The Pediatric Patient
Ophthalmologists can play a key part in helping young patients with visual processing and other learning problems.
Harold P. Koller, MD, and Kenneth B. Goldberg, Psy.D. Philadelphia
When facing a child who has been labeled a slow learner, our first job is to determine whether visual dysfunction is present and correct it, if possible.
Any significant refractive error, whether myopia or hyperopia, may interfere with learning. Even if a hyperopic child can accommodate to J1, he may experience asthenopia during extended reading. Plus single-vision lenses or bifocals often help.
Media opacities from ptosis to cataract can obstruct vision and sometimes result in amblyopia. However, as long as one eye functions well, learning problems typically do not result.
Children with bilateral partial vision loss due to optic nerve disease, congenital retinal dystrophies, nystagmus or the post-op complications of ocular surgery can certainly experience difficulties in school. However, these children can usually benefit from magnifiers, large-print reading materials, front-row seating and support and understanding from both parents and teachers. Many children with reduced vision go on to become excellent learners.
Children with amblyopia secondary to strabismus or anisometropia typically need patching to maximize vision in the amblyopic eye. Patching can preclude the child's seeing effectively in kindergarten and the first and second grade, especially if vision in the amblyopic eye is poorer than 20/40. Patching can also provoke ridicule and affect the child's self-image, which can interfere with learning. If either is the case, the parents must weigh the benefits of patching against the drawbacks.
If the child has accommodative esotropia, or excess convergence at near due to hyperopia, it's typically possible to provide relief with single-vision plus or bifocal glasses.
Motor nerve paralysis can also result in strabismus and interfere with learning. The solution is to correct the cause, if possible. Some children may still be left with a head turn that makes it somewhat difficult but not impossible to read in the classroom. If you see a sudden sixth-nerve palsy combined with a personality change and difficulty with learning, of course, rule out brain-stem tumor with a possible extension.
Exotropia can disrupt binocular efficiency and eventually make reading difficult. The answer typically is surgery; this form of strabismus has the most favorable prognosis of any strabismic condition. If the child's chin is constantly elevated or depressed, look for "A" and "V" pattern strabismus. Once again, surgery is often an excellent option.
Kids with incomitant deviations (caused by Duane's, Brown's or general fibrosis) typically compensate well, with few or no reading difficulties and minimal or no head turn. In severe cases, it's possible to do surgery.
Children with certain types of phorias, including convergence excess or insufficiency, sometimes suffer from asthenopia or fatigue when reading. Plus lenses can often make reading easier for kids with convergence excess. Kids with convergence insufficiency may benefit from "push-ups." Have the child focus on a small target and try to bring a single image closer and closer to the bridge of the nose. The child should do this exercise several times a day.
Both the congenital and acquired varieties of nystagmus can certainly affect reading, but we find most children learn to compensate unless the nystagmus results in severely reduced vision or from a severe ocular or brain disorder.
Remember to ask about chronic ocular allergies. Constant itching, tearing and burning can certainly interfere with learning. Avoiding allergens and seeking rapid or even prophylactic treatment can help in these cases. Also consider diseases that result in excessive tearing, like lacrimal obstruction and dry eye secondary to xerophthalmia or familial dysautonomia. Chronically wet or dry eyes result in intermittent blurring. Treat the diseases accordingly.
Migraine
When school-age children complain of visual problems but the eye
exam is normal, consider this difficult-to-diagnose syndrome.
As with adults, children can experience intermittent blurred vision
secondary to the fortification phenomenon common in classic migraine.
They can also suffer from an uncommon variety called acute confusional
migraine. The child will inexplicably become confused, disoriented,
agitated, apprehensive and combative. At first, the child may
not complain of headache, but this almost always develops later.
Remember, these children are often perfectionists. Unexplained symptoms may make it harder for them to concentrate in school. The best course often is referral to a pediatric neurologist or neuro-ophthalmologist.
True Learning Disabilities
Most often, slow learning is related not to ocular disorders nor
to headache, but to one of the four types of learning disabilities.
