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UnfoldingOrigami:ConsideringDifferentialDiagnosesforDyslexiaEvaluations

12/7/18

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Unfolding Origami: Considering Differential Diagnoses for Dyslexia Evaluations

Kristina Breaux, Ph.D.Adam Scheller, Ph.D.

December 7, 2018

Financial Disclosures

Adam Scheller and Kristina Breaux are both employees of Pearson. Some examples provided during this presentation reference either Pearson research or assessment products.

In addition, Kristina is co-author of the book (receiving royalties): Breaux, K. C., & Lichtenberger, E. O. (2016). Essentials of KTEA–3 and WIAT–III assessment. Hoboken, NJ: Wiley.


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Learner Outcomes

1. List three disorders that often co-occur with Dyslexia

2. List the combination of symptoms and correlates that distinctly identify Dyslexia.

3. Identify key constructs identified through assessment that differentiate between Dyslexia and related disorders.

The Framework for Dyslexia Assessment Should Start with

Understanding the Development of Reading

Let’s investigate ”typical” to find what’s “atypical”


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Reading is Language:Developmental Acquisition of Language

Phonological SkillsReceptive – Language by ear

Expressive – Language by mouth

Orthographic SkillsReceptive – Language by eye

Expressive – Language by hand

Typical Development of Reading Skills**High Level**

Pre-K

Kindergarten

Grade 1

Grade 2/3

Grade 3/4

• “Pre-reading”: Letter ID, Rhyming, ID Letters/phonemes in spoken words

• Letter/sound correspondence

• Sight word development

• Decode new words accurately…fluently.

• Transfer oral language vocab to written language vocab

• Integrate word decoding and sentence comprehension.

• Read for comprehension


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The Neurobiology of Reading (Typical)

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Vocalization, Articulation(Inferior Frontal Gyrus)

Word Analysis(Parieto-Temporal)

Word Recognition, Automaticity(Occipito-Temporal)

Shaywitz (2004)

What is Dyslexia?


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Defining Dyslexia (IDA, 2002; Cassidy-Mikulski Senate Resolution 275, 2015)

1. …a specific learning disability that is neurobiological in origin. 2. … an unexpected difficulty in reading for an individual who

has the intelligence to be a much better reader…3. …language based...4. …characterized by difficulties with accurate and/or fluent word

recognition and by poor spelling and decoding abilities…5. …typically result from a deficit in the phonological component of

language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction…

6. …secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge…

7. …often (not always) present with an uneven cognitive profile…

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(Adapted from Shaywitz S: Overcoming dyslexia: a new and complete science-based program for reading problems at any level. New York, 2003, Alfred A. Knopf. Copyright 2003 by S. Shaywitz. Adapted with permission.)


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Dyslexia symptoms, causes/correlates, and

risk factors

How do I predict…?Incremental Variance

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Existing Variance

New Variance

New Variance

Dyslexia(Example)

Poor performance on CBM

Below avg. WM

Below avg. RANDifficulty with SpellingEtc…


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Breaux, K. & Eichstadt, T. (2017). Pearson C

linical Assessment Solutions: A D

yslexia Toolkit. N

CS Pearson, Inc. San Antonio, TX.

**Low scores on a dyslexia screening test

Possible Strength Profile

• Possible strengths in:• Fluid reasoning and problem solving• Oral language (including listening, speaking,

vocabulary, and grammar)• Math

• The development of interventions/strategies should consider an individual’s cognitive processing strengths.

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Reynolds, C. R. (1981). Neuropsychological assessment and the habilitation of learning: Considerations in the search for the aptitude x treatment interaction. School Psychology Review, 10(3), 343–349.

Shaywitz, S. E. (2005). Overcoming dyslexia. New York, NY: Alfred Knopf.


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Key IndicatorsInternational Dyslexia Association (2002). Definition of dyslexia. Retrieved from www.dyslexiaida.org: and Berninger et al., 2008.

• Symptoms1. Letter knowledge and Phonics2. Decoding Pseudowords3. Word Reading4. Reading Fluency5. Spelling (Most persistent impairment for individuals with

dyslexia: Berninger et al., 2008)6. Written Expression

• Causes/Correlates1. Phonological processing (including phonological awareness

and phonological coding)2. Rapid automatic naming (the phonological loop of working

memory)3. Auditory verbal working memory

• Risk Factors1. Receptive Vocabulary

Why is this so challenging?

Within the dyslexia assessment space…

1. Comorbidity is the norm, not the exception2. Misdiagnosis common (similar symptoms across

disorders)3. False negatives common (failure to identify)4. Unreliable, inconsistent classification systems

(criteria for eligibility and diagnosis vary)5. Heterogeneity 6. Complex or unusual histories/learning profiles


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How do I select tests for Diagnostic Assessment?

