I found this book to be all that the book jacket promises. Since I cannot improve on that description, the following is directly from the cover of this book.
“The Neonatal Intensive Care Unit (NICU) is a place where humanity, ethics, and science collide in dramatic and deeply personal ways, as parents, physicians, and nurses grapple with sometimes unanswerable questions. When does life begin? When and how should life end? And what does it mean to be human?
The NICU is a place made of stories – the stories of parents and babies who spend days, weeks, and even months waiting to go home, and of the dedicated clinicians who care for these tiny, developing humans. Early explores the fascinating evolution of neonatology and its significant breakthroughs – modern medicine can now save infants at five and a half months gestation who weigh less than a pound, when only fifty years ago there were a few effective treatments for premature babies. Each year, nearly four hundred thousand babies are born prematurely in the United States. When the scope is widened to include the entire world, that number climbs to fifteen million.
For the first time, journalist Sarah DiGregorio tells the rich and complex story of one of the most boundary-pushing medical disciplines – and the many people it has touched. Weaving her own story and those of other parents and NICU clinicians with in-depth reporting, DiGregorio examines the history and future of neonatology: how the first American NICU was set up as a sideshow on the Coney Island boardwalk; how modern advancements have allowed viability to be pushed to a mere twenty-two weeks; the political, cultural, and ethical issues that continue to arise in the face of dramatic scientific developments; and the clinicians at the front lines who are moving to new frontiers. Eye-opening and vital, Early uses premature birth as a window into our own humanity.”
Vision is complex and each person’s combinations of problems and circumstances is unique. Vision doesn’t function in isolation. It is represented in more areas of the brain than any other sense. It is involved in almost everything we do. How we see the world is an integral part of who we are. It follows that enhancing essential visual functions;
-eye alignment and movement,
-object perception, spatial perception, and guidance of movement
is messy and complex and that it is naïve to think that therapy is not influenced by the patient’s mindset, age, conflicts, and prior experiences.
All of this must be taken into consideration to treat patients. Computerized programs cannot do this but they can be useful to stimulate attention and motivation. It also requires more than a list of techniques. Doctors and therapists need to be ready and able to modify plans to match the patient’s current visual abilities. Optometric vision therapy is provided by doctors and therapists with specialty qualifications. Certified doctors are Fellows in the College of Optometrists in Vision Development (FCOVD). Certified therapists earn the title, Certified Optometric Vision Therapists (COVT). The College of Optometrists in Vision Development is the certifying body for this specialty.
Relationships between providers, patients, and their families are integral to the success of all healthcare, especially incremental care. Atul Gawande wrote about one of thirteen centers for treating patients with cystic fibrosis in the US in his book Better. One center had much better outcomes than all of the others even though the centers all followed the same protocol. The difference was that the director in one center got to know his patients personally. The better understanding and communication that resulted from these personal relationships fostered improved compliance. Atul Gawande also addresses this in his article on The Heroism of Incremental Care.
Therapy is an interplay between treatment and assessment as the patient progresses. The doctor and therapist continue to learn about patients from the way each patient responds. Dwight D. Eisenhower stated in reference to war that “Plans are useless, but planning is indispensable.” This also applies to other complex, messy situations.
Vision therapy is not easy and can be frustrating. Plasticity in Sensory Systems makes therapy possible. While neuroplasticity declines with age, it continues throughout life. Motivation can recruit surprising amounts of plasticity. The Power of Habit balances our ability to change. Habit enables us to function without consciously thinking through everything we do, which is not possible, but it can also cause us to err when conditions change. Therapy develops new visual habits. Focused rehearsal under a variety of circumstances facilitates supplanting existing habits with new skills and makes them more automatic than the dysfunctional patterns that they are replacing.
Optometric vision therapy takes advantage of neuroplasticity and the messiness in our visual system to make change possible. Therapy creates new visual patterns to be more efficient, more comfortable, and less taxing. Patients must achieve this for themselves, but appropriate feedback at the right time can be powerful, which is why doctors and therapists are indispensable in this process. Daniel Coyne provides example which demonstrate this in The Talent Code as does Norman Doidge in The Brain that Changes Itself. Humans are endowed with amazing abilities to learn and to adapt.
