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Case study of Amelia, a five-year-old reader who enjoys reading at home

Felicity holt-goldsmith.

  • Case Studies of young readers / 

Amelia* is a middle ability pupil in a mixed ability class of thirty one children, with a ratio of eighteen boys and eleven girls. The school is average size for a primary school and most of the pupils are drawn from the immediate neighbourhood. When I met Amelia she was graded at Level 1c for her reading, slightly below average for the class. The school endeavours to provide an atmosphere where the enjoyment of reading is promoted and nurtured. Children have reading books from the Oxford Reading Scheme which they take home every day and home and school links are made through reading journals. There is also a selection of books in the classroom and the school is in the process of renovating the library.

Comprehension

To try and gain an understanding of Amelia as a reader I undertook a reading conference and made observations of her reading in a range of different contexts. However, the limited amount of time spent at the placement means that only a speculative analysis can be made. Amelia was still learning to decode but she was able to utilise higher order reading skills such as comprehension. She was an able meaning maker and engaged with a variety of texts. In terms of The Simple View of Reading (Rose, 2006: 40) she would be placed in the section of ‘poor word recognition; good comprehension’ although her skills of decoding words improved quite significantly even during the short time I was at the school. Cain (2010) argues that to understand a text’s meaning a reader needs to establish local and global coherence. Local coherence is described as the ability to make links between adjacent sentences and global coherence is described as the ability to make sense of a text as a whole and relate this to personal experiences (p. 52). Amelia was able to understand the narrative of a story and could relate stories to her own life and other texts. During the reading conference I asked her about a book that she had read a few weeks ago; she was able to retell the story in great detail and described which parts were her favourite. There was also evidence that Amelia was able to engage with the meanings of individual words. For example, when reading aloud to me she read the word ‘buggy’ and said that ‘pram’ could be used as an alternative. It would be important to encourage this interest in the meanings of words in order for Amelia to progress with her comprehension skills. As Cain (2010) suggests, vocabulary knowledge is strongly associated with good reading comprehension.

Phonics and other strategies

Amelia was still learning to decode and used a number of different strategies. She used her knowledge of phonics as one way to decode words. She would split a word up into individual phonemes and then blend these together to read the word aloud. She often used her finger to cover up parts of the word in order to try and make this process easier. However, for some words she did not use this strategy. She struggled to read the word ‘children’ and said that it was too difficult to sound out because it was too long. However, when we read a different book the week after she did not have any trouble reading this word. She explained that she was able to read it because she recognised it and not because she sounded it out, suggesting that she read it from sight. Amelia did use her knowledge of phonics to read although this strategy was used in addition to others. On several occasions she looked at the pictures before attempting to read the text and would subsequently make predictions of what was going to happen in the story. She was also receptive to learning new reading strategies. When she struggled to read the word ‘snowball’ I suggested she split it into two words that she may recognise: ‘snow’ and ‘ball’. The next week we read the same book again and she used the same strategy. Amelia’s use of different reading strategies appeared to be effective and it would be important to encourage her to continue to use a variety of strategies in order for her reading to progress.

Taking it further

Amelia is an enthusiastic reader and enjoys reading at home. She reads to her mother and father on a daily basis and explained that her father reads to her and her sister every night before bed. It appeared that her home life fosters a positive attitude to reading and this was arguably beneficial to her reading progress. Clark (2011) has found that there is a positive relationship between the number of books a child has at home and their reading attainment level. Goouch and Lambirth (2011) also suggest that children who read at home would have a head start at school ‘with their knowledge of how stories work, patterns and tunes in stories, the relationship between illustration and print as well as some clear information about print drawn from reading and re-reading favourite tales’ (p. 8). As previously discussed Amelia seemed to be an able meaning maker and this could partly be due to the fact that reading is a part of her daily routine at home.

It would be crucial to encourage Amelia’s enthusiasm and enjoyment of reading in order for her reading to progress further. Ofsted reports have consistently argued for a greater emphasis on reading for pleasure within the taught curriculum in both primary and secondary schools (Ofsted, 2012: 42). Amelia enjoys reading books about animals and it would be important to consider her interests and try and incorporate this when suggesting reading books. Lockwood (2008) argues that it is important to discuss children’s reading choices and reflect this when updating book stocks. This would be a way of promoting reading for pleasure not only for Amelia but for all the children in the class.

In conclusion, Amelia appeared to have good comprehension skills and her ability to decode was developing. She engaged with texts and was able to express opinions on books that she had read. She used her knowledge of phonics to decode words but did not rely on this strategy alone. Amelia enjoys reading and reads in a variety of different contexts. It would be crucial to encourage this positive attitude to reading in order for her reading to develop further. This could be done in various ways, including ensuring that her interests were reflected in the books that were available to read in the classroom. It would also be important to provide choice and to demonstrate the joy of reading by reading stories together as a class. Trying to promote reading for pleasure would be beneficial not only for Amelia but for all the children in the class.

* A pseudonym

Cain, K. (2010) Reading Development and Difficulties West Sussex: Blackwell Publishing Ltd.

Clark, C. (2011) Setting the Baseline: The National Literacy Trust’s first annual survey into reading London: National Literacy Trust.

Goouch, K. and Lambirth, A. (2011) Teaching Early Reading and Phonics London: Sage.

Lockwood, M. (2008) Promoting reading for pleasure in the primary school London: Sage.

Ofsted (2012) Moving English Forward. Available at:

http://www.ofsted.gov.uk/resources/moving-english-forward  (Accessed: 3rd March 2014).

Rose, J. (2006) Independent review of the teaching of early reading. Available at: http://webarchive.nationalarchives.gov.uk/20130401…

https://www. education.gov.uk/publications/eOrderi… (Accessed: 5th March 2014) 

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  • Published: 31 March 2017

Helping children with reading difficulties: some things we have learned so far

  • Genevieve McArthur 1 &
  • Anne Castles 1  

npj Science of Learning volume  2 , Article number:  7 ( 2017 ) Cite this article

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  • Human behaviour

A substantial proportion of children struggle to learn to read. This not only impairs their academic achievement, but increases their risk of social, emotional, and mental health problems. In order to help these children, reading scientists have worked hard for over a century to better understand the nature of reading difficulties and the people who have them. The aim of this perspective is to outline some of the things that we have learned so far, and to provide a framework for considering the causes of reading difficulties and the most effective ways to treat them.

