Executive dysfunctions, reading disabilities and speech-language pathology evaluation.

Original Paper Folia Phoniatr Logop 2014;66:37–47 DOI: 10.1159/000363655

Published online: November 14, 2014

Executive Dysfunctions, Reading Disabilities and Speech-Language Pathology Evaluation Yvette Hus TAV College, Montreal, Que., Canada

Abstract Background: Many students with reading disabilities exhibit persisting reading problems despite intervention. The crucial difference between effective and struggling readers is their executive functions (EFs), and improved functions impact positively on learning to read and reading to learn. Objectives: Firstly, to show that high-risk and struggling students’ persisting language and reading difficulties are accompanied by executive dysfunctions. Secondly, to present one student’s daily struggles at school in a narrative based on teacher, parent and child interviews. Method: This retrospective study is based on speech-language pathology (SLP) evaluations of a clinical sample of 23 girls and boys aged 6–16 from a range of middle class families. While language and reading evaluations were tailored to the students’ particular situation, i.e. age, grade, languages or complaint, EFs were examined in all with the Behaviour Rating Inventory of Executive Function teacher questionnaire. Results: Virtually all students exhibited executive dysfunctions, and many showed a high risk of attention deficit hyperactivity disor-

© 2014 S. Karger AG, Basel 1021–7762/14/0662–0037$39.50/0 E-Mail [email protected] www.karger.com/fpl

ders. Conclusions: This study demonstrated that inclusion of EFs in SLP evaluations is valuable in uncovering executive dysfunction comorbidity that may underlie persisting reading disorders. It is proposed that speech-language pathologists explicitly and routinely braid language and reading with EFs in their evaluations so to effectively predict, uncover and prevent persisting reading disabilities in students. © 2014 S. Karger AG, Basel

Introduction

While struggling readers are engaged in ‘learning to read’, effective readers ‘read to learn’, a process that includes learning to decode, comprehend, evaluate texts critically, and employ the information they read in new and diverse contexts [1, p. 170]. In short, effective readers understand that the reading objective is comprehension, that it depends on the given text and task, they choose useful strategies, and allocate attentional and memory resources accordingly [2–6]. In fact, great numbers of students with reading disabilities are identified with persisting reading comprehension problems even after exposure to phonological and/or verbal language-related prevention or remediation programs [7]. What could underlie Yvette Hus 21 Crestwood Avenue Montreal West, QC H4X-1N3 (Canada) E-Mail yhus @ videotron.ca

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Key Words Executive dysfunction · Reading disabilities · Speech-language pathology evaluation

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Folia Phoniatr Logop 2014;66:37–47 DOI: 10.1159/000363655

ing disturbances that affect efficient and fluent word and text reading as in dyslexia (primarily a decoding and encoding disorder; under the ‘specific learning disorders’ rubric in the DSM-5 [12]), text comprehension, or both; they may even persist in the face of intact listening comprehension and may result from neurobiological deficits or experiential factors [13–15]. The sample does not include children with reading disorders due to intellectual disabilities, speech sound disorders (SSD) or autism spectrum disorders (ASD). Finally, although in some regions speech-language pathologists may not engage directly in the diagnosis and management of reading and writing disorders, in many other regions difficulties in these are considered a communication disorder and so fall under their domain [16], even while remaining of significant interest to many other disciplines. In fact, it is commonly accepted that oral language is key to reading development, and while oral language difficulties predict reading impairment, its improvement positively impacts reading comprehension [17].

What Are EFs?

EFs have become synonymous with frontal cortex function but actually these consist of anatomically and functionally distinct regions [18], with links to other cortical centres [19], and are subserved by flexible networks within deeper layers in the brain [20]. The study of EF processes is still evolving and to date lacks a clear unifying definition as those offered reflect perspectives from divergent fields within neurosciences and education [18, 19, 21–23]. Nonetheless, it is generally agreed that EF is not a unitary construct [17] but rather ‘an umbrella term for the complex cognitive processes that serve ongoing, goaldirected behaviors’ [22, p. 1, 10, 20, 24]; these processes are dynamic as they are highly sensitive to individuals’ internal (biological) and external (environmental) context factors [25]. EFs include key elements such as attention, impulse control and self-regulation, initiation of activity, WM, mental flexibility, effective use of feedback, planning and organizing, and selection of efficient problem-solving strategies [26, p. 131]. In Meltzer’s view [22], EFs include goal setting and planning, organization of behaviours over time, flexibility, attention and WM as guiding systems, and self-monitoring, a self-regulatory process. Diamond and Lee [27] propose EFs required in meeting modern life needs: creativity for finding new solutions to problems, and discipline to stay focused on tasks till comHus


