia are just as smart as kids without dyslexia. The key thing that most kids with dyslexia have in common is difficulty with phonics (sounding out words). Dyslexic readers are choppy readers, not smooth readers; reading aloud is a challenge for most dyslexic readers; and spelling is a challenge for most dyslexic readers.”

3. Give the parents written information that reinforces and expands on what they have  learned at their visit.

Suggestions:

Give them hard copies. If they receive only a list of websites or links to articles, it is much less likely that they will ever read them.

Less is more: The parent might receive a stack of articles an inch thick, but she is unlikely to go through them. It is better to choose a few articles/references/resources deemed most pertinent and ideally were written for parents or at least laypeople. Assemble these into a own “Dyslexia packet” that can be handed to the parent hears a brief summary of each item.

Suggested Dyslexia Packet contents:

a. AAPOS (American Association for Pediatric Ophthalmology and Strabismus) Learning Disabilities Task Force publications:

• ”Learning Disabilities and Dyslexia” brochure. A brief but thorough description of what dyslexia is and its key features, how it is diagnosed and remediated, and why vision oriented remedies are not the answer.
• ”Learning Disabilities Resource List for Parents.” Contains a list of websites regarding dyslexia, for parents and for kids; legal information regarding dyslexia; learning materials; information on multisensory programs; reading programs; online programs for remediation; movies regarding dyslexia; newspaper/magazine articles; other online resources; reading lists; scientific articles; books on dyslexia for parents; books for parents to read with struggling readers; and books for struggling readers to read by themselves.
• And for motivated parents, A Parent's Guide to Dyslexia (Reading Disability), a 33-page booklet that describes in detail the features of dyslexia; associated conditions; how parents can work together with schools and with their primary care physician to help their children; why vision-oriented remedies are not the answer;  encouraging information regarding famous and accomplished people who have dyslexia; and an extensive list of online and print resources.

(Note that in addition to the publications above, the AAPOS LD Task Force has also produced two informational cards regarding dyslexia, meant to be displayed in a rack in your office, for patients to take—one for kids and one for parents.)

The AAPOS Learning Disabilities publications described above are available from AAPOS: http://www.aapos.org/resources/learning_disabilities_patient_information_/

b. One or 2 articles written for parents. See the AAPOS Resource List (above) for options. One good choice: “Outsmarting Dyslexia” (Heyworth KK, Parents magazine December 2011 http://www.parents.com/kids/development/learning-disabilities/help-children-with-dyslexia/), which is specifically written for parents, quotes authorities in the field, describes clearly the key features of dyslexia, and lets parents understand that it's not just one ophthalmologist’s assessment that dyslexia is a language problem, rather than a vision problem, and therefore, vision-oriented remedies are not the answer.

c. (Optional) The AAP/AAO/AAPOS/AACO Joint Technical Report—Learning Disabilities, Dyslexia, and Vision. http://pediatrics.aappublications.org/content/127/3/e818.full. This is written for physicians, and some parents have commented that it is “inaccessible” (ie, too hard to read). Nevertheless, it is comprehensive and authoritative. Consider directing parents particularly to the sections headed “Controversial theories and therapies,” “Management summary,” and “Conclusions.”

d. (Essential) A list of local resources parents can contact in their area for evaluation and remediation. Include specific contact information: don't make parents look it up. It is useful to include other information the clinician wishes included, including fees, particular practice emphasis (kids in elementary school, teens, etc.)

e. This will require some research on your part to identify and contact these resources, but it is an essential part of your dyslexia packet: if you just tell the parent that the eyes are not the problem and give them general resources, you have not really helped them. You must point them in a particular direction: you must give them hope and a plan.

Wrapping it up with the parent:

Consider saying something like, “So, Mrs. Jones, I do think it's worth having Johnny checked to see if he may have dyslexia. I want to emphasize that, even if he does, it does not in any way mean he's not smart! But if he does have dyslexia, the sooner he gets help, the better, because treatment for dyslexia works best at a young age. And while dyslexia can't be cured, it can almost always be helped, and does not need to keep him from going to college (or even medical school!) If he does not get help I'm concerned that he may become increasingly frustrated and discouraged. So I hope the information and resources I've given you will be helpful. If you have trouble reaching one of the people whose names I've given you, please let me know, and if any of Johnny's teachers or tutors or therapists would like to talk with me about his eyes, I'd be happy to. There is every reason to be hopeful, and I do wish you the best."

f. Being the patient's advocate with the school

First, inform the school of your findings and recommendations. Send them a letter directly, or send them a copy of your letter to the referring physician, stating that the child has no eye disorder that would cause or contribute to any reading difficulty he may be having (assuming that is indeed the case), and that you recommend educational evaluation and remediation as opposed to vision therapy, tinted overlays, or other vision-oriented remedies.