As many as 15 percent of all school-age children suffer from one
of these disorders. They include:
* Language-based disorders, or the inability to produce or understand the spoken and written word. The most common of these are articulation disorders. In fact, these occur in as many as one in 10 children. These children struggle with correct pronunciation, saying, for instance, "weft" for "left," but otherwise understand language and choose words normally. The condition may be a result of central nervous system problems like controlling air flow due to poor muscle coordination, physical abnormalities in the mouth or tongue or faulty hearing.
Other children have expressive language disorders. These kids have a limited vocabulary, substitute improper words for proper ones, and curtail their speech. The child may say "want cookie" rather than "I want a cookie." It can be helpful to refer to a speech/language pathologist in these cases.
The final category is receptive language disorder. The best known form of this disorder is dyslexia, or the inability to develop reading skills due to problems with sound-symbol relationships.
Dyslexic children have great difficulty recognizing words and reading prose.1 This usually becomes obvious in the first or second grade. Prior to this, the child may exhibit speech delays, difficulty learning colors and animal names, word-finding problems, and difficulty understanding spoken language. Psychoeducational testing can confirm dyslexia.
Dyslexia may be an inherited dysfunction of the left hemisphere,2 involving chromosomes 6 and 15.3 The main treatment is tutoring with a reading specialist. Positive psychological reinforcement in school, from family and friends, and from counseling professionals is also important to prevent frustration and the formation of a negative self-image.
Nonverbal learning disabilities. These poorly understood conditions may represent as many as one in 10 learning disabilities.4 Children with these conditions tend to exhibit well-developed reading and verbal skills, but have problems with visual-spatial perception, visual memory, psychomotor coordination, complex tactile-perceptual skills, reasoning, conceptualization and math. They are often anxious and have difficulty concentrating, causing professionals to occasionally diagnose attention deficit/hyperactivity disorder. The cause is thought to be right hemisphere and possibly frontal lobe white matter dysfunction.5
Without treatment, children with nonverbal learning disabilities can develop troubled social relationships, have difficulty picking up on environmental cues, and ultimately become isolated and depressed. Treatment includes working on direct sensory motor skill training, visual spatial training, mechanical arithmetic training, rote instruction and psychological intervention.
Some optometrists believe a therapy known as vision training is helpful for these patients. This therapy involves optical correction of refractive errors and strabismus, orthoptics for convergence insufficiency, and laterality training and spatial eye-hand coordination exercises. How these therapies work other than through repetitive positive reinforcement is controversial.
AD/HD
Children and adults with attention deficit/hyperactivity disorder
typically have a short attention span, are impulsive and may or
may not be hyperactive. ADHD affects 5-10 percent of school-aged
children, and 10 times as many males as females.6 The cause may
be genetic or environmental. Some believe such children have pathology
in the right frontal striatal system.7
The first symptoms typically appear between ages 3 and 7. When the child is a toddler, parents often observe that he "is into everything" or that "his motor is always running."
Later, they may notice that the child: squirms in his seat and fidgets with the hands or feet; is unable to remain seated; is easily distracted; blurts out answers before the question is finished; has difficulty following instructions; is unable to concentrate; interrupts or intrudes on others; does not appear to listen; loses items such as toys, pencils and books; often engages in dangerous activities without considering the consequences.8
These children may also be afflicted with other behavioral conditions, including Tourette's, Conduct Disorder, Oppositional Defiant Disorder and Tic Disorder. Treatment often includes psychostimulant medications in combination with behavior management at home and at school.
Pervasive Developmental Disorders
Children affected with these syndromes have difficulty not only
with language but with socialization as well. The most well-known
form of PDD is autism. Children with this disorder begin manifesting
its signs and symptoms as early as 2 to 3 years of age. They have
little interest in others and engage in repetitive self-stimulating
behaviors. Their ability to communicate typically is poor, and
other mental functions also are delayed in most autistic children.
Studies show that these children have atrophy of the cerebellum
and enlarged lateral ventricles. Their parietal and frontal cortices
and subcortical structures do not work together properly.
