Reading Comprehension

I’ve written previously about some issues we were concerned about with our oldest child at the beginning of the school year. We had her evaluated by a Vision Therapy Professional to see if something between her eyes and her brain was causing her to have more trouble learning than she should. While we ended up not pursuing vision therapy at this time, we were very glad we had the testing done.

One of the things I was really concerned about was her reading – or lack of desire and ability in this area. In the spring of 2008, she was reading on second grade level (while at the end of her first grade year). In the fall of 2008, she had regressed to reading very little on her own and tested at a comprehension level equal to a beginning first grader. She struggled. She hated reading.

Fast forward four months to today. It has been a fast and amazing ride with this child. Twice a week, we use McCall-Crabbs Standard Test Lessons for Reading. Per the instructions, we average every ten tests to see where her reading comprehension is. Here is a summary of her results after thirty selections.

First set of 10:             Average 2.7
Second set of 10:         Average 3.4
Third set of 10:            Average 4.1

I have been having a hard time making sure she has appropriate level reading material because of her amazing progress in the past four months. It is a good problem to have!

We can definitely thank our wonderful local eye doctor for helping us make sure she has clear vision. My spouse and I have discussed how we might have attributed this zooming progress to the vision therapy had we done it. I’m not knocking Vision Therapy – I have heard WAY too many success stories and encouraging words since we embarked on this path to say it isn’t worth it. But, I am content in our decision – at this time – not to pursue it.

In the spirit of full disclosure, Child #1′s spelling hasn’t improved very much in the same time period. It has improved – but not by a huge amount. Her coloring (in the lines) has greatly improved to where we have a hard time telling the difference between her coloring sheets and those of her younger (artistically-inclined) sibling. And she still hates to use a pencil to write anything.

Vision Therapy Evaluation – Our Plan

Based on the test results we were given, their interpretation, and plan of action, we do not see an overriding reason to pursue Vision Therapy at this time.

To go back to our reasons for looking into Vision Therapy:
 - Reading Issues – Not wanting to read anymore, comprehension going down, etc.
 - Writing Problems – Pencil phobia, fine motor skills – coloring out of the lines, bad manuscript handwriting — can we remove barriers to make school easier / less of a struggle?
 - Sports - Less coordinated than peers
 - See if there were eye-related issues that could be helped

Their results showed deficiencies in the following areas:
 - Eye Tracking & speed of focus
 - Fine motor (hand-eye coordination)
 - Gross motor as it pertains to bilateral movement
 - Visualization & visual memory as it relates to “sight words”, normal or above averages with shapes)
 - Directional confusion in terms of automatic & accurate self-awareness of laterality and directionality.

Their proposed plan deals with eye focusing and tracking, development of directional concepts, visual recognition and memory, body awareness and control, and improving fine motor skills. They indicated that for “no additional cost or time,” they could roll-in the areas they felt our child was not “up to her potential” in and make her a “superstar.” (Something some parents would be thrilled to hear, I assume. We are not looking for a superstar.)

These look like good matches, don’t they? So why not move forward with it?
 - If we did go ahead, we would ask for the “visual recognition” part to be removed from the proposed plan. I do not want to work at cross-purposes with my daily phonics work. While the actual therapist said it would not be anti-phonics, the doctor said what they planned on doing would “REMOVE” her phonics and “REPLACE” it with “whole word” approaches.

 - The body awareness/directionality do not worry us overmuch. We will plan games and work on this as part of our homeschool plan.

 - Fine motor – I realized as I was talking to the actual therapist (after meeting with the doctor) that much of their prescription will be “practice.” In the case of Fine Motor skills, it is not an eye issue (as shown by the visual score being slightly above average) – it is a “motor” problem. The “integration between eye and body” tested in the normal range, although low. Her “pencil phobia” will not be improved with more writing. That will only fatigue her and frustrate her. However, their results did show I need to spend some more time correcting inappropriate habits she has developed in what she does write. Her cursive is already showing improvements over her manuscript.

