crossreadnovel

PERSPECTIVEOPENHelpingchildrenwithreadingdifculties:somethingswehavelearnedsofarGenevieveMcArthur1andAnneCastles1Asubstantialproportionofchildrenstruggletolearntoread.
Thisnotonlyimpairstheiracademicachievement,butincreasestheirriskofsocial,emotional,andmentalhealthproblems.
Inordertohelpthesechildren,readingscientistshaveworkedhardforoveracenturytobetterunderstandthenatureofreadingdifcultiesandthepeoplewhohavethem.
Theaimofthisperspectiveistooutlinesomeofthethingsthatwehavelearnedsofar,andtoprovideaframeworkforconsideringthecausesofreadingdifcultiesandthemosteffectivewaystotreatthem.
npjScienceofLearning(2017)2:7;doi:10.
1038/s41539-017-0008-3INTRODUCTIONOver20yearsago,TheDyslexiaInstituteaskeda9-year-oldboycalledAlexandertodescribehisstrugglewithlearningtoreadandspell.
Hebravelywrote:"Ihaveblondher,Blueeysandaninfeckshossmill.
PealpietellmumhawgorgusIamandisentshelookytohaveme.
ButunderthesurfaceIliveinatumoyl.
Wordslooklikeswiglesandritingstorysisadisasterareabecauseofspellings.
Therewerenoplytimesatmyoldschooluntillworkwasneshedwichmentnoplytimsatall.
ThechersseadIwasclevorbutjustdidn'ttry.
Shoutingwastheonlywaythetechorscomuniccatidwithme.
UtherboysmadefunofmeandsoIbeckamelonlyandmishroboll".
1Alexander'sexperienceisnotunique.
Sixteenpercentofchildrenstruggletolearntoreadtosomeextent,and5%ofchildrenhavesignicant,severe,andpersistentproblems.
2Theimpactofthesechildren'sreadingdifcultiesgoeswellbeyondproblemswithreadingHarryPotterorSnapchat.
Poorreadingisassociatedwithincreasedriskforschooldropout,attemptedsuicide,incarceration,anxiety,depression,andlowself-concept.
3–6Itisthereforeimportanttoidentifyandtreatpoorreadersasearlyaswepossiblycan.
Scientistshavebeeninvestigatingpoorreading—alsoknownasreadingdifculty,readingimpairment,readingdisability,readingdisorder,anddevelopmentaldyslexia(tonamebutafew)—foroveracentury.
Whileitmaytakeanothercenturyofresearchtoreachacompleteunderstandingofreadingimpairment,therearenumberofthingsthatwehavelearnedaboutreadingdifculties,aswellasthechildrenwhoexperiencereadingthem,thatprovidekeycluesabouthowpoorreadingcanbeidentiedandtreatedeffectively.
POORREADERSDISPLAYDIFFERENTREADINGBEHAVIOURSOnethingthatwehavelearnedaboutpoorreadersisthattheyarehighlyheterogeneous;thatis,theydonotalldisplaythesametypeofreadingimpairment(i.
e.
,"readingbehaviour";7–12).
Somepoorreadershaveaspecicproblemwithlearningtoreadnewwordsaccuratelybyapplyingtheregularmappingsbetweenlettersandsounds.
7,8,13,14Thisproblem,whichisoftencalledpoorphonologicalrecodingordecoding,canbedetectedbyaskingchildrentoreadnovel"nonwords"suchasYIT.
Otherpoorreadershaveaparticulardifcultywithlearningtoreadnewwordsaccuratelythatdonotfollowtheregularmappingsbetweenlettersandsounds,andhencemustbereadviamemoryrepresentationsofwrittenwords.
7,13,15,16Thisproblem,whichissometimescalledpoorsightwordreadingorpoorvisualwordrecognition,canbedetectedbyaskingchildrentoread"exception"wordssuchasYACHT.
Incontrast,somepoorreadershaveaccuratephonologicalrecodingandvisualwordrecognitionbutstruggletoreadwordsuently.
17–19Poorreadinguencycanbedetectedbyaskingchildrentoreadwordlistsorsentencesasquicklyastheycan.
Incontrastyetagain,somepoorreadershaveintactphonologicalrecodingandvisualwordrecognitionandreadinguency,butstruggletounderstandthemeaningofwhattheyread.
