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.

The Early Literacy Foundations (ELF; UQ, 2006) program is produced by the Speech Pathology and Occupational Therapy faculties at the University of Queensland. It is designed for “boosting a range of literacy skills in year one students” (p. 8). The program uses the term ‘literacy’ in a broad sense to encompass the skills of reading (at the word-level), spelling and handwriting. It is designed as a withdrawal program for small groups. This feature will be sure to grab the attention of cash strapped learning support co-ordinators. The aim of the program is to “provide students with strategies to boost their literacy, including listening, spelling, reading, handwriting, and a range of the motor skills important for school participation” (p. 9).

The program consists of a resource manual and a theme book that provides instructions and student materials. The teacher instructions are clear and could be followed by a paraprofessional. Being largely developed by speech pathologists it is unsurprising that there is a strong emphasis on phonological awareness. There is also a strong emphasis on postural, sensory and motor skills and here’s where the first problem arises. It is true that motor coordination weaknesses co-exist with learning difficulties (e.g., Kaplan, Wilson, Dewey, & Crawford, 1998). However, far from 100% of students with reading difficulties have motor weaknesses and there is no evidence that motor weaknesses are causal in the reading difficulties. It is therefore strange that a literacy program would include a motor component. In this author’s opinion, motor activities have no place in a reading program and it would be far better to select the students who have motor disorders for a separate program. The rest of this review will ignore the motor component of the program and focus on the ‘literacy’.

Teaching is preceded by a screening test that consists of various phonological awareness activities, a spelling task and a nonword spelling task from the SPAT. I like the author’s suggestion to rank order scores and select all students who score below the mean for intervention. This is unlikely to occur in the real-world but it shows the right intent.

The program has 12 “themes”. Each theme consists of a number of activities. Together, the activities in each theme take approximately 1-1.5 hours to administer.  If true, this means that students will receive a maximum of 18 hours of instruction. In reality, the amount of reading instruction will be even less as a large part of the program involves motor skill activities. This seems light for an intervention program.

The phonological awareness part of ELF progresses through the developmental stages of this metalinguistic skill (e.g., Adams, 1990; Yopp, 1992). Themes 1 and 2 consist of rhyming, segmenting sentences into words and syllabification activities. Themes 3 and 4 focuses on onset-rime activities while later themes focus on phoneme-level activities. Here’s the next problem.

There is certainly evidence suggesting that phonological awareness is correlated with reading and many draw the inference that it is involved in learning to read (e.g, Foorman, Francis, Novy & Liberman, 1991; Hatcher, Hulme & Ellis, 1994; see Snowling, 2000 for review) but the case is far from proven (see Castles & Coltheart, 2004 for review). There are cases of reading difficulties in which no phonological problems are present (Castles, 1996; Zoccolotti & Friedmann, 2010) and, despite popular belief, there is actually limited evidence showing that teaching phonological awareness has any additional benefit above and beyond teaching letter-sound conversion rules.

Even if one accepts that phonological awareness is a skill required for learning to read, the question becomes how much phonological awareness is required? Many people agree that being able to segment and blend words of 4-5 phonemes is sufficient. This makes the phoneme manipulation, deletion and substitution activities in the later Themes of ELF somewhat redundant. It should be noted that the major concern is not that these activities are bad, but that they are unnecessary. Reading programs need to target reading and spelling skills, not distal factors like phonological awareness. Students need as many repetitions of letter-sound conversion rules and decoding and spelling attempts using the letter-sound rules as teachers can possibly give them; excessive teaching of phonological awareness distracts from this essential requirement.

A positive is that ELF teaches letter sounds. The letter sequence is t, f, j, g, m, n, h, v, w, y, sh, th, ch, k, p, b, d, i, a, u, o, e, r, l, s and z. However, the sequence is somewhat odd with easily confused letters (e.g., p, d and b) taught together and low-frequency letter-sounds (e.g., v, w, y and z) taught before more frequently occurring letter-sound conversion rules.

It is not until Theme 5 that students begin spelling nonsense words using the letter-sound conversion rules. It is worth noting that the reading and spelling activities provide a limited number of repetitions compared to other intervention programs (e.g., Understanding Words and Minilit).

So I have a few problems with the program, but does it work? The answer is that we don’t know. There are no published peer-reviewed studies on effectiveness.

Finally, I was surprised to read that the authors recommended using the program in semester 2 of Grade 1 or even in Grade 2. They claim that this will give students the opportunity for 6-months of classroom instruction and gain some exposure to both phonics (a dangerous assumption) and handwriting. They provide no evidence for this suggestion and it seems an odd one. They are almost recommending a wait-and-see-who-fails approach.  Surely an early literacy foundations program should target Prep/Kinder students or at least from the very start of Grade 1?

Conflict of Interest:

Craig Wright is the author of the Understanding Words reading intervention program.

Models of reading: The dual-route approach

There are a number of different models of how we read, the most appealing of which is Max Colheart’s Dual-Route Approach. 

