Dr. Susan R. GrantLutherville, MD USAdrsrgrant@aol.com

www.drsusanrgrant.com

IDENTIFYING THE WARNING SIGNS AND ASSESSING THE RISK MARKERS FOR

LEARNING

Yesterday’s brain imaging: how it shaped our thinking

Today’s brain Imaging: how it shapes our thinking

A highly connected system

•What are the behaviors that you might observe that would place a child at risk for learning?•Do all children who struggle with language struggle withlearning to read or reading to learn?•What are some of the early warning signs that a child, at risk for reading failure, may exhibit?•How will language deficits impact learning?•Will appropriate early intervention “fix” the problem?

Today’s workshop is intended to give you the answers to the following questions:

Neurological Considerations

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� Not born prewired to read or write� Reading “software” gets added to “hard-drive” of the language

machinery designed for phonological processing.� Processes that sub serve reading were designed to support

language acquisition.� Learning to read changes the brain organization.� Inheritability and genetic factors influence ease of reading

acquisition.

Neurological risk factors� 40% of children with delayed speech and language onset are

at risk for reading failure or associated learning disabilities

� 40% genetic predisposition for dyslexia

What are some of the early warning signs that would place a child at risk for difficulty with reading acquisition?What are some of the warning signs that would place a child at risk for poor reading comprehension?How early can you determine if a child is struggling with reading, that it is likely to be a Reading Disorder?

What is developmental dyslexia?

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� Reading and dyslexia can NOT be attributed to a single process.

� Dyslexia is a partially heritable condition that involves a complex cluster of processes or behaviors including: sensory processing (phonological processing), working memory, sensorimotor coordination

� Dyslexia affects 5 to 15% of children� The biological mechanisms of these “clinical” behaviors

are just now being investigated, but are still relatively poorly understood

Reading is a learned skill which is only possible because of the brain’s extraordinary ability to make new connections among existing structures.

When one learns to read, the brain is forever changed both physiologically and intellectually.

Maryanne Wolf

Characteristics of a Reading Disorder vs. Dyslexia� Umbrella term:

Decoding- evident in early grades in initial acquisition of learning to read.

Comprehension/processing- becomes evident in third or fourth grade as complexity of print increases. Maybe good at decoding but misses intent, can’t infer or predict. Compromised in reading to learn.

The longer a child remains a poor reader the harder it is to catch up

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� Lack of reading practice

� Lack of varied reading

� Limited reading of classroom material and learning

� Loss of interest in reading and learning

� Compromises fluency

� Compromises growth of vocabulary and general knowledge

� Compromises growth of essential information

� Compromises school success

Classroom “signs” of a reading disability:� Trouble with alphabetic learning; connecting sound

to print; rhyming� Difficulty remembering the letter names or “hearing”

the sounds� Difficulty with sound sequencing or sequencing in

general (days of the week, months of the year etc.)� Difficulty with any ideographic learning, such as

number names; confuses math symbols� Difficulty with spelling� Difficulty with word retrieval� Difficulty understanding what they read

The Practice Effect

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The Practice Effect(Torgenson)

Books

Assigned Text

At-Risk behavioral manifestations for reading disability

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� Deficits in phonological awareness� Deficits in phonological sequencing (transpositions)� Deficits in immediate or short term auditory memory� Deficits in word or phoneme retrieval� Genetic history

FREQUENCY of Occurrence of READING DEFICITS:National statistics (US)� 40% of the population likely to have academic achievement

problems related to poor reading skills� 70 -80% of minority /high poverty school populations have

academic achievement problems related to poor reading� 20 % of elementary population (1:5) struggle with reading

acquisition and is at risk for academic failure without appropriate remediation

Frequency of Overall Reading Disabilities� 70-80% - poor phonological awareness skills that

compromise learning to decode and spell (dyslexia)� 10-15% - lack reading automaticity despite word decoding

accuracy� 10-15% - poor reasoning ability, background and vocabulary

knowledge, and language skills to aid comprehension

Stumbling Blocks to Becoming a Good Reader

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� Difficulty learning to read words accurately and fluently.� Insufficient vocabulary, general fund of knowledge and reasoning

skills to support comprehension of written language.� Lack of motivation to read and a failure to develop a mature

appreciation of the rewards of reading.

Age of Mastery of Phonological Skills

q 3 years - recitation of rhymesq Rhyming patternsq Alliteration

q 4 years - syllable counting (50% of children)q 5 years - syllable counting (90% of children)q 6 years - initial consonant matching

q Blending 2 – 3 phonemesq Counting phonemes (70% 0f children)q Rhyme identification and productionq Segmenting initial and final sounds in a word

q 7 years - blending 3 phonemesq Phonetic spellingq Phoneme deletion

q 8 years - consonants cluster segmentation (such as st, cl)q Deletion within cluster (separate s and t in st)

Andre 5.1 yrs. Montessori kindergartenReferred by the teacher and parents to look comprehensively at his learning profile of strengths and weaknesses, in light of disproportionate struggle with learning the alphabetic code in the context of an otherwise clearly “intelligent” little boy. There is a significant genetic history of Dyslexia paternally.

