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ANRV331-PS59-17 ARI 1 December 2007 16:42
lad in the school if the instruction were en- speaking, reading, writing, and mathematics.
tirely in oral . . . (Morgan 1896, p. 1378). In contrast to this undifferentiated construct,
the current definition explicitly categorizes
What is so striking is the similarity of Accommodations:
dyslexia as a “specific learning disability.” New adaptations within
Percy F. to the children we continue to see to to the current definition over the previous the classroom, use of
this day. Such clinical descriptions from ev- one is reference to dyslexia’s “neurobiologi- assistive technology,
ery corner of the globe attest to the invari- cal origin,” reflecting the significant advances or provision of extra
ance of dyslexia over both time and place. In in neuroscience, particularly the brain imag- time allowing
his clinical vignette, Dr. Morgan captures the learning-disabled
ing of reading and dyslexia that is discussed in students to
essence of dyslexia: an unexpected difficulty in detail below. demonstrate their
reading. New, too, is the incorporation of, and em- full knowledge
phasis on, the importance of fluent reading: Decoding:
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
consonant
dyslexia as an unexpected difficulty in read- is now supplanted by reference to “difficul- combinations within
ing has remained constant across definitions ties with accurate and/or fluent word recogni- the word
of dyslexia (Critchley 1970, Lyon 1995) as tion,” acknowledging converging data point-
evidenced by the most current definition ing to the critical lack of the development of
provided by a working group meeting in fluent reading as a hallmark of dyslexia that
Washington, D.C., in 2002: persists into adolescence and then adulthood,
Dyslexia is a specific learning disability that
even when accuracy improves. The lack of flu-
is neurobiological in origin. It is character-
ent reading is observed clinically by reading
ized by difficulties with accurate and/or flu-
that is effortful and slow; it is often consid-
ent word recognition and poor spelling and
ered the sine qua non of dyslexia, especially in
decoding abilities. These difficulties typi-
young adult and adult readers (Bruck 1998,
cally result from a deficit in the phonological
Lefly & Pennington 1991, Shaywitz 2003).
component of language that is often unex-
This renewed appreciation of the importance
pected in relation to other cognitive abili-
of fluency should encourage its measurement;
ties and the provision of effective classroom
otherwise, many dyslexic children who can
instruction . . . (Lyon et al. 2003, p. 2).
read accurately, but not fluently, will continue
to go unnoticed (and untreated) within the
Refinements from prior definitions. classroom (Katzir et al. 2006).
Dyslexia (also referred to as specific reading As in the prior definition (Lyon 1995),
disability) is a member of the family of emphasis is on the phonological weakness
learning disabilities; in fact, reading disability giving rise to the reading (and speaking)
is by far the most common learning disability, difficulties characterizing dyslexia. A range
affecting over 80% of those identified as of studies has indicated phonological diffi-
learning disabled (Lerner 1989). Although culties as the most robust (Fletcher et al.
the recognition of dyslexia as a discrete entity 1994, Shaywitz et al. 1999, Stanovich & Siegel
dates back over a century, the concept of a 1994) and specific finding (Morris et al. 1998)
learning disability is relatively new. in dyslexic children and adolescents, sup-
The term “learning disabilities,” as ini- porting the phonological-core variable differ-
tially proposed by Samuel Kirk (Kirk 1963) ences model proposed earlier by Stanovich
and later operationalized in the Federal (1988). Critical to the notion of a phonolog-
Register (U.S. Office Educ. 1977), refers to a ical weakness as causal in the development of
broad group of difficulties involving listening, the concatenation of difficulties observed in
dyslexia has been the repeated demonstration ing discrepant to simply low-achieving poor
that remediation of the phonological weak- readers (defined on the basis of a reading
ness leads to the amelioration of the decod- score below a certain cut point, e.g., below
ing and word-reading weaknesses in dyslexia a standard score of 90) find overlap between
(Bradley & Bryant 1983; Byrne & Fielding- the two groups on reading-related constructs
Barnsley 1995; Byrne et al. 2000; Foorman but not on IQ-related measures (Stuebing
et al. 1998; Hatcher et al. 1994; Schneider et al. 2002). In addition, both low-achieving
et al. 1997; Torgesen et al. 1999, 2001). and discrepant readers demonstrate compa-
rable growth rates in word reading during
Core definitional concept: an unexpected the school years (Francis et al. 1996). Knowl-
difficulty in reading. Perhaps the most con- edge of long-term adult outcome may shed
sistent and enduring core of any definition of light on possible differences between the two
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
dyslexia is the concept of dyslexia as an un- groups not captured by studies during child-
expected difficulty in reading. “Unexpected” hood; such efforts are now under way us-
refers to the presence of a reading difficulty ing data from the Connecticut Longitudinal
in a child (or adult) who appears to have all of Study (Ferrer et al. 2007, Shaywitz et al. 2003).
by University of Malaga on 05/16/08. For personal use only.
the factors (intelligence, motivation, exposure Not only do poor readers identified by either
to reasonable reading instruction) present to discrepancy or low-achievement criteria re-
be a good reader but who continues to strug- semble one another on measures of reading
gle (Shaywitz 1998). More challenging has and growth rates of reading, but each group
been the question of how to operationalize also differs along multiple dimensions from
the unexpected nature of dyslexia. Thus, us- groups of typically achieving boys and girls
ing differing methods and criteria, definitions (Fletcher et al. 1999, Lyon et al. 2001).
