Você está na página 1de 16

Ann.

of Dyslexia
DOI 10.1007/s11881-015-0109-8

Reading under the skin: physiological activation


during reading in children with dyslexia and typical
readers
Valentina Tobia 1 & Paola Bonifacci 2 &
Cristina Ottaviani 3 & Thomas Borsato 1 &
Gian Marco Marzocchi 1

Received: 20 August 2014 / Accepted: 30 June 2015


# The International Dyslexia Association 2015

Abstract The aim of this study was to investigate physiological activation during reading and
control tasks in children with dyslexia and typical readers. Skin conductance response (SCR)
recorded during four tasks involving reading aloud, reading silently, and describing illustrated
stories aloud and silently was compared for children with dyslexia (n=16) and a control group
of typical readers (n=16). Childrens school wellness was measured through self- and parentproxy reports. Significantly lower SCR was found for dyslexic children in the reading-aloud
task, compared to the control group, whereas all participants showed similar physiological
reactions to the other experimental conditions. SCR registered during reading tasks correlated
with BChilds emotional difficulties,^ as reported by parents. Possible interpretations of the
lower activation during reading aloud in dyslexic children are discussed.
Keywords Developmental dyslexia . Reading aloud . Reading silently . Skin conductance

* Valentina Tobia
valentina.tobia@unimib.it
Paola Bonifacci
paola.bonifacci@unibo.it
Cristina Ottaviani
cristina.ottaviani@uniroma1.it
Thomas Borsato
t.borsato@campus.unimib.it
Gian Marco Marzocchi
gianmarco.marzocchi@unimib.it
1

Department of Psychology, University of Milan-Bicocca, Building U6, room 3124,


Piazza dellAteneo Nuovo 1, 20126 Milan, Italy

Department of Psychology, University of Bologna, Bologna, Italy

Department of Psychology, Sapienza University of Rome, Rome, Italy

V. Tobia et al.

Introduction
Around 36 % of children (3.13.2 % in the Italian population; Barbiero et al., 2012) are
affected by a specific reading disorder with neurobiological origin, or developmental dyslexia
(DD), characterized by difficulties in accurately and fluently recognizing printed words at a
level appropriate for the chronological age, despite adequate intelligence, age-appropriate
education, and the absence of sensory deficits (American Psychiatry Association, 2000;
Hulme & Snowling, 2009; Vellutino, Fletcher, Snowling, & Scanlon, 2004). Longitudinal
and cross-sectional studies have reported that people with dyslexia are often affected by
behavioral, relational, and emotional difficulties, probably originating in the impact of their
reading problems on everyday life, which could be confined to the learning context but also
extend to other domains of life (e.g., Hall, Spruill, & Webster, 2002; Ingesson, 2007; Karande
& Venkataraman, 2012; Tabassam & Grainger, 2002; Undheim, 2003). In particular, learning
disabilities are often related to negative emotional manifestations, such as anxiety and stress; it
is recognized that reciprocal relationships between anxiety and cognition are common and
influential on multiple aspects of life (see Manassis 2013, for a recent review). A recent metaanalysis reports higher mean scores on measures of emotional arousal and anxiety in a clinical
group of school-aged students with learning disabilities compared to typically developing
peers (Nelson and Harwood, 2011), and a review that specifically included studies on
internalizing correlates of dyslexia (Mugnaini, Lassi, La Malfa, & Albertini, 2009) showed
that reading problems contribute in a relevant way to higher emotional arousal in students from
first grade to university. However, not all the studies that investigated internalizing symptoms
have found evidence of significant differences between children with dyslexia and typical
readers (Lamm & Epstein, 1992; Miller, Hynd, & Miller, 2005), and variability in results
might also be related to the source of information considered (children, parents, or teachers)
(Carroll, Maughan, Goodman, & Meltzer, 2005; Dahle, Knivsberg, & Andreassen, 2011;
Knivsberg & Andreassen 2008; Snowling, Muter, & Carroll, 2007; Willcutt & Pennington,
2000, Dahle & Knivsberg, 2014). In particular, it has been suggested that different sources
could report partially different information (Achenbach, McConaughy, & Howell, 1987). For
example, some studies report a tendency for mothers to perceive childrens quality of life in the
school context in a more negative way, whereas they overestimated their physical and
emotional well-being (Rotsika et al. 2011; Ginieri-Coccossis et al., 2012). Furthermore,
children may have difficulties to describe accurately their internalizing problems via selfreport measures (Korotitsch & Nelson-Gray, 1999). Thus, in the evaluation of dyslexic
childrens internalizing and externalizing symptoms, it would be worth considering multiple
points of views (e.g., Dey, Landolt, & Mohler-Kuo, 2013) and multiple measures, such as both
subjective and physiological concomitants of such symptoms. Direct measurement of physiological variables can produce data that are highly sensitive to physiological processes, as
physical sensation of fear and worry, that are often outside of the childs awareness and not
accessible to observers (Korotitsch & Nelson-Gray, 1999).
A specific analysis of the emotional reaction of children and young adults with learning
disabilities to academic tasks, involving literacy abilities, has been rarely studied. According to
Bandura, Pastorelli, Barbaranelli, and Caprara (1999), the perceived difficulties in managing
potential threatening events, as reading aloud may be for children with dyslexia, are a source of
anxiety. Carroll and Iles (2006) evaluated anxiety symptoms in undergraduates with a selfreport questionnaire, showing higher states of anxiety in dyslexic students just before starting a
reading task as compared with a control group. Butkowsky and Willows (1980) measured

