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July2010 Vol.47 Issue:      3 (Supp.) Table of Contents
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Reversing Letters, Asymmetric Tonic Neck, Neck Retraction Reflexes and Apraxia are Predictive of Dyslexia

Hala A Shaheen


Department of Neurology, Fayoum University; Egypt



Background: Dyslexia prevalence, diagnosis, risk factors and even awareness are quite uncertain in Egypt. One of the limitations in dyslexia evaluation for Arabic readers is the absence of rapid easy diagnostic test. The only available Arabic Reading Test for dyslexia is lengthy and only applicable at age 9-10 year where it is late for treatment of dyslexia. Objective: The objective of this study was to find out the frequency, easy neurological predictors of dyslexia and to increase teachers’ awareness of dyslexia.  Methods: Two hundred and six students aged 9-10 years old were assessed individually for dyslexia using Arabic reading tests. Detailed history taking and neurological examination with particular emphasis on symptoms suggestive of dyslexia, cerebellar signs, primitive reflexes, and tests for apraxia; were done for all students. Results: Twenty two students (10.67%) were found to be dyslexic. Dysdiadokinesia, asymmetric tonic neck, neck retraction, palmar reflexes and apraxia were significantly higher in dyslexic, P value (0.02, 0.001, 0.02, 0.001, 0.001) respectively. Reversing letters, persistence of the asymmetric tonic neck, neck retraction and apraxia were predictive of dyslexia. Simple instructions for the teachers make their diagnostic efficiency to detect dyslexia (72.1%). Conclusion: Dyslexia is frequent. Asymmetric tonic neck, neck retraction and apraxia tests were predictive of dyslexia. Large national project to tackle dyslexia is recommended. [Egypt J Neurol Psychiat Neurosurg. 2010; 47(3): 453-459]

Key Words: Dyslexia, prediction, primitive reflexes, apraxia.


Correspondence to Hala A. Shaheen, Department of Neurology, Fayoum University, Egypt.

Tel.: +20107965888. Email



Dyslexia is defined as reading difficulty disproportionate to the student’s age and intellectual abilities1. Its prevalence rates vary; according to many factors; from 3.3% to 24.2%2. Fortunately about 95 percent of dyslexic can be brought up to grade level if they receive early effective help. If help is given in fourth grade (rather than in late kindergarten), it takes four times as long to improve the same skills by the same amount3. It is important to raise that dyslexics have problems that extend beyond the range of language deficits. They said to have difficulties with balance4. Functional neuroimaging studies revealed significant cerebellar hypoactivation in dyslexic during reading task5. Furthermore Dyslexics have underlying developmental delay that was suggested to be related to persistence of primary reflexes2. Persistence of primary reflexes leads to poor ocular motor control consequently they found difficulty in tracking words in the lines; make errors in shifting to next line. Moreover they cannot change focus rapidly;

book to board to teacher to book; which are a fundamental classroom skills6. Movement intervention program designed to stimulate the development of secondary reflexes reduced levels of primary reflexes and balance board exercises. Both were found to be effective in aiding the maturation of oculomotor skills and improving reading scores of dyslexic7. There is a substantial link between dyslexia and apraxic. Seventy five% of apraxic children were found to have dyslexia. Therapy used to treat apraxia had positive effect on dyslexia8. Early appropriate instruction in morphological analysis was found not only improve reading scores, but also increase brain activation such that quantity and pattern of activation for children with dyslexia after treatment closely resembled that of non dyslexic9.

The aim of this study was to find out the frequency, easy neurological predictors of dyslexia and to increase teachers’ awareness of dyslexia. 





This is a cross sectional study conducted on 206 Egyptian school students; 117 boys and 89 girls. Their age ranged from 9-10 years old in 3rd and 4th grade primary school. With no visual, hearing problems, motor impairment, mental retardation (IQ less than 90%) or major psychological disorder. According to results of Arabic reading test {ART}10; the students were classified into two groups: Group (1) students with dyslexia and Group (2) students without dyslexia.



