Reintroducing Dyslexia: Early Identification and Implications for Pediatric Practice Joseph Sanfilippo, MS, EdM,a,b Molly Ness, PhD,c Yaacov Petscher, PhD,d Leonard Rappaport, MD, MS,a,e Barry Zuckerman, MD,f,g Nadine Gaab, PhDa,e,h Dyslexia is a common learning disorder that renders children susceptible to abstract poor health outcomes and many elements of socioeconomic difficulty. It is commonly undiagnosed until a child has repeatedly failed to learn to read in aDivision of Developmental Medicine, Boston Children’s elementary school; this late diagnosis not only places the child at an academic Hospital, Boston, Massachusetts; bSchool of Medicine, disadvantage but also can be a precursor to psychiatric comorbidities such as Faculty of Health Sciences, Queen’s University, Kingston, Ontario, Canada; cGraduate School of Education, Fordham anxiety and depression. Genetic and neuroimaging research have revealed University, New York, New York; dFlorida Center for Reading that dyslexia is heritable and that it is undergirded by brain differences that Research, Florida State University, Tallahassee, Florida; eDepartment of Pediatrics, Harvard Medical School, Harvard are present even before reading instruction begins. Cognitive-behavioral University, Boston, Massachusetts; fDepartment of research has revealed that there are early literacy skill deficits that represent Pediatrics, School of Medicine, Boston University, Boston, fl Massachusetts; gBoston Medical Center, Boston, red ags for dyslexia risk and can be measured at a preschool age. Altogether, Massachusetts; and hHarvard Graduate School of Education, this evidence points to dyslexia as a disorder that can be flagged by Harvard University, Cambridge, Massachusetts a pediatrician before school entry, during a period of heightened brain Drs Gaab, Rappaport, and Zuckerman conceptualized plasticity when interventions are more likely to be effective. In this review, we the review, participated in the drafting of the initial discuss the clinical implications of the most recent advances in dyslexia manuscript, and continuously reviewed and revised fi the manuscript; Mr Sanfilippo conducted the research, which converge to indicate that early identi cation and screening literature review, led in the writing and design of the are crucial to the prevention or mitigation of adverse secondary final manuscript, consolidated coauthor feedback, consequences of dyslexia. We further highlight evidence-based and practical and continuously revised the manuscript; Drs Ness strategies for the implementation of early risk identification in pediatric and Petscher contributed their respective expertise in writing significant components of the manuscript practice so that physicians can be empowered in their ability to treat, educate, and reviewed and revised the manuscript and advocate for their patients and families with dyslexia. throughout; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2019-3046 The development of reading proficiency experience poverty, are more likely to Accepted for publication Jan 29, 2020 in childhood is a public health issue: find employment, and achieve higher Address correspondence to Nadine Gaab, PhD, literacy is a widely recognized average incomes as adults compared Division of Developmental Medicine, Boston determinant of health outcomes and is with children who fail to achieve Children’s Hospital, 1 Autumn St, Office 643, Boston, 3 MA, 02215. E-mail: nadine.gaab@ associated with many indices of reading proficiency. For many children childrens.harvard.edu academic, social, vocational, and with reading impairments, however, the 1 process of learning to read is rife with PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, economic success. In a recent National 1098-4275). Academy of Medicine summary, the struggle and frustration, and these children are left susceptible to adverse Copyright © 2020 by the American Academy of author highlights that duration of Pediatrics secondary outcomes, including anxiety education, which is highly dependent FINANCIAL DISCLOSURE: and depression. A neurobiologically The authors have indicated on reading proficiency, is a better they have no financial relationships relevant to this based specific learning disorder, predictor of health and long life than article to disclose. dyslexia, affects 5% to 10% of cigarette smoking or obesity.2 Children children4,5 and is a persistent barrier to skilled in reading perform better in To cite: Sanfilippo J, Ness M, Petscher Y, et al. reading acquisition. school, attain higher levels of education, Reintroducing Dyslexia: Early Identification and experience lower rates of disease, are Dyslexia (or word-level reading Implications for Pediatric Practice. Pediatrics. 