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UNLOCKING THE CODE. DYSLEXIA ASSESSMENT, TREATMENT & DEVELOPMENTAL THEORY ANN W ALEXANDER,M.D. THE MORRIS CENTER GAINESVILLE, FL JANE LAWYER M.ED. WELINGTON.

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Presentation on theme: "UNLOCKING THE CODE. DYSLEXIA ASSESSMENT, TREATMENT & DEVELOPMENTAL THEORY ANN W ALEXANDER,M.D. THE MORRIS CENTER GAINESVILLE, FL JANE LAWYER M.ED. WELINGTON."— Presentation transcript:

1 UNLOCKING THE CODE

2 DYSLEXIA ASSESSMENT, TREATMENT & DEVELOPMENTAL THEORY ANN W ALEXANDER,M.D. THE MORRIS CENTER GAINESVILLE, FL JANE LAWYER M.ED. WELINGTON ALEXANDER CENTER SCOTTSDALE, AZ IDA 11 / 07

3 WHAT IT IS ? DYS = TROUBLE LEXIA = WORDS TROUBLE WITH “ WRSD ” (WORDS)

4 THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) ORAL LANGUAGE CHALLENGES LISTENING Memory for word sequence (phone numbers, directions ) Poor PHONOLOGICAL AWARENESS Foreign Language SPEAKING Word Finding Multi - syllables Sequencing Ideas Foreign Language

5 THE PICTURE OF DYSLEXIA WRITTEN LANGUAGE CHALLENGES (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) READING MechanicsComprehension Speed Mechanics Speed SPELLING/WRITING Expressing Ideas

6 CLINICAL PICTURE NONLINGUISTIC  COGNITIVE: PHONOLOGICAL WORKING MEMORY, EF  SENSORIMOTOR  FINE MOTOR SEQUENCING  WEAK ORAL / FINGER SOMATOSENSORY MAPS  LOW TONE, POSTURAL INSTABILITY  SLOW RESPONSE TIME  IMPAIRED PROCESSING OF RAPIDLY PRESENTED SEQUENTIAL AUDITORY, VISUAL, & SOMATOSENSORY INPUT DEFICITS IN :  DEPRESSION, OCD, ANXIETY  ADHD %  BEHAVIOR

7 THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) ACCOMPANYING CHALLENGES (SENSORIMOTOR) Oral Motor Messy Eating Writing/knots Fingers Eyes Tired Words Swim Lose Place Spatial Awareness Up/Down Left/Right

8 THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) ACCOMPANYING CHALLENGES (BEHAVIORAL) Parents with similar challenges Brain / Behavior Disorders Attention / Executive Function Anxiety Depression OCD Oppositional Behavior

9 MORRIS CENTERFLORIDA STATE KATIE PRE - Rx KEY PPVT – VOCABULARY PIQ – PERFORMANCE IQ, WISC-3 CELF – ORAL LANGUAGE :RECEPTIVE & EXPRESSIVE WRMT-R – ORAL READING : WORD ATTACK, WORD ID, COMPREHENSION OUR CAT MIMI LIKES TO SIT ON THE ROOF. MIMI GOES UP TO THE TALL TREE BY THE HOUSE. THEN SHE JUMPS ON THE ROOF. SHE SITS AND LOOKS AT BIRDS. BUT SHE ALWAYS COMES DOWN WHEN IT IS TIME TO EAT.

10 DEVELOPMENTAL DIFFERENCES  PRESCHOOL: SENSORIMOTOR ORAL LANGUAGE ATTENTION  EARLY ELEMENTARY: PRINT RECOGNITION LETTER – SOUND KNOWLEDGE MECHANICS OF READING HANDWRITING ATTENTION

11 DEVELOPMENTAL DIFFERENCES  HIGH SCHOOL / ADULT: READING EFFICIENCY COMPREHENSION FOREIGN LANGUAGE ATTENTION  MID ELEMENTARY / MIDDLE SCHOOL: COMPREHENSION WRITTEN EXPRESSION ATTENTION

12 LANGUAGE (BUILDING BLOCKS) PHONOLOGY (FORM) PRAGMATICS (FUNCTION) SEMANTICS (MEANING) SYNTAX (FORM) READING WRITING SPELLING METALINGUISTIC