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Introduction

Over 20 years ago, The Dyslexia Institute asked a 9-year-old boy called Alexander to describe his struggle with learning to read and spell. He bravely wrote: “I have blond her, Blue eys and an infeckshos smill. Pealpie tell mum haw gorgus I am and is ent she looky to have me. But under the surface I live in a tumoyl. Words look like swigles and riting storys is a disaster area because of spellings. There were no ply times at my old school untill work was fineshed wich ment no plytims at all. Thechers sead I was clevor but just didn’t try. Shouting was the only way the techors comuniccatid with me. Uther boys made fun of me and so I beckame lonly and mishroboll”. 1

Alexander’s experience is not unique. Sixteen per cent of children struggle to learn to read to some extent, and 5% of children have significant, severe, and persistent problems. 2 The impact of these children’s reading difficulties goes well beyond problems with reading Harry Potter or Snapchat. Poor reading is associated with increased risk for school dropout, attempted suicide, incarceration, anxiety, depression, and low self-concept. 3 , 4 , 5 , 6 It is therefore important to identify and treat poor readers as early as we possibly can.

Scientists have been investigating poor reading—also known as reading difficulty, reading impairment, reading disability, reading disorder, and developmental dyslexia (to name but a few)—for over a century. While it may take another century of research to reach a complete understanding of reading impairment, there are number of things that we have learned about reading difficulties, as well as the children who experience reading them, that provide key clues about how poor reading can be identified and treated effectively.

Poor readers display different reading behaviours

One thing that we have learned about poor readers is that they are highly heterogeneous; that is, they do not all display the same type of reading impairment (i.e., “reading behaviour”; 7 , 8 , 9 , 10 , 11 , 12 ). Some poor readers have a specific problem with learning to read new words accurately by applying the regular mappings between letters and sounds. 7 , 8 , 13 , 14 This problem, which is often called poor phonological recoding or decoding, can be detected by asking children to read novel “nonwords” such as YIT. Other poor readers have a particular difficulty with learning to read new words accurately that do not follow the regular mappings between letters and sounds, and hence must be read via memory representations of written words. 7 , 13 , 15 , 16 This problem, which is sometimes called poor sight word reading or poor visual word recognition, can be detected by asking children to read “exception” words such as YACHT. In contrast, some poor readers have accurate phonological recoding and visual word recognition but struggle to read words fluently. 17 , 18 , 19 Poor reading fluency can be detected by asking children to read word lists or sentences as quickly as they can. In contrast yet again, some poor readers have intact phonological recoding and visual word recognition and reading fluency, but struggle to understand the meaning of what they read. These “poor comprehenders” 20 can be identified by asking them to read paragraphs aloud (to ascertain that they can read accurately and fluently), and then ask them questions about the meaning of what they have read (to ascertain that they do not understand what they are reading). It is important to note that most poor readers have various combinations of these problems. 21 For example, Alexander’s spelling suggests that he would have poor phonological decoding (since he misspells words like playtimes as “plytims”) and poor sight word knowledge (since he misspells exception words like said as “sead”). Thus, poor readers vary considerably in the profiles of their reading behaviour.

Reading behaviours have different “proximal” causes

Another thing we have learned about poor readers is that the same reading behaviour (e.g., inaccurate reading of novel words) does not necessarily have the same “proximal cause”. A proximal cause of a reading behaviour can be defined as a component of the cognitive system that directly and immediately produces that reading behaviour. 22 , 23 , 24 Most reading behaviours will have more than one proximal cause. Reflecting this, several theoretical and computational models of reading comprise multiple cognitive components that function together to produce successful reading behaviour (e.g., refs 25 , 26 , 27 , 28 ). While these models vary in some respects, all include cognitive components that represent (1) the ability to recognise letters (e.g., S), letter-clusters (e.g., SH), and written words (e.g., SHIP), (2) the ability to recognise and produce speech sounds (e.g., “sh”, “i”, “p”) and spoken words (e.g., “ship”), (3) the ability to access stored knowledge about the meanings of words (e.g., “a floating vessel”), and (4) links between these various components. Impairment in any one of these components or links will directly and immediately impair aspects of reading behaviour. Thus, guided by theoretical and computational models, we have learned that a poor reading behaviour can have multiple proximal causes, and we have some idea about what those proximal causes might be. 10 , 11 , 12

Reading behaviours have different “distal” causes

We have also learned that even if two poor readers have exactly the same reading behaviour with exactly the same proximal cause, this reading behaviour will not necessarily have the same “distal cause”. A distal cause has a distant (i.e., an indirect or delayed) impact on a reading behaviour. 22 , 23 , 24 Distal causes reflect the fact that reading is a taught skill that unfolds over time and across development. It depends upon a range of more cognitive abilities, such as memory, attention, and language skills, to name but a few. Depending on children’s strengths and weaknesses in these underlying abilities, and how these abilities affect learning over time, children will have different profiles of developmental, or distal, causes of their reading impairment. Stated differently, there can be different causal pathways to the same impairment of the reading system.

To provide an example, as mentioned earlier, a common reading behaviour observed in poor readers is inaccurate reading of new or novel words, which can be assessed using nonwords such as YIT. Indeed, some researchers have described this as the defining symptom of reading difficulties. 29 According to theoretical and computational models of reading, one proximal cause of impaired reading of nonwords is impaired knowledge of letter-sound mappings. But what is responsible for this proximal cause of poor nonword reading? There are multiple hypotheses. The prominent “phonological deficit hypothesis” proposes a pervasive language-based difficulty in processing speech sounds that affects the ability to learn to associate written stimuli (e.g., letters) with speech sounds. 30 The “paired-associate learning deficit hypothesis” proposes a memory-based difficulty in forming cross-modal mappings across the visual (e.g, letters) and verbal domains (e.g., speech sounds) that affects letter-sound learning (e.g., ref. 31 ). And the “visual attentional deficit hypothesis” proposes an attention-based impairment in the size of the attentional window, affecting the formation of the sub-word orthographic units (e.g., letters) used in the letter-sound mapping process. 32 These three hypotheses illustrate why a single reading behaviour (e.g., poor nonword reading) with a common proximal cause (impaired knowledge of letter-sound mappings) might not have the same distal cause (e.g., a phonological deficit, a paired-associate learning deficit, or a visual attention deficit). These hypotheses also raise the possibility that the distal causes of poor readers’ reading behaviours may vary as much (if not more) than the proximal causes and the reading behaviours themselves.