2020;146(1):e20193046 less likely to be incarcerated or difficulty6) is predominantly Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 146, number 1, July 2020:e20193046 STATE-OF-THE-ART REVIEW ARTICLE characterized by a core deficit in of children with language disorders weaknesses. The clinical implications phonological processing (the ability have dyslexia.20 Dyslexia typically of a reluctance to use dyslexia as to recognize and manipulate speech results from a core deficit in a diagnostic label include children sounds), which results in phonological processing; however, it failing to receive an adequate impairments in decoding (“sounding is important to note that language response to early risk signs, out” words), spelling, and word deficits (eg, low vocabulary or low appropriate interventions in school, recognition.7 These impairments oral listening comprehension) can and mental health support. almost always lead to difficulties in also lead to reading problems, In this article, we provide an up-to- reading fluency and comprehension, especially problems with reading date overview of dyslexia, specifically reduced vocabulary, lower content comprehension. Importantly, speech addressing common knowledge gaps, knowledge,8 and a decline in overall and language problems commonly neurobiological underpinnings of the school performance.9 Dyslexia cannot precede problems in learning to disorder, and ways in which be explained by poor hearing or read, so children with speech and pediatricians can play an active role vision, low language enrichment, or language problems should be flagged in the early identification of lack of motivation or opportunity.10 as being at increased risk for dyslexia risk. According to the Diagnostic and dyslexia.21 Statistical Manual of Mental Disorders, There are many other developmental Fifth Edition, dyslexia falls under the THE ETIOLOGY OF DYSLEXIA and psychiatric conditions that are umbrella of a “specific learning frequently comorbid with dyslexia, The etiology of dyslexia is disorder” that “impedes the ability to further jeopardizing these children’s multifaceted, including genetic, learn or use specific academic skills health and academic outcomes. In perceptual and cognitive, (eg, reading, writing, or total, 20% to 40% of children with neurobiological, and environmental arithmetic).”11 attention-deficit/hyperactivity factors.9 Dyslexia is strongly Although there are many negative disorder have dyslexia,22 and children heritable, occurring in up to 68% of outcomes associated with dyslexia, with autism spectrum disorder are identical twins of individuals with particularly salient to the pediatrician also at increased risk of having dyslexia and up to 50% of individuals is the association between dyslexia dyslexia.23 Other behavioral who have a first-degree relative with – – and poor mental health.12,13 Children disorders, such as conduct disorder dyslexia.19,28 30 Several genes31 34 with dyslexia are more likely to suffer and oppositional defiant disorder, are have been reported to be candidates from generalized anxiety14,15 and also also associated with dyslexia.24 As for dyslexia susceptibility; it is exhibit higher rates of many as 85% of children with thought that most of these genes play depression.14,16 Because screening dyspraxia (developmental a role in early brain – for dyslexia is not routinely coordination disorder) have development.31,34 38 performed, the direction of causation dyslexia,25 and children with Furthermore, various studies have between dyslexia and comorbid mood dyscalculia (math learning revealed atypical brain characteristics disorders in each case is unclear, and disorder)26 and dysgraphia (writing in individuals with dyslexia compared this uncertainty can preclude learning disorder)27 are more likely with their peers.39 In functional MRI effective early treatment. A mood to have dyslexia than those without. studies, researchers have indicated disorder may be identified in a child Knowledge of dyslexia within that reading for typical readers takes with unidentified comorbid dyslexia pediatric practice is paramount in place predominantly in left- when it is the dyslexia that is considering the most appropriate hemispheric sites of the brain, antecedent and causative, obscuring treatments for these many coexisting including the inferior frontal, superior the primary target for intervention. disorders. temporal, temporoparietal, and In addition to mood disorders, speech Despite increasing collaboration occipitotemporal cortices.40 As and language problems are frequently among educators, physicians, a group, individuals with dyslexia comorbid with dyslexia because both neuroscientists,