Dyslexia is a clinical diagnosis. How do we bring the parts together and synthesize the symptoms, signs, and test data into a diagnosis? The most consistent and enduring core of the definition is the concept of dyslexia as unexpected underachievement. The evaluation follows the universal definition of dyslexia which prescribes it's typical impact on several areas, including speaking, word retrieval, reading accuracy, and fluency, spelling, and learning a second language. It is important to consider each of the components of the diagnostic puzzle, what each component contributes, and how to synthesize all the pieces to arrive at a diagnosis. Current practice recognizes that dyslexia is a clinical diagnosis based on clinical judgment made by an experienced clinician who considers both the individual's history and symptoms and his or her learning profile, including cognitive and achievement abilities that may point to an unexpected difficulty in reading as well as the reasons for this difficulty. While test are helpful, they are only one component will be in an important one of the evaluation process. Let me give you an example, Supreme Court Justice Sonia Sotomayor understands this, prior to her tenure on the Supreme Court, Judge Sotomayor's served as US District Court Judge for the Southern District of New York State. In this role, presiding over a trial involving the dyslexic attorney suit, charging the New York State bar with discrimination for denying the plaintiffs requests for accommodations. Judge Sotomayor astutely made these remarks concerning the diagnosis of dyslexia. Here's what she said, "By its very nature, diagnosing a learning disability requires clinical judgment, not quantifiable merely by test scores." Dyslexia is neither diagnosed nor accurately represented by a single score on a test. It is identified best by consideration of a broader clinical picture of the disorder. This makes it imperative that educators and evaluators become more deeply knowledgeable about dyslexia. What are the necessary steps to take in arriving at a diagnosis? The diagnosis of dyslexia is basically no different than that for any other condition. Guided by knowledge of the underlying pathophysiology, the clinician seeks to determine through history, observation, and psychometric assessment if there is evidence to support a diagnosis of dyslexia. There are three steps of the evaluation process are to, one, establish a reading problem according to age and or level of education, two, gather evidence supporting its unexpectedness, that is high learning capability may be determined on the basis of an intelligence test, three, demonstrate evidence of a phonological weakness with other higher-level language functions, relatively unaffected. There is no one single test score that makes the diagnosis of dyslexia. As with any other scientifically based diagnosis, the diagnosis of dyslexia should reflect a thoughtful synthesis of all the clinical data available. What the clinician is seeking is converging evidence of a phonologically based reading difficulty or reading disability as indicated by disparity by the individual's reading and phonological skills on the one hand and his intellectual capabilities or age on the other. Dyslexia is distinguished by the unique circumscribed nature of the phonological deficit, one not generally intruding into other linguistic or cognitive domains. To determine if someone has an unexpected difficulty in reading, it is critical to obtain a measure of intelligence. Finding reading scores that are unexpectedly low for age or intelligence is the first step in the diagnosis of dyslexia. In the school-age child, reading is assessed by measuring accuracy, fluency, and comprehension. While accuracy is critical early on, the ability to read fluently gains in importance as the child matures and this is important. A child who reads accurately but not fluently is dyslexic. One important element of the evaluation is how accurately the child can decode words, that is read single words. This is measured with standardized untimed test of single real-world and pseudo word reading. A comprehensive evaluation also includes measures of phonological skills, measures of speeding single word reading, measures of speeded connect to text reading, and a measure of silent reading rate and comprehension. Of course, reflecting what the history and observation have provided, one might also want to add other assessments, for example, for attention, anxiety, and memory or other areas of concern. After a child is evaluated, we know exactly what to look for in the test results to diagnose dyslexia. We look for both accuracy and this is important effort required by reading. Difficulty reading single words, poor phonological skills, particularly difficulty decoding nonsense or unfamiliar words. A particular difficulty in reading single words when speed is required. Lack of fluency is demonstrated by inaccurate, slow, and labored oral reading and a lack of inflection, that is prosody, reflecting the content. Trouble reading short function words such as that, is, an, for. Poor spelling. Reading comprehension is often superior to decoding individual words, and yes, I'll repeat that because it's surprises many, reading comprehension often superior to decoding individual words. Average or even superior intelligence, disparity between intelligence and reading. I want to caution, there is no one single test score that ensures a diagnosis of dyslexia, it is the overall picture that matters. An extremely bright child who has a reading score in the average range, but who struggles and cannot learn to read fluently and who has all the signs just described for dyslexia has dyslexia. Caution, beware of being told to get a genetic test to diagnose dyslexia. Dyslexia is not explainable by one or even a few genes. As science writer Ed Yong noted, if you told a modern geneticist that a complex trait like reading was the work of just 15 genes, they'd probably laugh. It's now thought that such traits are the work of thousands of genetic variants working in concert, the vast majority of them have only tiny effects. As distinguished geneticist Simon Fisher explains, there's an enormous gap between DNA and the distal outcome, reading. Dyslexia is best explained by multiple genes, each contributing a small amount toward the expression of dyslexia. Parents, and this is so important, parents should be skeptical about any genetic testing that claims to diagnose dyslexia, don't believe it. Parents should look to evidence, evidence-based screening and diagnostic assessments that do in fact reliably diagnose dyslexia. You can find more about this in Overcoming Dyslexia, second edition, page 118. I would certainly try to educate teachers because our teachers are our front-line and yet so many teachers don't understand this issue. For as many teachers that Rafe has had who really liked Rafe, but would tell me, "No, he just doesn't seem to pay attention." Or "He doesn't try hard enough, he's maybe a little lazy." These are descriptions that could not be more opposite of Rafe. Anybody who really knows him and knows him over the years knows that that is absolutely the case, so to have been told ever in his life, let alone multiple times in his life, that he's not trying hard enough is outrageous. I think that it's really important to start with the partnership because when you see your child struggle and then at some point in that process you understand that the source of that struggle is from dyslexia and that the teachers, particularly for the school and sometimes the teachers and the school are not on the same page, are working against your child in terms of policy and practice, it's very easy to get angry. The first reaction, obviously, is anger and so I would urge parents to put that anger aside and work as positively as possible with their teachers and with their schools because if you want to be an advocate for your child, you have to get the teachers in the schools to be an advocate for your child as well.
