Hyperlexia: An SLP's Point of View - Phyllis Kupperman, MA, CCC-SLP/L www.csld.org

Hyperlexia:
An SLP’s Point of View
  Phyllis Kupperman, MA, CCC-SLP/L
           phyllisk@csld.org
           www.csld.org
                 © 2018

A Brief History
•   My story: How I became aware of
    hyperlexia.
•   History in the literature
    – There is no clear agreement on definition in the
      literature.
    – Silberberg and Silberberg (1967) introduced the term
      hyperlexia
    – Others had described precocious and unexpected
      reading abilities previously (Parker, 1919; Phillips,
      1930; Kanner, 1943)

Differing Views on the Definition
•   Authors agreed that the reading decoding
    level was unexpected when compared to
    age or intellectual functioning.
•   Authors agreed that decoding was more
    advanced than reading comprehension.
    •   Most agreed that reading comprehension was
        impaired.
    •   Most agreed that deficits in reading
        comprehension were related to deficits in
        language comprehension.

Differing Views on the Definition, cont.
 •   Authors agreed that hyperlexia is often
     associated with ASD.
     •   However, hyperlexia may also be associated
         with other disorders.
 •   Hyperlexia may not be caused by the
     disorder with which it is associated.

Prevalence
•   Few studies of prevalence have been done.
•   Since it is not a stand-alone diagnosis, the prevalence
    may be under-reported.
•   Burd and Kerbeshian (1985) using the DSM III definition
    of PDD at the time, identified four children in a group of
    66 with PDD who presented with hyperlexia (6 percent).
•   Grigorenko, Klin, Pauls, Senft, Hopper and Volkmar
    (2002) found in a sample of 80 children referred for
    evaluation at the Yale Developmental Disabilities Clinic,
    12 were identified with hyperlexia (15 percent). All of
    those identified with hyperlexia also were diagnosed
    with autism or (PDD-NOS) in their referred sample.

Profile of Strength & Weakness
        Characteristics of Children
         Who Develop Hyperlexia
•   Children who develop a hyperlexic reading style have a
    particular profile of cognitive and linguistic abilities,
    coupled with considerable reading experience, plausibly
    resulting from narrow-focused preoccupations with
    reading
•   Relative strengths - phonological and orthographic skills,
    rote memory
•   Relative weaknesses - semantic skills
•   Exceptional levels of practice and exposure to print
(Nation, 1999)

Profile of Strength & Weakness
       Characteristics of Children
     Who Develop Hyperlexia, cont.
•   Does this profile of strengths and weaknesses arise
    from differences in neural organization?
•   Are these children’s brains “wired differently” as a
    result of their underlying disorder and relative to
    their hyperlexia?
•   Recent developments in neuroimaging are
    beginning to illustrate these differences, but do not
    yet tell us why the differences occurred.

Neural Organization
•   Data from earlier electroencephalogram
    (EEG) studies is inconsistent and conflicting
    (Elliott & Needleman, 1976; Goldberg &
    Rothermel, 1984; Huttenlocher &
    Huttenlocher, 1973; Mehegan & Dreifuss,
    1972).
•   Some found variations in EEG’s and some
    did not. Sample sizes were small.

Neural Organization, cont.
•   Landmark study - Turkeltaub, Lynn-Flowers, Miranda,
    Gareau, and Eden (2004)—The Neural Basis of Hyperlexic
    Reading: An fMRI Case Study
    •   During a covert reading task, the functional magnetic
        resonance imaging (fMRI) of a 9-year-old boy with
        hyperlexia was compared to two groups in a previous
        normative study
        •   Chronological age matches
        •   Reading age matches
•   Results - The 9-year-old boy with hyperlexia showed:
    •   Greater activity in the left inferior and superior temporal
        cortices than chronological age—and reading age-matched
        controls
    •   Greater activity in the right inferior temporal sulcus than
        reading age-matched controls

Neural Organization, cont.
Turkeltaub et al. (2004), cont.
• Findings suggest:
  •   simultaneously drawing on both left hemisphere
      (phonological) and right hemisphere (visual
      systems) brings about precocious reading
  •   hyperlexic reading is associated with
      hyperactivation of the left superior temporal
      cortex (Note: dyslexia is associated with
      hypoactivation in this area)
  •   follow-up studies have not been done yet

Human Connectome Project
Diffuse Tensor Imagining mapping neural connectivity

Human Connectome Project
   Diffuse Tensor Scan

Human Connectome Project
  White Matter DT Scan

Neural Organization, cont.
Neuron (http://www.cell.com/neuron/abstract/50896-6273(14)00651-5)
August, 2014

• Researchers found a surplus of synapses in brains
  of autistic children and adolescents due to
  slowdown of pruning process. A drug that restores
  normal pruning can improve autistic-like behaviors
  in mice, but has side effects.

