Most Australian State education systems provide limited funding to students who have been diagnosed with Intellectual Impairment (II), Speech Language Impairment (SLI), autism, and physical disabilities. Funding is also provided for students who have vision and hearing impairments. The funding is allocated to the school rather than to the child so the principal or special needs committee are able to decide how the funding is used.

The diagnosis of SLI is made on the basis of a score <70 on a standardised language instrument; usually the CELF4. The child also has to have “non-verbal” IQ within normal limits. A standard score of 70 represents performance worse than at least 98% of age peers. In at least some States the child’s score has to be <70 on both expressive and receptive scales to obtain funding.

The <70 criterion is used in an incredibly inflexible manner. There is no practical difference between a student who scores 69 and a student who scores 71, yet the first child receives funding and the second doesn’t. There is no recognition of measurement error and confidence intervals play no part in interpreting test scores.

The most important point for this blog is that most States require that a re-assessment and funding review take place every 3-5 years. I have no problem with re-assessment; however, the current system requires the student to score <70 (i.e., <2nd percentile) on the CELF4 or other standardised instrument at each re-assessment or they will lose their funding. In most schools, no funding equals even more limited support.

The problem with this practice is that all students diagnosed as SLI receive some form of support. The support varies from weekly contact with a speech-language pathologist (SLP), to group work with a teacher assistant using a ‘program’ designed by a SLP, to in-class support from a teacher assistant. We could argue about the quality of different types of assistance but that is not the point. The point is that almost anything you do with a child will improve their performance (see Hattie, 2008). Even putting that aside, regression to the mean makes it likely that the student’s score will fall closer to the mean on repeat testing.  Therefore, it is highly likely that a student’s scores will have improved 3-5 years after the initial assessment (which usually occurs around 6-7 years of age).

So what does this mean for students with SLI? It often means that they lose their funding, and therefore at least some of their support. We know that children whose language problems have not resolved by 5.5 years do not get better. In fact, they are subject to a Matthew Effect with the gap between them and other children widening as time goes by. If longitudinal research shows that students who language problems at 5.5 years remain impaired and in many cases get worse, why do the Australian State education systems remove their funding when they manage to drag themselves over an arbitrary funding cut-off? In effect we are discriminating against students who manage to make some improvement. Should we not be recognising the chronic nature of SLIs and rewarding improvement rather than punishing it?

This point was brought home to me this week when I saw a boy that I had seen 5 years ago when he was in his Prep (Kindy year). He was 5 years old at the time. He had been identified by the school SLP as having low scores (Core Language Score of 65 on the CELF 4) and I had to perform an IQ test. The test duly performed the boy qualified for SLI funding. What was done with that funding and the appropriateness of the intervention he has received is for another day and another blog. The main thing is that his mother returned to me in a very distressed state. She informed me that the school SLP had re-tested her son and that he no longer qualifies for SLI funding. His scores on the CELF 4 were in the 70-80 bracket. Still very low, but not low enough to continue to meet the <70 funding criteria.

The mother was desperate because our boy continued to have significant functional language and literacy problems. She reported that he struggles to follow simple functional instructions and that his reading remains poor despite quite a bit of help. She has now been told that the in-class support he was receiving will now disappear and that he may also lose at least some of the literacy support.

Surely a child like this should continue to receive financial and educational support? His language problems have not resolved; even if he did score slightly better on the CELF4. Again, we could argue about how funding is often used in schools and how effective the “treatments” are but if we get past that and just consider the child, surely he deserves continued support?

I recognise that funding criteria are developed by bean counters who have to come up with arbitrary rules to allow them to allocate a limited pot of money. I also recognise that they look for ways of justifying taking the funding from a child who has improved slightly and giving it to another child. However, the system as it stands seems to be discriminatory and inequitable. It should change but I know it won’t.