this persisting problem? The crucial difference between effective and struggling readers-learners is their metacognitive competence and self-regulation skills, processes of two interactive domains comprising ‘executive functions’ (EFs), a term referring to a wide range of powerful complex cognitive processes and behavioural competencies that, when impaired in any component, may negatively impact individuals’ everyday life and school function in a significant way [8]. This paper attempts to explain EFs and their connection to communication disorders (reading disabilities and language disorders), and highlight the importance of including EF investigations in speech-language pathology (SLP) evaluations of youth as a ‘standard practice’ to help battle the persistence of reading-learning disorders. A clinical sample of 23 school age struggling readerslearners, and a narrative (its use is inspired by ‘narrative medicine’) [9] are included to demonstrate that routine EF investigation in SLP evaluations provides a vista into the affected individuals’ experience in school, and to suggest that exposing EF deficit comorbidity is clinically useful as it may serve to predict and uncover persisting reading disorders and accordingly allow measures for reversing this trend. A clarification preamble is needed here since this paper differs from other investigations of EFs in important ways. It is not based on an experimental design and does not include performance-based investigations of EFs [8], but rather presents a retrospective study of a clinical sample of school-aged children’s real-world or ecologically valid EF function [10] with descriptive data to highlight their behavioural EF dysfunction coexisting with school distress which cannot be explained by their reading or language levels alone. Here, EF data is based on the Behaviour Rating Inventory of Executive Function (BRIEF) [11]. The BRIEF contains 8 scales corresponding to 2 domains: ‘inhibit’ (restraining impulsivity), ‘shift’ (showing flexibility in problem solving), and ‘emotional control’ (regulating emotional responses) comprise the Behavioural Regulation Index (BRI). ‘Initiate’ (getting started on tasks independently), ‘working memory’ (WM; holding on to information until the task is completed), ‘plan/organize’ (setting goals and developing steps for carrying out an activity), ‘organization of materials’ (organizing and keeping track of one’s possessions), and ‘monitor’ (checking one’s own performance) form the Metacognitive Index (MCI). The study includes a wide range of ages highlighting the presence of EF deficiencies from early on and their impact on school function. In addition, reading disabilities refer here to all forms of read-

How Are EFs Measured?

lighted with another rating instrument [34]. The utility and efficacy of the BRIEF were also shown with a Dutch version [31]. Ozonoff and Schetter [35] suggest that the BRIEF is ecologically valid in evaluating ASD children since it can expose their executive dysfunction and its impact on their everyday behaviours. In sum, despite its shortcomings, the BRIEF’s clinical utility was shown in its ease of administration, and more importantly, in its ability to reveal real-life behaviours that may be detrimental to school and social function.

Who Tends to Have EF Issues?

EF deficits exist in diverse groups of youth such as those with acquired neurological impairments [10, 24, 36], deaf youth with cochlear implants [37, 38], non-verbal learning disabilities [39], neurodevelopmental disorders such as ASD [35], specific language impairment (SLI) [40], SSD and dyslexia [17, 41, 42], reading comprehension disorders (RCD) [43, 44], and ADHD [28, 45]. The neurodevelopmental disorders are complex and tend to be highly comorbid [41, 46–49]. Pennington [41] reasons that ADHD, ASD and dyslexia are often explained using a single deficit model but comorbidity of these disorders, as evidenced by shared genetic and cognitive risk factors underlying their aetiology, can best be explained with a multiple cognitive deficit model. Reading disorders, for example, are often comorbid with SSD, both forms of a language disorder which may be comorbid with ADHD, a disorder in EFs. Pennington exposed shared genetic traits between dyslexia and mainly inattentive ADHD, and while SSD with SLI (deficits in grammar and vocabulary) results in dyslexia, SSD without SLI may not. These studies highlight the complexity in accurately characterizing neurodevelopmental disorders and the importance of identifying comorbid conditions.

