PEDIATRIC CLINICS (OF NORTH AMERICA, Poi nN Am S4 (2007) 609-623, Management of Dyslexia, Its Rationale, and Underlying Neurobiology Sally E. Shaywitz, MD", Jeffrey R. Gruen, MD*, Bennett A. Shaywitz, MD’ ind. adul jon considered necessary for accurate and fluent rea lexia (or specific readi edi W rights reserved, ‘petri theclnies.comoccur along a continuum, with representing the lower tail of a normal distribution of reading abj ia is perhaps the most common neurobehavioral heritable [16]. Family history is one of h 23% to as much as 65% of reported to have polygenic nature, create confusing transmission patterns that | mendelian rules governing recessive, domi iked single-gene disorders. Regardless of these complexities, linkage studies, enabled in large part by the Genome Project, have identified broad locations on human Of the nine described dyslexi DYX?2 located on the “ (6p2), spanning nearly 20 million bases. Recently, jon of the DCDC2 gene encoded on 6p22 with several reading ascent oF va. exa ou sso Pe | wo ‘ | $e Bas «00 b © 6 Age (years) ony say Sra, Ovreming Dyn, 2009 of the genetic effect Other candidate genes for dyslexia have been described. Encoded just 500,000 bases away from DCDC2, Cope and colleagues [20] described a sec~ iid make for more convincing evidence [21,22]. Gene the dyslexia loci remains an active area of study, rong consensus support- speech is natural and«2 suvwirzet ab inherent, whereas reading is acquired and must be t ginning reader must recognize that the letters and letter raphy) represent the sounds of spoken langua particles of speech (phonemes) and that the letters in a written word sent these sounds [3]; such awareness is largely missing in dyslexic child and adults [3,12,23-27]. Results from large and well-studied populatio in phonology repres and specific correlate of reading disability [30,31]. Such findings form the by sis for the most successful and evidence-based interventions designed t improve reading [32] Neurobiologie studies of disabled readers Neural systems influencing reading were first proposed over a cent ity to read. Tt has o been within the last two decades that neuroscientists have been able to termine the neural systems that influence and reading disal fing the neural bases of reading and dys ven by the development of functional neuroimaging, technique that measure changes in metabolic activity and blood flow in specific br the principle of autoregulation of cerebral blood flow, Details of function MRL are reviewed elsewhere [34-36] ‘A number of research groups have used positron emission tomography @ ly have validat to reading. For e pl study c half of were struggling reader nonimpaired readers, the authors: found significant differen n patterns during phonoloy Children in predominantly left hemisphere sites (including he inferoe fi tal, superior temporal, parietotemporal, and middle temporal-middle oc ‘These data converge with reports that show a hemisphere posterior brain systems to fu and indicate that dysfunction already present in dysle time of poor reading [5,39]. Although dyslexic readers exhi in posterior reading systems, they seem to develop compensatory syste MANAGEMENT oF DYSLEXIA 613 involving areas around the inferior frontal gyrus in both hemispheres and right hemisphere homolog of the left occipitotemporal word form area (38) ‘These sturlies indicate that in addition to the posterior systems, an ante- rior system is also involved in reading. The anterior network in the inferior frontal gyrus (Broca’s area) has long been associated with articulation and also serves an important function in silent reading and naming (35,40). The 10 posterior regions seem to parallel the two systems proposed by Logan [41,42] as critical in the development of skilled, automatic reading. One sys- tem involves word analysis; operates on individual units of words, such as phonemes; requires attentional resources: and processes information rel Lively slowly, It is reasonable to propose that this system involves the par A :cond posterior network, I ized to a region termed the “visual word-form area” (43), influences skilled, reading. Dehaene and associates [44-46] have suggested a systematic 1g within the left occipitotemporal region, with more pos- regions coding for letters and letter fragments and more anterior coding for bigrams and words. Furthermore, recent evidence indi- hat the disruption in the left occipitotemporal word form area in ‘xic individuals is found not only for reading words, but for naming pictures of the words, the disruption in this region In other words, reduced activation in the same occipitotemporal may underlie the reading and naming deficits observed in develop- ‘mental dyslexia” (Fig. 2) [47] MRI has been hetpful in clarifying potent authors used data from the Connecticut Lon- aple of now young adults who have been prospectively followed since 1983 when they were age 5 years and who have had their reading performance assessed yearly throughout their primary and secondary schooling. Three groups were identified and imaged: (1) nonim- paired readers who had no evidence of reading problems; (2) accuracy im- Proved readers (AIR) who were inaccurate readers in third grade but by hinth grade had compensated to some degree so they were accurate (but ot fluent); and (3) persistently poor readers (PPR) who were inaccurate grade and remained inaccurate and not fluent in ninth grade. word reading, tivation patterns in the two groups of ed readers (AIR and PPR) diverged, with ATR demonstrating the typ- ly different types to that observed in nonimpaired readers, despite the icantly better reading performance in nonimpaired readers compared PPR on every reading task administered. Evidence indicated that ather than decoding words, the PPR group was reading primarily by mem- ry. Because it is a longitudinal study, data from the Connecticut614 suavwrrzet al MANAGEMENT OF DYSLESIA ois Ongoing studi differences between these groups may help confirm or refut waging has been helpful sypothesi Saran ‘examining whether the neural sys- (word ara) ve reading intervention, 8 who received other types of intervention, th struggling reader cig temporal (wort om) icy regarding teaching children to read: the provision of an evidence-based 1g intervention at an carly age improves reading fluency and facilitates ‘development of those neural systems that underlie skilled reading. Diagnosis ages, dyslexia is a rough history, observa unexpected dil Shaywitz S. Overcoming dh At New York a a igence, or level of c problems at the level of phonologic ind first grade were avail jeaders (PPR and ATR) feature reading vantaged schools. s . : honologic deficit, ‘These snd other findings suggest that PPR may be doubly disadvantaged ins. being exposed to a less rich language environment at home and then y lay or of not attending to effective reading ins tory factors, such environment a of their phonologic deficit so th nonimpaired readers on a e 1g comprehension. ‘These findings of differences, neurobiologically, cognitively, and edu tionally, suggest that the two types of reading disability observed iit e may represent different ly sounding out words. may have their 18 Even after acquiring decoding ictors. Other factors aoe ssiavwrrzet al MANAGEMENT OF D years. Mainly, such tests are centered on a chiles 3 and jonemes, the basic p ‘words. Tests of phonologic capabilities and reading readiness are becoming ble; one such testis the Comprehensive Test of Phonolog- ly standardized for age 5 through adui [49]. In addition to phonology, knowledge of letter names and sounds rongest predictors of a child's readiness to read. An appropriate battery of tests for the early recognition of reading problems includes tests ter names and sounds, vocabulary, print conventions, and ng comprehension. Tests of reading are also useful because they allow ‘comparison of & th his or her peers a important to note th effortfal reading sine qua non of a a reading disability. Assessment of prereading and reading Even before the time a child is expected to read, a chi read may be assessed by measurement of the skills, especially phon related to reading success, Following a predictable developmental pat real word and pseu- and the Woodcock doword reading, such Reading Mastery Tests [5 decode nonsense or made-up words, is a particularly have memorized the words; each nonsense word must be sounded ou word reading are referred to as "word attack.” Silent reading n may be assessed by cither Woodcock test, Reading fluency, need to apply the child to read aloud using the Gray Oral Reading Test [52]. This test con- lowed by five comprehen- nd comprehension areous cach word. Listening to a leaves no doubt al authors recommend listening to the child grade level reader. Keeping a set of graded readers a\ serves the purpose and does not require the child to bi reading and writing. ther to recognize or to measure the lack of tomaticity in reading is perhaps dyslexia in older chi of their struggles to read. sess reading accuracy but not automat! commonly used for school-age represents an exception [56]. Any ive to peers with the sam degree of education or professional Developmental course and outcome they dem the development of reading xie readers may become quite proficient in reading a finite dor nts and young "their dyslexia, llege and even jo remember that these older dyslexic stu= ir unimpaired peers on untimed measi nue to suffer from the phonologic defic gradua unimpaired context to 1g classroom lectures; usin to access texts and other books they have di opportunity to take tests in alternate 3, such as sl Reading instruction and intervention fe span perspec problem. As a cl ms, Effective intervention programs provide children wi ‘on in each of five critical components of reading: (1) phonemic yy to focus on and manipulate phonemes, speech 2) phonics (understan sound correspuuraging, indicating ing evidence-based methods can reme systems and may even prevent, reading diffic n primary with an lary systems (eg, potheses regarding the fy suggested co} comprehension, yet continue to suffer from makes reading | data now provide strong evidence for the necessity of e with dyslexia, Functional MRI data demonstrate a di form area, the region suppor skills to the surrou they cannot en +h accommodations, many students with dyslexia are m here is no one “magical” program 1 number of programs following the wve proved to be highly effective in s reading diffi ines provided previously Shay Within the last two decades 0 ries has converged to indicate the cogni 1 dyslexi resents a wnguage system and more speci L system, phonologic processing. the subcomponent processes of reading now allow ing in br id as a result provide for the firs ing a biologic signature idence from a number of laboratories using, fu es @ disruption of left hemisphere posterior y. 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