Poor readers have concurrent problems with their cognition and emotional health

Another thing we have learned about poor readers is that many (but not all) have comorbidities in other aspects of their cognition and emotional health. Regarding cognition, studies have found that a significant proportion of poor readers have impairments in their spoken language. 33 , 34 , 35 , 36 , 37 , 38 , 39 Studies have also found that poor readers have atypically high rates of attention deficit disorder—a neurological problem that causes inattention, poor concentration, and distractibility (e.g., refs 40 , 41 , 42 ). Regarding emotional health, there is evidence that poor readers, as a group, have higher levels of anxiety than typical readers (e.g., refs 43 , 44 ). The same is true for low self-concept, which can be defined as a negative perception of oneself in a particular domain (e.g., academic self-concept; e.g., refs 45 , 46 ).

The fact that poor readers vary in their comorbid cognitive and emotional health problems—as well as in their reading behaviours, and the proximal and distal impairments of these behaviours—creates an impression of almost overwhelming complexity. However, it is possible to simplify this complexity somewhat using a proximal and distal schema. Specifically, comorbidities of poor reading might be categorised according to whether they represent potential proximal or distal impairment of poor reading—or possibly both. For example, a child’s current problem with spoken vocabulary might be considered a proximal cause of their poor word reading behaviour since, according to theoretical and computational models of reading, vocabulary knowledge may directly underpin word reading accuracy or reading comprehension. However, a child’s previous problem with spoken vocabulary, which may or may not still be present, might be considered a distal cause of their poor word reading: A history of poor understanding of word meanings might reduce a child’s motivation to engage in reading (distal cause), which would impair their development of phonological recoding and visual word recognition (proximal cause), and hence their word reading accuracy and fluency (reading behaviour). Thus, the proximal and distal schema can prove useful in clarifying the causal chain of events linking a reading behaviour to a potential cause.

The proximal and distal schema can also be useful in clarifying reciprocal or circular relationships between comorbidities of poor reading and reading behaviours. For example, if a poor reader has low academic self-concept (distal cause), this may stymie their motivation to pay attention in reading lessons (distal cause), which will impair their learning of letter-sound mappings (proximal cause), and hence their poor word reading (reading behaviour). At the same time, a reverse causal effect may be in play: A child’s poor word reading in the classroom (distal cause) may create a poor perception of their own academic ability (proximal cause) that lowers their academic self-concept (behaviour). Thus, the proximal and distal schema can be used to help develop hypotheses as to whether comorbidities of poor reading are proximal and/or distal causes or consequences of poor reading. Ultimately, of course, all of these hypotheses must be tested through experimental training studies.

Proximal intervention is more effective than distal intervention

Poor readers have inspired, and have been subjected to, an extraordinary array of interventions such as behavioural optometry, chiropractics, classical music, coloured glasses, computer games, fish oil, phonics, sensorimotor exercises, sound training, spatial frequency gratings, memory training, medication for the inner ear, phonemic awareness, rapid reading, visual word recognition, and vocabulary training, to name just a selection. It is noteworthy that while many of these interventions claim to be “scientifically proven”, few have been tested with a randomised controlled trial (RCT)—an experiment that randomly allocates participants to intervention and control groups in order to reduce bias in outcomes. RCTs are the gold standard method for assessing a treatment of any kind, and the method that must be used to prove the effectiveness of a pharmaceutical treatment.

In order to make sense of the chaotic variety of interventions that claim to help poor readers, it may again be helpful to use the proximal and distal schema outlined above to subdivide interventions into two types: “proximal interventions” that focus training on proximal causes of a reading behaviour that are proposed to be part of the cognitive system for reading (e.g., phonics training, vocabulary training) and “distal interventions” that focus on distal causes of a reading behaviour (e.g., coloured lenses, inner-ear medication). The idea of making a distinction between proximal and distal interventions is supported by the outcomes of a systematic review of all studies that have used an RCT to assess an intervention in poor readers. 47 These studies assessed the effect of coloured lenses or overlays, medication, motor training, phonemic awareness, phonics, reading comprehension, reading fluency, sound processing, and sunflower therapy on poor readers. One key finding of this review is that it only identified 22 RCTs, which is a small number of gold-standard intervention studies given the huge number of interventions that claim to help poor readers. A second key finding is that the majority of RCTs of interventions for poor readers have assessed the efficacy of phonics training, which trains the ability to use letter-sound mappings to learn to read new or novel words. A third key finding is that only one type of intervention produced a statistically reliable effect. This was phonics training, which focuses on improving a proximal cause of poor word reading (i.e., letter-sound mappings). In contrast, interventions that focused on distal causes of poor reading did not show a statistically reliable effect in poor readers. The outcomes of this systematic review suggest that interventions that focus on phonics—a proximal cause of reading behaviour—are more likely to be effective than interventions that focus on a distal cause. In other words, the “closer” the intervention is to an impaired reading behaviour, the more likely it is to be effective.

Translating what we know (thus far) into evidence-based practice

At first glance, what we have learned (so far) about poor readers and reading difficulties paints a picture of such complex heterogeneity that it is tempting to throw one’s hands up in despair. And yet, somewhat paradoxically, it is this very heterogeneity that provides some important clues about how to maximise the efficacy of intervention for poor readers. First, the fact that poor readers vary in the nature of their reading behaviours suggests that the first step in identifying an effective intervention for a poor reader is to assess different aspects of reading (e.g., word reading accuracy, reading fluency, and reading comprehension). There are numerous standardized tests provided commercially (e.g., the York Assessment for Reading Comprehension available from GL Assessment) 48 or for free (e.g., the Castles and Coltheart Word Reading Test—Second Edition (CC2) available at www.motif.org.au ) 49 that can be used to determine if a child falls below the average range for their age or grade for reading accuracy, fluency, or comprehension. In our experience, a teacher who has appropriate training in administrating such tests can carry out this first step effectively.

