unlocking the code. dyslexia assessment, treatment & developmental theory ann w alexander,m.d....
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UNLOCKING THE CODE
DYSLEXIA
ASSESSMENT, TREATMENT
&
DEVELOPMENTAL THEORY
ANN W ALEXANDER,M.D.THE MORRIS CENTER
GAINESVILLE, FL
JANE LAWYER M.ED.WELINGTON ALEXANDER CENTER
SCOTTSDALE, AZ IDA 11 / 07
WHAT IT IS ?
DYS = TROUBLE
LEXIA = WORDS
TROUBLE WITH
“WRSD”
(WORDS)
THE PICTURE OF DYSLEXIA(ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
ORAL LANGUAGECHALLENGES
LISTENING
Memory for word sequence
(phone numbers, directions)
Poor PHONOLOGICAL
AWARENESS
ForeignLanguage
SPEAKING
Word Finding
Multi-syllables
SequencingIdeas
ForeignLanguage
THE PICTURE OF DYSLEXIA
WRITTEN LANGUAGECHALLENGES
(ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
READING
Mechanics Comprehension
SpeedMechanics
Speed
SPELLING/WRITING
ExpressingIdeas
CLINICAL PICTURENONLINGUISTIC
COGNITIVE: PHONOLOGICAL WORKING MEMORY, EF SENSORIMOTOR
FINE MOTOR SEQUENCINGWEAK ORAL / FINGER SOMATOSENSORY MAPS LOW TONE, POSTURAL INSTABILITY
SLOW RESPONSE TIME IMPAIRED PROCESSING OF RAPIDLY PRESENTED SEQUENTIAL AUDITORY, VISUAL, & SOMATOSENSORY INPUT
DEFICITS IN :
DEPRESSION, OCD, ANXIETY
ADHD 20-50 %
BEHAVIOR
THE PICTURE OF DYSLEXIA(ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
ACCOMPANYING CHALLENGES(SENSORIMOTOR)
Oral MotorMessy Eating
Writing/knots Fingers
Eyes
Tired
Words Swim
LosePlace
Spatial Awareness
Up/Down
Left/Right
THE PICTURE OF DYSLEXIA(ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
ACCOMPANYING CHALLENGES(BEHAVIORAL)
Parents with similarchallenges
Brain / BehaviorDisorders
Attention /Executive Function
Anxiety
Depression
OCD
OppositionalBehavior
MORRIS CENTER FLORIDA STATE
KATIE PRE - Rx
40
50
60
70
80
90
100
110
PPVT P IQ CELF-R CELF-E WRMT-A WRMT-I WRMT-C
ST
AN
DA
RD
SC
OR
E
PRE
KEY
PPVT – VOCABULARY
PIQ – PERFORMANCE IQ, WISC-3
CELF – ORAL LANGUAGE :RECEPTIVE
& EXPRESSIVE
WRMT-R – ORAL READING : WORD ATTACK,
WORD ID, COMPREHENSION
OUR CAT MIMI LIKES TO SIT ON THE ROOF.
MIMI GOES UP TO THE TALL TREE BY THE HOUSE.
THEN SHE JUMPS ON THE ROOF. SHE SITS AND LOOKS AT BIRDS.
BUT SHE ALWAYS COMES DOWN WHEN IT IS TIME TO EAT.
DEVELOPMENTAL DIFFERENCES
PRESCHOOL:
SENSORIMOTOR ORAL LANGUAGE ATTENTION
EARLY ELEMENTARY:
PRINT RECOGNITION
LETTER – SOUND KNOWLEDGE
MECHANICS OF READING
HANDWRITING
ATTENTION
DEVELOPMENTAL DIFFERENCES
HIGH SCHOOL / ADULT: READING EFFICIENCY
COMPREHENSION
FOREIGN LANGUAGE
ATTENTION
MID ELEMENTARY / MIDDLE SCHOOL: COMPREHENSION
WRITTEN EXPRESSION
ATTENTION
LANGUAGE(BUILDING BLOCKS)
18 MONTHS ___
1 MONTH ___
9 MONTHS ___
5 YEARS ___
9 YEARS ___
PHONOLOGY(FORM)
PRAGMATICS(FUNCTION)
SEMANTICS
(MEANING)
SYNTAX
(FORM)
READING
WRITINGSPELLING
METALINGUISTIC
WHAT IT IS ?