Physiological activation during reading

initial expectancy of success in fifth graders with good, average, and poor reading ability just
before starting a reading task, finding that expectancy decreased with lowered reading ability;
furthermore, poor readers showed lower persistence during the task and inferred external
causes for successes and internal causes for failures. These results reflect low self-concepts of
ability in reading that could be associated with anxiety symptoms, emotional withdrawal, and
passivity, affecting motivation to read (Polychroni, Koukoura, & Anagnostou, 2006; Riddick,
Sterling, Farmer, & Morgan, 1999; see also Bonifacci, Candria, & Contento, 2008 for results
on writing). All these studies used instruments such as self-reports, questionnaires, and
interviews to analyze socio-emotional correlates of learning disabilities.
A few studies employed physiological measures to identify autonomic indicators of stress
and threat response in children with learning disabilities, using measures such as skin
conductance response (SCR) and heart rate (HR). SCR is a low-cost, easy-to-detect, and
robust measure to indicate threat response, cognitive load, and emotional arousal; in fact, brain
mechanisms underlying SCR are integrated with those involved in emotional processing
(Bchel, Morris, Dolan, & Friston, 1998; Critchley, Elliott, Mathias, & Dolan, 2000). This
measure reflects changes in the sympathetic nervous system; it is nonintrusive and therefore
suitable for use with children. Another physiological measure easy to detect and adapt for
children is cardiac responsivity, usually assessed by HR, which is the number of beats per unit
of time. It has been showed that even small physiological changes revealed by such indices
may have long-term consequences on peoples health (Vrijkotte, van Doornen, & de Geus,
2000).
The majority of psychophysiological studies of children with learning disabilities that used
SCR and HR were conducted in the 1970s and 1980s, and results were controversial. For
example, by comparing learning-disabled, hyperactive, and typically developed childrens
basal levels of physiological functioning, some studies have found generally higher
activation, in terms of skin conductance and HR, in learning-disabled and hyperactive children
than in controls (Ackerman, Dykman, & Peters, 1977; Zahn, Little, & Wender, 1978) whereas
some of them showed lower skin conductance level (Rugel & Rosenthal, 1974) or similar SCR
and HR (Dykman, Ackerman, Oglesby, & Holcomb, 1982; Zahn, Abate, Little, & Wender,
1975). Findings from studies of autonomic responsivity to various stimuli showed lower
activation in children with learning disabilities compared to controls. For example, Hunter,
Johnson and Keefe (1972) studied autonomic reactivity in dyslexic children and controls during
a simple reaction time task composed of three series of stimuli, to test habituation of the orienting
response, reaction times, and auditory threshold. Their hypothesis was based on the assumption
that the habituation of the orienting response could be considered a measure of attention or level
of Barousal,^ a process that was considered deficient in dyslexics in the literature of the 1960s
(Johnson & Myklebust, 1967). Results showed lower basal skin conductance levels and a rapid
drop-off of skin conductance levelconsidered an indicator of lower attentional levelin
dyslexic children, whereas controls appeared to remain alert. The authors interpreted their
findings as a difficulty of dyslexic children to maintain a constant attentional level during the
task. Dykman et al. (1982) analyzed HR and skin conductance measures recorded during a
visual search task in hyperactive, reading-disabled, hyperactive reading-disabled, and typical
developing children from primary school. Control subjects showed anticipatory HR deceleration
more consistently than clinical groups. Again, the authors explained this difference in terms of
less effort expended by clinical children to remain attentive during the task. However,
some studies found no differences in autonomic responsivity of children with learning
difficulties. For example, Bryant (1976) analyzed SCR to a reading-aloud task in 60 children

V. Tobia et al.

from primary school classified for their reading ability (below, average, and above average) and
found no significant differences in arousal level between the three groups. Specifically, the
author analyzed group differences at the Bfrustrational level,^ which is when the child is unable
to cope with the reading task and shows signs of tension and discomfort (Ekwall, Solis, & Solis,
1973).
Higher physiological activation, namely, increasing SCR and HR, has been interpreted as a
consequence of the activation of the behavioral inhibitory system, which is important in
stemming impulsiveness and keeping arousal at appropriate levels to focus attention and carry
out intentional behaviors (Gray, 1972; Dykman, Ackerman, Holcomb, & Boudreau, 1983).
According to Gray (1972, 1978; see also Fowles, 1980; Fowles, Kochanska, & Murray, 2000),
the behavioral inhibition system could also produce withdrawal or anxiety and inhibits
behavior in the presence of a threat or risk of punishment.
In summary, most of the studies indicate that children with learning disabilities and controls
are physiologically different in terms of baseline and reactivity levels. However, conclusions
on this topic are inconsistent probably due to the lack of sample homogeneity, e.g., grouping
together children with varying degrees and types of learning disability, with or without
attention deficit disorders and hyperactivity (Dykman et al., 1983). Furthermore, these studies
used different types of stimulation to measure autonomic responsivity; therefore, their results
are difficult to compare. Finally, the main purpose of this branch of research was to identify
physiological abnormalities in hyperactive children, paying minor attention to children with
learning disabilities.

Aim of the study


The primary aim of this exploratory study was to investigate psychophysiological responses to
specific tasks in children with dyslexia and in a group of typical readers. Physiological
assessment measures may allow to detect small but significant changes in physiological
responses that might not be detected by self-report measures (Korotitsch & Nelson-Gray,
1999). In particular, electrodermal responses to reading tasks were analyzed and compared
with responses to control tasks. Two main points are addressed:
(1) Considering the group of children with DD, we expect a significant difference in SCR
indices between reading and nonreading tasks, whereas we expect to find a similar activation
pattern for tasks involving reading, or not, in a control group of typical readers. Considering
past studies that analyzed autonomic responses in children with learning disabilities (Dykman
et al., 1982; Hunter et al., 1972) and studies that investigated emotional reaction to reading
tasks in poor readers (Butkowsky & Willows, 1980; Carroll & Iles, 2006), we expected to find
higher physiological activation (e.g., higher levels of SCR) in response to reading tasks
compared to tasks involving the description of illustrated stories. We hypothesized that reading
tasks may have the potential to act as a threatening stimulus in dyslexic children (Mugnaini
et al., 2009), thus provoking a stronger increase in physiological arousal indexed by higher
SCR (Bchel et al., 1998) compared to a less threatening task such as the description of
illustrated stories.
Within the dyslexic group, we want also to investigate eventual differences in SCR when
reading silently or aloud. In educational and clinical practice, it is well known that reading
aloud can be a threatening stimulus for dyslexic children; nonetheless, to date, no studies
systematically explored the effects of reading aloud versus reading silently in children with and
without reading difficulties. These observation, together with the studies cited above, led to the

Physiological activation during reading

hypothesis of a higher activation in aloud versus silent reading in dyslexic children, compared
to controls. The higher activation would be operationalized by higher levels of SCR.
(2) We expect significant differences between children with DD and typical readers in the
activation in response to reading tasks but not to tasks involving the description of illustrated
stories. In particular, we expect higher SCR scores for dyslexic children in the two reading
tasks, due to the emotional arousal related to the request of reading (Carroll & Iles, 2006).
Furthermore, this study analyzed differences between dyslexic children and controls in
components of school wellness, through self-report questionnaires administered to children
and their parents. In this case, we expected dyslexic children to have a worse emotional
attitude toward school, lower scores on self-efficacy, and poorer relationships with teachers
and classmates, compared with controls (e.g., Ginieri-Coccossis et al., 2012; Ingesson, 2007).
We also expected that their parents would report more childrens emotional and behavioral
problems (e.g., Carroll et al., 2005; Dahle et al., 2011).

