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Dyslexia in the Context of Developmental Language Disorders
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Understanding Dyslexia in the
Context of Developmental
Language Disorders
Suzanne M. Adlof a and Tiffany P. Hoganb
Purpose: The purpose of this tutorial is to discuss the
language basis of dyslexia in the context of developmental
language disorders (DLDs). Whereas most studies have
focused on the phonological skills of children with dyslexia,
we bring attention to broader language skills.
Method: We conducted a focused literature review on
the language basis of dyslexia from historical and
theoretical perspectives with a special emphasis on
the relation between dyslexia and DLD and on the
development of broader language skills (e.g., vocabulary,
syntax, and discourse) before and after the identification
of dyslexia.
Results: We present clinically relevant information on
the history of dyslexia as a language-based disorder,
the operational definitions used to diagnose dyslexia
in research and practice, the relation between dyslexia
and DLD, and the language abilities of children with
Conclusions: We discuss 3 clinical implications for working
with children with dyslexia in school settings: (a) Children
with dyslexia—with and without comorbid DLDs—often
have language deficits outside the phonological domain;
(b) intervention should target a child’s strengths and
weaknesses relative to reading outcomes, regardless of
diagnostic labels; and (c) those who have dyslexia, regardless
of language abilities at the time of diagnosis, may be at
risk for slower language acquisition across their lifetime.
Longitudinal studies are needed to assess multiple
language skills early, at the time of the diagnosis of
dyslexia, and years later to better understand the complex
development of language and reading in children with
vision impairment or with neurodevelopmental syndromes or
who have had a prior head injury may experience reading
and spelling difficulties as a result, but they would not be
considered to have dyslexia. Some definitions further specify that poor instruction should be ruled out as a cause of
reading and spelling difficulty (APA, 2013; Lyon et al., 2003).
In research and practice, the operationalization of these inclusionary and exclusionary criteria varies widely, leading
to sizeable variation in estimated prevalence rates—from as
low as 3% to as high as 20% of the population (Rutter et al.,
2004; Shaywitz, 1996; Spencer et al., 2014).
One source of confusion concerns perceptions about
the oral language abilities of children with dyslexia. On
the one hand, dyslexia has been described as a “languagebased” disorder for many years; such descriptions have
been focused primarily on phonological deficits as a core
feature of dyslexia (Lyon et al., 2003; Moats, 2008). On
the other hand, there is less clarity about the extent to
which other aspects of language development, such as
vocabulary, syntax, and discourse, are affected in individuals with dyslexia. Although one line of research has
established that dyslexia and developmental language
lthough the term dyslexia is familiar to most of
the lay public, there is no consensus on precise
diagnostic criteria. Most definitions of dyslexia
agree on primary inclusionary criteria, including marked
difficulties with word reading, decoding, and spelling as
evidenced by low accuracy and/or fluency on standardized
assessments. There is also a general agreement that these
difficulties should be inconsistent with or “unexpected” in
consideration of other aspects of development, including
general intellectual abilities (American Psychiatric Association
[APA], 2013; Lyon, Shaywitz, & Shaywitz, 2003; National
Institute of Neurological Disorders and Stroke, 2017; Tunmer
& Greaney, 2010). For example, children with hearing or
University of South Carolina, Columbia
MGH Institute of Health Professions, Boston, MA
Correspondence to Suzanne M. Adlof: [email protected]
Editor-in-Chief: Julie Barkmeier-Kraemer
Editor: Marleen Westerveld
Received March 20, 2018
Revision received June 12, 2018
Accepted July 15, 2018
Publisher Note: This article is part of the Clinical Forum: Dyslexia.
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
Language, Speech, and Hearing Services in Schools • Vol. 49 • 762–773 • October 2018 • Copyright © 2018 The Authors
This work is licensed under a Creative Commons Attribution 4.0 International License.
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disorder1 (DLD; Bishop, Snowling, Thompson, Greenhalgh,
& CATALISE-2 consortium, 2017) are separate disorders
that frequently co-occur (Catts, Adlof, Hogan, & Weismer,
2005), some experts have suggested that the presence of
DLD would make word reading difficulties no longer “unexpected” and therefore should exclude a child from the
classification of dyslexic (Badian, 1999; Silliman & Berninger,
2011; Spencer et al., 2014; Tunmer & Greaney, 2010). In this
article, we consider the language basis of dyslexia from a
historical and theoretical perspective drawing from pertinent empirical work. We discuss the overlap of dyslexia
and DLD and their relative frequency, followed by clinical
implications and directions for future research.
