Dyslexia Assessment Challenges FAQs
1. How can the effects of attention-deficit/hyperactivity disorder (ADHD) be separated from those of dyslexia in an evaluation?
Dyslexia and ADHD co-occur more often than would be expected by chance. The diagnostic process is similar for the two conditions, but the primary indicators differ. The primary indicators for a diagnosis of dyslexia are poor basic reading and spelling skills. The primary indicator for a diagnosis of ADHD is a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with an individual’s development or their ability to function.
Both types of evaluation require a thorough review of the individual’s medical, family, and academic history. Evaluators also typically
- observe the individual in different settings
- review the student’s work on curriculum-based tests, assignments, or projects
- conduct direct assessments
- interview the individual
- consider information from self, parent, and teacher rating scales
The focus of this information is to determine the extent to which the examinee has the characteristics associated with dyslexia and/or ADHD.
Diagnostic indicators of ADHD are found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) (American Psychiatric Association, 2022). Diagnosis of dyslexia may be guided by the DSM-5-TR or by each state’s Department of Education criteria for special education eligibility.
If an examiner identifies enough indicators, such as inaccurate decoding, slow reading, and poor spelling, a diagnosis of dyslexia may be provided. Importantly, according to the DSM-5-TR, the word dyslexia is an alternative term used to refer to a pattern of learning difficulties. Dyslexia may be evidence of a specific learning disorder.
Similarly, if a person has enough specific indicators of inattention, hyperactivity/impulsivity, or both, a diagnosis of ADHD may also be provided. An examiner uses the information from a psychoeducational assessment to determine if criteria for dyslexia or ADHD are present. For those with sufficient evidence of dyslexia and ADHD, both diagnoses may be appropriate.
One other consideration is that some students with ADHD can pay attention in a one-on-one situation, such as during an assessment, but have difficulty sustaining attention in a classroom setting. Evaluations often provide short, focused tasks that change frequently, enhancing interest. A student’s problems with attention and/or impulsive behavior may be more apparent during classroom observations than in a quiet, distraction-free one-on-one setting.
Reference:
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, fifth edition, text revision. www.appi.org/Products/dsm
2. How can autism affect reading and dyslexia assessment?
Autism spectrum disorder (ASD) is characterized by difficulties with social interactions, verbal and nonverbal communication delays, and behavioral rigidity (Pennington et al., 2019). Like dyslexia, ASD can occur across the range of intellectual abilities. Around 30% of those identified with ASD also meet the criteria for intellectual disability (Pennington et al., 2019).
The main characteristics of dyslexia and autism differ. Dyslexia is characterized primarily by difficulties with decoding words, spelling, and reading fluency. ASD is associated with difficulties with language comprehension and expression. Many autistic individuals read words easily. Some have a limited awareness of their meanings and possible usages.
Typically, the referral concerns for ASD and dyslexia will be quite different. Examiners should be alert to patterns of performance. In summary, although many autistic people do quite well on measures of basic reading skills and even reading fluency, some may falter on tasks that involve reading comprehension and vocabulary. Individuals with dyslexia will often exhibit the opposite pattern.
Reference:
Pennington, B. F., McGrath, L. M., & Peterson, R. L. (2019). Diagnosing learning disorders: From science to practice (3rd ed.). Guilford.
3. How can dyslexia be diagnosed in deaf/hard-of-hearing students?
Typically, reading relies on auditory/phonological and visual abilities. Deaf/hard-of-hearing examinees may have auditory/phonological limitations, depending on the degree of hearing loss and the age at which they lost hearing ability. Some deaf children may develop very little or no phonemic awareness. Reading is likely to be difficult for these individuals because reading depends on mastery of sound–symbol relationships. For that reason, reading and spelling are difficult to learn for many deaf/hard-of-hearing examinees.
Even so, there is some evidence that deaf/hard-of-hearing individuals develop a sense that letters represent phonemes (McAnally et al., 1999). It’s possible to develop awareness that phonemes exist as abstractable and manipulable components of language (Adams, 1990). These individuals can ultimately learn to rely more on orthographic elements of the language; to communicate visually; and to comprehend print, the goal of reading.
