How did we get started? Learning Related Visual Problems in - - PDF document

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Learning Related Visual Problems in Baltimore City; A Long-Term Program

Paul Alan Harris, OD

Fellow, College of Optometrists in Vision Development Fellow, Australasian College of Behavioral Optometry Fellow, American Academy of Optometry

How did we get started?

• Did I write a great proposal?
• Did I “take” a meeting with an influential

person?

• Did I respond to a request for proposals

(RFP)?

• Did I even want to do the program at all?

The Foundation Reads

The Abell Foundation employs people whose job it is to read newspapers around the country to look for things that are interesting to investigate with their funds in the city of Baltimore.

The Foundation Reads (2)

They came across the work of Antonia Orfield, OD a faculty member of The New England College of Optometry program and her class project at the Mather school in Boston.

The Foundation Investigates

That story triggers a process that was to change my life!

The Problem

During the academic year 1997-98, Baltimore City had 17.6% of its students in special education. The national average is 12%.

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The Costs

• Cost to educate a non-special education

child: $3,100.00 per year.

• Cost to educate a child in special

education: $9,700.00 per year.

• Based on 110,000 total enrollment 1936

more children are in special education than the national average.

• Thus, $12,777,000 per year extra is being

spent in Baltimore for education!

So why me?

• At the time of first contact I was living in

Denmark!

• My time was fully committed, or so I

thought!

• They got copies of papers I had written.
• They did a background search.
• When they called they knew what they

wanted!

Abell Foundation, “We want to see if vision therapy will help solve the education problem.”

• What’s the first step?

– 20/20 Hindsight…..how much $$$ do you have budgeted for this? – Actual: I begin thinking about the design of the study and then try to figure out how much it will cost to do the work! Generally, you end up low-balling everything and get shortchanged in the end. From my experience with the JD project I had something to work from.

Q1: Prevalence

• The answer to the question of prevalence of visual

problems in my population would provide answers to much of the study design.

• Knowns:

– 23% of the general population – 93% of LD or PL 94-142 – 96% of JD – 85% of inner city children

• Step 1 then is to do a screening to see where we

are.

Prevalence: How much of a problem did we have in Baltimore?

• Prior to developing protocols for testing and

treatment we needed to determine what the prevalence was of visual problems in Baltimore City.

• The higher the prevalence the more children in a

single school that could be used in the study in both control and research groups.

• The lower the prevalence the more schools would

have to be involved increasing the complexity of the design.

Prevalence: Screening

Two of the 112 elementary schools in Baltimore City were chosen by the Abell Foundation as being representative of the types of populations we would find in Baltimore. Both were in economically depressed areas, one each in the West and East sides of the downtown areas. One area was predominantly Caucasian and the other was predominantly African-American.

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How did these schools rank?

MSPAP Scores (scores out of 100) Westport, which was near the lowest scores in the state: 2.8 in 1994, 3.5 in 1995, 3.3 in 1996 Hampstead Hill, which was in the highest 10%

• f all of the Baltimore City Schools:

13.8 in 1994, 11.4 in 1995, 15.9 in 1996

Who should we test?

• I could choose from Kindergarten to Fifth

grade or from ages 6 to about 11.

• I balanced many things. There are plusses and

minuses with each group; young vs. older.

• I chose first and third graders.

What should be screened?

• The answer depends on what the purpose of

the screening is.

• The purpose of this screening was solely to

be used for planning purposes for the

• verall design of the study.
• Therefore the question was, how many of

these can we help in a significant way?

More on the screening

• Since I was still living in Denmark at the

time of the screenings I wanted to set up a screening that could be done exclusively by my staff.

• I had experience with the NYSOA

Screening Battery and used this with a few minor modifications.

Screening Test Battery

• NPC/CNP
• Visual acuity distance/near
• +1.50 flipper at distance
• Keystone 4-ball test at distance and near
• 30-second +/- 2.00 flipper test
• Randot stereo acuity
• NYSOA King-Devic Saccadic Test

Pass/Fail Criteria

• Pass/fail criteria should be established
• beforehand. It is not good to set these

criteria post-hoc. This makes it look like you are adjusting the pass/fail borderline for your own purposes.

