Cognitive and emotional challenges in children with reading difficulties

Abstract

Aim:

Dyslexia is characterised by a primary difficulty in both reading and cognitive control. Children with reading difficulties also experience a broad range of social and emotional difficulties, such as low self-esteem, anxiety and depression. The aim of the study was to determine whether there is a linkage between emotional and cognitive-control difficulties and challenges in reading in children with reading difficulties compared to typical readers.

Methods:

Children 8–12 years of age (N=98) either with reading difficulties or typical readers participated in the current study. Cognitive control, specifically executive functions, and emotional and reading abilities were compared between the two groups and correlated.

Results:

Children with reading difficulties showed significantly lower executive functions and emotional abilities compared to typical readers. Decreased reading ability was related to decreased executive functions and emotional abilities.

Conclusion:

The results provide insight regarding the relationship between cognitive, emotional and reading abilities: executive functions difficulties may cause emotional stress, which in turn decreases the ability to monitor, inhibit and pay attention to the written material, which impair reading to a greater degree. Results support the need for an emotional evaluation in children with reading difficulties that can be performed in a paediatrician’s consulting room.

INTRODUCTION

Dyslexia is characterised by a significant difficulty in reading that is not explained by any other intelligence, motivation, or environmental deficit (1). Children with reading difficulties share challenges in language acquisition and impairments in both perception and articulation of speech (2). Recent studies have indicated that individuals with reading difficulties also share challenges in areas outside of language/reading domains, including writing, arithmetic abilities, coordination and attention capacity (3, 4). Similar to reading, these abilities also rely on cognitive control and deficits may indicate a common malfunction in executive functions in individuals with reading difficulties (2). Other studies suggest that the mentioned challenges all stem from the source of a basic difficulty in cognitive control (5).

In many instances, children with learning difficulties, and reading difficulties specifically, experience a broad range of social and emotional challenges, such as low self-esteem, anxiety, depression and peer rejection (6). These children may arrive to their paediatricians due to one of these social-emotional difficulties. Therefore, connecting reading and cognitive-control challenges to emotional difficulties in this population is important for an early evaluation and treatment and was the focus of the current study. This connection is particularly important in the medical arena to prevent misdiagnosis or missed treatment for individuals with reading difficulties.

Due to the relationship between cognitive-control and emotional abilities, some studies suggest an alteration in emotional state as one of the causes of reading difficulties and that emotional challenges such as anxiety, harm avoidance, depression and low self-esteem may result generally in learning difficulties and in reading difficulties specifically (6). For example, studies have reported inefficient processing and weakened memory functioning due to negative affective states (7, 8). Normandeau and Guay found that language and maths scores in 6 year-old children can be predicted by anxiety questionnaires completed by the teachers (9). Other studies suggested an alternative causal model and claimed that reading difficulty was actually the cause for the emotional difficulties: children who experienced academic difficulties may develop anxiety symptoms in response. To support this model, researchers have determined that anxiety and other emotional issues are predicted by learning difficulties (6).

These two alternatives suggest a third path of bi-directional influence that generates a positive feedback loop: initial struggle or difficulty in reading acquisition leads to an emotional distress, which in turn leads to additional and broader reading difficulty, and so on (4). Clearly, there are several challenges from which children with reading difficulties suffer, and it is challenging to objectively determine cause. With the development of imaging technologies, a better understanding of neural circuits supporting the mentioned challenges is possible.

Difficulty with reading is reflected in a variety of challenges. In some cases, inability to acquire intact reading capabilities, no matter how much effort is invested in learning and exposure to language and written language specifically, can be explained by common deficit in cognitive-control domains, specifically executive functions. Executive functions are a common terminology for a collection of monitoring and optimisation conscious processes, including working memory, inhibition of responses, selective attention and attention shifting, and error monitoring. These abilities are needed for facing and integrating different stimuli, appropriate reaction, setting goals and planning, and many of these are crucial for the reading process (10).

The specific interest in executive functions is due to the fact that they are highly involved and dominant in reading tasks (11). An impairment in speed of processing, visual attention, working memory and error-monitoring functions, which are controlled by brain regions or networks related to executive functions, is involved in the deficit in reading acquisition from which children with reading difficulties suffer. However, although the relationship between the limbic and executive functions systems has been researched (12), the relationship between these and the challenges in both abilities shared in this population is still unknown. Identifying these challenges is critical due to the potential additionally needed therapies in this population.

