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Brunsdon & Coltheart, 2005
Assessment and Treatment of Reading Disorders:
A Cognitive Neuropsychological Perspective
DeCog Research Unit (Developmental Cognitive Neuropsychology Research Unit)
MACCS, Macquarie University
Rehabilitation and Psychology Departments, The Children’s Hospital at Westmead
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Brunsdon & Coltheart, 2005
Overview
! Assessment of reading! Diagnosis of reading impairment ! Treatment of reading difficulties
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LetterIdentification
SUBLEXICAL
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Dual Route Model of Reading
! Skilled readers use two main procedures for reading aloud
• Lexical Reading Route• relies on whole-word recognition and allows successful
and efficient processing of words that are familiar to the reader
• Sublexical Reading Route• involves rule-based letter to sound conversion and allows
the skilled reader to ‘sound-out’ unfamiliar words and nonwords.
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Brunsdon & Coltheart, 2005
Developmental Dyslexia
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Brunsdon & Coltheart, 2005
Developmental Dyslexia
! Developmental Dyslexia is heterogeneous
! Main Subtypes
• Phonological• Surface• Mixed
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Brunsdon & Coltheart, 2005
Developmental Dyslexia - Subtypes
! Phonological Dyslexia• children who have difficulty acquiring skills
for converting letters into sounds
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Brunsdon & Coltheart, 2005
Phonological Dyslexia
! Phonological Dyslexia
• Difficulty with the Sublexical Reading Route • the route that relies on letter to sound correspondences
to assemble a pronunciation.
• Over-reliance on the Lexical Reading Route• the route that relies on whole word recognition
• where the reader gains access to an internal store of the visual representations of familiar words
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SUBLEXICAL
LetterIdentification
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
PhonologicalDyslexia
! Phonological Dyslexia:
• good reading of familiar words• Poor nonword reading• Difficulty reading unfamiliar word• Nonword reading errors
• visual similar real words• eg. tapple → table
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Brunsdon & Coltheart, 2005
Developmental Dyslexia - Subtypes
! Surface Dyslexia• children who have difficulty learning to
recognise words as whole units
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Brunsdon & Coltheart, 2005
Surface Dyslexia
! Surface Dyslexia
• Difficulties with Lexical Reading Route• the route that relies on whole word recognition
• Over-reliance on the Sublexical Reading Route
• the route that relies on letter to sound correspondences to assemble a pronunciation.
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LetterIdentification
LEXICAL
SUB LEXICAL
Visual Word Recognition
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Surface Dyslexia
! Surface Dyslexia:
• good nonword reading• good reading of regular words (e.g., little)• poor reading of irregular words (eg. quay)• regularisation errors when reading
• eg. quay → “kway”colonel → “kollonell”
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Brunsdon & Coltheart, 2005
Assessment
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Brunsdon & Coltheart, 2005
Assessment
! Assessment of phonological, surface and mixed dyslexia in children:
• Standardised word reading tasks inadequate (eg. WRAT, WIAT)
• Only diagnose delay in general reading development
• Do not detect specific types of dyslexia
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Brunsdon & Coltheart, 2005
Assessment
! Cognitive Neuropsychological Assessment
• Structured according to existing models of normal reading
• to determine which subprocesses are intact and which are not
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Brunsdon & Coltheart, 2005
Assessment
! Core assessment Tools
• PALPA - Psycholinguistic assessment of language processing in aphasia
Kay, Lesser & Coltheart (1992).
• Word/Nonword list Coltheart & Leahy (1996)
• Graded Nonword Reading TestSnowling, Stothard, & McLean (1996).
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LetterIdentification
SUBLEXICAL
LEXICAL
Visual Word Recognition
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Assessment
• Sublexical Reading
• intact if nonword reading is age appropriate• Word/Nonword list (Coltheart & Leahy, 1996)
• Graded Nonword Reading Test (Snowling, Stothard, & McLean, 1996)
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Brunsdon & Coltheart, 2005
Assessment
• Lexical Reading
• intact if irregular word reading is age appropriate• Word/Nonword list (Coltheart & Leahy, 1996)
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Brunsdon & Coltheart, 2005
Assessment
• But, if impaired:• why is the child having difficulties with the lexical
and/or sublexical processing routes?• How do we treat the problem?
