Develop. Med. Child Neurol.

1973, 15, 663-687

Special Article

Elena Boder

Developmental Dyslexia: a Diagnostic Approach Based on Three Atypical Reading-spelling Patterns

Introduction The widening recognition of developmental dyslexia* as a specific learning disability of major importance has increased the need for practical direct diagnostic criteria that will facilitate its early identification and its differentiation from nonspecific reading retardation. There is also a growing awareness of the heterogeneity of developmental dyslexia, and attempts are being made to identify clinical subtypes. The delineation of subtypes of dyslexia is of particular relevance to educators since it offers a rational basis for new approaches to remedial teaching. The objectives of this paper are: (1) to describe three atypical patterns of reading and spelling (revealed through an empirically evolved diagnostic screening procedure) which provide a basis for classifying dyslexic children into three subtypes; and (2) to discuss some of the implications of this threefold classification for prognosis and remedial management. Inasmuch as developmental dyslexia is a multidisciplinary problem which calls for a 'neuro-psycho-educational' team approach to its diagnosis and management, a direct diagnostic approach through patterns of reading and spelling offers special advantages. Because it is based on an analysis of familiar reading and spelling tasks, this approach is easily used by a variety of professional personnel and thus facilitates early diagnosis and remediation. Behavioral and learning disorders are becoming an increasingly important aspect of pediatric practice, and the pediatrician can play an important r61e in the early diagnosis of developmental dyslexia. His unique contribution is to make the differential diagnosis, and the knowledgeable pediatrician can effectively act as coordinator of the multidisciplinary team effort which is essential for making a complete diagnosis of the dyslexic child, to be used as a basis for total management.
The Diagnostic Approach The prevailing diagnostic criteria for specific developmental dyslexia vary according to the discipline of the professional making a diagnosis. Within each field, many professionals are reluctant to make the diagnosis of specific dyslexia, even when confronted with a severe persistent

* Terminology: the terms dyslexia, specific dyslexia, and specific developmental dyslexia are used here interchangeably with developmental dyslexia. None is used as a broad term encompassing non-specific reading disorders.

Department of Pediatrics, University of California School of Medicine, Los Angeles, California 90024.

663

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1973, 15

inability to read that cannot otherwise be accounted for (Thompson 1966, Boder 1971b). One important reason for the reluctance is that the emotional overlay which is characteristic of dyslexic children tends to be interpreted as the primary cause of their inability to read, rather than as being secondary and reactive to it. Most important, no definitive diagnostic criteria for developmental dyslexia have been established. A critical review of prevailing diagnostic concepts has been published elsewhere (Boder 1971b). Briefly, developmental dyslexia is usually diagnosed in one or more of the following ways: ( 1 ) by a process of exclusion: (2) indirectly, through neurological or psychometric concomitants; or ( 3 ) directly, on the basis of the frequency and persistence of certain types of errors in reading and writing. Diagnosis by exclusion is the approach most widely used by physicians, being essentially a differential diagnosis. It relies on ruling out other explanations of the childs inability to read-physical, mental, emotional or educational. Although it has provided useful operational definitions* of developmental dyslexia, this approach has the disadvantage of excluding from consideration the crucial fact that developmental dyslexia may co-exist with, and be aggravated by, one or more contributory factors. The indirect diagnostic approach relies on
The definition of specific developmental dyslexia accepted by the Research Group on Developmental Dyslexia of the World Federation of Neorology reads: A disorder manifested by difficulty in learning to read despite conventional instruction, adequate intelligence, and sociocultural opportunity. It is dependent upon fundamental cognitive disabilities which are frequently of constitutional origin. (Critchley 1970). Eisenbergs (1966) definition is similar: Operationally, specific reading disability may be defined as the failure to learn to read with normal proficiency despite conventional instruction, a culturally adequate home, proper motivation, intact senses, normal intelligence,, and freedom from gross neurological defects.

eliciting the typical neurological or psychometric and psycholinguistic concomitants. Though useful, this approach is insufficient in itself for the diagnosis, since most of these concomitants can also exist without developmental dyslexia. The most widely used direct diagnostic approach is based on analyzing the socalled dyslexic errors in reading and spelling performance and relating them to deficit functions. A weakness of this classic and practical approach has been a tendency to consider the deficits in reading and spelling separately from the assets with which they may be associated. Another weakness has been an underlying assumption that children with developmental dyslexia constitute a homogeneous group, among whom the variety of dyslexic errors occur at random. Direct and indirect diagnostic approaches have been combined to delineate a variety of syndromes or subtypes within the general population of dyslexic children. Among the notable contributions demonstrating that they are a heterogeneous rather than homogeneous group is Myklebusts (1965) delineation of auditory dyslexia and visual dyslexia. Quiros (1964), in a study of Spanish-speaking children, has also described two syndromes of dyslexia which manifest deficits in central auditory and visual processes necessary for reading. Kinsbourne and Warrington (1966) delineate two syndromes in a group of backward readers with marked verbalperformance discrepancy on the Wechsler Intelligence Scale for Children (WISC)the language-retardation group and the Gerstmann group. Both are considered to be syndromes of developmental cerebral deficit based on difficulties in the language sphere and sequential ordering respectively; extraneous-letter errors are typical in the spelling of the first group, and letter-order errors of the second.
664

ELENA BODER

Bannatyne (1966) identifies two main dyslexic subgroups: those with genetic dvslexia, which he views as representing the lower end of a normal continuum in verbal ability, and those with minimal neurological dysjunction dyslexia, viewed as neurologically abnormal. Bateman (1968) identifies three subgroups among disabled readers on the basis of characteristic profiles on subtests relating t o visual and auditory memory in the Illinois Test of Psycholinguistic Ability (ITPA). Smiths (1970~) three subgroups of retarded readers are identified on the basis of characteristic subtest profiles on the WISC. She identifies her WISC Pattern 1, showing strength in spatial ability and deficit in symbol manipulation and auditory sequencing, with Bannatynes genetic dyslexia (and with the writers dysphonetic dyslexia, discussed later), and her WISC Pattern 2, showing a variety of deficits in spatial ability, with Bannatynes minimal neurological dysfunction dyslexia. Ingram et al. (1970), on the basis of types of errors in reading, describe three subgroups of specific dyslexia-audiophonic, visuospatial, or mixed. The errors of the majority were found to be mixed. The diagnostic approach to be discussed here can be considered an extension of earlier direct approaches and one of the growing number of diagnostic approaches which demonstrate developmental dyslexia to be heterogeneous, both etiologically and clinically. It differs from other direct approaches primarily in analyzing reading and spelling as interdependent functions, thus revealing how the reading and spelling of the dyslexic child are related to each other. Moreover, it seeks to identify diagnostic patterns in the total reading and spelling performance, rather than in the errors alone, thereby considering the dyslexic childs functional assets as well as his deficits (Boder 1968a and b, 1971a and b). 665

Diagnostic Screening Procedure for Developmental Dyslexia Our Diagnostic Screening Procedure for Developmental Dyslexia is used as an integral part of the comprehensive neuropediatric evaluation done on every child referred to our pediatric neurology clinics for school behavioral or learning problems. The screening procedure and our neuropsycho-educational approach to diagnosis and management have been described in detail elsewhere (Boder 1966, 1971a and b). The main purpose of the screening procedure is to make a qualitative evaluation of the childs ability to read and spell. It is the analysis of how the child reads and spells, rather than at what grade level, that enables the examiner to make a diagnosis of specific dyslexia and give guidelines for remedial teaching. The sequence of tasks is therefore designed not merely to disclose the number and kinds of errors in reading and spelling but also to enable the examiner to determine the childs over-all readingspelling pattern and the subtype into which he falls (Table I).

Reading Test The Diagnostic Screening Procedure begins with a Word Recognition Inventory (Boder 19716), based on word-frequency counts in standard basic readers. It consists of eight lists of 20 words each, graded from the pre-primer level through to the sixth grade.* (See Appendix.) Adapting a standard technique used by reading specialists, the word lists are presented in two ways: flash presentation, which determines the childs sight vocabulary (i.e. the words he recognizes instantly as whole-word configurations, or gestalts) ; and untimed presentation, which calls upon the childs ability to analyze un-

* A revised graded word list and an instructional manual for the Diagnostic ScreeningProcedure are in preparation.