13 WHAT IT IS ? DYS = TROUBLE LEXIA = WORDS TROUBLE WITH “ WRSD ” (WORDS)

14 PHONOLOGY EXECUTIVE FUNCTION / INTENTION WORKING MEMORY HOLD / MANIPULATE ( PERCEPTION / PRODUCTION) ATTENTION / AROUSAL ACOUSTIC SUBREPRESENTATION VISUAL SUBREPRESENTATION MOTOR ARTICULATORY SUBREPRESENTATION SOMATOSENSORY ARTICULATORY SUBREPRESENTATION PHONEMICREPRESENTATION PROSODIC REPRESENTATION (WORD LEVEL)

15 EARLY READING DEVELOPMENT UNLOCKING THE CODE

16 VISUAL / ORTHOGRAPHY AUDITORY / PHONOLOGY LANGUAGE SEMANTICS SYNTAX COMPREHENSION FLUENCY 3 – LEGGED STOOL

17 VISUAL / ORTHOGRAPHY AUDITORY / PHONOLOGY LANGUAGE SEMANTICS SYNTAX COMPREHENSION FLUENCY 3 – LEGGED STOOL AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY AUDITORY / PHONOLOGY

18 PHONOLOGICAL AWARENESS THE CORE DEFICIT

19 WHAT IS PHONOLOGICAL AWARENESS?

20 PHONOLOGICAL PROCESSING  A CORE INGREDIENT FOR ORAL AND WRITTEN LANGUAGE DEVELOPMENT  THREE COMPONENTS  LEXICAL RETRIEVAL / RAPID NAMING  PHONOLOGICAL AWARENESS  PHONOLOGICAL WORKING MEMORY

21 THE “PHON” WORDS PHONOLOGICAL AWARENESS  PHONOLOGICAL SENSITIVITY (e.g. RHYMING)  UMBRELLA TERM THAT INVOLVES ABILITY TO APPRECIATE THAT WORDS ARE COMPRISED OF CHUNKS OF SOUNDS

22 THE “PHON” WORDS PHONEMIC AWARENESS  ABILITY TO APPRECIATE AND MANIPULATE INDIVIDUAL SOUNDS IN WORDS (e.g.BLENDING AND SEGMENTING)  FALLS UNDER UMBRELLA OF PHONOLOGICAL AWARENESS

23 THE “PHON” WORDS PHONICS  IS NOT PHONOLOGICAL AWARENESS  SKILL THAT MUST BE TAUGHT  PHONOLOGY + ORTHOGRAPHY  READ “BRUP,” “SPROIGILTY”

24 THE “PHON” WORDS ANOTHER CORE DEFICIT PHONOLOGICAL WORKING MEMORY ESSENTIAL FOR EXECUTIVE FUNCTION  DISTINCT PHONEME REPRESENTATIONS  ATTENTION

25 CLINICAL EVALUATION OF LANGUAGE FUNDAMENTALS -REVISED

26

27 GROWTH IN “PHONICS” ABILITY OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND LETTER KNOWLEDGE Low PA K Ave. PA GRADE LEVEL CORRESPONDING TO AGE READING GRADE LEVEL Average Low (Torgesen & Mathes, 2000)

28 GROWTH IN SIGHT WORD READING ABILITY OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND LETTER KNOWLEDGE 6 Low PA K Ave. PA GRADE LEVEL CORRESPONDING TO AGE READING GRADE LEVEL Average Low ( Torgesen & Mathes, 2000)

29 GROWTH IN READING COMPREHENSION OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND LETTER KNOWLEDGE SAME VERBAL ABILITY – VERY DIFFERENT READING COMPREHENSION K 6.9 GRADE LEVEL CORRESPONDING TO AGE READING GRADE LEVEL Average Low ( Torgesen & Mathes, 2000)

30 WHAT TO DO !! ASSESSMENT OF STRENGTHS AND WEAKNESSES  NEUROCOGNITIVE  PSYCHOSOCIAL ASSESSMENT DRIVES TREATMENT

31 BELL SHAPED CURVE NORMAL POPULATION DISTRIBUTION

32 PROFILE GRAPH BRAIN TEAM

33 PROFILE GRAPH BRAIN TEAM PERFORMANCE SEVERE AT RISKAVERAGE SUPERIOR GIFTED WEAKNESSRANGE STRENGTH Standard Scores Percentiles 1st2nd5th9th16th25th37th50th63rd75th84th91st95th98th99th WRITTEN LANGUAGE Word Reading (Real) Word Reading (Rate) Word Reading (Nonsense) Word Reading (Rate) Passage Comprehension Passage Fluency Writing/Written Expression Writing Fluency Spelling ARITHMETIC Concepts Operations Applications Fluency