have attempted to capture the “unexpected” These findings have strong educational
nature of dyslexia by requiring a discrepancy implications: It is not valid to assume that dis-
of a certain degree between a child’s measured crepant children require instructional strate-
IQ and his reading achievement. For example, gies that differ from those for low-achieving
schools have typically relied on criteria based readers. It also is not valid to deny the ed-
on an absolute discrepancy, most commonly ucation services available for disabled or at-
one or one-and-one-half standard deviations risk readers to low-achieving, nondiscrepant
between standard scores on IQ and reading children. On the other hand, the observed
tests; others, including many researchers, pre- similarity of the discrepant and low-achieving
fer regression-based methods adjusting for groups in reading-related constructs argues
the correlation of IQ and reading achievement for identification approaches that include
(Reynolds 1984, Stuebing et al. 2002). both low-achieving children and those strug-
We want to emphasize that the difficulty gling readers who are discrepant but who do
has been not with the notion of a discrep- not satisfy an arbitrary cut point for designa-
ancy, but rather with the real-life practical tion as low achieving. Seventy-five percent of
effect of implementing this model in a pri- children identified by discrepancy criteria also
mary school setting. For example, children meet low-achievement criteria in reading; the
who were clearly struggling as early as kinder- remaining 25% who meet only discrepancy
garten or first grade had to wait, often until criteria may fail to be identified and yet still
third grade or later, until their failure in read- be struggling to read (Shaywitz et al. 1992a).
ing was of such a magnitude that they met A recognition of these difficulties com-
discrepancy requirements. And so it is under- bined with accumulating data indicating
standable why this approach has often been the importance of early intervention (Lyon
referred to as a wait-to-fail model. Attempts to et al. 2001; Torgesen et al. 1999, 2001) has
clarify the criteria by meta-analyses compar- prompted researchers and educators to search
for alternative approaches that would pro- Thus, like hypertension and obesity, dyslexia
mote earlier intervention or prevention for occurs in degrees of severity. A dimensional
at-risk readers. One such approach focuses on model also argues that although cut points
RTI: response to
a more dynamic assessment, particularly ap- are placed to help define groups, these are ar- intervention
plicable to early grades, where the ongoing bitrary and may have no biological validity;
Evidence-based
development of fluency in component read- those on one or the other side of such a cut reading instruction:
ing skills (e.g., letter recognition, word read- point will differ from one another by degree, programs and
ing) is measured frequently and is compared but not kind. Clinically, for school identifica- methods for which
with expected norms (Kame’enui et al. 2000). tion of children for special services, this means there is reliable and
valid evidence
Another approach, termed “response to inter- that “children who do not meet these arbitrar-
published in a
vention” (RTI; Fuchs & Fuchs 2006), has gen- ily imposed criteria may still require and profit peer-reviewed
erated considerable interest. Here, all chil- from special help” in reading (Shaywitz et al. journal of
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
pared with those delivered in the later years flecting what is known about the relation-
of primary school (Torgesen et al. 2006). ship between spoken and written language,
the phonological model, has received the most
by University of Malaga on 05/16/08. For personal use only.
no clues to its segmental nature (Liberman Hatcher et al. 1994; Torgesen et al. 1999,
et al. 1967). Thus, the word “bat” is com- 2001). Acquisition of phonological awareness
posed of three phonemes, “b,” “aaaa,” and “t,” follows a systematic, hierarchical model of
Orthography: the
but the listener hears this as the holistic word word structure, progressing from larger to specific writing
“bat” and not as three separate sounds. It is the smaller phonological units (Anthony et al. system of a language
seamless nature of spoken language, giving no 2003). Accordingly, children first develop a Morphemes: the
clue to its underlying segmental nature, that sensitivity to, or awareness of, spoken whole smallest meaningful
presents a challenge to the would-be reader. words, then syllables, then phoneme-level linguistic units, for
Spoken language is innate, observed in all units of language. The latter is referred to example, prefixes,
suffixes
societies on earth, and has been with us for as phonemic awareness. Good evidence sup-
tens of thousands of years. Exposing a baby ports the belief that reading itself is critical for
to a natural speaking environment results in the development of PA. Thus, PA is primarily
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
sound mappings are, the easier it is for chil- recessive and dominant transmission observed
dren to learn to read words accurately. Thus, in different cases, with at least 50% or more
the initial steps of literacy acquisition oc- of the variance explained by genetic factors
cur earlier and with more ease in languages
by University of Malaga on 05/16/08. For personal use only.
Gore 1997, Frackowiak et al. 2004, Jezzard are malleable and whether the disruption in
et al. 2001). Using this technology, neurosci- these systems in struggling readers can be in-
entists have been able to identify and local- fluenced by a reading intervention. Specific
ize several interrelated left hemisphere neural interventions are discussed below; here, we
networks in reading: an anterior network in focus on brain imaging as a tool to inter-
the inferior frontal gyrus (Broca’s area), long rogate the plasticity of these systems and to
associated with articulation that also serves examine the influence of reading instruction
an important function in silent reading and on the development or reorganization (repair)
naming (Fiez & Peterson 1998, Frackowiak of these neural systems. For example, in a
et al. 2004), and two in left hemisphere pos- study of second- and third-grade dyslexic and
terior brain regions, one around the parieto- nonimpaired readers, compared with dyslexic
temporal region serving word analysis, the readers who received other types of interven-
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
other in the left occipito-temporal region, tion, children who received an experimental
the word form area, critical for skilled, flu- evidence-based phonological intervention not
ent reading. A number of functional brain only improved their reading but also demon-
imaging studies in disabled readers converge strated increased activation both in left an-
by University of Malaga on 05/16/08. For personal use only.
