5/9/2016
The Struggling Student: 4 Case Types
Optometry’s Meeting 2016 Boston
Learning Disorders
1. Learning Related Vision Problem
2. Dyslexia or specific reading disorder
3. Attention Deficit Hyperactivity Disorder
4. Autism Spectrum Disorder
Case Reports and critical issues related to each case
John ‘JT’ Tassinari OD FCOVD
Diplomate Binocular Vision Perception Pediatric Optometry Section, Amer Acad of Optom
assoc prof Western Univ Health Sciences College of Optometry
[email protected]
Learning Disorder: A Clinical Model
Potential
Achievement
Normal
LD
Potential: Innate intelligence
Achievement: Grades, reading level, state testing of
academic levels etc
Nothing to Disclose
Learning Disorder Etiologies
Potential
• Mild Moderate Severe
Achievement
Language Processing
Sensory Processing Disorder
Primary Mental Illness
Physical Impairment
Learning Disorder Varieties
• Uneven: characteristic of ADHD
Vision
Dyslexia
ADHD
Autism
Psychoeducational Evaluation
• Administered by Educational Psychologist & others
• Purpose:
1. Establish potential (intelligence)
2. Evaluate behavior/mental health
3. Evaluate foundations to learning (language, vision,
motor)
4. Test academic achievement
5. Definitively state if learning disability is present
6. Formulate an individualized educational plan
• Mixed: characteristic of dyslexia
• Gifted / High intelligence
• Multifactorial common
Sample Psych-Ed Reports in Lecture
• List of tests administered shows IQ, achievement
levels and tests for 7 of the 8 LD etiologies (medical is
from interview)
• Report letter shows diagnoses:
1. LD nos
2. Mathematics Disorder
3. ADHD inattentive type
• Report letter shows extensive contents of educational plan
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Learning-Related Visual Problem
L R V P
• ↓ Visual Efficiency Skills, esp saccades
• ↓ Visual Information Processing
• Corresponding symptoms and performance
concerns
• Causes mild to moderate learning disorder
Difficulty Copying – LRVP Symptom
•
•
•
•
Accommodative infacility
Vergence infacility
Oculomotor dysfunction (deficient saccades)
Deficient VIP:
ƒ Visual Motor Integration
ƒ Visual Spatial
ƒ Visual Memory
ƒ Visual Figure Ground
LRVP Evaluation.
• Primary eye and vision exam
• Comprehensive Case History including written
questionnaires and other reports (psycho-ed)
• Visual Efficiency Evaluation
Accomm
Verg
Saccade / Pursuit
• Visual Information Processing Evaluation
Visual Spatial Visual Analysis
Visual Memory
Visualization
Visual Motor Integration
Visual Auditory Integration
Hallmark LRVP Symptoms
Visual Efficiency
• Asthenopia / blur / diplopia
• Difficulty keeping place while reading
• Difficulty copying
Visual Information Processing
• Difficulty copying
• Poor Penmanship
• Sight word recognition errors
• Applied spelling errors
• Reversal or sequence errors
LRVP Symptoms DDx
• Asthenopia / blur / diplopia
• Difficulty keeping place
while reading
• Difficulty copying
• Poor penmanship
ADHD
Primary Motor Problems
Dysgraphia
• Difficulty keeping place while reading
• Sight word recognition errors
• Applied spelling errors
DYSLEXIA
• Reversal or sequence errors
LRVP A & P
• Manage refractive or eye disease problems first
• Rate VE and VIP Skills
• Reconcile VE and VIP with symptoms
eg Visual Motor Integration / V Spatial vs Dysgraphia
• Ascertain contribution of LRVP to LD
• Recommend VT: Treatment length
• Establish prognosis
i. prognosis for ↑ V Skills is usually very good
ii. Prognosis for lessening of LD…….. Challenging to determine
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5/9/2016