• Each process relies on the intact functioning of a number of subprocesses each of which may be dysfunctional
• We now need to assess each subcomponent of Lexical and Sublexical Route
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LetterIdentification
SUBLEXICAL
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Assessment
! Intact if:• child can complete a cross case
matching task normally (PALPA Test 19 and 20)
Abstract LetterIdentification
aA
e
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LetterIdentification
SUBLEXICAL
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Assessment
Print! Intact if :
• irregular word reading aloud is normal (Coltheart and Leahy, 1996)
• child can complete a lexical decision task normally (PALPA Test 27)
Abstract LetterIdentification
Visual Word Recognition
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Brunsdon & Coltheart, 2005
Assessment
! Lexical Decision: child must decide whether a string of letters is a word
! stimuli• regular words (like, fresh)• exception words (have, both)• pseudohomophones (brume, gane)• nonwords (mide, noast)
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Brunsdon & Coltheart, 2005
Assessment
! child with a lexical deficit will rely on phonological decoding (‘sounding-out’)
• correctly accept regular words (e.g., like)• incorrectly reject exception words (e.g., both)• incorrectly accept pseudohomophones (e.g., brume)• correctly reject other nonwords (e.g., mide)
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LetterIdentification
SUBLEXICAL
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Assessment
! Intact if:• child demonstrates normal
knowledge of word meanings through another modality (other than reading)
• ie. child can name pictures normally (PALPA Test 53)
• child can match spoken words to pictures (spoken word picture matching, PALPA Test 47)
Abstract LetterIdentification
Orthographic Input Lexicon
Semantic System
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LetterIdentification
SUBLEXICAL
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Brunsdon & Coltheart, 2005
Assessment
Print Abstract LetterIdentification ! Intact if:
• picture naming is normal (PALPA Test 53)
• spontaneous speech is normal
• child can provide a name when given a spoken definition
• e.g.. “What animal is large, grey and has large floppy ears and a long trunk?”
Visual Word Recognition
Semantics
Spoken Word Production
Speech
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LetterIdentification
SUBLEXICAL
Visual Word Recognition
LEXICAL
Spoken Word Production
Speech
Letter to Sound ConversionSemantics
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Spoken Word Retrieval
Speech
Visual Word Recognition
LetterIdentification
Semantics
Letter-Sound Associations
Breaking the word into ‘letter-chunks’
SoundBlending
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Brunsdon & Coltheart, 2005
• Break up the word into appropriate ‘chunks’ (eg. chooth or thick)
• Assign a sound to each ‘chunk’ - associate a letter/grapheme with its corresponding sound
• Blend the sounds together -convert a string of sounds into a single unified spoken form
Breaking the word into ‘letter-chunks’
Letter(s)-Sound Associations
Sound Blending
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Brunsdon & Coltheart, 2005
Assessment
! Intact if:• Child can break down a
word into appropriate chunks
• chick → ch i ck
Berndt & Mitchum (1994)Brunsdon et al (2002)
Breaking the word into ‘letter-chunks’
Letter(s)-Sound Associations
Sound Blending
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Brunsdon & Coltheart, 2005
Assessment
! Intact if:• Child has age
appropriate knowledge of letter to sound rules
• Letter sounding and spoken letter-written letter matching (PALPA test 22)
Berndt & Mitchum (1994)Brunsdon et al (2002)
Breaking the word into ‘letter-chunks’
Letter(s)-Sound Associations
Sound Blending
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Brunsdon & Coltheart, 2005
Assessment
! Intact if:• Blend sounds together to
make a single unified pronunciation
• ie. if given the correct phonemes (sounds) the child can blend them together to make the target word or nonword
Berndt & Mitchum (1994)Brunsdon et al (2002)
Breaking word into ‘letter-chunks’
Letter(s)-Sound Associations
Sound Blending
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Brunsdon & Coltheart, 2005
Treatment
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Brunsdon & Coltheart, 2005
Treatment
Cognitive Neuropsychological Rehabilitation
• Always follows a systematic and theoretically driven assessment of the cognitive disorder
• Focus on direct remediation rather than compensatory strategies• Conducted at an individual level• Tailored to an individual’s specific pattern of impairment • Carefully designed to evaluate treatment efficacy
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Brunsdon & Coltheart, 2005
Treatment
CASE STUDIES:
! Sublexical Treatment! Lexical Treatment! Letter Processing Treatment