EFs tend to be evaluated by performance or neuropsychological measures that focus on response time and accuracy in carrying out specific tasks, and by rating measures based on real-life observations of behaviours. Both these measures present challenges [18, 25, 26] and the degree of convergence between these measures varies considerably [28]. Nonetheless, researchers agree that rating scales have clinical utility and are easy to administer; however, because performance tests and ratings capture different aspects of EF, rating measures should not be used to replace performance tests [28, 33, 34, 26]. Toplak et al. [28], for example, demonstrated some convergence between performance measures and BRIEF scales, and the clinical utility of both parent and teacher ratings in predicting attention deficit hyperactivity disorders (ADHD) in adolescents as well as parent ratings in identifying ADHD subtypes (parent ratings were significantly correlated with Connors’ parent report, a ubiquitous instrument in ADHD identification). They suggest that reported variability in the convergence degree between performance and rating measures may reflect differences in sample type, size, participants’ neurological status, and EF variables and measures chosen. While rating variability exists between the BRIEF parent and teacher versions, the cultural dependence of ratings was high-

Schraw and Moshman [3] explain that skilled readers possess metacognitive knowledge and benefit from its positive impact on their school performance. Metacognitive knowledge improves with learning and influences learning in turn [50, 51]. Regulatory skills also improve reading performance by promoting a better use of attention and time, a better choice and use of strategies, and an increased awareness of comprehension breakdowns [52]. Researchers [6] identified executive control processes in-

Executive Dysfunctions in Reading Disabilities


What Is the Connection between EFs and Reading?

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pleted, WM for managing and seeing connections between vast amounts of data, flexibility to be able to consider different perspectives, and self-control to avoid behaviours that may be regretted. Elliot [20, p. 50] states that ‘co-ordination, control and goal-orientation are … at the heart of the concept of executive function’. In these views metacognitive and self-regulation processes are integrated under the EF ‘umbrella’. They represent separate but interrelated complex processes responsible for goal-directed problem-solving behaviour that change differentially over the course of development [11, 25, 28] in a ‘spiraling loop’ manner [23, p. 7]. These processes are recruited by learners ‘as needed’, i.e. more for complex and novel tasks, and less for automatic, simple and familiar tasks [11]. EFs work autonomously and jointly depending on the task [29, 30] and are served by progressively internalized language [29]. They have a long developmental trajectory: typically a rudimentary presence in infancy, they improve in early childhood, reach maturity in late adolescence or early adulthood [11, 25, 31], and decline with age [19, 32].

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dysfunction abound in children with a variety of neurodevelopmental disorders. EFs are significantly knotted with reading comprehension processes, and effective reading comprehension requires both strong foundation skills and intact EFs. Investigators of EFs in the various disorders advocate evaluating and treating EFs in conjunction with communication disorders to better understand their contributions to communication problems and to address both more effectively.

Why Routinely Include EF Investigation in SLP Evaluations?

The cited studies clearly demonstrate the negative impact of EF deficits on reading comprehension, a link that provides support for the need of EF investigation in SLP evaluations. Although EFs are investigated by various professions in clinical or research contexts [8], they are not routinely examined in SLP evaluations. School success depends on students knowing more than the ‘what’ of the academic curriculum – they need to know ‘how’ to think and learn, knowledge based on a complex of EFdependent competencies [21, 48, 63]. Intact EFs are obviously essential for adequate school function, underscoring the need for SLPs to investigate EF status in students who are navigating unsuccessfully through the complexities of school demands and are in fact experiencing academic distress. Furthermore, deficient EFs tend to limit social and communication skills, and hamper generalization of SLP intervention targets [64], facts that demand determining their presence. Indeed, EFs are more powerful than IQ tests, reading, and math adeptness in telling us about children’s school readiness, are more valued by kindergarten teachers, are better able to predict reading and math scores from preschool to high school, and generally underlie academic achievement throughout the school years [65]. Bonney and Sternberg [1, p. 186] identified EFs as one of three interdependent process sets underlying problem solving and function in all contexts: executive processes to plan, monitor and evaluate problem solving; performance processes to implement or execute the plans, and knowledge acquisition processes to learn how to solve problems. In sum, student competence in school depends on the successful integration of the processes reviewed above [1] with cognitive-linguistic, social and motivational resources in the presence of intact EFs, to be able to coordinate and manage the complexities of what is needed to thrive academically. Intact EFs are essential in the chalHus


