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DIAGNOSIS AND TREATMENT

DIAGNOSIS AND TREATMENT: DYSLEXIA


Russell D. Snyder, M.D., and Joan Mortimer, MA.
From the Departments of Pediatrics and Neurology, University of New Mexico School of Medicine, and
the Educational Service Center, University of New Mexico, Albuquerque

N 1 1 -YEAR-OLD, fifth grade boy was referred for to please. Visual acuity was 14/14 in both eyes.
medical evaluation because of a severe read- Hearing was acute to the whispered voice. No ab-
ing problem. normalities were noted on complete neurological
The boy was the third of four children. At the evaluation, including careful examination for “soft
time of his birth, his mother was 23 years of age neurological signs,” except for a slight dysarthria.
and his father was 25 years of age. The mother He was right-footed and right-eyed. He preferred
had two miscarriages between her second and his right hand for writing, but used either hand for
third children. This pregnancy was 36 weeks’ in throwing and eating. An EEC was normal.
duration but was otherwise uncomplicated. Birth Management comprised tn-weekly sessions with
weight was 3,135 gm. Transient cyanosis was a reading tutor. After 6 months, he was able to
noted at 6 hours of age. No cause for the cyanosis read at the second grade level.
was established. He did not sit until 1 year of
age and did not walk until 13 years of age. Al- In this review, the term dyslexia refers
though his first meaningful words were at 8 to unusual or disproportionate difficulty
months of age, lie did not put words together in learning to read displayed by normally
until 3 years of age, and his speech has never
intelligent children who have intact sensory
been clear. At 2 years of age, he struck his head
in a fall and was unconscious for several minutes. mechanisms and are not emotionally dis-
He then recovered without apparent sequelae. turbed. Such children are a major challenge
He had measles at 4 years of age with lethargy to physicians and educators.
for several days.
The subject of dyslexia has been admira-
An older male sibling allegedly had trouble
bly reviewed by several authors.16
reading until the fourth grade, when the diffi-
culty resolved spontaneously. Both the boy’s Although the problem is not new, it is
mother and her twin sister were poor readers and currently receiving considerably increased
spellers. A female maternal first cousin has been attention as evidenced by the burgeoning
diagnosed as having strephosymbolia. list of publications dealing with the subject
The child’s performance in first grade was
and by the recent appointment of a Na-
satisfactory’. In second grade, he was unable to
keep up with the class in reading and was very tional Advisory Committee on Dyslexia and
poor in spelling. His written work contained Related Reading Disorders. Several states
many letter reversals and inversions. Second grade ( e.g., Texas, California, and Massachu-
was repeated with minimal improvement. The setts ) have passed legislation relating to spe-
parents attempted home tutoring, but they dis-
cia! programs for dyslexic children.
continued it because of the family friction that was
Many other terms have been applied to
generated.
The Gilniore Oral Reading Test revealed in- poor reading achievement, including word-
ability to read at first grade level; comprehen- blindness, congenital word-blindness,5 spe-
sion of auditory material was normal. On a test of cific reading disability,9 developmental dys-
the 220 “basic sight words,” which make up between
lexia3 and However,
60% and 75% of almost all reading material, lie was
these terms are not necessarily synonymous
able to identify only 2 of the first 16 and the test
was discontinued. Errors included relatively ran- with dyslexia or with each other.
dom guesses such as up for go and come for good.
On the WISC he earned a Verbal I.Q. of 85, Per- INCIDENCE AND IMPORTANCE
formance I.Q. of 92, and Full-Scale I.Q. of 87.
The magnitude of the specific problem of
Peabody Picture Vocabulary test score was 96,
placing him at the 38th percentile. dyslexia is unknown. A significant percent-
General physical examination revealed no abnor- age of school children are poor readers.
malities. He was cooperative and seemed anxious Rabinovitchll claims that 10% of elemen-

ADDRESS: (R.D.S.) University of New Mexico School of Medicine, 2211 Lomas Blvd., N.E., Albuquer-
que, New Mexico 87 lOft
PEDIATRICS, Vol. 44, No. 4, October 1969

