2. OVERVIEW OF DYSLEXIA ANN W ALEXANDER, M.D. MORRIS CENTER GAINESVILLE, FL TIM CONWAY, PhD UNIVERSITY OF FLORIDA GAINESVILLE, FL JANE WELLINGTON LAWYER, MEd WELLINGTON ALEXANDER CENTER SCOTTSDALE, AZ IDDIDD IDA 2006

3. KEY TO DYSLEXIA

4. THE PICTURE OF DYSLEXIA  WHAT  WHY  WHAT IT LOOKS LIKE  WHERE  WHEN  WHAT TO DO  WHO THE &

5. WHAT IT ISN’T DYSLEXIA IS …  NOT A VISUAL PROBLEM  NOT A LACK OF INTELLIGENCE  NOT DUE TO LACK OF EFFORT  NOT RESPONSIVE TO STANDARD READING INSTRUCTION  NOT UNCOMMON – 5 – 17.5 % OF POPULATION A DEVELOPMENTAL LAG.  NOT A DEVELOPMENTAL LAG.

6. WHAT IT IS DYS = TROUBLE LEXIA = WORDS TROUBLE WITH WORDS  NEUROLOGIC IN ORIGIN - GENETIC  LIFELONG – ENVIRONMENT MAY ALTER COURSE  CORE DEFICIT IN PHONOLOGICAL COMPONENT OF LANGUAGE  READING COMPREHENSION > WORD READING  ACCOMPANYING CHALLENGES ( 50% )  ADHD  SENSORY MOTOR DIFFICULTY  BEHAVIORAL PROBLEMS  MORE CHALLENGING TO REMEDIATE

7. WHY “OUT OF LINE NEURONS” ( ECTOPIAS ) FRONT

8. http://www.thebrain.mcgill.ca/flash/d/d_02/d_02_cl/d_02_cl_vis/d_02_cl_vis.html#3 LAYERS OF BRAIN CORTEX

9. NEURAL MIGRATION http://www.thebrain.mcgill.ca/flash/a/a_09/a_09_cl/a_09_cl_dev/a_09_cl_dev.htm GENETICALLY PROGRAMMED

10. NEURAL MIGRATION GONE AWRY IN DEVELOPMENTAL DYSLEXIA http://www.thebrain.mcgill.ca/flash/a/a_09/a_09_cl/a_09_cl_dev/a_09_cl_dev.htm X

11. ECTOPIC CELLS Ramus, 2004

12. NEURONAL CONNECTIONS

13. “OUT OF LINE NEURONS” ( ECTOPIAS ) FRONT

14. TYPICAL LANGUAGE ACTIVATION AREAS SPEECH PRODUCTION AREA AUDITORY PROCESSING AREA VISUAL-LANGUAGE ASSOCIATION AREA VISUAL / VERBAL AREA LEFT HEMISPHERE

15. TYPICAL READING ACTIVATION AREAS LEFT HEMISPHERE WORD ANALYSIS AUTOMATIC (SIGHT WORD)

16. Strong activation pattern Weak activation pattern BRAIN ACTIVATION WITH READING “SIGNATURE” BRAIN, Shaywitz, 2005 Simos, Fletcher, Bergman, et al 2002 BACK OF LEFT BRAIN BACKOFRIGHTBRAINBACKOFRIGHTBRAIN

17. PHONOLOGICAL AWARENESS THE CORE DEFICIT

18. WHAT IS PHONOLOGICAL AWARENESS?

19. PHONOLOGICAL AWARENESS  THE UNDERSTANDING THAT WORDS ARE MADE UP OF SMALL BITS OF SOUND – PHONOLOGICAL SENSITIVITY SMALL BITS OF SOUND – PHONOLOGICAL SENSITIVITY  INNATE IN A TYPICAL BRAIN RECEIVING APPROPRIATE LANGUAGE INPUT APPROPRIATE LANGUAGE INPUT Do the words cat and fat sound the same at the end? What is the first sound in the word man? Torgesen, www.fcrr.org