Defining Dyslexia as a “Language-Based” Disorder
When William Berlin first introduced the term dyslexia
in 1887, he used it to describe adult patients who had reading problems as a result of cerebral disease, and the disorder was conceptualized within the general class of aphasias
(Richardson, 1992). The first published case study of a developmental reading disorder was written by W. Pringle
Morgan, who used the term congenital word blindness, in
1896. Morgan’s description of “Percy,” a 14-year-old boy
with severe reading difficulty, bears striking resemblance to
the current characterizations of children with dyslexia: “He
has been at school or under tutors since he was 7 years old,
and the greatest efforts have been made to teach him to
read, but, in spite of this laborious and persistent training,
he can only with difficulty spell out words of one syllable….
I may add that the boy is bright and of average intelligence
in conversation. His eyes are normal…and his eyesight is
good. The schoolmaster who has taught him for some years
says that he would be the smartest lad in school if the instruction were entirely oral” (Morgan, 1896). Subsequent
articles by James Hinshelwood (1907, 1917) reported six
cases of children with congenital word blindness across two
generations of a single family, providing suggestive evidence
of a genetic component that is consistent with modern-day
evidence (Snowling & Melby-Lervåg, 2016). Approximately
30 years after Morgan’s first case was reported, Samuel
Orton examined over 1,000 children in the state of Iowa to
determine the prevalence of word blindness, finding that
one in 10 children had marked difficulty with reading words
(Orton, 1937). Orton observed that many of these children
had a history of oral language problems, and he was one of
the first to frame dyslexia as part of a larger set of DLDs.
Since those foundational studies, dyslexia has been referred
Recently, there has been a movement to raise awareness about
developmental language disorders, in part by promoting a common
terminology (Bishop et al., 2017). Before this movement, the most
commonly used term in research was specific language impairment
(SLI). All children with SLI qualify as having DLD, but the reverse
is not true, as the criterion for normal nonverbal cognitive skills is
stricter for children with SLI than children with DLD. In this
article, we use the term DLD, although many cited studies involved
children with SLI.
to by many other terms such as visual agnosia for words,
psycholexia, strephosymbolia, and specific reading disability (Wolf & Ashby, 2007).
Contemporary researchers have confirmed Orton
and Morgan’s notion of dyslexia as a language-based disorder (Elbro, Borstrøm, & Petersen, 1998; Shaywitz, 1998;
Snowling, 1998), based primarily on deficits in the phonological domain. In a 1989 article entitled “Defining Dyslexia
as a Language Based Disorder,” Hugh Catts stated, “Dyslexia is a developmental language disorder that involves a
deficit(s) in phonological processing. This disorder manifests
itself in various phonological difficulties as well as a specific
reading disability” (Catts, 1989, p. 50; see also Catts, 1996;
Catts & Kamhi, 1999). Explicitly labeling dyslexia as a
language-based disorder was, in part, a strong and direct response to the misperception that dyslexia is a visually based
disorder (cf. American Academy of Pediatrics, 2009). It is
noteworthy that Hinshelwood had also presented strong
arguments against a visual deficits explanation for word
blindness as early as 1900 (Hinshelwood, 1900). The primary phonological deficit associated with dyslexia negatively impacts the specificity at which sounds are stored and
recalled in words as well as an individual’s ability to manipulate sounds in words and connect sounds to letters to read
words. There is now an abundance of evidence that children with dyslexia, on average, perform poorly on tasks
that involve phonology including phoneme awareness, word
and nonword repetition, and word retrieval (see review by
Vellutino, Fletcher, Snowling, & Scanlon, 2004).
As we have reviewed, dyslexia is defined as a difficulty with word level reading and spelling skills, which are
in turn caused by phonological deficits. However, being a
good reader involves more than only reading the words
on a page. As conceptualized in the simple view of reading
(Gough & Tunmer, 1986; see also Foorman, Petscher, &
Herrera, 2018; Language and Reading Research Consortium,
2015), reading comprehension is the product of accurate
and efficient word reading and language comprehension.