• Test selection for Diagnostic Assessment should evaluate key components of Dyslexia

• Strengths• Response to treatment (effective instruction)• Potential areas of weakness

• Symptoms• Cognitive Correlates• Risk Factors

• Psychometric support vs theoretical support• Test for reading vs. for dyslexia

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Key Theoretical Frameworks


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A deficit in phonological processing is necessary and

sufficient to cause dyslexia.

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Single Deficit Model of Dyslexia

Wolf and Bowers (1990s):

● Phonological Deficit○ Impaired word level decoding and spelling

● Naming Speed Deficit○ Accurate reading, poor fluency

○ Difficulty retrieving words and math facts

● Double Deficit○ Most severe form of dyslexia


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Dorothy Bishop & Margaret Snowling (2004): Two Dimensions of Impairment

Poor comprehender Normal reader

Virginia Berninger (~2000-2015):

Hallmark Levels of Impairment


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● Phonological deficit is not the single and universal

cause of all reading/spelling difficulties

○ RAN, Language comprehension, Orthography

● Inconsistency in terminology and classifications

○ OWL-LD or Dyslexia with poor comprehension:

Same concept, different labels (also: SLI, LLD)

Key Takeaways

4 Steps to Differential Diagnosis and Assessment for

Intervention


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Step 1: Analyze Problem and Develop Hypotheses

• Gather background information

• Interviews, observation data, classroom

performance

• Evaluate exclusionary factors

• Assess risk factors and onset of difficulty

Copyright©2018Pearson,Inc.Allrightsreserved.

Exclusionary Factors for Dyslexia


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Assess risk factors and onset of difficulty

● Family history of dyslexia or SLI?

○ 4-5x greater likelihood of dyslexia with family history

● Onset of difficulty: Key difference between dyslexia and OWL-

LD

OWL-LD DyslexiaOnset of Difficulty Preschool KindergartenEarliest Symptoms Late talking, delays

in combining wordsDifficulty naming/ writing letters, associating sound with letter

Step 2: Collect Assessment Data to Test Hypotheses

● Symptoms, causes/correlates,

strengths/intact abilities

● Focus on key skills and abilities that

differentiate similar conditions


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Comorbid Conditions for Dyslexia

• Language and Communication disorders ~50%• ADHD ~25-40%• Mental disorders (anxiety, depression, bipolar) ~20%

• Dyspraxia (developmental coordination disorder) ~50%

• Dysgraphia ~40%• Dyscalculia (math disorder) ~25%

**SLD in written expression is associated with dyslexia, dysgraphia, or OWL-LD


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Assessment Data for Comorbid Conditions

• Dyspraxia

• Poor spatial awareness, balance, coordination

• Dysgraphia

• Illegible handwriting, poor letter formation and

spacing, slow/labored writing

• Dyscalculia

• Number concepts, math calculation

Step 3: Synthesis and Interpretation of Data

• Look for patterns (beyond scores)• Consider hallmark profiles of reading/writing

difficulties • Consider comorbid conditions• Apply diagnostic criteria appropriate to your

setting • Consider using a hybrid model

• Summarize diagnostic impressions


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Hallmark Profiles of Reading/Writing Classifications

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Dyslexia OWL-LD Poor Comprehender

Fluency/ Naming Speed

Global (garden variety)

Core Symptoms

Reading accuracy & fluency, decoding, spelling, LC>RC

Oral language, written expression, LC, RC

LC, RC Reading fluency, word retrieval

All areas of reading, listening comp

Processing Weakness

Phonology/ Orthography (RAN, WM, PS)

Grammar/ syntax, verbal comp, WM

Verbal comp, working memory

RAN Low avg cognitive ability

Intact / Strength

Oral language, cognitive ability, fluid reasoning

Nonverbal cognitive ability

Phonology, RAN, reading fluency, word reading, decoding

Word reading, decoding

Adaptive functioning

● Problem: High rates of misdiagnosis and false negatives (misses)

● Basing decisions on a single indicator (such as Poor PA, IQ-Ach discrepancy, or Poor RTI) is unreliable

● Hybrid models offer a promising solution by combining multiple indicators to improve the reliability of diagnosis○ Avoid cut off scores and requiring a single indicator○ Consider n or more symptoms, including poor RTI

For more info and research citations, search: Pearson Dyslexia Toolkit White Paper (pdf)

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Hybrid Model for Dyslexia Identification


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Step 4: Intervention Development and Evaluation

• Develop intervention approach and continually evaluate the intervention

• Recursive: revise with new/updated information learned during the intervention process

Case Study


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• Referral concern:• Persistent history of difficulties with spelling and

writing

• Review of writing samples• Very limited output• Spelling and grammatical errors (omits words, word

endings)• Simple vocabulary

Harrison & McManus (2017). Clinical Reasoning in the Assessment and Intervention Planning for Writing Disorder. Canadian Journal of School Psychology, 32(1), 73-86.

