Dealing with dyslexia

Anne Harriss and Kerry Ricketts explain why failure to recognise the condition in the workplace has implications for both employee and employer.

On this page:
Dyslexia
Condition
Vision and reading
Assessment of fitness to work
Work environment
Legal aspects
Role of the OHN
References.

Dyslexia is a common condition that many assume relates only to reading and writing. However, it is more complex than merely having problems processing written material.

The Department for Children, Schools and Families defines dyslexia as: "A specific difficulty, typically characterised by an unusual balance of skills. Dyslexia affects information processing (receiving, holding, retrieving and structuring information) and the speed of processing information. It therefore has an impact on skills such as reading, writing, using symbols and carrying out calculations."

There are implications for a number of posts and professions. A review of the literature into dyslexia conducted by Dale and Aitken (2007) for the Royal College of Nursing (RCN) in 2007 resulted in the RCN calling for the introduction of national standards of anti-discriminatory practices for people with dyslexia in the NHS and the private healthcare sectors.

This was followed in May 2009 at RCN Congress by a resolution to lobby employers to recognise and make provision for the needs of dyslexic nurses and students.

Unrecognised dyslexia is a concern in healthcare environments as it has implications for patient safety. It may also be encountered as a performance issue and result in a referral to the occupational health (OH) service. Unfortunately, OH practitioners may have little understanding of workplace implications. The aim of this article is to raise awareness of the causes and impacts of dyslexia, so that OH practitioners can develop a broader understanding of the underpinning cause and associated difficulties to effectively support dyslexic employees.

Dyslexia

Badien (1997) suggests that in western society, dyslexia is four times more common in men than in women, with the total number of people affected being 4%. However, Everatt (2000) suggested that the gender ratio is closer to parity.

Condition

Dyslexia covers a broad spectrum of difficulties, from mild to significant. One of the most significant problems is processing and sequencing information, which proves particularly problematic for those with administrative facets in their posts. Pennington (1990) concluded that up to 10% of the population show some signs of dyslexia, particularly when it has been diagnosed in other family members.

The British Dyslexia Association (BDA) offers a broad definition: "Dyslexia is one of several distinct learning disabilities. It is a specific language-based disorder of constitutional origin characterised by difficulties in single-word decoding usually reflecting insufficient phonological processing. These difficulties in single-word decoding are often unexpected in relation to age and other cognitive and academic abilities; they are not the result of generalised developmental disability or sensory impairment. Dyslexia is manifested by variable difficulty with different forms of language, often including, in addition to, problems reading, a conspicuous problem with acquiring proficiency in writing and spelling." 

There are three main types of dyslexia: dysnemkinesia/dysgraphia (motor); dysphonesia (auditory); and dyseidesia (visual).

Dyslexia is sometimes dismissed as an excuse by middle-class parents for their under-performing, lazy children. An appreciation of the differences in brain structure of those with dyslexia helps OH practitioners identify the genuineness of their difficulties.

Galaburda (1993) proposes that dyslexia is an impairment in the mechanism of information processing associated with undeveloped cells, or ectopias, present in the brain cortex - the area responsible for cognitive activity. Bradford (2003) supports this theory, referring to the results of MRI brain scans demonstrating differences in brain structure in those with dyslexia. Specific cells located beneath the surface of the brain in those with dyslexia are located on the brain surface in non-dyslexic people. These ectopic cells are located in the left and frontal lobes of the brain, the areas responsible for reading and writing.

Bradford proposes that during foetal development, cells guided by radial glial cells migrate, forming the cerebral cortex. A membrane is formed stabilising these cells and maintaining their position through the neural pathway. Breaks in this membrane could allow ectopic cells to migrate through the breach and locate beneath the surface of the brain.

Galaburda also noted that those with dyslexia had a smaller magnocellular system compared to his non-dyslexic patients. The magnocellular pathway (MCP), along with the parvocellular pathway (PCP), the occipital and parietal lobes of the brain, allowing information to be processed in the cerebrum via the thalamus. Both the parietal and temporal regions of the cortex process magnocellular information. The posterior parietal cortex is involved in visual spatial attention, peripheral vision, eye movement and control and attention tasks.

Travis (1996) identified that any small defects in the MCP can lead to an amplified deficit of the parietal cortex, resulting in difficulty concentrating and remaining focused when reading, symptoms experienced by many dyslexic people.