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Visual Screening Pass/Fail Criteria

• NPC/CNP: 4” from the nose or further.
• Randot Stereo: Greater than 50 seconds of arc.

(test has 3 finer gradations: 40, 30 and 20!)

• Keystone 4-ball: any response other than 3 balls
• +1.50 Distance: 20/20 or better VA
• Visual acuity: worse than 20/40
• 30-second +/- 2.00 flippers: less than 8 flips
• NYSOA KD: 1st grade >150 seconds 3rd grade

>100 seconds both are more than 2 SD’s off.

Visual Screening Data

First number=# of failures (percentage of total failed) Hampstead Hill First Grade Hampstead Hill Third Grade Westport First Grade Westport Third Grade Number of students tested N=60 N=69 N=79 N=57 NYSOA King-Devic Saccadic Test 34 (56.6%) 12 (17.4%) 55 (69.6%) 19 (33.3%) CNP/NPC 9 (15%) 15 (21.7%) 14 (17.7%) 12 (21.0%) Randot Stereo Acuity 23 (38.3%) 10 (14.5%) 29 (36.7%) 21 (36.8%) Keystone 4-Ball Test Distance 23 (38.3%) 29 (42.0%) 30 (37.9%) 24 (42.1%) Keystone 4-Ball Test Near 18 (30%) 17 (24.6%) 20 (25.3%) 22 (38.6%) 30-second +/- 2.00 Flipper Test 25 (41.6%) 14 (20.3%) 33 (41.8%) 22 (38.6%) +1.50 Distance Test 8 (13.3%) 8 (11.6%) 8 (10.1%) 3 (5.3%) Visual Acuity 0 (0%) 0 (0%) 0 (0%) 0 (0%)

The Schools Want a Summary Vision Development Gessell

“A vision development problem is a child development problem viewed optometrically.” “To understand the child one must understand the nature of the child’s vision. To understand the child’s vision, one must understand the nature of the child.”

Vision Development

2 4 6 8 10 12 14 16 18 1 3 5 7 9 11 13 15 Chronologic Age Developmental Age Vision Development Normal Vision Development Abnormal

Vision/Child Development

Vision Development -- Treatment at Age 5

2 4 6 8 10 12 14 16 18 1 3 5 7 9 11 13 15 Chronologic Age Developmental Age Vision Development Normal Vision Development Abnormal - No treatment Vision Development Abnormal - Treatment

Changes if Treatment Begun at Age 5

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Vision Development -- Treatment at age 9

2 4 6 8 10 12 14 16 18 1 3 5 7 9 11 13 15 Chronologic Age Developmental Age Vision Development Normal Vision Development Abnormal - No treatment Vision Development Abnormal - Treatment

Changes if Treatment Begun at Age 9

Questions to be Answered

• How many groups?
• Treatment & control
• Treatment, control, & placebo treatment
• Treatment & placebo treatment
• How many subjects?
• How many schools?
• Would the schools have the space?
• Would I get access to the kids?
• Would I have the cooperation of the administration?
• Would I have the cooperation of the teachers?
• Would the community accept this?

Some Schools Come Forward School Visitations

• Considerations

– Location – driving distance – Safety of access – Space availability for VT and testing – Enthusiasm for the program – Were there enough kids? – What about access to the kids?

School Visitations

• Sacred Reading Time
• Direct Instruction

OK what next?

• Testing protocols established. Test everything

and throw in a few more things. You never know exactly which will show the biggest changes! I recall much of what Ludlam, Giglio, Wittenberg, & Harris went through with the myopia research project.

• I wanted to use tests I had experience with,

could teach, and could interpret, and which I knew others could do for me!

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My role?

• As chief investigator I knew I could not do

any testing.

• I could not do any vision therapy.
• I could teach the testers and therapists.
• I could monitor them for quality control but

that would best be done by someone else.

• I had to be the PR and front man with the

school, the foundation and the public.

• I had to be the problem solver.

Which tests?

• Optometric chair testing

– VA DV/NV OD/OS with and without Rx – Cover test distance and near – NPC – Reach grasp release – Color – Randot Stereo – Stress point retinoscopy – Worth 4-dot: Dist, Near, +/-2.00 flippers – Ocular motility assessment – General eye health

Which tests? (2)

• An analytical: for detail see appendix to the

article by Harris published by OEPF, “The Prevalence of Visual Conditions in a Population of Juvenile Delinquents.”