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1973, 15

familiar words phonetically-his word analysis-synthesis skills. The child is asked to look at each word in turn and read it aloud. If he recognizes a word within one second, this is recorded with a checkmark in the flash column and he continues down the list. If he misreads the word or does not read it at all, he is asked to try again. If he identifies the word correctly within about 10 seconds, this is recorded with a checkmark in the untimed column. Words that the child reads only untimed or not at all are termed his unknown vocabulary. Misreadings are recorded for later evaluation of the childs characteristic errors. The highest grade level at which the childs sight vocabulary includes at least 50 per cent of the word list is considered his reading level. Comparison of the number of correctly read words in the flash and untimed columns indicates whether the child is reading through both whole-word gestalts and phonetic analysis or predominantly through one or the other.
Spelling Test Our Spelling Test is complementary to the Reading Test. It has two sections and is presented in two columns-known words (i.e. sight vocabulary) and unknown words (i.e.not in sight vocabulary). The child is first asked to write to dictation ten known words (or fewer if the sight vocabulary is not large enough) selected from the flash column at his reading level and within two grades below, and then to write the same number of unknown words selected from the untimed column at his actual grade level or above, preferably words he was unable to decode phoneticaliy. In the list of known words the examiner notes the number of correctly spelled words and whether they include both phonetic and non-phonetic words; in the list of unknown words the examiner notes how

many of the written words, correctly spelled or not, are good phonetic equivalents of the dictated words. Analysis of the spelling of known words reveals the childs ability to revisualize words in his sight vocabulary, and analysis of his list of unknown words reveals his ability to spell phonetically words not in his sight vocabulary. Thus the two spelling lists are designed to tap the central auditory and visual processes necessary for spelling, in the same way that the flash and untimed columns of the reading test tap the central visual and auditory processes necessary for reading. It is clear that the spelling list of unknown words reveals the childs phonetic word-analysis skills. It is less certain that his spelling list of known words can reveal his ability to revisualize sight vocabulary independently of phonetic clues--except when the task word is strikingly non-phonetic (e.g.talk, laugh).
Supplementary Tasks A number of supplementary tasks may be given. Though not essential to the Diagnostic Screening Procedure, they can provide an additional index to the severity of the childs reading-spelling disability, corroborate the subtype into which he falls, and offer additional guidance to remedial teaching. Reciting and writing the alphabet test the childs auditory and visual sequential memory, as well as his ability to recognize and reproduce individual letters. Reading of a paragraph can demonstrate whether ability to read improves when the words are in context. If a child gives evidence of being unable to decipher words phonetically, several phonetic words are selected from the unknown vocabulary to see if the child can read them given help in dividing the words into syllables (i.e. in syllabicating). The childs performance enables the examiner to determine whether the deficit in phonetic

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ELENA BODER

TABLE I Classification of children with specific developmentaldyslexia, based on diagnostic reading-spelling patterns Group I: Dysphonetic dyslexia Children whose reading-spelling pattern reflects primary deficit in symbol-sound (grapheme-phoneme) integration, resulting in inability to develop phonetic word analysissynthesis skills. (They have no gross deficit in gestalt function.) Group 11: Dyseidetic dyslexia* (Gestalt-blind) Children whose reading-spelling pattern reflects primary deficit in the ability to perceive letters and whole words as configurations, or visual gestalts. (They have no gross deficit in analytic function.) Children whose reading-spelling pattern reflects primary deficit both in the ability to develop phonetic word analysis-synthesis skills and in the ability to perceive letters and whole words as visual gestalts.

Group 111: Mixed dysphonetic-dyseidetic dyslexia (Alexia)

skills is in the analytic process of soundsymbol association or in the synthetic process of blending component letter sounds into syllables and syllables into words. Similarly, several grossly misspelled words from the childs spelling lists are selected to see whether he can write good phonetic equivalents with help in oral syllabicating.
Comment on the Diagnostic Screening Procedure The exploration of the childs differential ability to spell known and unknown words to dictation is the crucial feature of the Diagnostic Screening Procedure (Boder 1968a and b, 1971a and b). It was the designing of the spelling tasks to complement the reading tasks, using information gained from the reading tasks, that disclosed a consistent relationship between how a dyslexic child reads and how he spells. This led t o the delineation of the three distinctive, atypical reading-spelling patterns described in this paper (Table I). Although the emphasis of the screening procedure is qualitative, the spelling tasks

have provided certain empirical quantitative criteria that have proved useful in making the qualitative analysis more objective. A preliminary scoring method based on these criteria is discussed in the following section. Reading-spelling Patterns Among Children with Developmental Dislexia We recognize that a variety of complex psycho-neurological functions, perceptual and integrative, are being tapped by the reading and spelling tasks in the Diagnostic Screening Procedure. Reading requires visual perception and discrimination, visual sequential memory and recall, and directional orientation (Benton 1962, Birch 1962); it also requires cross-modal integration-including the translation of visual symbols into meaningful auditory equivalents (Bauza et al. 1962, Ingram 1963, Birch and Belmont 1964, Rabinovitch 1968). (The still higher levels of integration required for reading in context and reading comprehension are not explicitly tapped by our screening procedure.) Spelling, in contrast, requires the translation of speech sounds into their visual-symbol equivah t S and is dependent upon auditory Perception and discrimination and auditory sequential memory and recall (Wepman 1962, Bannatyne 1966, Bakker 1970). Writing requires, in addition, fine motor 667

* The terms dysphonetic and dyseidetic were coined as descriptive clinical terms which have remedial implications (Boder 1971a and b). Dyseidetic, from eidos meaning form or shape in Greek (as Gestalt does in German) is synonymous with gestalt-blind, the term originally applied to all dyslexic children by de Hirsch (1952) and Bender (1959).

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1973, 15

and visuo-motor co-ordination and tactilekinesthetic memory (Bannatyne 1966, Johnson and Myklebust 1967). Reading may be said to be essentially a two-channel function, requiring the integration of intact visual and auditory processes, both peripheral and central. It is essential for normal reading that these component processes go forward automatically (de Hirsch 1963, Wiener and Cromer 1967). A normal reader recognizes the familiar words which constitute his sight vocabulary through the visual channel as instantaneous visual gestalts of whole words, without having to discriminate individual letters or component syllables; he reads familiar words on sight, or visualizes them (Myklebust 1965). On the other hand, it can be said that unfamiliar words are read by the normal reader through the auditory channel, by a process of phonetic analysis and synthesis. He sounds out, or reads by ear, or auditorizes (Myklebust 1965) the words that are not in his sight vocabulary. It is these two processes underlying reading-gestalt and analytic-that are basic to the two standard methods of reading instruction. The whole-word, or look-and-say, technique relies on the childs ability to experience the whole printed word as a visual gestalt, and the phonics technique relies on the ability to analyze words into their phonetic components. In the dyslexic child, the normal reading process is dissociuted (Bachmann 1927, The Heller 1963,Boder 1968a and b, 1971~). normal automatic interplay of gestalt and analytic-synthetic processes is disrupted. The dyslexic child reads and spells differently from the normal reader both qualitatively and quantitatively (Orton 1937, Bauza et al. 1962, Ingram 1963, Boder 1966,1971aY Thompson 1966, Johnson and Myklebust 1967). My own observations 668

suggest that the basic defects of dyslexic children in apprehending language symbols can be in the analytic or the gestalt function, or both, and that these specific deficits are reflected in abnormal patterns of reading and spelling. The Diagnostic Screening Procedure has revealed three distinctive patterns of reading and spelling among dyslexic children. One or other of the patterns is found consistently in all severely retarded readers who fulfill the standard operational definitions of specific developmental dyslexia noted above. None of the three patterns is found among normal readers, i.e. children who are up to or above grade level in reading and spelling. On the basis of the three patterns, three subtypes of dyslexic children have been delineated (Table I). The description of the reading-spelling patterns is purely clinical ; no attempt is being made at present to relate these patterns and the deficits they reflect to the differentiated gestalt and analytic functions of the right and left hemispheres, on which there have been a number of relevant reports (Bogen 1969, Sperry et al. 1969). The Three Dyslexic Subtypes Group I. Dysphonetic Dyslexia Reading Pattern. The dysphonetic child typically has a limited sight vocabulary of whole words that he recognizes on flash presentation and reads fluently. He reads words globally as instantaneous visual gestalts-rather than analytically. In the early grades he may not yet be able to identify the component letters of the words he can read. When he sees a word, however common or phonetic, that is not yet in his sight vocabulary, he is typically unable to decipher it. Though he may have an idea of phonetics, he lacks word-analysis skills; he is unable to sound out and blend the component letters and syllables of a word. He may guess a word from minimal clues;

