Karen J. Rooney, Ph.D.
President, Educational Enterprises, Inc.
3108 N. Parham Road
Richmond, Virginia 23294
In 1937, Dr. Samuel Torrey Orton, a professor of Neurology and Neuropathology at Columbia University, published a book entitled Reading, Writing and Speech Problems in Children (Orton, 1937). The target audience was teachers, parents and physicians and the message stated that disorders in the acquisition of language result in academic and emotional problems in children. The book summarized Dr. Orton's ten year study of language acquisition disorders.
"Acquisition of language" refers to the "capacity to understand the spoken word and to reproduce it verbally, the capacity to understand the written word and to reproduce it,and, less commonly, the ability to understand and to reproduce gestures which may carry specific meaning" (Orton, 1937, p. 16). When this definition is compared with the National Joint Committee on Learning Disabilities' definition of learning disabilities which states that learning disabilities are "significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities," the similarities are striking. On one hand, the importance of the work of Samuel Orton in the establishment of the field of learning disabilities is obvious and, on the other hand, confusion about the use of the term dyslexia as opposed to specific learning disability was inevitable.
The use of the term "dyslexia" has seen its popularity rise and fall since the early 30's and it shares a commonality with other terms that have been coined to describe individuals with learning disabilities such as minimal brain dysfunction (mbd), specific language disability or specific learning disability. Currently, a resurgence in the use of the term has increased the confusion surrounding the terminology. Because of this confusion, the National Institutes of Health allocated funds to support research to study dyslexia and identify successful interventions to help individuals with dyslexia. The studies have accumulated research data that has identified appropriate guidelines for treatment of dyslexia as well as provide some clarification to distinguish dyslexia from other learning disabilities and attention disorders.
THE CONCEPT OF DYSLEXIA
The World Federation of Neurology defined dyslexia as "a disorder mainfested by difficulties in learning to read despite conventional instruction, adequate intelligence, and socio-economic opportunity. It is dependent upon fundamental cognitive disabilities which are frequently of constitutional origin (Critchley, 1970, p. 11)." The basic assumption underlying the concept of dyslexia is the importance of unilateral cerebral dominance (the importance of one side of the brain) as the crux of language acquisition. Thus, deviations from this dominance can result in language acquisition difficulties described as dyslexia. Individuals with dyslexia are frequently viewed as having "right brain" strengths or strong conceptual reasoning powers but weak "left brain" skills as seen in weaknesses in spelling, reading and writing.
Orton's early research studies focused on five major areas looking at language processing deficits: alexia (word blindness), auditory aphasia (word deafness), motor agraphia, motor aphasia, and laterality.
In alexia studies, damage to certain areas resulted in the inability to read and write; individuals could not recognize words and their respective meanings at an automatic level. The ability to copy (handwriting) could remain intact though production or written language was impaired. Deficits in the ability to perceive minor differences resulted in the omission of short words when reading or word endings when reading or writing. Oral spelling could be average but written spelling could be be very weak.
In the studies of auditory aphasia (word deafness), damage resulted in the inability to understand the spoken word though the skills were previously intact. These individuals had difficulty understanding speech if the sentences were longer, more complex and faster so slower presentation with simpler speech constructions made a difference in their comprehension. Some of the group could work with single words but not groups of words organized into sentences or phrases, and others could follow individual commands but not a series of commands.
Motor agraphia referred to the loss of the ability to express ideas in writing because of problems with expression or motor production (also referred to as dysgraphia). Written production was difficult to read, tremulous or labored though reading and oral spelling abilities remained strong. The motor component interfered with the expression of ideas. Motor aphasia, more well-known because of the research with stroke patients, referred to loss of speech. Individuals were able to understand speech but production was lost or strained which resulted in laborious effort when trying to communicate orally or in writing.
Laterality studies concentrated on the effects of dominance of hand, foot and eye in the development of language; however, no conclusive answer was found to the question regarding the benefits or harm accrued by trying to change dominance.
Though Orton is often seen as the founder of the movement, other researchers were describing disabilities in their practices that mirrored the data gathered by Orton. In 1917, Hinshelwood published a study on congenital word blindness. The study presented information about a number of children who had been referred to Hinshelwood (an English ophthalmologist) because they couldn't read. Hinshelwood posited that there was a region in the brain responsible for reading and damage likely had occurred in this area which then interfered with the ability to read. This view has not been supported over time but Hinshelwood did introduce the concept of "twisted symbols" (strephosymbolia) which was referred to frequently in the development of the field of learning disabilities in the 60's. Reversals of similar letters such as b and d, p and q and words such as saw and was were documented in these children and spelling was found to be even more impaired because of the recall difficulties paired with production weaknesses. Frequently, children knew the word was not spelled right but did not know how to correct the spelling. Writing of individuals with reading disability was found to be variable. Reading disabilities related to comprehension were also documented. Individuals who could recognize words and know their meanings were not able to comprehend the message of sentences, paragraphs or text.