to indicate a failure of left hemisphere poste- terior (inferior frontal gyrus) and left poste-
rior brain systems to function properly dur- rior (middle temporal gyrus) brain regions
ing reading (Brunswick et al. 1999; Helenius (Shaywitz et al. 2004). These findings in-
et al. 1999; Horwitz et al. 1998; Paulesu et al. dicate that teaching matters and that how
2001; Rumsey et al. 1992, 1997; Salmelin children are taught can foster the develop-
et al. 1996; Shaywitz et al. 1998) (Figure 2). ment of those automatic neural systems that
This neurobiological evidence of dysfunction serve skilled reading. Other investigators, too,
in left hemisphere posterior reading circuits have found that reading interventions influ-
is already present in reading-disabled chil- ence neural systems in brain. For example,
dren and cannot be ascribed simply to a life- one study in adults demonstrated greater acti-
time of poor reading (Seki et al. 2001, Shay- vation in the left prefrontal cortex after train-
witz et al. 2002, Simos et al. 2000, Temple ing compared with before training (Temple
et al. 2000). Anterior systems, especially in- et al. 2000). Other studies in children have
volving regions around the inferior frontal reported intervention-associated changes in-
gyrus, have also been implicated in disabled cluding fMRI changes in left inferior frontal
readers in reports of individuals with brain and posterior areas as well as in right hemi-
lesions (Benson 1994) as well as in func- sphere and cingulate cortex (Temple et al.
tional brain imaging studies (Brunswick et al. 2003); changes in lactate concentration dur-
1999, Corina et al. 2001, Georgiewa et al. ing magnetic resonance spectroscopy in the
2002, Paulesu et al. 1996, Rumsey et al. 1997, left frontal regions (Richards et al. 2000);
Shaywitz et al. 1998). Although dyslexic read- fMRI changes in left frontal and left posterior
ers exhibit a dysfunction in posterior reading regions (Aylward et al. 2003); changes in mag-
systems, they appear to develop compensatory netoencephalography in the left superior tem-
systems involving areas around the inferior poral gyrus (Simos et al. 2002); and changes
frontal gyrus in both hemispheres as well as in fMRI in dyslexic adults in posterior reading
the right hemisphere homologue of the left systems (Eden et al. 2004). Still to be deter-
occipito-temporal word form area (Shaywitz mined is the precise relationship among the
et al. 2002). type of intervention, changes in brain activa-
tion, and clinical improvement in reading.
Malleability of neural systems for read-
ing. A number of investigators have focused fMRI and mechanisms of reading. fMRI
on whether the neural systems for reading has also been very useful in understanding
the mechanisms of reading, knowledge that to that seen in nonimpaired readers, occurred
offers the possibility of providing more indi- during reading Kana. In contrast, LPMOT
vidualized interventions to dyslexic children activation, comparable to that observed in
LPMOT: left
posterior and medial and adults. Neurobiological evidence is be- dyslexic readers, was noted during reading
occipito-temporal ginning to emerge to support behavioral data of Kanji script (Nakamura et al. 2005), sug-
region indicating that many dyslexics are not able to gesting that the LPMOT region functions
LALOT: left make good use of sound-symbol linkages as as part of a memory-based system. Together,
anterior and lateral they mature, and instead, they come to rely these behavioral and recent neurobiological
occipito-temporal on memorized words. Behavioral studies in- findings lead us to suppose that as dyslexic
region
dicate phonologic deficits continue to charac- children mature, this posterior medial system
terize struggling readers, even as they enter supports memorization rather than the pro-
adolescence and adult life (Bruck & Treiman gressive sound-symbol linkages observed in
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
unfamiliar words. Brain imaging now reveals provide neurobiological evidence that illu-
that such readers demonstrate an aberrant minates and clarifies current understanding
neural connectivity pattern. Thus, in nonim- of the nature of dyslexia and its treatment.
paired readers, functional connections were For example, brain imaging has taken dyslexia
observed between the left occipito-temporal from what had previously been considered a
word form area and other components of the hidden disability to one that is visible—the
left hemisphere reading system. In contrast, in findings of a disruption in posterior reading
persistently poor readers, functional connec- systems are often referred to as a neural sig-
tions were observed between the left occipito- nature for dyslexia.
temporal word form area and right frontal Important, too, is the demonstration of a
neural systems regions associated with mem- disruption in the occipito-temporal or word
ory (Shaywitz et al. 2003). form system, a system that converging brain
A more recent fMRI study (Shaywitz et al. imaging studies now show is linked to flu-
2007) also demonstrates the importance of ent (automatic, rapid) reading. Disruption in
memory systems in dyslexic readers. This this system for skilled reading has very im-
study found that brain regions developing portant practical implications for the dyslexic
with age in dyslexic readers differ from those reader—it provides the neurobiological evi-
in nonimpaired readers, primarily in being dence for the biologic necessity for additional
localized to a more left posterior and me- time on high stakes tests (see Accommoda-
dial (LPMOT), rather than a more left ante- tions section below).
