The Right Book for the Right Child

There’s an interesting discussion in the New York Times “Room for Debate” series concerning finding appropriate reading material for children.  The “debate” centers around whether to allow children to read whatever they want, even if the book they select may present themes and issues that may be difficult for the child to understand.  Is Harry Potter appropriate for a precocious 6 year old?  What about other “chapter books” that expose children to evil, war, death, and intolerance? or diversity, love, and overcoming adversity?

There are 8 “debaters” that present their ideas on this topic.  Most center around whether it is a good or bad idea to allow children to read books when they may not be emotionally mature enough to grapple with these issues.  Here are some of the opinions:

• “But because reading is such a collaboration between the reader and the storyteller, young readers are likely to “self select” when it comes to the maturity level of their choices. If a child doesn’t have what’s required for a particular book, they’ll put it down.”  (Matt de la Pena)
• “It is a disservice to children to introduce them to books they are not emotionally ready for or to books that they do not yet have the narrative, historical or cultural scaffolding to understand. They may read the words, but it will not be the emotionally consuming, imaginative, unforgettable pleasure that readers seek.”  (Janice Harrington)

I especially like the opinion of Deborah Pope.  She frames the question differently.   She writes of the trend away from picture books, especially for gifted children.  Why rush?  She feels there is much to be gained from spending time enjoying picture books: visual literacy.

• “Children learn certain critical comprehension skills from picture books that cannot be taught through chapter books: interpreting imagery based on the information given in the text; understanding that there is more to a story than what the words alone convey; and visualizing a story in their own mind’s eye. Mastering visual literacy is fundamental to success with more advanced material.”

She then goes on to conclude that if we want our children to be successful, independent and motivated learners, we must share the experience of reading with them.

I remember a conversation I had with a woman I met while traveling.  She had 2 children, and when they were very young, their father began to read to them every morning during breakfast.  Ten years later, that family tradition continues, because the children continue to ask him for this simple gift.

When my parents moved to Florida, my father would make his own “books on tape” for my children.  He started with simple picture books when they were very young, and eventually moved up to children’s classics.  When those books conjured up images and memories of his own childhood adventures, he would include them in his rendition.   The tapes were not tied to any birthdays or holidays.  When he finished, he would mail the tapes and the book… my children loved receiving those packages.  And now, though my father is gone, his storytelling is still with us.

So start a family tradition, pick a book, one with lots of pictures, and read it to your child.  You  will be building your child’s visual literacy, and so much more.

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The Need (part 1)

Research presented this morning at COVD’s annual meeting had an uber important message:  we need more vision therapy!  Drs. Lisa Christian, Angela Peddle, and 4th year students Shannon Pennifeod and Beth Schellenberg presented the preliminary results of a very important study.

The doctors and students from Waterloo School of Optometry reviewed the records of young patients, all of whom  had been identified as learning disabled by the district school board.  Before writing an individual education plan (IEP) for each, the school board advised that each student have a comprehensive vision examination performed by the pediatric service of Waterloo School of Optometry.

The records of 68 students ranging in age from 6-12 years were reviewed.  None of them had ever had a previous eye exam.  Children requiring spectacles were not included in the study.  The number of vision problems discovered in this population was astounding.

• 43% had reduced stereo vision
• 67% had binocular dysfunction at near
• 36% had signs of convergence insufficiency
• 38% had deficient accommodative skills

Six measurements of binocularity were obtained; 60% of patients failed two or more of those tests.

Children with reading problems who require individual education plans are at high risk for vision problems. What would have happened if these children were not referred for a comprehensive vision examination?  They would have continued to struggle with undiagnosed vision problems.  We need comprehensive vision examinations for ALL children entering school.  Many of theses children will also require vision therapy.

Does your child have a reading or learning disability?  Please make sure that child has a comprehensive vision examination.  Make it happen.

Find a doctor in your area.

Read more about comprehensive eye examinations here.

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The Splash – From Ripples to Waves

Check out this video highlighting a child that has been helped with vision therapy.  In the feature story, the child says he went from C’s and D’s to A’s and B’s in a matter of months.  To me it is another great example of how these developmental life altering vision problems can impact school performance and beyond.

