Did you know you can screen for dyslexia as early as age four? Yes, you read that right. If your gut instinct is to say, “Ummm, that’s a reading disorder, and most four-year-olds don’t know how to read, so that makes no sense!” you’re not alone.
As a pediatrician, I always assumed that a learning disorder could only be assessed after a child enters school and struggles with reading. Even when I suspected that one of my own children would have some challenges with reading, I figured that I would wait and see how things go once they entered school.
If only the 2020 AAP report had come out just a little sooner!
It turns out dyslexia isn’t “just” trouble learning to read. Dyslexia is a neurological difference in how the brain processes language. The AAP report, Reintroducing Dyslexia: Early Identification and Implications for Pediatric Practice, is chock-full of helpful pearls about this common condition.
Some highlights from the report:
In this month’s episode of Peds RAP
Join Liza and me as we talk about early screening and diagnosis of Dyslexia. In part 2, I interview Marjorie Hsu, pediatrician and mom of a son with dyslexia, who provides insight into some of the early signs and shares tips she learned along the way. You’ll gain insider wisdom to help guide your families more effectively.
Literacy as a health predictor
Children who are strong readers don’t just excel in school – they enjoy health benefits that ripple into adulthood. Research shows that children who read proficiently have lower rates of disease, are less likely to face incarceration or poverty, and are more likely to find employment with higher incomes as adults. In short, literacy isn’t just an academic milestone; it’s a powerful health predictor.
The “wait to fail” approach
For most kids with dyslexia, the diagnosis typically arrives at the end of second grade or the beginning of third grade (and often much later). Why? Many parents are told that a child can’t be assessed until they’ve been exposed to a few years of reading instruction. The AAP refers to this as the “wait to fail” approach, and for good reason. By the time they’re diagnosed, a child has typically struggled mightily with reading, leading to a drop in self-esteem. They often feel “stupid,” which may contribute to the higher rates of depression and anxiety observed in children with dyslexia. And of course, it’s much harder to catch up once a child has already fallen behind their peers.
Pre-literacy signs of dyslexia
Pre-literacy signs of reading difficulties? This is a term I had never heard before reading this report. Almost sounds like an oxymoron. But as I read the list, I recognized the little “quirks” I’d noticed in one of my own children as part of a larger picture. Suddenly the difficulty with nursery rhymes, or trouble naming colors, fit together in a way that explained so much.
How are those things connected? Pre-literacy signs include:
Poor letter-sound correspondence
This one makes sense. Some kids have a hard time matching letters with their corresponding sounds – like associating the letter “F” with the sound “fff” or the confusingly named “Double-You” with “www”. Understanding how letters represent sounds is foundational to reading. Often, this challenge can manifest in avoidance behaviors – kids will do anything under the sun to avoid playing a game that involves letter-sound correspondence. Other times, you might see them guessing with wildly unrelated sounds, even after you thought they’d learned the letter.
Identifying rhyming sounds
Many kids delight in the playfulness of rhyming. By age four most kids can recognize a rhyme. By five, they’re capable of creating rhymes. For children with dyslexia, though, it’s harder to hear that “map” and “rap” rhyme. This difficulty can make it tough for them to enjoy rhyming games, which are actually great tools for reinforcing literacy skills.
Rapid automatized naming
This is a fancy way to say “the ability to name things.” It can look like difficulty learning shapes, animals, or names. A child might be perfectly capable of pointing to the monkey but have a much harder time answering the question, “What animal is this?” They are often slow to respond to simple factual questions. In later years, kids will do a lot of vague substitutions like “that thing” or “this place.” I remember laughing (out of exasperation) when my child once asked, “Mom, where’s my thing from that place that we put with the stuff?”
Pseudoword repetition
This one can be more subtle. Kids usually love repeating nonsense words, but for children with dyslexia, nonsense words – like those made famous by Dr. Seuss – are particularly tough to repeat. It’s a small but telling sign of their struggles with phonological processing.
Problems with oral language comprehension
While understanding spoken words is generally easier for kids with dyslexia than understanding written language, there’s still a struggle with comprehension. These gaps can lead to frequent miscommunications. Some children will pretend to understand instructions rather than ask for clarification.
Problems with expressive and receptive vocabulary
Any child with a history of speech delays should be monitored closely for other early signs of dyslexia. This is true for receptive, expressive or articulation difficulties. Speech delays can often be an early indicator of more complex challenges with language and literacy.
Other associated signs
Some signs of dyslexia didn’t make the “top 6 list” for the AAP report, but can also show up early in some children. Dr Marjorie Hsu highlights other possible early signs such as:
When dyslexia teams up with other challenges
Children with dyslexia are are more likely to have other conditions like:
I used to think that if a child struggled in both math and reading, this was a sign that dyslexia wasn’t the issue. It turns out I was wrong about this! Having ADHD or dyscalculia doesn’t make it less likely a child has dyslexia. These conditions are actually risk factors that increase the possibility of dyslexia.
So, what’s the role of the pediatrician in all this?
How can we better serve our patients with this emerging knowledge? To start, just knowing that these signs can be assessed so early can affect how we respond to parents who come to us with concerns about their younger children.
Looking back, I wonder if I used to be too quick to shrug off concerns about a four-year old not wanting to learn their letters, saying, “at that age they should be learning to share, not memorizing letters!” I still believe that focusing on social emotional development is critical at that age. But now I take those concerns more seriously, asking more questions to tease out the active, physical kid who isn’t interested from the child who is showing us early signs of struggle.
Screening for dyslexia
The AAP recommends screening (not diagnosing) children as young as four for dyslexia. The goal is to flag children at higher risk, giving them a better shot at benefiting from early intervention. It doesn’t mean that all children who struggle with pre-literacy skills will go on to have dyslexia, but it does help identify kids who need extra support before they fall too far behind.
Unfortunately, there isn’t a standard screening assessment that is endorsed by the AAP. But pediatricians can ask about family history of dyslexia and early pre-literacy signs as part of their developmental assessment at various ages. The AAP also recommends making sure to include dyslexia in the differential for any child presenting with anxiety, depression, low self esteem or disruptive behaviors.
Diagnosis
To make an official diagnosis, you’ll need to refer your patient to a specialist such as a neuropsychologist, educational psychologist, or developmental pediatrician. But you might be surprised to learn that sometimes a speech and language pathologist (SLP) can make the diagnosis. If you can find an SLP who’s trained to do this, it can be a faster and more affordable way for families to get answers.
Schools can also assess reading difficulties, though they often diagnose a “learning disorder in reading” rather than dyslexia. The AAP estimates that 80% of children diagnosed with a learning disorder in reading actually have dyslexia. So, many children with dyslexia may never receive the specific label. While some might say the label doesn’t matter as long as the child gets support, I think understanding the broader language-based challenges – not just the reading difficulties – can be helpful for both parents and children.
The Dyslexic Advantage
One of my favorite books that I came across during my journey as a parent of a child with learning differences, is the book The Dyslexic Advantage. It highlights the unique strengths that can accompany dyslexia. The authors argue that the same pattern of brain organization that leads to struggles with reading also leads to advantages like increased creativity, visuospatial skills, “big-picture” thinking, and making connections where other people fail to see them.
Just as I’d felt resonance reading the AAP report and recognizing my child’s struggles in their description of deficits, here, too, I felt resonance in seeing my child’s special strengths highlighted. It helped me understand that dyslexia is not just about the struggle (though struggle is certainly part of the picture!). And it’s helped me reframe to my child what it means that their brain is wired a little differently than others.
Do I wish we’d gotten the diagnosis a little earlier? Yes. But I’m grateful we got the diagnosis when we did, and I deeply appreciate being given a window into my child’s unique (but not so unique!) way of experiencing the world of language. It’s also helped me hone in on those patterns when I see them in my patients.
Tune in to our segment on dyslexia screening to learn more about early screening, associated conditions, and the power of early intervention. And in our Part 2 segment, listen to Dr Marjorie Hsu share her personal story of early signs in her child, along with her insights and helpful tips in navigating services for her child.