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Educational Vision Therapy System PUSD Special Education Alternative Classroom Solution For Behavioral Based Vision Therapy What is Vision Therapy? • A method attempting to correct or improve ocular, visual processing and perceptual disorders • Also referred to as visual training or vision training. • Vision Therapy Consists of Two Broad Categories: 1. Orthoptic 2. Behavioral Orthoptic Vision Therapy • Non surgical techniques to correct conditions which might be responsible for eye fatigue and discomfort with close work. Orthoptic Vision Therapy Used to correct: •Convergence insufficiency ( the inability to have the eyes come together toward a near target without undue effort) •CI is one of the few ocular problems that can interfere with the physical act of reading. It can cause blurring of vision and the sensation that letters and words run together especially during times of prolonged reading or near work. •Most common treatment for CI is pencil push ups in which the patient practices turning his/her eyes inward to converge on a near target such as a pencil point. Orthoptic Vision Therapy Also used to correct: •Accommodative insufficiency ( the inability of the eye to focus properly on an object) After age 40 it is considered part of the aging process. Usually seen in conjunction with convergence insufficiency. •Heterophorias ( misaligned eyes) •Refractive errors ( need for glasses) Note : Orthoptics can provide excellent results for patients who have reading difficulty secondary to convergence and accommodative problems. However……… these ocular disorders are the less common causes of true reading disabilities. Behavioral Vision Therapy • Eye movement and hand-eye coordination training techniques which attempt to improve visual processing skills, visual perception and visual-motor integration. • May also include the use of colored overlays or filters and glasses for mild refractive errors with or without prisms. Behavioral Vision Therapy Requires a number of office visits depending upon the severity of the problem diagnosed by the vision therapy provider. Typical length of the program ranges from several weeks to several months and may include activities to perform at home. Note : There is NO consistent scientific evidence that supports the use of behavioral vision therapy as an effective treatment for learning disabilities or for the remediation of complex pediatric neurological conditions such as autism spectrum disorders. Two Schools of Thought American Optometric Association VERSUS American Academy of Ophthalmology American Academy of Pediatrics American Association for Pediatric Ophthalmology and Strabismus Association for Science in Autism Treatment American Optometric Association Policy Statement •Optometric intervention for people with learning related vision problems consists of lenses, prisms and vision therapy. •Vision therapy does not directly treat learning disabilities or dyslexia. • Vision therapy is a treatment to improve visual efficiency and visual processing, thereby allowing the person to be more responsive to educational instruction. American Academy of Ophthalmology American Academy of Pediatrics American Association for Pediatric Ophthalmology and Strabismus •Do not recognize behavioral vision therapy as a treatment option for reading disorders. Their criticism includes studies that are anecdotal in origin, lack matched control groups and seem to be designed with the bias that reading problems are caused by one factor. •A further concern is for the patient’s time, financial resources and expectations. The costs of vision therapy are often not covered by insurance and can be substantial. •These direct costs are in addition to the cost of lost wages, time and productivity for working parents who may have to take time off to bring a child in for repeated treatments. Finally, a program of vision therapy may provide false hope and expectations. Educational Perspective • DIS services such as Vision Therapy have been provided to students on IEPs • The provision of such services is defined and described in our Special Education Code Article 4, 56363 (a)(b)(c). Educational Perspective • Designated Instructional Services (DIS) or Related Services are services designed to enable an individual with exceptional needs to receive a free appropriate public education as described in the IEP • DIS services may also be required to assist an individual to benefit from special education. DIS Services (including but not limited to) • Language and Speech • Audiological Services • Orientation and Mobility Services • Instruction in Home/Hospital • APE • PT and OT • Vision Services • Specialized Driver Training • Counseling and Guidance • Psychological Services • Parent Counseling and Training • Health and Nursing • Social Worker Services • Specially Designed Vocational Ed. and Career • Recreation Services • Specialized Services for Low-Incidence • Interpreting Services Educational Perspective • Later on in the Education code, each DIS service is further defined in Article 5, 3051-3051.18 • Interestingly enough, 2 DIS services appear in addition to those listed in Article 4 • Services for Pupils with Chronic Illnesses or Acute Health Problems AND Vision Therapy Vision Therapy in PUSD • The District has been providing Vision Therapy to students through their IEPs for many years • As time has progressed, many difficulties have surfaced with identification and delivery of Vision Therapy services Difficulties with Vision Therapy in PUSD • Poor communication between VT providers and school staff • Inability to connect service to an area of need and specific goal on the IEP • Students who are evaluated