The magnocellular system is specialised for motion and spatial relationships, which explains some of the difficulties with spatial awareness that some dyslexic people experience. This pathway extends from the large M-type ganglion cells in the retina to the magnocellular layers of the lateral geniculate nucleus. Neurons throughout the system respond rapidly, but only transiently. Retinal ganglion cells consist of 10% magnocells used for fast responses, timing events, detecting visual motion, directing attention, eye movements and eye fixation,  and 80% parvocells used for colour, fine detail and slower responses.

Signals from the retinal ganglion cells are relayed through the magnocellular layers of the lateral geniculate nucleus. The signals are then relayed to the medial superior temporal area, and to the visual motor area of the parietal lobe (Kumar, and others, 2007).

Vision and reading

The majority of visual references received by the brain are processed in the magnocellular system. Galaburda's findings indicate that people with a smaller magnocellular system have difficulties processing visual referencing information, thus leading to the difficulties associated with dyslexia. This is analogous to the difference in the amount of information received through a broadband internet connection compared to a modem connection. While it is thought that both malfunctions occur in early development, it is unproven whether ectopic cells are responsible for all such malfunctions.

Stein (1997) highlights that reading difficulties result from structural differences in the parietal and temporal regions of the cortex, both of which process magnocellular activity. In particular, the posterior parietal cortex is involved in visual-spatial attention, peripheral vision, eye movement, control and attention tasks. Having proper control over eye movements and the ability to concentrate and remain focused are crucial to the reading process.

Stein concluded that reading requires three elements: rapid visual identification of letters; rapid sequencing of their order; and rapid translation for the sounds they stand for. He concluded that any magnocellular weakness would cause visual instability, resulting in letter position confusion and poor orthographic skill.

There are various explanations for this weakness. The eyes have to converge when reading; this convergence is dominated by the visual magno system. Retinal magnocellular ganglion cells receive 45% of information from red-light receptors, 45% from green, and 10% from blue. Dependent on where the area of weakness is, it is believed that the use of coloured filters can rebalance magno input in an individual, and therefore improve reading ability and co-ordination.

Stein identified that post-mortem examination indicates that highly unsaturated fatty acids (HUFA) constituted 20% of the weight of the brain, and this percentage was lower in dyslexics. More importantly, it was noted that HUFAs influenced the magnocellular function. It is thought that these fatty acids preserve the membrane flexibility that permits the rapid conformational changes of channel proteins enabling the required transient sensitivity (Burns 2000).

Research showed that increasing the amount of HUFAs in the diet improved attention, co-ordination and reading ability.

Another theory gaining momentum is that dyslexia is a result of a genetic malfunction. Both Snowling (2000) and Brooks (1994) have identified an involvement of a quantitate trait on the short arm of chromosome 6, and therefore dyslexia could be categorised as a genetic condition. And Pennington (1991) estimated that people with a dyslexic father have a 40% risk of having dyslexia, which reinforces the theory of a genetic link.

Assessment of fitness to work

An assessment of an employee who is thought to have dyslexia should include a history of their difficulties and an occupational and social history, including identification of any difficulties they may have in managing their job.

Dyslexic people may have problems with some elements of their job requirements, but they are likely to have strengths in other areas. Unfortunately, many employees and managers fail to recognise these strengths, and tend to focus on the weaknesses.

Some of the most obvious signs of a dyslexic condition described by the BDA (2000), include:

• text looking "fuzzy";
• difficulty in focusing;
• taking a long time to read a page;
• difficulty in remembering which line is being read, requiring re-reading;
• poor concentration and retention of information; and
• tired eyes.

These difficulties may result in a referral to an assessment centre where a dyslexia screening tool would suggest that dyslexia is a likely cause of difficulties. This could precipitate a referral to an occupational psychologist, which may confirm that dyslexia is the underlying cause of work difficulties and, if so, what interventions may assist the person to fulfil their job requirements. This can be facilitated through the government's Access to Work scheme.

Some people with dyslexia find coloured paper or coloured overlays improves reading accuracy. Also, adjusting the background colour on a computer screen may assist. In some cases, referral to an optometrist with an interest in dyslexia may be helpful as glasses with coloured (Harris) filters may increase reading speed and be helpful as the provision of a coloured overlay film.

Once the results of an assessment confirm a diagnosis, it is essential that the OH nurse (OHN) involves the client's line manager to identify which supportive measures may be helpful. Dyslexia could be covered by the Disability Discrimination Act (DDA) and it is important that people with the condition are supported, and robust policies should be in place and adhered to.

