The average adult in the US reads at a 7th or 8th grade level. Most medical communication specialists suggest medical information should be written at the 5th to 6th grade level to reach the widest audience.
Why is that important? Because the average neuropsychological evaluation is written at about the 12th to 16th grade level!
Source: poster I presented with my colleagues Alison Wilkinson-Smith [lead author] and Alice Ann Spurgin at AACN based on a study we did where we asked neuropsychologists to upload a de-identified, 'average' NP report to assess readability.
What do we do about this gap?
Lately I've been working on improving the readability of my reports. For a rough estimate of report readability, I use Microsoft Word's readability stats. I look at:
Fleisch-Kincade Grade Level
Reading Ease (a number from 0-100; under 60 is hard for many readers)
Number of passive sentences (my aim is 0%)
When I just write the way I naturally write, I generally am at the 13th to 16th grade level (!!). When I think more about my audience, I'm generally at the 10th grade to 11th grade level. Lately, I've been trying to improve on those numbers.
Here's a (very de-identified) report summary I wrote with a grade level of 8.1 and a readability score of 61, which is within the "plain English" range. The way I write reports, this summary would fit on two pages (1 page double-sided) and would be right at the beginning of the report.
What are your thoughts?
SUMMARY AND IMPRESSIONS
Jane Doe is an outgoing, bilingual (English/Hindi) 8-year-old girl in the third grade. Her parents brought her in for an evaluation because she is struggling to learn to read. This evaluation shows Jane has a lot of strengths, like her thinking and communication skills. However, she also has a learning disability and slow processing speed. These concerns are affecting her progress at school and causing her emotional distress. Jane’s diagnoses are listed below, while the next few paragraphs describe her full profile of strengths and weaknesses.
Diagnoses:
· ICD 10 Code F81.0: Dyslexia
· At risk for anxiety/depression due to learning challenges
What Are Jane’s Strengths?
Jane’s test results show she can solve a wide variety of problems. In other words, Jane’s cognitive skills are developing nicely. Her cognitive skills are in the high average range and at the 86th percentile for her age. She is equally good at solving problems that are verbal, visual, hands-on, and abstract. Jane’s verbal skills will help her take in new information, compare and contrast ideas, and express what she knows using words. Her visual-spatial skills will help her solve puzzles, build, design, and navigate. Jane’s abstract thinking skills will help her understand patterns, sequences, and quantities.
Jane also show strengths in her language and memory skills when tested in English. Her overall language development in English is in the high average range and at the 79th percentile. Like many bilingual children, her language skills are very strong in the language she speaks at school. Jane has especially strong receptive language skills, or ability to understand others. Her expressive language skills, or ability to communicate her wants and needs, are also good. Jane’s memory for stories is also strong and at the 65th percentile. Jane’s learning difficulties are clearly not due to being bilingual or to limited English proficiency.
Jane has solid sensory and motor skills. Her fine-motor skills are well above average. Jane also has good visual perception. This means she can accurately interpret what she sees. Jane also has good visual-motor integration, or hand-eye coordination. These skills will help her complete hands-on tasks at home and at school.
Jane also has nicely-developed executive functioning skills. Executive functions are the skills students use to organize their thoughts, feelings, and behaviors in order to set and reach goals. Executive functions include things like focusing and coming up with a plan. Jane’s test scores show she can pay attention as well as other students her age. She also has an average short-term memory span. This means she can mentally “hold on” to information while she is following directions or performing a task. Jane can also break a large task down into steps and work through those steps. This means her organizational and planning skills are average for her age. Jane’s parents also rated her everyday executive functioning as average for her age. Jane can clearly focus, keep ideas in mind while working, and stay organized.
Jane also has many personal strengths. She is friendly, hard-working, and eager to please. She is well-behaved at home and at school. She is also well-liked by adults and peers. Jane has a lot of interests and especially enjoys active play and sports. She participates in soccer, tumbling, and parkour. She also loves art.
What Are Jane’s Vulnerabilities?
Jane struggles with the basic learning processes that support efficient reading and writing. She has weaknesses in her:
Sophisticated phonological awareness: This is the ability to understand how sounds combine to form words. Students need this skill to know how to sound out or spell words. Jane’s skills are at the 25th percentile, which is at the low end of the average range. I am concerned at the big ‘gap’ (24 points) between her phonological awareness score and her verbal problem-solving score.