20.  THE ABILITY TO IDENTIFY, THINK ABOUT, AND MANIPULATE THE INDIVIDUAL SOUNDS MANIPULATE THE INDIVIDUAL SOUNDS (PHONEMES) IN WORDS (PHONEMES) IN WORDS  THE IMPLICATION OF A GROWING ABILITY TO IDENTIFY INDIVIDUAL SOUNDS IN WORDS. IDENTIFY INDIVIDUAL SOUNDS IN WORDS. PHONEMIC AWARENESS Torgesen, www.fcrr.org

21. EARLY LANGUAGE DEVELOPMENT  BRAIN IS TUNED TO PARENTS’ LANGUAGE  NEWBORN: INTEGRATES:  ORAL-FACIAL MOVEMENTS  SPEECH SOUNDS – PHONOLOGY  SOCIAL – EMOTIONAL (NON VERBAL TONES & GESTURES) - PRAGMATICS

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

23. PRINCIPLES OF LEARNING  WHAT FIRES TOGETHER, WIRES TOGETHER – MULTIPLE SENSES STRENGTHEN PATHWAYS  OPTIMAL ATTENTION  CONSISTENT INPUT  INTENSITY  SALIENT  FREQUENT  REPETITION, REPETITION, REPETITION Alexander, 2003

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

25. THE EFFECTS OF WEAKNESSES IN ORAL LANGUAGE ON READING GROWTH (Hirsch, 1996) 5678910111213141516 16 15 14 13 12 11 10 9 8 7 6 5 Reading Age Level Chronological Age Low Oral Language in Kindergarten High Oral Language in Kindergarten 5.2 years difference Torgesen, www.fcrr.org

26. EARLY READING DEVELOPMENT BREAKING THE CODE

27. DECODING (MECHANICS) LANGUAGE COMPREHENSION READING COMPREHENSION + RECIPE FOR READING

28. WHAT IS “PHONICS”? IT MUST BE TAUGHT NEED PA (SOUNDS) TO HOOK TO ABSTRACT WRITTEN SYMBOLS (LETTERS) IT’S A LEARNED SKILL PRONOUNCE THESE WORDS… blitfrachet

29. GROWTH IN “PHONICS” ABILITY OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND LETTER KNOWLEDGE (Torgesen & Mathes, 2000) 6 2 4 12345 1 3 5 5.9 2.3 Low PA K Ave. PA GRADE LEVEL CORRESPONDING TO AGE READING GRADE LEVEL Average Low ` Torgesen, www.fcrr.org

30. GROWTH IN WORD READING ABILITY OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND LETTER KNOWLEDGE (Torgesen & Mathes, 2000) 6 Low PA 5.7 3.5 2 4 1 3 5 K Ave. PA GRADE LEVEL CORRESPONDING TO AGE 1 2 34 5 READING GRADE LEVEL Average Low Torgesen, www.fcrr.org

31. GROWTH IN READING COMPREHENSION OF CHILDREN WHO BEGIN FIRST GRADE IN THE BOTTOM 20% IN PHONEME AWARENESS AND LETTER KNOWLEDGE (Torgesen & Mathes, 2000) 12345 Low PA 3.4 2 4 6 1 3 5 K Ave. PA 6.9 GRADE LEVEL CORRESPONDING TO AGE READING GRADE LEVEL Average SAME VERBAL ABILITY – VERY DIFFERENT READING COMPREHENSION Low Torgesen, www.fcrr.org

32. AUDITORY / SOUNDING OUT VISUAL / SIGHT WORDS LANGUAGE / VOCABULARY GRAMMAR COMPREHENSION FLUENCY 3 – LEGGED STOOL NORMAL READER

33. AUDITORY / SOUNDING OUT VISUAL / SIGHT WORDS LANGUAGE / VOCABULARY GRAMMAR COMPREHENSION FLUENCY 3 – LEGGED STOOL AUDITORY / SOUNDING OUT AUDITORY / SOUNDING OUT AUDITORY / SOUNDING OUT AUDITORY / SOUNDING OUT AUDITORY / SOUNDING OUT AUDITORY / SOUNDING OUT DYSLEXIA