The overall aim of this study was to determine the relationship between emotional and executive functions deficits and reading ability in English-speaking children with reading difficulties compared to that in typical readers and to provide paediatricians a better differential diagnosis between psychological, psychiatric and reading difficulties. We hypothesised that children with reading difficulties would have lower executive functions and emotional scores compared to typical readers and that executive functions measures would positively correlate with both emotional scores and reading ability among the entire study population.

MATERIALS AND METHODS

We recruited 98 children ages 8–12 years; amongst them, 42 children were diagnosed with reading difficulties (mean age: 9.87±1.07, 51% males), 56 were typical readers (mean age: 10.03±1.18, 42% males), and all were matched for age (t=−0.71, p=0.514). The study was carried out in Cincinnati Children’s Hospital, Ohio, USA between the years 2015–2017.

All study participants were Caucasian, native-English speakers with parental reports of an average socioeconomic status; and all were right-handed, displayed normal or corrected-to normal vision in both eyes and had normal hearing. Exclusion criteria included a history of neurological or emotional disorders and a history of psychiatric impairments including attention deficit participants. To verify children’s non-verbal abilities within the average range (100 with a standard deviation of 15), all study participants were assessed for nonverbal abilities using the Test of Nonverbal Intelligence (13) and attention abilities using the Sky Search subtest from the Test of Everyday Attention for Children battery (14). Children who were diagnosed with attention deficit hyperactive disorder were excluded from the study. Participants were recruited from posted ads and through commercial advertisements. All participants signed informed written assent and their parents provided informed written consent prior to inclusion in the study, and all were compensated for participation. Cincinnati Children’s Hospital Institutional Review Board approved the study. All participants underwent reading, executive functions and emotional testing.

Reading difficulty was confirmed by a battery of normative reading tests in English. Characteristics of reading difficulties were determined by the inclusion criteria of the study. Turkeltaub et al reported that children in the reading difficulties group scored below 25% on at least two of the reading tasks (15). Therefore, in order to be included in the reading difficulties group, children were required to score below 25% on at least two of the following reading tests: Phonemic awareness from the Elision subtest of the Comprehensive Test of Phonological Processing (16), Automatic words-reading accuracy or orthography from the Test of Words Reading Efficiency (17), Automatic decoding from the Pseudo-words Reading Efficiency subtest of the Test of Words Reading Efficiency (17), a non-timed words-reading accuracy or orthography (18), a reading-comprehension test (18) and non-timed decoding of pseudo-words reading (18). To be included in the typical readers group, participants had no history of neurological or psychiatric disorders including attention difficulties as well as had fluent and accurate reading (according to norms), meaning scores greater than 25% in all of the study reading tests.

Executive functions were measured using several sub-tests from different batteries. Speed of processing ability was tested using the Object-naming subtest from the Comprehensive Test of Phonological Processing (16) and the coding and symbol search subtests (19). Working memory was assessed using the digit span task from the Wechsler intelligence scale for children (19). Inhibition ability was assessed using the Stroop subtests (20). Attention ability was measured using the speed and accuracy subtests from the Test of Everyday Attention for Children battery, using the Sky Search, Score and Sky Search DT subtests (14). Switching ability was tested using the Wisconsin Card Sorting Task (21). The overall score of general executive functions as well as initiation, planning and organizational abilities, and monitoring were assessed using a parental report standardized questionnaire called the Behavioural Rating Inventory of Executive Functions, or BRIEF (22). Higher scores in the Behavioural rating inventory of executive functions mean lower abilities.

Children were assessed for emotional ability using the emotional subtest in the normalised Behavioural Rating Inventory of Executive Functions parental report questionnaire (22). High parental emotional scores in this inventory mean more emotional difficulties. These questions included information regarding the child’s reaction to an event in an appropriate way without emotional outbursts and information regarding mood changes and periods of feeling sad or upset.

Two-sample t-tests for the behavioural measures were performed between the two groups. To determine the relationship between the reading, executive functions and emotional measures, Pearson correlations were performed between the reading, executive functions and emotional tasks across the entire study population.