Writing disorders (developmental agraphia) were also documented. The first type of writing disorder was observed in the ability to form the letters well but with such a laborious process that written production was impaired. The second type referred to children who had an inferior product in terms of organization, clarity and legibility.
Auditory disorders (developmental word deafness) occurred in children with normal hearing who had difficulty with understanding spoken language. Some individuals did have high frequency hearing loss that affected the processing of oral information because of weaknesses in the ability to distinguish the high-pitched sounds in certain letters such as s, f and th and short vowel sounds of a, e, i and u. The importance of auditory processing in the process of the normal language development of a young child was clear because of the dependence on oral language in the acquisition of language at that stage. Weaknesses in word distortion, vague word definitions, and omissions of word parts affected accurate word retrieval (dysnomia), vocabulary development and comprehension.
More current research by Geschwind (1962, 1982), Galaburda and Kemper (1979), and Tallal and Fitch (1993) has supported the findings of Orton.
RESEARCH ON INTERVENTION
Research on interventions to remediate the problems related to dyslexia has provided clear guidelines to implement in instruction. Problems are related to mastering phonics (the ability to sound out words fluently), to sound blending and to analyzing sounds in words. Difficulties frequently occur at the word level rather than text level and interfere with the development of accurate and fluent word reading abilities. These word identification problems may result in slower reading rates and inaccuracies that interfere with comprehension. Interventions for remediation of dyslexia must be more explicit (more direct), more intensive and more supportive (more encouragement, more feedback) than more generic reading instruction (Torgeson, 1996). Many programs designed to remediate dyslexia incorporate these principles identified by research and are generically referred to as Orton-Gillingham (OG) aprroaches.
BASIC PRINCIPLES OF ORTON-GILLINGHAM APPROACHES
The hallmark of Orton-Gillingham instruction is a highly structured, multisensory approach to instruction. Order of presentation and multi-modal techniques such as saying, seeing and feeling are important components to facilitate learning. Repetition, review and drill attempt to make skills automatic and frequently programs will continue to work with basic language skills after the traditional curriculum has moved away from these skills. Though many variations among programs exist, a commonality exists among all programs that fall under the rubric of Orton-based instruction. The instruction involves highly structured teaching methods in a carefully planned sequence of presentation, utilizes a multisensory approach to information processing followed by frequent practice/drill and then training for the extension of the learned skills. The development of phonological awareness and the extension of these phonetic skills to the reading process is a basic goal of Orton-based instruction.
Phonological awareness refers to the reader's ability to be cognizant of the phonological structures of words in language. This awareness of the pieces, patterns, and structures of language is critical to the development of automatic, fluent reading skills. Decoding (sounding out) words is a necessary skill for fluent reading. If individuals can't identify words in print, they can't comprehend their meaning even if general knowledge, intelligence and vocabulary are in the superior range. If excessive energy flows into word identification, comprehension will be diminished.
The movement among the three perceptual processes (visual, auditory and kinesthetic) is a critical feature of all OG programs. Moving from the visual to the auditory and kinesthetic in oral reading and moving from the auditory to the kinesthetic and visual in spelling/ writing are examples of these linkages. The involvement of the three sensory modalities enables the student to access learning through all available channels rather than isolate instruction to the auditory or visual or kinesthetic. The curriculum is individualized through an on-going diagnostic\prescriptive process based on an analysis of the student's performance. The student's progress determines the pace, content and plan of the instruction.
The basic patterns of language are taught directly starting from sound\symbol association of consonants and vowels and proceeding to the six predictable syllable patterns which are found in about 85% of the English language. Another category is used for special sounds that often are frequent in the language but do not follow the predictable patterns such as to, do, and were.
The instruction includes a great deal of practice in the identification of the patterns in nonsense and real words with a constant emphasis on review being incorporated into the new instruction. A student notebook is often used to organize and record instruction, be a cumulative file for the student's work and provide a review system. The skills using the predictable patterns are then extended into reading, spelling and writing.
Examples of some reading programs using Orton-Gillingham approaches are The Herman Method, Auditory Discrimination in Depth, Lindamood-Bell Learning Process, Project Read, The Slingerland Approach, The Spalding Method, and The Wilson Language Training Program. The approach is also being used in foreign language instruction for students with learning disaiblities.