ELENA BODER

for example, from the first or last letter and the length of the word. He also tends to read words better in context, though he may substitute a word similar in meaning but dissimilar phonetically. Without remedial teaching, a severely dysphonetic reader may not achieve a sight vocabulary beyond the 4th or 5th grade level even when in high school. Even after he has gained word-analysis skills through remedial teaching, they seldom become as effortless and automatic as those of normal readers. He tends to persist in the gestalt approach, preferring to guess at unfamiliar words rather than employ his word-analysis skills. Spelling Pattern. The dysphonetic child attempts to spell by sight alone and not by ear, for he has difficulty in learning what the letters sound like. He is a Door s~eller. his spelling level being consistently below his reading level (i.e. the grade level of his sight vocabulary). Because he cannot read

phonetically, he cannot spell phonetically. He spells correctly to dictation only those words in his sight vocabulary, phonetic or not, that he can revisualize. Typically, the correctly written words are islands in a sea of dysphonetic mis-spelling, in which the original words can seldom be identified even by himself-although some idea of phonetics may be evident (e.g. sleber for scrambled in Fig. 1). In his spelling list of known words selected from his sight vocabulary a non-phonetic word may be written correctly, whereas in the list of unknown words (not in his sight vocabulary) a phonetic word as simple as stop or did may be bizarrely mis-spelled (Fig. I). Extraneous-letter errors and omitted-syllable errors are characteristic. In the same way that he is typically unable to decompose the visual gestalt of a Printed word analytically, he is unable to analyze the auditory gestalt of a spoken word into its

Age

Grade-

0
UNKNOnr WORD8

mom

WORDS

m v
t]

(farther) (remember)

/.

(rough)
(character.) (scholar) (doubt) (inventor) (marmalade) (scrambled) (varnish)

3 &

(human)

=
c

(believe)

lfm

C m b m

Fig. 1. Non-phonetic spelling in dysphonetic Group I. A 15-year-old boy, 10th grade, IQ 92 (Stanford-Binet LM). Reading level 4th grade (sight vocabulary) word-analysis skills minimal even though he had been in, a special reading class for three years. (Known words: 25 per cent correct, mis-spellings67 per cent dysphonetic. Unknown words: none correct, mis-spellings 100 per cent dysphonetic.)Note that some phonetic concepts are evident in his strikingly dysphonetic performance on the unknown word list.

%-=P

&

(delight) (cottage)

I-

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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1973, 15

component sounds and syllables: he is unable to syllabicate. Word substitutions are so characteristic of this group of dyslexic children as to be virtually pathognomonic. The substitutions may be based on the similarity of the visual configurations, such as reading horse for house, monkey for money, and stop for step. The most striking substitutions, however, primarily in reading but also in spelling, are closely related conceptually but not phonetically to the original word. Generally referred to simply as word-substitutions (Critchley 1970), such errors may be more descriptively termed semantic-substitution errors (Boder 1968a, 1971a) (e.g. funny for laugh, chicken or quack for duck, answer for ask, stairs for step, airplane for train, person for human, planet for moon, Los Angeles for city). Group II. Dyseidetic Dyslexia Reading Pattern. The dyseidetic child reads laboriously, as if he is seeing each word for the first time. Unlike the dysphonetic child in Group I, who has difficulty learning what the letters sound like, the dyseidetic child has a poor memory for visual gestalts and therefore has difficulty learning what the letters look like. The term letter-blind may be aptly applied to him. Although he has good auditory memory and can usually recite the letters of the alphabet fluently, he may not be able to recognize or write the letters until he is in the 4th or 5th grade, unless he has the benefit of remedial teaching. Even when no longer letter-blind, he may still be said to be word-blind or gestalt-blind. He is an analytic reader and reads by ear, through a process of phonetic analysis and synthesis, sounding out familiar as well as unfamiliar combinations of letters, rather than by whole-word visual gestalts. The sight vocabulary of the dyseidetic 670

child is at a much lower level than that of the dysphonetic child. Nevertheless, in contrast to the dysphonetic child, he can often read the word list by phonetic analysis up to or near his grade level, missing only words that cannot be decoded phonetically. For example, laugh may not be read at all or read as log or loge; business may be misread as bussyness and talk as talc. Spelling Pattern. The dyseidetic child, like the dysphonetic child, spells poorly, though as a rule not bizarrely. He spells as he reads-by ear. His mis-spellings are therefore phonetic, and the original word can usually be readily identified in his spelling list, by himself and others (e.g. laf for laugh, burd for bird, tok for talk, hows for house, lisn for listen, bisnis for business, onkl for uncle, vakashn for vacation). His occasional non-phonetic, or bizarre, mis-spellings seem to be the result of an effort to spell a word in his sight vocabulary list by revisualizing it, and thus failing to make use of his more efficient auditory channel (e.g. glaf for laugh, blowe for blue). A striking finding is that simple nonphonetic words in the dyseidetic childs limited sight vocabulary are usually written incorrectly in his known-words list, whereas an unfamiliar phonetic word not in his sight vocabulary may be written correctly in his unknown-words list (Fig. 2). He can also write good phonetic equivalents of non-phonetic words that he cannot read, for example, reading talk as talc and writing it as tok. Group III. Mixed Dysphonetic-dyseidetic Dyslexia (Alexia) Reading Pattern. Group 111 comprises the dyslexic children who are usually the most severely educationally handicapped. They are both dysphonetic and dyseidetic, though not necessarily equally so. They cannot read either on sight or by ear.

ELENA BODER

KNOWN

WORDS

UlpKTlOvN

WORDS

(does)

XT I '\en
W 4XoF 3 p;;i
7 5fq

C
(came) C
(sa%d)

(believe) (heavy) (law)

3 K,c\

wur

5qJb75T

(almost)
C (=.emember)

(chance) (blue) Fig. 2. Phonetic spelling in dyseidetic Group 11. An If-year-old boy, 3rd grade, IQ 145 (Stanford-Binet LM).

tft7t-t b

(sour) C

06

l-eme ~/r,r b 8,C.h"1 1 c 3

7

6f;'D T f

Reading level 1st to 2nd grade (sight vocabulary), 3rd to 4th grade (word-analysis skills). (Known words: 50 per cent correct, misspellings 100 per cent phonetic. Unknown words: 12 per cent correct, mis-spellings 100 per cent phonetic.) Note that the only correctly spelled words in both the known and the unknown word lists are the phonetic ones and that none of the mis-spellings are definitely dysphonetic. Note also that as in Groups I and 111, the total of correctly spelled words in the known words list is far below his reading level.

