Out of the water

The last time I posted things were in a rut, but now they have turned around a bit.  I can't exactly pinpoint what changed but I'll list a couple things.

First, we have been playing more of our version of "Munchkin", and he seems to enjoy the cards more.  I've noticed that he still gets lower case "b" and "d" (and sometimes "p") mixed up.  I fixed our printer (ie had the printer clean the nozzles) and printed out the next set of "Flesch Cards".  In hindsight, it was long overdue to move beyond the first set.  He liked cutting out the new cards (we got him scissors and he's all about cutting paper) and wanted to read the new cards.  He also understands now a lot more when I explained to him the theme of the cards (ie, these all have "e" in them, so they make the "ehh" sound).

Next is that I was at Costco and saw that they had a deal on six "Biscuit" books for 10 dollars.  I had read that these were great reading introduction books from reading a flyer at one of our local libraries so I went ahead and got them. Actually, I had previously borrowed from the library the first "Biscuit" book a couple months ago but didn't think it was that special at that time.  This time, however they have been really great for getting him to read independently.  The vocabulary in the books is more extensive than a "Bob" book, but interspersed throughout each story is the voice of Biscuit, who invariable says "Woof", or "Woof, woof!", or "Woof, woof! Woof, woof!".  This might sound boring but actually I saw it give a lot of confidence in pointing to the words and knowing what they said, so much so that it is easy for him to slide into the next sentence and read that out as well.

Thirdly to my surprise he's picked up how to spell simple CVC (consonant vowel consonant) words.  We discovered this on accident by spelling some words and he said them.  Today, I quizzed him because I didn't really believe my wife, and he was able to tell me what C/B/R/S-A-T and G-O and M-O-M.

Now, if only I could find a way to get him to stop saying "butt, butt, butt, butt" every time he wants to be funny....

Treading Water

I don't think that there has been much of a significant change since the last time I posted two weeks ago. I worked a week of nights and so I wasn't able to do as much reading with my son. He's still in this phase where he can sound out individual words when asked, but doesn't really have a large memorized sight word vocabulary.  Sometimes it is a struggle to get him to read what the books actually say rather than what he is guessing them to say. To help with this, I'm trying have him focus more on pointing to each word as he reads it so that he has to register.  I haven't done the flash cards for over a month now.  I made an excel sheet to record the number of "memorized" sight words he knows because I thought it might be fun to look back at it someday.  So far, it's been a plateau.

Back in Seattle

Our time in Yakima was fun, though not as productive for me as I would like.  The difference in location and the proximity of Grandma's house with the allure of the trampoline and my old toys made nap time a struggle.  Unfortunately, nap time is key to my overall sanity and ability to work on projects.  On the other hand, since we've been back in Seattle I have actually made it a habit of having him put himself to sleep and it has never been easier (the key has been to use ask him if he wants a dim light on or totally off, and he puts himself to bed now without any issues).

Potty training is now pretty much complete, and I have been looking at preschools now to try and get him more social interaction with other kids (will probably write more on this later). It seems that for at least Montessori schools in this area, things seem to be pretty competitive, and it looks like I missed the boat for getting considered for admission by several months (some schools have stop accepting applications in January 2016 for the 2016-17 school year!).

With regards to reading there has been some progress!  About 3-4 nights ago he started to read books completely by himself (Bob Books, specifically the first couple books 'Mat', 'Sam', and 'Dot').  Yesterday he also read a short story from an old 80s phonic learner as well by himself.  There was a large plateau period where he wouldn't read by himself and everything felt like pulling teeth so I was worried I was just pushing him and ruining reading for him but then there were a couple changes on my end that I think made the difference.

The first was getting him to point at the words. For some reason I never thought that this was important until about a week ago.  I started asking him to point to the words as I  read them and I think this helped him "put it all together", because for the longest time he could sound out words when asked but would just stare at a sentence and would rarely jump to the next word. Another trick was then having him point to the words but I would read it.  This helped me slow him down when he would skip over words or just jump lines.  Finally, one night he didn't want to go to bed so I allowed him to delay sleeping if he read me the books, which he did quite well.  Since then most of his independent reading continues to be done when he is just trying to delay going to bed (that is, he still doesn't pick up a book 'for fun' and try reading it), but yesterday he wanted to read by himself while we were reading for fun I think things are trending in the right direction.

