research paper on dyslexia

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Defining and understanding dyslexia: past, present and future

Margaret j. snowling.

a Department of Experimental Psychology and St John’s College, University of Oxford, Oxford, UK

Charles Hulme

b Department of Education, University of Oxford, Oxford, UK

Kate Nation

c Department of Experimental Psychology, University of Oxford, Oxford, UK

Dyslexia is a difficulty in learning to decode (read aloud) and to spell. DSM5 classifies dyslexia as one form of neurodevelopmental disorder. Neurodevelopmental disorders are heritable, life-long conditions with early onset. For many years, research on dyslexia proceeded on the basis that it was a specific learning difficulty – specific meaning that the difficulty could not be explained in terms of obvious causes such as sensory problems or general learning difficulties (low IQ). However, the failure to find qualitative differences in reading, and phonological skills, between children with dyslexia and children with more general learning problems led this kind of ‘discrepancy’ definition to fall from favour. The Rose Review stated that dyslexia can occur across the IQ range and that poor decoding skills require the same kinds of intervention irrespective of IQ. In this paper, we argue that loosening the criteria for dyslexia has influenced common understanding of the condition and led to diagnostic confusion. In the longer term, the use of the term may need to change. Implications for research and practice are discussed.

A central theme in the history of dyslexia is the tension between the specificity of the disorder and its complex association with other forms of learning disability. Since its earliest description over 100 years ago, through the case files of the Word Blindness Centre (Whyte, this issue ) and of Tim Miles (Evans, this issue ) to more recent neuropsychological case studies (e.g. JM; Snowling & Hulme, 1989 ) is the notion that dyslexia is specific – a particular problem with reading and spelling that is somehow unexpected and therefore requiring a diagnosis and an explanation, as well as specialist intervention. At the same time, the history of dyslexia captures a sense of complexity that there might be ‘several “species” of dyslexia’ and it reflects a ‘family of disabilities’. These tensions play out in perennial discussions surrounding the definition of dyslexia, whether there are different ‘subtypes’ and questions about whether it even exists. In this article, we argue that loosening the criteria for dyslexia means that a far wider range of individuals now receive the label; furthermore, by understanding the co-occurrence of dyslexia with other disorders, we reach a better understanding of the heterogeneity of its manifestations.

Dyslexia – the discrepancy definition

For many years, research on dyslexia proceeded on the basis that it was a specific learning difficulty. The term ‘specific’ here referred to the fact that children with dyslexia have difficulties in the domain of reading (and spelling) that are ‘out of line’ with expectation, given age and IQ. Educational and clinical psychology practice was to look for a discrepancy between expected and actual reading attainment in order to ‘diagnose’ dyslexia. However, the failure to find qualitative differences in reading (and the phonological skills that underpin it) between children with dyslexia and children with more general learning problems led this kind of ‘discrepancy’ definition to lose credibility. To understand the implications of moving away from a discrepancy-based definition, we begin by reviewing how such a definition was operationalised and the evidence against its validity.

Originally conceived of as a measure of General Cognitive Ability or ‘g’, an individual’s IQ is simply their score on an IQ test. The most widely used measures of IQ are the Wechsler Scales which can be used to assess preschoolers, children and adults (e.g. Wechsler, 1974 ). For present purposes, it is important to note that these scales separate tests tapping verbal skills from tests tapping non-verbal or performance skills (though the division is not clean). The verbal tests include measures of vocabulary, verbal concepts, knowledge of the world and mental arithmetic. The performance tests primarily require practical responses, such as putting blocks together to make a pattern, or pieces of a puzzle to make an object; unlike the verbal tests, they are timed and hence tap speed of processing. An individual who has taken an IQ test typically obtains a Verbal IQ, Performance IQ and a Full-Scale IQ combining across both. Assuming no obvious neurological or sensory impairment and no lack of educational opportunity, children with average or above average Full-Scale IQ who nevertheless show problems with reading and spelling may be classified as dyslexic. This category corresponds to ‘Specific Dyslexia’, as used in the context of the Word Blind Centre (Naidoo, 1972 ). Dropping the discrepancy definition broadens this category.

One of the early critics of the discrepancy definition of dyslexia was Stanovich ( 1991 ). There were two main tenets of Stanovich’s argument against this approach. First, learning to read has a positive effect on verbal skills and vocabulary. Children who are good at reading read more and therefore have a greater opportunity to learn new information via print than children who are poor at reading. The corollary of this is a ‘Matthew effect’: the verbal skills of children who read less fail to keep pace with their peers (Stanovich, 1986 ). On this view, lower Verbal IQ (and, by extension, Full-scale IQ too) can be a consequence of poor reading and therefore the use of an IQ-based ‘discrepancy’ formula to differentiate different groups of readers is flawed. Second, Stanovich and Siegel ( 1994 ) showed that irrespective of IQ, poor readers experience the same core phonological difficulties (problems in dealing with the speech sounds of words). Given that reading skills show a continuous distribution in the population and that there are no clear qualitative or quantitative differences in reading as a function of discrepancy, effectively this means using the term ‘dyslexia’ for any cases of poor reading. While defensible on statistical grounds, to regard dyslexia ‘just’ as poor reading (and spelling) fails to capture the fact that it has an early onset (in preschool) and is persistent over time.

In an attempt to reconcile these views, the Diagnostic and Statistical Manual of the American Psychiatric Association (American Psychiatric Association, 2013 ) uses the term ‘Specific Learning Disorder with impairment in reading’ to describe what others, and lobbyists in particular, call dyslexia. The DSM5 definition notes that the term refers to a pattern of learning difficulties characterised by problems with accurate or fluent word reading, poor decoding, and poor spelling ‘that must have persisted for at least 6 months, despite the provision of interventions that target those difficulties’ (p. 66). It also notes that a good indicator is ‘low academic achievement for age or average achievement that is sustainable only by extraordinarily high levels of effort or support’ (p. 69).

In summary, dropping the IQ-discrepancy definition of dyslexia has proven controversial for many, particularly for those who see ‘dyslexia’ as a special category of disorder and reject the view that it is only a reflection of poor reading. We will argue here that it is important is to have a better understanding of the dimensionality of reading disorders and how they frequently occur with other difficulties.

Putting learning into the definition of dyslexia and the phonological deficit hypothesis

Although intellectual disability precludes a diagnosis of specific learning disorder, once the practice of restricting the diagnosis of dyslexia to those principally with above-average IQ is abandoned, the kinds of learning difficulties to which the label ‘dyslexia’ applies widen and now include children with a broader range of learning problems. Such children have a range of problems with reading which are not best characterised as affecting only accuracy and fluency. A more principled approach then is to first consider the demands of learning to read and then consider how specific aspects of learning are affected in different ‘types’ of poor reader.

At the core of dyslexia is a difficulty in learning to decode and to spell. It is important therefore that our understanding of dyslexia is cast within a framework of learning to read. Reading development is a complex process (for a review see Castles et al., 2018 ). In simple terms, learning to read starts with learning mappings between print and sound. In alphabetic languages, the mappings are at a fine-grain between phonemes (the smallest units of speech) and graphemes (letter and letter groups), and in English there are many inconsistencies in the mappings, making learning to read difficult. As children grasp this alphabetic principle, they can translate print into sound and from that access the meaning of familiar words. This decoding process provides a mechanism for acquiring detailed orthographic knowledge about how written language works. Over time, and with reading experience, reliance on overt decoding declines as word recognition becomes increasingly efficient and automatised, allowing children to go from print to meaning rapidly and effortlessly.

More formally, we can consider reading development within the context of the influential ‘triangle model’, a computational model devised by Seidenberg and McClelland ( 1989 ). The triangle model comprises three sets of representations (phonological, orthographic and semantic) that interact and connect together to constitute the word recognition system.

Well before learning to read, children have well-developed phonological knowledge (of the sounds of words) that has connections with their semantic system (the meaning of words). Faced with written words, children need to form mappings from orthography to phonology and thus to meaning. Semantic knowledge can also support the development of word reading, providing the means to adjust a partial decoding attempt (such as reading school as ‘s-chule’) and bring it in line with a known word. Reading experience allows orthographic representations to become structured and for the whole system to embody the statistical regularities that exist between print and sound, and print and meaning.

In dyslexia, children are slow to learn to decode words and become fluent; they also struggle to generalise, that is, to read novel words they have never seen before. It is well established that in cognitive terms, dyslexia is caused by problems at the level of phonological representation (e.g. Shankweiler et al., 1979 ; Snowling & Hulme, 1994 ). This hypothesis has its roots in long-standing clinical observations, arguably starting with Orton ( 1937 ) and continuing with Bannatyne ( 1974 ), who noted difficulties in ‘auditory sequencing, auditory discrimination, and associating auditory symbols with sequences of visual symbols’. A considerable body of research has since detailed the nature of ‘auditory’ problems in dyslexia, narrowing the deficit to one affecting the sound (phonological) structure of speech (Griffiths & Snowling, 2001 ; Vellutino et al., 2004 ): problems with phonology lead to difficulty in learning mappings between orthography and phonology and other difficulties which include problems learning new spoken words, poor verbal short-term memory and problems with word retrieval and picture naming (see Snowling, 2019 for review). Although learning to read has a reciprocal influence on phonological skills (Morais & Kolinsky, 2005 ), there is good evidence that phonological deficits in dyslexia are present in the preschool years, long before reading instruction begins (Snowling, Nash et al., 2019 ). Moreover, training phonological skills and letter knowledge improves reading ability, strengthening the claim that phonological skills are causally related to reading development (Hulme et al., 2012 ).

Nonetheless, despite the strength of the phonological deficit hypothesis, it seems that phonological difficulties are neither necessary nor sufficient to account for dyslexia (Pennington, 2006 ). While poor phonology is the impairment most consistently associated with dyslexia, many children at family risk of dyslexia who do not succumb to reading difficulties also have problems with phonological awareness (Snowling & Melby-Lervåg, 2016 ) and many individuals with dyslexia have deficits outside of the phonological domain (Saksida et al., 2016 ; White et al., 2006 ). According to the influential theory by Pennington ( 2006 ), dyslexia is the outcome of multiple risks which accumulate towards a threshold for what is usually termed ‘diagnosis’. What are these additional risks and how can they be conceptualised?

To consider these questions, we can begin by looking within the reading system itself. While learning to read depends initially on learning mappings between orthography and phonology, other factors are also important. Semantic knowledge adds another source of variation: children with low language show relative weaknesses in learning to read words, especially evident for those words that are difficult to decode (Nation & Snowling, 1998 ). More generally, longitudinal studies show that preschool variations in oral language are associated with word reading ability in 8–9 year-olds (Hulme et al., 2015 ). Other research has focussed more directly on the learning mechanisms involved and asked whether the reading difficulties seen in dyslexia are associated with differences in paired-associate learning or statistical learning (see Nation & Mak, 2019 for a review). In addition, some children have been shown to have particular difficulty with letter position coding, making errors when dealing with words where precision is needed (e.g. pirates and parties; smile and slime ; Kohnen et al., 2012 ). Together these findings indicate that an individual child’s score on a standardised test of word reading reflects multiple sources of variation (and difficulty). As computational models make clear, dyslexia is characterised by heterogeneity and individual differences (Harm & Seidenberg, 1999 ; Perry et al., 2019 ). However, to understand dyslexia fully we need to look beyond the details of the reading system itself and ask how additional factors influence reading and its development.

In summary, some of the complexity associated with dyslexia arises because the predominant proximal cause – a phonological deficit – is often not the only deficit that is observed. Moreover, phonological skills are themselves dimensional and can affect one or more aspects of reading. In particular, if the phonological difficulties occur as a ‘downstream’ effect of earlier language problems then reading comprehension as well as word decoding will be significantly affected.

Comorbidities of dyslexia

Comorbidity refers to the co-occurrence between two (or more) disorders in the same individual. Comorbidity can be found between disorders within the same diagnostic grouping, e.g. reading disorder and mathematics disorder (both learning disorders with shared risk factors) as well as between disorders from different diagnostic groupings, such as between reading disorder and behavioural and emotional disorders (Angold et al., 1999 ). Rates of comorbidity between reading disorder and other neurodevelopmental disorders vary widely but, on average, about 40% of the children with a reading disorder/dyslexia will have another disorder as well (Moll et al., 2020 ). Many children with dyslexia have oral language problems extending well beyond the phonological domain. This was recognised by the Invalid Child’s Aid Association in setting up the Word Blind Centre (Whyte, this issue ) and is highlighted by Maughan et al. ( 2020 ) drawing on data from the Isle of Wight studies in the 1960s. An inevitable consequence of removing the discrepancy definition is that more children with poor reading in the context of broader and more serious language difficulties will be labelled ‘dyslexic’. Since reading for meaning draws on language skills, it follows that many poor readers also have poor reading comprehension skills. Thus, whereas in classic discrepancy-defined dyslexia, reading comprehension is only an issue insofar as poor decoding presents a bottleneck to the construction of meaning, this is not the case for children with dyslexia who have co-occurring language problems; these children have poor reading comprehension too (Bishop & Snowling, 2004 ).

Some children with dyslexia meet criteria for Developmental Language Disorder (DLD), a disorder characterised by persistent difficulties in expressive and/or receptive language (Bishop et al., 2017 ). While usually considered a communication disorder separate from learning disorders, DLD is a major risk factor for dyslexia. Indeed, McArthur et al. ( 2000 ) showed that among children with specific reading difficulties (dyslexia), some 40% had significant language impairments; on the other hand, children who enter school with DLD are at high risk of literacy difficulties (Bishop & Adams, 1990 ). In short, the boundaries of dyslexia are not clear-cut: it is not uncommon for children with dyslexia to have language problems and some children also meet clinical criteria for DLD (Catts et al., 2005 ; Snowling, Nash et al., 2019 ). These language problems are under-diagnosed but are likely to affect response to intervention (Adlof & Hogan, 2019 ).

DLD is not the only disorder that co-occurs with dyslexia. Dyslexia is also often comorbid with attentional and motor coordination problems (Gooch et al., 2014 ; Rochelle & Talcott, 2006 ). There is also an overlap between dyslexia and speech sound disorder (Pennington & Bishop, 2009 ), socio-emotional and behavioural disorders (Carroll et al., 2005 ) and internalising problems such as anxiety and depression (Francis et al., 2019 ). None of these comorbidities should be viewed as ‘core’ features of dyslexia, but they can complicate both its presentation and response to intervention (Rose, 2009 ). Importantly for the present discussion, following relaxation of the discrepancy definition and hence the IQ cut-off, the number of ‘symptoms’ co-occurring with dyslexia has increased.

Another disorder that is frequently comorbid with dyslexia is mathematics disorder (or dyscalculia). Like reading disorder, mathematics disorder is classified as a specific learning disorder in DSM5 (American Psychiatric Association, 2013 ); it is comorbid with dyslexia in between 30% and 70% of the cases (Landerl & Moll, 2010 ). Like reading, mathematics is also a complex skill with multiple components. The overlap with dyslexia is high because many aspects of mathematics depend on verbal skills, e.g. number knowledge, counting, retrieval of number facts and verbal problem solving (Göbel & Snowling, 2010 ; Moll et al., 2018 ). However, mathematics also involves non-verbal skills; these include the ability to estimate numerosity and to compare differing magnitudes (Malone et al., in press ). Further, numeracy problems have been associated with poor visual-spatial skills, poor executive function and working memory deficits; such deficits are commonly features of the kinds of non-verbal learning difficulty associated with lower Performance IQ (Gillberg & Gillberg, 1989 ). We can think of IQ as a broad measure of many aspects of cognition (including language, spatial, and attentional skills). Statistically, if we insist that only children with average IQ can be diagnosed with dyslexia, this will make dyslexia appear to be a specific disorder (because children with language or attentional problems will tend on average to have lower than average IQs and so fail to be diagnosed as dyslexic).

