Dr. Kissel speaks on learning disorders versus learning disabilities, some common learning disabilities, and a deeper dive in to dyslexia. While also discussing what to be aware of as a pediatrician.
Hi everybody, thanks for joining online or in person. Um, I'll try to look at the computer screen cause I think most of you are online, but hi to my in-person people. Um, and thanks to everyone for inviting me today. October actually is Dyslexia Awareness Month. Um, I should have a pen. I do not. Um, and so we are gonna do a lecture mostly on the basics of specific learning disorders today, but we will do a little special focus on dyslexia, um. Both because it's really important and because it is that month. I don't have any relevant disclosures or conflicts of interest. I do also use this slide to just remind myself to talk a little bit about language. Um, there is in many populations I work with, including things about learning disorders, um, and dyslexia, there are people who like person first language, a person with dyslexia. There are people who actually relate well to being called dyslexic. You will hear me use both. That's not cause I'm insensitive, that is because I'm aware there are on both sides. So, some of these goals actually went out ahead of time, um, but just to go over them briefly, we're gonna spend a little time talking about some of the differences or clarification between when we call something an SLDS specific learning disorder versus when we call it a learning disability. We are gonna talk about the medical sides, the DSM, the diagnostics and statistical manuals, um, actual outline of what is a specific learning disorder. And what changed in the most recent edition about that. We are gonna go over some common learning disabilities, um, that pediatricians should kind of be aware of. Some of them are from some of my older districts in Texas and some are from here, um, but you should be kind of aware of most of those so that if you see them in a kids' school plan, you know what's going on. We'll talk a little bit. Briefly about the school piece, so sort of how to help parents advocate, um, some of those educational processes. We won't focus too, too long on that cause it's a huge topic, and I actually have a separate lecture I sometimes do, um, at different community pediatrician sites and on my rotation with residents about that. And then we'll talk about what else can you be aware of so that you're helpful as a pediatrician. At the end, again, that deeper dive into dyslexia. So, to start with clarifications, just to make things hopefully slightly less confusing, um, when we talk about a lot of conditions that are mental or behavioral health conditions that then may be quote treated, given an intervention at school, they often switch the term slightly. So a specific learning disorder is a medical term. It's a neurodevelopmental disorder. We can talk about the focus on the word disorder at the end as well, but it begins during school age, may not be recognized until later, causes problems, right? And we'll get into a further DSM definition. Usually in those three categories, and you can subdivide them, but in reading, writing, or math. Learning disability, that switch, is usually what the educational or legal system calls it. So you'll hear me and you'll hear most people use those terms sort of interchangeably, but since it's a lecture about it, I wanted to let you guys know when it's sort of a medical diagnosis, it's an SLD learning disorder. When it's used in the school system or legal system, they call it a learning disability, and that indicates that you're eligible to receive a certain service. Learning difference is sort of everyone's attempt to not say disorder or disability, um, and that's OK except for since it's so rooted in the medical versus legal and education system, you will hear me use those first two terms. So the specific DSM definition, how good you put, it's a type of neurodevelopmental disorder that impedes the ability to learn or use a specific type of academic skill. Again, you can subdivide, but think of it as reading, writing, math. These are foundational for other academic learning, and we'll talk more about that. And then this difference is unexpected, meaning you're kind of doing well in other areas of life, and this is an unexpected sort of learning issue. Um, other signs of development seem to be OK. These signs can and do, and I hope to convince you, will appear very early in preschool years, but oftentimes we don't actually get to them, see them, um, recognize them until later. Um, and so, after formal education is in the official DSM and we'll talk a little bit about why that is as well. Because I'm sort of obsessed with what mental and behavioral health things look like across cultures and countries and languages. I have a slide in here just to emphasize that while this is actually at, and we'll talk about this, about 20% of the population across cultures, across countries, it can manifest a little differently. This example on the right is primarily targeted at Dyslexia, but it talks a little bit about how in the English language, which if you don't know, or if you do know, cause it's your second language, is a very difficult language to learn, and it has a very intricate relationship between a phonics, between the letter and sound association. I see some people nodding. Um, so kids in English really have trouble with that decoding, right? So that letter sound association, whereas an adult with dyslexia, hopefully with intervention has maybe mastered some of that, but still may be the person who reads really effort effortfully, right, with a lot of effort, um, or slowly. There are some other language, Japanese comes to mind, in which there isn't as much of that complicated. Phonic structure to the signal to the letter, and those kids and adults actually both tend to master quicker