There is also a cultural conditioning side to the drug movement. The university student of today has been exposed to the most profound and shattering cultural and values conditioning program experienced by a youthful generation. The Beatles, The Jefferson Airplane, The Doors, The Rolling Stones and other acid rock music groups served as a link between the psychedelic cult and the youthful generation. Rock sessions became lecture series set to music. Dezelsky and Toohey (6) report that although the lyrics were abstract, when students were asked to interpret the music, they acknowledged that heavy drug themes were prevalent.

The drug theme is gone from pop music, but the drug behavior is still here.

Concluding Remarks The question is always asked relative to a

study of this nature, did the students tell the truth, did they under or overexaggerate?

* *

Since no great inconsistencies occurred in reporting any aspect of illicit drug use, one might at least conclude that if lying did occur, it was done with consistent sophistication. I, therefore, conclude that the surveys reflect an honest reporting of student drug use and drug abuse behavior.

1 .

2.

3.

4.

5.

6.

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BIBLIOGRAPHY Zeinberg, N . E., Weil, A. T. and Nelson, J . M‘ “Clir$cal and Psychological Effects of Marijuana in Man. The International Journal of the Addictions, Vol. 4, No. 3, pp. 427451. Klechner, J . H. “Personality Differences $tween Psychedelic Drug Users and Non Users. Psy-

McGfothlin, W. H., Cohen, S. and McGlothlin, M. S. “Personality and Attitude Changes in Volunteer Subjec:? Following Repeated Administration of L.S.D. Paper presented March, 1967. Blum, Richard. Students and Drugs, Jossey-Bass, Inc., Chapter 3. Kleber, H. H. “Students Use of Hallucinogens.” Unpublished Manuscript 1965. Dezelsky, T. L. and ‘koohey, J. V. “Are You Listening To The Lyrics?” The Journal of School Health. Vol. 40, No. 1. January, 1970, pp. 4 M 2 .

cholo y, 1968, 5 (2), 66-71.

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VISION AND ITS ROLE IN READING DISABILITY AND DYSLEXIA

HAROLD P. MARTIN, M.D.

Department of Pediatrics, J .F .K . Child Development Center, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver, Colorado 80220

Reading disability is a common problem in this country. While reports vary, a t least 5y0 to 15% of our children are considered to be deficient in their reading abilities (1-14). Inas- much as reading is a process which is obviously dependent upon seeing, questions continue to arise as to the role of the eyes in children who are not reading well. Let us first look at terminology.

Terminology Reading disability, while defined somewhat

differently by various authors, is a term referring to children who are significantly below their age level in reading abilities on some other basis than mental retardation. We are basically talking about children who are not reading as well as we would expect and predict. This term tradi- tionally eliminates children who are mentally retarded, seriously emotionally disturbed, or legally blind.

The term dyslexia, also called developmental dyslexia, specific dyslexia, or congenital word- blindness, was first described in the late 1800’s.

This is a term used to describe a group of children who are seriously deficient in their ability to read. It is thought that their poor reading is a result of a congenital or inborn inability to decipher the written word. Dr. Leon Isenberg (4) describes specific dyslexia as a situation where a child is unable to learn to read with proper facility, despite normal intelligence, intact senses, proper instruction and normal motivation. Other authors, such as Dr. MacDonald Critchley, in his classic book “Developmental Dyslexia” (4) excludes children who have brain damage or brain dysfunction. However, he, as well as other authors, indicates that neurological signs may be found in these children. This admission obscures the etiology.

Rabinovitch (12) suggested that we consider poor readers in three groups. First is a group of children in whom poor reading is on the basis of various exogenous factors. He considered these to be children having secondary reading retardation. The rest of the children could be considered as having a primary reading retarda-

468 The Journal of School Health

tion, and he subdivided these children into those who had brain damage and those who had no evidence of brain damage. Blom and Jones (1) in a review of the literature have outlined four paradigms in which to consider reading dis- orders-using function , etiology, theoretical models or nosological systems as the bases for subclassification.