Second, the fact that poor readers’ reading behaviours can have different proximal causes suggests that the next step is to test them for the potential proximal causes of their poor reading behaviours. This is where cognitive models of reading are a useful roadmap, providing an explicit account of the key processes directly underpinning successful reading behaviour. Again, this can be done using standardized tests that are available commercially (e.g., the Peabody Picture Vocabulary Test Fourth Edition available from Pearson) 50 or for free (e.g., the Letter-Sound Test available at www.motif.org.au ). 51 And well-trained teachers can administer these tests.

Third, the fact that poor readers vary in the degree to which they experience comorbid cognitive and emotional impairments suggests that it would be useful to assess poor readers for their spoken language abilities, attention, anxiety, depression, and self-concept, at the very least. This knowledge will reveal if they need support in other areas of their development, or if their reading-related intervention needs to be adjusted to accommodate their concomitant impairment in order to maximise efficacy. Trained speech and language therapists typically carry out the assessment of children’s spoken language; neuropsychologists are experts in assessing children’s attention; and clinical psychologists have the expertise to assess children’s emotional health.

Once a poor reader’s reading behaviours, proximal impairments, comorbid cognitive, and emotional health problems have been identified, it should be possible to design an intervention that is a good match to their needs. According to the systematic review conducted by Galuschka et al. 47 , current evidence suggests that this intervention should focus on the proximal impairment of a child’s reading behaviour, rather than a possible distal impairment. Two more recent controlled trials 52 , 53 and a systematic review 54 further suggest that it is possible to selectively train different proximal impairments of poor reading behaviours in order to improve those behaviours. The outcomes of these studies and reviews tentatively suggest that proximal interventions can be executed by a reading specialist or a highly-sophisticated online reading training programme.

In sum, over the last century or so, we have learned important things about reading difficulties and the people who have them. We have learned that poor readers display different reading behaviours, that any one reading behaviour has multiple proximal and distal causes, that some poor readers have concomitant problems in other areas of their cognition and emotional health, and that interventions that focus on proximal causes of poor reading behaviours may be more effective than those that focus on distal causes. This knowledge provides some clues to how we might best assist children with reading difficulties. Specifically, we need to assess poor readers for (1) a range of reading behaviours, (2) proximal causes for each poor reading behaviour, and (3) comorbidities in their cognition and emotional health. It should be possible to design an individualised intervention programme that accommodates for a poor reader’s comorbid cognitive or emotional problems whilst targeting the proximal causes of their poor reading behaviour or behaviours. This approach, which requires the co-ordinated efforts of teachers and specialists and parents, is no mean feat. However, according to the scientific evidence thus far, this is the most effective approach we have for helping children with reading difficulties.

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Understanding, Educating, and Supporting Children with Specific Learning Disabilities: 50 Years of Science and Practice

Elena l. grigorenko.

1 University of Houston, Houston, USA

2 Baylor College of Medicine, Houston, USA

Donald Compton

3 Florida State University, Tallahassee, USA

4 Vanderbilt University, Nashville, USA

Richard Wagner

Erik willcutt.

5 University of Colorado Boulder, Boulder, USA

Jack M. Fletcher

Specific learning disabilities (SLD) are highly relevant to the science and practice of psychology, both historically and currently, exemplifying the integration of interdisciplinary approaches to human conditions. They can be manifested as primary conditions—as difficulties in acquiring specific academic skills—or as secondary conditions, comorbid to other developmental disorders such as Attention Deficit Hyperactivity Disorder. In this synthesis of historical and contemporary trends in research and practice, we mark the 50th anniversary of the recognition of SLD as a disability in the US. Specifically, we address the manifestations, occurrence, identification, comorbidity, etiology, and treatment of SLD, emphasizing the integration of information from the interdisciplinary fields of psychology, education, psychiatry, genetics, and cognitive neuroscience. SLD, exemplified here by Specific Word Reading, Reading Comprehension, Mathematics, and Written Expression Disabilities, represent spectrum disorders each occurring in approximately 5–15% of the school-aged population. In addition to risk for academic deficiencies and related functional social, emotional, and behavioral difficulties, those with SLD often have poorer long-term social and vocational outcomes. Given the high rate of occurrence of SLD and their lifelong negative impact on functioning if not treated, it is important to establish and maintain effective prevention, surveillance, and treatment systems involving professionals from various disciplines trained to minimize the risk and maximize the protective factors for SLD.

Fifty years ago, the US federal government, following an advisory committee recommendation ( United States Office of Education, 1968 ), first recognized specific learning disabilities (SLD) as a potentially disabling condition that interferes with adaptation at school and in society. Over these 50 years, a significant research base has emerged on the identification and treatment of SLD, with greater understanding of the cognitive, neurobiological, and environmental causes of these disorders. The original 1968 definition of SLD remains statutory through different reauthorizations of the 1975 special education legislation that provided free and appropriate public education for all children with disabilities, now referred to as the Individuals with Disabilities Education Act (IDEA, 2004). SLD are recognized worldwide as a heterogeneous set of academic skill disorders represented in all major diagnostic nomenclatures, including the Diagnostic and Statistical Manual-5 (DSM-5, American Psychiatric Association, 2013) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11, World Health Organization, 2018).

In the US, the SLD category is the largest for individuals who receive federally legislated support through special education. Children are identified as SLD through IDEA when a child does not meet state-approved age- or grade-level standards in one or more of the following areas: oral expression, listening comprehension, written expression, basic reading skills, reading fluency, reading comprehension, mathematics calculation, and mathematics problem solving. Although children with SLD historically represented about 50% of the children aged 3–21 served under IDEA, percentages have fluctuated across reauthorizations of the special education law, with some decline over the past 10 years ( Figure 1 ).