often never attend sessions • Lack of involvement in daily program by VT providers Difficulties with Vision Therapy in PUSD • Tracking of completed sessions and reviewing progress in timely manner at IEP meetings • Cost Cost to PUSD • From 2005-2008, Vision Therapy cost PUSD $237, 590.00 • We expect to have to spend another $80,000 for the current school year!!! Alternative Solution • The Special Education office has been working on an alternative solution to Vision Therapy • The alternative focuses on a classroom program that can address educational deficits a student could have that may have previously resulted in a Vision Therapy referral Alternative Solution • As with any IEP need, it’s important to look to resources and programs that will interfere the least with a student accessing the General Education curriculum and environment • An alternative classroom based program to Vision Therapy can reach more students in a less restrictive way at less expense to the district Alternative Solution • As a case manager or classroom teacher, you will often be the first point of contact for a parent who may have concerns about Vision Therapy • It will be important for you to have updated and research based information to support a classroom based program versus a referral for a Vision Therapy evaluation Research: Reading and the Eye • Since we typically use our eyes to read the printed word, it would, at first glance, seem that problems with reading equate to eye problems. As a result, many misconceptions regarding reading have ensued. • Although the eyes are obviously necessary for vision, the brain interprets visual symbols. Therefore, correctly subtle visual defects cannot alter the brain’s processing of visual stimuli. Dyslexia Misconceptions Reality Research Dyslexia : Misconception, Reality and Research • Misconception : • Dyslexia was once thought to be a visually based learning problem causing students confusion in the way they see letters and words. Dyslexia : Misconception, Reality and Research • Reality : • The standard definition of dyslexia is “unexpected difficulty in reading in children and adults who otherwise possess the intelligence, motivation and schooling considered necessary for accurate and fluent reading”. • The definition does not include reversing letter, mirror writing or other commonly held misbeliefs. Dyslexia : Misconception, Reality and Research • Research : • The vast majority of students with severe reading difficulties have substantial weakness in auditory related skills such as identifying sounds with words ( phonemic awareness) and associating sounds with written letters ( sound-symbol relationship). • Fletcher and Lynon 1998; Shaywitz 1996 and Torgeson, 1998 Dyslexia : Misconception, Reality and Research • Reality : • Dyslexia is a language deficit and varies from language to language. • Interestingly, the phonemic complexity of a language corresponds to the prevalence of dyslexia, confirming the linguistic and not ocular origin of the problem. • Dyslexia in English-speaking countries is twice as common as in Italy. Over 1000 different combinations of letters represent the 40 sounds used to speak in English. In contrast, Italian has only 25 sounds represented by 33 combinations of letters. Dyslexia : Misconception, Reality and Research • Research : • Functional magnetic resonance imaging (FMRI) has made it possible for scientists to watch the neural systems at work as readers attempt to transcribe letters into sounds. • FMRI research has left no doubt that the core problem in dyslexia is phonologic : turning print into sound. • (Shaywitz 2003) Reading : A Complex Process • Identification of individual words – Decoding and accuracy • Constructing Meaning – Using global intelligence, vocabulary, reasoning and concept formation Alternative Solution • Given what we know about Vision Therapy and reading research, what can we do to address educational deficits our students may have without using up unnecessary resources from our District? The Educational Vision Therapy System by Dr. John Hannaman A Structured and Sequential System to Develop : • Directionality • Tracking • Letter Discrimination in Text • Mid-Line Crossover Skills Directionality and Letter/Word Discrimination – A learned and trainable visual perceptual skill. – The ability to attach meaning to objects and concepts in the physical world by judging them to be right- left or backfront relative to other things. Directionality and Object Permanence • Everyday objects do not change their meaning based upon their direction. • A pencil is a pencil whether it is held upside down or sideways. • Letters are different………when the letter d is turned upside down, it becomes the letter p. • This is a developmentally learned task and not even the same in every language. Directionality and Word Reading • The words “was” and “saw” or “bad” and “dad” may be interpreted as the same or different depending on which side of the word the eyes are aimed at to begin decoding. Visual Tracking and Saccades • Reading is accomplished by saccades ( fast eye movements) from one word to the next. • Tracking lines of print is a practiced task and becomes self-correcting with enhanced understanding of what is read. Skilled Readers and Saccades • When reading English, people use predominantly rightward saccades with intermittent fixations. • About 20% of the saccades in normal reading are leftward verification or regression saccades. • Regression saccades are more prevalent with increasing difficulty of the text and also in students beginning to read as well as struggling readers. • Although some have postulated that regression saccades are responsible for poor reading; most experts consider