Inclusive Education for Specific Learning Difficulties
The objective of this assignment is to explain the identification process of dyslexia by looking at the legal framework and the diagnostic tools used. It will also look at how to identify students with dyslexia and how to meet an individual learners needs by creating a dyslexia friendly learning environment. Current research will be critically analysed and reflected upon particularly to explain the causation theories. Theory will be related to practice by focusing on a student with dyslexia.
The student will be referred to as Student X in order to maintain anonymity and his place of study will be referred to only as the School of Pharmacy. Student X is a mature student and was referred in 2009 for an assessment for SpLDD whilst at the School of Pharmacy following concerns regarding his work. He has not received any support prior to studying at the university to address the difficulties he experienced in school. Student X has succeeded in gaining nationally recognised qualifications at GCSE and A Level, and has gained a HNC and BSc in Chemistry, but unfortunately has to re-sit his Level 2 dispensing assessment from the previous academic year.
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There are many definitions of dyslexia which have changed over the last 100 years because of advances in research. Early definitions talked of a 'word blindness' or inability to acquire literacy skills. Hornsby (1995) referred to dyslexia as a disability that can be overcome. Her programme of training resulted in people making 'miraculous recoveries' giving the impression of an illness. However, in other research the terminology has changed to talking about learning difficulties rather than disabilities. Stein (2009) talks about how a dyslexic's brain is wired up differently to non-dyslexics, not wrongly, but just differently. Most definitions focus on the unusual balance of skills in reading, writing, and spelling compared to generally ability. Phonological processing may be a problem as can information processing and many definitions state that dyslexia is a problem that persists across a lifetime although strategies can be developed with correct teaching that will enable the learner to achieve. My favourite definition of dyslexia is 'Dyslexia should be seen as a different learning ability rather than a 'disability' (Pollock and Waller 1994). This removes the idea that the learner is not academically able, but that they learn in a different way. Drawing on my learning from Initial Teacher Training, learning theories describe the various ways in which people learn and dyslexics may need to use a different learning approach to the non-dyslexic but can still reach the same end goal with good teaching.
Before looking at the causal models of dyslexia, I will discuss how dyslexia can be identified and diagnosed. A simple screening checklist can be used to look for dyslexic tendencies but these are not designed to give a diagnosis. These can be useful for an initial assessment and can be used by non-specialists. However, the results may be misinterpreted and only give a probability of the person being dyslexic. For the adult dyslexic in particularly, strategies may have been found that then mask the results of their true dyslexia profile. Diagnostic tools can be used to confirm dyslexia and pin-point the specific areas of difficulty. Specialist or physiological assessments take a long time and can be costly but show the specific strengths and weaknesses of the person, and are designed to be used for different age ranges from 3 year and 6 months for the PREST test and up to 74 years of age with the WRAT-3 test (Wilkinson 2002).
In order to be effective, tests need to take into account cultural or even regional differences. Tests over ten years old may no longer be relevant, for example, technology has changed rapidly and young children would struggle to name a picture of an original Sony Walkman cassette player compared to an MP3 player. Tests should be conducted each time in the same conditions as the tests are normed in order to provide reliable and valid. Factors affecting the results include the level of noise, warmth and brightness in the room. The person being assessed should be comfortable and relaxed so that low self-confidence or anxiousness does not affect the tests. Although the literature is dated, McLoughlin, Fitzgibbon and Young (1994) state that formal diagnosis of dyslexia involves psychological testing using careful observation and clinical judgement. Professional judgement is used to assess the personality and current situation of the person, meaning that the assessor may have to quickly establish if the person had arrived at the assessment centre without any stress or recent problems in their personal life which could affect their ability to concentrate during the assessment process and therefore affect the results of the diagnosis.
The assessor that carried out student X's assessment commented on the conditions in which the test took place in order to validate the results of the test against the norm and took into account Student X's background and personality. His family history was considered to see if other members of the family may be dyslexic and therefore establish if there is a genetic predisposition. His medical background was investigated to see if there could be any other reasons for his difficulties and no medical/health problems were identified.
Which diagnostic tests can be used depends on the qualification of the person conducting the assessment. For example the WAIS-III (Wechsler Adult Intelligence Scale) is restricted to use by educational psychologists whereas the WRIT (Wide Range Intelligence Test) can be used by non-psychologists yet are both designed to establish the intelligence levels of the person being assessed. A wide range of tests are needed in order to obtain a detailed picture of the areas of difficulty and to eliminate the possibility of other types of learning difficulties such as dyspraxia or dyscalculia. A generally low achiever would not perform well in most areas and a high achiever would perform well in all areas, but a dyslexic would have a discrepancy or a 'spikey' learning profile with a high ability in certain areas but some specific areas of weakness depending on the nature of their difficulty.