These"poorcomprehenders"20canbeidentiedbyaskingthemtoreadparagraphsaloud(toascertainthattheycanreadaccuratelyanduently),andthenaskthemquestionsaboutthemeaningofwhattheyhaveread(toascertainthattheydonotunderstandwhattheyarereading).
Itisimportanttonotethatmostpoorreadershavevariouscombinationsofthesepro-blems.
21Forexample,Alexander'sspellingsuggeststhathewouldhavepoorphonologicaldecoding(sincehemisspellswordslikeplaytimesas"plytims")andpoorsightwordknowledge(sincehemisspellsexceptionwordslikesaidas"sead").
Thus,poorreadersvaryconsiderablyintheprolesoftheirreadingbehaviour.
READINGBEHAVIOURSHAVEDIFFERENT"PROXIMAL"CAUSESAnotherthingwehavelearnedaboutpoorreadersisthatthesamereadingbehaviour(e.
g.
,inaccuratereadingofnovelwords)doesnotnecessarilyhavethesame"proximalcause".
Aproximalcauseofareadingbehaviourcanbedenedasacomponentofthecognitivesystemthatdirectlyandimmediatelyproducesthatreadingbehaviour.
22–24Mostreadingbehaviourswillhavemorethanoneproximalcause.
Reectingthis,severaltheoreticalandcomputationalmodelsofreadingcomprisemultiplecognitivecomponentsthatfunctiontogethertoproducesuccessfulreadingbehaviour(e.
g.
,refs25–28).
WhilethesemodelsvaryinsomeReceived:22April2016Revised:16February2017Accepted:1March20171DepartmentofCognitiveScience,ARCCentreofExcellenceinCognitionanditsDisorders,MacquarieUniversity,Sydney,NSW2109,AustraliaCorrespondence:GenevieveMcArthur(genevieve.
mcarthur@mq.
edu.
au)www.
nature.
com/npjscilearnPublishedinpartnershipwithTheUniversityofQueenslandrespects,allincludecognitivecomponentsthatrepresent(1)theabilitytorecogniseletters(e.
g.
,S),letter-clusters(e.
g.
,SH),andwrittenwords(e.
g.
,SHIP),(2)theabilitytorecogniseandproducespeechsounds(e.
g.
,"sh","i","p")andspokenwords(e.
g.
,"ship"),(3)theabilitytoaccessstoredknowledgeaboutthemeaningsofwords(e.
g.
,"aoatingvessel"),and(4)linksbetweenthesevariouscomponents.
Impairmentinanyoneofthesecomponentsorlinkswilldirectlyandimmediatelyimpairaspectsofreadingbehaviour.
Thus,guidedbytheoreticalandcomputationalmodels,wehavelearnedthatapoorreadingbehaviourcanhavemultipleproximalcauses,andwehavesomeideaaboutwhatthoseproximalcausesmightbe.
10–12READINGBEHAVIOURSHAVEDIFFERENT"DISTAL"CAUSESWehavealsolearnedthateveniftwopoorreadershaveexactlythesamereadingbehaviourwithexactlythesameproximalcause,thisreadingbehaviourwillnotnecessarilyhavethesame"distalcause".
Adistalcausehasadistant(i.
e.
,anindirectordelayed)impactonareadingbehaviour.
22–24Distalcausesreectthefactthatreadingisataughtskillthatunfoldsovertimeandacrossdevelopment.
Itdependsuponarangeofmorecognitiveabilities,suchasmemory,attention,andlanguageskills,tonamebutafew.
Dependingonchildren'sstrengthsandweaknessesintheseunderlyingabilities,andhowtheseabilitiesaffectlearningovertime,childrenwillhavedifferentprolesofdevelopmental,ordistal,causesoftheirreadingimpairment.
Stateddifferently,therecanbedifferentcausalpathwaystothesameimpairmentofthereadingsystem.
Toprovideanexample,asmentionedearlier,acommonreadingbehaviourobservedinpoorreadersisinaccuratereadingofnewornovelwords,whichcanbeassessedusingnonwordssuchasYIT.
Indeed,someresearchershavedescribedthisasthedeningsymptomofreadingdifculties.
29Accordingtotheore-ticalandcomputationalmodelsofreading,oneproximalcauseofimpairedreadingofnonwordsisimpairedknowledgeofletter-soundmappings.
ButwhatisresponsibleforthisproximalcauseofpoornonwordreadingTherearemultiplehypotheses.