them the result-not the cause of difficulty reading text. • No evidence suggests that saccade training results in better reading………..but improved reading has been shown to change saccades patterns. The Educational Vision Therapy System • Designed for students who exhibit poor eye coordination and/or sense of directionality. • Includes multi-sensory- kinesthetic, auditory and visual exercises • Starts with gross motor skills and moves to fine motor skills. The Educational Vision Therapy System- 25 Exercises • 1- Gross motor movement for right, left, up and down • 2- Right-Left dominance ( Ball Bounce) • 3- Visual directionality with lines- first step in transferring from a gross to a fine skill • 4- Reverse directionality • 5- Body orientation and reversal The Educational Vision Therapy System • 6- Directionality Reinforcement • 7- Spatial Orientation of letters ( p,b,d,q) • 8- Spatial Orientation of letters (n,u,h,m) • 9- Letter Identification for “b” • 10-Letter Identification for “d” • 11-Letter Identification for “p” • 12-Letter Identification for “q” The Educational Vision Therapy System • 13- Letter Identification for “n” • 14- Letter Identification for “u” • 15- Letter Identification for “h” • 16- Letter Identification for “m” • 17- Letter combinations “bd, db, pd” • 18- Identification of letter patterns ( p, q) • 19-Identification of letter patterns (n,u,h,m) The Educational Vision Therapy System • 20-Letter Identification within text (“b”) • 21-Letter Identification within text ( “d) • 22-Letter Identification within text (“p”) • 23-Letter Identification within text (“b,d,p”) • 24-Word Identification for commonly reversed words ( bad, dad) • 25-Word Identification within text The Educational Vision Therapy System • Exercises must be done every day: • Step 1- Set up a reward system with the student for each successfully completed exercise. Record the outcome of the days work on the daily log • Step 2- Do not assume the student can perform a task. Begin at the first exercise and test the student. Students can progress quickly through the exercises if they meet the success criteria under practice duration and frequency. The Educational Vision Therapy System • PRACTICE DURATION and FREQUENCY is dependent upon each exercise, on average 3-5 days per exercise. • For example: • Exercise 1- to be practiced for 5 minutes twice a day until student is correct 100% of the time. • Exercise 10- to be completed once a day for a minimum of 3 days until the student can complete with 100% accuracy within one minute. Appropriate Candidates Appropriate candidates for the Educational Vision Therapy System are: • Students who may have difficulties with eye coordination, sense of directionality and/or tracking • Students whose parents or family optometrist have inquired about Vision Therapy Appropriate Candidates • You will know the students in your Reading/English classes that have difficulties with directionality and/or tracking • If you need more information, be sure to check the Initial/Triennial testing for results from the TVPS or other visual discrimination tests • Consult your School Psychologist How to get started? • When a teacher notices a specific deficit or receives an informal parent request for Vision Therapy, he/she can notify the Special Education office of the need for an Educational Vision Therapy System workbook • PUSD has a license to reproduce the individual workbook for each child who may need it How to get started? • This program is an independent work program for students • After some basic instruction on how to complete exercises, each student should be able to complete the daily exercises in his/her workbook independently in the classroom How to get started? • This program (like any instructional material) will not be specifically listed in the IEP nor will you document Vision Therapy on the front page • If you have noticed a specific deficit for a student in directionality or tracking, then an IEP goal can be written Formal Requests for Vision Therapy • When a teacher receives a formal or written request for a Vision Therapy evaluation, an IEP team meeting should be convened • The Program Specialist should be invited to this IEP meeting • Prior testing should be reviewed and a PUSD evaluation should be conducted if necessary (please see the VT procedures in the handbook) Formal Requests for Vision Therapy • • • • At the IEP, the teacher and Program Specialist will discuss with the team: Research about Vision Therapy (please see the article entitled Learning Disabilities, Dyslexia, and Vision by David Granet, M.D.) The Educational Vision Therapy System we can implement at school How we will track the student’s progress in the program and use data to make decisions What the team can do if the program is not effective and when to consider a referral to an optometrist/ophthalmologist Formal Requests for Vision Therapy • Should the parents continue to formally request a Vision Therapy evaluation, work with your Program Specialist to identify the next steps and use your Procedural Handbook as a reference for necessary paperwork and procedures Procedural Handbook • 1 page handout describes the basic information from this presentation. This new information can be placed in your handbook as a reference and will be integrated into the Vision Therapy section of the handbook for the following school year Final Thoughts • If there is no scientific evidence to support behavioral vision therapy, then why would we spend our time on it? • What else can we do to improve reading if behavioral vision therapy will not help? Questions? Educational Vision Therapy System PUSD Special Education Alternative Classroom Solution For Behavioral Based Vision Therapy