A Data-Driven Guide to Better, More Relaxed Parenting from Birth to Preschool
This book fulfills its promise, but not as you might expect. Emily Oster is an economist. Her qualification for writing this book is her ability to evaluate research. Her reason is to enable others to avoid some of the confusion, worry, and guilt that she and her husband went through during this phase of parenting. The book’s primary message is to not feel guilty due to arguments opposed to your decisions. You need to do what works best for you and your family. Most parenting is not supported by credible research. This is due to constraints on how research is conducted and to human variability. Much research that is used to support positions only demonstrates correlation, not causation. Breast feeding is an example. While breast-fed children have been shown to have advantages, it is inconclusive because the mothers who decide to breast feed also tend to have advantages which cannot be factored out.
The following information is supported by credible research which is not true about much of what you read on the internet. It is easy to read and is sprinkled with humorous anecdotes which demonstrates that parenting is not easy for anyone.
Postpartum depression occurs in 10 to 15 percent of births and is treatable. Approximately half of the time, the depression starts during the pregnancy which usually goes undetected. It usually becomes evident soon after giving birth, but it can appear months later. A personal history of depression or a family history of depression are predisposing factors.
90% of SIDS deaths occur in the first four months of life. The causes of SIDS are still poorly understood but significant risk factors have been identified. This is similar to many drugs that have been demonstrated to be effective even though we don’t fully understand the mechanism. There is good evidence that infants who sleep on their back are at a lower risk for SIDS. There is moderate evidence that bed sharing is risky. This risk is much higher if you or your partner smokes or drinks alcohol. Infants should have a wearable blanket in the crib. Sleeping on a sofa with an infant is very dangerous.
Vaccinations are among the most significant public health triumphs of the past hundred years… The scientific evidence of vaccinations is extremely clear: vaccinations are safe and effective…. There is one vaccination risk that is common and, while not serious, can be scary. The MMR vaccine is linked with febrile seizures – seizures that occur in infants or young children in association with a high fever. They typically do not have long-term consequences, but are very scary in the moment… About 2 to 3 percent of children in the US will have a febrile seizure before than are five years old (most of these are not vaccine associated)….In a study of 537,000 children – all the children born in Denmark from 1991 to 1998, they found no evidence that vaccinated children are more likely to be autistic; if anything, the results suggest vaccinated children are less likely to be diagnosed with autism.
In a group of children who were more likely to have peanut allergies, children who were exposed to peanuts were less likely to be allergic to them at the age of five than children who were not exposed. In the group that didn’t get peanuts, 17 percent of the children were allergic to peanuts at age five. (Remember, this figure is higher than it would be in the general population because of the way the researchers selected the sample.) However, only 3 percent of the children who were given peanuts were allergic… In the wake of these peanut findings, the recommendations about exposure have changed completely. Early exposure to peanuts is now the normal recommendation, especially for children at risk for allergy. (Let Them Eat Dirt)
There is a large range within which normal children meet developmental milestones. The following table is from the book. Many more could be added that are cognitive or behavioral. Note the extreme variations that are normal without long-range consequences.
Sitting without support 3.8 to 9.2 months
Standing with assistance 4.8 to 11.4 months
Crawling (5% of kids never do) 5.2 to 13.5 months
Walking with help 5.9 to 13.7 months
Standing alone 6.9 to 16.9 months
Walking alone 8.2 to 17. 6 months
It is recognized that there isn’t any benefit, and perhaps some harm, from trying to accelerate development. Research shows that the average age of potty training has been delayed because it has been found that the children master it faster when they are older. How can wide developmental ranges be accepted as normal while educational expectations are narrow? It is expected that all children will be ready to read at the same time and to do so earlier than prior generations. There are many skills which need to have developed before children can start to learn to read without excessive effort and frustration; auditory-visual integration, the ability to sit still, prolonged attention, working memory, eye teaming, tracking, visualization, and delayed gratification. Being pushed to read before a child is ready does not have the same outcome as naturally learning to read when they are ready. If any of the prerequisite skills are outside normal variation, specific intervention is indicated.