that decoding or phonics and then just end up both in the category of slower, sort of more effort in reading. Again, it's a subtle difference, but just to show you that even though dyslexia itself persists across countries and cultures, it manifests slightly differently depending on what the basis of and origin of that language structure is. So, I told you we talked a little bit about changes, and I hesitate to say in the most recent DSM cause it is the most recent, but it's so old, and I cannot wait for the new edition to come out, it's 2016, um. We now call a specific learning disorder one big sort of overarching category, so SLD and then we name what the impairment is, is in, with impairment in, right? And then we kind of go to that reading, writing math, right? Oh, that will make more sense in a second. We also no longer depend upon a gap in your IQ and your achievement to be able to diagnose a learning disorder. Again, a little tricky, and we'll talk about it more. I should tell you, the IQ achievement gap was replaced with these 4 criteria you have to meet, so we'll talk about those first. The first is some of the key characteristics of learning disorders. The second is how we measure them. The 3rd is the age at which this can onset, and the fourth is what else do we rule out to be able to say this really is a learning disorder. So criteria A, at least one of 6 symptoms over 6 months, 6 and 6, right? And it's in these what are sort of more broken down categories, right? Reading, understanding written material, spelling, written expression, number concepts, mathematical reasoning. Don't have time in this lecture to talk about exactly why we named them this way, but again, overarching category of learning disorder with impairment in one of these areas, or more than one of these areas. Criteria B, so affected academic skills, this is like everything else. The DSM, right? It has to be substantial and it has to be impactful, right? We don't get to say you have anxiety if you just have like a tiny bit of anxiety that sometimes rears up before you do a presentation, right? So it has to be really impactful and it has to be substantially different than someone else, for instance, like a peer. Again, I don't put this up here to read through this. I put it up there in case people keep slides, so they have some of the common achievement measures that we look at when we're measuring. Um, so things like the Wechsler, the Woodcock-Johnson are really common. You'll see KTEAs come back in some of these school testing. Again, not nothing, not anything you need to know the minute details of, but in terms of what are they looking at when they're trying to tell us, hey, this is how a kid performs at school. And then classroom assessments at the bottom, much more intuitive, right? So some tests and grades, sometimes benchmark testing or state testing, certainly teacher parent input, all of these are things we're using to paint a picture of how this kid performs in the classroom. Only during school age years, right? Although it may not fully manifest until you're a little bit older, I will say beware, and it happens a lot in high achieving careers like, um, residents of medicine. Beware of the person who sort of outworked it, right? So this doesn't get picked up till a lot later in some individuals. Who perhaps still got straight A's through school, but maybe we're doing like 6 hours of homework instead of the 2, it should have taken them, right? This can be missed for those reasons. It also only occurs during school age years, implies like, oh, it just shows up then, and as I said, it's definitely present sooner. So criteria D, our last one here. These are the things we rule out in order to say it's a learning disorder and not X, right? X could be intellectual disability is a big one they don't like you to co-diagnose, right? Auditory or visual problems, and then at the bottom you can see, of course, we don't want to say somebody has a learning disorder when there was some other big thing going on, like we weren't teaching in their native language, or they had some other reason that access and equity was not there. OK. Even though it's old, I told you this was a change in that DSM. So what were we doing before, and in some cases, unfortunately, depending on the district, maybe sometimes still doing, and why does that matter? So first we were doing what we call sort of test to diagnose. Second, we were always testing IQ and this actually still tends to happen. We will test IQ on almost every kid that gets school testing even though it's not required. The third is we would go in and say this kid is struggling in math. I'm gonna test them to make sure that they don't have a learning disorder in math. And we'd be real specific, and then if it turned out they were struggling in a different area, we had to go back to the process to test them in that different area. And so, because that wasn't very efficient, none of these were, some of the changes took place after the most recent DSM. So first, testing to diagnose versus response to intervention. Testing and diagnose, basically, like I said, means there's a problem, oh my gosh, we had to test this kit, right? And testing, I just listed some of it there, includes a lot of stuff, right? Sometimes cognitive achievement tests that I showed you, you know, classroom observations, this 30, 60, 30 rule of testing and deciding if we need a plan and making a plan, and lots of meetings. It's a, it's a heavy lift, and that's great, if that's what you need. But As we know, there are a lot of reasons kids struggle at school, right? So this shift to from, oh my gosh, they're struggling, we have to test right away, to response to intervention, meaning, OK, there's a problem, I see something's going on. Let's see if we can make some accommodations. Let's pull that kid to like a small group, let's maybe sit them at