All the students were submitted to detailed history taking, general and neurological assessment with particular emphasis on symptoms suggestive of dyslexia as reading difficulty, low Arabic score, low spelling score, reversing numbers, reversing letters in the word, doing better in oral exam than in written one, right left disorientation, difficulty reading news papers or stories. Arabic reading test {ART}10 was applied to all students individually. It includes items that test phonological awareness namely rhythm, blending and segmenting of words, recognition of first and mid sounds in a given words, deletion of first, mid and last sound of a given words, sound addition to a given words. Auditory perception, short term memory, comprehension and spelling were also tested. Reversing or counting letters during {ART} were noted.

Cerebellar signs, primitive reflexes11 namely suckling, snout, palmar, palmo-mental, mouth open finger spread, asymmetric tonic neck (ATNR) and neck retraction reflexes, were done for all students. Tests for apraxia were also applied by asking the students to pantomime 3 complex commands. Teachers were asked about dyslexia. Then after explaining to them symptoms suggestive of dyslexia, they were asked to report names of students suffered from dyslexia to assess increase in their awareness of the problem.


Statistical Analysis

Statistical analysis was performed using SPSS version 15. The Chi square test was used for Comparisons between qualitative variables groups. Independent sample T test were used for normally distributed quantitative variables and non parametrical mann-whitney test for none normally distributed quantitative variables. P-value was considered significant at ≤ 0.05 level. The logistic regression analysis was done to test for significant predictors of dyslexia. Sensitivity and specificity of question and neurological signs as diagnostic marker of dyslexia were also calculated.




Frequency of dyslexia

Twenty two students out of 206 (10.67%) were found to be dyslexic.


Diagnosis of dyslexia



Most questionnaire items were significantly higher in dyslexics. Age, sex and grade of the students did not differ between the 2 groups (Table 1). Almost all questions are specific but not sensitive as diagnostic marker for dyslexia (Figure 1).


Arabic Reading Test

Mean of Arabic reading test (ART) for items given score ˃ 3 and numbers of students were not able to do commands for items given 1-3 score differed significantly between dyslexic and non dyslexic groups (Tables 2 and 3). Overall, children with dyslexia were significantly more likely reverse or count letters during {ART} than nondyslexic. Reversing or counting letters during {ART} were found to be highly specific (98.4%, 95.1%) but only 27.3%, 45% sensitive respectively in diagnosing dyslexia.


Neurological examinations:

Cerebellar signs in form of dysdiadokinesia, persistent primary reflexes (namely asymmetric tonic neck, neck retraction and grasp reflex palmar) and apraxia were statistically higher in dyslexic group (Table 4). Finger to nose test, tandem walking were normal in all students. No overshooting was detectable. Suckling and palmomental reflex were negative in all students. Neurological signs as diagnostic markers of dyslexia were highly specific but not sensitive (Figure 2).


Significant Dyslexia Predictors

Logistic regression analysis revealed that history of reversing letters in the words; asymmetric tonic neck reflex, neck retraction reflex and apraxia are significant predictors of dyslexia.


Problem Awareness

Teachers awareness almost was not exist when they were asked about dyslexia. After the definition of dyslexia and symptoms suggestive of the condition was explained to them, the teachers diagnostic efficiency of dyslexia became (72.1%); 89.7% specificity and 54.5% sensitivity.

Table 1. Questionnaire of dyslexic and non dyslexic groups.



