Dr. Steven Feifer

3/27/2011

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Steven G. Feifer, D.Ed., NCSP, ABSNPWake County, North Carolina

[email protected]

The Neuropsychology of Reading and Written

Language Disorders: A Framework for Effective Interventions

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PRESENTATION OF GOALS

1. Discuss the role of school neuropsychology, within an RtI

framework, as a more viable means to both assess and

remediate learning disorders in children.

2. Explore the neuropsychological underpinnings of reading and written language disorders by examining the underlying neural circuitry involved in processing this type of academic information.

3. Introduce a brain-based educational model of diagnosingreading and written language disorders by classifying each into four subtypes, with specific remediation strategies linked to each subtype.

4. Introduce the 90 minute LD evaluation as a more comprehensive means to assess eight core cognitive constructs associated with learning disorders in children.

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Currently, approximately 6.7 million children receive

special education services under IDEA, which

corresponds to approximately 9 percent of all children

aged 3-21 in public education.

Approximately 40 percent of those children receiving services are classified as being “learning disabled”

due primarily to reading and/or written language

deficiencies.

Clearly, literacy is the single most important educational attribute paving the road for not only school success,

but perhaps for successful life endeavors as well.

Kavale and Forness (2000) revealed nearly 50% of students classified as having a learning disability do not

demonstrate a significant discrepancy between

aptitude and achievement due in part to the statistical

impreciseness of this method.

BASIC LITERACY FACTS (National Literacy Council, 2008)

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Traditional Problems with Special

Education Service Delivery Model

A deliberate separation of regular education from special education.

Undocumented benefit of special education for children with high incidence disabilities.

A disconnect between testing for eligibility purposes versus testing for what

interventions work best.

A reactive model not geared toward early intervention services.

IEP’s that rarely emphasize the “I”.

Inconsistent qualification decisions since there

is no universal agreement on what

constitutes a significant discrepancy.

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1. There is no universal agreement on what the

discrepancy should be, or developmental guidelines

for discrepancy expectations.

2. It remains unclear as to which IQ score should be

used to establish a discrepancy.

3. A discrepancy model of learning disabilities precludes

early identification and creates a “wait and fail” policy.

4. A discrepancy model of reading assumes that IQ is the

best predictor of successful reading.

What is the relationship between IQ and reading?

Discrepancies only represent unexpected underachievement!!

MAIN PITFALLS OF DISCREPANCY

MODEL

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3-Headed Monster of Reading

DECODING FLUENCY COMPREHENSION

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IDEA REATHORIZATION - signed into law by President

Bush in December, 2004.

States may opt out of using the discrepancy model to identify learning disabilities, and replace with

RTI.

Gives school districts flexibility to craft policy whereby students who do not respond to

scientifically based reading program can be

eligible for SPED.

Requires districts with disproportionate number of minorities in SPED to consider eliminating the use

of IQ tests.

IDEA REAUTHORIZATION

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(1) Universal Screening - for all students a

minimum of three times per year.

(2) Baseline Data - using curriculum-based

measurement as primary data gathering means.

(3) Measurable Terms - define problem areas

numerically.

(4) Accountability Plan – monitor fidelity of

selected intervention.

(5) Progress Monitoring – how, where, and when

intervention results will be measured and

recorded.

(6) Data Based Decision Making – ongoing analysis

of data to drive future intervention decisions.

Six Components of an Effective RTI Model

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RESPONSE TO INTERVENTION MODEL

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Curriculum-Based Measurement

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RtI strengths: allows for earlier intervention.

non-categorical.

excellent for progress monitoring.

utilizes data to make decisions.

systemic deployment of interventions.

RtI weaknesses: is not sufficient to identify a learning disability

(National Joint Commission on Learning Disabilities, June 2005)

RtI is incapable of differential diagnosis and offers

little in identifying other emotional conditions or attention

factors hindering learning (Reynolds, 2008).

Run the risk of delaying assessment and denying a

student eligibility for services (OSEP memo, 2010).

RtI models often promote standard protocol

interventions and assume a “one size fits all” approach to

remediation (Feifer & Della Toffalo, 2007).

Evidence based interventions require evidence based assessments!!