This child’s developmental optometrist is Dr. Carol Scott.  She is the reason I am a developmental optometrist today.  During my first year of optometry school, Dr. Scott came and lectured about children she was working with.  She talked with passion about how so many of these smart, intelligent children were struggling in school due to treatable vision problems.  She talked about the profound impact treating these vision problems had on these children – in many instances, completely altering the trajectory of their lives.  Unfortunately, in our society,  if you cannot read well and therefore cannot perform well in school, so many doors quickly close to your future.  I knew during that lecture that this was the part of my profession I wanted to practice for the rest of my life.

In thinking about that moment, it is amazing how Dr. Carol’s seemingly small act of lecturing to a group of first year optometry students had such a profound impact on my life.  Before attending her lecture, I had considered vision therapy to be one of the last things I wanted to do in my future practice.  Now as a developmental optometrist I see the lives of children change everyday.

And so it is with vision therapy.  The way we will reach the many people who can benefit from developmental optometry  will be the accumulation of many little ripples.  The ever-growing number of lives affected and the ever-mounting body of evidence supporting vision therapy are becoming the waves that will bring our brand of optometry to the mainland.

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The Science: Performance-Related Symptoms

Convergence insufficiency (CI) is a common visual disorder that is characterized by great difficulty maintaining binocular eye alignment when looking at something close up (such as a book or a writing assignment).  This landmark study, funded by the National Eye Institute, provides strong evidence that office-based vision therapy is the most effective treatment for CI.  Treatment success can and should be measured 2 ways: objectively (looking at changes in measurements used in the diagnosis of CI) and subjectively (looking at changes in symptomology associated with CI).

The Convergence Insufficiency Symptom Survey (CISS) was developed to quantify the frequency and severity of symptoms reported by patients with CI.  The 15 symptoms on the CISS can be divided into 2 categories: performance- related and eye-related.  There are 6 performance-related symptoms evaluating visual efficiency when reading and/or performing near work:

• Loss of place
• Loss of concentration
• Having to re-read
• Reading slowly
• Trouble remembering what you read
• Getting sleepy when reading

The 9 eye-related symptoms include blur, headaches, double vision, tired, sore, uncomfortable eyes, words that move and jump, and pulling sensations around the eyes.

This study evaluated the symptomology of children with Convergence Insufficiency before and after optometric vision therapy.   Before vision therapy, the six most frequently reported symptoms were the six performance -related items. Fifty percent of all the children in the study responded “fairly often or always” when asked if they lose their place when reading.  Similarly, 45% of the children reported loss of concentration and having to re-read; 40% read slowly; 38% have trouble remembering what they read; and 37% get sleepy when they read.

Children with parent-reported ADHD (attention-deficit hyperactivity disorder) had significantly higher symptom scores on the CISS and the higher score was almost entirely attributed to an increase in the frequency and severity of these performance-related symptoms.

The good news is that ALL the children who responded to treatment reported a decrease in ALL their symptoms.  And while this study did not look at academic performance, the authors do note this relationship when they state: “the treatment of symptomatic CI may have a positive impact on reading performance and attention.”

What is the take home message?  If your child has a convergence insufficiency, it is important to consider both eye-related and performance-related symptoms.  Your child may not be complaining of blurred or double vision, but they still might have performance-related symptoms.  Loss of place, re-reading, poor reading comprehension, slow reading, sleepiness, poor concentration….. am I describing your child’s symptoms?  Have you considered a vision problem as a possible explanation?

Read more about convergence insufficiency here.

Reading more about vision and ADHD here.

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The Splash – Persistent Parents

Our guest blogger this month, Carrie Hall,  is one of the very talented vision therapists at my practice. She brings a unique perspective to the blog since she works with patients every week often times for many months.  Because of this,  she often gets to know the patients and their families on a very personal level and truly gets to know the struggles, trials, and triumphs patients go through.  At the conclusion of COVD’s National Vision and Learning month, I think her perspective into one of our patients is a perfect addition to what has been a great highlight of many inspiring vision therapy success stories.