In summary, we argue that cases of ‘specific dyslexia’ exist and they are most apparent when a strict discrepancy definition (reading poorer than expected for a child’s age and IQ) is adopted. However, when it is dropped, a wider range of difficulties are observed among children with reading disorders. The clinical and educational reality is that for many children, poor reading sits within a constellation of difficulties each of which represents a dimension. As the history of dyslexia shows, these are far from newly recognised issues; they have dogged dyslexia since it was first identified in the 19 th century (Kirby, this issue ).

Dyslexia diagnosis and treatment

A growing concern among educators is the increasing incidence of dyslexia in school and in higher education. Do the increasing rates of this learning disorder reflect increased awareness of the condition or do they reflect over-diagnosis, particularly among those with the financial means to seek private educational assessment? This is the nub of an argument that has surfaced in a variety of forms since the first cases of reading disorder were described (Kirby, 2019 ). One of the main criticisms of those who are concerned with labelling dyslexia as a categorical impairment is that there are no clear cut-off criteria behind the diagnosis (Elliott & Grigorenko, 2014 ). DSM5 (American Psychiatric Association, 2013 ) stipulates that the term should only be used if there is restricted progress in learning (to read/spell) and no catch-up with peers despite extra help at home or school; there should also be a low academic achievement. While precise criteria are avoided given the dimensional nature of the disorder, the manual does suggest that achievement (e.g. in literacy or numeracy skills) more than 1.5 standard deviations below the mean (a standard score of 78) assures the greatest diagnostic certainty; it also goes on to assert various exclusionary criteria and continues to advocate the importance of clinical judgement.

Arguably, it is the issue of clinical judgement which lies behind the dyslexia debate – and yet for all clinical conditions including infections and diseases, clinical judgement needs to be exercised before treatment can be determined. 1 We should also emphasise that dimensional disorders are common in many other areas of medicine and psychology – there are no clear cut-offs for diagnosing hypertension, obesity or depression; but for each of these very real conditions there need to be clinical decisions made about when an individual needs treatment. The same is true for dyslexia. To avoid the issue of clinical judgement and poor reliability around diagnostic thresholds, some have advocated the use of ‘response to intervention’ as an approach to diagnosis (Fletcher & Vaughn, 2009 ). Such an approach undoubtedly makes sense – if a child responds to treatment positively and can catch up with peers, then the label of ‘dyslexia’ is not appropriate because the condition is not persistent. Such children might be regarded as ‘instructional causalities’ – not having been taught properly in the first place or having suffered a set-back, for example, because of a poor command of the language in the case of migration. However, implementation of the response-to-intervention approach has not borne the anticipated fruit; children who fail to respond to well-founded intervention are just as likely to be identified following a comprehensive assessment with objective standards for referral for intervention as after their poor response to intervention – so why wait? Moreover, the characteristics of ‘treatment resistors’ include the phonological deficits that characterise dyslexia (Al Otaiba et al., 2014 ; Vellutino et al., 2004 ).

So where does this leave the issue of diagnosis and more broadly the practice of labelling a child or adult as having dyslexia? First, we propose that the term dyslexia should not be used as a shorthand for ‘reading disorder’ but should be used to refer to a difficulty with decoding and spelling fluency which is evident from the early school years and persistent over time. Second, it should affect academic functioning, such that progress is less good in literacy-based areas of the curriculum than that of peers in a similar setting. Third, if there are co-occurring features, these should be labelled as such but should not be considered core to the ‘diagnosis’. Finally, the diagnosis should be qualified as mild (fully compensated when appropriate arrangements are in place), moderate or severe; we hypothesise that those with ‘severe’ difficulties are often those with a range of comorbid conditions.

In a similar vein, Miciak et al. ( 2014 ) criticised approaches that focus on a range of features in order to ‘diagnose’ dyslexia. Rather, they suggest that assessments should focus on the defining symptoms of reading difficulties, the functional impairments and co-occurring conditions. Such clarity is important if the causes of dyslexia are to be properly understood and the concept is to be fully embraced in educational policy. Another issue that has concerned those who do not support the use of the term ‘dyslexia’ is the fact that the types of intervention that are known to be helpful do not differ from the interventions that are useful for other poor readers. This is, however, a simplistic view. Dyslexia does equate with poor decoding and word reading, and therefore to say it requires similar treatment to poor reading is a tautology. The most robust evidence for the effectiveness of reading interventions comes from randomised trials (e.g. Connor et al., 2013 ; Hulme & Melby-Lervåg, 2015 ; Melby‐Lervåg & Lervåg, 2014 ). To date, the evidence suggests that the most effective interventions for children with dyslexia are phonologically based, involving training in phoneme awareness and letter knowledge combined with structured reading practice (McArthur et al., 2012 ). These interventions tackle the decoding deficit in dyslexia directly. However, there is a dearth of evidence for the efficacy of interventions to improve spelling and writing fluency – future research must address these important questions as a matter of urgency. There is also a need for treatment plans to consider the comorbidities that are associated with dyslexia, particularly language problems, and to consider their impact on the developing reading system. If these are not addressed, then response to intervention is likely to be poor.

In summary, elaborate comprehensive assessments are not required to identify a child as in need of reading intervention. What needs to be recognised is that reading is a dimension that is correlated with other skills and co-occurring difficulties (comorbidities) need separate management.

Conclusions: when is dyslexia a disability?

The term dyslexia can be properly used to describe children who experience problems learning to read and write; often when a basic level of reading and spelling ability is established, there are persisting problems with reading fluency. Dyslexia is a dimensional disorder, however, with no clear cut-off from poor reading. This does not mean it is not a handicap. If difficulties in learning and in developing fluency persist, then we would argue the term should be used, not least to signal the need for intervention. In addition, it should be recognised that assessment is needed to identify co-occurring problems; if present, these may require separate management, but they do not define dyslexia . The need to intervene is clear: children with poor reading are at elevated risk for a range of emotional and behavioural difficulties. Moreover, longer-term follow-up studies make clear that problems with literacy persist into adulthood, and are associated with lower levels of educational attainment, higher rates of unskilled employment, and often periods of unemployment (e.g. Maughan et al., this issue ). At the same time, since some individuals with dyslexia can compensate for their difficulties, dyslexia need only be disabling if the individual remains unable to cope with the literacy demands of study or work even when appropriate arrangements are in place.

How dyslexia is recognised by the education system, and by society more generally, has changed over its history, and continues to evolve. Here we have aimed to clarify some of the consequences that have followed from dropping the IQ-discrepancy definition of dyslexia. While questions remain, how reading develops and how best to teach it are now well understood (Castles et al., 2018 ) and policy implications are clear (Seidenberg, 2017 ). Despite best efforts, some children will continue to find reading difficult. Optimal outcomes for these children require us to embrace the dimensional nature of dyslexia and its associated complexities; to fail to do so is negligent and arguably morally indefensible.

Biographies

Margaret J. Snowling is President of St. John’s College and Professor of Psychology, University of Oxford. She is also professionally qualified as a clinical psychologist. Her research on children’s reading and language is at the interface of psychology and education.

Maggie was awarded the British Psychological Society Presidents’ Award (2003) and the Samuel T Orton Award of the International Dyslexia Association (2005); she is Past-President of the Society for the Scientific Study of Reading and former Joint Editor of the Journal of Child Psychology and Psychiatry. She served on Sir Jim Rose’s Expert Advisory Group on provision for Dyslexia, was advisor to the Phonics Screening Check and Reception Baseline Assessment in England and an expert member of the Education for All: Fast Track Initiative group in Washington DC in (2011).

Maggie has been awarded honorary doctorates from Goldsmiths London, University College London, Warwick and Bristol Universities for contributions to the science of reading and dyslexia.

She is Fellow of the British Academy, Fellow of the Academy of Medical Sciences and Fellow of the Academy of Social Sciences. She was appointed CBE for services to science and the understanding of dyslexia in 2016.

Charles Hulme is Professor of Psychology and Education at the University of Oxford. His research interests are in reading, language and memory and their development and he is an expert on randomised controlled trials in Education. Publications include a number of assessment materials including the York Assessment of Reading for Comprehension (2009), the Phonological Abilities Test (1997), Sound Linkage (2014) and The Test of Basic Arithmetic and Numeracy Skills (2015) as well as several books dealing with various aspects of reading development. He is a former Editor-in-Chief of the journal ‘Scientific Studies of Reading’ and a former Senior Editor of the Association of Psychological Science’s flagship journal, Psychological Science. In 2009 he published ‘Developmental disorders of language, learning and cognition’ (Wiley-Blackwell; co-authored with Maggie Snowling). He received the Feitelson Research Award from the International Reading Association (1998), the Marion Welchman International Award for Contributions to the study of Dyslexia from the British Dyslexia Association (2016) and the Society for the Scientific Studies of Reading Distinguished Scientific Contributions Award (2019). He is a Fellow of the British Academy and of the Academy of Social Sciences, holds an honorary doctorate from the University of Oslo (2014), and is a member of Academia Europea.

Kate Nation is Professor of Experimental Psychology at the University of Oxford and a Fellow of St John’s College, Oxford. Her research is concerned with with language processing, especially reading development. She is interested in how children learn to read words and comprehend text, and more generally, the relationship between spoken language and written language. Her research spans both typical and atypical development. A key aim at present is to investigate the mechanisms involved in the transition from novice to expert. She also studies language processing in adults, addressing the issue of how skilled behaviour emerges via language learning experience. Kate has contributed to building links between psychological research and educational policy and practice. She has served on a number of Editorial Boards and her research has been recognised by awards from the British Psychological Society and the Experimental Psychology Society . For more information see www.readoxford.org and follow her on twitter drofxOdaeR@ .

Funding Statement

This work was funded by the Wellcome Trust Institutional Strategic Support Fund and supported by St. John’s College, University of Oxford.

1. Michael Rutter, contribution of oral history to the Dyslexia Archive, 2019.

Disclosure statement

No potential conflict of interest was reported by the authors.

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The Etiology of Dyslexia

The dyslexia paradox and the risks of delayed diagnosis, the role of pediatricians and their professional organizations in dyslexia risk screening, a more proactive approach: screening and advocacy, conclusions, reintroducing dyslexia: early identification and implications for pediatric practice.

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Joseph Sanfilippo , Molly Ness , Yaacov Petscher , Leonard Rappaport , Barry Zuckerman , Nadine Gaab; Reintroducing Dyslexia: Early Identification and Implications for Pediatric Practice. Pediatrics July 2020; 146 (1): e20193046. 10.1542/peds.2019-3046

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Dyslexia is a common learning disorder that renders children susceptible to poor health outcomes and many elements of socioeconomic difficulty. It is commonly undiagnosed until a child has repeatedly failed to learn to read in elementary school; this late diagnosis not only places the child at an academic disadvantage but also can be a precursor to psychiatric comorbidities such as anxiety and depression. Genetic and neuroimaging research have revealed that dyslexia is heritable and that it is undergirded by brain differences that are present even before reading instruction begins. Cognitive-behavioral research has revealed that there are early literacy skill deficits that represent red flags for dyslexia risk and can be measured at a preschool age. Altogether, this evidence points to dyslexia as a disorder that can be flagged by a pediatrician before school entry, during a period of heightened brain plasticity when interventions are more likely to be effective. In this review, we discuss the clinical implications of the most recent advances in dyslexia research, which converge to indicate that early identification and screening are crucial to the prevention or mitigation of adverse secondary consequences of dyslexia. We further highlight evidence-based and practical strategies for the implementation of early risk identification in pediatric practice so that physicians can be empowered in their ability to treat, educate, and advocate for their patients and families with dyslexia.

The development of reading proficiency in childhood is a public health issue: literacy is a widely recognized determinant of health outcomes and is associated with many indices of academic, social, vocational, and economic success. 1   In a recent National Academy of Medicine summary, the author highlights that duration of education, which is highly dependent on reading proficiency, is a better predictor of health and long life than cigarette smoking or obesity. 2   Children skilled in reading perform better in school, attain higher levels of education, experience lower rates of disease, are less likely to be incarcerated or experience poverty, are more likely to find employment, and achieve higher average incomes as adults compared with children who fail to achieve reading proficiency. 3   For many children with reading impairments, however, the process of learning to read is rife with struggle and frustration, and these children are left susceptible to adverse secondary outcomes, including anxiety and depression. A neurobiologically based specific learning disorder, dyslexia, affects 5% to 10% of children 4 , 5   and is a persistent barrier to reading acquisition.

Dyslexia (or word-level reading difficulty 6   ) is predominantly characterized by a core deficit in phonological processing (the ability to recognize and manipulate speech sounds), which results in impairments in decoding (“sounding out” words), spelling, and word recognition. 7   These impairments almost always lead to difficulties in reading fluency and comprehension, reduced vocabulary, lower content knowledge, 8   and a decline in overall school performance. 9   Dyslexia cannot be explained by poor hearing or vision, low language enrichment, or lack of motivation or opportunity. 10   According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , dyslexia falls under the umbrella of a “specific learning disorder” that “impedes the ability to learn or use specific academic skills (eg, reading, writing, or arithmetic).” 11  

Although there are many negative outcomes associated with dyslexia, particularly salient to the pediatrician is the association between dyslexia and poor mental health. 12 , 13   Children with dyslexia are more likely to suffer from generalized anxiety 14 , 15   and also exhibit higher rates of depression. 14 , 16   Because screening for dyslexia is not routinely performed, the direction of causation between dyslexia and comorbid mood disorders in each case is unclear, and this uncertainty can preclude effective early treatment. A mood disorder may be identified in a child with unidentified comorbid dyslexia when it is the dyslexia that is antecedent and causative, obscuring the primary target for intervention.

In addition to mood disorders, speech and language problems are frequently comorbid with dyslexia because both dyslexia and developmental language disorders can be characterized by poor phonological awareness 17 – 19   and other language deficits (eg, oral language comprehension). 20   Approximately one-half of children identified with dyslexia have language disorders, and approximately one-half of children with language disorders have dyslexia. 20   Dyslexia typically results from a core deficit in phonological processing; however, it is important to note that language deficits (eg, low vocabulary or low oral listening comprehension) can also lead to reading problems, especially problems with reading comprehension. Importantly, speech and language problems commonly precede problems in learning to read, so children with speech and language problems should be flagged as being at increased risk for dyslexia. 21  

There are many other developmental and psychiatric conditions that are frequently comorbid with dyslexia, further jeopardizing these children’s health and academic outcomes. In total, 20% to 40% of children with attention-deficit/hyperactivity disorder have dyslexia, 22   and children with autism spectrum disorder are also at increased risk of having dyslexia. 23   Other behavioral disorders, such as conduct disorder and oppositional defiant disorder, are also associated with dyslexia. 24   As many as 85% of children with dyspraxia (developmental coordination disorder) have dyslexia, 25   and children with dyscalculia (math learning disorder) 26   and dysgraphia (writing learning disorder) 27   are more likely to have dyslexia than those without. Knowledge of dyslexia within pediatric practice is paramount in considering the most appropriate treatments for these many coexisting disorders.