“While people usually think of learning as requiring the
  formation of new synapses, the removal of inappropriate
  synapses may bejust as important.” (Sulzer, 2014)

Questions
•   Can we use hyperlexic reading to improve language
    skills?
•   Can the precocious reading skills be used to improve
    social and behavioral functioning?
•   Are there implications for academic success in children
    with hyperlexia?
•   Children with hyperlexia often display similar language,
    social, and behavioral patterns. Is hyperlexia the
    central characteristic with associated behaviors, or is
    hyperlexia is a symptom displayed by some individuals
    who are diagnosed with language, social, or behavioral
    disorders?

The Blind Men and the Elephant

Clinical Cases at the Center for
        Speech and Language Disorders
•   During the past 30+ years, we have seen hundreds of
    children with hyperlexia. Our experiences have mirrored
    those reported in the literature. These include:
    •   Monozygotic twins concordant for autism and hyperlexia
    •   Micro-preemies with early brain insults with hyperlexia who also
        met criteria for ASD
    •   Nonverbal apraxic children, with and without autism, with
        precocious reading and spelling skills
    •   Children with all degrees of severity of ASD who were hyperlexic
    •   Children who were clearly not ASD, but who had language disorders
        and hyperlexia
    •   Children whose deficits improved dramatically with therapy and
        children whose primary deficits persisted

Clinical Cases at the Center for
Speech and Language Disorders, cont.
•   Some of these children were precocious spellers as
    well. They could type, write or arrange plastic
    letters at an early age.
•   Reading comprehension was deficient, mirroring
    their deficits in language comprehension.
    Conversely, they could understand what they could
    read about as well as they could understand oral
    language. Higher-level comprehension of inference
    and abstraction was deficient.

Clinical Presentation
•   We define hyperlexia in terms of the
    following clinical presentation:
    – Children who read unexpectedly and
      precociously within the context of another
      developmental disorder
      •   Autism spectrum disorder
      •   Language disorder
      •   Cognitive impairment
      •   Nonverbal learning disability
      •   Social (pragmatic) communication disorder

Clinical Presentation, cont.
•   We will not define hyperlexia solely as a discrepancy
    between decoding and comprehension since that
    definition does not describe precocious and unexpected
    reading abilities in the context of other deficits.
•   Typical readers can decode material that they do not
    comprehend because they may lack the background
    knowledge or schema necessary for higher-level
    comprehension. This discrepancy is not characterized as
    hyperlexia.
•   We will not dismiss hyperlexia as mere “word-calling”
    since the children we see understand many of the words
    they read.
•   We do not marginalize hyperlexia as a “splinter skill” since
    it is a key element of the child’s learning style.

Common Characteristics
•   May decode phonetically
•   May learn many sight words
•   Reading decoding occurs before the age of five
•   May spell (orally, type, write or “air-write”)
•   Early reading may begin with high interest words,
    logos, titles, signs
•   Early fascination with letters and words may be
    intense
•   May attend to written words better than to pictures
•   May teach themselves to read by intense repetition of
    children’s videos, computer programs and/or books

Common Characteristics, cont.
•   Reading comprehension generally lags
    behind.
•   Reading comprehension mirrors difficulties
    in language comprehension.
•   Early reading comprehension for concrete
    material may be adequate, but difficulties
    arise in higher-level interpretation of
    abstract and inferential material.

Effect of Gestalt Processing
                 (Prizant, 1982)
•   Reduced flexibility in   •   Echoed language
    comprehension and            patterns, chunks of
    use of language to           language are used.
    communicate.
                             •   Precise intended
•   Literal comprehension        meaning of the
    of language.                 speaker not conveyed.
•   Reduced discerning of    •    Need to listen for
    nuances of meaning            meaning.
    and intention.

Identifying Hyperlexia
•   Since hyperlexia is not a stand-alone
    diagnosis, nor is it a distinct syndrome
    described in the DSM-5, it is identified on
    the basis of its presenting symptoms.
•   If the child demonstrates precocious and
    unexpected reading within the context of
    another developmental disability in formal
    and informal assessment, the term
    hyperlexia can be applied.