601

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602 DYSLEXIA

tary school children in the United States in the few patients who have been studied
have reading handicaps. However, it would postmortem.1 It should also be acknowl-
he an error to equate all reading retarda- edged that meticulous clinical, neurologic,
tion with dyslexia. A number of other con- or neuropathologic examination may not
ditions contribute to the population of poor detect all neuroanatomic and neurophysio-
readers. Some children encounter difficulty logic defects.
in reading because of intellectual limita- A strong familial tendency to dyslexia is
tions, bilingualism, environmental depriva- frequently found. This is especially noted
tion, sensory handicaps, emotional distur- in the male members of a family.3 These fa-
bances, delayed neurological maturation, or milial cases suggest a genetic predisposition
inadequate teaching. for some cases of dyslexia.
Zintz12 has established that as much as Many of the signs associated with dys-
90% of the average school day in elementary lexia are present normally in preschool chil-
school may require reading and writing dren. Therefore, persistence into the school
skills. He and others have demonstrated years may merely manifest a delay in neti-
that academic achievement, as schools are rologic maturation.
presently organized, is contingent on the Dyslexia occasionally is claimed to be an
acquisition of reading skills. Learning to expression of a primary emotional distur-
read is the principal academic task facing bance. In our experience, this type of dis-
the child in the early years of school. By turbance is extremely rare, although secon-
about the fourth grade, a child is assumed dary emotional problems are common.
to have developed his reading skill to the
point that it is a useful tool. Thereafter, CLINICAL MANIFESTATIONS
learning in social studies, science, and even
The ability of dyslexic children to relate
mathematics depends in part on adequate printed or written verbal symbols to the au-
reading ability. ditory properties of words is impaired.
They display obvious difficulties soon after
ETIOLOGY entering school, frequently repeat first or
The etiology of dyslexia is unclear. Be- second grade, and usually encounter in-
cause it may appear as a consequence of creasing or, at least, continuing problems
acquired cerebral lesions in adults,13 the throughout the school years. Reading is
possibility that childhood dyslexia repre- slow and labored, and comprehension is
sents a specific neurologic lesion has been poor. Efforts to teach sight vocabulary meet
investigated, but with inconclusive results. with little success, and teachers complain
Slight electroencephalographic abnormali- that these children do not remember even
ties of uncertain significance have been the simplest words. Oral reading is charac-
noted in some dyslexic children. Rabino- terized by omissions, insertions, and word
vitch found definite or suggestive evidence recognition errors. Handwriting tends to he
of brain damage in 23 of 50 children with awkward and sloppy, letters are badly or
severe reading disability.15 Many of these incorrectly formed, and spelling is bizarre.
children displayed certain minor neurologic Typical errors include rotation of individual
signs, such as non-specific clumsiness, letters, confusion of near opposite letters
crossed or mixed dominance,16 and poor vi- (d/b, p/q, b/p) and transposition of let-
sual pursuit movements.” However, con- ters within a word ( quiet/quite, left/felt).
trolled studies have cast doubt upon the In unaffected children these types of errors
significance of these “soft” signs.1’18 Finally, are normal in first grade, less common in
no structural abnormality of the brains of second grade, and rare thereafter’s The
these children has been demonstrated by majority of normally intelligent, adequate-
presently available pathological techniques ly motivated poor readers who do not

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DIAGNOSIS AND TIIEAT\IENT 603