Even in high school, a Group I11 child may remain a non-reader and virtually alexic, unless he has had intensive remedial reading therapy. The occasional word that he recognizes on sight or can write correctly is typically on the primer or preprimer level. Characteristically, his response to usual remedial teaching is painfully slow. Like the dyseidetic children of Group TI, he has a deficit in gestalt function and has difficulty in learning what the letters of the alphabet look like; like the dysphonetic children of Group I, he has a deficit in analytic function and has difficulty in learning what the letters sound like. In addition, he often has marked visuo-spatial difficulties in reading and writing and tends, more than children in Group I do, to confuse the reversible letters (b-d-p-q, m-w, and n-u) and letters with subtle

graphic differences (e.g. h-n and v-y). Spelling Pattern. His spelling pattern is dysphonetic, like that of Group I, but his mis-spellings appear even more bizarrecommonly a sequence of letters unrelated to the dictated word, one wrong initial letter, or a scribble (Fig. 3). In the same sense that he may be said to be a nonreader, he is a non-speller. The Group I11 child can be differentiated from Group I by the much lower grade level of his sight vocabulary and from Group I1 by his lack of word analysissynthesis skills. His sense of defeat and phobic withdrawal from reading and writing tasks are often striking. Classic Dyslexic Errors in the Three Groups Confusion of reversible letters (the socalled 'static reversals') and mirror-reading and -writing (the so-called 'kinetic rever-

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DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1973, 15

Fig. 3. Non-phonetic spelling of mixed dysphonetic-dyseidetic Group 111. A 10-year-old boy, 5th grade, IQ 87 (WISC: verbal [Q 72, performance IQ 103). Reading level pre-primer (sight vocabulary), no word-analysis skills. (Known words: 37 per cent correct, mis-spellings 100 per cent dysphonetic. Unknown words: none correct, mis-spellings 100 per cent dysphonetic.) Note that the only correctly spelled words, as in Group I, are in the list of known words, selected from the child's very limited sight vocabulary.

sals') (Orton 1937) have been observed in all three groups, but mostly among the younger children. Letter-order errors, found by Kinsbourne and Warrington (1966) to be characteristic of the developmental Gerstmann syndrome, have also been observed in all three groups and are, as with the classic reversals, diagnostically significant. The distribution of visuo-spatial reversals and letter-order errors in the three groups has not yet been analyzed statistically; therefore it cannot be said whether any of these errors is more characteristic of one group than of another. However, the clinical impression is that reversals occur more frequently in Groups I1 and I11 and persist for a longer time. 672

Preliminary Scoring Method for Spelling In addition to the fundamental qualitative association between how a given dyslexic child reads and how he spells, there is a consistent quantitative dissociation between his achievement levels in reading and spelling; in all three groups spelling achievement is consistently at a lower level than reading achievement. It may be said that dyslexic children are found to be consistently more dysorthographic than dyslexic. This combination of a qualitative association and a quantitative dissociation between reading and spelling is the basis for a preliminary approach to scoring. Two percentages are recorded : the percentage of correctly spelled words in the

ELENA BODER

list of known words and the percentage of good phonetic equivalents in the list of unknown words. The first is an index to the childs ability to revisualize sight vocabulary; the second, as a measure of his ability to write phonetically a word he cannot read as a gestalt, is an index to his word analysis-synthesis skills in spelling and therefore in reading. It is my observation (Boder 1971a), recently corroborated by Whiting (1972), that normal readers can write correctly to dictation 70 to 100 per cent of their sight vocabulary at grade level and below, and can write good phonetic equivalents of 80 to 100 per cent of words not yet in their sight vocabulary (Fig. 4a and b). In contrast, dyslexic children in all three groups can seldom spell correctly to dictation as many as 50 per cent of the words in their sight vocabulary at their actual reading level or below, and the children in Group I or I11 can seldom write a recognizable phonetic equivalent of an unknownword, the typical range being 0 to 30 per cent. Groups I and I11 are differentiated from each other by the degree of reading retardation, the actual reading level for Group I11 children being much lower at all age levels-usually at the primer or preprimer level, even for older children (Figs. 1 and 3). The two-column spelling performance of Group I1 children presents a striking combination. As in Groups I and 111, fewer than 50 per cent of the words in their sight vocabulary list are spelled correctly, but the percentage of good phonetic equivalents in their unknown-words list is within the normal range of 80 to 100 per cent (Fig. 2). This preliminary approach to scoringthat is, the two percentages considered in conjunction with the degree of reading retardation and the empirically established ranges-has proved useful in distinguishing on a more objective basis the three subH

types of dyslexic children from each other and from normal readers. It has also proved useful in distinguishing the dyslexic child from poor readers with a normal reading-spelling pattern, whose reading retardation can be assumed to be nonspecific (Fig. 5). Distribution of Reading-spelling Patterns Among Dyslexic Children A preliminary survey was undertaken to determine the distribution of the three reading-spelling patterns in a group of dyslexic children seen in the first eight months of 1968 in our School Neurology Clinics (Boder 1971a and b). On the basis of a differential diagnosis, some 300 children were identified who fulfilled the standard operational definitions of specific developmental dyslexia discussed earlier. Of these, 107 were selected to constitute our sample. These 92 boys and 15 girls came from a variety of socio-economic backgrounds and included 39 siblings from 16 families. The 107 children in the sample were in the third to tenth grades, their ages ranged between 8 and 16 years, and all had been regularly enrolled in school. They were all two or more years retarded in reading and spelling according to the Jastak Wide Range Achievement Test, and were similarly retarded in reading on our own Word Recognition Inventory. They were all of normal intelligence (IQ scores of 90 or above on the Stanford-Binet, Form LM, or on either the Verbal Scale or the Performance Scale of the WISC). All had essentially normal hearing and vision, were in good general health, and were free from gross neurological defect and overt primary psychiatric disorder. Of the 107 children in the sample, 100 clearly exhibited one of the three readingspelling patterns; only 7 had to be placed in an undetermined group. Of the total sample, 67 fell into Group I, 10 into 673

DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.

1973, 15

Group 11, and 23 into Group I11 (Table 11). Some of the children in the sample had been followed for as long as seven years, and though their reading-spelling patterns remained consistent on the whole, it became apparent that differentiating young Group I1 children from Group I11 children on the basis of reading-spelling patterns may present difficulties. Until the Group II child has been sufficiently exposed to phonics, his relatively good ability to develop word-analysis skills is not reflected

in his reading-spelling pattern. Thus, Group 111 in our sample may contain some Group I1 children who had not yet had the benefit of remedial phonics. Experience has shown, however, that young Group I1 children without phonic skills can be identified through their good auditory sequential memory, as revealed by such supplementary tasks as reciting the alphabet and oral word-blending. Another difficulty in differentiating the group into which a reading-spellingpattern

.......

...

........ _.

...

....

..................

9*

+ &

..........
.~

..

(optometry)

- ...........

.....

........ ?. .IucrcrrnavL
._ .............

__

..

-.

.~ ........

Fig. 4a
Fg 4a and b. The normal spelling patterns of a bilingual child. A 9-year-old Colombian boy whose native i. language is Spanish: 3rd grade in an American school in Bogota; reading above grade level; no IQ scores available. (a) Normal spelling pattern in English. (Known words: 100per cent correct. Unknown words: 10 per cent correct, mis-spellings 100 per cent phonetic.) (b) Normal spelling pattern in Spanish. (Known words: 80 per cent correct, mis-spellings 100 per cent phonetic. Unknown words: 60 per cent correct, mis-spellings 100 per cent phonetic.)

674

ELENA BODER

falls may arise from the similarity in the dysphonetic spelling patterns of children in Groups I and 111. These children can usually be differentiated, however, by the much more limited sight vocabulary of Group 111. Young Group 111 children may have no sight vocabulary or letter recognition at all; the sight vocabulary of older Group I11 children typically remains at the primer or pre-primer level unless they have had intensive remedial training. morn WORDS ......... ...... .c.
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It is of interest that the largest of the three groups is the one to which the term gestalt-blind, used as a synonym for specific dyslexia (de Hirsch 1952, Bender 1959), is not really applicable. The term is appropriate only to the dyseidetic children of Groups I1 and 111. Implications for Remedial Teaching In reflecting the childs functional assets as well as his deficits, each of the three

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Fig. 46 Note in both (a) and (b) that this bilingual normal reader can revisualize and write correctly. between 80 and 100 per cent of words in his sight vocabulary, whether phonetic or non-phonetic. Mis-spellings in both languages are written phonetically, and perfectly phonetic words are spelled correctly, whether in the known or unknown list. (This child sounded out unfamiliar words so rapidly that technical terms had to be included to ensure that none of the words in the unknown list were in his sight vocabulary.) The fact that 60 per cent of the unknown words in Spanish are actually spelled correctly as compared with 10 per cent in English reflects the much greater phonetic regularity of Spanish. Except for this difference, the normal readingspelling pattern is identical in Spanish and English.