Methods
Participants
Thirty-two third- through eighth-grade students participated to the study: 16 children (37.5 %
girls, mean age=10.411.93 years, age range=8.1713.50 years) had a diagnosis of developmental dyslexia (DD), whereas 16 children (50 % girls, mean age=10.791.91 years, age
range=8.5014.00 years) were in the control group of typical reading children (TR). All the
participants had Italian as their first language and they were all volunteers recruited through an
advertisement.
All children in the DD group had a formal diagnosis of dyslexia following the ICD-10
(World Health Organization, 2004), and at least two parameters among reading speed and
accuracy of words and pseudo-words (Battery for the evaluation of dyslexia and spelling
disorder; Sartori, Job, & Tressoldi, 2007) that were <1.5 SD. Exclusion criterion was the
additional clinical diagnosis of attention deficit hyperactivity disorder (ADHD) according to
the DSM-IV (American Psychiatric Association, 2000). The control group was composed of
typically developing children who attended school regularly and were typical readers (at least
three parameters among reading speed and accuracy of words and pseudo-words >1.5 SD). A
chi-square test indicated that the composition of groups was balanced by gender (2(1)=.51, p>.
05) and by the attended grade (L2(5)=5.19, p>.05), and an independent sample t test showed no
significant age differences between the two groups (t(30)=.56, p>.05).

Measures and material


Experimental tasks A total of four experimental conditions, plus baseline recording, were
administered to all participants. In the baseline condition, SCR was measured in a 1-min
session before the experimental tasks; in this session, children were asked to wait for a few
seconds without doing anything. The reading task consisted of a set of 42 short sentences
(Palladino, 2005), randomly assigned to two lists of 21 sentences each. The sentences length
varied from 5 to 13 words (mean=8.52 words, SD=1.76), and they were adequate for children
from second grade, considering their meaning, syntactic structure, and lexicon (Palladino,
2005). An example of a true sentence is BThe postman delivers letters and postcards,^ and an

V. Tobia et al.

example of false sentence is BAt the zoo you can see famous paintings.^ Children were invited
to read one list aloud and the other one silently; moreover, for each sentence, they had to
indicate if it was true or false. This procedure allowed verifying that children read the
sentences also in the silent modality. For each list, the time limit was 5 min.
Finally, 12 illustrated stories, each composed of three or four vignettes (e.g., in Fig. 1), were
randomly assigned to two lists of 6 stories; each list consisted of a total of 21 vignettes, and the
children were asked to produce one short sentence to describe each vignette. For one list, the
sentences had to be pronounced aloud, for the other list, children were asked to produce them
silently. At the end of each brief story (three or four vignettes), the child had to indicate, on a
three-point Likert scale, how clear the vignettes were in illustrating the story. This task
prompted children to produce similar verbal material to that produced in the reading task
(i.e., short simple sentences) without the reading component. The spontaneous production of
sentences was required, offering a guideline (the illustrated stories) to make sure that the
number of sentences pronounced was exactly the same as the sentences that they read; in fact,
children were instructed to say just one sentence for each of the 21 vignettes that were
presented for each condition (silently vs. aloud).
The order of the four tasks was counterbalanced across participants; furthermore, the two
lists of sentences and illustrated stories were alternated, between participants, among aloud and
silent tasks.

Reading ability Words and pseudo-words reading tasks from the BBattery for the evaluation
of dyslexia and spelling disorder^ (Sartori et al., 2007) were administered in order to assess
childrens reading speed and accuracy. The first reading task consists of four lists of 28 isolated
words with different frequency, whereas the pseudo-words reading tasks comprise three lists of
16 pseudo-words with different orthographic complexity. Syllables for second and number of
1

Fig. 1 Example of illustrated story

Physiological activation during reading

errors for each task were recorded, and then raw scores were converted to z-scores according to
the Italian norms (Sartori et al., 2007).

School wellness The Questionnaire on School Wellness (QSW; Tobia & Marzocchi, in press)
is a questionnaire created to investigate the school experience in children with learning
disabilities, considering three different perspectives: children, parents, and teachers. In particular, the QSW investigates the emotional and motivational impact of their difficulties within
the learning context, by self-report and/or considering parent and teacher observations.
Furthermore, it analyzes emotional distress connected to childrens difficulties experienced
by parents and teachers. In the present study, the QSW was administered to children (QSWchildren) and to one of their parents (QSW-parents). The childrens version is composed of 27
items and five subscales: Gratification obtained by school results (=.76; e.g., BI am satisfied
with the results I get at school^), Relationship with teachers (=.78; e.g., BI trust my
teachers^), Relationship with classmates (=.74; e.g., BI feel accepted in my class^),
Emotional attitude towards school (=.62; e.g., BIm ashamed to speak in front of the whole
class^), and Self-efficacy (=.62; e.g., BUsually I have good ideas^). Total score was obtained
by adding the mean scores obtained in the five subscales.
The parents version includes 36 items and five subscales: Personal experience in relation to
the childs difficulties (=.84; e.g., BI feel alone in front of my childs difficulties^),
Evaluation of learning processes (=.85; e.g., BMy child experiences difficulties in reading^),
Childs emotional difficulties (=.72; e.g., BMy child is anxious when he/she has a school
examination^), Childs behavioral problems (=.68; e.g., BMy child is lazy when its time to
do his/her homework^), and Relationship with teachers (=.82; e.g., BMy childs teachers
collaborate with our family to help him/her^). QSW-parents total score is the sum of the mean
scores obtained in the first four subscales, minus the mean of the scores obtained in the
Relationship with teachers subscale. Responses were obtained on a three-point Likert scale
ranging from not true (0) to very true (2). Cronbachs alphas for the QSW-children were
calculated on a community sample of 250 primary (fourth and fifth grades) and middle school
students. A confirmatory factor analysis (CFA) was also performed to analyze the factorial
structure of the questionnaire. Results showed acceptable fit indices (Hu & Bentler, 1999):
root-mean-square error of approximation (RMSEA) =.046, 90 % confidence interval
(CI)=.037.056, Comparative Fit Index (CFI)=.93, and Tuker-Lewis Index (TLI)=.92.
Cronbachs alphas for the QSW-parents were obtained on a sample of 223 questionnaires administered to parents of children with and without specific learning disabilities (Tobia & Marzocchi 2011); on the same sample, a CFA showed acceptable fit
indices considering the five subscales described (RMSEA = .059, CI = .053.065,
CFI=.91, TLI=.90).

