Optometric Vision Training

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conspiracy by people in the missing child business. That includes the media, which feast off the sensation, which is sad enough without hype or press agentry.

What can pediatricians do? As always, we must

stand up to the winds of fashion and expedience,

and speak out for the best interests of children.

Both on the national, state, and local levels, we

should demand that “authorities” who make claims

about missing children cite the sources oftheir data.

This does not mean ignoring the horrible problem

of stranger abductions. It does mean putting the

matter in perspective.

The qualifications of those involved in the

var-ious child-finding organizations should be known.

Professional help should be available to children

who are “found.” Support services for runaways

would seem more appropriate than placing their

pictures on grocery sacks. The capability of the

criminal justice system to deal with abductions by

noncustodial parents needs improvement in most

communities. In general, if the corporations

climb-ing on the missing-child bandwagon would

subsi-dize the hiring of a few extra detectives instead of

self-serving advertising, fewer children would be

frightened, and more missing children would be

found.

ABRAHAM B. BERGMAN, MD

Department of Pediatrics

Harborview Medical Center and

the University of Washington Seattle

Optometric

Vision Training

Optometric vision training is controversial, and

knowledgeable individuals question its targets and

efficacy. In responding to a position paper of the

American Academy of Pediatrics, the American

Association for Pediatric Ophthalmology and

Stra-bismus, and the American Academy of

Ophthal-mology on learning disabilities, dyslexia, and

vi-sion,’ Flax et a12 raise issues worthy of close scru-tiny, and recent literature provides useful perspec-tive.

Before commenting on the issues, the air should

be clear on the central perspective: the American

Academy of Pediatrics, American Association for

Pediatric Ophthalmology, and American

Associa-tion for Pediatric Ophthalmology and Strabismus

have expressed one, and only one, concern in

pro-mulgating their position: the best interests of people with learning disabilities. The number of American

Academy of Pediatrics, American Association for

Pediatric Ophthalmology, and American

Associa-tion for Pediatric Ophthalmology and Strabismus

members who perform “vision training” is

negligi-ble, if not zero. Therefore, they have no vested

interest in the evaluation of such techniques, and

take a position only as patient advocates.

The Flax response2 was, unfortunately, directed

to a preliminary document and not to the final

approved position statement; as such, some of the

criticism does not pertain. Withal, Flax et a!

ob-serve the confounded nature of the literature on

this subject. Indeed, this is a major and persistent problem, in particular, for advocates of optometric vision training.

Flax et a! allege that the statement is “aimed at

discrediting optometry”2; this is incorrect. The pur-pose is to look disapassionately at the evidence for

involvement of ocular and visual dysfunctions in

the learning process and at certain proposed

inter-ventions, be they optometric or other.

Unfortu-nately, the strident tenor of the response does not

advance the issue; the pejorative approach-to

“dis-credit the basis of the AAO[American Academy of

Ophthalmology] policy”-is conspicuously narrow

and diminishes the claims of developmental

optom-etry. A concerned professional will wish to read the citations (plus those referenced herein) to draw his or her own conclusions.

Now, to the issues. Several questions are worthy

of further consideration.

What are learning disabilities? To arrive at

con-sensus definitions would benefit all who are

con-cerned for affected individuals. Curiously, Flax et

a! rail against a lack of definition while avoiding

providing one of their own, a consistent deficit in

optometric vision training literature. In fact, the

final, approved policy statement does refer to

char-acterizations by others.3’4 Beyond this, there are

straightforward operational5 and statutory6

defini-tions. For the American Academy of

Ophthalmol-ogy and American Association for Pediatric

Oph-thalmology and Strabismus to define learning

dis-abilities probably goes inappropriately beyond their

legitimate roles. To comment on the purported

association of visual and ocular problems certainly

is within their purview.

Are there differences in ocular function between

learning-disabled and normal populations?

Helves-ton et a!7 have collected compelling evidence in a

carefully controlled study that there are no

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PEDIATRICS

Vol. 77 No.

1 January

1986

ance and visual function. Similar conclusions were

reached by Scandinavian researchers noting a

dis-turbingly high number of unnecessary spectacles

provided to poor readers.8 In a prior comment, Flax

et al#{176}muse on the “potentially additive nature between visual factors and reading ability,” without

demonstrating the synergy. The authors

acknowl-edge that optical and “problems involving ocular

health do not occur with unusual frequency in a

learning disability population.” Yet they vaguely

suggest that hyperopia, convergence, and

accorno-dation are “more positively related to learning prob-lems,” and that “a number of more subtle binocular

dysfunctions h,ave been implicated.” These “subtle”

dysfunctions are unspecified and unquantified;

per-haps they are illusory. The failure to demonstrate and quantify these “dysfunctions” is characteristic

of optometric vision training literature. This is a

core issue: ifthere is no difference in visual function

between normal and learning-disabled individuals

(apparently the case), there is little rationale for vision training.