Group (1) Dyslexic (22)

Group (2)

Nondyslexic (184)

P value

Reading difficulty

8 (36.4%)

4 (2.2%)


Low Arabic score

2 (9.1%)

0 (0%)


low spelling b score

9 (40.9%)

3 (1.6%)


Reversing numbers

4 (18.2%)

8 (4.4%)


Reversing letters in the word

8 (36.3%)

12 (6.6%)


Doing better in oral exam than in written

5 (22.7%)

1 (0.5%)


Right left disorientation

7 (31.8%)

6 (3.3%)


Difficulty reading news papers

4 (18.15%)

2 (1.1%)


Difficulty reading stories

4 (18.1%)

1 (0.5%)


Age            9 years

12 (14.3%)

72 (85.7%)


                  10 years

10 (8.2%)

112 (91.8%)

Sex            Male

12 (10.3%)

105 (89.7)



10 (11.2%)

79 (88.8%)

Grade 3

14 (12.5%)

98 (87.5%)


Grade 4

8 (8.5%)

86 (91.5%)

Positive family history

3 (13.6%)



*Significant at p<0.05                                                                                ** Significant at p<0.01




Figure 1. Sensitivity and specificity of the questionnaire for dyslexia.



Table 2. Mean±SD of Arabic Reading Test items given score ˃ 3 in dyslexic and non dyslexic groups.


Arabic reading test (ART)

Group (1) Dyslexic


Group (2) Nondyslexic (n=184)

P value

Total score




Phonological awareness 








Recognition of  mid sounds in  given words




Deletion of mid  sound in given words




Sound addition of a given words




Short term memory












Data are expressed as mean±standard deviation

* Significant at p<0.01


Table 3. Number and percentage of students in Arabic Reading Test items given score1-3 in dyslexic and non dyslexic groups.


Arabic reading test (ART)

Group (1) Dyslexic (n=22)

Group (2)

Nondyslexic (n=184)

P value

Blending words                                   0

7 (31.8%)

23 (12.5%)



15 (68.2%)

161 (87.5%)

Segment words                                   0,1

5 (22.7%)

6 (3.3%)



17 (77.3%)

178 (96.7%)

Recognizing first sound in  words      0,1

14 (63.6%)

57 (31%)



8 (36.4%)

127 (69%)

Deleting first sound in  words             0

6 (27.3%)

5 (2.7%)



16 (72.7%)

179 (97.3%)

Deleting last sound in words               0,1

13 (55.2%)

23 (12.5%)



9 (44.8%)

161 (87.5%)

Auditory perception                             0,1


32 (17.4%)





Reversing letters during {ART}

6 (27.3%)

3 (1.6%)


Counting letters during {ART}

10 (45.5%)

9 (4.9%)


Data are expressed as frequency (percentage)

* Significant at p<0.01



Table 4. Neurological examinations of dyslexic and non dyslexic.


Neurological Examination

Group (1)


Group (2)


P value


3 (13.6%)

6 (3.3%)


Asymmetric tonic neck

8 (36.4%)

2 (1.1%)


Mouth open finger spread

3 (13.6%)

25 (13.6%)



3 (100%)

18 (72%)



0 (0%)

7 (28%)






2 (66.6%)

4 (16%)

Neck retraction reflexes

4 (18.2%)

10 (5.4%)


Grasp reflex palmar

5 (22.7%)

1 (0.5)



1 (4.5%)

4 (2.2%)



6 (27.3%)

2 (1.1%)


Data are expressed as frequency (percentage)

* Significant at p<0.05 ** Significant at p<0.01





Figure 2. Sensitivity and specificity of neurological signs in diagnosing dyslexia



