Hierarchy of Therapy

[emonline]

I have completed some therapies with my daughter, but she is still having some issues. I have had evaluations, and have had some conflicting advice regarding how to proceed. I believe I read (somewhere) on this forum advice on how to proceed; that is, which therapies should be started first, followed by other therapies, and then finalized with academic tutoring, I believe. If anyone knows this hierarchy, could you please post it again (examples of any relevant programs in each category would be very helpful as well). I would also be interested in any therapies you have found particularly successful. We have already begun ST, and have finished OT, The Listening Program, and Fast ForWord. My daughter is 7 years old. Thank you very much.

[Claire]

You seem to be on the right track. Here are the guidelines for the "bottom-up" developmental model that I believe is the most likely to achieve optimal remediation.

First level are sensory therapies and language -- ST, motor therapies (OT, NeuroNet, Interactive Metronome), auditory therapies (TLP, FFW), NeuroNet (OT), and vision therapy (begun towards the end of OT). Sports and athletics are good to start here also -- swimming, therapeutic horseback riding, gymnastics, martial arts being among the most beneficial.

Middle level is cognitive skills training. The best programs available today are probably LearningRx and PACE.

Academic remediation is the last step. You can start reading remediation programs earlier, even while doing even sensory-level therapies, and it's a good idea especially to start working on phonemic awareness skills that early. However, it is usually after all the above therapies have been completed, including cognitive skills training, that you see the most optimal academic learning (including reading skills).

These are like big circles of development and can overlap. The above is just a generalized ordering of therapeutic interventions. Doing them in this order does not guarantee that full academic remediation will take place. However, IMO it does optimize your chances for that.

[emonline]

Claire, Thank you so very, very much! This is exactly what I was looking for! I have been unable to find either Learning RX or PACE in my area (they are both with professional providers, right?) Do you have any other "next best" suggestions? Do you have any information on NACD?

[Claire]

From what I know of NACD, it is best for younger children and those with fairly severe disabilities.

Of the home programs available, Audiblox might be a good one for you. It was originally developed as a preschool readiness program, so can be used with children as young as 4. It works on more fundamental cognitive skills development than LearningRx or PACE. Unlike LearningRx and PACE, it does not incorporate use of a metronome so is less useful for developing processing speed. It also does not include the segmenting, blending and phoneme manipulation exercises of LearningRx and PACE. Finally, it does not have as much variety in its exercises, so it becomes more tedious to stick with. As with any cognitive skills training program, you may not see much improvement until after you have put in 40 to 60 hours of one-on-one training. With Audiblox progress may be slower and you may need to stick with it longer to optimize results. You can always follow up with another program (such as PACE or LearningRx) later.

Cognitive Calisthenics is a home program that is supposed to become available sometime this year. I would think you could start with Audiblox now, and then switch to CC when it finally goes on the market.

BrainSkills was the home version of PACE, but the company stopped selling it last year. This would actually be the best home program to do, but it's very hard to find a kit unless you get really lucky scouring the internet.

[emonline]

Claire, I tried to do an internet search for the Cognitive Calisthenics program, but couldn't find a thing! Can you tell me where I can find more info? Could you elaborate on why you think this will be a good program?

I actually have Audiblox and had used it for about 10 weeks earlier (about two years ago actually). Then she started Fast ForWord, and it became difficult to keep both programs going as the Audiblox was no longer unique and interesting, and the Fast ForWord was quite time consuming. I suppose I could pull it out again,, but was actually thinking there would be a program that was at a bit of a higher level. As I said, I thought Brainskills would be that program, but that is obviously just not supposed to be.

Thank you for all of your helpful information. You are so informed about all these programs!!

[Claire]

Here is the website (http://www.optometrists.org/Stephey/) of the developer of Cognitive Calisthenics, Dr. Doug Stephey. Your best bet is to call or email him to ask about it. He had beta (testing) versions out last year, but still had to create the instructional DVDs to go into the kit. I know he's trying to get it on the market sometime this year. It should be somewhat similar in scope to BrainSkills. Dr. Stephey trained in PACE, Lindamood-Bell LiPS, and quite a few other programs, so his background is very good. He has an excellent reputation.

[Claire]

I should mention that there are other programs available, but I know very little about them in terms of how well they work or how practical they are. One is Captain's Log. There is another software program that was introduced about two years ago, but I can't remember the name of it. I'm pretty sure that one was developed by a partner of the PACE/LearningRx company after they split (apparently could not agree on how to translate PACE into a computerized version). If I find the name of it, I'll post it here. Both of these sound good, but I have not seen any posts from parents who have actually used the programs and that always makes me hesitate.

[Laurie4b]

It seems like you have made a very solid start. What issues are left?