Procedure
Parents were informed of the aim and procedures of the research and signed the informed
consent. Children were tested in one 30-min session in a quiet laboratory at the university. First,
children familiarized for 5 min with the instrument used to measure SCR, and then baseline was
registered. Afterward, the four experimental tasks were administered with SCR continuously
recorded using the BPsycholab Satem VD13SV,^ a portable device used to collect psychophysiological data. The measurement unit for SCR is microsiemens (s), and it was

V. Tobia et al.

monitored through two gold-plated sensors (surface=1 cm2) placed on the volar surface of the
middle phalanx of index and middle fingers of the subjects left hand.
The words and pseudo-words reading tasks were then presented. Finally, children filled in
the QSW-children and a parent filled in the QSW-parents.
The entire procedure and the following scoring phase were conducted by a trained doctoral
student who was also qualified as a clinical psychologist.
The experiment was approved by the Research Ethics Committee of the university.

Data treatment
Independent sample t tests were run to analyze differences between the two groups (dyslexics
and typical readers) on reading speed and accuracy of words and pseudo-words z-scores.
Physiological recordings from the first minute of each task were isolated for each child to
obtain a comparable amount of time for each participant. Then, SCR values corresponding to 0
(0.95 % of total number of measurements) and considered recording errors were removed.
Finally, SCR change scores (task minus baseline) were calculated for each experimental task.
To test the first hypothesis and conduct an analysis of differences between tasks within each
group, two 22 repeated measure multivariate analyses of variance (MANOVAs; Production:
silent vs. aloud; Material: read sentences vs. describing illustrated stories) were run separately
for DD and TR groups. To support our hypothesis, we expected to find, for the DD group,
significantly higher SCR reactivity to the reading tasks compared to the describing stories
tasks, i.e., significant Material main effect and/or Production Material interaction. We did not
expect to find these effects in the TR group. To better understand the relationships that drive
the interaction effects eventually found with the MANOVAs, repeated measure t tests on DD
and TR groups separately were performed.
To test our second hypotheses, a MANOVA with Group as a between-subject factor and the
mean SCR change for the four tasks as dependent variables was performed. According to
hypothesis 2, we expected to find significant Group effect for SCR recorded during reading
tasks (only reading aloud or both reading silently and reading aloud) but not during describing
illustrated stories tasks.
Finally, associations between questionnaire scores and SCR were analyzed. First, to test for
between-group differences at the QSW, two MANOVAs were run to compare QSW subscale
scores obtained by dyslexic children and their parents with those obtained by the control
group; two ANOVAs were performed to analyze differences in total scores. Then, Pearson
correlations were run to investigate associations between scores of the QSW subscales (parents
and children versions), and SCR change scores in each condition; correlation analysis was
performed on the entire sample.
The effect sizes (ESs) were computed: To interpret main effects and interactions
produced by the ANOVAs and MANOVAs, eta squared (2; Cohen, 1988) was
calculated, whereas effect size according to the Hedges formula (Hedges g;
Hedges, 1981) was computed in order to understand the differences between groups.
For paired comparisons, the formula by Morris and DeShons (2002; corrected ES)
that includes the correlations between means was applied. The magnitude of effect
size for groups or paired comparisons may be interpreted applying Cohens (1988)
convention for small (0.2), medium (0.5), and large (0.8) effect sizes. Considering
Cohens (1988) guidelines to interpret eta squared, values of .01 are small, .06 are
medium, and greater than .14 are large.

Physiological activation during reading

Results
Independent sample t tests indicated significant differences between groups in all the reading
variables considered: reading words speed (t(30)=7.216, p<.001, g=2.49) and accuracy
(t(30)=3.663, p<.01, g=1.26), and reading pseudo-words speed (t(30)=6.617, p<.001, g=
2.27) and accuracy (t(30)=6.095, p<.001, g=2.10).
No significant differences between groups were found for SCR baseline (t(30)=.43,
p>.05; DD mean=13.17, SD=9.44; TR mean=11.99, SD=5.64; g=.15).
Considering children with DD (Fig. 2a), the 22 repeated measure MANOVA showed no
significant main effect of Material (F(1, 15)=.116, p=.738, 2 =.008) or Production (F(1,
15)=.246, p=.627, 2 =.016), whereas a significant Material*Production interaction effect was
found (F(1, 15)=5.874, p=.028, 2 =.281). Repeated measure t tests showed that, whereas
aloud production is related to higher SCR change scores when describing illustrated stories
(t(15)=2.77, p=.014; describing illustrated stories aloud mean SCR change score=.53, SD=
6.12; describing illustrated stories silently mean SCR change score=1.15, SD=6.05;
corrected ES=.69), the reading task is associated to a similar activation in the aloud and silent
modalities (t(15)=1.06, p=.304; reading aloud mean SCR change score=.59, SD=6.51;
reading silently mean SCR change score=.49, SD=5.41; corrected ES=.27).
The same analysis on the TR group (Fig. 2b) showed a significant main effect of Production
(F(1, 15)=17.690, p=.001, 2 =.541), with a globally higher activation in the tasks using aloud
production (p=.001). Neither the main effect of Material (F(1, 15)=2.064, p=.171, 2 =.121)
nor the interaction Material*Production (F(1, 15)=.228, p=.640, 2 =.015) was significant.
Repeated measure t tests showed that SCR change scores were higher for the aloud production,
both for describing illustrated stories (t(15)=2.753, p=.015; describing illustrated stories aloud
mean SCR change score=3.07, SD=4.68; describing illustrated stories silently mean SCR
change score=1.50, SD=4.73; corrected ES=.68) and for reading tasks (t(15)=2.920, p=.011;
reading aloud mean SCR change score=4.10, SD=4.24; reading silently mean SCR change
score=.49, SD=3.28; corrected ES=1.39).

