Reading difficulty in children: Clinical features and evaluation

INTRODUCTION — Reading is critical to the academic, economic, and social success of children [1]. However, many children complete schooling without achieving more than basic literacy [2]. Pediatric clinicians are well positioned to identify children at risk for reading difficulties and children who have unexpected difficulties in learning to read. Early identification and timely intervention for such children improve long-term outcome. Clinicians who use standardized, validated screens will identify at-risk children more accurately than those who rely solely on clinical judgment [3].

The clinical features and evaluation of reading difficulty in children will be reviewed here. Normal reading development and the epidemiology, etiology, and treatment of reading difficulty are discussed separately. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty" and "Reading difficulty in children: Interventions".)

General issues related to learning disorders also are discussed separately. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States" and "Specific learning disorders in children: Clinical features" and "Specific learning disorders in children: Educational management".)

TERMINOLOGY — A variety of terms are used to describe reading problems. Different terms may be used in different settings and by different groups (eg, educators, health care providers). Definitions for the terms that are used in this topic review are provided below. A detailed discussion of terminology is provided separately. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Terminology and conceptual framework'.)

Reading difficulty — "Reading difficulty" is defined from a normative perspective (ie, how a child performs in reading compared with peers or educational expectations) [4]. Reading difficulty has a number of causes, including reading disability, borderline to low average cognitive abilities (ie, intelligence quotient [IQ] between 70 and 89), language disorders, intellectual disorder, and inadequate prereading stimulation or instruction.

Reading disability — Reading disability is best defined as "an unexpected difficulty in learning how to read despite adequate intelligence, instruction, and motivation" [4]. The terms "dyslexia," "developmental dyslexia," "specific learning disorder with impairment in reading," "specific reading disability," and "reading disorder" also are used to describe this condition [5], although a more specific definition for "dyslexia" is provided below.

Dyslexia — The term "dyslexia" is used as a synonym for specific reading disability [6,7]. The International Dyslexia Association defines dyslexia as follows [8,9]:

"Dyslexia is a specific learning disability that is neurologic in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonologic component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede the growth of vocabulary and background knowledge."

This definition also has been adopted by the United States National Institutes of Child Health and Human Development. In the text that follows, "reading disability" is used synonymously with "dyslexia."

CLINICAL FEATURES

Presentation — Children who are at risk for reading difficulty/disability or who have reading difficulty/disability may present to medical attention with a variety of concerns, depending upon the age of the child and their ability to compensate for the reading problem. Early diagnosis and intervention are critical to improving outcome; three-quarters of children who have poor reading skills in third grade continue to have reading problems in high school and beyond [10,11].

Although symptoms of reading difficulty may be present in kindergarten, reading disability is seldom diagnosed before formal reading instruction begins (typically at the end of kindergarten or beginning of first grade) [5]. When reading disability occurs in children with high intelligence quotient (IQ), it may not be apparent until fourth grade or even later.

Preschooler at risk — Preschool children who are at risk for reading disability can be identified before kindergarten. Such children may have difficulty with the following skills (table 1A) [10,12-17]:

●Learning nursery rhymes

●Playing rhyming games

●Pronouncing words (may confuse words that sound alike)

●Learning and remembering the names of letters

●Poor expressive language

In longitudinal observational studies, language impairment was associated with increased risk of reading difficulty, especially in children who also had a family history of reading disability [18-20]. The risk of dyslexia was particularly pronounced if language impairment persisted at school entry; the risk was modestly increased in children whose language difficulties resolved before school entry [19].

Primary school

●Kindergarten and first grade – The typical presentation of reading disability is that of a late-talking child who did not learn letters in kindergarten and who, by the middle to end of first grade, cannot read words and has difficulty spelling [13]. The ability to name letters by the end of kindergarten is a strong predictor of reading ability in first grade [14,18,21,22].

During the early elementary school years, children with reading disability have difficulties with spelling and reading aloud; they read slowly, guessing at or sounding out words they do not know, and making many errors (table 1A) [5,23]. They do relatively poorly on tests that ask them to name a pictured item and relatively well on tests that ask them to point to the picture of the spoken word [13]. Higher-level cognitive functions that are not affected by reading disability and in which the child may have relatively strong skills include oral vocabulary, comprehension of stories that are heard, curiosity, imagination, understanding of new concepts, and ability to figure things out [10].

