SLIDE 1 Tier 3 Differential Diagnosis of Specific Learning Disabilities
Virginia W. Berninger
University of Washington
Director, Multidisciplinary Learning Disabilities Research Center, Literacy Trek Longitudinal Study, and The Write Stuff Intervention Project, and School Psychology Internship Program vwb@u.washington.edu CASP March 4, 2005 Riverside, CA
SLIDE 2
Making the Case for Tier 3
Ø Special education placement decisions and differential diagnosis are not the same. Diagnosis should be made even if student is not given services. Ø For efficiency, use differential diagnosis for identifying disorder and branching diagnosis for planning treatment: Ø Implications for etiology, treatment, and prognosis
SLIDE 3
What Is Dyslexia?
Ø Not all learning disabilities involve reading. Ø Not all reading disabilities are dyslexia, but dyslexia exists and is one specific learning disability Ø Dyslexia has genetic basis, neuroanatomical signatures, and changing phenotype (observable behavioral signs) across development as curriculum requirements change.
SLIDE 4
Neuroanatomical Differences between Good Readers (left) and Dyslexics (right)
SLIDE 5
What Is Dyslexia?
Ø First signs in kindergarten: Unusual difficulty in learning to name letters and attach phonemes to letters. (Orthographic- Phonological Mapping Relationships)
1st grade—Unusual difficulty learning to read single words out of sentence context (sight words and/or phonological decoding).
SLIDE 6 What Is Dyslexia?
2nd – 3rd grades May learn to read single words accurately but reading rate (automaticity of single word reading and/or fluency of oral reading of text) impaired 4th grade and thereafter Spelling problems typically persist and may interfere with writing
- development. Silent reading comprehension tends
to be better than oral reading accuracy and fluency.
SLIDE 7 What Is Dyslexia?
Ø Does not go away with maturation alone: Systematic and explicit instruction improves accuracy of single word reading. Ø Assessing reading only in context may mask the difficulty dyslexics have in reading single words. Ø Assessing only real word reading may mask unusual difficulty in reading pseudowords (translating the
- rthographic word form into the phonological word form) .
Ø Assessing only accuracy of word reading and decoding may mask reading rate problems (accuracy vs rate disability, Lovett, 1987)
SLIDE 8 Etiology of Dyslexia
Genetic Constraints in UW Family Study: Ø preciseness of the phonological word form and phonological short- term memory, CTOPP Nonword Repetition Ø accuracy and rate of phonological decoding (orthographic- phonological-morphological mapping), TOWRE Phonemic Reading Efficiency; WIAT II pseudoword reading or WJ III Word Attack Ø written spelling, WRAT 3 or 4 or WIAT II Spelling and Ø executive function for inhibition and self-regulation of attention during processing of written word forms or their parts. Delis Kaplan Inhibition; Delis Kaplan Verbal Fluency Letters; Rapid Alternating Switching (Wolf letter and number switching attention)
SLIDE 9
Etiology of Dyslexia
Dyslexia is a Language (Not Perceptual) Disorder Ø Problem in preciseness of phonological word form, phonological short-term/working memory, orthographic- phonological mapping, inhibition,and executive support of language functions that manifests itself in written language at the word level. Ø Language markers in phenotype: Deficits in orthographic, phonological, and rapid naming skills. Ø Relative strengths in morphological and syntactic skills Ø May occur with or without ADHD (inattention more common), specific arithmetic disability, handwriting problem
SLIDE 10 Research-Supported Diagnosis of Dyslexia
Ø Discrepancy of at least 15 standard score points between WISC III
- r IV Verbal Comprehension Factor and a measure of single word
reading (WRMT-R or WJ III Word Identification and/or Word Attack, WIAT II
Word Reading and/or Pseudoword Reading, TOWRE sight word efficiency and/or phonemic reading efficiency), oral reading (GORT-3 accuracy or rate), and/or
spelling (WRAT 3 or 4, WIAT II Spelling); the measures of single word reading, oral reading, or spelling must be below the population mean. Ø Deficits in one or more of the language markers for dyslexia that interfere with word reading and spelling: orthographic coding (PAL
receptive coding, expressive coding, word choice), phonological coding (CTOPP elision, nonword repetition, phoneme reversal or PAL Syllables, Phonemes, Rimes),
and/or rapid automatic naming (RAN) (Wolf Letters, Letters and Digits; PAL
Letters, Words, Letters and Numbers) + or – executive dysfunction (DK Inhibition, Repetitions)
SLIDE 11
What Is Dysgraphia?
Ø Developmental dissociation between transcription and text generation skills in writing development Ø Dysgraphia = Impaired + Hand (Language by Hand Produced by the Grapho-Motor System) or Letter Ø Transcription Skills affected are handwriting and/or spelling.
SLIDE 12
Relationship between Dyslexia and Dysgraphia
Ø All dyslexics have dysgraphia (spelling is always affected, handwriting may or may not be affected). Ø Not all dysgraphics have dyslexia Only handwriting may be affected (IQ irrelevant as long as in the normal range). Only spelling may be affected (underdeveloped for vocabulary knowledge, VIQ) Both handwriting and spelling may be affected—if so, worst prognosis for writing.