It is possible to assess the ability to assign meaningful nonverbal symbols to particular objects and interactions. Examiners can assess this skill level using nonverbal interactions such as gestures, pictures, and manipulatives (Bracken & McCallum, 2016). You can silently assess the ability of deaf/hard-of-hearing students to make sense of text, and you can use the results to guide instruction. Ultimately, it may be impossible to make a definitive diagnosis of dyslexia for examinees who cannot hear well enough to connect phonemes with graphemes.
It’s important for evaluators to ensure fairness and accessibility when assessing deaf/hard-of-hearing students. Another important consideration is your own experience and training. If you are not prepared to competently deliver the assessment, it’s advisable to search for or collaborate with an expert in the field.
References:
Adams, M. (1990). Beginning to read: Thinking and learning about print. MIT Press.
Bracken, B. A., & McCallum, R. S. (2016). Universal Nonverbal Intelligence Test. PRO-ED.
McAnally, P. L., Rose, S., & Quigley, S. P. (1999). Reading practices with deaf learners. PRO-ED.
4. How can other learning disorders such as dyscalculia and dysgraphia complicate a dyslexia diagnosis?
Dyscalculia is a specific and persistent difficulty in understanding numbers, and this difficulty can lead to a range of difficulties with mathematics (British Dyslexia Association Handbook, 2022). Like dyslexia, dyscalculia is a developmental learning disorder; dyscalculia affects the acquisition of mathematics.
The primary linguistic risk factors related to math disability include limitations in
- oral language
- verbal working memory
- processing speed
- rapid automatized naming
Children who have trouble automatizing letter names, letter sounds, and words often have difficulty automatizing math facts. At the same time, lack of reading fluency or comprehension skills can negatively impact math problem solving. Many people with dyscalculia also have dyslexia (Pennington et al., 2019).
For students who struggle with reading and mathematics, the authors of the Tests of Dyslexia (TOD™) recommend both of these:
- a comprehensive assessment of mathematical skills
- a comprehensive battery that assesses reading, spelling, and related skills (e.g., the TOD)
Dysgraphia is characterized by impaired letter writing by hand. Difficulty with handwriting can interfere with learning to spell words in isolation and in written text. Children with dysgraphia may have
- only impaired handwriting
- only impaired spelling (without reading problems)
- both impaired handwriting and impaired spelling (International Dyslexia Association, n.d.)
People with dyslexia often have difficulty with written expression and poor spelling. Those difficulties often contribute to weaknesses in handwriting and written expression more generally (Hebert et al., 2018).
Poor spelling has been linked to writing less and writing with less sophistication. People with these characteristics often find that writing requires extra effort. For that reason, they may avoid writing when possible (Wood et al., 2020).
When someone has difficulty writing, they often struggle with reading. That may be because reading and writing involve many of the same skills. For example, to read, a student must decode words using the phonological ability of blending. Spelling requires people to encode words using the phonological ability of segmenting.
Writing and reading also overlap in two other ways: Writing requires people to take relevant information from reading, and many people reread their writing to check for errors (Hebert et al., 2018).
Dyslexia and dysgraphia often co-occur. For students with significant handwriting and spelling difficulties, the authors of the TOD recommend both of these:
- a comprehensive assessment of written expression
- a comprehensive test of reading, spelling, and relevant linguistic risk factors
All of these capabilities can be assessed using the TOD.
References:
British Dyslexia Association Handbook (2022). Dyscalculia. Retrieved from https://www.bdadyslexia.org.uk/dyscalculia
Hebert, M., Kearns, D. M., Hayes, J. B., Bazis, P., & Cooper, S. (2018). Why children with dyslexia struggle with writing and how to help them. Language, Speech, and Hearing Services in Schools, 49(4), 843–863. https://doi.org/10.1044/2018_LSHSS-DYSLC-18-0024
International Dyslexia Association. (n.d.). Understanding dysgraphia. Retrieved from https://dyslexiaida.org/understanding-dysgraphia/
Pennington, B. F., McGrath, L. M., & Peterson, R. L. (2019). Diagnosing learning disorders: From science to practice (3rd ed.). Guilford.
