Joint Technical Report-Learning Disabilities, Dyslexia, and Vision abstract
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Organizational Principles to Guide and Define the Child
Health Care System and/or Improve the Health of all Children
Joint Technical Report—Learning Disabilities,
Dyslexia, and Vision
Sheryl M. Handler, MD, Walter M. Fierson, MD, and the
abstract SECTION ON OPHTHALMOLOGY AND COUNCIL ON CHILDREN
WITH DISABILITIES, AMERICAN ACADEMY OF OPHTHALMOLOGY,
Learning disabilities constitute a diverse group of disorders in which AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND
children who generally possess at least average intelligence have STRABISMUS, AND AMERICAN ASSOCIATION OF CERTIFIED
problems processing information or generating output. Their etiolo- ORTHOPTISTS
gies are multifactorial and reflect genetic influences and dysfunction KEY WORDS
of brain systems. Reading disability, or dyslexia, is the most common learning disabilities, vision, dyslexia, ophthalmology, eye
examination, vision therapy
learning disability. It is a receptive language-based learning disability that
ABBREVIATIONS
is characterized by difficulties with decoding, fluent word recognition,
ADHD—attention-deficit/hyperactivity disorder
rapid automatic naming, and/or reading-comprehension skills. These dif- IDEA—Individuals With Disabilities Education Act
ficulties typically result from a deficit in the phonologic component of ADA—Americans With Disabilities Act
language that makes it difficult to use the alphabetic code to decode the IEP—individualized education plan
EBM—evidence-based medicine
written word. Early recognition and referral to qualified professionals for SSS—scotopic sensitivity syndrome
evidence-based evaluations and treatments are necessary to achieve the This document is copyrighted and is property of the American
best possible outcome. Because dyslexia is a language-based disorder, Academy of Pediatrics and its Board of Directors. All authors have
treatment should be directed at this etiology. Remedial programs should filed conflict of interest statements with the American Academy of
Pediatrics. Any conflicts have been resolved through a process
include specific instruction in decoding, fluency training, vocabulary, and approved by the Board of Directors. The American Academy of
comprehension. Most programs include daily intensive individualized in- Pediatrics has neither solicited nor accepted any commercial
struction that explicitly teaches phonemic awareness and the application involvement in the development of the content of this publication.
of phonics. Vision problems can interfere with the process of reading, but The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
children with dyslexia or related learning disabilities have the same visual
into account individual circumstances, may be appropriate.
function and ocular health as children without such conditions. Currently,
This technical report supports the joint policy statement from the
there is inadequate scientific evidence to support the view that subtle eye American Academy of Pediatrics, American Academy of
or visual problems cause or increase the severity of learning disabilities. Ophthalmology, American Academy of Pediatric Ophthalmology and
Because they are difficult for the public to understand and for educators to Strabismus, and American Association of Certified Orthoptists titled
“Learning Disabilities, Dyslexia, and Vision,” which is available at
treat, learning disabilities have spawned a wide variety of scientifically www.aap.org (direct link: www.aappolicy.org/cgi/reprint/pediatrics;
unsupported vision-based diagnostic and treatment procedures. Scien- 124/2/837.pdf) and www.aao.org(direct link: www.aao.org/about/
tific evidence does not support the claims that visual training, muscle policy/upload/Learning-Disabilities-Dyslexia-Vision-2009.pdf).
exercises, ocular pursuit-and-tracking exercises, behavioral/perceptual All technical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
vision therapy, “training” glasses, prisms, and colored lenses and filters revised, or retired at or before that time.
are effective direct or indirect treatments for learning disabilities. There is
no valid evidence that children who participate in vision therapy are more
responsive to educational instruction than children who do not partici-
pate. Pediatrics 2011;127:e818–e856
INTRODUCTION
www.pediatrics.org/cgi/doi/10.1542/peds.2010-3670
Reading is the complex process of extracting meaning from abstract
doi:10.1542/peds.2010-3670
written symbols. In modern societies, reading is the most important
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
way to access information, and in today’s Western society, literacy is a
prerequisite for success. In elementary school, a large amount of time Copyright © 2011 by the American Academy of Pediatrics
and effort is devoted to the complicated process of learning to read.
Because of the difficulties encountered in teaching some children to
read, Congress mandated that the Eunice Kennedy Shriver National
e818 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
Institute of Child Health and Human De- angular gyrus immediately posterior proving perceptual and/or perceptual-
velopment assemble a national panel to Wernicke’s area.4 Morgan,2,5 a gen- motor development, they were
of educators and scientists to re- eral practitioner from England, pub- ineffective in improving academic per-
search the optimal methods of teach- lished the first case of a child with formance.9–12 Although the use of per-
ing children to read. The 2000 report of congenital word blindness in 1896. ceptual and perceptual-motor training
the National Reading Panel, titled Subsequently, Hinshelwood turned his by educators persisted for a time, by
Teaching Children to Read: An attention to both congenital and ac- the mid-1980s its use had waned
Evidence-Based Assessment of the Sci- quired word blindness. He credited the considerably.
entific Research Literature on Reading term “dyslexia” to Berlin.6 In 1917, he Attempts at improved understanding
and Its Implications for Reading In- highlighted the potentially inherited of dyslexia led to the rejection of the
struction,1 linked research findings aspect of reading disability. Hinshel- visual theories. This process began
with recommendations for specific ap- wood estimated that 1 in 1000 students with a series of related studies that
proaches to teaching reading to all in elementary schools might have systematically evaluated traditional
children. The panel concluded that word blindness and postulated that and widely accepted etiologic concep-
existing evidence supported early the primary disability was in visual tualizations, such as Orton’s optical re-
explicit instruction in phonemic memory for words and letters. He versibility theory,7 Hermann’s spatial
awareness, phonics-based reading strongly advocated intensive, individu- confusion theory,13 and other theories
programs, and guided oral reading to alized personal instruction.2,4 that implicated deficits in visual pro-
improve fluency. cesses, such as visualization, visual se-
Beginning in the 1920s, Orton,2,7,8 a neu-
Learning disabilities may interfere ropsychiatrist, demonstrated a hered- quencing, and visual memory, as basic
with children reaching their full poten- itary component for reading disabili- causes of reading difficulties.14,15
tial. The inability to read and compre- ties in children. His studies led to an Although Orton attributed dyslexia to
hend is a major obstacle to learning expanded definition of reading disabil- visual dysfunction, he was the first to
that may have long-term educational, ities that was much broader than Hin- advocate intensive phonics instruc-
social, and economic implications. shelwood’s and included a graded se- tion, sound-blending, and multisen-
Teaching children with reading diffi- ries of all degrees of severity of sory training.2,8 Orton’s work served as
culties is a challenge for the student, disability. This more liberal definition the stimulus for Gillingham and Still-
parents, and educators. Therefore, the increased the presumed prevalence to man,16 who also emphasized multisen-
causes and treatment of reading dis- more than 10% of schoolchildren. IQ sory training. Subsequently, the Orton-
orders have been the subject of con- testing revealed that these children Gillingham phonics techniques have
siderable thought and study. scored near or above average. In 1925, served as the basis for many remedia-
This report discusses how we learn to Orton attributed dyslexia to a problem tion programs. The International Dys-
read, the phonologic model, the recog- in the visual system, which suggests lexia Society, formerly the Orton Dys-
nition and treatment of reading diffi- that an apparent dysfunction from lexia Society, provides information and
culties, visual function and reading, “mixed cerebral dominance” caused resources to professionals and par-
the magnocellular deficit theory, col- problems in visual perception and ents regarding reading disabilities.
