Evidence-Based Practice
To effectively assess and treat dyslexia, clinicians develop a treatment plan that matches the client’s diagnostic profile, apply treatment strategies, and conduct subjective and objective testing at intervals to assess progress.
Decades of research have attempted to draw conclusions about best assess-ment tools, best intervention tools, best treatassess-ment methodology, and best measures of outcome to determine effectiveness in reading remediation.
For the past few decades, particular focus has been given to quality assurance efforts, referred to as evidence-based practice (EBP). Most EBP research for written language is still emerging in terms of what is best. The research seems to be coming from two directions that sometimes merge.
One line of EBP research addresses educational management of reading, examining methods of identifying reading levels, teaching reading, moni-toring reading development, and providing different tiers of intervention for children lagging in reading acquisition (Gersten et al., 2009, p. 6).
The other line of EBP research for speech-language pathology involve-ment in reading has been addressed by the American Speech-Language-Hearing Association’s National Center for Evidence-Based Practice in Communication Disorders (Coleman, Venediktov, Troia, & Wang, 2013). In their review of research addressing literacy in children with developmental language disorders, they state that, to draw conclusions and offer guide-lines for best practice, researchers will need to clarify what reading skills are being addressed, delineate the severity of the reading disability, and estab-lish operational definitions of the population being researched, treatments, and outcomes. The center recommends that writing intervention research be inclusive to participants with spoken and/or written language-learning difficulties and exclusive to certain other conditions. Practice suggestions are that a variety of reading intervention categories have a positive impact on language-based learning difficulties such as developmental language How is clinical
effort traditionally documented?
How are educators addressing
instructional effectiveness for reading?
How is ASHA addressing clinical effectiveness of reading intervention?
delay, especially interventions using the category referred to as synthetic activities, or methodologies based on word decoding at a phonemic level.
Articles cited in the center for EBP report classify reading difficulty using several designations, for instance, dyslexia, developmental aphasia, developmental language disorder with dyslexia, developmental language disorder without dyslexia, specific learning disability, language-learning disability, or specific language disability. Such a wide range of disorder clas-sifications raises many questions about the homogeneity of the population being studied and any conclusions drawn from such disparate terminol-ogy. The studies also vary in terms of professional disciplines involved in treatment, the basic nature of programs (educational or clinical), diagnos-tic classifications, intervention programs, measurement tools, and delivery settings, which may account for the statistically marginal outcomes, with hidden successful strategies probably buried in the difficulty controlling variables. The culling process ahead will be arduous in trying to identify evidence for best practices. It might be helpful for future research to use the National Institutes of Health’s definition of dyslexia, that is, unexpected difficulty learning to read, as a starting point and limiting research to oral and written language diagnostic and treatment procedures conducted by speech-language pathologists (SLPs).
In the meantime, the SLP still has the capability of assessing concerns about reading difficulties, selecting diagnostic tools and administering them, arriving at diagnoses, developing a plan of treatment based on find-ings, and beginning and adjusting treatment depending on client response so that if the strategy that usually works does not, a change is made, sensing patterns of change in client responses, administering objective and subjec-tive measures, providing statements of what changed and how much, and recommending next steps. This may not be an exactly replicable process, but no client is exactly replicable either. Clinicians can be assured that research will continue to guide understanding of communication disorders, and they will welcome input concerning effective treatment tools, methods, and strategies that will eventually be validated in clinical practice.
Outcomes of Phonology Focus in Early Years
Blachman (1991), in Getting Ready to Read, cites an important study com-paring two groups of Danish kindergarteners, one with structured, sys-tematic phonologic perception activities over the year with no reference to letters and the control group with unstructured, spontaneous reference to phonologic awareness during play activities. The experimental group outperformed the control group in spelling at the end of first grade and out-performed the control group in spelling and reading at the end of second grade (Lundberg, Frost, & Peterson, 1988). Liberman, Shankweiler, and Liberman (1991, pp. 11–12) note that the only way transcription of words to letters can make sense to a beginning reader is for the child to under-How is dyslexia
designated in communication disorder research?
How does the SLP proceed with diagnosis and treatment of dyslexia?
How does a child show readiness for beginning reading?
Measuring Outcome 31
stand that the transcription has the same number and sequence of units as the spoken word. It requires an intensive phonologic perception training period for a child to have a firm grasp of phonemes and phoneme pat-terns in words. One year of kindergarten exposure to phonologic percep-tion activities without reference to letters seems to be an excellent start to written language acquisition.
At some point, children will discover that they can expect a phoneme to be associated with one letter more often than others, but they will also discover that they must consider other options as well, maybe six or eight or even more, and then store in memory the correct letter choice for that word. Telling children about patterns and leading them to discover patterns are two entirely different processes. Leading children to understand creates knowledge as they experience varied input, discern the differences, find the patterns, and experience discovery. Discovery makes the rules theirs.