Despite increasing collaboration among educators, physicians, neuroscientists, speech and language pathologists (SLPs), and psychologists, dyslexia is often overlooked in the field of general pediatrics, perhaps because the diagnostic label of dyslexia is not often used in practice, having been replaced largely by education language of strengths and weaknesses. The clinical implications of a reluctance to use dyslexia as a diagnostic label include children failing to receive an adequate response to early risk signs, appropriate interventions in school, and mental health support.

In this article, we provide an up-to-date overview of dyslexia, specifically addressing common knowledge gaps, neurobiological underpinnings of the disorder, and ways in which pediatricians can play an active role in the early identification of dyslexia risk.

The etiology of dyslexia is multifaceted, including genetic, perceptual and cognitive, neurobiological, and environmental factors. 9   Dyslexia is strongly heritable, occurring in up to 68% of identical twins of individuals with dyslexia and up to 50% of individuals who have a first-degree relative with dyslexia. 19 , 28 – 30   Several genes 31 – 34   have been reported to be candidates for dyslexia susceptibility; it is thought that most of these genes play a role in early brain development. 31 , 34 – 38  

Furthermore, various studies have revealed atypical brain characteristics in individuals with dyslexia compared with their peers. 39   In functional MRI studies, researchers have indicated that reading for typical readers takes place predominantly in left-hemispheric sites of the brain, including the inferior frontal, superior temporal, temporoparietal, and occipitotemporal cortices. 40   As a group, individuals with dyslexia show hypoactivation in the left-hemisphere reading systems. 41   The structural and functional atypicalities in these brain regions include reduced gray matter volume, 42   hypoactivation in response to reading-related functional MRI tasks, 43   and weaker functional connectivity between key areas of the reading network. 44   Importantly, differences in brain structure and function characteristic of dyslexia can be observed before the start of formal reading instruction, indicating that dyslexia does not result from a struggle to learn to read but, rather, represents a biological disposition present at the preschool age or perhaps as early as infancy. 45 – 47   Altogether, these neuroimaging findings suggest that children predisposed to dyslexia enter their first day of school with a brain that is less equipped to learn to read.

It is worth noting that reading proficiency is strongly associated with socioeconomic status 48 – 50   : 80% of fourth grade students from low socioeconomic backgrounds read below grade-level proficiency. 51   In particular, children with inadequate exposure to language are more likely to struggle with reading. 52   However, the diagnosis of dyslexia does not include socioeconomic disadvantage as a potential cause. Although these children do not necessarily meet a diagnosis of dyslexia, children who struggle with reading, regardless of etiology, have been shown to suffer the same adverse health and psychosocial consequences and benefit from interventions that have been primarily developed to address deficits associated with dyslexia. 53 – 55  

Although neuroimaging research has been invaluable in establishing the biological basis of dyslexia and reading impairments, neuroimaging technology (eg, brain MRI) does not have the ability to screen or diagnose dyslexia on an individual level, nor is it likely that this will be the case in the future. At this point, neuroimaging is not able to clearly disentangle differential neurobiological effects of dyslexia versus other reading impairments. 39 , 56   For these reasons and many others, cognitive-behavioral strategies are much more useful in screening.

The classic simple view of reading posits that skilled reading involves ≥2 major cognitive components: word recognition (including decoding and phonological awareness) and language comprehension (eg, knowledge of vocabulary and language structures); together, these strands coalesce to form what is classically known as the “reading rope.” 57   Although the simple view of reading has been borne out by evidence, 58   its components are not single entities but are multifactorial, malleable, and context dependent (especially language comprehension) and cannot be captured in a single assessment. 59   Furthermore, recent research has revealed that skilled reading, especially in older children, is contingent on knowledge of academic language and the additional cognitive skills of perspective-taking and reasoning. 60  

In the past, dyslexia was diagnosed in the context of a discrepancy between reading ability and IQ, such that reading ability had to be 1 SD below cognitive abilities (IQ) for dyslexia to be diagnosed. However, this discrepancy model has been disproven, and dyslexia is no longer considered to be associated with IQ. 61  

Dyslexia is related to deficits in ≥1 strands of the reading rope and particularly to early struggles in phonological and/or phonemic awareness. 62   Other predictors include struggles in letter-sound correspondence, pseudoword repetition (the ability to pronounce spoken nonsense words), identifying rhyming sounds, rapid automatized naming (the ability to automatically retrieve the names of objects, letters, or colors), and deficits in oral language comprehension and receptive and expressive vocabulary. 63   These measures have been shown to be strong predictors of reading ability in the English language; in other languages, the precursors vary, and screening approaches should be tailored to a child’s language environment. In this review, we focus on monolingual English speakers, however, and, among these children, these key linguistic and preliteracy measures can be assessed in children as young as 4 years old, and they can serve as crucial markers in identifying children at risk for dyslexia or other reading impairments. 64 – 66   Some of these literacy precursors measured in kindergarten have been shown to predict reading comprehension in the 10th grade. 67  

As children progress through the school system, reading becomes the expected vehicle for content learning; thus, it is imperative that children with dyslexia are identified early and receive intervention without delay. When at-risk beginning readers receive intensive early reading intervention, 56% to 92% of these children achieve average reading ability. 68   However, many children are diagnosed with dyslexia long after they first demonstrate recognizable struggles with preliteracy milestones. 69   Currently, children are typically diagnosed with dyslexia at the end of the second or beginning of third grade (and many much later), after they have already failed to learn to read over a long period of time and have fallen behind their peers academically. 70   This wait-to-fail approach fails to capitalize on the most effective window for intervention, which is during an earlier period of heightened brain plasticity in kindergarten and first grade. 70 , 71   Referred to as the “dyslexia paradox,” 63   the gap between the earliest time at which identification is possible and the time at which identification and treatment typically occur can preclude effective intervention and has profound academic and socioemotional implications for the developing child. Children at the 10th percentile of reading ability may read as many words in 1 year as a child at the 90th percentile reads in a few days. 72  

In addition to the poor academic outcomes associated with untreated dyslexia, diagnosing children after a prolonged period of failure can have severe implications for children’s mental health. Often perceived as lazy or labeled as “stupid,” children with dyslexia may develop decreased self-esteem, which can progress to anxiety and depression. 16   Furthermore, children with learning disorders are less likely to complete high school, 73   less likely to attend programs of higher education, 74   and at increased risk of entering the juvenile justice system: 28% to 45% of incarcerated youth 75   and 20% to 30% of incarcerated adults 76   have a learning disorder. Additionally, adults with learning disorders are more likely to be unemployed and, on average, earn annual incomes well below the national average. 5   Given the prognostic benefit of early diagnosis and intervention and the many adverse consequences that can be avoided or mitigated, there is great value in identifying early risk for dyslexia in the pediatric clinic.

It is important to distinguish between screening for dyslexia risk and diagnosing dyslexia. Screening refers to a brief assessment that determines the risk of having or developing dyslexia, which can be undertaken at an early age before school entry. 75 , 77   Conversely, a formal diagnosis can only occur after reading instruction has begun and requires a more comprehensive neuropsychological evaluation, which can be motivated by a previous screening result. 76   Although attention to both screening and diagnosis is vital in ensuring that the appropriate interventions are implemented for the child, screening for risk of dyslexia is possible earlier in the developmental time course than is diagnosis; thus, it represents an opportunity for expeditious early intervention.

The consideration of any screening regimen requires that a valid and acceptable test be available, an effective and accessible means of treatment be available, and the potential benefits of screening outweigh the risks 78   without an undue burden to the practitioner or patient. In the case of dyslexia, screening children individually for risk can be accomplished quickly and inexpensively through a consideration of family history and through short behavioral assessments of early literacy abilities. Extensive evidence has revealed the benefit of an early evidence-based response to screening, 70 , 79 , 80   and the risks of implementing a screening process are minimal to negligible. A review of a child’s family history of dyslexia is a worthwhile start to the process of early identification: a family history with positive results necessitates close monitoring, whereas a family history with negative results still requires a level of ongoing observation.

The risk of a false-positive result is present with any screening program, and, in the case of dyslexia screening, the risk is tantamount to further evaluation, monitoring, and educational supports. Although through these processes, demands are placed on the child and represent cost and effort on the part of practitioners, the burden of failing to identify these children early is ultimately greater than the burden of providing supplemental resources to a child needlessly. As discussed, although not all children who struggle with reading will meet the criteria for a dyslexia diagnosis, most children who struggle with reading will benefit from interventions designed to address dyslexia.

With the recognition that early literacy predictors of dyslexia can be identified before the start of kindergarten, 63 , 65   we can no longer afford to wait for screenings in children’s first formal schooling experiences. In a 2009 position article negating visual deficiencies as the origin of dyslexia, the American Academy of Pediatrics stated that pediatricians should “be vigilant in looking for early signs of evolving learning disabilities.” 81   The pediatrician's existing role in monitoring early child development and our understanding of the importance of early support for language and literacy development present pediatricians with the opportunity to implement dyslexia screening in well-child visits even before children are school-aged.

Pediatricians can contribute to a collaborative effort to screen for children at risk by capitalizing on their unique role in a child’s early developmental trajectory and by taking advantage of their network of health and educational resources. It is important to note that many parents desire this proactive stance from their child’s health care provider: more than one-third of surveyed parents indicated that they have not discussed reading with their pediatrician; nearly one-half of that group believed such conversations would be useful. 82   Pediatricians can also provide referrals to outside experts, such as neuropsychologists and SLPs, and communicate with patients’ schools. 83  

Pediatricians typically rely on a developmental milestone checklist in evaluating a child’s development in various domains; however, recent research reveals that there is great variability between the many available checklists, both in content and milestone age ranges. 84   Furthermore, although receptive and expressive language is accounted for in these checklists, a comprehensive inventory of key early literacy measures that are crucial for assessing dyslexia risk is not included.

Early warning signs of dyslexia are visible before school entry 63 , 65   ; thus, the pediatrician may be a child’s first health or educational professional capable of identifying these signs and implementing a management plan. For example, pediatricians can document the extent to which a child can recognize rhyming sounds, repeat nonsense words, or report the sound that a letter makes. It is important to note that phonological deficits can present differently in different children, and children with dyslexia will vary in the specific tasks with which they show difficulty. Thus, screenings are used to pinpoint particular early literacy skills that may require remedial attention and also identify children who may eventually require a more detailed evaluation to come to a definitive diagnosis of dyslexia.

There are many methods by which pediatricians can work toward systematic early screening of dyslexia in their practices. Pediatricians should elicit a family history of dyslexia, recognize assessments done by schools that indicate a risk and/or diagnosis, and include dyslexia in the differential diagnosis for low self-esteem, depression, anxiety, or disruptive behaviors. The governing bodies of associations of pediatricians should provide training on dyslexia assessments and interventions as a part of ongoing continuing education so that pediatricians can become adept at implementing screening processes and at interpreting, monitoring, and responding efficiently to evaluations and interventions performed outside the clinic. The appropriate referral to outside consultants and interventionists should also be involved in this training when needed. Given the high overlap between dyslexia and deficits in speech and language, physicians should consider referring children who are at risk for dyslexia to an SLP who is trained in early literacy. 21   Furthermore, pediatric associations can partner with dyslexia researchers and education specialists to create educational resources and trainings that can assist pediatricians in providing education and support to their patients and families with or at risk for dyslexia.

Checklists, questionnaires, and interviews can be completed in conjunction with a child’s parent to assess a child’s key risk factors. Although these methods provide a quick account of a child’s risk, they are often tools that are not scientifically validated or reliable 85   and are thus intended for a preliminary formative assessment only. Commonly used questionnaires like the Ages & Stages Questionnaires, for example, can be helpful as a starting point but do not provide a detailed assessment. Rigorously validated screeners composed of child-centered behavioral assessments (see ref 86 for a nonexhaustive evaluation of screening tools) are used to provide a reliable and unbiased testament of a child’s risk status.

Pediatric clinics could consider hosting “screening days” with a literacy focus that can aim to simultaneously screen for early predictors of dyslexia while also facilitating a literacy-rich environment by making literacy materials available to families. Many pediatricians have already made great strides in promoting literacy within their clinics. The Reach Out and Read program has been effective in facilitating language and preliteracy skills in children through the distribution of books through primary care clinics. 87   A similar program with an additional screening component could be even more beneficial in supporting emerging literacy while also identifying children at risk for dyslexia.

A further possibility is the use of a standardized, brief 2- or 3-question first-step questionnaire, the likes of which have already been demonstrated to be successful in prescreening other conditions like depression 88   and attention-deficit/hyperactivity disorder. 89   Although no such standardized questionnaire yet exists, pediatricians can pose questions to a preschool-aged child’s caregiver(s) pertaining to key risk factors for dyslexia. Affirmative answers to these first-step questions can be used to lead to a more detailed, validated screening tool that can be used to identify specific deficits present. There are storybooks and tablet- and smartphone-based gamified and self-administered screening tools currently being developed for the use in schools, clinics, or a child’s home. These tools are being designed to be entertaining for the child and will be informative to the clinician in determining the appropriate next steps and referrals for further evaluation and intervention.

As new screening tools continue to become available in the coming years, it will be important for practitioners to be knowledgeable about the characteristics of an appropriate dyslexia screener and discerning in their selection. The ideal screener has been validated in a representative sample; has strong evidence for reliability, validity, and classification accuracy; has developmentally appropriate content given the age or grade level of the child; and has the capacity to measure both word recognition and linguistic comprehension. 77   A list of available dyslexia screening tools, along with an indication of their fulfillment of characteristics like those listed above, is presently available for practitioners to consult (see ref 86 ). An additional resource for practitioners is the What Works Clearinghouse, which is used to provide evidence-based evaluations on literacy screening products as they become available. 90  

In addition to child-directed assessments, given the strong heritability of dyslexia, a crucial component of early identification is an assessment of the reading history of the child’s parent(s) to determine the child’s familial risk of dyslexia. Family history is both quick to elicit and informative in the global assessment of a child’s risk. The Adult Reading History Questionnaire is an inventory 91   of an adult’s literacy abilities and habits and can be used to indicate a reading impairment (see ref 92 for a digital version). Follow-up questions should be presented to a parent with a high-risk score to rule out an environmental explanation for reading impairment (eg, lack of formal reading instruction). This distinction is particularly important to consider in communities with considerable immigrant populations, who may be flagged by the Adult Reading History Questionnaire as “at risk” simply because they are adult learners of the dominant language. Regardless of a parent’s dyslexia status, the quality of the home literacy environment is a strong predictor of reading outcome. 52 , 93 , 94   Thus, this parent inventory is useful not only because it can be used to indicate a child’s possible familial risk but also because it can reveal less literacy-rich home environments that leave children with insufficient literacy materials and support, illuminating additional targets for intervention.