Consider presenting your findings to the school using a form such as the School Vision   Evaluation Form (developed by Gregory Ostrow, MD, and Laura Kirkeby, CO), which is available on the AAOPS Website, via this link:http://www.aapos.org//client_data/files/2011/426_aapos_schoolvisionform_readerenabledfillable.pdf

This form allows document in detail of why the child does not need vision therapy.

Offer to speak personally with any of the child's teachers or school staff to discuss your findings   and recommendations. If there is a chance to speak with them, do so with respect: they may not know as much as the physician or the patient's parent think they should know about dyslexia, but in most    cases they are doing their best, so treat them accordingly. Consider it a chance to educate them.   Offer to come to the school and give an in-service on the role of the eyes in reading and learning disorders; it is quite likely that the local vision therapist has already done so, and the teachers and administrators at your patient's school deserve to hear your views on the issue.

Second, support the patient's parent in her efforts to get help through the school system. This begins with learning about what rights and options parents have in dealing with the school system. This is complicated, involving federal laws regarding disabilities as well as state laws that may vary from state to state; and their application may vary from school district to school district within a state.

By federal law (the Americans with Disabilities Act Amendments Act), difficulties with learning, reading, or communicating qualify as disabilities, and under the Individuals with Disabilities Education Act Specific Learning Disability (which under that act includes dyslexia) qualifies for special education. Federal law requires public schools to evaluate any child who is thought to have a Specific Learning Disability, and the parent has the right to request the evaluation, which may be formally requested by either the parent or the teacher. If the child is found to require special education, those services are provided free of charge to the parent (funded through the IDEA).

(Parents of children in private schools may request that testing be done at a local public school, or they may pursue and pay for private testing. If testing revealed the need for special education, the child could transfer to a public school and receive those services free of charge, or remain in the private school and receive services at the parents' expense.)

Eligibility for special education is determined by the school's Individualized Education Program (IEP) team, which determines whether the disability is severe enough to warrant special education. Thus, simply being diagnosed with dyslexia does not mean the child will qualify for an IEP. But if the dyslexia is deemed severe enough, the child will receive an IEP, which describes the child's needs, specific learning goals, what services are to be provided and by whom, instructional methods, as well as any accommodations or modifications required. Your patient's parent is a part of the IEP team, and should not sign off on the IEP until she understands it and is satisfied with it.

Note that if the IEP team determines that the child's dyslexia is not severe enough to qualify for special educational services, the parent may request and Independent Educational Evaluation.(IEE). If this too determines that the dyslexia is not severe enough to require special education services, the child may still be a candidate for a 504 plan, which may include accommodations and modifications but which, unlike and IEP, is not funded, meaning that any expenses associated with these accommodations or modifications would be borne by the parent.

As is evident even from this limited outline, the process is complex. It is important to know that there are “professional educational advocates” whose job it is to help parents navigate the system, and who can also help make the parent's case before the IEP team. These can be found through the IDA website, www.interdys.org.

So, to help the parent work with the school get help for her child, communicate the findings and recommendations to the school and offer to speak with the patient's teacher or school  psychologist re: findings and recommendations give the parent an overview of the IEP process make sure she knows the importance of her direct involvement in the process make available to her any of the findings and recommendations as she prepares her letter to the school district requesting evaluation let her know her options if the initial findings of the IEP team are unfavorable encourage her not to accept a “wait and see” approach, which too often becomes “wait and fail.”

g. Coordinating care with the primary care physician

Respect the primary care physician's role as the “quarterback” of the child's health care team. At the very least this means informing her of the findings and recommendations, as described above in the section on communicating with the school. In a similar way, this is an opportunity to educate the primary care physician regarding dyslexia and why vision-oriented remedies are not the answer. (Offer to give a grand rounds or a less formal talk at your hospital's pediatrics or family medicine staff meeting on the role of the eyes in reading and learning disorders.) The ophthalmologist should be available to the primary care physician to discuss findings and recommendations regarding the patient. Send copies of your findings and recommendations to any psychologists, neurologists, or educational therapists involved in the child's case, but always keep the primary care physician not just in the loop but at the center of the loop.

h. Summary

Each time a struggling reader comes to the office, there is an opportunity to change a life for the better. This may be the most important work—more important that treating   amblyopia, even more important than straightening crossed eyes!

