Dyslexia Series Part 2: How is Dyslexia Identified?

If you are worried that your or your child might have dyslexia, you probably have many questions about what is involved in the evaluation process. You might wonder where you should get an evaluation, what you or your child should expect from upcoming appointments, and what types of questions you should ask. This article is part two of a three-part series on dyslexia, and it will discuss how dyslexia is identified in children and adults.

Testing Components

A comprehensive evaluation is required in order to identify dyslexia in both children and adults. There are a significant differences in the way different agencies evaluate for dyslexia, but here are some general things to expect.

• Collection of thorough background information:

  • A developmental interview

  • Review of records

  • Information from parents and teachers

  • information from the student

  • In a school this would also likely include collection of data related to response to intensive intervention, often termed RTI data or progress monitoring data

  • For adult clients, information from parents and teachers might or might not be available.

  • Information from outside sources would not be sought without client consent.

• In depth assessment in many areas, such as:

  • Assessment of overall cognitive abilities or intellectual functioning

  • In depth assessment of academic achievement, or abilities in reading and writing particularly but also perhaps math

  • Assessment in areas related to language, such as vocabulary or listening comprehension

  • Assessment in areas related to phonological awareness, or the ability to understand and manipulate the sounds within words, and phonics, or the ability to relate sounds to letters or groups of letters

  • Assessment of other skills related to reading, such as rapid naming skills

Individual testing is often a lengthy process, and it might be broken into multiple sessions. Often, evaluators might conduct the intellectual assessment in one setting, and conduct the reading-based assessments in a separate session in order to avoid test fatigue. Scheduling decisions are often made based on the age of the student and family preferences and availability.

School versus Private evaluations:

Psychologists or evaluators with very similar training might go about a dyslexia evaluation in a very different way, depending on the type of setting they are working in. The biggest difference in evaluations might be between school-based and private evaluations. Here is a brief description of different agencies or places that students might be evaluated for dyslexia as well as a few pros and cons associated with each setting.

Schools

Schools are required by federal guidelines to actively identify students that might have a disability and might need specialized services to access a free and appropriate public education. It makes sense that school districts provide comprehensive evaluations that consider whether or not a child has dyslexia and/or a learning disability in reading. (For a finer point discussion on the way dyslexia is often viewed within the school setting, see the previous blog post in this series, What is Dyslexia?) For many families, schools are the best choice for accessing an evaluation.

Pros

Cons

Evaluation will be provided at no cost to the family. Evaluation will meet state guidelines for special education eligibility. Information is readily available to the school system in order for program planning, if services are indicated. Evaluations often occur at the school in which the student is enrolled, so the family is not tasked with transporting the child for evaluation. Evaluation staff often knows the school and the child very well and has access to rich background information to help with the evaluation.

Family loses some control over the process. For example, you are often unable to select a specific evaluator. The evaluation process might be lengthy, depending on state guidelines. The family cedes some control over information. School-based evaluations become a part of the student’s educational record. Evaluations are only available for school-aged children (or some preschool children, depending on circumstances).

Private Practices/Psychologist Offices

Many psychologists that work independently in private practice also provide psychoeducational evaluations. These evaluations often occur at the psychologist’s office.

Pros

Cons

The family gains some control over the evaluation process--for example, an evaluator can be specifically selected. Wait times and evaluation time lines are often shorter. The family can choose what type of information that want to disclose to other agencies, such as schools or universities.

Private evaluations can be expensive, and they are often not covered by insurance. Reimbursement might be possible but requires legwork. The family has to transport the child to the office. There is no guarantee that an outside evaluation report will meet school-based standards or that it will be accepted by an educational institution if the family is seeking school-based services or accommodations. The psychologist might or might not specialize in psychoeducational assessment, and they might or might not specialize in dyslexia specifically.

Clinics that specialize in assessment

There are many psychoeducational clinics that specialize in assessment. These could include a group of psychologists that provide assessments and/or treatment, but other common settings could be within universities or at other types of community agencies, such as a mental health cooperative. Some clinics have a variety of assessment personnel, such as speech language pathologists, occupational therapists, and physical therapists that all work together from one location.

Pros

Cons

Like above, the family gains control, there are often shorter time lines, and the family can choose what information to disclose. Additionally, clinics that specialize in assessment provide a specific type of expertise--they are very good at conducting assessments. If the clinic is associated with a training program, there are often excellent assessments that are available from graduate students that are under the supervision of experts, and these evaluations are often available at a discount.

Like above, clinic evaluations are often expensive and might or might not be reimbursed by insurance. Again, there’s no guarantee that the evaluation will meet educational standards for any given institution, such as a public school district, private school, university, or testing board. Even if the psychologist specializes in assessment, they might or might not specialize in dyslexia specifically.