Why Identify Hyperlexia?
•   In our experience and as reported in some
    literature, the precocious reading can be
    used as a powerful tool in language
    intervention.
•   It is a key element in the child’s learning
    style.
•   It is a strength that can be used to scaffold
    and remediate weaknesses.

Intervention
•   Although the literature is contradictory as
    to whether the presence of hyperlexia
    affects the outcome in children with ASD
    (Grigorenko et al. 2002; Burd & Kerbeshian,
    1988), the following two articles describe
    how using written language and reading as
    an intervention strategy improved language
    skills.

Intervention, cont.
•   Kistner, Robbins and Haskett (1988)
    reported on a study of a minimally verbal
    girl with hyperlexia and autism, whose
    ability to decode words was used to
    increase her functional speech.
•   Written prompts resulted in rapid increase
    in appropriate verbal responses in
    naturalistic settings.

Intervention, cont.
•   Craig and Telfer (2005) describe a case study of scaffolding
    language growth over time in a boy with hyperlexia and
    ASD.
•   Although this boy’s comprehension lagged behind his
    reading decoding and writing abilities, intervention was
    successful in using these abilities to build oral language
    comprehension, expression, academics and social
    interactions.
•   Visual priming and written schedules aided school
    performance.
•   In general, using his strengths provided an excellent
    in-road into his growth in language comprehension when
    auditory stimuli were not adequate.

Intervention, cont.
•   Whether or not reading is used in therapy, work toward
    meaningful comprehension must be the primary goal of
    intervention.
•   As Aram (1997) phrased it, “If the printed words provide a
    motivational ‘in’ or help concretize what is being taught,
    then print might well be appropriate. If, on the other
    hand, the printed word becomes a stimulus for over
    learned, ritualistic behavior largely devoid of meaningful
    comprehension, then print is not appropriate for
    furthering such a child’s comprehension abilities.”
•   Although Aram’s point is well taken, in our experience we
    have been able to develop ritualistic decoding into
    meaningful intervention by drawing children into new
    activities based on their obsessions.

Intervention, cont.
•   Goals for treatment are created relative to
    the child’s primary diagnosis and
    presentation. Language goals will relate to
    the child’s language disorder or to the
    communication deficits related to ASD.
•   Treatment is based on efficacious methods
    to meet established therapy goals for each
    child, taking into account the child’s
    learning style and adding written language
    as a support.

Intervention, cont.
•   Typical learning style
    – Visual learner
    – Pattern seeker
    – Difficulty with auditory/language processing
    – Gestalt processor of language (Prizant,1982)
        • Learns language in chunks and through echolalia without
          necessarily attaching meaning to each word
    –   Strong auditory and visual learning memory
    –   Strong verbal imitation skills
    –   Concrete, rigid and literal thinker
    –   Likes routines

Intervention, cont.
•   Typical learning style, cont.
    –   May have focused interests
    –   Difficulty picking up incidental
        language/information from the background
    –   Difficulty with language formulation
    –   Difficulty with social reciprocity, perspective-
        taking (ToM) and conversation

Intervention, cont.
•   Match intervention tactics to learning style
    –   Use strengths in reading decoding to develop
        weaknesses in language comprehension
    –   When in Doubt, Write it Out! (Beedham, n.d.)
    –   Write, write, write because children with
        hyperlexia will read, read, read (Miller, 1993)

Intervention - General Tactics
•   Write lists, rules, and schedules
•   Offer choices
•   Use written and visual models
•   Use cloze sentence formats and patterned language
•   Use scripts and models and ask the child to repeat
•   Provide demonstrations rather than explanations
•   Teach one way, and then reverse the process
•   Use rote learning and frequent repetition
•   Write questions and write answers

Intervention - General Tactics , cont.
 •   Build background information (schemas)
 •   Use high interest activities
 •   Teach reading comprehension directly
 •   Read, write and tell stories
 •   Use a positive reward system
 •   Use social stories and social rules
 •   Collaborate with parents and school staff

 (adapted from Hyperlexia: Therapy that Works, CSLD 2002)

Outcomes
•   We have followed several hundred children with
    hyperlexia over the past 30+ years.
•   Outcomes have varied with the severity of the
    language disorder, the presence and severity of
    co-morbid autism spectrum disorders, and with
    the type and intensity of intervention offered.
•   While the precocious reading can be used for
    initial language scaffolding, the issues of higher-
    level language comprehension and social
    functioning become paramount as the child gets
    older.