675

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Fig. 5. Normal spelling pattern in a child with non-specific reading retardation. An 8-year-old boy, 3rd grade, IQ 102 (WISC: verbal IQ 109, Performance IQ 94). Frequent exclusions from school for hyperkinetic, disruptive behavior. Reading level 1st to 2nd grade (both sight vocabulary and word-analysis skills). (Known words: 83 per cent correct, ms-spellings 100 per cent phonetic. Unknown words: none correct, mis-spellings 83 per cent phonetic.) With successful behavior modification through psychotropic drug therapy, his sight vocabulary was up to grade level within two months without remedial reading instruction.

TABLE I1 Distribution of reading-spellingpatterns among children with developmental dyslexia

I
I.

Group

Number

Percentane

11. Dyseidetic dyslexia 111. Mixed dysphonetic-dyseidetic

Dysphonetic dyslexia

67
10 23

63 22
6
9

dyslexia (Alexia) Undetermined

reading-spelling patterns indicates the sensory modality, or channel, upon which the initial remedial techniques should be based. This permits the teacher to begin by teaching to the abilities rather than to the disabilities of dyslexic children and
676

ensures the initial successes that help to motivate them. Although a variety of multisensory approaches to reading remediation should ultimately be used for all dyslexic children, the initial techniques vary with each group.

ELENA BODER

Dysphonetic children (Group Z) can be called visile, as distinct from audile (Wepman 1962) (Table I). Since their primary deficit is in the auditory channel and they are unable to analyze words phonetically, they fall into the category called auditory dyslexia by Myklebust (1965). The initial remedial procedure of choice for these children (contrary to general practice and belief) is whole-word techniques, as advocated by Johnson and Myklebust (1 967) for auditory dyslexia, and by Bateman (1968) for children with good visual memory and poor auditory memory as revealed by the ITPA. The teaching of remedial phonics should be initiated only after the dysphonetic child has developed sufficient sight vocabulary (reinforced by tactile-kinesthetic clues) to provide an adequate foundation. It is important for the teacher t o be aware from the outset that phonetic skills will not come easily to the Group I child. The spelling of this child, like that of the Group I11 child, tends to be unintelligible except for those few words, phonetic or not, in his sight vocabulary that he is able to revisualize and thus write correctly. My own experience suggests that the initial remedial efforts to improve his spelling should be directed toward converting him from a dysphonetic to a phonetic speller, so that he himself and others can read the words he writes. The concept of good errors in spelling, i.e. learning to write good phonetic equivalents, has also proved to be very useful in motivating dyslexic children and setting realistic goals for remedying their spelling disability (Boder 1971b). Dyseidetic children (Group ZZ) can be called audile, as distinct from visile (Table I). Because they have a primary deficit in the visual channel and are unable t o perceive whole words as visual gestalts, they fall into the category called visual dyslexia by Myklebust (1965). If a dysei-

detic child has not yet learned t o identify and write the letter-forms of the alphabet, initial remedial teaching should use tactilekinesthetic techniques (Fernald 1943). Remedial phonics, e.g. the Orton-Gillingham technique (Slingerland 1966), would be the indicated initial method if he can recognize letter-forms. In contrast t o Groups I and 111, the child in Group I1 learns readily through phonics. Tactilekinesthetic techniques would also be required to develop a sight vocabulary. The remedial implications for the dyseidetic child are in accord with the remedial procedures advocated by Johnson and Myklebust (1967) for the visual dyslexic, who, being rarely able to learn by an ideovisual approach, needs an initial phonetic or phonovisual approach. Similarly, Bateman (1968) advocates that phonics be used initially for children who reveal good auditory memory and poor visual memory on the ITPA. Dysphonetic-dyseidetic children (Group ZZZ)are neither visilenor audile. Because they have primary deficits in both visual and auditory channels, they have the combined deficits of Groups I and I1 (Table I). The initial remedial approach of choice calls for emphasizing a third channel (i.e. tactile-kinesthetic techniques) in learning letters and whole words. This remedial approach is in accord with that advocated by Bateman (1968) for the third subgroup she identifies: children with both poor visual and poor auditory memory. When the Group I11 child can recognize letter forms, remedial phonics reinforced by multisensory techniques can be introduced. The initial goal in improving his spelling is the same as for the child in Group I, that is, to convert him from a dysphonetic to a phonetic speller. At the same time, the development of nonlanguage skills at which the child can succeed should be encouraged.

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Reading-spelling Patterns in Grouping for Remedial Teaching The three reading-spelling patterns offer a rational basis for homogeneous grouping of dyslexic children for prescriptive remedial teaching, the groups being formed according to shared functional assets and deficits in visual and auditory channels. Because of the shortage of skilled remedial reading teachers and of special classes, this approach to meeting individual needs on a group basis offers immediate practical advantages.

Discussion Validity of the Reading-spelling Patterns The question arises as to whether the reading-spelling patterns of Groups I and I1 may not be the results of methods of teaching, for dysphonetic children read as if they had been taught only by wholeword techniques and the dyseidetic as if they had been exposed only to phonics. However, reading instruction in the Los Angeles City Schools for the last decade has been eclectic as a matter of policy, and both whole-word and phonetic techniques have been used (Nubling 1970). Quite apart from the continuing controversy over the relative advantages of whole-word versus phonetic teaching, it is generally accepted that most children learn to read by either method. Whichever method is introduced initially, the normal reader discovers for himself the other style of reading. Moreover, children who read poorly are likely to have been exposed to more phonics than children who read satisfactorily. Yet Group I, the largest of the three groups, comprises precisely those dyslexic children who do not learn readily by phonics. It is clear, therefore, that the observed reading-spelling patterns reflect a learning style rather than a teaching style. The validity of the three reading-spelling patterns is supported by a number of observations. As has been noted, one or
678

other of the three patterns has been found consistently in all severely retarded readers identified as developmental dyslexics through diagnosis by exclusion, and none of the three patterns has been found in normal readers and spellers. A consistent relationship is found between the reading and spelling of dyslexic children; how they read and how they spell are mutually predictive. Moreover, long-term observation indicates that reading-spelling patterns remain consistent, though less obvious, even when the grade level of reading and spelling rises significantly. It appears, therefore, that the readingspelling patterns can be diagnostic. In addition, the three patterns represent the dyslexic childs total performance in the reading and spelling tasks-his achievements as well as characteristic errors. Thus, by reflecting assets as well as deficits in the visual and auditory processes necessary for reading, the patterns have prognostic and therapeutic implications. Further support for the validity of the reading-spelling patterns as diagnostic indicators is found in the marked preponderance of Group I children in our sample, which is consistent with a growing number of observations (Wepman 1962, Bannatyne 1966, Bateman 1968, Ingram et al. 1970) indicating that audiophonic deficits are far more important as a basic underlying cause of developmental dyslexia than are visuo-spatial perceptual deficits. The familial incidence of developmental dyslexia is widely viewed as corroborative evidence for the diagnosis (Hallgren 1950, Hermann and Norrie 1958, Critchley 1970, Childs 1972). In our sample, a positive family history of reading disability was elicited for most of the children in all three groups. In fact, there is a suggestion that a genetic factor may exist for each of the three reading-spelling patterns; 14 of the 16 sets of dyslexic siblings in our sample

