Disorders of Reading and Writing
Tim Conway, Ph.D.
VAMC Brain Rehabilitation Research Center,
University of Florida, Depts of Clinical and Health
Psychology, and Pediatrics
Gainesville, Florida
This work was supported by VA RR&D Associate Investigator Award #B3480H
Language development
 What
language system develops first, oral
or written?
 What is the purpose of a written language
system?
 What do graphemes represent?
Language development (cont)
 When
do we first learn the sounds (phonemes) of
English, Spanish, Japanese, French…?
 What sensory systems aid learning speech sounds?




Visual
Auditory
Tactile kinesthetic and somatosensory
Infant studies (see Kuhl, et al., 2006)
Language development (cont)
 What
sensory input is consistent in
phonemes?
 Categorical speech perception (Liberman and
Mattingly, 1987)
 The
awareness of speech sounds or
phonemes in words is called…
 phonological processing (Wagner and Torgesen, 1987)
Language development (cont)
 Why
is the perception of phonemes,
phonological processing, important?
 When does phonological processing begin
developing?
 Does phonological processing occur in
speech, reading and spelling?
Language development (cont)
 How
does phonological processing aid the
development of speech, reading and spelling? e.g.
learning to say, read and spell new words.
 If you have trouble perceiving the phonemes in
words (poor phonological processing), how do
you know what letters to use for spelling?
 How would difficulty segmenting a word into its
constituent sounds affect spelling, reading,
speech?
Language development (cont)
 What
determines the shape of a grapheme?
 What kind of mistakes would someone with poor
phonological processing make on language tests?
 Is the development of speech, reading and spelling
an errorful or errorless learning experience?
 How does phonological processing/awareness aid
the development of an ability to perceive errors in
speech, reading, and spelling? (DEMO – spell and
read)
 STROSK
 THROIGE
Phonological Awareness

“one’s sensitivity to, or explicit awareness
of, the phonological structure of the words
in one’s language.” (Torgesen, 1994); e.g.
the number, identity, and order of
phonemes.
Comparator Function

Holding two words in memory &
comparing their sameness or difference in
phoneme number, order and identity is
called comparator function (Lindamood, Bell, and
Lindamood, 1997).
Language development (cont)

1.
2.
3.

Three things that individuals with well
developed reading and spelling skills can do are:
Sound out words (a phonological approach)
Memorize words (a visual memory approach)
Use semantics/meaning (story context)
Phonological processing aids an indirect route
(grapheme to phoneme conversion or vice versa)
to reading and spelling.
Basic 2 Route Model of Reading
(Coltheart, 1985)
PRINT
Visual Word
Recognition
Grapheme-Phoneme
Conversion System
Semantics
Spoken Word Production
SPEECH
SPEECH
Area Spt (left)
auditory-motor interface
pIFG/dPM (left)
articulatory-based
speech codes
STG (bilateral)
acoustic-phonetic
speech codes
STS phoneme
representations
Hickok & Poeppel (2000), Trends in Cognitive Sciences
Hickok & Poeppel (2004), Cognition
pMTG (left)
sound-meaning interface
Subtypes of Dyslexia and Alexia

Dyslexia: (developmental reading disorder)

Developmental Phonological (poor at sounding out pseudowords or novel real words)

Developmental Surface (not established but believed to exist; poor at reading sight
words, good at sounding out words)

Alexia: (acquired reading disorder)
 Phonological (misread pseudowords or novel real words)
 Surface (misread sight words or words that can not be sounded out, like
yacht).
 Deep (same as phonological but also make semantic paraphasias, says
“duck” when reading swan).

Pure (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
reading”)
Subtypes of Agraphia (see Roeltgen’s
chapter in Heilman and Valenstein’s, Clinical
Neuropsychology, 4th Ed)
 Agraphia:
(acquired spelling disorder;
linguistic components)
 Phonological
 Surface/Lexical
 Deep/Semantic
 Apraxic
 Pure?
What is the purpose of diagnosis?
 Treatment
comes in three forms:
 Prevention
 Remediation
 Rehabilitation
Prevention of Developmental
Dyslexia
Preventing Reading Failure in Young Children
with Phonological Processing Disabilities: Group
and Individual Responses to Instruction
Joseph K. Torgesen
Richard K. Wagner
Carol Rashotte
Elaine Rose
Patricia Lindamood
Tim Conway
Cyndi Garvan
(1999). Journal of Educational Psychology 91, 579-593.
*NICHD, National Center for Learning Disabilities, Donald D. Hammill Foundation
Prevention study - participants
 1,436
children in 13 kindergarten classrooms were
screened with a serial letter naming test.
 Bottom 30% received a second screening to estimate
IQ and measure phonological skills (elision).
 180 children selected with an estimated VIQ > 75
and the lowest combined scores on serial letter
naming and phoneme elision (bottom 12%).
 Random assignment: NTC, RCS, EP, PASP (ie. LiPS
program)
 LiPS:
20 min. x 4 days per week x 2.5 years (88
hours); 50% with untrained aides.
Prevention study – LiPS group
outcome data
45
Percent
retained
in K or 1
40
35
30
25
20
15
10
PASP
0
EP
5
RCS
end of 2nd grade: 50th
percentile in word reading skills
(accuracy AND fluency).
 LiPS - Significantly stronger in
phonological awareness,
phonemic decoding, & word
reading than all other groups.
 Best predictors of growth in
reading: attention/behavior, home
background, and P/A.
NTC
 At
Remediation of Developmental
Dyslexia
Intensive Remedial Instruction for Children with
Severe Reading Disabilities: Immediate and Longterm Outcomes from Two Instructional Approaches
Joseph K. Torgesen
Ann W. Alexander
Richard K. Wagner
Carol Rashotte
Kytja Voeller
Tim Conway
(in press). Journal of Learning Disabilities.
Supported by NICHD, NCLD, DDHF
Remediation study - participants
60 children, 8-10 yoa, staffed ESE/SLD (exceptional
student education or specific learning disability)
 Teacher referred, VIQ > 75, >=22 SS below average on
word identification and word attack, below grade level
phonological awareness (LAC test).
 Randomly assigned to two groups (LiPS and Embedded
Phonics [EP]).
 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 weeks
 Follow-up testing over a 2 year time period; n = 26 and
24.
 ADD/ADHD comorbidity 81% & 71% (LiPS and EP).

Remediation - Outcome data
 Effect
sizes of growth in reading skills were 4.4 and 3.9 (LiPS
and EP; vs. pre-intervention measures of reading.
 LiPS
- fastest rate of growth in word attack, reading rate and
accuracy, and developmental spelling.
 Significant
growth in nonword repetition, rapid naming (digits
and letters), and
 The
phonological awareness.
intensity and frequency of intervention significantly
impacts growth in reading skills.
Remediation – LiPS Outcome data
(cont)

40% staffed out of ESE within 1 year of intervention;(vs. 5% national
norm).

Reading comprehension, phonemic decoding accuracy and text reading
were Average at 2 yr f/u, and fluent at 4 year f/u.

66% of children demonstrated comprehension of written language >=
1SD above their receptive language abilities.

Best predictors of growth in reading skills were attention/behavior
(confound), receptive language skills (CELF-III), and prior phonological
awareness (an inverse relationship).
Alexia Rehabilitation
Treatment of a case of phonological alexia with
agraphia using the Auditory Discrimination in
Depth (ADD) Program
Tim Conway
Patricia Heilman
Leslie Gonzalez-Rothi
Ann W. Alexander
Stephen Nadeau
John Adair
Bruce Crosson
Kenneth Heilman
Journal of the International Neuropsychological Society (1998), 4,
608-620.
Alexia Rehabilitation - case study
 50
year old male, 14 years education,
ambidextrous (left for writing & eating).
 Sudden onset of aphasia, alexia, agraphia,
limb apraxia, and visual field cut.
 15 months post onset of CVA
(cerebrovascular accident).
 Resolving conduction aphasia, mild
phonological alexia, & mixed dysgraphia.
 Goal: rehabilitate phonological awareness
deficits & improve reading ability.
Alexia 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 probes
Read aloud
simple nonword
probe
100
80
Read aloud
complex nonword
probe
60
40
Read aloud
multi-syllable
nonword probe
20
0
Baseline
Post Oral
Awareness
Post
Simple
Post
Complex
Post
Multisyllable
Spell irregular
word probe
Alexia Case Study - dependent
measures
 Improved
pseudoword reading (73, 93, 90% correct on pre,
post, and follow-up testing [Battery of Adult Reading Function, Rothi et al.,
1984;]; 99, 112, 115 Standard Score [WRMT-R, 1987])
 Improved word identification (99, 103, 113 Standard Score
[Wodcock Reading Master Test-Revised WRMT-R, Woodcock, 1987])
 Improved auditory working memory & phonological
awareness (LAC-MAC 50, 92, 100%; Lindamood Auditory
Conceptualization Test-Multisyllable Auditory Conceptualization, Bell & Lindamood,
1996).
 Self-report
of improvement after only 30 hours of treatment.
Alexia Rehabilitation (cont)
Alterations in the Functional Anatomy of Reading
Induced by Rehabilitation of an Alexic Patient.
John Adair
Stephen Nadeau
Tim Conway
Leslie Gonzalez-Rothi
Patricia Heilman
Isaac Green
Kenneth Heilman
Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 13 (4), 303311.
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 Tasks
 Language
- silent reading of pseudowords
 Nonlinguistic
Maze task
- visual tracing of Porteus
Alexia case study – increased
Cerebral Blood Flow (CBF)
Language 2 > Language 1 (increased activity from
post-treatment versus pre-treatment comparison)
 Right hemisphere:



 Left
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).
Hemisphere:
 large


contiguous areas of modest increase
Frontal (inferior gyrus & premotor; BA 44 & 6)
Parietal Opercular (BA 40)
Alexia Conclusions - Participant #1
 Effective
rehabilitation of mild phonological
alexia that appeared to engage right-hemisphere
cortex, homologous to left-hemisphere areas
usually involved in reading and language. Also,
may have re-connected spared Left-hemisphere
language structures.
 Possible aids to treatment outcome: intact
Broca’s area, ambidexterity, highly motivated,
mild level of impairment, intensity and
frequency.
Alexia Case study #2 (different CVA
participant)
 Single-subject,
multiple-baseline design and
pre- post-treatment testing.
 92 hours of treatment over a 12-week
period, (LiPS )
TM
 treatment
description in Kendall et al, 2003.
Alexia Case study #2
right handed, 48-year-old male, 12th grade education, with an
ischemic stroke 81 months prior to the current study.
 T1 weighted MRI showed infarction in left hemisphere operculum and
frontoparietal involvement.
 He demonstrated phonological alexia, agraphia, anomia, and nonfluent
aphasia before treatment.
 Imaging tasks included pseudoword repetition and pseudoword
reading, only repetition data is presented here;
 Behavioral change:

improved pseudoword repetition post-treatment
 pseudoword reading improved over 47 standard scores points from pretreatment to 3 month follow-up

Multiple-probes Pseudoword Repetition
100
90
80
% correct
70
Baseline
Baseline
Phase
Phase
Treatment
Treatment
Phase
Phase
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Alexia Case study #2
- Nonword repetition
Pre-treatment
L
Post-treatment
R
L
R
Alexia Conclusions – Participant #2
 Generalization
of a phonological-motor treatment to pseudoword
repetition involved increased activity in some left perilesional
cortex and the right-hemisphere SMA.
 Decreased activity in the right hemisphere was evident posttreatment.
 Increased activity in two perilesional regions, decreased activity in
several regions (mostly on right hemisphere)
 Improved behavioral performance indicates neural reorganization
towards increased cortical efficiency following a successful
phonological-motor treatment.
THANK YOU FOR YOUR
ATTENTION AND
PARTICIPATION