By Stuart Warren

Evidence base for the treatment

of problems found on iCept

iCept Training The iCept software trains low level visual and auditory skills.

• It trains in the following areas:1. Eye Tracking – accuracy of voluntary eye movements (reading accuracy)2. Visual Span – window of visual attention (reading speed)3. Visual Count – recognition of number concept (basic arithmetic)4. Visual Spatial – visual spatial attention (position, recognition, visualization)5. Auditory discrimination – discriminating differences in sound (spelling)

ie. volume, gap detection, frequency & temporal order

• Before training however there must be a stable near visual platform – that is, vision must be clear, single and steady as per the 3 Point Check Test of near vision.

Training Principles• Hebb’s Rule – synaptic transfer improves if the synapses are successfully used.• To achieve this, the task being trained needs to be:

i) task specificii) performed on a regular daily basis (eg. 15 minutes a day)

• The iCept training targets low level development but is considered “top-down”. That is, training starts with the student having to think about the skill at a conscious level but through regular daily practice it becomes part of their skill repertoire requiring little conscious effort.

REFERENCES1. Hebb D. The organization of behaviour: A neuropsychological theory. New York: Wiley, 1949

Is Vision a Factor? • The role of vision in dyslexia and learning disabilities has been debated for decades. • Early eye tracking studies failed to show a link with dyslexia.1,2,3

• Further, since the work of Vellutino on visual perception in the 70’s many authorities have taken the view that vision does NOT contribute to dyslexia – a view still promoted by organizations such as the American Academy of Ophthalmology.4,5

• More recently a fMRI brain imaging study found that dyslexics have reduced visual activity (V5/MT) but this was interpreted as being a consequence of insufficient reading practice rather than a cause of dyslexia.6

REFERENCES1. Brown B, Haegerstrom-Portnoy G, Yingling C.D, Herron J, Galin D, Marcus M. Tracking eye movements are normal in dyslexic children.

American Journal of Optometry & Physiological Optics 1983, 60(5): 376-3832. Stanley G, Smith G, Howell E.A. Eye-movements and sequential tracking in dyslexic and control children. British Journal of Psychology

1983, 74:181-1873. Black JL, Collins DW, De Roach JN, Zubrick S. A detailed study of sequential saccadic eye movements for normal –and poor reading

children. Perceptual Motor Skills 1984, 59(2):423-4344. Vellutino F, Fletcher J, Snowling M, Scanlon D. Specific reading disability (dyslexia): what have learned in the past four decades? J Child

Psychol Psychiatry 2004, 45(1):2:-405. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities, American Academy of Ophthalmology,

American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. JOINT STATEMENT—LEARNING DISABILITIES, DYSLEXIA, AND VISION. Pediatrics 2009, 124(2):837-44

6. Olulade O, Napoliello E, Eden G. Abnormal visual motion processing is not a cause of dyslexia. Neuron 2013, 10(1):180-90

Is Vision a Factor? • In contrast, there exists a body of evidence to show that vision does contribute to dyslexia –

a view held by the American Academy of Optometry.1 This does not deny the importance of phonological awareness which is the prevailing view, but rather argues for a multi-factorial view of dyslexia2

• Recently a group of Italian researchers have shown that visual skills are more predictive of future reading ability in beginner readers (followed over 3 years) than other approaches and provide evidence for a link between vision and dyslexia independently of auditory-phonological skills.3,4 A reduced visual capacity in preschool children suggests this cannot be solely attributed to a lack of reading practice.

• The same researchers also show that training visual attention improves reading ability in both children and adults arguing for a causal relationship between vision and dyslexia, thus closing a 30 year debate and paving the way for visual based interventions.5

• This review will consider evidence for the training tasks found in iCept…

REFERENCES1. VISION, LEARNING AND DYSLEXIA: A Joint Organizational policy statement of the American Academy of Optometry & the American

Optometric Association. J Am Optom Assoc 1997, 68(5):284-2862. Mesman G, Kibby M. An examination of multiple predictors of orthographic functioning. J Learn Disabil 2011, 44(1):50-623. Franceschini S, Gori S, Ruffino M, Pedrolli K, Facoetti A. A Causal Link between visual spatial attention and reading acquisition. Current

Biology, 2012 DOI: 10.1016/j.cub.2012.03.013 4. Gori S, Seitz A, Ronconi L, Franceschini S, Facoetti A. The causal link between magnocellular-dorsal pathway functioning and dyslexia.