It appears to be most appropriate to consider children who are reading poorly for their age and grade level despite adequate intelligence and sound instruction and who have no serious emotional or sensory problems as constituting the group of children with reading disability. Most experts agree that a significant lag in reading ability requires the demonstration of reading skills that are a t least, two years behind one’s age and grade level. The use of the term dyslexia is disputed, its definition is unclear and continues to vary with different experts in the field, and it is of little use to the classroom teacher or the child’s physician. Inasmuch as its definition has been inexact and bastardized, the use of this term may be more harmful than helpful in trying to understand children who are reading poorly.

Significance The problem of reading disability is a sig-

nificant one in numbers and in consequence. In some school districts as many as 15 percent of the students are two grades or more behind in their reading abilities. In a recently published study (13) of over 2000 children ages 9 to 10, 6.6 percent were found to be reading a t least two years behind what would be expected when one considered their age, grade level and intelli- gence. What the consequences of poor reading may be are not well delineated. However, it was noted that in 1955, 75 percent of the juvenile delinquents of New York were illiterate (4). In Rutter, Tiaard and Whitmore’s recently published study, there was a close correlation between anti- social behavior and poor reading. In Chapter 14 (13), the authors point out the considerable overlap between reading retardation and anti- social behavior. Of the children who were severely retarded in reading, one-third exhibited antisocial behavior. Similarly, of the group of antisocial children over one-third of this group were a t least 28 months retarded in their reading aft,er I& was partialed out.

Opht halmologic Implications In Kutter’s very large study, three groups of

children were compared-those who were men-

tally retarded, those who had reading disabilities, and a control group of normal children. Below is a table indicating the percentage of the children in these three groups who had an overt squint, a latent or an overt squint,, normal vision or serious visual defect. The children with reading disabilities did not have a higher incidence of strabismus or visual defect than the control group. Indeed, there were fewer, although insignificant, differences in the reading disability group with a higher percentage of children with reading disabilities having normal vision than the control children.

- ._

Mentally Reading Retarded Disability Control

Squint-Overt 15% 0% 1%

Overt 19% 5% 12%

6/9 or 6/6 76% 93% 89%

6/24 or worse 13% 1% 3%

Squint-Latent or

Normal Vision-

Visual Defect-

Critchley states in Chapter 7 of his book (4) that developmental dyslexia is independent, of errors or refraction, muscle imbalance and imper- fect binocular fusion. He quotes Gruber (6) as stating that no correlation exists between the degree of binocular coordination and reading ability.

In 1965, a multidisciplinary symposium entitled “Reading Disorders” was presented (5). One of the participants in that symposium was Dr. George Campian, who was Clinical Professor of Ophthalmology and Medical Director, Cur- riculum in Orthoptic Technique a t the University of California, San Francisco School of Medicine. He makes several statements that need under- lining. He states that poor visual acuity is rarely a deterrent to learning t,o read even with very poor vision. The print may have to be held closer to the eyes and reading may be slow but it will be accurate. Poor visual acuity per se can rarely be blamed for inability to read. He further states that oculo-motor problems do not interfere with the recognition of symbols. This is true of strabismus or squint and cross- eyes. He mentions that in his own experience it is difficult for an ophthalmologist to convince parents of a cross-eyed child that the eyes are not the cause of reading disability. This is not to say that defect in muscle imbalance and convergence should not be corrected, however

469 The Jourml of School Health-November, 1971

He feels that if an orthoptic program aimed atl muscle balance and convergence is associated with any improvement in reading, the reading improvement must result from the patient’s increased concent,ration rather than from the exercises themselves. He also points out that refractive errors are of negligible importance in reading disorders.

The Central Nervous System And Reading Disability

Poor functtion of the central nervous system as manifested by subtle or soft neurologic signs is another area of erudite dispute. Both Arnold Geselle and Catrina de Hirsch have stated that subtle neurologic dysfunction which can readily be recognized by the preschool teacher, is seen in children who later have reading disabilities (14). This is not to state that all children with reading disabilities will have such neurological abnor- malities.

