Disorders of Reading and Writing Tim Conway, Ph.D. VAMC Brain Rehabilitation Research Center, University of Florida, Depts of Clinical and Health Psychology,

Disorders of Reading and Writing

Disorders of Reading and Writing

Tim Conway, Ph.D.Tim Conway, Ph.D.

VAMC Brain Rehabilitation Research Center, VAMC Brain Rehabilitation Research Center,

University of Florida, Depts of Clinical and Health University of Florida, Depts of Clinical and Health Psychology, and PediatricsPsychology, and Pediatrics

Gainesville, FloridaGainesville, FloridaThis work was supported by VA RR&D Associate Investigator Award #B3480HThis work was supported by VA RR&D Associate Investigator Award #B3480H

Language developmentLanguage development

What language system develops first, oral What language system develops first, oral or written?or written?

What is the purpose of a written language What is the purpose of a written language system? system?

What do graphemes represent?What do graphemes represent?

Language development (cont)Language development (cont)

When do we first learn the sounds (phonemes) of When do we first learn the sounds (phonemes) of English, Spanish, Japanese, French…?English, Spanish, Japanese, French…?

What sensory systems aid learning speech sounds?What sensory systems aid learning speech sounds? VisualVisual AuditoryAuditory Tactile kinesthetic and somatosensoryTactile kinesthetic and somatosensory Infant studies (see Kuhl, et al., 2006)Infant studies (see Kuhl, et al., 2006)


What sensory input is consistent in What sensory input is consistent in phonemes?phonemes?

Categorical speech perception Categorical speech perception (Liberman and (Liberman and Mattingly, 1987)Mattingly, 1987)

The awareness of speech sounds or The awareness of speech sounds or phonemes in words is called…phonemes in words is called…

phonological processing phonological processing (Wagner and Torgesen, 1987)(Wagner and Torgesen, 1987)


Why is the perception of phonemes, Why is the perception of phonemes, phonological processing, important?phonological processing, important?

When does phonological processing begin When does phonological processing begin developing?developing?

Does phonological processing occur in Does phonological processing occur in speech, reading and spelling? speech, reading and spelling?


How does phonological processing aid the How does phonological processing aid the development of speech, reading and spelling? e.g. development of speech, reading and spelling? e.g. learning to say, read and spell new words.learning to say, read and spell new words.

If you have trouble perceiving the phonemes in If you have trouble perceiving the phonemes in words (poor phonological processing), how do words (poor phonological processing), how do you know what letters to use for spelling?you know what letters to use for spelling?

How would difficulty segmenting a word into its How would difficulty segmenting a word into its constituent sounds affect spelling, reading, constituent sounds affect spelling, reading, speech? speech?


What determines the shape of a grapheme? What determines the shape of a grapheme? What kind of mistakes would someone with poor What kind of mistakes would someone with poor

phonological processing make on language tests?phonological processing make on language tests? Is the development of speech, reading and spelling an Is the development of speech, reading and spelling an

errorful or errorless learning experience?errorful or errorless learning experience? How does phonological processing/awareness aid the How does phonological processing/awareness aid the

development of an ability to perceive errors in speech, development of an ability to perceive errors in speech, reading, and spelling? (DEMO – spell and read)reading, and spelling? (DEMO – spell and read)

STROSKSTROSK THROIGETHROIGE

Phonological AwarenessPhonological Awareness

“ “one’s sensitivity to, or explicit awareness one’s sensitivity to, or explicit awareness of, the phonological structure of the words of, the phonological structure of the words in one’s language.” (Torgesen, 1994); e.g. in one’s language.” (Torgesen, 1994); e.g. the number, identity, and order of the number, identity, and order of phonemes.phonemes.

Comparator FunctionComparator Function

Holding two words in memory & Holding two words in memory & comparing their sameness or difference in comparing their sameness or difference in phoneme number, order and identity is phoneme number, order and identity is called comparator function called comparator function (Lindamood, Bell, and (Lindamood, Bell, and

Lindamood, 1997)Lindamood, 1997)..


Three things that individuals with well Three things that individuals with well developed reading and spelling skills can do are:developed reading and spelling skills can do are:

1.1. Sound out words (a phonological approach)Sound out words (a phonological approach)

2.2. Memorize words (a visual memory approach)Memorize words (a visual memory approach)

3.3. Use semantics/meaning (story context)Use semantics/meaning (story context) Phonological processing aids an indirect route Phonological processing aids an indirect route

(grapheme to phoneme conversion or vice versa) (grapheme to phoneme conversion or vice versa) to reading and spelling.to reading and spelling.