Which tests? (3)

• Performance testing

– NYSOA King-Devic – Groffman Visual Tracing – Wold Sentence Copy Test – Motor Free Visual Perception Test – Jordan Left-Right Test Part 1 – Eye-Hand Coordination Sub test of the DTVP-II – Visagraph

Which tests? (4)

• Berger performance testing. These are a series
• f tests put together by Ron Berger and Harry

Wachs which investigate auditory manipulation, auditory short-term memory, parquetry block design replication with and without transformations and integration between auditory and visual performance. A final test was done where the motivation of the child to get better was rated from 1 to 5.

Testing Time

• I estimated 2 hours of testing per child.
• I broke this up into 4 separate parts which

could be done by different teams.

– Chair tests & analytical by OD’s – Performance tests: Staff – Berger performance tests: OD’s – Visagraph: Staff

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How long to get the testing done?

• 2 hours per child
• 5 hours a day that we can get kids to test
• It could take as long as 40 full school days

for 100 children to get tested using OD’s

• nly.
• Therefore, must go with a team and station

approach.

How many kids could be treated?

• How is the VT to be delivered?

– Homework or no homework? – How many days/week in the program? – How long for each session? – What time of day? – One-on-one or group?

• Based on criteria each therapist could only

work with 10 children. To have 50 children in VT at any one time would require 5

• therapists. Simple math!

How many kids could be treated?

• But I didn’t have the space for 5 kids at once!
• At most we could only handle 3 at once.
• So it was decided to hire 3 therapists when approval
• f the budget came through.
• A crash course training program for them to learn to

be a vision therapist was formulated.

– Video learning from the BABO/OEP VT1 & VT2 courses. – Instruction from me and Dennis Hoover – Hands-on work in my office under direct supervision of me and my therapists.

Preliminary Time Plan 1st Year Second year time plan A School is Selected

• Harford Heights Elementary Plusses

– Largest elementary school in the entire NE of the US. The whole thing could be in one school.

• Easier to monitor one school
• All children in same environment, easiest to control

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A School is Selected (2)

• Harford Heights Elementary Minuses

– All eggs in one basket – If something happens at this school or in this community it would affect everything.

A School is Selected (3)

• 20/20 Hindsight

– I would have insisted on a 4-school design with 2 schools each being controls and 2 schools each being research schools. All 4 schools would be matched as closely as possible or at least the subsets of children chose would be statistically similar. – This would have taken much longer to get going and would have been much more expensive and at the time in my life would have been too big of a demand.

Budget Year 1

• Staff expenses

– Vision therapists (280 days/year/3 therapist & training) – Optometrists (1200 hours) – Quality assurance (10% FTE)

• VT Equipment
• Testing Equipment
• Administration

Budget Year 1 Create the forms

• Exam form
• Questionnaire
• Folder control sheet

Exam form

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Exam form (2) Exam form (3) Exam form (4) Exam form (5) Questionnaire Questionnaire (2)

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Questionnaire (3) Folder flow control Gearing up cautiously

• We had been told that the board would

approve the budget. However without that approval in hand I didn’t want to begin hiring and training staff for the project and then be on the hook for the funds myself. At the same time I didn’t want to waste too much time after we got the go ahead. How to get prepared ahead of time!

We get approval – or, be careful you might get what you wish for!

• The foundation board met in the middle of

September of 1998 and approved the project.

• Now it was into high gear.

– Hire – Train – Purchase equipment – Setup space – Setup the computer programs to keep the data – Meet with statistician to be sure of randomization method!

Testing Begins

• 178 Fourth graders at Harford Heights

Elementary School are tested.

