Background eading disability* is the most common learning disabil- ity. More than 80% of those identified as learning disabled R 1 have a reading disability, and the preva- lence of reading problems in the general population ranges from 3%-20%2. It is believed that individuals with read- ing difficulties “possess the intelligence and motivation considered necessary for Diagnosing Reading accurate and fluent reading”3 but have a fundamental deficit in the ability to Disabilities at a translate individual letters and letter combinations into sounds; this is known Graduate School Level as phonologic awareness4. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), three main criteria are considered in the diag- Sandra Rainwater-Lawler, MA nosis of a Reading Disorder5: Jasmine Wong Yumori, OD • “Criteria A: The essential feature of Reading Disorder is reading achievement (i.e., reading accuracy, speed, or comprehension as mea- sured by individually administered standardized tests) that falls sub- stantially below that expected given the individual’s chronological age, Abstract measured intelligence, and age-ap- propriate education. Reading disability is the most common learning disability. While reading dis- • Criteria B: The disturbance in abilities are commonly diagnosed by the fourth grade, symptoms of a well- reading significantly interferes with disguised reading difficulty may manifest during graduate school, when more academic achievement or with ac- complex reading and writing skills are required. We report on a medical student tivities of daily living that require reporting increased difficulty with academic tasks and review the process typical- reading skills. ly used in identifying individuals in graduate school with a reading disability. • Criteria C: If a sensory deficit is Key Words: Reading disability, dyslexia, academic accommodations present, the reading difficulties are in excess of those usually associated with it.” An evaluation of a student’s medical, de- velopmental and family history is neces- sary to determine risk factors for a read- Ms. Rainwater-Lawler is Assistant Director, Accommodations and Resource Center (AARC), ing disability and to rule out secondary Western University of Health Sciences, Harris Family Center for Disability and Health Policy. forms of reading difficulties. While ge- netic conditions6, traumatic brain inju- Dr. Yumori, is an Assistant Professor at Western University of Health Sciences College of Optom- ry6, low birth weight7, visual, hearing or etry. motor disorders and mental retardation can lead to learning difficulties (and thus reading difficulties) and need to be iden- tified and addressed, they are not includ- ed in the federal definition of learning disabilities8. Along with personal medi- cal and developmental history, family history is also important to consider. Individuals with a family history of lan- guage, speech or reading difficulties are at a higher risk of developing reading *The terms “reading disability” and “dyslexia” are often difficulties, with more prevalence among used interchangeably in the literature. 15 first-degree biological relatives5. There is

Optometric Education 24 Volume 36, Number 1 / Fall 2010 an approximately 60% concordance of knowledgeable about reading disabili- disability was given. To accommodate phonologic deficiency between identi- ties. We report on a case of a student in his reading disorder the student was cal twins9. Furthermore, 23%-65% of medical school that was self-referred for provided with double time for exams, children with a parent who has a read- an assessment of learning difficulties. audiotaping of lectures, note-taker or ing disability will also have a reading Case Report provision of class notes and, whenever disability10. possible, early access to course material. A self-referred 26-year-old Asian Amer- Although a medical examination may ican male medical student presented Discussion reveal signs of neuro-developmental to the Accommodations and Resource delays, the neurologic examination of Reading disability is a complex prob- Center (AARC) at the Harris Family lem that requires early diagnosis, edu- an individual with reading disabilities Center for Disability and Health Policy is usually normal11. This may be be- cational intervention and appropriate at Western University of Health Scienc- accommodations. Educators should be cause other factors can also contribute es requesting an assessment of learning to reading difficulties. Environmental knowledgeable about signs of reading difficulties. He reports that he is an ex- disability in their students. Signs of a factors such as poverty, an understimu- cellent student and denied any special lating home environment, low parental reading disability in an adult individual courses or instruction prior to graduate