Basic 2 Route Model of Reading (Coltheart, 1985)

Basic 2 Route Model of Reading (Coltheart, 1985)

PRINTPRINTVisual WordVisual WordRecognitionRecognition

Grapheme-PhonemeGrapheme-PhonemeConversion SystemConversion System

SemanticsSemantics

Spoken Word ProductionSpoken Word Production

SPEECHSPEECH SPEECHSPEECH

STG (bilateral)acoustic-phonetic

speech codespMTG (left)

sound-meaning interface

Area Spt (left)auditory-motor interface

pIFG/dPM (left)articulatory-based

speech codes

Hickok & Poeppel (2000), Trends in Cognitive SciencesHickok & Poeppel (2004), Cognition

STS phoneme representations

Dyslexia: (developmental reading disorder)Dyslexia: (developmental reading disorder) Developmental PhonologicalDevelopmental Phonological (poor at sounding out pseudowords or novel real words)(poor at sounding out pseudowords or novel real words)

Developmental SurfaceDevelopmental Surface (not established but believed to exist; poor at reading sight (not established but believed to exist; poor at reading sight words, good at sounding out words)words, good at sounding out words)

Alexia: (acquired reading disorder)Alexia: (acquired reading disorder) PhonologicalPhonological (misread pseudowords or novel real words) (misread pseudowords or novel real words) SurfaceSurface (misread sight words or words that can not be sounded out, like (misread sight words or words that can not be sounded out, like

yacht). yacht). DeepDeep (same as phonological but also make semantic paraphasias, says (same as phonological but also make semantic paraphasias, says

“duck” when reading swan). “duck” when reading swan). PurePure (Word and nonword reading are very slow, and the patient normally reads by spelling out the (Word and nonword reading are very slow, and the patient normally reads by spelling out the

word or nonword aloud (naming each letter in left-to-right sequence) - hence the term "letter-by-letter word or nonword aloud (naming each letter in left-to-right sequence) - hence the term "letter-by-letter reading”)reading”)

Subtypes of Dyslexia and AlexiaSubtypes of Dyslexia and Alexia

Agraphia: (acquired spelling disorder; Agraphia: (acquired spelling disorder; linguistic components)linguistic components) PhonologicalPhonological Surface/LexicalSurface/Lexical Deep/SemanticDeep/Semantic ApraxicApraxic Pure?Pure?

Subtypes of Agraphia (see Roeltgen’s chapter in Heilman and Valenstein’s, Clinical Neuropsychology, 4th Ed)

Subtypes of Agraphia (see Roeltgen’s chapter in Heilman and Valenstein’s, Clinical Neuropsychology, 4th Ed)

What is the purpose of diagnosis?What is the purpose of diagnosis?

Treatment comes in three forms: Treatment comes in three forms: PreventionPrevention RemediationRemediation RehabilitationRehabilitation

Prevention of Developmental DyslexiaPrevention of Developmental Dyslexia

Preventing Reading Failure in Young Children Preventing Reading Failure in Young Children with Phonological Processing Disabilities: Group with Phonological Processing Disabilities: Group

and Individual Responses to Instructionand Individual Responses to Instruction Joseph K. TorgesenJoseph K. Torgesen Richard K. WagnerRichard K. Wagner

Carol RashotteCarol Rashotte Elaine RoseElaine Rose

Patricia LindamoodPatricia Lindamood Tim ConwayTim Conway Cyndi GarvanCyndi Garvan

(1999). Journal of Educational Psychology 91, 579-593.(1999). Journal of Educational Psychology 91, 579-593. *NICHD, National Center for Learning Disabilities, Donald D. Hammill Foundation*NICHD, National Center for Learning Disabilities, Donald D. Hammill Foundation

Prevention study - participantsPrevention study - participants

1,436 children in 13 kindergarten classrooms were 1,436 children in 13 kindergarten classrooms were screened with a serial letter naming test.screened with a serial letter naming test.

Bottom 30% received a second screening to estimate Bottom 30% received a second screening to estimate IQ and measure phonological skills (elision). IQ and measure phonological skills (elision).

180 children selected with an estimated VIQ > 75 180 children selected with an estimated VIQ > 75 and the lowest combined scores on serial letter and the lowest combined scores on serial letter naming and phoneme elision (bottom 12%).naming and phoneme elision (bottom 12%).

Random assignment: Random assignment: NTC, RCS, EP, PASP (ie. LiPS NTC, RCS, EP, PASP (ie. LiPS program)program)

LiPS: 20 min. x 4 days per week x 2.5 years (88 LiPS: 20 min. x 4 days per week x 2.5 years (88 hours); 50% with untrained aides. hours); 50% with untrained aides.