There has been considerable dispute about the role of left-handedness or mixed dominance in children with reading disabilities. This was particularly highlighted by Samuel Orton (10, 11). Numerous investigators have failed to find a significantly greater number of children with reading disabilities among those who are either left-handed or ambidexterous. In the recent study of Rutter, Tizard and Whitmore (13), there was no increased prevalence of left-handedness, left-eyedness, discrepant hand-foot dominance or discrepant hand-eye dominance in children with reading disabilities as compared to the control children.

On the basis of examinations by trained neurologists, Rutter et a1 found a greatly increased incidence of neurologic abnormalities in the retarded children but did not find an increased number of children with reading disability having gross neurologic abnormalities although they did find an increased rate of soft neurologic signs in children with reading disability. They further found that children with reading disability had a significantly increased rate of slow motor develop- ment in infancy, poor coordination, poor ability in drawing and motor impewistence. Again, while the retarded children had a statistically significant higher incidence of small birth weight, and birth weights that were small for the length of the pregnancy, this was not found in children with reading disabilities. There was no higher incidence of abnormal pregnancies, multiple births, abnormal deliveries or complications in the first two weeks of life. This is at variance with other investigators such as Pasamanick (8)

who have correlated difficult pregnancies with reading disability. While hospitalizations and seizures are related to mentally retarded children, they are not related in a significant fashion to children with reading disabilities.

Vision Seeing, perceiving and underst,anding what one

reads is a complicated process. The image of the printed word is detected by the end organ, the eye, and the retina of the eye. An impulse travels through the optic nerve to the brain which receives the impulse. Understanding and interpreting what one sees is a complicated process which takes place neither in the eye nor the optic nerve. There are associations between the centers of the brain that receive messages from the eye and other parts of the brain so that what one sees will be associated with words one has heard, meanings of those words, and reactions to one’s visual perceptions. I n children who have reading disability, the problem is rarely in the eye itself or in the nerve of the eye. It is hypothesized that the difficulty lies in tJhe parts of the brain that interpret and associate the visual message with past memory, with spoken words, and with thinking.

Management Treatment programs for children with reading

disability can be grouped into those wherein the treatment is direct teaching of reading and those in which indirect treatment is hoped to result in improvement of reading skills.

Indirect training and teaching programs are difficult to assess. These programs will vary in keeping with the multiple theories put forth to explain reading disability. Several precautious are in order. One should be leery of any treat- ment program promising a cure. Programs which, in their rigidity, are not altered to account for the child’s strengths and weaknesses are similarly. suspect. Before putting a child into psychotherapy, perceptual training, motor train- ing, etc., it is essential the child be carefully studied to determine if that area of the child’s repertoire is deficient and seems to be the etiology of the reading disability. The author urges caution in supporting any treatment program which exclusively focuses on only a small facet of the child’s personality or neurologic function.

Krippner (9) very nicely discusses the intense controversy as to the role of vision and the ocular apparatus in the treatment of reading disorders. This controversy is seen in sharpest

470 The Journal of School Health

focus in the views on writings of Ophthalmolo- gists and Optometrists. The paucity of research on the validity of visual training indicates that even when ocular motor function is deficient,, evidence is slim as to its etiological significance (9). As discussed earlier, subtle neurologic abnormalities of substance are found in many of the children with reading disabilities. In this clinic’s experience, poor motor control, dyskinetic voluntary motor acts and dyspraxia of various degrees are not found in isolated motor acts. That is, movement of fingers hands, tongue, eyes, mouth, lower extremities are all seen as lacking facility and keen coordination. This suggests to this author that in many children with reading disability, the neurologic function of the child is immature or impaired. It is not clear whether this is a causal relationship or merely an association of impaired function of the nervous system affecting neuromuscular function, perhaps perceptual ability and higher neuro- logical functions needed for reading. It clearly stretches the bounds of reason to assume that training in a narrowly isolated function such as tongue movements or finger to thumb approxima- tion or ocular muscle function is approaching the etiologic basis for difficulty in reading. A treat- ment program which approaches multiple areas of neurologic function may have merit, although studies of their effectiveness in improving reading skills are scarce and unconvincing (3).

