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From Myths to Realities: Lessons to be drawn from over 600 student assessments

David Grant,

Dyslexia Diagnosis Specialist, London david.grant6@virgin.net

Abstract

Effective policy is grounded in fact, not opinion. In spite of over 100 years of research much still remains to be learnt about the dyslexias. Analysis of over 600 assessments of students referred for diagnosis to determine whether they might be dyslexic suggests very strongly that it is misleading to characterise dyslexia as being mainly a male condition; nor is it accurate to characterise dyslexics as being visually gifted. [It is suggested that the higher proportion of students following art and design courses reflects a 'least barriers' strategy rather than one based on being 'gifted'.] This paper proposes that it is preferable to use the term dyslexias rather than dyslexia, and highlights the co-morbity of dyslexia and dyspraxia as well as the necessity to appreciate that being dyslexic affects a person's life in general, not just aspects relating to reading and writing. As an example of this life-style concept attention will be drawn to an overlooked aspect of being dyslexic, namely a difficulty with getting to asleep. This is an everyday aspect of life reported by over 90% of dyslexic students that may be related to a working memory deficit. The policy and theoretical implications of moving to an understanding of the dyslexias stripped of its myths will be discussed.

The word dyslexia was first used by Berlin in 1887 to describe a case of what we now refer to as acquired dyslexia [Smythe, 2001, dyslexia@jiscmail.ac.uk March 21]. Ten years earlier Kussmaul described a particular type of acquired word difficulty which he referred to as 'word-blindness' or 'caecitas verbalis'. In 1896 Morgan wrote up a case study of a 14-year-old boy who, in spite of his being 'one of the most intelligent children in the school', was having severe problems with reading and spelling, [Temple, 1997, p 164]. This is probably the first research paper to be published about a case study of what we would now refer to as developmental dyslexia. By 1917 the first book on developmental dyslexia, Hinshelwood's work on congenital word-blindness, was published.

In spite of a history of research stretching for well over a century I am surprised by the number of misperceptions that still exist about dyslexia, even within the research community. As these misperceptions, in my opinion, distort research, a key function of this paper is to identify them. In order to expose these I will drawn heavily on data I have gathered from the carrying out of more than 900 diagnostic assessments over the past four-and-a half-years. These assessments have overwhelmingly been undertaken on students who are in higher education so, by definition, the dyslexics in the sample are, almost exclusively, of above average verbal intelligence.

As a key element of my professional practice, I have carried out a reflective annual review, and used this as an opportunity to revise my diagnostic interview pro forma. This has enabled me to collect data that might otherwise have been neglected.

The myths I will explore in this paper are:

• Dyslexia is a homogeneous condition
• More males than females are dyslexic
• Dyslexics are visually gifted
• Dyslexia is a 'narrow' condition.

The realities as I see them are that dyslexia is a heterogeneous condition; the incidence of co-morbidity [particularly with dyspraxia] is high; almost as many females as males are dyslexic; students select educational and career options that present the least barriers to success; and being dyslexic is best thought of as being a life style that is reflected in many everyday experiences, such as difficulty with getting to sleep.

The term dyslexia is perhaps an unfortunate one, for it implies a uniform condition. If this were the case the study of dyslexia would be much simpler. However, as Christine Temple points out, 'Despite Hinshelwood's [1917] early documentation of the multiple formats of developmental reading disorders, the multiple syndrome nature of developmental dyslexia continues to be ignored in many studies' [page 175]. Although many researchers act as if dyslexia were a homogeneous condition, they do so in spite of a long history of reports that describe the different forms that dyslexia can take [e.g. Schonell, 1945; Boder, 1971].

An analysis of my own WAIS-III data has consistently revealed that while the WAIS-III profile for many dyslexics reveals above average scores for verbal and visual reasoning, and below average scores for working memory and processing speed [Fig. 1], there are also significant variations to this averaged profile. [See Figs 2, 3 and 4 for Hugh, Juliette and Mary respectively].

Just as importantly, the co-morbidity of dyslexia and dyspraxia is high. Since carrying out my first annual review in 2000 I have been very aware that any assessment should automatically consider dyspraxia as a possible diagnostic outcome as well as dyslexia.