rior and lateral (LALOT) occipito-temporal Studies demonstrating the effects of a
region. This difference in activation pat- reading intervention on neural systems for
terns between dyslexic and nonimpaired read- reading have important implications for pub-
ers has parallels to reported brain activation lic policy regarding teaching children to read:
differences observed during reading of two The provision of an evidence-based reading
Japanese writing systems, Kana and Kanji. intervention at an early age improves read-
Kana script employs symbols that are linked ing fluency and facilitates the development
to the sound or phoneme (comparable to En- of those neural systems that underlie skilled
glish and other alphabetic scripts); Kanji script reading (see section on interventions). fMRI
uses ideographs where each character must studies focusing on the mechanisms of read-
be memorized. In the imaging study of these ing indicate that poor readers rely on mem-
writing systems, LALOT activation, similar ory rather than understanding how letters link
to sounds. Furthermore, these studies under- retrieve phonological elements has an impor-
score the importance of fluency; many bright tant function in speaking—for example, in re-
but struggling readers memorize words and trieving phonemes from the internal lexicon
Phonological
can read them relatively accurately but not au- and serially ordering them to utter the spo- processing: a
tomatically, and so they read slowly and with ken word. Thus, it should not be surpris- category of oral
great effort. ing that problems with spoken language, al- language processing
Thus, evidence is beginning to emerge to beit more subtle than those in reading, are involved with
accessing the specific
indicate that many dyslexics compensate for often observed. These include late speaking,
sounds making up
their poor reading by memorizing words. The mispronunciations, difficulties with word re- spoken words
problem, of course, for poor readers, is that trieval, needing time to summon an oral re-
memory has a limited capacity. For exam- sponse, and confusing words that sound alike,
ple, by third or fourth grade, a reader comes for example, saying “recession” when the in-
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
across perhaps 3000 or more new words a year. dividual meant to say “reception.” A range
Many of these words are difficult to memo- of problems are noted in reading (especially
rize because they are long, complicated, new, small function words and unfamiliar words,
or rare words. Those typical readers who have slow reading); difficulties in spelling; ability to
by University of Malaga on 05/16/08. For personal use only.
learned about the sound-symbol organization master a foreign language; handwriting; and
of written language are able to analyze words attention (Shaywitz 2003). The lack of reading
based on the letter-sound linkages and have fluency brings with it a need to read “manu-
a distinct advantage over the dyslexic reader. ally” (a process consuming great effort) rather
The reliance on memory systems in these than automatically; the cost of such reading is
populations of older disabled readers may a tremendous drain on attentional resources.
have implications for treatment of dyslexia. This is often observed in the classroom when
For example, it suggests that more pragmatic struggling readers, asked to read quietly, de-
interventions focusing on sight words (such plete their attentional resources as they strug-
as those occurring in assigned reading mate- gle with the print, and consequently appear
rials) and provision of accommodations such to be daydreaming or not attending to the as-
as aural presentation of literature (e.g., books signed reading. Some have posited that the
on tape; see Accommodations section be- need to call upon exceptional attentional re-
low) might take on a more significant role sources during reading leads to the clinical ap-
in these older dyslexic individuals than would pearance of attentional difficulties, in this in-
an approach used in younger students that stance, secondary to the reading difficulty and
is based primarily on teaching sound-symbol not primary (Pennington et al. 1993). That
associations. is, it is to be viewed as distinct from a pri-
mary attentional problem. In addition, it has
long been known that there is also a high
DIAGNOSIS AND TREATMENT comorbidity between dyslexia and attention
deficit/hyperactivity disorder, ranging from
Diagnosis of Dyslexia 15% to 50% (Biederman et al. 1996, Shaywitz
Dyslexia is more than simply a score on a et al. 1994). Therefore, both primary and sec-
reading test. Reflecting the core phonolog- ondary attentional difficulties are often noted
ical deficit, a range of downstream effects in individuals who are dyslexic.
is observed in spoken as well as in written In contrast to these difficulties, other cog-
language. Phonological processing is critical nitive abilities, including thinking, reasoning,
to both spoken and written language. Al- vocabulary, and listening comprehension, are
though most attention has centered on the usually intact. Intact higher-level abilities of-
print difficulties (and they are the most se- fer an explanation of why reading comprehen-
vere), the ability to notice, manipulate, and sion is often appreciably above single-word
reading accuracy and fluency in dyslexia (re- in a Report to Congress. The panel worked
viewed in Shaywitz 2003). for two years reviewing the extant data on
Dyslexia is a clinical diagnosis, best made teaching children to read published in peer-
National Reading
Panel: by an experienced clinician who has taken a reviewed journals, performing meta-analyses
Congressionally careful history, observed the child or young where the data allowed, and reporting to
mandated in 1998 to adult reading, and administered a battery of Congress on its findings in April 2000. As a re-
review research tests that assess the child’s cognitive abil- sult of its exhaustive review, the panel found
literature on
ity, academic skills including reading accu- that five essential elements should be incor-
teaching reading,
and in 2000 reported racy, fluency, and comprehension, spelling, porated into effective reading instruction—
on the most effective and mathematics (an area in which skills phonemic awareness, phonics, fluency, vocab-
methods and are often high), and language skills, partic- ulary, and comprehension (Rep. Natl. Read-
approaches ularly phonological processing (Marzola & ing Panel 2000)—and that these are optimally
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
Phonics: an Shepherd 2005, Shaywitz 2003). The uneven taught systemically and explicitly. These em-
approach to early peaks and valleys of both cognitive and aca- pirically rooted findings converge with what
reading instruction
demic functioning contribute to the clinical we know about why print has meaning. As
emphasizing
picture of dyslexia: a weakness in phonolog- noted above, a core deficit in phonological
by University of Malaga on 05/16/08. For personal use only.
