Once the problem of a child or adolescent has been diagnosed as dyslexia, the pediatrician will be asked about treatment. As the previous authors have noted, the basic treatment of dyslexia is educational. In this article we plan to outline the principles of remediation for the dyslexic person and to suggest practical ways to help the pediatrician find a remediation program in his community that will be suitable for dyslexic patients.
We operate a private reading center in Rochester, Minn., that has been offering diagnostic, consultative, and remedial services to dyslexic patients for 25 years.
Our students, ranging in age from five to 65, have come from public and private elementary and secondary schools, colleges, and universities. Other sources of referral have been agencies, such as vocational rehabilitation services, mental health centers, medical centers, welfare agencies, and judicial agencies. Some of the older patients find their own way to our door because they have been on a continuing search for answers to their reading and spelling problems.
Obviously, the dyslexies we see represent a select sample. Most of them are perfectly normal, apart from their problems with dyslexia. (If, during our evaluation procedures, we suspect the possibility of other problems, the patient is referred to appropriate professionals for further evaluation.)
Although we have been working with dyslexies for many years, we are continually struck by the devastation this disability wreaks on the lives of those affected, no matter what their age. Living without appropriate help in a literate society, these people have been plagued by their inability to cope with the written word since early childhood. Unless he receives help, the dyslexic will continue to suíer from his affliction from the first moment he attempts to learn his ABCs to the last days of his life.
How many people have dyslexia? In literate societies the rate is approximately one in 10, according to several studies.1 So, if the patients the physician sees in his practice have the same incidence of dyslexia as the overall population, one in 10 would be dyslexic.
Dr. Bertil Sòderling, a Swedish pediatrician, phrased it in a simple and succinct way in an article in 1962, in Acta Paediatrica:2 "A pupil, otherwise capable of learning, who is unable to read and/or spell during the first three years of school, is dyslectic and accordingly handicapped. He should be treated as dyslectic [dyslexic]." In the early 1960s, when very few pediatricians accepted the existence of and diagnosis of this disability, Dr. Sòderling was strong in his convictions.
Dyslexia is a handicap that compounds many of the problems of everyday life. While there are still some who hold that emotional conflicts are the primary cause of language disabilities, thanks to the advances in understanding that have taken place in recent years, virtually everyone working in the field agrees that such a view is at variance with the facts.
Since the pediatrician is often the first physician to be consulted by the parents of a dyslexic child, we believe he should include as part of his diagnostic work-up an assessment of the patient's language skills. The evaluation to confirm a diagnosis of dyslexia is sometimes made more complicated than necessary. Confirmation can be fairly simple. As Silver and Hagin have observed, "If a child is seriously retarded in reading and has normal intelligence, chances are about nine in 10 that he has a specific language disability."3
When the patient's history and the physician's observations both point to the fact that the child is having difficulties in school, the simple office procedure outlined below should confirm the existence of reading or spelling problems. First, of course, one should determine that the patient is otherwise physically well, has intact or corrected vision and hearing, has intelligence within the average range or above, does not have a primary emotional problem, has been exposed to the usual educational opportunities, and is not socially or culturally deprived.
If these conditions have been met and there is still a complaint of trouble with reading and spelling, the assumption can be made that the patient is dyslexic. The diagnosis can be confirmed by a five-step procedure: school history, family history, estimate of intelligence, oral-reading sample, and spelling sample. We would like to discuss each of these in turn.
The school history. Ask the patient to tell in his own words what happened to him in school, from the first grade on. An educational history must also be obtained from the parents. Appropriate questions are: What do you remember about learning to read and to spell? What special help did you receive, if any? Did you find that this special help met your needs? How did you get along with your teachers and with your peers? What subjects were easiest for you? Which ones were hardest? Do you feel that you need help now? In what areas? What are your future hopes ana plans?
Often, in order to protect himself from being thought of as stupid, the child will have worked out his own explanations for difficulties or failures. For example, he may say, "My first-grade teacher was old and ready to retire," or "I was sick for a month during the third grade and missed school," or "I needed glasses and couldn't see the board."
If the patient is a young child and the school history is being given by the parents, they are likely to report that teachers have told them their child lacks motivation, is lazy, daydreams, is disruptive, or does not pay attention. The physician who is unfamiliar with language disabilities may be tempted to take such explanations at face value rather than looking at them as possible rationalization-avoidance symptoms. Under these circumstances, it could then appear that the child or adult did have these problems because he was disturbed.