volved in comprehension as planning, prioritizing, organizing, shifting mindsets flexibly, self-checking and selfassessing; the primary function of EF is the efficient use of these processes. Students with developmental language disabilities exhibit EF deficiencies when performing linguistic or communication tasks [53], and those with low language competence have less capacity to develop age-appropriate EFs [25]. Indeed, poor EFs were demonstrated in preschool, school age and adolescent subjects with SLI [40, 54, 55]. Furthermore, EFs influence theory of mind or the appreciation that others know, want, and feel things as we do. They are closely related to theory of mind neurologically and developmentally, and both are deficient in individuals with ASD [35, 56], as is their social-pragmatic language, play development and reading comprehension [42, 57–59]. A study of 9- to 14-year-olds with reading difficulties found that while individuals with both word recognition and RCD and those with mainly RCD showed weaknesses in oral language and contextual fluency, the RCD group also exhibited striking EF weaknesses [43]. The study provided a useful caveat regarding RCD assessment when results showed that demands on foundational skills, oral language and EFs varied with different reading comprehension measures. Many students with ADHD exhibit WM deficits and reading-learning disabilities, necessitating comprehensive evaluations to uncover and address their specific EF and learning difficulties [60]. A study with 7- to 12-yearold Hebrew speakers showed that a reading disorder comorbid with ADHD results in more severely impaired rapid naming and verbal WM deficits than either unique disorder, prompting the authors to recommend that EF be investigated in those with reading disorders [61]. In fact, research with 6- to 17-year-old boys showed those with reading and math disorders with ADHD comorbidity exhibited severer EF dysfunction and were more prone to school failure [46]. Studies of EF effects in 9- to 15year-olds with various reading disorders comorbid with ADHD revealed a strong contribution of EF deficiencies to reading comprehension problems (but less so to word recognition) beyond oral language, fluency, decoding and beyond the ADHD factor [44, 62]. In sum, the occurrence of combinations of communication disorders with ADHD and EF deficits is common [19, 41, 49], and ADHD comorbidity was found to have long-term debilitating effects on the life of individuals in terms of personal, educational and mental health costs [47]. Reading disabilities in conjunction with executive

The Present Study

EF deficits were uncovered in the routine inclusion of EF investigation of students of various ages referred for SLP evaluations because of noted academic distress and frequent failure to acquire reading competence. Their EF, language and reading evaluation results are reported here, and one of the students’ narratives is included to help ‘flesh out’ the challenges these students face while trying to construct academic knowledge and function in school more or less successfully. The Clinical Sample The sample (excluding those with intellectual disabilities, ASD and SSD) consists of 23 girls and boys aged 6–16 from a range of middle class families. Most were receiving reading remediation and/or subject support at school in the resource room in groups or individually, and many were tutored privately. The majority (70%) was bilingual with varied first languages and English as first, one of the first or as a second language (and French in table 1, case 9). In other words, the students were either simultaneous or sequential bilinguals, and all were attending either multilingual (one or two school languages with English and French as second language) or bilingual schools (English language instruction and French as second language). The bilingual factor is noted here since English language learners with any learning challenges struggle to acquire languages and reading simultaneously [66, 67], and these students were referred for an evaluation by school personnel, other professionals or parents because of high academic risk or noted persistent academic distress. Nonetheless, research found that bilinguals tend to perform similarly to monolinguals and those with reading disorders in one of their languages show problems in the other [68–70].

ined in all with the Rapid Automatized Naming/Rapid Alternating Stimulus Tests [72] (only ‘poor’ results are reported here), and EF was examined in all with the BRIEF teacher questionnaire [11, 73]. Since EFs are context dependent and dynamic and may even vary from moment to moment [25], an ecological instrument suitable in a clinical setting [40] was chosen to portray the student’s actual school function. The BRIEF, described earlier, converts raw data to T scores with 50 as the mean, and 10 the standard deviation so that the higher the T score above the mean, the severer the EF difficulty. For clinical purposes and to allow for severity descriptors which are often useful in educational settings, the T scores were interpreted as follows: ≤59 = adequate function; 60– 65 = behaviourally significant dysfunction; ≥66 = clinically significant dysfunction [11]. Behavioural significance indicates a noted difficulty but of a less persistent or severe nature as compared to a clinically significant dysfunction. In addition, in lieu of the index T score (see BRIEF [11]), a severity category was assigned to each index based on the number of its affected scales (≥60 score, i.e. behaviourally and clinically significant dysfunction): in BRI (with 3 scales), 0 = adequate function; 1–2 = behaviourally significant dysfunction; 3 = clinically significant dysfunction; in MCI (with 5 scales), 0–1 = adequate function; 2–3 = behaviourally significant dysfunction; 4–5 = clinically significant dysfunction (the current author routinely uses this approach as it is useful in explaining EF results to educators and parents).