include: education and inadequate instruction school. However, since his entry into play a role in reading and are important graduate school he has had to request • deficits in reading comprehension to examine. Early identification of and assistance from professors to develop • low reading speed and accuracy intervention for children with reading memory strategies and worries that tu- disabilities is beneficial, and the prog- tors have not been able to adequately • difficulty with note-taking nosis is good in a significant percent- 12 address his concerns. He also explains • trouble organizing essays and ex- age of cases . Remediation, such as that he often goes more in-depth than pressing ideas in writing providing highly structured, intense, necessary when studying and feels he individualized instruction emphasizing • problems with spelling and gram- needs to know everything to feel con- mar.16 phonologic awareness and phonics in- fident. By report from the individual struction, is crucial in early childhood. and his family, his medical history is Other behavioral signs to look out for While many individuals with reading nonsignificant with no history of in- include problems with: disabilities are diagnosed by the fourth jury, trauma or atypical illness. He at- • short term memory grade, well-disguised reading difficulty tained developmental milestones at the • concentration can become more noticeable, severe and expected stages and he grew up in an debilitating in graduate school. As more intact middle-to-upper-middle class • distinguishing right from left complex reading and writing skills are English-speaking community. • self-organization required, and the demands for greater At the Neuropsychological Assessment, • visual perception.13 accuracy and speed of decoding in- the student completed the Wechsler crease, symptoms of reading disabilities Adult Intelligence Scale – Fourth Edi- These signs may be particularly indica- can manifest. For older students, accom- tion (WAIS IV) and Nelson Denny tive of a reading disability if seen in an modations such as test accommodations Reading Test (NDRT). The WAIS IV individual who excels in other academ- (extra time for reading, reader, scribe, indicated his current level of intellec- ic areas such as math. Some students distraction-reduced test-taking environ- tual functioning in the average range. with a reading disorder may have been ment), tape recorders in the classroom, His Verbal Comprehension Index score misidentified as lazy when in fact may alternative textbooks and instruction in was recorded and demonstrated perfor- be working harder than their peers to word processing are helpful. mance in the High Average range. How- overcome obstacles and obtain the As optometrists and educators, it is ever, on the NDRT, his performance same grades. important for us to better understand ranged from Borderline to Average. His If an otherwise normal student is sus- how individuals with reading disabili- NDRT Reading Rate and Comprehen- pected of suffering from a reading disor- ties, particularly those in a graduate sion were in the Borderline range, more der, academic support such as tutoring level setting, are diagnosed and what than two standard deviations and more and study skills instruction, including, resources and accommodations are than one-and-one half standard devia- for example, effective note-taking, essay available to facilitate their success. Fur- tions, respectively, below his overall in- planning, exam revision, referencing thermore, because of the changing dy- tellectual functioning, both significant and time management, may be good namics of our educational system, such differences. In contrast, his NDRT Vo- first steps. At our institution, students as fairer exam provisions and increased cabulary score was in the Average range, suspected of having a learning disability academic support, there has been a rise somewhat below expectation. such as a reading disorder may be re- in the number of students with read- ferred to either AARC or our Learning 13 Based on this difference between his Av- ing disabilities in higher education . erage aptitude scores (and High Average Enhancement and Academic Develop- In the United Kingdom, the number score in the Visual Comprehension In- ment (LEAD) office. The LEAD Office of students in higher education with dex) and noncorresponding Below Aver- focuses on providing academic-based dyslexia increased from 0.74% in 1994 counseling, tutoring services and skill 14 age achievement scores with a negative to 1.00% in 1996 . It is important medical, developmental and environ- development directed at time man- for optometrists and educators to be mental history, a diagnosis of reading agement, critical thinking, test taking Optometric Education 25 Volume 36, Number 1 / Fall 2010 strategies