(a)
7
6
5
4
3
2
1
0
-1
-2
-3
-4
-5

Children with Developmental Dyslexia

(b) Typical readers

Aloud
Silently

Read sentences

Describe
vignettes

Read sentences

Describe
vignettes

Fig. 2 Separately for children with development dyslexia (a) and for typical readers (b), mean skin conductance
response (SCR) change scores in the first minute of the four experimental conditions: reading sentences aloud,
reading sentences silently, describing vignettes aloud, and describing vignettes silently

V. Tobia et al.

The analysis performed to investigate hypothesis 2 showed a significant difference only for
the reading aloud condition, with DD group showing lower SCR than the TR group (F(1, 30)=
5.842, p=.022, 2 =.163; DD mean=.59, SD=6.51; TR mean=4.10, SD=4.24; g=.83).
Both the MANOVA on QSW-children subscales and the ANOVA on the total score showed
no significant main effect of Group. Parents results showed a significant main effect of Group
for the following subscales: Personal experience in relation to the childs difficulties (F(1,
30)=9.83, p<.01, 2 =.25), Evaluation of learning processes (F(1, 30)=136.12, p<.001,
2 =.82), and Childs emotional difficulties (F(1, 30)=11.31, p<.01, 2 =.27). A significant
main effect of Group was found also for the QSW-parents versions total score (F(1, 30)=
34.77, p<.001, 2 =.54). Descriptive statistics and effect sizes of significant differences are
presented in Table 1.
Significant inverse correlations were found between SCR change scores and the Childs
emotional difficulties subscale of the QSW-parents: A score indicating more emotional
difficulties was related to lower SCR change in the reading aloud (r=.46, p=.009), reading
silently (r=.39, p=.027), and describing illustrated stories silently (r=.35, p=.048) tasks.
No significant correlations emerged between SCR change scores and the QSW-children.

Discussion
The main purpose of the present study was to analyze physiological reactions to a series of
reading tasks considering a sample of dyslexic children and a control group. The first aim was
to test differences in SCR, between reading and describing stories tasks in children with DD
and TR. We expected higher SCR on reading tasks only for the DD group. The main effect of
type of Material was not significant for both groups, but results showed an interaction effect
Table 1 Descriptive statistics and effect sizes for the subscales and total scores of the questionnaires for school
wellness (QSW)
Task

QSW-children

QSW-parents

DD (n=16)
Mean (SD)

TR (n=16)
Mean (SD)

Effect size
(Hedges g)

Gratification obtained by school results

1.56 (0.43)

1.28 (0.51)

Relationship with teachers

1.55 (0.38)

1.32 (0.54)

Relationship with classmates

1.50 (0.52)

1.60 (0.52)

Emotional attitude towards school

0.98 (0.47)

1.22 (0.35)

Self-efficacy

1.47 (0.30)

1.37 (0.35)

Total score

7.06 (1.30)

6.80 (1.36)

Personal experience in relation to


the childs difficulties

0.83 (0.44)

0.43 (0.25)

1.09

Evaluation of learning processes

1.35 (0.38)

0.13 (0.18)

4.00

Childs emotional difficulties

0.89 (0.47)

0.41 (0.33)

1.15

Childs behavioral problems

1.02 (0.32)

0.81 (0.35)

Relationship with teachers

1.09 (0.51)

1.30 (0.71)

Total score

3.00 (1.38)

0.49 (0.99)

2.04

Score range is 02 for subscales, 010 for QSW-children version total score, and 06 for QSW-parents version
total score
QSW Questionnaire on School Wellness, DD developmental dyslexia, TR typical readers

Physiological activation during reading

for the DD group, with higher activation for aloud than silent production when describing
illustrated stories, but not when reading; for this task, children with DD showed a similar SCR
in the two modalities, close to the baseline. On the other hand, for the TR group, a generally
higher activation was found for both tasks involving aloud production. This result is consistent
with past studies: Reading aloud and talking, in the absence of emotional content, have been
shown to elicit significant sympathetic nervous system activation (Bernardi et al., 2000).
Therefore, the main hypothesis was not supported, but a significant difference in the pattern
of SCR change in DD group, compared to TRs, was found. With reference to the second
hypotheses of the study, the principal result was a significantly weaker SCR for the DD group
in the reading aloud tasks (large effect size), whereas the SCR change scores in the other tasks
were similar in DD and TR groups.
Therefore, the main result of the present study was an atypical skin conductance activation
during the reading-aloud task in dyslexic children, whereas their physiological activation to the
reading silently and the control tasks was comparable to that showed by the controls. Children
with dyslexia did not present the Bordinary^ higher activation for aloud tasks, compared to
silently tasks, when reading was involved. In particular, the difference resulted in a hypoactivation in children with dyslexia, compared to the control group, when reading aloud. This
result is in contradiction with our hypothesis (namely, higher SCR during reading tasks in
children with DD). A possible interpretation refers to the fact that low or decreased SCR could
be related to some strategies aimed to control the negative emotions elicited by a stimulus;
examples of these strategies are reappraisal (McRae, Ciesielski, & Gross, 2012; Ottaviani et
al., 2014) and distraction (Sheppes, Catran, & Meiran, 2009). Sympathetic hyporeactivity or
absence of sympathetic hyperreactivity has been also observed in worried (e.g., Delgado et al.,
2009; Thayer, Friedman, & Borkovec, 1996) or depressed (Ellis, Vanderlind, & Beevers,
2013) people, and interpreted as an autonomic nervous system dysregulation. Another possible
explanation involves literature that showed how certain types of cognitive load may reduce
electrodermal arousal. For example, early physiological literature has reported that, when
stressful tasks involve a heightened focus of attention, skin conductance often decreases
(e.g., Harrison & MacKinnon, 1966). This result has been replicated in more recent studies
of cognitive load and its effect on arousal (e.g., Leal, Vrij, Fisher, & van Hooff, 2008). On the
other side, tasks requiring attention involve greater arousal (Rugel & Rosenthal, 1974), and a
low SCR could also reflect a lack of attention to the task, possibly due to a passive attitude
toward the reading aloud task by dyslexic children.
This interpretations could lead to the conclusion that reading aloud was perceived, by
dyslexic children, as a threat that activates an autonomic response to avoid the negative
consequences associated with this critical request. However, this reaction was specific to the
reading-aloud tasks and was not evoked by other cognitive requests, even when they implicated silent reading; furthermore, it was not due to baseline differences between the dyslexic
and control groups. Past studies that reported alterations in basal skin conductance or HR in
children with learning disabilities suggested that it was caused by expectations of failure
(Dykman et al., 1983) or it was a reaction to nonspecific background stimuli experienced in a
novel and busy environment such as a laboratory (Zahn, Rapoport, & Thompson, 1980). In the
present study, children were all informed that they were going to read sentences and describe
illustrated stories before starting the baseline recording, and they were all tested in the same
environment; however, no alterations in baseline skin conductance were observed. Therefore,
the present results does not support the assertion that learning-disabled children are Blacking in
those specific arousal or emotive supports necessary for sustained attention and learning^