• 4 test areas identified
• Chair tests - analytical examination
• Visagraph
• Performance Testing
• Berger Performance Testing

Symptoms Checklist (17 total items)

5 10 15 20 25 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Number of Symptoms Number of Children Responding

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Top 5 Complaints on the Symptoms Checklist

Headaches 84.3% Uses finger to keep place with reading 78.1% Eyes tired with reading/school work 70.8% Loses place when reading 70.2% Rubs eyes during the day 52.8%

Distance Cover Testing

Esotropia 4 Intermittent exotropia (>10 pd) 1 Significant esophoria (>10 pd) 4 Significant exophoria (>10 pd) 13 Orthophoria, low exophoria, low esophoria 149

Near Cover Testing

Esotropia 4 Exotropia 1 Low esophoria 4 Low exophoria 42 Moderate exophoria (>10 pd) 6 Orthophoria 106

Convergence Near Point (CNP/NPC)

Average break point 1.82 inches with a standard deviation of +/- 1.4 inches. Only 4 of 171 (2%) students had a convergence insufficiency based on 4 inches or more being a failure. Using 3 inches; 11 subjects or 6% fail. Using 2 inches; 35 subjects or 20% fail.

Ocular Motility Testing

Head Movement: only 19/171 subjects or 11.1% showed significant amounts of head movement. Accuracy of tracking: 30/171 subjects or 18% were graded as fair or poor.

Random Dot Stereo

Score (seconds of arc) Number of Subjects 20 112 30 14 40 8 50 3 70 5 100 6 200 3 400 7 600 6 None seen* 13 *The child was not able to appreciate depth

• n even the grossest targets, which had 600

seconds of arc of stereo acuity.

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Stereo Test Comparisons

43 of 177 students or 24% were worse than 40 seconds of arc. Williams, using the TNO test found that 52.7%

• f 7-year-olds got 60 seconds of arc or better.

This increase to 83.52% for 9-year-olds and 84.8% for 11-year-olds.

Refractive Findings (OEP #7)

Subjective Sphere Value Standard Deviation Most Plus Most Minus OD Sphere +0.53 +/- 1.36 +7.75

• 7.75

OS Sphere +0.58 +/- 1.36 +8.50

• 8.50

Analytical Prism Testing

Finding Data O EP Expecteds 6 N= DV Base-out break 25.35 19 151 DV Base-out recovery 6.73 9 147 DV Base-in break 15.87 9 152 DV Base-in recovery 2.73 5 151 N V Base-out break 28.74 21 147 N V Base-out recovery 8.68 15 144 N V Base-in break 23.04 22 150 N V Base-in recovery 7.75 18 149

PRA/NRA Testing

Finding Value in Diopters Standard Deviation O EP Expected PRA # 20

• 2.57

+ /- 1.47

• 2.25 to
• 2.50

NRA # 21 + 2.65 + /- 0.67 + 1.75 to + 2.00

NYSOA KD Saccadic Test Demo NYSOA KD Saccadic Test 1

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NYSOA KD Saccadic Test 2 NYSOA KD Saccadic Test 3 NYSOA KD Results

82.91 seconds +/- 19.51 Norm for age 8 is 79.13 seconds Norm for age 9 is 73.4 seconds Average age when tested 9 years 5 months. 14% were below the 7-year-old norm!

Groffman Visual Tracing Test Form A Groffman Visual Tracing Scoring Form

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Groffman Visual Tracing Scores

13.3 points Standard Deviation +/-10.1 Age 7 norm is 10 points Age 8 norm is 17 points Age 9 norm is 22 points 39.3% scored below the 7-year-old norm!

Wold Sentence Copy Test Comparison of Danish and American Children

Rakel Jóhannsdóttir, Thorunn Káradóttir, Paul Harris Age Sample Size Average

(Seconds)

Minimum

(Seconds)

Maximum

(Seconds)

Standard Deviation USA Score

(Seconds)

8 39 327.9 162.8 749.6 139.6 166.3 10 45 142.9 74.7 317.9 49.5 144.1 12 37 92.6 63.7 159.5 19.5 121.1 14 45 74.2 50.4 117.2 15.0 105.0

Wold Sentence Copy Test Scores

127.24 seconds St. Dev. +/- 32.35 seconds Grade 2 = 166.3 seconds Grade 3 = 157.0 seconds Grade 4 = 144.1 seconds Grade 5 = 130.6 seconds Grade 6 = 121.1 seconds Grade 7 = 113.7 seconds 14% were slower than the grade 2 norm.