BT, 4th Gr M. 9;6
Case Hx
Questionnaire,
Parents
• “Grades are OK, not failing. He works extremely hard to get a B-”
• Low reading scores on state standardized testing
• Educational Hx:
Regular placement in a private school
Home tutor
Summer reading program
• PEH: Nearpoint plus in late 2nd grade, no benefit
• PMH: Healthy, no meds
• Development: normal
Good family environment
Primary Care Eye Exam
•
20/20 emmetropia
•
No strab, color, stereo, VFs normal
•
Ocular health status good
Case Hx
Questionnaire,
Teacher
Teacher Vision & Learning Questionnaire
• Achievement below potential in reading rate and writing
• Reading comprehension: average
• Math: above average
Note applied
spelling errors
(spelling tests are
satisfactory)
• Reading rate problem consistent with VE and VIP deficits
• Reading compreh avg despite slow reading rate. Suggests
good language processing and intelligence (pure LRVP)
BT, Accommodation
BT, Vergence
0/2XP’
DIV
CONV
DIV’
CONV’
x/5/1
6/16/4
8/16/6
6/10/2
x/5/3
9/18/10
12/21/11
12/18/10
NPC x/10/15
x/3/5
V Facil 8cpm*
15cpm
*BI slower
(3BI/12BO)
Distance
Near
MEM +.25 0 - +.50
NRA +1.25 +2.00
Amps
OD 8D
OS 8D
OU -
PRA -1.50
-2.25
+/200 AF
12D
4cpm*
4cpm*
Fail -
10cpm
7cpm
*plus harder
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Oculomotor
NSUCO
PURS
SACC
Visual Information Processing
BT 9;6 4th
Ability Body Head Accuracy
5
5
4
3 4
5
5
3 4
3 4
Developmental Eye Movement Test
Vertical Horizontal (adj) Errors
43sec
62s
10
35th%ile
8th %ile
1st%ile
Ratio
1.44
9th%ile
V I Processing (cont.)
Visual Memory
TVPS3 V Memory
“ V Seq Memory
PTS Tachistoscope
RS
10
11
6
%ile
25th
63rd
16th
Visualization
Getman V Manipulation 7
PMA Spatial Relations
13
fail
19th
Visual Spatial
RS
Piaget
stage 2
Gardner Reversal Recog -6
Visual Analysis
DTVP-2 Position in Space 17
“
Figure Ground
10
“
Form Constancy 16
Visual Closure
6
%ile
Pass
18th
9th
16th
63rd
5th
V I Processing (cont.)
Visual Motor Integration
Beery DTVMI
DTVP-2 V Motor Speed
Grooved Pegboard
Wold S. Copy
RS
16
11
63sec
52 l/min
%ile
18th
25th
60th
28th
Visual-Auditory Integration
Birch-Belmont AVI-T:
VADS Auditory-Written:
17
6
60th
75th
Auditory / Dyslexia Screening
TAPS ANM Forward 29points 37th percentile
TAPS ASM
5 points 50th percentile
DDT: No Dyslexia
TOWRE* Phonemic Decoding 33points 55th %ile
*Test of Auditory Perceptual Skills
*Test of Word Recognition Efficiency
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BT, 4th Gr 9;6 Assessment & Plan
• Deficient VE (all 3)
• Deficient VIP (5 / 6)
Outcome:
All deficient visual skills
improve to an overall
rating of near or above
50th percentile
• Symptoms and Deficits; Good match
• Case Hx and screening suggest no other LD
factors are present
• LD: Mild-moder = LRVP
Presenting symptoms
gone or less
School performance
elevated
PLAN: 1. Office Based VT 3 x 8
2. Re-assess educational plan if LD persists
LRVP severity vs LD severity
2. Dyslexia or Specific Reading Disorder
BT (before VT)
LRVP
Mild
Moderate
Severe
BT
LD
Mild
Moderate
Words & Language
Spoken word
Severe
Assign visual
symbols to word
sounds and write
those symbols.
Encode it
Encoded (printed) word
Take the encoded
word out of its
code. Decode it
• Unexpected Learning Disability in Reading/Spelling
• Manifests as poor word recognition (decoding) and poor
spelling (encoding)
• “Dyscdodia”
• Permanent
• Autosomal Dominant
• Neurobiological
• Prevalence: 5 – 17 %
• Ranges in severity
Educational Characteristics & Diagnosis
Slow to learn alphabet
Phonics slow/problematic – but not always.