DYS = TROUBLE
LEXIA = WORDS
TROUBLE WITH
“WRSD”
(WORDS)
PHONOLOGY
EXECUTIVE FUNCTION / INTENTION
WORKING MEMORYHOLD / MANIPULATE
(PERCEPTION / PRODUCTION)
ATTENTION / AROUSAL
ACOUSTIC
SUBREPRESENTATION
VISUAL
SUBREPRESENTATION
MOTOR ARTICULATORY
SUBREPRESENTATION
SOMATOSENSORY ARTICULATORY
SUBREPRESENTATION
PHONEMIC REPRESENTATION
PROSODICREPRESENTATION
(WORD LEVEL)
EARLY READING DEVELOPMENT
UNLOCKING THE CODE
VISUAL /
ORTHOGRAPHYAUDITORY /
PHONOLOGY
LANGUAGE
SEMANTICS
SYNTAX
COMPREHENSION
FLUENCY
3 – LEGGEDSTOOL
VISUAL /
ORTHOGRAPHYAUDITOR
Y /
PHONOLOGY
LANGUAGE
SEMANTICS
SYNTAX
COMPREHENSION
FLUENCY
3 – LEGGEDSTOOL
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
AUDITORY /
PHONOLOGY
PHONOLOGICAL AWARENESS
THE CORE DEFICIT
WHAT IS PHONOLOGICAL AWARENESS?
PHONOLOGICAL PROCESSING
A CORE INGREDIENT FOR ORAL AND
WRITTEN LANGUAGE DEVELOPMENT
THREE COMPONENTS
LEXICAL RETRIEVAL / RAPID NAMING
PHONOLOGICAL AWARENESS
PHONOLOGICAL WORKING MEMORY
THE “PHON” WORDS
PHONOLOGICAL AWARENESS
PHONOLOGICAL SENSITIVITY (e.g. RHYMING)
UMBRELLA TERM THAT INVOLVES ABILITY TO APPRECIATE THAT WORDS ARE COMPRISED OF CHUNKS OF SOUNDS
THE “PHON” WORDS
PHONEMIC AWARENESS
ABILITY TO APPRECIATE AND MANIPULATE INDIVIDUAL SOUNDS IN WORDS (e.g.BLENDING AND SEGMENTING)
FALLS UNDER UMBRELLA OF
PHONOLOGICAL AWARENESS
THE “PHON” WORDS
PHONICS
IS NOT PHONOLOGICAL AWARENESS
SKILL THAT MUST BE TAUGHT
PHONOLOGY + ORTHOGRAPHY
READ “BRUP,” “SPROIGILTY”
THE “PHON” WORDSANOTHER CORE
DEFICIT
PHONOLOGICAL WORKING MEMORY
ESSENTIAL FOR EXECUTIVE FUNCTION
DISTINCT PHONEME REPRESENTATIONS
ATTENTION
RECEPTIVE LANGUAGE (RLS)
Oral Directions (OD)
Word Classes (WC)
Semantic Relationships (SR)
Listening to Paragraphs (LP)
CLINICAL EVALUATION OF LANGUAGE FUNDAMENTALS -REVISED
EXPRESSIVE LANGUAGE (ELS)Formulating Sentences (FS)Recalling Sentences (RC)Sentence Assembly (SA)
CLINICAL EVALUATION OF LANGUAGE FUNDAMENTALS -REVISED
GROWTH IN “PHONICS” ABILITY OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME
AWARENESS AND LETTER KNOWLEDGE
6
2
4
1 2 3 4 5
1
3
5
5.9
2.3
Low PA
K
Ave. PA
GRADE LEVEL CORRESPONDING TO AGE
RE
AD
ING
GR
AD
E L
EV
EL
AverageLow
(Torgesen & Mathes, 2000)
GROWTH IN SIGHT WORD READING ABILITY OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND
LETTER KNOWLEDGE 6
Low PA 5.7
3.5
2
4
1
3
5
K
Ave. PA
GRADE LEVEL CORRESPONDING TO AGE 1 2 3 4 5
RE
AD
ING
GR
AD
E L
EV
EL Average
Low
(Torgesen & Mathes, 2000)
GROWTH IN READING COMPREHENSION OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND
LETTER KNOWLEDGE
SAME VERBAL ABILITY – VERY DIFFERENT READING COMPREHENSION
1 2 3 4 5
3.4
2
4
6
1
3
5
K
6.9
GRADE LEVEL CORRESPONDING TO AGE
RE
AD
ING
GR
AD
E L
EV
EL
AverageLow
(Torgesen & Mathes, 2000)
WHAT TO DO !!