Beyond the clinic, the medical community can be vocal advocates in national conversations about dyslexia, many of which are currently happening in state legislatures; as of now, only a few US states lack state-level legislation focusing on early screening, teacher training, and/or instructional support (for an overview of state legislation, see ref 95 ). Despite such recent attention, there is much room for growth in pediatric neurocognitive research funding, which has lagged compared to adult neurocognitive disorders. Increased funding and research must be used to explore etiologic models, examine comorbid relationships, refine tools for the early identification of children at risk for dyslexia and other reading impairments, investigate additional tools for use in children for whom English is not their first language, and develop and evaluate intervention strategies and their effectiveness. A first-order goal should be the development of screening guidelines and tools for use during pediatric visits for 4- and 5-year-old children that can be used to identify children at risk before the optimal window for early interventions closes, while also refining guidelines to identify older children who were not screened earlier. Finally, with the help of policy makers, the current “failure” model of dyslexia must be replaced with a “support” model that enables school-, clinic-, and community-based early screenings and subsequent evidence-based response to screening through empowered and well-trained teachers within the general education framework. Physicians can be powerful agents of these positive changes, both at the level of their clinical practices and as advocates in their communities and beyond.

Our current knowledge of the neurobiological basis for dyslexia, its reliable developmental-behavioral predictors, the effectiveness of early intervention, and the myriad adverse effects of reading failure reveal a demand for a proactive, preventive approach (instead of a deficit-driven approach) to identify and treat children at risk. Early identification should start with an assessment of family history and should be followed with validated behavioral screening tools. After a positive screen, referrals to diagnosticians such as SLPs or neuropsychologists should be made. Diagnoses, when they occur, should be followed with letters to schools requesting the implementation of literacy intervention.

With time, new and innovative formats for screening will emerge. In acknowledging the significant effort devoted by pediatricians to screening various conditions, the future will require a consideration of novel approaches to office visits or increased community-based collaboration with preschools to accomplish screening for disorders that, like dyslexia, are of nontrivial prevalence and are associated with available and effective interventions. Pediatricians occupy a unique role in the lives of children such that they are well positioned to recognize and respond to risk factors for dyslexia even before children enter the education system; however, the delivery of dyslexia interventions is and will largely continue to be implemented outside the scope of the pediatrician’s practice. Thus, the contributions of both pediatricians and other health and educational professionals are crucial to optimizing the process of identifying and treating dyslexia. Although the response to dyslexia screening and intervention is multifaceted and longitudinal, the trajectory of children’s literacy outcomes has the potential to be improved through the implementation of early identification in pediatric practice.

Drs Gaab, Rappaport, and Zuckerman conceptualized the review, participated in the drafting of the initial manuscript, and continuously reviewed and revised the manuscript; Mr Sanfilippo conducted the literature review, led in the writing and design of the final manuscript, consolidated coauthor feedback, and continuously revised the manuscript; Drs Ness and Petscher contributed their respective expertise in writing significant components of the manuscript and reviewed and revised the manuscript throughout; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded by the National Institute of Child Health and Human Development (grant R01 HD065762). Funded by the National Institutes of Health (NIH).

speech and language pathologist

Competing Interests

Re: a pediatrician’s role in dyslexia: where theory meets practice.

I want to applaud the article by J Sanfilippo and colleagues titled ‘Reintroducing Dyslexia: Early Identification and Implications for Pediatric Practice.” This article joins other recent articles and position statements that call for pediatricians to view literacy as a developmental domain and to participate in screening for future literacy concerns as early as preschool age.1-3 As a pediatrician, I agree wholeheartedly with their statement that “The development of reading proficiency in childhood is a public health issue.” The evidence linking lack of reading proficiency with school failure, lack of meaningful employment, and involvement in the criminal justice and welfare systems is robust, as is the mental health consequences of reduced self esteem, anxiety and depression. As pediatricians we should be aware of and attempt to modify all of these negative outcomes by helping to identify risk factors for future reading disabilities and referring our struggling readers for further evaluation and remediation if available.

Yet, is it really that simple? To answer this question I would like to point out the current barriers out there that make executing the article’s recommendations difficult if not near impossible. My perspective is based on my experiences as a community pediatrician who currently cares for mostly low income Medicaid patients, many of whom come from non-English speaking households, as well as from my experience being the parent of a now 10 year old daughter with dyslexia. As a disclaimer, this perspective is based on the educational landscape of my State of Colorado where I live and may not be representative of other educational and healthcare systems.

Our oldest child was first pulled out for reading intervention in the first grade. Despite my pediatric training, I was ill prepared to interpret what screening and interventions the school was providing her and I trusted that the school would know to teach her how to read. By middle of 2nd grade, after 18 months of intervention without improvement, my pediatrician spidy-sense told me it was time to get her privately tested. She seemed to be on the wait to fail trajectory which statistically occurs in 4th or 5th grade when the child has entered into the reading to learn stage. The results of her private testing revealed what I knew in my gut all along, she has dyslexia. We brought the 13 page evaluation to our school with lists of accommodations and recommended intervention expecting that all would now be fine. It wasn’t. The intervention provided her was ineffective (as it had been prior) and her teachers could not seem to accept that she had dyslexia. Not even an IEP could grant us recommended modifications for her.

It was not until I listened to the eye-opening documentaries of Emily Hanford from American Public Media4-7 that the light bulb went on as to why the school was reacting this way. Many years ago education abandoned the teaching of phonics for whole language and balanced literacy which teaches our children to guess at words rather than decode them. What all children need, especially struggling readers, is systematic and explicit phonics that is based on the science of reading. Yet to my dismay, many teacher preparation programs still do not teach the science of reading. In fact, in Colorado, the largest teacher prep program was cited again by the State Board of Education for “failure to adequately prepare students to teach children how to read.”8 Perhaps this is why in 2018 State testing showed that only 40% of Colorado third graders were reading at grade level. Another likely reason for this is many Colorado schools are not using reading curriculum approved by the Colorado Department of Education (CDE).9,10

What my dyslexic daughter needed was Structured Literacy which can be found in the explicit multi-sensory scope and sequence approach of programs such as the Orton-Gillingham (OG) method. This was not available in her classroom so we paid privately for twice weekly OG tutoring and moved her to a public charter school who used an approved CDE reading curriculum and required all K-3 teachers to be trained in Structured Literacy. The result has been life changing for my daughter’s mental health and reading proficiency.

However, I wish I can say that my low income pediatric patients who are struggling readers and who are experiencing the behavioral and mental health consequences of school failure have had the same experience. Their school may proceed slowly with Multi-Tiered System of Supports (MTSS)11 that relies on response to intervention as well as literacy assessment tools such as iReady12 and Istation13 that do not always provide important data on word level reading and oral reading fluency. The article mentions that pediatricians should become adept at interpreting and responding to these educational assessments and interventions which I believe are out of the scope of pediatric practice and to circumvent this I have relied on professional courtesy of qualified educational neuropsychologists and speech-language pathologists to interpret these for me.

For my patients who have IEPs, their parents are typically not aware of the type of intervention the child receives or whether the school’s reading curriculum is supported by the science of reading. Even in the rare case I have been able to secure grant funding for a private evaluation that confirms dyslexia, the child’s school usually does not have qualified staff trained in Structured Literacy to remediate it. As the child’s pediatrician, there are few if any outside referral options for Structured Literacy reading intervention as not all speech language pathologists have the additional training in literacy nor do insurance payers typically cover reading intervention.

It is heart breaking for me to see my patients year after year for their well child exam and not know how to help them overcome all of these systemic barriers that prevent them from obtaining grade-level reading proficiency. Understanding the glacial speed that my local school systems are moving toward structured literacy and science-based reading curriculum, all that we pediatricians and parents of dyslexic children have left is advocacy to create more immediate resources for our struggling readers that are external to the child’s school yet work symbiotically with it. What we need are programs like the Promise Project14 that can be grant funded and implemented to provide identification and remediation for all children with significant reading deficiencies while continuing to advocate at the State level for continued educational reforms in teacher preparation programs and science-based reading curricula. Pediatricians also need to advocate for State legislation that requires insurance payers to cover evaluations as well as remediation for children with dyslexia given the preponderance of medical evidence of its neurobiological origin. Insurance coverage that provides access to early identification and remediation of dyslexia could mitigate commonly associated physical and mental health ramifications of stress, anxiety, depression, and suicide that result in great personal and economic costs later on.

References: Literacy as a Distinct Developmental Domain in Children. JAMA Pediatrics March 30, 2020 Pediatricians Have a Role in Early Screening of Dyslexia. Examiner, Volume 8, Issue 3. October 2018. Available at https://dyslexiaida.org/an-invitation-to-pediatricians-for-early-dyslexi... School-aged Children Who Are Not Progressing Academically: Considerations for Pediatricians. Pediatrics 2019;144. Hard Words Why aren’t kids being taught to read. Available at https://www.apmreports.org/episode/2018/09/10/hard-words-why-american-ki... At a Loss for Words How a flawed idea is teaching millions of kids to be poor readers. Available at https://www.apmreports.org/episode/2019/08/22/whats-wrong-how-schools-te... Hard to Read. How American schools fail kids with dyslexia. Available at https://www.apmreports.org/episode/2017/09/11/hard-to-read New salvos in the battles over reading instruction. Available at https://www.apmreports.org/episode/2019/12/20/new-people-organizations-r... Colorado’s largest teacher preparation program dinged over reading instruction — again https://co.chalkbeat.org/2020/6/9/21285846/colorados-largest-teacher-pre... Colorado wants schools to use reading curriculum supported by science. Here are the ones that made the cut. https://co.chalkbeat.org/2020/4/23/21233583/colorado-wants-schools-to-us... Why do so many Colorado students struggle to read? Flawed curriculum is part of the problem. https://co.chalkbeat.org/2020/3/27/21231320/why-do-so-many-colorado-stud... Multi-Tiered System of Supports (MTSS). Available at https://www.cde.state.co.us/mtss/handouts-mtss-overviewshpgbreakoutsept-... iReady. Available at https://www.curriculumassociates.com/products/i-ready/i-ready-tour-seein... ISTATION READING. Available at https://www.istation.com/Reading Promise Project. Available at https://www.promise-project.org/promise2/ ?

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Dyslexia, Literacy Difficulties and the Self-Perceptions of Children and Young People: a Systematic Review

• Open access
• Published: 09 November 2019
• Volume 40 , pages 5595–5612, ( 2021 )

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• Rosa Gibby-Leversuch   ORCID: orcid.org/0000-0002-1695-877X 1 ,
• Brettany K. Hartwell 2 &
• Sarah Wright   ORCID: orcid.org/0000-0002-6500-370X 2  

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This systematic review investigates the links between literacy difficulties, dyslexia and the self-perceptions of children and young people (CYP). It builds on and updates Burden’s ( 2008 ) review and explores how the additional factors of attributional style and the dyslexia label may contribute to CYP’s self-perceptions. Nineteen papers are included and quality assessed. Quantitative papers measured the self-reported self-perceptions of CYP with literacy difficulties and/or dyslexia (LitD/D) and compared these with the CYP without LitD/D. Qualitative papers explored the lived experiences of CYP with LitD/D, including their self-views and how these were affected by receiving a dyslexia diagnosis. Results suggest that CYP with LitD/D may be at greater risk of developing negative self-perceptions of themselves as learners, but not of their overall self-worth. Factors found to be relevant in supporting positive self-perceptions include adaptive attributional styles, good relationships with peers and parents, and positive attitudes towards dyslexia and neurodiversity. In some cases, CYP with LitD/D felt that others perceived them as unintelligent or idle; for these CYP, a diagnosis led to more positive self-perceptions, as it provided an alternative picture of themselves. There is a need for further research to explore the impact of attributional style and the potential for intervention, as well as CYPs’ experiences of diagnosis and the associated advantages or disadvantages.

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A broad field of dyslexia research exists, some of which has focused on the social and emotional aspects of dyslexia, specifically self-perceptions. Research in this area has revealed mixed findings: some papers indicate that dyslexia is linked with experiences of stigmatisation and lowered self-concept (e.g. Polychroni et al. 2006 ; Riddick 2000 ) whereas others find that dyslexia is not associated with negative self-perceptions (e.g. Burden and Burdett 2005 ) or that the labelling of dyslexia can increase self-esteem (e.g. Gibson and Kendall 2010 ; Solvang 2007 ). Some of the differences in findings can certainly be attributed to the array of definitions and measurement tools used, with some papers conflating self-esteem and self-concept.

Two reviews have looked specifically at LitD/D and self-perceptions: Chapman and Tunmer ( 2003 ) and Burden ( 2008 ). Chapman and Tunmer found that reading self-perceptions develop in response to actual reading performance as early as the first year of school. Burden found that while academic self-concept tended to be lower in CYP with dyslexia, compared to typically achieving peers, this did not necessarily impact on self-esteem. His paper is highly relevant to the current review, however, the majority of papers included were written prior to 2000. Both review papers suggested that attributional style may be an important factor in developing self-perceptions and should be further researched.

This review extends Chapman and Tunmer’s ( 2003 ) and Burden’s ( 2008 ) reviews by looking at literature in the 10 years since, by operationalising self-perception terms and considering the impact of differing definitions of dyslexia. This review imposes definitions on a dataset that uses multiple definitions and terms relating to self-perceptions, one of the weaknesses of the previous literature that was highlighted by Burden’s review.

In addition, this review will evaluate the research within the context of current systems of education and dyslexia assessment, including considering some of the pertinent issues that were not explored in previous reviews: looking beyond within-child factors by exploring the impact of the CYP’s educational setting on their self-perceptions. It has been suggested that there are differences in the self-perceptions of CYP educated in specialist compared to mainstream settings (e.g. Tracey and Marsh 2000 ). Furthermore, researchers have questioned whether the label itself may influence experiences, beliefs and self-perceptions (e.g. Riddick 2000 ) so this is also considered.

Definitions

Definitional confusions have been key to the mixed findings in this area of research and will be addressed in this first section.

Despite the reported prevalence of dyslexia, the diagnostic term itself is not consistently defined in professional, research or social domains (Solvang 2007 ). A wide range of associated terms are also used within Europe (e.g. ‘specific learning disability’ ‘literacy difficulties’) without clear distinction or agreement on what they mean (Elliott and Grigorenko 2014 ). Educational Psychologists (EPs) in Britain often use the BPS definition (British Psychological Society 2005 ):

‘Dyslexia is evident when accurate and fluent word reading and/or spelling develops very incompletely or with great difficulty. This focuses on literacy learning at the ‘word level’ and implies that the problem is severe and persistent despite appropriate learning opportunities. It provides the basis for a staged process of assessment through teaching.’ (p.11).

This definition clearly highlights the importance of appropriate teaching and that dyslexia cannot be a result of inadequate teaching, but is evident when difficulties persist in spite of good teaching. The definition does not make a distinction between dyslexia and other forms of literacy difficulties, or provide a cut-off for what should be considered ‘severe and persistent’. An alternative is the discrepancy definition, which defines dyslexia as reading at a level significantly below what would be expected based on predictions from intelligence scores (Siegel 1992 ). However, this has been largely discredited as it only identifies a certain subset of individuals and lacks empirical validity (Elliott and Grigorenko 2014 ; Snowling 2013 ; Tanaka et al. 2011 ). Despite this, it continues to be used in research (e.g. Novita 2016 ) and perpetuated by organisations such as The International Dyslexia Association (‘Definition of Dyslexia’, n.d.).

For the purposes of this review, the terms dyslexia and literacy difficulties will both be used, but not to imply that they are necessarily distinguishable, only that, in one case, a diagnosis has been given and in another, it has not. In reviewing the research, the terminology used will reflect the paper being discussed. The term ‘literacy difficulties and/or dyslexia’ (LitD/D) will be used to speak generally about children and young people (CYP) who have difficulties with literacy, diagnosed or not.