Clinics that specialize in dyslexia

There are certainly some clinics that specialize in the assessment of dyslexia and/or learning disabilities. They might only do these types of assessments, and they might also have treatment programs that are specially designed to address dyslexia or other learning disabilities.

Pros

Cons

Similar pros as the previous two settings--flexibility, possibly shortened timelines, greater control for the family. Evaluators are often highly regarded experts in the diagnosis and treatment of dyslexia. If there are other factors that might complicate identification of dyslexia--such as intellectual giftedness, or the presence of other disabilities, such as ADHD or autism--an expert in a specific area might be more equipped to provide a differential diagnosis. If the speciality clinic has a treatment program attached, the evaluation might be a precursor to accessing that program.

Like above, these evaluations are more likely to be expensive, might or might not be reimbursed, and might or might not be accepted by an educational institution or testing board. If you go to a clinic that specializes in a specific disorder, such a dyslexia, there is a greater risk of over-identification of that disorder and underidentification of other, similar problems. A clinic that is specialized for a particular disorder, such as dyslexia, might not be equipped to look at other types of problems that might cause reading difficulties, such as intellectual disability, autism, attention-deficit hyperactivity disorder (ADHD), or emotional disorders.

Questions to Ask Practitioners:

If you are seeking a dyslexia evaluation, it is obvious that there are many different avenues available to you. The first step for many families will likely be to access a free evaluation through their public school system. In order to get that process started, you should talk to your child’s principal or teacher about your concerns. However, a school-based evaluation might not be right for all families, and if you are seeking a private evaluation for dyslexia, here are some questions you should make sure to ask the evaluator before you get started:

1. Ask if the evaluator is familiar with dyslexia. Ask about the evaluator's experiences working with and assessing students with dyslexia.
2. Ask about what areas will be included in the evaluation. At the least, the following areas should be assessed: 

   • Intellectual functioning or cognitive abilities

   • Word recognition

   • Word decoding

   • Spelling

   • Reading comprehension

   • Reading fluency

   • Written expression

3. If you have possible concerns in other areas, such as with ADHD or autism, be sure to ask if the evaluation will look at all possible diagnoses, rather than focusing on only dyslexia.
4. Ask about the timeline for the evaluation--how long will the testing take, and how long will it take to receive the evaluation report after the evaluation is completed?
5. Finally, make sure that the evaluator knows any reasons that you are seeking the evaluation. If you want to be able to share results with a school district for possible special education services or general education accommodations or if you are seeking accommodations on the SATs or ACTs, it is important to say that up front.

Undergoing an evaluation can be a daunting process for families. Hopefully this article has helped to provide some additional information about how to seek out an evaluation for dyslexia, and what to expect to be included. If you have additional questions or concerns, be sure to reach out to us! We are happy to help. The final part of our three-part dyslexia series is coming soon, and it will focus on research-based treatments and accommodations for dyslexia.

Dyselxia Series Part 1: What is Dyslexia?

Dyslexia is a term that many people have heard before, but there are many misconceptions and misunderstandings about what it means. This post is part one of a three-part series on dyslexia, and it focuses on what dyslexia is.

WHAT IS DYSLEXIA?

In general, dyslexia is a term that is used to describe problems in reading that are characterized by difficulties with accurate or quick word recognition, poor decoding (ability to sound out unfamiliar words), and poor spelling abilities. Learning disabilities are unique, and there are many characteristics that might or might not apply to any single person diagnosed with a learning disability, but most researchers agree:

• Learning disabilities are the results of difficulties with cognitive abilities--the way the brain processes certain types of information.

• The cognitive processing deficits associated with learning disabilities are generally not related to visual-perceptual difficulties (e.g., the way that the student sees words) but rather related to language processing, such as vocabulary, the ability to retrieve information from memory, or the ability to recognize and process sounds and match them to letters or symbols.

• Some learning disabilities might be related to genetics or inherited within families.

• Reading disabilities are much more common than disabilities in math or writing.

• Learning disabilities fall within a spectrum of severity.

• Effective instruction, supports, and accommodations can offset the impact of a learning disability within a classroom.

• Learning disabilities often co-occur with other types of difficulties, such as attention-deficit/hyperactivity disorder (ADHD), communication disorders, developmental coordination disorder, autism, or other disorders. This makes differential diagnosis that much more complicated.

What are signs of dyslexia?

• Language delays (e.g., trouble with vocabulary, word finding, imprecise language, etc.)