J Vis 2015, 15(12):195. doi: 10.1167/15.12.1955. Gori S, Sietz AR, Ronconi L, Franceschini S, Facoetti A. Multiple causal links between magnocellular-dorsal pathway deficit and developmental dyslexia. Cereb Cortex 2015, 22. pii: bhv206. [Epub ahead of print]

Voluntary Eye Saccades• Voluntary eye saccades are unique because they involve systematically moving our eyes

between words when reading (unlike video games or looking around a room).• This can be tested using an anti-saccade task (ie. where the student looks to the opposite side

of the test stimulus) as this taps into the voluntary saccade pathway.1

• Voluntary eye saccades take years to reach adult maturity; around mid to late teens.2,3,4

• It is argued that in order to determine if an ocular motor abnormality is associated with a specific learning disability, a large group must be assessed with objective eye movement recordings and an age matched control group performing academically well must be studied in exactly the same fashion.5

• Surprisingly, very few investigators have done this (including most eye tracking studies on dyslexia) however such a study was performed by the Optomotor Laboratory at the Freiburg University who found a large difference exists between dyslexics and non dyslexics in the accuracy of their voluntary saccades.3

REFERENCES1. Everling S, Fischer B. The antisaccade: a review of basic research and clinical studies. Neuropsychologia 1998, 36(9):885-8992. Klein C, Foerster F. Development of prosaccade and antisaccade task performance in participants aged 6 to 26 years. Psycholophysiology 2001, 38(2):179-1893. Biscaldi M, Fischer B, Hartnegg K. Voluntary saccadic control in dyslexia. Perception 2000, 29:509-5214. Fukushima J, Tanaka S, Williams JD, Fukushima K. Voluntary control of saccadic and smooth-pursuit eye movements in children with

learning disorders. Brain and Development 2005, 27(8): 579-588.35. Hoyt CS. Visual training and reading. Am Orthopt J, 1999;49:23-25

Training Voluntary Saccades• Studies show that voluntary saccades can be trained with regular daily practice.1-4

• Fischer & Hartnegg (2000) have shown that 3 to 8 weeks of saccade training for about 10 minutes a day can accelerate the rate of maturation by at least 10 times. This is not likely to be due to placebo effects since training non voluntary or “reflex” eye movements using the same device does not alter voluntary saccades.4

• Saccade training transfers to reading resulting in less errors and improved fluency.5-9

REFERENCES1. Dyckman KA and McDowell JE. Behavioral plasticity of antisaccade performance following daily practice. Experimental Brain Research,2005:

162(1); 63-692. Temple E, Deutsch GK, Poldrack RA, Miller SL, Tallal P, Merzenich MM, Gabrieli JDE. Neural deficits in children with dyslexia ameliorated by

behavioural remediation: Evidence from functional MRI. Proceedings of the National Academy of Sciences of the United States of America 2003, 100(5): 2860-2865

3. Kveraga K, boucher L, Hughes H. Learning to look the other way. Journal of Vision Abstract 2002;2(7):172a4. Fischer B, Hartnegg K. Effects of visual training on saccade control in dyslexia. Perception 2000;29(5):531-5425. Fischer B, Hartnegg K. Saccade control in dyslexia: development, deficits, training and transfer to reading. Opt Vis Dev 2008, 39(4):196-2056. Okumura T, Laukkanen H, Tamal H. Computerized saccadic eye movement therapy to improve oculomotor control during reading and

reading rate in adult Japanese readers. Opt Vis Dev 2008, 39(4):191-1977. Leong D, Master C, Messner L, Smith C, Starling A. The effect of saccadic training on early reading fluency. Clin Pediatr 2014, 53(9):858-8648. Solan H, Larson S, Shelley-Tremblay J, Ficarra A, Silverman M. Role of visual attention in cognitive control of oculomotor readiness in

students with reading disabilities. Journal of Learning Disabilities 2001, 34(2):107-11859. Clisby C, Fowler MS, Hebb GS, Walters J, Southcott P, Stein JF. Outcome of treatment of visual problems in children with reading difficulties.

Professional Association of Teachers in Special Situations (PATOSS), Bulletin Nov.2000, 9-14

Training Voluntary Saccades• The graph in the bottom left shows the number of misses (ie. errors made that were failed to

be corrected) versus age for dyslexics (red) and non-dyslexics (green). After training dyslexics were similar to non-dyslexics (black).1

• The graph in the bottom right shows the transfer to reading in terms of reduction of reading errors (green bars) compared to reading instruction alone (red bars).2

• The same anti-saccade training paradigm is used for iCept training.

REFERENCES1. Fischer B, Hartnegg K. Effects of visual training on saccade control in dyslexia. Perception 2000;29(5):531-5422. Fischer B, Hartnegg K. Saccade control in dyslexia: development, deficits, training and transfer to reading. Opt Vis Dev 2008, 39(4):196-205

The iCept Saccade Task• The graph below shows the normal age development profile of voluntary saccades as

measured by the iCept test on the iPad. The test flashes a star to one side of the screen followed briefly by a number on the opposite side. The student is required to enter the number seen (ie. to look the other way). The results show a steep development up until 10 years and a slower development extending to the end of high school.