Slow to build up sight word recognition - always
Oral Reading: Mistakes words & then mistakes again later
Slows down, poor fluency
Spelling ALWAYS poor (Spelling Tests vs Applied Spelling)
Comprehends normally, esp when read to
DIAGNOSIS Psycho-educational assessment:
Establish normal intelligence
Decoding/encoding vs comprehension
R/O language processing LD
Look for comorbidity
Screening - Optometrist
Dyslexia Determination Test
Case History
Severity of LRVP vs LD
DEM Vertical score
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5/9/2016
RV 3rd Gr M 8;8
• Significantly behind in reading. “Will
visual therapy exercises help my son?”
• Educ Hx:
Repeated K (August birthday)
Phonics slow
Diagnosed with dyslexia late 2nd
Completed Lindamood-Bell summer
2nd/3rd grade
RV 3rd Grade. LRVP Symptoms
•
•
•
•
•
•
•
Difficulty keeping place while reading - YES
Asthenopia/Diplopia: “sometimes”
yes
Blur:
none
Reversals:
No
Penmanship / Copying:
“yes and no”
Written math:
“great, no problems”
Sight word recognition and spelling: POOR
Plan
• Office Based VT, 6 visits total
• Parent education regarding outcome of
VT (minor impact)
• Support current educational plan
RV 3rd Gr. Present Educ Status
• Hates reading. Very slow reader.
• Decoding errors: “yes”
• Spelling:
“awful”
• Good at math / Great athlete
• Dad: poor speller, minimal reading
• Works with educational therapist 2x week
VT Work-up Results
• Basic Vision Good, Eyes Healthy
• Vergence
NPC: x/8/18
Conv at near: x/16/6
• Accomm: strong
• Oculomotor
DEM Ratio 1.33 24th percentile
• VIP: strong
DEM Vertical
75 seconds, < 1st percentile
RV, VT OUTCOME….
NPC:
TTN
x/18/8
Conv’:
x/24/16
x/16/6
DEM Ratio: 1.25 45th %ile 1.33 24th %ile
• Ed. Therapist: “place keeping much
improved. Less reliant on bookmarker.
Longer focus”
• Mom: “I guess he is keeping his place better
and he doesn’t complain his eyes hurt. He
still hates reading. His spelling is still so
bad”
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5/9/2016
3. Attention Deficit Hyperactivity Disorder
A D H D
A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with
functioning or development
3 types:
1. Predominantly inattentive type
2. Predominantly hyperactive-impulsive type
3. Combined type
Ranges in severity: mild moderate severe
ADHD & Vision
• Acomm / Verg dysfunction can tax visual
attention span and thus mimic ADHD
• VT for can improve some markers of Attention
• ADHD can cause symptoms that mimic LRVP
symptoms
• ADHD can cause artificially low scores in a VT
workup
• ADHD can inhibit progress in VT
Tests Prone to Low Scores
because of ADHD
• Steady state / boredom / visual distractions
• Examples:
1. Pursuits
2. Behind Phoropter
3. Wold Sentence Copy
A D H D (cont.)
•
•
•
•
•
•
•
•
•
•
Prevalence: 4 to 12% depending on diagnostic method
Neurobiological
Highly heritable (80%)
Onset prior to age 12 years
ADHD behaviors present in at least 2 settings for at least 6
months
Usually diagnosed with behavioral checklists (Conner’s)
Clear evidence that behaviors interfere or reduce quality of
social, school, or work
Hyper-attention possible
Comorbidity with LD common, esp dyslexia
Tx: Stimulant medications vs behavioral
MC,2ndGr F 7;8. Recent ADHD Dx
• “She has ADHD. Is it her eyes? Her
psychologist wants her tracking, her eyes
together tested”
• Psychologist advised r/o of BV dysfunction. Child
often assumes unusual gaze/head postures
• No meds for ADHD (yet)
• Bright girl “always in motion, can’t sit still”
• High verbal
• Achievement < Potential
Wold
Sentence
Copy.