Another form of PDD is Asperger's syndrome. These children typically develop linguistic and intellectual skills normally, but they do not develop social skills. Children with this disorder refuse to make eye contact.
Treatment involves behavioral modification to encourage social interaction and interest in new activities.9
Getting a slow learner on the right track may not fall under the definition of classical ophthalmology. It does take some extra time and trouble to implement. But few services we offer are more important to the lives and welfare of our patients.
Dr. Koller is clinical professor of ophthalmology at Thomas Jefferson University and chairman of the Section on Ophthalmology, American Academy of Pediatrics. Dr. Goldberg is director of neuropsychology at the Institute for Graduate Clinical Psychology at Widener University in Chester, Pa.
1.Pennington, BF. Diagnosing Learning Disorders. New York:
The Guilford Press. 1991;45-64.
2. Galaburda, AM, et al. Planum temporale asymmetry. Neuropsychologia
1987;25;853-868.
3. Shawitz, S. Dyslexia: Current Concepts, N. Eng J Med; 1998,
Vol. 338; p. 307-311.
4. Ozols, EJ, Rourke, BP. Dimensions of social sensitivity in
two types of learning-disabled children. In BP Rourke (ed.) Neuropsychology
of Learning Disabilities: Essentials of Subtype Analysis. New
York: The Guilford Press, 1985; p. 281-301.
5. Myklebust, HR. Nonverbal learning disabilities: Assessment
and intervention. In HR Myklebust (ed.) Progress in Learning Disabilities.
New York; Grune and Stratton, 1975; v. 3 p. 85.
6. Koller, H. How does vision affect learning? J Ophth. Nrsing
Techn., Jan./Feb. 1999, Vol. 18.
7. Heilman, KM et al. A possible patho-psychologic substrate of
attention deficit hyperactivity disorder. J Child Neurol 1991;6;S76-81.
8. American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders (4th ed.). Washington: 1994.
9. Lovaas, OJ. Behavioral treatment and normal educational and
intellectual functioning in young autistic children. J. Consult
and Clin Psychology;1987;SS;3-9.
During my 34 years in ophthalmology, I have had many discussions with medical teachers and colleagues about children with dyslexia and learning disabilities. We've long been told that this disorder or group of disorders was outside the field of ophthalmology because the brain is the main organ active in the process of thinking and learning, and not the eyes.1,2,3
Although I understood the term dyslexia, other aspects of learning disabilities were not stressed to ophthalmologists. So, I pursued the typical interests of most pediatric ophthalmologists--strabismus and cataract surgery, plus genetic and congenital disorders.
For almost 30 years, when the family of a visually normal pediatric patient would consult me to rule out eye disease in determining the reason for a learning difference, I'd say there was nothing wrong with their child's eyes and that they should return to their pediatrician or family doctor for further evaluation and referral. I always assumed that the child would be appropriately worked up and treated. I found, though, that the parents would return in a year or two with the child still having academic problems and, more surprising, no real diagnosis of what was wrong in most cases.
I decided to learn more. The public believes that ophthalmologists know as much about visual perception, visual processing, visual learning and reading as we do about visual function, ocular disease and optical, pharmacological and surgical therapy. I felt that I could help make this public perception a reality. The first step was to introduce the knowledge of psychiatry, educational and neuropsychology, physical and occupational therapy and educational science in all forms relating to learning differences to the community of ophthalmology.
This article incorporates Dr. Goldberg's neuropsychologic approach and my ophthalmologic constructs.
Harold P. Koller, MD
Migraine Risk Factors
Always ask about family history of migraine, not only in the immediate family but in grandparents, aunts and uncles, even cousins. Also ask about the following risk factors:
* Infantile colic
* Lactose intolerance
* Unexplained, recurrent abdominal discomfort
* Light and/or noise sensitivity
* Motion sickness
* Sleep disturbances, including night terrors and talking
* A "type A" personality
* Macropsia/micropsia
* Visual phenomena such as sparkling lights, silver foils and
colors;
* Brief bouts of double vision (due to ophthalmoplegia)