Table 1 below shows my diagnostic categories in percentage terms for the academic years 2001-2002 [3rd review], and 2002-2003 [4th review].

Table 1 Percentages of students diagnosed as being dyslexic or dyspraxic for the academic years 2001-2002 and 2002 to 2003

Over the course of these two years, of the 400+ students I have diagnosed as being dyslexic, dyspraxic, or a combination of both, dyspraxia was present to a greater or lesser extent in approximately 29% - 30% of instances.

I would not claim that my data is unusual, for a number of authors acknowledge the fundamental issues of heterogeneity and co-morbidity [e.g. Ramus,R. et al, 2003; Richardson,A.J. 2004]. What is surprising is just how many researchers still select cases on the basis of being dyslexic, without checking on type of dyslexia or whether any other condition is present. This non-discriminatory approach guarantees that the resulting data will be noisy. It could be argued that if the data requires sophisticated statistical analyses, it probably lacks clinical meaningfulness.

The second myth I will explore is that dyslexia is gender-related. Many texts and research articles assert that dyslexia occurs with a greater frequency in males than females [e.g. Templeton, 1997; Jones, 2002, Stein, 2004]. However, this assertion is highly questionable, for several surveys which have sampled school populations with a view to identifying frequency of dyslexia have reported that dyslexia occurs only marginally more frequently in males than females [e.g. Wagner & Garon, 1999, page 89]. Surprisingly overlooked is the data embedded in the survey undertaken by Stevenson et al, 1982, across three countries [USA, Taiwan & Japan]. Their data reveals a ratio of 1.2 dyslexic boys for every girl, not the figure of 3 to 1 cited by some researchers. This ratio of 1.2 to 1 accords with those survey figures cited by Wagner & Garon.

I became interested in this question as my first annual review revealed that more females than males were referred to me for assessment. [In general, 56% - 61% of the students referred to me are female.] In addition, for a higher proportion of females than males, this was their first diagnosis. This pattern has held true across the last three years.

A percentage breakdown by gender and year of review of those students who had not had a previous formal diagnosis is presented below in Table 2.

Table 2 Percentage of men & women not previously diagnosed

In compiling my annual reports I am always conscious that any trends I note may be an artefact of the universities I draw my students from, and that I only see referred students. For this reason I am grateful to Geoff Coates of the University of Central Lancashire for publishing an analysis of the age at which a formal diagnosis of dyslexia was made, using a cohort of students from his university [Dyslexia mailbase, 17 Jan, 2003]. He concluded that his data 'show clear patterns of late identification particularly of females with specific learning difficulties'. That is, his data mirrors clearly the pattern I have recorded.

Drawing on the American research literature, I have argued that this late identification represents cultural patterns of responding and expectation. For example, many female students report themselves as 'hiding' in class to avoid being noticed, and working very hard at school work. Although such cultural patterns can be notoriously difficult to change, it is very pleasing to note that the British Dyslexia Association now acknowledges that almost as many girls as boys are dyslexic.

I have also recently read that the same is being said in America. The World of Dyslexia Newsletter of 3 September 2003 quotes from an article on dyslexia in Time magazine of 31 August 2003 that 'Boys and girls are equally likely to suffer from dyslexia.'

It is clear that those who use the argument of gender imbalance as an explanatory device in seeking a causal explanation for dyslexia are working from a false premise. It also suggests that there are many more undiagnosed dyslexic girls and women than undiagnosed dyslexic boys and men.