and stress management tech- aptitude testing, a disability is suspect- Additional assessment tests may be used niques.17 ed. Three commonly used achievement to diagnose patients with a reading dis- If such support does not improve aca- tests are the Woodcock-Johnson, NDRT ability, such as tests that evaluate oral demic performance despite earnest ef- and Wechsler Individual Achievement language skills. Specific oral language fort, LEAD refers students to the As- Test (WIAT). The Woodcock-Johnson skills are evaluated within two main sistant Director of AARC for further is commonly used because it has co- categories: higher level language skills normed tests for measurements of ap- and auditory processing/phonological determination of their needs (i.e., learn- 19 ing disability evaluation). During the titude and achievement. The WIAT, a awareness . Educational testing within initial evaluation with a psychologist, nationally standardized, comprehensive the realms of word reading and decod- focus is placed on ensuring that the stu- achievement test, is often used because ing, fluency, reading comprehension, dent has had a stable medical, develop- it is co-normed with the WAIS and thus spelling, written expression and hand- mental, environmental and academic allows comparison of both scores. Find- writing may also be elements included background. As such, a thorough case ings of a deficit between aptitude and in assessment. Common tests for eval- history with the student is conducted achievement are supplemented and sup- uating adult individuals with reading through a structured interview and/or ported with results from below-average difficulties are outlined in Table 1. It results on the NDRT, which is the most may be more difficult to detect a read- questionnaire and referral(s) to a neu- 20 rologist and/or other specialists may be widely used reading test in education . requested if appropriate. A review of Table 1 old transcripts, classroom observation and a review of prior remediation strat- Commonly Used Tests for Evaluating Adult Individuals egies may also be performed. with Reading Disability

If academic counseling and additional Test Ages Screening Parameters Notes educational support do not fully resolve General Intelligence Functioning(19): Measures aptitude; what is this person’s capacity? Would he/she the student’s reading difficulties, and a have the capability to perform at a higher level without a learning disability? thorough history to rule out second- Wechsler Adult Intelligence 16 years and Global IQ, Verbal IQ, Perfor- Expected IQ of at least Scale Fourth Edition (WAIS older mance IQ 85 in dyslexic individu- ary causes of a reading disability such IV): Similarities, block design, als(22); co-normed with as medical, developmental and envi- digit span, digit symbol the WIAT ronmental causes comes back negative, Stanford-Binet 2-23 years Fluid reasoning, knowledge, quantitative reasoning, visual- testing is necessary to identify individu- spatial processing, working als with a reading disability. According memory to the traditional definition of learning Sample of Educational Tests: Measures achievement; at what level is this person actually performing? disabilities, a learning disability is a di- Wechsler Individual Achieve- 4-86 years Basic reading, reading com- Co-normed with the ment Test (WIAT) prehension, math calculations, WAIS agnosis given to otherwise normal indi- math reasoning, written expres- sion, oral expression, listening viduals with at least average intelligence comprehension who have achievement deficits18. Thus, Nelson Denny Reading Test 9-16 years, Vocabulary, comprehension and diagnosis of any learning disability typ- adult reading rate ically starts with a measure of ability or Gray Oral Reading Test: Pas- 6-18 years Oral reading skills (pronuncia- Expected less than or sage reading tion, fluency, comprehension, equal to 82 in dyslexic aptitude. reading rate) individuals(22) Aptitude measures ensure that the per- Wide Range Achievement 5-11 years, 12 Reading (recognizing and nam- Expected less than or Test (WRAT): Word reading, years and older ing letters and words), spelling equal to 82 in dyslexic son has the basic cognitive ability to be spelling (writing symbols, names and individuals(22) able to perform. Common tests used to words) evaluate general intelligence function- Woodcock Reading Mastery 5 years and Individual strengths and weak- Tests older nesses in reading skills; word ing include the Wechsler Intelligence reading and decoding, reading Scale for Children, WAIS, Woodcock- comprehension Johnson and Stanford-Binet19. In our Informal Reading Inventories Varied Spelling, handwriting (e.g., Bader Reading and case above, aptitude was evaluated us- Language Inventory, Ekwall/ ing the WAIS IV. In evaluating students Shanker Reading