Understanding dyslexia

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1 Understanding dysexia

2 About this free course This free course is an adapted extract from the Open University course DSE212 Exporing Psychoogy: This version of the content may incude video, images and interactive content that may not be optimised for your device. You can experience this free course as it was originay designed on OpenLearn, the home of free earning from The Open University There you aso be abe to track your progress via your activity record, which you can use to demonstrate your earning. The Open University, Waton Ha, Miton Keynes, MK7 6AA Copyright 2016 The Open University Inteectua property Uness otherwise stated, this resource is reeased under the terms of the Creative Commons Licence v4.0 Within that The Open University interprets this icence in the foowing way: Copyright and rights faing outside the terms of the Creative Commons Licence are retained or controed by The Open University. Pease read the fu text before using any of the content. We beieve the primary barrier to accessing high-quaity educationa experiences is cost, which is why we aim to pubish as much free content as possibe under an open icence. If it proves difficut to reease content under our preferred Creative Commons icence (e.g. because we can t afford or gain the cearances or find suitabe aternatives), we wi sti reease the materias for free under a persona enduser icence. This is because the earning experience wi aways be the same high quaity offering and that shoud aways be seen as positive even if at times the icensing is different to Creative Commons. When using the content you must attribute us (The Open University) (the OU) and any identified author in accordance with the terms of the Creative Commons Licence. The Acknowedgements section is used to ist, amongst other things, third party (Proprietary), icensed content which is not subject to Creative Commons icensing. Proprietary content must be used (retained) intact and in context to the content at a times. The Acknowedgements section is aso used to bring to your attention any other Specia Restrictions which may appy to the content. For exampe there may be times when the Creative Commons Non- Commercia Shareaike icence does not appy to any of the content even if owned by us (The Open University). In these instances, uness stated otherwise, the content may be used for persona and noncommercia use. We have aso identified as Proprietary other materia incuded in the content which is not subject to Creative Commons Licence. These are OU ogos, trading names and may extend to certain photographic and video images and sound recordings and any other materia as may be brought to your attention. Unauthorised use of any of the content may constitute a breach of the terms and conditions and/or inteectua property aws. We reserve the right to ater, amend or bring to an end any terms and conditions provided here without notice. A rights faing outside the terms of the Creative Commons icence are retained or controed by The Open University. 2 of 58 Wednesday 7 September 2016

3 Head of Inteectua Property, The Open University Edited and designed by The Open University. Printed in the United Kingdom by The Bath Press, Bath Contents Introduction 4 Learning Outcomes 5 1 Approaches to the definition of abnormaity Introduction Definitions of normaity Overview of normaity Experiencing dysexia Defining dysexia Positive indicators for dysexia Dysexia as a distinctive condition Refecting on definitions of abnormaity 23 2 Expanations of dysexia Behavioura, cognitive and bioogica perspectives Cognitive expanations of dysexia Bioogica expanations of dysexia Differences in brain architecture Biochemica factors Environmenta expanations of dysexia? Refecting on expanations of abnorma deveopment: the case of dysexia 39 3 Treatment and management Thinking about intervention Behavioura approaches Cognitive approaches Bioogica approaches Evauating intervention studies Refecting on dysexia 50 Concusion 52 5 Further reading 52 Keep on earning 53 References 54 Acknowedgements 57 3 of 58 Wednesday 7 September 2016

4 Introduction Introduction Dysexia is a condition affecting iteracy skis. This course anayses how our image of normaity affects the way we as a society define such conditions. You wi earn how important it is to integrate the different psychoogica accounts of dysexia in order to provide a fu expanation of potentia causes and strategies for remediation. This OpenLearn course provides a sampe of Leve 2 Socia sciences 4 of 58 Wednesday 7 September 2016

5 Learning Outcomes After studying this course, you shoud be abe to: identify and discuss the issues that reate to the definition, expanation and remediation of abnorma psychoogica functioning understand the compexities invoved in identifying, expaining and managing dysexia.

6 1 Approaches to the definition of abnormaity 1 Approaches to the definition of abnormaity 1.1 Introduction You may have noticed that we often discuss peope with the assumption that there is a norma pattern of behaviour, which some peope do not conform to, whie the rest do. This idea of normaity is impicity subscribed to in many areas of psychoogy. We theorise about norma deveopment, norma memory functioning, typica perceptua experiences, gender appropriate behaviour, and refer more expicity to exampes of unusua psychoogica functioning as being of interest, because of what they can te us about norma functioning. The concept of psychoogica normaity is not simpe. This course addresses the issues surrounding the idea of norma psychoogica deveopment, and shows that how we define normaity wi infuence the way we think about and dea with abnorma psychoogica functioning. To iustrate how abnormaity is defined in practice, and what issues are important when considering its causes and treatment, we wi refer to the specific exampe of deveopmenta dysexia. However, these issues wi aso appy to many other types of abnorma functioning. We need to consider mutipe perspectives in psychoogy, as our understanding of a topic is enhanced by the comparison of research findings from different perspectives. This course shows how research from cognitive, bioogica and neuropsychoogica perspectives can be combined to offer a more compete account of conditions ike dysexia. The course therefore presents dysexia as a case study in how different perspectives might be compementary to each other. 1.2 Definitions of normaity What do we mean when we say something is norma? Activity 1 Write down what you woud consider to be norma for each of the foowing exampes: women's height; eyesight; behaviour when waiting for a bus; consumption of acoho. Each of your answers to Activity 1 wi refect a different approach to defining normaity. We wi examine each of these approaches in turn. Note that there are quotation marks around the word normaity. This is to show that we are exporing the 6 of 58 Wednesday 7 September 2016

7 1 Approaches to the definition of abnormaity meaning of the word, and accept that there is no one unprobematic definition. Throughout the chapter, quotation marks around any word indicates that there are issues or debates about the definition of the word Statistica approaches to normaity What did you base your idea of norma height on? It might have been based on your own experience, refecting the average height of women in your community. Simiary, abnormaity can be defined in terms of ow statistica frequency. If what is most common in the genera popuation is considered norma, then any behaviour or psychoogica characteristic that occurs ony rarey may be regarded as abnorma. From this viewpoint, above average individuas are just as abnorma as those who are beow average. This approach is particuary suited to variabes that are dimensiona, such as height or scores on a test. These variabes end themseves to measurement on a continuous scae. You can reate this to what you have aready earned about the norma distribution. If you ook at Figure 1, you can see the norma distribution curve with the mean vaue in the midde. About 68 per cent of a vaues are within one standard deviation of the mean (Dancey and Reidy, 2002). This is termed the norma zone of the curve. Note that this choice of the percentage of vaues which comes under the norma zone of the curve is arbitrary in the sense that it was defined by statisticians, and does not refect any natura circumstance or aw. Figure 1 The norma distribution curve (Source: Dancey and Reidy, 2002, p. 89) The standard deviation for a set of scores can therefore be used to define the boundaries of what norma might be. Another exampe is that of IQ scores, which are constructed to be normay distributed with a mean of 100 and a standard deviation of 15. This means 7 of 58 Wednesday 7 September 2016

8 1 Approaches to the definition of abnormaity that IQ scores between 85 and 115 are considered to be norma. Scores ower than 85 are regarded as abnormay ow (the bottom 16 per cent), and scores higher than 115 are seen as abnormay high (the top 16 per cent). This seemingy simpe and objective approach to defining normaity is in fact quite probematic. If deviation from statistica norms is used to define abnorma functioning, then the foowing questions about measurement must be answered. 1 How are psychoogica characteristics (such as inteigence) quantified? Can they be measured on a continuous scae or are they better captured by discrete categories? 2 Do the reevant measures have a norma distribution? If not, mean scores and standard deviations are ikey to be inappropriate reference points (Dancey and Reidy, 2002). 3 Are the assessments reiabe? Tests that are going to be used for diagnostic purposes need to have extremey good interna and externa reiabiity. 4 Are the assessments vaid? To address this, we need to be cear about the purpose of measurement and consider different types of vaidity. 5 How is a behaviour cassified as abnorma? The one standard deviation away from the mean criterion can be a rather over-incusive indicator of abnormaity for some tasks, especiay if the consequences of such an assessment woud be to give that person a negative abe. More extreme boundaries of 1.5 or 2 standard deviations from the mean are sometimes chosen instead. Any cut-off point for cassifying peope into discrete categories of norma and abnorma is arbitrary if the characteristic in question reay is dimensiona. 6 Does it matter if someone is scoring higher than the average popuation? On some measures very high scores may be just as worrying as very ow scores (e.g. persistent over-arousa, refecting stress or anxiety). On other measures, ony one extreme of the distribution may be considered abnorma in the sense of probematic. The statistica approach to defining normaity does not make these kinds of judgements, so ceary other criteria are being appied in these situations Medica approaches to normaity What did you write for norma eyesight? The abiity to see ceary without gasses? It is unikey that you wrote down short- or ong-sightedness as an exampe of norma eyesight, even though they are very common. However, they are not seen as norma because having to wear gasses is perceived as a imitation or even a form of disabiity. This reates to one of severa so-caed medica modes of normaity, which centre on the idea of uniformity of physica and psychoogica functioning across individuas. These modes are often reductionist, proposing that disease or physica disorder of some kind can expain abnormaity, athough such expanations frequenty acknowedge socia and externa factors that may trigger the physica cause of a probem. Psychoogica conditions ike depression can be viewed using medica approaches as the resut of abnorma functioning of the brain systems that govern mood and arousa. As a resut, medica modes often provide the rationae for many drug treatments (e.g. antidepressants) aimed at correcting the presumed biochemica imbaances to restore norma functioning. However, these simpe reductionist approaches have proved unsuccessfu because: 8 of 58 Wednesday 7 September 2016

9 1 Approaches to the definition of abnormaity 1 The identification of many psychoogica disorders can be very difficut in practice, because they appear to fa on a continuum with norma functioning, so any cear distinction between norma and abnorma is frequenty difficut to draw. 2 Biochemica (drug) treatments often go hand-in-hand with a medica approach. However, there is sti considerabe uncertainty about the precise nature and origins of any biochemica abnormaities associated even with we-studied conditions ike depression or schizophrenia, for which various drug treatments are in routine use. For others such as eating disorders, even ess is known about possibe biochemica contributions, if any exist at a. 3 It is evident that many of our most common diseases are actuay systemic they arise from a breakdown of many compex interacting systems, and medica approaches acknowedge this. They shoud not be thought of as simpe or reductionist expanations for physica or psychoogica disorders. For exampe, both heart disease and cancer arise from the interaction of genetic predisposition with environmenta and ifestye factors that incude both bioogica and sociocutura infuences. There is no reason to suppose that psychoogica disorders are any simper. The sheer compexity of the many interacting systems invoved in human deveopment and functioning means that even in physica disorders, reaistic medica approaches are rarey simpe or reductionist. In the same way that good medica modes refect compex interactions between different factors, so too shoud our modes of psychoogy Cutura approaches to normaity What is norma in terms of the simpe act of waiting for a bus? In the UK it is expected that peope wi organise themseves into a queue, so those who have waited the ongest can board the bus first. However, this is not true of a cutures. Yet, if someone from a cuture that does not queue were waiting for a bus in Manchester and did not wait her turn, she woud be chastised for it. So, another approach might be to define as abnorma any behaviour that contravenes socia norms, vaues or expectations. Using a cutura approach, what is defined as abnorma wi depend on expectations and standards of the society, and thus on poitica and economic as we as socia factors. The criteria used may differ between societies, over time within the same society, and between groups within the same society. One thing to consider is whether a deficit or abnormaity is defined as such by context. For exampe deficits in one area may be inked to abnorma strengths in another. We sha consider this in more detai in reation to dysexia ater in the course. Another issue is whether what is considered norma shoud then aso be considered as natura. Human behaviour is compex and is determined by interactions between a variety of infuences, interna and externa. Consequenty, the idea that some behaviours are natura because they are determined in some part by our physioogy, is not a satisfactory justification on its own for considering them norma Persona distress Another way of defining psychoogica abnormaity is to ask whether certain behaviours or styes of functioning cause distress to the individua concerned. Think about your 9 of 58 Wednesday 7 September 2016

10 1 Approaches to the definition of abnormaity response to what you consider to be norma acoho consumption. Perhaps you specified a maximum number of units per day or week? If so, why did you do this? Is it because of the heath probems associated with excessive drinking, or because of its association with antisocia behaviour? Some of you may beieve that any acoho consumption is inappropriate, for medica, cutura or reigious reasons. Aternativey, some of you might have specified an age criterion that refects the ega age for acoho consumption in your country. These are not trivia points. Many peope see excessive acoho consumption, even if within cutura norms, as abnorma because of the persona distress it wi cause. They beieve that heavy drinking can ead to acoho dependency or heath probems that have the potentia to ruin a person's ife. An obvious difficuty with the criterion of persona distress is that in some cases, such as acohoism or drug use, persona distress is not necessariy manifest. Whose distress are we considering? Are we reay intervening in the interests of the person showing the behaviour, or in the interests of their famiy or society? Moreover, who makes the decision to intervene wi vary depending on what the behaviour is. The degree to which individuas are pressurised to compy wi aso vary depending on whether it is a doctor or a friend who is trying to intervene. Ceary, this criterion raises some compex issues to do with the imposition of other peope's vaues and the acceptabiity of setting imits to individua freedom. Tobacco use is associated with substantia heath risks and socia issues, but woud intervention, in the form of bans on its use, infringe persona freedom? If the answer is yes, then why does this not equay appy to behaviours such as eating disorders? Is it because of sociocutura notions of what constitutes norma behaviour? Furthermore, does the arge number of peope engaging in a behaviour, such as smoking, make it somehow more norma? Box 1: Definitions Dimensiona Used to refer to variabes that end themseves to measurement on a continuous scae (e.g. height is dimensiona, but eye coour is not). Systemic: Beonging to or affecting the system or body as a whoe. For exampe cardiovascuar disease, with origins invoving many interacting subsystems, is usuay seen as systemic, whereas tubercuosis, caused by a singe infectious agent, is not. 1.3 Overview of normaity Before we can specify what might be abnorma, we must first have a cear idea of what we mean by normaity. However, within psychoogy this is much more difficut than it first appears. As our discussion has shown, psychoogica normaity can be defined in terms of: what is average or typica with respect to statistica frequency; ack of disabiity where normaity is defined by reference to an idea or perfect state of functioning; conformity to socia, cutura or historica expectations or norms; 10 of 58 Wednesday 7 September 2016