ASSESSMENT OF STRENGTHS AND WEAKNESSES
NEUROCOGNITIVE
PSYCHOSOCIAL
ASSESSMENT DRIVES TREATMENT
BELL SHAPED CURVENORMAL POPULATION DISTRIBUTION
PROFILE GRAPHBRAIN TEAM
SEVERE AT RISK AVERAGE SUPERIOR GIFTED
WEAKNESS RANGE STRENGTH
Standard Scores 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135
Percentiles 1st 2nd 5th 9th 16th 25th 37th 50th 63rd 75th 84th 91st 95th 98th 99th
ATTENTION/ INTENTION
Visual
Auditory
INTELLIGENCE/COGNITION
Verbal IQ
Executive Processes
Processing Speed
ORAL LANGUAGE
Phonological Awareness
(Morpho)Syntactic Awareness
Receptive (Listening)
Expressive (Speaking)
Word Retrieval (Naming)
MEMORY
Aud. Working Memory
Vis. Working Memory
SENSORIMOTOR
Visual Processing
Visuo/Motor Ability
PROFILE GRAPHBRAIN TEAM PERFORMANCE
SEVERE AT RISK AVERAGE SUPERIOR GIFTED
WEAKNESS RANGE STRENGTH
Standard Scores 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135
Percentiles 1st 2nd 5th 9th 16th 25th 37th 50th 63rd 75th 84th 91st 95th 98th 99th
WRITTEN LANGUAGE
Word Reading (Real)
Word Reading (Rate)
Word Reading (Nonsense)
Word Reading (Rate)
Passage Comprehension
Passage Fluency
Writing/Written Expression
Writing Fluency
Spelling
ARITHMETIC
Concepts
Operations
Applications
Fluency
REMEDIATION STUDY
2 TREATMENTS – BOTH EXPLICIT PHONICS RX
SEVERE DYSLEXIA 2nd %ILE FOR WORD READING 35th %ILE IQ (SS 92)
Torgesen, et al, 2001, NICHD
OLDER CHILDREN (8 – 10 YRS)
A “BOTTOM UP” (LiPS) VS. A “TOP DOWN” (EP)
LANGUAGE DEVELOPMENT
(BUILDING BLOCKS)
18 MONTHS ___
1 MONTH ___
9 MONTHS ___
5 YEARS ___
9 YEARS ___
PHONOLOGY(FORM)
PRAGMATICS(FUNCTION)
SEMANTICS
(MEANING)
SYNTAX
(FORM)
READING
WRITINGSPELLING
METALINGUISTIC
PRINCIPLES OF LEARNING WHAT FIRES TOGETHER, WIRES
TOGETHER – MULTIPLE SENSES
ATTENTION
CONSISTENT INPUT
INTENSITYSALIENTFREQUENT REPETITION IS KEY
REMEDIATION STUDY
EQUAL TIME AND INTENSITY 1:1
100 MINS DAILY
8-9 WEEKS
TOTAL 67.5 HRS
RESEARCH DEMONSTRATES BOTH IMMEDIATE & LONG LASTING RESULTS IN BROAD
READING (DECODING+COMPREHENSION)S
tan
dar
d S
core
75
80
85
90
95
InitialTest
Pre-Treatment
Test
Post-Treatment
Test
1 YearAfter
Treatment
2 years
Normal Range of Performance
9-WeekIntensiveProgram
Torgesen, Alexander, Wagner et al, 2001
16 Mos.
Special Ed Class
72
96
*91
*
91
*
TWO YEAR FOLLOW UP
READING RESULTS
GORT-R
70
80
100
STA
ND
AR
D
SC
OR
E
90
WORD ATTACKWRMT-R
TEXT READING
ACCURACY
READING COMP.