Outcomes, cont.
•   Here is a sampling of some of our case outcomes:
    – AF - Affected by ASD and epilepsy. His reading decoding
      skills and written expression are far above his reading
      comprehension and social language abilities. He is a well-
      behaved and pleasant young man who loves to peruse
      cookbooks and take adventure trips with his dad.
    – CT - Diagnosed with a language disorder and hyperlexia
      when he was four. He graduated from college with a
      degree in computer information systems.
    – JM - Diagnosed with an ASD and hyperlexia, earned his
      college degree in music. He works full-time at a national
      laboratory using computer skills. He lives on his own and
      drives his own car.

Outcomes, cont.
–   CM - Despite a successful high school career in
    academics and sports, he has had a difficult time
    motivating himself to pursue higher education. He
    lives at home, has a steady job, but likes his
    routines.
–   OL - With a few residual mild symptoms of ASD. He
    graduated from college, is doing well at his job, and
    just bought his own townhouse.
–   KD - With a diagnosis of Asperger's. This
    accomplished poet is living with her parents and
    slowly pursued an associate degree at a
    community college and maintained an “A” average.

Outcomes, cont.
•   Younger children with hyperlexia are in a variety of
    educational settings depending on the degree of their
    co-morbid disorders.
•   Some are in general education with support services.
•   Some are fully included in general education with an
    aide.
•   Some receive resource services for up to 50 percent of
    the school day.
•   Some are in instructional special education classes.
•   Some parents have opted for home school or private
    school programs.
•   All receive speech and language pathology services.

Lessons to be Learned
•   Craig and Telfer (2005) summed it up well,
    “[Jason’s] case underscores the importance
    of attending to a client’s strengths as well
    as weaknesses. As clinicians, we may
    identify strengths, but then ignore them as
    we focus on the deficit areas. This case
    study demonstrates how beneficial it can
    be to use a child’s strengths in one domain
    to leverage language growth in others.”

A Final Note
“It has been my pleasure to join the journeys of
these interesting and unusual children and their
devoted families. While they have taught us much
about the nature of hyperlexia, as can be seen from
the literature, the enigma remains.”
- Phyllis Kupperman

References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental
     disorders (5th ed.). Washington, DC: Author
Aram, D. (1997). Hyperlexia: Reading without meaning in young children. Topics in
     Language Disorders, 17(3), 1-13.
Beedham, E. (n.d.). When in doubt, write it out! Retrieved from
     http://judyanddavid.com/cha/our_story/eric.html.
Burd, L., Fisher, W., Knowlton, D., & Kerbeshian, J. (1985). Hyperlexia: A marker for
     improvement in children with pervasive developmental disorder. Journal of the
     Academy of Child and Adolescent Psychiatry, 26(3), 407-412.
Burd, L., & Kerbeshian, J. (1985). Inquiry into the incidence of hyperlexia in a statewide
     population of children with pervasive developmental disorders. Psychological Reports,
     57, 236-238.
Center for Speech and Language Disorders (2002). Hyperlexia: Therapy that works: A
     guide for parents and teachers. Elmhurst, IL: Author.
Cossu, G., & Marshall, J. (1986). Theoretical implications of the hyperlexia syndrome: Two
     new Italian cases. Cortex, 22, 579-589.
Craig, H.K., & Telfer, A.M. (2005). Hyperlexia and autism spectrum disorder: A case study
     of scaffolding language growth over time. Topics in Language Disorders, 25(4), 364-
     374.
Elliot, E., & Needleman, R. (1976). The syndrome of hyperlexia. Brain and Language, 3,
     339-349.