• This long lasting development suggests that eye movements may be amenable to improvement with practice.

n=700

iCept Saccade Training

iCept Saccade Training

Binocular Fixation Stability

• This is also described in the literature as the binocular co-ordination, disconjugacy, or drift velocity of saccades as it measures the relative velocity difference between the eyes.

• Instability of binocular fixation can be likened to a wobble between the eyes.• This is a greater issue for younger children (ie. under 12) at near (see graph next page).• This cannot be assessed on observation but it can be measured using a binocular eye tracker.• Although binocular fixation stability improves with age, dyslexics are more likely to have a

problem with this independently of reading.1-6

• This is less likely to be affected by attentional factors.

REFERENCES1. Stein JF, Fowler MS. Unstable binocular control in children with specific reading retardation. J Res Reading 1993, 16:30-452. Fischer B, Hartnegg K. Stability of gaze control in dyslexia. Strabismus 2000:8:119-1223. Kapoula Z, Ganem R, Poncet S, Gintautas D, Bremond-Gignac D. Poor binocular yoking of the saccades independently from reading in

dyslexic children. Perception 2006: 35 ECVP Abstract Supplement4. Bucci MP, Bremond-Gignac D, Kapoula Z. Poor binocular co-ordination of saccades in dyslexic children. Graefe’s Archive for Clinical

and Experimental Ophthalmology 2008, 246(3):417-4285. Ghassemi E, Kapoula Z. Is poor co-ordination of saccades in dyslexics a consequence of reading difficulties? A study case. Journal of

Eye Movement Research 2013, 6(1): 5, 1-116. Seassau M, Gerard C, Bui-Quoc E, Bucci M. Binocular saccade coordination in reading and visual search: a developmental study in

typical reader and dyslexic children. Front Integr Neurosci 2014, 8:85

The stability of the two eyes during fixation periods

Binocular Fixation Stability• Binocular fixation stability can be improved by occluding one eye for short periods of reading

or close work. This has been shown by independent studies – one by alternate patching1 (see graph bottom right), the other by patching the left eye only in a randomized placebo trial.2,3

• Although this skill is not tested by iCept, alternate occlusion is sometimes recommended when doing eye tracking training – especially if the central fixation result is failed.

REFERENCES1. Fischer B, Hartnegg K. Instability of fixation in dyslexia: development – deficits – training. Optom Vis Dev 2009, 40(4):221-228 Stein JF,2. Richardson AJ, Fowler MS. Monocular occlusion can improve binocular control and reading in dyslexics. Brain 2000, 123:164-1703.

Fawcett, A. J. Mono-ocular Occlusion for Treatment of Dyslexia. The Lancet 2000, 356, 89-90

Dyslexics

Controls %

Inst

abili

ty

Visual Fixation• Consistent with other oculomotor skills, a recent study assessing the fixation ability of 55

dyslexic children found that dyslexics performed significantly worse compared to both chronologically and reading aged matched control groups between the ages of 7 to 14 years.

• The task involved looking at a central fixation target for 30 seconds. The results showed that dyslexic children produced a significantly higher number of unwanted saccades which failed to improve with age like the other groups.

REFERENCES1. Tiadi A, Gerard C, Peyre H, Bui-Qoc E, Bucci M. Immaturity of visual fixations in dyslexic children. Front Hum Neurosci 2016, 17;10:58. doi: 10.3389/fnhum.2016.00058. eCollection 2016

• Also noteworthy, fixation was significantly worse in the last 15 seconds for the dyslexic group compared to the first 15 seconds - an important finding since most studies do not consider how eye movements in dyslexics change with time.

• These findings can be explained either in terms of impaired attention or an immaturity of cortical areas that control eye fixation, with the latter explanation being favored.

Side: Eye Trackers • There is presently no standard method for quantitatively assessing eye movements clinically.• The iCept Test on the iPad is a conservative test only (ie. some students can pass the eye

tracking test despite having poor saccades). Also, it does not test other related oculomotor problems such as fixation strength and binocular stability.

• To address this gap VFL are currently developing software for a head free eye tracker using a similar approach to Fischer & Hartnegg.1,2 The goal is to create a comprehensive, user friendly test of eye movements that can be used by clinicians.

• It is hoped this can be scaled to provide a more portable, lower cost approach (see below).

Tobii TX300

REFERENCES1. Fischer B, Gezeck S, Hartnegg K. The analysis of saccadic eye movements from gap and overlap paradigms. Brain Research Protocols 1997,

754:285-297 2. Hartnegg K, Fischer B. A turn-key transportable eye-tracking instrument for clinical assessment. Behav Res Methods Instrum Comput

2002, 34(4):625-629

Visual Span

• Some studies define this as the amount of information that can be processed per look, while other studies refer to it as how far a person can see per look. Either way, the visual span probes our window of visual attention and compares it with those of similar age.