• Difficulties with rhyming or other tasks that involve playing with sounds within words

• Difficulties with alphabetic knowledge, including recognizing letters or identifying letter sounds

• Trouble sounding out even simple words, like cat, top, or bat

• Slow, unsteady reading (i.e., dysfluent reading)

• Poor spelling

• Avoiding reading

• Trouble finishing classwork or homework in a reasonable period of time

What about reading backwards or right to left? What about backwards letters? Aren’t those types of reading behaviors associated with dyslexia?

Trouble with reading from right to left and from top to bottom is likely more a symptom of reading difficulties rather than a cause of dyslexia, per sé. Jumping around on the page could occur when the child is having difficulty reading words in order, so they skip ahead to words that they recognize. Alternatively, the student may need additional training in print conventions and directionality of text, because this is not a habit that has been solidified in his or her reading behaviors. In general, there is limited evidence to suggest that eye movement abnormalities better explain dyslexia rather than difficulties with word recognition and language processing.

Reversing letters while writing is considered age-appropriate through about age seven or second grade. These types of errors are often more related to difficulties with phonics and inexperience and difficulty reading rather than seeing the letters backwards. After the end of second grade, reversing letters is often a sign that further evaluation might be needed, but this is all dependent upon information from a variety of sources. Just because a child is in the second grade or below does not mean that he or she would not benefit from practice writing letters the correct way. Working on letters one at a time in isolation and incorporating multi-sensory techniques might help a child who is struggling to remember letter orientation to catch on a bit quicker.

Brain processes related to reading development and dyslexia

As brain imaging science has become more advanced, some studies have been conducted to look at the brain pathways that are associated with both efficient and inefficient reading. There is not space here to provide an in depth discussion of what research suggests about reading development and brain pathways. However, there are some general trends from research in this area that might be of interest here.

Functional brain imaging studies (i.e., fMRI) have been used to provide information about the neural pathways related to efficient reading. Three main pathways have been identified:

1. The parieto-temporal system is essential for phonetic decoding in reading: that is, looking at the letters within a word, associating those letters with sounds, determining the sound units within the words, and then ultimately identifying the word itself. Children who are learning to read rely initially on the parieto-temporal system almost exclusively.

2. As readers develop more skill, a different pathway in the brain becomes more active: the occipito-temporal pathway. The occipito-temporal pathway is more related to whole-word reading--that is, the whole word is recognized automatically, rather than being broken down into phonetic parts, as it is in the parieto-temporal system. This neural activation related to whole word recognition allows the reader to access each word more quickly, allowing for more fluent reading, rather than relying on the slower, phonetic decoding of each word within the text.

3. There is a third area associated with phonetic decoding that has also been identified, and that area lies within the frontal lobe in Broca’s area. Again, this neural pathway for reading is not as efficient as the occipito-temporal pathway.

Brain imaging studies have suggested differences in activation between these neural pathways with more efficient readers and readers who have been identified with dyslexia.

• Good readers have been shown to have more consistently rely upon the occipito-temporal pathway, with less activation in the other two, front pathways.

• Children with dyslexia have shown the opposite pattern, with two distinct patterns:

  • Children with dyslexia often can activate all three brain pathways individually but have trouble with activating them simultaneously.

  • There is often an overactivation of the third pathway associated with Broca’s area, which appears to be the endpoint for the brain’s articulation system.

  • Using these two systems, children with dyslexia are often able to break apart the sound structures within words and pronounce the sounds within their head, but because they have trouble activating the more efficient system, their reading is less fluent and less automatic than a child without dyslexia.

• Effective intervention systems have been shown to help children with dyslexia develop the posterior, automatic system and improve fluency.

As a wrap up, brain imaging studies seem to suggest real differences in the neural pathways that are activated during reading when skilled readers are compared to children with dyslexia, which supports a biological basis for dyslexia. However, imaging studies have also shown that effective intervention can strengthen more efficient neural pathways even in children diagnosed with dyslexia.

Terminology in schools versus other settings

Dyslexia is a term that has traditionally been used more by researchers and within medical settings than in schools. Its counterparts in other areas of learning include dysgraphia (learning disability in writing) and dyscalculia (learning disability in mathematics).

In schools, terminology is often driven by laws and procedural guidelines from the federal and state departments of education, and the current federal guidelines provide a classification called specific learning disability which includes several different categories within that broad classification (e.g., specific learning disability in basic reading skills). The federal guidelines specifically reference dyslexia as a possible diagnosis that would fall under the educational classification of specific learning disability.

Sources:

• Lichtenstein, R. (2010). Learning disabilities identification: A primer for parents from Helping Children at Home and School III from the National Association of School Psychologists.

• Miller, D. C. (2013). Essentials of School Neuropsychological Assessment, Second Edition.