The answer to helping these children will undoubtedly lie in educational research and practice. Educational approaches to teaching reading to the disabled reader must be developed. There is cause for optimism in an increased interest in such research. An example of one such study is Dr. Camp’s recently published article (2) describing what is contended to be a successful approach to teaching reading to children with very serious deficits. The children with whom she worked had been diagnosed with a variety of bases for their reading disability. Rather than concentrating on what might be indirect causes for poor reading, she took an approach to teaching reading which helped many of these children.

At present, it seems most prudent to try to understand how the child can best learn rather than only focusing on the reasons he doesn’t learn when taught by traditional methods. If educators and other professionals can recognize the factors and the environment in which the child will best Iearri-including motivation, perceptual strengths, style of learning-indi- vidualization of that child’s teaching to capitalize

on those strengths presently holds our most promising assistance to the handicapped child.

Summary In summary, reading disability is a term that

is used to describe children who are reading very poorly for their age, grade level and intelligence. A small percentage of these children have poor vision that can be corrected by the ophthalmolo- gist. While some of these children will have poor coordination of their eyes, there is considera- tion data to indicate that poor eye coordination, poor ability to converge one’s eyes and dis- crepancy between one’s dominant eye and one’s dominant hand or leg are not significantly related to reading disability and when present, are not the basis for the poor reading. While the causes of reading disability may be numerous and poorly understood, the role of the traditional ophthalmologist will be minor in helping the teacher and parents of the child who is reading poorly. The central nervous system may be functionally immature or impaired in children with reading disabilities but this central nervous system dysfunction, when present, is not localized to the ocular apparatus.

Acknowledgment This paper was part of a symposium on Read-

ing Disabilities given to teachers in the Denver Public Schools. The symposium was organized by Mildred Doster, M. D. and John Lampe, M. D.

Participants, in addition to this author, in- cluded James Woodward, M. D., Loretta Crouch, Edna Licht, and professional staff from the Denver Public Schools.

REFERENCES 1. Blom, Gaston and Jones, Arlene. Basic of Classifi-

cation of Reading Disorders. Journal of Learning Disabilities, 3 : 606417, December 1970.

2. Camp, Bonnie. RRmedial Reading in a Pediatric Clinic. Clinical Pediatrics, 10: 36-43, January 1971.

3. Cratty, Bryant and Martin, Margaret. Perceptuul- Motor Eficiency in Children. Lea and Febinger, Philadelphia, 1969.

4. Critchley, MacDonald. Developmental Dyslexia. William Heinemann Medical Books Limited, Lon- don, 1964.

5. Flower, Richard, Gofman, Helen and Lawson, Lucie. Reading Disorders-A Multidisciplinary Symposium. F. A. Davis Company, Philadelphia, Pennsylvania, 1965.

6. Gruber, E. Reading Ability, Binocular Coordina- tion and Ophthalmograph. Archives Ophthalmology, 67: 280-288, 1962.

7. Helveston, Eugene. The Role of the Ophthalmologist in Dyslexia: Report of an International Seminar. Institute for Developmental Educational Activities, Inc. Melbourne, Florida, 1969.

8. Kawi, A. and Pasamanick, B. Association of Factors of Pregnancy with Reading Disorders of Childhood. Journal A .M.A. , 166: 142Ck1423, 1958.

The Journal of School Heulth-November, 1971 471

9. Krippner, Stanley. On Research in Visual Training 12. Rabinovitch, R. D. A Research Approach to Read- and Reading Disability. Journal of Learning Dis- ing Retardation. Res. Publ. Assn. Neur. Men!. Dis.,

Kingsley. Education, Health and Behavior. Long- man Group Ltd., London, 1970.