DYSLEXIA AND ATTENTION DISORDERS
Estimates of comorbidity of specific learning disabilities with attention disorders have ranged from 10% (August & Holmes, 1984) to 92% (Silver,1981). Elbert (1993) has found the comorbidity to be approximately 45-55% and also found that significant underachievement was found for students identified as attention disordered, particularly the group identified as having hyperactivity. Word attack was affected by the attention problems as was comprehension. Research by Felton and Wood (1989) has shown that attentional issues must be addressed in the intervention for students with attention disorders to make optimal progress in the area of reading. Organizational strategy training in addition to remediation is particularly important for individuals with dyslexia with secondary attention problems or concomitant attention disorders (Rooney, 1990).
IMPLICATIONS FOR ASSESSMENT
Dyslexia refers to difficulties with language processing and dyslexics have trouble "with reading, spelling, understanding language that they hear, or expressing themselves clearly in speaking or writing" (Wilkins, Garside & Enfield, 1993, p.2) at a level inconsistent with their abilities and results in underachievement in school. Since the criteria put forth in the definition of dyslexia are clear, these criteria should be used as the basis for assessment and since the overlap between attention disorders and reading disability is so high, the same areas should be assessed when a student is evaluated for a possible attention deficit. An assessment of attention disorders that does not look for academic deficiencies resulting from the attentional problems as well as for concomitant learning problems such as dyslexia may not provide adequate information for thorough diagnosis or intervention.
The following components are recommended to obtain the necessary information during an assessment:
1. Structured Interview
2. Behavioral Data Across Multiple Settings and Observers (ie., Connors Scale, Achenbach Scale, Behavioral Data Organizer for Learning and Attention Problems)
3. Developmental History
4. School History
5. Self-report Measures to Assess Emotional Functioning
6. Psychoeducational Battery that includes intelligence testing and measures of phonemic awareness, phonetic processing, vocabulary, spelling, oral expression, written expression, reading, mathematics and general knowledge (ie., the appropriate level of Wechsler Intelligence Test and the Woodcock-Johnson Psycho-educational Battery, Parts I and II or the Wechsler Individual Achievement Test plus additional measures as needed).
7. Behavioral observations during testing.
8. Work samples to provide information about writing skills when longer assignments are involved. These components will provide the information for a practitioner to make appropriate diagnoses, identify comorbid conditions and plan interventions to meet the needs of the individual.
COMMON FLAWS IN ASSESSMENTS
The most common flaws which interfere with the effectiveness of the assessment process and the accuracy of the intervention planning include:
1. Lack of a comprehensive test battery: Best practice requires a comprehensive battery on a similar norming sample to provide the most accurate information possible from standardized testing.
2. Inadequate measures of achievement: Achievement measures are inadequate to provide sufficient information about learning disabilities including dyslexia or the impact of an attention disorder on the individual's achievement. A Wide Range Achievement Test III (WRATIII) may be an appropriate measure of spelling but simple word identification is not a sufficient measure of language processing. Evaluations that compare a Wechlser Intelligence Scale with WRAT III scores are not appropriate assessments of reading or language processing.
3. Lack of clarity in the presentation of results: Evaluations that do not answer the presenting questions concerning the presence of a specific learning disability, of dyslexia, and/or of attention disorders are incomplete even though results are described extensively.
4. Too great an emphasis on quantitative data: Quantitative or discrepancy analysis often is the core of the evaluation with little assessment of qualitative measures of learning/behavioral indicators of language processing disorders.
5. Lack of sufficient data: Sufficient information is not gathered to identify dyslexia as a concomitant condition once the diagnosis of attention disorder is made.
6. Vague recommendations: General recommendations such as "Jane should receive additional support in her school program," "John should receive support instruction in reading comprehension" and "Fontaine needs additional help in spelling and writing skills" do not transfer the evaluation data to the intervention. Recommendations such as "Barbara will be able to identify the following sound/symbol associations in nonsense words: consonants, short and long vowels, blends, consonant digraphs and vowel digraphs," "James will be able to identify the six common syllable patterns which include Consonant-vowel-consonant, open, closed, vowel + r, le and vowel digraph syllables in isolation, in nonsense words and in real words," and "Structured language activities such as reverse diagramming (producing sentences to match a visual representation of the organization), structured writing (filling in missing pieces in a sequence) and structured language processing activities such as cloze procedure practice are recommended to develop an understanding of the deep structures of language" will guide the intervention program based on the individual pattern of strengths and weaknesses obtained during the evaluation.
THE IDENTIFICATION PROCESS
The role of the pediatrician is very important in the identification of dyslexia, specific learning disabilities and attention disorders but the role can also be confusing because of the need for interdisciplinary collaboration when such problems are suspected. Since these problems overlap and coexist frequently, a multidisciplinary approach is considered best practice so adequate information and expertise are available to ensure thorough diagnosis, minimize overidentification and operationalize the intervention.