The language comprehension component (sometimes called
“linguistic comprehension” or “listening comprehension”)
encompasses all of the linguistic knowledge and skills required for a listener to comprehend a text if it was read
aloud, including vocabulary and semantic processing, syntax, inferencing, and discourse. In contrast to the large
amount of evidence for phonological deficits in children
with dyslexia, the status of their broader language abilities
in these domains outside phonology is less clear. Many
studies have reported that, in addition to phonological deficits, children with dyslexia also have weaknesses in other
aspects of language including vocabulary, morphology,
syntax, and discourse, often before the onset of formal
reading instruction (e.g., Catts, Fey, Zhang, & Tomblin,
1999; Scarborough, 1990; Snowling, Gallagher, & Frith,
2003). However, two factors complicate the determination
of language (dis)abilities in children with dyslexia. The first
is variation in how the definition of dyslexia is operationalized for diagnosis. The second is variation in the time
of onset of oral language difficulties. Noting the time of
Adlof & Hogan: Understanding Dyslexia
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onset is important because reading difficulties can themselves
cause slower language development, as much of language is
learned via reading experience (Cunningham & Stanovich,
1997; Huettig, Lachmann, Reis, & Petersson, 2017).
Operationalizing the Definition of Dyslexia
Morgan’s (1896) description of Percy was the first
documented case of childhood dyslexia, and it included
multiple characteristics present in contemporary definitions
of dyslexia (APA, 2013; Lyon et al., 2003): (a) a severe difficulty learning to read, despite (b) normal vision, (c) adequate instruction, and (d) average intelligence. Given these
characteristics, as well as the boy’s ability to learn from
oral instruction, the reading problem is quite “unexpected”
(cf. Lyon et al., 2003). However, how is this “unexpected”
deficit operationalized in the diagnosis of dyslexia, and
how do language skills outside the domain of phonology
factor in? Although Morgan’s description of Percy noted
strong oral language abilities, that characteristic does not
appear in most contemporary definitions of dyslexia (but
see Tunmer & Greaney, 2010).
Traditionally, an IQ achievement discrepancy approach
was used to operationalize dyslexia definitions for diagnosis
for educational or research purposes. Under this approach,
children were considered to have dyslexia when their word
reading skills, as measured by norm-referenced measures
of word reading speed or accuracy, were “discrepant”
from their intelligence (Pennington, Gilger, Olson, &
DeFries, 1992; Shaywitz, Shaywitz, Fletcher, & Escobar,
1990). Under this approach, it was assumed that the IQ
score was an indicator of a child’s potential, and a word
reading score that fell significantly below an IQ score was
viewed as evidence that the child was not performing at his
or her full potential. Also under this approach, IQ was often quantified by a full-scale IQ that was a composite of
both verbal and nonverbal IQ scores. Thus, under this approach, children with broad language deficits were less
likely to qualify for a dyslexia diagnosis than children with
normal language abilities because children with broad language deficits would be unlikely to achieve a high verbal
IQ score. Instead, children with IQ scores commensurate
with their word reading deficits were often referred to as
“garden variety” poor readers, and it was believed that that
they would not experience the same benefit from reading
interventions as children with dyslexia (Gough & Tunmer,
1986; Stanovich, 1991).
The IQ achievement discrepancy model fell out of
favor for several reasons. First, there were statistical issues:
The size of the observed discrepancy would depend on the
tests used (i.e., some word reading and IQ tests were easier
than others), and because of regression to the mean (i.e.,
extreme scores are statistically more likely to be preceded
or followed by less extreme scores), children with high IQs
were more likely to qualify as dyslexic than children with
low IQs (Francis et al., 2005). In addition, because reading
requires formal instruction, it could take several years for
test scores to suggest a “significant” discrepancy between
IQ and reading achievement (Fletcher et al., 1998), often
delaying access to interventions. Finally, there was a lack
of evidence that reading profiles were different between
discrepant and nondiscrepant poor readers (Siegel, 1989;
Stanovich, 1991), and both groups were able to improve
their reading skills when provided an evidence-based intervention (Vellutino, Scanlon, & Jaccard, 2003).