• The visual span is affected by font size, contrast, crowding and our ability to resolve details in the periphery. Of these, crowding is the most likely to affect the visual span.1 For example, if a letter or number is flanked on either side by another letter or number (ie. crowding), this will reduce the visual span by around a factor of four from 18 to 4.5 characters from the point of fixation!

• A reduced visual span is not primarily due to poor memory, phonological skills or a lack of reading experience.1,2,3,4

REFERENCES1. Yu D, Legge G, Wagoner G, Chung S. Sensory factors limiting horizontal and vertical visual span for letter recognition. J Vis 2014,

14(6):3 2. Lobier M, Zoubrinetzky R, Valdois S. The visual span deficit in dyslexia is visual and not verbal. Cortex 2012, 48(6):768-733. Zoubrinetzky R, Collet G, Serniclaes W, Nquyen-Morel M, Valdois S. Relationship between categorical perception of phonemes,

phoneme awareness and visual attention span in developmental dyslexia. PLoS One 2016, 11(3): e0151015. doi: 10.1371/journal.pone.01510154. Lobier M, Valdois S. Visual attention deficits in developmental dyslexia cannot be ascribed solely to poor reading experience.

Nat Rev Neurosci 2015, 16(4):225

A measure of the window of visual attention without moving the eyes

Visual Span & Reading• The visual span should not be confused with the PERCEPTUAL SPAN which is associated with a

dynamic reading span, shown to be greater to the right of fixation.• The visual span is a strong predictor of reading performance and in particular reading speed.1,2

• A narrow visual span means a student has to make more eye movements to read the same amount of material and hence will read more slowly – a hallmark trait of dyslexia.

• A large study of French & British students has shown that many dyslexics suffer from a reduced visual span – at least as many as with phonological deficits – and that up to 23% have a visual span deficit with no phonological deficit at all.3

• An exception to dyslexics having a smaller visual span is when they have to identify one item in the periphery displayed on one side. This is called the “Form Resolving Field” (FRF). This is may be due to the dyslexic allocating more attention to the task however this rapidly changes once additional items are added and the task involves multi-element parallel processing.

REFERENCES1. Bosse M, Vladois S. Influence of the visual attention span on child reading performance: a cross sectional study. Journal of Research in

Reading 2009, 32(2):230-2532. Legge GE, Cheung S, Yu D, Chung ST, Lee H, Owens DP. The case for the visual span as a sensory bottleneck in reading. J Vis 2007, 7(2):911-

915 3. Bosse M, Tainturier M, Valdois S. Developmental dyslexia: The visual attention span deficit hypothesis. Cognition 2007, 104(2): 198-2304. Zegarra-Moran O, Geiger G. Visual recognition in the peripheral field: letters versus symbols and adults versus children. Perception 1993,

22(1) 77 – 90

Training the Visual Span• Despite a variety of ways of measuring & training the visual span (eg. Trigram Method, Letter

String – partial or global, Form Resolving Field etc) all of them can be improved with training resulting in faster reading speed, by at least 40 to 60%.1,2,3,4

• This faster reading speed is probably due to a larger window of attention allowing more items to be seen per look rather than improved spatial attention or crowding.2,5

• Improvements are also transferable to different locations in the visual field and print sizes.• Using reading specific training stimuli is NOT more effective for improving reading speed.6

REFERENCES1. Chung ST, Legge GE, Cheung SH. Letter-recognition and reading speed in peripheral vision benefit from perceptual learning. Vision Res

2004, 44(7):695-7092. Lee H, Kwon M, Legge G, Gefroh J. Training improves reading speed in peripheral vision: Is it due to attention? Vision Res 2010,

50(9):860-8693. Valdois S, Peyrin C, Lassus-Sangosse D, Lallier M, Demonet J, Kandel S. Dyslexia in a French-Spanish bilingual girl: behavioural and neural

modulations following a visual attention span intervention. Cortex 2013, 53(1):120-1454. Geiger G, Lettvin J, Fahle M. Dyslexic children learn a new visual strategy for reading: a controlled experiment. Vision Res 1994, 34(9):12235. Chung S. Learning to identify crowded letters: Does it improve reading speed? Vision Res 2007, 47(25):3150-31596. Bernard J, Arunkumar A, Chung S. Can reading-specific training stimuli improve the effect of perceptual learning on peripheral reading

speed? Vision Res 2012, 1(66):17-25

The iCept Visual Span Task

REFERENCES1. Braine L. Asymmetries of pattern perception observed in Israelis. Neuropsychologia 1968, 6(1):73-88 .

• The iCept Visual Span test is uncrowded but requires the student to identify a number on BOTH sides of fixation (see previous slide). Like other approaches, the iCept test shows a long development period with the most rapid increase occurring during the primary school years (up to 10 years). It shows that older students have 2 to 3 times the span as younger children.

• Interestingly, the visual span is greater on the left side, a fact noted by other investigators who have shown that character recognition is better on the left - even in students who read from right to left.1

The normal Visual Span for students no more than 6 months behind in reading, spelling and math (n=700).