Prevention study – LiPS group outcome dataPrevention study – LiPS group outcome data

At end of 2nd grade: 50th At end of 2nd grade: 50th percentile in word reading skills percentile in word reading skills (accuracy AND fluency).(accuracy AND fluency).

LiPS - Significantly stronger in LiPS - Significantly stronger in phonological awareness, phonological awareness, phonemic decoding, & word phonemic decoding, & word reading than all other groups.reading than all other groups.

Best predictors of growth in Best predictors of growth in reading: attention/behavior, home reading: attention/behavior, home background, and P/A. background, and P/A. 0

5

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45

NT

C

RC

S

EP

PA

SP

Percentretainedin K or 1

Remediation of Developmental DyslexiaRemediation of Developmental Dyslexia

Intensive Remedial Instruction for Children with Intensive Remedial Instruction for Children with Severe Reading Disabilities: Immediate and Long-Severe Reading Disabilities: Immediate and Long-term Outcomes from Two Instructional Approachesterm Outcomes from Two Instructional Approaches

Joseph K. TorgesenJoseph K. Torgesen Ann W. AlexanderAnn W. Alexander Richard K. WagnerRichard K. Wagner

Carol RashotteCarol Rashotte Kytja VoellerKytja Voeller Tim ConwayTim Conway

(in press). Journal of Learning Disabilities.(in press). Journal of Learning Disabilities. Supported by NICHD, NCLD, DDHFSupported by NICHD, NCLD, DDHF

Remediation study - participantsRemediation study - participants

60 children, 8-10 yoa, staffed ESE/SLD (exceptional 60 children, 8-10 yoa, staffed ESE/SLD (exceptional student education or specific learning disability)student education or specific learning disability)

Teacher referred, VIQ > 75, >=22 SS below average on Teacher referred, VIQ > 75, >=22 SS below average on word identification and word attack, below grade level word identification and word attack, below grade level phonological awareness (LAC test). phonological awareness (LAC test).

Randomly assigned to two groups (LiPS and Embedded Randomly assigned to two groups (LiPS and Embedded Phonics [EP]). Phonics [EP]).

1:1, 2-50 min. x 5 days/week x 8 or 9 weeks (67.5 1:1, 2-50 min. x 5 days/week x 8 or 9 weeks (67.5 hours); generalization 50 min. x 1 day/week x 8 weekshours); generalization 50 min. x 1 day/week x 8 weeks

Follow-up testing over a 2 year time period; n = 26 and Follow-up testing over a 2 year time period; n = 26 and 24. 24.

ADD/ADHD comorbidity 81% & 71% (LiPS and EP).ADD/ADHD comorbidity 81% & 71% (LiPS and EP).

Remediation - Outcome dataRemediation - Outcome data

Effect sizes of growth in reading skills were 4.4 and 3.9 Effect sizes of growth in reading skills were 4.4 and 3.9 (LiPS (LiPS

and EP;and EP; vs. vs. pre-intervention measures of readingpre-intervention measures of reading.. LiPS - fastest rate of growth in word attack, reading rate and LiPS - fastest rate of growth in word attack, reading rate and

accuracy, and developmental spelling. accuracy, and developmental spelling.

Significant growth in nonword repetition, rapid naming Significant growth in nonword repetition, rapid naming (digits (digits

and letters), and letters), and phonological awarenessand phonological awareness.. The intensity and frequency of intervention significantly The intensity and frequency of intervention significantly

impacts growth in reading skills.impacts growth in reading skills.

Remediation – LiPS Outcome data (cont)

Remediation – LiPS Outcome data (cont)

40% staffed out of ESE within 1 year of intervention;(vs. 5% national 40% staffed out of ESE within 1 year of intervention;(vs. 5% national

norm).norm).

Reading comprehension, phonemic decoding accuracy and text reading Reading comprehension, phonemic decoding accuracy and text reading

were Average at 2 yr f/u, and fluent at 4 year f/u.were Average at 2 yr f/u, and fluent at 4 year f/u.

66% of children demonstrated comprehension of written language >= 66% of children demonstrated comprehension of written language >=

1SD above their receptive language abilities. 1SD above their receptive language abilities.

Best predictors of growth in reading skills were attention/behavior Best predictors of growth in reading skills were attention/behavior

(confound), receptive language skills (CELF-III), and prior phonological (confound), receptive language skills (CELF-III), and prior phonological

awareness (an inverse relationship).awareness (an inverse relationship).