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Current research by the British Psychological Society (BPS 2009) raises concerns about the comparison of the WRIT and WAIS-III, specifically that the validity of using the WRIT as part of a diagnostic battery appears to have discrepancies between the comparable scores which could have diagnostic implications, in that it can mask a working memory deficit. As the research is written by the BPS, the results probably would favour their own version of intelligence test, but without further research it would be unjustified for me to state an opinion as to which test provides the most accurate results. However, with the information that is available to me I believe that if other tests are used in conjunction with WRIT, then validity of the results should be achieved. Using one test alone, even though broken down into several subtests, could produce a false result especially if adult learners have developed their own strategies for overcoming their difficulties. For instance, when given an opportunity to write freely, a person can select topics and words that they are confident at getting right even though they understand or could verbally express a much higher level of knowledge and understanding.
Student X was assessed by a qualified specialist teacher with an OCR Diploma for Teachers of learners with Specific Learning Difficulties (AMBDA). The tests used were the Wide Range Achievement Test (WRAT), Spadafore Diagnostic Reading Test, Wide Range Intelligence Test (WRIT), Dyslexia Institute digit memory test, Specialist Matters test, Wordchains test and the Comprehensive Test of Phonological Processing (CTOPP). These tests are used to diagnose specific areas of difficulty. For example, the Spadafore Diagnostic Reading test assesses word recognition, oral reading comprehension, silent reading comprehension and listening comprehension, whereas the Dyslexia Institute Digit Memory test assesses verbal memory difficulties by asking the person to repeat pairs of digits forwards and backwards until the person reaches a point where they cannot recite the pairs. Being able to repeat a string of numbers after being told them would involve recalling information and this is different from the listening comprehension as this would require a demonstration of understanding the content of what has been heard and therefore distinguishes between the areas of difficulites.
The assessment results for Student X showed a 'spikey' profile with areas of strength in verbal and non-verbal ability, understanding information presented orally, single words reading/spelling skills, good decoding skills, and being able to articulate ideas well. The weaknesses identified by the tests were auditory/visual sequencing memory which affects the ability to make sense of and recall information, and the ability to process at speed or multitask when processing blocks of information or units of sound within a word. So, although student X does not seem to have difficulties with reading and decoding single words, reading and extrapolating information slows down his reading/writing speed.
The dispensing assessment involves reading and interpreting text from key reference books in order to verify whether prescriptions are clinically appropriate and safe for patients and completing a written worksheet. Students are given three hours to complete five prescriptions as well as role-play interaction with the prescriber of the prescription in order to rectify any errors. Even without learning difficulties, some students do not finish the exam in the time given. If a student has a specific learning difficulty with processing speeds, such as Student X, then extra time would be beneficial and other dyslexics with different areas of difficulty such as letter reversals or omitting the end of words or whole words, may not need the extra time to process information, but could make use of the extra time to check for accuracy which is also vital in dispensing.
A variety of definitions for dyslexia have already been discussed and they are not specific enough for a diagnosis to be made and some only describe the symptoms of dyslexia (Roderick and Fawcett 2008). There is no one agreed upon definition due to there being various theories about the causes of dyslexia. Frith (1999) has created a causal model which focuses on the biological, cognitive and behavioural links between the main theories including the phonological deficit, magnocellular deficit and the cerebellar deficit theory, and these will be discussed in more detail. The three-level framework underpinning the main theories is shown in Figure 1.
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There are other theories such as Wolf and Bowers double-deficit hypothesis which suggests a deficit in phonological processing and a processing speed deficit. Dyslexics with the double-deficit have the most severe problems as they show a
Figure 1. The three-level framework
slowed response to tasks even when language is not involved e.g. pressing buttons to choose a response (Fawcett 2001). In a review for the Department for Education and Skills in 2001, Fawcett outlined the main theories of dyslexia, and much of the theory is still current today. I have therefore used the review for much of the basis of the following discussion.