the front of the class so they're not distracted. Let's maybe let them have a little extra time or repeat some instructions. Right? And if that stuff helps, it's really unlikely they have an actual learning disorder, right? And so we avoided testing them if we can show, hey, these tiny interventions help, right? Keep in mind there's other things, some things I treat like ADHD that can also make you perform. A little bit less in school, even with good cognitive strength, right? So this jumped from we have to test absolutely everyone who's not doing well in school to what can we do, what can we put in place to see if we can bring them up? And if we can't, it's probably not a learning disorder. And if we can't, then we do need to go on to test that kid. But it causes a lot, a lot of confusion for family. One of them is that when we say response to intervention, they often talk about tiers of intervention. I put these in here just so if you ever see them, you're familiar. I really dislike it because I want tier one to be tier 0, cause tier 1 is just normal classroom, right? So it doesn't really seem like an intervention. I guess we're doing that to be kind and say like everyone universally should have greatness in their classroom, and that is true. I do believe that, but just, you know, tier 1 is sort of your normal classroom. Tier 2 is that targeted sort of small little things we're doing to adjust maybe your place um or things in the classroom. Tier 3 is that didn't work, and so individually on this kid we're doing something extra, maybe pulling them to the resource room, that kind of thing, right? So these are the different steps of intervention, you may go through. You may need to fail before you go on to testing. Causes confusion for parents. A word of warning, response to intervention is meant to be a good thing, right? It's meant to be done in good faith, meaning we really think we could tweak this and you might do OK. It's never meant in the way it's written to prevent testing. So there are cases where parents feel like, seriously, we're gonna spend 6 months on this intervention, that seems like it's almost just buying time. And you can't use it for that reason. I'll give you an example to kind of hopefully hammer that home. I have many, many families, but a particular family I'm thinking about with 4 boys. The 3 oldest boys have dyslexia. The 3rd boy came up on Kinder and showed all the classical kind of pre-dyslexic signs, right? And the school said, well, we're thinking of doing a 6 to 9 month RTI. For reading intervention, to which I wrote back a letter, no, that's ridiculous. He has 3 older brothers with dyslexia. He doesn't have letter sound awareness, he can't rhyme, right? Like, come on. And they were like, yeah, OK, so they tested him he had dyslexia, he went into the program, but so for instance, you cannot use it like that, right? It has to be in good faith. I really think these interventions could solve the problem and that we might not need to test. Um, the other thing that's really important about an RTI that I always arm the parents with is go back and ask, what are our parameters for success or failure. And when, right? Cause oftentimes they'll come back to me and say, oh, you're right. It turns out that if he's not caught up to the class by December, they're gonna test. And this solves a lot of communication, right? Because there are many times the parent feels like the school is ignoring what's going on with their kid, and when you're really asking the right questions, things like, well, does Johnny do anything differently? No, absolutely not. OK, so nothing different. Well, he goes to the resource room 3 times a week, and sometimes he works in a small group, right? That's not a bad thing. You say, great, it sounds to me like he's in the middle actually of an intervention, if you're an intervention. So let me explain that to you. They work through this process. If it doesn't work, they go on to testing, go back and ask them what's the criteria for success or failure, and when, and oftentimes that solves the problem right there. 2, I told you, we don't have to have an IQ achievement gap anymore to call something a specific learning disorder. So why do we keep always, always testing it even when we're not suspicious of a cognitive problem? Um, this gets a little tricky, so I'm gonna just start with basics, and I apologize if it's too basic, but I want you to think about your IQ as your learning potential, so your cognitive potential. In a way, I want you to think about this as what you should be able to do given your brain, OK? Your achievement is what you are actually doing, it's your performance. So your cognitive potential could be quite high, but if your achievement, your performance, your grades, what you're doing in class is lower, right, then we begin to get suspicious. And formally, that's really all we use to talk about a learning disorder. We said you should be able to do this, you're doing this. If you can't see me online, I'm doing two different things. Um, and so therefore you must have a learning disorder. But the problem with that, again, as we talked about, is there are many reasons that you could be performing poorly, and they're not all learning disorders, right? They could be that you do not get enough to eat. They could be that you have ADHD, right? There's a lot of other things that can go in there. The new model focuses a little bit more on you versus your peers, so like aged peers. Um, you don't have to, you can, and you can use that, but you don't have to have this discrepancy between IQ and achievement. So, obviously, if you do, it may make sense that you have a learning disorder, right? If we ruled out some of these other issues. But again, sort of like RTI you can't use it to be exclusive. So I'm gonna give you another example, hopefully to drive this home, which is in the past, in