As an alternative to the IQ discrepancy approach, a
somewhat more liberal approach to diagnosing dyslexia
has been to use an IQ cutoff to rule out low cognitive abilities with no stipulation of a discrepancy between IQ and
word reading abilities (Vellutino, Scanlon, & Reid Lyon,
2000; Wimmer, Mayringer, & Landerl, 2000). In practice,
this meant that children with dyslexia had low word reading in the presence of “normal” intelligence. Although both
verbal and nonverbal IQ scores have been used with this
approach (e.g., Casalis, Leuwers, & Hilton, 2012; Zoccolotti
et al., 2013), most current diagnostic criteria for dyslexia
quantify adequate cognition using only nonverbal IQ measures and a liberal cutoff that does not qualify the child as
being “cognitively impaired,” for example, within 2 SDs
of the mean (e.g., Alt et al., 2017). Relative to the IQ discrepancy approach, the IQ cutoff approach provides a greater
opportunity for children with language deficits beyond the
domain of phonology to be identified as having dyslexia because it does not require that a child have a high verbal IQ.
As the field grappled with how to operationalize
“average intelligence” in the diagnostic criteria for dyslexia,
the importance of “adequate instruction” also came into
the forefront. An influential study by Vellutino and colleagues
(1996) focused on first-grade students with poor word reading abilities. When these children were provided one semester of high-quality, evidence-based reading instruction, the
majority of them showed substantial improvement, such
that they were no longer considered poor readers. The smaller
group of children that did not respond to treatment showed
poorer phonological skills before the onset of instruction
than those who did respond. The authors recommended
that only those who do not respond to high-quality, evidencebased reading instruction should be considered reading
disabled, whereas the others may have demonstrated initially
low reading scores due to experiential or instructional deficits. On the basis of the results of this study and others like
it (Al Otaiba & Fuchs, 2002; Torgesen, 2000; Wolf, 1999),
the reauthorization of the federal special education law in
2004 (Individuals with Disabilities Education Improvement
Act, 2004; PL 108-446) allowed for identification of learning disabilities based on a student’s failure to respond to
scientifically based instruction. The diagnosis of dyslexia
then became less important for public schools using this
approach because it was a failure to respond to intervention, rather than a specific diagnostic label, that led to special education services. However, children meeting the
standard criteria for dyslexia would still be identified for
these services if they were not making adequate progress in
response to evidence-based instruction in the regular education system. Research that has examined predictors of response to instruction has shown that children with broader
Language, Speech, and Hearing Services in Schools • Vol. 49 • 762–773 • October 2018
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language deficits, including problems with vocabulary and
grammar, tend to show poorer responses to instruction than
children whose language difficulties are restricted to phonology (Al Otaiba & Fuchs, 2006; F. J. Duff et al., 2008; Vadasy,
Sanders, & Abbott, 2008; Whiteley, Smith, & Connors,
The Relationship Between DLD and Dyslexia
To some, the characterization of dyslexia as a
language-based disorder may be confusing in light of another prominent language disorder, DLD. Children with
DLD have an unexpected deficit in language abilities despite adequate environmental stimulation and cognitive
abilities with no neurological impairments (Bishop
et al., 2017; L. B. Leonard, 2014; National Institute of
Deafness and Other Communication Disorders, 2017).
These children may have language deficits across multiple
dimensions of language—phonology, morphology, syntax,
vocabulary, and pragmatics—but operational definitions
often require deficits in more than one language domain
(Bishop et al., 2017; Tomblin et al., 1997). Although DLD is
recognized as a persistent disorder with negative impacts
on literacy, academic progress, and employment opportunities (Nippold, Mansfield, Billow, & Tomblin, 2008; Snowling, Duff, Nash, & Hulme, 2016; Whitehouse, Watt, Line,
& Bishop, 2009), evidence suggests that a large proportion
of children who qualify as having DLD are either not identified or are identified in later school grades, based on problems with reading comprehension (Catts, Adlof, & Weismer,
2006; Conti-Ramsden, Simkin, & Pickles, 2006; Nation,
Clarke, Marshall, & Durand, 2004; Tomblin et al., 1997).
It has been argued that parents and teachers may be more
aware of problems with speech articulation and word
reading than problems with understa …
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