letter-sound linkages
ically based skills in the context of often- processing is observed in a majority of chil-
stronger cognitive and academic skills in dren and adults with developmental dyslexia
nonreading-related areas. (Liberman & Shankweiler 1991). Thus, it is
As children mature, compensation often not surprising that a majority of the many re-
occurs that results in relatively accurate, but cent well-controlled research studies have fo-
not fluent, reading. Awareness of this devel- cused on preventing or remediating these core
opmental pattern is critically important for phonological deficits.
the diagnosis in older children, young adults,
and beyond. The consequence is that such
dyslexic older children may appear to perform Early Intervention
reasonably well on a test of word reading or Probably the most hopeful research has been
decoding; on these tests, credit is given irre- early intervention studies of children at-
spective of how long it takes the individual risk for dyslexia based on their problems
to respond or if initial errors in reading are with phonological processing or initial word-
later corrected. Accordingly, tests of reading identification skills (Lonigan 2003) in kinder-
fluency—how quickly and accurately individ- garten or the first grade. Both classroom-
ual words and passages are read—and tests as- level interventions (Adams & Carnine 2003,
sessing reading rate are keystones of an as- Foorman et al. 1998, Fuchs & Fuchs 2005)
sessment for, and an accurate diagnosis of, and pullout remedial approaches (Blachman
dyslexia. 1997, D’Agostino & Murphy 2004, Torgesen
et al. 1999, Vellutino et al. 2006) and
combinations of classroom and pullout ap-
Teaching Reading to Dyslexic proaches (O’Connor 2000, Simmons et al.
Students 2003, Vaughn et al. 2003) have reported pos-
Within the past decade, an evidence-based itive results. Although definitions of reading-
approach to teaching children (including disabled or dyslexic subjects in these studies
dyslexic children) to read has emerged. Much varied, on average, large effects sizes (>0.70)
of the evidence base was synthesized by the were reported. Together, these studies sug-
National Reading Panel established by the gest that prevention programs that explicitly
U.S. Congress in 1998 with a mandate to focus on phonemic awareness, phonics, and
review existing research on teaching chil- meaning of text in the earliest grades of read-
dren to read and then to present the data ing instruction reduce the base rates of at-risk
students to below 5%. Although one can- ties below the fifth percentile. The investiga-
not explicitly define such children as having tors showed that these explicit programs re-
dyslexia because they are typically just learn- sulted in significant improvements in reading
ing to read, and it is difficult to define a on standardized reading measures following
word-reading deficit at this level of reading the interventions, and many of the students
development, it appears that these systematic tested in the average range on word identifi-
programs can significantly improve core read- cation measures (but not fluency measures).
ing skills in the weakest readers at these ages. More importantly, the gains made in word
identification lasted for more than two years
post intervention.
Interventions for Older Students These and many other studies (for more
For older students the remedial research lit- comprehensive reviews, see Fletcher et al.
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
erature includes a range of intervention pro- 2007; Shaywitz 2003; Swanson et al. 1999,
grams, including those described as direct in- 2003) have provided the evidence that phono-
struction and those that are more strategy logically based decoding and word recog-
based (Swanson et al. 1999). Here, the ev- nition skills are “teachable aspects of read-
by University of Malaga on 05/16/08. For personal use only.
idence is less encouraging than for younger ing for most children” (Moats & Foorman
children. Investigations using remedial inter- 1997, p. 188). This corpus of evidence in-
ventions that begin after the second grade in- dicates that focused, intense, systematic, and
dicate it is more challenging to bring chil- explicit interventions can positively impact
dren or adults up to expected grade levels word-reading development, with some ex-
once they fall behind, although significant pected transfer impacting comprehension, in
improvements in reading can still occur (ef- even the most severely disabled dyslexic read-
fect sizes >0.60). As an example, Lovett et al. ers and that many different types of remedia-
(2000) combined a program referred to as an tion programs can be effective. This is an im-
explicit, scripted direct-instruction approach portant finding, for there is often a tendency
(based on Reading Mastery; Engelmann & to search for the one (magical) program that
Bruner 1988) that focused on phonologi- will address all struggling readers’ difficulties.
cal analysis and blending of phonemes with Current knowledge supports several types of
a strategy-based program (an expanded and intervention programs as effective. Evidence
adapted version of the Benchmark program; is not yet available that would allow the selec-
Gaskins et al. 1986) that focused on teaching tion of one specific program over others or to
children metacognitive strategies to assist in support the choice of an individual program
word identification. This combined program, that would be specifically more beneficial to
and adaptations of it for different grade levels, particular groups of dyslexic readers.
have been evaluated with severe dyslexic stu-
dents in both elementary and middle school
in randomized experimental designs with con- Beyond Word Accuracy
trol groups. Results of implementation of such Fluency. The consistent improvement in
combination programs indicated that this ap- phonologically based word attack and de-
proach resulted in significantly better stan- coding skills has not always generalized to
dardized reading measure outcomes than the accurate, fluent text reading or adequate
individual components alone or other contrast reading comprehension, the ultimate goal of
programs (Lovett et al. 2003). all reading interventions (Lovett et al. 1989,
In an intensive eight-week evaluation of Torgesen et al. 1997). Moats & Foorman
two different phonologically based programs, (1997) review this problem and state, “gener-
Torgesen et al. (2001) focused on older el- alization and transfer of decoding proficiency
ementary students with word-reading abili- to fluent word recognition and better reading
comprehension was not automatic . . . ” effect sizes 0.35–0.50). This finding suggests
(p. 188), a conclusion that has continued to that it’s the amount of reading that is criti-
be echoed by other studies and reviews (Lyon cal in supporting the development of fluent
Scaffolding: a
teaching strategy & Moats 1997, Rayner et al. 2001, Rep. Natl. and automatic reading. Chard and associates’
where the teacher Reading Panel 2000, Snow 2002, Torgesen (2002) review of studies specific to students
provides scaffolds et al. 1997). with dyslexia found slightly higher average ef-
(supports) that These results and questions have more re- fect sizes (0.50–0.70) for a range of interven-
facilitate the child’s
cently raised significant interest in whether tion approaches focused on fluency.