Wood, C., Schatschneider, C., & Wanzek, J. (2020). Matthew effects in writing productivity during second grade. Reading and Writing, 33, 1377–1398. https://doi.org/10.1007%2Fs11145-019-10001-8
5. How can an examiner clarify the overlap between language development problems and dyslexia?
Dyslexia is often characterized as a localized weakness (e.g., the phonological component or module) within the larger language system. According to Shaywitz and Shaywitz (2020), the phonological area in the brain is where the sounds of the language combine to form words. In the same area, the elements within words are, or can be, isolated as building blocks comprising these same basic sounds. This ability is sometimes referred to as phonological coding. It has been described as the ability to use knowledge of letter–sound correspondences to read words.
A second fundamental skill also helps people recognize printed words: Known as orthographic coding, this is the ability to recognize letter and word patterns to help people pronounce words. People with dyslexia may have deficits in both phonological coding and orthographic coding (Mather & Wendling, 2012). Both abilities have been linked to specific and localized differences in the structure of the neural systems for reading (Seidenberg, 2017).
Although dyslexia and language impairments co-occur, some problems within the language system are characterized as dyslexia, but others are not. Even though all language elements are linked, assessment experts separate them for practical reasons. For example, people with dyslexia have difficulty learning the phonological and orthographic aspects of written language, resulting in limitations in basic reading and spelling skills. In contrast, these individuals often have good ability to comprehend spoken language.
References:
Mather, N., & Wendling, B. J. (2012). Essentials of dyslexia assessment and intervention. John Wiley & Sons.
Seidenberg, M. (2017). Language at the speed of sight: How we read, why so many can’t, and what can be done about it. Basic Books.
Shaywitz, S., & Shaywitz, J. (2020). Overcoming dyslexia (2nd ed.). Alfred A. Knopf.
6. How can sensory and executive function issues impact dyslexia and dyslexia assessment?
In some cases, sensory problems may underlie academic skill deficits. For example, people with significant hearing loss or auditory discrimination difficulties may be unable to discern the phonological aspects of language, particularly the subtle differences in some speech sounds.
As a result, they will have trouble mastering the phoneme–grapheme relationships essential for basic reading and spelling.
Similarly, some vision problems may limit development of the orthographic processing skills needed to master sight words and spelling patterns. When basic reading problems occur, it’s important to rule out hearing and vision difficulties first.
Poor executive function abilities can also negatively impact the development of basic reading skills. In some situations, a neuropsychological assessment may be needed. Executive function is an umbrella term for abilities such as these:
- goal setting
- planning
- problem solving
- self-monitoring
- behavior adjustment
Limitations in executive function can affect how well people build academic skills in general. They can also impact the ability to master early reading skills (e.g., impaired ability to set reading goals, trouble with learning strategies, difficulty persisting with challenging tasks).
7. How can a student with dyslexia and anxiety, self-esteem problems, or other internalizing symptoms be supported?
First, it is critical to recognize that anxiety, low self-esteem, and other internalizing problems (e.g., depression) can develop from struggles with academic problems such as dyslexia. For that reason, dyslexia can go undiagnosed in students with internalizing problems because these students do not upset the classroom routine as do those who exhibit externalizing problems (e.g., bullying, acting out). Parents, teachers, and other educators need to be alert to the behaviors that characterize these internalizing symptoms. These students often need both academic and social supports.
It is essential to address the reading difficulties as soon as possible by determining the extent of the problem(s). This involves
- collecting good assessment data, including classroom work samples and screening/progress-monitoring results
- building instructional supports (perhaps within a three-tiered model) into the school culture
- providing additional tutoring support after school or at home, if needed
- referring students with internalizing problems to school counselors or school psychologists, who can develop intervention plans to address concerns
8. How can a dyslexia assessment be adapted for English learners?
According to Everatt et al. (2010), individuals who are learning to read in a language different from their native language will exhibit poor reading skills, at least temporarily. In addition, in bilingual settings, young learners have to cope with the demands of two languages simultaneously. They may struggle with basic phonemic awareness because they have limited English vocabulary.
Mather and Wendling (2012) note that assessing an English learner for dyslexia is challenging and that clinical judgment is important. They provide this summary of common evaluation practices from the literature, and Ortiz (2011) notes the limitations of each:
- Some evaluators modify or adapt tests, including eliminating or changing items. Researchers point out that such changes are not consistent with standardized administration procedures and may bias results, rendering the scores invalid.
- It’s also possible to work with an interpreter or translator. This strategy could be problematic if the examinee doesn’t understand directions because of limited native language or if they lack knowledge of test content.