the old model of you must have this huge gap between your IQ and your achievement, there was a big section of kids who were sort of what we'd call lower average, so Intellectual disability begins under 70, right? A mean cognitive score is 100, 15 is a standard deviation, 2 standard deviations below the mean is 70. But what if you're 74? What if you're 81? There were these kids who had sort of a lower IQ score, and school would look at them and say, of course you're doing not as well, you have a low IQ. You don't have a gap that can let me say you have a learning disorder. And that was a big problem because there's a huge subsection of kids in that group. And so one of the reasons to switch to this is to be able to say, OK, so this kid has a lower IQ, but somehow with this or that or parent help or whatever, all this effort, they're getting B's and C's. Why are they blatantly failing math? And school would say, I don't know, but it's just sort of all expected, and now we would say, no, no, it's not. I still want them tested to see if there's actually a learning disorder in math, because there's no longer a requirement that there be this huge gap between their IQ and their achievement. Hopefully that makes a little bit of sense. OK, this one's a little easier. It doesn't make sense to do all this testing, only focused on reading and say, OK, you have a reading disorder, and then the next year realize you also struggle in math and go back and do all this testing in math to say, OK, you have a math disorder, hence the overarching category now of learning disorder with deficits in blah blah blah blah. And so you test all those areas and say it's in reading, it's in written expression, it's in math, whatever you need to do. What now? First coffee and whatnot. OK, so, as a pediatrician, and I'm sort of aiming this at unedes, but I first want you to be familiar with some common, common learning concerns. I'm calling them concerns. The slides I'm gonna show you are written as disabilities. The top one is one that's very big in Texas, although I have seen it more in Missouri. Um, and this is again, just some of the things you'll see coming out of the papers from school. So, I'm sure some of you have seen central auditory processing, um, disorder. This is a real thing. I'm not saying it's not, but it is a big one that gets picked when they have a kid who they think maybe has a sound system disorder. They're not totally sure what's going on. There's no actual functional problems with hearing, vision, that kind of thing. Um, there is a language processing disorder that's a subtype of this. Auditory processing disorder. I think this is a real thing, but unfortunately it does often get called in a kid who's just not had an autism assessment yet either. So just some things to kind of be aware of. Um, dyscalculia, we just really made that as difficult as possible to say, is the dyslexia of math, right? So dysgraphia of writing, dyslexia, we will go to go into more detail later. Nonverbal learning disabilities are very interesting. I mostly left them up here just cause it's often actually confused with autism, and this is sort of a kid with higher verbal skills. Um, there are certain genetic disorders that really remind me of these kids where we're really sort of extroverted and have high verbal skills, um, and sort of a weaker sort of almost developmental coordination disorder look to their motor component. Um, and to their and sort of weaker social skills. So they often have trouble with interpreting nonverbal cues or body language, and then like I said I can have poor coordination. They do not tend, I won't get too much on a tangent, they tend to have those more lacking aspects in, in the same as some people with autism, meaning difficulty interpreting social cues. They don't tend to have the positive aspects like stereotype and some of those other things you may see. Visual perception motor, uh, deficits of anything is truly affecting your vision or hearing is gonna get called out in a learning plan, and I will show you the 13 eligibility criteria as we go on, and that will make it more clear and then related, these are not learning disabilities, but you know, we have to think about things like ADHD, dyspraxia, other executive functioning functioning issues, and working specific memory. So, those are some learning disabilities. How do you help coach families kind of based on what we've talked about. The first is teach them to ask for the testing, right? And this is better done in writing and dated, because of, again, don't have time to go fully into it because the law does state they have 30 days from that request to decide whether or not they're gonna go ahead and test your kid and give you a formal notice of action to tell you that, right? So they may spend those 30 days doing some of those classroom observations or gathering evidence to say, yeah, this kid warrants or doesn't warrant testing. They also could come back to you and say, actually, we want to start an RTI, right? So asking formally is really important. I call this a full individual evaluation, that's Texas language, but I will tell you just saying testing for learning disabilities, and the school knows what you mean, um, is really important. And then I really like to remind families that The sentiment behind education law is to help you lift your kid up in all these areas they could be struggling in. So while in school, we tend to focus on how you do in reading, writing, and math, there are other people that may be involved in your kid's case who could be important to be at that meeting where you talk about testing or you talk about a plan. And those could be everyone from the school counselor to a speech language pathologist. Um, you know, someone who's there to help assist vision or hearing. So don't let the parents forget like this doesn't have to just be meeting with them