The third myth I wish to explore is that dyslexics are visually gifted [e.g. T. West, 2002, www.gmu.ed/news/gazette/0210/krasnow.html ] Three years ago I explored, at the York BDA conference, the assumption that dyslexics are more creative than non-dyslexics. [Grant, 2001 www.bdainternationalconference.org/presentations/sat_sb_b_4.htm ]. It is my view that being dyslexic is the key to what dyslexics become. This process is expressed very clearly in a comment made by David Bailey. When asked whether being dyslexic had influenced his photography, the world famous photographer, David Bailey replied: "I feel dyslexia gave me a privilege. It pushed me into being totally visual" [www.Showstudio.com 12 February, 2003]

There is no doubt that some dyslexics are visually very skilful. However, this is not reflected in the average profile of art or design students. For example, I calculated the mean WAIS-III Index scores for 50 dyslexic higher education students who were enrolled at a college of art & design [see Table 3 below]

Table 3 Mean WAIS-III Index scores expressed as percentiles for 50 design students

If it were the case that dyslexics are visually gifted you would anticipate that the mean score for visual reasoning skills [Perceptual Organisation] would be much higher than that for verbal reasoning skills [Verbal Comprehension]. This is not the case. Of the 50 students, 28 scored higher on visual than verbal reasoning. This is well within chance factors.

In addition, about 10% of the students had English as an additional language. This factor skews the data towards the proposition that dyslexics are visually gifted. In spite of this skew the data reflects an even distribution of verbal and visual reasoning skills. [I acknowledge that the WAIS-III is not an assessment of such skills as creativity, aesthetics or colour-balance.]

Why then do so many dyslexics enter art and design? I think we can understand this better by considering more closely the process of becoming. When given a choice, students choose those subjects for which they will achieve better marks. I call this process the 'least barriers route'.

Intuitively, it would be anticipated that dyslexia and dyspraxia will differentially influence students' choice of subject. For example, dyslexic students are more likely to opt for non-humanities subjects such as art, design and science as these require less in the way of independent reading and writing, whilst dyspraxic students are more likely to avoid subjects such as art and design which place an emphasis on fine hand-eye coordination.

As part of my exploration of underlying trends for the year 2002/2003, I allocated students to one of three categories of institution: the Russell Group students I see are composed almost exclusively of students from Imperial College and Oxford University. My second specialist group is students from a college devoted to art and design.

The 'Standard' group includes all other universities I have seen students from. This group is mainly composed of students from Kingston, Brunel, Westminster and Queen Mary.

In Table 4 [below] I have allocated students to one of three diagnoses: dyslexia as the primary diagnosis, dyspraxia as the primary diagnosis, dyslexia with dyspraxia.

Table 4 Percentage of students by diagnostic category and institution attended

This data needs to be treated with caution because of its preliminary nature. Also, the sample is non-random in that it is based on students who have been referred on to me, but it does suggest that type of specific learning difficulty is associated with institutional choice. This is a reflection of what I refer to as the 'least barriers route', in that paths chosen from GCSE onwards reflect the subjects in which students feel they are likely to succeed. These are not always the ones they are particularly interested in.

The last myth I wish to explore is that dyslexia can be viewed in very narrow terms. I would argue that this is a particular danger when dyslexia is defined narrowly, as in the proposition that phonological processing is the defining characteristic. It is my view that being dyslexic is a way of life. It is not just confined to issues of reading, spelling or phonology.

As dyslexia and dyspraxia are reflected in a variety of soft signs in everyday behaviours and experiences, I usually take at least an hour to complete a detailed personal history at the start of each diagnostic assessment. About eighteen months ago, after several students had spoken of significant difficulties with getting to sleep, I modified my assessment interview pro forma so that I began systematically asking all students about whether they had any problems with getting to sleep.

Many students, although surprised to be asked this question, reported that they did. For a large number of dyslexic students, it appears that they cannot switch their mind off and use this time to go through the day's events and plan for the following day. A similar type of phenomenon has been reported for dyspraxics [Portwood, 2000]. I have not been able to locate a report of this phenomena for dyslexics.

To provide a comparison with the dyslexic students I see, my son, Matthew Grant, collected data on difficulties with getting to sleep from 96 students - 36 males and 60 females. All but two of these students are at a Russell group university. Each student was asked the question 'In general, would you describe yourself as someone who: very rarely has difficulty with getting to sleep; experiences occasional difficulty with getting to sleep; frequently has difficulty getting to sleep; almost always has difficulty getting to sleep?'

Because a problem with getting to sleep has previously been reported for dyspraxics, I went through my records and selected the last 100 students I have assessed as being purely dyslexic [e.g. students with a diagnosis of dyslexia with signs of dyspraxia were not included]. 50 were female and 50 male.