ELENA BODER

fell into the same reading-spelling pattern groups. Additional support for the validity of the reading-spelling patterns as diagnostic indicators of specific assets and deficits has been provided by Smiths subtest analysis of WISC profiles among significantly retarded readers, which identified three distinct patterns of performance (Smith 1970a). The children exhibiting Smiths WISC Pattern I, with strength in spatial ability and deficit in symbol manipulation and sequencing ability*, appear to correspond to dysphonetic Group I. The notable frequency of WISC Pattern I (67 per cent) in her sample closely approximates that of Group I (63 per cent) in our sample. She has verified that children with WISC Pattern I exhibit the dysphonetic reading-spelling pattern of Group I, and has also found indications of a similarity between WISC Pattern I1 and dyseidetic Group I1 (Smith 1970b). Most recently, additional suggestive evidence that the reading-spelling patterns are diagnostic has been provided in the computerized study of electroencephalograms (EEGS) by Sklar et al. (1972), comparing 12 dyslexic children, selected at random from our sample of 107 children, with 13 age-sex matched normal controls. The investigators were able to differentiate the dyslexic children from the controls on the basis of spectral estimates of their EEGS. The children were monitored during various mental tasks and rest situations. The most prominent spectral differences appeared in the parieto-occipital region during the rest, eyes-closed, phase. Overall, the differences occurring most often in dyslexic children were higher theta-band

activity and, during reading tasks, higher coherence between regions of the same hemisphere. The identification of the three readingspelling patterns corroborates Myklebusts (1965) concept of auditory and visual dyslexia, which is shared to some extent by Quiros (1964), and extends it to include a third distinct subtype, a combined visual and auditory dyslexia, and therefore a virtual alexia. The dysphonetic readingspelling pattern of Group I is diagnostic of Myklebusts auditory dyslexia, and the dyseidetic reading-spelling pattern of Group I1 is diagnostic of visual dyslexia. Identification of the Group I11 subtype permits a more precise delineation of the other two subtypes. It would appear that the distinctiveness of Myklebusts two groups of dyslexia may have been obscured by the inclusion, in one or both groups, of children with combined deficits. My own diagnostic approach differs from Myklebusts and that of Quiros in other respects. In contrast to their delineation of auditory and visual dyslexia as syndromes on the basis of a total language evaluation and associated variables (Quiros 1964, Myklebust 1965, Johnson and Myklebust 1967), the three subtypes of the present study are delineated on the basis of correlated patterns of reading and spelling alone.

* According to Bannatyne (1966), the subtests of spatial organization in the WISC are Picture Arrangement, Block Design and Object Assembly in the Performance Scale; the subtests of symbol manipulation are Information, Arithmetic and Digit Span in the Verbal Scale.
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Reading-spelling Patterns vs. Classic Dyslexic Errors as Diagnostic Criteria Identification of the three readingspelling patterns helps to clarify why the classic dyslexic errors do not distinguish subtypes among dyslexic children and even tend to obscure their heterogeneity. All of the classic errors, notably the static and kinetic reversals, have been observed in all three of our subtypes. It would appear, therefore, that although the classic errors are valuable diagnostic signs, especially significant in older children, they are not

DEVELOPMENTAL MEDICINE AND CHILD

NEUROLOGY. 15 1973,

invariable concomitants of developmental dyslexia. The three reading-spellingpatterns reveal that most of the errors made by dyslexic children do not occur at random, but in patterns of errors. Aside from the classic reversals, most of the dyslexic errors fall into two main groups-the intelligible phonetic errors and the unintelligible dysphonetic errors. The so-called bizarre errors of Groups I and I11 are consistently dysphonetic (Figs. 1 and 3); the semanticsubstitution errors in both reading and spelling are typical and virtually diagnostic of Group I, whereas the errors of Group I1 are consistently phonetic (Fig. 2). Extraneous-letter errors, omitted-syllable errors, and letter-order errors can all be understood as examples of the dysphonetic spelling of Group I children, and omittedletter errors as an example of the phonetic spelling of Group 11. Diagnosis through dyslexic readingspelling patterns, reflecting both function1 assets and deficits, offers a fuller range of prognostic and therapeutic implications than does traditional diagnosis through dyslexic errors, which reflect functional deficits alone.
Reading-Spelling Patterns in Diferential Diagnosis In common with other investigators, I regard specific developmental dyslexia as being frequently of genetic origin and only infrequently due to brain damage (Hallgren 1950, Hermann and Norrie 1958, Bannatyne 1966, Critchley 1970). In its milder and transient forms, developmental dyslexia may represent a normal variation in psychoneurological maturation, i.e. a maturational lag in reading-readiness (de Hirsch 1952, Bender 1959, Ingram et ul. 1970). On the other hand, non-specific reading disorders-or secondary reading retardation (Rabinovitch 1968)-may have a variety of non-specific causes: physical,

mental, emotional, cultural and educational. The diagnostic objective therefore is to differentiate between specific dyslelfia and non-specific reading retardation, since specific dyslexia calls for remedial reading techniques which are not essential in the management of non-specific reading disorders. A child with a nonspecific reading disorder reads poorly but has normal reading potential. The reading and spelling performance of such a child is quantitatively, but not qualitatively, different from that of a normal reader, whereas a dyslexic child, as has been noted, reads differently both quantitatively and qualitatively. The child of normal intelligence whose reading retardation is non-specific reads and spells normally at whatever grade level he has achieved, i.e. his performance in terms of sight vocabulary and word-analysis skills is indistinguishable from that of an average younger reader at the same grade level. There are none of the atypical readingspelling patterns characteristic of dyslexic children and no persisting dyslexic errors, such as static and kinetic reversals, beyond the age of eight years (Fig. 5). Unlike the reading disability of dyslexic children, which is often selective and in sharp contrast with their other abilities and achievements, non-specific reading retardation is usually part of a global underachievement, particularly in the emotionally disturbed or poorly motivated child. Moreover, it appears that reading retardation secondary to emotional factors alone is usually one or two years at most, and is rarely as severe in relation to grade Ievel and mental age as the reading retardation of dyslexic children. The hyperkinetic syndrome is generally recognized to be typically associated with secondary, non-specific reading retardation. There is growing awareness that it is also frequently associated with developmental dyslexia (de Hirsch 1952, Boder 680

ELENA BODER

1966). The atypical reading-spelling patterns can serve to differentiate the hyperkinetic child with developmental dyslexia from the one whose reading retardation is secondary to his behavioral disorder (Fig. 5). Reading retardation secondary to mental retardation is also part of a global underachievement, but it is commensurate with the childs mental age. Developmental dyslexia and mental retardation may coexist, however. A diagnosis of developmental dyslexia can be made in a mentally retarded child, and it is important to do so; a retarded dyslexic child also needs remedial reading if he is to learn to read. The combined diagnoses should be considered if the retarded childs reading level is two or more years below grade level and his mental age, particularly if he presents one of the delineated reading-spelling patterns or meets the standard criteria for developmental dyslexia in children of normal intelligence. The screening of mentally retarded children for developmental dyslexia is also important in order to avoid misdiagnosis, since a dyslexic child characteristically showsawide scatter in his psychologicaltest results which may bring his over-all IQ score into the mentally retarded range (Fig. 3). The use of atypical patterns of reading and spelling as diagnostic criteria also permits diagnosis of developmental dyslexia in a child of superior intelligence. Although his reading and even his spelling may be at grade level, a diagnosis of developmental dyslexia should be considered if performance in reading and spelling is two or more years below mental age and he exhibits a dysphonetic or dyseidetic reading-spelling pattern.
Implications f o r Prognosis Although there are many factors involved in the prognosis for a dyslexic child (Boder 1971b), the three reading-spelling patterns have been found in long-term

observation to have definite prognostic implications, which differ for each group (Boder, unpublished data). As might be expected, the prognosis for Groups I and 11, in which only one channel function (gestalt or analytic) is deficient, is more favorable than the prognosis for Group 111, in which both channel functions are affected. Without intensive long-term remedial teaching, the prognosis for Group I11 must be guarded. None of our severe Group I11 patients has so far achieved proficiency in reading or spelling, even at high school level. The child in Group I approaches normal proficiency in context reading as he gradually acquires a sight vocabulary at and even in some cases above grade level. Nevertheless, his word-analysis skills usually do not improve to the point of becoming fully automatic, and spelling tends to remain relatively poor, characterized by telltale dysphonetic mis-spellings, even in college. The Group I1 child tends to remain a slow and laborious reader and, in contrast to Group I, usually does not achieve a sight vocabulary commensurate with his agegrade level and mental age even with remedial teaching. The absence of the dyslexic readingspelling patterns also has been found to have diagnostic and prognostic implications. Their absence in a child with reading retardation points to a non-specific reading disorder and a normal reading potential. The prognosis-even with conventional teaching methods-is therefore excellent, if the causal factors can be alleviated: for example, when reading under-achievement without abnormal reading-spelling patterns is found in association with the hyperkinetic syndrome, controlling the childs behavioral disorder through psychotropic drug therapy has usually proved sufficient to result in a rapid rise in reading level within half a school year, even without individual tutoring. 68 1