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Brunsdon & Coltheart, 2005
CASE DT
Brunsdon, R. K., Hannan T. J., Nickels, L., & Coltheart, M. (2002). Successful treatment of sublexical reading deficits in a child with dyslexia of the mixed type. Neuropsychological Rehabilitation, 12(3), 199-229
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Brunsdon & Coltheart, 2005
Case Description
! DT
• 9 year old boy • Year 5, mainstream primary school
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Brunsdon & Coltheart, 2005
Case Description
! Neuropsychological Assessment Results
• Severe deficits in• Language processing• Verbal new learning and memory• Sustained and divided attention• Problem solving• Reading, spelling and numeracy
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Brunsdon & Coltheart, 2005
Treatment Study
• Pretreatment Assessment
• lexical processing• sublexical processing• semantics• naming
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Brunsdon & Coltheart, 2005
Pre-treatment Assessment
• General Reading
10% (3/30) z <-2.41 17% (5/30) z <-2.41 3% (1/30) ) z <-2.27
0%
Word/Nonword Test
IrregularRegularNonwords
Graded Nonword Reading Test
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Spoken Word Retrieval
Speech
Visual Word Recognition
LetterIdentification
Semantics
Letter-Sound Associations
Breaking the word into ‘letter-chunks’
SoundBlending
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Brunsdon & Coltheart, 2005
Sublexical Processing
20% Sound blending (aural)
56% 12%
Letter(s)-Phoneme KnowledgeLetter SoundingGrapheme sounding (e.g., ‘ch’)
30% Breaking words into chunks
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Spoken Word Retrieval
Speech
Visual Word Recognition
LetterIdentification
Semantics
Letter-Sound Associations
Breaking the word into ‘letter-chunks’
SoundBlending
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Lexical Processing
10% (3/30) z <-2.41
Word/Nonword Test
Irregular
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Spoken Word Retrieval
Speech
Visual Word Recognition
LetterIdentification
Semantics
Letter-Sound Associations
Breaking word into ‘letter-chunks’
SoundBlending
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Brunsdon & Coltheart, 2005
Lexical Processing
poorpoormany identified as words
Visual Lexical decision
Regular wordsException wordsPseudo homophones
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Brunsdon & Coltheart, 2005
Semantics and Naming
88% Spoken picture naming95% Spoken word-picture matching
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LetterIdentification
Breaking the word into ‘letter-chunks’
Spoken Word Retrieval
Speech
Visual Word Recognition
Letter-Sound AssociationsSemantics
SoundBlending
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Brunsdon & Coltheart, 2005
Pre-treatment Assessment
! Reading• Mixed dyslexia • Total inability to read non-words
• impairment in sub-lexical reading route• Poor sight word vocabulary
• underdeveloped lexical reading route• Comorbid cognitive difficulties
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Brunsdon & Coltheart, 2005
Treatment
! Aims:
• To improve the operation of the sublexical reading route
• To improve DT’s ability to ‘sound-out’ new words.
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Brunsdon & Coltheart, 2005
Treatment Study
! Aim• To improve the functioning of all three
sub-components of the sublexical reading route
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Brunsdon & Coltheart, 2005
Treatment Study
! Two treatment phases (over 4 months)
1. Letter to sound associations
2. ‘Letter-chunking’ and sound blending
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Brunsdon & Coltheart, 2005
Treatment - Phase 1
1. Grapheme to phoneme associations• Target stimuli
• 14 single letters• 27 graphemes (e.g., ch, sh)
• Duration • 8 weeks
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Brunsdon & Coltheart, 2005
Dd
Place this sheet in front of the child. Say “We are going to work on the sound ‘d’ (point to the D/d at the top of the page). “Repeat after me” (sound ‘d’ 3 times allowing the child to repeat each time). Say“Each of these words have the sound ‘d’ in them. Listen carefully and repeat after me”. (For each line sound the letter “d” and then read the word - point to the letter ‘d’ and then the word as you read them. Repeat each line 3 times).
d dogd dod dayd goodd downd underd dadd digd madd and
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Brunsdon & Coltheart, 2005
Treatment - Phase 2
2. Letter chunking and sound blending
• Stimuli• 2 nonword lists
• Duration • 8 weeks
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Brunsdon & Coltheart, 2005
Treatment Study
2. ‘Letter-chunking’ and sound blending• Method
• DT was required to:
1. Circle each letter-group2. Sound out each letter-group serially 3 times3. Combine the sounds
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Brunsdon & Coltheart, 2005
Treatment Study
Did treatment work?
