Learning to read is an extremely complex process, which has been described to be as challenging as learning rocket science.1 Therefore, it is not too surprising that, for many reasons, over 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.
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 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 letters, which is a skill needed to decode the written word. Alternatively, dyslexia in some children results from problems with oral language skills, sight word recognition, processing speed, comprehension, attention, or verbal working memory.
Anatomical and imaging studies investigating brain development and function show a corresponding physical basis for dyslexia in language-related areas of the brain. The brains of persons with dyslexia function differently 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 compensatory use of the bilateral inferior frontal gyri of both hemispheres and the right occipitotemporal area.3
In discussing the definition of dyslexia and its causes, it is also useful for pediatricians to be aware of the many myths and misperceptions that exist. Dyslexia is not a condition where readers see letters or words upside down or backwards. 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, normal, and high intelligence quotients (IQs) alike. The fact that dyslexia 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 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 and diagnosis
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 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 dyslexia include prematurity, neurological problems, and developmental or language delays.
Early warning signs for dyslexia in preschool-aged 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 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 exist, 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.
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 5 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 (eg, recorded books, text reading software, note takers, spell checkers) as well as provisions to enable test taking (eg, extended testing time, a special quiet room, or preferential seating).
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2. Nation’s Report Card. Nine subjects, three grades, one report card. Available at: http://www.nationsreportcard.gov/. Accessed July 19, 2016.
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11. American Academy of Pediatrics. Books Build Connections Toolkit. Available at: https://littoolkit.aap.org/Pages/home.aspx. Accessed July 19, 2016.