This book developed from the exchange of two professors. Pasi Shalhberg came to the United States from Finland and William Doyle went to Finland from the United States. The shock caused by the differences between the two educational cultures caused them to expand their research to many other countries and to write this book.
The driving force of play is fun, for children and for juvenile animals, but play serves a much larger purpose. Since some think all learning has to be serious, the authors suggest thinking of play as SEED (systematic, exploration, experimentation, and discovery). Children learn many things during play that cannot be learned as well any other way. Free play stimulates problem-solving, collaboration, curiosity, and creativity. It helps children develop coordination and endurance. The coordination of mind and body during play is obvious. Play provides immediate lessons from consequences which matter to the child. During play, children probe and expand their limits. Not being successful prompts trying again, particularly when playing in groups. It isn’t all successes. In the beginning, it usually doesn’t match expectations.
Play is a curriculum for
socialization and compromise. Free play is a forum for learning to work
problems out without adult involvement. Getting hurt, physically or
emotionally, is part of the experience as is becoming resilient and learning to
recover. Children experience being the recipient of empathy or neglect which
has the potential for them to think how they may want to treat others. While it
is vital to protect children from hazards, play is an opportunity to learn to
handle risk which is critical to developing executive function which is perhaps
our most important character trait. Children learn how to occupy themselves and
become self-reliant. They become adaptable. When play is spaced throughout the
school day, it provides important breaks which improve attention in the
Many skills that we take for granted also need to be developed and are most effectively developed through active play; judging size and distance, following a moving object, balance, body-image, focusing near and far, eye-hand coordination, throwing, catching, motor planning, and predicting the path and timing of moving objects.
Play is being eroded during the school day and outside of school because it has become accepted in much of the world that the way for children to do better on standardized tests and to become better workers is to test them more (which costs billions of dollars each year in the United States and reduces instructional time). It is assumed that pushing children to do things sooner is better. This has been coordinated with the increase of the use of technology in the classroom starting in kindergarten or first grade. There was an article last week in the Wall Street Journal about how increasing the use of technology has not improved scores on standardized tests.
There isn’t any research to support the benefit of homework in elementary school. Children are over-scheduled. Children need time to think, to daydream, explore, read, and pursue what interests them. (Adults need this also.) They need to be outside and not isolated on screens. The arts and humanities are not unnecessary frills. Just like play and learning is not a dichotomy, the arts and humanities are not a dichotomy with science, technology, engineering, and math (STEM). Exploring the whys of life and the hows of life should be integrated educational goals.
A large study has demonstrated that delaying education by one year significantly decreases the diagnosis of ADD/ADHD. Accelerating the curriculum and decreasing physical education classes and time for play increases these diagnoses.
Expecting all children to read and meet other educational standards at the same time is absurd. This has always been a challenge for education. More testing and more time spent on learning to read will not change this. Most children of at least average intelligence will learn to read given time and appropriate opportunities, just not all at the same time. Some children learn to walk at 9 months of age. Some children do not learn to walk until 15 months of age. With rare exceptions, they are all walking equally well when they get to school. Many children will not learn to read until the age of 7 but will do fine if they are not stressed and discouraged starting in preschool. Finland, for example, which has extremely high literacy rates, does not introduce formal reading instruction until age 7 and does not ignore individual differences. They ask if the school is ready for the child, not if the child is ready for the school.
The rates of anxiety, depression, loneliness, and suicide have been increasing dramatically. Complex problems rarely have single causes, but this educational experiment has been a failure for many children. GERM (Global Education Reform Movement) has been pushed by politicians, and many people who do not have knowledge and experience about how children learn. They do not see what happens to children who are not succeeding because they are not ready. Some of the time and money spent on testing, preparing for tests, and electronics could be used to enhance teachers’ knowledge in child development and create programs which address natural developmental diversity instead of assuming that it can be ignored.
Education is not easy. We need our best people to guide our children. Education should be run by trained educators and be evidence-based, not by politicians and ideologues. Education should not be politically polarized other than deciding how much money to spend on education relative to other needs. How the money is spent should not be decided by politicians, testing companies or those selling electronics. Decisions should be made by teams of qualified educators with expertise in child development.