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The Individuals with Disabilities Education Act (IDEA), enacted in 1975 as Public Law 94–142, mandates that children and youth ages 3–21 with disabilities be provided a free and appropriate public school education in the least restricted environment. The percentage of children served by federally mandated special education programs, out of total public school enrollment, increased from 8.3 percent to 13.8 percent between 1976–77 and 2004–05. Much of this overall increase can be attributed to a rise in the percentage of students identified as having SLD from 1976–77 (1.8 percent) to 2004–05 (5.7 percent). The overall percentage of students being served in programs for those with disabilities decreased between 2004–05 (13.8 percent) and 2013–14 (12.9 percent). However, there were different patterns of change in the percentages served with some specific conditions between 2004–05 and 2013–14. The percentage of children identified with SLD declined from 5.7 percent to 4.5 percent of the total public school enrollment during this period. This number is highly variable by state: for example, in 2011 it ranged from 2.3% in Kentucky to 13.8% in Puerto Rico, as there is much variability in the procedures used to identify SLD, and disproportional demographic representation. Figure by Janet Croog.

This review is a consensus statement developed by researchers currently leading the National Institute of Child Health and Human Development (NICHD) supported Consortia of Learning Disabilities Research Centers and Innovation Hubs. This consensus is based on the primary studies we cite, as well as the meta-analytic reviews (*), systematic reviews (**), and first-authored books (***) that provide an overview of the science underlying research and practice in SLD (see references). The hope is that this succinct overview of the current state of knowledge on SLD will help guide an agenda of future research by identifying knowledge gaps, especially as the NICHD embarks on a new strategic plan. The research programs on SLD from which this review is derived represent the integration of diverse, interdisciplinary approaches to behavioral science and human conditions. We start with a brief description of the historical roots of the current view of SLD, then provide definitions as well as prevalence and incidence rates, discuss comorbidity between SLD themselves and SLD and other developmental disorders, comment on methods for SLD identification, present current knowledge on the etiology of SLD, and conclude with evidence-based principles for SLD intervention.

Three Historical Strands of Inquiry that Shaped the Current Field of SLD

Three strands of phenomenological inquiry culminated in the 1968 definition and have continued to shape current terminology and conventions in the field of SLD ( Figure 2 ). The first, a medical strand, originated in 1676, when Johannes Schmidt described an adult who had lost his ability to read (but with preserved ability to write and spell) because of a stroke. Interest in this strand reemerged in the 1870s with the publication of a string of adult cases who had lived through a stroke or traumatic brain injury. Subsequent cases involved children who were unable to learn to read despite success in mathematics and an absence of brain injury, which was termed “word blindness” ( W. P. Morgan, 1896 ). These case studies laid the foundation for targeted investigations into the presentation of specific unexpected difficulties related to reading printed words despite typical intelligence, motivation, and opportunity to learn.

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A schematic timeline of the three stands of science and practice in the field of SLD. The colors represent the strands (blue—first, yellow—second, and green—third). Blue: provided phenomenological descriptions and generated hypotheses about the gene-brain bases of SLD (specifically, dyslexia or SRD); it also provided the first evidence that the most effective treatment approaches are skill-based and reflect cognitive models of the conditions. Yellow: differentiated SLD from other comorbid conditions. Green: stressed the importance of focusing on SLD in academic settings and developing both preventive and remediational evidence-based approaches to managing these conditions. Due to space constraints, the names of many highly influential scientists (e.g., Marilyn Adams, Joseph Torgesen, Isabelle Liberman, Keith Stanovich, among others) who shaped the field of SLD have been omitted. Figure by Janet Croog.

The second strand is directly related to the formalization of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM). Rooted in the work of biologically oriented physicians, the 1952 first edition (DSM-I) referenced a category of chronic brain syndromes of unknown cause that focused largely on behavioral presentations we now recognize as hyperkinesis and Attention Deficit Hyperactivity Disorder (ADHD). The 1968 DSM-II defined “mild brain damage” in children as a chronic brain syndrome manifested by hyperactive and impulsive behavior with reference to a new category, “hyperkinetic reaction of childhood” if the origin is not considered “organic.” As these categories evolved, they expanded to encompass the academic difficulties experienced by many of these children.

After almost 30 years of research into this general category of “minimal brain dysfunction,” representing “... children of near average, average, or above average general intelligence with certain learning or behavioral disabilities ... associated with deviations of function of the central nervous system.” ( Clements, 1966 , pp. 9–10), the field acknowledged the heterogeneity of these children and the failure of general “one size fits all” interventions. As a result, the 1980 DSM-III formally separated academic skill disorders from ADHD. The 1994 DSM-IV differentiated reading, mathematics, and written expression SLD. The DSM-5 reversed that, merging these categories into one overarching category of SLD (nosologically distinct from although comorbid with ADHD), keeping the notion of specificity by stating that SLD can manifest in three major academic domains (reading, mathematics, and writing).

The third strand originated from the development of effective interventions based on cognitive and linguistic models of observed academic difficulties. This strand, endorsed in the 1960s by Samuel Kirk and associates, viewed SLD as an overarching category of spoken and written language difficulties that manifested as disabilities in reading (dyslexia), mathematics (dyscalculia), and writing (dysgraphia). Advances have been made in understanding the psychological and cognitive texture of SLD, developing interventions aimed at overcoming or managing them, and differentiating these disorders from each other, from other developmental disorders, and from other forms of disadvantage. This work became the foundation of the 1968 advisory committee definition of SLD, which linked this definition with that of minimal brain dysfunction via the same “unexpected” exclusionary criteria (i.e., not attributable primarily to intellectual difficulties, sensory disorders, emotional disturbance, or economic/cultural diversity).