Self-esteem, self-concept and self-efficacy have been explored by researchers looking at similar constructs, but are not always appropriately defined. As Marsh ( 1990a , 1990b ) pointed out: ‘Self-concept, like many other psychological constructs, suffers in that ‘everybody knows what it is,’ so that researchers do not feel compelled to provide any theoretical definition of what they are measuring’ (p. 79). In order to review and discuss the included papers, the different terminologies are operationalised in Table  1 .

The Current Review

This review investigates the links between literacy difficulties, dyslexia and the self-perceptions of CYP, highlighting their voices and experiences. Five research questions were addressed. The first two aim to update Burden’s ( 2008 ) review and the following three offer novel contributions to a review of this field:

What is the impact of LitD/D on global self-perceptions?

What is the impact of LitD/D on domain-specific self-perceptions?

Does the type of educational setting that a child attends impact on self-perceptions?

How are attributional styles linked with self-perceptions amongst CYP with LitD/D?

Does the dyslexia label influence self-perceptions?

Search Strategy

The papers included in this review were sourced via systematic searching and a manual search of relevant papers (Fig.  1 ). The systematic searches were conducted within three electronic databases: PsychINFO, Web of Science (WoS) and ERIC. Search terms relating to dyslexia, self-perception and attribution were generated based on reading of known papers on these topics (Table  2 ). The databases were searched for papers with titles containing dyslexia AND self-perception terms, then dyslexia AND attribution terms. Only papers published in the English language, between 2000 and 2017, in academic journals were retrieved.

Paper identification and screening process

Additional papers were identified through manual searches, including searching two relevant review articles (Burden 2008 ; Chapman and Tunmer 2003 ). The two review papers themselves were excluded as the majority of papers cited were written prior to the year 2000.

Once papers from the self-perceptions, attributions and manual searches were complete and screened, 48 papers remained, at this point, all of the pre-determined inclusion and exclusion criteria were applied (Table  3 ). The papers in this review were restricted to studies conducted in Europe due to differences in diagnosis in other parts of the world.

The initial systematic search was conducted on 08-09-2017 and the search for papers including attribution terms was conducted on 13-10-2017 (Table 4 ).

Selected Papers

Data extraction.

The 19 selected papers were reviewed systematically and data were extracted relating to authors, year and country, sample characteristics, design and methods, measures and inclusion criteria, and main relevant findings. The extracted data is detailed in Table  7 .

Quality Assessment

Quality assessment of the qualitative papers was completed using the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist (Critical Appraisal Skills Programme 2017 ). The CASP Checklist was adapted to include two additional criteria relevant to the review question.

Quantitative studies were assessed using a checklist created by the author, based on two well-used checklists; the Downs and Black Checklist (Downs and Black 1998 ) and the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Heart, Lung and Blood Institute 2014 ). A new quantitative checklist was created to ensure that it included questions most appropriate to the cross-sectional methodologies of the included studies, as well as the addition of further items designed specifically to answer the review question. Tables  5 and 6 give the outcome of the quality assessment for each paper (Table 7 ).

The contribution of each individual paper has been considered and assessed for quality. Based on the results of the quality assessment (Tables 5 and 6 ), the authors afford more emphasis and weight to reporting and analysing the findings of higher quality studies.

Qualitative Papers

The majority of papers used individual semi-structured interviews, which allowed researchers to uncover the priorities of participants and be flexible in the topics discussed, meaning that the researcher reduced the impact of their own beliefs and expectations of the research and gathered rich data. However, only two of the studies provided their interview schedules (Gibson and Kendall 2010 ; Glazzard 2010 ), which reduced transparency and replicability.

As a dataset, there were a number of weaknesses. No papers adequately considered the researcher-participant relationship nor reflected on the researcher’s role in data collection and analysis. As many of the participants were children, considering the balance of power and influence of the researcher as an adult is important.

Further weaknesses were apparent in the reporting of procedures and data analysis. Five studies did not provide sufficient description of their data analysis. However, Casserly ( 2013 ) and Singer ( 2005 ) gave detailed descriptions of the frameworks used and the process of coding and drawing out themes. Singer ( 2005 ) also transposed coded data into a numerical system and determined interrater reliability.

Three papers (Burton 2004 ; Casserly 2013 ; Humphrey and Mullins 2002b ) gave adequate consideration to their use of self-perception terms. Armstrong and Humphrey ( 2009 ) looked at individuals’ conception of the self and identity, incorporating a range of self-perceptions, although no definitions were provided. Four papers (Gibson and Kendall 2010 ; Glazzard 2010 ; Singer 2005 ; Stampoltzis and Polychronopoulou 2009 ) discussed self-esteem without providing any definition. Glazzard, and Stampoltzis and Polychronopoulou used a number of self-perception terms interchangeably without explanation.

Six of the eight studies scored >6 out of 12 and all studies were deemed to make a valuable contribution to their area of research and to the review question.

Quantitative Papers

Ten out of 13 papers clearly described the inclusion and exclusion criteria for participation although fewer provided sufficient information on recruitment procedures. Sample sizes ranged from 19 to 242, with some studies analysing data from large comparison groups and others only including CYP with LitD/D.

A wide range of outcome measures were utilised and all papers clearly described these. Five papers gave insufficient evidence to demonstrate the accuracy, validity and reliability of their outcome measures. One of these (Saday Duman et al. 2017 ), used a measure of self-concept (The Piers-Harris Children’s Self-Concept Scale) that has been criticised by previous researchers for using a composite measure of global self-concept (Bear et al. 2002 ).

The self-perception measures used were almost entirely self-report by CYP. Given that participants in every study had literacy difficulties, any self-report measures needed to be appropriately administered, either orally or with consideration of reading level. However, only three papers (Burden and Burdett 2005 ; Frederickson and Jacobs 2001 ; Lindeblad et al. 2016 ) acknowledged this and reported steps taken to address the issue.

A strength of the dataset is that 10 of the 13 studies provided definitions of their self-perception terms and used them consistently and accurately. In addition to providing definitions, several papers discussed the importance of terminology in detail. However, this was still a weakness in some papers (Polychroni et al. 2006 ; Saday Duman et al. 2017 ; Terras et al. 2009 ).

Burton’s ( 2004 ) intervention study provided a clear and replicable description of the intervention that was carried out, however Saday Duman et al.’s ( 2017 ) intervention was insufficiently described.

On the whole, the quantitative studies provided valuable information to the review question and scored well in terms of quality, with all but 3 studies scoring ≥8 out of 16.

Findings from Papers

The results of the review are discussed in terms of the five research questions.

What is the Impact of LitD/D on Global Self-Perceptions (GSP)?

Seven papers utilised quantitative measures of self-esteem or self-worth, including two papers from Burden’s ( 2008 ) review. In order for useful comparison and conclusions to be made, only measures that fit with the definitions of this review were included.

When drawing conclusions, the results of quality assessment should be considered. The three studies that found no difference in GSP amongst CYP with LitD/D (Frederickson and Jacobs 2001 ; Lindeblad et al. 2016 ; Terras et al. 2009 ) were high and medium scoring papers, whereas the three papers that did detect a difference (Alexander-Passe 2006 ; Humphrey and Mullins 2002b ; Saday Duman et al. 2017 ) were all low scoring. This suggests, especially if taken in conjunction with the findings from Burden’s 2008 review, that LitD/D are not directly linked with lowered GSP in any consistent or predictable way. Two papers suggest that task-based coping styles may be a protective factor in preventing difficulties in specific areas from impacting on overall sense of self-worth (Alexander-Passe 2006 ; Singer 2005 ). Other influencing factors will be considered throughout this review.

Across the seven studies discussed, six different GSP measures were used; both Frederickson and Jacobs ( 2001 ) and Terras et al. ( 2009 ) used the Self-Perception Profile for Children (Harter 1985 ) and found no differences in GSP for CYP with LitD/D. The measures used in some studies appeared to have greater construct validity than others, with the Self-Perception Profile’s self-worth scale fitting well with the definition used for this review.

Two of the seven papers reported cross-sectional studies that assessed GSP in groups of children with and without dyslexia. Frederickson and Jacobs ( 2001 ) found no significant differences between scores in each group on their self-worth subscale. However, Humphrey and Mullins ( 2002b ) reported significantly lower global self-concept amongst CYP with dyslexia in mainstream schools, compared with a control group, although not amongst CYP with dyslexia attending specialist provision. However, Humphrey and Mullins’ ( 2002b ) findings are treated with caution as the ‘total self’ scale of the SDQ (Marsh 1990b ) includes accrued scores from responses to domain-specific statements. As GSP is its own distinct aspect of self-perception, it should not be a composite of domain-specific items (Mruk 2006 ). An individual may have low self-perceptions in a specific domain but still view themselves highly in terms of overall self-worth.

Three of the studies assessed GSP by comparing participants with dyslexia to previously gathered data. Terras et al. ( 2009 ) and Lindeblad et al. ( 2016 ) found no discrepancy between participants’ self-reported self-esteem and norm-referenced data, using two different GSP measures. Terras et al.’s findings were also corroborated by parent reports.

Alexander-Passe ( 2006 ) did find differences between 19 adolescent participants with dyslexia and norm-referenced data for self-esteem, depression and coping style. The participants reported below-expected self-esteem; however, this was accounted for entirely by the female participants. The difference in self-esteem and gender seemed to be explained by differences in coping styles: the female participants used more emotion-based coping styles (internalising or externalising behaviours), whereas the male participants used task-based coping (being proactive and persistent), which has previously been associated with more effective coping. Similar effects around coping style were found in Singer’s ( 2005 ) qualitative study: task-based coping methods were found to effectively protect self-esteem.

In Stampoltzis and Polychronopoulou’s ( 2009 ) qualitative research, 9 out of 16 university students reported low self-esteem related to their dyslexia. The remaining seven students did not feel dyslexia affected their self-esteem. Clearly, these are mixed findings in terms of the link between LitD/D and self-worth; individual differences in coping style (emotion-based vs. task-based) may be one factor influencing this link.

Two intervention studies aimed to increase the self-perceptions of CYP with dyslexia; one by directly targeting self-perception (Burton 2004 ) and the other through literacy intervention (Saday Duman et al. 2017 ). Both of these studies reported some positive findings, but both were rated as being of low quality. No real conclusions can be drawn from these two intervention studies; however, further research of this nature could be extremely useful in determining causal links between LitD/D and self-perceptions.

What is the Impact of LitD/D on Domain-Specific Self-Perceptions?

Ten papers used self-perception measures related to specific domains. The most commonly assessed domain was academic self-concept: beliefs about the self in terms of academic performance. These scales had various names (e.g. perceived scholastic competence, school-based self-esteem) but related to the same construct. Generally, research suggests that individuals with dyslexia are less likely than their peers to develop positive self-perceptions in certain domains. These domains relate directly to the difficulties that are typically experienced by CYP with LitD/D: reading, writing and school achievement. Preliminary findings also suggest that CYP with dyslexia may hold lower self-perceptions than CYP who are reading at the same level, but do not have a dyslexia diagnosis (Frederickson and Jacobs 2001 ). Although there appears to be a risk factor associated with LitD/D, an individual’s environment, as well as their personal characteristics and social support, seem to also play an important role.

Many papers utilised other subscales in addition to those relating to academic self-perceptions. Commonly, self-perceptions relating to social/peer acceptance, physical appearance/performance and behaviour were assessed. Findings were mixed, but available evidence suggests that LitD/D is not linked with differences in these other domains.

Novita ( 2016 ) found that children with dyslexia reported significantly lower school-based self-esteem than a control group, with a weak-medium effect size. Similar findings were reported by Alexander-Passe ( 2006 ), Saday Duman et al. ( 2017 ) and Frederickson and Jacobs ( 2001 ), and by Terras et al. ( 2009 ) who compared their participants with dyslexia to norm-referenced data and found significantly poorer perceptions of scholastic competence as rated by children and their parents.

Terras et al. also found that when parents held positive attitudes towards dyslexia and had a good understanding of their child’s difficulties, their children had higher self-esteem. The authors concluded that children’s close relationships, social support and knowledge about their difficulties contributed to psycho-social adjustment and positive self-image.

Five qualitative studies also found that social and family support were integral to coping with dyslexia and maintaining self-esteem (Armstrong and Humphrey 2009 ; Gibson and Kendall 2010 ; Glazzard 2010 ; Singer 2005 ; Stampoltzis and Polychronopoulou 2009 ). Singer found that children whose parents responded more negatively to their emotions about dyslexia were more likely to experience shame, hide their feelings and develop internalising coping styles; they emphasised their powerlessness as a method of protecting self-esteem. Other children demonstrated externalising behaviours that aimed to conceal their feelings of shame or guilt; these children were also less likely to share feelings with parents. On the other hand, children who described their parents as academically and emotionally supportive showed greater desire for self-improvement and experienced fewer negative emotions. Being able to safely discuss feelings with parents seems to be a protective factor in developing more positive self-perceptions and coping styles.

Frederickson and Jacobs ( 2001 ) and Polychroni et al. ( 2006 ) additionally looked at the impact of actual academic performance amongst children with dyslexia and their peers. Frederickson and Jacobs administered word reading tests and used this data to evaluate self-perceptions whilst controlling for actual reading performance. The children with dyslexia were found to be more likely to hold negative self-perceptions of their scholastic competence, even when compared to peers reading with the same level of accuracy, but without dyslexia.

Polychroni et al. ( 2006 ) compared children with dyslexia separately to high and low achieving peers. The children with dyslexia reported significantly more negative self-concepts regarding penmanship/neatness, arithmetic and school satisfaction, when compared with both high and low achieving peers without dyslexia, and regarding reading/spelling and general ability compared to the high achieving peers only. Unfortunately, the authors do not provide information that makes it possible to compare the achievement levels of the different groups; therefore, it is unclear whether the children with dyslexia had comparable achievement to either of the other groups.

Humphrey and Mullins ( 2002b ) was a low quality paper that reported mixed findings, but highlighted slightly lower than average school-based self-concept for children with dyslexia in mainstream schools. In Humphrey’s other paper (Humphrey 2002 ), he used an alternative method of measuring self-perceptions, known as the ‘semantic differential method’ (p.31). This measure reflects the difference between a person’s current self-concept and their ideal self in relation to a number of different constructs, providing the evaluative element of self-esteem. Using this method, Humphrey ( 2002 ) found that, in comparison to children with no learning difficulties, a sample of children with dyslexia in mainstream schools demonstrated significantly lower self-perceptions in the domains of reading, writing, spelling, intelligence, English ability, popularity and importance, but not maths or being hardworking.

A Swedish study (Lindeblad et al. 2016 ), looked at literacy related self-efficacy through a questionnaire designed to assess participants’ beliefs about how they would perform on a specific task (e.g. ‘I can read an email from a friend’) (p.456). Based on standardised literacy assessment, the participants were not performing at the level typically expected, but the GSP of these children had not been negatively impacted. The results of the self-efficacy assessment indicated that the majority of participants felt confident to manage their school work and perceived few, or very few, limitations in their literacy ability. Although this is in contrast with their actual performance, the authors linked the positive self-attitudes of these participants with broader changes in the country towards inclusive schooling and improved attitudes and understanding of dyslexia, perhaps leading students to make fewer peer comparisons and focus more on their own progress.

Does the Type of Educational Setting that a Child Attends Impact Self-Perceptions?