and the principal or them and the teachers. There are a lot of auxiliary people that they can invite that if they feel like that would offer more perspective to what their kid needs. We kind of went over this, but you have a parent come in and they say, Jimmy's struggling, it's not always a boy, that's me. Cathy is struggling in math, and they won't test her, right? Um, the two things I like to think about first are, does the school know that they're struggling, and we'll talk about if not on the next slide. And if they do, again, you go through this, ask the right questions, right? Have you received an NOA, a notice of action, that tells you they're gonna test or not test them. It can come in paper, it can be an email, right? Do you think they're in the middle of the RTI? I promise you, 99% of the time it's the RTI. I tell the residents I work in like, even if I get to the point where I have to call the school cause we can't figure it out, and I'm convinced it's an RTI and the parent is swearing it's not, it is. So it's almost always an RTI. Make sure you ask about that. And then encourage that we want success. We don't want necessarily labels, right? They're OK if we need them, but the point is to do well. So if your kid is in a tier 2 or 3 RTI and the school says, hey, we're willing to keep up these accommodations, and he's getting grades like the rest of the class or better. Leave it there. It's not that we have to push for testing, it's not that we have to get a diagnosis of a learning disorder. We have to do well, and it's OK to say, stay in a tier if we're doing well. There's no problem with formalizing that. We'll talk a little bit about 504 plans that tend to formalize some of those accommodations. There's also no problems depending on the district of just staying in that tier. So when does the school not know that a kid is struggling? Sometimes we have these missed strugglers, um. We talked a little bit about a case where maybe the cognitive score is too low. We can also talk about a case where maybe the kid is extremely smart. And actually getting A's, but you find out mom and dad are doing their homework with them for 8 hours every night. That's an exaggeration, but I have a case that's very close to that. Um, and you say, well, what if you weren't doing that, you know, what if you just did your homework for 2 hours and mom and dad didn't help, and they're like, oh, I would get an F. Right, so like we can talk about helicopter parenting another time, but the point being that sometimes that gets missed too, and we have to go back and say, yeah, we get that he's smart and he's doing well, but this is a Herculean effort to do that, and there's a mismatch there, and I'm wondering if he's sort of outworking this, right? And do we need to see if actually his brain works differently and we could put into place some things that would be more helpful. Sometimes, I'm not pointing to anyone, but sometimes when I give this lecture, I just like see people's heads go. Like that was me, right? Um, and it often is these really like high achiever learners, so just things to think about. Again, I didn't put this in here to read it to you. This is an example, the name has changed. Of sort of a letter that I've had to write sometimes calling out even the fact that as we all know, the IQ achievement gap has been removed, right? So just some language that can sometimes be helpful if you're trying to assist families and sort of reaching out to the school, cause again, you don't reach out and ask for testing, you sort of assist but can provide some medical documentation to help the school, to help the families reach out for testing. And then you have these kids who maybe have these really what we call sort of Um, introverted, you know, issues or something where you have ADHD just an attentive presentation, and you try to get writers from the school to say, hey, could this be part of the problem or a learning disorder and you're trying to figure it out, and the school says something like, or the teacher says something like, oh, she's so great. And you're like, no, I agree. She's so great, but actually what I'm asking is, can she pay attention? Oh, she never makes trouble in class. Oh, OK, um, you know, or is she on task, right? So these people with anxiety or I have a very extreme case, which we probably won't have time, but if we have time, I'll tell you about that's very interesting about selective mutism and culture and language and all that, but where these kids are really only harming themselves and not the class and not the environment, and so the teachers are less likely to maybe say, hey, there's a problem going on here. And then you have the opposite, so kids are really acting out, maybe tearing up the classroom, and you guys probably even on your prep and your boards and stuff, get a classic question about like, is it ADHD? Maybe, but maybe that kid's checking out because they have a learning disorder, don't understand, and it's easier to act out. Then admit that, right? And be like, I don't get what's going on. So just being careful on each side, and then uh Saint Louis has a lot of religious and private schools, so remembering that even if you're at a private school, you have the right to request your testing through your public school district. So it's not like just cause you go to private school, you can't have any of these services. Really briefly, again, whole separate lecture, but this comes up a lot. What is an IEP versus a 504? In brief, I want you to think of a 504 at accommodations. An accommodation is I'm gonna change your environment or the approach to your education, so that you can learn the same thing, the same curriculum alongside your peers. So accommodations for ADHD, which is one of the most common ones you'll see, maybe small group, maybe front of the class, so you don't get distracted, maybe you test in a quiet