- Another option is to use nonverbal tests. These tests typically assess only cognitive abilities, which are less relevant for identifying dyslexia than the direct assessment of reading and spelling.
- Evaluators may also use translated native-language tests. These are typically standardized only on monolingual individuals in the native language.
- Some evaluators use English language tests. The concern is that these may be biased because they contain vocabulary words and directions unfamiliar to English learners.
Mather and Wendling (2012) suggest some additional best practice strategies. One is to begin an English learner evaluation with early reading intervention, periodically measuring progress in reading and oral language over time. If reading development continues to lag behind oral language development, the examiner should conduct standardized academic testing (in both languages if possible).
Also, it is important to conduct interviews with parents and teachers and to obtain rating scale data. The Tests of Dyslexia (TOD™) includes parent rating scales in English and Spanish for both the TOD-Early and the TOD-Comprehensive. Ideally, the evaluation team would include in the decision-making process an individual who is fluent in the native language and/or an expert in evaluating individuals from diverse backgrounds.
References:
Everatt, J., Ovampo, D., Veii, K., Nenopolou, S., Smyth, I., al Mannai, H., & Elbeheri, G. (2010). Dyslexia in biscriptal readers. In N. Brunswick, S. McDougal, & P. de Mornay Davies (Eds.), Reading and dyslexia in different orthographies (pp. 221–246). Psychology Press.
Mather, N., & Wendling, B. J. (2012). Essentials of dyslexia assessment and intervention. John Wiley & Sons.
Ortiz, S. O. (2011). Separating cultural and linguistic differences (CLD) from specific learning disability (SLD) in the evaluation of diverse students: Differences or disorder? In D. P. Flanagan & V. C. Alfonso (Eds.), Essentials of specific learning disability identification (pp. 299–325). John Wiley & Sons.
9. How can dyslexia be diagnosed when there aren’t phonological weaknesses, but other reading difficulties exist?
First, it is critical to know the characteristic linguistic risk factors associated with dyslexia. Phonological weaknesses are limitations within oral language, but they are not the only potential risk factors. These abilities may have been improved by targeted instruction. Other linguistic risk factors, such as these, can contribute to reading difficulties:
- working memory
- rapid automatized naming
- orthographic processing
Second, it is important to identify the exact nature of the reading difficulties. Are the difficulties related to poor accuracy, poor fluency, and/or poor spelling? Dyslexia may be identified not only by weaknesses in linguistic risk factors, reading, and spelling, but also by cognitive and academic strengths. That is, many people with dyslexia have average or better overall general cognitive ability and typical academic functioning in nonaffected areas (e.g., math, science). For that reason, it’s a good idea to use a comprehensive test like the Tests of Dyslexia (TOD™)(now available) to rule in/out dyslexia by assessing a wide range of abilities.
10. What important characteristics should you consider when assessing students who have reading difficulties and who have experienced trauma?
People with reading difficulties often experience shame and anxiety related to their reading difficulties (Children of the Code, n.d.). The impact can be greater for children and adolescents who have experienced adverse childhood events (ACEs) or trauma.
When assessing students for dyslexia, follow informed approaches, particularly if there is a known or suspected history of trauma. Trauma can have long-lasting effects (National Association of School Psychologists, n.d.). A “trauma-sensitive focus on education fosters a school climate where students feel safe and confident in their ability to learn, can differentiate between trauma induced behavior and appropriate behavior, and connect with adults and peers in a positive manner” (National Education Association, n.d.).
In assessment, then, it is particularly important for examiners to establish rapport by creating a safe and nonjudgmental climate. The examiner should become familiar with the student’s history and avoid questions or comments that might trigger negative feelings or perceptions. Examiners should be responsive to an examinee’s verbal and nonverbal behaviors as well as provide breaks and encouragement as appropriate.
References:
Children of the Code. (n.d.). Shame: The dark heart of reading difficulties. Retrieved from https://childrenofthecode.org/tour/index.htm
National Association of School Psychologists. (n.d.). Trauma. Retrieved from https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-safety-and-crisis/mental-health-resources/trauma
National Education Association. (n.d.). Trauma-informed schools. Retrieved from https://www.nea.org/professional-excellence/student-engagement/trauma-informed-schools