The steps to diagnosing dyslexia need to be focused on the individual, must follow a structure, and must reflect current scientific research. An evaluation should include a comprehensive case history, an observation of speaking and reading, and a specific battery of assessments targeting language and reading. A number of factors can contribute to dyslexia, and some younger children may initially appear to be learning to read; therefore, it is helpful if the examiner has experience in assessing and diagnosing dyslexia as well as providing effective treatment.
Examiners should be able to explain reading and spelling as language-based skills and give examples of how your child's phonological (sound) awareness and knowledge of orthography, vocabulary, morphology, semantic relationships, and mental orthographic images contribute to the reading and spelling process. They should also be able to give recommendations for activities that target specific language deficits to improve your child's reading, spelling, and writing skills at school and at home. And they should be well versed in current research on dyslexia and related disorders.
First sign—You notice your child is struggling to read
Very often it is the parents that first notice their child is not "really reading." Kids are smart and many find ways to "hide" their reading difficulty. For example, a child may have memorized the story that the parent or teacher read to them and may appear to be "reading." One parent eventually discovered that her child would only select books from the library that had already been read to her at home or at school. Some children can hide their reading disability as far as the 3rd grade, and by this time they may be more than two years or more behind typically-developing children. Spelling problems are a little more difficult to hide.
As soon as you suspect a reading or spelling problem you should consider a referral for testing. Talk to your child's teacher or another professional.
It is never too late to be evaluated
While intervention is most successful when dyslexia is diagnosed early in life, getting an evaluation at any age can provide invaluable information for potential treatment, accommodations for school and or work, and understanding learning strengths and weaknesses.
The Case History—Preassessment information
By carefully filling out the case history form, you will supply the examiner with important information that will be taken into account when diagnosing dyslexia. The case history form will most likely include questions on personal information, birth complications, languages spoken, medical history, and educational history. In addition, it will ask if there is a family history of dyslexia or suspected dyslexia, learning disabilities, speech and language delays, or other factors that may be related. Also, it will inquire whether your child has or had an individual education plan (IEP) that will be reviewed. Reports from other professionals, such as an educational psychologist, physician, teacher, and/or audiologist should also be included. Having this information will aid your examiner in selecting assessment tools that will not only assist in the accurate diagnosis of dyslexia, but will also assist in possibly identifying co-occurring disorders and in making accurate recommendations.
The examiner will typically discuss the case history form with you and may ask for more specific information such as vision difficulties, hearing difficulties, delay in development of speech and language, and specific medications being taken.
During this time, the examiner may informally talk with your child before testing. The examiner will be closely listening and watching how your child communicates in this type of setting. This informal observation of communication serves several purposes: getting information about the speech, language and pragmatic (social) language in an informal setting; giving information about what will take place during the testing; and developing a rapport to make the assessment process as relaxed as possible. An experienced examiner should easily be able to accomplish this in about 15 minutes or so.
The examiner should explain the testing process at an age appropriate level. Most likely, by the time a child is in second grade, sometimes earlier, they will be aware that they are having a challenging time learning to read. Discussing these challenges with a child is valuable information for an examiner. The questions, "Do you like to read?" and "What have you read?" often provide additional valuable insights. Asking about favorite classes/subjects and least favorite classes/subjects also provides information about strengths and weaknesses.
Battery of Assessments targeting language and reading
The evaluation must be individualized for your child and test selection will take into account her age and education in addition to the background information from the case history and face to face initial meeting. Most assessments will start with a hearing screening to rule out any hearing acuity difficulties. If a hearing screening is failed, an examiner may decide to reschedule the testing after the hearing has been examined further by an audiologist. While selection of types of tests in assessment for dyslexia may vary, specific areas must be tested to accurately make a diagnosis of dyslexia. Foundational testing includes the following areas:
- Phonological awareness
- Rapid naming/word fluency
- Reading fluency
- Reading comprehension
Oral language provides the foundation for the development of reading and writing. Individuals with oral language problems can develop disorders of literacy. An examiner will want to include a test of language that will give information about an individual's receptive and expressive language abilities, language processing, morphological skills and pragmatic language skills. An individual with dyslexia may or may not have a co-occurring language disorder, especially when they are younger. However, the inability to read and write often prevents an individual from using language at higher levels and as a result vocabulary development may be compromised. Over time, dyslexia limits reading, which may also artificially depress IQ scores. A formal assessment of language with a standardized test may also be accompanied by an informal assessment such as a language sample and questions to parents and teachers about an individual’s pragmatic language skills.
The most distinguishing feature of dyslexia is poor phonological awareness, which manifests in an inability to identify and blend together individual phonemes (sounds) in words. Clinical expectations of phonemic awareness vary depending on an individual’s age. Children who have difficulties in phonemic awareness may have difficulties producing rhymes and recognizing words that rhyme; counting phonemes in a word (segmenting); deleting, adding, or moving sounds around in a word (elision); and hearing sounds in isolation and blending them together to form a word (blending).