Theprominent"phonologicaldecithypothesis"proposesapervasivelanguage-baseddifcultyinprocessingspeechsoundsthataffectstheabilitytolearntoassociatewrittenstimuli(e.
g.
,letters)withspeechsounds.
30The"paired-associatelearningdecithypoth-esis"proposesamemory-baseddifcultyinformingcross-modalmappingsacrossthevisual(e.
g,letters)andverbaldomains(e.
g.
,speechsounds)thataffectsletter-soundlearning(e.
g.
,ref.
31).
Andthe"visualattentionaldecithypothesis"proposesanattention-basedimpairmentinthesizeoftheattentionalwindow,affectingtheformationofthesub-wordorthographicunits(e.
g.
,letters)usedintheletter-soundmappingprocess.
32Thesethreehypothesesillustratewhyasinglereadingbehaviour(e.
g.
,poornonwordreading)withacommonproximalcause(impairedknowledgeofletter-soundmappings)mightnothavethesamedistalcause(e.
g.
,aphonologicaldecit,apaired-associatelearningdecit,oravisualattentiondecit).
Thesehypothesesalsoraisethepossibilitythatthedistalcausesofpoorreaders'readingbehavioursmayvaryasmuch(ifnotmore)thantheproximalcausesandthereadingbehavioursthemselves.
POORREADERSHAVECONCURRENTPROBLEMSWITHTHEIRCOGNITIONANDEMOTIONALHEALTHAnotherthingwehavelearnedaboutpoorreadersisthatmany(butnotall)havecomorbiditiesinotheraspectsoftheircognitionandemotionalhealth.
Regardingcognition,studieshavefoundthatasignicantproportionofpoorreadershaveimpairmentsintheirspokenlanguage.
33–39Studieshavealsofoundthatpoorreadershaveatypicallyhighratesofattentiondecitdisorder—aneurologicalproblemthatcausesinattention,poorconcentration,anddistractibility(e.
g.
,refs40–42).
Regardingemotionalhealth,thereisevidencethatpoorreaders,asagroup,havehigherlevelsofanxietythantypicalreaders(e.
g.
,refs43,44).
Thesameistrueforlowself-concept,whichcanbedenedasanegativeperceptionofoneselfinaparticulardomain(e.
g.
,academicself-concept;e.
g.
,refs45,46).
Thefactthatpoorreadersvaryintheircomorbidcognitiveandemotionalhealthproblems—aswellasintheirreadingbehaviours,andtheproximalanddistalimpairmentsofthesebehaviours—createsanimpressionofalmostoverwhelmingcomplexity.
However,itispossibletosimplifythiscomplexitysomewhatusingaproximalanddistalschema.
Specically,comorbiditiesofpoorreadingmightbecategorisedaccordingtowhethertheyrepresentpotentialproximalordistalimpairmentofpoorreading—orpossiblyboth.
Forexample,achild'scurrentproblemwithspokenvocabularymightbeconsideredaproximalcauseoftheirpoorwordreadingbehavioursince,accordingtotheoreticalandcomputationalmodelsofreading,vocabularyknowledgemaydirectlyunderpinwordreadingaccuracyorreadingcomprehen-sion.
However,achild'spreviousproblemwithspokenvocabulary,whichmayormaynotstillbepresent,mightbeconsideredadistalcauseoftheirpoorwordreading:Ahistoryofpoorunderstandingofwordmeaningsmightreduceachild'smotivationtoengageinreading(distalcause),whichwouldimpairtheirdevelopmentofphonologicalrecodingandvisualwordrecognition(proximalcause),andhencetheirwordreadingaccuracyanduency(readingbehaviour).
Thus,theproximalanddistalschemacanproveusefulinclarifyingthecausalchainofeventslinkingareadingbehaviourtoapotentialcause.
Theproximalanddistalschemacanalsobeusefulinclarifyingreciprocalorcircularrelationshipsbetweencomorbiditiesofpoorreadingandreadingbehaviours.
Forexample,ifapoorreaderhaslowacademicself-concept(distalcause),thismaystymietheirmotivationtopayattentioninreadinglessons(distalcause),whichwillimpairtheirlearningofletter-soundmappings(proximalcause),andhencetheirpoorwordreading(readingbehaviour).
Atthesametime,areversecausaleffectmaybeinplay:Achild'spoorwordreadingintheclassroom(distalcause)maycreateapoorperceptionoftheirownacademicability(proximalcause)thatlowerstheiracademicself-concept(beha-viour).