ored lenses and overlays, vision ther- visual memory, characterized by per-
apy, and the roles of the pediatrician ception of letters and words in Learning Disabilities
and ophthalmologist. reverse. Learning disabilities constitute a di-
BACKGROUND The theory that visual dysfunction verse group of disorders in which chil-
caused dyslexia led to a proliferation dren who generally possess at least
History of training programs developed for average intelligence have problems
In 1877, Kussmal2,3 first described a visual-perceptual and/or visual-motor processing information or generating
case of acquired word blindness in an disabilities. In the 1960s, those promi- output. Learning disabilities can affect
adult alexic patient with a parietal lobe nent in developing and promoting neurocognitive processes and may
lesion. Hinshelwood,2,4 an ophthalmol- these programs included Kephart, manifest as an imperfect ability to lis-
ogist from Scotland, studied and de- Frostig, Getman, Barsch, Dorman, and ten, speak, read, spell, write, reason,
scribed an adult with word blindness Delacato. Research into the programs concentrate, solve mathematical prob-
in 1895. In 1903, an autopsy of this pa- revealed that, although these pro- lems, or organize information. Some
tient revealed abnormalities in the left grams were sometimes effective in im- children may have associated difficul-
PEDIATRICS Volume 127, Number 3, March 2011 e819
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015ties with motor coordination. Learning interactions, and motor function and as writing.28 People with dyslexia read
difficulties can be associated with and may show inappropriate response to slowly, but not all people who read
complicated by attention-deficit/hy- sensory information.23 slowly have dyslexia.
peractivity disorder (ADHD),17,18 oppo- Approximately 80% of people with
sitional defiant disorder, obsessive Dyslexia
learning disabilities have dyslexia,
compulsive disorder, anxiety, or de- Difficulties in reading are found in a which makes it the most common
pression.19 Problems in self-regulatory diverse group of conditions that in- learning disability.24,25,30–35 Depending
behaviors, social perception, and so- clude dyslexia and secondary forms of on the definition chosen, the preva-
cial interaction may exist with learning reading difficulties caused by visual or lence of reading disability is approxi-
disabilities but do not, by themselves, hearing disorders, intellectual disabil- mately 5% to 20% of school-aged
constitute a learning disability. Al- ity, experiential and/or instructional
children in the United States.21,24,31,34
though learning disabilities may occur deficits, and other problems.14,24–26
Reading disabilities seem to affect
concomitantly with other disabilities Dyslexia is defined as a primary read-
males slightly more than females,36–38
(eg, sensory impairment, intellectual ing disorder that is separate from
although schools identify boys with
disability, serious emotional distur- secondary forms.14,24–26 The terms
them twice as often as girls.22,31 Both
bance) or with extrinsic influences (eg, “specific reading disability,” “reading
environmental and genetic influences
cultural differences, insufficient or in- disability,” “reading disorder,” and
affect the expression of dyslexia.39 Dys-
appropriate instruction), they are not “dyslexia” are often used interchange-
lexia has been identified as having a
the result of those conditions or influ- ably in the literature.14 The term “dys-
strong genetic basis.14,24–26,30,31,40,41 Ap-
ences.20 Results of recent studies sug- lexia” is derived from Greek and
proximately 40% of siblings, children,
gest that approximately 20% of the means “difficulty with reading words.”
or parents of an affected person will
population has some degree of a learn- Dyslexia is often unexpected in relation
have dyslexia. Although dyslexia may
ing disability.21 In 2007, 2.7 million to the child’s other cognitive abilities.
be inherited, it may also exist in the
public school students (5.5% of all It is a receptive language-based learn-
absence of a family history. Results of
students in public schools) were iden- ing disability that is characterized
family and twin studies have sug-
tified as having learning disabilities by difficulties with decoding, fluent
gested that 50% of the problems in
and were eligible to receive educa- word recognition, and/or reading-
performance can be accounted for by
tional assistance under the Individuals comprehension skills. These difficul-
heritable factors; environmental influ-
With Disabilities Education Act (IDEA).22 ties typically result from a deficit in the
ences are greater in children with
phonologic component of language
Specific learning disabilities include lower IQ scores.42
that makes it difficult to use the alpha-
dyslexia (reading disability), dys- betic code to decode the written word. Reading ability and reading disability
graphia (writing disability), and dys- Secondary consequences may include occur along a continuum; reading dis-
calculia (mathematics disability). Al- reduced reading experience that can ability is represented within the lower
though not included in the Diagnostic impede growth of vocabulary, written tail of a normal bell-shaped distribu-
and Statistical Manual of Mental Disor- expression, and background knowl- tion of reading ability.21 The lower tail
ders, Fourth Edition, Text Revision23 as edge.27 A common misconception is is actually composed of reading diffi-
a specific learning disability, nonver- that dyslexia is a problem of letter or culties from both primary dyslexia and
bal learning disability comprises word reversals. Reversals of letters or secondary causes. Dyslexia is a life-
difficulties with social interactions, in- words and mirror writing occur nor- long condition that varies in degrees of
terpersonal skills, nonverbal problem- mally in early readers and writers. severity. Most children with reading
solving, visuospatial skills, motor Children with dyslexia are not unusu- disabilities have relatively mild read-
skills, reading comprehension, and ally prone to reversals. Although they ing disabilities, and a smaller number
mathematics and often coexists with do occur, reversal of letters or words, of them have more severe reading dis-
strengths in verbal skills and with flu- or mirror writing, is not included in the abilities.21,30 Because reading skills oc-
ent and accurate reading.23 Autism definition of dyslexia.14,28,29 People with cur on a continuum with no clear dis-
spectrum disorder, although not a dyslexia may be very creative and tinction between typical readers and
specific learning disability, certainly bright. In many cases, their high-level readers with dyslexia, some experts
affects learning, because people with thinking is unaffected, and they may be assert that the term “dyslexia” should
autism have difficulties with verbal gifted in mathematics, science, the be reserved for the 2% to 5% with the
and nonverbal communication, social arts, or even in unexpected areas such most severe reading deficits.43
e820 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
Dyslexia occurs at all levels of intelli- atic for older children, who are ex- derstanding that segmented units of
gence and is a persistent problem that pected to read increasingly sophisti- speech can be represented by printed
does not represent a transient devel- cated texts.53 forms.55 Phonologic awareness is the
opmental lag.* Children with poor oral Many children with reading disability basis for scaffolding written language
language skills in kindergarten often are observed to grow ashamed as they onto oral language.55
become poor readers. Over time, good struggle with skills that their class- Phonemes are the speech sounds that
readers and poor readers without in- mates master easily. This shame may enable us to tell 1 word from another.