RESULTS

No significant differences between the two groups were found in general nonverbal ability or in attention abilities; however, children with reading difficulties scored lower in the general verbal ability test compared to typical readers (Table S1).

Children with reading difficulties demonstrated significantly lower scores in all reading measures compared to typical readers. Individuals with reading difficulties showed decreased phonemic awareness, timed words and pseudo-words reading efficiency, reading comprehension, and orthographical and phonological abilities (Table S1).

Children with reading difficulties had significantly lower scores in most of the cognitive-control tasks compared to typical readers (Table S2). Children with reading difficulties showed decreased speed of processing, inhibition, working memory visual attention, switching and shifting, initiation, planning and organization, monitoring as well as decreased emotional abilities compared to typical readers.

Pearson correlations between reading and executive functions abilities across the two groups revealed significant positive correlations between most reading and executive functions abilities. Results suggest that greater reading ability is related to higher executive functions scores. Significant positive correlations were found between reading comprehension scores and verbal speed of processing (r=0.43, p<0.001), inhibition (r=0.42, p<0.001), working memory (r=0.37−0.52, p<0.001), visual attention (r=0.28, p<0.01), switching (r=0.33, p<0.001) and monitoring (r=0.34, p<0.001). Positive correlations were also found between orthographical abilities and most of the executive functions measures: speed of processing (r=0.7, p<0.001), inhibition (r=0.68, p<0.001), working memory (r=0.49, p<0.001), visual attention (r=0.34, p<0.01) and switching in the ability-to-learn category (r=0.36, p<0.001).

Results from the Pearson correlation suggest that lower reading skills were associated with increased emotional challenges. The correlation analysis conducted between emotional and reading measures across the two groups revealed significant negative correlations between emotional and reading abilities. Emotional ability was negatively correlated with timed and nontimed orthography abilities (r=−0.321, p<0.01; r=−0.236, p<0.05, respectively), timed decoding (r=−0.293, p<0.01) and reading comprehension (r=−0.25, p<0.05) across the two groups.

Lower executive functions abilities were associated with higher emotional scores, which indicate emotional difficulties, between the groups. Significant negative correlation between emotional and executive functions measures was observed across the two groups for speed of processing (r=−0.2, p<0.05), inhibition (r=−0.29, p<0.01), visual attention (r=−0.28, p<0.05) and switching in the sub-category of the ability to learn (r=−0.3, p<0.05). High positive correlations were found between emotional skills and working memory, inhibition, shifting initiation, planning, and organisation and monitoring skills (r=0.45–0.65, p<0.001).

DISCUSSION

Paediatricians are typically the first medical professionals parents contact if there is any concern regarding the child. Due to reports of additional difficulties in executive functions and emotional challenges in children with reading difficulties, we sought to establish the relationship between these components in a diagnosed population of children with reading difficulties. Having this established will enable paediatricians to inquire about reading aspects when concerns regarding emotional challenges such as anxiety or social challenges are reported, or when challenges in attention, shifting, or monitoring are reported that are related to difficulties in executive functions. The current study aimed to reveal a link between reading difficulties and emotional and executive functions abilities in children. The results support our hypotheses and demonstrate that children with reading difficulties had lower emotional and executive functions scores in comparison with typical readers. We also demonstrated the relationship between lower reading scores and decreased emotional and executive functions abilities and determined that lower executive functions abilities were associated with lower emotional abilities.

As suggested by previous studies, children with reading difficulties share challenges in areas outside of the reading domain that indicate malfunction in cognitive control and executive functions (2–5). Our results support this point by showing that children with reading difficulties had lower scores in cognitive control and executive functions tests compared to typical readers. This finding supports a battery of studies done in this area, emphasises the importance of executive functions abilities in the reading process and shows specifically that deficits in executive functions are highly correlated with reading difficulties in children.