The teacher who is unfamiliar with language disabilities may also be at a loss to explain her pupil's failure in school. To protect herself, or perhaps because she can think of no other explanation, she may resort to describing the child's behavior as causal.
Parents, accustomed to depending on school personnel for educational guidance, may accept these reasons for failure if they are not familiar with the problems of dyslexia. Tortured by guilt and self-doubt, they may blame themselves for the child's difficulties. They ask themselves where they have failed. Total frustration and anger often devolve on the child. Thus begins a self-defeating cycle, repeated only too often in the cases of dyslexic children with which we are familiar, with the dyslexic himself the ultimate victim - and this only because of a lack of knowledge on the part of all concerned of the nature of his language disability. Fortunately, the understanding of the problem of specific developmental language disability is much greater today, thanks to continuing research in the field and greater publicity about the nature of the disorder. Thus there is less possibility that the diagnosis will be missed than there was just a few years ago.
The family history. It should be determined whether the mother or father, siblings, uncles and aunts, or grandmothers and grandfathers had difficulties with reading and spelling. How many years did they attend school? Do the patient's brothers and sisters have unusual problems with their schoolwork?
In the 63 years of our combined experience in evaluating dyslexic children and adults, it has been extremely rare to find a true dyslexic without a familial history of similar problems.
Estimate of intelligence. Included in the school and family histories may be information about IQ tests given the patient. We believe it is essential for the physician to add to any test information his own informal evaluation, based on the patient's conversation, interests, behavior, and history. Too often, we have found, tests have been administered by those whose training did not provide the necessary information to enable them to understand and evaluate dyslexic persons. If the patient has auditory-processing problems, an IQ test may be even more unreliable in measuring his potential ability. In assessing these estimates of intelligence made by others, it must be remembered that the dyslexic child learns to fear tests and expect failure very early in his school career. The test situation, therefore, is usually not the best setting for measuring the dyslexic's intelligence accurately.
When evaluating the child, ask the family to provide added information concerning concrete tasks he can perform, how well he copes, and what he does in nonacademic situations.
Do not underestimate the problem of the child with superior potential. If his reading and spelling skills and his grades are average, he is still working with a handicap. His dyslexia is prohibiting his full use of his inherent ability. No one is more aware of this than the child himself. He feels that somehow he is failing himself, his family, and his teachers, for expectations are high for excellent performance from this group. Even low-average ability does not preclude learning the basic skills in reading and spelling that are necessary for functioning in a literate society.
Group IQ tests should never be accepted as measures of intellectual potential. They depend completely on the child's ability to read the questions asked and are thus a measure of reading ability and not of intelligence.
Oral-reading sample. An oral-reading test is the best way to determine a student's actual reading skills. The Gray Oral Reading Paragraphs Test4 has been widely used for many years by educators and physicians. It is easy to administer. It consists of a series of grade-level paragraphs, first through 12th, and gives the examiner an idea of the reader's proficiency level and his pattern of errors. It is unnecessary, for the physician's purpose, to grade the test. A qualitative analysis gives the needed information.
Figure 1. Second-grade paragraph from the Gray Standardized Oral Reading Paragraphs test.4 (Copyright by the Bobbs-Merrill Company. Used with permission.)
Figure 2. Fifth-grade paragraph from the Gray test. (Copyright by the Bobbs-Merrill Company.)
Spelling sample. In order to obtain a writing/spelling sample, dictate a short standardized list of words, one that has a scoring scale indicating grade equivalents.5 In addition, the patient should be asked to write a paragraph on a specified topic, such as "My Favorite Person" or "My Pet." Such a sample will provide evidence of misspelling patterns, confusions, and syntactic distortions. By observing the patient at work, the physician will be able to assess the amount of effort required to produce written work.
Typical error patterns that are found in the reading and spelling of dyslexies are shown in Table 1. For example, when a 10-year-old with a full-scale IQ on the Wechsler Intelligence Scale for Children (WISC) of 1 1 1 was asked to read the second-grade paragraph from the Gray Standardized Oral Reading Paragraphs Test shown in Figure 1, this is what he read:
One there-three-there were a little pig.
He liked with his mother-mom-mother in a pin.
One day he was his front feet.
"Mother," he said, "what can I do with me-my
His mother sayd, "You can-could run with them."
So the little pig run round the round the pin.
There are eight errors. The student took 56 seconds to read the paragraph. Another student, 13 years old and in the eighth grade, was asked to read the paragraph shown in Figure 2. The student took three minutes and 16 seconds to read the paragraph, with this result:
Once of the most intel . . . birds with never lied in my bird-room was a blue- jay named Jack. He was beautiful of busyness of morning tell night, even still. He had been stolden from a nest long before he could fly, and the had been read in a house long before he had been even to me as a present.