tervention tend to maintain their rela- cause a loss of motivation to learn to For example, “pet” and “bet” are distin-
tive positions along the spectrum of read that can further compound the guished by the sounds of their initial
reading ability. Children who get off to situation. Untreated or poorly treated consonant; thus, changing the “p” to
a poor start in reading rarely catch up dyslexia may lead to frustration, low “b” changes the meaning of the word.56
on their own. A poor reader in 1st self-confidence, and poor self-esteem, Coarticulation is the merging and
grade will almost invariably stay a which substantially increases the risk overlapping of sounds into a sound
poor reader; more than 88% of these of developing psychological and emo- “bundle,” which makes oral communi-
children display similar difficulties at tional problems.19,30 cation much more efficient.55 To make
the end of 4th grade.35,44,50 Seventy-four
Approximately 15% of students with normal conversation possible, 8 to 10
percent of those children identified in
reading disability also have ADHD, phonemes per second are strung to-
3rd grade as reading disabled will re-
whereas approximately 35% of stu- gether and blended so thoroughly that
main so in the 10th grade.30,34,43,51 Read-
dents with disorders of attention also it is often impossible to separate them.
ers with dyslexia must expend more
have reading disability.19,24,30,54 How- A written word like “cat” has 3 letter-
attention, concentration, and energy
ever, the 2 disorders are distinct and sound units, although the ear hears
on the task, which makes reading un-
separable. only 1 sound, not 3, when the word
pleasant, tiring, and difficult.39 Stu-
Dysgraphia is a learning disability that “cat” is spoken aloud.
dents who cannot read well read less.
Lost practice opportunities make it dif- affects writing abilities. Disorders of Oral language development has been
ficult to acquire even average levels of written expression can manifest them- found to play a critical role in learning
reading fluency. Both inaccurate read- selves as difficulty with spelling and to read.1,35,57–59 Oral language acquisi-
ing and diminished reading practice problems putting thoughts on paper. tion is preprogrammed into human de-
cause slow growth of fluent word- The spelling deficits in dysgraphia may velopment; a drive for expression
identification skills and vocabulary be oral and/or written. Dysgraphia can through organized vocalization seems
growth. The vocabularies and concept also manifest itself as difficulty with innate to infant development, although
knowledge of children who read less writing motor coordination or poor specific languages need to be ac-
will plateau as their reading peers im- handwriting. Dysgraphia is the learn- quired. On the other hand, writing, an
prove.52 The consequences of a slow ing disability that most frequently co- artificially designed use of abstract
start in reading become monumental occurs with dyslexia because of their symbols to represent language, is an
as they accumulate exponentially over directly related phonemic base. Decod- acquired skill.34 English uses an alpha-
time.35 In the later grades, when chil- ing breaks the code receptively and en- betic system in which each letter is a
dren switch from learning to read to coding (spelling) puts it back together symbol that is an abstract building
reading to learn, reading-impaired expressively. block of that language’s phonemes
children are prevented from fully ex- (sounds). English is a phonemically
ploring science, history, literature, Phonologic Model complex language in which the 26 let-
mathematics, and the wealth of infor- Currently, the most accepted model ters of the alphabet create 44 sounds
mation that is presented in print. With for the acquisition of the ability to read or phonemes in approximately 70 let-
interventions, people with dyslexia is the phonologic model. Phonologic ter combinations.32,33,60 The phonemic
may learn to read accurately, but they awareness is the sensitivity to the complexity of a language corresponds
have a persistent problem with flu- sound structure of oral speech and to the prevalence of dyslexia, which
ency and continue to read slowly and phonemic awareness is the under- points to the linguistic origin of dyslex-
not automatically throughout their standing that speech can be seg- ia.14,29 Manifestations of dyslexia are
lives.39 The fluency deficit is problem- mented or broken into individual often worse in English because of the
sounds that signal differences in greater number of inconsistencies
*Refs 14, 20, 24–26, 28–31, 34, 35, and 44– 49. meaning, whereas phonics is the un- and exceptions within the English lan-
PEDIATRICS Volume 127, Number 3, March 2011 e821
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015guage, but dyslexia is confined neither spelling (dysgraphia) because of im- rately is a necessary skill, reading
to the United States nor to English perfectly stored representations of speed and fluency become critical fac-
speakers.14 words, although not all children with tors in ensuring that children gain
Learning to read and write is a com- poor spelling skills have dyslexia. comprehension. Fluency forms the
plex process that requires active Children with more severe forms of bridge between decoding and compre-
learning. Reading is more difficult than dyslexia may have a second deficit in hension.34
speaking, because children must be rapid automatic naming that causes Comprehension is impaired without
aware of the sound structure in spo- slow naming of letters, numbers, and efficient automatic word-recognition
ken language and then break the al- pictures, which creates a double defi- skills.55 If reading is slow and labored
phabetic code to acquire the sound/ cit.14,31,66– 69 Other children with severe because of decoding difficulties and
symbol connection. Developing this forms of dyslexia may have problems requires a large portion of their avail-
awareness is not automatic, because with their short-term working memory able conscious attention, children do
phonemes are not separated in or attention or an additional compre- not have enough attentional capacity
speech. To decode a written word, the hension deficit.70 Some children with and cognitive energy to remember
sounds must be broken apart. Unless reading difficulties also experience a what they have read, much less relate
the child can convert the printed char- deficit in orthographic skills, which the ideas to their own background
acters into the phonetic code, these are defined as difficulties with letter/ knowledge.32–34,64 Current theory main-