There is a pervasive belief that reading problems are somehow often of a visual nature. Consequently, one of the first referrals school staff make is often to an optometrist. There are at least three side effects of this belief and custom. First, reading problems are almost never caused by visual factors. Second, there is a high probability of becoming mixed up with a behavioural optometrist who will prescribe ineffective vision therapy. Third, vision therapy costs parents money and worse, time is lost in getting to the core of the problem and to the appropriate educational treatment. This blog will look at the research that shows that dyslexia/reading problems tend not be visual and the evidence for the efficacy of vision therapy.

Vision and reading

There is no doubt that the eyes and processing within the primary visual cortex and extra- striate cortical areas are necessary for decoding written text. Reading does require efficient visual abilities, including the ability to process the spatial location of letters while the eyes move across text.

Many people have attributed reading problems to one or more subtle ocular or visual abnormalities, including Samuel Orton, who wrote about the difficulty he thought children with dyslexia had with reversible letters and words (eg. b/d, god, dog). However, Orton’s view and other views that reading problems are the result of issues with visual processing, visual perception or visual memory are almost certainly incorrect.

In the 1970′s Frank Vellutino and colleagues performed a series of studies in which they compared poor and good readers on a variety of visual processing tasks (e.g., visual discrimination, spatial orientation, visual memory, and visual learning). Most importantly, the tasks carefully controlled for verbal coding ability.

For example, Vellutino et al. found that memory for visually presented words and letters that were visually similar (e.g., b/d, was/saw) was the same in good and poor readers when a written rather than a verbal response was required. In other words, the kids with dyslexia see the same thing and can replicate the symbol but have more difficulty producing the letter or word name verbally. Another experiment showed that good and poor readers performed equally on visual recognition and recall of symbols from the Hebrew script with which both groups were equally unfamiliar. Finally, poor readers do make more ‘visual’ errors when reading compared to good readers of the same age. However, they DO NOT make more ‘visual’ errors than younger children of the same reading age. These data tell us that ‘visual’ errors are the result of poor reading, not the cause.

Eye movements and dyslexia

The eye movements of individuals who have dyslexia do differ from those of skilled readers (Rayner, 1998). While reading, the people with dyslexia exhibit longer duration of eye fixation, shorter saccades and a higher proportion of regressions (backward) saccades than controls (Huxler et al., 2006). However, research has demonstrated that abnormalities in eye movements occur specifically in reading tasks. When people with dyslexia and controls are compared on non-reading visual tasks that require similar perceptual and ocular motor demands to reading, there are no differences between eye movements of the groups. Hence the divergent eye movement patterns of people with dyslexia during reading reflect difficulties in the reading process rather than a primary impairment of ocular motor control (Huxler et al., 2006). This conclusion is supported by studies that have demonstrated that the eye movements of people with dyslexia do not differ from younger, reading age matched controls (Hyona & Olson, 1995) and that when people with dyslexia are given reading-level texts, their eye movements are comparable to controls (Olson et al., 1983).

I often read the term “visual tracking” in reports produced by behavioural optometrists, usually followed by some sort of statement implying causation in reading and/or learning difficulties. However, well controlled studies have shown that people with dyslexia do not differ from good readers in smooth pursuit eye movements (visual tracking) (e.g., Olson et al., 1983; Palatajko, 1987; Stanley et al., 1983). Furthermore, pursuit movements play no role in reading so even if an optometrist finds ‘visual tracking’ weaknesses in a student it is unlikely to be causal in reading problems.

Vision therapy

Vision therapy involves eye exercises, eye-hand coordination tasks and other exercises designed to improve the individual’s motor memory activity. Although in widespread use, vision therapy has limited evidence for efficacy (e.g., Bishop, 1989). In response to concerns regarding the use of visual therapies, a number of influential bodies have conducted reviews and released policy statements for their members. The joint statement of the Committee on Children With Disabilities, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology states the following in regard to visual therapy:

“No scientific evidence supports claims that the academic abilities of children with learning disabilities can be improved with treatments that are based on 1) visual training, including muscle exercises, ocular pursuit, tracking exercises, or ‘training’ glasses; 2) neurological organisational training (laterality training, crawling, balance board, perceptual training); or 3) coloured lenses.”