Examples of rotations, reversals, and omissions so typical of dyslexies can be seen in the word list in Figure 3. Note that this 13-year-old managed to spell just seven of the 20 words correctly.
Figures 4 and 5 provide additional examples.
EXPLAINING THINGS TO THE CHILD
An explanation is the first essential therapeutic step in the treatment of any dyslexic.6 It is devastating to anyone's concept of self to be aware of his failure to keep up with his peers in reading and writing without understanding the reason for his failure.7 Along with the explanation of what dyslexia is, special reassurance must be given that the problem is not directly related to intelligence. This is important, for in our experience most of those with the problem have assumed for many years that they are stupid or inadequate.
ERROR PATTERNS IN DYSLEXIC PERSONS
Figure 3. Typical spelling errors of a dyslexic. This 13-yearold eighth-grader had a verbal IQ of 1 04. Only seven of the 20 words are spelled correctly. Words dictated were catch, black, warm, unless, clothing, began, able, gone, suit, track, watch, dash, fell, fight, buy, stop, walk, grant, soap, news.
Of course, the situation must be explained in terms the patient can understand. Children can be told as much as they can absorb in language appropriate to their age level, and a more detailed explanation can be given to the parents.
The dyslexic should then be told that his problem is treatable: his written-language problem is remediable, and there are special teaching techniques that can enable him to learn the skills he needs to have in order to read and spell. He can be given further reassurance by being told that efforts will be made to find a school program or a special teacher to provide the help he needs.
We have found it helpful to use the bell curve shown in Figure 6 to help dyslexies understand the nature of their problem. As used in reference to the person's ability to deal with written words, the curve represents a continuum from word blindness, at the extreme left, to eidetic imagery, or photographic memory for words, at the extreme right. While it is obviously an oversimplified explanation, it is helpful in relaying the concepts of dyslexia to those who have the problem.
Employing the same curve, other analogies can be used to illustrate such things as the ability to distinguish musical pitch (with the continuum ranging from tone deafness to absolute pitch) or the ability to coordinate muscular activity (dyspraxia to superior athletic ability). Obviously, the terminology has to be geared to the patient's verbal understanding.
Figure 4. Writing of a dyslexic 12-year-old seventh-grader, rated high average on the WISC. When we asked him what he meant to write, he said: "The dogs are getting bigger and their eyes are open. Well (?) is and in 2 weeks they will be walking real good and they are learning to walk now and they will be old enough to hold." He was unable to figure out what he meant by the fourth word on the second line.
Figure 5. Writing of a dyslexic 12-year-old. His IQ as measured by the WISC is verbal, 92, and performance. 128. This paragraph was meant to read: Straight ahead there was the meanest, ugliest, biggest and tallest most grossest bunny rabbit I've ever seen! I could see it descending on me with little beady teeth, gnashing them as he came. I slowly raised my shotgun and took one shot. It didn't even stop it. It was now only 40 feet from me. But something told me I was O.K.. especially when it picked up a carrot and asked, "What's up?"
The dyslexic person has a problem with visual imagery for words. One way of explaining this to patients or parents is to use the analogy of the camera. Some people retain "photographs" of words easily. Others do not.
Along with lack of visual imagery or retention of written symbols in the correct sequence, many dyslexies also have problems with auditory processing of spoken sequences. Just as poor visual imagery can be compared with a poor "photographic" system for words, so poor auditory processing can be compared with a poor taperecording system. The bell-shaped curve again can be used to give a graphic representation of the continuum (Figure 7). The person's difficulties can range from mild problems, in which he finds it more difficult than most people to organize verbal-abstract material, to finding it quite difficult to remember two verbal directions given at one time. Infants sometimes have difficulty in learning how to sequence sounds so as to begin talking - or later to distinguish similar speech sounds, such as e from Z and ch from /'. Though a dyslexic's difficulty with auditory processing is not related to basic intelligence or hearing acuity, it does interfere with tasks that require sequential auditory organization. That is why these persons have great difficulty remembering verbal concepts gained through reading or organizing their own ideas to be expressed either orally or in writing.
Figure 6. Visual pathway.
Figure 7. Auditory pathway - verbal.
Many of these children are bright. But even bright students with auditory-processing difficulties may not be able to retain a sequence of five or six digits or accurately repeat unfamiliar foursyllable words. They are the ones who keep saying "What?", act as if they do not understand, or are repeatedly sent to doctors to have their hearing checked even though previous reports have documented that there is no hearing loss.