RtI Strengths and Limitations

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School Neuropsychological Assessment

Reports based upon a brain-behavioral paradigm which attempts to describe how a

child learns and processes information.

Focus on why the child has not been

successful in school as opposed to IQ

scores.

Less emphasis on whether or not the

student qualifies for special education

services.

Examine the cognitive and emotional strengths and weaknesses of the child and

link to specific educational strategies and

interventions.

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Forest Grove School District case reached the Supreme Court in June, 2009. The local school psychologist

evaluated a child and concluded there was no

disability present.

The parents sought a private assessment that was more comprehensive and examined multiple cognitive

constructs. There was evidence of a disability. The Due

Process Hearing Officer concluded that the school

district failed to provide FAPE and that the school district

is liable for private school services.

Supreme court justice John Paul Stevens agreed with the Due Process Hearing Officer because the school had

overlooked a disability because they had not completed

a comprehensive evaluation in all areas of the suspected

disability. Cost of tuition…$5200 per month.

Do you agree?

Supreme Court and School Neuropsychology

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Competing Neuropsychological Models1. Cattell-Horn-Carroll (CHC) model emphasizes

cross battery assessment examining broad and

narrow abilities (Dawn Flanagan).

2. Discrepancy/consistency approach utilizing the

PASS model of information processing

(Jack Naglieri).

3. Cognitive Hypothesis Testing (CHT) model links

assessment to intervention using a demands

analysis (Brad Hale & Cathy Fiorello).

4. School Neuropsychological Conceptual model

of information processing (Dan Miller).

5. 90 Minute Learning Disorders model teasing

out subtypes of each disorder (Steven Feifer).

*Let us begin our discussion on how reading

is represented in our brain.

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1. In all word languages studied to date, children with

developmental reading disorders (dyslexia) primarily

have difficulties in both recognizing and manipulating

phonological units at all linguistic levels (Goswami,

2007).

2. English speaking children tend to develop phonemic

processing more slowly than children in more

phonologically consistent languages such as Spanish

or Italian (Goswami, 2007). Still, children in all

languages initially become aware of larger acoustical

units within the words themselves such as syllable,

onset, and rhyme.

Four Universal Truths of Reading

Heschl’s Gyrus

Superior

Temporal Gyrus

Angular Gyrus

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The English language includes over 1,100 ways of representing 44 sounds (phonemes) using a series of

different letter combinations (Uhry & Clark, 2005). By

contrast, in Italian there is no such ambiguity as just 33

graphemes are sufficient to represent the 25 phonemes.

Therefore, 25% of words are phonologically irregular (i.e. “debt”, “yacht”, “onion”, etc..) or have one spelling but

multiple meanings (i.e. “tear”, “bass”, “wind”, etc..)

The six types of syllables that compose English words must be directly taught as orthographic representations.

a) Closed syllables (just one vowel…”cat”)

b) Open syllables (ends in long vowel…”baby”)

c) Vowel-Consonant E Syllables (silent e elongates vowel...”make”)

d) Vowel-Team Syllables (two vowels make one sound…”caution”)e) R-Controlled Syllables (vowel followed by “r”changes sound…”hurt”)

f) Consonant-le Syllables (end of word ending in “le”…..”turtle”)

How Complex is English????

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3. Specific neuroimaging techniques have

demonstrated that phonological processing is

a by-product of the functional integrity of the

temporal-parietal junctures in the left

hemisphere of the brain ….supramarginal

gyrus (Pugh et al., 2000, McCandliss & Noble,

2003; Shaywitz, 2004; Sandak et al., 2004).


Supramarginal

Gyrus

Heschl’s Gyrus

Superior

Temporal Gyrus

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4. According to the National Reading Panel(2000), the

most effective method of teaching a phonologically

challenging language such as English is through a

direct and explicit model of phonological

development.


COMPREHENSION

LANGUAGE

FLUENCY

PHONICS

PHONEMIC AWARENESS

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(1) The younger the child, the better the outcome.

(2) The “at-risk” child responds best to small group

instruction (3:1), with phonological awareness

training being combined with explicit phonics.

(3) Highly trained teachers achieve the best results.

(4) Frequency of instruction (4-5 days per week) was

more effective than sporadic instruction (2 days per

week).

(5) Gains were maintained in most children at long-term

follow up.