Thus,theproximalanddistalschemacanbeusedtohelpdevelophypothesesastowhethercomorbiditiesofpoorreadingareproximaland/ordistalcausesorconsequencesofpoorreading.
Ultimately,ofcourse,allofthesehypothesesmustbetestedthroughexperimentaltrainingstudies.
PROXIMALINTERVENTIONISMOREEFFECTIVETHANDISTALINTERVENTIONPoorreadershaveinspired,andhavebeensubjectedto,anextraordinaryarrayofinterventionssuchasbehaviouraloptome-try,chiropractics,classicalmusic,colouredglasses,computergames,shoil,phonics,sensorimotorexercises,soundtraining,spatialfrequencygratings,memorytraining,medicationfortheinnerear,phonemicawareness,rapidreading,visualwordrecognition,andvocabularytraining,tonamejustaselection.
Itisnoteworthythatwhilemanyoftheseinterventionsclaimtobe"scienticallyproven",fewhavebeentestedwitharandomisedcontrolledtrial(RCT)—anexperimentthatrandomlyallocatesparticipantstointerventionandcontrolgroupsinordertoreducebiasinoutcomes.
RCTsarethegoldstandardmethodforassessingatreatmentofanykind,andthemethodthatmustbeusedtoprovetheeffectivenessofapharmaceuticaltreatment.
Inordertomakesenseofthechaoticvarietyofinterventionsthatclaimtohelppoorreaders,itmayagainbehelpfultousetheproximalanddistalschemaoutlinedabovetosubdivideinterventionsintotwotypes:"proximalinterventions"thatfocustrainingonproximalcausesofareadingbehaviourthatareHelpingchildrenwithreadingdifcultiesGMcArthurandACastles2proposedtobepartofthecognitivesystemforreading(e.
g.
,phonicstraining,vocabularytraining)and"distalinterventions"thatfocusondistalcausesofareadingbehaviour(e.
g.
,colouredlenses,inner-earmedication).
TheideaofmakingadistinctionbetweenproximalanddistalinterventionsissupportedbytheoutcomesofasystematicreviewofallstudiesthathaveusedanRCTtoassessaninterventioninpoorreaders.
47Thesestudiesassessedtheeffectofcolouredlensesoroverlays,medication,motortraining,phonemicawareness,phonics,readingcompre-hension,readinguency,soundprocessing,andsunowertherapyonpoorreaders.
Onekeyndingofthisreviewisthatitonlyidentied22RCTs,whichisasmallnumberofgold-standardinterventionstudiesgiventhehugenumberofinterventionsthatclaimtohelppoorreaders.
AsecondkeyndingisthatthemajorityofRCTsofinterventionsforpoorreadershaveassessedtheefcacyofphonicstraining,whichtrainstheabilitytouseletter-soundmappingstolearntoreadnewornovelwords.
Athirdkeyndingisthatonlyonetypeofinterventionproducedastatisticallyreliableeffect.
Thiswasphonicstraining,whichfocusesonimprovingaproximalcauseofpoorwordreading(i.
e.
,letter-soundmappings).
Incontrast,interventionsthatfocusedondistalcausesofpoorreadingdidnotshowastatisticallyreliableeffectinpoorreaders.
Theoutcomesofthissystematicreviewsuggestthatinterventionsthatfocusonphonics—aproximalcauseofreadingbehaviour—aremorelikelytobeeffectivethaninterventionsthatfocusonadistalcause.
Inotherwords,the"closer"theinterventionistoanimpairedreadingbehaviour,themorelikelyitistobeeffective.
TRANSLATINGWHATWEKNOW(THUSFAR)INTOEVIDENCE-BASEDPRACTICEAtrstglance,whatwehavelearned(sofar)aboutpoorreadersandreadingdifcultiespaintsapictureofsuchcomplexheterogeneitythatitistemptingtothrowone'shandsupindespair.
Andyet,somewhatparadoxically,itisthisveryheterogeneitythatprovidessomeimportantcluesabouthowtomaximisetheefcacyofinterventionforpoorreaders.
First,thefactthatpoorreadersvaryinthenatureoftheirreadingbehaviourssuggeststhattherststepinidentifyinganeffectiveinterventionforapoorreaderistoassessdifferentaspectsofreading(e.
g.
,wordreadingaccuracy,readinguency,andreadingcomprehension).
Therearenumerousstandardizedtestsprovidedcommercially(e.
g.