The phonological deficit theory is the most accepted theory for the cause of dyslexia and there is evidence of a difference in the anatomical structure and function in the peri- and extra-sylvian fissure and planum temporale area of the brain which is involved with language. In Friths causal model, this biological factor has a cognitive effect on phoneme/grapheme knowledge which results in poor reading skills because of poor phoneme awareness and poor short-term memory resulting in a poor naming speed (see figure 2). The phonological theory however, does not account for the visual problems that some dyslexics have such as scotopic sensitivity, known as Meares-Irlen Syndrome where text seems to move or swim on the page making it difficult to follow from word to word, or line to line (online 2011), or the difficulties in organisation or knowing left from right. Using the phonological deficit model could imply that a person is not regarded as dyslexic as they do not have problems with phonology but do not learn to read and write because of environmental factors such as culture or teaching methods.
Left Hemisphere 'disconnection'
Poor grapheme/ Phonological
phoneme knowledge deficit
Poor Poor Poor Poor
reading phoneme short-term naming
awareness memory speed
Figure 2. A causal model of dyslexia as a result of phonological deficit (Frith 1999)
The three main theories related to the magnocellular deficit include visual magnocellular deficit, auditory magnocellular deficit and pansensory magnocellular deficit. It was thought that visual magnocellular deficit causes a 'visual persistence' when the eye moves meaning that there is still an image from the previous letter when moving onto the next one. This causes words to blur and drift therefore making reading difficult and causes problems with rapid processing (Stein and Walsh 1997). Tallal, Merzencih, Miller and Jenkins (1998) report that a deficit in auditory pathways cause problems with telling the difference between sounds that are presented closely together and this would account for phonological difficulties associated with the magnocellular deficit.
Neither of these theories would account for all of the range of symptoms that a dyslexic may have and so the pansensory magnocellular deficit hypotheses that both visual and auditory processing may be affected simultaneously. However in later research, Stein claims that the magnocellular system is not responsible for visual persistence and included motor and muscular control systems into his theory. According to Nicholson and Fawcett (2008) the pansensory magnocellular deficit becomes hard to distinguish from the cerebellar deficit hypotheses. Figure 3 shows Friths illustration of the magnocellular deficit theory.
Slow Temporal Processing
Auditory Deficit Visual Deficit
Poor Poor Poor Poor
reading speech tone motion
development discrimination detection
Figure 3. A causal model of dyslexia as a result of magnocellular abnormality
The cerebellar deficit theory focuses on the fact that dyslexics have problems with a wide range of skills including motor skills, balance and rapid processing, and acknowledges the phonological difficulties. The pattern of difficulties fits in with another theory of 'automatisation deficit' where there is a problem with acquiring skills that should come automatically after extensive practice. The cerebellar deficit theory was disputed as there were no known links between the cerebellum and language but this is being contested with the advance of science and it is now known that the cerebellum is linked with the frontal cortex including Broca's language area (ref). A deficit of automaticity causes problems when dealing with more than two motor tasks at the same time, or with motor and mental skills such as thinking and doing or reading and making notes. This would fit in with Student X's difficulties as well as the phonological deficit theory. Friths three-level framework for the cerebellar deficit is shown in figure 4.
I am in agreement with Fawcett that theorists should work together for the benefit of the dyslexic in order to find the causes, the symptoms of and treatment for dyslexia rather than trying to identify that only their theory is the correct theory for dyslexia. In later research with Nicholson (2008), Fawcett maintains that there is more than one cause and that they distinguish the various sub-types of dyslexia.
Phonological Deficit Motor Control Deficit
Poor Poor Poor Poor Poor
reading naming time motor balance
speed estimation development
Figure 4. A causal model of dyslexia as a result of cerebellar abnormality
Fawcett uses an analogy that medicinal and engineering research usually finds one cause for a problem that can produce a range of symptoms with specific treatments available, whereas in education and psychology a problem can have multiple causes which can lead to primary and secondary symptoms that can be treated in a variety of ways.
One could argue that a secondary symptom of dyslexia is anxiety or stress and Cole (2008) has added a 4th level to Friths causal model to show the emotional impact of dyslexia (see figure 5). Lee (2000) categorises anger, frustration, embarrassment, fear, shame, loneliness, low self-esteem and confidence as secondary features of dyslexia that can be reduced by specialist teaching, whereas McLoughlin, Fitzgibbon and Young (1994) found that for adult learners in particularly, dyslexia cause's feelings of frustration, lack of confidence and low self-esteem even after success has been achieved.