Keogh’#{176} proposes three additional important

questions. What is optometric vision training? The

policy statement does not ‘refer specifically to

op-tometric vision training, only to some elements

included in many optometric vision training

regi-mens. Virtually all optometrists who perform

op-tornetric vision training use spectacles, often with low (sometimes no or trivial) power, often multiple

prescriptions, with or without prisms, bifocals, etc;

nearly all employ some form of ocular movement

and/or manipulation of accommodation (focusing).

Many optometric vision training regimens

encom-pass other elements, including general body

move-ment, exercise, diet, perceptual training, and

im-portantly, standard remedial educational

tech-niques. Despite proprietary hubris (“the only

profession specifically licensed to practice vision

training”2’9), all of these components may be and

legitimately are provided by other professionals, especially remedial education specialists.

But what, specifically, are the necessary and

suf-ficient components of vision training? A review of

the literature concludes they are “unspecified, thus untested.”’#{176} Indeed, it seems that there are “almost

as many training programs as there are vision

trainers.” Furthermore, it is “somewhat

paradoxi-cal” that vision training is being recommended and

“used for a broad range of problems . . . reading

readiness screening for school, the treatment of

juvenile delinquency as well as the treatment of

learning disabilities.”’0 In this regard, optometrists

assume broader roles as family counselors and

con-sultants on problems of development, educational

advisers, and sources of information on nutrition

and child-rearing. One may legitimately question

the ability of an optometrist to function in such

complex substantive areas.’#{176}

For whom is vision training appropriate? This

question is not simply answered, as the literature presents a “confused, even conflicting picture of the

relationships between reading, behavior, visual,

cognitive, and linguistic functions. To focus on a

single aspect of learning problems and to interpret

an association or relationship as if it had causal

implications goes beyond the evidence. If visual

inefficiency is not the cause of any reading

prob-lems, vision training is not the treatment of

choice. . 1O; and the evidence is considerably less

than compelling.5”#{176}” Optometric vision training

literature intimates that the target population is

extraordinarily diverse, including, for example, ju-venile delinquents and people suffering from

learn-ing disabilities and mental and/or motor

retarda-tion; this view strongly suggests that the benefit (if any) of optometric vision training is nonspecific.

What is the evidence for the effectiveness of

vision training practices? Keogh’#{176}has concluded

that the efficacy question is unanswerable given

present data. The literature is rife with the follow-ing problems: there is a “broad range of techniques

and methods”; there is “inconsistency and

con-founding in the nature of the samples used,”

yield-ing a “heterogeneity of subject characteristics”;

there is a low, but “consistent relationship among

many individual difference attributes,” possibly

representing sampling artifacts; and a particular

problem “is that many studies are not ,available

through the usual professional and scientific

pub-lications . . . and do not meet rigorous research

standards.”#{176}

Levine” comments: “Several heuristic tendencies

have undermined the scientific basis of research

into the causes and treatments of learning

disor-ders. These have included (1) overreliance on

an-ecdotal evidence; (2) a lack of carefully matched

comparison groups (both normal and

dysfunc-tional) and, consequently, a poor appreciation of

what constitutes normal variation and factors

corn-mon to multiple forms of deviation; (3) and initial

preconception that a factor in isolation causes a

reading disability in contrast to a condition being

the end result of multiple convergent influences;

(4) an exclusive stress on mean differences between groups of good and poor readers rather than cluster analyses that consider multiple interactive factors

and subgroups of affected students; (5) an

assump-tion that there exists only one method by which

normal children read; (6) a tendency to interpret

findings narrowly so that inattention to visual

de-tail, for example, might be regarded as a visual

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

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defect rather than a broader manifestation of

atten-tional weakness in all modalities; (7) a failure to

control for nonspecific gains accrued simply by

bestowing more attention upon a child (such as

through tutoring, visual training, a rigid diet, or

even oboe lessons); and (8) a peculiar tendency for

research on therapy to be undertaken by individuals with a vested interest (often pecuniary) in a positive outcome.” Long-term follow-up studies of learning-disabled persons, affected by any intervention, will