Although its exclusionary criteria were well specified, the definition of SLD did not provide clear inclusionary criteria. Thus, the US Department of Education’s 1977 regulatory definition of SLD included a cognitive discrepancy between higher IQ and lower achievement as an inclusionary criterion. This discrepancy was viewed as a marker for unexpected underachievement and penetrated the policy and practice of SLD in the US and abroad. In many settings, the measurement of such a discrepancy is still considered key to identification. Yet, IDEA 2004 and the DSM-5 moved away from this requirement due to a lack of evidence that SLD varies with IQ and numerous philosophical and technical challenges to the notion of discrepancy (Fletcher, Lyon, Fuchs, & Barnes, 2019). IDEA 2004 also permitted an alternative inclusion criterion based on Response-to-Intervention (RTI), in which SLD reflects inadequate response to effective instruction, while the DSM-5 focuses on evidence of persistence of learning difficulties despite treatment efforts.

These three stands of inquiry into SLD use a variety of concepts (e.g., word blindness, strephosymbolia, dyslexia and alexia, dyscalculia and acalculia, dysgraphia and agraphia), which are sometimes differentiated and sometimes used synonymously, generating confusion in the literature. Given the heterogeneity of their manifestation and these diverse historical influences, it has been difficult to agree on the best way to identify SLD, although there is consensus that their core is unexpected underachievement. A source of active research and controversy is whether “unexpectedness” is best identified by applying solely exclusionary criteria (i.e., simple low achievement), inclusionary criteria based on uneven cognitive development (e.g., academic skills lower than IQ or another aptitude measure, such as listening comprehension), or evidence of persisting difficulties (DSM-5) despite effective instruction (IDEA 2004).

Manifestation, Definition, and Etiology

That the academic deficits in SLD relate to other cognitive skills has always been recognized, but the diagnostic and treatment relevance of this connection has remained unclear. A rich literature on cognitive models of SLD ( Elliott & Grigorenko, 2014 ; Fletcher et al., 2019) provides the basis for five central ideas. First, SLD are componential ( Melby-Lervåg, Lyster, & Hulme, 2012 ; Peng & Fuchs, 2016 ): Their academic manifestations arise on a landscape of peaks, valleys, and canyons in various cognitive processes, such that individuals with SLD have weaknesses in specific processes, rather than global intellectual disability ( Morris et al., 1998 ). Second, the cognitive components associated with SLD, just like academic skills and instructional response, are dimensional and normally distributed in the general population ( Ellis, 1984 ), such that understanding typical acquisition should provide insight into SLD and vice versa ( Rayner, Foorman, Perfetti, Pesetsky, & Seidenberg, 2001 ). Third, each academic and cognitive component may have a distinct signature in the brain ( Figure 3 ) and genome ( Figure 4 ). These signatures and etiologies likely overlap because they are correlated, but are not interchangeable, as their unique features substantiate the distinctness of various SLD ( Vandermosten, Hoeft, & Norton, 2016 ). Fourth, the overlap at least partially explains their rates of comorbidity ( Berninger & Abbott, 2010 ; Szucs, 2016 ; Willcutt et al., 2013 ). Fifth, deficiencies in these cognitive and academic processes appear to last throughout the lifespan, especially in the absence of intervention ( Klassen, Tze, & Hannok, 2013 ).

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Results of meta-analyses of functional neuroimaging studies that exemplify the distribution of activation patterns in different reading- ( A ) and mathematics- ( B ) related networks, corresponding to componential models of the skills. A (Left panel, light blue): A lexical network in the basal occipito-temporal regions and in the left inferior parietal cortex. A (Middle panel, dark blue): A sublexical network, primarily involving regions of the left temporo-parietal lobe extending from the left anterior fusiform region. A (Right panel): Activation likelihood estimation map of foci from the word>pseudowords (light blue) and pseudowords>words (dark blue) contrasts. The semantic processing cluster is shown in green. B (Left panel): A number-processing network, primarily involving a region of the parietal lobe. B (Middle panel): An arithmetic-processing network, primarily involving regions of the frontal and parietal lobes. B (Right panel): Children (red) and adult (pink) meta-analyses of brain areas associated with numbers and calculations. Figure by Janet Croog.

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A schematic representation of the genetic regions and gene-candidates linked to or associated with SRD and reading-related processes (shown in blue), and SMD and mathematics-related processes (shown in red). Dark blue signifies more studied loci and genes. Blue highlighted in red indicate the genes implicated in both SRD and SMD. Figure by Janet Croog.

The DSM-5 and IDEA 2004 reflect agreement that SLD can occur in word reading and spelling (Specific Word Reading Disability; SWRD) and in specific reading comprehension disability (SRCD). SWRD represents difficulties with beginning reading skills due at least in part to phonological processing deficits, while other language indicators (e.g., vocabulary) may be preserved ( Pennington, 2009 ). In contrast, SRCD ( Cutting et al., 2013 ), which is more apparent later in development, is associated with non-phonological language weaknesses ( Scarborough, 2005 ). The magnitude of SRCD is greater than that of vocabulary or language comprehension difficulties, suggesting that other problems, such as weaknesses in executive function or background knowledge, also contribute to SRCD ( Spencer, Wagner, & Petscher, 2018 ).

Math SLDs are differentiated as calculations (SMD) versus problem solving (word problems) SLD, which are associated with distinct cognitive deficits ( L. S. Fuchs et al., 2010 ) and require different forms of intervention ( L. S. Fuchs et al., 2014 ). Calculation is more linked to attention and phonological processing, while problem solving is more linked to language comprehension and reasoning; working memory has been associated with both. Specific written expression disability, SWED ( Berninger, 2004 ; Graham, Collins, & Rigby-Wills, 2017 ) occurs in the mechanical act of writing (i.e., handwriting, keyboarding, spelling), associated with fine motor-perceptual skills, or in composing text (i.e., planning and revising, understanding genre), associated with oral language skills, executive functions, and the automaticity of transcription skills. Although each domain varies in its cognitive correlates, treatment, and neurobiology, there is overlap. By carefully specifying the domain of academic impairment, considerable progress has been made in the treatment and understanding of the factors that lead to SLD.