letters remain a mystery of lines and number orientation recognition and tains that the deficit in lower-order
circles that are devoid of linguistic memory, although these skills may im- phonologic linguistic decoding func-
meaning.34 According to Moats61 and prove with development.14,71 tion blocks access to the usually intact
the American Federation of Teachers, higher-order cognitive and linguistic
A child must first accurately decode a
teaching reading is rocket science! functions.15,24,25,30–35 Thus, it is difficult
word before it can be read fluently. Flu-
Reading comprises decoding, fluency, ency is the ability to read connected to apply general intelligence and rea-
and comprehension and requires ade- text with expression rapidly, smoothly, soning, vocabulary, and syntax to the
quate memory and sustained atten- effortlessly, and automatically with lit- reading endeavor to obtain compre-
tion. The foundation for reading is de- tle conscious attention to decoding. An hension.24,25,34 In some cases, however,
coding. Decoding, or word attack, is inexperienced reader will use the pho- other children can show comprehen-
the ability to sound out words. Poor netic method to sound out most words sion difficulties in the absence of word-
decoding is the core characteristic of and consequently will read slowly. No recognition problems. Vocabulary ac-
poor reading. Most people with dys- fluent reader uses phonics routinely. quisition in a child with dyslexia often
lexia have a neurobiological deficit in Poor decoders are stuck on the task of may not keep pace with that of a child’s
the processing of the sound structure trying to sound out words to make peers, because the less a child reads,
of language, called a phonemic deficit, sense of the text.52 The next task for the the fewer the new words to which the
which impairs decoding and prevents beginning reader is to move from the child is exposed. In addition to decod-
word identification.† The ability to early phases of “sounding out” words ing deficiencies, inadequate vocabu-
learn to decode print is determined to the more skilled phase in which lary, verbal reasoning, attention, mem-
primarily by phonologic skills such as word recognition occurs almost in- ory, and limitations in background
phonologic awareness, facility in al- knowledge also can cause reading-
stantly. Word recognition is the ability
phabetic mapping, name encoding and comprehension difficulties. Thus, any
to read words without sounding them
retrieval, and verbal memory.14 The or all of these problems can interfere
out.52 Experienced readers use the
reader with dyslexia experiences diffi- with the ultimate purpose of reading,
whole-word method and will quickly
culty in decoding and identifying which is comprehension.34
recognize most words as individual
words because of a specific impair-
units. Average readers require 4 to 14
ment in the neural representation, Neurobiology
exposures to a word before it becomes
storage, retrieval, and coding of pho-
a sight word,32,33 whereas students Dyslexia is currently believed to be
nemes.‡ Children with dyslexia often
with learning disabilities may need up neurobiological in origin, which means
experience even more difficulty with
to 40 exposures.33,72 Fluent reading re- that the problem is located physically
quires automatic phonemic decoding in the brain. There is strong scientific
†Refs 1, 14, 15, 20, 24–26, 30–35, 43, 46– 49, 55, 60,
and 62– 65. and word recognition.1,24,25,31–34,64 Al- evidence that supports the neurobio-
‡Refs 1, 24, 25, 31–34, 39, 46– 49, and 64. though the ability to read words accu- logical basis for the phonologic-coding–
e822 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
deficit theory of dyslexia.§ Both ana- written words into spoken words. It is exposure to drugs or alcohol; infec-
tomical and brain-imagery studies postulated that this abnormality is tions of the central nervous system; se-
have revealed differences in the way causal, not a result of poor reading ex- vere head injuries; cognitive difficul-
the brain of a person with dyslexia de- perience. Functional MRI studies have ties; or developmental delay.28 An early
velops and functions. Neuroanatomi- also shown brain plasticity in that history of language difficulties such as
cal changes, microarchitectural dis- the dyslexia-specific brain-activation delay or difficulty in developing speech
tortion, and MRI findings in language- profile improves after successful and language, learning rhymes, or rec-
related areas have been observed in evidence-based phonologic remedial ognizing letters and sound/symbol
the brains of patients with dyslexia, in- intervention.48,80,85 connections, may be an early indica-
cluding the absence of the normal White-matter abnormalities have also tion of dyslexia.14,24,34,35,58,62,81 Parents or
asymmetry in the language areas of been detected in association with dys- teachers may detect early warning
the brain and similar volume in the left lexia. In people with dyslexia, white- signs of learning difficulties in
and right planum temporale; normally, matter organization seems to be preschool-aged children, and early
the left planum temporale is larg- weaker in the left posterior brain re- evaluation and intervention should be
er.86– 88 Functional MRI and positron gion and seems to project too weakly considered. It is not in the child’s best
emission tomography (PET) scans within the primary reading pathways interest to “wait and see” or hope that
measure changes in metabolic activity of the linguistic left hemisphere and the child will “grow out of” his or her
and blood flow during cognitive tasks too strongly between hemispheres.53
in specific brain regions. In typical problems.91
White-matter pathways of the brain
readers, functional MRI and PET-scan However, in many cases, learning dis-
may be characterized by diffusion ten-
studies have shown that reading abilities are not discovered until chil-
sor imaging that provides a quantita-
takes place predominantly in left- dren experience academic difficulties
tive index of the organization of large
hemisphere sites including the infe- in elementary school.24,25,34,81 Many par-
myelinated axons that constitute the
rior frontal (Broca) area, which is as- ents who had noticed that their child
long-range connections of brain net-
sociated with articulation, naming, was exhibiting learning difficulties
works. Young children are able to un-
and silent reading; 2 areas in the pos- waited a year or more before acknowl-
dergo diffusion tensor imaging.