Ethan: Age 13, Grade 7

Ethan: Analyze Problem and Develop Hypotheses

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● Background ○ Lives with parents and two younger sisters - strong family relations

○ Only English is spoken at home

○ Normal medical and developmental history, normal vision and hearing

● Academics: Possible reading concern?○ Math is a relative strength

○ Ethan says he hates writing, he prefers speaking his ideas.

○ Ethan considers himself fine at reading but prefers audio books because his eyes get tired

● Socio-emotional: Elevated stress, low self-esteem: possible anxiety or depression?

○ Socially competent, age appropriate peer relations and extra curricular pursuits

○ Ethan’s father is concerned about Ethan’s self-esteem

○ Ethan reports disliking school and a desire to drop out

○ His teachers believe his academic struggles are taking an emotional toll


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Copyright©2018Pearson,Inc.Allrightsreserved.

Ethan: Exclusionary Factors for Dyslexia

● Risk factors○ Dyslexia screening results? None available○ Family history of dyslexia: Positive ○ History of language impairment: No

● Onset of difficulty○ Had some problems learning to read (Kindergarten - Grade

3) - received some learning support○ School records indicate he was a “slow” reader, difficulty

comprehending text or written instructions.

Hypothesis: dyslexia or similar reading/writing disorderOnset does not support OWL-LD (will confirm)

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Ethan: Risk factors and onset of difficulty


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Ethan: Collect Assessment Data to Test Hypotheses

Consistent with dyslexia profile: weaknesses in PP/OP, RAN, AWM, PS

Intact VCI does not support OWL-LD

Cognitive Assessment● No concerns with cognitive

ability (23rd percentile)● Processing Weaknesses

○ Phonology/Orthography○ RAN○ Auditory Working

Memory○ Processing Speed

● Intact verbal comprehension

Ethan: Collect Assessment Data to Test Hypotheses

Academic Assessment● Very poor spelling ● Very poor WE

○ Omitted words/word endings, mechanics

● Poor WF (slow writing)● Writing was legible with

adequate spacing, letter formation

● Poor decoding, word reading fluency, reading comprehension (RC<LC)

● Strong math skills - no issues writing or aligning numerals

Consistent with dyslexia profile: word level difficulties in reading and spelling.


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Intact Skills and Abilities / Relative Strengths● Cognitive ability, fluid reasoning (not global/garden variety poor reader)● Oral language comprehension, expression, grammar (not OWL-LD)● Math problem solving, calculation (not dyscalculia)● Handwriting: letter/numeral formation (not dysgraphia)

Key Academic Weaknesses● Word level decoding and spelling (not poor comprehender or fluency

profile)

Social-Emotional Functioning (BASC-2)● Elevated ratings for anxiety indicated across all raters ● At risk for sense of inadequacy

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Ethan: Synthesis and Interpretation of Data

Diagnostic Impressions● Ethan’s learning profile supports a diagnosis of dyslexia● Consistent with early difficulty acquiring reading skills, although his

reading impairment has gone undetected (strong compensatory strategies).

● Elevated symptoms of anxiety at home and at school suggest a secondary social emotional impact of his learning difficulties

● Meets DSM-5 diagnostic criteria for SLD with ○ moderate impairment in reading (315.00) for word reading

accuracy and reading rate or fluency and ○ moderate impairment in written expression (315.2) for spelling

accuracy and clarity and organization of ideas in writing

Criteria: Impairment (at or below 1.5 SD from the mean) in one or more subskills after ruling out exclusionary criteria

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Ethan: Synthesis and Interpretation of Data


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● Initial intervention goals: Improve...○ Academic self-efficacy and motivation for writing○ Knowledge and skills in the process and products of writing○ Lower level transcription skills and higher level clarify and

organization○ Productivity in writing

● Self-regulated strategy development model (SRSD; Project Write)

○ Systematic and collaborative writing instruction ○ Students develop and apply positive self-statements about

writing○ Duration: 12 weeks, 45 min/week○ Evaluation: 3 baseline probes, 12 intervention probes, CIWS

*Initial intervention recommendations focused only on writing

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Ethan: Intervention Development & Evaluation

• Dyslexia is as much a writing disorder as it is a reading disorder

• Spelling is the most persistent impairment for individuals with dyslexia (Berninger et al., 2008)

Key Takeaways


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Thank you for attending!

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Unfolding Origami - Pearson Assessments · Unfolding Origami: Considering Differential Diagnoses...

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