ability. For example,
the teacher reads a fluency deficits can be treated in reading-
passage slightly more disabled and dyslexic subjects and whether Reading comprehension. Although chil-
difficult than the such interventions (see Kuhn & Stahl 2003, dren and adults with dyslexia are defined by
child is able to read Rep. Natl. Reading Panel 2000 for more their word identification and decoding prob-
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
by him/herself. The
comprehensive reviews) should be focused lems, some may also have reading compre-
child then reads the
same passage on connected-text or word-level strategies. hension difficulties that are not due to an un-
repeatedly and Meyer & Felton (1999) found that most flu- derlying oral language disorder. Because of
ency programs use repeated reading of con- this, some researchers have focused on inter-
by University of Malaga on 05/16/08. For personal use only.
gradually learns to
read this previously nected text, although some newer programs vention programs aimed at reading compre-
difficult section with
focus on broader developmental models of hension abilities. Most remedial approaches
facility
fluency encompassing both building semantic have developed comprehension-related strat-
knowledge and orthographic pattern aware- egy instruction or specific comprehension-
ness (Wolf et al. 2000). related skill instructional types of programs.
As examples of the repeated reading Strategy-related programs have focused on
approaches, Stahl & Heuback (2005) and developing critical thinking skills related to
Young and associates (1996) reported signif- understanding of text and constructing its
icant gains in their poor readers’ text read- meaning based on the reader’s prior knowl-
ing fluency using connected text methods, edge, prediction of text, monitoring of text
whereas Levy and associates (1997) and Tan structure, and question asking, as examples.
& Nicholson (1997) focused their interven- Skill-related programs focus more on finding
tions at the word level and showed similar but ideas and facts, developing multiple meaning
less robust gains in connected text fluency. A of words and increasing vocabulary, and sum-
key aspect of most fluency-focused interven- marizing text.
tion programs with dyslexic students is that Several reviews ( Jenkins & O’Connor
they require significant reading of connected 2003, Swanson et al. 1999, Vaughn &
text with scaffolding support by either peers Klingner 2004) suggest that various types of
or teachers. The conceptual framework be- comprehension-focused intervention studies
hind these approaches is that as word identi- in reading-disabled children and adults, par-
fication becomes more automatic, due to in- ticularly those using explicit, strategy-focused
creasing orthographic awareness via practice, approaches, were effective. Unfortunately,
an improving reader requires less strategic at- because of the wide range of methodologies
tention on the act of reading as it becomes used in these studies and the variety of pro-
automatic and can direct more cognitive en- grammatic approaches, the resulting range of
ergy and focus on comprehension of mean- effect sizes seen in comprehension-focused
ing. Kuhn & Stahl’s (2003) review of fluency- intervention studies of dyslexic students is
oriented instructional approaches found that typically broad (0.20–0.70). It appears that
repeated reading of text with scaffolding typi- many of these studies support the efficacy of
cally produces gains in fluency and reading- the comprehension-focused remediation pro-
related skills similar to reading the equiva- grams’ ability to teach their specific strate-
lent amounts of nonrepetitive text (average gies, but the ability of students to apply those
strategies in new text reading and comprehen- still have not mastered reading due to their
sion situations is less consistent. underlying individual core phonological and
linguistic deficits. In addition, some students
have experienced both factors. Such problems
Treatment Resisters are not easily addressed via one-time evalua-
In their focus on treatment resisters, Torgesen tions or interventions without some develop-
& Mathes (2000) highlighted a key set of find- mental perspective and sequential evaluations
ings across all intervention studies: A number over time.
of children and adults do not respond to pro- The thrust of RTI frameworks (Fuchs &
grams that are shown to be effective in their Fuchs 2006) is to address these traditional
peers. Such results highlight the heterogene- limitations in the treatment of persons with
ity of the dyslexia population, but also sug- dyslexia by focusing on change over time. A
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
gest that no one explicit remedial instructional typical model would screen all students on
program, whether focused at the level of word core academic abilities—in this case reading—
identification, fluency, or comprehension, or and identify those at risk using somewhat
any combination of these processes, will be liberal criteria (resulting in more false posi-
by University of Malaga on 05/16/08. For personal use only.
able to successfully address the needs of all tives). These students are then followed us-
such readers. The kinds of issues raised by ing frequently repeated reading-focused eval-
such consistent findings of treatment-resisters uation probes during an academic year (or
across different interventions focus on con- years) while they are receiving systematic
textual or procedural factors rather than con- reading instruction. Those students who do
tent itself. Questions include how best to un- not make adequate progress compared with
derstand the role of (a) instructional intensity their typically developing peers (comparing
(length of intervention, hours of instruction, the amount of change over a given time pe-
optimal ratios of teachers to students, read- riod) are then provided with increasingly in-
ing time, etc.); (b) program integrity/fidelity; tense and, as needed, alternative approaches
(c) teacher ability/experience; (d ) program to reading interventions and continue to be
focus/explicitness/multidimensionality; and monitored over time. Students who receive
(e) individual student prior instructional ex- the best available quality instruction and who
periences/exposure and reading abilities. The do not respond to these increasingly explicit,
ways in which these factors, individually and intense, and alternative approaches over time
together, affect treatment outcomes is just would then be classified as dyslexic or learn-
beginning to be addressed, particularly for ing disabled (Presid. Commiss. Excell. Spec.