V. Tobia et al.

(Dykman, Walls, Suzuki, Ackerman, & Peters, 1970), supported also by Hunter et al. (1972),
or that they have an atypical physiological activation that is the result of general attentional
problems (Dykman et al., 1983). Conversely, we showed that the atypical physiological
activation observed in children with dyslexia is task-related and not a general abnormal
response to cognitive exercise. In particular, their psychophysiological activation is comparable to that of typical readers during tasks involving silent reading and aloud or silent
production of sentences from visual stimuli, whereas they show a specific SCR response
alteration to the specific cognitive request of reading aloud. We may speculate that repeated
frustrating experiences and persistent struggling with reading dispose dyslexics to show
atypical physiological reactivity when placed in a situation demanding specific literacy skills,
such as fluent reading aloud. If reading tasks should be considered a threatening stimuli per se
for dyslexic children, in the reading aloud condition, children may add to the Bcognitive load^
of reading the Bshame^ of performing the task aloud, a condition in which the child might
experience the fear of being judged for his/her difficulties. Further investigation would be
needed to analyze in greater depth the differences in physiological activation and psychological correlates between reading aloud and reading silently. However, this first insight seems to
support educational practices that recommend that dyslexic children abstain from reading
aloud in class.
Another aim of the present study was to analyze differences between clinical and control
groups in variables related to school wellness, such as satisfaction regarding school results,
emotional attitude toward school and learning activities, relationship with teachers and
classmates, and self-efficacy. Questionnaire scores revealed significant differences between
dyslexic and controls when considering parents reports, but not when considering children
self-evaluation. We can speculate that children with dyslexia showed ratings similar to controls
on school wellness variables because they underestimate the fatigue experienced in the school
context to protect themselves from a stressful recognition of it. This interpretation would
parallel the activation of the behavioral inhibition system during reading-aloud tasks,
in terms of a similar response to avoid threatening stimuli. Alternatively, children may
struggle with describing their internalizing problems via a self-report measure
(Korotitsch & Nelson-Gray, 1999).
Parent evaluation of childrens emotional difficulties was correlated with childrens SCR
recorded during reading tasks and during describing illustrated stories silently task. This
subscale from the QSW-parents does not specifically investigate threat response to reading
but could be considered an index of emotional arousal linked to learning problems, containing
four items that asked parents to rate their childrens levels of anxiety, rage, worry, and sadness
considering their learning difficulties. The correlation with physiological measures detected
during reading tasks could be interpreted in terms of identification by parents of a distress
expressed by children through physiological activation, but not through self-reports.
Speculating, it seems that, in some way, parents are able to recognize and report an emotional
arousal not recognized or reported by their children but detectable through physiological
measures. This is one of the possible interpretations of such results and, as suggested, should
be considered only a speculation.
Furthermore, the significant differences between dyslexic and controls, found only for the
QSW-parents versions scores and not for the childrens version, suggest low childparent
agreement on school wellness; this is in line with Rotsika et al.s (2011) study that provided
evidence on differences in childparent ratings of variables such as quality of life in the school
context, considering children with a specific learning disability (see also Bonifacci, Storti,

Physiological activation during reading

Tobia, & Suardi, 2015). This result indicates the importance of broadening the focus on the
emotional consequences of DD through different instruments, also involving Bsignificant
others^ such as parents, as critical informants. However, it should be also considered that
parents of children with dyslexia are themselves characterized for having higher
parental distress, mainly due to the perception of having a difficult child, in comparison to parents of typical developing children (Bonifacci, Montuschi, Lami &
Snowling, 2014), and this higher level of distress might elicit a higher attribution of
distress to their children.
A clear limitation of the present study is the small sample size, composed by children with a
wide age range; to partly obviate to this limitation, we supported the significance of our results
reporting appropriate effect sizes for each analysis, basing on the literature that strongly
criticizes the exclusive use of p value, in particular with small clinical samples (e.g., Agnoli
& Furlan, 2008; Anderson, Burnham, & Thompson, 2000; Cohen, 1988). Also, we excluded
children with an additional diagnosis of ADHD, but it is possible that participants presented
subthreshold symptomology of ADHD; the absence of specific instruments to evaluate this
component is a second limit of this study. Unfortunately, we did not have information
regarding children attending private or public school, regarding the families socio-economic
status, and regarding eventual past reading treatment; such information would be useful to
investigate potential moderators of childrens wellness, for example. Finally, the questionnaires
did not specifically and exhaustively investigate threat response to reading tasks and stress
symptoms but gave a general picture of childrens wellness in the school context, considering
also emotional arousal linked to learning difficulties.
Future investigations should imply the enlargement of the sample, incorporate multiple
autonomic indicators, and combine physiological measures with more specific self- and
parent-proxy reports to analyze childrens experience during different sets of tasks from
different perspectives. Then, it would be useful to know if and how the physiological
alterations observed in dyslexic children during reading aloud affect reading performance,
also examining possible influences over time. In addition, it would be important to experimentally investigate possible factors that could attenuate the physiological effect of the
stressful task, in order to intervene on the atypical autonomic activation. Finally, it would be
useful to involve a control group of reading-age matched children, to disentangle whether
differences in autonomic response relate to the task difficulty as experienced by the participants or to the task anxiety specific to dyslexia.

References
Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional
problems: implications of cross-informant correlations for situational specificity. Psychological Bulletin,
101(2), 213.
Ackerman, P. T., Dykman, R. A., & Peters, J. E. (1977). Teenage status of hyperactive and nonhyperactive
learning disabled boys. American Journal of Orthopsychiatry, 47(4), 577596.
Agnoli, F., & Furlan, S. (2008). La differenza che fa la differenza: dalla significativit statistica alla significativit
pratica [The difference that makes the difference: from statistical significance to practical significance].
Psicologia Clinica dello Sviluppo, 12(2), 209243.
American Psychiatric Association (Ed.) (2000). Diagnostic and statistical manual of mental disorders: DSM-IVTR. American Psychiatric Pub.
Anderson, D. R., Burnham, K. P., & Thompson, W. L. (2000). Null hypothesis testing: problems, prevalence, and
an alternative. The Journal of Wildlife Management, 64(4), 912923.