Visual Span Training: iCept

Visual Count

• This is measured by flashing small circles quickly (100ms) on a screen to be recognized and or counted by the observer.

• Humans can subitize up to about 5 items after which they need to count them.• The response time depends on the number of items being displayed which can be recorded

as a measure of their visual processing speed.• Visual counting improves well into the teenager years.• Students with dyscalculia and also dyslexia often have a problem with this task irrespective of

gender (graph next page).1-3

A basic visual capacity to recognize & count objects rapidly

REFERENCES1. Koontz KL, Berch DB. Identifying simple numerical stimuli: processing inefficiencies exhibited by arithmetic learning disabled

children. Mathematical Cognition 1996, 2:1-242. Landerl K, Bevan A, & Butterworth B. Developmental dyscalculia and basic numerical capacities” a study of 8-9 year old

students. Cognition 2004, 93:99-1253. Fischer B, Gebhardt C, Hartnegg K. Subitzing and visual counting in children with problems in acquiring basic arithmetic skills.

Optometry & Vision Development 2008, 39:24-29

Visual Count

REFERENCES1. Fischer B, Gebhardt C, Hartnegg K. Subitzing and visual counting in children with problems in acquiring basic arithmetic skills.

Optometry & Vision Development 2008, 39:24-29

• The Optomotor Group at Freiburg University have found a significant difference in visual counting for students with dyscalculia and dyslexia, both in terms of accuracy & response times (see graph below).

Training Visual Count• Studies have shown training subitizing & visual counting improves the speed of both subitizing

and number comparisons with transfer to tasks of basic arithmetic in school aged children.1,2

• By contrast, attentional training using video games for students with developmental dyscalculia does not improve basic numerical abilities despite improvements in attention. This suggests that deficits in attention and numerical processing originate from different sources.3

• Training may also help with reading as there is a known comorbidity between students with arithmetic and reading disorder.4

• One possibility is it allows a student to more accurately predict the number of letters in a word for rapid processing and to optimally position their eyes.

REFERENCES1. Fischer B, Kongeter A, Hartnegg K. Effects of daily practice on subitizing, visual counting and basic arithmetic skills. Optom Vis Dev

2008, 39(1):30-342. Wilson A, Revkin S, Cohen D, Cohen L, Dehaene S. An open trial assessment of “The Number Race”, an adaptive computer game for

remediation of dyscalculia. Behavioral and Brain Functions 2006, 30(2):20-363. Ashkenazi S, Henik A. Does attentional training improve numerical processing in developmental dyslexia?

Neuropsychology 2012, 26(1):45-564. Raddatz J, Kuhn J, Holling H, Moll K, Dobel C. Comorbidity of arithmetic and reading disorder: basic number processing and calculation

in children with learning impairments. J Learn Disabil 2016, Jan 15. pii: 0022219415620899

Training Visual Count

REFERENCES1. Fischer B, Kongeter A, Hartnegg K. Effects of daily practice on subitizing, visual counting and basic arithmetic skills. Optom Vis Dev 2008,

39(1):30-34

• The Optomotor Group found that daily practice over 3 weeks could improve these skills to reach age normal levels for the majority of students as shown in the graph below (bottom left) with 75% improving in both speed and accuracy and a further 21% improving in at least one of these variables.1

• The training also resulted in a significant transfer to basic mathematical operations on the DEMAT (T- Group 1, green) shown in the graph below (bottom right) compared to a wait group (W-Group 2, red). This transfer effect continued to improve after training (blue) and the wait group also improved following 3 weeks of training (yellow).

Training Visual Count

REFERENCES1. Wilson A, Revkin S, Cohen D, Cohen L, Dehaene S. An open trial assessment of “The Number Race”, an adaptive computer game for

remediation of dyscalculia. Behavioral and Brain Functions 2006, 30(2):20-36

• Software that trains numerical comparisons for 7 to 9 year old children with mathematical difficulties showed an increase in performance of the speed of comparison (by several hundred milliseconds) a well as subitizing speed and subtraction accuracy (shown below) but not for accuracy of addition. Training was over 5 weeks, 4 days a week.

• Although the study was small and larger controlled studies are needed, it supports the previous study showing that training can increase performance of core number sense tasks with likely transfer to higher level arithmetic.

The iCept Visual Count Task

The mean Visual Count task findings for students no more than 6 months behind in reading, spelling and math (n=700).

• The iCept Visual Count task shows a long development period for the response times when 1-2 items (bottom left) or 4-8 items (not shown) are presented and accuracy (bottom right).

• The rate of development is greatest from age 7 to 10 years old.

Visual Count Training: iCept

Visual Spatial

• Academic skills such as spelling, maths and handwriting require visual spatial perception in order to visualize words and numbers or to know where one is looking on the page.

