Reading Matters:
Supporting Struggling Readers

Adapted from a power point presentation by Dr. Jeanne R. Paratore of Boston University. If you are interested in reading the entire document, it is available at:
http://www.wera-web.org/Best_Practice_2002.ppt

One of the visitors to this page, Merle Rubin, adds the following suggestion:
It is essential that a teacher of all readers, but especially struggling readers, knows where the student is in their understanding of the reading process when they come to you: their phonics knowledge, what they already know about text structure (how books work), what words they already know how to write and of course reading level.

 If a child makes reversals . . .

     Rule out any vision problems.

     Trace a word or letter from left to right, following the direction of an arrow at the top of a page or word card (tracing materials may come from newspapers, magazines, overhead transparencies).

     Copy a word or letter on a typewriter or word processor.

     Print a word, making the first letter green (go) and the last letter red (stop).

     Do activities that require awareness of left to right directionality (Simon Says and the Hokey Pokey).

     Physically guide the child's hand.

     Use flexible practice (over teach!). In other words, try to get flexibility by having the child construct the word or letter in different places with a variety of materials such as magnetic letters, MagnaDoodle, with chalk, on the carpet, in the air, on a white board, make it with etc.

     Use a hole punch as a tactile anchor to indicate where to begin writing.

     Provide an individual number line/alphabet strip for easy reference.

     Trace over dots to form letters/numbers.

     Sort letters by structure/feature (circles, lines, etc.).

     Use sandpaper letters, writing in salt and/or sand.

     Talk through letter formation. There are commercial programs that provide the "talk," but the ones that teachers, parents and kids make up on their own often seem to work the best for those individuals. Their own language helps as a memory tool.

     Purchase and use school font software that has arrows to show directionality. Enlarge the letter in a Word document, and place in a plastic sleeve for tracing activities. This produces action in the whole hand and wrist. The one I have and use also offers dotted patterns for tracing handwriting attributes.

     See handwriting activities and tips on Teacher Trail.

If a child reads word by word,
uses incorrect phrasing or lacks fluency . . .

     Make sure that you have a strong understanding of fluency and the role it plays in
     comprehension. See Reading Fluency for more information.

    Tape record a paragraph, listen to the tape, record it again with attention to units of meaning, and listen for improvement. Repeat this process until fluency is reached.

    Read a paragraph silently and underline groups of words that go together.

    Read orally with a good reader and imitate the good reader's phrasing and expression.

    Implement repeated and/or timed readings for building fluency.

    Modeling: the teacher and fluent readers are both good models. Commercial or teacher-made story tapes also serve this purpose. Read Naturally has a wonderful program that is affordable for the classroom teacher. I believe that their materials can be found at readnaturally.com. I used them with students from 1st through seventh in my reading specialist program. Students make great gains with this program.

    Echo reading: the student imitates the teacher's oral rendition, one sentence or phrase at a time. Begin with a taping of the student reading a passage, followed by echo reading, and culminating in a second taping of the student reading the same passage. The student compares the results and notes the improvement.

Choral reading: less fluent readers are grouped with fluent readers as they read a selected passage in unison. The teacher either reads with the group or serves as a conductor. This is a real confidence builder and at risk readers will feel safe enough to take risks in reading.

    Reread easy books, songs, poems.

    Text chunking: students read aloud a passage that has been marked with slash marks to show phrase boundaries. Passages from poetry, speeches, or songs usually work best, although narrative with frequent punctuation marks can also be used.

    Repetition: the use of repeated readings-contextualized reading practice-is one of the most effective ways of improving fluency. The material should be "easy reads" for students, to provide problem-free reading experiences. These passages or selections should also be high-interest so that students will not become bored with the repetition.

    Readers theater: this technique gives groups of students an opportunity to practice and demonstrate fluency. Each student is assigned a particular role (one or more character's words or thoughts, the "narrator" who reads the narrative) to dramatize a story that is then presented to classmates. I particularly like to use stories that are very familiar to the students (i.e. The Three Little Pigs, The Three Bears, etc.) The children can easily predict what dialogue is coming next and how it should sound (prosody). "Someone has been sleeping in MY bed!" roared Papa Bear.