I have pretty much stopped using the "Flesch Cards" except when we play "Munchkin".  Munchkin is a Steve Jackson card game that is a satire on D&D.  We have come up with a morphed version of it that involves going through a dungeon, encountering monsters or good guys and fighting the monsters by rolling a die and counting it (and then the game further morphed into that number being how many cards he needs to read in order to defeat the monster).  Honestly, I probably overdid the cards and he has never really caught on to them.  We have never done more than the first three sets.

As an aside while doing some spring cleaning I found a LeapPad that my grandmother gave us that I hadn't used yet because I was prejudiced against it.  I cleaned it up and we started trying it yesterday and actually the modules that we have for it are right at the level I want for him (things like CVC words, vowel sounds).  He really likes it and can actually set it up himself although the thing is buggy and occasionally wonks out. He's already learned the old NES trick of blowing in the cartridge and reinserting it.

Back in the Homeland

With regards to reading, we have been making steady progress.  Sounding out three letter and some four letter words is no problem as long as they follow "the rules" (ie no th, ch, ph, and all the vowels have their short sound).  Occasionally he get's tripped up by lower case 'b', 'd', and 'p'.  Also, he will occasionally guess the word when he sounds out the first two letters rather than reading it to the end.  I still feel that at times I am pushing him too much with the cards.  Interestingly, after rereading Larry Sanger's essay, I have been much more about making my sound out the words himself rather than reading them to him, and this may be why he continues to sound out the words rather than instantly recognize words that he's seen before (such as cat).

In meta-news, we are in Yakima for three weeks.  Sort of a trial run to see if my wife will end up liking to do her commitment here for the NHSC. Hospitalist work here will be a different beast, but I can do anything for a while, and perhaps there are more opportunities to help (such as with the residency or the new DO school), that might make it fulfilling.

A breakthrough and then....

About two weeks ago I was giving my son a bath when I decided to try and put the foam letters we have in the bottom of a large cup so that they spelled a simple CVC (consonant vowel consonant) word.  It was great! He sounded out the letters and was able to read words, consistently! He really liked the cheering we did (although I wonder if that means I am putting an external focus of achievement on him rather than having him discover the fun of reading himself?).

Since that time we do that game every bathtime.  I have found that it has not always been transferable to other reading contexts.  For example, I have been able to get him to do the reading cards that I have mentioned before (in fact yesterday he got through the first batch perfectly), but he is not always interested.  When reading books, he often just wants to guess what the word is supposed to be by looking at the pictures rather than looking at the letters. Or, he will look at the letters, sound them out, and then give a different word that is almost correct but is obviously a guess based on the context of the story.

I've also noticed he still gets lower case 'b' and 'd' mixed up, so there is definitely a need to keep reviewing the alphabet until it is second nature.  Likewise, he sometimes forgets the 'soft' sounds of the letters 'e' and 'i', giving the soft 'a' sound instead.

So, although I am happy and excited that he understands the method of reading, I'm more aware that things don't just suddenly accelerate away and take care of themselves.  We still have a long way to go.

Incidentally, my sister has been having a lot of success teaching reading to her son with this programmatic textbook.  I can't remember the title but it looked good.  When I have more time to see them again I will write about that too.

Reading III

The day after my last post we had a big breakthrough in reading.  I had forgotten to mention that he knows a couple words by sight in addition to 'stop'. One of these is 'zoo', and more recently he's learned 'exit' (which is great word to point out because there are signs for it everywhere). He was playing on our keyboard when he said "Hey Dad, it say's exit." I went over there and sure enough, there was an 'exit' button on the keyboard. This is the first time he's pointed out a sight word without prompting from me (aside from 'stop'). 

In addition to the above I had another cause to be happy this weekend. We were away at my wife's family's house this weekend.  While there I was having him show his grandparents that he could read letters in a word.  I pulled a magnet off the shelf that said "Boston" and he went through all the letters, which is something he can do pretty easily now.  What surprised me was when I asked him to sound it out, he went through and made the right sounds for each letter (like this: "Bh - oh - sss - t - oh -nnnn").  Now, he didn't string it all together and say Boston, but this is the first time he has sounded something out like this without any help from me.

He still doesn't like the "Flesch/Flash" cards when I bring them out.  He usually puts up with one or two of them before wanting to read a book or do something else instead. I find it's much easier to get him to sound out words while we read a book. I think this just reinforces the point that what works for each parent/child is different and the important thing is to just do the things you guys like to do (but find a way to incorporate learning the alphabet, letters, etc.. into it).

