20Q: Dyslexia - Foundations and Clinical Practice

PART II: Clinical and Educational Practices 

9. Why are speech-language pathologists uniquely qualified to identify young children at risk for dyslexia?

As noted in ASHA's (2001) Ad Hoc committee paper entitled, Roles and Responsibilities of Speech-Language Pathologist with Respect to Reading and Writing in Children and Adolescents, oral language is the foundation for learning to read.  SLPs possess the knowledge needed to examine the range of spoken language skills that are foundational to later literacy and to differentiate strengths and weaknesses across these component skills of oral language (i.e., vocabulary, comprehension) and across other skills that fall under the overarching domain of phonological processing and known to predict reading ability. 

An understanding of all components of the child’s oral language abilities is essential in determining the nature of a reading ability.  Impairments in oral language put children at risk for dyslexia (Catts et al., 1999; Adolf & Hogan, 2018). One fundamental question that SLPS need to address is,  Does the child show difficulties in phonological processing and other literacy related skills such as fluent word recognition and nonword decoding in spite of typical receptive and expressive language skills (pattern common in children who have dyslexia) or does the  child exhibit difficulties with receptive and/or expressive spoken language skills in addition to difficulties with component skills of reading (pattern in children with a broader language-based reading disability).

10. What are early signs of dyslexia that place a child at risk?

There are a number of signs that young children can demonstrate that place them at risk for dyslexia. It is important to keep in mind that these signs are associated with dyslexia if they are unexpected for the individual’s age, educational level, or cognitive abilities. Because dyslexia runs in families, a family history of reading and/or spelling difficulties is a major risk factor at any age. For more information about early signs of dyslexia, please refer to the Reading Rockets website (www.readingrockets.org). Below are some other common early signs that place a child at risk for dyslexia:

Preschool years:

• Produces first words and 2-word combinations later than expected
• History of speech-sound errors
• Difficulty reciting nursery rhymes
• Difficulty learning the alphabet and numbers
• Difficulty learning the days of the week, colors, and shapes
• Difficulty recognizing the letters in his/her own name
• Difficulty telling or retelling a story in the correct sequence

Kindergarten and first grade:

• Difficulty segmenting spoken words into syllables and later into sounds (t-o-p)
• Slow to learn the connection between letters and sounds (phonics)
• Difficulty decoding simple, regular words, such as “mop”.
• Difficulty spelling simple regular words
• Trying to guess the target word on a page based on the initial letter or context of the sentence
• Complains that reading is hard or avoids reading

Beyond first grade:

• Very few sight words or words can be read automatically without decoding
• Difficulty decoding regular words
• Guesses written words based on initial letter or context of sentence
• Difficulties with reading comprehension, but not with listening comprehension
• Continues to use phonetic spellings into third grade (e.g., plate as plat or when as wen) instead of producing conventional spellings.
• Difficulty reading and spelling words with vowel teams (boat) or consonant digraphs (match)
• Transposes numbers and confuses arithmetic signs (+ - x / =)
• Writing is characterized by spelling, capitalization and punctuation errors
• Written paragraphs are not well organized, contain unexpected spelling errors and simple sentence structure
• Difficulties saying multisyllable words, such as aluminum or refrigerator.
• Shows frustration when completing reading and writing tasks and avoids reading and writing.
• Difficulties memorizing rote math facts such as the times tables

11. What kinds of assessments are included in an evaluation to diagnose a reading disability, such as dyslexia?

Reading is a language-based skill and as such, oral (listening and speaking) and written (reading and writing) language skills should be evaluated to determine the underlying cause of the reading difficulties. Examining both oral and written language skills allows for the differential diagnosis of the reading disorder. Specific oral and written language skills to measure include:

• Alphabet knowledge (for children in pre-k through first grade)
• Phonological processing (PA, PM, RAN)
• Rapid automatic naming
• Decoding and decoding fluency
• Sight word reading and sight word reading fluency
• Oral reading fluency
• Reading comprehension
• Spelling
• Sentence and paragraph writing
• Listening comprehension of various vocabulary and linguistic structures
• Oral expression

12. What does a typical profile of a student with dyslexia look like on a norm-referenced battery?

Two profiles of students who were diagnosed with dyslexia are shown below.

Case 1: PJ, an 8-year, 6-month-old female, has just completed 2nd grade. She has an IEP for a speech impaired and a diagnosis of ADHD.  She has been receiving Tier 2 reading instruction daily for over 5 months in the classroom with a reading specialist using a structured literacy approach with an emphasis on phonics instruction. PJ is not showing expected gains on regularly administered progress monitoring probes.  She has a positive family history for reading disability.