environment, right? I'm changing the approach to the environment so you can learn the same curriculum alongside your peers. An IEP is I'm going to modify your curriculum in some manner. So good examples to think of is if you truly have dyslexia or intellectual disability, and I put you at the front of the class, are you gonna be able to read better? No, it doesn't make any sense, right? So you cannot subsist on just accommodations, right? You're gonna need a modification to your curriculum. These listed down here, um, starting with specific learning disabilities, are those 13 categories of eligibility. That come in an IEP from school. So you have to hit in some way one of those categories, although you see OHI, otherwise health impaired, so some of our kids get sort of lumped in there if we can't figure out exactly what's going on or some of our complex sort of chronic medical kids may get lumped in there. But again, 504 sort of I'm gonna change the approach to same curriculum and IEP I'm gonna modify some part of the curriculum cause you meet one of these eligibility categories. Two quick things that I don't think we talked about enough, I want you to know them so you can talk to families about them, remediation. So oftentimes a kid will get tested and they'll say, great, starting in 2026, this is the new plan. And I'm looking at this like, What's the backup, how, what's the backup plan? We don't have those skills, right? So making sure that an IEP includes some information on how we're gonna remediate, how we're gonna go back and get this kid caught up before we try to move forward, that's a very important part of the plan. Continuous monitoring. So again, we can't say this sounds great. We're gonna take the standardized map or star testing at the end of the year and see if it worked. No. There has to be a lot more monitoring in between to see if we're on track, is the plan working? Do we need to adjust? So, remediation, continuous monitoring, important to know as a pediatrician. Third, what else to ask and worry about? This will be very easy. You guys are already excellent at this stuff, but I'm sure I don't have to convince you that learning disabilities are, of course, things that interfere with learning basic skills like reading, writing, and math, but they can also interfere with other areas, right? So, abstract reasoning, organization, time planning, long and short term memory, attention, um, and then even above that, relationships. Families, workplace scenarios, our language, especially in the United States, but really globally at this point. In society is so language based. I mean, even on social media, right, means, whatever, you know, everything is texting, everything is, I mean, how often, I don't even want to know. I was gonna say how often do you guys pick up the phone and actually call someone, but I don't want to know, right? Not a lot. We're texting, right? And we're like looking things up online, so that language being impacted in that way can have a huge, huge impact on other areas of someone, um, someone with a learning disability's life. So. We're at higher risk for anxiety, depression, low self-esteem, uh, suicide and suicide attempts and school dropout, and that probably doesn't surprise most pediatricians. What can you do? Certainly look to see if you, as a pediatrician, as someone who has a point of contact with that patient more often than a lot of other people, right, can see if there are other things in the way. Things like anxiety and ADHD or autism or ACEs, right? I deal in a lot of A's, as you guys know at the top there. Um, but things like bullying, gender dysphoria, anything that's impacting what could be going on at school, um, in a way, and of course you're not gonna disclose to the school that a kid has anxiety without talking to the parents or the kid about that, but you might wanna offer and say, hey, I know that we're looking at learning disabilities, but also is there any way that that his anxiety could be impacting. You know, anxiety could be a reason for certain accommodations. Do you want me to provide a medical letter saying you have this diagnosis, right? And thinking about some of those other ACE things, right? Like access and transportation, food issues, things like that. It's very surprising. I didn't put in here, I had to take out a lot of studies to keep this really like practical and clinical base, but there have been really, there's been really interesting research on just food insecurity and performance at school, and I don't think that would surprise you, but it's very sad that that's still, still going on. OK, I promised some special notes about dyslexia. I think I'm OK on time. We're aiming for. Um, October is dyslexia Awareness Month. I told you guys that. Um, this is from a patient. Uh, they told me I'd never be good at poetry because I'm dyslexic, but so far I've made 3 jumps in a vase, and they're lovely. Um, I had a 14-year-old patient at when I was at UT Southwestern, I split time between Maine DVP and Luke Waite Center for Dyslexia and Learning Disorders. Um, and she brought this in A, because I do use the word lovely a lot, um, and B, because actually this wasn't written about her, but this did actually happen to her. She kind of, she didn't make the jugs in the vase, but she was talking to her English teacher about how excited she was to do the pottery, and he had to like break it to her that that's not what she signed up for, so. Anyway, it was brought in for that reason. Um, for those of you who are here, sorry, people who are online, but you can go to this link, um, we often talk about reading difficulty and dyslexia. I wanted to also give you a little writing exercise that's interesting to do. Um, because of the impact in the way that dyslexia affects your brain, it doesn't just affect sort of reading, decoding, it also affects sort of writing, even if you're