11 1 Approaches to the definition of abnormaity individua we-being or ack of persona distress. It is important to recognise that these approaches are not mutuay excusive. Thus, normaity can be defined by cacuating statistics on what is most common, as we as by trying to find vaid, bioogicay based criteria of heathy functioning. It can aso be cuturay defined, encompassing socia vaues and expectations, as we as invoving appreciation of individua differences and persona we-being. Each of these factors may carry more or ess weight, depending on the circumstances and the behaviour(s) being considered. There is so much natura variation in human behaviour and psychoogica functioning that it is amost impossibe to arrive at any universa definition of normaity. This means that attempts to define abnorma psychoogica functioning can be probematic and miseading uness carefu consideration is given to the reasons for seeking such a definition. Why do we need to make a distinction between norma and not norma when we are acutey aware that human psychoogica ife is so diverse? Do you think that society or the individua within it benefits from identifying some types of behaviour as abnorma? 1.4 Experiencing dysexia To iustrate just how probematic the idea of abnormaity is in practice, we wi consider the condition of deveopmenta dysexia, dysexia for short. Dysexia is reativey common and you may have knowedge of it from friends or persona experience. The foowing section iustrates many of the difficuties experienced by peope with dysexia, and it aso highights more generay some of the probems that can occur if you are not, in some sense, norma. A case study in abnormaity Aexander Faudy is severey dysexic. Dysexia is a condition that is primariy manifested by a difficuty in earning to read and write, athough its behavioura symptoms are far more wide ranging than this. At the age of 11 Aexander was sti ony abe to write two egibe words per minute, and coped with reading by using book tapes intended for bind peope, which he woud isten to whie foowing the text of the book. He was aso extremey cumsy and uncoordinated. Unabe to read at a for a ong time, he suffered buying at schoo. In these respects his story is not untypica of many peope with dysexia. However, Aexander is aso not norma in another respect he has an extremey high IQ. By the time he was 11 he had passed GCSE and A-Leve Engish Literature and had begun a foundation course with The Open University. To achieve a this, Aexander and his parents had to persuade schoos and examination boards to change their thinking about the ways they assessed and examined dysexic students' work. Aexander dictated his work to his parents who woud copy down what he said verbatim. At 15 he won a pace at Peterhouse Coege, Cambridge as the youngest student since Pitt the Younger, studying Theoogy and History of Art. 11 of 58 Wednesday 7 September 2016

12 1 Approaches to the definition of abnormaity Aexander's story in his own words, aged 12 At payschoo, other chidren were taught to read. They tried to teach me, but I was never any good at it, and even when I did earn to read I was very sow When I was five, an important marker in my dysexic case history emerged. The use of my eft and right hands became more or ess even, and in paces, aternated, a fact that puzzed my cass teacher I was physicay weak and uncoordinated. My contemporaries at schoo concuded that I wasn't one of them. I wasn't any good at throwing a ba, reading, or beating someone up for no apparent reason Despite my wide iterary knowedge, I was no good at my Engish cass, something that rather upset me. My speing was bad, and handwriting sow and abominabe. It hurt to write, because I had to write so quicky to keep up I did bady in Engish and Maths and it was suggested my quaities were incompatibe with the next part of the schoo. I was humiiatingy sent down in the period before unch to the bottom cass to be taught how to write etters propery Officia confirmation that I had dysexia came in 1990, when I was seven When I was sti in the pre-prep, I got my parents Otheo cassettes and fuyiustrated text, and set about reading and istening to it simutaneousy (a method which was ater to serve me in good stead). My parents asked me to tak about the pay on tape. They then showed me more new texts and pays which expanded my mind and heped me to see that ife cannot just be tacked by attacking a surface but by digging out the root At the beginning of the spring term in 1992, when I was nine, my parents finay et out the secret to me a the reading of Shakespeare and Donne had had a purpose: I had been doing a GCSE. I fet a sense of achievement unike anything before. By this time I had entered the ower schoo My form teacher, who took me for Maths, gave me a D at the end of term, and tod me to try harder, for I was using my dysexia as an excuse for aziness and that it wasn't the probem my parents and I were making it out to be My handwriting got worse as I was expected to write at speed. A normay we-meaning and kind science teacher ripped out severa pages of my work in front of the entire cass because he thought them insufficienty neat. I fet humiiated and dejected I received my GCSE resuts during the summer. It was a very specia day. Taking a GCSE had raised my standard of thinking and heped me put the concerns of my contemporaries in perspective. They woud fee great sorrow if they kicked a footba the wrong way, but I had earned about the rea sorrows of death, ove, hate, kindness, greed, treachery, avarice, power and corruption. I coud earn more about ife from poetry than I coud by trying to kick a arge spherica object between two posts. (Faudy, 1998, p. 3) 12 of 58 Wednesday 7 September 2016

13 1 Approaches to the definition of abnormaity Activity 2 Make notes on which difficuties experienced by Aexander were the resut of his condition, and which were constructed by having to fit in to norma ways of doing things? In some senses dysexia itsef is a construction because it was not identified as a difficuty unti there was a societa expectation that everyone shoud be iterate. The difficuties in earning to read and in physica coordination (incuding writing) experienced by Aexander are genuine probems, but the negative socia and emotiona consequences of them are not: they resut from expectations of the eve of performance he shoud attain and imited toerance by others to his being different. This is evidenced not just in the buying, but aso in the way that his teachers responded to his work, as they wanted him to conform to the norma set of skis and abiities defined as appropriate to his age and cuture. Aexander's success in Engish using his technique of istening to book tapes and dictating his work suggests that there was imited need for such an emphasis on traditiona forms of iteracy to demonstrate his competence in the subject. The comments of Aexander's mathematics teacher iustrate another aspect of having dysexia: having a abe that effectivey says this person is not norma. Peope react to abes in different ways, sometimes positivey, sometimes negativey. Labes reate to stereotypes and can resut in prejudicia attitudes towards the individua concerned. The teacher here suggests such an attitude: the idea that dysexia is used by parents as an excuse for itte more than aziness on the part of their chid. It aso suggests that the teacher may be sceptica about dysexia itsef. This scepticism persists in some quarters because there has been debate about the nature and causes of dysexia, 13 of 58 Wednesday 7 September 2016

14 1 Approaches to the definition of abnormaity whether it differs from genera reading difficuties, and how. In this course we consider the evidence that dysexia exists as a distinct syndrome with a bioogica basis What is dysexia? Dysexia invoves difficuties in earning to read and write. However, this is not the ony form of difficuty that peope with dysexia experience. They usuay have particuar difficuties with coding: earning and retrieving associations between verba and visua information. The most obvious exampe is when we have to earn what sounds the etters of the aphabet make, but this difficuty can aso affect the speed with which dysexic peope are abe to earn and reca the names for objects. Generay, peope with dysexia have difficuty deaing with phonoogica information (speech sounds) in short-term memory, so any task that requires the processing of verba information wi prove difficut. For this reason menta arithmetic is aso often difficut, and mathematics generay can suffer because of the coding that is often necessary when earning mathematica symbos and their functions. Another genera area of weakness is the sequencing of information. Poor sequencing can affect the written expression of ideas, or methods of working in mathematics, but it most obviousy affects information that is usuay earned by rote, such as the months of the year, or mutipication tabes. Directiona confusions are aso common, and peope with dysexia often have difficuty remembering eft from right. Box 2: Key characteristics of peope with dysexia compared to peope without dysexia A deay or deficit in understanding etter sound correspondences. A deay in earning to read. Poor speing. Difficuty generating written anguage. Some initia difficuty in recognising rhyme. Poor short-term memory. Poor menta arithmetic. Difficuty in earning abes (e.g. names for new objects). Difficuty naming objects and word finding. Difficuty earning sequences (e.g. months of the year, the order of a sequence of tasks). Sowness in earning text or verba information. A subte difference in form and function of some areas of the brain. Dysexia is reativey common, with an estimated prevaence of around 5 per cent in its severe form, and as much as 10 per cent if mider cases are incuded. Prevaence depends on the definition used and there are severa different ways in which the identification of dysexia can be approached. There is a wide variety of terms used to describe specific difficuties in earning to read. The origina term word bindness was rejected in the 1960s and repaced by the more famiiar term dysexia, which is preferred by peope with dysexia and their famiies. However, it is disiked by many psychoogists, 14 of 58 Wednesday 7 September 2016

15 1 Approaches to the definition of abnormaity who beieve that it impies a degree of certainty about the existence of a distinct syndrome. In fact, there is continued debate about the core symptoms of dysexia and its potentia causes. The terms specific earning difficuty or specific reading difficuty are preferred because they are more neutra and ess suggestive of a distinct and cohesive medica syndrome. Box 3: Definitions Deveopmenta dysexia: Refers to a congenita condition that resuts in a primary difficuty in earning to read and write. Specific earning difficuty: Used to refer to specific difficuties in one area of earning such as reading or mathematics. Specific reading difficuty: Used to refer to specific difficuties in earning to read, but in no other areas of academic study. 1.5 Defining dysexia The ongoing debate about dysexia is refected in the different approaches that have been taken to formay define it. Ceary this impacts on how dysexia is defined in practice. The next three sections summarise how definitions of dysexia have changed as our knowedge has increased. In short, there have been three main approaches to defining dysexia: definition by excusion, discrepancy definitions and the identification of positive indicators Definition by excusion A person is dysexic if no aternative expanation can be offered for their reading and writing difficuties. In the UK, interest in chidren who showed a specific ack of abiity in iteracy grew as a chidren became entited to a basic education. For the first time there was an expectation that a aduts shoud be iterate. Initiay, it was proposed that specific difficuties in earning to read and write were visua in nature, and the term congenita word bindness was used by James Hinshewood (a Scottish eye surgeon) to refer to: a congenita defect occurring in chidren with otherwise norma and undamaged brains characterized by a difficuty in earning to read so great that it is manifesty due to a pathoogica condition, and where the attempts to teach the chid by ordinary methods have competey faied. (Hinshewood, 1917, p. 40) Notice that Hinshewood identifies the dysexic popuation by reference to two norms: the chidren have normay functioning brains, and that norma methods of teaching resut in faiure. What this quote refects is how itte was understood about the causes of reading difficuties. This ack of knowedge resuted in dysexia being defined and diagnosed by excusion. One exampe of this is the definition from Critchey: 15 of 58 Wednesday 7 September 2016

16 1 Approaches to the definition of abnormaity A disorder manifested by difficuty in earning to read despite conventiona instruction, adequate inteigence, and sociocutura opportunity. It is dependent upon fundamenta cognitive disabiities which are frequenty of constitutiona origin. (Critchey, 1970, p. 11) That is, if the chidren's disabiity coud not be attributed to other potentia causes (i.e. the chidren are apparenty norma in key respects), then they were given the abe of dysexic diagnosis by excusion. Diagnosis by excusion is probematic as it is based on assumptions about what factors might affect one's abiity to earn to read. The most probematic excusionary criterion is that of adequate inteigence. Whie IQ tends to correate with reading abiity, a ow IQ is not a barrier to earning to read. The idea that someone with a ow IQ is expected to fai to read is no onger sociay acceptabe. Dysexia is not a set of difficuties that can ony be experienced by the inteigent. Simiary, the criterion of sociocutura opportunity impies that peope from househods with few books, or chidren who are read to ess by their parents, either because of financia, cutura or inguistic reasons can aso be reasonaby expected to fai to earn to read. You may find that you yoursef satisfy one of these criteria. Did you experience difficuties earning to read and write? How reasonabe do you beieve these criteria to be? Think aso about what they say about our expectations of chidren from diverse socia and cutura backgrounds, in terms of standards that are being set concerning the conditions necessary for norma deveopment. More fundamentay, definition by excusion is unsatisfactory on ogica grounds. If dysexia represents a particuar abnorma pattern of deveopment with a bioogica basis, then there is no reason why it coud not coincide with other factors that may aso be disadvantageous to the deveopment of iteracy skis. Dysexia can in fact be found across the whoe range of inteigence, athough it may be more easiy recognised in a chid who otherwise appears to be highy taented, and it occurs at fairy simiar rates in a countries and cutures where universa iteracy is demanded. Socia, economic, cutura and persona factors can certainy infuence the rate and extent of someone's deveopment in iteracy skis, as we sha discuss ater. However, these factors may aso be quite independent of the predisposition to dysexia. The fact that they have often been used to expain away reading faiure amongst chidren whose background does not conform to desired standards may account for why dysexia has been mocked as a midde-cass disease Discrepancy definitions The abe is given if there is a discrepancy between perceived potentia to earn to read (as indicated by genera abiity) and actua eve of reading achievement. The most common way of diagnosing dysexia is to ook for a discrepancy between someone's genera abiity as measured by an IQ assessment and his or her performance on standardised measures of reading and speing. However, there are many variations in the procedures for measuring a discrepancy between potentia and actua reading abiity, 16 of 58 Wednesday 7 September 2016