 - Gross motor / bilateral integration: This area is beyond my skills to address, but could be worked on with physical therapy which we will look into separately.

 - Eye tracking and focusing – This is the one area I am most concerned with. Several parents with children who have issues like my daughter have impressed on me the benefits of vision therapy. We plan on waiting for a couple more years and looking back into VT with another provider then to address this key area.

Vision Therapy Evaluation – Other Results

In this post, I will outline other tests performed at my child’s Vision Therapy evaluations and their suggested plan.

The Gardner Test of Visual Perceptual Skills (TVPS) were administered. There were memory and non-motor subtests – seven in all. On average, my child scored just above average (60%), but had two scores that stood out. “Visual Form Constancy” measures the child’s ability to turn a shape mentally and identify a figure that represents the rotate shape. On this test, my child scored at the lowest end of “normal.” (Would this tie into the left/right tests results when she was unable to mentally project left/right onto another or mentally “turn” ideas of left/right as instructed?)

In contrast, she scored at the top end of the chart (99%) on “Visual Spatial Relationships.” This is an important skill for an engineer and if you are good at jigsaw puzzles, you may test well on this subtest. With two engineers for parents and knowing we do a LOT of jigsaw puzzles at our house, this was not surprising.

What was surprising was that the VT people focused in on the one high score in this battery of TVPS. They surmised that because of that one off-the-chart skill, my child’s potential is likely not being realized “in the other areas.” Does that make sense to anyone else? It wasn’t like two or three of the scores were high. Only one of the several was outside the “normal” range, yet they indicated that they thought she could be brought up to that extremely high level in the other areas. It seemed a bit of a leap. Besides, we aren’t looking for a “superstar” (word they used!), we just wanted to see if we could smooth out the bumps in the road, if there were any.

A Phonological Awareness Skills Program (PASP) test was administered and it showed her “test age equivalent” of 1-4 years high than her age.

The Birch-Belont Auditory-Visual Integration test was administered which probes the child’s ability to match what she hears with what she sees. This was pointed out to be an important skill for phonics and music reading. I do not know how to interpret the raw results, but their write-up says my child performed at an “age-expected level.”

Wold Sentence Copy- In terms of raw results, this test showed 12 letters per minute and 1 letter per glance. She was marked “inadequate” for letter formation, word spacing, pencil grip, inconsistent working distance (6-16″) and variable paper support. They noted that she sub-vocalizes as she writes (whispering or lips moving) and that her “visual-motor performance is demanding and inefficient” and that she performance at a “level that is significantly below age appropriate norms for speed of letter writing.”

Their Plan
They prescribed a plan to “develop the necessary visual abilities of academic achievement” that emphasize:
- monocular activities designed to equalized the focusing, tracking, and pointing of each eye
- Visual-spacial tasks to develop integrated sequential and directional concepts
- visualization program that improves the speed and span of visual recognition as they pertain to short & long-term visual memory
- Visuo-motor tasks to improve body awareness and control, and visually directed fine motor skills.

They believe it will take 6-12 months of in-office optometric visual therapy to rehabilitate her vision, based on an assumption of five days per week home practice and regular attendance at weekly in-office therapy. The six months is the minimum commitment – lump sum paid in advance.

Vision Therapy Evaluation – Results (Red Flags)

So, I wrote previously that we had our parental consultation for my oldest’s Vision Therapy evaluation. The results mostly indicated my child was on par with her peers with only a few “red flag” areas, in their opinion. Sections in quotes are taken directly from the letter they wrote to us.

Visual Motor Integration- Her VMI is below normal. This is then broken down into three parts to see where the further problem can be pinpointed. Visual – Her brain processes what she sees fine. Integration – She is within the average range (albeit low) in how her brain communicates what she sees to action. Motor – Her (fine) motor skills are definitely below average.

Other tests confirm that fine motor skills (showing up for me in drawing, coloring, and handwriting) are below normal range. These results are consistent with what I see every day. You could say she is “just messy” and assign more practice. But this would be torture for some, especially if they truly have a developmental issue.

