Dyslexia Screening Test
Review of the Dyslexia Screening Test by KAREN T. CAREY, Professor of Psychology,
California State University-Fresno, Fresno, CA:
DESCRIPTION. The Dyslexia Screening Test (DST) is designed as a screening instrument for
use with children from 6 years 6 months to 16 years 5 months of age. Based on the World
Federation of Neurology definition of 1968, dyslexia is "a disorder in children who despite
conventional classroom experience, fail to attain the language skills of reading, writing, and
spelling commensurate with their intellectual abilities" (manual, p. xi). The measure consists of
11 subtests including three Tests of Attainment (One Minute Reading, Two Minute Spelling, and
One Minute Writing); eight Diagnostic Tests (Rapid Naming, Bead Threading, Postural Stability,
Phonemic Segmentation, Backwards Digit Span, Nonsense Passage Reading, Semantic Fluency,
and Verbal Fluency); and an At-Risk Quotient. Tests of Attainment include reading, writing, and
spelling based on the definition from the World Federation of Neurology. The Diagnostic
subtests are tests that the authors believe, based on their literature review, give "positive
indicators of dyslexia" (manual, p. 3). The kit comes with an audiocassette tape for
administering the Backwards Digit Span subtest and scoring keys. The test can be used by
teachers and other school personnel and was normed in England on 1,000 children. It takes
approximately 30 minutes to administer. In addition, the authors provide a list and brief
description of programs available to assist children with dyslexia. This includes specific
remedial academic program packages, books, information on associations, and journal references
on dyslexia.
DEVELOPMENT. The authors' goal in developing the test was to "construct a quick, simple
enjoyable test that could be used by school professionals and provided a simple 'at risk' index for
dyslexia" (manual, p. 3). The United Kingdom Education Act of 1993 led to substantial changes
in the country for meeting the needs of special education students and the tool was developed to
be used as an objective measure to identify special needs children and assist in the development
of intervention plans for such children. According to the authors, the tool was developed after
several years of research and testing, although the specifics are not discussed in the manual.
The test format was selected and then norms were established for each of the subtests so that a
child's performance on the test could be compared to what would be expected of a child of the
same age. Each of the 11 subtests was developed in different ways based on a review of the
literature. For example, the Phonemic Segmentation test was developed from the work of Rosner
and Simon (1971) and Nonsense Passage Reading was selected and modified from work by
Finucci, Guthrie, Childs, Abbey, and Childs (1976). One subtest, Postural Stability, was
developed from work by Nicolson, Fawcett, and Dean (1995). The authors of the DST state that
"dyslexic children show difficulties consistent with slight abnormalities in the cerebellum.... This
test is based on clinical procedures for establishing cerebellar abnormalities" (manual, p. 46). A
"balance tester" is included in the materials, which is a plastic device with a collar that slides
back and forth. The examiner stands behind the child and holds the balance tester on the two
vertebrae above the small of the child's back. This procedure seems quite dangerous as the
examiner could potentially hurt the child.
Individual subtests were developed in this manner and pilot studies were conducted to ensure
that children "enjoyed doing it" (manual, p. 9) and teachers were able to use the tool reliably.
Several preliminary subtests were eliminated and others were modified due to poor reliabilities.
The tests are the same for all age groups with four exceptions. The Nonsense Passage Reading,
One Minute Writing Tests, the One Minute Reading, and the Two Minute Spelling Tests were
modified for age differences, making the tests appropriate for children of different ages.
TECHNICAL. Children from selected schools in Sheffield, London, and Wales participated in
the norming sample with at least 100 children at ages 6 years 6 months to 7 years 5 months, 7
years 6 months to 8 years 5 months, and then every 2 years (e.g., 8 years 6 months to 10 years 5
months). Norms were derived for each subtest for each age resulting in every score assigned a
percentile point on average performance. The scores for each age group were ranked resulting in
percentile ranks for each test. The actual percentile ranks used for scoring were developed
through interpolation and smoothing for each age group.
The percentile scores are collapsed into five categories: very highly at risk, which the authors
refer to as triple minus (---) (percentile ranks 1-4); highly at risk, double minus (--) (percentile
ranks 5-11); at risk, single minus (-) (percentile ranks 12-22); normal performance, no minus (0)
(percentile ranks from 23-77); and well above average performance, a + (percentile ranks 78100). To obtain the At-Risk Quotient (ARQ), the mean of the at-risk scores (triple minus, double
minus, single minus, and 0) was weighted; those individuals scoring not at-risk were not
included. An ARQ of 1.0 or greater is considered "at-risk."
Construct validity was investigated through the administration of the DST to 17 children who
had been diagnosed as dyslexic on other scales. Fifteen of the students ranging in age from 10 to
15 years had an ARQ of 1 or higher. Unfortunately, the sample for these studies is very small
and must be interpreted with caution.
Test-retest reliability was estimated from 34 children, ages 6 years 6 months to 12 years, who
were retested about 1 week apart. No information related to the ages of these children or whether
they were at-risk is included in the manual. The correlations range from .72 to .99 on the
subtests. A test-retest correlation for two forms of the One Minute Reading Test was .959.
Interrater agreement for the postural stability subtest, which requires some judgment on the part
of the examiner, was .98.
COMMENTARY. The DST needs to be further researched before it is widely used. The test has
not been adequately evaluated for technical requirements including reliability and validity. In
addition, the sample is limited to children in the United Kingdom, and as it has not been used in
the United States or other countries, the norms must remain in question for use in countries other
than the U.K. As the norms are limited and with the use of interpolation and smoothing of the
norms to the degree done in this instrument, the DST does not appear appropriate for making
individual decisions regarding students' with academic difficulties. Reliability and validity were
not adequately assessed, resulting in questions regarding the consistency and accuracy of the
tool.
In general, the academic subtests including Rapid Naming, One Minute Reading, Phonemic
Segmentation, Two Minute Spelling, Nonsense Passage Reading, One Minute Writing, and
Verbal and Semantic Fluency selected for inclusion in the test seem appropriate for this type of
assessment. However, although the authors attempt to make cases for including Bead Memory,
Postural Stability, and Backwards Digit Span, there is not enough evidence for including such
subtests on a scale assessing dyslexia. In addition, the Postural Stability has the potential for
harming children and would not be recommended for use in many school districts in the United
States.
The scaling is difficult to understand with the minuses and plus and the development of these
procedures. The resulting categories identified from the minuses and plus of highly at risk to well
above average are not defined and the specifics of how the categories discriminate from one
another are not explained. In addition, the authors do not address the potential problem for errors
of measurement in their categorizations. In the final section of the manual, prior to the
descriptions of the subtests, the authors do provide some information for users related to
developing interventions for children identified as dyslexic. However, the material provided is
simply a list of possible packages and readings for the examiner. Specific interventions for each
subtest would be far more beneficial.
SUMMARY. The DST needs further evidence of technical adequacy before it can be used on a
large scale basis. No information other than the ages of the norming sample are provided so it is
unknown whether or not the test would be appropriate for boys and girls, children of different
ethnic backgrounds, and children in different social economic classes. The reliability and validity
evidence for the test is insufficient for individual decision making and although the authors state
the test can be used to help develop interventions, it is unclear how this can be done. Overall, it
appears more useful information could be obtained from conducting a thorough observation in
the student's classroom.
REVIEWER'S REFERENCES
Finucci, J. M., Guthrie, J. T., Childs, A. L., Abbey, H., & Childs, B. (1976). The genetics of
specific reading disability. Annals of Human Genetics, 40, 1-23.
Nicolson, R. I., Fawcett, A. J., & Dean, P. (1995). Time estimation deficits in developmental
dyslexia: Evidence for cerebellar involvement. Proceedings of the Royal Society: Biological
Sciences, 259, 43-47.
Rosner, J., & Simon, D. P. (1971). The auditory analysis test: An initial report. Journal of
Learning Disabilities, 4, 384-392.
Review of the Dyslexia Screening Test by JAMES E. YSSELDYKE, Associate Dean for
Research, College of Education and Human Development, University of Minnesota-Twin Cities,
Minneapolis, MN:
DESCRIPTION. The Dyslexia Screening Test (DST) is an individually administered, normreferenced test designed to provide an "at risk" dyslexia index for children ranging in age from
6-6 to 16-5. The DST was created to be a dyslexia screening instrument that could be
administered by school professionals other than educational or clinical psychologists. The
authors explain that the test can also be used (a) to derive a profile of a child's strengths and
weaknesses in order to guide in-school supports, (b) as a basis from which to request formal
assessment, and (c) to provide educational psychologists with an instrument that provides a valid
index of dyslexia, thereby establishing a foundation for further assessment.
The DST test battery takes about 30 minutes to administer and includes 11 subtests: 3
Attainment tests and 8 Diagnostic tests. The purpose of the Attainment tests is to assess those
areas in which dyslexic children typically demonstrate difficulties: Reading, Writing, and
Spelling. The Diagnostic tests are designed to assess skills that the authors believe are affected
by dyslexia, thereby providing a profile of a child's difficulties that is intended to inform (a) the
causes of attainment difficulties, and (b) the skills that need to be targeted for intervention.
Raw scores for each individual subtest are converted into age-appropriate "at-risk index" scores,
which are derived from the norm sample. Five "at-risk index" scores are possible for each
subtest: triple minus (--- ; bottom 4%), double minus (-- ; bottom 5-11%), minus (- ; bottom 1222%), zero (0 ; midrange, 23-77%), and plus (+ ; top 22%). The "at-risk quotient" (ARQ) is
found by adding the individual subtest indices (triple minus = 3; double minus = 2; minus = 1;
zero and plus = 0) and dividing that sum by 10. Although there are 11 subtests, Semantic
Fluency is not included in this division because this is a supposed strength of dyslexic children.
If the ARQ is 1 or greater, a child is considered "at-risk" for dyslexia.
DEVELOPMENT. Although the authors claim that test development "entailed a lengthy series of
studies" (manual, p. 9), the manual provides little detail of the item development process. After
reviewing the dyslexia literature, the authors originally developed 14 possible tests to be
included in the DST. Through a series of studies, the authors established norms for performance
on each test while also examining reliability, consistency of implementation, and student
enjoyment of tasks. Following these studies, three tests were removed due to problems with
reliability and/or test equipment, and other tests were modified to improve reliability and ease of
use.
Attainment tests. The DST was developed under the assumption that dyslexic children typically
demonstrate difficulties in reading, writing, and spelling, so the three attainment tests included in
the DST specifically assess these areas. A description and the rationale or origin of each
attainment test is included below.
