How did we get started? Learning Related Visual Problems in Baltimore City; • Did I write a great proposal? A Long-Term Program • Did I “take” a meeting with an influential person? • Did I respond to a request for proposals Paul Alan Harris, OD (RFP)? Fellow, College of Optometrists in Vision Development Fellow, Australasian College of Behavioral Optometry • Did I even want to do the program at all? Fellow, American Academy of Optometry The Foundation Reads The Foundation Reads (2) The Abell Foundation employs people whose They came across the work of Antonia job it is to read newspapers around the Orfield, OD a faculty member of The country to look for things that are interesting New England College of Optometry to investigate with their funds in the city of program and her class project at the Baltimore. Mather school in Boston. The Foundation Investigates The Problem During the academic year 1997-98, That story triggers a process that was Baltimore City had 17.6% of its students in to change my life! special education. The national average is 12%. 1
The Costs So why me? • Cost to educate a non-special education • At the time of first contact I was living in child: $3,100.00 per year. Denmark! • Cost to educate a child in special • My time was fully committed, or so I education: $9,700.00 per year. thought! • They got copies of papers I had written. • Based on 110,000 total enrollment 1936 • They did a background search. more children are in special education than the national average. • When they called they knew what they wanted! • Thus, $12,777,000 per year extra is being spent in Baltimore for education! Abell Foundation, “We want to Q1: Prevalence see if vision therapy will help • The answer to the question of prevalence of visual solve the education problem.” problems in my population would provide answers to much of the study design. • What’s the first step? • Knowns: – 20/20 Hindsight…..how much $$$ do you have – 23% of the general population budgeted for this? – 93% of LD or PL 94-142 – Actual: I begin thinking about the design of the study and then try to figure out how much it will cost to do – 96% of JD the work! Generally, you end up low-balling – 85% of inner city children everything and get shortchanged in the end. From my • Step 1 then is to do a screening to see where we experience with the JD project I had something to work are. from. Prevalence: How much of a Prevalence: Screening problem did we have in Baltimore? • Prior to developing protocols for testing and Two of the 112 elementary schools in Baltimore treatment we needed to determine what the prevalence City were chosen by the Abell Foundation as was of visual problems in Baltimore City. being representative of the types of populations • The higher the prevalence the more children in a we would find in Baltimore. Both were in single school that could be used in the study in both economically depressed areas, one each in the control and research groups. West and East sides of the downtown areas. One • The lower the prevalence the more schools would area was predominantly Caucasian and the other have to be involved increasing the complexity of the was predominantly African-American. design. 2
Who should we test? How did these schools rank? • I could choose from Kindergarten to Fifth MSPAP Scores ( scores out of 100 ) grade or from ages 6 to about 11. Westport, which was near the lowest scores in the state: • I balanced many things. There are plusses and 2.8 in 1994, 3.5 in 1995, 3.3 in 1996 minuses with each group; young vs. older. Hampstead Hill, which was in the highest 10% • I chose first and third graders. of all of the Baltimore City Schools: 13.8 in 1994, 11.4 in 1995, 15.9 in 1996 What should be screened? More on the screening • The answer depends on what the purpose of • Since I was still living in Denmark at the the screening is. time of the screenings I wanted to set up a screening that could be done exclusively by • The purpose of this screening was solely to my staff. be used for planning purposes for the overall design of the study. • I had experience with the NYSOA Screening Battery and used this with a few • Therefore the question was, how many of minor modifications. these can we help in a significant way? Screening Test Battery Pass/Fail Criteria • NPC/CNP • Pass/fail criteria should be established • Visual acuity distance/near beforehand. It is not good to set these • +1.50 flipper at distance criteria post-hoc. This makes it look like • Keystone 4-ball test at distance and near you are adjusting the pass/fail borderline for • 30-second +/- 2.00 flipper test your own purposes. • Randot stereo acuity • NYSOA King-Devic Saccadic Test 3
Visual Screening Data Visual Screening Pass/Fail Criteria First number=# of failures Hampstead Hill Hampstead Hill Westport Westport • NPC/CNP: 4” from the nose or further. (percentage of total failed) First Grade Third Grade First Grade Third Grade Number of students tested N=60 N=69 N=79 N=57 • Randot Stereo: Greater than 50 seconds of arc. (test has 3 finer gradations: 40, 30 and 20!) NYSOA King-Devic 34 (56.6%) 12 (17.4%) 55 (69.6%) 19 (33.3%) Saccadic Test • Keystone 4-ball: any response other than 3 balls CNP/NPC 9 (15%) 15 (21.7%) 14 (17.7%) 12 (21.0%) Randot Stereo Acuity 23 (38.3%) 10 (14.5%) 29 (36.7%) 21 (36.8%) • +1.50 Distance: 20/20 or better VA Keystone 4-Ball Test 23 (38.3%) 29 (42.0%) 30 (37.9%) 24 (42.1%) Distance • Visual acuity: worse than 20/40 Keystone 4-Ball Test Near 18 (30%) 17 (24.6%) 20 (25.3%) 22 (38.6%) • 30-second +/- 2.00 flippers: less than 8 flips 30-second +/- 2.00 Flipper 25 (41.6%) 14 (20.3%) 33 (41.8%) 22 (38.6%) Test • NYSOA KD: 1 st grade >150 seconds 3 rd grade +1.50 Distance Test 8 (13.3%) 8 (11.6%) 8 (10.1%) 3 (5.3%) >100 seconds both are more than 2 SD’s off. Visual Acuity 0 (0%) 0 (0%) 0 (0%) 0 (0%) The Schools Want a Summary Vision Development Gessell “A vision development problem is a child development problem viewed optometrically.” “To understand the child one must understand the nature of the child’s vision. To understand the child’s vision, one must understand the nature of the child.” Changes if Treatment Begun at Age 5 Vision/Child Development Vision Development -- Treatment at Age 5 Vision Development 18 18 16 Vision Development Developmental Age 16 14 Normal Developmental Age 14 12 12 Vision Development 10 Vision Development Abnormal - No 10 Normal 8 treatment 8 Vision Development 6 Vision Development 6 Abnormal 4 Abnormal - Treatment 4 2 2 0 0 1 3 5 7 9 11 13 15 1 3 5 7 9 11 13 15 Chronologic Age Chronologic Age 4
Questions to be Answered Changes if Treatment Begun at Age 9 • How many groups? • Treatment & control Vision Development -- Treatment at age 9 • Treatment, control, & placebo treatment 18 • Treatment & placebo treatment 16 Vision Development Developmental Age • How many subjects? 14 Normal • How many schools? 12 Vision Development 10 • Would the schools have the space? Abnormal - No 8 treatment • Would I get access to the kids? 6 Vision Development • Would I have the cooperation of the administration? 4 Abnormal - Treatment 2 • Would I have the cooperation of the teachers? 0 • Would the community accept this? 1 3 5 7 9 11 13 15 Chronologic Age Some Schools Come Forward School Visitations • Considerations – Location – driving distance – Safety of access – Space availability for VT and testing – Enthusiasm for the program – Were there enough kids? – What about access to the kids? OK what next? School Visitations • Testing protocols established. Test everything and throw in a few more things. You never • Sacred Reading Time know exactly which will show the biggest • Direct Instruction changes! I recall much of what Ludlam, Giglio, Wittenberg, & Harris went through with the myopia research project. • I wanted to use tests I had experience with, could teach, and could interpret, and which I knew others could do for me! 5
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