The pleasure we feel after a good hard day’s work is linked
to a positive experience of willpower. It was tempting to break off; you could
have put it off until tomorrow (you’ve often done that in the past); you could
have become distracted (which is achingly familiar); you could have stayed
physically at your desk but actually been fantasizing about an impossible
dream. But you didn’t. You stuck with the big thing. It’s also to do with a
sense of mastery; in anticipation we slightly feared the task. But we got on
top of this tricky thing and we tamed it. There were points when it felt we
might not: it was too difficult; a solution seemed elusive.
The pleasure of a being productive hints at a bigger theme. It’s not simply about this moment and the particular tasks we’ve polished off. It’s a promise that other problems can be faced as well. We’re reminded of a capacity within ourselves to deal with difficulties, to get on top of challenges and to keep going until they are under control. We’re seeing in ourselves an antidote to the fear of drifting. We naturally worry we’ll be swamped by demands; we know our own unfortunate tendency to let things fester. We’re capable of rousing ourselves, of focus and sustained effort. We can stick with something difficult and keep going through the temptations to break off and seek distraction. We’ve been just a little bit heroic and we know it and it feels nice.
If we, as adults, are enriched by the empowerment provided by these experiences, how much more important are these experiences for children? How many of these experiences have the children that we work with had? We cannot make them happen for someone else. What we can do is to arrange conditions to increase the likelihood that they will happen. Despite our most ingenious and subtle designs, success is not guaranteed. It takes time with successes mixed with failures, but each time there is success, the message is that it can be done. We can help them connect the feeling of self-satisfaction with the effort that they have made and accept that there will also be failures from which they will also learn. The temptation to help them is strong, but the potential self-satisfaction of “I did it myself”, and all that can derive from this feeling, are then lost. Intelligence and skills are not adequate without the willingness to take risks and the perseverance to continue. This is emotional intelligence and character. The first two paragraphs are from Small Pleasures which is published by The School of Life.
this three-month-old boy reminds us of the journey that is the development of
eye-hand coordination, whether we wind up with adequate skills or exceptional
skills like those of athletes and musicians.
As we watch,
he is attracted to an object and his eyes converge to localize the object and
lock in his visual attention. He wants it. After he reaches out with both eyes,
he then reaches out with both arms and hands. As he brings his arms and hands
in to capture with his hands what he has captured with his eyes, his fingers
reflexively close as his arms close. He cannot grasp it and winds up with his
fists in his mouth instead of the toy… and he repeats….and he repeats.
This is the reach stage of reach, grasp, manipulate, and release; a hierarchy of eye-hand skills. Arnold Gesell started filming children doing developmental tasks almost 100 years ago so they could be carefully studied. There is a general order in which the stages take place. Subsequent research has confirmed that the order and timing have not changed, nor has its importance. These stages are the precursor to the entire range of eye-hand coordinations such as stacking blocks, cutting, tying shoes, throwing and catching a ball, buttons, zippers, drawing shapes, and writing. Gesell understood vision as critical to the development of human intelligence. Vision, Its Development in Infant and Child
In addition to building visual skills and manual skills for later applications, the child is selectively attending; he is practicing learning and becoming empowered through failure, success and perseverance; he is acting on internal motivation; and he is enjoying the challenge. He is not being taught. He is learning implicitly through experience. His parents’ role is to provide a safe opportunity to stimulate his curiosity and determination, to monitor, and to change the environment when appropriate. What would be the difference if he was not given the opportunity? How would the experience be different if the toy was just given to him? How important is it to just be watched by your parents? How much more effective is it to go through these processes naturally instead of going back later to fill in the missing gaps or trying to teach specific skills without these prerequisite abilities?
I have reviewed the differences in education across cultures in The Smartest Kids in the World and How They Got that Way and in The Learning Gap . There are also differences within our own culture in child rearing, education, socialization, and remediation which have taken place over the past few generations; some due to philosophy and some due to technology. I believe that there are insights to be gained into these extremely complex questions through comparing these differences. While it is difficult to see through the filter of our own perspective and our own culture, the effort to do so is important.