In written language, the process begins with listening, is confirmed with listening, is stored through listening, and can be reevaluated through listen-ing, even though the process involves visual letters.
The Neurolinguistic Approach to Reading (NAR) program is often described with reference to children because, fortunately, we now recognize the condition of dyslexia early enough that intervention typically begins in childhood, albeit later than would be ideal. Many adults, however, also have dyslexia to varying degrees and have not received remedial treat-ment for their inefficient reading for various reasons. One of the important features of NAR is that it can be used with preschool, elementary, middle, and high school children; college students; and adults. The stages of this program are relatively few and relatively simple, but consistency of effort over sufficient time to gain mastery is important.
NAR Outcomes
Most indicators of the effectiveness of NAR are based on subjective, clinical judgment. Hundreds of children have been exposed to systematic appli-cation of NAR principles, strategies, and activities at The Kamara Center (TKC) over the years. Objective testing has overwhelmingly documented statistically significant progress. Reading and writing scores have depend-ably improved, sometimes gradually over years, other times dramatically over 1 year. Clinicians have been confident that NAR is the critical factor that accounts for written language gains. Despite clinical confidence that the program is effective, it has not been possible to isolate NAR as the factor that accounts for client gains.
Perhaps the most limiting factor to verifying effectiveness is that NAR is not the only treatment being administered to children because their varied profiles require varied treatments. Typically, dyslexia is not a stand-alone communication disorder, and other strategies and programs must What is the
difference between discovering and being told about patterns?
Does NAR apply to adults?
How has NAR effectiveness been measured?
What variables need consideration in effectiveness assessment?
be applied to different children who exhibit other conditions in addition to dyslexia such as abnormal auditory processing, dysnomia, dysphasia, dyspraxia, short-term memory deficit, working memory deficit, articula-tion disorder, disfluency, dysarthria — whatever other condiarticula-tions SLPs treat.
Still, clinicians can sort responses to each regimen’s effectiveness by how the child responds to a series of tasks. Granted, gains in one area can boost gains in another, but even that can be analyzed clinically. Occasionally, post-treatment testing results in unanticipated findings, more often positively, occasionally negatively, but usually clinical judgment gathered from client responses to activities coincides with posttreatment test findings. Perhaps the best way to preserve an on-course treatment plan with accurate assess-ment of progress is to maintain a reasonable caseload that allows clinical judgment to guide treatment with objective testing confirming outcome.
This may not serve as a national best practice standard, but it is reassuring to the child’s parent or adult and the clinician delivering the service.
Stripping variables to allow parallel comparisons of different dyslexia treatment outcomes is extremely difficult and brings into question the applicability of findings to an individual, real, and complex child. Research may support broad generalizations such as the findings that increasing phonologic perception improves reading, but even these studies often have marginal results, leaving questions about the studies’ ability to control for children’s clinical profiles, clinician variables, adherence to the treatment protocol, and basic distinctions made between phonics and phonology in the program design. Even research on discrete, step-by-step computer pro-grams such as Fast ForWord have reported difficulty controlling variables such as protocol adherence. Perhaps clinical judgment functions like the language acquisition device, sorting through all the variables to find the relevant patterns!
These points are not meant to disparage research but to alert that it is the blue ribbon panel of experts that establishes the benchmark for effec-tiveness. Researchers are simply trying to ferret out what factors the blue ribbon panel is using so that, hopefully, less-experienced clinicians can con-sider and implement the panel’s view.
References
Blachman, B. A. (1991). Getting ready to read: Learning how to print maps to speech.
Timonium, MD: York Press.
Coleman, J. J., Venediktov, R. A., Troia, G. A., & Wang, B. P. (2013, July). Impact of literacy on achievement outcomes of children with developmental language disorders:
A systematic review. Retrieved from http://www.asha.org/uploadedFiles/EBSR-Impact-of-Literacy-Intervention.pdf
Gersten, R., Compton, D., Connor, C. M., Dimino, J., Santoro, L., Linan-Thompson, S., & Tilly, W. D. (2009, February). Assisting students struggling with reading:
Response to intervention (Rtl) and multi-tier intervention in the primary grades (NCEE What makes human
behavioral research difficult?
To what is clinical outcome ultimately matched?
Measuring Outcome 33 2009-4045). Washington, DC: Institute of Education Sciences, U.S. Department of Education. Retrieved from http://ies.ed.gov/ncee/wwc/pdf/practice_guides/
rti_reading_pg_021809.pdf
Liberman, I. Y., Shankweiler, D., & Liberman, A. M. (1989). The alphabetic principle and learning to read (pp. 1–33). Ann Arbor: University of Michigan Press.
Lundberg, I., Frost, J., & Peterson, O. (1988). Effects of extensive program for stimu-lating phonological awareness in preschool children. Reading Research Quarterly, 23, 263–284.
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