V. Tobia et al.
Bandura, A., Pastorelli, C., Barbaranelli, C., & Caprara, G. V. (1999). Self-efficacy pathways to childhood
depression. Journal of Personality and Social Psychology, 76(2), 258269.
Barbiero, C., Lonciari, I., Montico, M., Monasta, L., Penge, R., Vio, C., et al. (2012). The submerged dyslexia
iceberg: how many school children are not diagnosed? results from an Italian study. PloS One, 7(10),
e48082.
Bernardi, L., Wdowczyk-Szulc, J., Valenti, C., Castoldi, S., Passino, C., Spadacini, G., et al. (2000). Effects of
controlled breathing, mental activity and mental stress with or without verbalization on heart rate variability.
Journal of the American College of Cardiology, 35(6), 14621469.
Bonifacci, P., Candria, L., & Contento, S. (2008). Reading and writing: what is the relationship with anxiety and
depression? Reading and Writing, 21(6), 609625.
Bonifacci, P., Montuschi, M., Lami, L., & Snowling, M. J. (2014). Parents of children with dyslexia: cognitive,
emotional and behavioural profile. Dyslexia, 20(2), 175190.
Bonifacci, P., Storti, M., Tobia, V., & Suardi, A. (2015). Specific learning disorders a look inside childrens and
parents psychological well-being and relationships. Journal of learning disabilities. doi:10.1177/
0022219414566681.
Bryant, H. W. (1976). Columbia. An investigation of childrens arousal levels. Doctoral dissertation, University
of British.
Bchel, C., Morris, J., Dolan, R. J., & Friston, K. J. (1998). Brain systems mediating aversive conditioning: an
event-related fMRI study. Neuron, 20(5), 947957.
Butkowsky, I. S., & Willows, D. M. (1980). Cognitive-motivational characteristics of children varying in reading
ability: evidence for learned helplessness in poor readers. Journal of Educational Psychology, 72(3), 408
422.
Carroll, J. M., & Iles, J. E. (2006). An assessment of anxiety levels in dyslexic students in higher education.
British Journal of Educational Psychology, 76(3), 651662.
Carroll, J. M., Maughan, B., Goodman, R., & Meltzer, H. (2005). Literacy difficulties and psychiatric disorders:
evidence for comorbidity. Journal of Child Psychology and Psychiatry, 46(5), 524532.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale: Erlbaum.
Critchley, H. D., Elliott, R., Mathias, C. J., & Dolan, R. J. (2000). Neural activity relating to generation and
representation of galvanic skin conductance responses: a functional magnetic resonance imaging study. The
Journal of Neuroscience, 20(8), 30333040.
Dahle, A. E., & Knivsberg, A. M. (2014). Internalizing, externalizing and attention problems in dyslexia.
Scandinavian Journal of Disability Research, 16(2), 179193.
Dahle, A. E., Knivsberg, A. M., & Andreassen, A. B. (2011). Coexisting problem behaviour in severe dyslexia.
Journal of Research in Special Educational Needs, 11(3), 162170.
Delgado, L. C., Guerra, P., Perakakis, P., Mata, J. L., Prez, M. N., & Vila, J. (2009). Psychophysiological
correlates of chronic worry: cued versus non-cued fear reaction. International Journal of Psychophysiology,
74(3), 280287.
Dey, M., Landolt, M. A., & Mohler-Kuo, M. (2013). Assessing parentchild agreement in healthrelated quality of life among three health status groups. Social Psychiatry and Psychiatric
Epidemiology, 48(3), 503511.
Dykman, R. A., Ackerman, P. T., Holcomb, P. J., & Boudreau, A. Y. (1983). Physiological manifestations of
learning disability. Journal of Learning Disabilities, 16(1), 4653.
Dykman, R. A., Ackerman, P. T., Oglesby, D. M., & Holcomb, P. J. (1982). Autonomic responsivity during
visual search of hyperactive and reading-disabled children. The Pavlovian Journal of Biological Science:
Official Journal of the Pavlovian, 17(3), 150157.
Dykman, R. A., Walls, R. C., Suzuki, T., Ackerman, P. T., & Peters, J. E. (1970). Children with learning
disabilities: conditioning, differentiation, and the effect of distraction. American Journal of Orthopsychiatry,
40(5), 766782.
Ekwall, E. E., Solis, J. K. E., & Solis, E. (1973). Investigating informal reading inventory scoring criteria.
Elementary English, 50(2), 271323.
Ellis, A. J., Vanderlind, W. M., & Beevers, C. G. (2013). Enhanced anger reactivity and reduced distress
tolerance in major depressive disorder. Cognitive Therapy and Research, 37(3), 498509.
Fowles, D. C. (1980). The three arousal model: Implications of Grays two-factor learning theory for heart rate,
electrodermal activity, and psychopathy. Psychophysiology, 17(2), 87104.
Fowles, D. C., Kochanska, G., & Murray, K. (2000). Electrodermal activity and temperament in preschool
children. Psychophysiology, 37(6), 777787.
Ginieri-Coccossis, M., Rotsika, V., Skevington, S., Papaevangelou, S., Malliori, M., Tomaras, V., et al. (2012).
Quality of life in newly diagnosed children with specific learning disabilities (SpLD) and differences from
typically developing children: a study of child and parent reports. Child: Care, Health and Development,
39(4), 581591.