As a vision therapist, I often see a theme among the parents that I encounter. Though they are of various ages, personalities, beliefs and styles, they often share one certain characteristic that sets them apart as vision therapy parents. They are incredibly persistent. They have been told many times in their lives that their children may not be capable of certain things. Perhaps by a doctor intending to give them a realistic expectation of the future, or perhaps by a teacher who is frustrated by a lack of success in their child. Whatever the source, I encounter parent after parent who has been informed that their child will not be capable of a certain level of ability, be it athletic,  academic, or just general life skill development.

Lynn was one such parent. Her daughter Shelby was simply not blooming in school like her older sister had. Reading was inexplicably difficult for this 8 year-old. Always a fight, often involving tears, Shelby simply would not take to reading. Lynn was baffled. Shelby was obviously bright and determined, a spunky and enthusiastic girl. It just didn’t add up. The pieces did not fit. Her eye doctors confirmed that Shelby’s vision was fine. She had 20/20 acuity, so the only reason why she shouldn’t be learning to read was if she simply wasn’t as smart as Lynn thought.
Perhaps some parents are more inclined to take the words of professionals at face value than others. Perhaps some parents simply refuse to be satisfied with an underwhelming determination of their children’s potential. Whatever is the mitigating factor, Lynn could not and would not be satisfied with this evaluation of her daughter. She persisted in her search. When she eventually found Washington Vision Therapy Center whose symptom checklist of vision-related learning problems read like a specific description of Shelby’s struggles, Lynn knew she had found her answer. When confronted with the financial strain that therapy would mean for her family, her persistence did not waiver. She would make whatever sacrifices were necessary: she would ensure her daughter’s chances for success in school and life no matter what.
Maybe persistence is a genetic trait as well. I certainly saw the same attributes in little Shelby that her mother demonstrated. Months after beginning therapy, after countless lifesaver cards and hart charts, Shelby was burnt out with it all. Who can blame her though? When the goal of all the work is just to get better at doing homework, it hardly seems a fair thing to ask of a girl of 8 who would rather be playing outside than getting better at reading any day of the week.
But like I said, maybe persistence is a genetic trait. Or perhaps it’s more nurture than nature. Whatever the case, Shelby persevered. Not only did she make it through therapy, she did great at it. She learned to be able to coordinate the use her two eyes like the best of them by the time it was all said and done. She and her mother developed a balanced working relationship in regards to this specific area in order to attack vision therapy head-on and accomplish every last bit of what Dr. Winters wanted to see from her clinically. Neither one of them would quit. Lynn pushed Shelby, and Shelby pushed right back in order to finish well. That little girl was the definition of persistence.
It’s the characteristic that marks out the parents, and the patients as well, for success. They are all up against diagnoses and school evaluations that make the future look bleak. They have been told repeatedly that they can’t, that they won’t. But they refuse to listen. Little fighters, they are, coming in and out of our offices defying the odds stacked up against them.
The other day, Shelby came up to her mother after doing some reading and said, “You know Mom, I think I like this reading thing.”  She is now at grade level in reading.  That is the payoff for any persistent mother.  Lynn has continue to fight to get Shelby’s story of hard work and persistence out to the public and she is now being featured on COVD for National Children’s Vision and Learning month.
http://www.cisionwire.com/college-of-optometrists-in-vision-development/r/mom-of-struggling-reader-finds-help-and-speaks-out-for-college-of-optometrists-in-vision-development,c9283372
Imagine that. A homeshooling mom from Yakima, Washington who believed her child’s struggles with reading were more than a resistant attitude or just that her daughter wasn’t smart enough. Persistence is a powerful thing.

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Building a House With Dr. Amorita Treganza

Amorita Treganza as “Miss Lemon Grove”

Dr. Amorita Treganza received the Skeffington Award  in 1986 .  She was another GIANT in developmental optometry.  She was instrumental in the birth of COVD as the national (and now international) organization of developmental optometry.  In fact she served as COVD’s first president, in 1971.   When I typed her name into Google, I was delighted to find this story about the celebration in Lemon Gove, CA, honoring her life and legacy , 100 years after her birth.  Dr. Treganza continues to be  an inspiration and role model for women pursuing optometry, especially those of us specializing in developmental vision.  Dr. Treganza is the co-author of Optometric Evaluation of Children with Academic Dysfunction, published by the Optometric Extension Program, from 1977-78. 