Results

Clinical Evaluations While language and reading evaluations were tailored to the students’ particular situation (selection of dynamic, curriculum-based or standard measures, dependent on age, grade, languages or complaint), naming speed deficits, recognized as a reading risk factor [71], was exam-

The individual participant results are compiled in table 1 according to age (youngest to oldest). Column 1 includes gender, identification initials, and age and grade (in years and months). Column 2 lists the student’s bilingual status (yes/no). Column 3 reports BRIEF teacher questionnaire results, column 4 includes language, and column 5 reading and poor naming speed. The EF column includes a dysfunction severity category (as delineated earlier) for each index, and names the affected scales. However, only the BRI inhibit scale is specifically named under affected scales, while the MCI organization of materials scale is not. Because the inhibit scale is meant to signal hyperactive-impulsive ADHD and WM to denote inattentive ADHD [11], both scales were named. Since planning, organizing and monitoring skills were strongly implicated in prominent RCD [43], the MCI ‘plan/organize’ and ‘monitor’ scales were named. The ‘ini-



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lenging academic journey for any student, but for those with EF deficits and the added burden of neurodevelopmental disorders, this voyage often includes reading acquisition failure and academic struggle that cannot be explained solely by their reading deficit levels.

Table 1. Evaluation results of EFs, oral language, reading/reading readiness and naming speed Bilingual

BRIEF teacher: severity and number of affected scales

Oral language deficits

Reading deficits

BRI: behav. sig. (2/3 S) MCI: clin. sig. (4/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate BRI: behav. sig. (1/3 S) MCI: clin sig. (5/5 S) Affected: WM; plan/organize; monitor; initiate BRI: adequate (0/3 S) MCI: adequate (0/5 S) (teacher rated SIFTER-failed academics, attention, class participation) BRI: behav. sig. (2/3 S) MCI: adequate (0/5 S) Affected: inhibit BRI: behav. sig. (1/3 S) MCI: behav. sig. (3/5 S) Affected: WM; plan/organize; monitor BRI: behav. sig. (1/3 S) MCI: behav. sig. (3/5 S) Affected: WM; plan/organize; monitor; initiate BRI: clin. sig. (3/3 S) MCI: clin. sig. (4/5 S) Affected: inhibit, WM; plan/organize; monitor; initiate BRI: behav. sig. (1/3 S) MCI: behav. sig. (3/5 S) Affected: WM; plan/organize; initiate

Mild-moderate expressive morphosyntax; moderate-severe receptive vocabulary

Intact reading readiness (letter names, letter sound, syllables, whole word)

Moderate-severe expressive morphosyntax; severe cognitive linguistic integration

Intact reading readiness (letter names, letter sound and syllables)

Moderate-severe receptive and expressive morphosyntax vocabulary, cognitive linguistic integration

Poor basic reading and comprehension Poor naming speed

Moderate-severe expressive morphosyntax, vocabulary, cognitive linguistic integration Moderate-severe expressive morphosyntax, vocabulary, cognitive linguistic integration Moderate receptive and expressive morphosyntax; moderate-severe cognitive linguistic integration Adequate receptive and expressive morphosyntax

Moderate-severe basic reading and comprehension

Moderate-severe receptive and expressive morphosyntax, vocabulary, cognitive linguistic integration Moderate-severe receptive and expressive morphosyntax, vocabulary, cognitive linguistic integration Moderate-severe expressive morphosyntax, vocabulary and cognitive linguistic integration

Moderate-severe reading comprehension

Moderate-severe cognitive linguistic integration Moderate expressive morphosyntax, vocabulary; severe cognitive linguistic integration

Severe hyperlexia (superior basic reading and moderatesevere reading comprehension) Severe basic reading and comprehension Poor naming speed

Moderate cognitive linguistic integration

Mild-moderate basic reading and comprehension

Moderate cognitive linguistic integration

Moderate basic reading and comprehension

Moderate receptive and expressive morphosyntax, vocabulary; moderate-severe cognitive linguistic integration Mild-moderate receptive and expressive morphosyntax vocabulary; moderate-severe cognitive linguistic integration