Children who have difficulty learning to read may avoid reading [10,24]. With less reading practice, they are exposed to fewer words and do not add new words to their sight-word lexicons at the same rate as their normally reading peers [23,25]. If they do not receive adequate remediation, they read less and learn less from reading than do their schoolmates [10,23]. (See "Reading difficulty in children: Interventions", section on 'Remediation'.)

●Second grade and older – As school progresses, children with reading disability may present with a decline in school performance or difficulty keeping up. They may dislike school and develop somatic complaints (eg, abdominal pain, headache) [26]. At this stage of education, the focus is on "reading to learn rather than learning to read." Difficulty with word recognition slows the learning process and takes up cognitive resources that are necessary for comprehension [12,27].

Reading disability should be considered in the differential diagnosis of all children who present with learning problems or a complaint that the child is not doing well in school [13]. Caregivers and teachers may not realize that the decline in school performance is related to reading difficulty; they may attribute it to "lack of motivation" [7].

Children with reading disability in the second grade and beyond may have particular difficulty learning spelling strategies (eg, prefixes, suffixes, root words), learning a second language, answering questions on multiple-choice tests, and solving word problems in math (table 1B) [13]. They may have better word recognition skills in areas of special interest (eg, sports, cars, fashion). They also may have relative strength in various other areas (eg, conceptualization, reasoning, imagination, abstraction, listening vocabulary, math, visual arts) [10].

Secondary school — During secondary school and beyond, the most consistent signs of reading disability are slow and laborious reading and writing, and poor spelling (table 1C) [13,28]. Adolescents and young adults with reading disability may have developed adequate decoding skills but cannot decode at the rate that is necessary for their work load. They typically avoid activities that involve reading [10,28].

Adolescents and young adults with reading disability may have better reading skills in their areas of interest [10]. They also may do better when given additional time on multiple-choice tests and when compositions are graded for content rather than spelling. Areas of relative strength for adolescents and young adults with reading disability may include conceptualization, insight, and problem solving [10].

Clinical course — Children who have reading difficulty that resolves during kindergarten typically become normal readers [29,30]. In contrast, reading disability persists throughout life; it is not a transient "developmental lag" [28,31,32]. Many children with reading disability become proficient in reading a set of words that recur in their areas of interest [13]. They also may be able to decode unfamiliar words accurately but not fluently or automatically [12,13,28,31]. Even after acquiring decoding skills, reading tends to be slow and laborious.

Longitudinal studies demonstrate that although the reading scores of children with reading disability improve as they get older, a gap remains between them and children without reading disability [11,28,31]. Over time, poor readers and good readers tend to maintain their relative positions along the spectrum of reading ability [11,28,33]. Most will experience life-long difficulties in reading fluency, comprehension, vocabulary, and spelling.

Coexisting conditions — Learning disorders, including reading disability, interfere with all aspects of life, not just academics [34]. Children who have reading disability may have associated deficits in attention, executive function, and social skills that can further interfere with school function; approximately 20 to 40 percent of children with reading disability meet Diagnostic and Statistical Manual of Mental Disorders criteria for attention deficit hyperactivity disorder (ADHD) [35-40]. Children with reading disability and ADHD are at particular risk for academic failure, psychosocial burden, and poorer adult outcomes [36,40]. Children with reading disability also may develop emotional and social problems and negative patterns of family interaction [34,41,42]. Anxiety and depression are common in children with reading disability [35,43,44]. Motor problems such as developmental coordination disorder are relatively common in children with reading disability. (See "Specific learning disorders in children: Clinical features", section on 'Comorbidities'.)