They go on to say that: “diagnostic and treatment approaches for dyslexia that lack scientific evidence of efficacy such as behavioral vision therapy, eye muscle exercises, or colored filters and lenses are not endorsed or recommended.”

Other recent reviews (e.g., The American Academy of Ophthalmology; Wright, 2007) have concluded that there is no scientific evidence that supports behavioural vision therapy or orthoptic vision therapy as effective treatments for reading difficulties. Claims of improvement after visual therapy have typically been based on poorly controlled studies and testimonials and reported benefits can often be explained by the traditional educational strategies with which vision therapies are usually combined or by placebo effects. Eye movements and visual perception are not critical factors in the reading impairment found in dyslexia and the majority of people with known ocular motility and eye movement defects read normally and even people with severely misaligned eyes can excel in reading and academics.

The risks

At first blush, it seems that vision therapy is unlikely to cause harm. However, let me use a real case to show what effect quackery can have on a family.

Ben is in Grade 5. His mother is well educated. His father has dyslexia and struggled at school. Ben probably has Asperger’s and possibly ADHD. Most importantly, he is illiterate. I often use that term to prove a point when in fact the child is not illiterate, they just have poor reading compared to their peers. But Ben actually fits the definition; he is 11 years old and knows just 3 words by sight, a handful of letter-sounds, and can’t decode a single unfamiliar word.

When Ben was in his Prep year (Kindergarten) his teacher told his parents that they should take him to a behavioural optometrist. His mother reported that she was made to feel as if it was mandatory. Inevitably, vision therapy was prescribed at a cost of $2000. The first side effect of vision therapy and of teacher suggestions to see a behavioural optometrist should require no elaboration.

Just as bad is the fact that over 12-months were lost on activities that have little relevance to reading and which have no demonstrated evidence of helping with reading problems. Given that the effects of early intervention are so much stronger than intervention that occurs after Grade 2, these lost months were critical. They should have been spent on teaching Ben to read.

Finally, there are two behavioural factors at play. First, Ben’s mother put a lot of effort into the vision therapy. Continued failure meant that her behaviour was essentially punished making it less likely that she will have much faith or energy to put into another round of educational treatment. Second, Ben had the expectation that the treatment would work and he put in considerable effort. How does he explain his world when he remains illiterate? The default positions have to be: I’m dumb, I will never read, etc. In fact neither are true. The lack of response to vision therapy also punishes Ben’s effort and will make it that much harder for me/teachers to ‘sell’ him on an appropriate form of reading intervention upon which we will soon have to engage.

Summary  

Behavioural optometry is an appropriate therapy if a child has an ocular problem. For example, if you have a child with a lazy eye a referral to a behavioural optometrist is entirely appropriate. However, there is no good evidence that vision therapy is an appropriate treatment for reading or other learning difficulties.

I think I am okay with teachers encouraging parents to have their child’s vision checked (more on this in an upcoming blog), but the evidence suggests that teachers should not encourage parents to have behavioural optometry assessment. The evidence also suggests that teachers should discourage the use of vision therapy for reading and other learning difficulties.

Perceptions of competence, contingency and control are all constructs related to coping and to emotional distress. Competence refers to the degree to which the individual believes himself or herself to be good (competent) at a task or skill. Contingency is the degree to which the individual believes that outcomes are contingent on their own behaviour. Control describes a general construct that measures how much control the individual feels in a given situation or for a given task. In the book Success and Dyslexia, authors Nola Firth and Erica Frydenberg take as their starting point that the coping strategies used by students who have dyslexia (and presumably other learning difficulties) tend to be passive and negative. These strategies typically betray a lower sense of competence, contingency and control than their higher-achieving peers. They recognise that passive and negative coping strategies not only adversely affect school performance but that they have the potential to lead to emotional distress. To help alleviate this problem they have developed an 11-step coping program.