A summary of the tools that I have found helpful:
-Reading books he likes every day (ie space, moon, monsters, dragons, pop-up books, etc...)
  -While reading occasionally asking him to identify a word
  -Making it a point to go to the library regularly to get new books
-Foam letters from the dollar store (these were great for teaching the letters and then sounds, and now we play with them in the bath to make "words" and practice sounding them out).
-Using a text editor, turn the font way up and let him press buttons (you can ask him to find the "a", for example.  You can use cap locks too if you want to limit to upper case).
-Some games on PBS Kids Online ("Pig's alphabricks", "Dog's Letter Pit")
-Pointing out words in the world, such as STOP signs, EXIT signs, OPEN signs, BUS signs
-For the alphabet just reading a lot of alphabet books (finding ones with lower case letters is more difficult)

Things I tried that he didn't like:
-I made cards for letters a couple months back, hoping he would like to match them for a memory game.  His interest in this was modest at best.
-Bob books are ok, but quite boring, and I find the simplified grammar in the early ones almost make them harder to read because he wants to add the right words in to keep them from being unnatural.  That being said, we do occasionally read them and he really liked the first page of each book where there were the letters being introduced and a picture of a word that starts with it.
-And as mentioned the flash cards with words on them, although perhaps at some point he'll like them

Reading Part II

So my son didn't like the cards. We just got through the holidays, and then everyone got very sick so there wasn't as much structure as I normally like when I am off.  Of course, everyone got better but then I had to work a week of nights so there was less time for me to read to him.  Now that things have settled down and I don't have to work I thought I would review what is new.

Yesterday I was surprised when he called me over to tell me that there was the word "exit" on the keyboard button, this is the first time he's really pointed out a word other than "STOP" on a stop sign (which of course have plenty of visual clues that don't require actually looking at the letters).  My "plan" has really not changed:  I try to sit down and read with him at least three times a day (probably 1-1.5 hrs total time) and switch between reading things for fun and pointing at the words as we go along, occasionally asking him to try and sound it out (haven't really had a successful sounding yet, although he is very good at identifying the letters).  Usually it goes like this:

I ask: "What does that say?"
JT: " C-A-T ... CAT!" (or HAT!, or some other word)

In addition we play some online reading games. It took a while to find games that asked to sound out letters and make words. My favorite for him at this stage is called "Dog's Letter Pit" and is on the PBS Kids website. He used to really like it but he now only tolerates it for about 3-4 words before getting bored.

Today the library opens at 11 AM so we can go get some more books.  This last checkout round (has it really been three weeks ago that we last went?) I especially enjoyed "Put Me in the Zoo" by Lopshire.

Things I've done to teach my son to read

I don't remember the exact age of  my son when started to focus more on reading. Ever since he was born I have tried to read to him, and as he became more of a little person and less of an animal (around 3-4 months?) the reading became more regular I think.

We are fortunate that we live within walking distance of a library, even though the hours aren't always convenient. I've made it a habit of having 5-10 books from the library at our house to supplement the usual books that he has had. I think that spending an hour a day of reading (not all at once) is the cornerstone of teaching to read.  I pick out books about things I know he likes (any book about space, the moon).  Sometimes he picks out books randomly but most of the time while we are there he is more interested in the blocks and puzzles they have.

I think teaching him the alphabet just happened by reading a lot of alphabet books and quizzing him on what the letters were.  Around a year and a half I found that he liked it when I would open a word processor, crank up the font size to 80 or so and then let him press the buttons to make the letters appear on the screen. I could also sneak in a little learning by asking to press specific letters.  Learning the sounds of the letters sort of just piggy backed on this with me asking him what sound each letter makes (either as we read an abc book or played the word processing game).  I haven't really used any online programs or computer programs.

This week I got around to trying out the "Flesch Cards" (ie flash cards based on Larry Sanger's essay on reading, where he makes a pun out of a method endorsed by the author of Why Johnny Can't Read). My son hated it immediately, I was able to get through maybe 3-4 cards. Perhaps if I had introduced it earlier he would tolerate it more but I think it is just so much different than our current style of how we interact that it isn't going to work for us.  Let's give it a couple more tries and see, otherwise I think I'll just stick to lots of reading with him and encouraging him to sound out the words.

Introduction to Case Reports

If you've never experienced a case report in person this will give you an overview of how they work.

A case report is a meeting, usually with a small to medium sized group that discusses a particular patient.  These patient's are usually chosen because they either have an unusual disease, have an unusual presentation of a common disease, present a therapeutic challenge, or an ethical dilemma. The presentation is divided into several parts (based on how information about a patient is usually temporally collected and organized) to allow group discussion and further questioning.  The following describes my experience during my residency which is probably similar to other places.