Student X recalled feelings of upset when he first read his assessment report. Although he can now admit that it is a true reflection of his difficulties, seeing the problems on paper was disappointing but also explained why he had found certain tasks difficult in the past. He feels that he has to work hard to achieve good grades and admits to focusing negatively on things that he has got wrong in assessment rather than celebrating what he has done correctly. He experiences frustration at what he calls 'silly mistakes' as he knows that he is capable of the work but somehow still gets thing wrong.
Figure 5. Modification to Frith's framework to include an emotional perspective (Cole 2008)
Carroll and Iles (2006) recently conducted research with a small group of dyslexic HE students and found that they had higher levels of academic and social anxiety compared to the non-dyslexic control group, and yet surprisingly levels of anxiety regarding appearance was relatively similar. Negative feelings were attributed to the competitive environment and demands for high literacy skills and these results are reflected in research carried out on young children with dyslexia. It would be interesting to know whether the HE students were diagnosed as dyslexic at a young age or since entering university, and whether they are in their first, second or final year. If they were diagnosed at a young age and still feel anxious about their literacy skills then this demonstrates the life-long effect that dyslexia can have and would justify a fourth-level in the causal framework. If diagnosed later in life then the feelings of anxiousness may well reduce once the student is more confident that they can achieve the level of literacy demanded in HE.
In a recent study by Gibson and Kendall (2010) dyslexics discussed anxiety problems in higher education due to negative teacher attitudes, lack of support and an expectation of low achievement on behalf of the teachers. Students valued those teachers that gave appropriate time in order to address their learning needs and also considered their personal, social and emotional needs. I believe it is therefore important that dyslexia awareness is high on the agenda for CPD for any staff involved in Higher Education from administration level to academic level in order for a supportive learning environment to be created which should hopefully lead to a reduction in the levels of stress and anxiety triggered.
An interesting area of research into dyslexia is looking at whether there are any precursors to dyslexia that can be identified in early childhood. The Code of Practice for Children with Special Education Needs (SEN), 1994 (DfES 2002) requires that schools diagnose and support dyslexic students. If dyslexia can be diagnosed at a very early age, intervention strategies can be put in place to help the child to progress rather than using the 'wait to fail' method. Nicolson and Fawcett (2008) have set a blue print for a cost effective and progress effective approach to dyslexia see figure 6) and advocate the use of screening tests as young as five years old. Depending upon the results of the screening test, interventions can be made.
Figure 6. A blueprint for dyslexia screening, intervention, and diagnosis (Nicolson and Fawcett 2008)
If the interventions are effective no further support may be necessary but in some cases specialist support and a full diagnosis may be required. It could be assumed that if anxiety and stress are caused by constant failure in reading, writing and spelling tasks, then adopting this kind of model of early intervention should reduce the risk of failure and therefore reduce the emotional impact on the learner in childhood and adulthood. It is surprising that this kind of model has not been used in the past and even with the wealth of research into dyslexia, children are still leaving school with undiagnosed dyslexia and literacy problems that could have been avoided with the use of early and on-going screening tests.
There is a legal framework that impacts upon the identification, assessment and support of dyslexia. The focus of this research is about adult dyslexia in the context of pharmacy education and will therefore discuss the legal framework for Higher Education and how this is impacted by the regulatory standards set by the General Pharmaceutical Council.
Rather than having a duty to diagnose and support students under the Code of Practice SEN 1994, Universities have a duty under the Higher Education Funding Council for England (HEFCE). In 2001, the Disability Discrimination Act (DDA) required FE colleges and HEIs to produce disability statements regarding their policy, provision and future plans. In the same year, the Special Educational Needs and Disability Act (SENDA) was introduced which made it illegal to discriminate against disabled students. Because of the updated DDA and the introduction of the Disability Equality Duty (DED) in the academic year 2005/2006, HEFCE and HEIs have been working towards inclusive practice for disabilities so that disability support becomes less of a focus and disability equality can be focused upon (HEFCE 2009). Inclusivity limits the use of additional practices for disabled students and adapts routine practices to meet the entitlements of all students. Good practice for inclusivity is anticipatory, proactive, flexible and embedded across the Institution.
However, even with good inclusive practice, there still may be a requirement for extra support or changes to routine practice to meet the needs of disabled people including those with dyslexia. Under the HEFCE Code of Practice (2009), students can use alternative methods to demonstrate that they have met the intended learning outcomes (ILOs) and this is backed up in a later publication from the Quality Assurance Agency (2010). Under the DED, disabled people can be treated more favourably than non-disabled but ILOs and competences must still be met and cannot be made easier. It is only the methods that demonstrate that the student has met the ILOs that can be changed, for example by allowing a student to answer exam questions verbally to a scribe or using assistive technology rather than writing. Other reasonable adjustments include giving extra time or rest breaks.