terior brain regions—the parietal edging that their child might have a
temporal region, which serves word Recent genetic-linkage studies have
problem and seeking assistance. In el-
analysis, and the left occipitotemporal identified many loci at which
ementary school, a child with reading
area, which is involved in word-form dyslexia-related genes are encoded.
disabilities may show difficulty with re-
and fluent reading; and the posterior Four candidate genes have been im-
plicated in neural migration, axonal membering words, reading, spelling,
inferior temporal cortex, which is as- handwriting, or writing speed. Teach-
sociated with lexical retrieval. Chil- growth, and brain development.89
These brain changes seem to cause ers are in a position to identify reading
dren with dyslexia, on the other hand,
phonologic and auditory processing problems before they progress signif-
use different areas of the brain when
abnormalities.89 icantly. Early identification of children
reading.㛳 People with dyslexia have
in early grades who are showing de-
demonstrated a dysfunction in the left-
RECOGNITION AND TREATMENT lays or difficulties should be a high pri-
hemisphere posterior reading sys-
Dyslexia is a disorder that affects peo- ority for elementary school teachers.
tems and have shown compensatory
use of the inferior frontal gyri of both ple of all ages, but its symptom profile Teachers need to have a strong under-
hemispheres and the right occipito- changes over time.81,90 Because dys- standing of the result of research in
temporal word-form area.¶ These lexia is both familial and heritable, af- reading theory and practice to become
studies have demonstrated that dys- fected younger siblings can often be well versed in reading development
lexia is an abnormality in the word- identified earlier. A child should be ob- and assessment.33 At all grade levels,
analysis pathways of the brain that in- served for early indications of dyslexia teachers must understand the course
terferes with its ability to convert if he or she has a family history of and the role of instruction in optimiz-
learning disabilities or has a history ing literacy development. After initial
§Refs 14, 24, 25, 30–35, 39, 40, 43, 46, 48, 49, 66, and of other factors that may be predictive school interventions have been unsuc-
73– 85. of learning disabilities including hear- cessful, evaluation for learning dis-
㛳Refs 14, 24, 25, 30, 31, 34, 39, 40, 46, 48, 49, 66, and
73– 85. ing, language, or speech problems; abilities should be considered for all
¶Refs 24, 25, 30, 31, 34, 40, 46, 48, 49, 66, and 73– 85. preterm birth; low birth weight; fetal children who present with school diffi-
PEDIATRICS Volume 127, Number 3, March 2011 e823
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015culties, even if reading difficulty is not reading disabled after 2nd grade ent or automatic, which results in a
the chief complaint.34 rarely catch up to their peers.43 Wait- slower reading rate.†† Although older
Parents should read aloud to their chil- ing for failure decreases the chances children and adults can be taught to
dren to help develop language skills of interventional success. Results of read, the time and expense of doing so
beginning as early as 6 months of longitudinal studies have shown that is enormous.34 Poor comprehension
age.92 Educational experts indicate when intervention is delayed until 3rd skills also persist and will impair the
that reading aloud to children is the grade or 9 years of age (the average ability to learn in general.
single most important activity for par- age at which these children receive Difficulties in early reading may be
ents and caregivers to do to prepare services), then approximately 74% of caused by experiential and instruc-
children to learn to read.33,35 Compre- these children will continue to have dif- tional deficits in addition to primary
hensive beginning reading instruction ficulties learning to read through high dyslexia. Some children enter school
is the best educational prevention for school.30,34,43,51 Gains are maintained with experiential deficits in oral lan-
reading problems. for at least 1 or 2 years by approxi- guage skills and general knowledge as
mately 50% of children after they re- well as delayed phonologic skills.35 Ex-
The best current approach to the prob-
turn to the school’s standard curricu- periential risk factors include being
lem of reading failure is to allocate re-
lum. These children who retain their raised in a high-poverty environment
sources for prevention and early iden-
benefits improve from year to year, but or in a home in which English is the
tification. The beneficial effects of early
they do not further catch up to typical second language or having limited ex-
identification and intervention are ap-
readers.53 posure to oral or written language. It is
parent in many studies.35 In the ele-
mentary grades, reading screening Dyslexia is most often identified in the important to recognize these children,
should be performed yearly and early primary grades, but it is not diagnosed differentiate them from children with
in the school year. Assessments for dif- in some students until later during true dyslexia, and provide proper re-
ficulties with alphabet recognition, middle or high school, when more mediation for them.
phonemic awareness and rapid nam- complex reading and writing skills are The IDEA, Section 504 of the Rehabilita-
ing in kindergarten,57,93 adding word required. In early elementary school, tion Act, and the Americans With Dis-
identification fluency in 1st grade, and some children compensate by using abilities Act (ADA) define the rights of
adding oral reading fluency in 2nd other strengths until the educational students with dyslexia and other spe-
grade can predict many of those who demands increase and make the read- cific learning disabilities.95–98 The IDEA
will have difficulty learning to read.# ing disability more evident. Reading defines a child with a disability as
Prevention and early phonologic problems diagnosed in the 4th grade someone who has any of 13 disabling
awareness intervention programs in or beyond may be secondary to poor conditions, including learning disabili-
kindergarten through 2nd grade can word recognition, a combination of ties, and who need special education
increase reading skills in many poor poor word recognition and poor com- and related services because of the
readers to average reading levels. prehension skills, or solely attribut- disability. The IDEA guarantees each
Torgesen reviewed many studies on able to poor comprehension skills. child a free, appropriate public educa-
early intervention and found that when Late emerging reading disabilities of- tion tailored to his or her individual
intervention began in the 1st grade, ten go undetected in schools. Approxi- needs and allows parents to request a
the expected incidence of reading dis- mately 10% of children with dyslexia formal educational evaluation by the
ability of 12% to 18% was reduced sub- have good word-reading skills but school district to determine if a child
stantially to 1.6% to 6%.94 If reading- have poor listening and reading- has a disability and qualifies for spe-
impaired children receive effective comprehension skills. Poor compre- cial education and related services. It
phonologic training in kindergarten hension skills are often attributable to allows parental access to all meetings
and 1st grade, they will have signifi- working-memory, semantic, and syn- and paperwork, transition planning,
cantly fewer problems in learning to tactic difficulties. Deficits in phono- and related services. The IDEA also pro-
read on grade level than do children logic coding continue to characterize vides funding for special education
who are not identified or helped until readers with dyslexia even in adoles- services.96 People with a physical or
3rd grade.** Children identified as cence and adulthood.34 Older children mental impairment that substantially
and adults may learn to read words restricts 1 or more major life activities
#Refs 1, 14, 20, 24, 30, 32–35, 43, 55, 58, 60, 64, 65, accurately, but they will not be as flu- are eligible for services under Section
and 93.