ALL: The Assessment of Literacy and Language (Lombardino, Lieberman, & Brown, 2020)
OWLS-II: Oral and Written Language Scales-II:RC/WE (Carrow-Woolfolk, 2011)

Case 2: JM, a nine-year-one-month-old male, just completed third grade and was promoted to fourth grade. He received Tier 2 reading instruction for most of third grade but made little progress. He does not have an IEP and has not been identified as having a reading disability; however, he was previously diagnosed with ADHD and is on medicine for attention difficulties. JM has a positive family history of reading difficulties.

CTOPP-2: Comprehensive Test of Phonological Processing-2 (Wagner, Torgesen, Rashotte & Pearson, 2013); TOWRE-2:  Test of Word Reading Efficiency-2  (Torgesen, Wagner, & Rashotte, 2012); GORT-5:  Gray Oral Reading Test-5 (Wiederholt & Bryant, 2012); TWS-2: Test of Written Spelling (Larsen, Hammill, & Moats, 2013); OWLS-II: Oral and Written Language Scales-II (Carrow-Woolfolk, 2011); written expression (WE); Listening Comprehension (LC); CELF-5: Clinical Evaluation of Language Fundamentals (Wiig, Semel, & Secord, 2013).

13. What are the diagnostic codes used for developmental dyslexia?

Two types of diagnostic codes are typically used to indicate a diagnosis of developmental dyslexia. The DSM-5 defines dyslexia as a specific learning disorder with impairment in reading, including word reading accuracy, reading fluency, and reading comprehension.  When writing (spelling, grammar, punctuation, and composition) is also affected, this is identified as a specific learning disorder with impairment in written expression. Because individuals with dyslexia typically have both reading and writing deficits, these diagnoses are usually combined and written as a specific learning disorder with impairment in reading and writing.

The International Classification of Diseases (ICD-10-CM) is a system of billable codes used for reimbursement. The ICD-10-CM codes for dyslexia are F81.0 (specific learning disorder with impairment in reading) and F81.1 (specific learning disorder with impairment in written expression). It is common to see both the DSM-5 and ICD-10-CM codes included in diagnostic reports.

14. What kind of reading instruction works best with children with dyslexia?

According to experts in reading and dyslexia, the most effective type of reading instruction is a Structured Literacy approach. A structured literacy approach has been found to be effective in teaching all individuals to read, not just those with dyslexia. Structured literacy is a type of reading approach that is systematic, cumulative, explicit and diagnostic in nature. It specifically addresses decoding skills and other aspects of language and reading including phoneme awareness, sound-symbol associations, syllable types, orthography, morphology, syntax, and semantics.

15. What are some common accommodations for individuals with dyslexia?

According to the International Dyslexia Association, “accommodations are adjustments made to allow a student to demonstrate knowledge, skills, and abilities without lowering learning performance or expectations and without changing what is being measured.” (pg. 1 Accommodations for Students with Dyslexia Fact Sheet). Accommodations help students participate meaningfully in grade-level instruction. Accommodations should be selected based on the student’s individual needs with input from the student, teacher, and parent. For students in elementary and secondary school, accommodations are provided for through an Individualized Education Plan (IEP) or a 504 Plan. There are four main types of accommodations: presentation, response, setting and timing/scheduling.

• Presentation accommodation refers to how information is presented to the student. They include the addition of verbal instructions, visual prompts such as highlighted text, speech-to-text software, and spell check.
• Response accommodations provide students with alternative ways to complete assignments and tests. Examples include dictating to a scribe, pointing to response choices or typing responses.
• Setting accommodations change the location in which a test or assignment is given or the conditions of the setting. Examples include individual or small group instruction and distraction-free room for testing
• Timing and scheduling accommodations change the length of time allowed for completion of a test or assignment or how it is organized, such as taking a test over several sessions or just one session and breaking down a long assignment into small chunks.

16. Is it ever too late to learn how to read?

The simple answer is no. According to Sally Shaywitz, most children and adults with dyslexia can learn to read, but it will take more effort.  With a structured literacy approach, individuals with dyslexia can become accurate readers, but they typically will remain slow readers. That is why the accommodation of extended time is so helpful to individuals with dyslexia. It is important to note that the older the individual is, the more difficult it will be to learn to read. Several studies have found that children who are poor readers at the end of first grade almost never acquire average-level reading skills by the end of elementary school (Francis, Shaywitz, Stuebing, Shaywitz, and Fletcher, 1996; Juel, 1988; Shaywitz et al., 1999; Torgesen and Burgess, 1998).