34 REMEDIATION STUDY  2 TREATMENTS – BOTH EXPLICIT PHONICS RX  SEVERE DYSLEXIA 2 nd %ILE FOR WORD READING 35 th %ILE IQ (SS 92) Torgesen, et al, 2001, NICHD  OLDER CHILDREN (8 – 10 YRS)  A “BOTTOM UP” (LiPS) VS.  A “TOP DOWN” (EP)

35 LANGUAGE DEVELOPMENT (BUILDING BLOCKS) 18 MONTHS ___ 1 MONTH ___ 9 MONTHS ___ 5 YEARS ___ 9 YEARS ___

36 PRINCIPLES OF LEARNING  WHAT FIRES TOGETHER, WIRES TOGETHER – MULTIPLE SENSES  ATTENTION  CONSISTENT INPUT  INTENSITY  SALIENT  FREQUENT  REPETITION IS KEY

37 REMEDIATION STUDY  EQUAL TIME AND INTENSITY 1:1  100 MINS DAILY  8-9 WEEKS TOTAL 67.5 HRS

38 RESEARCH DEMONSTRATES BOTH IMMEDIATE & LONG LASTING RESULTS IN BROAD READING (DECODING+COMPREHENSION) Standard Score Initial Test Pre- Treatment Test Post- Treatment Test 1 Year After Treatment 2 years Normal Range of Performance 9-Week Intensive Program Torgesen, Alexander, Wagner et al, Mos. Special Ed Class

39 72 96 * 91 * 91 * TWO YEAR FOLLOW UP READING RESULTS GORT-R STANDARD SCORE 90 WORD ATTACK WRMT-R TEXT READING ACCURACY READING COMP. TEXT READING RATE th percentile Torgesen, Alexander, Wagner et al, 2001 * p= <.05 N = 50

40 SPOKEN LANGUAGE GAINS REMEDIATION STUDY

41

42 CELF-R OUTCOMES: 67.5 HOURS OF INTENSIVE INTERVENTION STANDARD SCORE 90 REC-LEXP-LREC-EPEXP-EP th percentile PRE 2yr PRE

43 EFFECT SIZE OF TREATMENT ON LANGUAGE COMPREHENSION & EXPRESSION LIPSEP PRE-POST PRE-2 YRSPRE-2 YRS PRE-POST RLS OD WC SR LP ELS FS RS SA P<= 0.05 ES of 0.5 – 0.7 moderate; large

44 MORRIS CENTER FLORIDA STATE KATIE 1 Yr. KEY PPVT – VOCABULARY PIQ – PERFORMANCE IQ, WISC-3 CELF – ORAL LANGUAGE :RECEPTIVE & EXPRESSIVE WRMT-R – ORAL READING : WORD ATTACK, WORD ID, COMPREHENSION PPVTP IQCELF-RCELF-EWRMT-A WRMT- I WRMT-C STANDARD SCORE POST Rx PRE Rx 1 Yr OUR CAT MIMI LIKES TO SIT ON THE ROOF. MIMI GOES UP TO THE TALL TREE BY THE HOUSE. THEN SHE JUMPS ON THE ROOF. SHE SITS AND LOOKS AT BIRDS. BUT SHE ALWAYS COMES DOWN WHEN IT IS TIME TO EAT.

45 LONG TERM GAIN RESISTERS VARIABLES RESULTING IN POOR PROGRESS  WEAK ATTENTION  LOWER SES 20 % OF SUBJECTS WHO HAD IMMEDIATE GAINS HAD NOT CONTINUED READING GAINS AT 2yr FOLLOW UP  POOR RECEPTIVE LANGUAGE

46 PREVENTION STUDY

47 PRESCHOOL PREDICTORS OF FUTURE READING SUCCESS NOT IQ !!! ALL OF THESE PREDICTORS ARE DEPENDENT ON A STRONG PHONOLOGICAL SYSTEM RAPID NAMING of OBJECTS, COLORS LETTER NAME KNOWLEDGE PHONOLOGICAL AWARENESS