17 1 Approaches to the definition of abnormaity and the precise boundaries that may be chosen as cut-offs wi aso vary depending on the purposes of the measurement. Different criteria may be used, for exampe, in research studies (where strict statistica boundaries may be needed for scientific reasons) than in educationa or other settings (where diagnoses may be used to guide more persona and/ or practica decisions). Notice that this approach to defining dysexia refects a psychometric perspective. Discrepancy based definition and diagnosis of dysexia assumes that an IQ assessment indicates a person's potentia for earning to read. However, IQ is ony weaky reated to reading achievement, and assessment wi invove some measurement error, so any predictions of expected reading achievement wi be insensitive at best. Keith Stanovich (1991) has argued for a different approach to discrepancy based diagnosis of dysexia, where reading abiity is compared to istening comprehension rather than IQ. Despite the academic support for such an approach, IQ based assessment remains the god standard method for identifying dysexia, but educationa psychoogists do not simpy ook for a discrepancy in scores. Instead they examine a person's performance on each IQ subtest as we as overa performance. This information is combined with evidence from other sources, such as the person's case history, before dysexia is identified. An overa discrepancy between IQ and reading abiity wi identify a broad range of peope with specific reading difficuties, but depending on the popuation studied, reading probems wi in some cases arise entirey from socia, emotiona or cutura infuences. This means that specific reading difficuties are not to be equated with dysexia, as this term refers to a broader deveopmenta syndrome proposed to have a (bioogica) basis. Discrepancy definitions refect the statistica approach to defining abnormaity. Other criteria are usuay required for any meaningfu definition of abnorma functioning and the methods used for assessment, their reiabiity and their vaidity are crucia issues. If someone's reading improves through specia hep and there is no onger a discrepancy, woud that make him or her ess dysexic? If we accept that dysexia has a bioogica basis which impacts on skis other than iteracy, then even if the reading difficuties go away the underying cause of the dysexia and other associated symptoms may remain. Box 4: Definitions Definition by excusion: A definition that identifies a person as having a condition if there is no other known reason that can account for their symptoms. Discrepancy definitions: A definition that identifies a person as having a condition by virtue of a perceived discrepancy between potentia and actua abiity. Positive indicators: A symptom or characteristic that can be used to identify a condition by its presence. Congenita word bindness: The term used by Hinshewood in 1917 to describe dysexia-ike difficuties in chidren. 17 of 58 Wednesday 7 September 2016

18 1 Approaches to the definition of abnormaity 1.6 Positive indicators for dysexia Dysexia is recognized if the person shows various core behavioura symptoms or other features associated with dysexia. As mentioned in the previous section, contemporary approaches aso invove identifying positive indicators that signa potentia dysexia by their presence. Dysexia invoves specific weaknesses in areas that reate to written anguage, but because it is not associated with a genera ack of abiity it aso often invoves compensatory strengths. For exampe, Aexander Faudy was verbay gifted from a young age (see the Case Study in section 1.3). For this reason, in addition to assessing the discrepancy between abiity and written anguage skis, psychoogists usuay take particuar note of the profie of strengths and weaknesses on cognitive tests. Discrepancies between verba and non-verba IQ may be significant. Peope with dysexia often show ower verba than non-verba abiity, but the reverse pattern is aso found, iustrating the variabiity within dysexia. Particuar profies on the sub-tests of IQ assessments have been suggested as characteristic of dysexia. One such profie emphasises deficits on Arithmetic, Coding, Information (genera knowedge) and Digit Span (short-term memory capacity) sub-tests. This is caed the ACID profie (Thomson and Grant, 1979). However, not a chidren diagnosed show deficits in a these areas. Bannatyne (1971) advocated grouping the sub-tests according to the kinds of abiities they tap. Studies using this procedure suggest that dysexic peope typicay show a profie of above average spatia and conceptua abiities, and beow average sequentia abiities and acquired knowedge. However, none of these procedures resuts in cear diagnosis, again emphasising the variation within any dysexic popuation. Behaviours that are indicative of dysexia incude a mixture of weaknesses and strengths, with some factors reated to reading and writing, and others apparenty unreated. For exampe, among his ist of positive indicators, Tim Mies (1983) cites directiona confusions, poor auditory sequentia memory, probems with word repetition and other members of the famiy with reading or writing probems. Screening for dysexia usuay incudes assessments of a wide range of skis, such as visua and auditory perception, integration of different types of sensory information, and aspects of motor function such as baance. If dysexia reay is a neurodeveopmenta syndrome, it is highy impausibe that this woud ony affect written anguage skis, and the evidence does impicate a broader range of abiities. Kinsbourne et a. (1991) assessed dysexic and non-dysexic aduts on a wide range of neuropsychoogica tests. They found many differences on tasks bearing no apparent reation to reading, such as rapid aternating movements of the hands or feet, and judging which came first of two simpe auditory or visua stimui presented in quick succession. Mies (1983) has argued that dysexia shoud not be seen as a form of reading disabiity but as a syndrome: a set of symptoms with a neuroogica basis. Athough each of these individua signs (such as probems teing eft from right) may aso be found in some peope with a norma reading abiity, the presence of more than a certain number of these indicators woud suggest a dysexic profie. When used together with standardised measures of reading and speing, these kinds of screening measures can provide usefu information to guide both research and educationa practice. Simpe exampes of assessments that focus on positive indicators rather than discrepancies are the checkists often used for initia screening before a forma 18 of 58 Wednesday 7 September 2016

19 1 Approaches to the definition of abnormaity dysexia assessment takes pace. Tabe 1 shows the one used by the British Dysexia Association. Tabe 1 British Dysexia Association adut dysexia checkist (1994) 1 Do you find difficuty teing eft from right? 2 Is map reading or finding your way to a strange pace confusing? 3 Do you disike reading aoud? 4 Do you take onger than you shoud to read a page of a book? 5 Do you find it difficut to remember the sense of what you have read? 6 Do you disike reading ong books? 7 Is your speing poor? 8 Is your writing difficut to read? 9 Do you get confused if you have to speak in pubic? 10 Do you find it difficut to take messages on the teephone and pass them on correcty? 11 When you have to say a ong word, do you sometimes find it difficut to get a the sounds in the right order? 12 Do you find it difficut to do sums in your head without using your fingers or paper? 13 When using the teephone, do you tend to get the numbers mixed up when you dia? 14 Do you find it difficut to say the months of the year forwards in a fuent manner? 15 Do you find it difficut to say the months of the year backwards? 16 Do you mix up dates and times and miss appointments? 17 When writing cheques do you frequenty find yoursef making mistakes? 18 Do you find forms difficut and confusing? 19 Do you mix up bus numbers ike 95 and 59? 20 Did you find it hard to earn your mutipication tabes at schoo? YES NO Nine or more yes responses on the questionnaire coud be indicative of dysexia-type difficuties. (Source: Vinegrad, 1994) You may answer yes to severa of these questions, but not have dysexia. This is why they are termed indicators and are ony used for screening purposes. They cannot diagnose dysexia on their own, and must be used in conjunction with background information and a psychometric assessment. The need for a baance between identifying dysexia by a discrepancy between potentia and actua achievement, and by the presence of cear symptoms is refected in a more recent definition from the Orton Dysexia Society, now known as the Internationa Dysexia Association: 19 of 58 Wednesday 7 September 2016

20 1 Approaches to the definition of abnormaity It is a specific anguage-based disorder of constitutiona origin characterized by difficuties in singe word coding, usuay refecting insufficient phonoogica processing abiities. These difficuties in singe word coding are often unexpected in reation to age and other cognitive and academic abiities; they are not the resut of generaized deveopmenta disabiity or sensory impairment. Dysexia is manifested by variabe difficuty with different forms of anguage, often incuding, in addition to probems of reading, a conspicuous probem with acquiring proficiency in writing and speing. (Mies and Mies, 1999, p. 169) ACID profie: Refers to the observed deficit in arithmetic, coding, information (genera knowedge) and digit span (short-term memory) that is associated with dysexia by some researchers. Syndrome: A combination of symptoms which reguary occur together and may have a shared neuroogica basis. 1.7 Dysexia as a distinctive condition Differentiating dysexia from other reading difficuties The idea that dysexia is distinctive from other forms of reading difficuty is sti debated. One viewpoint is that reading abiity is a simpe continuum, with exceptionay gifted readers at one end and peope with dysexia at the other. However, as we have aready seen, dysexia invoves more than just difficuties in reading and writing. Reading difficuties must be specific and accompanied by a variabe profie of cognitive abiities. It is the presence of other characteristics unreated to reading that makes dysexia distinctive. Activity 3 If dysexia were simpy part of a continuum (i.e. it was dimensiona), can you suggest how we might go about identifying peope with dysexia? Section 1.2 mentioned that conditions that are part of a normay distributed continuum end themseves to identification by statistica means, perhaps using the standard deviation as a boundary between norma and dysexic readers Differentiating within dysexia acquired versus deveopmenta dysexia and the search for subtypes There has aso been continued debate regarding the variabiity within any dysexic popuation, the apparent variety of forms that dysexia can take. Given the compexity of the skis required to deveop fuent reading and speing perhaps this is not surprising. The variabiity within dysexia may simpy refect the fact that this compex process can go wrong in different ways and for different reasons. 20 of 58 Wednesday 7 September 2016

21 1 Approaches to the definition of abnormaity The term dysexia was originay used to refer to the acquired dysexias specific disorders of reading or writing that can foow from brain injury in aduts. The study of peope with such acquired difficuties has provided invauabe insights into how written anguage may be processed in the brain. These peope often suffer seective impairments, where some abiities are ost whie others are preserved. For exampe, peope with acquired phonoogica dysexia may have no probem reading famiiar words by sight, but they can no onger sound out unfamiiar words, or find a pronunciation for nonsense words ike fad. Conversey, some peope with surface dysexia may have no troube with reguary spet words such as bat or pronounceabe nonsense words such as pux, but they seem to have ost the abiity to recognise words purey by sight (i.e. without decoding each etter). They tend to misread even famiiar words ike pint which they woud pronounce to rhyme with fint. Even more bizarre are the errors made by peope with deep dysexia, who may misread ion as tiger, or symphony as orchestra. They seem to have difficuties with both the visua and phonoogica components of reading, and yet their errors suggest that they sti have some access to the meaning of words they cannot read. The different patterns of impairment found in the acquired dysexias indicate that skied reading requires the interpay of many sub-processes. It is therefore not surprising that the search for subtypes in deveopmenta dysexia has been modeed on the different kinds of acquired dysexia. However, there are good reasons why comparisons between acquired and deveopmenta reading disorders may not be appropriate. For exampe, there is evidence that the deveopment of iteracy skis is not an additive process (where the eariest skis are extended and eaborated upon in ater stages), but may invove substitution, with ater stages or processes repacing earier ones (Morton, 1989). If so, the deveopment of reading and writing skis may be more akin to a metamorphosis, such that the mature written anguage processing system bears itte reation to its eary components. There are ikey to be important differences between a system that deveoped normay but was then damaged, and one where the process of deveopment itsef was abnorma. The search for subtypes within deveopmenta dysexia has engendered much research, but no cear and consistent subgroups have stood the test of time and experimenta investigation. The most frequent distinction has been between auditory probems (i.e. difficuties in identifying and manipuating etter sounds within words) and visua probems (difficuties in visuay recognising and remembering words). These categories broady resembe the phonoogica and surface forms of acquired dysexia. However, many peope with deveopmenta dysexia show both types of impairment. It has even been suggested that both kinds of difficuties have a common basis, as we sha see ater. The truth is that no simpe picture emerges from attempts to define subgroups, and it may be more appropriate to think about severa distinct but overapping components to dysexic type difficuties. We sha return to the issue of subtypes in Section 2 of this course Differentiating dysexia from other deveopmenta conditions Whie dysexia is distinctive, there are other deveopmenta syndromes that often co-occur with it. Exampes incude: deveopmenta dysphasia specific difficuties with spoken anguage attention deficit/hyperactivity disorder invoving particuar probems with concentration and/or behaviour 21 of 58 Wednesday 7 September 2016

22 1 Approaches to the definition of abnormaity deveopmenta dyspraxia deveopmenta coordination disorder. Deveopmenta dysphasia Deveopmenta dysphasia invoves primary probems in the deveopment of speech and anguage skis. Despite abiities in other areas, some chidren are sow to achieve the usua miestones in the deveopment of spoken anguage, such as uttering their first words, putting together meaningfu sentences, and/or understanding compex verba instructions. It is perhaps unsurprising that these chidren can go on to show specific difficuties in acquiring the abiity to write anguage. Attention deficit/hyperactivity disorder (ADHD) This refers to persistent and age inappropriate difficuties in reguating attention and/or behaviour. This diagnosis remains somewhat controversia, but it invoves specific difficuties in either or both of two distinct dimensions: inattention difficuties maintaining concentration on the task in hand, high distractibiity, working memory probems and tendencies to daydream hyperactivity-impusivity excessive motor restessness, and apparent difficuties in the inhibition of impuse, eading to inappropriate and often reckess behaviour. Chidren may be diagnosed with ADHD if they show either or both of these kinds of probems, so there is considerabe variabiity within such popuations. The overap between dysexia and ADHD is high (between 30 and 50 per cent in both directions), but it appears to be stronger for attentiona probems than it is for the purey hyperactive-impusive form of ADHD. Deveopmenta dyspraxia This broady refers to specific difficuties in motor coordination (corresponding to the diagnosis used in the USA of deveopmenta coordination disorder ) but the term stricty refers to probems in the panning and execution of any compex, sequenced actions (incuding speech and writing). Dyspraxic chidren typicay have difficuties in earning to do up buttons or tie their shoeaces, in baance and ba skis, and in copying and handwriting. Mothers often report that as babies they never went through the crawing stage, but simpy got up and waked. At pay or sports they appear cumsy, and they often show specific weaknesses in visua-perceptua skis and visua-motor coordination (reative to their other abiities) as we as marked attentiona and organisationa probems. The dyspraxia syndrome remains ess widey recognised than dysexia, but the overap between the two appears to be very high, as around 50 per cent of dyspraxic chidren typicay show dysexic difficuties, and vice-versa. In summary, there is considerabe overap between dysexia and other abnorma deveopmenta conditions such as dysphasia, ADHD and dyspraxia, athough each syndrome can aso occur in isoation. As we as their frequent co-occurrence in the same individua, these conditions aso tend to associate within famiies, suggesting that there may be some common predisposing factors. We wi return to this issue in Section 2 of this course. Activity 4 Reread the case study of Aexander Faudy presented in Section 1.3. As we as dysexia, does his account suggest features of any of the other conditions discussed here? 22 of 58 Wednesday 7 September 2016

