Dyslexia (Specific Reading Disability) - Mydoctor.ca

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language-cognitiondyslexiaFigure 3. Schematic of brain activation maps in nonimpaired and dyslexic readersengaged in phonologic processing during the pseudoword rhyming test. Nonimpairedreaders activate: 1) an anterior system in the left inferior frontal region; 2) aparieto-temporal system involving the angular gyrus, supramarginal gyrus, and posteriorportions of the superior temporal gyrus; and 3) an occipito-temporal system involvingportions of the middle and inferior temporal gyrus and middle occipital gyrus. In contrast,dyslexic readers demonstrate a relative underactivation in both posterior systems and anincreased activation in the inferior frontal gyrus. Copyright © 2002, S. Shaywitz.read single words in isolation). This is measured withstandardized tests of single real word and pseudowordreading, such as the Woodcock-Johnson III and theWoodcock Reading Mastery Test. Difficulties oftenemerge on tests of spelling, which depend on these sameabilities. Reading fluency (reading connected text) isassessed by oral reading aloud, using the Gray OralReading Test. This test consists of 13 increasingly difficultpassages, each followed by five comprehension questions.Single-word reading efficiency may be assessed byusing the Test of Word Reading Efficiency (TOWRE), atest of speeded reading of individual words. For screeningby primary care physicians in the office, we recommendlistening to the child read aloud from his or herown grade level reader. Keeping a set of readers fromkindergarten through grade 4 available in the officeserves the same purpose and does not require the child tobring in schoolbooks. Oral reading is a very sensitivemeasure of reading accuracy and, even more importantly,of reading fluency.The most consistent and telling sign of a readingdisability in an accomplished young adult is slow andlaborious reading and writing. It must be emphasizedthat the failure either to recognize or to measure the lackof automaticity in reading is perhapsthe most common error in thediagnosis of dyslexia in older childrenand in accomplished youngadults. Simple word identificationtasks will not detect a person whohas dyslexia but is sufficiently accomplishedto be in honors highschool classes or to graduate fromcollege and attend law, medical, orany other graduate school. Testsrelying on the accuracy of wordidentification are inappropriate fordiagnosing dyslexia in accomplishedyoung adults because theyreveal little of the person’s strugglesto read. It is important to recognizethat because they assess readingaccuracy but not automaticity(speed), the reading tests commonlyused for school-age childrenmay provide misleading data onbright adolescents and youngadults. The most critical tests arethose that are timed, which are themost sensitive to a phonologic deficitin a bright adult. However, veryfew standardized tests for young adult readers are administeredunder timed and untimed conditions, with theexception of the Nelson-Denny Reading Test. Anyscores obtained on testing must be considered relative topeers who have the same degree of education or professionaltraining.Physical and Neurologic Examination andLaboratory TestsA general physical examination has a very limited role inthe evaluation of dyslexia. Primary sensory impairmentsshould be ruled out, particularly in young children. Inspecific instances, examination for the features of sexlinkedgenetic disorders, such as Klinefelter syndrome,that may be associated with language and reading problemsalso may be productive. Otherwise, the examinationshould be governed by any nondyslexic symptoms thatindicate specific areas of concern. Results of the routineneurologic examination usually are normal in childrenwho have dyslexia. Laboratory measures, such as imagingstudies, electroencephalography, or chromosomal analysis,are ordered only if there are specific clinical indications.At this time, functional imaging is restricted toresearch studies and is not used for clinical diagnosis.150 Pediatrics in Review Vol.24 No.5 May 2003
language-cognitiondyslexiaTreatmentThe management of dyslexia demands a lifespan perspective.Early in the child’s life, the focus is remediation ofthe reading problem. As a child matures and enters themore time-demanding setting of secondary school, theemphasis shifts to the important role of accommodations.The primary goal of effective intervention programsis to remediate the underlying problem in phonemicawareness, but all too frequently the standardinstruction provided through remediation is too little,too general, and too unsystematic. Most recently, basedon the work of the National Reading Panel, evidencebasedreading intervention programs have been identifiedthat provide instruction in the most important elementsof reading. Effective interventions used withyounger children and even with older children includeprograms to improve phonemic awareness (PA), which isthe ability to focus on and manipulate phonemes (speechIt is important to appreciate that phonologicdifficulties in dyslexia are independent ofintelligence.sounds) in spoken syllables and words. The elementsfound to be most effective in enhancing PA, reading, andspelling skills include teaching children to manipulatephonemes with letters, focusing the instruction on oneor two types of phoneme manipulations rather than onmultiple types, teaching children in small groups, andproviding systematic explicit instruction rather than incidentalinstruction. Providing instruction in PA is notsufficient to teach children to read. Effective interventionprograms encompass teaching phonics, that is, makingsure that the beginning reader understands how lettersare linked to sounds to form letter/sound correspondencesand spelling patterns. Also critical to teachingphonics is explicit and systematic instruction. Phonicsinstruction enhances children’s success in learning toread, and systematic phonics instruction is more effectivethan “whole word” instruction, which teaches little or nophonics or teaches phonics haphazardly or in a “by-theway”approach.Fluency refers to the ability to read orally with speed,accuracy, and proper expression. Fluency is criticallyimportant because it allows for the automatic, attentionfreerecognition of words, thus permitting these attentionalresources to be directed to comprehension. Althoughfluency is an important component of skilledreading, it often is neglected in the classroom. The mosteffective method to build reading fluency is guided repeatedoral reading, in which the child reads aloud repeatedlyto a teacher, an adult, or a peer and receivesfeedback. The evidence indicates that guided oral readinghas a clear and positive impact on word recognition,fluency, and comprehension at many grade levels andapplies to both good readers and those experiencingreading difficulties. The evidence is less secure for programsfor struggling readers that encourage largeamounts of independent reading, that is, silent readingwithout any feedback to the student. Thus, even thoughindependent silent reading is intuitively appealing, theevidence at this time does not support its contribution toimproved reading fluency. No doubt there is a correlationbetween being a good readerand reading large amounts, butthere is a paucity of evidence for acausal relationship. In contrast toteaching phonemic awareness,phonics, and fluency, interventionsfor reading comprehension are notwell established. In large measurethis reflects the nature of the complexprocesses influencing readingcomprehension. The limited evidenceindicates that the most effective methods to teachreading comprehension involve teaching vocabulary andteaching strategies that encourage active interaction betweenreader and text.Large-scale studies to date have focused on youngerchildren; as yet, few or no data are available on the effectof these training programs on older children. The managementof dyslexia for students in secondary school andespecially college and graduate school is primarily relatedto accommodation rather than remediation. High schooland college students who have a history of childhooddyslexia often present a paradoxic picture: they are similarto their unimpaired peers on measures of word recognition,but they continue to suffer from the phonologicdeficit that makes reading less automatic, more effortful,and slow. For readers who have dyslexia, extra time is anessential accommodation that allows them the time todecode each word and to apply their unimpaired higherordercognitive and linguistic skills to the surroundingcontext to determine the meaning of words that theycannot decode entirely or rapidly. Other helpful accommodationsinclude allowing the use of laptop computersPediatrics in Review Vol.24 No.5 May 2003 151
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