(6) The following characteristics were associated with

poor outcome:

a) attention or behavior concerns

b) low socioeconomic status

c) poor verbal skills

d) poor rapid naming skills

NATIONAL READING PANEL:

Conclusions K-1st grade

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(1) Readers at this age respond to explicit phonological

instruction, though gains were not as strong as with

younger children.

(2) These readers were less responsive to explicit

phonological instruction, though did better in one-to-

one or small group instruction.

(3) More intensive work for a longer duration required.

(4) Spelling and fluency did not improve much, though

some improvement with reading comprehension.

(5) Computer instruction served as an effective aid, but

was not effective by itself.

(6) The following characteristics were associated with

poor outcome:

a) attention or behavior concerns

b) low socioeconomic status

c) poor verbal skills

d) poor rapid naming skills

NATIONAL READING PANEL:

Conclusions 2nd – 6th grade

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Neural Circuitry of Reading Disorders

Nonimpaired readers activate primarily

posterior portions of left hemisphere.

Impaired readers under-activate posterior

regions and activate primarily frontal

areas.

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Question: Can brain chemistry actually become altered

as a result of practice and effective interventions???

London cab drivers showed direct correlation between number of years on the job and hippocampal

volume (Maguire et al., 2000)

Bilingual individuals have more gray matter in the left angular gyrus than monolingual students, no matter

when the second language was acquired (Green et al.,

2007)

There is a correlation between the size of Heschl’s gyrus and the amount of time practicing an instrument

(Schneider et al., 2002)

Dyslexic students fail to activate brain regions associated with phonological processing and

automaticity (Shaywitz & Shaywitz, 2005).

Our Adaptive Brain

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Our Adaptive Brain

Researchers (Hoeft, et al., 2010) were able to predict with 90% accuracy which teens could improve their reading based upon

neural activation in the right inferior frontal gyrus of the brain.

This was more accurate than any standardized reading measure

including the Woodcock Reading Mastery Test.

The strongest gains were in reading comprehension rather than phonological awareness. The right longitudinal fasciculus,

a pathway connecting front and back speech zones, tended to

show greater activation. (Proceedings of the National Academy of Science).

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Four Subtypes of Reading Disorders

(1) Dysphonetic Dyslexia – difficulty sounding

out words in a phonological manner.

(2) Surface Dyslexia – difficulty with the rapid

and automatic recognition of words in print.

(3) Mixed Dyslexia – multiple reading deficits

characterized by impaired phonological and orthographic

processing skills. Most severe form of dyslexia.

(4) Comprehension Deficits – mechanical

side of reading is fine but difficulty persists deriving

meaning from print.

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UNDERSTANDING THE NOTION OF

SUBTYPING

Inferior Frontal Gyrus Supramarginal

Gyrus

Heschl’s Gyrus

Angular

Gyrus

Superior Temporal

Gyrus

Fusiform

Gyrus

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SUBTYPING

KEY BRAIN REGIONS IN DYSLEXIA

(1) Heschl’s Gyrus- auditory perception and

discrimination.

(2) Superior Temporal Gyrus – modulates the 44

phonemes of the English Language.

(3) Angular Gyrus – cross modal association area

mapping symbols to sounds.

(4) Supramarginal Gyrus – cross modal association

area underlying the spatial appreciation of sounds.

(5) Fusiform Gyrus – automatic word recognition center

for reading.

(6) Inferior Frontal Gyrus – key region for passage

comprehension.

* Posterior portion of the brain decodes.

* Anterior portion of the brain comprehends.

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Over Age 12: Wilson Reading System

SRA Corrective Reading

(Top- Down) Read 180

Ages 7 - 12: Alphabetic Phonics (Orton-Gillingham)

Recipe for Reading

SRA Corrective Reading

Earobics II

SIPPS

LIPS

LEXIA

(Bottom-Up) Horizons

Read Well

DISTAR (Reading Mastery)

Under Age 7: Fast Forword (Tallal)Earobics IPhono-GraphixLindamood Phoneme Sequencing ProgramSuccess for AllLadders to LiteracyFundations

Road to the Code

DYSPHONETIC DYSLEXIA

INTERVENTIONS

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Under Age 7: Analytic or Embedded

Reading Recovery

Early Steps

Ages 7 - 12: Great Leaps program

Read Naturally

Quick Read

RAV-O

Over Age 12: Neurological Impress

method

Wilson Reading System

Laubauch Reading Series

Read 180

SURFACE DYSLEXIA (FLUENCY)

INTERVENTIONS

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4 REMEDIATION STRATEGIES FOR

MIXED DYSLEXIA

(1) Balanced Literacy - An eclectic and approach capitalizing

on the particular strengths of the child. Consider using a

multi-sensory type of Orton-Gillingham program, coupled

with a fluency model such as Read Naturally, and the

computerized models of Read 180.