The OHN is well placed to advise employee and employer on appropriate technology. This may include a variety of hardware and software, including:

• voice-activated software;
• a dictaphone to record discussions and meetings;
• talk-to-text and text-to-talk software;
• asking co-workers to send the most important written information in a precise and concise manner to help those with dyslexia to deal with written material most effectively;
• adjusting the type font and colour of paper, or introducing coloured overlays to suit the client; and
• allowing more time for the worker to deal with the administrative requirements of their post.

Some people with dyslexia have difficulty organising an efficient filing and retrieval system for written materials as they may not be able to remember which category they have stored a document under. Keeping electronic versions of important documents may be helpful, as materials may be more easily retrieved by using key words as part of a search strategy on their computer.

Work environment

The Murugiah and others' (2002) Fitness to Work Framework for Assessment tool proposes that an OHN should have knowledge of all employee job specifications to establish a suitable framework to allow the employee to remain in work. It is essential that the OHN visits the client's work area to identify adjustments that could be made. Working in an open-plan office may prove distracting for the employee and co-workers, particularly when voice-activated software is recommended.

Legal aspects

The employer has a legal obligation under the Health and Safety at Work etc Act 1974 to ensure, so far as reasonably practicable, the health, safety and welfare at work of all employees. Cox (2002) highlights three main aspects for employers to consider: common law, statute law, and European directives.

Statue law provides the DDA. This was introduced to prevent discrimination against, and unfair dismissal of, disabled people. An employer has a duty to make "reasonable adjustments" in the workplace for any disabled staff that it employs. Although the definition of a disabled person is not precise, the DDA defines a disability as: "A physical or mental impairment, which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities."

Dyslexia is included in the mental impairments section of the act.

Role of the OHN

The OHN has an obligation and a duty of care to employee and employer. This includes offering advice to both, or recommending a strategy or assessment to allow employees to continue working in a safe environment. By carrying out this process, the organisation is able to improve the job satisfaction of the client, and ensure the employer can retain a valued member of staff while complying with the relevant legislation.

OHNs are well placed to offer advice to all parties on the complexities of dyslexia, providing early intervention and an initial screening assessment, thereby determining if the client is dyslexic.

The OH service can liaise between Access to Work and support organisations, such as the BDA. This support is important as most of those affected do not present with dyslexia, but with other symptoms, such as stress or depression.

Dyslexia cannot be cured, but intervention in the workplace can make life easier for sufferers, which will improve productivity and cost effectiveness for employers.

References

• Badien, N (1997) Dyslexia, Annals of dyslexia,Vol 47 IDA.
• Bradford, J (2003) What causes dyslexia? Dyslexia Parents Resource (external website).
• Brooks, L (1997) Dyslexia: 100 years on brain research and understanding Dyslexia Action (external website).
• British Dyslexia Association (external website).
• Cox, R (2002) Fitness to work: the medical aspects, third edition, Oxford University Press.
• Dale, C and Aitken, F (2007) A review of the literature into dyslexia in nursing practice: final report, London: RCN Practice Education Forum.
• Department for Children, Schools and Families (2001) Guidance to support pupils with dyslexia and dyscalculia, London: DCSF.
• Everatt, J (2000) An eye for the unusual: creative thinking in dyslexics (1) 28-46.
• Galaburda, A (1989) Ordinary and extraordinary brain development, anatomical variation in developmental dyslexia, Annals of dyslexia 39: 67-80.
• Galaburda, A (1993) Dyslexia and development Neurobiological aspects of extraordinary brains, Uni Press Harvard.
• Kumar, V; Abbas, A; Fausto, N; Mitchell, R (2007) Robbins Basic Pathology 8th Edition, Elsevier Oxford.
• Murugiah S; Thornbory, G; Harriss, A (2002) Assessment of fitness, Occupational Health, April 2002, pp.26-29.
• Pennington, D (1990) Phonological processing skills and deficits in adult dyslexics, Child Development 61(6) 1755-1778.
• Snowling MJ, (2000) Dyslexia, Blackwell Oxford.
• Stein, J (1997) To see but not to read: the magnocellular theory of dyslexia, Trends Neurological Science 20: 147-52.
• Travis, J (1996) Let the games begin, Science News, Vol.149 No.7, p.104.
• Dyslexia Awareness Week 2009: 1-7 November. For more information, go to the British Dyslexia Association website.

Anne Harriss is course director of OH nursing programmes at London South Bank University, and Kerry Ricketts is an OHN.