SLIDE 13
What is Language Learning Disability (LLD)? (Wallach & Butler, 1994)
Ø Deficits in morphological and syntactic processing and executive functions for language (e.g. CELF Sentence Formulation) Ø Persisting profile of expressive < receptive even if language development in normal range; may have subtle to severe word retrieval and/or oral motor planning problems Ø Deficits in reading comprehension and word decoding— deficits in reading comprehension may be greater than those in word decoding Ø Typically no VIQ-achievement discrepancy (because of morphological and syntactic impairment that lowers VIQ)
SLIDE 14
What is Language Learning Disability (LLD)? (Wallach & Butler, 1994)
Ø Learn language but have difficulty using language to learn despite normal intelligence—analogy to Chall’s learning to read and reading to learn Ø can learn well using nonverbal strategies see research by Elaine Silliman University of Florida Tampa Ø Need explicit instruction in (a) processing instructional language across the curriculum, (b) using language to learn, and (c) reading comprehension (PAL Lesson Set 6)
SLIDE 15
Early Preschool Signs of LLD vs Dyslexia
In contrast to children with primary language disability or specific language impairment who have significant developmental delays in acquiring language milestones, Ø Language learning disabled acquire language-- slowly but within the lower limits of the normal range—fast responders to early language intervention Ø Dyslexics show normal early language development (words and sentences) until written language introduced.
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Differential Diagnosis
Ø To diagnose dyslexia, dysgraphia, or language learning disability must rule out mental retardation, pervasive developmental disorder, autism, primary language disorder, and slow(er) learner. Ø Need to assess these domains of development: gross and fine motor, cognitive (memory and abstract reasoning), language and communication, attention and executive function, and social/ emotional.
SLIDE 17
Differential Diagnosis
Mental Retardation= all domains of development are delayed (outside normal range) Pervasive Developmental Disorder= delays in two or more domains of development Autism= Impaired Language and Communication, Social/Emotional (+ or – Mental Retardation)
SLIDE 18
Differential Diagnosis
Primary Language Disorder= Language development outside the normal range and significantly underdeveloped compared to nonverbal reasoning in normal range. Slow(er) Learner= Developmental profile consistently at the lower end of the normal range but does not meet criteria for LLD.
SLIDE 19 Conditions for Which Dyslexia Is Inappropriate Diagnosis
Ø Trauma to mother or child during gestation
- r labor or adverse drug or vaccine reaction
Ø Significant Prematurity (Low Birth Weight) Ø Disease (e.g. menegitis) or injury (e.g. cerebral palsy) Ø Fetal Alcohol or Effect or Substance Abuse Ø Other neurogenetic disorders (fragile X, Down Syndrome etc.
SLIDE 20 Importance of Differential Diagnosis
The nature of the diagnosis has implications for treatment planning, for example
Ø Dyslexics benefit from explicit and intensive phonological, morphological, and orthographic training for word learning; they do not need intensive work in comprehension. Ø Language learning disabled need the same training for word learning plus more intensive morphological and syntactic treatment and very explicit comprehension instruction. Ø Dysgraphics need and benefit from explicit handwriting and keyboarding instruction rather than merely accommodation; delivery
- f this instruction depends on whether they also have dyslexia or
language learning disability.
SLIDE 21 Importance of Differential Diagnosis
The nature of the diagnosis has implications for prognosis (determining when a student has reached an expected level of achievement and no longer needs specialized instruction), for example, Ø Students with language learning disability may need specialized instruction longer than do those with only dyslexia Ø Students whose cognitive development falls
- utside the normal range cannot be expected to
read and write at grade level.
SLIDE 22 Teaching Reading and Writing to Students with Other Disorders
Should specialized instruction be offered to students with reading problems but developmental or learning disorders other than dyslexia, dysgraphia,
- r language learning disorders? YES YES YES
But we need longitudinal instructional intervention studies for all these disorders to validate what kind
- f instruction is effective at various stages of
development for each kind of Tier 3 disorder.
SLIDE 23 Reading about Differential and Branching Diagnosis
- 1. Berninger, V., Thomson, J., & L. O’Donnell. (2004). Differential
diagnosis of dyslexia, dysgraphia, language learning disability, and
- ther learning disabilities. In A. Prifitera, D. Saklofske, L. Weiss, &
- E. Rolfhus (Eds.), WISC-IV Clinical use and interpretation. San
Diego, CA: Academic Press.
- 2. Berninger, V. , Dunn, A., & Alper, T. (2004). Integrated models for
branching assessment, instructional assessment, and profile
- assessment. In A. Prifitera, D. Saklofske, L. Weiss, & E. Rolfhus
(Eds.), WISC-IV Clinical use and interpretation (pp. 151-185). San Diego, CA: Academic Press.
- 3. Berninger, V. (2001). Understanding the lexia in dyslexia. Annals of
Dyslexia, 51, 23-48.
- 4. Berninger, V. (2004). Understanding the graphia in dysgraphia. In D.
Dewey & D. Tupper (Eds.), Developmental motor disorders: A neuropsychological perspective. New York: Guilford.
