Vision Therapy on Children\'s Reading

¶ … Vision Therapy on Children's Reading Ability

An Analysis of the Impact of Vision Therapy Intervention on Vision-Impaired Children's Reading Ability

Background of Problem child's ability to read efficiently has been shown time and again to be directly correlated to a wide range of academic and social outcomes (Corcos, Kruk & Willows, 1993). According to Kameenui and Simmons (1998), "Professional educators and the public at large have long known that reading is an enabling skill that traverses academic disciplines and translates into meaningful personal, social, and economic outcomes for individuals" (p. 1). Similarly, it is widely recognized that reading is the fundamental component of all academic pursuits, what Kameenui and Simmons term "the pivotal ability that stabilizes and leverages children's opportunities to learn and to become reflective, independent learners" (p. 2). There is ample societal evidence to support the need for providing all students with the best opportunities to learn how to read efficiently.

While there remains a paucity of research concerning the basic aspects of how reading acquisition occurs, there is an abundance of examples of what effect not being able to read efficiently can have on society in general. Today, America's prisons are full of inmates who are functionally illiterate. These people are not able to hold down meaningful or gainful employment, and seek to earn a living through the only career path available to them: crime. These inmates were not born in prison, of course, but their lack of reading ability has been shown to have contributed to a lifestyle that helped to get them there. According to Kameenui and Simmons, "One need not look beyond the school dropout data, prison rosters, or recipients of federal public assistance to find that poor reading ability is pervasive and common to many who are not succeeding in today's society -- a society whose literacy demands continue to galvanize the distinctions between the 'haves and have nots'" (1998, p. 2). A number of past studies of those individual who were later found to be resilient to personal and societal adversity in life also suggest that the ability to read has powerful and far-reaching positive effects; across the board, these studies have shown that literacy levels are both negatively associated with lower annual earnings and higher unemployment.

According to Cornwall and Bawden (1992), "The absence of proficient reading skills is a considerable risk factor associated not only with academic failure and school dropout but unemployment and adjudication" (p. 282). Despite this virtual universal acknowledgement of the importance of reading to success in life, research into how and when children begin to read has only received scholarly attention in the relative recent past (Gould & Gould, 2003). The studies to date, though, suggest that there is a very limited window of opportunity in which effective reading comprehensive skills can be taught, with a child's ability to acquire these skills being seriously eroded thereafter; consequently, time is of the essence both in terms of timely research and the point at which interventions are introduced to help disadvantaged children overcome these constraints to learning.

Statement of the Problem

According to Gould and Gould (2003), American educators invest an enormous amount of time and resources in an effort to help students solve the cognitive problems that impede their learning. In some cases, though, these authors maintain that it is the fundamental problems that educators are unable to immediately discern that first need to be addressed. For instance, Gould and Gould note that two of the most urgent issues in American education today are the demands for improving academic performance and higher test scores and the mandate to close the achievement gaps between poor and more affluent students and minority and nonminority students; in response, educators have paid increased attention to staff development that focuses on instructional methods, reading strategies, differentiated teaching and learning, test-taking strategies for students, and so forth.

Nevertheless, before these initiatives can begin to bring about improved student performance and close the achievement gaps, schools must address a much more basic issue affecting learning for many students, especially those who live in poverty: "This is the issue of undetected and uncorrected vision problems" (emphasis added) (Gould & Gould, 2003, p. 325). It has been estimated that one out of four school-age children have undiagnosed vision problems that are sufficiently significant to affect their performance in school and in life; furthermore, studies have shown that in at-risk populations, such as children who are born into poverty, this percentage is likely to be much higher (Gould & Gould, 2003). Regrettably, many children who suffer from undiagnosed vision problems are characterized as being intellectually deficient and are denied the learning opportunities afforded otherwise-normal students (Gallimore, 1999).

Unfortunately, even when sufficient time and resources exist for schools to conduct such vision assessments, there are a number of constraints involved that may limit the ability of children to receive the level of follow-up attention and medical care they require to overcome these vision impairments. According to Gould and Gould, "screening students for uncorrected vision problems and referring them for eye examinations and glasses is the easy part" (p. 325). Minority, low-income and foster care children are particularly challenged in this regard (Gould & Gould, 2003). Visually impaired students in general, then, and those from disadvantaged socioeconomic backgrounds especially, stand much to gain from any initiative that provides educators with some step-by-step guidance on how to best approach teaching these children how to read. In fact, according to Tager-Flusberg (1994), "We will not really understand language acquisition until we know how it both affects and is affected by concurrent social, cognitive, and biological development. Although researchers have traditionally separated these areas in order to make them more tractable, a broader view encompassing as many relevant strands as possible is periodically necessary" (p. 213). Such a broader view of as many relevant strands as possible is the purpose of this study, the specifics of which are discussed further below.