    Neurological impress: the teacher, aide, or volunteer reads slightly ahead of, and louder than, the student. As the student gains fluency, the teacher's voice becomes softer and "shadows" (comes just behind) the student's. This is a highly effective technique, especially good with students acquiring English. A note of caution: I have found that this doesn't always work, especially for those students who can't tune our peripheral noise.

     Read different genre to create different moods and show voice (prosody).

     Use familiar reading on a daily basis. Each child should have a personal basket or box of familiar texts to read as part of their seatwork during your guided reading period. Journals may also be considered as familiar text. Repeated reading of text that they have mastered during guided reading increases reading rate.

    Implement "power reading" with your emergent and early readers. My first grade struggling readers loved this activity, pleaded with me to do it more often, and always wanted to take the books home to "show Mom and Dad!" It's simple. Gather an assortment of their recent guided reading books that have moved from the instructional to independent level. Challenge them to see how many books they can read in ten minutes. With older students you may want to use poems in their poetry notebooks. Please note that this works just as well for building writing fluency. Students use a lap sized white board and marker. Read through high frequency words in order from the first word (the) to a number that is appropriate for a group or individual. Vary your pace according to their writing speed. Believe me, they will rapidly pick up speed as you practice. I prefer doing this in a very small group or with individuals who really need it. Parent volunteers or instructional assistants can do this one-on-one. Students who generally misspell common words on paper are proud of their "power writing." They forget about letter formation and neatness and focus on spelling the word correctly and as rapidly as they can. This is also a good self-esteem builder for students with fine motor skill difficulties. It also facilitates the development of automaticity and letter/word recall.

     Make sure that the content of the text is within the realm of the child's listening and speaking vocabulary.

If a child shows little awareness of structural analysis when reading . . .
(inflectional endings, prefixes, suffixes, contractions,
compound words, syllabication and accents)

    The best way to improve ability in structural analysis is to read widely from a variety of interesting materials.

    Count the number of syllables in a spoken word by clapping, tapping a pencil, or holding up one finger for each sound.

    Match two root words that make a compound word.

    Create words from a flip chart that contains root words in the center, prefixes at the beginning, and suffixes at the end.

    Underline the root words on a list of words with affixes.

    Choose the word with the correct suffix for a sentence. (Sally           [walk, walks, walked, walking] a mile yesterday.)

    Use Elkonin boxes while blending sounds to form words.

    Sort picture cards into categories: one syllable, two, etc.

    Reinforce efforts: "I like the way you tried to work that out."

    Make child aware of root words by "making and breaking " words with manipulative letters.

    Cut student generated sentences/words apart at critical points to emphasize chunks. "Where would I cut the word friendly to leave off the /ly/ chunk?" When the child reassembles and rereads the sentence, they have to pay attention to the suffix. Students who have difficulty often discover that they have an ed, ing, or ful left over when they put the sentence together. They usually act surprised and say, "Oh, yeah, I need to put this part over here." This shows the advantage of going from whole to part and back to whole again. With beginning writers in Reading Recovery® I often asked them where to cut off rime chunks to separate blends or clusters from the word family pattern. (ie. "Where would I cut of the -ink chunk in the word think?")

    Model strategies to access chunks (cover -ing or -ed endings with your thumb). Use word sorts (Words Their Way).

    Create a cloze passage with missing morphemes.

     Refer to Complete Reading Disabilities Handbook (Miller) pages 316-317.

    Use the word wall to play "What's my rule? ",  drawing attention to structure (silent e, double consonants, # of syllables, -ing, vowel teams, etc.).

    Assess the child's awareness of structure (blends, digraphs, etc.) and use appropriate activities to teach and practice.

    Teach students to use the "circle, circle, underline" strategy when decoding multi-syllabic words (circle the prefix, circle the suffix, and underline the vowels in the root word). This activity only takes a few minutes every day, but increases student ability to break down and understand multi-syllabic words.

    Make sure child recognizes letters and produces sounds of phonemes with automaticity.

    Distribute word cards to students to practice compound word development. Each child finds his/her word partner to create a compound word. Each pair pronounces the new word for the class.

     Play "Team Word Building." Divide the class into two teams. Give each team an equal number of root word cards. Team A displays a card and calls on a member of Team B. If that person cannot give four words using the root word plus an affix, he must join Team A. However, if he can, he selects a person from Team A to join his team. Play until the cards run out or all players are on one team.

     Play Prefix or Suffix Spelling Jeopardy (soon to be added to this site on Word Way).