Because their behavior closely resembles that of the daydreamer, the unmotivated, the inattentive, or the hard-of- hearing, many persons with poor auditory perception are diagnosed as having emotional problems. Persons recognized as having this difficulty need a careful explanation of this facet of their language disability.
When the dyslexic has auditory-processing difficulties, the physician will want to speak more slowly and clearly and use simpler vocabulary so that the patient can comprehend what is being said. Physicians who are highly verbal will need to be especially careful to speak slowly and use words that the dyslexic patient can understand.
The dyslexic student who also has auditoryprocessing difficulties thus has two serious handicaps that constantly interact to compound his difficulties in learning the code system necessary for reading and spelling. There are only three pathways to academic learning - visual, auditory, and kinesthetic-tactile - and the child with problems in both visual and auditory processing cannot rely securely on two of them. So the kinesthetic pathway must be utilized far more than in other persons to relay essential information.
Unfortunately, little has been written concerning auditory processing. What has been written has been mainly limited to the area of theoretical research. Little has been published in the way of concrete suggestions for helping these persons compensate for their difficulties. Often the tragic result of not understanding the effects of these combined disabilities is misplacement of a student in a class for the retarded.8
AFTER IDENTIFICATION, WHAT?
Once the patient has been identified as a dyslexic, the parents are likely to look to you for finding appropriate help. Where can you refer the dyslexic child or adult for treatment?
Help for the school-age child can be found within the school system in some communities. In others, only private agencies, tutors, or colleges or university clinics or programs can offer help. In many areas it will be difficult to find anyone with the specialized training needed for working with the dyslexic person.
It is well to realize that the programs usually planned for remedial reading classes in schools are not designed to meet the special needs of the dyslexic. (Many are led to think that they do, only to find out otherwise after valuable years have been wasted. Unfortunately, even the possession of a graduate degree in learning disabilities does not mean that the remedial teacher possesses the techniques needed for teaching dyslexies.)
The physician, then, faces real difficulties in many instances in assessing whether a program is adequate or not. He should look for a program that uses (1) multisensory reinforcement, (2) phonics, (3) rules and generalizations, and (4) a structured system progressing from the simple to the complex.
A multisensory approach. This means using all three pathways to implement learning - visual, auditory, and kinesthetic-tactile.
The visual presentation is the obvious one, and it is used generally - sometimes exclusively - in a great many teaching programs. It is the one approach that is certain to cause the dyslexic the greatest difficulty. In a visual presentation, words are supplied to the student for him to look at and memorize for subsequent use in reading and spelling. This is not difficult for children with no impairment of visual imagery for words; but for the dyslexic student who is not able to retain wholeword images securely, it ranges from difficult to impossible.
Phonics. We mention phonics as a guideline in selecting an adequate remediation program for the dyslexic because the dyslexic must learn the phonic units of the language in order to succeed at reading and writing. When looking at these phonic units, he must be trained to recognize them visually and to pronounce the appropriate speech-sound equivalents.
When the dyslexic hears himself pronounce the sounds of words, he gets simultaneous auditory reinforcement.
The student must also be trained to be aware of kinesthetic reinforcements he receives from the muscle movements of the speech mechanisms. For those with severe problems, special emphasis must be placed on becoming aware of the feeling of movements of the mouth, the tongue, the throat, and the lips as various words are pronounced. Kinesthetic reinforcement can also be provided by hand and arm movement. The student should write or trace each phonetic unit, saying the sound simultaneously, until he has mastered it. The more severe the dyslexia, the more essential it is to train the patient to trace or write the language units.* Rules and generalizations. In a reversal of the process outlined above, the dyslexic student must also be trained to hear speech sounds and to name or write all the phonic units used to represent each sound.
Some speech sounds can be written only one way - for example, /, p, and y. Others may be written two, three, or even more ways. For example, there are two ways to spell the ch sound (ch, tch), four ways to spell ô (au, aw, augh, ough), and even more ways to spell e and a.
Figure 8. Phonic units are presented visually on a card, and the student is asked to give the sound equivalent. The examples show units from different card packs: top left, card from a basic phonics pack; top right, card from a prefix pack; bottom left, card from a suffix pack; bottom right, card from a root pack.
The student must be taught where these various letters or combinations of letters are used in a word, and he must also be taught what rules and spelling patterns are employed. For example, the tch spelling is used only after a short vowel ("catch," "pitcher"). The ch spelling is used in all other instances. After learning this, the student is then exposed to the four common exceptions ("such," "much," "rich," and "which").