**Refs 1, 14, 19, 32, 33, 35, 41, 43, 47, 54, 60, 64, 65, 88, 90, and 95. ††Refs 14, 24, 25, 34, 35, 39, 54, 60, and 65.
e824 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
504 of the Rehabilitation Act of 1973.97 rectly in an educational intervention on a discrepancy between IQ and read-
This act protects the civil rights of stu- program when he or she first experi- ing achievement for a diagnosis of dys-
dents with disabilities and attempts to ences academic difficulties. Struggling lexia has outlived its usefulness except
remove barriers to allow them to par- learners are provided with interven- in limited circumstances.34,44,104 There
ticipate freely. Students who do not tions at increasing levels of intensity is no single standardized test used to
have 1 of the 13 included disabilities or to accelerate their rate of learning. make the diagnosis of dyslexia. Be-
meet the severity criteria but still re- The individual student’s progress is cause the hallmark of dyslexia is the
quire some assistance to be able to closely monitored to assess both the presence of a phonologic deficit in the
participate fully in school may be a learning rate and level of perfor- context of relatively intact overall lan-
candidate for a Section 504 plan. Some mance. Educational decisions about guage abilities, the diagnosis of dys-
schools use Section 504 to support the intensity and duration of interven- lexia can be far more specific.34 Indica-
learning-disabled students who need tions are based on the individual stu- tors of phonologic difficulties can be
only accommodations. Children with dent’s response to instruction. Only detected by a child’s history, by obser-
ADHD who do not need more compre- the children who do not show signifi- vation, and/or by specific tests. Fur-
hensive special education support cant improvement with the first-tier thermore, dyslexia is not diagnosed
also are frequently served under this group intervention program and the with testing in the areas of vision,
law. The ADA protects people who have second-tier targeted intense individual sensory-motor skill, or auditory pro-
a physical or mental impairment that intervention program will undergo a cessing, and it is not determined solely
restricts 1 or more major life activities full diagnostic educational assess- by medical screening or psychologi-
from discrimination. Because learning ment.14,100,101 The majority of these stu- cal/IQ testing alone.105
is considered such an activity under dents undergoing educational assess- A comprehensive evaluation is neces-
the ADA, students served under the ment will likely be identified as reading sary to determine the appropriate di-
IDEA also are covered by this law.99 disabled and qualify for special educa- agnosis for children who present with
Congress recently passed the ADA tion services. Ideally, this approach reading weaknesses. Comprehensive
Amendments Act of 2008, which be- will allow earlier and more effective evaluation in all areas of the suspect
came effective in 2009. It expanded the identification and treatment than the disability should be conducted. Such
list of major life activities to include traditional method in which the child evaluation is multifaceted and gener-
reading, thinking, and concentrating.99 must show persistent poor academic ally involves interviews with the child
As a result, more people with learning achievement for a few years before re- and family; questionnaires and rating
disabilities are now able to satisfy the ferral, assessment, and remediation. A scales completed by parents, teach-
definition of disability, gain access to “wait-to-fail” situation can occur when ers, and the student; social, develop-
reasonable accommodations, and be an ability-achievement discrepancy mental, medical, and educational his-
protected from discrimination. formula is used to determine if a stu- tories; observation of the child in the
The latest revision of the IDEA, the fed- dent qualifies for a formal diagnostic classroom; and evaluation of test da-
eral law that governs special educa- assessment for a learning disabili- ta.26 The testing can be conducted by
tion, offers 2 approaches that can be ty.35,43,65,100,101 Thus, the student has suf- trained school or outside specialists.
used in the young underachieving fered the academic and emotional The composition of testing by a school
child.14 The first method is called the strains of failure for 2 to 3 years before psychologist varies according to state
response-to-intervention (RTI) method potentially effective instruction can and school district. An evaluation by
and is designed primarily for the ele- begin. a developmental/behavioral pediatri-
mentary school grades. RTI is a multit- At all ages, dyslexia is a clinical diagno- cian, school psychologist, educational
iered approach to the early identifica- sis.81 A formal evaluation is needed to psychologist, clinical psychologist with
tion and support of students with discover whether a person has a learn- special training in learning assess-
learning and behavior needs. The RTI ing disability. The assessment tech- ments, or neuropsychologist consists
process begins with high-quality in- niques should be evidence based.102,103 of a battery of tests that will provide
struction and screening of all children Although many schools still use a dis- information on a child’s overall abili-
in kindergarten to identify any child crepancy formula to qualify students ties, particularly learning style,
who exhibits the early signs of poten- for special education, there is an information-processing abilities, aca-
tial reading difficulties. In the RTI emerging consensus among research- demic skills, and describing areas of
method, the child will be placed di- ers and clinicians that the dependence strength and weakness. The assess-
PEDIATRICS Volume 127, Number 3, March 2011 e825
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015ment may include information pro- therapy, and school-related records ment recommendations, accommoda-
vided by parents; health and develop- (ie, Section 504 plans and individual- tions, and referral suggestions.