What to expect at an initial intake appointment for psychological testing

You’ve sought out an evaluation for yourself, your child, or your loved one, and the initial intake or consultation appointment is coming up, but you aren’t sure what to expect. This article will help give you an idea about what to expect and also give you some suggestions for questions you should ask yourself and your evaluation professional. The exact structure of intake appointments may vary between agencies, but there are absolutely specific things you should expect.

Expect to fill out forms

Like a doctor’s appointment, often at an initial intake appointment for testing, you will need to fill out client intake forms, sign acknowledgements of office procedures, and sign a billing agreement. If you are going to an office that bills insurance, be prepared to provide additional information about your coverage. You will likely be provided with specific information about your rights to confidentiality as well as limits to these rights. Before beginning any sort of evaluation, the provider is required to document your informed consent for the evaluation, and this might occur at the beginning of the meeting, or it might occur after initial discussion.

You might also be given lengthier forms to fill out prior to the initial meeting, such as a developmental history for yourself or your child. Some evaluators like to have this information completed prior to the meeting in order to streamline the process and allow them to prepare more effectively to meet with you. If this is the case, they might go into the intake appointment having already reviewed your information, and they will be ready to ask you follow up questions about what you have reported.

Expect to have an intake interview with an evaluation professional

Even if you submitted information ahead of time, be prepared for the evaluator to ask in-depth follow up questions. It is essential for the evaluator to collect ample information before they begin testing.

While some providers like to collect a broad range of information prior to the initial appointment, other evaluators prefer to collect this information in person via an interview, which can be more flexible and allows for them to respond to your body language throughout the interview.

Be prepared to be asked lots of in depth questions about a broad range of topics, such as social history, developmental milestones, current concerns, and medical and educational history. These questions can sometimes be difficult to answer. Take your time--it is okay to feel somewhat overwhelmed when answering these questions. If you do not remember to say everything during the initial appointment, you should have opportunity to provide additional information later in the testing process.

What to do prior to the initial meeting

Think about how to describe the concerns that are leading you to seek this evaluation:

• Do you have specific questions about your or your child’s functioning in a specific area, such as concerns about possible ADHD, autism, or dyslexia?

• Do you want updated information about strengths and weaknesses?

• Are you looking for accommodations at college or on standardized tests?

• Are you seeking a second opinion after you or your child was evaluated at school or another agency?

• Were you referred by someone specific, such as a physician or therapist? 

All of these reasons will shape the way that the evaluator collects information and provides your results, so make sure to spend some time thinking about what you want when the process is over. It might to help to jot down your specific goals and concerns you have for testing.

Gather any documents you have that might be relevant to your referral concerns or evaluation.

The evaluator might provide you with a specific list of documents to bring to the appointment, but if not, be prepared to make sure that you are getting the best value and most productive use from your initial appointment.

• Make sure to bring any previous evaluation reports or results, even if they aren’t psychological. For example, bring any speech therapy, occupational therapy, feeding therapy, or physical therapy reports, if applicable.

• If you or your child has an accommodation plan, service plan, or educational program from any agency, be sure to bring documents related to that.

• If you or your child is receiving services from another agency (e.g., tutoring or speech, occupational, or feeding therapy), gather up any progress notes that you have related to these services. If you or your child previously received services but has been dismissed or graduated from services, bring any case closeout or summary notes.

• If you are seeking accommodations from a specific agency (e.g., testing board; university disability office) and the agency provided you with any guidelines, be sure to bring those.

Think about follow up questions about cost, timelines, and expectations.

It helps to think about the questions you need to ask the evaluator prior to your meeting. It might help you to write down these questions, so you are sure to make sure that you get the answers you need. Some questions might include:

• How much will the evaluation cost? When are you expected to furnish payment, and how is payment accepted? Is insurance accepted? If not, are they willing to provide you with documents that you can submit to insurance for reimbursement?

• How long will the evaluation take? How many sessions do they expect to need? What will the structure of the assessment sessions be like? Are they willing to work with you to make sure that you or your child are being assessed at the most ideal time of day?

• What type of report will be provided? How long after the final evaluation session will it take to receive the report? Are they willing to provide a report that will meet your needs (e.g., if you are seeking ACT or SAT accommodations or accommodations via a university disability office)?  

It can be stressful not to know what to expect at something as important as an initial evaluation intake meeting. This stress is only compounded by long wait times and confusing jargon. Hopefully this article has given you an idea about some things to expect at your intake appointment and also given you some ideas on how you can prepare for your appointment.

If you have any other specific questions about what to expect at an initial intake appointment, we are happy to provide you with any additional information you might need to alleviate any anxiety and help you feel prepared!

Reach out to us in the comments or at info@nashvilleassessment.com