Because of the way in which the sleep data for these students had been collected it was not possible to assign a student to a category of 'frequent' or 'almost always', so these were treated as students who experienced frequent problems with getting to sleep. Frequency comparisons between the dyslexic and non-dyslexic students are provided below in Table 4.

Table 4 Percentages of dyslexic and non-dyslexic students reporting difficulties with getting to sleep.

Approximately 3 times as many dyslexic as non-dyslexic students report that they have trouble getting to sleep.

Given that this observation could have been made at any time in the past century of research into dyslexia, a pertinent question is why this phenomenon has been overlooked. I suspect it may be because the word dyslexia focuses attention solely on literacy, not on aspects of everyday life. And yet, inspection of most WAIS-III profiles reveals weaknesses in both working memory and speed of visual processing, factors that are evident in everyday experiences and behaviours.

Why difficulty with getting to sleep is more common in dyslexics than non-dyslexics is very much an open question. As so many report that they find themselves engaged in sorting through the day's events and planning for the next day, this may reflect a failure of working memory during daytime. Memory is essentially a goal-directed activity and may be seen as a fundamental process allied to survival.

It could be argued that as working memory in many dyslexics is overloaded during the daytime, it is only at times of quietness and relaxation [i.e. at the point of trying to get to sleep], that working memory is free of competing demands and is able, as it were, to process and conclude unfinished business from the day.

Alternative hypotheses are possible. For example, it often takes a dyslexic or dyspraxic longer to perform certain types of task. This may well result in a higher anxiety level, particularly in higher education where deadlines are important. 14% of dyslexic students reported that they kept a notebook close to their bed to write down important ideas as soon as they occurred to them. This noting down reduces the level of anxiety associated with thinking of something that would otherwise be forgotten. A number of students also reported that they no longer experienced frequent difficulties with getting to sleep as they had developed strategies for 'emptying the mind'.

The key point I wish to make at this stage is that being dyslexic, or being dyspraxic, influences and colours a wide range of everyday experiences. We can see this occurring in sport sporting activities. For several years now I have included a range of questions about sporting inclinations and achievements.

Of the students I have seen over the past two-and-a-half years, one was a world sailing champion, one was an English cycling time trial champion, and three had represented their country in their chosen sport [synchronised swimming for England, swimming for Singapore, and ice skating for Finland].

In 2002 I reported that 13% of the students I had seen over the previous year had represented their county at a given sport. In 2003 I reported that 11% of the students diagnosed as being either dyslexic or dyspraxic had represented their county. [These figures raise some interesting questions for the universality of the cerebellar theory]. 27% of all students in 2003 [compared with 33% the previous year], reported that they tried to avoid taking part in sports.

It would be expected that dyspraxic students are more likely to be over-represented in the 'avoids sports' group and under-represented in the County level group. This is in fact the case. Just one student in the County level group - a male cross-country runner - was diagnosed as being dyspraxic. This figure of 5% of dyspraxic students in the County level group compares with 39% of dyspraxic students in the 'avoids sports' group.

Being selected to represent your county is a public recognition of having already attained a high level of sporting achievement. An average figure of 12% struck me as being higher than expected. I was also conscious that a slow speed of visual processing might be a limiting factor, so I undertook an exploratory analysis of the WAIS-III Indexes for county level achievers to see whether they represented a subgroup of dyslexics with a relatively high Processing Speed Index.

My son Matthew Grant constructed a matched sample and calculated means and standard deviations. Each County level student was matched with another student of the same sex, type of HE institution and same diagnosis.

The mean percentile WAIS-III Index figures and standard deviations for the four Indexes for men and women are given below in Tables 5 and 6.

Table 5 Percentiles for the four WAIS Index factors for dyslexic male students by levels of sport

Table 6 Percentile means and standard deviations for the four WAIS Index factors for dyslexic female students by levels of sport

For both men and women, the difference score between the Index scores for Perceptual Organisation and Processing Speed is smaller for county level achievers than for non-sporting students [29.4 vs 40.1 for men; 11.4 vs 19.2 for women].