In her case presentation to parents, Dr. Treganza would often begin by separating the vision problem and the reading problem.  She would use the analogy of building a house.

Vision is the foundation.  Vision provides the platform, the stability and the strong beginning on which the remainder of the house will be built.  Reading is the structure of the house; the framing, walls, ceiling and finishing work.  The visual dysfunction affects reading efficiency.  It eliminates or puts crack in that foundation that is supposed to provide stability and strength.  Learning to read and reading to learn are both more difficult.  Attempts to teach that child to read may add a few boards to the walls of the house, but what might we expect if the foundation is unstable and weak?  The pieces won’t fit together and won’t function properly.  At best it will be disorganized, and at worst, it will be unusable!  In order to treat the academic dysfunction, it is necessary to start at the beginning, by rebuilding the foundation.  This can be accomplished with optometric vision therapy.  Then, it is possible to address the reading problem with the appropriate educational intervention.  The framing, walls, ceiling and finishing touches can be built.  Just as building a house requires a team effort (contractor, plumber, electrician, carpenter, etc) so does treatment of the academic dysfunction.  Optometrists, parents and educators must work together.

–August is National Children’s Vision and Learning Month–

So let’s build some houses, from the ground up.   If your child has academic problems, please schedule a vision examination today! 

Find a developmental optometrist in your area.

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The Science – Visual Factors a Primary Cause of Beginning Reader Failure

August is National Children’s Vision and Learning Month!

As promised I wanted to take the next few Science entries to highlight great research showing the correlation between vision and academic performance.

One thing that always amazes me is how just about every mom in America knows that their child needs to get their child’s teeth checked by a dentist before they enter school.  Yet, very few know that they they should get their child’s eyes checked by their eye doctor before those very first days learning how to read.  To which I always think, “How much learning do you do with your teeth.”

A great study named “Visual Factors – A Primary Cause of Failure in Beginning Reading” published in Optometry and Vision Development* looked to see if vision was something that impacted children’s ability to learn to read.  I think all of us can imagine that visual acuity or the ability to see clearly would impact a child’s ability to learn to read, which the study affirmed, but the study also found something else important.  Binocular function, or the ability to use the eyes together in tandem, was also a significant factor in impeding beginning reading.  And doesn’t that make sense?  If we cannot get the two eyes to point to the same place on a book, then a child will see doubling or overlapping of letters on the page.  Obviously, that could make an already difficult task of learning to read much more challenging.

So let’s think about the school screening or the vision check that pediatricians do.  We stand the child 20 ft from the letters on a wall and ask the child to cover an eye.  How much does that check how well the child can use both eyes up close for 5 hours a day at school?  Unfortunately, not very much.  Now, this is not to fault the dedicated school nurses and pediatricians.  Vision is not their specialty.

It does tell us however, that every child needs to have their vision checked before they enter school by their family eye doctor and every one to two years thereafter.  And it also tells us that every parent needs to know the warning signs of a vision problem that may need to be addressed by a developmental optometrist.

• Headaches, eye strain, or tired eyes with school work
• Slow or hesitant reading
• Skipping words or lines on a page when reading
• Words moving, doubling, or floating on the page
• Taking hours to do 20 minutes of schoolwork

August is National Children’s Vision and Learning Month!

Schedule a vision examination for your child TODAY!

To find a developmental optometrist near you, follow this link .

For more information on vision problems that affect school performance, learning, and reading please visit the COVD website at www.covd.org.

*Young B, Collier-Gary K, Schwing S. Visual factors – a primary cause of failure in beginning reading. J Optom Vis Devel 1994;25(Winter):276–88.

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Dr. Harold Solan — Visual Attention and Reading

Dr. Harold Solan received the Skeffington Award in 1990.  At that point, his body of work was quite impressive.  But he was only getting started!  He continued his research, writing and scholarship for many more years.  In many ways, his post-Skeffington Award work was even more influential.  It is very difficult to choose one “topic” or article to highlight his contributions to developmental optometry.  I suppose I shall have to write more about Dr. Solan’s work. 

