Medical Care

Appropriate referrals to a special education (SPED) setting, specialized tutoring setting, or both can prove important for long-term progress and improved reading performance. Once the learning disorder of dyslexia or dyscalculia have been recognized and delineated, various methods of treatment should be used to assist the child's academic development. Remedial teachers, speech and language therapists, and occupational therapists can all be very valuable in the management of children with learning disorders and may also further refine the spectrum of clinical findings for the pediatrician. Remedial help has been found to have some benefit for dyslexic children, although the research is not universally supportive.

Various treatments regarding ocular dominance, eye teaming, and scotopic sensitivity have been applied to children with reading disorders. Evidence-based clinical research over the past 30 years has determined many of these alternative treatments to be ineffective. The physiological basis of dyslexia is not materially impacted by treatments that do not address the underlying neuroanatomic dysfunction in the phonemic processing.

The pediatric ophthalmologist and pediatric neurologist must explain to the parents that dyslexia is not a disorder of the visual system but rather is a disability in processing separate from the visual pathways to the occipital cortex and is based in neurophysiological maldevelopment of various regions of language development. Visual training, including eye muscle exercises, ocular pursuits, and training with or without bifocals does not benefit children with dyslexia, dyscalculia, or other learning disorders. Tinted lenses or Irlen lenses have also been unhelpful for children with dyslexia.

Balance board training, crawling exercises, and perceptual training have also been ineffective for children with dyslexia and other learning disorders. Some of these controversial methods can even result in delayed diagnosis or delayed treatment for the affected child.

Children with a concomitant diagnosis of ADHD or hyperactivity may benefit from pharmaceutical treatment. However, the parents should be cautioned to realize that such treatments, although they may improve behavior and attention, are not directly associated with improvements in academic performance. The child still requires specific treatments tailored to the management of the dyslexia. Children with associated psychiatric disorders, including depression, anxiety, aggression, or oppositional behavior, can be managed by the child psychiatrist. Many children with dyslexia can become depressed due to the psychosocial impact of being taught separately from peers or the imposed academic expectations of parents who do not yet realize the child has a learning disorder.

School consultations

The Individuals with Disabilities Education Act (IDEA) requires public schools to provide free and appropriate evaluations and education for children with learning disabilities.^[14]Because as many as 20% of all children may have phonologically based reading problems, not all children are evaluated by the school.

If a parent or health care provider suspects a significant reading problem, the parent should make a formal request (ie, a dated letter) for evaluation to the school and request to develop an appropriate individual education plan (IEP). With parental permission, a second letter from a health care provider requesting the evaluation often helps; however, the parent must make the initial request. Although state and local school district regulations differ, most districts must comply with a request for evaluation within 60 school days.

SPED services provided for a child with a reading disability typically include some time each day in a small group with a reading specialist. The child spends the remainder of the day in a standard classroom.

In addition to SPED, many elementary schools also offer the Title I enhanced reading program, which is designed to address the reading needs of economically disadvantaged children. In schools that offer the Title I program, a parental request for those services is often the sole requirement. No formal assessment is required for participation in Title I, although assessment might help some children. In many school districts, all reading programs in kindergarten and first and second grades are administered through the Title I mechanism; SPED is reserved for reading problems in the higher grades.

Intervention strategies

Reading problems affect many children; however, skillful early intervention at school or home can help ameliorate mild reading difficulties. The following strategies apply both to early intervention and to remedial work for an older child who reads poorly:

Phonemic awareness tasks in kindergarten include rhyming, making discriminations between similar but different words, blending sounds into words, isolating sounds from words, and segmenting words. These tasks prepare the child for reading, and all have shown some effectiveness in research settings.
Explicitly teaching children about segmenting and blending words has proven more effective in teaching reading than programs that do not explicitly teach those skills.
In first grade, explicit instruction in how the most common sounds are spelled enhances both reading and spelling skills.
Showing children how to sound out words and providing texts they can decode helps in practicing and retaining learned sound-spelling relationships.

Some schools do not emphasize these processes. The only option for children in these schools is to find an appropriate reading tutor or after-school reading programs. Programs that use the Orton-Gillingham or Lindamood-Bell methods have some success teaching students with reading disorders. Both systems emphasize sound recognition and sound-symbol relationships as the basis for reading.

Parents should evaluate private reading clinics and should also inquire about reading clinics offered by local colleges of education. Helpful software programs are also available to teach phonemic recognition; programs such as Reader Rabbit or Blues Clues can be effective adjuncts to tutoring and classroom intervention.

Medication

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Author

Eric R Crouch, MD Associate Professor of Ophthalmology, Eastern Virginia Medical School; Assistant Professor of Pediatrics, Children's Hospital of The King's Daughters; Consulting Staff, Virginia Pediatric Eye Center

Eric R Crouch, MD is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Peter M Dozier, MD Assistant Professor of Pediatrics, Eastern Virginia Medical School; Director, Division of Child Psychiatry, Children’s Hospital of The King’s Daughters

Peter M Dozier, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Angelo P Giardino, MD, PhD, MPH, FAAP Wilma T Gibson Presidential Professor and Chair, Department of Pediatrics, University of Utah School of Medicine; Chief Medical Officer, Intermountain Primary Children's Hospital

Angelo P Giardino, MD, PhD, MPH, FAAP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, International Society for the Prevention of Child Abuse and Neglect, Ray E Helfer Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author W Douglas Tynan, PhD, to the development and writing of this article.