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.

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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What are Executive Functions?

The Executive Functions (EF) are a set of cognitive functions that provide the infrastructure for acquiring skills and knowledge and that coordinate the production and organisation of that knowledge. They include the ability to inhibit motor responses and other actions, to initiate effort, to sustain attention and effort, to shift attention or strategy, the controls of memory, and the ability to plan and organise for task performance.

Teachers may be more familiar with the term metacognition. This term may be misleading because it creates a false impression of a little meta-person running all cognition or thinking. In fact, the EF are no more or no less important than other cognitive operations and academic skills. The latter can be thought of as the ingredients for a task while the EF provide the recipe. One cannot prepare a meal without the ingredients and the recipe.

Dysfunction in the core EF of behavioural inhibition (the ability to inhibit or stop behavioural responses to stimuli) is now considered to be the a major deficit in Attention-Deficit/Hyperactivity Disorder (ADHD). Executive dysfunction in various forms is also present in a number of other disorders including learning disabilities, Autistic Spectrum Disorders, anxiety disorders and depression.

The adverse effects of executive dysfunction

The EF exist within the brain at a cognitive level and therefore cannot be directly observed. The behaviours that EF dysfunction creates can, however, be observed and include:

• Having difficulty inhibiting behaviour (i.e., stopping and thinking).
• Being impulsive, rushing work, and blurting out answers.
• Failing to pay close attention to details.
• Having difficulty sustaining mental effort and avoiding tasks that require sustained effort.
• Being easily distracted and switching from one task to something less important.

• Difficulty with organisation and planning.
• Appearing to make the same mistakes repeatedly despite seeming to understand rules and the use of appropriate discipline.
• Parents and teachers having to continually repeat rules.
• Some students may manifest hyperactivity verbally (i.e., talk excessively).
• Becoming fixated on particular things (e.g., television or computer).
• Failing to learn from previous behaviour and consequences.
• Only being motivated to perform when there is something in it for them (i.e., they need external motivation).
• Having poor perception of time and poor ability to use time to plan behaviour.
• Appearing sluggish and taking a long time to process information.
• Needing constant assistance in solving problems.
• Poor short-term memory and general forgetfulness; including forgetting things they need for school or forgetting to hand things in at school.
• General difficulties with regulating emotion. Emotional responses to situations may appear extreme. It can be difficult for them to remain calm and think things through. They can become overexcited and ‘throw tantrums’ more regularly than their peers.
• Becoming overwhelmed by tasks that should be manageable.
• Talking a lot, but not really saying anything.
• Disorganised speech/language and poor grammar (i.e., their sentences are poorly constructed).
• These kids have been described as carrying around an excitement meter that they use to evaluate every stimulus in their immediate environment. Essentially, the thing with the highest reading wins (i.e., gets their attention).

Consider the child in a classroom who is faced with both a page of maths problems and his peers talking about BMX bikes. Which stimulus is he to choose? For most kids with EF dysfunction there is no option – they go for the more exciting discussion about BMX. And what happens? They are seen as ‘inattentive’ and in some cases ‘disruptive’. In actual fact, they are being quite attentive to the BMX conversation; it’s just that it may be inappropriate to do so in the classroom.

Once attention has been allocated to an exciting and rewarding stimulus, it can also be hard to get the child to inhibit that response and return to the original task. 

Inconsistency

An individual with EF dysfunction is likely to be inconsistent in academic performance and behaviour; some days they will and some days they won’t, rather than simply not being able to do something at all. They will often have the skills necessary for a task (i.e., the ingredients), but fail to produce adequate performance or output because the EF controls (the  recipe) do not provide the necessary regulation on performance.

Managing Executive Dysfunction

If a child displays some of the symptoms described above and those symptoms are causing them a problem it is appropriate to have them assessed. The psychologist will need to determine what is causing the problems, make the appropriate diagnosis(es) and design a specific treatment plan.

Some individuals, particularly those with a diagnosis of ADHD, may benefit from a stimulant medication or non-stimulant such as atomoxetine. It is important to recognise that medications do not teach skills. They can, however, give the child a greater ability to stop, think, and to perform what they know. Medication does not work for every child but if you consider it worth a trial you should discuss the matter with a medical specialist.

Management of EF should always include a behavioural component and requires a team-based approach. Ideally, the school counsellor and learning support team can assist with management. However, it may be wise to arrange a meeting of all stakeholders at the school to discuss the case. These meetings should be used to further define the problem behaviours within the classroom and to develop methods for improving attention to detail and task and for increasing consistency and output.

More information on EF

lanlfoundation

Lynn Meltzer

National Resource Center on ADHD

Russ Barkley

Russ Barkley 2