Evaluation of Dyslexia

I have recently found myself describing the ins and outs of Dyslexia evaluations for several families, and thought it would probably be a helpful blog topic.

Dyslexia is a neurobiological learning disability. It most commonly impacts reading abilities, although presentation can be quite different for various individuals. I generally describe Dyslexia symptoms as presenting in two distinct forms. The first is the classic, and stereotyped conception, that Dyslexia is all visual and presents as reversing letters and words when reading and writing. Phonetic weaknesses may or may not be present for these individuals. The second is auditory phonetic weaknesses that are apparent in the inability to mimic the sounds of words heard. Severe Dyslexia is often the result of weaknesses that significantly impact both visual and auditory processing of symbols and language as this limits one’s ability to compensate for learning difficulties.

This description is somewhat reductionistic as individuals with Dyslexia can display weaknesses in a number of cognitive/learning abilities including rapid automatized naming (retrieval difficulties), phonological awareness, blending sounds together when reading, segmenting words down into individual sounds, manipulation of auditory phonemes, problems with working memory performance, orthographic (visual) processing, left and right directional confusion, and difficulties with visual-verbal paired learning. What makes evaluation and diagnosis of Dyslexia even more complicated is that every individual compensates for these weaknesses differently, which impacts how symptoms are observed.

The term “Dyslexia” is really best considered a broad canopy term for multiple variations of learning difficulties. In fact, Dyslexia is no longer used as the actual diagnosis in the Psychiatric Diagnostic And Statistical Manual of Mental Disorders (DSM-V is current). Now Specific Learning Disorders in reading, writing, and/or math are given, while Dyslexia can be used as an add on descriptor of the types of learning difficulties that are present.

Stealth Dyslexia is worth mentioning at this point as smart individuals, who perform relatively well in comparison to their same age peers at school, can also have Dyslexia. They often display complex compensation strategies that minimize their visible Dyslexic errors. Evaluations often help these individuals to better understand how smart they are, how much they are having to over-compensate, and illuminate how they are often underperforming educationally. School systems will rarely evaluate these individuals for Dyslexia as they are performing at or above grade level in reading and writing. Despite their intelligence, these individuals still greatly benefit from educational accommodations.

It is important to note that school districts are not able to clinically diagnosis Dyslexia. If a label of Dyslexia is given by a school it is considered an “educational designation”, which establishes the need for specific learning accommodations within that school system. This educational designation often does not translate into a clinical diagnosis needed for accommodations or services outside of that particular school system. While school testing for Dyslexia can quickly jumpstart the development of needed accommodations in the form of a 504 or IEP plan, I always recommend to families to also get evaluation in the community. Every parent wants clarity on what all is going on for their child as soon as possible, and not years later. A comprehensive evaluation ensures all potential variables are considered, correctly diagnosed, which then ensures appropriate accommodations, correct educational tutoring/training techniques are utilized, and support for other conditions is available.

In seeking evaluation for Dyslexia, or really any other specific learning disorder, it is important to rule out other potential causes including ADHD, organic brain issues including within the visual system, mental health issues, etc. Options for evaluation of Dyslexia include clinical psychologists, neuropsychologists, psycho-educational specialists (of various levels of training), and speech language pathologists.

From my perspective, clinical psychologists and neuropsychologists are going to have the most comprehensive training and evaluation process. They are going to rule out possible causes of reported symptoms and hone in on what is actually occurring at the level of error patterns. They will have specific training in neurocognitive issues that should be ruled out including ADHD, frontal lobe injuries, visual conditions in the brain, etc. that other evaluators (SLPs and psycho-educational evaluators) will likely not have. Neuropsychologists are more likely to provide comprehensive evaluations that span two to four days of evaluation. For most cases of Dyslexia, this would be excessive. Generally, one day of evaluation is sufficient for Dyslexia evaluation.

When testing for Dyslexia, ADHD should also be evaluated for, even if not previously expected. I frequently see young children referred for Dyslexia evaluation from local school systems that actually have ADHD. Idaho has required schools, by law, to screen for Dyslexia for the past few years. That screening is generally very brief in nature.

You can certainly have both Dyslexia and ADHD and in these cases I carefully talk with individuals and their families about the potential benefits of considering medication treatment for ADHD, even when it was not a suspected diagnosis going into the Dyslexia evaluation. If executive functioning improves in the frontal lobe with introduction of a stimulant medication, then it is common to see significant reduction in Dyslexic errors and improved ability to compensate. By no means do stimulant medications cure Dyslexic symptoms. Rather they provide greater clarity on the actual severity of Dyslexic symptoms once variability in executive functioning is addressed. For many this results in their Dyslexia actually being milder than previously thought.

Some Speech Language Pathologists (SLP) can do specific Dyslexia evaluations. They excel in visual and auditory evaluation of phonetic weaknesses and are often the best fit for children with complex hearing/speech issues. I would just make sure they are knowledgable about ADHD and administer a full scale intelligence quotient (FSIQ) as part of their Dyslexia evaluation. Having both psycho-educational measures and a FSIQ are considered essential. This will ensure that individuals are able to use the evaluation report to pursue and receive accommodations in other settings down the road (SAT, ACT, college, occupational, professional licensing exams, state driver’s license tests, etc.).

Psycho-educational evaluators are often school psychologists or individuals who at least have some education/certification in administering various educational measures (but these individuals may not be able to provide clinical diagnoses). Who and what types of licenses fall into this category will vary per state. While these individuals are sometimes the best trained in giving specific recommendations for learning accommodations, they are often the least specialized in ruling out brain conditions, mental health issues, and ADHD. I tend to think of these evaluations as being similar to school system evaluations in a public context. They can be a good option for individuals with a prior diagnosis of Dyslexia with a comprehensive report who need updated testing for fine tuning of specific accommodations.

In summary, a comprehensive clinical evaluation for Dyslexia should rule out other possible causes of symptoms, especially ADHD. A battery should include psycho-educational measures (reading, writing, math, and/or auditory phonetic abilities) and a FSIQ. If ADHD and/or mental health issues are present then other measures should also be included. Generally, testing for Dyslexia should be no longer than one scheduled day. Generally, psychologists (whether clinical or neuropsychological) are going to be the best option, although SLP’s or psycho-educational evaluators may be a good fit in some situations. It is important to check with your insurance coverage about testing for learning disabilities, as many will deny this. Pursuing a more comprehensive evaluation with a psychologist, especially when there is also a question of ADHD, mental health issues, and/or brain related conditions may help to get full or partial coverage for the evaluation. Evaluation reports for Dyslexia can be used to seek accommodations for school (504 or IEP plan), SAT and ACT tests, college, professional licensing exams, state drivers licensing tests, occupational, etc.

A final note worth mentioning on my evaluation style. I find it extremely helpful to have parents in the room for their child or teen’s evaluation, especially during evaluation of reading, writing, math, and auditory phonetic abilities. As part of the process, I help to highlight real time identification of error patterns, so that parents can understand what is occurring for their child. This provides evidence of how they are attempting to compensate for learning weaknesses, whether effectively or ineffectively. I also provide this form of feedback to adults when they are completing their own evaluation.