34. WHERE  “SIGNATURE” BRAIN IMAGES ARE THE SAME  DIFFERENT LANGUAGES AFFECT THE PICTURE  ITALIAN VS ENGLISH  ANYWHERE

35. WHO  ANYONE  ALL AGES  ALL WALKS OF LIFE  PREPONDERANCE IN :  ARCHITECTS  ENGINEERS  SURGEONS  ENTREPRENEURS  SCHOOL DROPOUTS  PRISON INMATES

36. WHEN  AS EARLY AS THE NEWBORN PERIOD  IDENTIFICATION OF A PHONOLOGIC “GLITCH”  THE WEAKER THE PHONOLOGY, THE EARLIER THE STRUGGLE

37. THE PICTURE OF DYSLEXIA WHAT DOES IT “LOOK” LIKE?

38. 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

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

40. 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

41. 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

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

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

44. WHAT TO DO ASSESSMENT OF STRENGTHS AND WEAKNESSES  NEUROCOGNITIVE  PSYCHOSOCIAL ASSESSMENT DRIVES TREATMENT

45. BELL SHAPED CURVE NORMAL POPULATION DISTRIBUTION

46. PROFILE GRAPH BRAIN TEAM

47. PROFILE GRAPH BRAIN TEAM RESULTS

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

49. TREATMENT  EARLY IDENTIFICATION  PREVENTION OF READING DIFFICULTIES  LATER IDENTIFICATION  INTERVENTION FOR READING DIFFICULTIES

50. PREVENTION STUDY  MID KG – END 2 ND GRADE  SCREENING - BOTTOM 10 TH %ILE  FREQUENCY – 20 MINUTES / 4 DAYS / WEEK  INTENSITY – 1:1, 67 HRS.  TEACHERS & AIDES  4 METHODS – PASP (MULTISENSORY, “BOTTOM UP”- LiPS) EP (TRADITIONAL RDG INSTRUCTION WITH EXPLICIT PHONICS) RCS (SUPPORT OF CLASSROOM TEACHING) NTC (NO TREATMENT CONTROL) Torgesen et al, 1999 NICHD

51. 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.

52. A SOLUTION TO THE PROBLEM OF THE FLUENCY GAP: PREVENTIVE INTERVENTIONS 10th 10th 70 80 90 100 STANDARD SCORE Accuracy Rate 4 th GRADE 2 nd GRADE 30 th % ile BEGINNING % ile TREATMENT AGE5-6 Torgesen et al, 2003 WORD READING

53. DYSLEXIA PREVENTION STUDY “BOTTOM-UP” VS “TOP-DOWN”  PASP (LiPS) USES A MORE EXPLICIT, CONCRETE, MULTISENSORY (“BOTTOM UP”) APPROACH TO DEVELOP PHONOLOGICAL AWARENESS NTC RCS EP LiPS 0 5 10 15 20 25 30 35 40 45 Percent retained in K or 1 Torgesen et al, 1999

54. 30 th 70 th 75 th 50 th 25 th OCTOBER JANUARY MAY NATIONAL PERCENTILE GROWTH IN WORD READING ABILITY Torgesen, www.fcrr.org

55. KINDERGARTEN FIRST GRADE LeftRight AT RISK READER BEFORE INTERVENTION AFTER INTERVENTION Simos et al, 2005

56. REMEDIATION STUDY  2 TREATMENTS – BOTH EXPLICIT PHONICS RX A “BOTTOM UP” (LiPS) VS A “TOP DOWN” (EP)  SEVERE DYSLEXIA 2 nd %ILE FOR WORD READING 35 th %ILE IQ  EQUAL TIME AND INTENSITY 1:1 100 MINS DAILY 8-9 WEEKS TOTAL 67.5 HRS Torgesen et al, 2001, NICHD  OLDER CHILDREN (8 – 10 YRS)