DIFFERENTIAL DIAGNOSIS — Reading disability is a primary reading problem; it is caused by cognitive deficits in basic reading skills (ie, phonologic processing). Secondary reading problems can be caused by a variety of conditions, including [5,6,12,13,45-47]:

●Hearing impairment

●Vision impairment (see 'Medical evaluation' below)

●Environmental or educational deprivation (lack of exposure to books and reading; inadequate instruction in prereading and reading skills; frequent school absence related to chronic disease)

●Expectations of caregivers or schools that are discordant with the student's abilities

●Cognitive impairment (eg, undiagnosed intellectual disability, borderline to low average cognitive abilities [ie, intelligence quotient (IQ) between 70 and 89])

●Other types of learning disorder (eg, specific language impairment)

•Genetic syndromes associated with language and reading problems (eg, Klinefelter syndrome, neurofibromatosis, 22q11.2 deletion, fragile X syndrome in females [males with fragile X syndrome more typically have intellectual disability]) (see "Clinical features, diagnosis, and management of Klinefelter syndrome" and "Neurofibromatosis type 1 (NF1): Pathogenesis, clinical features, and diagnosis" and "DiGeorge (22q11.2 deletion) syndrome: Epidemiology and pathogenesis")

•Neurologic problems (eg, traumatic brain injury; central nervous system infection, tumor, or vascular injury; subclinical seizures; periventricular nodular heterotopia [48,49])

•Toxins (eg, lead poisoning, fetal alcohol exposure)

●Family dysfunction and social problems (eg, caregiver separation, divorce, child abuse and neglect, illness or death of an immediate family member, caregiver psychopathology, early parenthood, substance abuse, poverty)

●Chronic illness

●Emotional illness (eg, depression, anxiety, low self-esteem, poor self-image)

Most of these conditions can be differentiated from reading disability through history, physical examination, evaluation of hearing and vision, and psychoeducational testing. Others may require additional testing (eg, genetic studies, electroencephalogram) if clinically indicated. Reading disability is distinguished from other types of learning disorder by its circumscribed nature (intelligence and oral comprehension are not affected). The response to intervention is sometimes used to distinguish primary reading disability from reading difficulty caused by lack of exposure to reading or inadequate instruction [6,29]. (See 'Responsiveness to intervention model' below.)

EVALUATION

Role of the primary care clinician — The primary care clinician plays an important role in promotion of literacy, early identification of children with reading problems or at risk for reading problems, evaluation for medical and psychosocial problems that affect reading ability, and provision of support to the child and family [26]. (See "Reading difficulty in children: Interventions", section on 'Early literacy promotion'.)

Although the formal assessment of children with reading difficulties most often occurs within the educational system, the most effective time for remediation of at-risk children occurs prior to their entry into school. The use of standardized, validated developmental screens improves the accuracy of detection of delayed and at-risk children [3]. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to screening'.)

Early detection — Children who are at risk for reading difficulty can be identified before formal schooling begins but are most often identified in first grade or later. Most children with reading disabilities are not identified until third grade, well after the optimal time for intervention [10,13,50].

●Importance of early detection – Early identification is important since timely intervention improves long-term outcome [27,29,30,51]. Interventions for reading disability are more effective when instituted before or during first grade than after [27]. Three-quarters of children who have poor reading skills in third grade continue to have reading problems in high school and beyond [10,11,33]. (See 'Clinical course' above and "Reading difficulty in children: Interventions", section on 'Outcome'.)

●Identification of children at risk – Primary care clinicians can identify children at risk for reading difficulty and children with reading difficulty through developmental surveillance and screening and by taking an educational and family history [51].

•Routine developmental surveillance and screening – The American Academy of Pediatrics (AAP) suggests that pediatric primary care clinicians provide developmental surveillance at every well child visit and formal screening for developmental and behavioral problems at specific visits (developmental screening at 9, 18, and 30 months; autism screening at 18 and 24 months) [52]. Developmental surveillance and screening should include assessment of speech and language skills. (See "Autism spectrum disorder in children and adolescents: Surveillance and screening in primary care", section on 'Approach to ASD surveillance and screening' and "Developmental-behavioral surveillance and screening in primary care".)

