Jack, age 9, is referred by his pediatrician for depression. He says that reading is “really hard” and that the kids in class make fun of him. When Jack submits drawings at school, they are quite detailed but the captions are difficult to read because the spelling is so poor. Jack’s teachers and parents feel that he just needs to work harder. However, Jack states that when he thinks about school—whether in person or virtual—he becomes sick to his stomach and is overcome with feelings of desperation. Jack’s father had similar difficulties that still persist, and his mother’s history is notable for use of SSRIs during her pregnancy with Jack.

Dyslexia is a specific type of learning and reading disability of neurological origin. According to the Yale Center for Dyslexia and Creativity, one in five people in the US have dyslexia, with presentations from mild to extreme (www.dyslexia.yale.edu). Dyslexia is highly heritable (50%–70%) and affects about 5%–10% of children (Hendren RL et al, Front Psychiatry 2018;9:101). Although it may present with otherwise strong cognitive function, dyslexia often co-occurs with ADHD, conduct disorders, anxiety disorders, and depressive disorders (Hendren et al, 2018). The DSM-5 does not provide specific criteria for diagnosing dyslexia. In this article, we help you understand what dyslexia is and give you tips for how to help children in your practice with this learning disorder.

What is dyslexia?
Most people with dyslexia have phonological awareness problems or rapid naming deficit, found on psychoeducational or neuropsychological testing. Phonological awareness problems make it hard to sound out words when reading or spelling. Rapid naming deficit refers to difficulty responding quickly with information even when the person knows it—the “tip of my tongue” experience. People with this type of dyslexia will know the name of an object but not be able to call it up fast enough to keep up in conversation. Rapid naming deficit also interferes with how smoothly the person can read (reading fluency), which also impairs reading comprehension. The combination of both phonological and rapid naming deficit is called a dual deficit.

Treating dyslexia
Dyslexia is the most common reason for reading and spelling problems in school-aged children. The gold standard treatment for dyslexia is structured literacy. These programs teach phonics skills, which are spelling and reading rules that avoid rote memorization. For example, in the words angel and angle, instead of memorizing which word has the soft G sound and which has the hard G sound, a structured literacy program teaches that the letter G makes the sound /j/ when followed by an E, but that it makes the sound /g/ when followed by a consonant. Programs that promote memorization of whole words have been shown to be ineffective (Shaywitz SE. Overcoming Dyslexia: A New and Complete Science-Based Program for Reading Problems at Any Level. New York: A.A. Knopf; 2012). (For more information on reading programs, see CCPR Jan/Feb/Mar 2020.)

In addition to structured literacy, research supports addressing the core deficits of dyslexia through phonological awareness activities, including games that involve rhyming, syllable tracking, and counting sounds such as in-rhythm games (Shaywitz, 2012). The IDA website (www.dyslexiaida.org) is a good place to start when referring patients for dyslexia treatment; it lists practitioners in each state along with the services they provide.

Working with families
Dyslexia can be confusing to family members because children with dyslexia are often intelligent, articulate, and talented, yet their reading and writing performance does not match their other skills. This paradox is sometimes difficult for the child to reconcile. They are often told, “Try harder,” “Stop being lazy,” or, “If you only cared as much about reading as you do about your other interests, you would be fine.” Therefore, it is important for parents to recognize that children want to do well and are trying their best. Parents should be encouraged to create positive literacy environments—for example, allowing the child to pick a book that is of high interest even if it might be below their grade level, then reading it together and talking about the content.

You can be a powerful advocate for your patients. Document the condition and help families seek 504 accommodations or Individualized Education Plan (IEP) services at school. Federal IDEA legislation and most states have laws that support children with dyslexia (www.tinyurl.com/y2gzacpl). Schools can provide children with research-based reading instruction in phonics. Text-to-speech technology can also be provided when working independently so that the child does not fall behind in comprehension and content knowledge. Also be mindful of situations that can elicit shame. Parents should insist that teachers only call on their child to read aloud or write in front of the class after checking with the child privately. Finally, encourage parents to advocate for their child to have opportunities to showcase strengths, both in and out of the classroom, that reinforce what they feel like they’re good at to build confidence and self-esteem.

You recommend that Jack’s parents advocate for a structured literacy program at school and that they take time to encourage Jack and read books with him that he finds fun and interesting. You hold off on medication with the caveat that if these measures are ineffective, you will revisit the issue down the line. Three months later, Jack is back in the office and appears a lot happier. The structured literacy program and parental attention have helped him make substantive progress. You will see him in another three months to check in.

CCPR Verdict: Reading difficulties are common and occur across all levels of intelligence and talent. Poor reading and writing experiences often result in depressive symptoms and low self-esteem. If we focus only on comorbid symptoms without looking through the lens of dyslexia, we miss the root of the problem. Families should be encouraged to create nurturing reading environments and to seek a structured literacy phonics program.