Two baseline assessments prior to treatment:
• Letter sounding• Grapheme sounding e.g., ‘ch’, ‘th’• Nonword Reading
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Brunsdon & Coltheart, 2005
Baselines
3%0%Nonword Reading
17%8%Grapheme – sounding(e.g., ch oo th)
58%54%Letter sounding
Baseline 2Base1ine 1
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Brunsdon & Coltheart, 2005
ResultsPhase 2Phase 1
68%74% *18%3%0%Nonword Reading
92%92%88% *17%8%Grapheme –sounding (eg. ‘ch’)
92%92%92% *58%54%Letter sounding
3 months post-treatment
Post-treatment
Mid-treatment
B2B1
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Brunsdon & Coltheart, 2005
Results
• Results
• Significant Improvement in:
• Sublexical reading skills (i.e., ‘sounding-out’ skills)
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Brunsdon & Coltheart, 2005
Results
• Generalisation to:
• word reading • general phonology
• Treatment effects enduring
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Brunsdon & Coltheart, 2005
CASE TJ
Brunsdon, R. K., Hannan T. J., Coltheart, M. & Nickels, L (2002). Treatment of Lexical Processing in Mixed Dyslexia: A Case Study.Neuropsychological Rehabilitation, 12(5), 385-418
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Brunsdon & Coltheart, 2005
Case Description
! TJ• 10 year old boy • Year 5, mainstream primary school• Poor academic achievement• Delays in receptive and expressive language
development
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Brunsdon & Coltheart, 2005
Case Description
! Neuropsychological Assessment Results• General cognition - low average range• Poor problem solving • Extremely limited reading and spelling
skills
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Brunsdon & Coltheart, 2005
Assessment
! Assessment:• Total inability to read non-words
• impairment of non-lexical reading route• Extremely limited sight word vocabulary
• underdeveloped lexical reading route
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LetterIdentification
Breaking the word into ‘letter-chunks’Visual Word
RecognitionLetter-Sound Associations
Spoken Word Retrieval
Speech
Semantics
SoundBlending
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Brunsdon & Coltheart, 2005
Treatment
! Aims: • To improve the operation of the visual word
recognition system • To increase TJ’s sight word vocabulary
• 100 words targeted for treatment• 14 or 15 words per week
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Brunsdon & Coltheart, 2005
Treatment Study
• Treat list 1• test lists 1, 2, 3, 4, 5, 6 etc
• Treat list 2• retest lists 1-6 etc
• Treat list 3• retest lists 1- 6 etc
• etc
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Brunsdon & Coltheart, 2005
Treatment Study
• Stimuli• Flash cards containing target words• No picture cues
• Treatment • Weekly training and testing sessions (≈30 minutes)• daily home practice (≈5 mins)
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Brunsdon & Coltheart, 2005
Results
• Significant overall treatment effect
Cor
rect
Weeks
0102030405060708090
100
B1 B2 1 2 3 4 5 6 7po
st 1
post
2
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Brunsdon & Coltheart, 2005
Results
• Significant generalisation to untreated words
0
5
10
15
20
25
30
1 2 3 4 5 6Weeks
% C
orre
ct
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Brunsdon & Coltheart, 2005
Results
• Significant improvement in spelling
0
10
20
30
40
50
60
70
80
% correct
pre post 1 post 2
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Brunsdon & Coltheart, 2005
Results
• Results
• Overall treatment efficacy• Generalisation of treatment effects to untreated words• Maintenance of treatment effects over time• Generalisation to spelling
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Brunsdon & Coltheart, 2005
• Cognitive neuropsychological theories and rehabilitation methods can be useful for children with severe mixed dyslexia.
• it is never to late to implement treatment even in children with virtually no functional reading skills
• Significant treatment gains despite severe comorbid phonological, language and cognitive impairment.