All this may sound needlessly complicated to the person without spelling problems. But to the person who has difficulty in visualizing words, it opens up a whole new area of possibilities. By learning the two spelling combinations, along with the rule for their use and the four exceptions, he is able to read and spell several hundred words that previously were beyond his grasp.
Learning rules and generalizations such as these helps the student feel more secure with the written language that he must master. And this sense of security allows him to function more adequately in situations in which he is required to read or write.
How many of these rules must a dyslexic learn? In order to achieve literacy, he must know all the sound-symbol relationships and their rules and generalizations. To finish high school and attend college, he should have a complete knowledge of Anglo-Saxon, French, Italian, Latin, and Greek roots, prefixes, and suffixes. To give just one example, knowing that -ess is a feminine ending of a noun, as in "waitress," and -ous is the ending for an adjective (e.g., "dangerous") takes much of the guesswork out of spelling.
A structured program. In educating a dyslexic student, "structured program" means (1) teaching necessary elements, from simple to complex a to -tch to Hon to -CtOUs)9 step by step; (2) teaching each new element until it is securely learned before introducing a new one, and (3) training the student to relate the new element to the other pieces of information he has already mastered.
EVALUATING THE REMEDIAL PROGRAM
In order for the dyslexic to master all the information he needs to know, certain procedures must be carried out routinely in the remedial program. We believe that if any part of these procedures is omitted regularly the dyslexic will not receive the training required to allow him to function to his maximum potential.
So the physician who evaluates a remedial program for one of his patients might consider the following components essential:
1. Visual drill work, in which phonic units are presented visually and the student responds with the sound or sounds each represents. Usually each unit is presented visually on a card, and the student is asked to give the sound equivalent (Figure 8). First, the units are learned in isolation, and then the student is trained to blend them together in order to read words. Blending training should begin as soon as the student knows two sounds and continue until he can readily read polysyllabic words.
2. Auditory drill work, in which sounds are presented and the student responds by naming or writing the letters or letter combinations that spell these speech sounds. In auditory drill work, the student should be trained to hear a word, separate the sounds in it, and write those sounds in the correct sequence. Auditory drill work should begin as soon as the student can recognize and blend two sounds. It continues until he can deal successfully with syllabic sequences in polysyllabic words.
3. Kinesthetic drill work, Kinesthetic reinforcement is utilized by requiring the student to write or trace and simultaneously sound aloud the unit he is learning (multisensory reinforcement). Whenever errors or confusions occur, the teacher helps the student correct them by having him use kinesthetic reinforcement.
4. Decoding and encoding skills. Reading and spelling are language skills dealing with the same sound-symbol relationships, so a program of remediation should contain both if the dyslexic is to benefit optimally. Educators refer to these as decoding and encoding skills.
By "spelling" we do not mean training dyslexies to memorize a list of words to be reproduced by rote. That, of course, would require the impossible task of rote memorization of the entire language. However, a few common nonphonetic words must be memorized (e.g., "could," "two," "buy"). For the dyslexic student, spelling training means learning to translate auditory input into kinesthetic output - translating what he hears as spoken language into written language, speech sounds into written symbols.
5. Learning rules and patterns. We spoke earlier of the need to teach dyslexies rules and generalizations. Simultaneously with learning to recognize and recall sound-symbol equivalents, the student should be taught the rules and patterns governing their use. This allows him to make appropriate choices when there are options.
The beginning student needs the information relevant to the level of written language he is dealing with. Thus, once the unit ck is introduced, the student is taught to use it for the k sound only when it occurs after one short vowel (usually at the end of short words, such as "sick" or "struck"). Once he learns the ai unit, he is taught to use it only at the beginning or in the middle of a word - never at the end (e.g., "aiming," "pain").
Advanced students can be taught rules appropriate for a more difficult vocabulary. They learn that there are three ways to spell shan; that -tion is the most commonly found (e.g., "vacation," "attention"); that -sion is used only when the root word ends in s or ss (as in "tension," "depression"); and that -cian is used to end the word for a person, the root word of which ends in c (as in "physician," "mathematician").
6. Reinforcement through kinesthetic pathways. Whenever the student has difficulty in mastering any of the material so far described, the kinesthetic pathway is used for both recognition and reinforcement. This entails both the speechmuscle mechanisms and hand-arm movements. Kinesthetic reinforcement is as useful for the advanced student who may be confusing pre- with per- as it is for a child with typical bid problems. The confusion will be more severe if the dyslexic has problems with visual imagery and auditory processing. The more severe the student's problem, the more the kinesthetic pathways will be used in the teaching process.