At best this is indicative of a tendency. These differences have to be viewed in the context of the large standard deviations that are present, and in the knowledge that an Index score change of one standard deviation is equivalent to a change of approximately 35 percentile points. Percentile differences of 10.7 for men and 7.8 for women are therefore very minor.

The one major factor which distinguished county level players from non-sporting students was the very low percentage of male dyslexic students who reported complications associated with their birth. Whereas 35% of dyslexic and dyspraxic students reported birth complications for the year 2002 - 2003, only 4% of male county level students reported birth complications across the period of 2001 - 2003.

An analysis based on type of sport raises some interesting observations. For example, 43% of the County level students did so in a team sport [e.g. football, rugby, cricket, hockey, lacrosse]. Such sports as cross-country and swimming were not counted as team sports since there is minimal interaction with other members of the team.

The most frequently occurring sport was swimming [23%]. Although 9% had represented their county in an athletics track event, there were no students who represented their county in a field event.

To provide a comparison for these tendencies, the survey that was carried out on a random sample of students to obtain data on sleep difficulties also sought information on levels of sporting achievement, and, if a student said they had represented their county, what sport that was.

Surprisingly, 25% of the sample of 96 students said they had represented their county. This very high figure may be accounted for by the sample demography. The survey was carried out in a Russell group university that is known to drawn about 50% of its students from public schools. In addition, many of the students were medical students. Of those who had represented their county in a sport, 63% had taken part in a team sport. Just 8% were swimmers and 17% were track athletics.

It is very clear that the data presented here offers a snap-shot view, and much more remains to be done. However, there is an underlying intuitive logic, in that team games require a good mastery of often complex rules and a fast speed of visual processing. Many dyslexic students would therefore be hindered in their performance in these games, even when deeply committed. It would not be unexpected to observe, once again, students choosing the 'least barriers' route to success, and that is the pattern that emerges here, hence the relatively high percentage of swimmers.

In conclusion, being dyslexic influences a wide range of everyday behaviours and experiences, and plays a part in shaping career choices and leisure preferences. We can only begin to claim an understanding of dyslexia through using a holistic, life-span approach while, at the same time, accepting the individuality of each case of dyslexia.

References

Boder, E. 1971 Developmental dyslexia: A diagnostic screening procedure based on three characteristic patterns of reading and spelling. In: Bateman, B, editor. Learning Disorders; Vol. 4, Seattle: Special Children Publications.

Grant, D. 2001 'That's the way I think' - dyslexia and creativity. Paper presented at the BDA 3rd International Dyslexia Conference, York.

Wagner, R.K. & Garon, T. 1999 Learning disabilities in perspective. In R.J. Sternberg & L. Spear-Swerling [Eds]. Perspectives on Learning Disabilities: Biological, Cognitive, Contextual. Westview Press, Oxford.

Jones,S. 2002 Y The Descent of Men. Little, Brown, London

Portwood, M. 2000 Understanding Developmental Dyspraxia. David Fulton Publishers, London.

Ramus, F. et al. 2003 Theories of developmental dyslexia: insights from a multiple case study of dyslexic adults. Brain, 126, 841-865

Richardson, A.J. 2004 Dyslexia, Dyspraxia and ADHD - can nutrition help? www.apraxia-kids.org/topics/richardson.pdf

Schonell, F.J. 1945 Backwardness in the Basic Subjects, 2nd edition. Oliver & Boyd, Edinburgh & London.

Stein, J. 2004. Dyslexia and VI [Visual Impiarment]. Paper presented at the NADO One-Day Spring Conference. March 11th. [Available from www.nado.org.uk]

Stevenson, H.W. et al. 1982 Reading Disabilities: The Case of Chinese, Japanese, and English. Child Development, 53, 1164-1181

Temple, C. 1997 Developmental Cognitive Neuropsychology. Psychology Press

Disclaimer: all the abstracts presented here have satisfied the academic committee as appropriate for presentation at an international conference. However, the material reflects the views of the authors, not necessarily those of the academic committee or the BDA. No endorsement of any approach, product or service is intended or implied.

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