Transcript PAL Story

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
[email protected]
CASP March 4, 2005
Riverside, CA
Making the Case for Tier 3
 Special education placement decisions and
differential diagnosis are not the same. Diagnosis
should be made even if student is not given
services.
 For efficiency, use differential diagnosis for
identifying disorder and branching diagnosis for
planning treatment:
 Implications for etiology, treatment, and
prognosis
What Is Dyslexia?
 Not all learning disabilities involve reading.
 Not all reading disabilities are dyslexia, but
dyslexia exists and is one specific learning
disability
 Dyslexia has genetic basis, neuroanatomical
signatures, and changing phenotype (observable
behavioral signs) across development as
curriculum requirements change.
Neuroanatomical Differences between Good
Readers (left) and Dyslexics (right)
What Is Dyslexia?
First signs in kindergarten: Unusual
difficulty in learning to name letters and
attach phonemes to letters. (OrthographicPhonological Mapping Relationships)
1st grade—Unusual difficulty learning to
read single words out of sentence
context (sight words and/or
phonological decoding).
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.
What Is Dyslexia?
 Does not go away with maturation alone: Systematic and
explicit instruction improves accuracy of single word
reading.
 Assessing reading only in context may mask the difficulty
dyslexics have in reading single words.
 Assessing only real word reading may mask unusual
difficulty in reading pseudowords (translating the
orthographic word form into the phonological word form) .
 Assessing only accuracy of word reading and decoding
may mask reading rate problems (accuracy vs rate
disability, Lovett, 1987)
Etiology of Dyslexia
Genetic Constraints in UW Family Study:
 preciseness of the phonological word form and phonological shortterm memory, CTOPP Nonword Repetition
 accuracy and rate of phonological decoding (orthographicphonological-morphological mapping), TOWRE Phonemic Reading
Efficiency; WIAT II pseudoword reading or WJ III Word Attack
 written spelling, WRAT 3 or 4 or WIAT II Spelling and
 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)
Etiology of Dyslexia
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Dyslexia is a Language (Not Perceptual) Disorder
Problem in preciseness of phonological word form,
phonological short-term/working memory, orthographicphonological mapping, inhibition,and executive support of
language functions that manifests itself in written language
at the word level.
Language markers in phenotype: Deficits in orthographic,
phonological, and rapid naming skills.
Relative strengths in morphological and syntactic skills
May occur with or without ADHD (inattention more
common), specific arithmetic disability, handwriting
problem
Research-Supported
Diagnosis of Dyslexia
 Discrepancy of at least 15 standard score points between WISC III
or 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.
 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)
What Is Dysgraphia?
Developmental dissociation between
transcription and text generation skills in
writing development
Dysgraphia = Impaired + Hand (Language
by Hand Produced by the Grapho-Motor
System) or Letter
Transcription Skills affected are
handwriting and/or spelling.
Relationship between
Dyslexia and Dysgraphia
 All dyslexics have dysgraphia (spelling is always
affected, handwriting may or may not be affected).
 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.
What is Language Learning
Disability (LLD)? (Wallach & Butler, 1994)
 Deficits in morphological and syntactic processing
and executive functions for language (e.g. CELF Sentence
Formulation)
 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
 Deficits in reading comprehension and word decoding—
deficits in reading comprehension may be greater than
those in word decoding
 Typically no VIQ-achievement discrepancy (because of
morphological and syntactic impairment that lowers VIQ)
What is Language Learning
Disability (LLD)? (Wallach & Butler, 1994)
 Learn language but have difficulty using language
to learn despite normal intelligence—analogy to
Chall’s learning to read and reading to learn
 can learn well using nonverbal strategies see
research by Elaine Silliman University of Florida
Tampa
 Need explicit instruction in (a) processing
instructional language across the curriculum, (b)
using language to learn, and (c) reading
comprehension (PAL Lesson Set 6)
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,
 Language learning disabled acquire language-slowly but within the lower limits of the normal
range—fast responders to early language
intervention
 Dyslexics show normal early language
development (words and sentences) until written
language introduced.
Differential Diagnosis
 To diagnose dyslexia, dysgraphia, or language
learning disability must rule out mental
retardation, pervasive developmental disorder,
autism, primary language disorder, and slow(er)
learner.
 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.
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)
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.
Conditions for Which Dyslexia Is
Inappropriate Diagnosis
Trauma to mother or child during gestation
or labor or adverse drug or vaccine reaction
Significant Prematurity (Low Birth Weight)
Disease (e.g. menegitis) or injury (e.g.
cerebral palsy)
Fetal Alcohol or Effect or Substance Abuse
Other neurogenetic disorders (fragile X,
Down Syndrome etc.
Importance of Differential Diagnosis
The nature of the diagnosis has implications for treatment planning, for example
 Dyslexics benefit from explicit and intensive phonological,
morphological, and orthographic training for word learning; they do
not need intensive work in comprehension.
 Language learning disabled need the same training for word learning
plus more intensive morphological and syntactic treatment and very
explicit comprehension instruction.
 Dysgraphics need and benefit from explicit handwriting and
keyboarding instruction rather than merely accommodation; delivery
of this instruction depends on whether they also have dyslexia or
language learning disability.
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,
 Students with language learning disability may
need specialized instruction longer than do those
with only dyslexia
 Students whose cognitive development falls
outside the normal range cannot be expected to
read and write at grade level.
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,
or language learning disorders? YES YES YES
But we need longitudinal instructional intervention
studies for all these disorders to validate what kind
of instruction is effective at various stages of
development for each kind of Tier 3 disorder.
Reading about Differential and
Branching Diagnosis
1. Berninger, V., Thomson, J., & L. O’Donnell. (2004). Differential
diagnosis of dyslexia, dysgraphia, language learning disability, and
other 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.