Purpose of the Study

The purpose of this study is three-fold:

1. To determine the current incidence of vision-impaired children in American schools;

2. To determine the extent to which current diagnostic procedures are failing to identify potentially vision-impaired children; and, 3. To identify efficacious treatment interventions to improve reading abilities in vision-impaired children.

Significance of the Study

Despite the overwhelming evidence that good reading skills help children achieve successful academic outcomes in virtually all settings, there remains a paucity of research concerning how vision therapy interventions on vision-impaired children's reading ability (Corcos, Kruk & Willows, 1993). According to Booth and Burman (2001), reading disorders are the most common form of learning problem in the United States today, with estimates ranging from 5 to 15% and therefore represent an issue of major importance. Because fully 70% of classroom learning depends on children's visual systems, students with uncorrected vision problems are at an enormous disadvantage before they even enter the classroom. It would therefore be reasonable to assert that if students are unable to see clearly, they are going to experience a wide range of problems in reading, writing, and even participating in nonacademic activities such as social programs and sports. Despite the enormity and incidence of the problem, Gould and Gould maintain that American parents and educators almost always overlook vision problems as a possible obstacle to learning. According to Gould and Gould, although there is no guarantee that once a vision-impaired student's vision problem is corrected, his or her grades will immediately improve; however, if the child has a vision problem that interferes with the ability to read or to learn, it will certainly constrain the student's performance. "Removing this roadblock will at least give the student a fighting chance to achieve his or her potential. We owe our students that much. Besides, our nation cannot afford to squander the abilities of bright, capable young people" (Gould & Gould, 2003, p. 326).

Research Questions

As noted above, the purpose of this study is three-fold; therefore, the following research questions will guide the direction of the research:

1. What is the current incidence of vision-impaired children in American schools?

2. What are current estimates concerning the extent to which current diagnostic procedures are failing to identify potentially vision-impaired children?

3. What treatment interventions have been proven effective in helping vision-impaired children improve their reading abilities?

Limitations and Delimitations

This study employs a case study approach to determine the answers to the guiding research questions; therefore, there will be no human subjects involved and no need for informed consent releases.

Definitions

Decoding.

This term refers to recognition of the printed word (Gould, 1998).

Low Vision and Visual Acuity. "Low vision has no commonly accepted or legal definition" (Ambrose & Corn, 1997); researchers have used functional terms to define a person with low vision as one "having difficulty accomplishing visual tasks, even with prescribed corrective lenses, but who can enhance his or her ability to accomplish these tasks with the use of compensatory visual strategies, low vision and other devices, and environmental modifications" (p. 81). Ambrose and Corn (1997) further define "functional vision" as vision that can be used to derive input for planning and performing tasks; the extent to which one uses his or her available vision is referred to as "visual efficiency."

Reading Skills. According to Carver (2002), "reading usually means to attempt to comprehend language in the form of printed words"; therefore, for the purposes of this study, the term "reading skills" will refer to an individual's ability to comprehend language in the form of printed words.

Chapter Summary

This chapter provided an introduction to the study, including the background and a statement of the problem of vision impairment on students' academic performance; a discussion of the purpose and significance of the study was followed by a description of the research questions that will guide the research process. An assessment of the study's limitations and delimitations was followed by a delineation of key terms used.

Chapter 2: Preliminary Review of the Literature

Background and Overview

Among the many serious problems facing American society today is the need to deliver effective educational services to an increasingly diverse population of students, both in terms of cultural and ethnic background as well as their levels of learning abilities. In an effort to "mainstream" as many learning disabled and minority children as possible into American classrooms, educators have been faced with a wide range of challenges and obstacles to providing this equitable distribution of educational services in a meaningful way. One of the major problems facing educators at all levels is students' ability to read in the first place. Without the ability to read efficiently, students are unable to achieve academic proficiency in almost any subject area without significant tutorial assistance and even then, the chances of success are not as great as if a child has already acquired the ability to read efficiently before entering the classroom. In this environment, what are teachers to do to help children whom they suspect of being unable to read because of a learning disability associated with visual acuity problems? Further, studies have shown time and again that diagnose and referrals for treatment interventions for visual acuity problems are the "easy part," with future follow-up being essential for any substantive gains in academic achievement to be possible.