TEXT READING
RATE
68
74
83
71
30th percentile
Torgesen, Alexander, Wagner et al, 2001
* p= <.05N = 50
SPOKEN LANGUAGE GAINS
REMEDIATION STUDY
Measurement Point
Pre Post 1 year 2 year
80
85
90
95
100PA
RAN
Sta
nd
ard
Sco
reDifferential Growth in Basic Processing Skills
MORRIS CENTER FLORIDA STATE
86.2
95.2
93.8
87.4
CELF-R OUTCOMES: 67.5 HOURS OF INTENSIVE INTERVENTION
70
80
100
STA
ND
AR
D
SC
OR
E
90
REC-L EXP-L REC-EP EXP-EP
79.7
76.2
85
78.5
30th percentile
PRE 2yr 2yrPRE
EFFECT SIZE OF TREATMENT ON LANGUAGE COMPREHENSION & EXPRESSION
LIPS EPPRE - POST PRE - 2 YRS PRE - 2 YRSPRE - POST
RLS
OD
WC
SR
LP
ELS
FS
RS
SA
1.05
0.75
0.61
0.61
0.62
0.85
0.60
0.24
0.75
0.97
0.75
0.44
0.93
0.58
0.71
0.70
0.54
0.49
0.49
0.31
0.50
0.37
0.03
0.70
0.44
0.20
0.76
1.05
0.46
0.84
0.43
0.38
0.67
0.60
0.16
0.78
P<= 0.05ES of 0.5 – 0.7 moderate; 0.8 + large
MORRIS CENTER FLORIDA STATE
KATIE 1 Yr.
KEYPPVT – VOCABULARYPIQ – PERFORMANCE IQ, WISC-3CELF – ORAL LANGUAGE :RECEPTIVE
& EXPRESSIVEWRMT-R – ORAL READING : WORD ATTACK,
WORD ID, COMPREHENSION
40
50
60
70
80
90
100
110
120
130
PPVT P IQ CELF-R CELF-E WRMT-A WRMT-I WRMT-CS
TA
ND
AR
D S
CO
RE
POST Rx
PRE Rx
1 Yr
OUR CAT MIMI LIKES TO SIT ON THE ROOF.
MIMI GOES UP TO THE TALL TREE BY THE HOUSE.
THEN SHE JUMPS ON THE ROOF. SHE SITS AND LOOKS AT BIRDS.
BUT SHE ALWAYS COMES DOWN WHEN IT IS TIME TO EAT.
LONG TERM GAIN RESISTERS
VARIABLES RESULTING IN POOR PROGRESS
WEAK ATTENTION
LOWER SES
20 % OF SUBJECTS WHO HAD IMMEDIATE GAINSHAD NOT CONTINUED READING GAINS AT 2yr FOLLOW UP
POOR RECEPTIVE LANGUAGE
PREVENTION STUDY
PRESCHOOL PREDICTORS OFFUTURE READING SUCCESS
NOT IQ !!!
ALL OF THESE PREDICTORS ARE DEPENDENT ON A STRONG PHONOLOGICAL SYSTEM
RAPID NAMING of OBJECTS, COLORS
LETTER NAME KNOWLEDGE
PHONOLOGICAL AWARENESS
PREVENTION STUDY MID KG - END 2ND GRADE
SCREENING - BOTTOM 10TH %ILE
FREQUENCY - 20 MINS/DAY - 4 DAYS / WEEK
INTENSITY - 1:1, 67 HRS.
TEACHERS & AIDES
4 METHODS - PASP, EP, RCS, NTC
Torgesen et al, 1999, NICHD
PREVENTION STUDY OUTCOME
ONLY PASP YIELDED SIGNIFICANT PHONOLOGICAL AWARENESS AND WORD READING GAINS
END OF 2ND GRADE: 50TH %ILE WORD READING SKILLS (ACCURACY AND FLUENCY).
OTHERS NO BETTER THAN NO TREATMENT CONTROL
BEST PREDICTORS OF GROWTH IN READING: ATTENTION/BEHAVIOR, HOME BACKGROUND, AND P/A.
A SOLUTION TO THE PROBLEM OF THE FLUENCY GAP: PREVENTIVE INTERVENTIONS
10th 10th
70
80
90
100S
TA
ND
AR
D S
CO
RE
Accuracy
Rate
4th
GRADE
2nd
GRADE
30th % ile
BEGINNING % ile
TREATMENT AGE 5-6 5-6
LATE VS EARLY INTERVENTION (PREVENTION)
WORD READING ACCURACY AND RATE
2nd 10th 10th 10th
70
80
90
100S
TA
ND
AR
D S
CO
RE
Accuracy
Rate
4th grade
2nd grade
30th % ile
BEGINNING % ile
TREATMENT AGE 8-11 5-6 5-68-11
PROJECTED GROWTH IN “SIGHT VOCABULARY” OF NORMAL READERS AND DISABLED CHILDREN
BEFORE AND AFTER REMEDIATION
Normal
InterventionSiz
e o
f “s
igh
t voca
bu
lary
Grade in School
1 2 3 4 5 6 7
Dyslexic
2nd Year follow-up
Later intervention does not close fluency gap – early intervention does
Torgesen, www.fcrr.org
EARLY INTERVENTION IS URGENT!