This approach uses the terms “lexical” and “non-lexical” to describe two ways in which words can be read aloud. “Lexical” refers to a route where the word is familiar and recognition prompts direct access to a pre-existing representation of the word name that is then produced as speech. “Non-lexical” refers to a route used for novel or unfamiliar words. As unfamiliar words are, by definition, unrepresented in the brain’s lexicon, they cannot be read directly. They have to be decoded using knowledge of grapheme-phoneme (or “letter-sound”) conversion rules (GPCs).

Figure 1 shows the Dual-Route model. The visual features and the global form of the printed word shelf are recognised as a familiar word, which activates the orthographic representation of shelf in the Orthographic Lexicon, in turn activating the word’s name in the Phonological Lexicon, before activating the word’s meaning in the Semantic Lexicon. The 4 Sub-Lexical Phonological Representations (speech sounds) (i.e., /sh/ /e/ /l/ /f/) are then activated and produced as the spoken word shelf.

In contrast, gallimaufry will not be read directly by anyone other than those with exceptional large vocabularies, because most mere mortals will have no pre-existing Orthographic or Phonological representations for this very low-frequency word. Instead, the individual letters are analysed using knowledge of GPCs (e.g., g = /g/), the appropriate Sub-Lexical Phonological Representations are accessed, before finally, the sub-lexical units are reassembled as a word and translated to speech. There is a feedback system in operation in this process that allows access to the word’s meaning and learning of new words to take place.

Figure 1. An adapted Dual-Route model of reading showing the different pathways by which the know word shelf and the unknown word gallimaufry may be read aloud. Source http://www.maccs.mq.edu.au/~ssaunder/DRC/.

Skilled readers mostly use the Lexical route. They retain the ability to use the Sub-Lexical route (consider how you read gallimaufry and bioluminescence), it is just that they don’t need to – they have had enough experience with reading to have developed sufficient lexical knowledge. In contrast, young readers, and individuals struggling with reading , do not possess word-specific lexical knowledge in sufficient quantities. How then, do we teach this skill?

The goal of all word-reading instruction should be to assist students to read most words fluently, using the lexical route. But how do we do this? The answer lies in the development of the sub-lexical route.

The development of Sub-Lexical Reading

The following describes what we think might happen in learning to read. However, readers should note that we have a good idea of how skilled reading occurs but we actually don’t yet know how we learn to read.

Imagine that the young student destined to become a skilled reader has, by virtue of genetic fortune, all of the skills required to read. Then imagine that the following words are the first they ever attempt to read:

sit

pat

The skilled-reader-to-be has some recognition that words can be segmented into speech sounds (e.g., sit has three: /s/ /i/ /t/). This helps them map the written letters s, i t, p, a onto a speech sound (e.g., s = /s/). Acquiring these “letter-sound mappings” gives the student access to the Sub-Lexical reading route. They can read any word that has any combination of those five letters without the help of an adult (i.e., they can independently read words like tap, tip, sap, spit).

Research has shown us that we have to accurately identity a word between 4-12 times before it becomes what teachers refer to as a “sight word”. That is, before a strong enough representation of the visual form of the word and its name is formed to allow reading using the Lexical route. At this point, reading begins to speed up. The student no longer has to laboriously decode every word; fluent recognition frees up cognitive space and energy which can be used for other functions, such as comprehension and learning unusual spelling patterns.

The process seems to be different for the unskilled reader. For whatever reason, when they see the first words sit and pat they have difficulty recognising the relationship between the speech sounds in the words and the written letters used to represent them. Acquisition of “letter-sound mappings” is therefore delayed, preventing access to the Sub-Lexical reading route. When the young, or unskilled reader sees the words below, how then do they read them?

sap tip

at pit

They can’t accurately decode them using the Sub-Lexical route. Instead, they guess. In some cases the guess may be ‘educated’, but a guess all the same. Sometimes they will try to predict the word from the meaning or structure of the sentence. Often they will look at a picture to help with the printed words. They may also rely upon salient visual cues within the words, such as the initial letter, word length, or other obvious letters. It is possible that an unskilled reader will read “A fat cat sat on the mat” as “A big kitten was sitting on the floor”.

Despite common belief in education circles, using contextual cues is not only inaccurate, but damaging to students’ reading. Research has shown that contextual cues only provide 5-25% accuracy rates; and for the important content words in sentences the accuracy rate is towards the bottom of that range. In addition, because prediction from context avoids use of both the Lexical and Sub-lexical routes, even if the student guesses correctly, it does not count towards the 4-12 successful decoding attempts required to learn a word “by sight”. Using contextual cues is therefore self-defeating.

Teaching students to read

Reading is a complicated process that requires instruction in, among other things, phonological awareness, letter-knowledge, phonics, spelling, strategy development, vocabulary, grammatical awareness, and comprehension strategies. The Understanding Words programme is a good example of an evidence-based reading intervention.

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