To recognize and to make the most of the opportunity, be prepared, and that begins with educating oneself regarding dyslexia. Know the key features of dyslexia, and how to identify a struggling reader even if reading difficulty is not the presenting complaint.

Do a proper eye examination, one that goes beyond the basics, so that you can rule out disorders of accommodation and convergence, which if present might affect reading comfort or stamina (but not the reading process itself).

Know why vision therapy, tinted overlays, and weak reading glasses are not the answer.

Be able to convey information to the parent in terms she can understand, and then give her specific information regarding how to get help for her child in her local area, both within the school system and outside it.

Partner with the parent, with the school, with the primary care physician, and with other physicians or therapists involved in the case to work as a team to help the child get the help he needs.

Give the struggling reader's parent hope and a plan. Otherwise, the vision therapist down the street most certainly will!

INFORMATIONAL WEBSITES: also see Section B3, A4, and D2

1. American Academy of Pediatrics (AAP) www.aap.org
2. American Association for Pediatric Ophthalmology and Strabismus (AAPOS) www.aapos.org
3. All Kinds of Minds www.allkindsofminds.org
4. Dyslexia Help – University of Michigan http://www.dyslexiahelp.umich.edu
5. Dyslexia Training Institute www.dyslexiatraininginstitute.org
6. International Dyslexia Association www.interdys.org
7. Learning Disabilities Association of America www.ldaamerica.org
8. Learning Disabilities On Line www.ldonline.org
9. National Center for Learning Disabilities www.ncld.com
10. Nemours Reading Bright Start www.ReadingBrightStart.org
11. Orton Academy www.ortonacademy.org
12. Proactive Parent www.proactiveparent.com
13. Reading Rockets www.readingrockets.org
14. Wrightslaw Special Education Law and Advocacy www.wrightslaw.com
15. Yale Center for Dyslexia & Creativity www.dyslexia.yale.edu

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29. Harris DA, MacRow-Hill SJ. Application of ChromoGen haploscopic lenses to patients with dyslexia: a double masked, placebo-controlled trial. J Am Optom Assoc. 1999; 70: 629-640.
30. Gole GA, Dibden SN, Pearson CC, et al. Tinted lenses and dyslexics—a controlled study. SPELD (S.A.) Tinted Lenses Study Group. Aust NZJ Ophthalmol. 1989; 17(2): 137-141.
31. Menacker SJ, Breton ME, Breton ML, Radcliffe J, Gole GA. Do tinted lenses improve the reading performance of dyslexic children? A cohort study. Arch Ophthalmol. 1993; 111 (2): 213-218.
32. Henderson LM, Taylor RH, Barrett B, Griffiths PG. Treating reading difficulties with colour. BMJ. 2014; Aug 19; 349.  
33. Henderson LM, Tsogka N, Snowling MJ. Questioning the benefits that coloured overlays can have for reading in students with and without dyslexia. J of Research in Special Education Needs. 2013; 13 (1): 57-65.

Section B.3

1. Handler SM, Fierson WM, Section on Ophthalmology and Council for Children with Disabilities for the  American Academy of Pediatrics, American Academy of Ophthalmology, American Association of  Pediatric Ophthalmology and Strabismus, & American Association of Certified Orthoptists. Learning  disabilities, dyslexia, and vision: Technical Report. Pediatrics. 2011;127:e818–e856 www.  aappolicy.aappublications.org/cgi/reprint/pediatrics;127/3/e818.pdf.
2. Learning Disabilities, Dyslexia, and Vision. 2009 Policy Statement of the AAP, AAPOS, AAO & AACO.  Pediatrics. 2009; 124: 837-844.