Developmental Test of Visual Perception II Developmental Test of Visual Perception II

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Developmental Test of Visual Perception II

Developmental Test of Visual Perception II Scores

8.41 years St. Dev. +/- 1.82 years Age range of performance: 4.2 to 11.4 32.0% performed below the age of 7.5!

Gates Oral Reading Test Gates Oral Reading Test Gates Oral Reading Test Scores

Average grade 4.62 St. Dev. +/- 1.06 years Only 7 children were found to have decoding skills below grade 3.0! These children can read! At least they can BARK

BARK at print!

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The Visagraph

Above is a first grade reading card with 9 lines of text. During analysis only the middle 7 lines (50 words) are used. To the left is a fourth grade card with 12 lines of text. During analysis the middle 10 lines (100 words) are used.

Eye movement recording from a good reader Eye movement recording from a less accomplished reader

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Highest Grade Level Demand on Visagraph

Highest level attained with at least 70% comprehension Number of children Percentage of total 1 15 8.47% 2 33 18.64% 3 79 44.63% 4 43 24.29% 5 7 3.95%

Visagraph Mechanics (178 subjects)

Mechanical Ability Average Score Grade Equivalent 4th Grade Norm Fixations/100 words 193.6 1.5 139 Regressions/100 words 43.5 1.8 31 Average Duration

• f Fixation

(seconds) 0.33 1.0 0.27 Reading Speed (words per minute) 105.8 1.5 158

Reading Speed by Comprehension Level

Highest Level Attained with at Least 70% Comprehension Number of Children Taylor Reading Speed Norms Reading Speed (words/min) 1 15 80 100.5 +/- 49.5 2 33 115 111.9 +/- 49.5 3 79 138 104.4 +/- 39.6 4 43 158 105.9 +/- 35.2 5 7 173 106.0 +/- 21.0

Randomize & Enroll

• Meet with the statistician and decide who

get treated and who is in the control group.

• Get permission slips out and back (or so I

think).

• Write up an explanation of the program at

the 4th grade level reading ability.

• Do a cover letter to parents.

Randomize the variance (sample) Randomize the variance (actual)

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Explanation of Program Explanation of Program (2) Parental Letter Parental Letter (2) Report to the teachers 12/98 goals

• Improved visual perceptual abilities to the point

that these are strengths not weaknesses

• Faster reading speeds – nearly up to grade level
• Better comprehension
• Higher difficulty levels of reading material

handled

• Better attention and ability to stay on task

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Meanwhile, back at the ranch

• Therapists have been hired and have been put

into their intensive training program of their

• wn.
• What exactly would they do?

– I wanted the program to be as much like what I was doing in my private practice as possible.

• Easier to monitor for quality assurance
• Easier to continue their training at the office
• Easier to have substitutes from my staff for illness
• Could build on my experiences over the years.

What about plus lenses you ask?

• Plus lenses were given to ALL subjects in

the treatment group. In some cases these were combined with compensatory lenses in bifocal form. In some instances they were given single vision lenses only.

• No glasses were given to the control group.

Were the lenses used?

• Hmmmmmmmm maybe!

– Lots of breakage & repair cycles over and over. – Even though they were to kept at school they were often brought home and lost. – Many teachers didn’t collect them and give them out each day, even for reading time and tests.

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Teacher orientation

• Free breakfast

– Most would not stay after school for a meeting – Most would not give up their lunch time – Even when we fed them breakfast I had maybe 15 minutes to explain things. – Some showed lots of interest but mostly they went about their business. – Teacher orientation was a real problem.

Scheduling

• Oy! What a hassle!

– Had to work around specials but they wouldn’t tell me when they were until very late in the process. – Reading time was initially off limits, but after several meetings with the Master Teacher we got this straightened out. – Teachers wanted the children taken out of class at a different time each day. – Just as we began one school room was flooded and we ended up sharing our workspace with one of the all-boy 4th grade classes until they got the room cleaned up and new carpet laid down (3 months!).