Dr. Harold Solan

Attention is often defined as the ability to focus on relevant stimuli as well as a decrease in responsiveness to irrelevant information.  In reading, visual attention increases the ability to read efficiently across a line of text.  Readers must learn to use the oculo-motor system to move their eyes accurately.  First they must focus on the first word on the line, then they must shift their attention to the right as they prepare to move their eyes to the next fixation point, then they must sustain their attention in order to allow for processing of the text.  These three principal elements of attention–focus, shift and sustain—are the link between perception and cognition.  Perception makes the visual information available but not necessarily recognizable.  Cognitive processes allow the reader to use the visual information in order to gain meaning.  In other words, reading comprehension is dependent upon visual attention as expressed by accurate oculo-motor control.  Therefore, vision therapy that is directed at improving focus on relevant stimuli, shifting attentional focus within a complex visual environment, and sustaining attention for an appreciable interval might be expected to improve reading comprehension.

Dr. Solan and colleagues investigated this relationship in a group of 6^th graders with moderate reading disabilities.  These students attended public school in New York City.  On a standardized reading test, their reading comprehension scores averaged 2.2 years below their grade level.  The students’ attention skills were assessed using a standardized testing battery.  Then they received 12 one-hour sessions of vision therapy.  The therapy consisted of specific procedures which were aimed at improving or enhancing focusing, shifting and sustaining visual attention during oculo-motor (eye movement) activities.  After completing the 12 hour therapy program, the students were retested with both the standardized reading and attention tests.  Their scores improved significantly on both measures.  After 12 hours of vision therapy over 5 months, their average reading scores jumped an entire grade level, from the 4^th to 5^th grade level.  This is in sharp contrast to the first 5 years of schooling, when their reading scores improved from a 1^st grade to a 4^th grade level.

Dr. Solan’s research supports the notion “that a link exists between visual attention, oculomotor readiness, and reading comprehension…”  He acknowledged that uncertainties still exist.  For example, the therapy also incorporated memory, speed of processing and executive functions.  How does the engagement of this triad influence cognitive performance and reading comprehension?  Dr. Solan’s research always answered BIG questions but at the same time, left more questions to consider.  That way, he never ran out of ideas for his next research project.  Now, he has left these unanswered questions for others to consider.

Read more about eye movements here.

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What is Dyslexia?

The following editorial appeared in Visions, which is COVD’s newsletter.  It was written by Dr. David Damari who is presently serving as COVD’s President. 

There has been some interest in the Kelley King Heyworth article in the December article in Parents magazine, “Outsmarting Dyslexia.” Your patients or their parents may be asking some hard questions based on this statement in the article—“Because dyslexia is a language disorder and not a visual problem, experts say there is no evidence that doing vision exercises or wearing special training lenses with colored lenses can benefit kids – even though there are companies that sell them.”  This statement is fraught with errors (I discuss them one by one below), as is the American Academy of Pediatrics political statement on “Dyslexia and Vision” from 2009, but it may raise questions. Here are my suggestions for a reasoned, literature-based response. These suggestions are based on my opinions formed from keeping up on the extensive literature in vision disorders and learning problems; they are not to be taken as official COVD policy.

As is my wont, I will start with my most controversial suggestion.  Our profession should stop using the term dyslexia: I would strongly recommend that we stopusing this term immediately. Why? Because here is how Shaywitz defines the word dyslexia in the December article in Parents: “the learning disability that prevents children from reading and spelling with ease and accuracy.” As everyone (and I do mean everyone) knows, there are a host of disabilities and disorders – learning, visual, auditory, mental, or emotional – that could cause difficulties with reading. The term therefore has no useful meaning; that is, labeling a child as dyslexic does nothingtoward improving that child’s life. For evidence, look no further than the article’s suggestions for treatment of children labeled as dyslexic.  None of the recommended “treatments” have been shown to improve reading to average levels in well-designed, long-term studies, and the remaining suggestions are accommodations, not solutions. Note that the article describes these measures as “methods that have been scientifically studied,” NOT as scientifically proven effective.  As an added irony, the Rave-O and Orton-Gillingham systems mentioned as possible management have elements of vision therapy included to improve the orthographic processing aspects of reading acquisition.

