Point of View:

David Boulton: To begin with, help us understand your passion and point of view.

Dr. Sally Shaywitz: All right. I'm a neuroscientist, but a pediatrician by training. My interest in trying to better understand learning disabilities, and particularly reading difficulties, came from my own experience as a resident, seeing many, many children and their families. I became aware of how worried mothers and fathers were about how their children were doing in school, and, also, how little we, particularly pediatricians, knew about it, and had to offer these families. Since that time I chose to not only be a pediatrician, but to specialize in developmental and behavioral pediatrics, and then further in learning disabilities, and then further in reading.

Over the years I've really gotten to know so many children and their families, and also I've seen the children grow up and got to know them as adolescents and young adults and even adults. I have seen the tremendous cost to these children and their families of having reading problems that often were unidentified and misunderstood and inadequately treated.

David Boulton: So, you connected up with and empathized with the challenges they're living through in some way that drew you in.

Dr. Sally Shaywitz: Oh, absolutely. As a neuroscientist I feel privileged to be studying the brain, but I think the passion that drives my husband and me, we work together, is really the knowledge and experience of what the cost is to individuals. It's an enormous, enormous cost and because it seems to be hidden, as I say in my book "Hidden only from those who don't have to live with it." It's frequently terribly misunderstood. Children who are struggling to read, are often told, "Well, you're not motivated," or, "You're not trying hard enough." Or if a parent is concerned, that parent might be told, "Oh, you're just worrying, don't worry, they'll outgrow the problem.” The idea that this is somehow a phase rather than something that will be with the child for life.

David Boulton: Yes. One of our interests is to explore what happens when children become so ashamed of how they feel about themselves in this process that it creates an almost preconscious aversion to it.

Dr. Sally Shaywitz: Well, I think that's true. I've had the good fortune to speak to many people who are dyslexic, and who've been highly successful by anyone's standards. But if you speak to them, as I have, and you ask them: "Well, what was it like for you when you were a child, particularly, what was school like?" And you see this terrible look on their face. Particularly they recall the really horrible experience of being called upon to read aloud in class, in front of everyone when they couldn’t do it.

David Boulton: Yes.

Dr. Sally Shaywitz: That's the kind of mental image and emotional experience that stays with a child. It's really remarkable how many adults will remember that and can picture that classroom and how they felt and how they wanted to get out of there and avoid that at all costs.

David Boulton: Right. Almost everyone we talk to speaks about this feeling level connection with people who are suffering with this challenge.

Dr. Sally Shaywitz: Yes, this isn't an academic abstraction, it's about real people who have to live with something that people don't see, and that's why I guess it's been a really wonderful thing that the science has progressed so far, and that we actually now have the ability to see the brain at work, so we can actually see what is happening at the most basic levels.

What Brain Scans Reveal:

David Boulton: Good. Thank you. That's a great place to start from. Relative to what you were just saying about being able to see the brain working on these fundamental levels, tell me a little bit about your research model, what you've been looking for and how you've gone about it.

Dr. Sally Shaywitz: Well, clearly, for anyone who's interested in reading and dyslexia, which was initially described over a hundred years ago, the goal has been to try to understand where, at a fundamental level, reading takes place; and obviously it takes place in the brain. However, the challenge has been how do you study a process within the brain of children who are otherwise healthy? Fortunately, we have a very nice hard skull protecting the brain. So, how do you look within the brains of healthy children? We've all been extraordinarily fortunate that two lines of research have converged. One is the understanding of the basic nature of reading and reading difficulties; and the other has been the extraordinary progress in technology that allows us in really quite a benign way to be able to image the brain at work. We use Functional Magnetic Resonance Imaging (fMRI), which allows us to image children and adults as they try to read without using radiation or injections or anything like that.

So, our first goal was to see if the technology could work, and to be able to identify and localize what are the brain systems used in reading. First we studied adults, good and poor readers. We found that good readers use three major systems on the left side of the brain. Then we found that poor readers had a disruption, a significant underactivation of two of the regions in the back of the brain. But when you see that, the question always is: Is this something that if you see it in an adult, is it the result of years and years of not reading?

David Boulton: Right, or mis-learning to read, as distinct from being something that's more neurobiological/structural in origin?

Dr. Sally Shaywitz: Well, yes -- not quite, maybe having not read... I'll get to something in a moment, and you'll see why I'm sort of hedging here.

David Boulton: Okay.

Dr. Sally Shaywitz: Anyway, so our next step was to study a very, very large group of children who were good readers and struggling readers, and we found exactly what we had found in the adults, a significant underactivation in the areas in the back of the brain. This study was really a very, very informative one because there was an unusually large number of children participating, 144. That is a very large number of children for an imaging study and that allowed us to do a number of things. It allowed us to begin to map out: Well, what do these areas do? What was particularly of interest to us was one of the areas -- have you seen my book?

David Boulton: I have it in front of me.

Dr. Sally Shaywitz: The area in the back of the brain, the left occipital temporal region, or the word forming area - activation in that area was significantly related to a child's skill as a reader. So, the individual differences in reading skills were related to individual differences in brain activation. That was very important, because this is a very important area in fluency, which is critical to being able to read not only accurately, but also rapidly and with good intonation. So, we went from simply geographically identifying the systems to being able to see the locations of potential differences between good and poor readers, and what the role of each of these systems is.

Connecticut Longitudinal Study:

Dr. Sally Shaywitz:  Then we were able to go even one step further. I directed a study called the Connecticut Longitudinal Study. This study has been ongoing since 1983, where we've followed an epidemiologic sample of Connecticut school children. The target population was to reflect and be representative of all children attending public kindergarten in the state of Connecticut.