treatment resisters. The answers to these Educ. 2002). Clearly, such multitiered models
unresolved questions will provide critical still depend on measures sensitive to change,
information to better understand the ways in definitions of adequate change, validated in-
which effective instructional programs may terventions of increasing intensity, instruc-
affect any specific student with dyslexia. tional integrity, and a systematic approach
at the school/teacher level to ensure that
all students are monitored. McMaster and
Response to Intervention colleagues (2005) have provided one of the
It has become increasingly apparent that sev- better examples of this approach to children
eral causes exist for students’ deficiencies in across 33 classrooms. Less than 5% of those
reading. Such students may be instructional children who, via the ongoing weekly mon-
casualties resulting from poor, inappropriate, itoring of reading, received increasingly in-
or noneffective reading instruction. On the tense and ultimately one-on-one instruction
other hand, some reading-deficient students were still considered not to have made ad-
have received quality reading instruction but equate progress in reading, compared with
studies. Fluency- and comprehension-focused types: (a) those that by-pass the reading dif-
interventions have had less investigation but ficulty by providing information through an
have still shown significant, albeit more vari- auditory mode, (b) those that provide compen-
able, effects on reading outcomes in these satory assistive technologies, and (c) those that
students. Programs that systematically inte- provide additional time so that the dysfluent
grate multiple-focused interventions are con- reader can demonstrate his/her knowledge.
sidered the most effective, although their spe- First, beginning quite early in their school-
cific sequencing, degree of overlap, and level ing, dyslexic readers require alternative modes
of focus on each component during each phase of acquiring information so that their vocab-
are still open to critical investigation. At this ulary and fund of knowledge better reflect
point, determining which instructional pro- their intellectual level than does their im-
gram works best is not necessarily important, paired reading ability. Access to recorded ma-
but rather determining what program works terials, whether they are based on the school
best for what kind of dyslexic student with curriculum or reflect what peers are reading
what kind of characteristics in what kind of for pleasure, are a necessity for such children if
implementation. they are to keep up with their classmates and
Overall, significant progress has been with their own intellectual curiosity and in-
made in understanding the cognitive basis of terests. Next, assistive technology, computers,
dyslexia and in using this knowledge to in- and both print-to-speech as well as speech-to-
form instructional practices. At the same time, print software provide further compensation
it must be kept in mind that we are only for oft-noted difficulties with handwriting,
in the early stages of discovering and devel- spelling, and lack of fluency. A major ad-
oping specific reading interventions that will vance has been the convergence of behavioral
consistently improve all components of read- and neuroimaging data providing evidence for
ing, including accuracy, fluency, and compre- the critical need for extra time on examina-
hension. Broad-stroke gains have been made tions for dyslexic students, particularly as they
in developing an overall template for pro- progress toward high school graduation and
viding reading interventions to dyslexic stu- beyond. Behavioral data indicating the per-
dents; however, we await evidence to guide sistence of dysfluent reading are now sup-
the more fine-grained selection of specific in- ported by neurobiological data demonstrating
terventions for individual struggling readers that the left anterior lateral occipito-temporal
at all ages and at all levels of reading ability. (word-form) region responsible for fluent,
rapid reading is disrupted in dyslexic children sures of word identification fail to capture dif-
and adults (Dehaene et al. 2005; Shaywitz et al. ficulties in fluent reading and so are often mis-
1998, 2003). As the neurobiological data indi- leading. In addition, since such nonautomatic
cate, dyslexic readers develop compensatory readers must call upon attentional resources
neural pathways, and these systems support during reading, these students are highly sus-
increased accuracy over time. However, the ceptible to noise and other distractions. Study
word-form region does not develop (Shaywitz and test taking in quiet, separate rooms al-
et al. 2007), and compensatory pathways do low these dysfluent readers to concentrate and
not provide fluent or automatic reading. Ac- make maximum use of their often strained at-
cordingly, if such students are to demonstrate tentional resources.
the full range of their knowledge, provision In summary, given that dyslexia represents
of additional time on examinations is a neces- a disparity between an individual’s reading
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
sity to compensate for the lack of availability and intellectual abilities; accommodations are
of the efficient word-form area. Currently, no critical to assure fairness and equity. Con-
quantitative data are available to serve as a re- temporary management of dyslexia provides
liable metric for gauging the specific amount evidence-based accommodations; these in-
by University of Malaga on 05/16/08. For personal use only.
of extra time needed by a student, and this clude access to recorded materials; computers
determination is best guided by the student’s and print-to-speech software; and additional
own experience over the years. Because the time on examinations, with the amount of
persistence of the reading difficulty is indi- time determined by the student’s experience
cated by both behavioral and imaging longi- (Shaywitz 2003). Such accommodations are
tudinal data, requiring that students in post- provided based on a student’s history, observa-
secondary settings be tested every three or five tions of his/her reading aloud, and test results.
years is not consistent with scientific knowl- With the provision of such accommodations,
edge. Furthermore, it is extremely expensive dyslexic students are entering and succeeding
and even problematic. As students progress in a range of professions, including journal-
through school to higher grades and compen- ism, literary writing, science, medicine, law,
sate in reading accuracy, simple reading mea- and education (Shaywitz 2003).