One qualitative and one quantitative study specifically explored the impact of mainstream versus specialist educational settings on the self-perceptions of CYP with dyslexia. There is very little research to be drawn upon to make conclusions about the impacts of different educational settings. However, by comparing mainstream and special settings, Casserly ( 2013 ) provides some useful insight into the factors that were beneficial in terms of improving the self-perceptions of CYP with dyslexia. Given the limited research available, this would be a key area for future explorations.

Humphrey’s research (Humphrey 2002 ; Humphrey and Mullins 2002b ) used two self-report methods and a teacher-report method; the semantic differential method and the questionnaire indicated that CYP with dyslexia in mainstream education held the most negative self-perceptions, whereas CYP in specialist provision held self-perceptions only marginally lower than the control group. However, teacher reports, measuring behavioural manifestations of self-esteem, showed the highest level of maladaptive behaviours to occur in the specialist setting, which both contradicts, and calls in to question the validity of the findings. Humphrey’s qualitative data (Humphrey and Mullins 2002b ) also revealed some themes that seemed to contradict the quantitative findings, with more CYP in the specialist setting than the mainstream setting reporting feeling ‘less intelligent than their peers’ (p.5).

Casserly ( 2013 ) followed 20 participants over four years, during which time all participants moved from mainstream to a specialist dyslexia setting and then back to mainstream. Through interviews with children, their parents and teachers, Casserly found that children generally had low reading self-concept and self-esteem upon entry to their specialist setting, which was increased through the targeted support that they received in their specialist setting and remained good after their return to mainstream.

When asked what they thought had improved their children’s self-perceptions, parents cited the benefits of increased praise and encouragement, teachers’ belief in their child’s ability, making academic progress, positive relationships, and peers with similar difficulties that they could relate to. The teachers reported a long list of strategies and approaches that they felt supported children’s self-perceptions, including teaching them about learning differences, promoting positive attitudes towards literacy and highlighting their strengths. They also cited smaller classes, with more individual attention as well as the benefits of being able to make more favourable peer comparisons.

Casserly discussed social comparison theory as a possible reason for improvements in self-esteem within the specialist settings. However, although social comparisons were mentioned by participants, it could be argued that this ignores the many strategies that were also put in place to support these children in their learning and wellbeing. Self-esteem remained high once they had left the provision and spent a year in mainstream class, even though they still reported finding things more difficult than other children. It may be the case that, due to the specialist provision, the children developed resilience that protected their self-esteem, suggesting that intervention in this area may be useful.

How are Attributional Styles Linked with Self-Perceptions Amongst CYP with LitD/D?

Four quantitative papers measured the attributional styles of CYP with LitD/D and one examined goal orientations, which link with attributions. Four out of five of these studies indicated that children with dyslexia are more likely to make attributions for success and failure that are outside of their control, meaning they have attributional styles that are associated with lower achievement, more negative self-perceptions and less effective approaches to learning. However, this is not always the case and research showed that with the right environment and support, children with dyslexia will make more adaptive attributions, linked to improvements in both performance and self-perceptions (Burden and Burdett 2005 ). Two qualitative papers also showed that some individuals developed a strong sense of determination associated with their dyslexia and adaptive attributional styles. However, Singer ( 2005 ) found that these children were in the minority. At this stage, the causal links are unclear; research into the impact of attribution retraining programmes on the performance and self-perceptions of CYP with dyslexia will help to shed light on this.

Humphrey looked specifically at the attributional styles of CYP with and without dyslexia (Humphrey and Mullins 2002a ) by asking CYP to rank order possible reasons for success or failure in fictional test scenarios. In success scenarios, participants with dyslexia were more likely to attribute their achievement to teacher quality (an external factor) than the children without dyslexia. This was seen as potentially detrimental by the authors, as children would not receive positive self-referential information as a result of their success (p.201). However, the authors were comparing the second most commonly cited reason for success, when, in fact, the most commonly cited reason given by both groups was effort.

In failure scenarios, the control group felt that lack of effort, followed by the difficulty of the test, would be the most likely causes, suggesting a belief that they could succeed on a difficult test in the future if they applied more effort. However, the children with dyslexia cited difficulty of the subject, followed by difficulty of the test as the most likely reasons for failure. As both of these things are outside of the individual’s control, this might imply that they could not control whether they succeeded on a difficult test in the future.

In Pasta et al.’s ( 2013 ) study, the attributional styles of children with SpLD also tended to reflect more emphasis on external, uncontrollable factors such as luck and task difficulty than their equally and higher achieving classmates. Teachers perceived children with SpLD as more dependent than their peers, including those with matched achievement. The authors suggested that this reflects the children’s external LoC and indicates that the children with SpLD underestimated their potential as independent learners.

Correlations between attributional style and test performance showed that the more pupils attributed results to effort (internal LoC), the better they performed and the more pupils attributed results to task difficulty (external LoC), the worse they performed. Emphasising the importance of effort is seen as an adaptive attributional style as it is within the control of the individual and is not fixed. Although the children with SpLD generally had less adaptive attributional styles, those who did have more adaptive styles achieved more highly. This could be an important area for intervention.

In Gibson and Kendall’s ( 2010 ) qualitative research, participants expressed a range of attributional styles relating to their success in school. One participant conveyed feelings of determination to do well in the face of others’ beliefs that they could not overcome their difficulties. Other participants demonstrated resignation at being assigned to lower sets that were perceived as being for less intelligent students. These participants seemed to have their sense of control stripped from them by an educational system that wanted to categorise and restrict them.

Burden and Burdett ( 2005 ) provided valuable insight into the nature of attributional styles amongst CYP with dyslexia by looking at a context in which students with dyslexia were thriving. Questionnaire responses revealed that the majority of students did not demonstrate learned helplessness or perceive themselves as being held back by their dyslexia. These successful pupils believed that effort is essential for success and would enable them to achieve their goals, suggesting strong internal LoC. Responses to certain items indicated that their internal LoC may be a protective factor for good self-esteem. Burden and Burdett concluded that whole-school promotion of personal responsibility and self-worth is essential for producing learners with a positive sense of self.

In Singer’s ( 2005 ) study, 16% of all participants were characterised as having adaptive approaches to protecting their self-esteem, including desire for self-improvement. These children emphasised the importance of effort and belief in their ability to improve, and maintained high levels of self-esteem. Compared with the others in the study, these children showed signs of having developed adaptive attributional styles.

Frederickson and Jacobs ( 2001 ) provided further evidence, finding that children with dyslexia were significantly more likely to make uncontrollable attributions than their peers and that uncontrollable attributions were associated with lower reading scores. Furthermore, children making uncontrollable attributions had significantly lower perceived scholastic competence than those who showed controllable attributions, even after controlling for actual reading accuracy. This was the case for both the children with and without dyslexia. The authors suggested a need for research evaluating the impact of attribution retraining programmes to further explore the causal relationships and practical implications of this research. They also suggested a link with learners’ goal orientations and the effects of learning vs. performance goals on self-perceptions amongst learners with dyslexia.

Goal orientations were explored by Polychroni et al. ( 2006 ): ‘surface’ approaches to learning are characterised by the intention to reproduce learned material for the sake of performance (performance orientation), and a ‘deep’ approaches to learning are characterised by an internal desire to seek meaning (learning orientation) (p.418). In this study, both the children with dyslexia and the children with matched achievement but no dyslexia, reported significantly higher levels of surface approaches than the higher achieving children. Amongst children with dyslexia, there were correlations between having a surface approach and having lower academic self-concept, suggesting that a deep approach to learning could be a protective factor against lowered self-perceptions, as well as being associated with more enjoyment, intrinsic motivation and greater achievement (Watkins 2010 ), making this a potential area for intervention.

Does the Dyslexia Label Influence Self-Perceptions?

Four qualitative papers explored the impact of receiving a diagnosis of dyslexia for their participants. Three of these were thematic analysis studies (Gibson and Kendall 2010 ; Glazzard 2010 ; Stampoltzis and Polychronopoulou 2009 ), all of which reported themes relating to labelling. The studies included a total of 29 participants between the ages of 14 and 26 attending school or university. Mixed results suggest that reactions to receiving a dyslexia label are individual and can be conceptualised as lying on a continuum from resistance to accommodation. A number of factors seem to influence where one may lie on this continuum; individuals who were labelled for the first time in late adolescence perceived dyslexia as stigmatising, did not feel they needed help, did not perceive the label as informative or supportive, and were more likely to resist the label. On the other hand, those who felt they had already been labelled with negative terms such as ‘lazy’, the label of dyslexia was a welcome alternative, providing a boost to their self-esteem.

In each study, references were made to the negative consequences of not having a recognised diagnosis; Gibson and Kendall described feelings of school failure amongst their participants, as well as lack of appropriate support and, in some cases, very negative attitudes and low expectations from teachers. Glazzard reported that having a diagnosis of dyslexia and owning that label was essential for creating a positive self-image amongst participants. Glazzard noted feelings of increased self-esteem once the diagnosis had been made, partly because it enabled them to explain their difficulties to themselves and others. This is mirrored by a quote from Gibson and Kendall’s research from a participant who said ‘ I didn’t know what it was, I thought I was thick .’ (p.192) indicating that the diagnosis of dyslexia relieved these feelings.

Amongst Greek participants (Stampoltzis and Polychronopoulou 2009 ), there were similar stories of not understanding difficulties prior to diagnosis and 9/16 participants reported having had low self-esteem. For most participants, diagnosis was associated with feelings of relief and increased understanding. However, some felt it was not helpful as it did not give useful information.

In all of the qualitative studies, references were made to alternative labels to dyslexia. Primarily, these included ‘thick’ ‘lazy’ or ‘stupid’. Many participants spoke about applying these labels to themselves, or having them applied by others who did not know about, or understand, their dyslexia. Some participants felt that their label changed others’ perceptions (Stampoltzis and Polychronopoulou 2009 ) and Glazzard ( 2010 ) alluded to the dyslexia label replacing these negative judgements and boosting participants’ perceptions of their own intelligence. In Singer’s ( 2005 ) study, children who tended to internalise their emotions of guilt or shame found that emphasising their label, and taking responsibility away from themselves, helped to protect their self-esteem. Negative comments from other people generally made participants feel bad about themselves, although, in one case, low expectations and negative attitudes from teachers added to a participant’s determination to succeed (Gibson and Kendall 2010 ).

The study by Armstrong and Humphrey ( 2009 ) was designed specifically to look at college students’ reactions to diagnosis. Using grounded theory, the authors developed a model of psychological reactions to diagnosis conceptualised on a continuum from resistance to accommodation. Resistance is characterised by not accepting dyslexia as part of the self and holding negative connotations of dyslexia, whereas accommodation involves integrating dyslexia into the notion of self and recognising both positive and negative aspects. The amount of resistance or accommodation displayed by individuals clearly stemmed in part from their perception of dyslexia: those who felt dyslexia was equal to stupidity were less likely to accept it into their notion of self, as this would damage self-perceptions. The authors suggested that individuals diagnosed later in life may require additional psychological support to accommodate their diagnosis, as participants who had been described as having dyslexia at a younger age seemed more willing to accommodate it.

Individuals who accommodated dyslexia were more likely to be motivated and successful in their studies, take up support, and adjust to their difficulties. Failure to accommodate, however, was suggested as a risk factor for increased negative self-views, use of self-defeating strategies, lowered self-esteem and negative emotions.

This paper addressed five research questions; the first two concerned the evidence base around the impact of LitD/D on both global and domain-specific self-perceptions. Consistent with findings from an earlier review (Burden 2008 ), evidence suggests that CYP with LitD/D are very aware of their specific difficulties and may experience negative self-perceptions relating to their academic competence and literacy skills. However, these domain-specific self-perceptions do not appear to have a consistent impact on overall self-worth; evidence suggests that CYP with LitD/D do not hold less positive global self-perceptions than their peers. Protective factors that contribute to maintaining positive self-worth include supportive family, teacher and peer relationships, and recognition of their successes in other areas.

The third research question addressed attributional style. Current evidence suggests that CYP with dyslexia are at greater risk of developing maladaptive attributional styles, based on an external LoC. However, those who emphasise the importance of their own effort in their achievement are more likely to succeed academically and to hold positive self-concepts. This suggests a link between maladaptive attributional styles, lower self-perceptions, and poorer performance amongst CYP with dyslexia, making this a potentially important area for intervention and support. Although the causal links amongst CYP with LitD/D are not yet clear, researchers have suggested that in the general population maladaptive attributions lead to lowered self-esteem, which impacts motivation and consequently academic performance (Chodkiewicz and Boyle 2014 ). Therefore, it may be the case that attribution retraining programmes could have a positive impact on both self-perceptions and performance amongst CYP with LitD/D. Preliminary evidence suggests that more adaptive attributional styles develop in the context of supportive and accepting environments in which CYP can experience success, however, more evidence around this is needed, along with research looking at the effects of attribution retraining interventions.

The fourth research question explored the impact of different educational settings for CYP with LitD/D. In this area, there were only a small number of research studies to review and more research is needed to draw conclusions about differences in the self-perceptions of those attending mainstream versus specialist settings. However, initial findings from one qualitative study have shed some light on the features of educational settings that may support CYP to hold positive self-perceptions. CYP with LitD/D and, arguably, all CYP, may benefit from settings that provide nurturing and acceptance, which support their students to understand dyslexia and provide high quality differentiated teaching. These approaches may contribute to more positive self-perceptions amongst pupils and the development of resilient learners. Findings from this review suggest that CYP with dyslexia thrive when they are accepted and their needs are understood, something that is not unique to any one setting, or to those with dyslexia.

The final research question addressed the potential impact of labelling on the self-perceptions of CYP with LitD/D. Frederickson and Jacobs ( 2001 ) found that children with literacy difficulties, but no dyslexia diagnosis, did not experience the same negative impact on self-perceptions. It may be that having attention drawn to one’s literacy difficulties (through diagnosis) increases the likelihood of a negative effect on self-perceptions. However, qualitative research sheds a different light on experiences of receiving a diagnosis. Individual reactions to diagnosis vary and may lie on a continuum between resistance and accommodation of the label (Armstrong and Humphrey 2009 ). Many CYP reported having been labelled, prior to their diagnosis, as ‘lazy’ or ‘stupid’ and felt that their label of dyslexia counteracted this experience. For others, the label was perceived as stigmatising and unhelpful. Given the mixed nature of these findings, there is a need for further research, carried out with CYP currently in education, to explore the subtle differences in how individuals with LitD/D respond to a label of dyslexia and their own perceptions of the advantages and disadvantages of this label.

When considered as a whole, the findings from this data set illuminate some key factors that may be influential for CYP with LitD/D, whilst also revealing gaps in our current understanding and raising some interesting and important questions. It appears that CYP benefit from LitD/D being identified, recognised and explicitly supported in terms of having a positive overall sense of self. The findings also strongly suggest that it is particularly helpful for CYP when parental, cultural and school attitudes towards LitD/D are understanding and help to cultivate a sense of personal responsibility, high expectations and self-worth. What is not yet known is whether the type of label used to recognise the LitD/D makes any difference, whether there are any gender differences to account for, how much variation there is in individual CYP’s resistance or accommodation of the label, and whether social comparison factors, or being placed in a special education group for LitD/D, has a significant impact.