,theYorkAssessmentforReadingComprehen-sionavailablefromGLAssessment)48orforfree(e.
g.
,theCastlesandColtheartWordReadingTest—SecondEdition(CC2)availableatwww.
motif.
org.
au)49thatcanbeusedtodetermineifachildfallsbelowtheaveragerangefortheirageorgradeforreadingaccuracy,uency,orcomprehension.
Inourexperience,ateacherwhohasappropriatetraininginadministratingsuchtestscancarryoutthisrststepeffectively.
Second,thefactthatpoorreaders'readingbehaviourscanhavedifferentproximalcausessuggeststhatthenextstepistotestthemforthepotentialproximalcausesoftheirpoorreadingbehaviours.
Thisiswherecognitivemodelsofreadingareausefulroadmap,providinganexplicitaccountofthekeyprocessesdirectlyunderpinningsuccessfulreadingbehaviour.
Again,thiscanbedoneusingstandardizedteststhatareavailablecommercially(e.
g.
,thePeabodyPictureVocabularyTestFourthEditionavailablefromPearson)50orforfree(e.
g.
,theLetter-SoundTestavailableatwww.
motif.
org.
au).
51Andwell-trainedteacherscanadministerthesetests.
Third,thefactthatpoorreadersvaryinthedegreetowhichtheyexperiencecomorbidcognitiveandemotionalimpairmentssuggeststhatitwouldbeusefultoassesspoorreadersfortheirspokenlanguageabilities,attention,anxiety,depression,andself-concept,attheveryleast.
Thisknowledgewillrevealiftheyneedsupportinotherareasoftheirdevelopment,oriftheirreading-relatedinterventionneedstobeadjustedtoaccommodatetheirconcomitantimpairmentinordertomaximiseefcacy.
Trainedspeechandlanguagetherapiststypicallycarryouttheassessmentofchildren'sspokenlanguage;neuropsychologistsareexpertsinassessingchildren'sattention;andclinicalpsychologistshavetheexpertisetoassesschildren'semotionalhealth.
Onceapoorreader'sreadingbehaviours,proximalimpair-ments,comorbidcognitive,andemotionalhealthproblemshavebeenidentied,itshouldbepossibletodesignaninterventionthatisagoodmatchtotheirneeds.
AccordingtothesystematicreviewconductedbyGaluschkaetal.
47,currentevidencesuggeststhatthisinterventionshouldfocusontheproximalimpairmentofachild'sreadingbehaviour,ratherthanapossibledistalimpairment.
Twomorerecentcontrolledtrials52,53andasystematicreview54furthersuggestthatitispossibletoselectivelytraindifferentproximalimpairmentsofpoorreadingbehavioursinordertoimprovethosebehaviours.
Theoutcomesofthesestudiesandreviewstentativelysuggestthatproximalinterventionscanbeexecutedbyareadingspecialistorahighly-sophisticatedonlinereadingtrainingprogramme.
SUMMARYInsum,overthelastcenturyorso,wehavelearnedimportantthingsaboutreadingdifcultiesandthepeoplewhohavethem.
Wehavelearnedthatpoorreadersdisplaydifferentreadingbehaviours,thatanyonereadingbehaviourhasmultipleproximalanddistalcauses,thatsomepoorreadershaveconcomitantproblemsinotherareasoftheircognitionandemotionalhealth,andthatinterventionsthatfocusonproximalcausesofpoorreadingbehavioursmaybemoreeffectivethanthosethatfocusondistalcauses.
Thisknowledgeprovidessomecluestohowwemightbestassistchildrenwithreadingdifculties.
Specically,weneedtoassesspoorreadersfor(1)arangeofreadingbehaviours,(2)proximalcausesforeachpoorreadingbehaviour,and(3)comorbiditiesintheircognitionandemotionalhealth.
Itshouldbepossibletodesignanindividualisedinterventionprogrammethataccommodatesforapoorreader'scomorbidcognitiveoremotionalproblemswhilsttargetingtheproximalcausesoftheirpoorreadingbehaviourorbehaviours.
Thisapproach,whichrequirestheco-ordinatedeffortsofteachersandspecialistsandparents,isnomeanfeat.
However,accordingtothescienticevidencethusfar,thisisthemosteffectiveapproachwehaveforhelpingchildrenwithreadingdifculties.
COMPETINGINTERESTSTheauthorsdeclarethattheyhavenocompetinginterests.
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