Adequate basic reading; moderate-severe reading comprehension

1

Girl, W.S., 6.3; kindergarten

No

2

Girl, F.G., 7.1; 1.8

Yes, ESL

3

Boy, A.J., 7.3; 1.6

No

4

Boy, B.N., 8.1; 4.0

No

5

Girl, K.M., 8.3; 2.4

Yes

6

Girl, F.S., 8.6; 3.4

Yes, ESL

7

Boy, A.T., 9.1; 3.8

Yes, ESL

8

Boy, W.L., 9.1; 3.8

No

9

Girl, I.C., 9.6; 3.9

Yes, ESL and FSL

10

Girl, D.L., 9.7; 4.10

Yes

11

Boy, N.G., 9.7; 3.9

No

12

Boy, A.A., 9.10; 4.3

No

13

Boy, M.Y., 10.1; 4.1

Yes, ESL

14

Boy, K.E., 10.5; 4.5

Yes

15

Boy, S.H., 10.9; 4.5

Yes

16

Boy, F.M., 11.2; 5.0

Yes

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BRI: behav. sig. (1/3 S) MCI: clin. sig. (5/5 S) Affected: WM; plan/organize; monitor, initiate BRI: behav. sig. (2/3 S) MCI: clin. sig. (5/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate BRI: adequate (0/3 S) MCI: clin. sig. (4/5 S) Affected: WM; monitor; initiate BRI: behav. sig. (1/3 S) MCI: clin. sig. (5/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate BRI: clin. sig. (3/3 S) MCI: behav. sig. (2/5 S) Affected: inhibit; WM; initiate BRI: clin. sig. (3/3 S) MCI: clin. sig. (5/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate BRI: behav. sig. (2/3 S) MCI: adequate (1/5 S) Affected: WM; plan/organize BRI: clin. sig. (3/3 S) MCI: clin. sig. (5/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate


Hus

Moderate-severe basic reading and comprehension Intact basic reading; moderatesevere comprehension

Severe basic reading and comprehension

Moderate-severe reading comprehension

Moderate reading comprehension

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Case Gender, initials, age and grade

Table 1 (continued) Case Gender, initials, age and grade

Bilingual

BRIEF teacher: severity and number of affected scales

Oral language deficits

Reading deficits

17

Boy, W.M., 11.10; 5.3 Yes, ESL

Boy, L.C., 11.10; 6.2

Yes, ESL

19

Boy, W.G., 12.2; 6.4

Yes

20

Boy, R.H., 12.2; 6.10 Yes

21

Girl, D.L., 12.7; 7.6

22

Boy, M.Y., 14.10; 8.5 Yes, ESL

Moderate-severe receptive and expressive morphosyntax, vocabulary, cognitive linguistic integration Moderate-severe receptive and expressive morphosyntax, vocabulary, cognitive linguistic integration Moderate receptive and mild expressive morphosyntax, vocabulary; moderate-severe cognitive linguistic integration Moderate-severe receptive and expressive morphosyntax vocabulary, cognitive linguistic integration Moderate-severe receptive and expressive morphosyntax, vocabulary, cognitive linguistic integration Mild-moderate expressive morphosyntax, vocabulary, cognitive linguistic integration

Severe basic reading and comprehension Poor naming speed

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23

Boy, G.S., 16.1; 9.8

BRI: behav. sig. (1/3 S) MCI: behav. sig. (3/5 S) Affected: inhibit; WM; monitor; initiate BRI: clin. sig. (3/3 S) MCI: clin. sig. (5/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate BRI: behav. sig. (1/3 S) MCI: clin. sig. (4/5 S) Affected: WM; plan/organize; monitor; initiate BRI: behav. sig. (2/3 S) MCI: clin. sig. (4/5 S) Affected: WM; plan/organize; monitor and initiate BRI: behav. sig. (1/3 S) MCI: clin. sig. (5/5 S) Affected: WM; plan/organize; monitor; initiate BRI: clin. sig. (3/3 S) MCI: clin. sig. (4/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate BRI: behav. sig. (1/3 S) MCI: clin. sig. (5/5 S) Affected: inhibit; WM; plan/organize; monitor; initiate

Severe receptive and expressive morphosyntax, vocabulary; moderate-severe cognitive linguistic integration


Yes

No


Moderate-severe basic reading and comprehension Poor naming speed Moderate-severe basic reading and comprehension

Severe hyperlexia (intact basic reading and severe reading comprehension) Profound-severe basic reading and comprehension Poor naming speed

ESL = English second language; FSL = French second language; behav. sig. = behaviourally significant dysfunction; clin. sig. = clinically significant dysfunction; S = scales; SIFTER = Screening Instrument for Targeting Educational Risk.

haviourally and clinically significant dysfunction respectively. That is, the occurrence of clinically significant dysfunction in MCI was in inverse relation to BRI where the majority demonstrated behaviourally significant dysfunction. While the affected scales showed BRI inhibit issues in only 52%, a large majority exhibited deficits in the MCI’s 4 scales: WM (91%), plan/organize (78%), monitor (83%) and initiate (83%).

BRIEF Results The majority of students (83%) showed dysfunctions in both BRI and MCI, while difficulties in BRI only occurred in 2 students and 1 in MCI only. One student only (table 1, case 3, A.J.) showed an adequate rating in both. In BRI 65 and 26% showed behaviourally and clinically significant dysfunction, respectively, while in MCI 13% showed adequate function, and 22 and 65% exhibited be-

Language, Reading and Naming Speed Results Only 1 student (table 1, case 7, A.T.) showed adequate language or no apparent deficit. The greater majority exhibited difficulties with morphosyntax (83%), vocabulary (74%) and cognitive linguistic integration (91%). In reading, 2 of the 3 youngest students (table 1, cases 1 and 2) showed adequate reading readiness. While no students exhibited a basic reading deficit only, 30% showed only a comprehension deficit. The majority (61%) demonstrated both basic reading and comprehension deficits. Poor naming speed occurred in only 22%.



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tiate’ scale was also listed as it points to a student’s lack of independence on tasks, a worrisome deficit in a classroom. The oral language results (column 4) include receptive, expressive, morphosyntax, vocabulary and the cognitive-linguistic integrative aspect (crucial to comprehension and school performance in general). Column 5, reading, includes basic reading and comprehension deficits, and poor naming speed where present. Frequency (percent) summaries of BRI and MCI severity categories and affected scales are shown in table 2, while reading and language frequency results are summarized in table 3.

Index severity category based on number of affected scales

Percent (n = 23) BRI/3

MCI/5

Adequate (0) Behaviourally significant (1 – 2) Clinically significant (3)

9 (2/23) 65 (15/23) 26 (6/23)

13 (3/23) 22 (5/23) 65 (15/23)

Affected scales

Percent (n = 23)

Inhibit WM Plan/organize Monitor Initiate

52 (12/23) 91 (21/23) 78 (18/23) 83 (19/23) 83 (19/23)

Table 3. Frequencies (%) of language, reading and naming speed

deficits (n = 23) Language deficits Adequate (no apparent deficit) Morphosyntax Vocabulary Cognitive linguistic Reading deficits Adequate reading/readiness Basic reading Comprehension Basic and comprehension Naming speed

4 (1/23) 83 (19/23) 74 (17/23) 91 (21/23) 9 (2/23) 0 (0/23) 30 (7/23) 61 (14/23) 22 (5/23)

Student Narrative The Student. A.T. (table 1, case 7) is the second born in a family with 5 children. He is a bright (noted in a psychological report) 9.1-year-old boy in grade 3.8 whose life at home and school is a disheartening daily struggle. He has pronounced difficulties in reading, writing and spelling, and lags in all academic areas. His adequate oral language comprehension and expression abilities stand in stark contrast to his failed literacy skills and academic performance. He is in constant conflict with peers, siblings and adults as he reacts to trivia with disproportionate anger and frustration. His evaluation showed clinically significant dysfunction in behaviour regulation (shift, inhibit and emotional control), and 4 of 5 scales on the MCI. Organization of materials is his only adequate EF. The school principal and teachers attribute his academic struggles to his maladaptive class behaviour which they feel is exacerbated by his struggles to acquire literacy 44


and his inability to persist in challenging tasks. The principal also felt that A.T.’s self-esteem and emotional wellbeing were compromised because of his conflicts with teachers. The principal noted that despite his awareness of his school issues, he is unable to achieve change even with his parents’ support. Parents’ View. His mother complained that his serious difficulties in school are caused by his behaviour and lack of attention. He is often disruptive, fails to participate and complete assignments, and is often asked to leave the classroom. A.T.’s dad observed that he spends more time in conflict with his teachers and outside of class than in class, consequently his work and progress in his studies are suffering despite his intelligence. Dad believed that A.T. has no problems with his class peers. Both parents admitted that he is difficult to manage at home as well. He has attention issues and, except during play, his mind tends to wander. He is prone to sudden unexplained tantrums during play or upon waking. He is oppositional, easily frustrated, impulsive, aggressive and has poor selfesteem. They felt great empathy for his suffering in school and were determined to find effective interventions ‘to help him shine’. Mom provided the examiner with A.T.’s itemized repair list he created (mom helped him spell) for a local bike shop where he left his bike for repair. It clearly showed adequate vocabulary, forethought and analytical ability in describing the problems he had with his bike, and identifying the defective components, highlighting his potential for academic work and his motivation when an evident beneficial goal leads his efforts. The Student’s View. A.T. noted (quotation marks represent the student’s words) that he has problems in every subject, and he claimed to understand only ‘a bit of English’. In reality, he had only some difficulty expressing himself in English, and at those moments, he asked his parents for help. He obviously underestimated his proficiency level. He stated that although he wants to listen in class, his mind wanders off, but he could not say what he is thinking about when this happens. He mentioned that he has an English tutor at school who is his ‘very favourite teacher in the school’. When asked whether he seeks help from other teachers, he said that he tries but ‘it is not helpful’, as his teacher does not like any interruptions. He was animated when he described one of his teachers: ‘He is crazy. He makes kids write lines for punishment. When they don’t listen, they go to the principal. Then they have to copy the whole book.’ He admitted that he disobeys often, and he was made to copy an entire book: ‘When a teacher says don’t do it, I do it!’ In contrast: ‘Every time, I listen to my parents.’ He confirmed that he has more Hus