•Risk factors for reading difficulty/disability – Risk factors for reading difficulty or disability include [12,13,18,53,54]:

-Premature birth and low birth weight

-A family history of language, speech, reading, or spelling difficulties

-History of attention deficit hyperactivity disorder [35,36]

-History of speech and language impairment

-Home with low-literacy environment (eg, caregivers or siblings do not read or avoid reading) [17,55,56]

Approximately 50 percent of children with a history of speech and language impairment develop a reading disability during the early school years [15]. Children with impaired language skills on entry to kindergarten are at particular risk [18].

●Primary care assessment of prereading skills – Prereading skills that clinicians can assess during an office visit beginning at approximately four years of age include [12-14,17,57-59]:

•Ability to recite a nursery rhyme or play a rhyming game

•Ability to recognize and name letters

•Phonemic awareness ("Tell me another word that starts with the same sound as 'ball'"; "Tell me another word that ends with the same sound as 'cat'"; "How many sounds do you hear in 'man'?")

•Ability to associate sounds with letters ("Which of these words begin with the same letter: doll, dog, boat?")

•Verbal memory (ask the child to repeat a sentence)

•Rapid naming (rapidly naming a continuous series of familiar objects, digits, letters, or colors)

•Expressive vocabulary or word retrieval (ask the child to name single pictured objects)

Children with risk factors for reading difficulty or who lack prereading skills before they enter formal schooling may benefit from early education programs (eg, prekindergarten or Head Start in the United States) before they enter school. They also should be monitored closely for reading difficulty once they enter school so that appropriate intervention can be instituted as early as possible [13]. Taking a "wait-and-see" approach is seldom successful. (See 'Clinical course' above and "Reading difficulty in children: Interventions", section on 'Remediation'.)

●Screening for reading difficulty – Primary care clinicians can screen for reading difficulty in the office by listening to the child read aloud from an appropriate reader (keeping a selection of primer books in the office is helpful in this regard) [13]. Oral reading is a sensitive measure of reading accuracy, and more importantly, reading fluency [13]. Validated and easy-to-use screening tools that can be used in the primary care setting also are available for school-age children (table 2) [60,61]. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Normal reading development' and "Developmental-behavioral surveillance and screening in primary care", section on 'Choice of screening test'.)

When reading difficulty is identified, intervention should begin as soon as possible. A range of services may be available through the public school system (eg, early intervention programs for reading, involvement with a reading specialist) [12]. (See 'Responsiveness to intervention model' below and "Reading difficulty in children: Interventions", section on 'Remediation'.)

Medical evaluation — The medical evaluation should include a complete history and physical examination. The primary goal is the identification of potential medical, neurologic, psychosocial, and behavioral factors that may contribute to the reading problem and the identification of coexisting conditions [38]. (See 'Differential diagnosis' above and "Specific learning disorders in children: Role of the primary care provider", section on 'Medical evaluation'.)

●History – When reading difficulties are suspected in a school-age child, the clinician should obtain additional information about the educational, developmental, and family histories (table 3). (See "Specific learning disorders in children: Role of the primary care provider", section on 'History'.)

●Examination – During the examination, the clinician can observe how the child follows commands and can judge the quantity and quality of expressive language. The physical examination of the child with reading difficulty is usually normal. However, it is important to look for signs of medical, neurologic, or genetic problems that may contribute to the reading difficulty as well as features of coexisting conditions, such as cutaneous findings or mild dysmorphic features (table 4) [47]. (See 'Differential diagnosis' above and "Specific learning disorders in children: Role of the primary care provider", section on 'Examination'.)

●Coexisting conditions – The primary care clinician is instrumental in identifying coexisting problems (eg, attention deficit hyperactivity disorder, anxiety) and initiating therapy or making referrals to appropriate specialty providers (eg, specialty medical providers, behavioral health providers, mental health providers as indicated. (See "Specific learning disorders in children: Clinical features", section on 'Comorbidities' and "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis", section on 'Evaluation'.)

●Ancillary evaluation – Children with reading difficulty should be screened for hearing and vision problems. Hearing or vision problems, rather than reading disability, may be the underlying problem or may exist along with a reading problem (see 'Differential diagnosis' above). There is no evidence that vision problems are substantially more common in children with reading disability than in their peers [62].