An additional finding that aligns with previous studies is the emotional difficulties we found in children with reading difficulties compared to typical readers. Previous studies showed that children who experience reading difficulties develop anxiety and other emotional difficulties symptoms in response (6). In this study, emotional difficulties were reflected in difficulties in emotional control as reported by parents, which adds other aspects of emotional difficulties, such as low self-esteem, anxiety, depression and peer rejection, that have been reported in previous studies (6). Correlations show differences between different reading abilities with regard to emotional difficulties. For example, reading comprehension and reading decoding abilities showed significant negative correlation with emotional scores; in other words, high emotional score indicates emotional difficulties, while phonemic awareness did not show significant correlation with emotional abilities scores. This indicates an impact of difficulties in reading as a whole process on emotional state, which might be proof that reading is a social activity that generates social-emotional difficulties. This supports the emotional difficulties that children with reading difficulties experience during their lifetime.

Do emotional difficulties in children cause reading difficulties, or do children who are not comfortable with their reading abilities gradually develop emotional disorders such as anxiety and low self-esteem? Additional research is needed to address this causality, and such a study might involve parents without reading difficulties, but with emotional difficulties, which would increase the chances that their children would suffer from emotional difficulties as well. Examining these children’s reading abilities might reveal the causality of this phenomenon and serve as a platform for paediatricians to discuss this with the parents and children when they come for a child-well visit or when they raise a concern related to one of these domains.

Our results also indicated significant negative correlations between emotional ability and cognitive-control measures. Speed of processing, inhibition, visual attention and switching abilities were the most prominent cognitive-control abilities found to be negatively correlated with emotional scores. Previous studies showed relationships between negative affecting states and inefficient processing and weakened memory functioning (7, 8). In addition, self-regulation, problem solving and information processing are impacted negatively by anxiety level in children (23, 24). Other studies have found that anxiety and other emotional issues can be predicted by learning difficulties (6). Here, we show that children with lower executive functions scores had more emotional difficulties as reflected in the reported emotional control. This relationship emphasises the third aspect of the Reading-Executive Functions-Emotional triad in children, and in children with reading difficulties specifically, and strengthens the relationship between emotional and cognitive difficulties and reading difficulties. Our results also support neurobiological findings demonstrating physical and functional connections between the limbic system related to emotional abilities and the frontal lobe related to executive functions (25). A future neuroimaging study of the relationship between these cortical and sub-cortical regions in children with reading difficulties is warranted.

One hypothesis that explains these relationships would be the existence of a “vicious cycle” between emotional and cognitive abilities, whereby increased stressful or anxious behaviour reduces monitoring, inhibition and attention abilities, which in turn reduces reading efficiency and may result in increased anxiety and low self-esteem, which then may lead to resentment and avoidance. Neuroimaging analysis of reading tasks may show the relationship of different brain areas and networks and lead to conclusions of the direction of impact.

The results of this study should be considered taking into account the following limitations. Although parents were asked 10 questions to cover the emotional abilities domain, only one emotional test was used in this study compared to a variety of subtests used for executive functions and reading. Despite this limitation it is important to note that the emotional test used covers a variety of domains, such as emotional control. A future study should collect additional emotional measures such as anxiety, self-efficacy, self-esteem and social behaviour. Moreover, the control group was matched on the basis of age, but not gender, and the frequency of females in the control group was 57% compared to 38% females in the reading difficulties group. The predominance of males in the reading difficulties group reflects the prevalence of reading difficulties in male school children, but was not matched for that of the control group.

Conclusions

This study demonstrated that children with reading difficulties also suffer from lower emotional skills that link to impairments in reading and executive functions. The clinical importance of adding such a measure to the evaluation process of reading difficulties is to provide an appropriate intervention to the emotional domain, if needed. Since executive functions and emotional challenges are also related to arithmetic abilities (9), more research is needed to examine the association between emotional difficulties and other cognitive difficulties like arithmetic. In addition, further studies are needed to assess the impact of intervention for reading improvement on emotional states, and vice versa. These studies would further an understanding of the causality of the relationship between reading difficulties and emotional difficulties.

Keynotes.

• Previous studies in children with dyslexia focused mainly on reading without attention to evidence related to these children’s emotional and cognitive-control, specifically executive functions, abilities.

• Children with reading difficulties demonstrated decreased emotional and executive functions abilities.

• Emotional abilities in children with reading difficulties are related to decreased executive functions and should be taken in consideration during diagnoses and when providing a treatment for these children.