     Play "What's My Rule?" with your word wall words. Read two words and ask the students for your rule or reason for putting those two words together. First, they have to find those two words and look at them carefully. They will often come up with rules that apply, but which aren't the rule you used. For example, the words suddenly and happening have many things in common: they both have suffixes, double consonant spelling and three syllables. Depending upon the group's ability, I might ask for another word that fits the rule. Be sure to compliment students when they come up with a good rule: "Good for you! That rule works, but it's not the one that I was thinking of."

     Play compound word concentration, build compound words  and match with pictures in a pocket chart, or put together compound word puzzles (all available on this site). Word Way has reproducible compound word acitivities.

If a child lacks knowledge of sight words . . .

    Associate pictures with words that have concrete referents.

    Identify names of familiar products that appear in advertisements.

    Read words from language experience charts and student-written stories as they appear both in context and on word cards.

    Build word banks of sight words and use them to create sentences or organize by naming or action words.

    Practice recognizing similar and confusing words, such as those beginning with th or wh, by circling difference in them on word lists and identifying them on flash cards.

    Highlight high frequency words in language experience charts.

    Review common words daily in context and in isolation, teaching the child to use context clues at unknowns.

    Say, write and read words many times to develop automaticity.

    Develop knowledge of spelling patterns, root word sight vocabulary, adding common prefixes and suffixes.

    Use multi-sensory techniques (see Project Read).

    Provide opportunities to practice fluency (timed drills).

    Provide peer tutoring, frequent interaction, paraprofessionals.

    Use the analogy approach: seeing similarities and differences among printed words.

    Reread predictable books for multiple exposure to high frequency words.

    Establish a high frequency word bank, or picture dictionary.

    Implement flexible practice on a regular basis, paying attention to details (ascending and descending letters, length, and configuration).

    "Make and break" words with magnetic letters.

    Brand Name Phonics (Cunningham), move from the known to the unknown.

    Provide a list to parents with information about grade level benchmarks.

    Use software programs that allow him/her to hear the word and see the word highlighted.

    Utilize a vocabulary attributes chart to help students visualize and understand words and their meanings.

    Students create jigsaw puzzles: word on the left and meaning on the right.

    Group flash cards by categories or word families.

    Label objects in the classroom using single words or sentences.

    Post and read daily schedules.

     Teach useful, meaningful sight words first: names, days of the week, months of the year, school subjects, etc.

    "Around the World" Game

    Sight Word Word Bingo

    Concentration

    Transformer Board Games

    Interact with the Word Wall

     Always take unfamiliar words back to context. Children should have a personal word bank. It doesn't matter what format you use (boxes, books, on a large ring, etc.) My favorite way of implementing this strategy is to have the student dictate a sentence using the unfamiliar, but important word. I always write it myself so that it looks like "book" writing with accurate spelling and legible printing. I underline or highlight the new word. Students may draw a picture below the sentence to serve as an anchor or visual reminder. Write the word itself in large print on the other side of the card. When studying their flashcards, students first try to read the word. If they can't recall the word, they turn the card over and read their sentence that contains the troublesome word. The context of their own language often triggers the correct reading of that word. If they're practicing with an adult, record each success with a tiny happy face on the word side of the card. When they have successfully read that side at least five times without the support of reading the sentence, you can consider that to be one of "their" words and remove it from their box or ring.

     During morning message, demonstrated or interactive writing, have students find and circle important sight words.

If a child demonstrates poor comprehension skills . . .

    Develop automaticity and word recognition skills. Comprehension breaks down with poor decoding skills, time lapse, and a slow reading rate (wpm).

    Build background knowledge, concept development and oral language skills. Plan direct and vicarious experiences to build schemata, which is necessary for reading comprehension.

    Provide instruction in understanding of story schema and story grammars. Expose students to well-formed stories (storytelling and story reading). Read a variety of stories with standard structures, building the ability to predict or anticipate.

    Activate student schemata through a teacher "think aloud."

    Match books to readers. When reading materials is too difficult, focus is diverted to decoding.

    Explore and interpret pronoun referents, deleted nouns and predicate adjectives.

    Make sure that students are aware of the aids to comprehension found in punctuation. Practice interpreting these marks.

    Teach students to make use of paragraphs that have specific functions. Use summary paragraphs to check their memory for important points in the selection.