Identification methods have searched for other markers of unexpected underachievement beyond low achievement, but always include exclusionary factors. Diagnosis solely by exclusion has been criticized due to the heterogeneity of the resultant groups ( Rutter, 1982 ); thus, the introduction of a discrepancy paradigm. One approach relies on the aptitude-achievement discrepancy, commonly operationalized as a discrepancy between measures of IQ and achievement in a specific academic domain. IQ-discrepancy was the central feature of federal regulations for identification from 1977 until 2004, although the approaches used to qualify and quantify the discrepancy varied in the 50 states. Lack of validity evidence ( Stuebing et al., 2015 ; Stuebing et al., 2002 ) resulted in its de-emphasis in IDEA 2004 and elimination from DSM-5.

A second approach focuses on identifying uneven patterns of strengths and weaknesses (PSW) profiles of cognitive functioning to explain observed unevenness in achievement across academic domains ( Flanagan, Alfonso, & Mascolo, 2011 ; Hale et al., 2008 ; Naglieri & Das, 1997 ). According to these methods, a student with SLD demonstrates a weakness in achievement (e.g., word reading), which correlates with an uneven profile of cognitive weaknesses and strengths (e.g., phonological processing deficits with advanced visual-spatial skills). Proponents suggest that understanding these patterns is informative for individualizing interventions that capitalize on student strengths (i.e., maintain and enhance academic motivation) and compensate for weaknesses (i.e., enhance the phonological processing needed for the acquisition and automatization of reading), but little supporting empirical evidence is available ( Miciak, Fletcher, Stuebing, Vaughn, & Tolar, 2014 ; Taylor, Miciak, Fletcher, & Francis, 2017 ). Meta-analytic research suggests an absence of cognitive aptitude by treatment interactions ( Burns et al., 2016 ), and limited improvement in academic skills based on training cognitive deficits such as working memory ( Melby-Lervåg, Redick, & Hulme, 2016 ).

Newer methods of SLD identification are linked to the development of the third historical strand, based on RTI. With RTI, schools screen for early indicators of academic and behavior problems and then progress monitor potentially at-risk children using brief, frequent probes of academic performance. When data indicate inadequate progress in response to adequate classroom instruction (Tier 1), the school delivers supplemental intervention (Tier 2), usually in the form of small-group instruction.

A child who continues to struggle requires more intensive, individualized intervention (Tier 3), which may include special education. An advantage of RTI is that intervention is provided prior to the determination of eligibility for special education placement. RTI juxtaposes the core concept of underachievement with the concept of inadequate response to instruction, that is, intractability to intervention. It prioritizes the presence of functional difficulty and only then considers SLD as a possible source of this difficulty ( Grigorenko, 2009 ). Still, concerns about the RTI approach to identification remain. One concern is that RTI approaches may not identify “high-potential” children who struggle to develop appropriate academic skills ( Reynolds & Shaywitz, 2009 ). Other concerns involve low agreement across different methods for defining inadequate RTI ( D. Fuchs, Compton, Fuchs, Bryant, & Davis, 2008 ; L. S. Fuchs, 2003 ) and challenges schools face in adequately implementing RTI frameworks ( Balu et al., 2015 ; D. Fuchs & Fuchs, 2017 ; Schatschneider, Wagner, Hart, & Tighe, 2016 ).

Prevalence and Incidence

Because the attributes of SLD are dimensional and depend on the thresholds used to subdivide normal distributions ( Hulme & Snowling, 2013 ), estimates of prevalence and incidence vary. SWRD’s prevalence estimates range from 5 to 17% ( Katusic, Colligan, Barbaresi, Schaid, & Jacobsen, 2001 ; Moll, Kunze, Neuhoff, Bruder, & Schulte-Körne, 2014 ). SRCD is less frequent ( Etmanskie, Partanen, & Siegel, 2016 ), but still represents about 42% of all children ever identified with SLD in reading at any grade ( Catts, Compton, Tomblin, & Bridges, 2012 ). Estimates of incidence and prevalence of SMD vary as well: from 4 to 8% ( Moll et al., 2014 ). Cumulative incidence rates by the age of 19 years range from 5.9% to 13.8%. Similar to SWRD, SMD can be differentiated in terms of lower- and higher-order skills and by time of onset. Computation-based SMD manifests earlier; problem-solving SMD later, sometimes in the absence of computation-based SMD ( L. S. Fuchs, D. Fuchs, C. L. Hamlett, et al., 2008 ). SWED is the least studied SLD. Its prevalence estimates range from 6% to 22% ( P. L. Morgan, Farkas, Hillemeier, & Maczuga, 2016 ) and cumulative incidence ranges from 6.9% to 14.7% ( Katusic, Colligan, Weaver, & Barbaresi, 2009 ).

Comorbidity and Co-Occurrence

One reason SLD can be difficult to define and identify is that different SLDs often co-occur in the same child. Comorbidity involving SWRD ranges from 30% ( National Center for Learning Disabilities, 2014 ) to 60% ( Willcutt et al., 2007 ). The most frequently observed co-occurrences are between (1) SWRD and SMD ( Moll et al., 2014 ; Willcutt et al., 2013 ), with 30–50% of children who experience a deficit in one academic domain demonstrating a deficit in the other ( Moll et al., 2014 ); (2) SWRD and early language impairments ( Dickinson, Golinkoff, & Hirsh-Pasek, 2010 ; Hulme & Snowling, 2013 ; Pennington, 2009 ) with 55% of individuals with SWRD exhibiting significant speech and language impairment ( McArthur, Hogben, Edwards, Heath, & Mengler, 2000 ); and (3) SWRD and internalizing and externalizing behavior problems, with 25–50% of children with SWRD meeting criteria for ADHD ( Pennington, 2009 ) and for generalized anxiety disorder and specific test anxiety, depression, and conduct problems ( Cederlof, Maughan, Larsson, D’Onofrio, & Plomin, 2017 ), although comorbid conduct problems are largely restricted to the subset of individuals with both SWRD and ADHD ( Willcutt et al., 2007 ).

The co-occurrence of SMD is less studied, but there are some consistently replicated observations: (1) individuals with SMD exhibit higher rates of ADHD, and math difficulties are observed in individuals with ADHD more frequently than in the general population ( Willcutt et al., 2013 ); (2) math difficulties are associated with elevated anxiety and depression even after reading difficulties are controlled ( Willcutt et al., 2013 ); and (3) SMD are associated with other developmental conditions such as epilepsy ( Fastenau, Shen, Dunn, & Austin, 2008 ) and schizophrenia ( Crow, Done, & Sacker, 1995 ).