The overall findings also suggest that the good overall self-concept associated with having widely-recognised and explicitly labelled LitD/D may be a ‘trade off’ that occurs at the expense of declines in CYP’s academic self-concept and a tendency to make unhelpful external attributions, when learning. The relief obtained from the difficulty not being construed as negatively (or from others taking a more tolerant and supportive approach) seems offset by CYP’s sense that their LitD/D is beyond personal control and they have less academic potential than peers. Whether it is possible to effectively support CYP with LitD/D to reduce any external attributions through intervention is, as yet, unclear.

Interesting and important questions raised by these mixed overall findings include whether CYP with LitD/D are a sufficiently homogenous group to allow us to draw generalisable conclusions, whether the support and encouragement from the culture and context are more important factors in determining positive global and domain specific self-perceptions than having an identified LitD/D label and, finally whether the benefit in having a positive overall self-concept outweighs the risk and detrimental effects that may come as a result of having a low academic self-concept and a less adaptive attribution style.

Implications

Mixed findings relating to the impact of the dyslexia label indicate that psychologists, dyslexia specialists, and school staff should continue to treat every student as an individual and exercise caution in terms of using the dyslexia label, considering, alongside the child, whether the label is justified and useful to the individual. Furthermore, it is important that an accessible and accurate explanation of any LitD/D is given, dispelling any pre-existing stigmatising or negative connotations that the child may have.

The evidence of the role of attributional style in the development of self-perceptions amongst CYP with LitD/D is emerging, but currently limited. However, there is evidence that teaching CYP about attributions can be beneficial for their achievement and motivation (e.g. Blackwell et al. 2007 ) and this is something that should be further explored amongst a sample of CYP with LitD/D.

Preliminary evidence from two intervention studies suggests that interventions targeting both self-perceptions and literacy skills can be beneficial for CYP with LitD/D. One such intervention, which is readily available to schools, is Precision Teaching (Lindsley 1995 ). Recent research suggests that Precision Teaching can have motivational benefits and increase self-esteem, as well as being highly effective for teaching literacy skills (Griffin and Murtagh 2015 ).

Self-efficacy is more malleable and less stable over time than self-concept or self-esteem; furthermore, it can be seen as an active precursor to self-concept (Bong and Skaalvik 2003 ). In which case, it may be useful to target interventions for CYP with LitD/D at self-efficacy rather than self-esteem, for example, asking students to make self-efficacy judgements before completing tasks. With repeated exposure and success, greater self-efficacy in specific domains may lead to enhanced self-concept in those domains. There would be benefit from future research evaluating this type of intervention amongst learners with LitD/D who are suffering from negative self-perceptions.

The importance of social and familial support in coping with LitD/D and maintaining self-esteem was highlighted in several studies. Being able to safely discuss feelings with parents helped children with LitD/D to maintain positive self-views, whereas negative interactions with peers could damage them (Glazzard 2010 ; Singer 2005 ). Furthermore, parents having a good understanding of dyslexia and associated needs may be a protective factor (Terras et al. 2009 ). Lindeblad et al. ( 2016 ) suggested that recent political reforms in Sweden, aiming to achieve greater equality within the education system, may be responsible for the positive psychological adjustment and self-perceptions found amongst their sample of CYP with LitD/D. They noted that being exposed to positive attitudes from significant others such as teachers or peers has the potential to protect against the development of negative self-perceptions. This highlights the importance of creating an accepting, understanding and inclusive atmosphere within schools.

Limitations

One major limitation of the body of research in this area relates to how researchers identify participants for their studies. It is important to note that at least half of research papers included in this review utilised a discrepancy-based definition, and most of the remaining papers did not specify whether a discrepancy-based definition had been used or not. This is likely to have impacted the findings of the review as children who meet the discrepancy-based definition of dyslexia have average or above-average IQ scores. Higher IQ scores are typically linked with better academic performance (Laidra et al. 2007 ), which may well lead to more positive academic self-concept. Therefore, individuals with LitD/D who do not meet the discrepancy-based definition may be at greater risk of low academic self-concept than the participants in the majority of studies reported here.

This paper operationalised self-perception terms in order to thoroughly review the research and, in most cases, authors had considered their use of self-perception terms. However, in some cases, where insufficient information was given, it was necessary to make assumptions about what exactly was being measured.

The majority of reviewed papers emphasised the voice of CYP through self-report measures or interviews. Seeking and valuing the voice of CYP should be acknowledged as a strength (and is in line with guidance from the UK Children and Families Act 2014 ). However, some may argue against over reliance on self-report measures due to their potential for bias. One such bias is the impact of transient mood states (Podsakoff et al. 2003 ). The majority of data from these studies was collected at a single time point, so individual variations in mood may have influenced self-perceptions. Yet, arguably, only the individual can provide insight into their own self-perceptions; therefore, report from others is less valuable and we may need to accept that there will be some biases with self-report data.

The papers in this review were restricted to studies conducted in Europe due to differences in diagnosis in other parts of the world. However, even within Europe there are wide ranging cultural differences in the construct of LitD/D. Furthermore, literacy difficulties themselves are different in different languages due to variations in orthography, which influence the prevalence of LitD/D in different countries (Paulesu et al. 2001 ), potentially impacting children’s self-perceptions. Given these differences, caution should be applied when making cross-cultural generalisations, considering that 12/19 of the studies reviewed were conducted in the UK. Additionally, it should be noted that most participants with LitD/D in these studies were male, which reflects the population being studied, but should be considered before generalising further.

A weakness of many papers was their failure to adequately consider the impact of localised and wider environmental, cultural and social influences on the emotional development of CYP. A number of the papers took a distinctly within-child perspective when discussing self-perceptions and environmental factors were rarely explored within the available research. For example, the value that the UK national curriculum places on traditional academic and literacy skills.

Recommendations for Future Research

School-based interventions for CYP with learning disabilities have been found to enhance self-concept (Elbaum and Vaughn 2001 ). However, as this review focused specifically on LitD/D, only two intervention studies were available, both of which were low quality. Further intervention studies would be beneficial in highlighting factors influencing the development of positive or negative self-perceptions. The current research provides evidence that LitD/D is linked with lower perceptions of academic competence and maladaptive attributional styles, but intervention studies would allow us to understand how these factors influence each other in a causal way.

More research is needed on attributional styles and approaches to learning amongst CYP with LitD/D, not only regarding differences, but how these styles develop and change over time. This kind of evidence could be sought through adding a qualitative element to the research and studying changes over time, as well as looking at the impact of attribution retraining programmes, as suggested by Frederickson and Jacobs ( 2001 ) and the benefits of deep approaches to learning.

A number of publications have focused on exploring attitudes to dyslexia and labelling (e.g. Arishi et al. 2017 ). Various authors have considered the practical use and validity of the dyslexia diagnosis (e.g. Elliott and Grigorenko 2014 ; Lauchlan and Boyle 2007 ); however, fewer have looked at CYP’s perceptions of their dyslexia label and fewer still have directly asked CYP about the benefits or harms of the label. Given the current labelling debate, research looking specifically at the advantages and disadvantage of the label from the perspectives of CYP would be beneficial.

This review extends current literature by systematically reviewing research exploring the links between self-perceptions and CYP with LitD/D. These CYP appear to be at greater risk of developing negative perceptions of themselves as learners, although, this does not necessarily impact on their general sense of self-worth. Current research suggests that some key factors may be relevant in supporting CYP with LitD/D to develop, and maintain, positive self-perceptions; these include holding adaptive attributional styles (having an internal LoC in relation to overcoming difficulties), good relationships with peers and parents, and positive attitudes towards dyslexia and neurodiversity. In some cases, CYP had negative educational experiences because of their difficulties and felt that they had been labelled as unintelligent or idle, for these CYP, the label of dyslexia led to more positive self-perceptions, as it provided an alternative picture of themselves. There is a need for further research to explore the impact of attributional styles and the potential for intervention, as well as CYP’s experiences of labelling and any associated advantages or disadvantages.

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Gibby-Leversuch, R., Hartwell, B.K. & Wright, S. Dyslexia, Literacy Difficulties and the Self-Perceptions of Children and Young People: a Systematic Review. Curr Psychol 40 , 5595–5612 (2021). https://doi.org/10.1007/s12144-019-00444-1

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ORIGINAL RESEARCH article

The 100 top-cited studies on dyslexia research: a bibliometric analysis.

• 1 Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
• 2 Department of Periodical Press and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
• 3 Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China

Background: Citation analysis is a type of quantitative and bibliometric analytic method designed to rank papers based on their citation counts. Over the last few decades, the research on dyslexia has made some progress which helps us to assess this disease, but a citation analysis on dyslexia that reflects these advances is lacking.

Methods: A retrospective bibliometric analysis was performed using the Web of Science Core Collection database. The 100 top-cited studies on dyslexia were retrieved after reviewing abstracts or full-texts to May 20th, 2021. Data from the 100 top-cited studies were subsequently extracted and analyzed.

Results: The 100 top-cited studies on dyslexia were cited between 245 to 1,456 times, with a median citation count of 345. These studies were published in 50 different journals, with the “Proceedings of the National Academy of Sciences of the United States of America” having published the most ( n = 10). The studies were published between 1973 and 2012 and the most prolific year in terms of number of publications was 2000. Eleven countries contributed to the 100 top-cited studies, and nearly 75% articles were either from the USA ( n = 53) or United Kingdom ( n = 21). Eighteen researchers published at least two different studies of the 100 top-cited list as the first author. Furthermore, 71 studies were published as an original research article, 28 studies were review articles, and one study was published as an editorial material. Finally, “Psychology” was the most frequent study category.

Conclusions: This analysis provides a better understanding on dyslexia and may help doctors, researchers, and stakeholders to achieve a more comprehensive understanding of classic studies, new discoveries, and trends regarding this research field, thus promoting ideas for future investigation.

Introduction

Dyslexia is a common learning disorder that affects between 4 and 8% of children ( 1 – 3 ), and often persists into adulthood ( 4 , 5 ). This neurodevelopmental disorder is characterized by reading and spelling impairments that develop in a context of normal intelligence, educational opportunities, and perceptual abilities ( 4 , 6 ). Reading and spelling abilities can be affected together or separately. The learning abilities of children with dyslexia are significantly lower than those of their unaffected pairs of the same age. Generally, difficulties begin to show during the early school years. Dyslexia is a complex multifactorial disorder whose etiology has not been fully elucidated, and it has caused great social and economic burdens. Over the last few decades, the research on dyslexia has made some progress. For example, some studies have shown that dyslexia has a strong genetic background that can affect brain anatomy ( 7 , 8 ) and function ( 9 , 10 ). But a citation analysis on dyslexia that reflects these advances is lacking.

The publication of study results in scientific journals is the most effective strategy to disseminate new research findings. A high number of citations can indicate the potential of a paper to influence the research community and to generate meaningful changes in clinical practice ( 11 ). Citation analysis is a type of quantitative and bibliometric analytic method designed to rank papers based on their citation counts. The latest and up-to-date research findings on dyslexia are well-reflected in recent scientific papers ( 12 ), particularly in the most cited ones ( 13 , 14 ). By analyzing the most cited studies, especially the 100 top-cited studies, we can gain better insight into the most significant advances made in the field of dyslexia research over the course of the past several decades ( 15 ). This retrospective bibliometric approach has been used for many other diseases, such as diabetes ( 16 ), endodontics ( 17 ), cancer ( 18 ). However, to date, no bibliometric analyses have been conducted in the field of dyslexia. Therefore, the aim of the present study was to analyze the 100 top-cited studies in the field of dyslexia.

Materials and Methods

Search method and inclusion criteria.

This retrospective bibliometric analysis was conducted using the Web of Science Core Collection database. The Web of Science Core Collection is a multidisciplinary database with searchable authors and abstracts covering a vast science journal literature ( 19 ). It indexes the major journals of more than 170 subject categories, providing access to retrospective data between 1945 and the present ( 20 ). On May 20th, 2021, we conducted an exhaustive literature retrieval, regardless of the country of origin, publication year, and language. The only search term used was “dyslexia” and the search results were sorted by the number of citations.

Article Selection

Two authors independently screened the abstracts or full-texts to identify the 100 top-cited articles about dyslexia. Disagreements were resolved through discussion. Only studies that focused on dyslexia were included in subsequent analyses. Studies that only mentioned dyslexia in passing were excluded.

Data Extraction

The final list of the 100 top-cited studies on dyslexia was determined by total article citation counts. We extracted the following data for each article: title, authors, journal, language, total citation count, publication year, country, journal impact factor, type of article, and Web of Science subject category. If the reprint author had two or more affiliations from different countries, we used the first affiliation as the country of origin. If one article was listed in more than one subject category, the first category was selected. If one article had more than one author, we selected the first-ranked author as the first author and the last-ranked author as the last-author.

Data Analysis

SPSS 11.0 (Chicago, IL, USA) was used to count the frequency. We analyzed the following data: citation count, year of publication, country, the first author, journal, language, type of study, and Web of Science subject category.

Citation Analysis

The 100 top-cited studies on dyslexia based on total citations are listed in Table 1 . The total citation count for these 100 articles combined was 42,222. The total citation count of per study ranged from 245 to 1,456 times, with a median citation count of 345. Only 3 studies were cited more than 1,000 times, and the rest of the studies were cited between 100 and 1,000 times. The title of the top-cited study, which also had the largest mean citation per year count ( n = 91), was “Reading acquisition, developmental dyslexia, and skilled reading across languages: a psycholinguistic grain size theory,” which was published by Ziegler et al. in Psychological Bulletin in 2005 ( 21 ). The second top-cited study, which also had the second-highest mean citation per year count ( n = 80), was published by Vellutino et al. ( 22 ). In addition, we also identified the 100 top-cited studies on dyslexia based on mean citation per year, whose results were shown in Supplementary Table 1 .

Table 1 . The 100 top-cited studies on dyslexia based on total citations.

The different journals of the 100 top-cited studies on dyslexia and their associated impact factors are listed in Table 2 . The 100 top-cited studies on dyslexia were published in 50 different journals, with the top three in frequency being “Proceedings of the National Academy of Sciences of the United States of America” ( n = 10), “Brain” ( n = 6), and “Journal of Educational Psychology” ( n = 6).

Table 2 . Journals of the 100 top-cited studies on dyslexia.

The journal with the highest total citation count was “Proceedings of the National Academy of Sciences of the United States of America.” However, the highest average citation count per study belonged to the journal “Psychological Bulletin.” The journal impact factors of the 100 top-cited studies on dyslexia ranged from 1.315 to 74.699. Of the 100 top-cited studies, 29 were published in a journal with an impact factor greater than 10. The standard “CNS” journals, with the exception of “Cell,” “Nature,” and “Science” published 2 and 3 studies, respectively. Regarding the top four medical journals, while the “New England Journal of Medicine” and “Lancet” published 2 studies each, no top-cited study was published by the “Journal of the American Medical Association” or the “British Medical Journal.”

Language and Year of Publication

The 100 top-cited studies on dyslexia were all published in English and were published between 1973 [by Boder et al. ( 23 )] and 2012 [by Norton et al. ( 24 ) and Peterson et al. ( 25 )] ( Table 3 ). The most productive years were 2000, 2001 and 2003, with 9, 8 and 8 published articles, respectively. The year of 2003 had the most total citations with a total count of 3,788 and an average citation count per study of 474.

Table 3 . Publication year of the 100 top-cited studies on dyslexia.