res1)Ofld to the usual classroom teaching of ers (xhihit 0r SOcial lI1(l OcatiOI1dl a(l-
reading and who make characteristic errors justment in later life. but more long-term
in writing can properly he classified as dys- studies in this area are needed. Hermann
lexic. claims that the difficulties in reading and
The clinical history of these children is writing persist to adult life in nearly all in-
familiar to the physician dealing with the stances in spite of special teaching.1 It is
school age child. An apparently normal boy generally agreed that these children rarely
starts to school at the usual age of 6 years. become efficient readers, even as adults.
He has difficulty with first grade reading Clearly, longitudinal studies of vell defined
skills and writes poorly. The papers he populations with dyslexia are needed. Such
brings home are sloppy, have many era- studies should include assessment of the ef-
sures, and show frequent letter inversions fects of treatment. A recent study liv Rav-
and reversals. The boy is passed on to the son2 suggests that the child with a reading
second grade, although the advisability of problem need not be considered a poor risk
the promotion may be questioned. In see- for academic and occupational achievement.
ond grade the problem becomes more se- Examination of adult populations in various
vere, and the child is unable to keep up fields of endeavor for levels of required read-
with the rest of his class in reading, writing, ing skill would also be of great interest.
and spelling. His performance in other
areas is often rated as acceptable by his DIAGNOSIS
teacher. He is inevitably aware of his rela-
If a child’s achievement in reading and
tively poor performance and senses concern
writing continues to be significantly below
on the part of his teacher. Parents, alerted
grade level standards through the first half
by the school to his lack of progress, be-
of his second year in school, evaluation
come disturbed. Anxiety and/or anger fre-
should l)e undertaken. The evaluation
quently are manifested in the parents and
should combine reading testing, psychologi-
the child. The child’s own sense of frustra-
cal studies of intellectual factors ( and, if in-
tion and concern are exaggerated by the re-
dicated, of emotional factors ) , specific test-
sponses he perceives in others, and school
ing of vision and hearing, and medical
and academic activities rapidly become Se-
history and examination. Clements and
verely distasteful. Emotional disturbances
Peters23 suggest that the psychological eval-
appear, evidenced by poor relations with
uation include an individual intelligence
peers, siblings, parents and teacher, and
test such as the Wechsler Intelligence Scale
sometimes by withdrawal from the school
for Children, with special attention to scat-
situation. Ultimately, unless the cycle is in-
ter among subtest scores, and the Bender
terrupted, the child may be severely dis-
Visual Motor Gestalt. A reading specialist
abled in learning and emotionally scarred
should obtain information concerning the
l)v a seemingly endless series of failures.
method used by the child to interpret un-
recognized words, the number and types of
PROGNOSIS
errors made in pronouncing them, the
The natural history of dyslexia has not speed and smoothness of oral reading, and
been documented. Does the condition im- the comprehension of material read. Spe-
prove spontaneously? With remedial help cific tests of basic perceptual abilities may
can dyslexic children improve until their also be employed. Data obtained should in-
skills approach normal or is this an unreal- elude a sample of the child’s writing of
istic and unattainable goal? Is being dis- upper and lower case letters and numbers,
abled in reading incompatible with success and a measure of his ability in spelling and
as a wage earner or housewife? Carter2#{176} copying. If outside testing resources for
and Anderson2l indicate that disabled read- evaluation of reading and writing skills are