Time to
complete, errors
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Tests that can grab attention and bypass ADHD
• Patient concludes test is novel / interesting
• Escalating difficulty
• Examples:
1. Getman Visual Manipulation
2. Visual Closure
3. Divided Form Board
MC,2ndGr F 7;8
• Penmanship “horrible, she rushes”
• Copying “usually does not finish
classroom copying”
• Reversals: “she used to do that a lot”
• Decoding Encoding Errors: “sometimes”
• Math: Good, completing math
homework difficult
Binocular / Vergence
• UCT: 0/0’ ACT: 0/0’
MC, 2nd Grade
Visual Efficiency Symptoms
• Blur:
no
• Words move double:
no
• Asthenopia:
no
• Difficulty keeping place:
MC: “yes, if I look away it always happens”
Mom: “Yes, most of the time”
MC, Refractive / Accommodation
(20/20 unaided D and N )
• Cycloplegic Refraction: +1.00 -.50 180
+1.00 -.50 180
• MEM plo-25 180 each eye
• Accomm Amps (pull-away method) 6cm e.e.
• Accomm Facility (+/- 2.00)
OD 15cpm
OU > 12cpm
OS unable
MC, 2ndGr 7;8: Eval (cont)
• Oculomotor: mixed results, purs very poor
Stereo normal
• NPC: refused, leaned way back (false low?)
• Prism Bar Vergence Ranges, near
BI: x/12/8
BO: x/35/25
• Vergence Facility (3BI/12BO): >15cpm
• VIP: mixed results
MCs Attention
Good
Normal to high scores
(DFB 45 sec, 65th %ile)
Weak
Lower scores
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ADHD VT Decision, MC
ADHD VT Decision
VT-Yes
Not hyperactive
Redirect possible
Max ADHD Tx
VT-No
Hyperactivity
Redirect poor
No ADHD Tx
VT-Yes
Not hyperactive
Redirect possible
Max ADHD Tx
↓Accomm & BV
↓ Accomm & BV
Accomm/BV normal 3
Accomm/BV normal
Genuine low scores
Genuine low scores
MC,
3
VT-No
Hyperactivity 3
Redirect poor
No ADHD Tx 3
2nd
3 Low visual skill scores
are “false low”
Low visual skill scores
are “false low”
Grade A & P
ML, 2nd Grade Boy. Large gap between potential (very high)
and achievement
IQ: 125
• No VT, Re-test in 6 months
• Report to Ed Psych: no visual problems
contributing to inattention
• Parent ed re odd gaze behaviors and head
postures
• 15 months later:
Taking methlyphenidate (Concerta 27mg)
BID with good benefit. Doing well in school,
VT workup normal
ADHD, +
meds
LRVP?
Dysgraphia
Grades Low. May
repeat 2nd. CET in place
ML, 2nd Grade LRVP Symptoms
+ Asthenopia / blur / diplopia
+ Difficulty K P
+ Difficulty copying
+ Penmanship slow & messy
+ Frequent Decoding errors
+ Applied spelling errors
+ Reversal & sequence errors
ADD
Dysl
+
+
+
+
Dysgr
+
+
+
+
+
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ML, 2nd Grade LRVP Symptoms (cont.)
+ Unusual fatigue & declining attention with desk
work and reading
ML, 2nd Grade LRVP Eval
• Primary Care Exam: normal
• ↓ VE all 3. Saccades = 5th percentile
+ Poor general coordination & balance
+ Difficulty completing written assignments
“He does try – it’s just so hard”
ML, 2nd Grade LRVP Symptoms
+ Asthenopia / blur / diplopia
+ Difficulty K P
+ Difficulty copying
+ Penmanship slow & messy
+ Frequent Decoding errors
+ Applied spelling errors
+ Reversal & sequence errors
After VT
B+
B+
B+
NC
NLP
NC
NC
• ↓ VIP all 6 subskills low
ex TVPS Visual Memory: 4 points, 2nd percentile
A: +LRVP (LD has 4 factors)
P: VT. Clearly state some symptoms may not change
Parents, after VT
“I have noticed an increase in spontaneous
written output. Less resistant when writing”
“Reading is smoother. No longer uses
bookmarker. Word recognition errors much less”
“Spelling still very poor. Just recently began to
self-correct some of his spelling errors”
“Thankyou very much for helping our son!”