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Implications for Counseling Parent and child counseling (Boder 1966, 1971b) is of paramount importance in dealing with the dyslexic child. The reading-spelling patterns, being readily demonstrable, can be used effectively to help parents gain a better understanding of the childs problem and the goals toward which remedial teaching should be directed. Interpreting the dysfunction of central processes in terms of visual and auditory channels that are open or closed is easily grasped by parents and children. The concept of three subtypes of dyslexia based on reading-spelling patterns is also effective in interpreting the dyslexic problems of individual children to school personnel. Implications for Research Most research on dyslexia has compared undifferentiated groups of poor readers with good readers in an effort to find correlates of reading disability. The often conflicting or inconclusive findings of such studies may result in part from the heterogeneity of the general category of poor readers. By combining diagnosis by exclusion

with direct diagnosis through the readingspelling patterns, the investigator can obtain more homogeneous samples than have heretofore been used in research on dyslexia. Such relatively pure groups are especially relevant to etiological and genetic studies and to trials of remedial teaching techniques. Identification of three clinical subtypes on the basis of three atypical readingspelling patterns also offers a fresh point of departure for transcultural studies designed to explore the influence of specific linguistic structures on the incidence, clinical manifestations, and remediation of developmental dyslexia. The Diagnostic Screening Procedure, being based on a sequence of simple reading and spelling tasks, is easily adaptable for such transcultural studies in any written language that includes a phonetic system.
Acknowledgements: I am indebted to Anne Ross Silver, M.A., for the statistical survey of the 107 dyslexic children, to Dr. C. Edward Meyers for his practical statistical consultation, and to Sylvia Jarrico, M.A., for her skilful editorial assistance in the preparation of the manuscript. It is also a pleasure to acknowledge the many valuable suggestions of Dr. Joseph E. Bogen and the thoughtful criticism of Drs. Marcel Kinsbourne and Robert P. Sedgwick.

SUMMARY

A method of diagnosing developmental dyslexia is presented, based on three atypical patterns of reading and spelling. These three atypical patterns enable dyslexic children to be classified into one of three main subtypes-dysphonetic (unable to integrate symbols with their sounds), dyseidetic (unable to perceive letters and whole words as configurations or gestalts), or a combination of both. One of these three patterns is found in all severely retarded readers who fulfil standard diagnostic criteria for developmental dyslexia, and none are found among children who read and spell normally. The relationship between a dyslexic childs pattern of reading and pattern of spelling is so consistent that one is predictive of the other. Long-term observation of the children in this study shows that the reading-spelling pattern remains consistent, though less obvious, even when the actual level of reading and spelling rises significantly. These findings strongly suggest that the three reading-spelling patterns are diagnostic in themselves, each of the three subtypes having different prognostic and therapeutic implications.
682

ELENA BODER

RESUMI?
Dyslexie de diveloppement: approche diagnostique basie sur trois schgmes atypiques de lecture et dorthographe Une mithode de diagnostic de la dyslexie de dtveloppement est dtcrite, baste sur trois sch6mes atypiques de lecture et dorthographe. Ces trois schkmes atypiques permettent de classer les enfants dyslexiques en trois sous-groupes principaux : dysphonttiques (incapables dintCgrer les symboles et les sons), dyseidetiques (incapables de considtrer les lettres et les mots comme des ensembles ou gestalts) ou une combinaison des deux. Un de ces trois patterns est trouvt chez tous les enfants gravement retardts dans la lecture et qui rtpondent aux critkres diagnostiques standard de dyslexie de dtveloppement et aucun ne sont trouvts chez les enfants qui lisent et tpellent normalement. La relation entre le type de lecture et le type dorthographe chez un enfant dyslexique est tellement forte que la prtsence dun pattern permet de prtvoir lautre. Une observation B long terme des enfants de cette etude montre que le pattern de lecture et dorthographe persiste alors m&meque lefficaciti rtelle de lecture et dorthographe augmente significativement. Ces dtcouvertes suggerent nettement que les trois schkmes de lecture-orthographe constituent des cattgories diagnostiques, chacun des trois sous-groupes ayant un pronostic et des implications thtrapeutiques differents.
ZUSAMMENFASSUNG

Entwicklungsstorung des Lesens: ein diagnostischer Annaherungsversuch begriindet auf 3 atypischen Lese- und Buchstabierverhaltensweisen Eine Methode, eine Entwicklungsstorung des Lesens zu diagnostizieren wird vorgestellt. Sie basiert auf drei atypischen Verhaltensweisen beim Lesen und Buchstabieren. Diese Verhaltensweisen ermoglichen es legasthenische Kinder in eine der drei Untergruppen einzuordnen, in die dysphonetische Gruppe (Unfahigkeit Symbole und Laute zusammenzufugen) in die dyseidetische Gruppe (Unfahigkeit die Bedeutung von Buchstaben und Wortern als Gestalten wahrzunehmen) und in die Gruppe, die auf einer Kombination beider Unfahigkeiten beruht. Eine dieser drei Arten ist bei allen schwer lesegestorten Personen zu finden sein, die die ublichen diagnostischen Kriterien einer Leseschwache aufweisen, keine davon wird man bei normal lesenden und buchstabierenden Kindern finden. Die verwandtschaft der Art zu Lesen und zu Buchstabieren ist bei einem legasthenischen Kind so ubereinstimmend, dass eines aus dem anderen hervorgeht. Langzeitbeobachtungen der Kinder dieser Studie zeigen, daD die Verhaltensweisen beim Lesen und Buchstabieren bestehen bleibt, selbst wenn die Fahigkeit zu Lesen und zu Buchstabieren signifikant zugenommen hat. Diese Ergebnisse legen nahe, daB die drei atypischen Lese und Buchstabierverhaltensweisen in ihrer Art diagnostizierbar sind. Jede der drei Gruppen hat eine unterschiedliche Prognose und verlangt eine unterschiedliche Therapie.
RESUMEN

Dislexia de desarrollo; una aproximacidn diagndstica basadu en tres patrones atipicos de lectura y ortograjlia Se presenta un mCtodo de diagnosticar la dislexia de desarrollo basado en tres patrones atipicos de lectura y ortografia. Estos tres patrones hacen posible el clasificar 10s niiios dislCxicos en uno de 10s tres siguientes subgrupos : Disfonttico (incapaz de integrar simbolos y sonidos), diseidetico (incapaz de percibir las letras y las palabras como esquemas, o gestalts) o bien una combinacidn de ambos.
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Uno de estos tres patrones se encuentra en todos 10s nifios con grave retraso de lectuia, yue cumplen con 10s criterios diagndsticos standard para la dislexia de desarrollo, mientras que no se encuentra ninguno en 10s nifios que leen y escriben normalmente. La relacidn entre 10s patrones de lectura y de ortografia en el nifio dislixico es tan consistente que uno es predictivo del otro. La observacidn a largo plazo de 10s nifios en este estudio muestra que el patrdn de lecto-escritura pernianece consistente, aunque menos obvio, incluso si el nivel de lectura y ortografia aumenta significativamente. Estos hallazgos sugieren fuertemente que 10s tres patrones de lecto-escritura son diagnosticos por si mismos, si bien cada uno de 10s tres subgrupos tiene una diferente implication prondstica y terapkutica.