SUMMARY POINTS
1. The core concept of dyslexia as an unexpected difficulty in reading has remained
invariant over the century since its first description; dyslexia is found in all languages
including both alphabetic and logographic scripts.
2. A deficit in phonological processing, accessing the individual sounds of spoken words,
represents the core weakness in dyslexia, and its remediation is the focus of early
intervention programs for at-risk and struggling readers.
3. Dyslexia is a chronic, persistent difficulty and is neither a developmental lag nor
outgrown; the implication is that reading problems must be recognized and addressed
early.
4. Evidence-based interventions are now available and have positive effects on reading.
The most consistent and largest effect sizes are associated with provision of prevention
programs explicitly focused on phonological awareness, phonics, and meaning of text.
5. Intervention programs for children beyond second grade, though effective, are chal-
lenging and have produced less-consistent results. Such evidence-based programs
focus on systematic, phonologically based instruction and teaching metacognitive
dyslexia. Brain imaging has also indicated a target (the left occipito-temporal word
form area) for intervention for skilled or fluent reading and that these systems are
malleable and respond to effective reading interventions. Such findings demonstrate
the importance and powerful impact of effective reading instruction.
by University of Malaga on 05/16/08. For personal use only.
8. Interventions, while promising, have yet to close the gap in the ability of dyslexic
children to read fluently; dyslexic children often remain accurate but slow readers.
Neurobiological evidence indicates that the failure of the word form area to function
properly in dyslexic children and young adults is responsible for their characteristic
inefficient, slow reading. Accommodations, particularly the provision of extra time,
are essential for dyslexic students to fully demonstrate their knowledge.
FUTURE ISSUES
1. To identify which specific instructional components/programs work best for which
specific types of dyslexic students and under what kinds of implementation practices.
2. To identify which specific instructional elements in which specific combination im-
prove fluency and reading comprehension, particularly in older students.
3. To identify the role of attentional difficulties in dyslexic readers.
4. To determine effective methods of identifying at-risk children earlier and more accu-
rately.
5. To determine mechanisms by which the phonology and orthography are integrated
in the word form region and how this process could be facilitated.
ACKNOWLEDGMENTS
The work described in this article was supported by grants from the National Institute of Child
Health and Human Development (P50 HD25802, RO1 HD046171, and R01 HD057655) to
Sally Shaywitz and Bennett Shaywitz.
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Figure 1
Trajectory of reading skills over time in nonimpaired and dyslexic readers. Ordinate is Rasch scores
(W scores) from the Woodcock-Johnson reading test (Woodcock & Johnson 1989) and abscissa is age
in years. Both dyslexic and nonimpaired readers improve their reading scores as they get older, but the
gap between the dyslexic and nonimpaired readers remains. Thus, dyslexia is a deficit and not a devel-
opmental lag. (Figure derived from data in Francis et al. 1996 and reprinted from Shaywitz 2003 with
permission.)
Figure 2
by University of Malaga on 05/16/08. For personal use only.
Neural signature for dyslexia. Schematic view of left hemisphere brain systems for reading observed
during fMRI in nonimpaired (left) and dyslexic (right) readers. In nonimpaired readers, three systems
are evident: one anterior in the area of the inferior frontal gyrus and two posterior, the top system
around the parieto-temporal region and the bottom system around the occipito-temporal region. In
dyslexic readers, the anterior system is slightly overactivated compared with systems of nonimpaired
readers; in contrast, the two posterior systems are underactivated. This pattern of underactivation in
left posterior reading systems is referred to as the neural signature for dyslexia. Figure reprinted from
(Shaywitz 2003) with permission.
Annual Review of
Contents Psychology
Prefatory
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
Consummatory Behavior
The Brain, Appetite, and Obesity
Hans-Rudolf Berthoud and Christopher Morrison p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 55
Sex
Neuroendocrine Regulation of Feminine Sexual Behavior: Lessons
from Rodent Models and Thoughts About Humans
Jeffrey D. Blaustein p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 93
Color Perception
v
AR331-FM ARI 15 November 2007 15:19
Cognitive Processes
The Mind and Brain of Short-Term Memory
John Jonides, Richard L. Lewis, Derek Evan Nee, Cindy A. Lustig,
Marc G. Berman, and Katherine Sledge Moore p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p193
Memory
Relativity of Remembering: Why the Laws of Memory Vanished
Henry L. Roediger, III p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p225
Anxiety Disorders
Social Bonds and Posttraumatic Stress Disorder
Anthony Charuvastra and Marylène Cloitre p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p301
Cognition in Organizations
Cognition in Organizations
Gerard P. Hodgkinson and Mark P. Healey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p387
vi Contents
AR331-FM ARI 15 November 2007 15:19
Emotion
Annu. Rev. Psychol. 2008.59:451-475. Downloaded from arjournals.annualreviews.org
Data Analysis
Sample Size Planning for Statistical Power and Accuracy
in Parameter Estimation
Scott E. Maxwell, Ken Kelley, and Joseph R. Rausch p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p537
Timely Topics
A Comprehensive Review of the Placebo Effect: Recent Advances
and Current Thought
Donald D. Price, Damien G. Finniss, and Fabrizio Benedetti p p p p p p p p p p p p p p p p p p p p p p p p565
Children’s Social Competence in Cultural Context
Xinyin Chen and Doran C. French p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p591
Grounded Cognition
Lawrence W. Barsalou p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p617
Neuroeconomics
George Loewenstein, Scott Rick, and Jonathan D. Cohen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p647
Indexes
Errata
Contents vii