Left/Right Orientation

One test checked her knowledge of rights and lefts for her own self and others (mirror image and 90/270°  orientation). She doesn’t have this skill set down and is behind her peers developmentally because of it, according to this test.

General Movement

They tested balance with eyes open and closed. She scored more than a year and a half beyond her age group in these balance tests. However, her bilateral integration is that of someone more than a year younger. She has limited ability to use both sides of her body in a coordinated manner.

This means that if she was in dance or gymnastics, she wouldn’t be very good at it. Swimming strokes are difficult for her to execute properly. Some other sports activities would be challenging because of her bilateral limitations.

These deficiencies could be addressed by physical therapists, they told us, but they cover them as part of the whole package.

Dyslexia Determination Test

They defined dyslexia as a written language coding dysfunction that results in a secondary comprehension problem. They break up the decoding process into two areas – “phonetic word analysis” and “eidetic word analysis.” If your angular gyrus says it knows the word already, they say you process it as a “whole word.” Unfamiliar words require the help of “wernicke’s area” where phonetic analysis takes place.

Their testing requires the child to read sets of words that are normed by grade level. Once they determine what level of words the child can no longer “decode” (read correctly?), they give a spelling test on all the “phonetically irregular” words that their testing said were “sight words” (defined by them as words read correctly within 1-2 seconds). If a child performs poorly on this section, they believe this shows a problem in the angular gyrus section of the brain because the child “cannot visualize the words as a whole.”

“Next, the child writes the words they could not identify by sight or phonemic decoding.” So, any words she pronounced wrong or said she didn’t know, she was asked to write “the way they sound” (Note: not with correct spelling. “Calf” would “correctly” be written for this tests as “kaf.”) This is their test of Wernicke’s area of the brain for problems with “phonemic decoding.”

On this test, she showed that she can decode two grade levels above her peers (one grade level above where I have her in homeschool). Her spelling was atrocious. Her phonetic versions of mispronounced words were graded as correct. This meant they scored her “sight word encoding” as being mildly deficient and her “phonemic encoding” as being above normal.

They also tested silent word reading without the requirement of pronunciation. Then, they used two subtests to check “sight word” and “phonemic decoding” to see how quickly and accurately she could pronounce printed words (real and made-up). Her silent word reading score (test 2) was slightly above average. Her sight word efficiency and phonemic efficiency scores (test 3) were also slightly above average.

I am no expert, but these three tests taken together showed mixed results. The Vision Therapy experts interpreted them to mean she has “mild visualization deficits and no phonetic word analysis deficits.”

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In the next post, I will outline other tests they performed & my observations as well as their overall summary and suggested plan for therapy. I will also have a post specifically about the dyslexia determination and what happened with the VT doctor when we were discussing the results of that test. Finally, I will lay out our plan.

Why Did I Ask about Vision Therapy?

What caused me to bring up vision therapy in the first place?

Honestly, if I wasn’t working with my child daily as part of homeschooling, I don’t think I would have. Child #1 might be referred to as an “auditory” learner. She loves to be read to, but complains bitterly at having to read anything herself. It is “too hard.” She can read at a second grade level, but her comprehension is very low. I have been known to ‘bait’ her by reading to the end of a chapter that completely leaves one hanging. Then, I will carefully close the book while she BEGS for me to read “just one more page.” I hand it to her and tell her she can read the next page herself. She desperately wants to know what happens next, but appears to be more than she can get herself to trudge through to find out.

If she were in “regular” school, I would probably say she was lazy.

Her (manuscript) handwriting is horrid. She can’t color within the lines without giving herself a headache. She absolutely hates writing anything with a pencil on paper. (I have started calling this her “pencil phobia.”) She will write using markers on the white board, however. She loves to use side walk chalk outside.

Compared to her peers, she is only about half as accurate at hitting a ball with a bat.

So, I questioned. Is there anything we can do to help her learning be smoother? Is she having issues totally unrelated to motivation or ability – something physical or mental (related to her eyes) – that is causing her to have to work harder to achieve the same results as other children her age?