Table 2. BRIEF BRI and MCI severity and affected scale frequency

Discussion

Virtually all students in the clinical sample demonstrated EF dysfunctions. Some showed deficits in behaviour regulation, others in the metacognitive domain; the majority, however, showed deficits in both, and many showed high risk for ADHD. However, in practice, a follow-up psychiatric examination is essential to confirm (or deny) ADHD and to treat this chronic disorder appropriately. A.J., the only student (table 1, case 3) in the adequate BRI and MCI category, failed an academic risk measure, the SIFTER [74], completed by another teacher who identified failure in academics (class standing and reading), attention (span and distractibility) and participation (class involvement, and initiating and completing work). The parent complaints regarding this student tended to support this teacher’s observations. A.J. presents with executive dysfunction, knotted with significant deficits in language, basic and reading comprehension, and naming speed, rendering him at high risk for persisting RCD. This case highlights the variability that may exist between responders on rating instruments and provides a caveat that a thorough investigation is necessary to establish the student’s true function. While 2 young students, W.S. and F.G. (table 1, cases 1 and 2), exhibited dysfunction in BRI, MCI and oral language, their reading readiness was intact. While W.S. was not yet receiving instruction beyond the reading readiness skills, F.G. was repeating grade 1 and was only able to demonstrate reading readiness skills. Nonetheless, both are at high risk for persistent RCD because of their EF and oral language deficits. The entire sample showed reading deficiencies; however, the occurrence of concomitant naming speed deficit was relatively rare in this sample (22%). Nonetheless, those with both disorders, i.e. ‘a double deficit’, are considered more resistant to remediation and present a higher risk for persisting reading difficulties [71, 72]. While nearly the entire clinical sample exhibited marked executive dysfunction and difficulties in oral language, basic reading and comprehension, the majority had received a variety of interventions (and/or accommodations) Executive Dysfunctions in Reading Disabilities

throughout their school years, evidence for a persistent reading difficulty. These clinical results show that dysfunctional EFs are indeed intertwined with readinglearning disorders in students with persisting academic struggles. These findings correspond to the observations that reading-learning disorders tend to persist in individuals with EF dysfunction despite remediation efforts, as they are an added burden to the learning disability [7, 53]. The bilingual factor did not seem to play a role in EF dysfunction, oral language or reading since the monolinguals exhibited difficulties comparable to those of the bilinguals in this clinical sample; however, here this may be due to the small number of monolingual representation (30%). In conclusion, SLP evaluations using the BRIEF uncovered the comorbidity of executive dysfunction that exists in students with language and reading disorders. This rating instrument was relatively easy to administer and useful in exposing these students’ EF deficits. However, a caveat is necessary here since there was evidence that one rating instrument may not be sufficient in uncovering the student’s true function (table 1, case 3). The clinical data and the student narrative presented here lend support to the findings of the various cited studies that EF comorbidity underlies persisting reading disorders and increases academic distress. A.T.’s situation is typical of students whose reading disorders and academic distress are intertwined with EF dysfunction, and who do not respond to conventional remediation. It is crucial that SLPs uncover communication disorders and EF comorbidity so that both can be addressed simultaneously in treatment based on sound pedagogical theory and evidence-based practice. Finally, the study has some weaknesses. Gottardo and Grant [75] discuss the difficulties posed when evaluating bilinguals. Indeed, standardized measures of language and reading were unsuitable for most of these students with varied home and school languages, a fact that speechlanguage pathologists confront on a daily basis when working with bilinguals, making it difficult to conduct a comparison study. The greatest weakness here is the sample size as it prohibited a comparison of bilingual and monolingual performance, and did not allow statistical procedures for identifying and determining effect sizes of EF scales that contribute most to reading difficulties; these would be made possible with larger bilingual and unilingual samples.


45


problems at school than at home, and that he gets along with only 6 out of the 20 students in class because the rest are ‘too wild’. During the interview, A.T. was openly concerned about his situation and expressed preference for home schooling so that he would no longer be faced with his ‘impossible’ situation at school.

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