Laboratory testing, imaging studies, electroencephalography, and genetic testing are not indicated, unless there are specific indications for these tests based upon the history or examination. Functional brain imaging provides insight into the neurophysiology associated with reading disabilities but is used only in research.

Advocacy and support — Primary care clinicians can be important advocates for children with reading difficulty. They can assist caregivers with the interpretation of school evaluations, psychological evaluation reports, and negotiation of the special education system. They also can help caregivers understand the evidence base that supports (or fails to support) various interventions [26]. (See "Reading difficulty in children: Interventions", section on 'Remediation'.)

Clinicians should work with the child's teacher and caregivers to review results of school testing and ensure the child receives additional testing, if appropriate. Having the child's caregiver(s) sign a form that authorizes the school to release information to the clinician and the clinician to release information to the school facilitates transmission of information. Many schools regularly test children with standardized achievement tests (eg, the California Achievement Tests, the Metropolitan Achievement Tests). Standardized achievement tests provide a profile of academic achievement within various subject areas. Younger children are tested on prereading skills, whereas high school students are tested on study skills and use of reference materials. These tests are designed to identify children who need further evaluation; they are not diagnostic instruments for learning disorder or reading disability.

Children for whom a diagnosis of reading disability is being considered should undergo comprehensive educational evaluation. Educational testing may include reading assessment or more comprehensive testing that includes measures of intelligence and academic achievement. (See "Specific learning disorders in children: Evaluation", section on 'Comprehensive evaluation'.)

Indications for referral — We generally refer children with reading difficulty for multidisciplinary evaluation through their public school system. This evaluation provides information about the child's reading skills, executive function skills, verbal intelligence quotient (IQ), etc. In the United States, the Individuals with Disabilities Education Act (IDEA) requires public schools to provide free assessment and intervention. Schools that use a "responsiveness to intervention" model generally provide intervention before comprehensive testing. Schools that use a discrepancy model generally test before providing services. These issues are discussed separately. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States", section on 'Individuals with Disabilities Education Act' and "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Reading disability'.)

Referral to a specialist (eg, developmental-behavioral pediatrician, neurologist, child psychiatrist, educational psychologist, neuropsychologist) may be warranted if the family is not satisfied with the results of the evaluation through the school system, or the clinician is concerned that the child has learning or reading problems that were not detected by the school evaluation. However, these evaluations may not be covered by insurance and can be expensive. Involvement of an educational or legal advocate may be necessary to ensure that appropriate evaluation and service are provided. The primary care clinician can provide advocacy and support to the family in these circumstances. (See "Specific learning disorders in children: Role of the primary care provider", section on 'Roles in management'.)

Reading assessment — Reading ability is assessed by measuring decoding, fluency, and comprehension [7,12]. Formal reading assessment is usually performed in the school system or by an educational psychologist or neuropsychologist. The information below is provided to help the clinician understand the components of the evaluation so that they can help the family interpret test results and determine whether additional testing is necessary.

A number of standardized tests may be used (table 2). An appropriate battery of tests for the early recognition of reading problems includes tests of phonology, letter names and sounds, expressive vocabulary, working memory (memory span), print conventions (eg, book orientation, print directionality, concepts of upper- and lowercase letters, punctuation), and listening comprehension [12,13,63]. Each of these areas also should be evaluated in children tested beyond first grade [12].

Once children have begun to learn to read (around the second half of first grade), measures of decoding ability and fluency are better predictors of reading disability than measures of phonemic awareness and rapid naming [23]. Assessment of reading fluency is a critical but often overlooked component of reading assessment [12]. Older children also should be tested in basic reading skills as described above (eg, phonology, letter names and sounds, expressive vocabulary, working memory, print conventions, and listening comprehension) [12].

Prereading skills — Components of the evaluation for reading readiness are discussed above. (See 'Early detection' above.)

The Comprehensive Test of Phonological Processing is a commonly used instrument in children with reading difficulty (table 2) [13,64,65].

Decoding — Decoding ability is measured with standardized tests of single real-word and single nonsense-word (pseudoword) reading (table 2) [7,12]. The words are presented in a list and read aloud. Measuring the child's ability to decode nonsense words is particularly useful since these words must be sounded out; tests of nonsense-word reading are referred to as "word attack" tests [13]. Assessment of single-word reading is important since reading a passage allows children to guess words from the context [66].