7. Repetition. Review and reinforcement are necessary until the dyslexic is able to automatically retrieve the sounds, rules, and patterns. Repetition is the means by which this is achieved. Thus, the hallmarks of a good remediation program for dyslexies have been described as the four Rs: recognition for reading, recall for spelling, reproduction for writing, and repetition for learning.
This process of being able to synthesize and analyze, to be able to take a single word apart and put it back together again, is basically the way the dyslexic student learns. The amount of drill work necessary to achieve success will depend on the severity of the disability with visual imagery and whether or not the student has problems with auditory processing or synthesizing the spoken sequences.
Until the 1920s, few attempts were made to teach dyslexic persons by other than conventional methods; when these were employed, they resulted in little but frustration for both student and teacher. But then a professor of psychiatry at the University of Iowa, noting that while some students were virtually illiterate they were often highly intelligent, conceived and developed a philosophy of teaching these persons that was so successful it has since been copied widely. From his pioneer research in recognizing and studying this disability, Samuel T. Orton, M.D., developed teaching methods that achieved greater success with dyslexies than any of his predecessors had hoped for.9
Dr. Orton devised the three-pathway, multisensory approach we have discussed above. During the 1930s and '40s, he continued to work with dyslexies while he was professor of neurology and neuropathology at Columbia University.
While at Columbia, Dr. Orton asked Anna Gillingham,10 a psychologist and remedial teacher who was working with him, to undertake the task of formalizing and organizing the procedures he was using to educate dyslexies in terms teachers without a medical or neurologic background could readily understand. The result of this collaboration is known today as the Orton-Gillingham approach to remediation.
Do not be alarmed, if you are investigating a remediation program for a dyslexic patient, to find that there are considerable variations in teaching styles among teachers. Each style is perfectly acceptable, provided the teacher understands the underlying philosophy required for teaching the dyslexic and the program includes the essential points outlined above.
Techniques used for teaching adolescent dyslexies are the same as those used for children, but of course the approach must be different. The sensitive, trained teacher will know this instinctively. You cannot take an older student with average or above-average intelligence and teach him effectively by using elementary phonics and vocabulary and low-level, low-interest reading material. The teachers must explain that they will be working on the mechanics of language and on reading word lists until the student can read material that is of interest to him.
Thus, instead of starting with basic phonics or single-letter units, the older dyslexic can start on phonetic prefixes (such as pre-, re-, ab-, and sub-) and roots (such as diet, ject, andgress). In this way he will learn the same thing taught the younger dyslexic (consonant and short and long vowel sounds) and then be able to put these more advanced units together into such words as "predict," "abject," "regress," etc.
Can the dyslexic profit from other programs now being offered in the community, such as adult basic education courses or vocational school curricula? In our experience, no. They seldom employ anything other than the conventional teaching approach used in elementary schools, and this - as we have seen - is not what the dyslexic person needs.
THINGS TO AVOID
We have mentioned seven characteristics that an adequate program for teaching dyslexies will have. On the negative side, there are a number of warning signs to indicate that a remediation program has not been planned for the optimum benefit of the dyslexic. We suggest that you avoid any program that:
* Does not employ a multisensory approach, with structured phonics and definite methods for teaching the dyslexic the structure of the language.
* Requires the dyslexic to learn most words as whole units through sight recognition.
* Emphasizes speed reading.
* Uses machines to any great degree. (Machines do not teach. They may, of course, be a helpful adjunct to a teaching program if there are many children in the class.)
* Relies heavily on spelling lists that must be memorized by rote.
* Requires pages of unsupervised work in workbooks.
* Promises that the dyslexic's problems will be solved by purchasing a new series of reading texts. (A new series is likely to benefit the publisher more than the student. Trained teachers are necessary for teaching dyslexies; books alone cannot do the job.)
* Uses a reading approach that depends almost exclusively on color coding of words or sounds or uses some other code system that changes standard letter forms. (The dyslexic student has to learn how to deal with standard English printed in standard type. It will be much less confusing for him to learn standard letter forms from the beginning rather than attempting to master two different printed alphabets.)
* Attempts to improve the dyslexic's academic achievements by having him perform coordination tasks, such as creeping, crawling, and walking balance beams.
* Uses eye-movement exercise.11,12
* Uses arbitrary and inflexible groupings of children for teaching purposes. (We are not speaking of individual or small-group help for language-disabled students, which of course has obvious value.)