REFERENCES Bachmann, F. (1927) Uber kongenitale wortblindheit (Angeborene Lesechwache). Abhandlungen aus der Neurologie, Psychiatrie, Psychologie und ihren Grenzgebieten, 40, 1. Bakker, D. J. (1970) Temporal order perception and reading retardation. In Bakker, D. J., Satz, P. (Eds.) Specific Reading Disability: Advances in Theory and Method. Rotterdam: Rotterdam University Press. p. 81. Bannatyne, A. (1966) The etiology o f dyslexia and the color phonics system. I n Money, J. (Ed.) The Disabled Reader: Edmztion of rhe Dyslexic Child. Baltimore: Johns Hopkins Press. p. 193. Bateman, B. D. (1968) Interpretation of the 1961 Illinois Test of Psycholinguistic Abilities. Seattle: Special Child Publications. Bauza, C. A., de Grompone, M. A. C., Ecuder, E., Drets, M. E. (1962)La Dislexia de Evolucion. Montevideo: Garcia Morales-Merchant, Graficos Unidos, S.A. Bender, L. (1959) Psychopathology of Children with Organic Brain Disorders. Springfield, Ill. : Charles C Thomas. Benton, A. L. (1962) Dyslexia in relation to form perception and directional sense. In Money, J. (Ed.) Reading Disability: Progress and Research Needs in Dyslexia. Baltimore: Johns Hopkins Press. p. 81. Birch, H. G. (1962) Dyslexia and the maturation of visual function. In Money, J. (Ed.) Reading Disability: Progress and Research Needs in Dyslexia. Baltimore: Johns Hopkins Press. p. 161. Belmont, L. (1964) Auditory-visual integration in normal and retarded readers. American Journal of Orthopsychiatry, 34. 852. Boder, E. (1966) A neuropediatric approach to school behavioral and learning disorders: diagnosis and management. In Hellmuth, J. (Ed.) Learning Disorders, Vol. 2, Seattle: Special Child Publications. p. 15. (1968~) Developmentaldyslexia :a diagnostic screening procedure based on three characteristic patterns of reading and spelling. A preliminary report. In Douglas, M. (Ed.) Claremont Reading Conference, 32nd Yearbook. Claremont, Calif. : Cfaremont University Center. p. 173. - (1968b) Developmental dyslexia: a diagnostic approach based on patterns of reading and spelling. (Abstract.) Proceedings of the Twelfth International Congress of Pediatrics, Mexico City, December 1968. (1971~) Developmentaldyslexia: a diagnostic screening procedure based on three characteristic patterns of reading and spelling. I n Bateman, B. D. (Ed.) Learning Disorders, Vol. 4. Seattle: Special Child Publications. p. 298. - (1971b) Developmental dyslexia: prevailing diagnostic concepts and a new diagnostic approach. In Myklebust, H. R. (Ed.) Progress in Learning Disabilities, Vol. 2. New York: Grune and Stratton. p. 293. Bogen, J. E. (1969) The other side of the brain. 1 . An appositional mind. Bulletin of the Los Angeles 1 Neurological Societies, 34, 135. Childs, B. (1972) Genetic analysis of human behavior. Annual Review of Medicine, 23, 373. Critchley, M. (1970) The Dyslexic Child, 2nd Edition. Springfield, Ill.: Charles C Thomas. de Hirsch, K. (1952) Specific dyslexia or strephosymbolia. Folia Phoniatrica, 4, 231. (1963) Concepts related to normal reading processes and their application to reading pathology. Journal of Genetic Psychology, 102, 277. Eisenberg, L. (1966) Reading retardation. I. Psychiatric and sociologic aspects. Pediatrics, 37, 352. Fernald, G. (1943) Remedial Techniques in Basic School Subjects. New York: McGraw-Hill. Hallgren, B. (1950) Specific dyslexia : a clinical and genetic study. Acta Psychiatrica et Neurologica, Suppl. 65. Heller, T. M. (1963) Word-blindness: a survey of the literature and a report of twenty-eight cases. Pediatrics, 31. 669. Hermann, K., Norrie, E. (1958) Is congenital word-blindness a hereditary type of Gerstmanns syndrome? Psychiatrica et Neurologica (Basel), 136, 59. Ingram, T. T. S. (1963) Delayed development of speech with special reference to dyslexia. Proceedings ofthe Royal Society of Medicine, 56, 199. - Mason. A. W.. Blackburn. I. (1970) A retromective study of 82 children with reading disability. Developmental Medicine and Child Neu;ology, 12,271.

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ELENA BODER

Johnson, D. J., Myklebust, H. R. (1967) Learning Disabilities: Educational Principles and Practices. New York: Grune and Stratton. Kinsbourne, M., Warrington, E. K. (1966) Developmental factors in reading and writing backwardness. In Money, J. (Ed.) The Disabled Reader: Education of the Dyslexic Child. Baltimore: Johns Hopkins Press. p. 59. Myklebust, H. R. (1965) Development and Disorders of Written Language: Picture Story Language Test. New York: Grune and Stratton. Nubling, L. (1970) Personal Communication. Orton, S. (1937) Reading, Writing, and Speech Problems in Children. New York: Norton. Quiros, J. B. de (1964) Dysphasia and dyslexia in school children. Folia Phoniatrica, 16, 201. Rabinovitch, R. D. (1968) Reading problems in children: definitions and classifications. In Keeney, A. H., Keeney, V. T. (Eds.) Dyslexia: Diagnosis and Treatment of Reading Disorders. St Louis: C. V. Mosby. p.1. Sklar, B., Hanley, J., Simmons, W. W. (1972) An EEG experiment aimed toward identifying dyslexic children. Nature, 240, 414. Slingerland, B. H. (1966) Public school programs for the prevention of specific language disability in children. In Hellmuth, J. (Ed.) Educational Therapy, Vol. I. Seattle: Special Child Publications. p. 391. Smith, M. M. (1970a) Patterns of intellectual abilities in educationally handicapped children. Unpublished doctoral dissertation, Claremont College, California. - (1970b) Patterns of intellectual functioning in E. H. children. Proceedings of the Fourth Annual Conference on the Educationally Handicapped, University of Redlands, California, March 1970. Sperry, R. W., Gazzaniga, M. S., Bogen, J. E. (1969) Interhemispheric relationships: the neocortical commissures; syndromes of hemisphere disconnection. In Vinken, P., Bruyn, G. (Eds.) Handbook of Clinical Neurology, Vol. 4. Amsterdam: North-Holland. p. 273. Thompson, L. J. (1966) Reading Disability: Developmental Dyslexia. Springfield, Ill. : Charles C Thomas. Wepman, J. M. (1962) Dyslexia: its relationship to language acquisition and concept formation. In Money, J. (Ed.) Reading Disability: Progress and Research Needs in Dyslexia. Baltimore: Johns Hopkins Press.
n.179.

Whiting, A. (1972 To be published. Wiener, M., Cromelr, W. (1967) Reading and reading difficulty: a conceptual analysis. Harvard Educational Review, 37, 620.

(See pages 6861687for Appendix)

685

WORD RECOGNITION INVENTORY"

Pro-Primer Flash Untimed Primer Flash Untimed

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

13. 14. 15. 16. 17. 18. 19. 20.

and big ball fast go green help I little mother not play red ride said stop the to we work
First Grade Flash Untimed

are black came did eat farm house like now on paint Put ready saw store tree your too white Yes

~~

. -

Second Grade Flash

Untimed

I . after 2. away
3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. blue call dinner faster funny guess here into like money now pocket sat stay then
toy was

with

across ask bird city does ever five girl happy just listen miss next over pull rolled step talk uncle wet

Vocabulary common to Ginn and AIlyn Readers and Bacon Readers, from pre-primer through to sixth grade. Selection based on word frequency counts. (From Boder 1 9 7 1 ~ ) .

686

WORD R ECOGNlTlON INVENTORY

Third Grade Flash Untimed Fourth Grade Flash Untimed

1. almost 2. awake 3. believe 4. business 5. chance 6. deep 7. earth 8. farther 9. front 10. great 11. heavy 12. important 13. laugh 14. minute 15. -other 16. promise 17. remember 18. should 19. traffic 20. wonderful
Fifth Grade Flash Untimed

automobile blindfolded characters cottage delight environment flight goggles human lame marry natural pain prisoners rough shallow soared study tourists whisper
Sixth Grade Flash Untimed

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

astronomy astonished curious crocodiles doubt equator forge genius height inventor lizard marmalade opposite position recognized scrambled scholar tomato vowed witness

apparatus badge burlap conceited decisions earthquake foreign hibernation immense knapsack legendary marveIous necessary persuade quest substituted treacherous utter varnish wisdom

687