be required to determine how inconsistencies may

be resolved.’2

In considering the efficacy issue, three aspects

are illustrative. First, experience reveals that spec-tacles are provided to the vast majority of children

undergoing optometric vision training, despite the

demonstrably low incidence of ocular motility or

refractive deficits.79 The justification for routine integration of spectacles into the program is

unsup-ported and often not discussed. The benefit of

excessive dispensing is important to document on

more than speculative grounds, given the

signifi-cant cost of these devices. Second, Flax et al claim

“salutary effects of perceptual training.”9 In this

area, the evidence would appear to be particularly

weak. Kavale and Mattson, using meta-analysis,

demonstrate “that perceptual-motor training is not

effective and should be questioned as a feasible

intervention technique.”13 Indeed, “Regardless of

how global or how discreet the aggregation, the

effects of perceptual motor training present an

un-broken vista of disappointment.”’4 And third,

ocu-lar pursuit or “tracking” deficiencies are alleged. Recent evidence demonstrates that these

“deficien-cies” disappear when content is corrected for

read-ing level, and “oculomotor control of dyslexic chil-dren is similar to that of normal children.”’5

There-fore, routine spectacles, perceptual training, and

“tracking” exercises are particularly vexatious

(from a rational perspective) components of

opto-metric vision training.

In sum, heterogeneities of both program and

sub-ject variables, plus superficial and inconsistent evaluation of data, do not permit a positive

conclu-sion about optometric vision training efficacy.

Keogh’#{176}concludes: there is limited consensus

about the content and targets for vision training;

there is little definitive evidence for its

effective-ness, and this may lead to a number of wasteful

and ineffective intervention efforts; and the role of the developmental optometrist needs clarification.

FUrthermore, legitimate and practical questions

re-main substantially unanswered: For whom is vision

training effective?, What are the necessary and

sufficient components of vision training?, What

does vision training do that other programs do not?

And what does vision training do better than other

treatments? It is insufficient to recommend

inter-vention (optometric vision training) on speculative or self-interest bases (“The more we do, the better off we are”’6). Keogh’#{176}suggests that there “may be

some merit to the approach,” and optometrists may

opine that “it works.” Yet, time and financial

re-sources are finite. Optometric vision training’s

ef-fectiveness has not been established, and it is

time-consuming and expensive. Concentrating efforts on

educational methods is not unlikely to be a more

direct and cost-effective intervention.

The goal of research should be to provide a sound and scientifically valid test of practices with respect

to vision training. Research should be designed to

avoid prevalent extraneous maturational, placebo,

Hawthorn, and Clever Hans effects. Rigors of

re-search include independent statistical design and

analysis, careful isolation of variables, appropriate

control groups, masking of therapists and

observ-ers, and independent evaluation of effects. Until

data that legitimately define the areas of

effective-ness of vision training (if any, for whom, by what

means) are extant, one may alternatively and

logi-cally conclude that vision training is only effective to the extent that it incorporates standard effective

remedial educational techniques or benefits from

extraneous effects.

We encourage optometry’s scientific evaluation

of these important issues. We agree that “(t)his

may require the expertise of optometrists,

educa-tors, psychologists, and medical researchers, possi-bly in tandem.”#{176} We believe that the American

Academy of Pediatrics, the American Academy of

Ophthalmology and the American Association for

Pediatric Ophthalmology and Strabismus are

corn-mitted to the appropriate remediation of

individu-als with learning disabilities and to fostering valid

research in this area.

REFERENCES

GEORGE R. BEAUCHAMP, MD

Chairman, Committee on Vision

and Learning Disabilities

American Academy of Ophthalmology

Cleveland

1. American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Oph-thalmology and Strabismus: Joint policy statement: Learn-ing disabilities, dyslexia, and vision. January/February 1984 2. Flax N, Mozlin R, Solan HA: Learning disabilities, dyslexia,

and vision. J Am Optom Assoc 1984;55:399-403

3. Mattis 5, French JH, Pepin I: Dyslexia in children and young adults: Three independent neurological syndromes.

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124 PEDIATRICS

Vol. 77 No. 1 January

1986

4. Mattis 5: Dyslexia syndrome: A working hypothesis that

works, in Benton A, Pearl, D (eds): Dyslexia: An Appraisal of Current Knowledge. New York, Oxford University Press,