* Pigeonholes students on the basis of one IQ test.
* Uses punishment or ridicule to "discipline" the dyslexic when he makes an error or becomes confused.
* Isolates children and requires them to work on their own. (Isolation in itself sets the child apart; when he is working alone, the lack of a teacher to monitor his errors serves to reinforce his confusions.)
PROGRAMS TO HELP
Public schools, private tutoring, and private schools. Public-school programs for those with dyslexia usually mean that the child will be placed in a small group rather than receiving individual tutoring. This is necessary because of the numbers that must be helped, limited finances, and limited number of trained personnel. If the program is a good one, it will include early detection and placement in a small group with other dyslexies for daily help during the reading, spelling, or English period. This should provide adequate help for all but the most severe problems, which will need additional individual work.
If the public school has no appropriate program, private tutoring is necessary until the school develops one. Tutoring should be done during school hours, for it is unfair to ask a child to work after a long day in school. Some school systems are still inflexible, however, and one has to settle for Saturdays and one or two days a week after school, with more intensive work done in the summer. Because repetition and practice are so essential for learning, at least four to eight weeks in the summer should be devoted to continued instruction. When private tutoring is financially unfeasible, some parents have obtained materials and learned how to teach their children.
If one is looking for a private school for a dyslexic student, the information included in the brochures and catalogues cannot always be taken at face value. A program advertised for those with learning disabilities may turn out to be much the same as the curriculum for ordinary students, except that it is more intensive and more individualized. As we have seen, this will not achieve the results that are needed for dyslexies; parents, unless they check the approach offered, may spend thousands of dollars on "remediation" of their dyslexic child without seeing the child make the progress that should be expected. The physician who follows the guidelines outlined above will be in a position to recommend remedial programs that will make optimal progress possible for the child.
Curriculum adjustment. It will be necessary to modify the school curriculum for most dyslexic students. An adequate remediation program will include coordination with the regular classroom teachers so that the appropriate adjustments can be made. An eighth-grader who is dyslexic and has fourth-grade reading skills may be able to do quite well in some eighth-grade subjects, but he cannot hope to be successful in reading and comprehending the standard eighth-grade textbooks or written examinations. Among the many possible changes to be considered are such things as taped reading assignments, oral examinations, extra-credit assignments that will not require extensive reading and writing, waiving of foreign-language requirements, and shortened or specially designed spelling lists. These adjustments should remain in force until the dyslexic student's skills have improved to the point where he can handle the reading and spelling requirements. Students with more severe dyslexia may need to have these curriculum adjustments maintained throughout their school years.
Coping mechanisms. While undergoing special training and modifications in school curriculum, the dyslexic student will gradually improve his capacity to function in society through the development of "coping mechanisms" through which he consciously or unconsciously compensates for his deficiencies in reading and writing. It is through the development of such coping mechanisms that many dyslexies have been able to survive academically in spite of their language disability.
For example, if he really understands his own language disability, a student can explain it to his teachers and help them understand the problems and the ways of helping circumvent them. An adult can do the same thing with his employer and fellow workers. When spelling is poor, taking notes during lecture classes is difficult. Taping the lectures and then taking notes from the tape recording is much easier. One can turn off the tape recorder in order to get essential points down in written notes, but one cannot "turn off the teacher." Finding someone to type reports from a rough draft, correcting spelling and punctuation, is also a good method of coping. The brighter the person, the better he is at finding ways of circumventing the effects of the deficits in writtenlanguage skills.
Physical "symptoms" sometimes manifested by the dyslexic. Among the children to be concerned about are the patient whose teachers and/or parents frequently ask for sight or hearing checks, even when earlier checks have proved negative; the child who has sleep difficulties; the one who complains often of stomachaches, headaches, or cold symptoms when it is time to leave for school; the one who cries either on leaving for or returning from school. These and other complaints are ones that are frequently reported to us by parents of children who are struggling in school with a specific language disability.
Social implications of dyslexia. It is rare to find an illiterate person who has been able to adapt comfortably to our literate society. A number of studies have been published indicating a causal connection between the inability to read and spell adequately and antisocial behavior.2,13 Another indication of this is the unusually high percentage of dyslexies in institutions for juvenile delinquents and in prison.1,7 Some dyslexies turn their frustrations in upon themselves and thus can exhibit symptoms of depression, anxiety, chemical dependency, or other mood disturbances serious enough for them to be referred for psychiatric help.7
WHEN HELP IS NOT AVAILABLE
The physician's diagnosis, recommendations, report to the school, and follow-up constitute the strongest professional support the parents of a dyslexic student can have. For the dyslexic who has dropped out of school, the physician's diagnosis of his condition and explanation of it to him provide the type of support every teenager (and adult) dyslexic needs. The assurance that he can be helped and that it is not too late to start is essential. The pediatrician can then advise him and his family concerning seeking appropriate remediation.