not truly dysgraphic. So an interesting exercise to go through there. This video is very, very sort of 80s. 90s old school, um, but it's one of the exercises we use at Luke weights um to sort of get people familiar with how it felt, maybe to write like that. So anyone with an iPhone or similar phone, you can do this, you can use a mirror if you prefer, um, but it's an interesting exercise. And if anyone wants to do it and show their star at the end, I would love it. Um, so, this definition from the International Dyslexia Association is gonna read very similar to just a specific learning disorder, right? There's some key components that look Very similar. So neurobiological in origin, characterized by difficulties with, in this case, accurate or fluent word recognition or spelling and decoding. These difficulties result from a deficit in phonological component of language. Again, that's unexpected, that term came up before, right, in relation to other things, meaning it's not that you are not smart. Luckily it happens in all sorts of people, including extremely smart people. Um, and the pro it's unexpected relation to cognitive abilities and the provision of effective classroom instruction. So that's almost where you're getting that language about targeted instruction in there again. Secondary consequences, as we talked about, can be a lot of things, reading comprehension, reduced reading experience, can impede. The growth of vocabulary and background knowledge. Why is this so, so worth talking about? We're gonna talk about the difficulties and struggles of dyslexia first, but then I'm also gonna end on hopefully a positive note about what is so fascinating about someone's brain when they have dyslexia. So how many? About 1 in 5. That's a lot. That's like a lot, a lot. And the interesting thing and some of the stuff we'll talk about at the end is that this percentage has sort of persisted over time, long time, 20%, that's a lot. What about in school specifically, so about, it could be anywhere from 14 to 20, but about 14% of kids in need special education in school, about half of those have a learning disorder or disability, the other half being some of those other categories that we listed there. And of the ones with learning disabilities, most of them are something that would almost fit in a dyslexia category, so reading and language processing. So it's huge. This is a huge percentage of society. What does that mean? I did leave one study in here, sorry, it's just so important. Um, this is a very interesting study that looked at when can we pick up this difference? If we wait till first grade, do we see it? If we give intervention, does it get better? So, one thing is very clear, that achievement gap is present. When these kids come into first grade. With the second thing is with intervention, it persists. That gap doesn't close. It didn't show it here, but if there's no intervention, it widens. I'm sure you could probably conclude that, but this is, this is sobering information to look at, right? And then this is, sorry, I should have told you, this was reading concepts, so what you'd really kind of focus on and look at in dyslexia, this is verbal IQ. So this is looking when you do a cognitive test, you tend to do a verbal component, a nonverbal component, and you put them together to get your full scale IQ. So again, this is how much you're using this in other aspects, not just reading and decoding. Gap was there. Yeah, persisted. In some skills, even with intervention like it. So I'm telling you, present at first grade, these kids are behind, and even with intervention they may not catch up. You can imagine what's happening in districts where they don't have an infection. So, we know, and I say this all the time, the residents who work with me are like sick of hearing it. Up until 3rd grade, we learn to read, and after 3rd grade we read to learn. OK, it just sounds like a cute catchphrase, but what we mean by this is that if you don't have those basic skills of reading down by 3rd. It's gonna affect you everywhere because everything becomes reading, right? So let's say that you didn't like reading cause you have dyslexia, and you're like, you know what, I'm gonna be a science math kind of guy. Well, then in 3rd grade, you know, math becomes word problems, and science becomes reading 5 pages of instructions to chemistry experiments, and all of a sudden, if you don't have those reading basics, the rest of school is gonna be very difficult, right? So up until 3rd we learn to read, after 3rd we read to learn anything, and I just showed you that we know that the differences in abilities in 1st grade are gonna mark a, like already, right, very sobering. So, your natural conclusion, I would hope would be like we must screen so early and just jump on this and treat these kids like before first, right? We should be getting on this like a birth, not a birth, guys, but a pre-K, right? We're kinder, we're first, right? Um, and I will say, and I don't always get to say super special stuff, but Missouri does actually have a law in place, um, that Reading screening, but it's sort of pre-dyslexia screening is supposed to take, sorry, supposed to take place in kinder 1st and 2nd grade. Illinois just joined us this year, so the 2025, 2026 school year is the first start of that version of the law for them. That is the good news. The harder news is that while the screening is right here. Everybody gets to sort of decide how they're going to treat or approach that. Now, there is language in the law that encourages it to be an evidence-based method, but I will be honest with you that that is not always what is occurring. So this can be a very frustrating process for kids or families who truly genetically or otherwise know that their kids are struggling with dyslexia. It's important to just know that while the letter of the law says yes we do it, it