Single-word identification tests measure accuracy but not automaticity (speed). Single-word reading tests, which are commonly used for school-age children, may provide misleading data for bright adolescents and young adults who can read accurately if given enough time and/or have a large lexicon of memorized words [7,66]. (See 'Pitfalls' below.)

Fluency — Fluency is the ability to read orally with accuracy, speed, and expression [12,13]. The ability to read fluently is an indication that words are read automatically without the need to apply attentional resources; fluency is crucial for reading comprehension [67].

Assessment of reading fluency is a critical, but often overlooked, component of reading assessment [12,13]. The failure to recognize or measure the lack of automaticity in reading is a common error in the diagnosis of reading disability in accomplished adolescents and young adults [13]. Timed measures of reading are required to assess fluency. (See 'Pitfalls' below.)

Reading fluency is assessed by asking the child to read aloud; oral reading forces a child to pronounce each word [13]. To ensure the child does not focus solely on fluency (at the expense of comprehension), the student is asked to summarize or answer questions about the text [27].

Tests used to measure reading fluency in school-aged children include the Gray Oral Reading Test-4, the Test of Word Reading Efficiency, and the DIBELS Oral Reading Fluency (table 2) [13,68,69]. The Nelson-Denny Reading Test is used to measure fluency in adolescents and young adults [13].

Comprehension — Reading comprehension is assessed by measures of vocabulary; syntax; ability to build relationships between words, sentences, and paragraphs; and ability to answer questions related to passages that are read.

Although phonologic processing is a necessary skill for reading comprehension, it is not the only one. Other cognitive skills that affect reading comprehension include spoken vocabulary, oral comprehension, verbal reasoning, inferencing, and logical deduction. These skills must be assessed before problems with reading comprehension can be attributed to reading disability [6,12].

Additional testing — Additional testing is necessary as part of a comprehensive evaluation for the child with learning disorder [6,45]. Psychoeducational and neuropsychological testing helps to identify the child's cognitive strengths and weaknesses, which are crucial to the development of a treatment strategy. (See "Specific learning disorders in children: Evaluation", section on 'Psychometric tests'.)

Verbal short-term memory should be tested since problems in verbal short-term memory have been linked to the core phonologic processing deficits in reading disability [23]. Verbal short-term memory is measured with tasks that require repetition of short sequences of digits or letters or of single nonwords that vary in length from 2 or 3 phonemes to 8 to 10 [23,70,71]. Phonemes are the smallest units of spoken language; the word "cat" consists of the phonemes /k/, /a/, and /t/.

Tests of intelligence (ie, IQ tests) are relatively poor predictors of reading difficulty or response to reading interventions, and IQ testing is only a component of the initial evaluation of the child with reading difficulty [12]. The 2004 amendments to IDEA do not allow states to require the use of IQ tests to identify children for special education services. Nonetheless, intelligence testing can contribute to a comprehensive evaluation since cognitive factors other than phonologic processing influence reading comprehension [6,12]. (See "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States", section on 'Individuals with Disabilities Education Act' and 'Responsiveness to intervention model' below.)

DIAGNOSIS

Clinical diagnosis — Reading disability is a clinical diagnosis based upon available information from the history, observation, reading assessment, and other psychometric assessments [6,9,13]. The two critical components of reading disability are:

●Unexpected difficulties in reading (based on the child's age, intelligence, and level of education)

●Associated linguistic problems at the level of phonologic processing

Reading disability is distinguished from other disorders that include reading difficulty as a prominent feature by the circumscribed nature of the phonologic deficit [13]. The response to intervention, as described below, is sometimes used to distinguish primary reading disability from reading difficulty caused by lack of exposure to reading or inadequate instruction [6,29]. (See 'Differential diagnosis' above.)