Dyslexia is a word that has been used against our profession time after time. It can be used this way because almost every writer who uses the term uses it broadly to meanany problem with reading but then conflates “dyslexia” with phonological processing disorder.  The logic of their argument then runs like this — dyslexia is any problemwith reading, the reading problems we have studied are phonological processing disorders, phonological processing disorders are language disorders, therefore vision has nothing to do with reading problems. When we use the term dyslexia, we only aid this flawed syllogism. Let’s not. But if you do use the word dyslexia, please be very clear about what you mean by it, and contrast your definition with how others misuse that term.

Continue to aid patients toward a useful diagnosis: If the patient has a binocular, accommodative, or other ocular motor dysfunction, find it and call it what it is. If he has a visual information processing disorder, find it and call it what it is. If she has a fine- or gross-motor delay, find it and call it what it is. If it becomes apparent that the problem is more of an auditory information processing or emotional or psychological disorder, refer appropriately.  The management suggested by the Parents article and most other allopathic medicine-based articles on reading problems are usually just variations on the “try harder and take longer” theme. We offer so much more, including good multidisciplinary approaches to care of complex developmental challenges. Don’t be afraid to demonstrate our capabilities. Educate, and provide references: One of my favorite resources on reading is Beginning to Read: Thinking and Learning about Print by Marilyn Jager Adams. This classic book clearly demonstrates the complexity of the reading process, including how visual the act of reading actually is, and how the interplay between visual and verbal abilities is critical to reading acquisition and reading fluency. This is demonstrated in study after study described in the book.

In fact, there is some good in the Heyworth article. As I mentioned, some of the approaches suggested actually include visual interventions, once you investigate them. What I have found in my review of these suggestions, though, is that they are all far less efficient than vision therapy. The study on Rave-O included 70 hours of interventional instruction! And ophthalmology says that our interventions are expensive! My suggestion would be to review the article point by point with your patients, or train your staff to do this.  Use what is good to reinforce the education you have already given your patient, and point out the flaws in the other aspects of the article. During the review, start with the offensive sentence quoted above, which is made easy by these major mistakes: Heyworth uses the term dyslexia to mean phonological processing disorder, she therefore implies that there is no visual process involved in reading even though every study indicates that is incorrect; she does not offer any references or state which experts make the contention that visual exercises don’t help, she ignores the myriad of studies – some of which were funded by the National Eye Institute – that demonstrate that vision therapy does help reading in certain people with reading problems, and she expands the population supposedly not helped to all kids.

The best places to look for good resources on vision and reading are the COVD andOEP websites. These sites offer a host of good, scientific articles on the subject of reading and the impact visual and other disorders can have on the process. Have your patients write to the magazine: If your patients or their parents would like to respond to the article they can do so at mailbag@parents.com.  Please ask them to send a cc to our Executive Director, Pam Happ at phapp@covd.org.

The CITT and brain injury literature have already had a great impact on reducing these types of articles, but as long as optometry remains an independent profession organized medicine will continue to distort what we do, or distort the science on reading, in order to attack vision therapy. A reasoned, patient-centered response will always serve us well when these attacks occur. Count on COVD  to help you with useful resources when discussing these issues with your patients and referral sources.

References:

1. 
http://tinyurl.com/8xh7vk5

2. www.covd.org

3. www.oepf.org

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The Splash – Success after Long Academic Struggle Highlighted on CBS Boston

This is a great article and video done by CBS Boston.  It beautifully highlights some children similar to the ones I see in my office everyday – children that struggle in school due to undiagnosed treatable vision problems.  Dr. John Abondanzza, a Fellow of the College of Optometrists in Vision Development (COVD), does a great job of describing the types of vision problems with which these children are struggling.  The story highlights a child named Jacob, whose mother is a school teacher, and who has struggled in school and with reading.  I especially love the part at the end of the video with little Jacob saying that he now “loves to read.”  Check it out at 
http://boston.cbslocal.com/2011/10/18/unusual-therapy-helps-kids-struggling-in-school/
.  If you feel that you or your child may struggle with a learning-related vision problem and would like to find a developmental optometrist near you, please follow this link.

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