When school districts do not recognize the incidence of dyslexia and fail to provide teachers trained to work with language disabilities, parents have organized to fight for needed programs. Communication with the schools is often a problem, because educators are sometimes unfamiliar with the term "dyslexia" and use such phrases as "learning disability," "language disability," or "perceptual problem" to categorize children with reading problems. It does not matter what terminology is used, as long as the school provides a program that meets the needs of the students.
The physician interested in helping dyslexies can assist in such cases by having articles available that will inform school officials and by explaining the diagnosis thoroughly, either in a report to the school or an appropriate agency or in meeting personally with school staff and others engaged in remediation.
If you decide to do this, be prepared in advance for a possible medical-educational conflict. More than one educator has felt threatened by such attempts to help and has adopted an attitude that says, in effect, "You take care of your patients, and I'll educate the students."
But if the patient does have dyslexia and no program of appropriate remediation is in effect, the patient is not being educated. And the physician who makes the diagnosis of dyslexia should, of course, want to see his patient's problem solved through appropriate remediation just as much as he would want to see a medical or surgical problem solved through an appropriate course of treatment. To make the diagnosis of dyslexia and not follow through is akin to diagnosing an acute appendicitis and not arranging for surgery.
Information about the location of remedial centers can be obtained from the Orton Society, 8415 Bellona Lane, Towson, Md. 21204, or the Association for Children with Learning Disabilities, 5225 Grace Street, Pittsburgh, Pa. 15236.
"For other kids, learning to read is like a feather," one nine-year-old dyslexic once told us. "For me, it's like a ton." It is for thousands of children and adolescent and adult dyslexies throughout the country who are now carrying this "ton" that the physicians' supportive help is so badly needed.
As Ellingson has observed, "these children are as handicapped by the ignorance surrounding their problem as by the problem itself."14
1. Critchley, M. Developmental Dyslexia, Second Edition. Springfield, ?1.: Charles C Thomas, Publisher, 1966.
2. Soderling, B. Studies on special disturbance within the reading and writing function in children ("dyslectic," "word blindness") A contribution to the question of origin. Acta Paediatr. 51, [Suppl. ] 135, 1962.
3. Silver, A. A., and Hagin, R. A. Profile of the first grade: a basis for preventive psychiatry. /. Am. Acad. Child Psychiatry 1 1 (1972), 645.
4. Gray, W. S. Gray Standardized Oral Reading Paragraphs. Indianapolis: The Bobbs-Merrill Company, 1955.
5. Wide Range Achievement Test, Wilmington, Del.: Guidance Associates of Delaware, 1965.
6. Cole, E. Afterword: Reflections after 40 years of treating children with specific reading disability. Psychiatr. Ann. 7 (1977), 488491.
7. Rome, H. P. The psychiatric aspects of dyslexia. Bull. Orton Soc. 21 (1971).
8. Thompson, L. J. Reading Disability - Developmental Dyslexia. Springfield, 111.: Charles C Thomas, Publisher, 1966.
9. Orton, S. T. Reading, Writing, and Speech Problems in Children. New York: W. W. Norton and Company, 1937.
10. Gillingham, A. Remedial Training for Children with Specific Disability in Reading, Spelling, and Penmanship. Cambridge, Mass.: Educators Publishing Service, 1956.
11. Dyer, J. (on the role of the ophthalmologist in the evaluation and treatment of dyslexia). Questions People Ask About Dyslexia, Pediatric Annals, current issue.
12. Goldberg, H. Vision, perception, and related facts in dyslexia. In Keeney, A. H., and Keeney V. T. (eds.). Diagnosis and Treatment of Reading Disorders. St. Louis: C. V. Mosby Company, 1968.
13. Hogenson, D. Reading failure and juvenile delinquency. Bull. Orton Soc. 24 (1974).
14. Ellington, C. The Shadow Children. Chicago: Topaz Books, 1967.
Figure 1. Second-grade paragraph from the Gray Standardized Oral Reading Paragraphs test.4 (Copyright by the Bobbs-Merrill Company. Used with permission.)
Figure 2. Fifth-grade paragraph from the Gray test. (Copyright by the Bobbs-Merrill Company.)
ERROR PATTERNS IN DYSLEXIC PERSONS