    Model metacognition, prediction checks during reading.

     Sequence pictures from story: beginning, middle and end.

    Utilize prereading strategies and activities: previews, computer simulations, anticipatory guides, and semantic mapping.

    Use reciprocal teaching to promote comprehension and comprehension monitoring: predicting, question generating, summarizing and clarifying.

    Use the cloze procedure as a strategy for teaching comprehension. Vary deletions when creating cloze passages: letters, word parts, whole words, phrases, or whole sentences. Always leave the initial and final sentences intact and delete no more than 10% of the words.

    Make a cloze story map. Place the main idea in the center of the map, connect key words for major concept or events, add subevents and subconcepts. Delete every fifth item.

    Follow up reading with story frame activities: story summary, important idea or plot, setting, character analysis and comparison.

    Practice locating details in a newspaper story, answering who, what, when, where, why, and how questions.

    Teach cause and effect relationships.

     Teach students to recognize sequence or time-order words. Reassembling comic strips provides useful practice.

If a child cannot find the main idea . . .

    Observe the teacher modeling ways to identify main idea (what the selection is mostly about, which idea covers all important aspects of a selection, etc.).

    Categorize objects, pictures, words, and finally sentences; name the category; and explain why items go together.

    Choose an advertisement, use the product as the main idea, and select several features of the product as supporting details.

    Read a paragraph that is constructed so that one sentence does not belong with the other sentences, remove the inappropriate sentence, tell why it does not belong, and state the main idea of the remaining sentences.

    Write a paragraph and give it a title that tells the main idea.

    Point out that the main idea or topic sentence will always contain one or more of the following: who, what, where, when, how.

    Utilize the reciprocity in reading and writing to demonstrate the development of main idea.

    Model, model, model.

    Practice, practice, practice.

     Practice finding main idea using the "rim rat" newspaper activity. ("Rim rats" write headlines for newspapers.) Match headlines to interesting articles from old newspapers.

If a child has difficulty using context clues
as a technique of word identification . . .

    Stress the importance of using semantic (context) clues in effective reading comprehension.

    Watch the teacher modeling ways of using semantic and syntactic context clues.

    Choose the correct word from several choices to fill in the blank in a sentence and give reasons for the choice. (Jimmy played outside with his [basketball, television, potato, and chair].)

    Fill in blanks with appropriate words in cloze selections. There are more than a hundred cloze activities available on this site (Word Way, using onsets and rimes, and Blends Boulevard).

    Brainstorm words that would make sense for the unknown word in a sentence and consider phonics clues (especially beginning sound) in deciding on the word.

    Underline specific types of context clues, such as definition or comparison.

    Teach students to recognize and use a variety of context clues as a means to ascertaining meaning: experience clues, association clues, synonym clues, summary clues, comparison or contrast clues and previous contact clues.

     Provide opportunities for children to experience wide reading of assorted materials: predictable texts, nursery rhymes, trade books, newspapers, magazines, student-generated writing, etc.

    Encourage students to supply words that make sense while reading, to become risk takers.

    Provide practice in listening for miscues using teacher-read material with intentional errors. Students indicate when the miscues occur and why they are inappropriate.

    Teach students to read to the end of the sentence. Words following an unknown usually provide more help than the words before it. It is also helpful to reread the prior sentence and the sentence following.

    Reinforce and praise the use of self-correcting in oral reading.

    Function words: Write function words such as a, an, and, or the on word cards. Use pictures to form noun phrases.

    Irrelevant Words: Create sentences with an extra, irrelevant word in each. Children read the sentence, delete the extra word and reread the sentence.

    Set a goal of 500 words in context for each lesson (Allington).

     Cover word or portion of the word (Guess the Covered Word from Pat Cunningham)

If a child does not self-monitor . . .

    Ask the child to go back to one-to-one pointing or tracking.

    Direct the child's attention to meaning.

    After an error, ask the child: "Where was the hard part?"

    When the child hesitates or pauses, ask the child, "Why did you stop?" Or "What did you notice?" Be specific with praise.

    Praise efforts at self-monitoring by saying, "I like the way you tried to work that out."

    Modify or adjust reading materials to the student's ability level.

    "You read it this way. Does that make sense? Is that the way we talk? Does that look right? Read it again for me."