mental history; knowledge of any ized education plans [IEPs]). Parents, After a comprehensive school evalua-
previous medical conditions; behav- teachers, and treating professionals tion, a learning disability will be diag-
ioral rating scales completed by par- are interviewed for their presenting nosed formally in some students. Un-
ents, teachers, and, if appropriate, the concerns. Neuropsychologists assess der the IDEA, a “child with a disability”
student; school observations; review intellect, memory, attention and con- is one who is eligible for special edu-
of school records; evaluation of intel- centration, perceptual and sensory cation and related services. Eligibility
lect, memory, attention, and concen- skills, executive skills, language, aca- for special education is determined by
tration; perceptual and sensory skills; demic achievement, motor skills, the IEP team. The evaluation is neces-
executive skills; language; academic social-emotional and behavioral com- sary for developing a proper treat-
achievement; motor skills; social- ponents, regulatory capacities, adap- ment plan and should also identify the
emotional and behavioral compo- tive levels, and other neuropsycholog-
different instructional methods that
nents; and adaptive levels. Such an ical phenomena to illuminate the
are most beneficial at various stages
evaluation traditionally has included neurocognitive underpinnings of spe-
of reading development for each
critical underlying language skills that cific learning disabilities as well as
child.55,59,104 To outline the educational
are closely linked to dyslexia, including their subtypes. This information is crit-
goals and services that the student
receptive-listening skills; expressive- ical in identifying the specific deficits
needs to be successful, an IEP contract
language skills; phonologic skills, in- relative to the reading weaknesses as
is developed. The IEP will describe
cluding phonemic awareness and well as other comorbid variables
goals and objectives; outline what ser-
rapid naming of letters and names; vo- that are also involved. These variables
vices will be needed, including specific
cabulary; reading accuracy; fluency; can include coexisting attention and
remedial interventions, accommoda-
and comprehension. A student’s ability concentration disorders, executive-
tions, modifications, and which type of
to read lists of words in isolation, as functioning weaknesses, and social-
program would be best; and set guide-
well as words in context, should also emotional factors (ie, anxiety, depression,
and oppositional features). Such infor- lines to measure future educational
be assessed. School assessments are progress. After there is agreement by
mation helps to identify whether atten-
usually performed to determine if a the school professionals and parents,
tional and/or emotional issues might
child qualifies for special education the services that the school system
be contributing to or resulting from
programs or therapies. These assess- will provide are listed in the IEP. The IEP
learning difficulties.19 Because neuro-
ments focus on achievement and the contract must be signed by the school
psychological evaluation is driven by
skills needed for academic success. professionals and parents before it
an understanding of the brain systems
If the focus of the studies is on educa- involved in different academic func- can be implemented. The IEP is re-
tional issues as well as on a broader tions, it can illuminate learning disor- viewed on an annual basis and, if nec-
assessment of brain function, the as- ders, allow predictions to be made essary, revised for the next school
sessment is called a “neuropsycholog- about future difficulties a child may en- year. Addendum IEPs can be held if is-
ical” evaluation. Neuropsychologists counter so that preemptive interven- sues in the initial IEP need to be
with a special competency in the area tions can be initiated, and bring to light changed or modified during the school
of pediatrics can perform extensive comorbid conditions that may not yet year. Every 3 years, the child will un-
evaluations that can lead to a compre- have become apparent. The determi- dergo comprehensive reevaluation. Al-
hensive understanding of the child’s nation of the underlying causes of the ternatively, parents may obtain an in-
cognitive and emotional processes disorder and comorbid conditions will dependent educational evaluation. If
and provide the gold standard for a clarify the types of interventions from parents obtain an independent educa-
learning-disability evaluation. Neuro- which the child is most likely to benefit tional evaluation on their own and it
psychologists can diagnose learning and will provide a road map on which meets the school’s criteria, those re-
or behavior disorders caused by al- evidence-based interventions and ac- sults and recommendations must be
tered brain function or development. commodations are based across considered by the IEP team. The IEP
In addition to test data, the assess- home and school environments. Refer- team would still need to determine if
ment also involves a review of the rel- ring professionals and parents are the disability and its severity qualify to
evant medical, psychiatric, educa- provided with a detailed written report obtain special education and related
tional, speech-language, occupational of test findings, the diagnosis, treat- services in school. Children with less
e826 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015FROM THE AMERICAN ACADEMY OF PEDIATRICS
severe disabilities who do not qualify present in these patients. Clinical psy- that it causes.24,30,33,34,55,60,63,81 The man-
for school services may still benefit chologists or other mental health agement of dyslexia demands a life-
from remediation and other therapies providers, including developmental/ span perspective; early on, the focus is
outside of school at the parents’ behavioral and neurodevelopmental on remediation.34 Remedial interven-
expense. pediatricians, can provide strategies tions should be aimed at the specific
Many struggling students will not to help children better cope with social needs of the child and viewed as a dy-
show severe enough difficulties on challenges that may be associated namic process. Because dyslexia is a
evaluation to receive a diagnosis of a with learning disabilities. Psychia- language-based disorder, treatment
learning disability and will not be eligi- trists, developmental/behavioral pedi- should be directed at this etiology.‡‡
ble for special education and related atricians, neurodevelopmental pedia- Reading instruction should be explic-
services. These students still may need tricians, or general pediatricians with itly taught, which means that children
targeted reading assistance to be able special expertise may prescribe medi- are not expected to infer key skills or
to participate fully in school and may cations or conduct therapy to improve knowledge.34 Students who are easily
be a candidate for a Section 504 plan. comorbid psychological disorders. confused are more likely to be suc-
The evaluation information may be Treatment for dyslexia consists of us- cessful when teachers demonstrate
used to decide what educational ac- ing educational tools to enhance the and clearly explain what they need to
learn.58 Most children with dyslexia
commodations may be needed in a ability to read. Educational therapists
need help from a teacher, tutor, or
regular education program. In that or educators who have been specially
therapist who has been specially
case, a Section 504 plan will be written trained in learning disabilities develop
trained in using a multisensory, struc-
that describes the areas of difficulty and implement intervention plans for
tured language approach. It is impor-
and lists the accommodations that will children with learning disabilities and
tant for these children to be taught by
be provided in the regular classroom. dyslexia. An appropriate treatment
a sequenced systematic and explicit
The diagnosis and treatment of a child plan will focus on strengthening the
method that involves several senses
who has learning disabilities depend student’s weaknesses while using the
(hearing, seeing, touching) at the
on the ongoing, coordinated collabora- strengths. Because many students
same time.107 Highly structured daily
tion of a multidisciplinary team that with learning disabilities receive most
intensive individualized instruction by
may consist of educators, educational of their instruction in general educa-
an educational therapist or skilled
remediation specialists, special ser- tion class, teachers need to be trained
teacher specially trained in explicitly
vices, psychologists, and physicians. on the instructional strategies essen-
teaching phonemic awareness and the
Speech therapists can evaluate and tial to success for these students.22
application of phonics is the founda-
treat underlying oral language difficul- Many children with dyslexia do well in
tion for remedial programs.§§ In addi-
ties often associated with dyslexia or small group instruction of matched
tion, students with dyslexia often need
help students learn phonemic aware- students, whereas others need one-on-
a great deal of structured practice and
ness. Physical and occupational thera- one help so that they can move for- immediate, corrective feedback to de-
pists do not treat dyslexia but do treat ward at their own pace. The instruc- velop automatic word-recognition
fine motor, gross motor, balance, pro- tion must be intensive enough and skills. Remedial programs should in-
prioceptive, and sensory-processing continue long enough to have a posi- clude specific instruction in decoding,
disorders that may coexist in some tive effect that will endure.105 If a stu- fluency training, vocabulary, and com-
children with learning disabilities.19 A dent with dyslexia has an outside aca- prehension.㛳㛳 The approach to learn-
vision specialist for the visually im- demic therapist, the therapist should ing decoding begins with detailed in-
paired may benefit children with dys- work closely with the child’s class- struction in phonemic awareness and
lexia who have low vision. Physicians, room teachers. then progresses to sound-symbol as-
including general pediatricians, devel- The critical elements for effective in- sociation (alphabetic principle), phon-
opmental/behavioral pediatricians, tervention include individualization, ics, awareness of rhyme, and word
family physicians, neurologists, oph- feedback and guidance, ongoing as- segmentation. Phonics is the system
thalmologists, otolaryngologists, men- sessment, and regular ongoing prac- of instruction used to teach children
tal health professionals, and other ap- tice.34 Remediation, educational ac-
propriate medical specialists may commodation, and modification are ‡‡Refs 1, 14, 24, 25, 30–35, 43, 55, 60, 63– 65, 81, and
106.