We've now followed and continue to follow ninety percent of that group, so they're now in their mid- twenties. We gave them reading tests every year and every other year ability tests; asked their teachers about them, asked the families about themselves, asked the children how they felt about themselves. It's a very broad range of information about the children.

What we were able to do as a result of that is when this group was in their early twenties a few years ago, identify three groups: one group who had never had a reading problem; one group who seemed to early on, in third and fourth grade, have a reading problem, but by the time they were in ninth grade, have really good accuracy, but still not fluent; and the third group, who we call persistently poor readers, they were poor readers in third grade and in ninth grade.

When we imaged them -- I'll make what could be a long story very short -- we found that the worst readers, the persistently poor readers, had the systems for reading in place, but they'd never been properly activated. They weren't connected up the same way as good readers. More importantly, because we had data on these young people from the time they entered school, we knew about their families and schools. What we found was that the persistently poor readers seemed to have lower verbal ability from the beginning and to attend more disadvantaged schools than the group that had compensated.

That has led us to hypothesize that we may be dealing with two different types of poor readers: one type, which would represent about a third of the total group of poor readers, who had their reading problems on an inherent basis. The other, which would represent two-thirds of the poor readers, seemed to have the systems for reading intact, but they'd never been properly activated. So these were shown primarily as environmental influences, perhaps from growing up in more disadvantaged circumstances and from not having received the kinds of reading instruction that would properly activate these systems.

Again, this is not to just to be simplistic and think that it's either all genetic or all environmental.

David Boulton: Right.

Dr. Sally Shaywitz: With every child it's always a combination. But in each child, also, there's a predominance of one or the other. What's very hopeful is that this large group representing two-thirds of all poor readers are children who really could be helped, who have the systems intact, who don't have that kind of disruption, but really haven't that that kind of stimulation either at home or at school that would allow these systems to be properly activated.

Inherent or Acquired?

David Boulton: Good. How do you differentiate the inherent from the acquired? You said that you were first testing them in the third grade?

Dr. Sally Shaywitz: Well, again, the inherent group is a group that seemed to have difficulty from third grade. By the time they were in ninth grade, they were able to read accurate, but not fluently.

David Boulton: Right.

Dr. Sally Shaywitz: They had improved their accuracy. They seemed to have higher verbal abilities to begin with, and to go to less disadvantaged schools. Now we're embarking on our genetic studies to actually see if we can find a genetic underlying basis for these reading disabilities.

David Boulton: Okay. But so far, are we close with any tests that actually differentiate the children before they're exposed to reading instruction?

Dr. Sally Shaywitz: That's a really good question. That's the hope. I think that apparently there are behavioral tests that reflect what we've known about reading and I think those can tell us which children are at high risk. I think those tests can pretty much pick up a very high percentage of those children who are at high risk. They also pick up children who turn out not to have reading problems. So, they end up, currently, over-identifying children. But that seems to be less harmful than...

David Boulton: Than under-identifying, yes.

Dr. Sally Shaywitz: So, as long as you don't label children, but say, "These children might benefit from getting extra help and getting highly explicit help," that seems to be a positive thing to be able to do.

Limitations of Current Brain Scans:

David Boulton: Do we have any brain imaging tests that you're aware of that allow us to see a signature distinction in the structure or processing of the brain before the process of learning to read that predicts difficulty in learning to read?

Dr. Sally Shaywitz: We don't. I know exactly what you're saying, and that would be just a really commendable goal. Currently, when we do functional brain imaging, children have to lie very still, and the youngest that I think we or others have done is about six-and-a-half. So then at that time that would be when children are about near the end of kindergarten. So, you'd expect them to have the rudiments of early reading in place.

It may be possible, with other technologies that are evolving, to be able to identify children earlier.

David Boulton: So, currently there's a rather significantly sized uncertainty about that threshold.

Dr. Sally Shaywitz: That's right.

David Boulton: Okay. Relative to your tests, how fast a frequency variation can you see? I mean, for example, with Keith Rayner's work we're seeing that the difference between graphemic and phonological follow-up is happening in a five to twenty-five millisecond time window when somebody is reading well.

Dr. Sally Shaywitz: Well, Functional Magnetic Resonance Imagining doesn't give temporal information.

David Boulton: So, then difficulties associated with the time precarious interactive interplay between these various modules you're identifying can't be seen with the equipment and setups we've got yet.

Dr. Sally Shaywitz: Certainly not with the Functional MRI. But what we can see, for example, that when we present words to children very quickly if they are using the word formation area that's critical for fluent reading. That's possible.

Now there are new techniques that show how the parts of the brain are connected, so we can have a sense -- and that's what I was just telling you about in the last research I mentioned, where we looked at the persistently poor readers who seemed to have all the systems in place, but they weren't connected appropriately, they weren't connected properly. I think this is an area where the technology is evolving very, very rapidly, so I think things are really changing as we speak.

David Boulton: So, we're heading towards being able to peer into this space. It seems when children are reading, if we really track their facial expressions and articulations, there's a hesitancy, or starting and stopping that happens for struggling readers, and that that starting and stopping has a correspondence to a number of things. One thing for sure is the kind of ambiguity they're processing at that moment, yes?

Dr. Sally Shaywitz: Well, yes, I think each of us would represent that a little bit differently.

David Boulton: Okay.

The Challenge of Learning to Read: