MS042 Differential Diagnosis and Treatment  for Dysgraphia, Dyslexia, OWL LD, and Dyscalculia

Virginia W. BerningerNicole Alston-Abel

University of Washington, Seattle, WA

NASP, Boston, Feb. 25, 2009, 2-3:50 pmMarriott Tufts (3rd Floor)

Today’s Presentation

• 1. Providing a Conceptual, Research-Based Model for Diagnosis and Treatment of 4 specific learning disabilities

• 2. Diagnostic Flow Charts for each specific learning disability

• 3. Treatment Implications• 4. Problem Solving Consultation with Teachers• 5. Building Trusting, Caring, Culturally Sensitive

Home-School Connections

Grant Acknowledgements

1. Multidisciplinary Learning Disabilities Research Center Grant, Biological and Educational Links to Learning Disabilities

P50 33812 1995-2006 from NICHD.2. Interventions for Component Writing Skills, HD 25858-06-12 from

NICHD, 1995-2008. 3. Assessment of Component Writing Processes, HD 25858-01-03

from NICHD, 1989-1992 4. Shannon Award, HD 15858-04-05 from NICHD, 1992-1994. 5. Identifying and Nurturing Early Mathematical Talent, 1993-1996,

from the US Department of Education (Javits Gifted Grant). 6. Early intervention to prevent reading disabilities in urban,

minority children. 1989-1990, Institute for Ethnic Studies in US. 7. Microcomputer-assisted diagnosis of writing disabilities. 1987-

1988, University of Washington Graduate School Research Fund.

People Acknowledgements

• Graduate students in school psychology and related fields at the University of Washington. Collaborators at the University of Washington, especially Dr. Robert Abbott, Statistician, and other institutions.

• Participating children and their teachers, parents, and families.• Psychological Corporation staff for translating research tasks

into nationally normed psychometric measures and peer reviewed instructional research into instructional tools: Especially Dr. Aurelio Prifitera for the idea and PAL Project Directors Dr. Donna Smith (1997-1999), Dr. Louise O’Donnell (2002-2006), and Dr. James Holdnack (2006-present) who worked closely with Dr. Larry Weiss. Dr. Sylvia Abbott (Ph.D. University of Washington) helped to write the PAL Lesson Plans.

Dysgraphia, Dyslexia, and OWL LD Are DiagnosesThat Have Treatment Implications

• Educational Paradox: For the most part assessment and treatment are divorced for academic skills in that professionals specialize in one but not the other.

Teachers teach. Psychologists assess. :. Teaching is often not tailored to assessment of the

individual student or differential diagnosis of the LDs. • In contrast, in the fields of medicine, mental health,

physical and occupational therapy, and speech and language

assessment and treatment of the individual are entrusted to the same professional who develops conceptual models for linking them.

Modeling Phonological Core Deficit within Working Memory

Word Form Storage (phonological*, orthographic*, morphological*)Phonological Loop (time-sensitive coordination of phonological codes) [RAN]*Executive Functions for phonological processes (Inhibition and Supervisory Attention* [RAS switching attention])Berninger et al. (2006) Scientific Studies in Reading * PAL II has measure.

PAL II Working Memory Model for Reading and Writing

Assessment and Instruction

Executive Functions Inhibition, Set Switching, Task Maintenance, and Retrieval Fluency

Syntax for Multiple Words

POM

P-O

P-M

Morphological

O-M

OrthographicPhonological

PhonologicalLoop

OrthographicLoop

For dysgraphia,orthographic coding and sequential hand movements—the orthographic loop--are critical.

Executive Functions Inhibition, Set Switching, Task Maintenance, and Retrieval Fluency

Syntax for Multiple Words

POM

P-O

P-M

Morphological

O-M

OrthographicPhonological

PhonologicalLoop

OrthographicLoop

For dyslexia, focus on 3 word forms, phonological loop, and executive functions.

PAL II Working Memory Assessment-Instruction Model

Executive Functions Inhibition, Set Switching, Task Maintenance, and Retrieval Fluency

Syntax for Multiple Words

POM

P-O

P-M

Morphological

O-M

OrthographicPhonological

PhonologicalLoop

OrthographicLoop

For OWL LD, focus on syntactic and morphological awareness and word finding strategies + all working

memory components.

PALII Working Memory Assessment-Instruction Model

Tier 3: Dyslexia Can Be Differentiated from Other Specific Learning Disabilities Affecting Written Language

Scientifically supported diagnosis is as important as scientifically supported instruction.

3 Research-Supported Specific Written Language Disabilities: Dysgraphia, Dyslexia, Oral and Written Language Learning Disability (OWL LD)

Require scientifically supported assessment and diagnosis by qualified psychologists and speech and language specialists.

Behavioral expression can vary across development. May have common and unique genetic and neurological

bases; effective treatment shares some common instructional components but also requires unique instructional components.

Relationship between Word Form Deficit in Working Memory and Diagnosis

PAL II User Guide

Morphological/SyntaxPhonological,Orthographic

Phonological,Orthographic

Ortho-graphic Dysgraphia

Dyslexia

Oral and Written Language Learning

Disability (OWL LD)

Dysgraphia

Problem in handwriting automaticity—retrieving and producing legible letters effortlessly and fast,

Problem in spelling with or without indicators of dyslexia, Problem in finger motor planning, and/or Problems in executive functions for self-regulating the

composing process (fluency and quality). Note: Handwriting problems may not show IQ-achievement

discrepancy but spelling and composing do. Typically those with dysgraphia do not qualify for occupational therapy services. Those who do have severe motor problems have handwriting problems for other reasons and also require treatment specialized for specific motor problems.

phonological

Phonological & ORTHOGRAPHIC LOOP and ExecutiveFunctions in Working Memory

morphological

ORTHOGRAPHIC

Teach Phonological and

Working Memory Skills Explicitly

Specialized Specialized Instruction for Instruction for DysgraphiaDysgraphia

Instruction for Dysgraphia

• Teach plan for letter formation (study numbered component strokes in model letter form) --overcomes sequential finger movement problem.

• Cover letter and hold letter form in working memory for increasing duration (photographic leprechaun).

• Write letter from memory and compare to model. Revise if necessary.

Instruction for Dysgraphia

• Only practice each of 26 letters once in session “writers’ warm-up (avoid habituation, all letters equal opportunity to become automatic).

• Always name letter at each stage (study, cover, see in mind’s eye in memory, write from memory, and compare to model)—facilitates retrieval fluency.

• Always teach for transfer—follow letter writing practice with composing on a teacher-provided prompt and share writing with peers (communication of ideas).

Instruction for Dysgraphia

• Teach for Letter Retrieval from long-term memory (Writing letters that come after and before other letters—transfers to longer compositions).

• Teach self-monitoring and other-monitoring of letter legibility (recognizable out of word context) in written compositions.

Instruction for Dysgraphia

• Monitor progress—assess automatic letter writing (first 15 seconds), total letter legibility, and letter writing speed (total time).

• Teach letter writing—do not just use keyboards as accommodation. Research is showing that in K to 6 writing by pen results in longer texts, faster writing, and more idea expression than writing by keyboard.

• Teach keyboarding explicitly before expecting students to use word processor for writing assignments.

Developmental Model

1. Teach Integrated Letter Form Writing and Letter Form Naming: Big Strokes for Little Folks (by Rubell, Therapy Skill Builders) introduces letters by common strokes and includes activities for developing motor control in forming legible letters. Goal: Legibility (others can recognize) and Accurate letter formation.

2. Teach automatic letter form writing (direct retrieval and production). PAL Lesson Set 3 or Handwriting Lessons.

3. Teach fluent retrieval of letter forms during composing. 4. Teach self-monitoring of letter writing.

Orthographic Lessons (Looking Games) PAL Guides 1998 (pp. 192)

Show written word (on chalk board, overhead, or written list at student’s desk) from the reading or spelling curriculum briefly (about 1 second) with this instruction while sweeping finger under the word in left to right direction: “Look carefully at each letter in this word.”

Then cover the word with a card and ask the children to spell the word or write a designated letter or letter group (orally taking turns or everyone writing independently).

Then uncover the word and play one of the games on the

next slide.

Orthographic Lessons (Looking Games) PAL Guides 1998 (pp. 192)

1. Direct children to look carefully at this written word: breakfast

2. Cover word for about 1 second.

3. 3a. Whole Word Game: Now spell what you saw (do not name the word—so children have to rely on memory for all the letters in the word). breakfast

4. 3b. Letter in a Word Game: Now name (or write) the first letter in the word (then the last letter). b, t

5. 3c. Letter Groups/Clusters in a Word Game: Now name (or write) the first two letters (br), the last two letters (st), and the third and fourth letters (ea).

PAL 1998b Handwriting Lessons

Instructions: “Study the numbered arrow cues in ____(name letter). Cover ____(name letter). (Start with 1 sec delay between covering and writing letter and increase.) Now write_____(name letter). Compare_____(name letter) to the model letter. If your ____(name letter) looks different from the model letter, fix it so it looks the same. ”

Instructional Adaptation: Ask children to name letters as they write them.

Alphabet Retrieval Game for Improving Automatic Retrieval PAL Guides (pp. 193)*

• Name or Write the letter that comes after these letters: a, s, w, g, m.

• Name or Write the letter that comes before these letters: u, r, t, l, i.24 sets of five after and five before items to use in the context of a writing lesson aimed at all levels of language.

• *also in the PAL II User Guide.

Instruction for Dysgraphia

• Teach manuscript letters first. If children become automatic in manuscript proceed to cursive.

• Research showed no advantage for cursive writing for at-risk 1st graders. Manuscript writing has greater transfer from writing to reading and from reading to writing (especially in word processing environment).

• Introduce cursive writing. If too difficult (e.g. child has dysgraphia) focus on becoming a reader of cursive rather than writer of cursive. Let children choose preferred writing format and teach and practice that until automatic. Research showed that good writers choose a mix of manuscript and cursive or manuscript only. In Australia children can choose their preferred writing format more choose manuscript.

Response to Instruction Letter Writing (by hand)

PAL II Alphabet Writing*: Print the letters of the alphabet in order as accurately and quickly as you can without making a mistake. Use manuscript not cursive writing.

PAL II Copy A*: Copy sentence with all the letters in the alphabet from a model (no memory requirements).

PAL II Copy B: Copy paragraph—sustain handwriting over time in three 30 second intervals.

Scores: *Automatic legible letter writing (first 15 seconds)

Legible letter writing.

Legible letter writing speed (total time)

Dyslexia

Problems in accuracy and rate of oral reading of words and text and pseudowords and/or spelling

Skills above discrepant from Verbal Comprehension Index (Verbal IQ) and below population mean.

Language (except for phonology) is a relative strength that can mask severe problems in working memory that are invisible without assessment.

Processing deficits in orthographic, phonological, RAN, and executive functions (Inhibition and RAS).

Writing as well as reading disability because spelling problems, which tend to persist beyond the reading problems, shown to be linked to written composition.

Reading problems may resolve in elementary grades but writing problems persist and these students need explicit instruction in writing and reading-writing integration K -12 (and not just accommodations).

phonological

Phonological& OrthographicLoops and ExecutiveFunctions in Working Memory

morphological

orthographic

Teach Phonological and

Working Memory Skills Explicitly

Specialized Specialized Instruction for Instruction for DyslexicsDyslexics

24 Phonological Lessons PAL Guides1998 (pp. 196-219)

Four games played to develop syllable segmentation skills:

Find the Hidden Is ant hidden in can’t? in Andy?

Say the Missing Say carelessly. Now say lessly. What is missing?

Say the Word Without Say friendliness. Now say it without ness.

Substitute Say garden. Now don’t say it with den, say it with ter.

Phonological Lessons PAL Guides 1998 (pp. 196-219)

Four games played to develop phoneme segmentation skills:

Find the Hidden Does the word begin with /m/ as in mother? make? time?

Say the Missing Sat mice. Now say ice. What is missing?

Say the Word Without Say wave. Now say it without /w/.

Substitute Say sad. Now say it with /h/ instead of /s/.