Developmental dyslexia is a common problem that impedes reading; a fundamental skill upon which all formal education depends12. Dyslexia has many personal and social consequences. The majority of dyslexics experience a huge amount of failure and lower self-esteem feel they are stupid and probably their teachers and parents also do. Fortunately about 95 percent of dyslexics can be brought up to grade level if they receive effective early help13. The prevalence of dyslexia varies according to many factors 2 its prevalence in the United States is estimated to be 5%-17%14. In this study 22 students out of 206 (10.67%) were found to be dyslexia. Taking into consideration this study was done in language school with good schooling condition, high parent education as a prerequisite for this school entry, good social conditions, all these factors are supposed to decrease the prevalence of dyslexia. This points to a much higher prevalence of dyslexia in Egypt. Though previous Egyptian study revealed much lower prevalence (1%)15. This difference could be partially attributed to difference in assessment method and elder students’ age in their study. Evidence has emerged that dyslexic as well as having language problems, often have co-ordination and balance difficulties16. In agreement with Nicolson et al.6, in this study dysdiadokinesia was found to be statistically higher in dyslexic group (13.6%) versus (3.3%) in nondyslexic, P (0.02) indicating poorly developed bilateral integration. How cerebellum affect reading is still a mystery. It has been proposed that cerebellar dysfunction leads to difficulties in acquisition, automatisation of elementary articulatory, visual and auditory skills16. Balance exercise treatment was reported to improve reading skills and the gains were long-lasting. Possibly due to improved oculomotor skills, cerebellar function; attentional ability and self-esteem17. In this study; in agreement with previous researches identified links between persistent primary reflexes and dyslexia.18 Asymmetrical Tonic Neck (ATNR) was statistically higher in dyslexic {36.6% versus 1.1% of nondyslexic, P (0.001)}. Retention of ATNR forms an invisible vertical midline barrier which impedes hand-eye coordination, pursuit and saccadic eye movements. A strongly retained ATNR interfere also with horizontal visual tracking leading to the reversal, transposing or omission of letters and therefore impact reading2. The neck retraction and grasp palmar reflex were also found to be more prevalent in dyslexic group. Persistent palmar reflex make tension in the hand due to conscious intention to oppose fingers flexion reflex triggered by the pencil. The concentration required to manipulate the pencil prevents an easy flow of thoughts7. Pupils followed a program with structured exercises designed to stimulate the development of secondary reflexes showed inhibition of persistent primary reflexes and improvement in pupils’ reading and spelling19. Some schools presented the programs in a child-friendly format, with singing, actions and rhythms. Others incorporated it into the physical education curriculum20. Developmental Dyspraxia is a hidden handicap. Very often the same individual will show features of both dyslexia and dyspraxia21. In this study apraxia was statistically higher in dyslexic group (27.3% versus 1.1%) in non dyslexic group, P (0.001). The link between dyspraxia and dyslexia Could be attributed to association of dyspraxia with problems of perception and language, Lack of rhythm, difficulty with eye movements, poor hand eye coordination and difficulty in fine motor skills. Lead to difficulty learning handwriting. Dyspraxia also associated with poor memory for symbolic material, both visual and auditory adding to suffers of dyslexics 22.

It was believed that dyslexia affected boys primarily. Others postulate referral bias23. Good evidence now indicates that dyslexia affects boys and girls comparably24. Similarly in this study twelve boys (10.3%) and 10 girls (11.2%) were found to be dyslexic P (0.822). Family history is one of the most important risk factors as genetic studies suggest heritability of around 50%25. In this study family history was positive in 75% of dyslexic versus (0.5%) of nondyslexic, P (0.001).

Problem awareness in Egypt almost does not exist. In this study the teacher was not aware of dyslexia. They were attributing children reading difficulty to the students’ poor cognitive abilities, or reluctance of the child or home side to learn Arabic. With simple information about dyslexia symptoms to the teachers their diagnostic efficiency of dyslexia becomes (72.1%). Teacher awareness is fundamental for dyslexia management. Instruction in morphological-analysis strategies with guided practice during reading holds promise not only to improve word reading and comprehension26 but also to normalize brain regions9 and functional connectivity of interest27.

Recommendations: Large national project in collaboration with ministry of education and school children health insurance sector of ministry of health to find out the prevalence, risk factors to increase awareness, to develop test for early identification of dyslexia (at kindergarten), to incorporate dysdiadokinesia, asymmetric tonic neck, neck retraction, palmar reflexes; and apraxia as screening test for dyslexia in students’ assessment at school entry and to reset teaching and examinations methods to decrease these students and their families suffer and allow them to cope normally.