Rapid Naming Speed: This is the ability to quickly and effortlessly recall of information learned through rote memory. Students need this skill to quickly “pull up” things facts know well. I measure this by seeing how fast Jane can name letters and numbers. In the real world, students with slow rapid naming speed have trouble quickly remembering sight words, high frequency words, and math facts. Jane’s rapid naming speed is low average and at the 10th percentile.
These two weaknesses are significantly affecting Jane’s progress in learning to read, spell, and write. Her academic test results show her reading and writing skills are much lower than we would expect. Her single-word reading skills, decoding, and reading fluency all are at the early second grade level. This is a full year behind her actual grade level. Jane’s single-word spelling skills fell at the mid-second grade level, which is also behind. Notably, Jane often left out sounds in words she was trying to spell. This shows her weakness in phonological awareness.
Importantly, Jane's overall Dyslexia Index score on a standardized achievement test is in the “moderate” range. This means there is a good chance she has dyslexia based on this score. This score is also 38 points below her cognitive abilities score. There is a clear and substantial ‘gap’ between Jane’s cognitive skills and her achievement in reading. She needs specially designed instruction at school to close this gap.
Most children with learning differences also have trouble with some executive functions. This is true for Jane as well. Overall, Jane’s executive functioning skills are developing nicely. She does not meet criteria for any attention or processing disorders. However, she has a relative weakness in her processing speed. That is, Jane works at a slow pace. Her score is in the low average range and at the 23rd percentile. Her profile shows there is a large ‘gap’ between how deeply Jane can think and how quickly she can produce work. It takes her extra time to 'show what she knows.'
I am also concerned about how Jane is doing emotionally. Based on her self-report and her parents’ ratings, she is experiencing symptoms of anxiety and depression. This is likely related to her learning challenges. She seems very aware of her learning problems. She may feel like her peers are more easily able to grasp things in school, and this makes her sad and anxious. It will be important to support Jane’s emotions while she gets support for her learning needs. We want to make sure she feels calm, comfortable, and confident. We want her to have the positive, growth-oriented mindset she needs to take risks, try new things, and learn new skills.
What Diagnoses Best Fits Jane’s Profile?
Jane’s test results meet criteria for a mild to moderate Dyslexia. Dyslexia means a student has processing problems that affect how easily and efficiently they can learn to read, spell, and write. Students with dyslexia often have two specific deficits: (1) a weakness in phonological awareness, and (2) a weakness in rapid naming. As students learn how to read and spell, they need phonological awareness to sound out unfamiliar words or to guess at the spelling of words. Fluent readers and spellers also need to effortlessly recognize high-frequency words. To do this, they need rapid naming speed. Students who struggle with phonological skills and rapid naming speed are doubly-disadvantaged when it comes to ‘mastering the code’ to learn how to read and write. These students have the double deficit of dyslexia. In addition to her dyslexia, Jane is also at risk for anxiety and depression. She has a high level of generalized stress and worry. She also has low self-esteem. At this time, I think this is probably due to her learning challenges.
How Can Jane Best Be Supported?
Jane needs dedicated support for her dyslexia at school. This would look like specialized instruction in reading and writing delivered in a small-group or one-on-one setting. This instruction should use a research-based, multisensory reading program. Jane may also need special support in math, especially in later grades. This is because students with dyslexia are at very high risk of struggling with math fluency and math word problems.
Jane also needs accommodations in class. She should have extra time to complete tasks or shorter assignments. This is important because she has a weakness in processing speed and works at a slow pace. Jane also needs opportunities to show her nonverbal and social strengths at school. For example, teachers can encourage her to share her ideas with the class or with younger students. They can also offer Jane the chance to complete assignments using multisensory methods, like doing a drawing or project to show what she has learned.
If we nurture her strengths in this way, we will be sure Jane continues to love school even when some parts of it are hard for her. We should also keep a close eye on how Jane is feeling. If she needs more emotional support, she should go see a therapist who is warm, caring, and can help her learn lots of great coping skills.
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