I agree with Claire that though the "bottom up" therapies may eventually make the academic remediation go much more quickly, that it's important to work with that from the beginning to the extent that the student is able.

[emonline]

Claire, I did contact Dr. Stephey. He emailed me that his program is available now by calling 626-332-4510. It is $225 plus shipping. I am strongly considering the purchase -- though I do love it when others have had positive experience with a product before I try it. I hope it is OK to post this information. BTW, this is a cognitive type program, right -- not vision therapy, per se (honestly, I do not know what vision therapy is).

[Claire]

Yes, it's a cognitive skills program. I trust Dr. Stephey, so I wouldn't have a problem ordering the kit from him. Did you find out if he had finished the training DVDs? I wonder why he isn't advertising it yet.....

[Rod Everson]

BTW, this is a cognitive type program, right -- not vision therapy, per se (honestly, I do not know what vision therapy is).

Hi,

You haven't told us much about your daughter's situation, but if she is having trouble learning to read, you do need to become familiar with vision therapy, in my opinion. In a nutshell, it is a therapy offered under the guidance of a developmental optometrist, that is, an optometrist trained to diagnose and treat developmental vision issues.

Again, if your daughter is having trouble learning to read, I would at a minimum seek out a developmental optometrist in your area and have your child's vision examined. (Your regular optometrist is not likely to be sufficient for this purpose.)

There's a lot of information on several threads in this site, and quite a bit of information on vision therapy on my own website, as well. To check on the whereabouts of the nearest developmental optometrist go to covd.org (http://covd.org) and put your zip code in the "Locate a Doctor" search box you'll find there.

Rod Everson
OnTrack Reading (http://ontrackreading.com)

[Claire]

I agree with getting a developmental vision eval before starting cognitive skills training. Thought she had already done VT, but looked back at the original post and see that I had missed that. It would not be good to start cognitive skills training if there are visual efficiency problems, and the only way to be sure there isn't a vision problem is to get a developmental vision eval.

[emonline]

My daughter has verbal apraxia. Along with this, she also has had some fine motor issues (handwriting, etc) which have been remediated to a large extent by OT. I still notice some small problems, but she was "dismissed" from OT. She has had some minor "low tone" which has also been mostly remediated. She has had overall educational testing. Basically, she has average IQ (over 100 -- higher non-verbal than verbal). She tested low for auditory processing, and so we worked with The Listening Program and Fast ForWord -- post testing showed very good gains. She is still less than graceful, and has some gross motor issues -- it was hard for her to learn to ride her two-wheeler and to skip rope -- that sort of thing. She reads above grade level, and does great on spelling. She is good at understanding what she is supposed to be doing, and can explain exactly what she is supposed to do. However, when left to work independently, often the work just doesn't get done. I am confused because if I sit with her, she can then do the work -- even if I don't help her! (However, sometimes, she works along just fine, even though the house is in chaos!) The only academic area where she struggles is math. She has memorized her facts fine, but struggles understanding any type of word problem. No one has ever suggested vision therapy to me before. Any suggestions would be most appreciated.

[Claire]

It doesn't sound as if vision is a problem. You could always get a developmental vision eval to make sure (about $250 at a non-profit where I live, but many private practice optometrists charge $400). This eval is not usually covered by medical insurance.

You might want to join the dyslexiasupport2 (http://health.groups.yahoo.com/group/dyslexiasupport2/) list. Linda, who posts there, has a dd with verbal apraxia and auditory processing issues. They did Lindamood-Bell Lips, Earobics, and recently PACE with benefits from each. You may want to exchange notes with her. (I think her dd is in 6th grade or so now.)

[Rod Everson]

She is still less than graceful, and has some gross motor issues -- it was hard for her to learn to ride her two-wheeler and to skip rope -- that sort of thing. She reads above grade level, and does great on spelling.....She has memorized her facts fine, but struggles understanding any type of word problem. No one has ever suggested vision therapy to me before. Any suggestions would be most appreciated.

I tend to agree with Claire that vision doesn't sound like an issue, with a few caveats:

1) Your daughter is only 7, and reading above grade level at that age doesn't entail much. Smart kids with vision issues, but good memories, can bluff people for the first year or so of schooling. And when taught with a good phonics course, kids with vision problems can learn to read (it just isn't much fun) and they can become good spellers, especially in the early grades, when memorizing all the words they're asked to spell isn't that big a challenge. However, they really don't like to read much, as their vision problems make it an uncomfortable experience, sometimes even causing headaches, though not always. Let me put it a more positive way: If your daughter always has her head in a book and is enjoying reading material of her own choosing, it's unlikely she has a vision problem of the sort addressed by vision therapy. On the other hand, if you are always having to encourage her to read.....