Awareness of Orthographic and Morphological Word Form and Parts

See Looking Games for Handwriting. Also in PAL Lesson Sets 11, 12, and 15.

See Morphological Awareness activities in PAL Lesson Sets 11, 12, and 15.

Instruction for Dyslexia*In Berninger and Abbott (2003) and PAL II User Guide.

*Teach PAL Lesson Set 11 (phonological, orthographic, and morphological awareness, word decoding, fluency, comprehension)

*Teach PAL Lesson Set 12 (phonological, orthographic, and morphological awareness, word decoding, fluency, and comprehension)

*Teach PAL Lesson Set 15 ( phonological, orthographic, and morphological awareness, decoding, fluency, and comprehension) Science Experiments

Note: To overcome working memory problems teach procedural knowledge rather than declarative knowledge (rules) and teach to all levels of language close in time.

PAL Lesson Set 11(Berninger et al., Journal of School Psychology, 2006)

Subword: Phonological (Sound Games with Jabberwocky words), Orthographic (Looking Games with Jabberwocky words), and Morphological (Inflectional Suffixes) Awareness + Alphabetic Principle (Talking Letters, reading direction) and Word Families (learned best as multi-letter units of more than 2 letters each)

+ Word: Applying Talking Letters to reading Jabberwocky words and Fry’s Instant Words (high frequency)

+ Text: Guided reading of chapter book and cold/hot rereadings of graded material for fluency (Read Naturally)

Progress Monitoring: List 12b letter and word probes; text rate probes

Intervention for Reading (Berninger, 2000 LDQ;;

S. Abbott & Berninger, 1999; Carlisle & Rice, 2004)

PAL Lesson Sets 12 and 15 for phonological, orthographic, and morphological awareness, decoding words of Latinate and Greek as well as Anglo Saxon origin, reading fluency, and reading comprehension.

4th Grade Carlisle (1996) Reasoning with Reading (Vocabulary Meaning, Sentence Interpretation, and Paragraph Understanding). Educators’ Publishing Service, Cambridge, MA.

Response to Instruction

Assess: accuracy and rate of oral reading of pseudowords

(PAL II, TOWRE, KTEA-2) accuracy and rate of oral reading of real words on

lists (WIAT II, PAL II Morphological Decoding, TOWRE, KTEA-2) or passages (GORT-4 accuracy, rate, fluency)

spelling real words (WIAT II Spelling, PAL II Word Choice) and pseudowords (WJ III Spell Sounds)

Response to Instruction

Assess for working memory components: accuracy (WIAT II items 4 to 29) and rate of letter naming

(RAN—single letters and letter groups, that is phonological loop),

awareness of phonological word form and its parts (PAL II rhyming, syllable, phoneme, and rime),

orthographic word form and its parts (PAL II receptive and expressive orthographic coding), and

morphological word form and its parts (PAL II Does it fit? Are they related? Finding the fixes), and

executive function (Rapid Alternating Switching, RAS).

OWL LD

• Who are the children who are low in oral reading and spelling but do not show IQ achievement discrepancy?

• Extremely impaired in morphological and syntactic awareness and often word retrieval

• Also impaired in all the working memory components that children with dyslexia are

• Fast responders to phonics but persisting real word reading and reading comprehension problems

Oral Language + Written Language Disability (OWL LD)

Problems in decoding, reading words, oral reading fluency, and/or reading comprehension

Problems in writing (spelling + syntax) Typically no IQ-achievement discrepancy based on Full

Scale (or Verbal IQ) But substantial oral language problems in phonological,

morphological, and syntactic awareness and often word retrieval that require treatment.

Struggle in learning oral language and then in using oral language to (a) learn from teacher talk and (b) learn written language.

phonological

Phonological & Orthographic Loops and ExecutiveFunctions in Working Memory

morphological

orthographic

Teach Phonological and

Working Memory Skills Explicitly

Specialized Instruction Specialized Instruction for OWL LDfor OWL LD

syntax

Dyscalculia

• Dyscalculia.ppt

To obtain additional materials from Dr. Beninger’s sessions at NASP-

• Go to:

www.brainshark.com/pearsonassessments/Berninger_NASP09