assist in diagnosing and treating any used as techniques for overcoming §§Refs 1, 14, 24, 25, 30–35, 55, 60, and 63– 65.
associated health problems if they are dyslexia and the educational deficits 㛳㛳Refs 1, 14, 32–35, 43, 55, 60, 63– 65, and 81.
PEDIATRICS Volume 127, Number 3, March 2011 e827
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015the connection between letters and and tests, shortened or modified as- who avoid reading are most in need of
sounds. Longitudinal data indicate that signments, help taking notes, lecture practice. Parents should help with
systematic phonics instruction results notes, computers for writing, a sep- practice and reinforcement at home
in more favorable outcomes for read- arate quiet room for taking tests, ex- with opportunities to check fluency
ers with disabilities than does a tra assistance using computers, and comprehension via interactive
context-emphasis (whole-language) spell checkers, a line guide, or tu- reading experiences. Reading practice
approach.¶¶ Later, syllable instruc- tors. Reading can be bypassed by us- at home should be conducted in a sup-
tion, morphology, memorization of ing tape recorders, recorded books, portive and nurturing environment
sight words, spelling, syntax, and se- text-reading computer programs, with adequate opportunity for the
mantics are taught.55 A child must first lecture tapes, taped tests, or other child to participate in other activities
accurately decode a word before it can testing alternatives.24,25,34,47,81 in which he or she excels. As the child
be read fluently, but accuracy does not Many good software programs cur- gets older, parents should help the
spontaneously evolve into fluency. rently exist and are affordable. Text- child use recommended alternative
Sight words need to be memorized, reading software programs provide learning strategies such as books on
and speeded word-repetition drills an excellent opportunity for students tape or computers.
should be performed. Daily fluency with dyslexia to keep up with reading Parents should provide ongoing feed-
practice involves repeated guided oral
assignments. They are also helpful back to remediating specialists and
reading of a large amount of text at the
with written examinations and hand- should be given the opportunity to ask
child’s independent reading level.
outs provided by the teacher. A porta- questions to maximize educational
Practicing reading aloud makes feed-
ble scanner can easily scan written outcomes. Parents need to serve as
back possible. Fluency forms the
material in the classroom and at the child’s advocate by speaking with
bridge between decoding and compre-
home and be used with these pro- the child’s teacher, pediatrician, and
hension.34 Comprehension is gained
grams. The text-reading rate can be other professionals; requesting an ed-
through fluency training, vocabulary
adjusted to assist with comprehen- ucational evaluation; and coordinating
instruction, and active reading com-
sion, and spaces can be created to remediation and other treatment. By
prehension.34,35 Techniques that en-
write notes in the text. Text-reading educating themselves in the areas of
hance active reading comprehension
software is also designed to be used learning disabilities, available ser-
include prediction, summarization, vi-
with writing software to allow a stu- vices, and state education rules and
sualization, clarification, critical think-
dent’s writing to be read aloud. The regulations, parents will increase
ing, making inferences, and drawing
software includes phonetic spelling their effectiveness as the child’s advo-
conclusions.14,24,25,33–35,60,63,65 To further
assistance and intelligent word- cate. Parents should work with educa-
gain comprehension, these activities
prediction features that can address tors to ensure that the school provides
should be combined with other activi-
the dysgraphia that often co-occurs the proper remediation and accommo-
ties to improve language develop-
ment.24,25,32–34,55,60,63,64 The brain learns with dyslexia. These programs should dations and should continue to moni-
best by practice, and practice is the be a key component of an educational tor their child’s progress and advocate
key to learning to read. plan, especially for older students. for their child when necessary.
They provide relief, promote self- The teaching of children with dyslexia
Schools can implement academic ac-
esteem, and are fun to use. Ongoing and learning disabilities is a challenge
commodations and modifications to
appropriate reading remediation for educators and parents; however,
help students with dyslexia succeed.
should continue along with these com- with proper remediations, educational
Because people with dyslexia have a
pensatory techniques. accommodations, and support, chil-
persistent problem and continue to
read slowly throughout their life, it of- Parental participation in a child’s edu- dren with dyslexia and learning dis-
ten becomes necessary to adapt the cation is of utmost importance but abilities can overcome obstacles to im-
learning environment.24,25,34,81 Accom- may be more difficult if the parents are prove their reading and writing.
modations allow access to higher-level functionally illiterate. The home is an Children with extreme deficits in basic
thinking and reasoning strengths. Ex- ideal setting for practice and rein- reading skills or those with the double
amples can include preferential forcement.34 Children should read deficit of phonologic and rapid auto-
seating, extra time for assignments aloud to their parents using fun, easy- matic naming difficulties are much
to-read books. Reading aloud will alert more difficult to remediate than chil-
¶¶Refs 1, 14, 30, 34, 60, 63, 65, 81, and 106. parents if a problem exists. Children dren with mild or moderate deficits.30
e828 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from pediatrics.aappublications.org by guest on September 21, 2015You can also read