doesn't always end up in practice being exactly what those kids need. Again, I'm sort of ending the, the struggle part, and I promise we'll switch gears here, but with just reminding you what you already know, um, which is that the things you see in a person who struggles with dyslexia are really the tip of the iceberg. There is a lot. That is impaired going on underneath and it can be a very significant life struggle and, and as pediatricians, we are uniquely aimed to not just say, you know, as one of the problems with, oh, dyslexia, but he's getting help at school to really ask other questions about how that could be impacting. A young woman or a man's life. OK, I'm gonna, I'm not gonna go like total conspiracy theory on you. I am going to just ask you though, a different question, which is, is the problem the dyslexia, or is it where a dyslexic mind sort of meets modern education? And the reason I'm asking you this is because there's some really fascinating anthropologic research about, well then why does 20% of the population still have dyslexia? Why has it, you know, even evolutionarily persisted? And there's some fascinating studies, both like through fMRI and all of this, and some psychological studies that talk a little bit about what could be the trade-off, right? So, clearly we know there are some extreme areas of difficulty, but is there this cognitive trade-off? And it's often described as like this explorative trade-off, right? So maybe there's some enhanced abilities in Discovery, invention, creativity, and I will tell you that when you look around that, for instance, just pick the category of entrepreneurs, there's a huge higher than the general population number of people with dyslexia. I find that very interesting, right? And I'll tell you some other groups and some other studies, so, and these references and resources are all at the end, but People with dyslexia are better at picking out impossible drawings. I don't even know what that is. There's a really cool artist who does these, but anyway, it's like picture it as a line drawing, so it's 2D that should represent something in 3D, but that your brain knows cannot actually be in 3D in that manner. It's an impossible drawing. And when people without and with dyslexia are shown these people with dyslexia can pick them out at a better, faster rate. It's interesting. Dyslexic astrophysicists in this one study where they're looking at certain formulations that cause, you know, that meant this was a black hole to do it better than people without dyslexia. How weird, right? College students were shown these like fuzzy images, you guys would laugh, it just looks like a bad X-ray from the 80s, but um and they were able to like memorize and then say yes, that was it, yes, that was not compared to people without dyslexia better. Makes you think a little. People with dyslexia, these are my fears, and this one's actually the New England Journal of Medicine, the one about sound, can distribute attention better. What do I mean by that? When they did a study that looked at flashing letters on a screen and some would flash in the middle and some would flash on the periphery, people with dyslexia were worse at saying every letter that flashed in the middle. But they were better at combining, saying at the same time, I saw this, this, this and this and this, and other people couldn't do that as well. The cocktail party scenario, so you're in a cocktail party, there's a bunch of people on the periphery, everybody's mingling holiday party style, I don't know, and someone with dyslexia will have a harder time telling you exactly what the conversation was with that primary person they're standing with, but if you ask with without dyslexia to pick out how many words you heard. The person with dyslexia will do a better job, grossly of picking out what they heard in the entire environment. So it's fascinating, right? So again, remember that just because we have these differences in someone's brain, and yes, I'm corny, and yes, I do this with my kids with ADHD too. I'm like, yes, you have a learning disability as, you know, or a difference or a struggle, right? Technically because of how we practice, function, teach. But also your brain is really unique and cool, right? There's a lot that says maybe this is we do miss the trees for the forest. Maybe with dyslexia you actually do a better job at picturing, picking out that global picture, right? And so one of the most fascinating interviews is the head of British GCHQ, so this is their communication headquarters, of spies, like cybersecurity and intelligence or whatever. There's actually 5 times the number of, you know, general population of people with dyslexia, and he actually talks about how he feels like, and they do interviews with some of the people in GCHQ with um dyslexia who talk about problem solving pattern recognition is a really big one. Um, and big picture thinking, simplification, things like that. So there may be actually some really significant, different, different than direct reading, writing, but really significant skills for people with dyslexia, which I think is positive and fascinating. So, I'll end on that positive note. These were our goals that we talked about, learning disorders versus disabilities, what's new with DSM, um, common ones from school, the school process, what to be aware of as a pediatrician, and sort of that deeper dive into dyslexia. I'm totally happy to take questions and see anyone star if they did that. Uh, but I want to quickly say, because I know we have a lot of gen Pes, especially, I put a lot of resources on the back here before my references. Some of these are dot phrases I use, parent navigation sites, some of these are accommodations I talk about with kids who have dyslexia when they want some examples of what would be good at school, and then the other pages are just references.