• Furthermore, studies show that poor readers make more letter reversals than good readers which has been linked to a problem with visuospatial orientation.1,2,3,4

• Early studies of spatial perception focused mainly on “lateral preference” (ie. handedness & eye/hand dominance) which was not found to be significantly related to reading difficulties however confusion of left & right side was found to be significant, a fact often overlooked.5

• Neuroimaging studies show that the more disrupted the spatial qualities of the text becomes, the more active is the spatial region of the brain, thus demonstrating a spatial link to reading.6

Eg. TrY REadinG lIKE tHIs AnD iT wiLL Be aLOt MOrE DiFfiCUlt!Eg. Lteters can be a taotl mses and you can sitll raed wothiut a porbelm (not strictly

true!)

The ability to view space such as direction, position & shape in the mind’s eye

REFERENCES1. Boone M. Relationship of left-right reversals to academic learning. Percept Mot Skills 1986, 62:27-332. Jordan B, Jordan S. Jordan Left-Right Reversal Test: An analysis of visual reversals in children and significant reading problems. Child

Psychiatry Hum Dev 1990, 21(1):65-733. Badian N. Does a visual-orthographic deficit contribute to reading disability? Ann Dyslexia 2005, 55(1):28-524. Lipowska M, Czaplewska E, Wysocka A. Visuospatial deficits of dyslexic children. Med Sci Monit 2011, 17(4):CR216-215. Birch H, Belmont L. Auditory-visual integration, intelligence and reading ability in school children. Percept Mot Skills 1965,20:295-3056. Pammer K, Hansen P, Holliday I, Cornelissen P. Attentional shifting and the role of the dorsal pathway in visual word recognition.

Neuropsychologia 2006, 44(14):2926-36

Visual Spatial• Recent evidence suggests the deficit in the Visual Word Form Area known to occur in dyslexia

might be secondary to an impairment of visuospatial processing in the middle occipital gyrus.• This is because visuospatial processing is thought to be important for the ordering of symbols

in unfamiliar word strings and is thus critical for fast word recognition in the VWFA.1,2,3

• As visual spatial processing is a learned skill, teaching left/right body awareness and other real world aspects of visual space could be a useful starting point for beginner readers to facilitate the discrimination of spatial awareness including mirror image letters.4

REFERENCE1 Vidyasagar T, Pammer K. Dyslexia: a deficit in visuo-spatial attention, not in phonological processing. Trends Cogn Sci 2010, 14(2):57-632. Grainger J, Dufau S, Ziegler J. A Vision of Reading. Trends Cogn Sci., 2016 Mar;20(3):171-9. doi: 10.1016/j.tics.2015.12.0083. Boros M, Anton J, Pech-Georgel C, Grainger J, Szwed M, Ziegler J. Orthographic processing deficits in developmental dyslexia: Beyond

the ventral visual stream. Neuroimage 2016, 128:316-274. McMonnies C. Visuo-spatial discrimination and mirror image letter reversals in reading. J Am Optom Assoc 1992, 63(10):698-704

Visual Spatial Tasks & Dyslexia• It is frequently claimed that dyslexics have superior spatial skills however a detailed investigation shows this

to be only true in specific circumstances.• A study by Winner looked at 15 visual spatial tasks in dyslexics and compared them to non-dyslexics. Her

research showed that dyslexics were the same and often worse in 14 of the 15 tasks except for Impossible Figures in which they excelled.

1. The Vandenberg Test of mental rotation – mental rotation of an image in 3d space2. Rey-Osterrieth Complex Figure Test – recall of a complex figure from memory3. Archimedes’ Screw – analyzing which way a screw turns to raise water4. Pyramid Puzzle – a three dimensional puzzle5. Drawing task – required to draw their own hand6. Spatial word problems – required to spatially visualize cubes if presented orally7. Bit Matrices – complete the pattern8. Hidden Figures – pick out a simple shape from a complex array9. Spatial Orientation – how would an image appear from another perspective10. Spatial Visualization – manipulating spatial forms (shapes) on a Form Board11. Figural Flexibility – finding multiple ways to arrange rectangular boxes in a container12. Closure Speed – the ability to unite n incomplete picture into a whole13. Scanning – a timed task where the student has to find a given letter in array of letters14. Reference Memory –recall the spatial relationship between 2 landmarks15. Impossible Figures – the ability to recognize if a figure was impossible (shown above)

REFERENCES1. Winner E, Karolyi C, Malinsky D, French L, Seliger C, Ross E, Weber C. Dyslexia and visual-spatial talents: compensation vs deficit model.

Brain Lang 2001, 76(2):81-110

Visual Spatial Tasks & Dyslexia• Another interesting study compared grade 5 dyslexic and non dyslexics students on the Clock

Drawing Test, a well recognized medical test of spatial awareness.1

• It found dyslexic readers performed significantly worse than good readers as shown below. Interestingly, the results did not correlate well with the Block Design Test in the WISC-R.