Responsiveness to intervention model — The "responsiveness to intervention" (RTI) model is a school-based educational strategy that emphasizes intervention over diagnosis. The RTI model is a move away from the traditional "test to diagnose" model (which has been used to limit eligibility for school-based special services to children with a defined discrepancy between ability and intelligence quotient [IQ]). The 2004 Amendments to the Individuals with Disabilities Education Act require states to permit school districts to use RTI as a means to identify children with reading disability [72].

A fundamental tenet of the RTI approach is that individuals "should not be identified as learning disabled until a proper attempt at instruction has been made" [73]. The RTI model takes into consideration the dimensional nature of reading disability, providing different levels of intervention to children with different abilities (eg, isolated difficulty with word recognition, isolated difficulty with language comprehension, or difficulty with both word recognition and language comprehension).

RTI uses screening to identify children who are "at risk" for reading difficulties. These children receive empirically supported treatment in reading; their progress is monitored regularly [12]. These changes most often consist of reading specialists who provide reading support to students in kindergarten through fifth grade who need supplementary help with reading in addition to their regular classroom reading instruction. The reading specialists work with small groups of children, early literacy groups, and individual students. They also go into classrooms to help with reading-related activities. Children who receive these services are not yet on an individualized education plan. (See "Specific learning disorders in children: Educational management", section on 'Response to intervention services'.)

Children who respond to this intervention continue to be monitored. Those who fail to respond receive more intensive levels of service and/or undergo evaluation for learning disorder [29,74,75]. This evaluation can be requested earlier in the process if a diagnosis of reading disability is suspected and more intensive services are required. Borderline and low average cognitive abilities (ie, IQ between 70 and 89) are a common cause of RTI-unresponsive reading difficulty [29,76].

Pitfalls — A common error in the diagnosis of reading disability in older children and accomplished young adults is the failure to recognize or measure the lack of automaticity in reading [13]. Tests measuring word accuracy alone may be inadequate to diagnose reading disability in the high-achieving young adult (eg, at the college, graduate, or professional-school level). Timed measures of reading (eg, the Nelson-Denny Reading Test) (table 2) are necessary to make the diagnosis. (See 'Fluency' above.)

Another important pitfall in the diagnosis of reading disability is the failure to consider and address coexisting conditions, particularly those that may affect treatment (eg, attention deficit hyperactivity disorder, anxiety, school avoidance).

RESOURCES — The following resources may provide additional information for caregivers and clinicians:

●"Overcoming Dyslexia" by Sally Shaywitz, MD (2020)

●LD OnLine

●Eunice Kennedy Shriver National Institute of Child Health and Human Development

●International Dyslexia Association

●Great Schools

●Reading Rockets for kindergarten through third grade students

●The Federation for Children with Special Needs

●Learning Ally

●The Florida Center for Reading Research

●Balanced Reading (available at: balancedreading.com)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Dyslexia (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Clinical features

•Presentation – Children who are at risk for reading disability or who have reading disability may present with a variety of concerns, depending upon the age of the child and their ability to compensate for the reading problem (table 1A-C). (See 'Presentation' above.)

Reading disability should be considered in the differential diagnosis of all children who present with learning problems. (See 'Primary school' above.)

•Clinical course – Children who have reading difficulty that resolves during kindergarten typically become normal readers. In contrast, reading disability persists throughout life. (See 'Clinical course' above.)

●Differential diagnosis – Reading disability is a primary reading problem; it is caused by cognitive deficits in basic reading skills (ie, phonologic processing). Secondary reading problems can be caused by a variety of conditions. (See 'Differential diagnosis' above.)

●Evaluation

•Reading difficulty and disability are usually diagnosed and managed in the educational system. However, the primary care clinician plays an important role in early identification, evaluation for medical and psychosocial problems that affect reading ability, and provision of support to the child and family. (See 'Role of the primary care clinician' above.)

•Reading ability is assessed by measuring decoding, fluency, and comprehension. Assessment of reading fluency is a critical, but often overlooked, component. (See 'Reading assessment' above.)

●Diagnosis – Reading disability is a clinical diagnosis based upon the following critical components (see 'Diagnosis' above):

•Unexpected difficulties in reading (based on the child's age, intelligence, and level of education)

•Associated linguistic problems at the level of phonologic processing