The program is designed for middle primary students and runs on two fronts: as a whole class program with additional small-group work for students who have dyslexia. Four sessions (1-3 and 5) are devoted to developing awareness of helpful and unhelpful coping strategies and to help the students understand their own coping mechanisms. Session 4 is a goal setting session in which students are encouraged to develop a realistic goal they want to achieve over the course of the program. Although the authors do not explicitly say so, presumably helping the student attain a goal with effort and active coping will help develop a sense of competence, improve perceived contingency and make it more likely they will be motivated by opportunities to develop competence in the future.

Sessions 6-11 teach cognitive-behavioural principles to help students become aware of the link between cognitions (thoughts and images), emotion and behaviour. There is a large psycho-education component and skills training that some teachers and clinicians will be familiar with from social skills programs. For example, students are taught about positive self-talk and how to use assertive language and body language. While at times the authors seem to confuse the cognition and behavioural components of the cognitive model, they have done well to simplify the core component of the program down to a choice between helpful and unhelpful choices.

The book includes sufficient information and materials to allow a clinician or educator to run the program with reasonable fidelity. Other positives include the focus on the affective and strategic aspects of learning difficulties that are too often ignored and the way in which class teachers and non-LD students are involved directly in the therapy. Teachers are also provided with a list of useful accommodations for students who have dyslexia (pp. 7-8). Implementing these strategies alone would likely lead to better academic, emotional and behavioural outcomes. However, in my experience, professional development, including ongoing support from a skilled learning support coordinator would be necessary to ensure successful application of the accommodations within the classroom.

On the downside, it was unfortunate that the authors felt the need to highlight the dubious practice of including an IQ test in the “diagnosis” of dyslexia (p. 6). It might also have been good to draw attention to the possibility that the Success and Dyslexia program is not a substitute for intensive skills intervention. Given the current state of practice in this Australia, one cannot presume that a student who gets to middle primary grades as a poor reader has had the systematic intervention that we know can significantly reduce the effects of dyslexia.  It is hard to imagine that a student will develop a strong sense of well-being when their perceptions of low competence and control are entirely rational. Indeed, most adults would leave a job that made them face the daily failure that students with dyslexia typically experience. Perhaps the Success and Dyslexia program would work best in combination with an intervention designed to directly improve academic skills.

Students who have Asperger’s Syndrome can display challenging behaviour. They may be ‘runners’ or they may lash out at teachers among other things. They usually do so because they are experiencing some form of emotional distress as a result of excessive/unpleasant sensory stimulation, because they have difficulty understanding other people’s perspectives, because they have difficulty coping with change, or because they have an otherwise inflexible behavioural repetoire, amongst other things.

A patient (male, 10 years of age) who we will call Jack (isn’t every second boy called Jack?) has been ‘running’ or punching/hitting/biting others, including teachers, when he is distressed. Jack’s support teacher has indicated to his mother that his behaviour is unpredictable and that therefore they are having difficulty managing him. In other words, they are finding it hard to identify the antecedents of his behaviour. Identifying antecedents is a good thing to do and changing them is very effective. For example, a child who becomes anxious about not knowing what to do when he first arrives in the classroom each morning (i.e., he doesn’t have a routine) can be assisted by getting him to class early and giving him a job (e.g., he can be book monitor or fish feeder etc). However, antecedents can be hard to find and it is not always possible to change them even if one is aware of them. Changing the behaviour of children who have Asperger’s therefore often requires a different type of behaviour therapy. Before we look at what that might be let’s quickly revisit B.F. Skinner’s laws of the universe.

1. Positive reinforcement. When a behaviour is followed by a rewarding stimulus the likelihood of the behaviour occurring again is increased.
2. Negative reinforcement. When a behaviour is successful in eliminating or reducing a distressing stimulus it is rewarded and the likelihood of the behaviour occurring again is increased.
3. Punishment. When a behaviour is followed by a punishment the likelihood of the behaviour occurring again is decreased.
4. Shaping. Human behaviour rarely changes immediately, just as young canines do not learn to walk without a leash on their first day of obedience training. Shaping is a conditioning procedure in which successive approximations of a behaviour are reinforced. Successive approximations refer to increasingly accurate representations of the behaviour desired by the teacher.  The principles of shaping can be illustrated in the training of a puppy. If one desires the puppy to sit and stay while you are out of sight, one doesn’t sit the puppy down and walk around the corner. Rather one teaches it to stay while you are beside it and have it on a tight leash. A reward is provided after it stays for the briefest of moments. The period for which it must stay and the distance between the puppy and owner is increased with rewards provided for successful performance at each increment until, finally, it is able to perform the desired behaviour.
5. Positive reinforcement is more effective at changing behaviour than punishment.
6. Behaviour management methods are neither right nor wrong; they’re just effective and ineffective.