To begin with, the presenter will give a brief one-three sentence introduction to the patient, something like "This is a 51 year old gentleman who is coming into the hospital with two days of abdominal pain" or "This is a 30 year old woman transferred to our hospital after seven days of worsening rash".  This will usually be followed by an overview of general questions you would ask every patient such as how long it has been going on for, where the symptom is located, etc...  Sometimes, in the interest of developing the participants' history taking skills, all of the history and review of systems (ROS) will need to be teased out through questioning.  For this to be particularly effective the presenter should also be asking the participants why they are asking certain questions, which will allow others to understand the reasoning behind certain lines of inquiry and how it can alter your differential diagnosis.

After the above back and forth to flesh out the HPI, the presenter will ask for initial differential diagnosis and why each one should be included.  So now we have an embryonic differential floating out there and the fun will be in seeing how more information will change/narrow our thoughts.

Next, the presenter will fill in all (unless there is some obvious juicy tidbit vital to the case) of the past medical history, meds, family history. The social history should be fleshed out by the participants, as it is often a very useful source of information in complicated patients. Sometimes there will be another pause to go back to the differential diagnosis or it will wait until after the next section.

After this will come the physical exam, and usually all the basic exam is given away.  If there are certain crucial exam findings that are beyond basic (basic usually defined as vital signs, general appearance, heart and lung sounds, abdomen, basic neuro exam, any obvious skin findings) these are withheld unless asked for by a participant.  Again, a jump back to the differential will occur at this point.

Finally, basic labwork will be given (CBC w diff, BMP, LFTs) and participants can ask for more labwork (if available) as well as the imaging studies, biopsy results, etc... that may or may not have been done (and of course the presenter should be asking "why" to every request so that others can understand why certain things are done).

It should be mentioned that at any point people can go back and ask a question pertaining to a previous part (for example, you might want to ask about travel history after seeing the eosinophils on the CBC).

Finally, we get together for one last discussion of the differential and the diagnosis is revealed.  There is usually some prepared learning from the presenter on the true diagnosis to cap it off (usually brief).  Sometimes, lingering questions that would best be served with a literature search are collected and an email is sent out with the results.

That is the basic overview.  The key to a good case presentation is participation and mutual respect.  Nobody should be felt like they are being pimped or ridiculed for asking a question since the point of this is to bring everybody up to a higher level. Case reports are great because they teach the method of diagnosing and deductive reasoning (something not easily conveyed in books) as well as information on particular disease. If nobody feels comfortable asking a question that might make them look ignorant than everybody suffers.

In Summary:
Brief Intro --> HPI/ROS (fleshed out by questions) --> Initial differential diagnosis --> Past medical history, family history, meds, etc... (Social Hx fleshed out) --> Differential revisited --> physical exam --> differential revisited--> labs/images/ecgs/pathology (fleshed out by questions) --> differential revisited --> Diagnosis revealed  --> Discussion

On Teaching Reading

Because of the shift work of my job, I get to spend a lot of time as a stay at home dad. One of my goals has been to see how young I can teach my son to read. To achieve this, I have done a bit of researching on how to teach children to read, and it's interesting how difficult it is to find good information that has been vetted by experts without pernicious influence.  If you just try to search "teach my child to read" you will have to wade through scores of companies trying to sell you something.

I did find the Department of Educations evidence based report, called the National Reading Panel which was request by Congress in 1997 to guide how one should go about teaching a child how to read (full report is 448 pages, which can be found here or there is am more reasonable  summary here). There are probably other state and local level resources as well (and perhaps teacher union or groups) which I am not aware of.  It's actually pretty sad how hard it is to find an entity that's acting (presumably) in the interest education rather than a commercial enterprise to make money.  There were a lot of broken links on the government's websites.  I haven't read the entire report, so although I am aware of the general overview, I'm not sure if there are a lot of details in how to teach reading in the most effective manner.

Personally, I just try to read to my son multiple times a day.  Learning the alphabet was actually pretty easy (at one point we stopped because he couldn't say the three syllable letter "w", although he knew all the capitol letters, and most of the lower case ones).  Next came teaching him the basic sounds of each letter, which wasn't that much harder (we haven't tried "sh", "th", etc... yet).  Now I am at the point where I am trying to have him sound out words, but it is hard because he "memorizes" (often incorrectly), his books and just wants to say what he thinks the picture says rather than what the words actually say.  I will post some of my own methods of teaching him in case it might help others.