Neglect dyslexia education resource
Estimated time: 30 minutes
Authors: Ronelle Hewetson, Keely McIntosh, Amanda Love
Last updated: 22/03/2026
Learning outcomes:
- Identify potential causes of reading difficulties after a right hemisphere stroke
- Describe neglect dyslexia: occurrence, models, clinical presentation
- Identify assessment tools and tasks to identify and describe neglect dyslexia
- Describe treatment options for neglect dyslexia
- Case based learning: analyse assessment data and determine management priorities
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Causes of reading difficulties after a right hemisphere stroke
Many people experience reading difficulties after a stroke.
Reading accuracy, speed, and comprehension might be affected. Whether it is reading a novel for pleasure, or responding to a work email, stroke-related reading difficulties can have a significant impact on a person’s ability to return to things they value in life.
The nature of the reading impairment usually depends on the location of the lesion.
A left hemisphere stroke is known to impact word recognition (lexical processes) and the ability to use the phonological pathway (sub-lexical processes) for reading.
Individuals with right hemisphere stroke also present with reading difficulties; however, the nature of these difficulties can be quite different to those experienced by people with a left hemisphere stroke.
When assessing or treating reading difficulties post stroke, it is important to consider causative and contributing factors.
Neglect dyslexia and spatial neglect
Spatial neglect is the impaired ability to explore and respond to visual, auditory, tactile stimuli from the side opposite the brain injury.
Depending on the time post stroke and the assessment used, 50 – 70% of people with right hemisphere stroke experience spatial neglect.
Most of our evidence about reading difficulties after a right hemisphere stroke comes from studies that explored neglect dyslexia.
Neglect dyslexia is often associated with spatial neglect; however, these conditions can also occur in isolation.
Neglect dyslexia definition
Neglect dyslexia is an acquired reading impairment that results in left lateralised reading errors.
Prevalence
A quarter of people with right hemisphere stroke experience neglect dyslexia.
37.5% of people with spatial neglect will also have neglect dyslexia.
The presence of spatial neglect is a predictor of worse improvement in reading ability.
Why does neglect dyslexia occur and why are there individual differences?
The most prominent models or theories attribute neglect dyslexia to a domain-general spatial attention deficit or to multiple mechanisms.
Support for the notion that multiple mechanisms might be at play comes from variation in clinical presentation across tasks. Attending to written language is likely mediated by different mechanisms than attending to non-lexical stimuli (e.g. when completing the apples test). Spatial neglect prevalence therefore varies depending on the use of a reading versus a non-reading task, for example on line bisection (63.8%), star cancellation (75.0%), or reading (37.5%).
Spatial attention deficit models
In this model, neglect dyslexia is pre-lexical in nature, and therefore is exclusively sensitive to the physical features of words, such as the location of the word on the page relative to the reader, word length, or a visual cue (such as a red line) towards the left of a word that draws attention.
In this model neglect dyslexia occurs because early stages of visual word recognition is impaired, e.g. detecting the location and physical appearance of a stimulus, which precedes the step where graphemes (letters) are recognised as writing and as representing a word.
Reading errors occur because of a reduced ability to attend to and process stimuli to the left of visual fixation, with improved performance as a word is moved to the centre of a reader’s visual field.
This model is based on the notion that the person is unable to attend to left-sided stimuli and therefore cannot access the stored lexical-orthographic representations of words.
Multiple mechanisms models
The multiple mechanism model is based on findings that reading accuracy improves when the psycholinguistic properties of reading material is manipulated.
When we see text on a page, there is an automatic increased attentional focus towards the left, which supports lexical access.
Written stimuli that are not consciously perceived and therefore omitted during reading are nevertheless processed by some individuals which is evident in their ability to say something about the word’s meaning.
Several psycholinguistic variables, unique to reading, can improve reading accuracy including word frequency, morphology, contextuality and predictability (e.g. based on syntactic structure).
When individuals are not sensitive to these lexical manipulation (e.g. same performance on high versus low frequency words), it is thought to support the spatial attention deficit model.
Neglect dyslexia errors
There are different criteria to identify and describe neglect dyslexia errors.
One way involves the spatial frame of reference:
- viewer-centered = more errors on the contralesional relative to the ipsilesional side of the viewer
- stimulus-centered = more errors on the contralesional relative to the ipsilesional side of the word irrespective of the midline of the viewer.
Another approach is to describe the type of errors. Omissions, substitutions and, less commonly, additions may occur when reading.