14. Thompson, Lloyd. Reading Disability-Develop 11. Orton, Samuel. Reading, Writing and Speech Prob- mental Dyslexia. Charles Thomas Publishers,

Springfield, Illinois, 1966.

abilities, 4: 65-76, February 1971. 34: 363-396, 1954. Orton, samuel. ~ ~ ~ ~ d i ~ ~ ~ ~ in ~~~~~i~~ to 13. Rutter, Michael, Tizard, Jack, and Whitmore, Read-A Neurological Explanation of the Reading Disability.

lems in Children.

School and Soc., 286-290, 1928.

Chapman and Hall, London, 1937. * * * * *

AN EDITORIAL : The crux of all (health) education is the facilita-

tion of learning. What is known about learning is not incorporated into the preparation of health educators as well as it should be; it is more im- portant to be a creative teacher than it is to be a technician, and pupils, not curriculum, should be the primary focus of health instructors. The above statement is likely to be met with general agreement; but despite the agreement, compara- tively little is being done to resolve these very basic questions in the day to day practices of health educators. I would like to offer some observations as to why.

Primary to these observations is teacher preparation, and in-service training of health teachers. Even in areas where health is included as a significant subject, a disintegrated approach to instruction may limit understanding of health and the teaching of it. The disintegrated ap- proach I am referring to is the fractionalized way many teacher colleges and universities approach health education. In most teacher preparatory institutions a distinction is made between back- ground courses and “teaching of’) courses. Typically students are prepared in biological and social sciences, courses in child development and educational psychology. Most instruction is didactic and single subject oriented. In addi- tion a personal and community health course and “methods” courses (as to how one could teach health) are included. These too tend to be di- dactic. Finally a practicum experience is pro- vided for teacher candidates where he or she is supposed to “get it all together”. Often as not the teachers selected may be traditional type health and physical educators. These experi- ences tend to be discrete and little relationship drawn between them. In teacher preparation course content becomes focused, intense and studied in depth. While this has its strength such strength is usually purchased a t the expense of relating the material to man’s holistic nature. Thus preparation in health belies what health actually is. It is hoped (against fate) that the health teacher will make his own integration of man, environment and teaching style. It is my

opinion that this is unlikely. Needed are 1) more ways to assure integration in the prepara- tion of health educators 2) research on out- comes in teacher preparation (which contributes more to teaching style how teachers themselves were prepared, and how much as to what they were “taught about teaching” 3) more ways to offer the practice teaching experience, early and continuous experiences with pupils under super- vision of health specialists 4) more interdiscipli- nary cooperation in the faculties of teacher train- ing institutions.

I believe i t is the basic question outlined above which leads to an additional error in judgment. This next error is the mistaken notion that the creation of a new health curriculum will com- pensate for the misunderstandings and misprac- tices gendered in the teacher candidates prepara- tory experience. I would like to offer a word of caution; a curriculum design will not supercede individual teacher’s shortcomings in understand- ing the facilitation of significant learning.

Much of modern health curriculum is animated by two premises-conceptual learning and objec- tives of instruction stated in behavioral terms. Although both these innovations are widely heralded, they may be so construed in practice as to be no improvement over the past.

Generalized ideas (or notions) towards health matters have always been outcomes in education. Indeed identifying them more clearly is a decided ad- vantage. This identification will turn to dis- advantage if the reality basis for concepts is substituted away for rote memorization of them. Lecturing replete with illustrations is not replace- ment for more learning experiences such as small group work, problem solving, sociodrama, and direct participation utilizing community problems and resources. Unfortunately these experiences aimed a t pupil participation are often looked upon by school administrators as a breakdown of discipline and subject centering characteristic of their own preparatory experience and past teach-

Let me attempt to clarify this.

472 The Jolirikal of School Heallh