1978, pp 45-58

5. Metzer RL, Werner DB: Use of visual training for reading disabilities: A Review. Pediatrks 1984;73:824-829

6. Saunders BA, Saunders HL: The role of eye disorders in learning disability. J South Med Assoc 1980;76:527-529

7. Helveston EM, Weber JC, Miller K, et al: Visual function and academic performance. Am J Ophthalmol 1985;99:346-355

8. Blika 5: Ophthalmological findings in pupils of a primary

school with particular reference to reading difficulties. Acta Ophthoimol 1982;60:927-934

9. Flax N, Solan HA, Suchoff IB: Optometry and dyslexia. J Am Optom Assoc 1983;54:593-594

10. Keogh B, Pelland M: Vision training revisited. J Learn

Disabil 1985;18:228-236

11. Levine MD: Reading disability: Do the eyes have it? Pedi-atrics 1984;73:869-871

12. Horn WF, O’Donnell JP, Vitulano LA: Long-term follow-up studies of learning disabled persons. J Learning Disabil

1983;16:542-555

13. Kavale K, Mattson PD: One jumped off the balance beam: Meta-analysis of perceptual-motor training. J Learn Disabil

1983;16:165-173

14. Kavale K, Glass GV: Mets-analysis and policy decisions in special education. In Keogh BK (ed): Advances in Special Education. Greenwich, CT, JAI Press mc, 1984, vol 4, pp 195-257

15. Black JL, Collins DWK, DeRoach JN, et al: A detailed study of sequential saccadic eye movements for normal-and poor-reading children. Percept Mot Skills 1984;59:423-434

16. National Panel Report: ODs push VT research, news review.

Rev Optom May 1985, p4

Health

Insurance,

Medical

Care,

and Children’s

Health

We welcome this opportunity to respond to

pre-viously published commentaries by Drs Haggerty,

Starfield, and Dutton on our discussions of how

cost sharing affects the use of medical services and health status.”2 Our purpose in responding is three-fold: to reiterate succinctly the major conclusions

of the Rand Health Insurance Experiment, to

re-spond to issues raised by the commentators, and to

emphasize certain points of agreement with them.

Our goal is to promote a better understanding of

the experiment and spur further discussion about

the structure of health insurance for children.

The views expressed are those of the authors and do not neces-sarily represent those of the Department of Health and Human Services or the Rand Corporation.

Reprint requests to (R.B.V.) The Rand Corporation, 1700 Main St, Santa Monica, CA 90406-9972.

WHAT

DID WE

SHOW?

In the Rand Health Insurance Experiment, a

total of 1,844 children from six areas participated

in a randomized experiment on the effects of cost

sharing in health insurance policies. Families were

assigned in an unbiased manner to insurance plans

that covered a broad range of medical services but

varied in the fraction of medical bills that the family

had to pay out-of-pocket. The out-of-pocket

ex-penditure was subject to a limit of $1,000 per year,

or 5%, 10%, or 15% of family income, whichever

was less. Families participated for 3 or 5 years;

participants received care from the physician of

their choice in the fee-for-service sector.

Our findings showed that for the average

Amer-ican child:

1. Free medical care increased expenditures by

one third over what occurs with moderate cost

sharing, such as most American children today

experience. Virtually all of the increase in

ex-penditures was attributed to an increased number

of outpatient visits.

2. This increase in the use of medical care did

not produce any measurable impact on health

sta-tus. Confidence intervals around our estimates were

sufficiently narrow to reject the hypothesis that

meaningful differences in health status produced

by different levels of insurance could have been

missed.

3. At the end of the experiment, substantial

numbers of children with free care had untreated

conditions for which medical care is effective. For

example, children entitled to free care averaged

more than three office visits per year; yet, 30% had

visual acuity problems that were inadequately

cor-rected.

4. For the child at risk of illness due to a

preex-isting condition, our findings on the use of services

were similar to those of the average child, but the

effects on health status were less certain. Although we did not find statistically significant differences

in our insurance plan contrasts, the confidence

intervals were wide enough for some measures to

include clinically important differences. In

partic-ular, differences for anemia and hearing could have

been missed for children from low income families

who began the study with these conditions.

Based on these findings, we concluded that

“pro-viding medical care free to all children is not justi-fled by the health benefits realized.” Providing free

medical care to children may be justified on other

grounds-for example, to meet societal

expecta-tions and desires. Clearly, a case for free care can

be made on the basis of equity for those chronically ill, because cost sharing for these children requires

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1986;77;121

Pediatrics

GEORGE R. BEAUCHAMP