Getting back to Jack; like many kids who have Asperger’s, he lacks the ‘software’ that allows him to make sense of his social world. He needs the adults around him to provide him with software ‘plug-ins’. How can we accomplish this? By using Skinner’s laws of positive reinforcement and shaping.

Jack is clearly trying to avoid distressing situations. That he continues to do so shows that the punishment being used by the school is not working and that his current behaviour, while maladaptive, is having a negatively reinforcing effect. A more effective method must be found.

The new approach can begin by writing a Social Story that describes for Jack how he might respond in a particular situation. This might include suggesting to Jack that when he begins to feel distressed in the classroom he is to (a) go to his teacher and ask for his iPod, (b) move to his quiet time area, (c) stay in his quiet time area until he feels like he can manage himself back in the class, (d) return to the class and discuss a solution to the problem with his teacher. Parents and the school then need to identify an external reward that may serve as positive reinforcement. Next, the teacher has to shape Jack’s behaviour by paying attention to him and trying to catch him doing something that resembles the terminal goal of following the ‘calm down’ procedure described above. When she catches him he should receive the stimulus we hope will be positively reinforcing.

A new shaping procedure begins once Jack is able to perform the terminal behaviour. At this point the teacher begins to fade the Social Story by requiring him to perform successively more difficult versions of the Social Story until he can eventually solve the problem/distress by simply leaving his seat and discussing a solution with his teacher.

Finally, learning doesn’t occur when the child is in distress. Teachers and parents are often so relieved when the child behaves appropriately that they forget to catch them being good and provide reinforcement. The trick to successfully teaching an kid with Asperger’s how to behave is to use these “good” times as teaching moments. Grab them (not literally for those readers who may have Asperger’s themselves:) and talk about the behaviours they used that were successful. Discuss why they might have been successful and how they might be used in the future. Refer back to them before future events and discuss whether the previously successful behaviour might be worth another shot. If it works, debrief again. Eventually, if a behaviour works often enough it can become a rule and we all know that Aspies love rules.

I often find myself playing the role of Grumpy Old Man in conversations about the selection of intervention programs and other teaching practices. A statement along the lines of “but there’s no evidence that it works” is often preceded by much face rubbing and hair pulling on my part. The response I hear most often is “but we see it working” which precipitates more face rubbing and hair pulling from yours truly. Perhaps the biggest barrier in these conversations is that teachers and scientists often have different definitions of what is meant by “evidence“. This blog attempts to explain what scientists mean by the term evidence.

Evidence-based practice

The term evidence-based practice began in medicine. It seeks to maximise the accuracy of clinical decisions based on evidence gathered from the scientific method. No one wants to see a doctor who prescribes a treatment just because they believe it works or because they heard a colleague give a presentation on it. There should be a burden of proof (and theoretically there is, although this burden doesn’t exempt doctors from making mistakes) on a doctor to make treatment choices that have been shown to work significantly better than no treatment or, if there are alternative treatments available, to choose the one that works most effectively with the fewest side effects. These statements are axiomatic but they aren’t often applied to education, an area of at least equal importance as health.

What constitutes scientific evidence?