[Disclosure: Author reports no conflict of interest]




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الملخص العربى


على الرغم أن عسر القراءة مشكلة رئيسية تمثل ما لا يقل عن 80٪ من أسباب الإعاقة التعليمية  ألا أن مدى انتشارها، وأسبابها، وتشخيصها، وعوامل الخطر، والآثار المترتبة عليها، وحتى الوعي بعسر القراءة غير موجود تقريبا في مصر. أضف إلى ذلك أن قراءة اللغة العربية للذين يعانون من عسر القراءة أصعب بكثير من اللغات الأخرى. لذلك أجريت هذه الدراسة  لمعرفة مدى تواجد عسر القراءة، ودلالاتها بالجهاز العصبي والتنويه لزيادة الوعي بهذه المشكلة على أمل أن يساعد ذلك فى علاجها.

تم عمل تقييم فردي لعسر القراءة باستخدام اختبار القراءة باللغة العربية لمائتان وستة أطفال من المدارس الابتدائية (الصف الثالث، الصف الرابع) الذين تتراوح أعمارهم بين 9-10 سنوات وتم أخذ التاريخ المرضى تفصيليا وفحص الجهاز العصبي مع التركيز على الأعراض التى تشير إلى وجود عسر القراءة، وعلامات المخيخ ، وردود الفعل الأولية، واختبارات الاأدانية الحركية لجميع الطلاب.

وقد وجد أن اثنان وعشرون طالبا من أصل 206 (10.67٪) يعانون من عسر القراءة. كما وجد أن صعوبة الحركات السريعة المتبادلة، واستمرار ردود الفعل الأولية (وهي منشط العنق والرقبة غير المتناظرة الرقبة اللاإرادي ورد الفعل المسك اللاإرادي) الاأدانية الحركية إحصائيا كانت أعلى في مجموعة عسر القراءة (13.6٪، 36.4٪، 18.2٪، 22.7٪ و 27.3٪) مقابل (3.3٪، 1.1٪، 5.4٪، 0.5٪ و 1.1٪)، تحليلات الانحدار المتعددة كشفت أن عكس الحروف، ومنشط الرقبة غير المتماثلة، وتراجع الرقبة اللاإرادي واختبارات الاأدانية الحركية كان لهم القدرة التنبؤية لعسر القراءة. مجرد تعليمات بسيطة للمعلمين جعل كفاءتهم التشخيصية للكشف عن عسر القراءة (72.1٪).

الاستنتاجات والتوصيات :

ومن هذا البحث نستنتج أن عسر القراءة مشكلة منتشرة  ذات صلة باختلالات المخيخ، استمرار ردود الفعل الأولية الاأدانية الحركية. أن استمرار ردود الفعل الأولية و الاأدانية الحركية يمكنهم التنبؤ بوجود عسر القراءة. مجرد تعليمات بسيطة للمعلمين جعلتهم كفء لاكتشاف عسر القراءة.

ونوصي بعمل مشروع وطني كبير بالتعاون مع وزارة التربية والتعليم وقطاع التأمين على المدارس بوزارة الصحة لمعرفة مدى انتشار عسر القراءة والعوامل الممهدة لها وزيادة الوعي بالمشكلة. وتصميم أختبار للكشف المبكر عن عسر القراءة وإدماج اختبارات ردود الفعل الأولية و الاأدانية الحركية اختلالات المخيخ لتقييم الطلاب عند دخول المدارس كمسح أولى لاكتشاف عسر القراءة مبكرا ونشر طرق العلاج للمدارس وأولياء الأمور ولإعادة أساليب التدريس والامتحانات لخفض معانة هؤلاء الطلبة وأسرهم وتمكينهم من التصدي لمشكلة عسر القراءة بشكل طبيعي.


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