Alexia Rehabilitation Alexia Rehabilitation

Treatment of a case of phonological alexia with Treatment of a case of phonological alexia with agraphia using the Auditory Discrimination in agraphia using the Auditory Discrimination in

Depth (ADD) ProgramDepth (ADD) Program Tim ConwayTim Conway

Patricia HeilmanPatricia Heilman Leslie Gonzalez-RothiLeslie Gonzalez-Rothi

Ann W. AlexanderAnn W. Alexander Stephen NadeauStephen Nadeau

John AdairJohn Adair Bruce CrossonBruce Crosson

Kenneth HeilmanKenneth Heilman Journal of the International Neuropsychological Society (1998), 4, Journal of the International Neuropsychological Society (1998), 4,

608-620.608-620.

Alexia Rehabilitation - case studyAlexia Rehabilitation - case study

50 year old male, 14 years education, 50 year old male, 14 years education, ambidextrous (left for writing ambidextrous (left for writing && eating). eating).

Sudden onset of aphasia, alexia, agraphia, Sudden onset of aphasia, alexia, agraphia, limb apraxia, and visual field cut. limb apraxia, and visual field cut.

15 months post onset of CVA 15 months post onset of CVA (cerebrovascular accident).(cerebrovascular accident).

Resolving conduction aphasia, mild Resolving conduction aphasia, mild phonological alexia, & mixed dysgraphia.phonological alexia, & mixed dysgraphia.

Goal: rehabilitate phonological awareness Goal: rehabilitate phonological awareness deficits & improve reading ability.deficits & improve reading ability.

Alexia RehabilitationAlexia Rehabilitation

Posterior two-thirds of left temporal lobe, portions of inferior parietal and occipital lobes (including AG, SMG, Wernicke’s & Heschyl’s gyri).

Alexia Case Study - reading probesAlexia Case Study - reading probes

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Baseline Post OralAwareness

PostSimple

PostComplex

PostMulti-

syllable

Read aloudsimple nonwordprobe

Read aloudcomplex nonwordprobe

Read aloudmulti-syllablenonword probe

Spell irregularword probe

Alexia Case Study - dependent measuresAlexia Case Study - dependent measures

Improved pseudoword reading (73, 93, 90% correct on pre, Improved pseudoword reading (73, 93, 90% correct on pre, post, and follow-up testing [post, and follow-up testing [Battery of Adult Reading Function, Rothi et al., Battery of Adult Reading Function, Rothi et al.,

1984;]1984;]; 99, 112, 115 Standard Score [; 99, 112, 115 Standard Score [WRMT-R, 1987]WRMT-R, 1987])) Improved word identification (99, 103, 113 Standard Score Improved word identification (99, 103, 113 Standard Score

[Wodcock Reading Master Test-Revised WRMT-R, Woodcock, 1987][Wodcock Reading Master Test-Revised WRMT-R, Woodcock, 1987])) Improved auditory working memory & phonological Improved auditory working memory & phonological

awareness (LAC-MAC 50, 92, 100%; awareness (LAC-MAC 50, 92, 100%; Lindamood Auditory Lindamood Auditory Conceptualization Test-Multisyllable Auditory Conceptualization, Bell & Lindamood, Conceptualization Test-Multisyllable Auditory Conceptualization, Bell & Lindamood,

19961996).). Self-report of improvement after only 30 hours of treatment.Self-report of improvement after only 30 hours of treatment.

Alexia Rehabilitation (cont)Alexia Rehabilitation (cont)

Alterations in the Functional Anatomy of Reading Alterations in the Functional Anatomy of Reading Induced by Rehabilitation of an Alexic Patient. Induced by Rehabilitation of an Alexic Patient.

John AdairJohn Adair Stephen NadeauStephen Nadeau

Tim ConwayTim Conway Leslie Gonzalez-RothiLeslie Gonzalez-Rothi

Patricia HeilmanPatricia Heilman Isaac GreenIsaac Green

Kenneth HeilmanKenneth Heilman Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 13 (4), Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 13 (4),

303-311.303-311.

Alexia case study (functional SPECT imaging data on same 50 yo CVA participant)

Alexia case study (functional SPECT imaging data on same 50 yo CVA participant)

Hypotheses A Significant difference in the pattern of

cerebral blood flow will be found between: baseline language task and nonlinguistic task in

right hemisphere, baseline language task and post-rehabilitation

language task in the right hemisphere, between the 2 language tasks in both ventral frontal

convexity regions.