• One explanation for these findings is a delay in low level spatial development. As the spatial task becomes more advanced (eg. Block Design) higher cognitive abilities come in to play.

• It is thus plausible that a dyslexic student who struggles with basic spatial tasks (eg. tying their shoe laces or left right awareness) learns to compensate for this deficiency by developing processing of spatial skills at a higher cognitive level whereby dyslexics may be observed to excel – particularly at a global level.2

REFERENCES1. Eden G, Wood F, Stein J. Clock drawing in developmental dyslexia. J Learn Disabil 2003, 36(3):216-2282. Von Karolyi C, Winner E, Gray W, Sherman G. Dyslexia linked to talent: global visual-spatial ability. Brain Lang 2003, 85(3):427-31

Training Visual Spatial Skills• Practicing Left/Right directions using simple visuo-motor activities (eg. touch screen game to

move a frog across a pond) has been shown to have a positive effect on number-space associations in pre-school children, even before they learn to read and write.1

• Discriminating sinusoidal gratings (that stimulate the magnocellular visual pathways) in combination with a left/right directionality task significantly improves reading for grade 2 & 3 students. 2

• Occupational therapy, developmental movement & perceptual-motor programmes that target directionality can improve visual spatial skills in younger children with learning difficulties.3,4,5

• There is currently a need for more evidence to support the efficacy of visual spatial training as a motor-based therapy however it is supported on both theoretical and developmental grounds, not only for reading but also for other aspects of learning such as gross and fine motor skills (eg. sports & handwriting) and visualizing letters and words (eg. spelling).6

REFERENCES1. Patro K, Fischer U, Nuerk H, Cress U. How to rapidly construct a spatial-numerical representation in pre-literate children (at least

temporarily). Developmental Science 2016, 19(1):126-1442. Lawton T. Training direction-discrimination sensitivity remediates a wide spectrum of reading skills. Optom Vis Dev 2007, 38(1):37-513. Mandani B, Farahbod. The efficacy of occupational therapy intervention in visual-spatial and visual analysis skills development among

children with learning disorders. Iranian Rehabilitation Journal 2009, 7(1):25-294. Fredericks C, Kokot S, Krog S. Using a developmental movement programme to enhance academic skills in grade 1 learners.

South African Journal for Research in Sport, Physical Education and Recreation 2006, 28(1):29-425. Pienaar A, Van Rensburg E, Smit A. Effect of a kinderkinetics programme on components of children’s perceptual-motor and cognitive

functioning. South African Journal for Research in Sport, Physical Education and Recreation 2011, 33(3):113-1286. McMonnies C. Visuo-spatial discrimination and mirror image letter reversals in reading. J Am Optom Assoc 1992, 63(10):698-704

The iCept Visual Spatial Task• The iCept Visual Spatial task requires the student to judge if a letter or number displayed on

the screen is the right way or wrong way around (ie. reversed).• Although reversals should rarely be seen by age 7½ the tendency for confusion persists until

well into the teenage years (see graph below), even in students without learning difficulties!• Like other perceptual skills, development is greatest during the primary school years.• Treatment is different from the testing and involves linking kinesthetic awareness with visual

direction. It is often combined with visualization strategies that involve picturing numbers, letters and words to help transfer to academic learning.

Visual Spatial Training: iCept• The iCept visual spatial task is suitable for students 7 to 10 years of age but could be

attempted by older students, especially if there is a history of gross motor delays.• Unlike the other tasks, the Visual Spatial task requires working with an adult.• In addition to training left/right awareness the iCept spatial activities target basic voluntary

eye movements, rapid recognition and visualization. • Specifically, the activities include stepping arrows (rapid recognition, left/right awareness &

basic eye movements), bdpq activities (same as for stepping arrows) and body map patterns (visualization) which become increasingly more difficult as the levels progress. On some activities the option exists to reduce the level of difficulty if necessary.

• Training is often supplemented with activities such as drawing numbers and letters on the child’s back (visualizing the direction of letters & numbers) and visualizing words (spelling).

Auditory Discrimination

• Auditory discrimination is one component of auditory processing that involves being able to differentiate between the smallest units of sound.