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Brunsdon & Coltheart, 2005
Discussion Point
• Traditionally used mnemonic cue may not increase efficacy of training for all children in early orthographic development
• ?May even be detrimental to efficient acquisition of orthographic representations
Samuels, 1967 Stuart, Masterson & Dixon, 2000
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Brunsdon & Coltheart, 2005
CASE ET
Brunsdon, R. K., Coltheart, M. & Nickels, L (In press). Severe Developmental Letter Processing Impairment: A Treatment Case Study. Cognitive Neuropsychology
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Brunsdon & Coltheart, 2005
Case Description
! ET
• 7 year old boy • Year 2, mainstream primary school
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Brunsdon & Coltheart, 2005
Case Description
! Neuropsychological Assessment Results
• Severe deficits in• IQ low average• History of language delay• Severe impairments in attention• Stimulant Medication since age 5
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Brunsdon & Coltheart, 2005
Case Description
! No reading or spelling abilities! Unable to name or sound letters! Very little improvement during Kindy
and Year 1
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Brunsdon & Coltheart, 2005
Assessment
! Assessment:
lower case upper case
• Letter Naming 6/26 7/26• Letter Sounding 5/26 0/26
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Brunsdon & Coltheart, 2005
Assessment
! Assessment revealed specific core deficits:
• Matching across case impossible• General letter knowledge impoverished
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Brunsdon & Coltheart, 2005
Treatment
! Aims: • To improve ET’s ability to:
• Sound letters
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Brunsdon & Coltheart, 2005
Treatment
Focus on core impairments:
• Poor abstract letter identification
• Poor semantic representation of letters
• Training in association of upper and lower case with a single sound
• Extensive semantic elaboration
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Brunsdon & Coltheart, 2005
Treatment Study
• Treatment
• Daily training (≈15 minutes) at home by mother• 26 letters
• 3 letters per week
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Brunsdon & Coltheart, 2005
Treatment
We used materials from Letterland (Manson & Wendon, 1997)
• Letterland flash cards• Letterland ABC Book
• contains a short story about each character • Letterland CD
• has a short song linking each letter character to their sound, set to a common nursery rhyme tune
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Brunsdon & Coltheart, 2005
Treatment
! Each day ET and his mother focussed on one letter
! They
• read the letter character story• looked at the lower case flash card and sounded the letter• sang the song• generated words beginning with the letter sound• looked at the upper case flash card and sounded the letter• Revision
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0
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100
Bas
elin
e 1
Bas
elin
e 2
Post
-trea
tmen
t
Follo
wup
Abstract LetterIdentification
Results%
Cor
rect
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%C
0
10
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40
50
60
70
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90
100
Base
line
1
Base
line
2
Post
-trea
tmen
t
Follo
wup
Letter Sounding
Resultsor
rect
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Brunsdon & Coltheart, 2005
Results
! Also improvements in:
! Reading words! Writing letters to dictation
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Brunsdon & Coltheart, 2005
What we have covered
! Assessment of reading• Identifying the underlying impairment
! Treatment of Reading Disorders• ‘Whole word’ processing• ‘Sounding out’ skills• Letter Processing
! Monitoring Treatment Efficacy
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References
Berndt, R., & Mitchum, C. (1994). Approaches to the rehabilitation of "phonological assembly": Elaborating the model of nonlexical reading. In G.W. Humphreys & M.J. Riddoch, (Eds) Cognitive Neuropsychology and Cognitive Rehabilitation. London: Lawrence Erlbaum.
Castles, A., & Coltheart, M. (1993). Varieties of developmental dyslexia. Cognition, 47, 149-180.
Castles, A., & Coltheart, M. (1996). Cognitive correlates of developmental surface dyslexia: A single case study. Cognitive Neuropsychology, 13, 25-50.
*Coltheart, M., & Leahy, J.(1996).Assessment of lexical and nonlexical reading abilities in children: Some normative data. Australian Journal of Psychology, 48, 136-140.
*Edwards, V., & Hogben, J. (1999). New norms for comparing children's lexical and nonlexical reading: A further look at subtyping dyslexia. Australian Journal of Psychology, 5, 37-49.
Gathercole, S., & Baddeley, A.(1996). The Children's Test of Nonword Repetition. London: The Psychological Corporation Ltd.
Kay, J., Lesser, R., & Coltheart, M. (1992). Psycholinguistic assessments of language processing in aphasia (PALPA). Sussex, UK: Lawrence Erlbaum Ltd.
Manson, J., & Wendon, L. (1997). Letterland Early Years Handbook. Letter Land International: Cambridge. (http://www.letterland.com)
Samuels, S.J. (1967). Attentional processes in reading: The effect of pictures on the acquisition of reading responses. Journal of Educational Psychology, 57, 337-40
Snowling, M., Stothard, S., & McLean, J. (1996). Graded Nonword Reading Test. Suffolk, England: Thames Valley Test Company
Stuart, M., Masterson, J., & Dixon, M (2000). Spongelike acquisition of sight vocabulary in beginning readers? Journal of Research in Reading, 23, 12-27.
*Norms for Word/Nonword Test