Perhaps the most alarming part of this problem is its pervasiveness, particularly among low-income, minority, and English as a second language (ESL) students who are confronted with a wide range of additional obstacles to learning how to read. Low income families do not have as much access to literary materials to retain in the home as their more affluent counterparts, certainly, but parents and educators can help these children - even the visually impaired - learn how to read more efficiently and by so doing, they can help also them achieve success in almost every other academic endeavor, as well as securing gainful and meaningful employment later in life. In a day and age characterized by an increasing "digital divide" already, it is vitally important then to understand the extent and nature of the profound problems facing visually impaired students in American schools today. These issues are discussed further below.

Incidence and Impact of Vision-Impaired Children in American Schools

As noted above, several studies have clearly associated visual acuity problems with poor academic outcomes; however, a number of studies have also found a clear link between uncorrected vision problems and juvenile delinquency as well. "One rather alarming statistic is that in the population of all school-age students, 25% suffer from undiagnosed vision problems; however, among juvenile offenders, it is estimated that 70% have undiagnosed vision problems" (Gould & Gould, 2003, p. 327). Because it is reasonable to assume that such vision problems will naturally result in skill deficiencies, difficulty in reading and learning, and poor academic performance, it is also reasonable to assume these in turn will lead to feelings of failure, low self-esteem, and lack of interest in academics. Therefore, the association between vision impairment and juvenile delinquency becomes readily apparent.

In their study "Abandoned in the Back Row: New Lessons in Education and Delinquency Prevention," the Coalition for Juvenile Justice determined that the "biggest finding is that school failure is one of the earliest and best predictors for future delinquent and criminal behavior" (Gould & Gould, 2003, p. 328). Another study cited by these authors entitled, "The Prevalence of Visual Conditions in a Population of Juvenile Delinquents," found that juvenile delinquents were a "population of nonreaders": "Poor and nonreaders frequently exhibit poor academic performance; lack interpersonal problem-solving skills; demonstrate problem behaviors in school, such as aggressiveness and disobedience; and become delinquent" (Gould & Gould, 2003, p. 329). Poor reading skills clearly have serious and long-lasting consequences, but here again there remains much to be done in terms of developing effective screening techniques and treatment interventions that can be used in the school setting.

Effective Diagnoses and Interventions Identified to Date

In response to the growing recognition that there is an increasingly severe visual acuity problem among marginalized students, in early 2001, educators and optometrists shared their findings on the topic of "Visual Problems of Children in Poverty and Their Interference with Learning" at a conference hosted by the Harvard Graduate School of Education. At this conference, Dr. Antonia Orfield, an optometrist at the Harvard University Health Services Eye Clinic and chief investigator of the Inner-City Vision and Learning Project at the Boston Mather School, addressed the high incidence of visual problems in urban poor children and reported that fully 53% of the children tested at one school had vision problems that could constrain their ability to learn how to read, and would further affect their ability to read efficiently in the future.

According to Gould and Gould (2003), though, school vision screenings ordinarily only check for nearsightedness (which affects reading at a distance such as looking at chalkboards or whiteboards). "Dr. Orfield recommended expanding the screenings to test for conditions that affect close-up (book) reading, such as farsightedness and problems with tracking" (p. 327). While this common-sense approach would appear obvious to most observers, improving the screening process itself is just the first part of the problem. Understanding how and when children learn how to read has been the source of much controversy in recent years.

According to Pollatsek and Rayner (1995), from a developmental perspective, because the question of how words are identified is clearly central to understanding reading, it would appear reasonable to assume that recognizing the printed word is the central problem of reading. For example, an otherwise-normal 6-year-old child already possesses a well-developed system for language understanding, and the major obstacle to be overcome to achieve reading coherency would be to learn how to interpret the letters that are on the page into that existing system. "If the child can learn to access the words of the spoken language from the written representation, then he or she should be able to understand the written representation. This suggests one central question about reading: Is word recognition all that needs to be learned?" (Pollatsek & Rayner, 1995, p. 61). The growing body of evidence suggests that there is a consistent point in time where there is sufficient overlap between stimulus-driven information and some internal lexical representation that the individual is then able to recognize the word (Balota, D'Arcais & Rayner, 1990). For example, there is Morton's (1969) logogen model that suggest "this magic moment is the point in time where a logogen's threshold is surpassed"; Becker's (1980) verification model ascribes this "magic moment" to the point in time "when there is sufficient overlap with a sensory-defined internal representation and the information residing in sensory memory about the stimulus word"; finally, in Forster's (1985) bin model, the "magic moment" refers to the point in time at which there is a sufficient match between an orthographic representation derived from operations on the stimulus word and a representation in an orthographically defined access bin. "In each of these models, it is only after this magic moment in word processing that the subject can access the goodies associated with the word, for example, meaning and syntactic class" (Balota et al., 1990, p. 24).