A very brief description of the scientific method in relation to treatments is as follows:

1. Select 2 equivalent groups. If they don’t share the same characteristics and the same level of skills before the intervention you can’t be certain that any differences observed after the treatment were due to the treatment itself or to the pre-existing differences between the groups.
2. Gather pre-treatment data using well-validated and reliable instruments that clearly measure the outcome in question. For example, a comparison of a group versus a one-on-one reading program should be evaluated with tests of reading ability not of motor skill.
3. Randomly allocate students to the groups. If students, parents or teachers actively select the groups it damages the results. For example, a recent study compared neurofeedback therapy for ADHD to a non-treatment group. The results showed that parent-report measures of ADHD symptoms improved in the neurofeedback group relative to the untreated group. However, because parents actively decided to enrol their child in the neurofeedback group or actively decided not to, all these data show is that if parents believe that neurofeedback is going to work they will report that it does work!
4. Implement the treatment while making sure that the treatment is run the same for everyone and that additional teaching or therapies are not going on at the same time.
5. Administer post-tests to determine outcome.

Additional points of note:

1. Children’s development is not static; they are in a constant state of personal improvement. Observations that students seem to improve over the course of a program/intervention are therefore mostly meaningless. All students will improve over time. The only way to tell if a teaching method works is to compare a child (or preferably a group of children) to an equivalent group who receive a different teaching method.
2. Placebo effects are large in children. They will often improve just because of the extra attention paid to them. Therefore, observations, or even more empirical data, collected on a treated group in the absence of a group receiving an equal amount of attention are prone to error.
3. Regression to the mean is a statistical artefact that holds that extreme scores (e.g., low scores on a reading test) are likely to return closer to the mean (average) on repeat testing. Hence, proponents of a brief intervention, say of 2-weeks, may claim that their treatment resulted in the student improving from a score of 70 to 80 and that change was significant when in fact the reason for the improvement may simply be regression to the mean.
4. Beware research using tests that measure what is taught in the treatment. See Merzenich et al. (1996) for an example.

An example of good data

Hatcher, Hulme, and Ellis (1994) compared four groups of children all of whom had comparable reading dififuclties. The children were randomly allocated to four groups each of which received a different treatment. One got phonological awareness training, one phonological awareness plus reading and another just did reading. The last group received no treatment. Although the 3 treated groups received different treatments, they received the same amount of instruction in terms of time, attention and contact with teachers. Because this study controlled for all other variables they were able to claim that the stronger reading growth in the phonological awareness plus reading group was due to that treatment being superior. These claims could not have been made if the students were not randomly assigned to groups, if they differed on some other variable before treatment, or if some other variable such as the time spent on intervention differed between the groups.

An example of poor data

I recently suggested to a teacher that their suggestion that a child with reading problems see a behavioural optometrist was not evidence-based. See here for a review of the evidence for visual therapy in reading difficulties. The person claimed that they had a student in a previous year who improved in their reading ability while doing vision therapy and that they therefore believed that vision therapy worked. Unfortunately, the belief simply cannot be supported by scientific principles. First, the improvements could have been a placebo effect. In fact, it is safe to assume that placebo effects represent at least part of all positive teaching outcomes for all students. Paying attention to them helps them improve. It is probably equally likely that the child would have improved if they recited the alphabet while standing on a wobble board each day. Second, children improve in almost all skills over the course of a year as a natural course of events. In this case, there is no way of being certain that the improvement wouldn’t have occurred anyway. Finally, teachers obviously want students to improve and history is full of examples where even eminent scientists have deluded themselves into believing something because they were keen for it to be true (e.g., see the case of cold fusion). In summary, beware of using observations of single cases like this as the basis for educational decisions.

Types of evidence

Carter and Wheldall (2008) have proposed 5 levels of evidence that can be used to guide interpretation of educational research.

Level 1 

Level 1 programs or practices meet two criteria. First, they are consistent with existing scientific evidence in terms of current theory and recommended practice. Second, there is evidence of efficacy from a number of independent randomised controlled trials. Carter and Wheldall (2008) refer to Level 1 as the ‘gold standard’ and suggest that programs and practices meeting these criteria may be recommended with confidence.

The Hatcher et al. (1994) study described above represents an example of the gold standard Level 1 evidence.

Level 2

Like programs or practices that meet Level 1 criteria, Level 2 programs or practices are consistent with existing scientific evidence in terms of current theory and recommended practice. They also have empirical evidence supporting their efficacy but the design of the studies may not quite meet the gold standard of a randomised controlled trial necessary for Level 1 rating. These programs represent the silver standard and can be recommended with reasonable confidence.