SUMMARY AND RECOMMENDATIONS: In addition to a genetic history of dyslexia, Andre presents with a cluster of behaviors that make him at even greater risk for expressing a dyslexic profile, including: compromised immediate rote auditory memory skills ; difficulty with sequencing; poor rapid automatized naming; and difficulty with producing and discriminating rhyming patterns. There is a developmental range within which children acquire reading, and there is no direct correlation between intelligence and early reading, however Andre’s weak rote auditory memory skills and his significant struggle with learning the alphabet code appears to be more pronounced than one would see as a result of developmental maturation.

The benefits of early intervention, as a prevention for reading failure is well documented.

ANDRE 6.3

Test Standard ScoreOWLS, Written Language 99WJ 3 Basic Reading Skills 114 (99)

Word Attack 122 (100)Spelling 113 (98)Letter Word Identification 100

DECODING SKILLS TEST (DST)Basal Vocabulary: 100% pre-primer (1.2 G.E.), 70% primer (1.5), 30% first reader

Phonic Patterns: 100% CVC , 60% CVCe & CCVCC

TEACHER OBSERVATION� Comprehension (oral and written)� Retrieval/memory� Attention (distractibility, impulsivity, inhibition, focus, motor

restlessness)� Following directions� Application of knowledge� Behavior (compliance, motivation, maturity, social skills)� Speech/language competence� Cognitive ability� Executive functioning

Assessment tools for dyslexia

Critical reading precursors Assessment tools

� Short term auditory memory

� Retrievals and rapid naming

� Reading efficiency

� Phonic knowledge

� TAPS-3, CTOPP Phonological memory subtests

� BNT (Boston Naming Test), CTOPP Rapid naming subtests

� TOWRE (Test of Word reading Efficiency), Reading fluency/rate: WJ-3. GORT-5

� DST (Decoding Skills Test), Word Attack-WJ3

Assessment tools for reading

Comprehension Assessment tools� Word list reading

� Reading vocabulary

� Paragraph reading

� Story retelling (oral/ listening comprehension)

� Word identification- WJ 4, KTEA-3, WIAT-3

� Word knowledge- PPVT-4, WJ-3 Reading Vocabulary subtest

� WJ-4, KTEA-3, GORT-5, WIAT-3 (Nelson Denny- for high school)

� WRAML-2, WJ-3 Story Recall subtest

Key to reading instruction for struggling readers

�Explicit instruction

�Systematic instruction

�Intensive instruction

Elements of a good instructional reading program� Alphabetic knowledge� Phonemic awareness� Vocabulary development� Systematic phonic instruction (decoding and encoding)� Text reading and reading comprehension� Reading fluency

By the end of third grade children should no longer be learning to read, but rather reading to learn.

70% of children not reading by the end of 3rd grade are not reading in 10th grade.

Tim is a 15 .5 yrs, left-handed male ,9th grade.Difficulty with reading acquisition by 3rd grade. Tutored regularlythrough 6th grade, completing the Spell Read Program . Historically,diagnosed with an Auditory Processing Disorder. Has continued tostruggle with processing speed.BEHAVIORAL OBSERVATIONS: Verbally engaging, charming ,highlycooperative and participatory. Quick to give up, as tasks becomechallenging, limited in his mental persistence. Approached math taskswith greater ease and speed. Good sustained attention .ACADEMIC PERFORMANCE:He presents with a “classic” dyslexic profile: struggles significantly withreading speed, decoding and encoding. With short passages cancomprehend. Strengths in his quantitative reasoning, slow math factautomaticity. Written language characteristic of Dyslexic profile: poorspelling in context, limited vocabulary, and less well developed orextended expository writing. Reading comprehension rate drops offdramatically with demands for lengthier, more integrated reading. HEDID NOT FINISH WITH EXTENDED TIME.

TEST SCORES: TIMWISC IV Verbal Comprehension Index- SS =108CTOPP Phonological Awareness = 73

Phonological Memory = 94Rapid naming = 58

TOWRE Sight Word Efficiency = 74Phonemic Word reading Efficiency = 73

WJ3 BROAD READING =84READING COMPREHENSION = 106WORDATTACK = 84WORD IDENTIFICATION = 84

NELSON DENNY READING COMPREHNSION(ET) =9th %ile

RECOMMENDATIONS:1. Access to recorded material. Register on www.learningally.org as a dyslexic

student. 2. Develop proficiency in listening to recorded material. Start with books or movies with which there is familiarity to make the listening task easier. This is 3. Continue to read print to improve efficiency and enrich vocabulary.4. Preview to limit demand on working memory Specifically, when reading preview literature: use abridged notes, read the jacket cover, epilogue, prologue and chapter headings, prior to reading the book previewing text: read comprehension questions, summary

paragraphs, anything captioned, italicized or bolded, prior to reading the text. Orally state a working hypothesis for which he can then read to confirm or negate, to make the reading process more active.5. Provide a reader for all standardized testing.6. Double extended time (100% increase) on in class and standardized tests, to compensate for slower processing speed.7. Full time access to a lap top for written work and to assist with spell and grammar check.8. Goal to sustain reading for 30 min. Target high interest material: short stories and articles or magazines, abridge books etc. 9. Use text to speech (Kurzweil) technology, and a SmartPen