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604 DYSLEXIA

not readily available, the physician may teachers are limited in number and fre-
find it convenient to utilize the Wide quent individual sessions are costly. Ses-
Range Achievement Test for quick screen- sions should be so constituted that the child
ing purposes. This well respected test in- finds them enjoyable and should not con-
cludes letter and number identification tasks, fbct with favorite recreational activities or
copying, spelling, reading, and arithmetic be prolonged to the point of fatigue.
subtests. The test is inexpensive, requires 2. Remedial reading classes which are
no special training of the examiner, and is part of the regular school program may be
easily and quickly administered and scored. helpful. Since such classes are smaller and,
A further source of diagnostic information hopefully, geared to the child’s own rate of
is a sample of the child’s school work. progress, they are preferable to frustrating
classroom reading situations.
THERAPY
3. Equally important is that the teacher,
A variety of therapeutic approaches is the parents, and the child himself develop
currently available. These include individ- an understanding of the nature of the prob-
ual reading instruction from a trained ther- lem. This understanding should include the
apist, remedial classes as part of a regular fact that dyslexia is not a manifestation of
school program, dominance training, eye intellectual deficit or disturbed behavior,
exercises, drug therapy ( methylphenidate, that it is not an uncommon problem, and
dextroamphetamine, primidone ) , and “pat- that it seldom responds to parental pres-
tering.” New approaches to dyslexia are sure. Nevertheless, parents should realize
constantly appearing. As with other condi- that distinct improvement can be achieved
tions of unknown pathogenesis and variable through patient and judicious guidance. It
)rogflOSis, it is difficult to substantiate should also be appreciated that childhood
claims of benefit from treatment. Improve- dyslexia is not incompatible with eventual
ment in reading skills has been reported by adult achievement. Such understanding will
advocates of all methods. Some techniques facilitate satisfactory progress.
have been discredited and others are still in 4. In addition, the school should be ap-
the experimental stage. Unfortunately, proached regarding the possibility of modi-
long-term follow-up and control popula- fying regular classroom procedures so that
tions are conspicuously absent, and physi- progress in cognitive development can con-
cians and educators lack a sound scientific tinue while attempts are being made to im-
basis on which to make decisions regarding prove the child’s reading. Arrangements can
management. Of the various possibilities, usually be made to have textbook material
professional remedial reading help seems, read to him by his family, classmates, or
in the experience of educators, physicians, others, and many teachers will even sched-
and psychologists, to be the best approach, ule oral rather than written examinations.
although final answers are not yet known. The goal should be to provide a meaningful
Treatment appears easiest and most sue- educational experience to the student in
cessful if begun early, preferably by the spite of his handicap.
second grade. It is not only appropriate but also highly
The following guidelines for manage- desirable for the physician to take the lead-
ment are suggested: ership in encouraging the parents and
1. Individual sessions with a reading spe- school to implement this approach to man-
cialist two or three times weekly appear to agement. However, one word of caution is
be the treatment of choice. Admittedly, this in order. Many educators, for a variety of
is not always easy to arrange as trained reasons, view the label dyslexia with con-
a Wide Range Achievement Test, Guidance As- siderable disapproval. They prefer more
sociates, 1526 Gilpin Avenue, Wilmington, Dela- general terms, such as reading or language
ware. disability. Physicians will therefore be well

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DIAGNOSIS AND TREATMENT 605

advised to avoid specific labelling in their 9. Eisenberg, L. : Reading retardation. I. Psychi-

conhments and recommendations. atric and sociologic aspects. PEo;A’rucs,


37:352, 1966.
10. Orton, S. T. : Visual functions in strephosymbo-
SUMMARY
ha. Arch. Ophthal., 30:707, 1943.
Dyslexia is a major problem in pediat- 11. Rabinovitch, R. D. : Reading problems in chil-
iics. Its clinical picture is characteristic dren: Definitions and classification. in Kee-
although its etiology and prognosis are un- ney, A. H., and Keeney, V. T., ed. : Dys-
lexia. St. Louis: C. V. Mosby, p. 1, 1968.
known. Therapeutic approaches are not al-
12. Zintz, M. V. : Education Across Cultures. Do-
ways satisfactory. A combination of reme- buque: W. C. Brown, p. 234, 1963.
dial reading, reduced pressure upon the 13. Geschwind, N. : Anatomy of acquired disorders
child for academic success, sympathetic un- in reading. in Money, J., ed. : Reading Dis-

derstanding of his problem, and measures ability. Baltimore: Johns Hopkins Press, p.
115, 1962.
to provide him with knowledge in spite of
14. Hughes, J. R. : Electroencephalography and
his reading handicap appears to be the learning. In Myklebust, H. R., ed. : Progress
most successful approach to management in Learning Disabilities, Vol. 1. New York:
at present. Of major importance is the di- Crune and Stratton, p. 113, 198.
15. Rabinovitch, R. D. : Acquired dyslexia and re-
rect participation of the physician in these
lated neurologic lesions. In Keeney, A. H.,
approaches to management.
and Keeney, V. T., ed. : Dyslexia. St. Louis:
C. V. Mosby, p. 110, 1968.
REFERENCES
16. McFie, J. : Cerebral dominance in cases of
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DIAGNOSIS AND TREATMENT: DYSLEXIA
Russell D. Snyder and Joan Mortimer
Pediatrics 1969;44;601

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DIAGNOSIS AND TREATMENT: DYSLEXIA
Russell D. Snyder and Joan Mortimer
Pediatrics 1969;44;601

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