One Minute Reading-This test measures how many words a child can read correctly from a onepage list in 60 seconds. The authors felt that a measure that assessed both accuracy and speed
would more accurately estimate a child's reading skills than a measure that assessed only
accuracy. It is based on the Dutch EMT test (Brus & Voeten, 1980, as cited in DST manual, p.
31).
Two Minute Spelling-During this test of spelling fluency, a child has 2 minutes to spell each
word that the tester reads. (The tester reads the next word as soon as the child has completed the
previous word.)
One Minute Writing-During this test, a child must copy text as quickly and accurately as possible
in the 1-minute time limit. The authors describe this task as an indication of "pure" writing
speed. One reason this test is included is to provide documented evidence for "slowness of
writing" (manual, p. 32) so that children can apply to examination boards for extra time in taking
tests.
Diagnostic tests. Because reading, writing, and spelling are all learned skills that can be at least
partially alleviated through extensive instruction, the authors additionally included diagnostic
tests to assess other difficulties typically associated with dyslexia (i.e., phonological skill,
fluency, working memory, and balance). A description and the rationale or origin of each
diagnostic test is included below.
Rapid Naming-This test measures the amount of time it takes a child to name a series of familiar
outline drawings (e.g., hat, ball). This test is based on the "Rapid Automatised Naming" test
introduced by Martha Denckla in the 1970s. In explaining the inclusion of this activity, the
authors claim there is evidence that dyslexic children are typically slower than normal when
asked to name a series of pictures.
Bead Threading-This test measures how many beads a child can thread in 30 seconds. The
authors explain that this activity is included because evidence suggests dyslexic children have
difficulties in fine motor skill activities that involve hand-eye coordination.
Postural Stability-This test measures how well a child can balance following a slight push in the
back. It is a clinical test of cerebellar abnormality and is included presumably because the
authors have found evidence for cerebellar abnormality in dyslexia. Moreover, the authors claim
this task successfully distinguishes between dyslexic children and nondyslexic poor readers (i.e.,
Unlike nondyslexic poor readers, dyslexic children face difficulties in balance).
Phonemic Segmentation-This test measures a child's ability to break down a word into its
component sounds and then manipulate those sounds (e.g., say "grandma" without the "ma"). It
is included because phonological difficulties are one of the most clearly established difficulties
in dyslexia. The test is based on earlier measures developed by Jerome Rosner.
Backwards Digit Span-This test measures a child's ability to repeat a sequence of numbers in the
opposite order in which they were verbally presented. It is a common measure of working
memory found on many IQ tests. Dyslexic children typically perform poorly on this task.
Nonsense Passage Reading-This test assesses a child's ability to read a passage that is
interspersed with nonsense words. This test is included based on evidence that dyslexic children
continue to have difficulty with unfamiliar words even after they improve their scores on
standard tests of reading.
Verbal Fluency and Semantic Fluency-In the Verbal Fluency test, children have 1 minute to
name as many words as they can that begin with a specific letter (e.g., G-good, grape, golf, etc.).
In the Semantic Fluency test, children have 1 minute to name as many animals as they can.
These tasks are included based on work by Frith and colleagues that suggests dyslexic children
do well on tasks of semantic fluency but do poorly on tasks of verbal fluency.
In order to justify the inclusion of these diagnostic tests, the authors reference a study they
conducted in which they distinguished dyslexic and nondyslexic children on the basis of an index
that combined "indications of difficulties in phonological skills, balance and speed of
processing" (manual, p. 4). Few details of this study are presented, making it difficult to examine
the validity of the claim.
TECHNICAL. Information about the norm sample is vague. The authors explain that through a
series of studies, "norms were derived for each test for each age" (manual, p. 9). The details
included in the manual indicate that the DST was standardized on whole classes of children who
attended school in Sheffield, London, and Wales. For the first 2 years (i.e., 6-6 to 7-5, and 7-6 to
8-5), at least 100 children represent each age group. At later ages, this number is spread over 2year increments. No information is presented about procedures for ensuring the sample was
representative of the population of children in the U.K., and no data are presented about how
well the norm sample matches this population.
The authors present evidence for test-retest, interform, and interrater reliability, and argue that
measures of internal consistency (another commonly reported reliability) are inappropriate for
this test. For test-retest reliability, the authors report on a study in which 34 children aged 6-6 to
12 years were administered the test on two separate occasions (there was about 1 week between
administrations). The majority of the test-retest reliabilities for each subtest exceed .80, with
three subtests having reliabilities between .70 and .80 (i.e., Bead Threading, Postural Stability,
and Semantic Fluency). The interform reliability for the One Minute Reading Test was found to
be .96 in a study with 22 children. Postural stability was the only subtest for which interrater
reliability was measured. It was measured by showing videotapes of 14 children participating in
this test, and having three experimenters independently rate the task. Reliabilities ranged from
.94-.98.
Evidence for validity is limited. The authors highlight the face validity of the DST by reiterating
that reading, writing, and spelling are three areas in which dyslexic children typically struggle,
and a poor performance in at least one of those areas is a prerequisite for a diagnosis of dyslexia.
Moreover, they claim that evidence has shown that dyslexic children face difficulties with the
remaining tests (except Semantic Fluency) as well. However, the reader is expected to take them
at their word as no detailed evidence of these links is provided in the manual. The authors do
reference a limited number of articles that might provide evidence regarding the inclusion of
certain subtests. The only evidence for construct validity that is presented comes from a study in
which DST was administered to 17 children ranging in age from 10-6 to 15-7 who had
previously been diagnosed with dyslexia, and 20 children who showed no sign of dyslexia. All
but 2 of the children diagnosed with dyslexia were identified as at-risk by their scores on the
DST, whereas none of the children who showed no signs of dyslexia were identified as at-risk on
the DST. Yet, no details are provided about the measures used initially to identify children as
dyslexic. Moreover, no children below the age of 10-6 were included in the sample even though
the test is supposedly valid for children as young as 6-6.
COMMENTARY. This is a strange mix of subtests that are to give the educator information that
is predictive and diagnostic. The authors do not provide evidence of the validity of the test for
the purposes they identify (see introductory paragraph). Those who use this test in a normative
manner are comparing students to an unspecified population in the U.K.
SUMMARY. The DST is intended as a screener for dyslexia, a nebulous condition. It consists of
a mixture of subtests that assess reading, writing, and spelling attainment, and measures of areas
thought to be affected by dyslexia. The norm sample is vague, scores are reliable, yet evidence
for validity is very limited.
Dyslexia
Dyslexia
What you need to know
Dr Handler is a pediatric
ophthalmologist in
private practice in Encino,
California. She is one of the
authors of the American
Academy of Pediatrics,
American Academy of
Ophthalmology, American
Association for Pediatric
Ophthalmology and
Strabismus, and American
Association of Certified
Orthoptists 2011 Joint
Technical Report, Learning
Disabilities, Dyslexia, and
Vision. She has nothing
to disclose in regard
to affiliations w ith or
financial interests in any
organizations that may
have an interest in any part
of this article.
18
By being vigilant to signs of dyslexia, dispelling the myths,
and coordinating care, pediatricians can help children
w ith dyslexia enjoy success in school and in daily life.
SHERYL M HANDLER, MD
Learning to read is an extremely complex pro
cess, which has been described to be as chal
lenging as learning rocket science.1Therefore,
it is not too surprising that, for many reasons,
over 60% of children in America fail to meet
standards for reading proficiency.2
M u ltip le issues m ay u n d e rlie th is
reading difficulty, including poor early
language development, inadequate instruc
tion, insufficient reading practice, lack of
background knowledge, and intellectual
disability. In some children, however, the
problem is the specific learning disability
called dyslexia.
Dyslexia is by far the m ost com m on
learning disability and is present in some
degree in up to 20% of c h ild ren .3 Just
as early detection and intervention are
crucial in m edical diseases, the same is
tru e in learning disabilities. The conse
quences of untreated dyslexia are broad
and can be significant, including effects on
academic success and psychosocial well
being. Children with dyslexia experience
intense frustration; may act aggressively
CONTEMPORARYPEDIATRICS.COM
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A UGUS T 2016
or withdraw; frequently become targets of
bullying and ridicule; have low self-esteem;
and may even develop mental health prob
lems, including anxiety and depression.
Pediatricians have the opportunity and
responsibility to enable detection and proper
treatment of dyslexia in children. This article
aims to provide information and strategies
that will allow clinicians to best assist and
advise patients and their parents.
Dyslexia defined
Dyslexia is a language-based learning dis
ability characterized by difficulties with
d e c o d in g (so u n d in g out) w o rd s, flu
ent w ord reco g n itio n , a n d /o r readingcomprehension skills. Children with dys
lexia often develop secondary problem s
with comprehension, spelling, writing, and
knowledge acquisition.
The difficulties found in dyslexia are
usually caused by a phonological deficit
(an auditory processing problem involving
hearing the sounds in speech). The pho
nological deficit leads to difficulty con
necting speech sounds to letters, which is
a skill needed to decode the written word.
peer-reviewed
1
tends to be identified earlier and
more often in boys, perhaps because
boys tend to “act out” when they are
unable to do a difficult task versus
girls who are inclined to make them
selves “invisible” in the classroom.
RISK FACTORS AND SIGNS OF DYSLEXIA
RISK FACTORS
o Family history
POSSIBLE SIGNS
o Prematurity or birth problems
° Language or speech problems,
including articulation
o Fetal exposure to drugs or alcohol
o Difficulty with rhymes
o Hearing, language, or speech
problems, including articulation
° Difficulty learning the names of letters
o Developmental delay
o Trouble connecting letters to
their sounds
o ADHD or other neurological problems
O Difficulty sounding out words
o Other chronic health problems that
may have caused school absences
o Difficulty with sight word recognition
o Slow reading
o Poor spelling
Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
Alternatively, dyslexia in some chil
dren results from problems with oral
language skills, sight word recogni
tion, processing speed, comprehen
sion, attention, or verbal working
memory.
Anatomical and imaging stud
ies investigating brain development
and function show a corresponding
physical basis for dyslexia in
language-related areas of
the brain. The brains
of persons with dys
lexia function differ
ently than the brains
of “typical readers”
before they even start
to read, as dyslexics use
an alternative pathway
for reading. Specifically, these
investigations reveal that persons
with dyslexia have dysfunction in
the left-hemisphere posterior reading
areas with corresponding compensa
tory use of the bilateral inferior fron
tal gyri of both hemispheres and the
right occipitotemporal area.3
In discussing the definition of
dyslexia and its causes, it is also use
ful for pediatricians to be aware of
the many myths and mispercep
tions that exist. Dyslexia is not a
condition where readers see letters
or words upside down or back
ward. It is not related to visual or
eye-tracking problems.4 In addition,
dyslexia is not a developmental issue
that children may be expected to
outgrow; rather, it is a persistent
lifelong condition.
Dyslexia also is not
related to intelligence
or laziness in a child.
Dyslexia occurs in
persons with low, nor
mal, and high intel
ligence quotients (IQs)
alike. The fact that dys
lexia is not related to IQ,
however, creates the potential
for a significant learning disability to
be overlooked in an otherwise bright
child. Dyslexics are often perceived
to be “lazy” or “not working up to
their potential” when, in fact, they
often work harder and longer than
their peers.
In addition, there is no male pre
dominance for dyslexia. It is found
almost equally in boys and girls, but
AUGUST
2016
I
D e te c tio n a n d
d ia g n o s is
A diagnosis of dyslexia is established
clinically based on history, observa
tion, and a battery of age-appropriate
educational tests interpreted by a
knowledgeable, qualified profes
sional. Although it is not up to pedi
atricians to make the diagnosis, an
understanding of dyslexia can help
to identify children by being attentive
to risk factors and signs that are elic
ited in the medical and social history
during well-child exams (Table 1).
Dyslexia is heritable and familial,
and so the history should ascertain
whether there is a family history of
speech and language problems or
dyslexia. Other risk factors for dys
lexia include prematurity, neurolog
ical problems, and developmental or
language delays.
Early warning signs for dyslexia
in preschool-aged children include
trouble learning nursery rhymes
or playing rhyming games; confus
ing words that sound alike; mis
pronouncing words; and trouble
recognizing letters of the alphabet.5
Early elementary school children
with dyslexia often have difficulty
learning the names and sounds of
the letters; separating and blending
sounds; sounding out words; rec
ognizing sight words; and spelling.
They often read slowly and dislike
reading. A parent’s complaint that
a child is not doing well in school
should prompt questions to explore
the presence of reading difficulties.
CONTEMPORARYPEDIATRICS.COM
19
peer-reviewed
Although many dyslexic students
are identified in the prim ary grades,
dyslexia’s possible presence should
not be overlooked in older children
and teenagers. Signs in adolescents
include a history of phonologically
based reading difficulties, slow read
ing, choppiness when reading aloud,
poor com prehension, and requir
ing more time to finish assignments
or tests.5 These adolescent students
also may have multiple school tru an
cies and/or behavioral issues, such
as anger, aggression, depression, or
even suicidal tendencies and possibly
alcohol or drug use.
If a family history of dyslexia or
other risk factors exists, the child’s
early language developm ent and
school progress should be carefully
monitored. A formal psychoeducational school evaluation is needed
to identify dyslexia and will p ro
vide an understanding of the child’s
s tre n g th s a n d w eak n esses, th e
severity of the problem, and whether
the child has a “specific learning
disability” that is eligible for special
education and support program s.
Severe dyslexia ty p ic a lly q u a li
fies a child for an Individualized
Educational Plan, special education,
and related services. The psychoeducational or broader neuropsycho
logical or developmental-behavioral
pediatric evaluation will identify
comorbid conditions, and the find
ings will provide the foundation for
a treatm ent plan.
Fortunately, individuals who have
severe dyslexia are in the minority.
The other side of the coin, however,
is that those students whose disorder
is more moderate or mild may not be
readily recognized and/or may not
qualify for treatment, although they
would benefit from those services.
20
T
STRATEGIES
FOR TREAT NG
DYSLEX
Explicitly teach reading skills
o Phonemic awareness
o Intensive systematic phonics
o Morphology— analysis of words
and word parts
o Memorization of sight words
o Fluency training— guided oral
reading
o Vocabulary building
o Comprehension techniques
Spelling— including the rules
Writing
Treating dyslexia
The prognosis for a child with dys
lexia depends not only on the spe
cific features of the disorder and its
severity, but also on the timeliness
and appropriateness of intervention
(Table 2). Studies show that begin
ning remediation in first grade versus
waiting 2 more years greatly increases
the chance that a child will later be
able to read at grade level.6 Neverthe
less, it is never too late to help.
Effective intervention for dyslexia
targets its etiology as a languagebased disorder and should be pro
vided by a professional w ith the
appropriate training. Children with
dyslexia are best served w ith les
sons provided in small group set
tings, which bring together students
who are at the same reading level
and include no m ore th an 5 stu
dents. Remediation program s that
follow the International Dyslexia
A ssociation guidelines call for a
“S tru ctu red Literacy A pproach.”
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AUGUS T 2016
These program s explain language
in an explicit, systematic, sequen
tial, an d m u ltise n so ry m anner.
They include training in the 5 read
ing skills: 1) phonem ic awareness
(h earin g th e so u n d s in words);
2) phonics (correlating sounds with
letters); 3) fluency (ability to read
w ith speed, accuracy and expres
sion); 4) vocabulary; and 5) compre
hension. Emphasis is also placed on
learning word structure, letter pat
terns, spelling, and writing.
W hereas early m anagem ent of
dyslexia focuses on remediation of
the reading problem, for older stu
dents there is a shift toward p ro
viding tools and accommodations.
Accommodations allow the student
to access his/her higher-level think
ing and reaso n in g skills. These
measures include access to assistive
technology (eg, recorded books, text
reading software, note takers, spell
checkers) as well as provisions to
enable test taking (eg, extended test
ing time, a special quiet room, or
preferential seating).
Pediatrician's role
Parents of children w ith dyslexia
often seek counsel from their pedia
trician about dyslexia treatments, so
clinicians should be aware of both
the proven and unproven interven
tions being recommended and heav
ily prom oted. By being inform ed
about the v ariety o f approaches,
as well as being able to discuss the
lack of evidence supporting the effi
cacy for th e unp ro v en in te rv e n
tions, pediatricians will be equipped
to educate patients and their fam
ilies, encourage positive proven
approaches, discourage the use of
unproven techniques, and thus pre
vent families from wasting valuable
peer-reviewed
time and resources pursuing expen
sive, nonproductive therapies.
Non-evidence-based approaches
promoted for remediation of read
ing difficulties in children with
dyslexia include medication for ves
tibular dysfunction, chiropractic
manipulation, physical exercises,
and dietary supplem entation or
restrictions.5 In particular, however,
the erroneous concept that dys
lexia is a vision-based disorder has
spawned a variety of interventions
with nearsightedness may have diffi
culty seeing the board. Symptomatic
convergence insufficiency, which
occurs more rarely in elementary
school-aged children, makes reading
at near blurry and uncomfortable.
Consequently, affected children may
read only for short periods of time,
and on that basis may be thought to
have dyslexia or attention-deficit/
hyperactivity disorder (ADHD),
especially the inattentive type.
Pediatric ophthalmologists play
Pediatric ophthalmologists play a role in
the assessment of children with suspected
learning disabilities, including dyslexia.
involving the use of training glasses,
eye exercises, behavioral/perceptual
vision therapy, and colored lenses
and overlays. Although visual prob
lems, including convergence insuf
ficiency, can hamper reading, they
are not the cause of dyslexia. Vision
problems are not more common
in children with reading im pair
ment.4 Not only are vision-related
approaches misdirected in theory,
but authors of systematic literature
reviews have concluded there is no
scientific evidence of their efficacy
for learning disabilities.3,7'9
Eye and vision problems occur
in approximately 5% to 10% of early
elementary students and 25% of high
school students, and pediatricians
should recognize that some treat
able vision problems can masquer
ade as a learning problem or may
be coexisting. For example, children
with large amounts of farsighted
ness or astigmatism may be unin
terested in books whereas children
22
a valuable role in the assessment of
children with suspected or estab
lished learning disabilities, including
dyslexia, to determine whether there
are any eye or vision problems that
could be interfering with learning
or reading. As part of the manage
ment team for children with dys
lexia, pediatric ophthalmologists can
help families by reinforcing informa
tion on the condition, dispelling the
myths, and providing guidance to
resources available online, in print,
and in the community.
Referral for an ophthalmologic
evaluation is ind icated when a vision
problem is suspected or the child
fails vision screening. The pediat
ric ophthalmologist will perform
a complete dilated eye and vision
examination, thoroughly evaluate
near vision, and perform a cycloplegic refraction. Most ocular condi
tions found in children, including
strabism us, am blyopia, conver
gence or focusing deficiencies, and
CONTEM PORARYPEDIATRICS.COM
|
AUGUST
2016
refractive errors, are treatable with
glasses and will improve quickly.
Children diagnosed with symptom
atic convergence insufficiency are
usually prescribed convergence eye
exercises to be performed at home.
These exercises usually result in
improved reading comfort within
a few weeks. In-office exercises with
at-home reinforcement are consid
ered if a child continues to show
signs and symptoms of convergence
insufficiency.
It is crucial to understand that
although these exercises may relieve
eye strain, they are not a treatment
for coexisting dyslexia. Furthermore,
pediatricians should know that con
vergence insufficiency is frequently
overdiagnosed. Any child who has
been diagnosed with convergence
insufficiency should be referred to
a pediatric ophthalmologist for a
second opinion as should any child
who has been recommended vision
therapy or tinted lenses or filters as
treatment for a reading disability.
Caring for other
conditions
The pediatric evaluation of a child
presenting with reading difficul
ties or dyslexia should also include
assessments for other potentially
contributing, m asquerading, or
coexisting conditions. In addition
to vision screening, these investiga
tions should include hearing screen
ing and evaluations for behavioral,
medical, and mental health disor
ders. Notably, ADHD and reading
disability are highly comorbid. The
inattentive type of ADHD has been
found in 18% to 42% of children
with dyslexia, and rates of dyslexia
among children with ADHD have
been reported to be within a similar
peer-reviewed
range.10 Dyslexia also may be asso
ciated with oppositional defiant
disorder, obsessive-compulsive dis
order, anxiety, and depression.
Counselling and
advocacy
t
ONLINE RESOURCES FOR
INFORMATION ON DYSLEXIA
International Dyslexia Association
www.eida.org
Learning Disabilities (LD) OnLine
www.ldonline.org
Some p ed iatrician s can help to
National Center for Learning Disabilities
advocate for the child as needed,
for example, by writing a letter to
Reading Rockets
request an evaluation or accom
Yale Center for Dyslexia and Creativity
modations. To ensure that children
University of Michigan— Dyslexia Help
get appropriate care, pediatricians
should be prepared to provide fam
ilies with names of professionals in
available educational materials and/
their area who are qualified to evalu
or lists of resources where families
ate and treat children with dyslexia.
can get information about dyslexia,
Children who have not been making
its evaluation and treatment, and
progress after a prior psychoeducatheir child’s rights for evaluation,
tional evaluation and interventions
special services, and accommoda
could benefit from referral for fur
tions as defined by the Individuals
ther evaluation by a developmentalwith Disabilities Education Act
behavioral pediatrician or neuro
(IDEA), and Section 504 of the
psychologist. Although private eval
Americans W ith Disabilities Act
uation of a child with suspected
(ADA). Table 3 lists several useful
dyslexia may be expensive, a proper
websites for more information.
diagnosis may save m any years
Finally, the role of the pediatri
of frustration and failed educa
cian in helping children to become
tion, as well as thousands
proficient readers begins
of dollars on unneces
early in the providersary and unsupported
fam ily relationship,
FAST FACT
treatments.
Attention-deficit/
long before consid
hyperactivity
Pediatricians
ering whether chil
disorder and reading
should be sym pa
dren are at risk for
disability are highly
thetic to the stress
or
showing signs of
comorbid.
that a child with dys
dyslexia. Recognizing
lexia and his or her fam
that oral language is the
ily are experiencing and
foundation for reading and
should provide encouragement and
that children with speech and lan
em otional support. In addition,
guage delay or difficulties have a
while counselling parents to support
50% likelihood of having difficul
their child’s efforts at reading, pedi
ties learning to read, pediatricians
atricians should also advise them to
can have an im portant impact by
pursue their child’s strengths and
promoting early language develop
allow time for activities in which the
ment. The Books Build Connections
child finds enjoyment and excels.
Toolkit, developed by the American
Pediatricians also should have
Academy of Pediatrics and Reach
AUGUST
2016
I
www.ncld.org
www.readingrockets.org
www.dyslexia.yale.edu
http://dyslexiahelp.umich.edu
Out and Read, contains material for
pediatricians and parents and offers
a practical resource to assist in these
efforts.11
Conclusion
Dyslexia is a common and lifelong
language-based learning disabil
ity that may be detected as early as
kindergarten or first grade. Affected
children are most likely to obtain
the greatest benefit when the prob
lem is identified early followed
by prompt initiation of appropri
ate language and reading instruc
tion. Care should be taken to avoid
using ineffective methods of treat
ment that waste time and family
resources and often critically delay
proper remediation.
By being vigilant to signs of
dyslexia, dispelling the myths sur
rounding this condition, helping
to coordinate care, and providing
support and encouragement, pedia
tricians with the aid of pediatric
ophthalmologists can help children
with dyslexia enjoy success in school
and in their daily life. ■
For references, go to
ContemporaryPediatrics.com/
dyslexia
O
CONTEMPORARYPEDIATRICS.COM
23
Copyright of Contemporary Pediatrics is the property of Advanstar Communications Inc. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.
59
OCTOBER 15, 2017 :: Ophthalmology Times
clinical diagnosis
Pediatric ophthalmology role vital
in detection, treatment of dyslexia
Involvement key in determining if vision problems may be interfering with learning, reading
By Sheryl M. Handler, MD
LEARNING TO READ is an extremely
complex process that has been described to
be as challenging as learning rocket science.1
Therefore, it is not too surprising that, for many
reasons, more than 60% of children in America
fail to meet standards for reading proficiency.2
Multiple issues may underlie this reading
difficulty, including poor early language development, inadequate instruction, insufficient
reading practice, lack of background knowledge,
and intellectual disability. In some children,
however, the problem is the specific learning
disability called dyslexia.
Dyslexia is by far the most common learning disability and is present in some degree in
up to 20% of children.3 Just as early detection
and intervention are crucial in medical diseases, the same is true in learning disabilities.
The consequences of untreated dyslexia are
broad and can be significant, including effects
on academic success and psychosocial well
being. Children with dyslexia experience intense frustration; may act aggressively or withdraw; frequently become targets of bullying
and ridicule; have low self-esteem; and may
even develop mental health problems, including anxiety and depression.
Physicians—including pediatricians with
the aid of pediatric ophthalmologists—have
the opportunity and responsibility to enable
detection and proper treatment of dyslexia in
children. This article aims to provide information and strategies that will allow clinicians to best assist and advise patients and
their parents.
DY SL E X I A DE F I N E D
Dyslexia is a language-based learning disability characterized by difficulties with decoding (sounding out) words, fluent word recognition, and/or reading-comprehension skills.
Children with dyslexia often develop secondary problems with comprehension, spelling,
writing, and knowledge acquisition.
The difficulties found in dyslexia are usually caused by a phonological deficit (an auditory processing problem involving hearing
the sounds in speech). The phonological deficit
leads to difficulty connecting speech sounds to
Table 1: Risk factors and signs of dyslexia
RISK FACTORS
POSSIBLE SIGNS
> Family history
> Language or speech problems, including articulation
> Prematurity or birth problems
> Difficulty with rhymes
> Fetal exposure to drugs or alcohol
> Difficulty learning the names of letters
> Hearing, language, or speech problems,
including articulation
> Trouble connecting letters to their sounds
> Developmental delay
> Difficulty sounding out words
> ADHD or other neurological problems
> Difficulty with sight word recognition
> Other chronic health problems that may
have caused school absences
> Slow reading
> Poor spelling
Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
TAKE-HOME
letters, which is a skill needed to
and the right occipitotempodecode the written word. Alterral area.3
In discussing the definition
natively, dyslexia in some chilBy being vigilant
of
dyslexia
and its causes, it is
dren results from problems with
to signs of dyslexia,
also
useful
for
pediatricians to
oral language skills, sight word
dispelling the myths,
be
aware
of
the
many
myths and
recognition, processing speed,
and coordinating
misperceptions
that
exist.
Dyscomprehension, attention, or
care, physicians —
lexia
is
not
a
condition
where
verbal working memory.
including pediatric
readers see letters or words upAnatomical and imaging
ophthalmologists
side down or backward. It is not
studies investigating brain de—can help children
related to visual or eye-tracking
velopment and function show
with dyslexia enjoy
problems.4
a corresponding physical basis
success in school and
In addition, dyslexia is not a
for dyslexia in language-related
in daily life.
developmental issue that chilareas of the brain. The brains
dren may be expected to outof persons with dyslexia funcgrow; rather, it is a persistent
tion differently than the brains
of “typical readers” before they even start to lifelong condition.
Dyslexia also is not related to intelligence
read, as dyslexics use an alternative pathway
or laziness in a child. Dyslexia occurs in perfor reading.
Specifically, these investigations reveal that sons with low, normal, and high intelligence
persons with dyslexia have dysfunction in the quotients (IQs) alike.
The fact that dyslexia is not related to IQ,
left-hemisphere posterior reading areas with
corresponding compensatory use of the bilat- however, creates the potential for a signifiContinues on page 60 : Dyslexia
eral inferior frontal gyri of both hemispheres
60
OCTOBER 15, 2017 :: Ophthalmology Times
clinical diagnosis
DYSLEXIA
( Continued from page 59 )
cant learning disability to be overlooked in
an otherwise bright child. Dyslexics are often
perceived to be “lazy” or “not working up to
their potential” when, in fact, they often work
harder and longer than their peers.
In addition, there is no male predominance
for dyslexia. It is found almost equally in boys
and girls, but tends to be identified earlier
and more often in boys, perhaps because boys
tend to “act out” when they are unable to do a
difficult task versus girls who are inclined to
make themselves “invisible” in the classroom.
DETECTION, DI AGNOSIS
A diagnosis of dyslexia is established clinically
based on history, observation, and a battery of
age-appropriate educational tests interpreted
by a knowledgeable, qualified professional.
Although it is not up to pediatricians to make
the diagnosis, an understanding of dyslexia
can help to identify children by being attentive to risk factors and signs that are elicited
in the medical and social history during wellchild exams. (Table 1 on Page 59)
Dyslexia is heritable and familial, and so
the history should ascertain whether there is
a family history of speech and language problems or dyslexia. Other risk factors for dyslexia
include prematurity, neurological problems,
and developmental or language delays.
Early warning signs for dyslexia in preschoolaged children include trouble learning nursery rhymes or playing rhyming games; confusing words that sound alike; mispronouncing words; and trouble recognizing letters of
the alphabet.5
Early elementary school children with dyslexia often have difficulty learning the names
and sounds of the letters; separating and blending sounds; sounding out words; recognizing
sight words; and spelling. They often read
slowly and dislike reading. A parent’s complaint that a child is not doing well in school
should prompt questions to explore the presence of reading difficulties.
Although many dyslexic students are identified in the primary grades, dyslexia’s possible presence should not be overlooked in older
children and teenagers. Signs in adolescents
include a history of phonologically based reading difficulties, slow reading, choppiness when
reading aloud, poor comprehension, and requiring more time to finish assignments or tests.5
These adolescent students also may have
multiple school truancies and/or behavioral
Table 2: Strategies for
treating dyslexia
Explicitly teach reading skills
> Phonemic awareness
> Intensive systematic phonics
> Morphology—analysis of words and word parts
> Memorization of sight words
> Fluency training—guided oral reading
> Vocabulary building
> Comprehension techniques
Spelling—including the rules
Writing
issues, such as anger, aggression, depression,
or even suicidal tendencies and possibly alcohol or drug use.
If a family history of dyslexia or other risk
factors exists, the child’s early language development and school progress should be carefully
monitored. A formal psychoeducational school
evaluation is needed to identify dyslexia and
will provide an understanding of the child’s
strengths and weaknesses, the severity of the
problem, and whether the child has a “specific
learning disability” that is eligible for special
education and support programs.
Severe dyslexia typically qualifies a child
for an Individualized Educational Plan, special education, and related services. The psychoeducational or broader neuropsychological
or developmental-behavioral pediatric evaluation will identify comorbid conditions, and
the findings will provide the foundation for a
treatment plan.
Fortunately, individuals who have severe
dyslexia are in the minority. The other side of
the coin, however, is that those students whose
disorder is more moderate or mild may not be
readily recognized and/or may not qualify for
treatment, although they would benefit from
those services.
T R E AT I NG DY SL E X I A
The prognosis for a child with dyslexia depends
not only on the specific features of the disorder and its severity, but also on the timeliness
and appropriateness of intervention (Table 2).
Studies show that beginning remediation in
first grade versus waiting 2 more years greatly
increases the chance that a child will later be
able to read at grade level.6 Nevertheless, it is
never too late to help.
Effective intervention for dyslexia targets
its etiology as a language-based disorder and
should be provided by a professional with the
appropriate training. Children with dyslexia
are best served with lessons provided in small
group settings, which bring together students
who are at the same reading level and include
no more than 5 students. Remediation programs that follow the International Dyslexia
Association guidelines call for a “Structured
Literacy Approach.” These programs explain
language in an explicit, systematic, sequential, and multisensory manner.
They include training in the five reading skills:
1) phonemic awareness (hearing the sounds
in words);
2) phonics (correlating sounds with letters);
3) fluency (ability to read with speed, accuracy
and expression);
4) vocabulary; and
5) comprehension.
Emphasis is also placed on learning word
structure, letter patterns, spelling, and writing.
Whereas early management of dyslexia focuses on remediation of the reading problem, for
older students there is a shift toward providing
tools and accommodations. Accommodations
allow the student to access his/her higher-level
thinking and reasoning skills. These measures
include access to assistive technology (e.g.,
recorded books, text reading software, note
takers, spell checkers) as well as provisions to
enable test taking (e.g., extended testing time,
a special quiet room, or preferential seating).
PEDIATRICIAN ROLE
Parents of children with dyslexia often seek
counsel from their pediatrician about dyslexia
treatments, so clinicians should be aware of
both the proven and unproven interventions
being recommended and heavily promoted.
By being informed about the variety of approaches, as well as being able to discuss the
lack of evidence supporting the efficacy for the
unproven interventions, pediatricians will be
equipped to educate patients and their families, encourage positive proven approaches,
discourage the use of unproven techniques,
and thus prevent families from wasting valuable time and resources pursuing expensive,
nonproductive therapies.
Non–evidence-based approaches promoted
for remediation of reading difficulties in children with dyslexia include medication for vestibular dysfunction, chiropractic manipulation,
physical exercises, and dietary supplementation or restrictions.5
In particular, however, the erroneous concept that dyslexia is a vision-based disorder
has spawned a variety of interventions involving the use of training glasses, eye exercises,
behavioral/perceptual vision therapy, and colored lenses and overlays. Although visual problems, including convergence insufficiency, can
61
OCTOBER 15, 2017 :: Ophthalmology Times
clinical diagnosis
hamper reading, they are not the cause of dyslexia. Vision problems are not more common
in children with reading impairment.4
Not only are vision-related approaches misdirected in theory, but authors of systematic
literature reviews have concluded there is no
scientific evidence of their efficacy for learning disabilities.3,7–9
Eye and vision problems occur in about 5%
to 10% of early elementary students and 25% of
high school students, and pediatricians should
recognize that some treatable vision problems
can masquerade as a learning problem or may
be co-existing.
For example, children with large amounts of
farsightedness or astigmatism may be uninterested in books whereas children with nearsightedness may have difficulty seeing the board.
Symptomatic convergence insufficiency, which
occurs more rarely in elementary school-aged
children, makes reading at near blurry and uncomfortable. Consequently, affected children
may read only for short periods, and on that
basis may be thought to have dyslexia or attention-deficit/hyperactivity disorder (ADHD),
especially the inattentive type.
Pediatric ophthalmologists play a valuable role
in the assessment of children with suspected
or established learning disabilities, including
dyslexia, to determine whether there are any
eye or vision problems that could be interfering with learning or reading. As part of the
management team for children with dyslexia,
pediatric ophthalmologists can help families
by reinforcing information on the condition,
dispelling the myths, and providing guidance
to resources available online, in print, and in
the community.
Referral for an ophthalmologic evaluation is
indicated when a vision problem is suspected
or the child fails vision screening. The pediatric ophthalmologist will perform a complete
dilated eye and vision examination, thoroughly
evaluate near vision, and perform a cycloplegic refraction.
Most ocular conditions found in children,
including strabismus, amblyopia, convergence
or focusing deficiencies, and refractive errors,
are treatable with glasses and will improve
quickly. Children diagnosed with symptomatic convergence insufficiency are usually prescribed convergence eye exercises to be per-
formed at home. These exercises usually result in improved reading comfort within a few
weeks. In-office exercises with at-home reinforcement are considered if a child continues
to show signs and symptoms of convergence
insufficiency.
It is crucial to understand that although these
exercises may relieve eye strain, they are not
a treatment for co-existing dyslexia.
Furthermore, pediatricians should know that
convergence insufficiency is frequently overdiagnosed. Any child who has been diagnosed
with convergence insufficiency should be referred to a pediatric ophthalmologist for a second opinion, as should any child who has been
recommended vision therapy or tinted lenses
or filters as treatment for a reading disability.
CAR ING FOR OTHER CONDITIONS
The pediatric evaluation of a child presenting
with reading difficulties or dyslexia should also
include assessments for other potentially contributing, masquerading, or co-existing conditions. In addition to vision screening, these investigations should include hearing screening
Continues on page 62 : Vision screening
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62
OCTOBER 15, 2017 :: Ophthalmology Times
clinical diagnosis
VISION SCREENING
Table 3: Online resources
for information on dyslexia
( Continued from page 61 )
and evaluations for behavioral, medical, and
mental health disorders. Notably, ADHD and
reading disability are highly comorbid. The
inattentive type of ADHD has been found in
18% to 42% of children with dyslexia, and rates
of dyslexia among children with ADHD have
been reported to be within a similar range.10
Dyslexia also may be associated with oppositional defiant disorder, obsessive-compulsive
disorder, anxiety, and depression.
COU NSELING, A DVOC ACY
Some pediatricians can help to advocate for
the child as needed, for example, by writing
a letter to request an evaluation or accommodations. To ensure that children get appropriate care, pediatricians should be prepared to
provide families with names of professionals
in their area who are qualified to evaluate and
treat children with dyslexia.
Children who have not been making progress after a prior psychoeducational evaluation
and interventions could benefit from referral
for further evaluation by a developmental-behavioral pediatrician or neuropsychologist. Although private evaluation of a child with suspected dyslexia may be expensive, a proper
diagnosis may save many years of frustration
and failed education, as well as thousands
of dollars on unnecessary and unsupported
treatments.
Pediatricians should be sympathetic to the
stress that a child with dyslexia and his or
her family are experiencing and should provide encouragement and emotional support.
In addition, while counseling parents to support their child’s efforts at reading, pediatricians should also advise them to pursue their
child’s strengths and allow time for activities
in which the child finds enjoyment and excels.
Pediatricians also should have available educational materials and/or lists of resources
where families can get information about dyslexia, its evaluation and treatment, and their
child’s rights for evaluation, special services,
and accommodations as defined by the Individuals with Disabilities Education Act (IDEA),
and Section 504 of the Americans With Disabilities Act (ADA).
Table 3 lists several useful websites for more
information.
Finally, the role of the pediatrician in helping children to become proficient readers begins early in the provider-family relationship,
long before considering whether children are
International Dyslexia Association
www.eida.org
Learning Disabilities (LD) OnLine
www.ldonline.org
National Center for Learning Disabilities
www.ncld.org
Reading Rockets
www.readingrockets.org
Yale Center for Dyslexia and Creativity
www.dyslexia.yale.edu
University of Michigan—Dyslexia Help
http://dyslexiahelp.umich.edu
at risk for or showing signs of dyslexia. Recognizing that oral language is the foundation
for reading and that children with speech and
language delay or difficulties have a 50% likelihood of having difficulties learning to read,
pediatricians can have an important impact by
promoting early language development. The
Books Build Connections Toolkit, developed
by the American Academy of Pediatrics and
Reach Out and Read, contains material for pediatricians and parents and offers a practical
resource to assist in these efforts.11
CONCLUSION
Dyslexia is a common and lifelong languagebased learning disability that may be detected
as early as kindergarten or first grade. Affected
children are most likely to obtain the greatest
benefit when the problem is identified early
followed by prompt initiation of appropriate
language and reading instruction. Care should
be taken to avoid using ineffective methods of
treatment that waste time and family resources
and often critically delay proper remediation.
By being vigilant to signs of dyslexia, dispelling the myths surrounding this condition,
helping to coordinate care, and providing support and encouragement, pediatricians with
the aid of pediatric ophthalmologists can help
children with dyslexia enjoy success in school
and in their daily life. ■
References
1. Moats LC. Teaching reading is rocket science: What
expert teachers of reading should know and be
able to do. Washington, DC: American Federation
of Teachers; 1999. Available at: http://www.aft.org/
sites/default/files/reading_rocketscience_2004.pdf.
Accessed July 19, 2016.
2. Nation’s Report Card. Nine subjects, three
grades, one report card. Available at: http://www.
nationsreportcard.gov/. Accessed July 19, 2016.
3. Handler SM, Fierson WM, Section on Ophthalmology;
Council on Children with Disabilities; American
4.
5.
6.
7.
8.
9.
10.
11.
Academy of Ophthalmology; American Association for
Pediatric Ophthalmology and Strabismus; American
Association of Certified Orthoptists. Learning
disabilities, dyslexia, and vision. Joint Technical
Report. Pediatrics. 2011;127(3):e818-e856.
Creavin AL, Lingam R, Steer C, Williams C.
Ophthalmic abnormalities and reading impairment.
Pediatrics. 2015;135:1057-1065.
Shaywitz SE, Gruen JR, Shaywitz BA. Management of
dyslexia, its rationale, and underlying neurobiology.
Pediatr Clin North Am. 2007;54:609-623.
Torgesen JK. Avoiding the devastating downward
spiral: the evidence that early intervention prevents
reading failure. Available at: http://www.aft.org/
periodical/american-educator/fall-2004/avoidingdevastating-downward-spiral. Accessed July 19,
2016.
Fletcher JM, Francis DJ, Morris RD, Lyon GR.
Evidence-based assessment of learning disabilities
in children and adolescents. J Clin Child Adolesc
Psychol. 2005;34:506-522.
Barrett BT. A critical evaluation of the evidence
supporting the practice of behavioural vision therapy.
Ophthalmic Physiol Opt. 2009;29:4-25.
Ritchie SJ, Della Sala S, McIntosh RD. Irlen colored
overlays do not alleviate reading difficulties.
Pediatrics. 2011;128:e932-e938.