(2) Top Down Strategies – Often atypical development

mapping individual sounds to the visual word form

association areas (Temple, 2002; Shaywitz, et al, 2003; Noble

& McCandliss, 2005).

(3) Socioeconomic Status - According to Noble and

McCandliss (2005), socioeconomic status (SES) is a very

strong predictor of reading skills due primarily to the home

literacy environment. Therefore, schools need to provide

more reading opportunities.

(4) Motivation and Confidence –Great Leaps, Read Naturally,

and Neurological Impress tend to give immediate feedback.

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1. Content Affinity - attitude and interest toward

specific material.

2. Working Memory - the ability to temporarily

suspend information while simultaneously

learning new information. The amount of

memory needed to execute a cognitive task.

3. Executive Functioning - the ability to self-

monitor performance and organize

information on a given problem solving task.

4. Language Foundation – most children enter

kindergarten with 3000 – 5000 words, though

graduate from high school with 60,000 words

(Pinker, 1994).

4 Reasons for Poor Comprehension

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Stop and Start Technique

Directional Questions

Story Maps

Narrative retelling

Read Aloud

Multiple Exposure

Active Participation

Create Questions

Reduce Anxiety

Medication Management

Practice Terminology

Classroom Discussions

Sequencing TasksIncrease Fluency

SOAR TO SUCCESS

READING COMPREHENSION

INTERVENTIONS

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Intelligence tests

Phonemic/Phonological Awareness

Rapid Naming

Verbal Memory Tests

Reading Fluency

Orthographic Skills

Attention

Executive Functioning

Family History

90 Minute Dyslexia Evaluation

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Phonemic/Phonological Awareness :

NEPSY II: Phonological Processing

PAL II: Phonological Coding

WIAT III: Pseudoword Decoding, Early Reading Skills

CTOPP

KTEA II

Rapid Naming:

PAL II: RAN, NEPSY II: Speeded Naming, CTOPP, KTEA II

Verbal Memory Tests:

CVLT-C , NEPSYII: List Memory,

PAL II Verbal Working Memory

Reading Fluency:GORT 4, CBM, WIAT III ORF,

WIAT III Word Reading

Orthographic Skills: PAL II Receptive Coding, Orthographic Spelling

Attention: NEPSY II Auditory Attn, Connors 3, TEACH

Executive Functioning: BRIEF, NEPSY II Inhibition,

WIAT III Reading Comp (Inferential vs. literal)

DKEFS

Dyslexia Assessment Instruments

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Sample Case: Bobby’s Psychological Profile

WISC IV: Full Scale IQ = 87

Verbal IQ = 83

Perceptual Reasoning = 96

Working Memory = 80

Processing Speed = 103

WJIII Achievement:Broad Reading = 86

Broad Math = 96

Broad Writing = 92

Most traditional school psychologists would not qualify Bobby since there is no discrepancy between IQ and achievement. Big mistake!!

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Bobby’s Neuropsychological ProfileCTOPP: Phonological Awareness = 80

Phonological Memory = 73

Rapid Naming = 90

PAL II: Orthographic Coding 96

Phonological Coding 76

Pseudoword Decoding 70

RAN (letters & words) 92

Verbal Working Memory 74

CBM: 36 words per minute correct

GORT IV: Oral Reading Quotient 70

Fluency 5

Comprehension 6

NEPSY II: Auditory Attn Response Set 78

Comprehension of Instructions 74

CVLT: Poor Semantic Recall

BRIEF: Significant

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Bobby’s Recommendations

Bobby needs a highly structured type of reading program focusing on teaching phonics through visual cues and morphology, and not acoustically based phonics programs with numerous rules to remember (i.e. Ladders to Literacy, Road to the Code, Fundations, Alphabetic Phonics, etc.).