Inventory) for a possible reading disorder, focus is General Intelligence Functioning and Educational Tests often placed on the Verbal Comprehen- Woodcock-Johnson 2-90+ years Comprehension-knowledge, fluid Can measure both apti- sion Index score of the WAIS because it reasoning, processing speed tude and achievement is considered a more accurate represen- Oral Language Skills(19) Clinical Evaluation of Lan- 5-21 years Higher-level language skills tation of reading function. guage Fundamentals Once we establish that the person is of Comprehensive Assessment 3-21 years Higher-level language skills of Spoken Language Test at least average intelligence, we look of Language Development: for a discrepancy between aptitude Primary or Intermediate Test of Adolescent and Adult and achievement scores. Achievement Language is quantified by performance on spe- Comprehensive Test of Pho- 5-24 years Auditory processing/phono- nological Processing logical awareness (phonologic cific educational tests. If an individual’s awareness, phonologic memory, achievement scores are significantly rapid naming, rhyming words lower than we would expect based on and decoding skills) Optometric Education 26 Volume 36, Number 1 / Fall 2010 ing disability in older students because ation where this may be highlighted, reading, a reading disability diagnosis they may have developed compensatory such as asking the student to read text is appropriate, and accommodations skills and techniques. Furthermore, test aloud in class. Other considerations to should be provided to support the stu- norms may be limited to adolescents. facilitate academic success for students dent. Individualized accommodations The student described in our case report with a reading disability include pro- are essential to the success of the stu- was diagnosed with a reading disabil- viding high-contrast course materials, dent’s academic career and ensure stu- ity because he presents with a negative avoiding putting too much information dents receive resources specific for their medical, behavioral and environmental on one page, writing in shorter, simpler own unique circumstances. Optom- history, has difficulties persisting despite sentences, avoiding fancy, particularly etrists and educators alike need to be academic-based counseling, tutoring italicized, fonts (12+ sans serif fonts aware of the signs of reading disability, services and skill-building, and dem- such as Arial are preferred) and consid- how reading disability is diagnosed and ering offering oral assessment opportu- what resources and accommodations onstrates adequate cognitive abilities 13 (as identified through aptitude testing) nities . Multimodal presentation and are available to allow equal access in the but significantly lower performance in rehearsal of material to facilitate reten- classroom and thus facilitate success. reading (as identified through achieve- tion of new information, including use References ment testing). A deficit of one-and-a- of different or novel presentation for- half standard deviations is considered a mats, may also be helpful. 1. Lerner JW. Educational interven- meaningful difference21. Notably, it is While individuals with a reading dis- tions in learning disabilities. J Am possible to diagnose a learning disabil- ability may need more time to process Acad Child Adolesc Psychiatry. ity in an individual with below-average and understand written material, they 1989;28(3):326-31. intelligence, but it is often difficult to can still proficiently perform in envi- 2. Snow C, Burns S, Griffin P. Pre- find a significant difference between ap- ronments with high reading and writing venting reading difficulties in titude and achievement. demands, such as within the healthcare young children. Washington, DC: Academic accommodations allowed profession. Recent study results indi- National Aacdemy Press; 1998. this student to better develop strengths cate that degree classifications achieved 3. Shaywitz SE, Shaywitz BA. Dyslex- to work through limitations from his by students with reading disorders were ia (specific reading disability). Biol not significantly different from those of disability. Besides allowing additional 13 Psychiatry. 