Vision Therapy Parental Consultation

We had our long-awaited parent consultation meeting for Vision Therapy (VT) this week for our oldest. Let me start by saying that if I had to do this all over again, I would definitely ask for the evaluation again. That said, we are probably not going to go forward with VT for our daughter. I will go into the reasons after I lay out the testing results and the therapy recommendations. I plan to break this into several posts for ease of reading.

Why Ask for Vision Therapy? [Summary]
Child #1 has alternating accomodative esotropia in botheyes. She wears glasses (withprogressive lenses) that help correct her eye turn and help her see 20/25 or better bothfar and near. She does not have a “weak eye” – bothwork, just not together or at the same time. She has “monocular vision.” I have written some previous posts about her eye sight. The reason I asked about Vision Therapy was because as I work everyday withher, I see things. Things that most parents may not notice because they aren’t there with the little details all the time. I am not a detail person, but a picture was being painted and I wanted to ask the experts what it meant. I have a whole post on this that I’ll put up later in the week.

Process for Us
Our local ophthalmologistreferred us to someone he has worked with previously and though a lot of. the first of what ended up being three (could have been four) evaluationappointments was a dilated, in depth eye exam.

Here are the tests performed at that appointment:
Eye Health examination with dilation
Visual Acuity – Distance and Near
Refraction
Oculomotor Evaluation

Then, we went to two one-hour appointments where our child took a series of normed, some timed, some untimed activities/tests. These were designed to find out where she is compared to her peers (four month span around her age) to diagnose if she has visual, visual-integration, or visual-motor processing issues. There were fine motor, gross motor, balance, coordination, visual memory, reading, phonetics, spelling, and other tests.

Here is the list of them:
Beery Developmental Test of Visual-Motor Integration (VMI-5th)
Tests of Visual-Perceptual Skills (non-motor) – 3rd Edition
Wold Sentence Copy Tests
Piaget Right/Left Awareness Test
Grooved Pegboard Test
Reversal Frequency Tests
Dyslexia Determination Test
Auditory-Visual Integration Test
Bilateral Integration Test (Angels in the Snow)
Test of Word Reading Efficiency
Test of Silent Word Reading Fluency

Results
Our daughter’s glasses prescription is right on. This doctor disagrees with our local doctor in regards to giving “progressive lenses” to children. Lined bifocals are preferred because then the child and adult can tell what level of magnification the child is using to look at something. (At least, that is what this specialist told us.) Our child’s eyes do not work together. One eye focuses, then the other. They do not have to “team” and our child is not at a good age (too young) to work on this. Eye focus is slower than average and eye movement (“tracking”) is not smooth. These two things can be addressed with vision therapy.

The other tests showed that our child is mostly an “average” child – tracking around her age group with a few skills where she performed higher than her peers and a handful of “red flags.” The “red flag” results will be in my next post.

Her official diagnoses were:
Developmental Delay
Developmental Dyslexia
Esotropia (Alternating)
Suppression of Binocular Vision
Visuo-Motor Dysfunction

In summary, they believe our oldest “evidences functional and perceptual visual deficiencies in eye-hand coordination and visual directional concepts.” In addition, they believe she “has a visualization deficit that causes spelling and sight word recognition problems.” More information in the next post.

Update: Vision Therapy #2

Child #1 completed her first visual perception / acuity testing session at the doctor’s office. I did not get to be present as I had to watch the other three children in their waiting room. The room Child #1 was in was more of a closet than a room. She described having to read, stand on one foot while crossing her arms, stand on one foot while crossing her arms with her eyes closed, drawing, matching, and other such activities. She pointed out that it was hard work and that they made her have a headache.

The doctor’s office indicated the testing would be “about an hour.” Child #1 took one hour and fifteen minutes. The extra time was explained by the fact that some of the tests are timed, but “some are not.” This was code word for “Your Child Took A Long Time To Do Them.” I understand. I’m her teacher, remember? Isn’t that one of the reasons we are here?

We have one more of these visual perception testing sessions and then a three week wait for our debrief meeting with the doctor to discuss a game plan for possible vision therapy.

