Harold P. Koller, MD Meadowbrook, Pa. Kenneth B. Goldberg, PsyD Chester, Pa

A large number of children, and often undiagnosed adults, seek ophthalmic care, because their parents or they believe that a difficulty with reading or learning is due to an ocular disorder. In addition, ophthalmologists are frequently the initial expert to whom pediatricians refer children they suspect of having a learning disorder.
For these reasons, ophthalmologists need to know the nature of learning disorders, when to suspect them during a routine eye exam, and the interdisciplinary approach to diagnosing and treating learning disorders. Here’s help.

Background
Neuro-psychology divides learning disorders into four main categories:
 • speech and language disorders;
 • nonverbal learning disorders;
 • attention disorders; and
 •autism spectrum disorders (pervasive de-velopmental disorders).

Today, we use the term learning difference, rather than disorder, when we want to acknowledge the wide spectrum of individuals who fall into each category. Many of those affected merely have a cerebral processing difference, which isn’t severe enough to be considered pathologic and dubbed a disorder.1

Learning differences appear to be caused by an underlying dysfunction in the central nervous system that prevents the individual from acquiring and adequately processing information for later usage. Those affected may experience any combination of difficulties in reading, writing, mathematics and both expressive and receptive language skills. One approach to classifying learning differences bases categorization on cognitive functional area, and neuropathological research has supported aspects of this type of classification system.

Language-based Learning Disorders
Children with language-based learning disorders can have a variety of presentations, including difficulties with receptive and expressive language skills. The most common one to appear in an ophthalmologist’s office is dyslexia, defined as “an unexpected difficulty in reading in children and adults who otherwise possess the intelligence, motivation, and schooling considered necessary for accurate and fluent reading.”1

A dyslexic child has difficulty matching the sound-symbol relationships of words and struggles to “decode” words. He must sound out every one and can’t develop an adequate sight vocabulary. Due to the energy spent on decoding words, comprehension also suffers. The inability to comprehend sound-symbol relationships affects the child’s spelling skills, as well. Research has shown abnormalities in the left hemisphere of these individuals.2,3

In many cases, the child’s pediatrician and parents notice the child’s difficulty with language skills and seek appropriate treatment with a speech-language therapist. An ophthalmologist’s involvement occurs when the parents and/or teacher believes the child’s underlying problem to be visual. A normal visual screening—including visual acuity, accommodation status, fusion, vergences, vestibular influences, saccadic movements and pursuit movements—safely rules out the visual and oculomotor aspects of a reading problem.

Figure 1. A basic office test can strengthen a suspicion of a nonverbal learning disability in a child of 6-12 years of age. The test involves presenting a simple pattern like the one shown (A) to the patient for 15 seconds and asking him to draw it from memory. While B is an acceptable, semi-normal drawn response, the others are abnormal samples that may indicate the presence of a nonverbal learning disorder.

Suspect dyslexia if the patient history reveals difficulty learning the alphabet, letter and word reversals after second grade, and poor reading skills. In such cases, refer the patient to a neuropsychologist or reading specialist for diagnosis. An audiologist may play a role by examining the patient’s hearing frequencies. Treatment for these children involves intensive, and in many cases prolonged, training in phonics with a reading specialist.

Nonverbal Learning Disabilities
These involve a constellation of symptoms in which the child has trouble with visual-spatial processing, visual memory, fine motor coordination (especially with the left hand), complex tactile perceptual skills (again, especially with the left hand), reasoning, concept formation and mathematical abilities.4 The underlying neuropathology indicates involvement of the right hemisphere.
Individuals with nonverbal learning disabilities tend to develop interpersonal difficulties as they age. They have trouble understanding social cues, such as gestures and prosody of speech, both believed to be mediated by the right hemisphere.5 These children can often read text quite well but comprehend it poorly. They miss inferential meanings and subtle contextual relationships. Many of these individuals are, therefore, diagnosed with psychiatric conditions in adolescence and early adulthood.6

The ophthalmologist may encounter these children at young ages, as their parents are searching for the reason behind their child’s coordination trouble, evident in their writing, scissors skills and/or artwork. A basic office test can sometimes raise your suspicion of nonverbal learning disabilities (See Figure 1).