50TH %ILE 5TH GRADE READER 600,000 WORDS A YEAR
AVERAGE STUDENTS RECEIVE ABOUT 10 TIMES AS MUCH PRACTICE IN A YEAR
(Anderson, Wilson, & Fielding, 1988)
10TH %ILE 5TH GRADE READER 50,000 WORDS A YEAR
PROFILE GRAPHBRAIN TEAM
SEVERE AT RISK AVERAGE SUPERIOR GIFTED
WEAKNESS RANGE STRENGTH
Standard Scores 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135
Percentiles 1st 2nd 5th 9th 16th 25th 37th 50th 63rd 75th 84th 91st 95th 98th 99th
ATTENTION/ INTENTION
Visual
Auditory
INTELLIGENCE/COGNITION
Verbal IQ
Executive Processes
Processing Speed
ORAL LANGUAGE
Phonological Awareness
(Morpho)Syntactic Awareness
Receptive (Listening)
Expressive (Speaking)
Word Retrieval (Naming)
MEMORY
Aud. Working Memory
Vis. Working Memory
SENSORIMOTOR
Visual Processing
Visuo/Motor Ability
PROFILE GRAPHBRAIN TEAM PERFORMANCE
SEVERE AT RISK AVERAGE SUPERIOR GIFTED
WEAKNESS STRENGTH
Standard Scores 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135
Percentiles 1st 2nd 5th 9th 16th 25th 37th 50th 63rd 75th 84th 91st 95th 98th 99th
WRITTEN LANGUAGE
Word Reading (Real)
Word Reading (Rate)
Word Reading (Nonsense)
Word Reading (Rate)
Passage Comprehension
Passage Fluency
Writing/Written Expression
Writing Fluency
Spelling
ARITHMETIC
Concepts
Operations
Applications
Fluency
HOW DOES THIS IMPACT TREATMENT PLANNING?
ASSESS THE ROOT CAUSE OF LANGUAGE DISORDER
TREAT FROM BOTTOM UP IN A DEVELOPMENTAL SEQUENCE
BEGIN WITH CORE LANGUAGE FOUNDATIONS
FOLLOW PRINCIPLES OF LEARNING
PRINCIPLES OF LEARNING WHAT FIRES TOGETHER, WIRES
TOGETHER – MULTIPLE SENSES
ATTENTION
CONSISTENT INPUT
INTENSITYSALIENTFREQUENT REPETITION IS KEY
RESPONSE TO INTERVENTION MODEL
APPLICATION OF EVIDENCE-BASED TREATMENT TO SCHOOLS
TIER 1: CLASSROOM BLOCK
TIER 2: PULL OUT SUPPORT + CLASS
TIER 3 :TOTAL PULL OUT (2 – 4 HRS)
A TIERED APPROACH
LITCHFIELD SD RESULTS 1st GRADE
101
113
96
70
80
100
STA
ND
AR
D
SC
OR
E
90
WORD ATTACK
WORD ID PASSAGE COMP.
83
72
85
30th percentile
N = 63
*
* p= <.05
110
**
101108
98
LITCHFIELD SD RESULTS 2nd GRADE
70
80
100
STA
ND
AR
D
SC
OR
E
90
WORD ATTACK
WORD ID PASSAGE COMP.
96
9395 30th percentile
N = 64
* *
* p= <.05
110
101100
96
LITCHFIELD SD RESULTS 3rd – 5th GRADES
70
80
100
STA
ND
AR
D
SC
OR
E
90
WORD ATTACK
WORD ID PASSAGE COMP.
9191
95 30th percentile
N = 126
* **
* p= <.05
CONCLUSION
TREATMENT IS MOST EFFECTIVE IF:YOUNGER AGE INTENSIVEEXPLICIT PHONOLOGICAL/PHONICSATTENTION IS OPTIMAL
“BOTTOM-UP” MORE EXPLICIT PHONOLOGIC APPROACH: PREVENTION YOUNGER DYSLEXIC
MILD TO MOST SEVERE DYSLEXIA LANGUAGE IMPAIRMENTAUDITORY WORKING MEMORY WEAKNESS
“TOP-DOWN” PHONICS APPROACH:AFTER 3RD GRADE
MILD TO MODERATELY SEVERE DYSLEXIA
Acknowledgments
National Institute of Child Health and Human Development
Joe Torgesen Carol Rashotte Rick Wagner Pat Lindamood Tim Conway Jane Lawyer