The frequency of occurrence of these three types of errors might vary depending on the reading stimuli used.
Errors may be defined as:
neglect-type errors where the target and error word are identical to the right of an identifiable neglect point, but share no letters in common to the left, or as
non-neglect reading errors which are common, and include omissions of entire lines, whole word substitutions, omissions of words anywhere on the page, intra-word errors that are not restricted to the left-hand side of the word. Non-neglect reading errors are reported to make up 14-60% of total reading errors committed by individuals with right hemisphere stroke.
Both types of errors are important to document.
A restrictive criteria of what constitutes neglect dyslexia contributes to an underestimation of reading impairment following right hemisphere stroke.
Assessment of reading after a right hemisphere stroke
Assessing neglect dyslexia is challenging due to the heterogeneity of reading impairments following right hemisphere stroke. Evaluation should combine standardized tools with ecologically valid tasks reflecting everyday communication.
Since no comprehensive assessment exists for differential diagnosis of reading disorders, a multidisciplinary approach is valuable to determine whether hemianopia, anosognosia, spatial neglect, or apragmatism (i.e. linguistic impairment) underlie, or contribute to, the reading difficulty.
Error analysis should document frequency of errors, type of errors (omission, substitution, addition of letters), location of errors in a word and location of errors depending on word location on the page
Assessment of spatial neglect generally involves one or more tasks, including line, letter, or shape cancellation tasks; line bisection; and copying and drawing tasks.
While such tasks are required to identify spatial neglect, they are not sufficient to diagnose neglect dyslexia, nor to describe the error patterns and influential variables.
A holistic assessment of neglect dyslexia should examine single word, sentence, and paragraph length material, as error frequency varies across tasks.
Commonly used tools include the Behavioral Inattention Test (BIT: Wilson et al., 1987) and Caplan’s Indented Paragraph (Caplan, 1987). The BIT also allows for exploration of reading of everyday functional materials such as a menu.
Both the physical and psycholinguistic characteristics of reading stimuli influence reading accuracy.
Physical factors include text orientation, position relative to the reader, paragraph layout, and word length.
Looking beyond physical factors, we see that individuals with right hemisphere stroke with and without spatial neglect are sensitive to manipulations of the psycholinguistic properties of stimuli. For example, errors may decrease with shorter, high-frequency words.
Assessment should systematically explore how these variables affect reading accuracy and consider their impact on everyday reading comprehension.
Treatment of neglect dyslexia
Many spatial neglect treatments have been applied to neglect dyslexia, but improvements in non-reading tasks do not automatically transfer to reading.
Reading accuracy should therefore be measured as a specific outcome when evaluating treatment.
Because error patterns differ between individuals, treatment selection and cueing strategies should be evaluated for each person. What reduces viewer-centred errors (losing place across a page) may not address word-centred errors (misreading the left side of individual words), and vice versa.
A wide range of treatments for spatial neglect has been described. These broadly fall into two categories:
Top-down (compensatory)
- Visual scanning training
- Attentional cueing: visual, verbal, motor
Bottom-up (addressing underlying impairments)
- Increasing self-awareness of neglect
- Visuo-motor adaptation through prisms
- Sustained attention training
Both approaches can be used simultaneously. A combined approach is generally more effective than any single treatment.
Clinical considerations
Education about neglect dyslexia, and cognitive-communication impairment in general will support collaborative goal setting and is the first step towards addressing anosognosia which may co-occur with neglect dyslexia. Greater treatment gains may occur when awareness and reading are trained concurrently.
Visual scanning training is reported most often in literature. Visual scanning training should be delivered in a progressive program to support habit formation, many practice opportunities will be required. In addition to visual anchors on the left, clinicians should teach pacing strategies (slower than usual reading rate), consider stimulus density (progressively increasing the words on a page or paragraph length and adjusting how text is displayed to mimic real world reading), and work towards fading of feedback and teaching self-evaluation and self-monitoring.
Influential psycholinguistic variables
Treatment programmes for spatial neglect highlight the value of manipulating the density of visual material.
No structured protocol exists to guide clinical decision making regarding the psycholinguistic characteristings of reading materials. However, current evidence supports the presence of better performance on particular types of words and sentences. This evidence can support stimulus selection based on linguistic characteristics, which should be done systematically from most to least likely to be read accurately.
This education resource offers an introduction to supporting individuals with neglect dyslexia.
To extend knowledge about this area, a list of recommended readings is offered: Recommended readings