48 PREVENTION STUDY  MID KG - END 2 ND GRADE  SCREENING - BOTTOM 10 TH %ILE  FREQUENCY - 20 MINS/DAY - 4 DAYS / WEEK  INTENSITY - 1:1, 67 HRS.  TEACHERS & AIDES  4 METHODS - PASP, EP, RCS, NTC Torgesen et al, 1999, NICHD

49 PREVENTION STUDY OUTCOME  ONLY PASP YIELDED SIGNIFICANT PHONOLOGICAL AWARENESS AND WORD READING GAINS  END OF 2ND GRADE: 50TH %ILE WORD READING SKILLS (ACCURACY AND FLUENCY).  OTHERS NO BETTER THAN NO TREATMENT CONTROL  BEST PREDICTORS OF GROWTH IN READING: ATTENTION/BEHAVIOR, HOME BACKGROUND, AND P/A.

50 A SOLUTION TO THE PROBLEM OF THE FLUENCY GAP: PREVENTIVE INTERVENTIONS 10th 10th STANDARD SCORE Accuracy Rate 4 th GRADE 2 nd GRADE 30 th % ile BEGINNING % ile TREATMENT AGE5-6

51 LATE VS EARLY INTERVENTION (PREVENTION) WORD READING ACCURACY AND RATE 2nd 10th 10th 10th STANDARD SCORE Accuracy Rate 4th grade 2nd grade 30 th % ile BEGINNING % ile TREATMENT AGE

52 PROJECTED GROWTH IN “SIGHT VOCABULARY” OF NORMAL READERS AND DISABLED CHILDREN BEFORE AND AFTER REMEDIATION Normal Intervention Size of “sight vocabulary Grade in School Dyslexic 2nd Year follow-up Later intervention does not close fluency gap – early intervention does Torgesen,

53 EARLY INTERVENTION IS URGENT!  50 TH %ILE 5 TH GRADE READER 600,000 WORDS A YEAR AVERAGE STUDENTS RECEIVE ABOUT 10 TIMES AS MUCH PRACTICE IN A YEAR (Anderson, Wilson, & Fielding, 1988)  10 TH %ILE 5 TH GRADE READER 50,000 WORDS A YEAR

54 PROFILE GRAPH BRAIN TEAM

55 PROFILE GRAPH BRAIN TEAM PERFORMANCE

56 HOW DOES THIS IMPACT TREATMENT PLANNING?  ASSESS THE ROOT CAUSE OF LANGUAGE DISORDER  TREAT FROM BOTTOM UP IN A DEVELOPMENTAL SEQUENCE  BEGIN WITH CORE LANGUAGE FOUNDATIONS  FOLLOW PRINCIPLES OF LEARNING

57 PRINCIPLES OF LEARNING  WHAT FIRES TOGETHER, WIRES TOGETHER – MULTIPLE SENSES  ATTENTION  CONSISTENT INPUT  INTENSITY  SALIENT  FREQUENT  REPETITION IS KEY

58 RESPONSE TO INTERVENTION MODEL  APPLICATION OF EVIDENCE-BASED TREATMENT TO SCHOOLS  TIER 1: CLASSROOM BLOCK  TIER 2: PULL OUT SUPPORT + CLASS  TIER 3 :TOTAL PULL OUT (2 – 4 HRS)  A TIERED APPROACH

59 LITCHFIELD SD RESULTS 1 st GRADE STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP th percentile N = 63 * * p= < * *

60 LITCHFIELD SD RESULTS 2 nd GRADE STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP th percentile N = 64 * * * p= <

61 LITCHFIELD SD RESULTS 3 rd – 5 th GRADES STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP th percentile N = 126 * * * * p= <.05

62 CONCLUSION  TREATMENT IS MOST EFFECTIVE IF :  YOUNGER AGE  INTENSIVE  EXPLICIT PHONOLOGICAL/PHONICS  ATTENTION IS OPTIMAL  “BOTTOM-UP” MORE EXPLICIT PHONOLOGIC APPROACH: PREVENTION YOUNGER DYSLEXIC MILD TO MOST SEVERE DYSLEXIA LANGUAGE IMPAIRMENT AUDITORY WORKING MEMORY WEAKNESS  “TOP-DOWN” PHONICS APPROACH: AFTER 3RD GRADE MILD TO MODERATELY SEVERE DYSLEXIA

63 Acknowledgments  National Institute of Child Health and Human Development  Joe Torgesen  Carol Rashotte  Rick Wagner  Pat Lindamood  Tim Conway  Jane Lawyer


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