Support Organizations for Parents
American Speech-Language-Hearing Association	1 (800) 638-8255, e-mail: actioncenter@asha.org, Web: www.asha.org.
Attention Deficit Information Network	(781) 455-9895, e-mail: adin@gis.net, Web: www.addinfonetwork.com.
CHADD (Children and Adults with     Attention-Deficit/Hyperactivity Disorder)	1 (800) 233-4050 or (301) 306-7070, e-mail: national@chadd.org, Web: www.chadd.org.
The International Dyslexia Association	(410) 296-0232, Web: www.interdys.org .
National Center for Learning Disabilities	1 (888) 575-7373 or (212) 545-7510, Web: www.ld.org
National Information Center  for Children and Youth with Disabilities	1 (800) 695-0285 or (202) 884-8200, e-mail: nichcy@aed.org, Web: www.nichcy.org

Occupational therapists can provide treatment for these children at a young age that is designed to improve their visual-motor coordination skills. Later, support services for mathematics and psychological issues should be considered, provided by a special education teacher and psychologist, respectively. In some cases of nonverbal learning disabilities, behavioral vision therapy that uses some of the same techniques occupational therapists use to teach motor awareness, motor planning and motor memory may be effective. No data supports its use as therapy for dyslexia, attention deficit disorder or attention deficit hyperactivity disorder, however.

Attention Deficit/Attention Deficit Hyperactivity Disorder
These disorders are a pattern of behavior that generally involves inattentiveness and impulsivity, with or without hyperactivity. Research has described a right-sided, frontal-striatal system pathology in affected individuals.7

The ophthalmologist may observe problems of attention and hyperactivity in the office. Hyperactive children won’t fully cooperate with the exam. Often, they’ll touch the exam equipment and instruments and squirm in the exam chair. Children affected by both disorders generally fail to pay attention to directions.

Sometimes, parents and teachers mistake a child’s difficulty reading and/or accurately seeing the chalk board for trouble sustaining attention with visual gaze. The diagnosis of attention deficit disorder or attention deficit hyperactivity disorder is based on a number of behaviors noted over time,9 and the American Academy of Pediatrics published new guidelines for diagnosis and therapy in 2000.8

If you suspect a patient of having one of these disorders, refer him to a pediatric neurologist and/or neuropsychologist for diagnosis and treatment. The latter combines pharmacological agents with behavioral management therapy.

Autism Spectrum Disorders
Two major deviations from normal development characterize autism spectrum disorders, formerly termed pervasive developmental disorders: social relatedness and language/communication skills.9 The most notable form of autism spectrum disorders is classic autism.

Many autistic children develop normally up to 1-2 years of age, at which point they regress. Usually, they are diagnosed prior to the age of 3, and research has shown multiple neurological deficits in these individuals, including cerebellar atrophy, ventricular enlargement and poorly developed cerebral integration.10,11,12 In milder forms of autism spectrum disorders, such as Asperger’s syndrome and ASD-NOS (Autism Spectrum Disorder-Not Otherwise Specified),9 children appear normal and often act quite normally.

Children with classic autism display a lack of social relatedness and fail to understand the subtleties of relationships, such as the punch lines of jokes or how inflection can affect meaning. Another diagnostic clue is these individuals’ repetitive limited range of interest, such as wanting only to bang on a drum. In ASD-NOS, the patient may exhibit any of these symptoms but on a more subtle level. The child may seem to get along with others but makes no friends at school and has a repeated interest in only one thing, such as a particular television program. A lack of eye contact in the ophthalmologist’s office, meanwhile, is a potential sign of Asperger’s syndrome in a child with a normal eye exam.

If you suspect a patient has an au-tism spectrum disorder, refer him to a pediatric psychiatrist. The treatment for autistic children has broken along two distinct lines. One takes the form of a discrete trial learning method, which involves intensive instruction with continuous redirection for “incorrect” behaviors.13 The other comprises educational strategies like the Treatment and Education of Autistic and Related Communication Handicapped Children (T.E.A.C.C.H.) method, all of which focus more on developing compensatory strategies (e.g., the use of pictures for words, iconic representations) to help aid the development of the child’s functional skills.14

Many assume that the diagnosis and remediation of learning disorders should be in the hands of educators, but learning actually involves a complex sequence of neuropsychological processing. As a result, the diagnosis and treatment of learning disorders is an interdisciplinary process in which the ophthalmologist frequently plays a role. While it’s not his place to make a definitive diagnosis of a learning disorder, it is appropriate that ophthalmologists have the knowledge to form a suspicion of one, to share that suspicion with the child’s parents, and to refer the child for further testing and treatment in a timely manner.

Dr. Koller is a clinical professor of ophthalmology at Thomas Jefferson University, and the immediate past chair of the Section on Ophthalmology, American Academy of Pediatrics.




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