4. Autism
• A developmental disorder of relating and communicating
• Persistent deficits in social communication and social
interaction across multiple contexts
• Restricted, repetitive patterns of behavior, interests, or
activities. Resistant to change
• ½ have normal intelligence
• Sensory processing disorder very common
• Comorbid LD very common
• Wide range of severity and very wide variety of presentations
• Male : Female
4.2 : 1
• Diagnosis: Behavioral checklists
SC, 3rd Grade. + High Functioning Autism
• Autism Dxd at age 2 years. Originally rated as moderate.
Upgraded to mild. IQ normal
• Early childhood therapies: Applied Behavioral Analysis (ABA),
occupational therapy (OT), speech-language therapy.
• +Learning disorder: repeated second grade. IEP was special
day class (SDC) and then altered (upgraded) to regular
classroom with resource room for reading.
• Very poor progress in reading
• Symptoms: Difficulty keeping place while reading, attention
declines with near work, decoding errors, encoding errors,
poor penmanship, copying is difficult, difficulty competing
written assignments, avoids reading
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5/9/2016
Autism, VT Decision
VT – YES
• Max OT completed
Needs OT
• ↓ accomm/BV
acomm/BV good
(accomm/verg dysfunction not as important as it is in ADHD)
• Genuine low scores
False low scores
• VIP deficits
VIP aptitude (some are gifted in VIP)
• Schedule open
(Other therapies completed)
Multiple therapies
Sample VT procedure from lecture
• Vergence range VT occupying/requiring central vision while
simultaneously utilizing peripheral vision & motor
• VT principles:
Raising or lowering demand
Loading: add something else to primary visual skill demand.
(1) Loading insures automaticity
(2) Important to load in autism but not to the point of
frustration / dysregulation
• Central-Peripheral Integration VT for patients with Autism can
be very helpful
VT for LRVP
•
•
•
•
•
•
•
SC, LRVP Evaluation
VT – NO
Appropriate Lenses first
VT for deficient VE and VIP skills
Target
Challenge <-> Load
Transfer
Neuroplasticity
Confirmation of LRVP piece of LD
Primary Eye and Vision Exam: normal
VEE: vergence dysfunction, accomm dysfunction, OMD
VIPE: Deficiencies in Visual Spatial, Visual Memory, Visualization,
Visual Auditory Integration, and Visual Motor Integration
Impression: Test scores genuine (no artificial low scores)
A: LRVP with symptoms
h/o of making progress in other therapies
P: VT 22 visits. Progr Eval on visit 11 and 22
SC, Outcome of VT.
Good attendance and home VT compliance
• Visual skills improve to an overall rating within the
average range. (Visualization low-average)
• All symptoms & concerns less or gone
• “He keeps his place so much better and he is more
willing to read. He reads longer too”
• Shopping: easily locates cereal box
• Maintenance VT assigned
• Re-eval in 6 months
READING REFERENCES
Griffin JR et. al. Optometric Management of Reading Dysfunction
Boston: Butterworth-Heinemann; 1997
Groffman S, Solan HA. Developmental & Perceptual Assessment of Learning
Disabled Children. Santa Ana, CA: Optom Ext Program Foundation 1994
Press LG. Applied Concepts in Vision Therapy. St. Louis: Mosby, 1997
Robinson RG. Autism Solutions. How to create a healthy and meaningful life
for your child. Buffalo: Harlequin, 2011
Scheiman MM, Rouse MW. Optometric Management of Learning Related
Vision Problems 2nd ed. St. Louis: Elsevier; 2006
[email protected]
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