Physiological activation during reading


Gray, J. A. (1972). The structure of the emotions and the limbic system. In R. Porter & J. Knight (Eds.),
Physiology, emotion and psychosomatic illness, Ciba Foundation Symposium 8 (new series) (pp. 87130).
Amsterdam: Associated Scientific.
Gray, J. A. (1978). The 1977 Myers lecture: the neuropsychology of anxiety. British Journal of Psychology, 69,
417434.
Hall, C. W., Spruill, K. L., & Webster, R. E. (2002). Motivational and attitudinal factors in college students with
and without learning disabilities. Learning Disability Quarterly, 25, 7986.
Harrison, J., & MacKinnon, P. C. B. (1966). Physiological role of the adrenal medulla in the palmer anhidrotic
response to stress. Journal of Applied Physiology, 21, 8892.
Hedges, L. V. (1981). Distribution theory for Glasss estimator of effect size and related estimators. Journal of
Educational Statistics, 6(2), 106128.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: conventional
criteria versus new alternatives. Structural Equation Modeling, 6, 155.
Hulme, C., & Snowling, M. J. (2009). Developmental disorders of language learning and cognition. Oxford:
Wiley-Blackwell.
Hunter, E. J., Johnson, L. C., & Keefe, F. B. (1972). Electrodermol and cardiovascular responses in nonreaders.
Journal of Learning Disabilities, 5(4), 187197.
Ingesson, S. G. (2007). Growing up with dyslexia interviews with teenagers and young adults. School
Psychology International, 28(5), 574591.
Johnson, D. J., & Myklebust, H. R. (1967). Learning disabilities: Educational principles and practices. New
York: Grune and Stratton.
Karande, S., & Venkataraman, R. (2012). Self-perceived health-related quality of life of Indian children with
specific learning disability. Journal of Postgraduate Medicine, 58(4), 246254.
Knivsberg, A. M., & Andreassen, A. B. (2008). Behaviour, attention and cognition in severe dyslexia. Nordic
Journal of Psychiatry, 62(1), 5965.
Korotitsch, W. J., & Nelson-Gray, R. O. (1999). An overview of self-monitoring research in assessment and
treatment. Psychological Assessment, 11(4), 415.
Lamm, O., & Epstein, R. (1992). Specific reading impairments-are they to be associated with emotional
difficulties? Journal of Learning Disabilities, 25(9), 605615.
Manassis, K. (2013). Cognitive findings in childhood anxiety: translations for clinical practice. Translational
Neuroscience, 4(1), 8895.
McRae, K., Ciesielski, B., & Gross, J. J. (2012). Unpacking cognitive reappraisal: goals, tactics, and outcomes.
Emotion, 12(2), 250255.
Miller, C. J., Hynd, G. W., & Miller, S. R. (2005). Children with dyslexia: Not necessarily at risk for elevated
internalizing symptoms. Reading and Writing, 18, 425436.
Morris, S. B., & DeShon, R. P. (2002). Combining effect size estimates in meta-analysis with repeated measures
and independent-groups designs. Psychological Methods, 7, 105125.
Mugnaini, D., Lassi, S., La Malfa, G., & Albertini, G. (2009). Internalizing correlates of dyslexia. World Journal
of Pediatrics, 5(4), 255264.
Nelson, J. M., & Harwood, H. (2011). Learning disabilities and anxiety: a meta-analysis. Journal of Learning
Disabilities, 44(1), 317.
Ottaviani, C., Borlimi, R., Brighetti, G., Caselli, G., Favaretto, E., Giardini, I., et al. (2014). Worry as an adaptive
avoidance strategy in healthy controls but not in pathological worriers. International Journal of
Psychophysiology, 93(3), 349355.
Palladino, P. (2005). Uno strumento per esaminare la memoria di lavoro verbale in bambini di scuola elementare:
taratura e validit. Psicologia Clinica dello Sviluppo, 9(1), 129150.
Polychroni, F., Koukoura, K., & Anagnostou, I. (2006). Academic selfconcept, reading attitudes and approaches
to learning of children with dyslexia: do they differ from their peers? European Journal of Special Needs
Education, 21(4), 415430.
Riddick, B., Sterling, C., Farmer, M., & Morgan, S. (1999). Selfesteem and anxiety in the educational histories
of adult dyslexic students. Dyslexia, 5(4), 227248.
Rotsika, V., Coccossis, M., Vlassopoulos, M., Papaeleftheriou, E., Sakellariou, K., Anagnostopoulos, D. C., et al.
(2011). Does the subjective quality of life of children with specific learning disabilities (SpLD) agree with
their parents proxy reports? Quality of Life Research, 20(8), 12711278.
Rugel, R. P., & Rosenthal, R. (1974). Skin conductance, reaction time, and observational ratings in learningdisabled children. Journal of Abnormal Child Psychology, 2(3), 183192.
Sartori, G., Job, R., & Tressoldi, P. (2007). Battery for the evaluation of dyslexia and spelling disorder. Firenze:
Organizzazioni Speciali.
Snowling, M. J., Muter, V., & Carroll, J. (2007). Children at family risk of dyslexia: a follow-up in early
adolescence. Journal of Child Psychology and Psychiatry, 48(6), 609618.

V. Tobia et al.
Tabassam, W., & Grainger, J. (2002). Self-concept, attributional style and self-efficacy beliefs of students with learning
disabilities with and without attention deficit hyperactivity disorder. Learning Disability Quarterly, 25, 141151.
Thayer, J. F., Friedman, B. H., & Borkovec, T. D. (1996). Autonomic characteristics of generalized anxiety
disorder and worry. Biological Psychiatry, 39, 255266.
Tobia, V., & Marzocchi, G. M. (2011). Il benessere nei bambini con disturbi specifici dellapprendimento e nei
loro genitori: uno studio pilota con il questionario sul benessere scolastico-versione per genitori [The wellbeing of children with specific learning disabilities and their parents: a pilot study with the Questionnaire on
the School Wellness-parents' version]. Ricerche di psicologia, 4, 499517.
Undheim, A. M. (2003). Dyslexia and psychosocial factors. a follow-up study of young Norwegian adults with a
history of dyslexia in childhood. Nordic Journal of Psychiatry, 57(3), 221226.
Vellutino, F. R., Fletcher, J. M., Snowling, M. J., & Scanlon, D. M. (2004). Specific reading disability (dyslexia):
what have we learned in the past four decades? Journal of Child Psychology and Psychiatry, 45(1), 240.
Vrijkotte, T. G., Van Doornen, L. J., & De Geus, E. J. (2000). Effects of work stress on ambulatory blood
pressure, heart rate, and heart rate variability. Hypertension, 35(4), 880886.
Willcutt, E. G., & Pennington, B. F. (2000). Psychiatric comorbidity in children and adolescents with reading
disability. Journal of Child Psychology and Psychiatry, 41(8), 10391048.
World Health Organization. (2004). ICD-10: International statistical classification of diseases and related health
problems (2nd ed.). Geneva: Author.
Zahn, T. P., Abate, F., Little, B. C., & Wender, P. H. (1975). Minimal brain dysfunction, stimulant drugs, and
autonomic nervous system activity. Archives of General Psychiatry, 32(3), 381387.
Zahn, T. P., Little, B. C., & Wender, P. H. (1978). Pupillary and heart rate reactivity in children with minimal
brain dysfunction. Journal of Abnormal Child Psychology, 6(1), 135147.
Zahn, T. P., Rapoport, J. L., & Thompson, C. L. (1980). Autonomic and behavioral effects of dextroamphetamine
and placebo in normal and hyperactive prepubertal boys. Journal of Abnormal Child Psychology, 8(2), 145
160.

Você também pode gostar