Fisher, W., Burd, L., & Kerbeshian, J. (1988). Markers for improvement in children with
    pervasive development disorders. Journal of Mental Deficiency Research, 32, 357-
    369.
Frith, U., & Snowling, M. (1983). Reading for meaning and reading for sound in autistic
    and dyslexic children. Journal of Developmental Psychology, 1, 329-342.
Glosser, G., Friedman, R., & Roeltgen, D. (1996). Clues to the cognitive organization of
    reading and writing from developmental hyperlexia, Neuropsychology, 10, 168-175.
Goldberg, T.E., & Rothermel, R.D. (1984). Hyperlexic children reading. Brain, 107, 759-
    785.
Grigorenko, E.L., Klin, A., Pauls, D.L., Senft, R., Hooper, C., & Volkmar, F. (2002). A
    descriptive study of hyperlexia in a clinically referred sample of children with
    developmental delays. Journal of Autism and Developmental Disorders, 32(1), 3-12.
Grigorenko, E. L., Volkmar, F., & Klin, A. (2003). Hyperlexia: Disability or superability?
    Journal of Child Psychology and Psychiatry, 44, 1079-1091.
Healy, J. (1982). The enigma of hyperlexia. Reading Research Quarterly, 3, 319-338.
Huttonlocher, P., & Huttonlocher, J. (1973). A study of children with hyperlexia. Neurology,
    23, 1107-1116.
Kanner, I. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217-250.
Kistner, J., Robbins, F., & Haskett, M. (1988). Assessment and skill remediation of
    hyperlexic children. Journal of Autism and Developmental Disorders, 18(2), 191-205.
Kupperman, P. (1997). Precocious reading skills may signal hyperlexia. The Brown
    University Child and Adolescent Behavior Letter, 13, 2-4.

Kupperman, P. (2010). The reading comprehension kit for hyperlexia and autism level 2.
    East Moline, IL: LinguiSystems. (www.proedinc.com)
Kupperman, P. (2012). The source for social competency. East Moline, IL: LinguisSystems
Kupperman, P.(2017). The source® Intervention in Autism Spectrum Disorders, Second
    Edition, Austin, TX: Pro-Ed. (www.proedinc.com)
McClure, P.H., & Hynd, G.W. (1983). Is hyperlexia a severe reading disorder or a symptom
    of psychiatric disturbance? Nosological considerations. Clinical Neuropsychology, 4,
    145-149.
Mehegan, C., & Dreifuss, F. (1972). Hyperlexia: Exceptional reading ability in brain
    damaged children. Neurology, 22, 1105 -1111.
Miller, S.M. (1993). Reading too soon. Lombard, IL: Center for Speech and Language
    Disorders.
Nation, K. (1999). Reading skills in hyperlexia: A developmental perspective. Psychological
    Bulletin, 125(3), 338-355.
Newman, T.M., Macomber, D., Naples, A. J., Babitz, T., Volkmar, F., & Grigorenko, E.L.
    (2007). Hyperlexia in children with autism spectrum disorders. Journal of Autism and
    Developmental Disorders, 37(4), 760-774.
Parker, S.W. (1919). Pseudo-latent for words. Psychology Clinics, 11, 1-7.
Pennington, B., Johnson, C., & Welsh, M. (1987). Unexpected reading precocity in a
    normal preschooler: Implications for hyperlexia. Brain and Language, 30, 165-180.
Phillips, A. (1930). Talented imbeciles. Psychology Clinics, 18, 246-265.

Prizant, B. (1982). Gestalt language and gestalt processing in autism. Topics in Language
    Disorders, 3, 16-23.
Richman, L., & Kitchell, M. (1981). Hyperlexia as a variant of developmental language
    disorder. Brain and Language, 12, 203-212.
Seymour, P., & Evans, H. (1992). Beginning reading without semantics: A cognitive study of
    hyperlexia. Cognitive Neuropsychology, 9(2), 89-122.
Siegel, L. (1993). The modularity of reading and spelling: Evidence from hyperlexia. In
    G.D.A. Brown, & N.C. Ellis (Eds.), Handbook of normal and disturbed spelling. Sussex,
    UK: John Wiley.
Silberberg, N., & Silberberg, M. (1967). Hyperlexia: Specific word recognition skills in young
    children. Exceptional Children, 34.
Smith, I.M., & Bryson S.E. (1988). Monozygotic twins concordant for autism and hyperlexia.
    Developmental Medicine & Child Neurology, 30(4), 527.
Snowling , M., & Frith, U. (1986). Comprehension in hyperlexic readers. Journal of
    Experimental Child Psychology, 42, 392-415.
Temple, C.M. (1990). Auditory and reading comprehension in hyperlexia: Semantic and
    syntactic skills. Reading and Writing: An Interdisciplinary Journal, 2(4), 297-306.
Treffert, D.A. (2002). Hyperlexia: Reading precociousness or savant skill? Retrieved from
    http://www.wisconsinmedicalsociety.org.
Turkeltaub, P.E., Lynn-Flowers, D., Verballs, A., Miranda, M., Gareau, L., & Eden, G.F.
    (2004). The neural basis of hyperlexic reading: An fMRI case study. Neuron, 41, 11-25.
Vicker, B., & Naremore, R. (2002). The wh- question test. Bloomington, IN: Indiana
    Resource Center for Autism.