Germanò E, Gagliano A, Curatolo P. Comorbidity of
ADHD and dyslexia. Dev Neuropsychol. 2010;35:475493.
American Academy of Pediatrics. Books Build
Connections Toolkit. Available at: https://littoolkit.aap.
org/Pages/home.aspx. Accessed July 19, 2016.
SHERYL M. HANDLER, MD
P: 818/789-2226
Dr. Handler is a pediatric ophthalmologist in private practice in Encino, CA. She is
one of the authors of the American Academy of Pediatrics, American Academy of
Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and
American Association of Certified Orthoptists 2011 Joint Technical Report, Learning
Disabilities, Dyslexia, and Vision. She has nothing to disclose in regard to affiliations
with or financial interests in any organizations that may have an interest in this article.
This article originally appeared in sister
publication ContemporaryPediatrics.
com/Dyslexia
Copyright of Ophthalmology Times is the property of Advanstar Communications Inc. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.
Learning and Individual Differences 49 (2016) 209–215
Contents lists available at ScienceDirect
Learning and Individual Differences
journal homepage: www.elsevier.com/locate/lindif
Predicting responsiveness to intervention in dyslexia using
dynamic assessment
Sebastián Aravena a,b,c,⁎, Jurgen Tijms a,b,c, Patrick Snellings a,c, Maurits W. van der Molen a,c
a
b
c
Department of Developmental Psychology, University of Amsterdam, Nieuwe Achtergracht 129B, 1018 WT Amsterdam, The Netherlands
IWAL Institute, Amsterdam, Tweede Hugo de Grootstraat 45a, 1052 LB, The Netherlands
Rudolf Berlin Center, Amsterdam, Valckenierstraat 65-67, 1018 XE, The Netherlands
a r t i c l e
i n f o
Article history:
Received 13 June 2015
Received in revised form 30 March 2016
Accepted 24 June 2016
Keywords:
Dyslexia
Dynamic assessment
Letter–speech sound learning
Treatment success
Response to intervention (RTI)
a b s t r a c t
In the current study we examined the value of a dynamic test for predicting responsiveness to reading intervention for children diagnosed with dyslexia. The test consisted of a 20-minute training aimed at learning eight basic
letter–speech sound correspondences within an artificial orthography, followed by a short assessment of both
mastery of these correspondences and word reading ability in this unfamiliar script. Fifty-five (7- to 11-yearold) children diagnosed with dyslexia engaged in specialized intervention during approximately 10 months
and their reading and spelling abilities were assessed before and after. Our results indicated that the dynamic
test predicted variance in reading skills at posttest, over and above traditional static measures, such as phonological awareness and rapid naming. These findings indicate that responsiveness to learning new letter–speech
sound correspondences has a prognostic value for the success of specialized reading intervention.
© 2016 Elsevier Inc. All rights reserved.
1. Introduction
Developmental dyslexia, henceforth referred to as dyslexia, is characterized by a specific and significant impairment in the automatic recognition of written words (Fletcher & Lyon, 2008; Peterson &
Pennington, 2012; Snowling, 2012). There is ample evidence that specialized intervention is effective in ameliorating reading and spelling
proficiency of children with dyslexia (see Galuschka, Ise, Krick, &
Schulte-Körne, 2014 for an overview). Unfortunately, not all dyslexic
readers benefit to the same extent and there is a substantial amount
of non-responders as well (Galuschka et al., 2014; Singleton, 2009;
Torgesen, 2005). Gaining more insight into factors that can predict responsiveness to intervention in dyslexia would be very welcome as it
could help us to identify nonresponders at an early stage and, by
doing so, to prevent wasting time, effort, and resources on interventions
that are not effective.
A framework that is particularly important in this context is response to intervention (RTI), which is a common practice in educational
settings across the United States and several European countries nowadays. RTI is an approach in which a tutor provides a pupil with progressively intense and individualized tiers of instruction with the aim of
finding the best possible way to educate children and of identifying
⁎ Corresponding author at: IWAL Institute, Amsterdam, Tweede Hugo de Grootstraat
45a, 1052 LB, The Netherlands.
E-mail address: s.aravena@uva.nl (S. Aravena).
http://dx.doi.org/10.1016/j.lindif.2016.06.024
1041-6080/© 2016 Elsevier Inc. All rights reserved.
children with learning disabilities (Fuchs & Fuchs, 2006; Grigorenko,
2009; Gustafson, Svensson, & Fälth, 2014). Pupils who do not respond
to Tier 1 receive more intensive and individualized instruction within
Tier 2, and those who are unresponsive to Tier 2 proceed with even
more rigorous instruction within Tier 3. Depending on the educational
system, the framework is sometimes complemented by a fourth tier,
which consists of placement in special education or referral to assessment and therapy within the health care system.
Although many pupils benefit from RTI as they receive high-quality
instruction as soon as learning difficulties arise, the notion that intervention should initially be of modest intensity has been questioned
(Denton et al., 2011; Vaughn, Denton, & Fletcher, 2010). Especially the
value of Tier 2 intervention for the most learning disabled continues
to be a subject to debate (Compton et al., 2012; Fuchs, Fuchs, &
Compton, 2010). Indeed, there is evidence that engaging in less intensive tiers of intervention may not be effective for addressing the reading
difficulties of children with dyslexia (Vaughn et al., 2010). Early identification of nonresponders could thus potentially improve their chance
to benefit from intervention by intensifying initial intervention.
A convenient starting point for identifying factors predicting intervention success would be to focus on the standard assessment of dyslexia, which typically consists of a combination of reading and writing
tasks along with a set of phonology-related tasks, such as phonological
awareness, rapid naming, and verbal short-term memory, as well as
some general cognitive measures. Indeed, several studies indicate that
some of these factors, among which poor phonological awareness in
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S. Aravena et al. / Learning and Individual Differences 49 (2016) 209–215
particular, can predict unresponsiveness to early literacy intervention
within children at risk for dyslexia (see Al Otaiba & Fuchs, 2002 and
Nelson, Benner, & Gonzalez, 2003 for an overview), but it is far less
clear whether these findings hold for children diagnosed with dyslexia
(Frijters et al., 2011; Hatcher & Hulme, 1999; Morris et al., 2012;
Tijms, 2011). For this group there is a paucity in our knowledge of factors moderating responsiveness to intervention (Démonet, Taylor, &
Chaix, 2004; Frijters et al., 2011; Hoeft et al., 2011; Shaywitz, Morris, &
Shaywitz, 2008; Tijms, 2011). A recent meta-analysis including twenty-two randomized controlled trial studies of reading disabled children
failed to identify subject-related moderators of responsiveness to intervention (Galuschka et al., 2014).
Dynamic assessment (DA) might be a viable approach for examining
potential moderators of responsiveness to intervention. The focus of DA
is on learning potential rather than learning outcome (Grigorenko,
2009; Gustafson et al., 2014). A typical DA procedure requires the
pupil to engage in a training in which feedback is provided. The effect
of training is then used to estimate the pupils' learning potential.
There is ample evidence that this kind of process-oriented testing better
predicts future learning than conventional testing within various academic domains, including reading skill (Caffrey, Fuchs, & Fuchs, 2008;
Fuchs, Compton, Fuchs, Bouton, & Caffrey, 2011; Grigorenko &
Sternberg, 1998; Gustafson et al., 2014; Jeltova et al., 2007; Spector,
1992). However, other studies have shown little advantage of dynamic
testing over static testing (Caffrey et al., 2008). In a recent study
Petersen, Allen, and Spencer (2014) compared the utility to predict
reading difficulty at first grade of two DA reading measures and two
commonly used one-point-in-time pre-reading measures administered
to 600 kindergarten children and found both DA measures to be superior to the common static measures. DA has also been used to examine
moderators of responsiveness to intervention recently. Cho, Compton,
Fuchs, Fuchs, and Bouton (2014) showed that DA predicted the responsiveness to a validated reading intervention program. In this study, firstgrade students received Tier 2 reading intervention within small groups
during 14 weeks. DA of decoding was found to be a significant predictor
of the growth in word identification fluency and the final level attained.
In the current study, we applied DA to children diagnosed with dyslexia in order to predict the success of subsequent specialized Tier 4 intervention. The DA we developed consists of a 20-minute training
aimed at learning eight new basic letter–speech sound correspondences, followed by a short assessment of both mastery of the correspondences and word reading ability in this unfamiliar script. Letter–
speech sound learning is the central focus of the training, because recent
research suggests that a fundamental letter–speech sound learning deficit is a key factor in dyslexia (Blomert, 2011; Kronschnabel, Brem,
Maurer, & Brandeis, 2014; McNorgan, Randazzo-Wagner, & Booth,
2013; Mittag, Thesleff, Laasonen, & Kujala, 2013; Peterson &
Pennington, 2015; van Atteveldt & Ansari, 2014; Žarić et al., 2014).
The advantage of adopting an artificial script is that differences in previous exposure to experimental stimuli can be ruled out, allaying concerns about noncontrolled factors influencing performance. In a
previous study we demonstrated that our DA procedure differentiates
between dyslexic readers and normal readers and predicts individual
differences in reading and spelling ability (Aravena, Tijms, Snellings, &
van der Molen, 2015). In the current study we examined whether, in addition to its diagnostic value, the DA procedure has prognostic value as
well. The participating children engaged in specialized Tier 4 intervention during approximately 10 months. We tested their reading and
spelling abilities before and after intervention and related these to the
scores on our DA, as well as to the scores on two conventional static
measures frequently used for the assessment of dyslexia, namely a phonological awareness task and an alphanumeric rapid naming task. Unlike most approaches to DA (Grigorenko, 2009; Grigorenko &
Sternberg, 1998), our assessment did not involve instruction but just associative learning from exposure and implicit feedback. The 20-minute
training consisted of a computer game in which children had to match
speech sounds to unfamiliar letters. As correct responses led to success
in the game and incorrect responses were penalized, children learned
the letter–speech sound correspondences just by playing the game,
without being aware of learning. Instructions were only related to the
specifics of the game and did not reveal the underlying learning objective. This approach was chosen to approximate letter–speech sound
learning as it naturally occurs and to measure the capacity to master
new letter–speech sound correspondences, without interference from
more general factors related to instruction, such as intelligence, verbal
comprehension, or attention.
In brief, in the current study we examined whether a new DA procedure predicted the success of a subsequent specialized intervention
within a group of children diagnosed with dyslexia. We expected this
procedure to be an adequate candidate for this purpose for two reasons.