• For this discussion it is limited to 4 tasks: frequency, volume, gap detection & temporal order.• Auditory discrimination has a long lasting development that extends well into the teens (see

graph next slide).1

• Dyslexic students are more likely to have a problem with auditory discrimination - especially the frequency & temporal order tasks – a finding that is supported by other investigators.1-5

The ability to discriminate differences in similar types of sounds

REFERENCES1. Fischer, Hartnegg. On the development of low-level auditory discrimination and deficits in dyslexia. Dyslexia 2004, (10):105-182. Stein J, Talcott J. Impaired neuronal timing in developmental dyslexia – The magnocellular hypothesis. Dyslexia 1999, (5):59-773. Tallal P. Auditory temporal perception, phonics and reading disabilities in children. Brain and Language 1980, (9):182-1984. Sharma M, Purdy SC, Newall P, Wheldall K, Beaman R, Dillon H. Electrophysiological and behavioural evidence of auditory

processing deficits in children with reading disorders. Clinical Neurophysiology 2006, 117(5):1130-11445. Wang H, Huss M, Hamalainen J, Goswami U. Basic auditory processing and developmental dyslexia in Chinese. Reading &

Writing 2010, 25(2):509-536

Auditory Discrimination

DyslexiaControls

REFERENCES1. Fischer, Hartnegg. On the development of low-level auditory discrimination and deficits in dyslexia. Dyslexia 2004, (10):105-18

Training Auditory Discrimination• Like visual skills, auditory skills can be trained (next slide).1-4

• Although studies show that auditory perceptual training can help with reading (converting words to sounds) studies are mixed.5

• Training may actually be more beneficial for spelling (converting sounds to words) and for following instructions (converting sounds to actions).

• Unlike visual perceptual skills there are a certain percentage of students that struggle to hear differences in sound at all. These are referred to as “Low Performers”.1

• For students who struggle to discriminate sound using computer based training then a more “hands-on” approach may be required that uses visual reinforcement.

• In some cases difficulty discriminating sounds may be due to difficulty visualizing the sounds – especially if there is a problem with spatial awareness.

REFERENCES1. Schaffler T, Sonntag J, Hartnegg K, Fischer B. The effect of practice on low-level auditory discrimination, phonological skills, and spelling in

dyslexia. Dyslexia 2004, (10):119-1302. Murphy CFB, Schochat E. Effect of nonlinguistic auditory training on phonological and reading skills. Folia Phonoiatrica et Logopaedica,

International Journal of Phoniatrics, Speech Therpy and Communication Pathology 2011, 63(3):147-1533. Gaab N, Gabrieli JDE, Deutsch GK, Tallal P, Temple E. Neural correlates of rapid auditory processing are disrupted in children with

developmental dyslexia and ameliorated with training: An fMRI study. Restorative Neurology and Neuroscience 2007, 25(3-4):295-3104. Hayes EA, Warrier CM, Nicol TG, Zecker SG, Kraus N. Neural plasticity following auditory training in children with learning problems.

Clinical Neurophysiology 2003, 114(4):673-6845. Agnew J, Dorn C, Eden G. Effect of intensive training on auditory processing and reading skills. Brian Lang 2004, 88(1):21-5

Training Auditory Discrimination

REFERENCES1. Schaffler T, Sonntag J, Hartnegg K, Fischer B. The effect of practice on low-level auditory discrimination, phonological skills,

and spelling in dyslexia. Dyslexia 2004, (10):119-130

Training Auditory Discrimination

REFERENCES1. Schaffler T, Sonntag J, Hartnegg K, Fischer B. The effect of practice on low-level auditory discrimination, phonological skills,

and spelling in dyslexia. Dyslexia 2004, (10):119-130

The iCept Auditory Tasks• The median findings of auditory discrimination tasks for students no more than 6 months

behind in reading, spelling and math is shown below.

Auditory Training: iCept

Auditory Training: iCept

Summary• Current research shows that visual and auditory delays are frequently found in students with

learning difficulties such as dyslexia. • According to Fischer, 99% of Dyslexics have a problem with at least one visual OR auditory skill

and 82-90% have a problem with at least one visual AND auditory skill.1

• The iCept intervention can be used by both dyslexics and non-dyslexics alike and targets multiple domains. It draws on independent research, especially from that of Fischer and co-workers who are one of the few groups to show how these skills change with age.

• Although low level sensory delays are not considered to be the cause of dyslexia (as similar problems can also be found in non-dyslexics), evidence shows that treating such problems can provide a significant benefit by reducing the barriers to learning.

REFERENCES1. Fischer B. Subitizing, Dynamic Vision, Saccade and Fixation Control in Dyslexia. Visual Aspects of Dyslexia, Oxford University Press, 2012

The Near Visual Platform• For training to be successful it first requires a stable near visual platform (clear, single, steady)

as shown by the 3 Point Check Test. • Together with iCept (which addresses visual and auditory development), these comprise an

intervention that could provide significant help to the learning disabled student.• The evidence-base for the 3 Point Check Test is provided elsewhere.

Practical Considerations• Young students with very poor attention may not be suitable for iCept training but instead be

better helped by a more interactive approach that targets general attention (eg. body awareness) and visual attention. This would involve working with adult.

• Such approaches may be offered by behavioural optometrists, occupational therapists or practitioners that work in the field of sensory motor integration.

• iCept training takes a significant effort to maintain on a daily basis. In some cases it may be possible to do much of the training at school on the iPad (as opposed to after school when students are tired and have other work requirements).

The End