Countries and Authors

Eleven countries contributed articles to the 100 top-cited studies on dyslexia ( Table 4 ). Most of the articles were from the USA ( n = 53), United Kingdom ( n = 21), Canada ( n = 7), and France ( n = 6). In addition, the USA had the highest total citation count (23,129), and Italy had the highest average citation count per study (665).

Table 4 . Countries of the 100 top-cited studies on dyslexia.

As shown in Table 5 , there were 18 first-authors and 13 last-authors who published more than one of the 100 top-cited studies on dyslexia. Among them, Shaywitz SE published the most top 100 articles ( n = 7) on dyslexia as the first author, followed by Galaburda AM ( n = 3) and Pugh KR ( n = 3). And for the last author, 8 studies of the 100 top-cited studies on dyslexia research were published by Shaywitz BA who was the most productive.

Table 5 . Authors with at least two first-author or last-author publications in the 100 top-cited studies on dyslexia.

Publication Type and Web of Science Subject Categories

As shown in Table 6 , there were 71 studies in the form of an original research article, 28 studies in the form of a review article, and one study in the form of an editorial material publication. The total citation counts for each publication type were 27,812, 13,899, and 511, respectively. Although the type of original research article had the highest total citation count, it had the lowest average citation count per study. In addition, a total of 12 Web of Science subject categories were extracted. Among them, “Psychology” was the most frequent category associated with studies [35], followed by “Clinical Neurology” [15], and “Multidisciplinary Sciences” [15], “Neurosciences” [12], and “Education” [6]. Consistent with the number of studies, the subject categories of “Psychology” and “Clinical Neurology” also had the highest total citation counts (15,683 and 6,427, respectively). The “Behavioral Sciences” subject category had the highest average citation count.

Table 6 . Type of study and subject categories for the 100 top-cited studies on dyslexia.

Although retrospective bibliometric approach has been conducted in many other diseases, to our knowledge, no citation analyses have examined publications on dyslexia. Therefore, this study is the first comprehensive analysis summarizing several features of the most influential studies on dyslexia. It has been suggested that a highly cited study can be considered as a milestone study in a related field and has the potential to generate meaningful changes in clinical practice ( 26 ). We believe that the present analysis of the 100 top-cited studies on dyslexia may be beneficial to the research community for the following reasons. First, the present study not only provides a historical projection of the scientific progress with regards to dyslexia research, but it also shows associated research trends and gaps in the field ( 27 ). Second, our findings provide critical quantitative information about how both the classic studies and recent advancements in the field have improved our understanding of dyslexia ( 28 ). Third, the present analysis may help journal editors, funding agencies, and reviewers critically evaluate studies and funding applications ( 28 ).

Our analysis discovered that the 100 top-cited studies on dyslexia were published in 50 different journals. This may reflect the fact that the 100 top-cited studies on dyslexia were very multidisciplinary in nature, unlike the top studies of other fields (e.g., psoriatic arthritis) where there is a more inherent researcher bias for journal selection ( 29 ). Of the 100 top-cited studies, 29 were published in a journal with an impact factor >10, and 62 studies were published in journal with an impact factor >5. However, there were only five studies published in the standard “CNS” journals and only four published in the top four medical journals, which suggests that most dyslexia researchers are more inclined to choose the most influential journals in their respective professional fields when submitting articles ( 30 ). This is in marked contrast with some other fields (e.g. vaccines), where the majority of top-cited articles are published in either the standard “CNS” journals or in the top four medical journals ( 15 ). Several other factors, such as the review turnaround time, likelihood of manuscript acceptance, publication costs, journal publication frequency, will all invariably also affect a researcher's journal selection ( 13 , 20 ).

According to the results of our analysis, nearly 80% of the 100 top-cited studies on dyslexia were published between 1990 and 2005, and the years of 2000 was found to have the most publications. The increase of landmark publications between 1990 and 2005 might reflect an increase in the interest in dyslexia research or that researchers had made some important scientific breakthroughs during this time period. All the top-cited studies on dyslexia were published in English, likely because English is the most commonly used language for knowledge dissemination in the world.

The top countries with regards to total citation count and number of papers in the top 100 list were the USA ( n = 53) and United Kingdom ( n = 21), which accounted for ~75% of the 100 top-cited studies. The USA published the most studies from the list, and this is probably because some of the world's top research centers are located in the USA and likely also the USA receives more research funding ( 31 ). Furthermore, the most prolific first-author (Shaywitz SE) and last-author (Shaywitz BA) were also from the USA. It is also worth mentioning that China had two studies on the top 100 list, which attests to the improvement of our national scientific research community with regards to knowledge dissemination.

In the present study, there were more original research articles ( n = 71) than review articles ( n = 28), but the latter had higher average citation counts per study. These results indicate that even though researchers pay significant attention to new findings on dyslexia, they regularly use information from review articles to convey relevant points in their own papers. We found that “Psychology” was the most frequent subject category associated with the top 100 articles, which indicates that researchers have been working to find effective treatments for people with dyslexia and that research in this field will continue to progress.

Like with other bibliometric analyses, there are some study limitations that should be highlighted. First, the 100 top-cited studies were extracted from the Web of Science Core Collection, which might have excluded some top-cited studies from other databases, such as Scopus and Google Scholar. Second, there was no citation data for recently published studies. Third, self-citations might have substantially influenced the results of the citation analysis. Moreover, this was a cross-sectional study, which implies that the identified 100 top-cited studies could change in the future. Despite these limitations, this descriptive bibliometric study could contribute new information about the scientific interest in dyslexia.

In conclusion, the present analysis is the first analysis to recognize the 100 top-cited studies in the field of dyslexia. This analysis provides a better understanding on dyslexia and may help doctors, researchers, and stakeholders to achieve a more comprehensive understanding of classic studies, new discoveries, and trends regarding this research field. As new data continue to emerge, this bibliometric analysis will become an important quantitative instrument to ascertain the overall direction of a given field, thus promoting ideas for future investigation.

Data Availability Statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author/s.

Author Contributions

YZ and HF designed the study. SZ and YZ acquired the data and performed statistical analyses. SZ, YZ, and HF drafted the manuscript. All authors critically revised the article and approved the final version of the manuscript.

This study was partly supported by National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University (Z2018B016).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.714627/full#supplementary-material

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Keywords: dyslexia, bibliometric analysis, top-cited, citation analysis, citation

Citation: Zhang S, Fan H and Zhang Y (2021) The 100 Top-Cited Studies on Dyslexia Research: A Bibliometric Analysis. Front. Psychiatry 12:714627. doi: 10.3389/fpsyt.2021.714627

Received: 25 May 2021; Accepted: 28 June 2021; Published: 22 July 2021.

Reviewed by:

Copyright © 2021 Zhang, Fan and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Hong Fan, fanhongfan@qq.com ; Yonggang Zhang, jebm_zhang@yahoo.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Dyslexia articles from across Nature Portfolio

Dyslexia is a disorder characterized by an impaired ability to comprehend written and printed words or phrases despite intact vision. It can be developmental or acquired, but in either case it interferes with academic achievement or with activities of daily living that require reading skills.

Latest Research and Reviews

Action video games normalise the phonemic awareness in pre-readers at risk for developmental dyslexia

• Sara Bertoni
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Disrupted network interactions serve as a neural marker of dyslexia

Functional connectivity analyses demonstrate that individuals with dyslexia process written stimuli via a dorsal decoding route and show stronger reading-related interaction with the right cerebellum, while also providing evidence for aberrant task-related connectivity as a neural marker for dyslexia that directly impacts behavioural performance.

• Sabrina Turker
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Regular rhythmic primes improve sentence repetition in children with developmental language disorder

• Anna Fiveash
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Cerebro-cerebellar networks facilitate learning through feedback decoupling

Behavioral feedback is critical for learning, but it is often not available. Here, the authors introduce a deep learning model in which the cerebellum provides the cerebrum with feedback predictions, thereby facilitating learning, reducing dysmetria, and making several experimental predictions.

• Ellen Boven
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Visuo-spatial attention deficit in children with reading difficulties

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Spatial attention in encoding letter combinations

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News and Comment

Reforming learning disorder diagnosis following covid-19 educational disruption.

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Findings from the Delphi Dyslexia Study

Thursday 16 May 2024

After more than a year of research, two papers summarising the findings of Delphi study into the definition of dyslexia have now been published in draft format on the Open Science Framework.

• Julia Carroll, Caroline Holden, Philip Kirby, Paul Andrew Thompson and Margaret J. Snowling (2024). Towards a consensus on dyslexia: Findings from a Delphi study. https://osf.io/preprints/osf/tb8mp
• Philip Kirby, Caroline Holden, Paul Andrew Thompson, Maggie Snowling and Julia Carroll (2024). Towards a consensus for dyslexia practice: Findings of a Delphi study on assessment and identification. https://osf.io/preprints/edarxiv/g7m8n

The Delphi dyslexia study aimed to establish ‘areas of consensus among a wide range of experts’ and to reduce ‘confusion and misinformation’ about how dyslexia should be defined.

It is important to note that the proposed definition identifies the same or similar underlying cognitive indicators of dyslexia, alongside recognition of its impact on individuals. For this reason, there is no suggestion that anyone diagnosed under the previous definition would not continue to meet the criteria for a diagnosis.

The Delphi dyslexia study papers are still being reviewed as part of the academic research process and it is possible that changes may be made. In light of this, the BDA is monitoring the progress of this review and will ensure that our members, stakeholders and those we aim to support have access to the latest information. We will also share further guidance from the SpLD Assessment Standards Committee (SASC) when it is published.

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The Causes of Dyslexia: Neurological and Genetic Factors

This essay about dyslexia explores its nature as a learning anomaly affecting reading, writing, and spelling abilities. It discusses the genetic and neurological factors contributing to dyslexia, such as familial clustering and brain structural differences. Phonological processing deficits are highlighted as a key aspect, impacting word identification and decoding. Additionally, environmental factors can exacerbate dyslexic challenges. Understanding the complex interplay of these factors is crucial for effective intervention and support for individuals with dyslexia, facilitating academic and personal success.

How it works

Dyslexia, a distinct learning anomaly, impairs an individual’s capacity for reading, writing, and spelling, despite normative cognitive abilities and educational access. This neurodevelopmental anomaly manifests as impediments in phonological processing, rendering word identification and decoding arduous tasks. Though widely documented and affecting millions globally, the precise etiology of dyslexia remains a subject of intensive inquiry. Current investigations suggest a multifaceted interplay of genetic and neurological determinants.

Genetics assumes a pivotal role in dyslexia’s genesis. Evidence underscores familial clustering of dyslexia, indicating a hereditary predisposition.

Twin analyses, comparing dyslexia prevalence in identical versus fraternal twins, evince higher concordance rates in identical twins, underscoring genetic influence. Identified genetic loci, such as DCDC2 and KIAA0319, implicated in neuronal migration and cerebral maturation, augment risk rather than guarantee dyslexia onset, highlighting its multifactorial nature.

The neurobiological underpinnings of dyslexia revolve around structural and functional cerebral disparities. Neuroimaging unveils divergences in brain architecture and activation patterns between dyslexic and non-dyslexic cohorts. Notably, reduced left hemisphere engagement, especially in parietotemporal and occipitotemporal domains during reading tasks, characterizes dyslexic cohorts. These regions, pivotal for phonological processing and lexical recognition, elucidate the reading impairments inherent in dyslexia. Furthermore, structural aberrations, like diminished gray matter volume, implicate neural circuitry efficiency and connectivity in reading processes.

At the crux of dyslexia lie phonological processing deficits. Phonological awareness, vital for fluent reading, pertains to discerning and manipulating word sound structures. Dyslexic individuals grapple with segmenting words into phonetic constituents, impeding symbol-sound correspondence. This impediment engenders laborious reading and compromises comprehension, orthography, and lexicon acquisition.

Environmental factors also modulate dyslexia’s phenotypic expression and severity. While not causative, inadequate linguistic exposure, dearth of reading materials, and non-supportive educational milieus exacerbate dyslexic challenges. Timely identification and intervention are imperative, as tailored strategies can ameliorate academic performance setbacks and fortify self-esteem.

Despite elucidated causes and predispositions, dyslexia’s etiological panorama remains intricate and variegated. It warrants recognition that dyslexic manifestations vary across individuals, from mild to severe. Moreover, dyslexia frequently co-occurs with comorbid learning disparities, like attention-deficit/hyperactivity disorder (ADHD), complicating diagnostic endeavors.

In summation, dyslexia ensues from a nexus of genetic and neurological determinants impacting language processing. Genetic susceptibilities and cerebral structural variances set the stage, while environmental influences modulate symptomatology. Grasping these foundational determinants facilitates efficacious interventions and nurturing educational ambiances. By perpetuating research endeavors and comprehending dyslexia’s intricacies, educators, clinicians, and families can furnish comprehensive support to dyslexic individuals, enabling scholastic and personal flourishing.

Cite this page

The Causes of Dyslexia: Neurological and Genetic Factors. (2024, May 12). Retrieved from https://papersowl.com/examples/the-causes-of-dyslexia-neurological-and-genetic-factors/

"The Causes of Dyslexia: Neurological and Genetic Factors." PapersOwl.com , 12 May 2024, https://papersowl.com/examples/the-causes-of-dyslexia-neurological-and-genetic-factors/

PapersOwl.com. (2024). The Causes of Dyslexia: Neurological and Genetic Factors . [Online]. Available at: https://papersowl.com/examples/the-causes-of-dyslexia-neurological-and-genetic-factors/ [Accessed: 19 May. 2024]

"The Causes of Dyslexia: Neurological and Genetic Factors." PapersOwl.com, May 12, 2024. Accessed May 19, 2024. https://papersowl.com/examples/the-causes-of-dyslexia-neurological-and-genetic-factors/

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PapersOwl.com. (2024). The Causes of Dyslexia: Neurological and Genetic Factors . [Online]. Available at: https://papersowl.com/examples/the-causes-of-dyslexia-neurological-and-genetic-factors/ [Accessed: 19-May-2024]

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Lexia Core5 Reading and Ohio’s Dyslexia Guidebook, Pre-K–5

What is lexia core5 reading.

Lexia® Core5® Reading supports educators in providing differentiated literacy instruction for pre-K–5 students of all abilities. Lexia’s research-proven program provides explicit, systematic, personalized learning in the six primary areas of reading instruction: Phonological Awareness, Phonics, Structural Analysis, Automaticity/Fluency, Vocabulary, and Comprehension. Core5 targets skill gaps as they emerge and provides teachers with the data and student-specific resources they need for individual or small-group instruction.

What is the Ohio Dyslexia Guidebook?

According to the Ohio Department of Education and Workforce website, it “contains best practices and methods for universal screening, intervention and remediation for children with dyslexia or children displaying dyslexic characteristics and tendencies. Districts and schools should use the guidebook to access critical information for successful implementation of Ohio's dyslexia support laws.”

How do these two align?

Core5 meets the Guidebook’s critical, evidence-based components including:

• Delivery of Dyslexia Instruction: Explicit and systematic instruction
• Structured Language and Literacy (SLL): Phonemic awareness, phonics and spelling, and reading comprehension
• Essential Instructional Skills: Small-group work, immediate corrective feedback, multiple practice opportunities, repeated reading, partner reading, teacher modeling, vocabulary, movement/manipulatives, and syntax, grammar, and work analysis.

Download this resource to review more detail about the alignments.

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