First, because it focuses on the formation of letter–speech sound correspondences, a process that appears to be disrupted in children with dyslexia. Second, because it focuses on learning rate rather than on learning
outcome.
2. Method
2.1. Participants
Participants were 55 primary education pupils (30 boys and 25 girls)
diagnosed with dyslexia recruited from a nation-wide center for dyslexia in the Netherlands. The children had a mean age of 9 years and
3 months (SD = 12.39 months, age range = 7.33–11.08 years). An estimate of general intelligence was obtained by averaging the standardized C-scores (M = 5, SD = 2) of the subtest Analogies from the SONR (Laros & Tellegen, 1991), a non-verbal reasoning-by-analogy task in
which the child had to extract a principle and to apply it to a new situation (r = 0.79, test–retest), and the subtest Vocabulary from the WISCIII (Kort et al., 2005), a measure of expressive vocabulary requiring the
child to describe the meaning of words of increasing complexity (r =
0.90, test–retest). The IQ estimates ranged from 3 to 8.5 (M = 5.57,
SD = 1.37). Informed consent was obtained from the parents of each
child.
Consistent with standard norms for severe dyslexia in the Dutch
health care system (Blomert, 2006), children were diagnosed with dyslexia when they met all of the following three inclusion criteria: (1) either word reading speed was 1.5 standard deviation (SD) or more
below average or, word reading speed was at least 1 SD below average
together with a spelling skill of 1.5 SD or more below average; (2) performance on at least two out of six administered phonology-related
tasks was at least 1.5 SD below average; and (3) the child had shown
a poor response to intervention provided at school. Exclusionary criteria
were uncorrected sensory disabilities, broad neurological deficits, low
IQ (b80), poor school attendance, and ADHD. Because we incorporated
Hebrew graphemes in our assessment, previous experience with Hebrew script was also an exclusionary criterion. All participants were native speakers of Dutch. The study was approved by the University's
Ethics Committee.
2.2. Dynamic assessment
The dynamic assessment (DA), which had a total duration of approximately 30 min, consisted of a 20-minute training dedicated to learning
non-existent letter–speech sound correspondences followed by a short
assessment of both mastery of the newly learned correspondences and
word reading ability in the artificial script. A summary of the different
components of the DA is provided below.
2.2.1. The letter–speech sound training
The training consisted of a computer game in which the child had to
match speech sounds to their corresponding orthographic representations (Aravena et al., 2015). Correct associations were rewarded while
S. Aravena et al. / Learning and Individual Differences 49 (2016) 209–215
incorrect associations were penalized. Fast playing was reinforced by
progressive time restrictions and by providing bonuses for fast playing.
More specific, children operated a cannon at the bottom of the screen,
moving it horizontally. The upper part of the screen was composed of
columns of balloons containing single graphemes. Children were required to act on speech sounds that were presented repeatedly in the
game. The response consisted of releasing bullets from the cannon and
associating them to their corresponding grapheme. When children
managed to clear a field of balloons, a new field was presented. As the
amount of distractor graphemes increased during the game, fields became gradually more complex. Fig. 1 depicts some screenshots from
the game.
The goal of the training was to learn a set of letter–speech sound correspondences from an artificial orthography. At the start of the game the
child was presented with a standardized instruction that was integrated
in the software. This instruction provided information regarding the
specifics of the game but did not reveal the underlying learning objective. After the instruction, children received a short practice trial to become familiar with the set-up and the controls of the game. During
the training session children were wearing headphones.
2.2.2. The artificial orthography
The artificial orthography consisted of eight Hebrew graphemes,
which were randomly matched to highly frequent Dutch phonemes,
thereby providing eight basic non-existing letter–speech sound pairs.
We adopted Hebrew script to capture the characteristics of graphemes
as they naturally occur. Evidence exists that letter shapes are not an arbitrary cultural choice but rather a product of our neural architecture
(Dehaene, 2009, p. 173). The phonemes, three vowels and five consonants, were selected based on their high frequency and their ability to,
by combining, create a large corpus of words. Combinations of phonemes producing strong coarticulation effects were avoided. Table 1
presents the letter–speech sound correspondences that were used.
The directionality of the script was left-to-right.
2.2.3. Letter–speech sound identification task within the artificial
orthography
In this task a phoneme was presented over headphones, while simultaneously two graphemes from the artificial orthography were
displayed at the screen. One of these graphemes corresponded with
the presented phoneme, while the other was as a distractor. By striking
the corresponding button the child had to decide, as fast as possible,
which of the graphemes belonged to the presented phoneme. The task
consisted of 56 items. Response speed and accuracy were recorded automatically by the software. The score for response speed was the median speed of correct responses and the score for accuracy was the
number of correct responses (respectively r = 0.96 and r = 0.90,
split-half).
211
Table 1
Letter–speech sound correspondences within the artificial orthography.
Letter
ט
כ
ם
ף
פ
צ
ך
ש
Speech sound (IPA)
[u]
[ε]
[α] [a]
[k]
[r]
[l]
[t]
[n]
Note. IPA, International Phonetic Alphabet.
2.2.4. Reading task within the artificial orthography
We administered a time-limited test (3MAST) consisting of a list of
22 high-frequent Dutch words written within the artificial orthography.
The words were presented in lowercase Arial typeface, font size 24, and
arranged in two columns of equal length. The child had to read (column-wise) as many words as possible within 3 min. The score consisted
of the number of words read correctly per second.
2.3. Traditional measures used for the assessment of dyslexia
2.3.1. Phonological awareness
We assessed phonological awareness with a phoneme deletion task
from the 3DM, a standardized and computerized battery for assessing
dyslexia (Blomert & Vaessen, 2009). In this task the child had to delete
consonants from aurally presented pseudowords (CVC or CCVCC structure) as fast as possible (for example /FOT/ minus /F/ makes /OT/). The
score consisted of the percentage of correct responses (r = 0.85, internal consistency).
2.3.2. Rapid naming
We assessed both rapid naming of letters and digits with a rapid
naming task from the 3DM (Blomert & Vaessen, 2009). The child had
to name aloud items presented on the computer screen as fast and accurate as possible. Within both domains sheets containing 15 items each
were presented two times. The score per subtask was the mean response time of the two sheets (r = 0.80 for letters and r = 0.83 for
digits, split-half reliability). In the current study we used a composite
measure of alphanumeric rapid naming consisting of the scores of
both the rapid naming of letters and digits.
2.4. Reading and spelling measures
2.4.1. Word reading
We assessed word reading with a time-limited task from the 3DM
(Blomert & Vaessen, 2009). This word-reading task included three different levels comprising high-frequency words, low-frequency words
and pseudo-words. Each level contained 75 words, displayed on 5
sheets with 15 items each. The difficulty of each level increased systematically from monosyllabic words without consonant clusters to 3 or 4
syllabic words with consonant clusters in the fifth sheet. The child was
instructed to read as many words as possible while maintaining accuracy within a time-limit of 30 s per level. Both accuracy (percentage of
Fig. 1. Screenshots from the training.
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S. Aravena et al. / Learning and Individual Differences 49 (2016) 209–215
correctly read words) and speed (number of words read correctly) were
measured (respectively r = 0.73 and r = 0.95, test–retest).
2.4.2. Spelling
We assessed spelling with a task from the 3DM (Blomert & Vaessen,
2009). In this task a word was presented over headphones while it was
also visible on the screen. In the visually presented word a letter or letter
combination was missing. By striking a key the child had to decide as
fast as possible which of four different letters or letter combinations represented the missing part. Word frequencies varied systematically and
words were either phonetically transparent (18 items) or needed the
application of a Dutch spelling rule (36 items). Scores consisted of the
percentage of accurate responses (r = 0.80, internal consistency).
2.5. Specialized intervention
The Dutch educational system utilizes a three-tier approach to reading instruction. Children who do not respond to intensive Tier 3 intervention are assessed for their reading deficiency and those diagnosed
with dyslexia receive specialized intervention within the health care
system, which in the Netherlands represents the fourth tier. The intervention used in this study was a Dutch computer-based Tier 4 intervention program for treating dyslexia (LEXY).
Intervention was provided by speech therapists and psychologists,
on a one-to-one basis in weekly 45-min sessions. Sessions took place
in a dyslexia center in the child's neighborhood. Besides these sessions
at the center, participants were required to practice at home three
times a week for 15 min.
LEXY provides insight into the way written language transcribes the
characteristics of the spoken language system by clarifying the phonological and morphological structure, and by explicitly training the
rule-systems that are essential for the graphic representation of spoken
language, using step-by-step algorithmic plans. All elements within the
learning environment (like phonemic and orthographic units and mapping operations) are graphically represented on the computer screen
(see Tijms & Hoeks, 2005 for a more detailed review of LEXY). The
LEXY program aims at achieving a mastery level for each element of
the program, which implies that participants do not pass through it at
a fixed pace. On average the duration of the intervention program is
48 to 60 sessions, but in the current study the posttest was administered
before the end of intervention, at 39 weeks. The program is in line with
guidelines regarding effective intervention for children with dyslexia
(Galuschka et al., 2014; Singleton, 2009) and its efficacy has been demonstrated repeatedly (Tijms, 2011; Tijms & Hoeks, 2005).
2.6. Design and procedure
The DA was administered as part of a standard diagnostic assessment consisting of two 3.5 hour-sessions within one week interval. A
trained psychologist administered the DA on a one-to-one basis during
the second session. The assessment took place in a silent room in the
dyslexia center. Children started with the intervention program approximately four months after the assessment. The pretest consisted of the
word reading and the spelling task and took place during the first session of the intervention. The posttest, which included the same tasks,
took place during the 39th session, which was after approximately
10 months (M = 43.0 weeks, SD = 1.9 weeks), depending on the
amount of cancelled sessions due to illness or holidays. In total, 33 sessions were used for intervention and 6 sessions were used for assessment purposes.
(M = 50, SD = 10) obtained at pretest from those obtained at posttest
for each individual. A one-sample t-test was then conducted to determine whether the mean of these gain values was significantly different
from zero.
To determine whether the three dynamic assessment (DA) variables
predict the improvement in reading and spelling skills during intervention we conducted a series of two-step fixed-entry multiple regression
analyses with the posttest scores of reading and spelling measures as
the dependent variables. In each of the analyses we entered the pretest
score in the first step to filter out variance due to differences at the start
of intervention. The three DA measures as well as phonological awareness (PA) and alphanumeric rapid naming (RAN) were added alternately in the second step to determine their individual contribution. In an
additional series of multiple regression analyses we compared the predictive potential of the combined DA measures to the combined traditional measures by entering both phonological awareness and rapid
naming in the second step and the three DA measures in the third
step and vice versa.