57. RESEARCH DEMONSTRATES BOTH IMMEDIATE & LONG LASTING RESULTS IN BROAD READING (DECODING+COMPREHENSION) Standard Score 75 80 85 90 95 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, 2001 16 Mos. Special Ed Class

58. 81 * 91 93 TWO YEAR FOLLOW UP READING RESULTS WRMT-R 70 80 100 STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP. 69 68 82 30 th percentile N = 50 * * p= <.05 * Torgesen, Alexander, Wagner et al, 2001

59. 72 96 * 91 * 91 * TWO YEAR FOLLOW UP READING RESULTS GORT-R 70 80 100 STANDARD SCORE 90 WORD ATTACK WRMT-R TEXT READING ACCURACY READING COMP. TEXT READING RATE 68 74 83 71 30 th percentile Torgesen, Alexander, Wagner et al, 2001 * p= <.05 N = 50

60. SPOKEN LANGUAGE GAINS

61. GROWTH IN SPOKEN LANGUAGE DURING INTERVENTION &

62. EFFECT SIZE OF TREATMENT ON LANGUAGE COMPREHENSION LIPSEP PRE-POST PRE-2 YRSPRE-2 YRS PRE-POST RLS OD WC SR LP ELS FS RC SA 1.05 0.75 0.61 0.62 0.85 0.60 0.24 0.75 0.97 0.75 0.44 0.93 0.58 0.71 0.70 0.54 0.49 0.31 0.50 0.37 0.03 0.70 0.44 0.20 0.76 1.05 0.46 0.84 0.43 0.38 0.67 0.60 0.16 0.78 P<= 0.05 ES of 5 – 7 moderate; 8+ large

63. Decreased activity in right hemisphere Increased activity in left hemisphere TREATMENTS EFFECTS ON BRAIN ACTIVITY Simos et al 2002

64. EXCITING RESULTS! HOWEVER……..

65. LATE VS EARLY INTERVENTION (PREVENTION) WORD READING ACCURACY AND RATE 2nd 10th 10th 10th 70 80 90 100 STANDARD SCORE Accuracy Rate 4th grade 2nd grade 30 th % ile BEGINNING % ile TREATMENT AGE 8-115-6 8-11

66. PROJECTED GROWTH IN “SIGHT VOCABULARY” OF NORMAL READERS AND DISABLED CHILDREN BEFORE AND AFTER REMEDIATION Normal Intervention Size of “sight vocabulary Grade in School 1 2 3 4 5 6 7 Dyslexic 2nd Year follow-up Later intervention does not close fluency gap – early intervention does Torgesen Torgesen, www.fcrr.org

67. 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

68. RESPONSE TO INTERVENTION MODEL  APPLICATION OF EVIDENCE-BASED TREATMENT TO SCHOOLS  TIER 1: CLASSROOM  TIER 2: PULL OUT SUPPORT  TIER 3 :TOTAL PULL OUT  A TIERED APPROACH

69. TIER TWO LITCHFIELD SCHOOL DISTRICT PHOENIX, ARIZONA  ID BY CLASSROOM TEACHER  SPALDING INSTRUCTION IN CLASSROOM  READING / PA ASSESSMENT BELOW GRADE LEVEL OR, AT GRADE LEVEL, BUT STRUGGLING  NOT QUALIFIED FOR SLD  EXPLICIT, MULTISENSORY PROGRAM (LiPS) 40 MINS DAILY, 120 DAYS, 80-100 HRS GROUPS : 6-8:1 (YOUNGER) 8-12:1 (OLDER)

70. LSD RESULTS 1 st GRADE 101 113 96 70 80 100 STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP. 83 72 85 30 th percentile N = 63 * * p= <.05 110 * *

71. 101 108 98 LSD RESULTS 2 nd GRADE 70 80 100 STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP. 96 93 95 30 th percentile N = 64 * * * p= <.05 110

72. 101 100 96 LSD RESULTS 3 rd – 5 th GRADES 70 80 100 STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP. 91 95 30 th percentile N = 126 * * * * p= <.05