The lack of phonemic awareness had been found to be a high predictor of a reading disability. Phonemic awareness is often confused with phonics and it is important to make sure the examiner has a clear understanding of each and does not confuse the two. The systematic teaching of phonemic awareness is critical for individuals diagnosed with dyslexia. Phonological awareness skills can be taught at any age and have been shown to improve decoding, reading fluency, reading comprehension, and spelling.
Rapid naming also called word fluency
Another strong indicator of dyslexia is problems with rapid naming, also called word fluency. Rapid naming is the ability to name symbols, words, or pictures rapidly, for example, "Tell me all the animals you can think of." This discriminating skill is based on speed, not accuracy. Poor readers are usually able to name symbols, words and pictures accurately, but they are characteristically slower than skilled readers. They may have more difficulty naming words than naming numbers.
Another indicator of a reading disability is difficulty reading non-sense words which would indicate difficulty with decoding as it relates to phonics and phonemic awareness. When reading a nonsense word such as fornalask, an individual with difficulties with the phonemic awareness skill of blending may know the phonics of how to decode each sound correctly, but may not be able to blend the sounds together to produce the nonsense word.
Reading fluency is the combination of the score of the accuracy of reading and the rate (speed) at which one can read. Reading fluency may be assessed in children who can read short paragraphs or longer reading passages. It is a measure of the average number of words read correctly per minute. Poor reading fluency indicates possible problems with phonemic awareness, decoding skills, comprehension, or vocabulary. A child who reads accurately but not fluently (at a slower rate) is dyslexic. Not being able to read fluently can hamper comprehension.
Reading comprehension is the understanding of the printed word. When reading short paragraphs, children with dyslexia may gain just enough content to score well on reading comprehension assessments. However, reading comprehension becomes more difficult with increasingly longer and more complex reading material. Although some people with dyslexia may be able to read fluently, they may still struggle with reading comprehension. For individuals who are fluent readers an assessment should be made of silent reading comprehension as well as oral reading comprehension.
Some dyslexic individuals with co-occurring language disorders may have good comprehension for literal (who, what, when, where) type information, but may have great difficulty comprehending inferential, or non-literal (why, how, what-if) information. Comprehension questions should assess both types of information.
Evaluating spelling proficiency can provide valuable diagnostic information about phonemic awareness and language in general. Spelling ability provides insight into other types of knowledge necessary for written communication. Poor spelling may reveal weaknesses in one or more of the following linguistic components:
- Phonemic awareness—hearing the sounds that make up words
- Orthographic knowledge—knowing letters and letter combinations, such as blends
- Semantic knowledge—understanding word meaning (vocabulary)
- Morphological knowledge—understanding morphemes such as -ed for past tense, -s for plural
Poor spelling may also be a possible indicator of a hearing deficit or auditory processing disorder.
Writing, in general, is the most complex form of language. In many cases, a child's language difficulties are most pronounced in his or her writing. Deficiencies such as spelling errors, syntactic and semantic errors, morphologic errors, omissions of words or word endings, and general incongruities may be present. In general, assessment for all types of writing should focus on:
- Productivity: e.g., How many sentences are there? How many clauses? How many paragraphs?
- Complexity: e.g., How sophisticated is the vocabulary and sentence structure?
- Appropriateness e.g., for audience and topic: Is the audience taken into consideration?
- Cohesiveness: e.g., Is there a smooth flow with topic shifts indicated?
- Mechanics: e.g., Are punctuation and capitalization rules followed?
- Analytic aspects: e.g., Can the child edit his writing?
More specific analysis of writing takes different forms depending on the audience and the purpose of the writing. Other types of writing that may be further assessed in older students include: narrative writing, expository writing, and persuasive writing.
One's cultural-linguistic background must be taken into consideration during an assessment of literacy. Narrative conventions vary across cultures. Standards of reading and writing in American English are not necessarily the same, or even similar, in other languages. When English is not the primary language spoken in the home, problems may develop with language and therefore learning to read. Be sure to talk with the examiner about your child's home language and culture.
Behaviors that your child might exhibit at school that could be indicative of dyslexia include: being very quiet in the classroom to avoid being selected to read aloud, selecting books to read that have been read aloud to him, covering up difficulty of reading by excelling in other ways, sometimes being the "class clown", or acting up out of frustration. In the case of the child who acts up, it is better to be thought of as bad than as stupid. Another sign is the need for you to do your child's homework or the fact that it takes forever for him to finish homework. Last, if your child is still not learning to read despite extra help in school, dyslexia could be the cause.
Making the diagnosis of dyslexia—the report
There are two primary methods for conveying clinical findings, recommendations, and conclusions: informational meetings and written reports. Both contexts should summarize the major findings of the assessments, identifying strengths and weaknesses. Clear conclusions should be drawn based on standardized information from the assessments in addition to all of the additional informal information gathered.
A written report should contain an overview of the presenting problem or initial status; a review of the medical, educational, and familial history; results of the assessments; interpretation of the results; recommendations; and a summary with prognosis. Although written reports vary across clinical settings, having all of the above mentioned information will assist your child's learning disabilities teacher or therapist in setting appropriate-level and systematic goals, as well as in measuring those goals as an individual makes progress.