Alexia case study - Imaging TasksAlexia case study - Imaging Tasks

Language - silent reading of pseudowords

Nonlinguistic - visual tracing of Porteus Maze task

Alexia case study – increased Cerebral Blood Flow (CBF)Alexia case study – increased Cerebral Blood Flow (CBF)

Language 2 > Language 1 (increased activity from post-treatment versus pre-treatment comparison) Right hemisphere:

Frontal (middle & inferior frontal gyrus; BA 9 & 45) Parietal (angular and supramarginal gyrus; BA 39& 40) Temporal (large contiguous area of modestly increased

regional counts - superior, middle, posterior middle and inferior gyrus; BA 21,37, & posterior 22).

Left Hemisphere: large contiguous areas of modest increase

Frontal (inferior gyrus & premotor; BA 44 & 6) Parietal Opercular (BA 40)

Alexia Conclusions - Participant #1Alexia Conclusions - Participant #1

Effective rehabilitation of mild phonological Effective rehabilitation of mild phonological alexia that appeared to engage right-hemisphere alexia that appeared to engage right-hemisphere cortex, homologous to left-hemisphere areas cortex, homologous to left-hemisphere areas usually involved in reading and language. Also, usually involved in reading and language. Also, may have re-connected spared Left-hemisphere may have re-connected spared Left-hemisphere language structures. language structures.

Possible aids to treatment outcome: intact Possible aids to treatment outcome: intact Broca’s area, ambidexterity, highly motivated, Broca’s area, ambidexterity, highly motivated, mild level of impairment, intensity and mild level of impairment, intensity and frequency. frequency.

Alexia Case study #2 (different CVA participant)

Alexia Case study #2 (different CVA participant)

Single-subject, multiple-baseline design and Single-subject, multiple-baseline design and pre- post-treatment testing.pre- post-treatment testing.

92 hours of treatment over a 12-week 92 hours of treatment over a 12-week period, (LiPSperiod, (LiPSTMTM) ) treatment description in Kendall et al, 2003treatment description in Kendall et al, 2003..

Alexia Case study #2Alexia Case study #2

right handed, 48-year-old male, 12th grade education, with an right handed, 48-year-old male, 12th grade education, with an ischemic stroke 81 months prior to the current study. ischemic stroke 81 months prior to the current study.

T1 weighted MRI showed infarction in left hemisphere operculum and T1 weighted MRI showed infarction in left hemisphere operculum and frontoparietal involvement.frontoparietal involvement.

He demonstrated phonological alexia, agraphia, anomia, and nonfluent He demonstrated phonological alexia, agraphia, anomia, and nonfluent aphasia before treatment.aphasia before treatment.

Imaging tasks included pseudoword repetition and pseudoword Imaging tasks included pseudoword repetition and pseudoword reading, only repetition data is presented here; reading, only repetition data is presented here;

Behavioral change:Behavioral change: improved pseudoword repetition post-treatmentimproved pseudoword repetition post-treatment pseudoword reading improved over 47 standard scores points from pre-pseudoword reading improved over 47 standard scores points from pre-

treatment to 3 month follow-uptreatment to 3 month follow-up

Baseline Phase

Treatment Phase

Multiple-probes Pseudoword Repetition

Baseline Phase Treatment Phase

Weeks

% c

orr

ect

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L R

Post-treatment

Alexia Case study #2 - Nonword repetition

Alexia Case study #2 - Nonword repetition

Alexia Conclusions – Participant #2Alexia Conclusions – Participant #2

Generalization of a phonological-motor treatment to pseudoword Generalization of a phonological-motor treatment to pseudoword repetition involved increased activity in some left perilesional repetition involved increased activity in some left perilesional cortex and the right-hemisphere SMA.cortex and the right-hemisphere SMA.

Decreased activity in the right hemisphere was evident post-Decreased activity in the right hemisphere was evident post-treatment.treatment.

Increased activity in two perilesional regions, decreased activity Increased activity in two perilesional regions, decreased activity in several regions (mostly on right hemisphere)in several regions (mostly on right hemisphere)

Improved behavioral performance indicates neural reorganization Improved behavioral performance indicates neural reorganization towards increased cortical efficiency following a successful towards increased cortical efficiency following a successful phonological-motor treatment.phonological-motor treatment.

THANK YOU FOR YOUR ATTENTION AND PARTICIPATION

THANK YOU FOR YOUR ATTENTION AND PARTICIPATION

Documents

Disorders of Reading and Writing Tim Conway, Ph.D. VAMC Brain Rehabilitation Research Center, University of Florida, Depts of Clinical and Health Psychology,