3. Results
3.1. Overall effect of the intervention
Table 2 presents the standardized T-scores for the reading and spelling tasks at pretest and posttest. A one-sample t-test showed that the
treatment had a significant beneficial effect on reading accuracy
(t(52) = 3.032, p = 0.004, d = 0.84) and on reading speed (t(52) =
7.071, p b 0.001, d = 1.96) as well as on spelling (t(52) = 5.937,
p b 0.001, d = 1.65). Note that the gains are expressed in standardized
scores, and thus reflect a shift in position within the normal distribution.
In other words, the reading disabled children that received intervention
made significantly more progress than their peers (from the national
norm) during the same period.
Despite the improvements that were made, the average accuracy
and speed scores of reading were still below the normal range after 39
sessions of treatment. This was not surprising, however, given that the
posttest was administered mid-term. The improvements found at the
end of this treatment are typically more substantial (Tijms, 2011;
Tijms & Hoeks, 2005).
3.2. Predicting reading and spelling gains during intervention
The results from the multiple regression analyses, presented in Table
3, indicate that neither PA nor RAN made a significant contribution to
predicting the improvement in any of the reading and spelling skills
during intervention. The same was true for the artificial orthography-related accuracy measure of the letter–speech sound identification task
(LSIa). The speed measure of the letter–speech sound identification
task (LSIs), however, accounted for 17% of the variance in reading accuracy and 6% of the variance in reading speed at posttest. The contribution to the variance in spelling at posttest was negligible. The amount
of words read per second within the artificial orthography (WPS)
accounted for 12% of variance in reading accuracy at posttest, but did
not contribute to the variance of any of the other measures.
The results from the additional analyses, which are shown in Table 4,
indicate that the three DA measures combined accounted for 23% of
Table 2
The development of standardized t-scores for reading and spelling during intervention.
t-Score at pretest
2.7. Analyses
In order to understand the predictive potential of the pertinent variables, we first had a look at the overall effect of the intervention. Gain
values were calculated by subtracting the standardized T-scores
Reading accuracy
Reading speed
Spelling
t-Score at posttest
Gain values (t-score)
M (SD)
M (SD)
M (SD)
32.44 (11.37)
29.60 (5.09)
37.07 (7.28)
37.25 (11.64)
34.94 (7.39)
44.49 (8.69)
5.11 (12.28)⁎⁎
5.45 (5.61)⁎⁎
7.75 (9.51)⁎⁎
⁎⁎ Significant at the 0.01 level.
S. Aravena et al. / Learning and Individual Differences 49 (2016) 209–215
Table 3
Regression models predicting reading and spelling measures at posttest.
Reading
accuracy
Steps
1
2
2
2
2
2
Pretest
PA
RAN
LSIa
LSIs
WPS
R2
ΔR2
0.19
0.21
0.21
0.19
0.36
0.31
0.19⁎⁎
0.02
0.02
0.00
0.17⁎⁎
0.12⁎⁎
Reading speed
Spelling
R2
ΔR2
R2
ΔR2
0.42
0.43
0.42
0.42
0.48
0.43
0.42⁎⁎
0.09
0.09
0.09
0.10
0.10
0.10
0.09⁎
0.00
0.00
0.01
0.01
0.01
0.01
0.00
0.00
0.06⁎
0.01
Note. PA, phonological awareness; RAN, rapid naming of alphanumeric items; LSIa, letter–
speech sound identification accuracy; LSIs, letter–speech sound identification speed; WPS,
number of words read per second.
⁎⁎ Significant at the 0.01 level.
⁎ Significant at the 0.05 level.
variance in reading accuracy at posttest when entered in the second
step and for 19% of additional variance when entered in the third step.
The three DA measures thus predicted variance in reading accuracy at
posttest, over and above traditional static measures, such as PA and
RAN.
4. Discussion
In the current study we used dynamic assessment (DA) for children
diagnosed with dyslexia to examine whether it would predict the success of a subsequent specialized intervention. In a previous study we
demonstrated that our DA predicts individual differences in reading
and spelling ability and differentiates between dyslexic readers and normal readers (Aravena et al., 2015). The results from the current study indicate that in addition to its diagnostic value our DA has prognostic
value as well. More specifically we found that the speed measure from
the letter–speech sound identification task (LSIs) made a significant
contribution to explaining variance in response to intervention on reading accuracy and speed and that the amount of words read per second
within the artificial orthography (WPS) accounted for another significant portion of variance in reading accuracy at posttest.
Our findings are consistent with previous findings demonstrating
the added value of DA in forecasting reading development (Caffrey et
al., 2008; Fuchs et al., 2011; Grigorenko & Sternberg, 1998; Gustafson
et al., 2014; Jeltova et al., 2007; Petersen et al., 2014; Spector, 1992)
and, more importantly, in predicting responsiveness to reading intervention (Cho et al., 2014). The current study strengthens and extends
available data by showing that DA has the potential to predict
Table 4
Regression models predicting reading and spelling measures at posttest.
Reading
accuracy
Steps
1
2
3
2
3
Pretest
PA
RAN
LSIa
LSIs
WPS
LSIa
LSIs
WPS
PA
RAN
Reading speed
Spelling
R2
ΔR2
R2
ΔR2
R2
ΔR2
0.19
0.19⁎⁎
0.42
0.42⁎⁎
0.09
0.09⁎
0.23
0.04
0.43
0.01
0.09
0.00
0.42
0.19⁎⁎
0.50
0.07
0.11
0.02
0.41
0.23⁎⁎
0.48
0.06
0.11
0.02
0.42
0.00
0.50
0.02
0.11
0.00
Note. PA, phonological awareness; RAN, rapid naming of alphanumeric items; LSIa, letter–
speech sound identification accuracy; LSIs, letter–speech sound identification speed; WPS,
number of words read per second.
⁎⁎ Significant at the 0.01 level.
⁎ Significant at the 0.05 level.
213
responsiveness to intervention beyond Tier 3 intervention within a
sample of children diagnosed with dyslexia. This is of particular interest
because so far the quest for predictors of responsiveness to intervention
for this group has not been very fruitful (Frijters et al., 2011; Hoeft et al.,
2011; Tijms, 2011). Our results indicate that a dynamic approach to assessment provides new opportunities to predict responsiveness to intervention even for the most reading disabled. From a clinical point of
view early identification of potential non-responders is valuable because it may assist practitioners adapting their educational strategies
at an initial stage or even start off a prompt deployment of alternative
ways of accessing written information, such as computer-based readers.
A possible explanation for the current success of our DA approach is
that it not only identifies an essential underlying factor, namely a letter–
speech sound binding deficit, but that it also provides an index of the extent to which this underlying problem interferes with learning to read.
This explanation is in line with findings from longitudinal studies indicating that deficits in the initial learning of letter–speech sound associations are an important risk factor for developing reading difficulties
(Caravolas et al., 2012; Lyytinen, Ronimus, Alanko, Poikkeus, & Taanila,
2007). According to Lyytinen et al. (2007) it is a serious reason for concern when a child struggles storing grapheme–phoneme connections in
memory in stable form. We think it is this ‘struggle’ that manifests itself
within the 20 min of playing the DA game and, thus, it might provide a
proxy for the responsiveness to reading intervention.
It is noteworthy that we did not find any moderating effect of phonological awareness or rapid naming on the responsiveness to intervention. Research has consistently demonstrated that these factors are
important predictors of variance in reading skills (see Melby-Lervåg,
Lyster, & Hulme, 2012 and Norton & Wolf, 2012 for reviews). Moreover,
some studies did obtain evidence to suggest that these factors can predict responsiveness in children at risk for dyslexia (Al Otaiba & Fuchs,
2002; Nelson et al., 2003 for reviews). The current lack of an association
between phonological awareness and rapid naming and response to intervention is in line with the notion that phonological factors may be
less important than is often assumed (Byrne, 2011). Observations that,
although phonological deficits are common in individuals with dyslexia,
a single phonological deficit is not necessary or sufficient to cause the
disorder, have led to the idea that poor phonological awareness and
rapid naming are two of multiple factors that interact in causing dyslexia (Pennington, 2006; Peterson & Pennington, 2012; Snowling, 2008;
Moll, Loff, & Snowling, 2013).
Although the current study did not focus on the effectivity of the intervention per se, but rather aimed at gaining insight into factors that
can predict responsiveness to intervention, the intervention gains
were derived from national normative data rather than from a direct
comparison with a control group within a randomized control trial
(RCT) design. Our study thus indicates that the DA procedure is able
to predict changes between pretest and posttest, but cannot establish
whether these changes result from the intervention. However, it is important to add that findings from a recent RCT-study on the effectivity
of the LEXY program demonstrated that children with dyslexia showed
substantial reading and spelling gains after the intervention and improved at a faster rate than both typical readers and waiting-list controls
(Fraga González et al., 2015).
Although our findings indicate that our DA is able to significantly
predict progress in reading and spelling skills during specialized intervention, with up to 19% of uniquely explained variance, its predictive
power is modest from a clinical perspective. It should be noted, however, that, as we focused on Tier 4 intervention, all children within our
sample were characterized by severe and persistent reading and spelling disabilities, limiting variability. Based on the results from other studies (for example Cho et al., 2014 and Petersen et al., 2014) it seems
plausible that the predictive potential of the DA will increase when applied to Tier 3 or even Tier 2 intervention.
The findings of the current study raise a number of interesting questions. First, why is LSIs the best predictor among the three DA variables?
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One possible explanation is that, while LSIa is related to the understanding of the newly learned letter–speech sound correspondences, LSIs, in
addition, provides an index of the ability to instrumentally use these
correspondences. This interpretation is in line with the literature on
dysfunctional letter–speech sound learning, suggesting that the amount
of automation of the concerning units at a neuronal level and in identification latencies at a behavioral level, reflects the extent to which the
quality of the learned association enables fluent reading (Aravena et
al., 2015; Blomert, 2011; van Atteveldt & Ansari, 2014; Widmann,
Schröger, Tervaniemi, Pakarinen, & Kujala, 2012). Within this context,
LSIs seems to be the purest measure of one's ability to automate the
learned associations and it is this ability that may to a large extent determine one's responsiveness to intervention.
A second interesting question is why progress in reading speed
seems much more difficult to predict than prog...
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