Monday Master Schedule What do things look like after the first year of treatment? Visagraph Data (First Cohort – Spring 1999)

Control (N=19) Treatment (N=16) Grade Level Change + 0.48 yr. + 1.22 yr. Reading Speed Change (percentage)

• 1.7% slower + 13.7% faster

Number of Fixations (percentage) + 3.9% increased

• 20.8%

decreased Number of Regressions (percentage)

• 15.0%

decreased

• 32.4%

decreased

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Selected Performance Tests (First Cohort – Spring 1999)

Control (N= 19) Treatment (N=16) Wold Sentence Copy Test (time) + 1.6% increased - 9.1% decreased Wold Grade Level Change

• 2 months

+ 10.7 months Groffman Visual Tracing (score) + 71.0% + 157.0% Groffman Grade Level Change + 15 months + 28 months NYSOA King Devic Saccadic Test (time)

• 14.6%
• 14.1%

Mid-Term Critique

Although several significant gains have been achieved as can be seen above I do not feel that we have gotten the maximum out of these children that we are capable of

• getting. The possible reasons include:

1. The alteration of my in-office program which normal takes 6-9 months with once weekly visits and daily homework being compressed to a daily in-school 70 treatment session program. 2. The use of new trainees rather than seasoned vision therapists. 3. The lack of full support of some of the teachers.

Mid-Term Critique (2)

• 4. The lack of understanding by the children of what

the program was about and why they had been chosen to be involved and what benefits they personally would derive.

• 5. The fact that the records of the children were not

made fully known to the therapists, meaning they were kept in the dark of the individual child’s problems so that every child was treated exactly the same.

• 6. Compliance with the glasses part of the program was

very poor.

Corrective Actions Taken

The easiest thing to institute was to first have a comprehensive debriefing session with the

• therapists. From this I have instituted the following

changes: (1) Additional comprehensive education for the therapists is taking place this summer with additional hands-on work in my office under my direct supervision.

Corrective Actions Taken (2)

(2) Each child will meet with a vision therapist

• ne-on-one prior to beginning treatment so that the

child can have explained to them why they have been chosen for this service and what it will help them do in the future. (3) I will review each comprehensive testing record with the therapists prior to beginning treatment so that they know exactly where each child is beginning and we will mutually set individual goals for each child.

Corrective Actions Taken (3)

(4) All efforts will be made to get together all 5th grade teachers for a comprehensive orientation about the project. It did not help us this past year that we began testing and treatment well after the school year was started without properly being about to orient the fourth grade teaching staff. Also the unsettled nature of where we would be housed within the school and the two moves created some difficulties of the teachers not knowing what and who we were.

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Corrective Actions Taken (4)

(5) A positive reward for positive use of the glasses system of behavioral modification will be instituted. Children will be awarded pencils and other educational items for demonstration of the use of the glasses during unannounced classroom visits by therapists or Dr. Harris.

Corrective Actions Taken (5)

(6) Some children needed extra time to master some of the foundation activities. The therapists were under the impression that for the sake of the research and uniformity they had to move the child along anyway to keep to the time schedule. This will be modified so that a particular child can stay with an activity until mastery of that activity.

Program Almost Shut Down

• Just what I thought might happen almost

did!

– Internal politics in the school and between the school and the school board led to the school being cut into 2 schools with 2 separate administrations! – In comes a new principal! – I begin to educate all over again.

Program Almost Shut Down (2)

• It takes 4 weeks to get an appointment with the new

principal.

– The meeting takes place with a foundation representative present. – Our main contact and support person gets transferred. – The principal agrees to honor past commitments by the school. – Time for orientation is requested and we are promised some time. – All the Teach for America teachers are sacked. – Sylvan Learning Center is thrown out. – 2 weeks prior to the beginning of school ½ the teaching spots are not yet filled!

Program Almost Shut Down (3)

• Finally the week before school I am given 30 minutes

to explain everything to the teachers.

– 4 spots are still not filled. – Specials have not been scheduled, I can’t make up a schedule for the therapists. – One teacher refuses to let us touch her kids.

• This set up a major power struggle between the master teacher and this
• ne classroom teacher.
• By the end of the year this teacher was relieved of duty.

– The year is filled with tension and turmoil as the new principal tries to take back control of the school! – Preparations for the MSPAP have everyone on edge and have many of the teachers deciding we can’t take children for large chunks of time at random times!

We plug on anyway!

• The second cohort begins while a few of the
• nes that were mostly finished last year

were finished up.

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Meetings held with teachers

• I met with each teacher and went over the data on each of

the children who we were taking out of the class for therapy.