2) Falling apart on the math word problems could be an indication that reading is a bigger challenge than her reading aloud would indicate.

3) Clumsiness can indicate a vision problem, especially if she has trouble (a lot of trouble) catching a ball thrown to her. Basically if both eyes aren't working well together kids have poor depth perception and are uncertain how far away things are (the ball, the ground, etc.) and react defensively, sometimes even walking with a careful gait to avoid stumbling over an undetectable (to them) rise or fall in the ground surface.

I certainly don't want you to waste money, but if you can locate a developmental optometrist and get a routine vision exam for your daughter, the expense will be higher than at a mall eye doctor, but will still be within reason. During that exam, you could explain your concern about your daughter's learning issues and see what the optometrist has found in the routine examination (which will usually be more in-depth than that you'll get at your regular optometrists, hence the higher cost...but not $400.)

Where you get into the hundreds of dollars is if the optometrist recommends a full developmental vision screening, and he would generally not do that unless his routine exam picked up something that concerned him (unless you raise so many issues that he feels that a full developmental exam is warranted regardless.)

Frankly, I recommend that virtually every child with learning issues should have at least their early routine eye exams done by a developmental optometrist. Better to rule out such problems at a reasonably small cost than to let them persist undetected for years at a huge cost to both you and your child. I feel particularly strongly about this recommendation if there is a family history of learning issues, since this sort of vision problem definitely runs in families. If begun at the outset, this is also a way to ascertain whether other more foundational therapies are having the desired impact on vision development.

Hope this is helpful,

Rod Everson
OnTrack Reading (http://ontrackreading.com)

[Laurie4b]

You know, you might consider getting a second opinion on whether she is really done all she can do with OT. Have you read the Out of Sync Child? Does she fit any of the descriptions? Some types of sensory processing issues can make concentration difficult and there are OT ways to help. Also another OT may see things to work with in the gross motor coordination.

What have you tried already in terms of her understanding the word problems?

[emonline]

She was in OT for quite a while, and finally "graduated" out of it. Mostly, they worked on fine motor, along with exercises to help the low tone. I had been looking at the "Learning Breakthrough" program, thinking that might help her, and had also considered therapeutic horseback riding (our OT had suggested the later as a good activity for her).

I have looked at the book you mentioned, but I guess not enough to realize there were different types. Regarding the math, I honestly haven't tried much of anything with her yet. As her diagnosed issues were mostly auditory processing and speech articulation, I have been focusing mostly on those two areas. I did the LiPS program with her before kindergarten, and she is now a pretty good reader, and reads a lot on her own -- though I do notice some issues with reading comprehension, so I am thinking that might be the core issue. I know Lindamood has a reading comprehension program (Visualizing and Verbalizing) and there is a home version of it put out by another company (Ideachain), but I was thinking I should try to remediate more broadly first with some type of cognitive processing program.

I am wondering -- if one had the opportunity to choose between Brainskills and CogCal -- does anyone have an opinion on which program would be best? Also, has anyone heard of a computer program call "Brainware Safari?" I found it while trying to find information on CogCal and Brainskills.

[Claire]

[QUOTE=emonline;115979I am wondering -- if one had the opportunity to choose between Brainskills and CogCal -- does anyone have an opinion on which program would be best? Also, has anyone heard of a computer program call "Brainware Safari?" I found it while trying to find information on CogCal and Brainskills.[/QUOTE]

Brainware Safari is relatively new. I'm pretty sure the company that developed it is the same one that worked closely with the PACE/LearningRx/BrainSkills company to try to computerize the PACE program. After several years of working together, they dissolved their relationship. I suspect that the PACE company did not think that enough of the program could be translated into computer software to really do a good job (although the company has subsequently come out with a computer software version for schools to use).

If I had to choose between Brainware Safari and BrainSkills, I would definitely choose BrainSkills because of the one-on-one human interaction. This makes it much more adaptable to an individual child's needs. Plus, a computer simply does not replace the warmth of having an interested adult working with you. The adult can also be a much more targeted "cheerleader", motivating and urging on to suit the child. The only time Brainware Safari could possibly work better for a child, IMO anyway, is for a child with Asperger's or autism who prefers computer work to working with an adult.

Since BrainSkills is no longer available as a home kit, it really isn't an option. I haven't seen the CogCal kit but I know Dr. Stephey from years of posting on the net. He was a PACE provider for many years, so I would expect he has incorporated much of his training and experience into his kit. I know last year he described CogCal as "PACE on steroids". I'm surprised he hasn't priced his kit higher, since BrainSkills was sold retail for $500. My bet is that he wants to try to make the program available to as many families as possible, especially in its early stages.