17. Is grade retention recommended for children with dyslexia?

Many schools recommend retention as a form of intervention to improve academic performance, but research indicates that it does just the opposite. The rationale for retention is that students with dyslexia just need more time to learn to read and having them repeat the grade and receive the same instruction a second time will give them the time they need to catch on. Retention in general is not recommended to improve academic performance, and it is specifically not recommended for children with dyslexia.  Study after study has found that retention not only doesn’t help students with dyslexia, but it can also be harmful.  A systematic review of studies examining the effects of retention found that most students did not make improvements during their retention year, and those that did improve, lost their gains within a few years (Jimerson, 2001). Retention also increases the chances that a child will drop out of school. Providing the student with a structured literacy approach to reading instruction as early as possible, along with class and test accommodations to support them as they increase their reading skills, has the most positive effects on a student’s academic, social, and emotional development.

18. What are some ways that parents can help their children be prepared to learn to read when they start school?

There are many things that parents can do in their everyday lives to help their children develop the skills that support reading. Because reading is a language-based skill, many of these activities have the benefit of also supporting oral language development. One of the most important activities that parents can do with their children is to read to them. It is never too early to start reading to children and parents should make reading with their children a part of their everyday routine. Shared book reading between a parent and child not only supports oral language growth, by exposing their children to new vocabulary and sentence structures, but also increases familiarity with letters, words, and how we read.  Below are additional suggestions outlined by Reading Rockets for parents of young children:

• While reading stories, name pictures in the book, ask questions, and discuss what is happening in the story
• Finger-point read (point to words as you read them out loud) to show children how printed words map to spoken words. This behavior also shows children that we read a page from top to bottom and from left to right.
• Point out printed words in the environment
• Listen to and recite nursey rhymes
• As children begin to learn the alphabet, have them point out letters on the page, in the environment, and in their name.

19. What are some resources for parents of children with dyslexia?

• Yale Center for Creativity and Dyslexia www.dyslexia.yale.edu
• Florida Center for Reading Research www.fcrr.org
• Dyslexia Help at the University of Michigan www.dyslexiahelp.umich.edu.
• Reading Rockets www.readingrockets.org
• International Dyslexia Association www.dyslexiaida.org
• Learning Disabilities Association of America www.ldaamerica.org
• National Center on Improving Literacy www.improvingliteracy.org

20. What are some current references that will help me become knowledgeable about the state-of-the-art research and educational practices in dyslexia?

• Adlof, S. M., & Hogan, T. P. (2018). Understanding dyslexia in the context of developmental language disorders. Language, Speech, and Hearing Services in Schools, 49(4), 762-773.
• Al Otaiba, S., McMaster, K., Wanzek, J., & Zaru, M. W. (2023). What we know and need to know about literacy interventions for elementary students with reading difficulties and disabilities, including dyslexia. Reading Research Quarterly, 58(2), 313-332.
• Catts, H. W., & Petscher, Y. (2018). Early identification of dyslexia. Achieving Literacy, 33.
• Clemens, N. H., & Vaughn, S. (2023). Understandings and misunderstandings about dyslexia: Introduction to the special issue. Reading Research Quarterly, 58(2), 181-187.
• Fletcher, J. M., Francis, D. J., Foorman, B. R., & Schatschneider, C. (2021). Early detection of dyslexia risk: development of brief, teacher-administered screens. Learning Disability Quarterly, 44(3), 145-157.
• Kearns, D. M., Hancock, R., Hoeft, F., Pugh, K. R., & Frost, S. J. (2019). The neurobiology of dyslexia. Teaching Exceptional Children, 51(3), 175-188.
• Krimm, H., McDaniel, J., & Schuele, C. M. (2023). Conceptions and misconceptions: what do school-based speech-language pathologists think about dyslexia? Language, Speech, and Hearing Services in Schools, 54(4), 1267-1281.
• Vaughn, S., Miciak, J., Clemens, N., & Fletcher, J. M. (2024). The critical role of instructional response in defining and identifying students with dyslexia: A case for updating existing definitions. Annals of Dyslexia, 1-12.
• Shanahan, T. (2023). A review of the evidence on tier 1 instruction for readers with dyslexia. Reading Research Quarterly, 58(2), 268-284.

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