• I provided information on those that were not in therapy if

the teacher wanted to know about them.

• This was done to get the teacher to buy into allowing the

children to participate. The teachers were reluctant at first to take the time to meet with me. During the meeting there was some enthusiasm for the information but soon after most returned to form. What they were doing was more important than what I was doing! We were involved in a battle and they perceived that I would be gone long after they would remain, and they were right!

And after 2 years? Standardized Math Scores

Math Score in Grade Equivalent Control (N=69) Treatment 1 (N=20) Treat 2 (N=27) CDT Math 3.64 3.30 3.24 CTBS Math 4.48 4.71 4.36 Net Change (years) +0.84 +1.41 (p=.007) +1.12 (p=.118)

Standardized Reading Scores

Reading Score in Grade Level Control (N=69) Treatment 1 (N=20) Treatment 2 (N=27) CDT Reading, Pretest 3.25 2.87 3.08 CTBS Reading Post-test 4.54 4.69 4.50 Net Change (years) +1.29 +1.82 (p=.137) +1.42 (p=.701)

Visagraph Reading Grade Level Improvement

Highest Grade Level Attainable with Minimum 70% Comprehension Control (N=71) Treatment 1 (N=20) Treatment 2 (N=27) Visagraph Grade Before 2.83 3.30 3.00 Visagraph Grade After 4.08 5.70 5.11 Net Change (years) +1.25 +2.40 (p=.004) +2.11 (p=.015)

Visagraph Reading Grade Level Improvement (with Junior High School = 8.0 Modification)

Highest Grade Level Attainable with Minimum 70% Comprehension Control (N=71) Treatment 1 (N=20) Treatment 2 (N=27) Visagraph Grade Before 2.83 3.30 3.00 Visagraph Grade After 4.13 6.00 5.30 Net Change (years) +1.30 +2.70 (p=.001) +2.30 (p=.009)

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Visagraph Speed Change Demand Controlled. Post King-Devic Post Groffman Post DTVP II Post Gates Hypothesis 1

The reading act is a complex process. When reading is tested or taught it cannot be reported as a single number as different aspects of the process may be at different levels of development.

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Reading Development Sequence

• Decoding only: Gates Oral Reading
• Visagraph grade level with comprehension
• Visagraph mechanics at easy reading levels
• Visagraph mechanics at higher reading

levels

• Standardized reading test scores.

Some Food for Thought

• What will happen to children with visual

deficits relative to auditory processing skills who spend more and more time immersed in an auditory educational situation?

• How can schools in the inner city cope with

the massive reading speed differences between their students and the students in the rest of the country without having a significantly school day?

More Food for Thought

• Are the textbooks designed for these schools

taking into account that in the 5th grade that these children need the information that ever

• ther 5th grader gets but written at the 3rd

grade level and written with such brevity that a child that reads as slowly as these children do won’t have to slave over the text for hours upon hours?

We Begin Again

• We began in year 3 with the idea of continuing

service to the children most in need while suspending formal research protocols.

– Give us time to plot the progress of the primary research group and to keep the treatment team together if there was to be expansion to other schools. – This time we let the teachers select those in need. We confirm this with our tests and if they have a visual problem we gave them treatment.

Preparation for massive expansion

• The initial excitement has the foundation asking

what would be involved in expanding to cover the entire Baltimore City Public School system.

– An expansion program was worked up with the following assumptions:

• 1 optometrist could manage 9 full time vision therapists

and take care of 4 elementary schools.

• Together they could serve 336 children per year with

complete vision care.

• Including full training fees and equipment costs in the first

year as well as administrative fees the cost per child served was $2129.91

Preparation for massive expansion (2)

• 1 new team would be brought on per year. This is one

OD, 9 therapists and 4 new schools.

• At the beginning of the 5th year 20 schools would be

being served by 5 OD’s, and 45 vision therapists.

• The total yearly cost including equipment and

administration and all middle level management personnel was projected to be $2,452,651!

• The cost for each of the 1680 children that would get

vision therapy would come down to $1459.91 per student.

26

Challenge

We hold the keys to helping massive numbers of these children. For this to happen we must be ready to look at alternative ways to deliver this type of care.