Recommendations (Tim)

Accommodations Remedial� Recorded text� Reader for standardized tests� Extended time� Laptop; spell check� No penalty for spelling errors� Text to speech software� Speech to text software� Teacher prepared outline or

syllabus

� Practice at listening to recorded material and software programs

� Sustained reading for 30 min daily; use hi interest material

� Tutorial in written language� Brainstorm writing projects with

an adult “scribe”� Teach spelling recognition� Master the 1000 most commonly

used words in writing and 100 most common misspelled words

Recommendations (Tim)

Strategies Modifications

� Preview test and literature (teach techniques)

� Use abridged notes� Watch movies or video

when available� Work in study groups

� Foreign language exemption

� Limit/ adjust course load� 5 year college plan

Inextricably Linked:causal vs. coexisting?

� Language vs. Attention� Attention vs. Memory� Language vs. Memory� Language vs. Reading

What are the behavioral symptoms?

Central Auditory/Language Processing Disorders (CAPD)� Definition: Auditory Processing refers to the brain’s

ability to interpret and use information it hears. This is a complicated process that involves more than just “listening.” CAPD is a deficit in processing the information in audible signals (sounds), that is not due to a hearing acuity deficit.

� CAPD results from one or more deficits in the ability to analyze, synthesize, organize, store, retrieve, and use information presented auditorily.

Language/ Auditory Processing� Language processing represents a constellation of process

that must be intact in order to “process” information:� Word/semantic knowledge� Short term auditory memory � Working memory� Syntactic/sentential integration� Attention

Characteristics of a Language Processing Disorder� May appear to be inattentive.� Will have difficulty following multistep directions.� Will often remember or follow the part of the direction

given first or last.� Will frequently request repetition of directions.� Will frequently need to reread.

Assessing Language Processing

Process Assessment tool/test

� Word knowledge-Receptive (recognition) and expressive (recall)

� Auditory Memory- rote and meaningful

� Language/ syntactic integration

� Attention

� PPVT-4, WJ-3 Picture Vocabulary subtest

� TAPS-3, WRAML 2

� Token Test for Children (especially Parts 3,4 and 5), CELF-5 Concepts and Directions, WJ-3 Oral Comprehension subtest

� Observation and questionnaires (BASC-2, BRIEF)

Classroom symptoms of language processing deficit� Difficulty paying attention to and remembering information presented orally.� Difficulty following multi-step directions.� Poor listening skills.� Poor eye contact and pragmatic language skills (especially in preschool children).� Slow processing speed.� Compromised academic performance (can be in reading, spelling, writing and

math).� Difficulty with learning vocabulary and syntax.� Frequent need to reread to aid comprehension.� Increased anxiety.

TO DO LIST FOR AUDITORY PROCESSING DISORDERPreschool and early elementary:

1. Simplify language and present information slowly.2. Pair auditory information with gesture, pictures, objects or other visual information.3. Encourage eye contact and language reciprocity.4. Teach “wh” questions (“what, who, where” and the “why, how come, when”.5. Improve semantic knowledge by teaching word attributes and synonyms.6. Develop categorizing skills, including likenesses and differences, develop story telling and story

sequencing skills.7. Directly teach math vocabulary including temporal- spatial concepts.8. Restate more complex information and repeat shorter but memory dependent directions.9. Tell child to “turn their ears on” when it is important to listen.10. Minimize background noise.11. Encourage listening activities.12. Use barrier games and other board games that encourage language reciprocity.13. Emphasize the “syntactic glue” that strings high content words together.14. Computer programs like Earobics (level1 and 2).

TO DO LIST FOR AUDITORY PROCESSING DISORDERMiddle School through High School:

1. Direct work on improving semantic knowledge by developing vocabulary. This can include structural word analysis, teaching synonym, antonyms and analogies.

2. Teach words with multiple meanings and idioms.3. Teach inferencing and predicting skills. 4. Provide overview of main concepts, outline or “scaffold” to help

with note taking.5. Use pre-teaching techniques to reduce the working memory

demands.6. Require previewing of all text material.7. Give additional time on tests to allow for rereading and slower

processing speed.8. Have student paraphrase lengthy directions.9. Student should study with an adult to provide additional “layer” of

rehearsal and to help identify essential from non- essential information.

10. Provide teacher prepared notes or pair student with classmate with whom notes can be shared.

11. Encourage listening to books on tape to improve listening skills (NOT instead of independent reading).

Expressive Language Disorders� Expressive language disorders can have many different

behavioral manifestations because expressive language has many different components.

1.speech articulation (can effect spelling and phonics)2.vocabulary knowledge and retrieval3. language sequencing, usage and knowledge of

grammar4.organization of thought 5.sociolinguistic and pragmatic skills

Some expressive language deficits are likely to effect written language performance.