73. TIER THREE EINSTEIN MONTESSORI CHARTER SCHOOL FLORIDA

74. www.einsteinmontessori.com

75. EINSTEIN MONTESSORI SCHOOL, INC (EMS)  CHARTER SCHOOL (1999)  REMEDIATE LITERACY SKILLS  LANGUAGE-BASED LEARNING DIFFICULTIES  2 ND - 8 TH GRADE  LITERACY SKILLS FOUR CLASS PERIODS/DAY 1. PHONOLOGICAL AWARENESS (LIPS) 2. READING 3. READING 4. WRITING  TEACHER TRAINING ACROSS ALL CLASSES

76. EMS GAINS 2004-2005 (GRADES 3-5)  SIGNIFICANT IMPROVEMENT (P <0.001)  WORD ATTACK  PASSAGE COMPREHENSION  PHONOLOGICAL PROCESSING  WORD & NONWORD READING EFFICIENCY  STATE ACHIEVEMENT TESTING  NON-SIGNIFICANT IMPROVEMENT  WORD IDENTIFICATION

77. EINTSTEIN MONTESSORI RESULTS HOWEVER….MANY MEASURES, WHILE SIGNIFICANT, DID NOT REACH 30 TH %ILE BENCHMARK THEREFORE….INSTITUTING AN INTENSIVE FOUNDATIONAL INTERVENTION (LiPS) 3 HOURS/DAY X 6 WEEKS SMALL GROUP

78. 0 50 100 150 200 250 300 350 4th5th6th7th8th GRADE DEVELOPMENTAL SCALE SCORE FLORIDA STATE AVERAGE ALACHUA COUNTY AVERAGE EINSTEIN MONTESSORI FCAT 2005 AVERAGE CHANGE IN READING DEVELOPMENT (IMPROVEMENT FROM 2004 TO 2005)

79. “TIER FOUR” 1:1 FOR THE TREATMENT RESISTERS  THE RESEARCH MODEL  THOROUGH BRAIN TEAM ASSESSMENT  TREAT OTHER FACTORS THAT MAY BE OBSTACLES ATTENTION BEHAVIOR SENSORIMOTOR

80. 81 * 91 93 RESEARCH RESULTS 3 rd – 5 th GRADES 70 80 100 STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP. 69 68 82 30 th percentile N = 50 * * p= <.05 *

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

82. PRINCIPLES OF LEARNING  WHAT FIRES TOGETHER, WIRES TOGETHER – MULTIPLE SENSES STRENGTHEN PATHWAYS  OPTIMAL ATTENTION  CONSISTENT INPUT  INTENSITY  SALIENT  FREQUENT  REPETITION, REPETITION, REPETITION Alexander, 2003

83. THE WONDERS OF DYSLEXIA

84. THE PICTURE OF DYSLEXIA (All Symptoms Do Not Occur With Everyone) STRENGTHS LEADERSHIP SKILLSTHINKING “OUT OF THE BOX” JFK PATTON CHURCHILL POLITICAL & MILITARY TED TURNER THOMAS EDISON (PHONOGRAPH) ENTREPRENEURS SCIENTISTS & INVENTORS

85. HANS CHRISTIAN ANDERSEN LEONARDO Da VINCI HARRISON FORD & STEVEN SPEILBERG THE PICTURE OF DYSLEXIA (All Symptoms Do Not Occur With Everyone) STRENGTHS CREATIVITY WRITERSARTISTSMUSICIANS ACTORS / DIRECTORS MOZART

86. THE PICTURE OF DYSLEXIA (All Symptoms Do Not Occur With Everyone) STRENGTHS VISUOSPATIAL / MOTOR SKILLS SURGEONSATHLETES NEUROSURGERYMOHAMMAD ALINOLAN RYAN

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

88. THANK YOU

89. 86 88 93 EMS RESULTS 3 rd – 5 th GRADES 70 80 100 STANDARD SCORE 90 WORD ATTACK WORD IDPASSAGE COMP. 91 85 30 th percentile N = 61 * * * p= <.05 *