A few generations ago, there was a significant emphasis on the importance of understanding child development from prominent developmentalists such as Jean Piaget, Maria Montessori , and Arnold Gesell who demonstrate that development tends to take place in a predictable sequence and at similar times in normal children who are raised in a developmentally healthy environment. Arnold Gesell felt that it is important to consider the normal ranges of development when determining behavioral and academic expectations. Gesell publishedVision: It’s Development in Infant and Childin 1949 from his decades of research at the Yale Clinic of Child Development.* Recent research has confirmed the consistency of developmental milestones over time.
To develop skills for which we have not evolved, such as reading and writing, we redeploy areas of our brains which evolved for other purposes. This cannot be done if these areas and their associated abilities have not developed adequately. From a developmental perspective, a defective visual skill is not viewed as a problem but as a symptom of a disturbance in development. Attempting to train a “splinter skill” may not be as effective as stimulating the child’s development to the appropriate level of readiness; the underlying processes are still not adequately adaptable.
The emphasis on development has decreased over the last 30 years. The Denver Developmental Screening and the Gesell Readiness Test including the Winterhaven Copy Forms are not used as they were in the past. Some of you may remember the McGuinness-Hammondsport Program which was used in many school districts. It was designed based on research to develop visual and auditory perception skills prior to the formal introduction of reading and mathematics. There have been hundreds of research studies over the years on the perceptual skills which are prerequisite to learning to read, write, and develop a number sense. Development is dependent on interactions between the environment and the genetic plan. Piaget distinguished between development and learning. He viewed development as flexible. It can be applied broadly such as an understanding of integers can be used to solve many problems. He saw learning as specific, such as learning a math fact. The importance of understanding the following developmental concepts may have increased in our current era of less hands-on play and accelerated academic demands.
Seeing is not a separate, isolable function; it is profoundly integrated with the total action system of the child – his posture, his manual skills and coordination, his intelligence, and even his personality make-up. Indeed, vision is so intimately identified with the whole child that we cannot understand its economy and its hygiene without investigating the whole child. He sees with his whole being. Eye care involves child care.
It takes a tortuous journey for the human child to reachieve what it took the race so long to attain. Motorwise, the action system is an exquisitely balanced machine. Not a movement can take place without affecting, more or less subtly, the equilibrium of the total machinery. A primary function of vision is to direct movements. In the development of ocular controls, fixation of movement is quite as important as execution of movements. The fixation response, therefore, involves the entire action system to some degree. When the neonate fixates an object of interest, his sporadic bodily activities tend to subside; he stops fretting; he assumes a postural set.
Visual defects and deviations express themselves not so much in failures of acuity as in discoordinations, various forms of awkwardness, faulty timing, and hesitations. Closely observed, these atypical preschool behavior patterns have significance for early diagnosis, prevention, and treatment of visual difficulties.
The developmental growth of a six-year-old expresses itself in his efforts to gain mastery of the oblique line in his eye-hand coordination. The five-year-old has a predilection for the vertical. The six-year-old shows an interest in oblique directionality. His eyes differentiate between a vertical and oblique stroke but, in his effort to execute an oblique stroke with his crayon, he twists his body and shifts his paper at various angles.
The infant takes hold of the physical world with his eyes long before he takes hold of it with his prehensory hands – a fact with far-reaching implications.
It is literally true that a baby can read signs which are more subtle than those of the printed page.
The culture sets standards of efficacy. The standards are not always valid. Often they are excessive and unreasonable.
Systematic examination and supervision of the visual functions in the preschool years will serve to identify children who present potential difficulties in learning and school tasks. This should not blind us to the fact that the culture is making unreasonable demands on many young children. The demands overburden the limited powers of spatial manipulation and, in many instances, rearrangement and amelioration of the cultural demands would be a more basic solution than a therapeutic approach to the visual handicap.
* One of the people who helped in the research and the writing of this book was Dr. G. N. Getman. I am honored to be the 2014 recipient of the G. N. Getman Award by the College of Optometrists in Vision Development. Dr. Getman and his wife were friends of Dr. and Mrs. Quick and Dr. Getman came to Owego to make a presentation to teachers 40 years ago.