There is very little literature on learning disabilities in medical and allied profession education (Hartley 2006). Until 2006, pharmacy students were not allowed extra time during their final pre-registration exam set by the Royal Pharmaceutical Society (RPS) and they did not publish any specific material about disability matters1. In the past, students at the School of Pharmacy have been allowed extra time or other provision for many of their assessments, but there have been no alternative assessment methods for the dispensing exam. The reason given for this was that the exam is 'practice based'. The principal function of pharmacy education includes
The regulatory duties of the Royal Pharmaceutical Society have now been replaced by the newly formed General Pharmaceutical Council.
establishing and promoting safe and effective practice of pharmacy and standard one is concerned with public and patient safety. Assessment criteria to meet this standard must be effective in order not to jeopardise patient safety. However under standard three, pharmacy applicants, students and trainees must not be treated unfairly on the grounds of disability under the requirements of the Equality Act 2010 which is replacing the Disability Discrimination Act (online direct.gov). Evidence must be provided that reasonable adjustments have been made to the delivery of the course and in meeting the learning outcomes, but because of the nature of the course, patient safety must be the primary concern and any demonstration of unsafe practice must result in failure regardless of ability or disability. Regulations for the award of Masters in Pharmacy may be more stringent than the university norms for other course and may include higher than average pass marks for assessment.
Because Student X did not pass the dispensing exam during his second year of study, progression to the third year cannot be granted for the reasons above. Having to re-sit the dispensing module and the subsequent mock and real exam, the module leader and I worked with Student X to provide extra support and to look at what practices the School of Pharmacy can adopt or improve to make the module dyslexia friendly for the future. Student X was recommended a range of allowances for teaching and assessment purposes (see appendix 1) however Student X did not want to use some of the adjustments. He wanted to be able to take the exam with as little intervention as possible as he 'wanted to know that he had passed it on his own merit'. He said that he needed to feel that he could pass the exam himself as he wouldn't have the benefit of a reader or be free of distractions once in employment as a Pharmacist, and this illustrates the importance of taking the individual needs into account when planning for inclusivity.
The use of 25% extra time was granted to all students with a specific need for the first time this year, and Student X claimed that this was most beneficial to him. Because of the pressure of the exam, Student X feels like he struggles even more with his comprehension than normal. Students have to submit four out of five prescriptions in order to pass the 3-hour exam and up until now, Student X has not managed to finish all five prescriptions. In the mock and real exam, Student X only used about 15 minutes of his extra time but this enabled him to finish all five prescriptions and therefore potentially gain marks for 100% of the exam rather than 80%. He was also given worksheets to record answers in his preferred paper colour of green which he finds reduces the visual stress when writing.
A specific change (see appendix 2)was made to the prescription labelling software before the exams and Student X trialled this to see if it helped him with labelling requirements. Because Student X and a few other students found the new version easier to use, it will be rolled out to all laptops in the Pharmacy Practice Suite at the start of the new academic year.
During discussions with Student X we found that he struggled with transposing information from reference book to prescription label and then to the worksheet. It was decided that he could print a label and annotate it with any extra information necessary. This was a great help to Student X as it simplified the process and minimised the risk of making errors when transposing information. Because a simple change like this was successful for Student X, all students are now allowed to use this method of annotation therefore increasing the dyslexia friendliness of the course.
Student X was also given the opportunity to attend extra dispensing sessions in order to gain extra practice before the exams as part of the learning styles for adult dyslexics is to overlearn by repeating the material to be learnt (Lee 2000). At the time of writing this assignment, the results for the dispensing exam have not been released, but in the mock exam Student X passed with a remarkable 86%. He feels that this was down to the adjustments reliving some of the pressure and anxiety that causes him to work less effectively that normal.
During the summer term, I made improvements to the prescription labelling software manual so that it is easier to follow and more compact. The original and new version is shown as appendix 3. The reasons for the changes were
Hornby, B. (1995) Overcoming Dyslexia - a straight-forward guide for families and teachers. London: Vermillian
McLoughlin, D., Fitzgibbon, G. and Young, V. (1994) Adult Dyslexia - assessment, counselling and training. London: Whurr Publishing
Nicolson, R. and Fawcett, A. (2008) Dyslexia, Learning and the Brain. USA: MITpress
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