Recommend: Horizons Fast Track Soar to Success

Great Leaps CBM to progress monitor!

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WRITTEN LANGUAGE: A Survival Skill!!

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Measuring Written Language

The National Center for Educational Statistics

administered writing samples to 276,000 students

in grades 4, 8, and 12 (2003).

Narrative Writing – involves the production of stories or personal essays to capture a reader’s imagination.

Can include responses to photographs, poems, and

cartoons.

Informative Writing – communicates information to the reader to convey a message, instruction, or an idea.

Includes reports, reviews, and letters.

Persuasive Writing – influence the reader to take action to bring about change. Should include reasons,

examples, comparisons. Examples included writing to a

friend, newspaper editor, or refute an argument in a

debate.

Scored as Basic, Proficient, or Advanced.

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National Center for Educational

Statistics (2007): 8th Grade Scoring

8th grade proficient level:

2007 – 33% at or above proficiency


1998 - 27% at or above proficiency

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Statistics (2007): 12th Grade Scoring

12th grade proficient level:



1998 - 22% at or above proficiency

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Statistics (2007): Males vs. Females

4th Grade Proficient Level: 20% Males 36 % Females 8th Grade Proficient Levels: 21% Males 42% Females 12th grade proficient levels: 14% Males 33% Females

* 2007 data showed 8 pt increase in males (grade 12 only) ; no other differences noted.

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Why the disconcerting trend?

Most students rely on writing,

either e-mail, text messages, word

processing, or other computerized

technology to communicate.

Downward extension of our

curriculum whereby reading and

written language are skills

emphasized in kindergarten.

Most state assessments require written language responses, short answers, and brief constructed

responses even in subjects such as mathematics.

Therefore, most school curriculums readjusted to

emphasize state testing requirements.

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The Cost of Poor Writing Skills

U.S. corporations spend an

estimated $3.1 billion annually

to remediate their employees’

writing skills (National Commission

on Writing, 2005).

State governments spend approximately

$221 million annually to do the same

(National Commission on Writing, 2005).

A 2005 ACT (American College Testing)

report indicated almost one-third of high

school students planning to attend

college do not meet the readiness

standards for college composition

courses.

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Curriculum-Based Measurement: Writing

6 Components to Assess Writing:

(1) Fluency: measure the number of words written and spelled correctly in a time period.

(2) Grammar: informally assess from passage.

(3) Vocabulary: assess variety by dividingnumber of different words by total numberof words.

(4) Sentence Structure: summarize sentences as being incomplete, simple, compound, complex, run-on, or fragmented.

(5) Conventions: percent of words spelled correctly, proportion of errors per 100 words, correct writing sequence.

(6) Content: develop analytic rating scale.

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Cognitive Constructs Involved with Written Language

Attention

– Poor planning

– Uneven tempo

– Erratic legibility

– Inconsistent spelling

– Poor self monitoring

– Impersistence

BRAIN REGION - Anterior Cingulate

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Spatial Production

– Poor spatial production

– Poor visualization

– Poor margination

– Organization problems

– Uneven spacing

– Poor use of lines

BRAIN REGION - Right Parietal Lobe


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Sequential Production

– Poor connected writing

– Letter reversals

– Organizational deficits

– Lack of cohesive ties

BRAIN REGION - Left Prefrontal Cortex


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Memory Skills

– Poor word retrieval

– Poor spelling

– Poor recall of grammar rules

– Preference for printing

– Loss of train of thought

– Deterioration of continuous writing

BRAIN REGION - Semantic memories stored in

Temporal Lobes. Retrieved by Frontal Lobes


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Language

– Poor vocabulary

– Poor written expression

– Dysphonetic spelling

– Lack of cohesive ties

– Unconventional grammar

– Simplistic sentence structure

BRAIN REGION - Left Temporal Lobe


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Intelligence

– Concrete ideation

– Poor development of ideas

– Poor audience awareness

– Weak opinion development

– Simplistic sentence structure

BRAIN REGION - Inferior Parietal Lobes


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Executive Functioning

– Organize and plan ideas

– Self monitor

– Task initiation

– Sustain attention to task

BRAIN REGION – Dorsolateral Prefrontal Cortex


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1. Dysphonetic dysgraphia - the hallmark feature of this disorder is an inability to spell by sound, thus rendering an over-reliance on the visual features of words.