2005;57(11):1301-9. time for exams, audiotaping of lectures, other students . Additional workplace support, such as proofreading by col- 4. Hamilton SS, Glascoe FP. Evalu- note-taker or provision of class notes ation of children with reading and, whenever possible, early access to leagues, typing by administrative staff and using dictation software, may be difficulties. Am Fam Physician. course material, other resources exist to 2006;74(12):2079-84. assist students with reading disabilities. advisable. Most employers are legally Technologies such as ReadPlease and required to make such reasonable ac- 5. Association AP. Diagnostic and TextHELP software allow students to commodations. Statistical Manual of Mental Dis- orders. Fourth Edition, Text Revi- simultaneously hear and see text on Conclusion their computer. More sophisticated sion ed. Washington, DC: Ameri- software, such as Kurzweil 3000, allows Reading disabilities are typically diag- can Psychiatric Association; 2000. printed material to be scanned and read nosed by the fourth grade, but well- 6. Gillberg C, Soderstrom H. aloud by the computer. Recordings for disguised reading difficulties may man- Learning disability. Lancet. the Blind and Dyslexic, which is a li- ifest in graduate school as reading and 2003;362(9386):811-21. brary that provides audio recorded text- writing tasks become more complex. 7. Litt J, Taylor HG, Klein N, Hack books, is also a commonly used and of- An evaluation to rule out medical, de- M. Learning disabilities in children ten helpful resource. Readers for exams velopmental and environmental condi- with very low birthweight: preva- and alternative text are other academic tions that can lead to secondary forms lence, neuropsychological corre- accommodations designed to ensure of reading difficulties is important, and lates, and educational interventions. equal access in the classroom. Special- academic-based counseling, tutoring J Learn Disabil. 2005;38(2):130- ized instruction may also be recom- services and academic skill-building 41. mended to help the student learn skills need to be considered. If such resources that tap into natural strengths in order do not fully resolve reading difficulties, 8. Scheiman MM, Rouse MW. Opto- to compensate for areas of weakness. testing administered by a trained pro- metric management of learning-re- lated vision problems. Second Edi- While individual accommodations are fessional is necessary to identify indi- tion ed. St. Louis: Mosby Elsevier; important, support from educators is viduals with a reading disability. 2006. necessary to facilitate optimal student Testing to diagnose a learning disabil- learning. As students with a reading ity, such as a reading disability, typically 9. Shaywitz SE. Dyslexia. N Engl J disorder may read slower and with focuses on ensuring that the otherwise Med. 1998;338(5):307-12. more difficulty than their peers due to normal individual has at least average 10. Scarborough HS. Very early lan- difficulties with phonological process- intelligence (aptitude) but has achieve- guage deficits in dyslexic children. ing, it is important for educators to ment scores that are below expected Child Dev. 1990;61(6):1728-43. avoid putting such students in a situ- levels. If such a deficit is found within

Optometric Education 27 Volume 36, Number 1 / Fall 2010 11. McPhillips M, Sheehy N. Preva- ment, editor. London, England; learning disabilities. J Learn Dis- lence of persistent primary reflexes 1997. abil. 1991;24(8):495-500. and motor problems in children 15. Vellutino FR, Fletcher JM, Snowl- 19. Association TID. Testing for Dys- with reading difficulties. Dyslexia. ing MJ, Scanlon DM. Specific lexia. 2004. Available at: http:// 2004;10(4):316-38. reading disability (dyslexia): what www.nybida.org/PDF/test- 12. Joint statement-Learning disabili- have we learned in the past four de- ing2..3.06.pdf. Assessed July 7, ties, dyslexia, and vision. Pediat- cades? J Child Psychol Psychiatry. 2010. rics. 2009;124(2):837-44. 2004;45(1):2-40. 20. Gordon B, Flippo R. An update 13. Lockley S. Dyslexia and higher 16. Mortimore T, Crozier WR. Dyslexia on college reading improvement education: accessibility issues. The and difficulties with study skills in programs in the southeastern Higher Education Academy; 2010. higher education. Studies in High- United States. Journal of Reading. Available at http://www.heacad- er Education. 2006;31(2):235-51. 1983;27:155-63. emy.ac.uk/assets/York/documents/ 17. Office L. Learning Enhance- 21. Office of Disability Services WOU. resources/resourcedatabase/id416_ ment & Academic Development: Learning Disability. Monmouth, dyslexia_and_higher_education. LEAD Services. Pomona, CA: OR: Western Oregon University; pdf. Assessed July 12, 2010. Western University of Health Sci- 2010. Available at: http://www. 14. Dearing R. Higher Education in ences; 2009. Available at: http:// wou.edu/student/disability/re- the Learning Society. Report of the www.westernu.edu/xp/edu/lead/ sources/learning.php. Assessed July National Committee of Inquiry lead-services.xml. Assessed July 12, 12, 2010. into Higher Education. In: Depart- 2010. 22. Felton RH, Naylor CE, Wood ment for Education and Employ- 18. Frankenberger W, Fronzaglio K. A FB. Neuropsychological profile review of states’ criteria and proce- of adult dyslexics. Brain Lang. dures for identifying children with 1990;39(4):485-97.

Optometric Education 28 Volume 36, Number 1 / Fall 2010