    Cover up word that was misread. "What would you expect to see at the beginning of the word               ? Does this word start like that? Read it again."

    Discuss what to do at unknowns before reading independently. Have child point out strategies used after reading.

    Tape record students reading, allowing them to hear errors, lack of fluency and expression.

    Model self-monitoring through a think aloud process.

    Strategies chart: students indicate what strategies they use during reading.

     Teacher makes error and student corrects.

If a child does not use one-to-one matching . . .

    Say, "Read it with your finger." Or "Did that match?" Or "Were there enough words?" Or "Did you run out of words?"

    Use two fingers to frame each word.

    Point along with the child and stop when he makes an error that could be corrected.

    Cut up student generated sentences and reconstruct and read.

    Clap oral and written sentences while counting number of words.

    Use a variety of pointers: glittered chopsticks, "monster" fingers

    Walk on words

    Model 1-to-1

    Write or highlight each word with a different color

    Teacher holds the child's and guides him when pointing

    Select books with few words on a page.

    Say: "Read it with your finger."

    Ask: "Did that match?" or "Were there enough words?"

    Point along with the child and fail to move on when he makes an error that you think he can correct.

    Say: "Point to each word" or "Use a pointer and make them match."

     Refer to Reading Recovery Guidebook, page 21-22.

If a child has difficulty remembering sound-symbol relationships . . .

    Check for possible hearing loss or history of ear infections.

    Over teach at an appropriate level, within a context.

    Play with words using letter cards, pocket charts, magnetic letters, and overheads.

    Read simple, decodable text.

    Develop anchors or supportive cues such as picture cards for each sound spelling so he/she can associate a letter with an image and a key word. Tactile-kinesthetic learners prefer action words as their cue words. Auditory/visual learners prefer nouns.

    Dramatize a sound, providing an anchor.

    Use other student names to move from known to unknowns. "Do you know someone whose name starts like that letter or has that letter in it?" Use a visible names chart. Send student ABC book home, giving each one anchor for each letter.

    Enlist parent help, stressing the importance of the sound-symbol relationship.

    Start with sounds in student's name, moving to friends and family names.

     Make an ABC book, writing only the letters the child recognizes, pasting student selected pictures for each. Child reads on a daily basis: "A a apple, B b ball," etc.

    Move from the known to the unknown: "Do you know a word that starts like that? Now get your mouth ready."

    Ask student to say the sound as he writes.

    Practice, practice, practice.

    Model during interactive writing, shared writing.

    Provide all at-risk students with a readily available desktop or folder sized chart of sounds, including letters, blends, and pictures for each.

    Global learners cannot learn sounds in isolation. Teach all phonics-related skills in the context of meaningful words, phrases and sentences.

    Teach consonants before vowel sounds.

    Include all the senses in learning the sounds.

    Raps and rhymes help kinesthetic students learn letter sounds more easily.

    Implement Project Read strategies (ie., salt trays, sky writing, catching words to sound out).      

    Stretch the word like a rubber band.

    Use mirrors to demonstrate mouth/tongue/teeth position.

    Jim Stone's Animated Alphabet

    Lakeshore manipulative tubs for sound sorts

     Letter collage

If a child refuses to try or fails to decode while reading
and/or lacks word attack skills . . .

    Provide time to analyze the word instead of being given the word.

    Model and use prompts that lead to developing strategies: What letter sounds do you know in the word? Are there any word parts (chunks) that you recognize in the word? Can you get your mouth ready? What else can you do? Could it be            ?

    Use assorted word attack skill games with the assistance of a paraprofessional or a peer tutor.

    Do word sorts (Words Their Way).

    Use picture books, poetry and songs that repeat a phonological element.

    Teach the student to scan for and underline known words.

    Use quality predictable text as well as decodable texts, depending upon the level and development of the child's phonological processes.

    Allow the child ample opportunities to read and reread easy books at an independent level in order to build sight word mastery and facilitate fluency.

    Use Reading Recovery's® "making and breaking "words strategy.

     See "does not self-monitor".

If a child cannot make inferences or draw conclusions . . .

    Observe the teacher modeling ways to draw inferences by thinking aloud about clues for meaning.

    Look at pictures or collections of objects, find reasonable connections among them, and create stories from them.

    Listen to a story and predict what will happen next.

    Underline word and phrase clues that lead to making an inference. (What season is it? The snow fell and the streets were icy. It was very cold outside.)