An example, of a Level 2 program is my own Understanding Words reading intervention program. The data we have on Understanding Words is summarised briefly below.

1. A clinic study showed that a group of students made significant improvements in response to two terms of Understanding Words teaching. The strength of the gains were strong and similar to the average growth seen in randomised trials reported in the literature. However, because the study didn’t have a control group we can’t guarantee that the changes were the result of the intervention rather than to some other variable.
2. A controlled study that showed that a group of Grade 1 students with reading difficulties, made significantly greater gains than a control group of average readers. In other words, the poor readers ‘closed the gap’ on the good readers as a result of the intervention. This study goes close to meeting the gold standard criteria except that the students were not randomly allocated to groups and the research was not independent of the program developer.
3. We also have four studies using well-controlled case series designs. These studies have showed that introduction of the Understand Words treatment prompts increased reading growth in individual students compared to baseline periods in which no treatment or an alternative treatment was being provided.

Together, these studies fall short of the gold standard of Level 1 evidence but the program fits into the Level 2 strata based on its theoretical soundness and treatment-outcome data.

Level 3

Level 3 programs and practices make theoretical sense. These programs could be said to be based on evidence because there is often empirical data showing the effectiveness of the type of teaching contained in the program. However, there have been no scientific studies documenting the effectiveness of the program or practice itself. These programs might be used in the absence of an alternative that has stronger evidence. However, they should be used with caution. An example may be the ELF reading program. Arguably, ELF has a reasonably sound theoretical basis; however, there is no evidence beyond observations that the program works. Teachers and clinicians who want to be evidence-based practitioners would be cautious about selecting the program when there are other programs with stronger evidence bases.

Level 4

Level 4 programs are Not Recommended. They provide little or no empirical evidence for efficacy. They often rely on testimonials and observational ‘data’ to support their claims. Examples include fish oil as a treatment for ADHD and behavioural optometry as a treatment for reading difficulties.

Level 5

Level 5 programs and practices represent those for which there is evidence that the program is unsafe or results in negative outcomes. These programs and practices should be avoided at all costs.

Summary

Teachers can do a lot of good by becoming evidence-based teachers. At present, most of teachers’ professional reading involves practically-oriented periodicals or books rather than research-based and peer-reviewed journals (Rudland & Kemp, 2004). It has also been reported that regular and special education teachers value the opinion of colleagues, workshops and in-service activities (which may present opinions with no evidence-base) as more trustworthy than professional journals (Landrum, Cook, Tankersley, & Fitzgerald, 2002). Further, Boardman, Arguelles, Vaughn, Hughes, and Klinger (2005) reported that when making decisions about classroom implementation of practices, special education teachers did not consider it important that they be research-based. I suspect that this is understandable as practical strategies may seem to be more applicable for teachers. However, it would be nice if these things began to change as they have in medicine. Teachers could become more critical about the claims made by proponents of educational practices and more critical of their own teaching methods. They could begin by asking themselves what the evidence is to support the use of programs and practices. They could actively seek out that evidence from peer-reviewed sources rather than relying on books, the Internet or the opinions of colleagues presenting PD. They could ask themselves: “Would I be happy if my GP used a Level 3, 4 or 5 treatment on me just because s/he believed that it worked?“. If not, they could ask another question: “Should I therefore be cautious in selecting educational programs that have limited evidence?“.

Final note

The last thing I intended was for this blog to be interpreted as teacher-bashing. I could write a similar blog about some of my psychologist, occupational therapist, or paediatrician colleagues. Nor am I immune to human foibles and biases. However, the fact is that we should all strive to do better for students who have learning difficulties and indeed all children. To do that we need to recognise the dangers of our belief system and of relying on the opinions of peers. We all need to strive to base decisions on science, not on philosophy or pseudoscience. We would also do better to recognise the limits of our knowledge. To paraphrase Donald Rumsfeld, the best teachers (and other clinicians) know what they don’t know.