23 1 Approaches to the definition of abnormaity Box 5: Definitions Acquired dysexia: A form of dysexia which is acquired as the resut of neuroogica damage. 1.8 Refecting on definitions of abnormaity The main thing to remember is that the way that abnormaity is defined wi have consequences for the method of identification. It wi aso impact on peope's expectations of their future deveopment. For exampe, we discussed the way that dysexia is defined in reation to a person's IQ. Does that mean that if someone has a ow IQ and an even ower reading age we shoud adjust our expectations of what that person can achieve with hep, or et IQ infuence how much hep is offered? Simiary, if positive indicators suggest that the probem is neuroogicay based, do we assume that it cannot be overcome? Moreover, do the individuas themseves beieve that they cannot overcome their difficuties? Definitions can be powerfu infuences on peope's beiefs and expectations. Finay, it is worth refecting on what dysexia has tod us about the way we think of peope who experience disabiity. It is easy to assume that everyone with a particuar difficuty wi have highy simiar characteristics but in practice these groups are much more heterogeneous than you might first expect. Again, this often refects the difficuties associated with identifying the precise nature of a psychoogica difficuty and differentiating it from other types of probems. More fundamentay, individuas differ in a kinds of ways, and the key issue is that deviation from the norm is not aways abnorma in the sense of pathoogica. The same characteristics that are disadvantageous in one situation can be advantageous in others. It may aso be, as we saw in the sub-section on positive indicators (see Section 1.4), that esser abiity in some skis may go hand-in-hand with greater abiity in others. Meanwhie, there is increasing recognition that peope shoud not be defined or characterised by the difficuties they experience, but rather understood as peope who have been affected by them. This is why you wi notice that psychoogica texts increasingy tak about peope with dysexia, rather than dysexics, peope with autism rather than autistics and so on. It shows that we reaise that peope do not conform to some kind of stereotype just because they experience difficuties in certain areas, and heps us to remember that they are a individuas first and foremost. However, even this terminoogy suggests that dysexia and autism are cear entities that peope do or do not have (and they aso sound ike medica abes, to which many peope sti object). In fact, a the evidence suggests that abes such as dysexia and autism are just that abes. They are usefu descriptions of coections of characteristics that can affect different peope in different patterns to different degrees. To capture this dimensionaity, it woud probaby be more accurate to identify peope as sighty, very or not at a dysexic (or whatever condition is under consideration), and incude penty of additiona information about the precise pattern of strengths and weakness that they show in reevant situations. By now you might reaise that during our discussion of dysexia the different approaches discussed in Section 1.2 have been refected in the way that dysexia has been defined. For exampe, discrepancy definitions of dysexia are based on a statistica definition of normaity. Definition by excusion, in emphasising the bioogica basis of dysexia, is subscribing to a medica 23 of 58 Wednesday 7 September 2016

24 2 Expanations of dysexia definition of normaity, as does the notion of positive indicators. Finay, the identification of dysexia as a probem in itsef is the resut of cutura expectations of iteracy being part of an adut's norma repertoire of skis. Summary of Section 1 Normaity and therefore abnormaity may be defined in a variety of ways: in reation to statistica frequency, perceived disabiity, cutura expectations or persona distress. No singe definition is appropriate for a purposes. Dysexia is a abe used to describe a condition invoving, but not confined to, specific difficuties in earning to read and write. The term dysexia has been used by approaches which propose that there is a (constitutiona) bioogica basis to those difficuties. Definitions of dysexia were originay based on excusion criteria, but are now based on the discrepancy between potentia and actua iteracy abiity. Modern assessments aso identify positive indicators of the presence of dysexia. As a resut of the heterogeneous nature of peope with dysexia, there have been attempts to cassify different combinations of symptoms into discrete subtypes of dysexia. These attempts have been unsuccessfu because peope often show the characteristics of more than one subtype. Dysexia is known to co-occur with other deveopmenta conditions. 2 Expanations of dysexia 2.1 Behavioura, cognitive and bioogica perspectives So far we have discussed what contributes to our ideas of abnormaity and these issues have been iustrated by examining the rea-ife exampe of dysexia. We wi now consider the different potentia expanations that have been offered to account for the observed symptoms of dysexia. Uta Frith (1999) has provided a usefu framework for thinking about the nature of deveopmenta difficuties (see Figure 2). Frith suggests that there are three main perspectives on any given deveopmenta condition: a behavioura, cognitive and bioogica one. In addition to this there are environmenta factors (iteray referring to the environments, bioogica or otherwise, that we are exposed to) that can have a roe in the accounts offered from these perspectives. 24 of 58 Wednesday 7 September 2016

25 2 Expanations of dysexia Figure 2 Frith's three eve framework (Source: Frith, 1999, p. 193) Behavioura perspectives provide a mode of the difficuty by describing the nature of the behavioura symptoms experienced, much as we have done in Section 1 above. Cognitive perspectives describe what menta processes are invoved in and affected by the difficuty (e.g. memory, perception, attention). As such, these descriptions offer a cognitive expanation of what may cause the types of behavioura symptoms observed. Bioogica perspectives offer descriptions of the behavioura difficuties in terms of their potentia bioogica origins, which can cover genetic, biochemica and neurophysioogica expanations. Thus, bioogica and cognitive perspectives offer theoretica expanations that require experimenta vaidation, whereas behavioura perspectives tend to be ess debated because the behaviours can be directy observed. Cognitive perspectives describe cognitive processes that might expain how the bioogica and behavioura accounts map onto each other. For exampe, damage to one area of the brain (bioogica perspective) may resut in an inabiity to store new ong-term memories (behavioura perspective), because the person is no onger abe to transfer information from short-term to ong-term storage (cognitive perspective). Frith's framework echoes the extent to which perspectives in psychoogy can be seen as compementary, conficting and co-existing. It aso suggests that, when discussing expanations of abnorma deveopment, it is wrong to think that bioogica and cognitive perspectives are competing with each other. In fact, cognitive and bioogica modes can be compementary rather than conficting. 25 of 58 Wednesday 7 September 2016

26 2 Expanations of dysexia We can use this framework to think about theoretica expanations of dysexia. As we have aready provided a behavioura account of dysexia in Section 1, we wi now consider cognitive and bioogica expanations of what may cause these behaviours and acknowedge environmenta infuences on their deveopment. After examining each expanation individuay we suggest how different perspectives can be put together to offer a compete account. 2.2 Cognitive expanations of dysexia The phonoogica processing deficit Reca Aexander Faudy's difficuties in earning to read and write, and the other behavioura characteristics associated with having dysexia. You might have noticed that many features of dysexia point to a difficuty with some aspects of memory. That is, peope with dysexia have difficuty with tasks that require short-term memory processing such as menta arithmetic, writing and earning new information. However, these tasks have an additiona feature in common: they contain a phonoogica component. That is, they invove the processing of speech sounds in short-term memory. It is therefore possibe to suggest that a deficit in phonoogica processing may provide an expanation of dysexia. To understand why a phonoogica deficit woud have an impact on reading and writing we need to understand how peope typicay earn to read (see Box 6). Box 6: Learning to read (after Frith 1985) It has been suggested that initiay we adopt two strategies. One strategy, widey suggested to be the first to deveop in beginning readers, is the whoe word, or ogographic strategy. This refers to the way chidren earn to associate a spoken word with its written form, without showing any awareness of the sounds that each of the individua etters make. This strategy is often encouraged in eary years cassrooms where objects are abeed with their names and teachers use fashcards to teach chidren a core sight vocabuary of common words. This technique is usefu in enabing chidren to buid a arge sight vocabuary quicky, which wi enabe them to begin reading with some degree of fuency. However, this approach paces huge demands on visua memory and does not provide chidren with a strategy for coping with unfamiiar words. To address these imitations, chidren aso need an aphabetic decoding strategy. This requires them to earn the sounds that each etter of the aphabet makes, and then earn how to bend those sounds together during reading to work out how to pronounce the word. Aphabetic decoding is aso needed during speing to anayse spoken words and break them down into their corresponding etter sounds. A skied reader is one who moves beyond etter by etter decoding and rapidy processes onger strings of etters that recur across different words (an orthographic strategy). Did you notice how these strategies refect what we know about reading processes from the acquired dysexias? The aphabetic decoding strategy draws heaviy on phonoogica processing both in the earning of etter-sound correspondences, and in the manipuation of those sounds 26 of 58 Wednesday 7 September 2016

27 2 Expanations of dysexia during reading and speing. Peope with dysexia often find it difficut to move beyond a ogographic strategy and probems with speing usuay persist into aduthood. The severity of the phonoogica deficit is best demonstrated by the awareness of rhyme by chidren with dysexia. Recognising that two words rhyme is a ski that most chidren acquire at an eary age. However, studies have repeatedy shown that chidren with reading difficuties have troube identifying words that rhyme (e.g. Bradey and Bryant, 1978). This is just one finding from a arge iterature showing that chidren with reading difficuties find it difficut to isoate and manipuate sounds in words. What is sti not cear is whether the phonoogica deficit is reated to the encoding or retrieva of phonoogica representations in memory. Whie there is evidence of difficuties in processing phonoogica information in short-term memory, there is aso specuation that the way this information is represented and stored in ong-term memory coud further expain the poor performance of peope with dysexia on phonoogica tasks. Much of the research into phonoogica awareness and reading disabiity has centred on Engish-speaking chidren. However, this presents a miseading picture, as etter-sound correspondences in Engish are compex. Often, the same sound can be spet a number of different ways (e.g. /f/ can be spet f and ph), and the same etter can make a variety of different sounds (consider the sound that a makes in bat, part and apron ). Furthermore, it is not a simpe case of one etter per sound: mouse has five etters but ony three sounds: /m/ /au/ /s/. The phonoogica awareness deficit that has been demonstrated with Engish speakers may not be a universa characteristic of reading disabiity, as many other European anguages have much more predictabe etter-sound correspondences. Research into phonoogica deficits in other anguages is ongoing, but there does seem to be evidence of phonoogica deficits in peope with dysexia (and at risk of dysexia) who earn to read in more reguar anguages (see Courcy, Béand and Pitchford, 2000; Müer, Saarenketo and Lyytinen, 2000). It has aso been suggested that measuring the speed of performance on tests may be a more universa indicator of reading difficuties across anguages. Amost a types of reading difficuty appear to be characterised by a phonoogica processing deficit, not just dysexia. However, this does not mean that because it appears to have the same underying cognitive deficit as other reading difficuties, dysexia is the same as other types of reading difficuty. Whie the phonoogica processing deficit may expain the reading and writing difficuties associated with dysexia, it cannot account for the fu range of behavioura symptoms that are observed, and that make dysexia a distinctive condition. Other cognitive accounts are needed to expain the origins of the other behavioura symptoms of dysexia. We have aready proposed in the previous section that dysexia can be thought of as consisting of severa overapping dimensions it seems ikey that a phonoogica deficit may be just one of severa cognitive components associated with the condition. Moreover the phonoogica deficit hypothesis is exacty that, a hypothesis. Whie it has a good dea of empirica support, it is a theoretica proposa but not something that we know definitey exists Visua deficit hypotheses Samue Orton was one of the eariest and most infuentia researchers into dysexia, athough he used the term strephosymboia iteray meaning twisted symbos. He noticed that chidren with specific reading difficuties often wrote etters back to front, 27 of 58 Wednesday 7 September 2016

28 2 Expanations of dysexia confused etters such as b and d, and woud swap the position of etters within a word during speing (e.g. was might be written saw ). From these and other observations, he suggested that their reading difficuties might refect some kind of visua processing impairment invoving incompete speciaisation between the eft and right sides of the brain. It is worth noting that the eft hemisphere of the brain is speciaised for processing anguage. As we saw in Section 1.4, the origina observations by Hinshewood about what he caed congenita word bindness aso emphasised a visua-perceptua contribution. Much eary research was therefore focused on trying to identify perceptua factors that coud contribute to dysexia. Visua deficit expanations fe out of favour during the 1970s and 1980s when psychoogists increasingy adopted a phonoogica deficit mode of dysexia, arguing that reading difficuties refect primary probems with anguage processing. Whie the phonoogica deficit expanation is sti popuar and widey researched, there has been a resurgence of interest in the idea that there may be an underying visua deficit that coud expain difficuties in earning visua-phonoogica correspondences (see Everatt, 1999; Whiteey and Smith, 2001). More recenty, the evidence for visua-sensory processing deficits in dysexia has become robust. The chaenge now is to determine whether these visua-perceptua probems affect the deveopment of visua processing required for fuent and skied reading, and if so how. Seymour (1986) has re-emphasised the obvious point that the cognitive systems specificay required for written anguage (as opposed to spoken anguage) are actuay in the visua domain. He and others have shown that the reading performance of many dysexic peope refects weaknesses in visua processing that can occur independenty of phonoogica difficuties. It has been caimed that phonoogica deficits are more common than visua deficits in dysexia, and the fact that many dysexic peope show superior visua-spatia abiities is cited as supporting evidence. The troube with this argument is that the psychoogica tests used to assess visuo-spatia abiities do not actuay measure the same kinds of visua processing that Seymour refers to, which is more perceptua in nature. In fact, mid visua disturbances are consistenty found in up to 70 per cent of peope with dysexia, and more importanty, these typicay co-occur with phonoogica probems (Lovegrove, 1991). It has even been suggested that both types of probem might have a common cause. As we have aready seen, it is miseading to think either that visua-perceptua and phonoogica probems must be mutuay excusive, or that a peope with specific reading difficuties are the same. What is more, variation in the cinica picture of dysexia (at either the behavioura or the cognitive eve of Frith's mode) does not in fact rue out some common underying cause at the bioogica eve. The compex interactions between bioogy and environment mean that the same bioogica probem can resut in different cognitive and behavioura consequences for different peope Automaticity and rate of processing hypotheses A proposa that attempts to address the broader picture of dysexic functioning is that dysexia may be caused by probems in the automatisation of skis. The concept of automatisation refers to the gradua reduction in the need for conscious contro as a new ski is earned. This eads to greater speed and efficiency and a decreased ikeihood of breakdown of performance under stress, as we as the abiity to perform a second task at the same time with minima disruption to either behaviour. Nicoson and Fawcett (1990, 1994) have pointed out that even highy competent dysexic readers show a distinct ack of fuency in written anguage skis: their reading and writing is more 28 of 58 Wednesday 7 September 2016

29 2 Expanations of dysexia aboured, more prone to error, and more susceptibe to interference from other tasks. They aso suggest that incompete mastery characterises many other features of dysexic performance, such as probems earning to ride a bicyce or tie shoeaces. However, a genera automatisation deficit woud be most evident during compex, highy demanding, muti-sensory tasks such as earning to read and write. One way of assessing the presence of an automaticity deficit is through the use of a rapid automatised naming task (RAN). For exampe, individuas may be presented with a set of 50 stimui consisting of five rows of 10 pictures of a given type in a random order and asked to name each picture as quicky as possibe (see Figure 3). Peope with dysexia typicay show a deficit in speed on this type of task. Figure 3 An exampe of a RAN task for pictures These resuts have been interpreted as further support for a phonoogica deficit in reading, as the task does require some phonoogica processing during the retrieva of the picture names. However, more recenty Wof and Bowers (1999) have suggested that difficuties in rapid naming are a separate, additiona deficit to phonoogica difficuties, and that such a deficit is sufficient to expain reading difficuties even if the person has good phonoogica awareness. They suggest that peope with reading difficuties fa into one of three subtypes, depending on the underying cause of their probem: phonoogy group: shows a phonoogica deficit, but no rea probems on the RAN task (sow naming) rate group: shows a RAN task time deficit, but no phonoogica probems doube deficit group: shows signs of a deficit in both phonoogy and naming rate and therefore has the greatest reading difficuties. Because the most common form of treatment recommended for reading difficuties in chidren focuses on improving phonoogica awareness, evidence for different forms of cognitive deficit in dysexia is important. If visua processing deficits do pay an important roe, or if there are rate and doube deficit subtypes as described above, then training in phonoogica awareness aone woud be unikey to address a reading difficuties. 29 of 58 Wednesday 7 September 2016

30 2 Expanations of dysexia However, it is aways important to ook carefuy at the nature of tests used to diagnose reading difficuties. RAN tasks come in two forms: seria presentation where the person is timed from start to finish, and discrete presentation where the symbos are presented one at a time and a reaction time for each item is recorded. Ony seria presentation procedures are consistenty associated with reading difficuties. This may be because seria tasks usuay require more sustained concentration in comparison to discrete presentation tasks (where there is no need to foow a ine of text or keep one's pace in the grid of symbos). In other words, the apparent difference between norma and dysexic readers on tasks of this kind coud be due to perceptua, attentiona or fatigue effects rather than differences in RAN abiity. This woud undermine the case for a separate RAN deficit. However, it aso raises a different, interesting question: why shoud dysexic peope be particuary susceptibe to these kinds of effects? It woud certainy be difficut to expain this fuy in terms of a pure phonoogica deficit hypothesis. We can see how the cognitive accounts expain many of the behavioura symptoms of dysexia. However, even when taken together, they cannot expain dysexia fuy, nor its variabiity between individuas. As Frith suggests, cognitive accounts taken in isoation are incompete: we aso need to consider bioogica expanations. Box 7: Definitions Logographic strategy: A hoistic approach to identifying written words via their overa visua appearance, sometimes aso referred to as sight word reading. Orthographic strategy: The approach skied readers use to identify written words, empoying both aphabetic and ogographic strategies as we as their existing knowedge of grammatica forms and simiar words. Letter-sound correspondences: The associations between individua etters, and the sounds that those etters can make in a given anguage. Strephosymboia: The term coined by Orton to describe dysexic-ike symptoms (iteray twisted symbos ). Automatisation: The process of making a ski automatic, so that performance no onger needs conscious monitoring. (If fuy automatised, a task can be carried out with no interference to another task being performed simutaneousy.) Rapid automatised naming task: A task requiring rapid naming of a series of etters, numbers, coours or common objects, which shoud invove automatic processes owing to the famiiarity of the stimui. Seria presentation: The presentation of test items one after the other in the form of a ist (or grid) that the participant has to work through in a systematic fashion. Discrete presentation: The presentation of test items one at a time. None of the other test stimui are visibe at the same time. 2.3 Bioogica expanations of dysexia Some physica characteristics appear to be typica of peope with reading difficuties, athough their reevance is debated. These incude being mae, tendencies towards efthandedness or mixed-handedness (i.e. inconsistency of hand preference across different tasks), and a variety of neuroogica 'soft signs and minor physica anomaies. We wi 30 of 58 Wednesday 7 September 2016

31 2 Expanations of dysexia consider each of these in detai in the sections that foow. There is aso some evidence that peope with dysexia (and their reatives) may show higher rates of aergic conditions such as asthma and eczema as we as other autoimmune disorders. On the surface these factors may appear to have itte to do with dysexia. However, by reating these physica characteristics to the observed behavioura symptoms of dysexia we may identify cues to the possibe bioogica mechanisms underying the condition Sex differences An intriguing aspect of dysexia is the apparent excess of maes who are affected. This coud simpy refect referra bias a tendency for boys to be identified as dysexic more readiy than girs. In the past, society's expectations of boys and girs were very different with respect to educationa achievement. There is now much ess overt stereotyping of this kind, but there may sti be other reasons why dysexia might be more readiy identified in boys. For exampe, evidence suggests that in mixed-sex casses, boys often dominate cassroom interactions. This might bring their genera abiity to the attention of teachers, who coud fai to notice the abiities of some quieter girs whose reading attainment is equay discrepant. Another possibiity is that boys and girs may respond differenty to the experience of reading faiure, with boys perhaps more ikey to externaise their frustrations over their reading difficuties than girs. Even awareness that dysexia is more common in boys coud serve to infuence the expectations of parents, teachers and others, thereby creating something of a sef-fufiing prophecy. Nevertheess, the evidence does suggest that as many as three or four maes may be affected for every femae (James, 1992). This apparent sex difference sti awaits adequate expanation, especiay given evidence from a recent twin study that found no gender difference in heritabiity of reading difficuties (Wadsworth et a., 2000). In some respects, the excess of maes with dysexia appears to be an exaggeration of the usua sight advantage that femaes, on average, tend to show for anguage-reated skis. Boys appear to show greater visua-spatia awareness than girs do, and you may wonder why these skis do not offer any advantage for processing written anguage. However, as we have aready observed, visua-spatia awareness does not prohibit the deveopment of visua-perceptua difficuties that are associated with dysexia. Maes are overrepresented to varying degrees across a whoe range of deveopmenta disorders. These incude not ony dysexia, but aso dysphasia, dyspraxia, ADHD and the autistic spectrum of disorders. What is more, a of these conditions tend to run in famiies, suggesting that they might share at east some common eements at the eve of bioogica predisposition Why are boys more vunerabe to some conditions? In some conditions that affect more maes than femaes (such as coourbindness), the expanation has been found to ie in genes on the X chromosome. Most femaes have two X chromosomes (one inherited from each parent) whie most maes have an XY combination. This means that if someone shoud inherit an X-inked gene predisposing to a particuar condition, compensation for this wi be easier for a femae (whose other X chromosome may have a norma copy of the gene) than for a mae. However, as yet no X-inked genes have been identified in connection with dysexia, dyspraxia, ADHD or autism. As we sha see ater, a combination of many different genes is probaby invoved in the predisposition to these conditions, and environmenta factors are aso crucia, because genes aone do not dictate outcome. What the evidence from famiy studies does suggest is that femaes may need a higher genetic oading (i.e. a stronger famiy history ) 31 of 58 Wednesday 7 September 2016

32 2 Expanations of dysexia than maes for these conditions to be expressed. Some protective factors therefore seem to be operating in femaes, but we do not yet know what these are Lateraisation It has ong been suspected that unusua patterns of cerebra ateraisation (i.e. the division of abour between eft and right hemispheres of the brain) may have some connection with dysexia. Eary researchers noticed an apparent excess of efthandedness in chidren with specific reading difficuties (and their reatives). However, most dysexic peope are in fact right-handed, and most eft-handed peope are not dysexic. Nonetheess, arge-scae anayses of the research findings have shown that mixed-handedness is more common than usua in dysexic peope (Egington and Annett, 1994). You wi reca how Aexander Faudy used his eft and right hands interchangeaby. Athough the reationship between handedness and other aspects of cerebra ateraisation is far from cear-cut, these findings are consistent with Orton's origina proposa that dysexia may invove a reative ack of speciaisation between the hemispheres. Neuroanatomica studies, in which brain structure is studied either from postmortem sampes or via brain imaging techniques such as magnetic resonance imaging (MRI) in ive participants, aso provide some support for this view. The typica human brain has a number of we-known structura asymmetries, which are more often reduced or reversed in dysexic peope (Hynd and Semrud-Cikeman, 1989). In particuar, brains of peope with dysexia often show an unusua symmetry across hemispheres of a region caed the panum temporae (see Figure 4), which is typicay arger in the eft hemisphere. This finding has attracted considerabe attention because this area is invoved in auditory and anguage processing. This panum symmetry appears to distinguish dysexic from ADHD chidren (Hynd et a., 1990) and there is some evidence that it may reate to poor phonoogica skis (Larsen et a., 1990). Figure 4 A cross-section of a norma brain showing asymmetry of the panum temporae region across hemispheres 32 of 58 Wednesday 7 September 2016

33 2 Expanations of dysexia (Source: adapted from Kaat, 2001, Figure 14.8, p. 402) So coud this reduced brain ateraisation be a bioogica marker for dysexia? And coud it be considered abnorma in the medica sense that we discussed in Section 1? It woud seem not. Firsty, genera popuation studies have shown that this abnorma pattern of panum temporae symmetry is shared by up to one person in every four (Gaaburda et a., 1987). This means that it cannot be a feature that is specific to dysexia (but it coud perhaps be one risk factor among others). Secondy, the degree of panum temporae asymmetry in the genera popuation is normay distributed on a continuum. If you reca our discussion in Section 1 about defining abnormaity, you wi remember that for dimensiona traits, any cut-off chosen to distinguish norma and abnorma is essentiay arbitrary. Another interesting point is that the norma asymmetric pattern invoves a arge panum temporae on the eft, and a smaer one on the right in keeping with the usua eft hemispheric speciaisation for anguage processing. However, the symmetry associated with dysexia appears to refect two arge regions (rather than two sma ones): the tota area of these brain regions may actuay be greater in peope with dysexia (and others who share this symmetrica pattern). This might possiby hep to expain the very superior anguage abiities shown by some peope ike Aexander Faudy. Box 8: Definitions 'Soft sign Any behaviour or response that may be inked to an underying cause (ike brain damage) but which is difficut to estabish or open to interpretation. Referra bias Any infuence on the composition of a study sampe that arises from the particuar method or source by which participants are recruited. Cerebra ateraisation Refers to the asymmetries found in many brain structures and functions, and/or the deveopmenta processes by which these differences between the eft and right sides of the brain usuay emerge. 2.4 Differences in brain architecture Organisation of brain ces Some findings that do appear to be more specific to dysexia are various microscopic anomaies in the actua organisation of brain ces, reported from post-mortem studies (Gaaburda et a., 1985). These incude coections of sighty mispaced ces (caed ectopias) and some minor disordering of the reguar ayering of ces in the cortex. They are often particuary concentrated in eft hemisphere regions invoved in anguage processing, athough their distribution varies consideraby between individua cases. Another interesting feature of these ectopias is that they are typicay accompanied by an unusuay rich and diverse pattern of connections to other brain regions, which may account for the apparent increased creativity that is sometimes observed in peope with dysexia. These minor disturbances of brain architecture are known to arise during prenata deveopment, and athough the reasons for their origin are sti uncear, it is thought that they coud refect unusua immune system effects on the deveoping brain. Research into their significance for brain function suggests that they coud interfere with the coding of 33 of 58 Wednesday 7 September 2016

34 2 Expanations of dysexia rapidy changing auditory stimui, ike sounds in speech. If so, this coud be reevant to the phonoogica deficits aready discussed. However, it is particuary interesting to note that these anomaies have so far ony been associated with auditory processing probems in maes (Herman et a., 1997). The discovery of minor structura differences in the brains of peope with and without dysexia woud support the idea that the predisposition to dysexia is constitutiona, particuary if these differences are present before birth. However, a major difficuty is that these differences can ony be observed post-mortem, so ony a imited number of brains have so far been studied in this way. This means that we shoud be very cautious about generaising these findings to a peope with dysexia. If these anomaies do have any causa significance for dysexia, then the fact that their regiona distribution varies so much between individuas coud hep to expain some of the variation observed in behavioura symptoms. For exampe, if this unusua brain microarchitecture were to occur in eft hemisphere areas important for auditory or anguage processing, woud we expect a more phonoogica form of dysexia than if it occurred in right hemisphere areas important for rapid visua processing? Finay, some specuation can aso be offered regarding these apparent differences in the hardware of the dysexic brain. Two points seem particuary reevant: the brain symmetry associated with dysexia may refect an increase in the tota number of neurons the microscopic disturbances of ceuar organisation are associated with greater connectivity between different regions. There is evidence from the study of artificia neura networks that this kind of arrangement (i.e. one with more ces and more interconnections) may be disadvantageous for some tasks such as earning associative rues but it may actuay be more efficient at tasks which require ess automatisation and more creativity Differences in sensory, perceptua and motor function As we saw in our discussion of cognitive expanations, there has been ongstanding debate over the possibe contribution of perceptua probems to dysexia. Subjectivey, many chidren and aduts with dysexic difficuties do report visua symptoms when trying to read. These incude etters and words appearing to move or bur on the page, particuar difficuties with sma, crowded print, and compaints of gare or other kinds of visua discomfort (see Figure 5). 34 of 58 Wednesday 7 September 2016

35 2 Expanations of dysexia Figure 5 Exampes of visua disturbances experienced by some peope with dysexia Experimenta studies now provide evidence of some perceptua difficuties in dysexia for tasks invoving the processing of rapidy changing information, such as the perception of ficker or motion (Stein, 1994). Such difficuties in processing rapid visua information impicate the magnoceuar visua system (Stein and Wash, 1997). Furthermore, neuroanatomica abnormaities reating to this visua pathway have been reported in the brains of dysexic peope post-mortem (Livingstone et a., 1991). The magnoceuar system is particuary important for the contro of eye movements and visua attention. Simiar difficuties in processing rapidy presented auditory information have aso been observed in peope with dysexia. Some have argued that this is evidence of genera difficuties with rapid auditory perception, which woud account for the difficuties in acquiring phonoogica awareness in dysexia (Taa et a., 1997). However, an aternative expanation that has increasing support suggests that the phonoogica awareness deficit is the resut of a specific probem with speech sounds ony, perhaps associated with difficuties in speech perception (Mody et a., 1997). Attention has aso turned to the possibe roe of the cerebeum in dysexia. This brain structure is important for motor coordination and panning, but is now recognised to pay an important roe in cognitive deveopment, particuary in the automatisation of skis and rote earning (i.e. earning facts off by heart, ike mutipication tabes). Brain imaging studies using positron emission tomography (PET) have shown differences in the activity of the cerebeum in dysexic versus non-dysexic aduts during motor earning tasks (Nichoson et at, 1999). In our discussion of cognitive expanations we noted that an automatisation deficit coud hep to expain a wide range of features of dysexic functioning, incuding (but not confined to) phonoogica deficits. Furthermore, because the cerebeum is known to act as a timing device, a cerebear deficit theory is aso 35 of 58 Wednesday 7 September 2016

36 2 Expanations of dysexia highy compatibe with the idea of probems in very rapid sensory processing (the magnoceuar hypothesis). If you reca our discussion of Frith's mode (see Figure 2), we emphasised that variabiity at the behavioura or the cognitive eve (e.g. phonoogica or visua probems) need not rue out some singe underying cause at the bioogica eve. It is perfecty possibe that microscopic differences in brain architecture coud have different effects according to the particuar brain areas affected. Figure 6 The cerebeum (Source: adapted from Martini et a., 2000, Figure 15 9 (a), p.395) Box 9: Definitions Ectopia: A coection of mispaced ces. Cerebeum: A part of the brain (situated underneath the rear cerebra cortex) invoved with motor and baance functions, and recenty shown to be invoved in the automatisation of many cognitive skis. Magnoceuar visua system: A visua sub-system speciaised for processing information that changes very rapidy over time, characterised by arge ces with fast responses. (Stricty, this refers to a specific sub-cortica pathway from retina to primary visua cortex, but it can aso incude further cortica areas to which these ces project.) 36 of 58 Wednesday 7 September 2016

37 2 Expanations of dysexia 2.5 Biochemica factors Highy unsaturated fatty acids As we saw in Section 1, medica approaches to some psychoogica conditions have focused on biochemistry and the use of corresponding drug treatments. Very itte research of this kind has been appied to dysexia. However, emerging evidence suggests that there may be a biochemica contribution invoving abnorma metaboism of highy unsaturated fatty acids (HUFA) essentia substances that pay a key roe in brain deveopment and the maintenance of norma brain function. In fact, just two fatty acids make up 20 per cent of the brain's dry mass, as they are essentia components of the membranes surrounding every ce (and structures within each ce). HUFA are aso needed to produce other substances that are crucia for reguating a very wide range of brain and body functions incuding ce signaing, immune system responses and cardiovascuar function. These essentia fatty acids from the so-caed omega-6 and omega-3 series are found in a wide range of natura foods. However, they are often seriousy acking from modern diets, especiay if these are high in saturated fats or processed foods with a high eve of artificia fats. In fact, ony fish and seafood provide significant quantities of the crucia omega-3 fatty acids. Most of us therefore rey on being abe to buid our own HUFA from simper compounds. However, this conversion process may be inefficient in some peope, who woud therefore have a higher dietary requirement. There is some evidence that this (and/or other inefficiencies in fatty acid metaboism) may be a factor in the bioogica predisposition to dysexia, as we as reated conditions such as ADHD and dyspraxia (Richardson et a., 1999; Richardson and Ross, 2000). Fatty acid deficiency eads to minor physica symptoms such as excessive thirst, frequent urination, rough dry skin and hair, and soft or britte nais. Research has shown that these characteristics are common in chidren with ADHD, and aduts and chidren with dysexia. Magnetic resonance (MR) imaging is a safe and non-invasive technique invoving the use of radiowaves within a very strong magnetic fied. It can be used to obtain either structura images (the we-known MRI) or information on the chemica composition of tissues (magnetic resonance spectroscopy, or MRS). MR brain imaging has aso reveaed differences in ipid metaboism in dysexic versus non-dysexic aduts that are consistent with HUFA deficiency, and increased eves of an enzyme that removes HUFA from ce membranes have been reported from bood biochemica studies of dysexia. If some features of dysexia and reated conditions ike ADHD refect fatty acid deficiency, then suppementing the diet with these fatty acids coud be hepfu in the management of these conditions. We wi return to this in Section Genetic expanations Eariest investigators noted that dysexia tends to run in famiies, and studies invoving extended famiies or twins have confirmed this. The heritabiity of dysexia is estimated at around 50 per cent about haf of the variabiity in dysexic traits found in the genera popuation coud be attributabe to genetic variation. However, the mode of inheritance is not known, and as with most behaviouray defined conditions, genetic studies of dysexia are compicated by a number of factors. The most obvious of these is the difficuty in arriving at a satisfactory definition of dysexia, as we have seen in Section 1. Another compication arises when individuas with the genetic tendency for dysexia fai to deveop 37 of 58 Wednesday 7 September 2016

38 2 Expanations of dysexia the condition, or when individuas without the genetic predisposition show probems that resembe dysexia. Moreover, the same condition in different peope may each be caused by a different gene. A these factors can make heritabiity estimates unreiabe. It is most ikey that a combination of different genes are invoved in dysexia. Why there can be no such thing as a gene for dysexia? In terms of human evoution, reading is a recent acquisition. The demand for iteracy has argey arisen within the ast 100 years, and is sti confined to deveoped societies. We can therefore be confident that no specific neura mechanism can have evoved for deaing with written anguage. Skied reading is aso a highy compex process, drawing on a wide range of abiities and requiring integration across many different domains of perception and cognition. Whatever genes are invoved, they may incude those associated with the structures necessary for anguage deveopment in genera, certain aspects of visua perception and cross-moda integration. Given the wide range of component processes invoved, it seems evident that variation in reading abiity (to the extent that this is geneticay determined at a) wi depend on interactions between many different genes. At most, what is inherited is a predisposition towards reading difficuties, but to expore this further we need to understand much more about the actua brain processes invoved in such difficuties. Box 10: Definitions Highy unsaturated fatty acids: Lipid moecues which make up 20 per cent of the brain's dry weight, and are crucia for norma brain deveopment and function. 2.6 Environmenta expanations of dysexia? Environment is often used to refer to ony socia or non-bioogica infuences. However, it actuay aso refers to the bioogica, cognitive and behavioura environments that we may be exposed to. If you refer back to Frith's framework (see Figure 2) you wi remember that the environment can be heaviy invoved in each perspective. An exampe of a bioogica environmenta infuence is a dietary deficiency such as insufficient consumption of fatty acids. The idea that dysexia has a non-bioogica environmenta expanation has been excuded: you may reca that externa environmenta factors were expicity rejected in excusion based definitions of dysexia. However, Spear-Swering and Sternberg (1998) beieve that there is some evidence to suggest that whie such factors may not expain dysexia, they can dramaticay affect the nature and extent of the difficuties experienced. For exampe, Adams (1990) has suggested that reading aoud to preschoo chidren resuts in rea benefits in ater reading deveopment. Snow (1991) found that chidren who have a iterate home environment were more ikey to progress in reading than peers who were exposed to ess iterate contexts. MacLean et a. (1987) have aso shown that chidren's knowedge of nursery rhymes can predict both reading performance and phonoogica awareness. Just as the home environment can infuence reading deveopment, so too can schoo environments. For exampe, chidren are exposed to different methods of reading instruction and it has been argued that some instructiona methods can effectivey prevent reading difficuties (Cay, 1990). Simiary, the overemphasis on either phonic (aphabetic) 38 of 58 Wednesday 7 September 2016

39 2 Expanations of dysexia or whoe word (ogographic) approaches to reading can exacerbate existing reading difficuties, because of the need for both skis to compensate for the reative weaknesses of each approach (Cha, 1996). Anderson et a. (1985) have aso found evidence that chidren who are streamed into ow abiity groups receive ess effective instruction due to ower expectations of what they can be expected to achieve. There is aso often a higher incidence of behavioura difficuties in such groups, which can disrupt opportunities for earning. we cannot bame reading faiure especiay extreme disabiity on either the chid or the initia method aone. Severe disabiity seems to resut when a chid has a predisposition (a set of characteristics that make it difficut for him to associate printed symbos with their spoken counterparts) and is exposed to an initia method that ignores this predisposition. (Cha, 1996, p. 175) 2.7 Refecting on expanations of abnorma deveopment: the case of dysexia We can draw the foowing genera concusions about cognitive and bioogica expanations of abnormaity from the materia presented above. Both cognitive and bioogica accounts of dysexia are offered as theories which expain the behavioura difficuties that are observed. Whie some theories may dominate accounts of a given condition (e.g. the phonoogica deficit hypothesis), and may resut in infuencing the nature of interventions, they are sti ony theories and aways need to be vaidated by consistent empirica evidence. Any singe eve of description, taken in isoation, wi provide an incompete account of what may cause the behavioura symptoms. Evidence and theories from different eves of description give a fuer account of a condition and better refect the systemic nature of dysexia. Research evidence provided at one eve of description can support a theoretica idea offered at a different eve. For exampe, the evidence suggesting that peope with dysexia show neuroogica abnormaities in the magnoceuar visua pathway (bioogica evidence) ends support to the visua deficit hypothesis (cognitive expanation). The case of dysexia iustrates a genera finding that few conditions are caused by a singe bioogica probem, which affects a singe cognitive process, which in turn resuts in a consistent set of behavioura symptoms. Within most conditions there wi be a good dea of potentia variabiity in the symptoms manifested, the cognitive processes affected and the bioogica factors proposed to expain them. This is because human behaviour is the product of the compex interpay between cognitive and other processes, infuenced by a whoe range of interconnected and modifiabe bioogica systems. Our environment (physica, psychoogica and bioogica) can impact on a these eves and either exacerbate or temper the severity of the condition as a resut. 39 of 58 Wednesday 7 September 2016

40 3 Treatment and management Summary of Section 2 Theoretica expanations of abnorma deveopment conditions need to take into account behavioura, bioogica, cognitive and environmenta evidence. Cognitive expanations of dysexia incude deficits in phonoogica awareness, visua perception and automatisation of skis. Bioogica expanations of dysexia refer to observed abnormaities in brain architecture, perceptua pathways and biochemistry. Externa environmenta expanations are specificay excuded from current definitions of dysexia. However, evidence suggests that certain home and schoo environments can contribute to successfu reading deveopment. 3 Treatment and management 3.1 Thinking about intervention So far we have ooked at issues reating to how we define abnorma behaviour, and how we think about expanations. Now we wi consider the more practica issue of how to approach the treatment of such difficuties. As in the previous section, we wi discuss behavioura, cognitive and bioogica perspectives on treatment and consider specific techniques from each perspective that are appicabe to the management of dysexia Treatment or management? In the preceding paragraph you wi notice that we taked generay about the treatment of conditions, but referred to managing dysexia. Why did we do this? It reates to the foowing important genera issues: Is treatment (i.e. intervention) warranted? We mentioned this issue when we were discussing sociocutura or persona distress based definitions of abnormaity. Intervention is not aways desirabe or sought by the individua, who may fee that what other peope perceive as abnorma is itte more than an individua difference that simpy requires increased awareness on the part of other peope. For exampe, some peope with hearing impairment do not use hearing aids, which they find unnecessary or distracting. A hearing aid may make ife easier for hearing individuas speaking to someone with a hearing impairment because it means that they do not have to adjust their own behaviour to accommodate the other person's difficuties. But it may not make ife easier for the hearing impaired person. From this perspective, such an intervention is just as unnecessary as it woud be if a hearing peope were required to communicate in sign anguage. Aexander Faudy's case study provides a good iustration of someone who has found a way of managing his difficuties, most of which are ony perceived as difficuties because of the constraints and expectations that he is expected to work within. 40 of 58 Wednesday 7 September 2016

41 3 Treatment and management Are a conditions curabe? In many cases it is simpy not possibe to treat the condition in the sense of curing it, and so the individua often has no choice other than to find a way of managing his or her symptoms. As aready noted, few psychoogica conditions have a singe cause that woud respond to appropriate treatment and disappear, because of the compex interaction of different factors and the difficuty in atering some types of bioogica difference. Moreover, it is worth considering what might be ost as we as gained if some types of psychoogica functioning were corrected. Dysexia is often associated with compensatory strengths (as described in the Case Study in Section 1.3). If a chidren coud be inocuated against deveoping dysexia, then these strengths may aso fai to deveop. A crucia point to consider is whether the gains of any intervention might outweigh the potentia osses. What caused it? Choice of intervention is often infuenced by what is beieved to cause the condition. For exampe, if the primary difficuty is beieved to be cognitive then the strategy for intervention may aso centre on addressing cognitive rather than bioogica or socia aspects of the situation. As we sha see, dysexia is a good exampe of a condition where intervention strategies have been argey cognitive in nature, but increased understanding of its bioogica basis is eading to new possibiities. In contrast, chidren with ADHD are aready offered drug-based treatments simpy because these appear to cam their disruptive behaviour, despite the ack of any cear evidence for corresponding bioogica theories of what causes this syndrome. However, the idea of prescribing such drugs to young chidren has proved controversia in the UK and raises issues to do with the appropriateness of some treatments. Do the ends reay justify the means? As we have seen, most probem behaviours are usuay sustained by many infuences operating at different eves. This means that in some circumstances any intervention that heps to break what is sometimes a vicious cyce may be beneficia. Athough it is hepfu if a cear primary cause can be identified and tacked, this is not aways necessary for treatment or management strategies to be effective. 3.2 Behavioura approaches Behavioura therapies are based on principes of cassica conditioning and operant conditioning (the atter being more propery referred to as behaviour modification therapy). Operant conditioning is about the presentation of a reinforcement being dependent (contingent) on the appearance of a given behaviour. Based on this idea, Skinner (1953) suggested that sometimes abnorma behaviour is the resut of bad contingency management, where inappropriate behaviours have been reinforced. He suggested that such behaviours coud be modified by a process of more appropriate contingency management to become norma. A simpe form of this is the so-caed token economy, often used by schoos in the UK to encourage chidren to engage in good work or behaviour, for which they receive awards such as god stars. Behavioura therapies are aso we suited to the treatment of conditions such as phobias where unwanted emotiona reactions can sometimes be extinguished by behavioura means (see Box 11). 41 of 58 Wednesday 7 September 2016

42 3 Treatment and management Box 11: The three stages of a contingency management programme (Kein, 1996) 1 Observations are made of the cient, and the frequency of the inappropriate behaviour is noted aong with the characteristics of the situations that it occurs in. From this it is possibe to generate hypotheses about what is reinforcing these behaviours inappropriatey. 2 Based on the data from stage one, an intervention is designed which seeks to estabish new contingent reationships between desirabe behaviours and suitabe reinforcement. 3 The situation is monitored as in stage one to ascertain whether the new reationships are having the desired effect. Changes to the contingent reationships are made if necessary. There are emotiona consequences of dysexia which can aso be treated using a programme of this kind. Athough there has been itte research in this area, the studies that have been conducted do show that poor sef-esteem and high eves of stress are rea probems (Riddick 1996; Riddick et a., 1999). If this is the case, remediation programmes need to address both the direct symptoms of dysexia and the emotiona difficuties that peope with dysexia often experience. One exampe of a study that has done this was the summer camp programme devised by Westervet et a. (1998) outined in Box 12 beow. Box 12: The Westervet et a. (1998) summer camp study Over a six-week residentia summer camp in the USA, 48 dysexic students aged between 9 and 14 years received daiy tuition in phonics using the Orton-Giingham mutisensory method (see Section 3.3) and ora reading. Student progress was monitored and individua achievements were shared in a weeky newsetter. Psychosocia difficuties were addressed by praising the chidren, encouraging them to praise and support each other and by creating opportunities for each chid to demonstrate success and receive recognition for it. Awards were presented daiy to chidren who had shown progress in sociaising. At the end of the summer camp the chidren showed significant gains in phonetic reading, speing skis and sef-esteem. However, it was noted that chidren who aso had ADHD showed itte gain in sef-esteem, despite showing the same degree of improvement on the iteracy measures. It woud seem that the additiona difficuties experienced by these chidren prevented them from receiving praise as readiy as the other chidren with dysexia did. You wi notice that this programme of intervention has a behavioura eement to it. It was observed that much of the chidren's ow sef-esteem was associated with faied attempts at reading and writing, and with sociaising with other chidren who might judge them. The researchers attempted to break this cyce by praising the chidren when they worked hard, rather than criticising them for their errors, and by rewarding the chidren with awards when they started to engage sociay with other chidren. Whie this benefited many chidren, the ADHD/dysexic chidren were not benefiting emotionay from the programme, and so some modification to the contingency management programme woud be needed for these chidren in future. 42 of 58 Wednesday 7 September 2016

43 3 Treatment and management Can you think of any modifications that might increase opportunities for praise for the chidren with ADHD/dysexia? Box 13: Definitions Contingency management: An aternative term to behaviour modification therapy, used to describe a behavioura intervention that is based on principes of operant conditioning. Cognitive therapy: Invoves working with a therapist who highights maadaptive beiefs that an individua may have about their situation. The individua is retrained to monitor their own thoughts, recognise when their thoughts are based on emotion rather than reaity, reject biased cognitions and earn to change whatever beiefs have caused them to distort their interpretation of reaity. 3.3 Cognitive approaches Cognitive approaches to therapy invove interventions that focus on addressing aspects of cognitive processing. For exampe, cognitive therapy is frequenty used to treat stress, depression or phobia, and invoves working with a therapist who highights maadaptive beiefs that an individua may have about their situation. The individua is retrained to monitor their own thoughts, recognise when their thoughts are based on emotion rather than reaity, reject biased cognitions and earn to change whatever beiefs have caused them to distort their interpretation of reaity. Another approach, referred to as cognitive behaviour therapy (CBT) invoves observing the therapist modeing the desired behavioura response to a situation, and the individua trying to copy that response and receiving feedback on their attempt. This behavioura rehearsa is repeated unti the behaviour has been mastered. It is caimed that this process, whereby the person reaises that they can now do something that they had previousy been unabe to, eads to the deveopment of a sense of sef-efficacy, wi aso encourage the person to cope with new situations. Interventions that directy address the cognitive deficits of a condition (i.e. rather than emotiona difficuties) through training may aso be thought of as cognitive therapy. As the primary difficuty for peope with dysexia is with acquiring iteracy, the most common approach to remediation is to deveop programmes that teach reading and writing in a way that addresses the cognitive deficits associated with dysexia. The difficuty shown in acquiring aphabetic and phonoogica awareness has ed to the deveopment of phonic teaching programmes. Phonic approaches to reading teach students how to break words down into their composite sounds, e.g. cat =/k/ /a/ /t/ (phonic anaysis) and how to bend individua sounds together to form words (phonic synthesis). At the time of writing, a Engish and Wesh chidren are routiney taught phonic strategies as part of the Nationa Literacy Strategy. Phonic strategies are aso incuded in reading programmes in other countries in Europe and in America. Earier we noted that phonic strategies shoud not be taught to the excusion of other approaches if they are to be successfu, and they rarey are athough they are an especiay important technique for chidren with dysexia to focus on due to their difficuties in achieving aphabetic reading. Moreover, phonic strategies aone are not enough to improve dysexic symptoms if they 43 of 58 Wednesday 7 September 2016

44 3 Treatment and management are taught in norma cassroom contexts so the way that they are taught to students with dysexia is an important feature of remedia programmes. One approach known as the Reading Recovery System, deveoped by Marie Cay in New Zeaand, emphasises the need for reguar periods of one-to-one tuition that focuses on the types of error each chid typicay makes. There is evidence that this eve of individua support is effective in bringing poor readers up to age-appropriate eves of performance, especiay when combined with tuition in phonics (see Iversen and Tunmer, 1993), but such programmes are expensive to maintain. They aso ack thorough evauation of the ong-term performance of chidren after the intervention period has finished. Other projects have found that parenta tuition and peer-support (where more abe friends teach strugging readers) can aso be effective, athough specific guidance on how to support the student must be given to the tutors. Ceary, one-to-one tuition is not aways a practica option. The more common approach to teaching phonics is known as mutisensory teaching. The origins of this idea appear to be with Hinshewood (1917) who recommended that when teaching reading to dysexic chidren, the teacher shoud simutaneousy provide input to verba, visua, motor and tactie memory centres. This sensory integration is intended to maximise the chid's abiity to make associations between visua and verba information by inking them via the other avaiabe senses. However, this idea is more widey credited to Samue Orton who, aong with Anna Giingham, deveoped the Orton-Giingham Technique. This invoved the constant use of associations of a of the foowing: how a etter or word ooks, how it sounds and how the speech organs or the hand in writing fees when producing it (Giingham and Stiman, 1956, p. 17). A wide variety of mutisensory teaching strategies have been deveoped based on this principe (e.g. the Hickey Mutisensory Language Course in the UK, or the Wison Reading System in the US). Studies have shown the mutisensory technique to be especiay effective in heping students with dysexia and it has aso been appied to the teaching of mathematics (Kibe, 1992) Mutisensory teaching for students Guyer et a. (1993) tested the effectiveness of the Wison Reading System for improving speing in higher education students with dysexia. They compared this technique to a non-phonic approach that teaches visua memory techniques to hep students to remember frequenty misspeed words. A contro group of students with dysexia but who had specificay requested no intervention formed the contro group. Both intervention groups were tutored in the given technique for two, one-hour sessions per week, for 16 weeks. Ony the mutisensory group showed a significant improvement in speing abiity at the end of this period. Activity 5 What is significant about the students in the contro group regarding (1) the ethics of conducting intervention studies of this kind and (2) the interpretation of the study's resuts? There are normay ethica probems in excuding peope from an intervention in order to form a contro group. When this happens it is normay necessary to offer the treatment to the contro group after the study has concuded to make sure that they have not been 44 of 58 Wednesday 7 September 2016

45 3 Treatment and management unfairy disadvantaged. However, Guyer et a. (1993) avoided this probem by using peope who did not want any hep for their dysexia as his contro group. However, this does raise some issues regarding the interpretation of their resuts because we do not know the reasons why this group did not want support. For exampe, the contro group may have achieved ess because they were ess motivated to improve, or because their primariy difficuties had been successfuy addressed esewhere. In other words, an important factor to consider when designing an intervention is to use a cosey matched contro group. As we have aready mentioned, phonic approaches do not address the wider difficuties of visua or attentiona processing, physica coordination or automatisation associated with dysexia. There may be some individuas with no primary probems in phonoogica awareness who need programmes specificay taiored to address their particuar difficuties. Box 14: Definitions Cognitive behaviour therapy: Invoves observing the therapist modeing the desired behavioura response to a situation, and the individua trying to copy that response and receiving feedback on their attempt. This behavioura rehearsa is repeated unti the behaviour has been mastered. Phonic approaches: An approach to teaching reading that emphasises the reationships between etters (graphemes) and their corresponding sounds (phonemes). Reading Recovery System: An intensive individuaised technique for teaching reading devised by Marie Cay. Mutisensory teaching: A technique that invoves teaching chidren via the simutaneous stimuation of as many senses as possibe. Orton-Giingham technique: A specific mutisensory technique for teaching reading. Matched contro group: A contro group that has been matched to the participants in the experimenta group on various key characteristics. 3.4 Bioogica approaches Certain kinds of psychoogica disturbances may be seen as mafunctions of the brain. If a psychoogica probem has an obvious bioogica expanation, then it may be possibe to direct therapeutic approaches at this eve. However, as we have seen, it is difficut to identify precise bioogica causes for compex psychoogica phenomena. Even if this were possibe, it woud not aways be practicabe to use treatments to change the underying bioogica factors. Genetic expanations provide the most obvious exampe of this probem. As we have seen, the genetic factors underying compex patterns of behaviour are rarey simpe, usuay invoving many different genes. Even if a singe mafunctioning gene coud be identified, the ikeihood of successfu gene therapies remains highy theoretica and woud be fraught with both ethica and practica difficuties. The most common medica method of treating psychoogica probems is through biochemistry. Numerous pharmacoogica (drug) treatments are aready in use for 45 of 58 Wednesday 7 September 2016

46 3 Treatment and management conditions such as anxiety, depression, schizophrenia and ADHD. However, prescription of these kinds of treatments ies in the province of psychiatry, not psychoogy, because their safe use requires speciaised medica knowedge and training. Nutritiona treatments offer a possibe aternative to drugs for correcting biochemica imbaances that contribute to psychoogica probems. It is easy to forget that what we consume can have powerfu effects on brain function, both in the short-term (e.g. the way that coffee or sugary foods provide a temporary ift in energy) and in the ong term, because our diet provides the substances we need to fue, maintain and repair our brain and body Pharmaceuticas or nutraceuticas? Nutraceuticas refers to the use of food suppements or herba remedies for heath purposes. For exampe, certain ingredients of the herb St John's Wort can be as effective in managing depression as conventiona anti-depressants, with fewer negative side effects (Greeson et a., 2001). However, research aso shows that this suppement can interact negativey with some commony prescribed drugs, such as the contraceptive pi. This highights the need for: proper research into food suppements and herba remedies; consuting a medica practitioner before taking any of the suppements. Simiary, doctors sometimes prescribe vitamins and mineras (e.g. vitamin B6 for depression, poor concentration or memory probems). Evidence has aso emerged that suppements of fish oi, which contains certain highy unsaturated omega-3 fatty acids, may hep to reduce the symptoms of serious mood disorders (Sto et a., 1999). As discussed earier, deficiencies in highy unsaturated fatty acids are aso suspected of paying a part in behavioura and earning probems ike ADHD, dysexia and dyspraxia. Even apparent evidence of benefits does not mean that the treatment is reay addressing the underying probem. For exampe, seeping pis may render someone unconscious, but can we reay say that this is addressing the underying probem? You may ask: does it matter if we don't know how something works, as ong as it works? The answer depends on a carefu evauation of both the costs and the benefits associated with a particuar treatment. However, even if a treatment appears to work, it can sti be difficut or impossibe to know whether the benefits observed resut from the treatment. The probem of evauating interventions, be they bioogica, cognitive or behavioura, is discussed in Section 3.5. As we saw in Section 2, we sti know comparativey itte about the physica brain differences that may contribute to deveopmenta dysexia, and what we do know suggests imited scope for direct bioogica interventions. Reated conditions such as ADHD are often treated using drugs, but there has been itte investigation of possibe biochemica contributions to dysexia. However, as discussed, there is some evidence of deficiencies in certain highy unsaturated fatty acids, and case studies suggest that nutritiona therapy may be hepfu in some cases (see Box 15). Large-scae doube-bind trias shoud soon revea whether dietary suppementation may be of more genera benefit in the management of dysexia. 46 of 58 Wednesday 7 September 2016

47 3 Treatment and management Box 15: A biochemica approach to dysexia (Baker, 1985) This report describes the case of a boy diagnosed with dysexia, for whom biochemica testing reveaed various imbaances. Correcting these with nutritiona suppements ed to cear improvements in his schoowork. His story iustrates the importance of treating the individua chid rather than the apparent probem of his dysexia (which had not responded to conventiona remedia teaching methods). Deficiencies in certain fatty acids were considered the singe most important factor in this case, but some vitamins and mineras were aso acking. Furthermore, to anyone famiiar with the signs, this chid's fatty acid deficiency was evident from simpe observation (athough biochemica testing was needed to confirm it). Michae had very dry, patchy, du skin. Like a matte finish on a photograph, his skin, as we as his hair, faied to refect ight with a norma ustre. His hair was easiy toused and when pued between the fingers it had a straw-ike texture rather than a norma siky fee. He had dandruff. The skin on the backs of his arms was raised in tiny cosed bumps ike chicken skin. His fingernais were soft and frayed at the ends. A of these findings point to an imbaance of fatty acids. (Baker, 1985, p. 583) This biochemica approach apparenty angered some speciaists, who took the view that Nutrition has nothing to do with dysexia. However, as the author notes: Improvement in Michae's schoo work coincided with the return of norma ustre and texture to his skin and hair. If he had been a cocker spanie his famiy woud have accepted the connection between his gossier coat and better disposition more readiy. The timing was convincing. Athough it is never enough to estabish proof in a given person, Michae was convinced. He saw and fet the changes together, and he understood the idea behind the work we did with him. With a twinke in his eye, he tod his grandmother that dandruff had been the cause of his dysexia. (Baker, 1985, p. 583) The doctor emphasised that he was simpy treating the individua chid, and did not regard dysexia as any kind of disease. Instead it was the non-medica speciaists who seemed pre-occupied with the dysexia abe. Reca too our discussion of expanations, where we saw that a proper understanding of any psychoogica probem requires an appreciation of three eves behavioura, cognitive and bioogica, as we as the way that environment (in this case diet) can impact on each of these. This report aso shows the vaue of a wedocumented singe-case study, athough randomised controed trias are necessary to provide unequivoca evidence of benefits from biochemica treatments. Some visua treatments, such as covering one eye when reading, have shown benefits in doube-bind trias (Stein et a., 2000). However, this kind of speciaist treatment is ony appropriate for chidren who have particuar visua deficits, and it requires proper professiona supervision. Others, such as using cooured enses or overays for reading, are popuar amongst some peope with dysexia and ead to improvements in reading abiity in open studies (Sawyer et a., 1994), but as yet there is imited evidence from pacebo-controed studies to suggest that they are effective (Francis et a., 1992). A few 47 of 58 Wednesday 7 September 2016

48 3 Treatment and management other unconventiona treatments for dysexia are widey advertised by private cinics as based on bioogica evidence, but have no reiabe evidence of their efficacy. One unorthodox approach that has support from randomised, doube-bind, pacebo-controed trias invoves specia physica exercises designed to improve aspects of motor coordination thought to refect neuroogica immaturities in dysexia (McPhiips et a., 2000). Benefits to physica coordination, reading and attention were reported. Box 16: Definitions Pacebo: Any therapy that is used for a specific symptom or disease, but which is actuay thought to be ineffective for that purpose. A pacebo is usuay empoyed in cinica trias for comparison with the active treatment under study. A study with no pacebo is an open study. 3.5 Evauating intervention studies Expectancy versus effect One of the biggest probems in evauating psychoogica interventions is that even if a treatment appears to work it can sti be difficut to ascertain whether the resuts were a consequence of the treatment itsef. The improvement might have occurred anyway, with or without the treatment, or the apparent benefits might have resuted from other factors, such as being abe to discuss the difficuties with a professiona who understands. Any treatment can ead to expectations of improvement that can be sef-fufiing. Even a treatment with absoutey no benefits for the condition in question can be foowed by substantia improvements if the person beieves that it wi hep. This is the so-caed pacebo effect. For biochemica interventions, professionas evauate treatments via randomised, doubebind, pacebo-controed trias (see Box 17). This kind of tria remains the benchmark of evidence-based medicine, as the most objective way to find out whether a treatment is effective. It can aso be used to evauate other types of intervention strategy where it is possibe to deveop a suitabe pacebo. Box 17: Randomised, doube-bind, pacebo-controed trias some definitions Pacebo-controed the treatment being tested (known as the active' treatment) is compared with another treatment (the pacebo ) that is beieved to be neutra with regard to the underying specific basis of the condition in question, but is otherwise indistinguishabe from the active treatment. Studies with no pacebo are known as open treatment studies. Doube-bind to eiminate as much bias as possibe, it is crucia that neither the participants nor those carrying out the study know which peope are receiving the active treatment and which the pacebo (i.e. everyone invoved in the study must be bind to treatment status unti a data have been coected and anaysed). Sometimes it is not possibe to achieve this owing to the nature of the treatment, in which case the next best 48 of 58 Wednesday 7 September 2016

49 3 Treatment and management option is the singe-bind study, in which the participant does not know what kind of treatment they are receiving but those carrying out the tria do. Randomised the kind of treatment that each participant receives must be determined by pure chance, otherwise there is an opportunity for bias (conscious or unconscious) in the aocation of treatments that coud infuence the resuts. Proof of efficacy is required before any new drugs are icensed for prescription, but inevitaby this evidence is often obtained under rather imited conditions. Individua differences in the metaboism of many drugs can mean that not everyone reacts biochemicay in the same way to a given dosage. For ethica or other reasons, cinica research trias often do not incude particuar groups such as chidren or women. Many drug-based interventions aso have undesirabe side-effects that have to be weighed against the possibe benefits. Since psychoogica probems usuay have a wide range of possibe interacting causes, in many cases drugs may not be the primary treatment option. There are difficuties inherent in carrying out pacebo-controed trias, particuary for non-pharmacoogica treatments, incuding: deception can it be justified? doube-bind tria can this be achieved when the experimenter is administering a cognitive or behavioura pacebo therapy? homogeneity for some medica probems it may be possibe to ensure cose simiarity of symptoms experienced across a participants. However, for many compex psychoogica conditions this is much more difficut Pre-post test studies Another method for evauating the effectiveness of a therapy is to use a pre-post test design. This is where a group of peope is assessed before and after a programme of intervention. Ideay, these peope woud be matched to a contro group who are aso tested twice, but do not receive the same (or any) intervention during that period. However, as with randomised controed trias, there are ethica issues if it becomes cear that the intervention is having an adverse affect on the experimenta group. Even if the intervention is successfu, there may be ethica issues as the contro group coud be seen as disadvantaged by not receiving the intervention. Finay, it is aways important to assess the ong-term effects of any intervention programme to see if the apparent benefits are sustained ong after the study has concuded Singe participant interventions A singe participant intervention study, studies the effects of an intervention in the case of one person, with the aim of estabishing those eements of the intervention which woud work with the majority of peope. This is because the method assumes that in a important respects, a human beings are the same, and the effects of the intervention in one case shoud be the same in a cases. It is a method that beongs to objectivity. Box 18: Featured method Singe participant experimenta designs 49 of 58 Wednesday 7 September 2016

50 3 Treatment and management Singe participant experimenta designs are used to assess the effectiveness of an intervention on a case by case basis. What may be effective for some peope may not work we for others, and given the heterogeneous nature of peope with reading difficuties it woud seem appropriate to adopt a singe case strategy to the design and assessment of interventions for this and simiary varied sampes. This approach is aso used in other areas of psychoogica intervention such as psychotherapy and psychoanaysis. There are a variety of designs that are used within this method, one of them being the ABAB Design (see Figure 7). A baseine measure is taken severa times before the intervention is introduced (A), and then during the intervention itsef (B). The intervention is then withdrawn for a sustained period (A) and reintroduced (B). This aternating pattern enabes the researcher to see if the intervention has any genuine effect on the individua, whether the benefit is reiabe (i.e. is it reproduced the second time the intervention is appied), and whether it has a continued benefit after the intervention is withdrawn. The participant aso acts as his or her own contro in a design of this nature. This design gives a richer picture of what is going on than a simpe pre-post test design woud. Figure 7 ABAB Design 3.6 Refecting on dysexia Throughout this course, dysexia has been evauated as an exampe of abnormaity, a difficuty, a probem in need of an intervention. However, research has shown that some aduts with dysexia are distinctive, not just in their difficuties, but aso in their increased eves of creative reasoning compared to norma peope (Everatt 1997). West (1997) reports that Nichoas Negroponte, the founding member of the Media Lab at the word renowned Massachusetts Institute of Technoogy has joked that dysexia is the MIT disease, because so many of the individuas at the forefront of their fieds have dysexia. 50 of 58 Wednesday 7 September 2016

51 3 Treatment and management The foowing are some of the strengths associated with dysexia (Reid and Kirk, 2001): Good visua and spatia skis in areas such as engineering and the physica sciences. Abiity to recognise patterns of information and represent three-dimensiona images. A faciity for mentay rearranging designs and information. A hoistic way of viewing the word, which aids the discovery of probem soutions. Rich coour memory and abiity to use fast mutisensory combinations. Creativity. Critica thinking skis. What is probematic in one situation can be advantageous in another. In Section 2.3 we saw that the brain anomaies associated with dysexia can resut in rich neura connections, and that computer modes with simiar patterns of connectivity are more efficient at tasks that require creativity but not automaticity. Simiary, the ease with which peope with dysexia transpose etters ike b, d, p and q, refects an abiity to manipuate and match images that can be hepfu in engineering. Rather than viewing it as a deficiency or abnormaity, it has been proposed that dysexia can be thought of as a unique cognitive stye that favours parae/hoistic reasoning over sequentia processing of information (Aaron et a., 1993). Remember what we discussed at the beginning of the course about socia or historica factors constructing normaity'? Dysexia was not recognised as a probem unti there was a socia expectation of and need for iteracy, even though the condition probaby did exist before then and affected peope's ives in other ways (e.g. poor memory). Written anguage is a technoogy, but technoogies change as we become more dependent on one, we wi become ess dependent on others. The increase in new technoogies is prompting a re-examination of the sorts of skis society needs. This might highight a need for the creative thinking that computers are unabe to do, but which many dysexic peope are skied in. As a fina postscript, not just to the ideas we have examined to do with dysexia, but with normaity generay, consider once more the case of Aexander Faudy (see the Case Study in Section 1.3). His story is worth refecting on in terms of what it tes us about normaity and abnormaity and the way that society responds to individuas who are exacty that individua. Summary of Section 3 There are important distinctions between treating and managing a condition. Therapies can be directed at behavioura, cognitive and bioogica eves. Interventions require effective evauation. Successfu approaches to managing dysexia incude mutisensory teaching of phonics, the promotion of sef-esteem through rewards, and addressing nutritiona deficiencies through dietary suppementation. 51 of 58 Wednesday 7 September 2016

52 Concusion Concusion This course has been about understanding the idea of psychoogica abnormaity and its impications. What we have earned is that normaity is defined in a variety of ways, and it is important to ask what mode of normaity is being subscribed to when ooking at abnorma popuations. Are we judging someone's behaviour according to medica, statistica or socia definitions of normaity? The point of giving a detaied exampe ike that of dysexia is to show that in practice there are difficuties in appying any one mode of normaity, and that they a have impications for defining a condition, which in turn wi have impications for diagnosis and management. Our discussion has shown that it is important to integrate the different psychoogica accounts of the condition in order to provide a fu expanation of potentia causes and strategies for remediation. Moreover, it is important to consider what can and shoud be addressed during remediation and which behaviours, however abnorma, are vauabe and even desirabe in particuar contexts. If you beieve that you may suffer from dysexia, we advise you to contact a nationa charity that wi be abe to offer assistance and guidance in the first instance. If you are based in the UK, you may wish to contact the British Dysexia Association, the Dysexia Institute or the Adut Dysexic Association. 5 Further reading Caridge, G. (1985) Origins of Menta Iness: Temperament, Deviance and Disorder, Oxford, Backwe. A cassic text on abnorma psychoogy. Faudy, T. and Faudy, A. (1996) A Litte Edge of Darkness: A Boy's Triumph Over Dysexia, London, Jessica Kingsey. This is the persona account written by Aexander Faudy and his mother, Tanya, of their experiences of understanding and managing Aexander's dysexia. Mies, T.R. and Mies, E. (1999) Dysexia: A Hundred Years On (2nd edn), Buckingham, Open University Press. A good introduction to the history, issues and research that reates to deveopmenta dysexia. 52 of 58 Wednesday 7 September 2016

53 Keep on earning Keep on earning Study another free course There are more than 800 courses on OpenLearn for you to choose from on a range of subjects. Find out more about a our free courses. Take your studies further Find out more about studying with The Open University by visiting our onine prospectus. If you are new to university study, you may be interested in our Access Courses or Certificates. What s new from OpenLearn? Sign up to our newsetter or view a sampe. For reference, fu URLs to pages isted above: OpenLearn Visiting our onine prospectus Access Courses Certificates 53 of 58 Wednesday 7 September 2016

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