I did get a chance to speak to a couple other parents in the waiting room about the process. There was a five-year old with intermittant (in his case, happens when he is tired) exotropia (eyes turn outward) who had just started his therapy. It was too early to see much difference, his mother said. Another mother came in with an eight year old who is 33-weeks into an estimated 36-week therapy. He is in the home stretch and she expressed much happiness with his progress.

Update: Vision Therapy Evaluation Appointment

I wrote previously about my oldest who was diagnosed around the age of three with accomodative esotropia. After a horrid experience at a “pediatric ophthalmologist” in the big city, our local eye doctor has successfully treated her by changing her prescription to cosmetically make her eyes look aligned while the lenses do the work of focusing, allowing her eyes to relax. At a meeting about the progressive lenses, I brought up the question of whether vision therapy would help her. After listening to my concerns, he suggested we go to an expert who deals with pediatric patients and vision therapy and get evaluated.

We had to wait almost a month for the first of four possible evaluation appointments. The first appointment was an intense eye exam. All the usual tests were done – with and without Child #1 wearing glasses. Her eyes were dilated and more testing and looking was done with all sorts of interesting devices. Child #1 was quite the trooper. The only tough part was when the doctor put on a kind of “miner’s helmet” complete with bright light. It was too bright for her dilated eyes and she couldn’t get herself to keep her eyes open. (I’ll admit that we ended up all (Child #1, doctor, & me) praying that she would have the strength to look past the bright light for three solid seconds so the doctor could get what she needed and move on.) It was tough, but she did manage two seconds of not rolling her eye up her head and we were able to move on.

The doctor (specialist) indicated that the prescription is exactly right, but that she does not believe in progressive lenses for children. She would rather have seen Child #1 in a bifocal. She also admitted that it might be a moot point for what we are doing. She pointed out that Child #1 sees JUST FINE close up (which is what I thought), but that her eye turn is HUGE when doing so. Our local eye doctor is trying to lower the eye turn by using the lens to take some of the focusing/strain off the eyes. The specialist said the eye turn is so large that it really doesn’t matter either way.

Another thing I learned is that Child #1′s esotropia is “constant” – in that it is always there and . . . here I didn’t take notes, so you’ll have to forgive me if I get this wrong, “intermittent” (or was it “alternating”?). Basically, Child #1 uses one eye at a time – but alternates between which one she uses. Her eyes don’t work as a “team.” There’s a term for it, but I can’t remember what it is (monocular?). (My spouse’s eyes don’t work together, either. He doesn’t remember them ever doing so. He compensates just fine.) The specialist said that if we wanted to have her eyes learn to work together, now is not the time to try it because of the emotional maturity needed for the treatment.

However, she wanted us to continue with testing at two future appointments. We are, in effect, skipping a visual evaluation appointment (#2 of 4) and continuing with Visual Perception testing (#3 & #4 of 4). After those, we will have an hour or more consultation with the specialist on what she recommends going forward. The next two appointments are in the upcoming weeks. Our consultation won’t be until near the end of October due to my spouse’s work schedule and the specialist’s schedule. I’ll let you know how it goes.

An Evaluation for Possible Vision Therapy

As I have written about previously, my oldest child has strabismus. She recently received progressive lenses which were hopefully going to help her see more clearly close up as well as continue to correct her eye alignment for farther away viewing. After getting the lenses installed over two weeks ago and a special educational and instructional session for us parents (so that we could help with tips on how to use them as needed), my evaluation is that she is doing the same as with the previous (single-vision) lenses.

In a candid conversation with my spouse several nights ago, our daughter asked, “Do you like to read?” When told that the answer was definitely “YES!“, she asked why. She then went on to explain that she no longer liked to read because she didn’t have the “patience” to try to read. This was a girl who was reading at a 2.8 reading level eight months ago.