At the preschool level, delayed speech/language development and family history of dyslexia are early warning signs but often the question of dyslexia does not surface until school entrance or even third or fourth grade. Taking a history that includes detailed reporting of early language development, motor development and behavior is critical to the early identification of possible learning problems.
Visual and auditory evaluations should rule out any weaknesses in hearing or vision that could be causative factors. Coordination, reflexes and gross/fine motor skills should be assessed from a developmental standpoint to see if significant delays exist. If physical causative factors have been ruled out as primary causes of the child's difficulties, a referral for psycho-educational testing is appropriate.
Prior to the research results being disseminated by the National Institutes of Health, the accepted stance toward the identification of dyslexia and other learning disabilities was a "wait and see" attitude advising assessment to be delayed until the child reached the ages of 8 or 9. Current research clearly shows that indicators of some reading disorders can be identified by the age of 5 or 6 and that waiting 3 or 4 years to begin remediation does not produce the best outcomes. Instead, early assessment and remediation are recommended though official diagnosis may be delayed until the primary developmental phase has ended (8 or 9). Thus, early assessment of language,reading or learning problems is recommended so a baseline can be established and intervention initiated as early as possible.
With the older child or adolescent, a full psychoeducational battery is recommended to obtain information about the child's learning style and achievement to identify primary and concomitant problems that will need to be addressed in the intervention planning and to assist the pediatrician in implementing the plan with the family and school. In addition to behavioral and educational interventions, counseling may be recommended as a helpful adjunct to assist the family with the emotional/social concerns related to dyslexia and concomitant problems.
The pediatrician may be the first contact and serve as a "hub" for the treatment plan but the expertise of both learning specialists and psychologists are critical adjuncts to provide additional expertise and support in the diagnostic and intervention planning process. According to Dr. Sylvia Richardson (1994), the assistance of a psychologist with a background in language and education, a speech/language pathologist and a learning disabilities specialist should be available to facilitate the process with the pediatrician.
Referral sources in both the public and private sectors can provide assistance in the areas of assessment and interventIon. The most obvious source of help is the public school system for which the child is zoned. In each public school, a Child Study Committee has been established to try to assist parents and teachers in creating plans to meet the needs of students who are referred to the Committee because of special concerns identified by a parent, teacher or advocate. The Committee may develop a regular education plan or may refer for an evaluation to determine if the child is eligible for special education services within the public school system.
Eligibility for special services under the federal special education law (IDEA) requires significant underachievement indicating that the child's special needs can not be met within the regular education program. Thus, a child who is dyslexic but is not found to be significantly below grade level may not be eligible for services and requests for accommodation/intervention within the regular education program or services under Section 504 of the Rehabilitation Act should be requested.
In addition to public school systems, state supported agencies such as the Child Development Clinics or hospital-based services such as the Educational Consultant Programs provide services for families on a reduced or sliding scale basis. Families may also be referred to the Virginia Department of Education for additional information about services available through the public school system.
In the private sector, psychologists and learning specialists offer evaluation, counseling and intervention services on a fee basis. An evaluation to augment the medical examination should include ability testing, educational testing and behavioral reports/observations to be a complete assessment. When dyslexia is suspected, the evaluation should include the aforementioned components but the educational component should include measures of language development, phonemic awareness, rapid naming, phonetic processing of nonsense words, word identification, reading comprehension, spelling and written language as a core with additional measures added as needed.
Intervention/remediation in the private sector can range from private tutorial to agencies providing private instruction. The tutors/teachers should be trained in multisensory approaches (generically described as Orton-Gillingham) and tutorial sessions typically take place two to four times a week for 45-60 minutes per session.
The Richmond area also has two private schools that were established especially for students with specific language-based learning disabilities (dyslexia). The Riverside School serves younger students utilizing individual language tutorial on a daily basis and The New Community School offers a college-prepatory program for older students.
In addition to public and private services, non-profit organizations have been established as sources of information and assistance. The Virginia Branch of The Orton Dyslexia Society (1-800-988-8336) and the Learning Disabilities Association of Virginia (1-804-363-9597) both provide information, sponsor training/support programs and hold conferences on topics related to dyslexia.
Though the concepts of dyslexia, specific learning disabilities and attention disorders are very complex and confusion persists because of overlapping characteristics, research is providing guidelines and clarification which must be utilized in both assessment and intervention to make remediation meaningful. Assessment must gather sufficient information to assess primary and concomitant problems, describe the individual's pattern of strengths and weaknesses and translate the evaluative data into operational recommendations. Interventions must be organized around the presenting problems (not a label), incorporate the principles of successful intervention outlined in the research and utilize the strengths of the individual while supporting the weaknesses. For this goal to be achieved, professionals must work collaboratively to combine their areas of expertise to provide meaningful services to individuals with dyslexia and their families.
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