2. Surface dysgraphia -this disorder is characterized

by a breakdown in the orthographic representation of

words. Miscues made primarily on phonologically

irregular words.

3. Mixed Dysgraphia - this disorder is characterized by a combination of both phonological errors and orthographical errors depicting faulty arrangement of letters and words.

4. Executive Dysgraphia - an inability to master the implicit rules for grammar which dictate how words and phrases can be combined. Deficits in working memory and executive functioning frontal lobe skills.

4 Subtypes of Written Language Disorders

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SUBTYPING

Inferior Frontal Gyrus Supramarginal

Gyrus

Heschl’s Gyrus

Angular

Gyrus

Superior Temporal

Gyrus

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(1) Motor Skills Automaticity: “Handwriting without tears”

(2) Spelling Automaticity: “Alphabetic Phonics”

(3) Language Automaticity: “ Scaffolding to enhance verbal fluency”

(4) Executive Functioning Automaticity: “Graphic

Organizers”

(5) Self Monitoring Automaticity: “Peer review

with COPS strategy”

5 INTERVENTION KEYS: AUTOMATICITY

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(1) Writing Strategies (effect size .82)

(2) Summarization (effect size .82)

(3) Collaborative Writing (effect size .75)

(4) Specific Product Goals (effect size .70)

(5) Word Processing (effect size .55)

(6) Sentence Combining (effect size .50)

(7) Prewriting (effect size .32)

(8) Inquiry activities (effect size .32)

(9) Process Writing Approach (effect size .32)

(10) Study of Models (effect size .25)

(11) Writing for Content Learning (effect size .23)

Research Based Interventions

(Graham & Perin, 2007)

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(1) Prewriting - use graphic organizers.

(2) Drafting – use model to take notes and model how to organize in a text form using topic sentences.

(3) Revising – second draft emphasizing content, and elaboration of ideas and making connections.

(4) Editing – re-read for capitalization and punctuation errors.

(5) Publishing – peer assisted strategies and teaching students to give and receive feedback.

5 Major Steps of Writing Process (Ray, 2001)

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Intelligence Measures

Visual-Motor Integration

Attention

*Working Memory*

*Executive Functions*

Writing and Spelling Skills

Phonological Awareness Skills

Retrieval Fluency Skills

90 Minute Dysgraphia Evaluation

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Visual-Motor Integration - WIAT III Alphabet Writing Fluency (30 sec), NEPSY II Design Copying, PAL II

Alphabet Writing, PAL II Handwriting Subtests

Attention - NEPSY II Auditory Attn & Response Set, NEPSY II Inhibition, Connors 3, Tea-CH, CAS-Receptive

Attention, WJIII- Auditory Attention.

Working Memory – WISC IV Integrated Subtests, PAL II Verbal Working Memory Subtests, SB5, CAS, WRAML-2.

Executive Functions - WIAT III Sentence Composition, PAL II Expository Note Taking, PAL II Narrative

Compositional Fluency, BRIEF, DKEFS, NEPSY II.

Writing and Spelling Skills – WIAT III Spelling (error

analysis) , PAL II Orthographic Spelling, WIAT III

Essay Composition, PAL II Expository Writing

Retrieval Fluency Skills - NEPSY II Word Generation, NEPSY II Speeded Naming, WJIII Retrieval Fluency.

DYSGRAPHIA ASSESSMENT INSTRUMENTS

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1) There should be data documenting that a student’s

RATE of learning is substantially slower than grade

level peers.

2) There should be data documenting that a student

has not responded to evidenced-based

interventions over a protracted period of time.

3) There should be data from standardized testing

indicating the presence of a psychological

processing deficit associated with the academic

skill in question. This may include measures of

phonological or orthographic processing skills,

language skills, working memory skills, executive

functioning skills, and rapid naming and retrieval

skills.

4) There should be data ruling out environmental,

medical, emotional, and cultural factors.

Proposed 4-Factor Model Defining a

Learning Disability

Documents

Dr. Steven Feifer