Due to a question on a questionnaire for a doctor’s office, I tested her a few days ago with her new lenses to find that she was at the very minimum of the scale (1.2 grade level). We use the McCall-Crabbs book and I used Lesson A4. I gave her three minutes to read the small selection and answer as many questions as possible. She answered three of the eleven in the time allotted and I let her answer the rest without stopping her. She answered only one question correctly out of eleven (number four - past the time deadline). Zero correct is indicated at a 1.2 grade level – the lowest on the chart.

To further my knowledge-gathering, I had her sit back, close her eyes, and listen to me read the SAME selection again out loud. I asked her the very same eleven questions out loud and she got nine of them correct.

I repeated this test a couple days later with test A41 with similar results. Her coloring, despite how much time and patience she puts into it, is not getting any closer to being “in the lines.” When taking her turn at hitting the softball with her cousins at the farm, she was barely able to connect with even half the balls her next younger sibling did. I just can’t help but wonder if she is having trouble processing the signals her eyes are sending her and matching them to her movements.

After a consultation with our wonderful local eye doctor, we have an appointment in mid-September for an evaluation with a specialist to see if Child #1 would benefit from vision therapy. This doctor, whose office is about an hour and a half from our home, deals specifically with younger people, strabismus, and vision therapy. We have a myriad of forms to fill out and bring with us and it looks like it will be an expensive ordeal. But we both would like our child to have the bumps smoothed out of the road. We are disappointed that it takes so long to get in for the evaluation appointment, but time will fly by quickly enough. It could take up to four visits to determine a path to take and then up to a year for the therapy. I will write about it again when we have more information.

Strabismus: Accommodative Esotropia & Progressive Lenses?

About three years ago, an observant neighbor noticed our eldest child’s eyes were both turning inward. I dismissed it to the neighbor, but passed along the mention to my husband. I hadn’t known that he had problems with his eyes when he was younger. He immediately jumped into the situation. Our pediatrician immediately referred us to a pediatric ophthalmologist in a big city about 1 1/2 hours away. The experience there was horrific and I am reduced to tears remembering the impatience of the doctor, how he didn’t listen to a word I said, the screaming of our child as she had to be held down to get drops in her eyes, the fifteen minutes in the waiting room calming her down, and the screaming when she realized she had to go back into the back office again. We came away scarred – with a prescription for glasses in our hands.

Once back at home, I called a local optometrist who attends our church. He assured me that he could treat our child locally and she did not need to go back to that doctor’s office again. Our local doctor is patient, understanding, and very hands-on. He answers all our questions about our daughter’s accomodative esotropia (intermittant turning in of the eyes). Admittedly, my husband is much more educated about her condition. I’m the one who doesn’t think of the tough questions or question any decisions. I just know when she wears her glasses, her eyes don’t turn inward much anymore.

We used to go every few months for an eye check and new prescription. Due to a slip of my memory, what was supposed to be a six-month interval became a 10+ month interval between appointments. On Wednesday, I dutifully brought the four children for her latest appointment. Her far vision has been corrected as much as it can be, but the doctor found that her close vision was blurry.

In the midst of trying to keep the toddler and crawler busy, my ears perked up. He held some lenses in front of her glasses and she reread the close eye chart. This time, it appeared, she didn’t have nearly the trouble as last time and got many more correct. The light bulb went off in my head.

You see, our eldest child’s reading took off in the middle of last year and I couldn’t keep her from reading books late into the night with her reading lamp in her room. Then, after about three months, I would check on her to find her asleep almost immediately – no book in sight. She preferred to go straight to bed to reading. I thought perhaps she was just tired. Instead, was she starting to have trouble focusing on the words and it was now too much trouble to read her precious books?

The doctor prescribed progressive lenses – something neither my husband nor I have any experience with. My husband had ten or more questions that I had not thought to ask. I have been told she will not have any trouble after the first few days adjusting to them. I am apprehensive, but hopeful.

When I was looking up some links for this blog article, I ran across several “success stories” about Vision Therapy. I know my husband has asked about therapy before, but I don’t remember much about the answer. I plan on bringing the subject back up when we go to pick up her new progressive lenses.

I want what is best for my child. Doesn’t every parent?