     Solve short mysteries.

     Teacher models through a think aloud lesson.

If the child has a limited or weak vocabulary . . .

    Expand experiences by watching films and listening to stories that contain new concepts and words.

    Keep a file or notebook or new words with his meanings and use some of these words in creative writing.

    Play games that use word knowledge, such as Password.

    Brainstorm with other children lists of synonyms and antonyms.

    Compare figurative and literal meanings of figurative expressions.

     Provide a rich environment with many varied, concrete experiences.

If the child is a second language learner . . .

    he/she should hear stories read frequently in small groups so that they can hear many different types of stories.

    Observe verbal and nonverbal cueing strategies (pauses, exaggerated intonation, gestures, and so on).

    Hear thought-provoking questions to promote interaction during story reading.

    Be exposed to predictable books and be encouraged to "read along."

    Hear and read well-illustrated books so that the pictures provide additional clues to meaning.

    Reread favorite stories to reinforce vocabulary, language patterns, and awareness of sequence.

    Do follow-up activities using different formats and materials.

    Use story grammars to analyze story elements.

    Write language experience stories.

    Participate in dramatizations and have direct experiences with concrete objects and activities.

    Have vicarious experiences (films, filmstrips, puppets, pictures, etc.).

    Develop functional oral language.

    Use Language Experience Method of teaching reading.

    Provide opportunities and materials for primary language reading practice for students who can read in their primary language.

    Use realia and apply lessons to real life situations

    Preteach a concept (into)

    Fill in the blanks (word substitutions).

    Use pictures first and then replace with words.

     Use technology and videos for building schema in the content areas.

     Teach students to use graphic organizers for summarizing and/or retelling.

     The Five W's Chart  is just one example that is available on this site.

If the child has difficulty with handwriting and/or fine motor skills . . .

Handwriting problems are frequently the result of neurodevelopmental dysfunctions and their associated information output and integration problems. These occur in children who have: a) fine motor-coordination problems; b) trouble expressing their thoughts on paper; and c) short attention spans with impulsivity. In my experience, I have seen many different reasons for handwriting difficulties: sensitivity to paper due to a neurological side effect of chemotherapy, and vision or eye disorders. If you believe that your student has a "handicapping condition," contact your administrator about a 504 plan for modification of work and support from the school.

The following are some suggestions that may help improve the writing abilities in children with severe problems:

    Always encourage the child while avoiding public criticism. We adults may need to change our attitudes based on a proper understanding of the reasons for the writing problem.

    Minimize or modify written work. Such an agreement may remain private (i.e., not known to the child's peers, who will frequently tease the child for problems they do not understand). You may want to assign an Alphasmart keyboard to the child or allow them to do written work on the computer in the classroom. If you have a strong feeling of "community" within the classroom, other children will understand the modification. Contact your student's parent about accepting computer generated homework as well.

    Increase time allowed for written task completion. By reducing pressure and anxiety, the child frequently responds with better written output.

    Vary priorities required during writing. On one task, emphasize organization, good ideas, and legibility, while on another, stress only the mechanics of writing (e.g., spelling, punctuation, capitalization). Many children with developmental dysfunctions can only effectively concentrate on one or two priorities at a time - they may "come unglued" when expected to handle multiple tasks they have not yet mastered.

    Stage long-term tasks. For example, a book report or research project could be broken down into units, with the child turning in a summary of each chapter, note cards, outline, etc. This will also teach study skills that will be a benefit throughout school.

    Grade to allow for success. Comments should be positive. The child who thinks he can't tends to give up.

    As soon as possible, introduce the child to typing and/or word processing. School typing should be allowed to completely replace written work, if needed in severe cases.

    If an ink pen is difficult or to messy to use, try alternative writing tools such as pencils or felt-tip pens. Graph paper for writing math problems helps with the organization and alignment.

    Allow printing if cursive writing is too cumbersome and frustrating for the child.

    Try placing a rubber pencil grip on the pen or pencil. Teacher supply stores have a wide variety of styles, colors and composition (some are softer than others). Find one that works!

    Reteach the pencil grip. Many children (and adults) have acquired an awkward pencil grip. 

Adapted from "Developmental Variation and Learning Disorders" by Melvin d. Levine, M.D.  1987. Educator's Publishing Service. Cambridge, MA.