Unfortunately, the research into this aspect of language acquisition and comprehension remains unclear, with some children apparently being able to make the mental leap between the formerly incomprehensible squiggles on the written page and actual words and others struggling over interpreting these symbols in a meaningful way. In fact, Gallimore (1999) suggests that the most salient academic difficulty experienced by children with reading disabilities involves learning to understand and apply the alphabetic principle in translating between the written and oral languages. Given this level of importance, it is somewhat surprising to find that it has been only recently that researchers have gained any true understanding of the underlying process involved. "One of the great discoveries in the study of reading in the last 25 years," Hulme and Joshi report, "is the realization that learning to read depends intimately on a child's phonological skills" (1998, p. 1). In fact, as early as 1972, researchers suggested that reading and listening comprehension represented the same internal processes when he stated that "there is only one, holistic ability to comprehend by language, and one should be able to comprehend equally well by listening or by reading, if one has been taught to decode well and other task variables are equalized" (Hulme & Joshi, 1998, p. 2). Likewise, in his chapter, "The Decomposition of Decoding," Gough (1998) notes that decoding, or the recognition of the printed word, is a fundamentally important part of reading: "There is, of course, much more to reading than decoding, but without decoding there could be no reading" (p. 19). As important as decoding is to the reading acquisition function, though, in and of itself, it is not sufficient to achieve true reading comprehensive, particularly among the vision deficient. As Gough puts it: "Reading (R) equals the product of decoding (D) and comprehension -: R = DA -- C" (p. 19). In sharp contrast to adults, the ability to decode accounts for most of the variance in reading ability in children. Gould cites a series of early studies that support this view. For example, Firth (1972) found a correlation of.92 between pseudoword naming and reading; Hoover and Gough (1990) determined that the ability to name pseudowords correlated.84,.80,.75, and.84 with the ability to comprehend text in the first, second, third, and fourth grades, respectively (in Hulme & Goshe, 1998).

In visually impaired students, though, these general decoding abilities will be adversely affected, perhaps according to the level of impairment, but also perhaps related to the student's frustration with his or her inability to succeed in learning how to read in the first place. According to Blachman (1997), "There appears to be considerable overlap at the neuroanatomical, neurophysiological, and neuropsychological levels between the pattern of deficits found in language-impaired and reading-impaired children" (p. 51). The results of longitudinal studies to date have shown a considerable degree of continuity between early language impairment and subsequent learning deficits, particularly reading (Blachman, 1997). These findings are supported by Leonard (2001) who states: "Children's approach to print differs. Some plunge in, others read slowly and without pleasure. After a century of study, we still do not know why these differences occur" (p. 158). Researchers remain unclear as to whether reading disability is a neurological disorder or if the brains of children with such deficits are somehow different. Further, there remains much unknown about how early reading experiences actually change the brain.

The research by Leonard provides compelling evidence that reading disabled children in general suffer from brain structure differentials that must be taken into account by clinicians and educators. "When disabled readers with oral language deficits are separated from those with no oral language deficits, modern imaging studies reveal differences in brain structures that have implications for diagnosis and educational practice" (Leonard, 2001, p. 159). As if this were not enough for the busy educator to consider, there is also the matter of what interventions have taken place in the past to help a child with visual impairment problems. If a problem is diagnosed early on, the effects of visual acuity problems at early ages can be remedied through various clinical interventions such as eyeglasses or surgery; further, there are some indications that the positive effects of such early deprivations on reading acquisition skills may last beyond the age of 3 years. The majority of subjects in a study by Harris and his colleagues received their first corrective glasses after the age of 6 years or so when reading difficulties at school first brought attention to their condition; however, one subject who suffered from a large amount of astigmatism obtained eyeglasses early, at the age of 3 years and he did not subsequently demonstrate any neural deficit in visual acuity; Harris concludes: