Treatment of Acquired and Developmental Alexia

Treatment of Acquired and Developmental Alexia

Is Is ItIt Too Too Late Late Or Or Can Can Developmental Developmental Phonological Phonological Dyslexia Dyslexia Be Be Successfully Successfully Treated Treated In In Adults? Adults? Tim Conway, Ph.D. The Morris Center, Inc. University of Florida Gainesville, Florida

Presentation at the Florida Association of Speech Language Pathologists and Audiologists May, 2010 Is It Too Late Or Can Developmental Phonological Dyslexia Be Successfully Treated In Adults? Abstract: Children with developmental phonological dyslexia typically grow up to become adults with phonological dyslexia. However, recent treatment studies report successful prevention and treatment of dyslexia in children. This raises the question of whether or not it is too late to help adults with dyslexia improve their phonological processing, phonological decoding, functional reading and language skills. We present a theoretical model of assessment and treatment of dyslexia that relies on an transdisciplinary team approach. Case studies of adults who have completed this approach are presented to highlight that successful remediation may be possible for many adults. Limitations of this model and approach as well as future directions are also discussed.

Three Learning Outcomes: 1. The participants will describe how a transdisciplinary team may guide assessment and treatment of phonological dyslexia. 2. The participants will identify a minimum of 3 disciplines that may collaborate on a transdisciplinary team. 3. The participants will be able to explain evidence that some adults are able to improve their phonological dyslexia following a transdisciplinary treatment. 4. Participants will understand how evidence from this transdisciplinary model of assessment and treatment may impact the future direction of phonological treatment. WHAT WHAT DYSLEXIA DYSLEXIA IS IS NOT NOT DYSLEXIA DYSLEXIA ..

is NOT A VISUAL PROBLEM .. is NOT A LACK OF INTELLIGENCE .. is NOT DUE TO LACK OF EFFORT .. is NOT A DEVELOPMENTAL LAG is NOT UNCOMMON: 517.5 % OF POPULATION .. is NOT RESPONSIVE TO STANDARD READING .. INSTRUCTION DYS = TROUBLE LEXIA = WORDS

DYSLEXIA IS NEUROLOGIC IN ORIGIN GENETIC LIFELONG ENVIRONMENT MAY ALTER COURSE CORE DEFICIT=PHONOLOGICAL AWARENESS (LANGUAGE) READING COMPREHENSION > WORD READING SKILLS DYSLEXIA MAY INCLUDE ACCOMPANYING CHALLENGES ADHD (50-70%) BEHAVIORAL PROBLEMS SENSORY MOTOR DIFFICULTY = MORE CHALLENGING TO REMEDIATE THE PICTURE OF DYSLEXIA (ALL STENGTHS DO NOT OCCUR FOR EVERYONE) (Alexander & Conway, 2007) STRENGTHS LEADERSHIP SKILLS THINKING OUT OF THE BOX TH

O PAT TON CHURCHILL JFK POLITICAL & MILITARY TED TURNER BUSINESS MA S ED ISO N

SCIENTISTS & INVENTORS THE PICTURE OF DYSLEXIA (ALL STENGTHS DO NOT OCCUR FOR EVERYONE) (Alexander & Conway, 2007) STRENGTHS CREATIVITY WRITERS ARTISTS H.C. ANDERSEN Da VINCI MUSICIANS ACTORS/DIRECTORS MOZART

SPEILBERG / FORD THE PICTURE OF DYSLEXIA (ALL STENGTHS DO NOT OCCUR FOR EVERYONE) (Alexander & Conway, 2007) STRENGTHS VISUOSPATIAL / MOTOR SKILLS SURGEONS NEUROSURGERY ATHLETES MUHAMMAD ALI

NOLAN RYAN THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) (Alexander & Conway, 2007) ORAL LANGUAGE CHALLENGES LISTENING Phonological Awareness SPEAKING Word Finding Multi-syllable Words Auditory Memory (word sequences, phone numbers, remembering directions) Foreign Language

Sequencing Ideas Foreign Language THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) (Alexander & Conway, 2007) WRITTEN LANGUAGE CHALLENGES READING Mechanics SPELLING & WRITING Comprehension Speed Mechanics Expressing Idea

Speed THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) (Alexander & Conway, 2007) ACCOMPANYING SENSORIMOTOR CHALLENGES Messy Eating Oral Motor Fingers Writing/knots Lose Place Eyes Words Swim Tired Left/Right Up/Down

Spatial Awareness Cognition Sensorimotor Pyramid Academic Learning ADLs Behavior Auditory Visuospatial Focus Perceptual- Language Perception Attention Motor Eye-Hand Ocular-Motor Postural Coord Control

Adjustment or y Sensory- Body Scheme Reflex Maturity Screen Input Motor Postural Security Bilateral Awareness Motor Planning Se ns Olfactory Tactile Visual Auditory Gustatory Vestibular Proprioception Central Nervous System

THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE) (Alexander & Conway, 2007) ACCOMPANYING CHALLENGES (BEHAVIORAL) Attention & Executive Function Brain / Behavior Disorders Anxiety OCD Oppositional Behavior Depression Parents with similar challenges

CHANGES CHANGES IN IN SYNAPSES? SYNAPSES? AT WHAT AGE DO NEURONS LOSE THE ABILITY TO MAKE NEW CONNECTIONS (SYNAPSES) WITH OTHER NEURONS? NEURONS NEURONS -- How How the the Brain Brain Works Works How Many Neurons In The Brain?

How Many Connections Exist in the Neural Networks Formed in the Brain? ~ 100 Billion ~ 100 Trillion How Many Connections for a Single Neuron? ~ 40,000 TYPICAL LANGUAGE AREAS VISUAL-LANGUAGE ASSOCIATION AREA VISUAL /

VERBAL AREA SPEECH PRODUCTION AREA AUDITORY PROCESSING AREA LEFT HEMISPHERE TYPICAL READING AREAS WORD ANALYSIS WORD ANALYSIS AUTOMATIC (SIGHT WORD) LEFT HEMISPHERE

Area Spt (left) auditory-motor interface pIFG/dPM (left) articulatory-based speech codes STG (bilateral) acoustic-phonetic speech codes STS phoneme representations Hickok & Poeppel (2000), Trends in Cognitive Sciences Hickok & Poeppel (2004), Cognition pMTG (left) sound-meaning interface

UNIQUE AND OVERLAPPING NETWORKS SENTENCE/SYNTACTIC, SEMANTIC, PHONOLOGICAL VIGNEAU et al., 2006 Developmental Developmental Building Building Blocks Blocks for for Language Language 9 YEARS METALINGUISTICS WRITING SPELLING READING 5 YEAR S SYNTAX

(FORM) 18 MONTHS SEMANTICS 9 MONTHS 1 MONTH (MEANING) PHONOLOGY PRAGMATICS (FORM) (FUNCTION) Is Is There There aa Neurobiological Neurobiological Basis

Basis to to Dyslexia? Dyslexia? NEURONAL MIGRATION www.thebrain.mcgill.ca X NEURAL NEURAL MIGRATION MIGRATION GONE GONEAWRY AWRY IN IN DEVELOPMENTAL DEVELOPMENTAL

DYSLEXIA DYSLEXIA OUT OF LINE NEURONS (ECTOPIAS) FRONT BACK NEURONAL MIGRATION (GALABURDA, LOTURCO, RAMUS, FITCH & ROSEN, 2006) Galaburda, 2006 From From Genes Genes to to Behavior Behaviorin in Developmental Developmental Dyslexia.

Dyslexia. Galaburda GalaburdaAM, AM,LoTurco LoTurcoJ,J,Ramus RamusF,F,Fitch FitchRH, RH,Rosen RosenGD. GD. Nat NatNeurosci. Neurosci.2006 2006Oct;9(10):1213-7. Oct;9(10):1213-7. Department of Neurology, Division of Behavioral Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, Massachusetts 02215, USA. All four genes thus far linked to developmental dyslexia participate in brain development, and abnormalities in brain development are increasingly reported in dyslexia. Comparable abnormalities induced in young rodent brains cause auditory

and cognitive deficits, underscoring the potential relevance of these brain changes to dyslexia. Our perspective on dyslexia is that some of the brain changes cause phonological processing abnormalities as well as auditory processing abnormalities; the latter, we speculate, resolve in a proportion of individuals during development, but contribute early on to the phonological disorder in dyslexia. Thus, we propose a tentative pathway between a genetic effect, developmental brain changes, and perceptual and cognitive deficits associated with dyslexia. BRAIN ACTIVITY DURING READING STRONG ACTIVITY PATTERN weak activation pattern SIGNATURE DYSLEXIC BRAIN Simos, et al 2002 TREATMENT CHANGES the BRAINS ACTIVITY

Decreased activity in right hemisphere (Simos et al 2002) Treatment = Increased activ ity in left hemisph ere Biology Cognition Behavior (RAMUS, 2004) (Alexander, 2006) DYSLEXIC

READING (PERCEPTION / PRODUCTION) EXECUTIVE FUNCTION / INTENTION PHONICS RULES WORKING MEMORY SEMANTIC / LEXICAL REPRESENTATION HOLD / MANIPULATE SYNTACTIC REPRESENTATION ORTH OGRAPHIC ARTICULATORY PHONOLOGIC

PROSODIC MORPHOSYNTACTIC REPRESENTATION REPRESENTATION REPREESENTATION REPRESENTATION REPRESENTATION ATTENTION / AROUSAL PHONOLOGY PHONOLOGY(PERCEPTION & PRODUCTION) (Alexander, 2006)

EXECUTIVE FUNCTION / INTENTION WORKING MEMORY PROSODIC HOLD / MANIPULATE (WORD LEVEL) PHONEMIC ORAL MOTOR SOMATOSENSORY REPRESENTATION ACOUSTIC ATTENTION / AROUSAL

VISUAL THEORETICAL THEORETICAL DEVELOPMENTAL DYSLEXIA: A MOTOR-ARTICULATORY FEEDBACK HYPOTHESIS (HEILMAN, VOELLER, ALEXANDER, 1996) The inability to associate the position of their articulators with speech sounds may impair the development of phonological awareness and the ability to convert graphemes to phonemes. Unawareness of their articulators may be related to programming or feedback deficits. Transdisciplinary Transdisciplinary Team Team for for Assessment Assessment & & Treatment Treatment

Disciplines: Neuropsychology Psychiatry Nursing/Nurse Practitioner/Developmental Pediatrics Clinical Psychology Occupational Therapy Speech-Language Pathology Education Transdisciplinary Transdisciplinary Team

Team Disciplines on the team Pediatrician/Psychiatrist Nursing/Nurse Practitioner Psychologist/Neuropsychologist Occupational Therapist Speech-Language Pathologist Teacher/Special Education Transdisciplinary Transdisciplinary Team Team Assessment Assessment Two Phase Assessment

Phase I: Screening & a Broad Neurodevelopmental Evaluation Phase II: Assessment of Specific Abilities - Identify an Individual Profile of Strengths & Weaknesses (for diagnostic and treatment planning purposes) Transdisciplinary Transdisciplinary Team Team Assessment Assessment Phase I Evaluation (broad screening) Neurodevelopmental evaluation (Nurse Practitioner)

Medical and Developmental History & Exam Screening of all sensory & cognitive systems including sensorimotor, learning & memory, attention, speech/language, vision, motor planning and cognition Nutrition, sleep, behavior, allergies, genetic history, other concerns Psychological evaluation (Psych or Psychiatry) Diagnostic interview psychosocial, educational, behavior, & family history Transdisciplinary Transdisciplinary Team Team Assessment Assessment Phase II identify an individual strengths and weakness:

Attention/Intention Intelligence/Cognition Oral Language Memory Sensorimotor Written Language Mathematics Behavioral Observations Transdisciplinary Transdisciplinary Treatment Treatment Program Program

Key treatment features are based on neuroscience and behavioral treatment research findings Intensity (# of hours per day) Frequency (# of days per week) Specificity (clarity of treatment program) Selective post-treatment assessment with standardized tests to document treatment gains Ongoing data collection of program effects for program self-evaluation Transdisciplinary Transdisciplinary Treatment Treatment Program

Program Treatment Targets Within and Across Disciplines Speech-Language Therapy Occupational Therapy Targets sensory and motor skills that may contribute to learning difficulties, e.g. sensory defensiveness, visual processing/perception, etc. Psychiatric/Medical

Targets improving foundational language skills that may cause the learning difficulty, e.g. phonological processing/decoding Medication and behavioral management of attention, mood or behavior disorders. Psychological Treatment Client - developing adaptive coping skills for academic and life stressors Parent - better behavior management, conflict resolution training, etc Client & Parent/Spouse (separately or combined) - d eveloping adaptive family or marital functioning, relative to learning and other difficulties. Case Case Study Study

High school student History of dyslexia since elementary school Parent is a school teacher Years of school-based academic intervention and specialized tutoring at franchised centers Starting athlete with scholarship potential, but he has body function and academic deficits in Case Case Study Study -- Assessment Assessment Findings Findings Deficits in:

Attention ADHD-Inattentive Language Phonological Reading Writing Spelling Written

comprehension Expression. Sensorimotor Visual vigilance Visual tracking Vestibular Visual perceptual Low Registration on Sensory Profile

Poor balance with eyes closed Poor supine flexion. Case Case Study: Study: Transdisciplinary Transdisciplinary Treatments Treatments Psychology: Individual therapy Therapy with mother Speech-Language:

Phonological Awareness (LiPS Program) Mental Imagery (Visualizing & Verbalizing) Written Composition (Visual-Kinesthetic Sentence Structure). OT Sensory modulation &

processing - esp. vestibular Oculomotor skills Joint stability Visual perceptual skills Balance Movement perception Sequencing. Case Case Study: Study: Transdisciplinary Transdisciplinary Treatment Treatment of of Dyslexia Dyslexia Treatment Schedule: Daily 4-6 hours treatment per day

~1 hour of OT ~3-5 hours language 5 days per week ~12 weeks Treatment Hours: Phonological/Cognitive: ~150 (LiPS) Semantic/Memory (V/V): ~50

Syntax/Cognitive (VKSS): ~50 Physical Medicine: ~45. Sensorimotor Sensorimotor Functions: Functions: Visual-Motor Visual-Motor Integration Integration (VMI) (VMI) 120 IQ=101 Pre Standard score 100 80 60 40 20

0 Visual-Motor Integration Motor Coordination Post Sensorimotor Sensorimotor Functions: Functions: Test Test of of Visual Visual Processing Processing Skills-3 Skills-3 Scaled score 20 15

10 5 0 Pre IQ=101 Post Language Language Functions: Functions: Comprehensive ComprehensiveTest Testof ofPhonological PhonologicalProcessing Processing(CTOPP) (CTOPP) 120

IQ=101 Pre Post Standard score 100 80 60 40 20 0 Phonological Awareness Alternate Phonological Awareness Improved Improved Sensorimotor Sensorimotor Functions

Functions Sensory Processing Low registration was improved with medication and arousal strategies for use at home and school. Processing/ Modulation of Vestibular Information - R & L LE balance without vision = 4 and 7 secs, improved to 21 and 18 secs; impaired supine flexion improved to 90 seconds while counting (without holding shoulders); depressed post rotary nystagmus was improved Oculomotor Skills - losing his place during reading and poor visual endurance (blinked excessively during visual tasks/testing), both visual tracking and endurance were improved and excessive blinking was markedly decreased Visual Perception

-TVPS=83 SS (below average) to TVPS=110 (high average) Graphomotor Skills - VMI Motor Coordination = 75 SS improved to 89 Academic Academic Functions: Functions: WECHSLER WECHSLERINDIVIDUAL INDIVIDUALACHIEVEMENT ACHIEVEMENTTEST TEST(WIAT-II) (WIAT-II) 100 90 Standard score

80 70 60 50 40 30 20 10 0 Pre Post pre-treatment skills post-treatment skills Treatment Treatment Summary Summary

Participant01 Demonstrated: Improved Attention, Language, Sensorimotor and Academic (passed high school proficiency tests and will get a standard diploma) Planning to enroll in Junior College and play sports on an athletic scholarship Conclusions Conclusions Adults with language-based learning difficulties may be able to make significant improvements in areas of attention, sensorimotor, visual perceptual, language and academic functioning. The multifaceted nature of the challenges for many adults with language-based learning difficulties may be best treated by a transdisciplinary team. Large scale studies are needed to identify if there are pre-treatment cognitive/sensorimotor profiles that may be more responsive to these types of intervention.

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