SLD is clearly associated with difficulties in adaptation, in school and in larger spheres of life associated with work and overall adjustment. Longitudinal research reports poorer vocational outcomes, lower graduation rates, higher rates of psychiatric difficulties, and more involvement with the justice system for individuals with SWRD ( Willcutt et al., 2007 ). Importantly, there is evidence of increased comorbidity across forms of SLD with age, with accumulated cognitive burden ( Costa, Edwards, & Hooper, 2016 ). Individuals with comorbid SLDs have poorer emotional adjustment and school functioning than those identified with a single impairment ( Martinez & Semrud-Clikeman, 2004 ).

Identification (Diagnosis)

Comorbidity indicates that approaches to assessment should be broad and comprehensive. For SLD, the choice of a classification model directly influences the selection of assessments for diagnostic purposes. Although all three models are used, the literature (Fletcher et al., 2019) demonstrates that a single indicator model, based either on cut-off scores, other formulae, or assessment of instructional response, does not lead to reliable identification regardless of the method employed. SLD can be identified reliably only in the context of multiple indicators. A step in this direction is a hybrid method that includes three sets of criteria, two inclusionary and one exclusionary, recommended by a consensus group of researchers (Bradley, Danielson, & Hallahan, 2002). The two inclusionary criteria are evidence of low achievement (captured by standardized tests of academic achievement) and evidence of inadequate RTI (captured by curriculum-based progress-monitoring measures or other education records). The exclusionary criterion should demonstrate that the documented low achievement is not primarily attributable to “other” (than SLD) putative causes such as (a) other disorders (e.g., intellectual disability, sensory or motor disorders) or (b) contextual factors (e.g., disadvantaged social, religious, economic, linguistic, or family environment). In the future, it is likely that multi-indicator methods will be extended, with improved identification accuracy, by the addition of other indicators, neurobiological, genetic, or behavioral. It is also possible that assessment of specific cognitive processes beyond academic achievement will improve identification, but presently there is little evidence that such testing adds value to identification ( Elliott & Grigorenko, 2014 ; Fletcher et al., 2019). All identification methods for SLD assume that children referred for assessment are in good health or are being treated and that their physical health, including hearing and vision, is monitored. Currently, there are no laboratory tests (i.e., DNA or brain structure/activity) for SLD. There are also no tests that can be administered by an optometrist, audiologist, or physical therapist to diagnose or treat SLD.

Etiological Factors

Neural structure and function.

Since the earliest reports of reading difficulties, it has been assumed that the loss of function (i.e., acquired reading disability) or challenges in the acquisition of function (i.e., congenital reading disability) are associated with the brain. Functional patterns of activation in response to cognitive stimuli show reliable differences in degrees of activation between typically developing children and those identified with SWRD, and reveal different spatial distributions in relation to children identified with SMD and ADHD ( Dehaene, 2009 ; Seidenberg, 2017 ). In SWRD, there are reduced gray matter volumes, reduced integrity of white matter pathways, and atypical sulcal patterns/curvatures in the left-hemispheric frontal, occipito-temporal, and temporo-parietal regions that overlap with areas of reduced brain activation during reading.

These findings together indicate the presence of atypicalities in the structures (i.e., grey matter) that form the neural system for reading and their connecting pathways (i.e., white matter). These structural atypicalities challenge the emergence of the cognitive—phonological, orthographic, and semantic—representations required for the assembly and automatization of the reading system. Although some have interpreted the atypicalities as a product of reading instruction ( Krafnick, Flowers, Luetje, Napoliello, & Eden, 2014 ), there is also evidence that atypicalities can be observed in pre-reading children at risk for SWRD due to family history or speech and language difficulties ( Raschle et al., 2015 ), sometimes as early as a few days after birth with electrophysiological measures ( Molfese, 2000 ). What emerges in a beginning reader, if not properly instructed at developmentally important periods, is a suboptimal brain system that is inefficient in acquiring and practicing reading. This system is complex, representing multiple networks aligned with different reading-related processes ( Figure 3 ). The system engages cooperative and competitive brain mechanisms at the sublexical (phonological) and lexical levels, in which the phonological, orthographic, and semantic representations are utilized to rapidly form representations of a written stimulus. Proficient readers process words on sight with immediate access to meaning ( Dehaene, 2009 ). In addition to malleability in development, there is strong evidence of malleability through instruction in SWRD, such that the neural processes largely normalize if the intervention is successful ( Barquero, Davis, & Cutting, 2014 ).

The functional neural networks for SMD also vary depending on the mathematical operation being performed, just as the neural correlates of SWRD and SRCD do ( Cutting et al., 2013 ). Neuroimaging studies on the a(typical) acquisition of numeracy posit SMD ( Arsalidou, Pawliw-Levac, Sadeghi, & Pascual-Leone, 2017 ) as a brain disorder engaging multiple functional systems that together substantiate numeracy and its componential processes ( Figure 3 ). First, the intraparietal sulcus, the posterior parietal cortex, and regions in the prefrontal cortex are important for representing and processing quantitative information. Second, mnemonic regions anchored in the medial temporal lobe and hippocampus are involved in the retrieval of math facts. Third, additional relevant regions include visual areas implicated in visual form judgement and symbolic processing. Fourth, prefrontal areas are involved in higher-level processes such as error monitoring, and maintaining and manipulating information. As mathematical processes become more automatic, reliance on the parietal network decreases and reliance on the frontal network increases. All these networks, assembled in a complex functional brain system, appear necessary for the acquisition and maintenance of numeracy, and various aberrations in the functional interactions between networks have been described. Thus, SMD can arise as a result of disturbances in one or multiple relevant networks, or interactions among them ( Arsalidou et al., 2017 ; Ashkenazi, Black, Abrams, Hoeft, & Menon, 2013 ). There is also evidence of malleability and the normalization of neural networks with successful intervention in SMD ( Iuculano et al., 2015 ).

Genetic and environmental factors

Early case studies of reading difficulties identified their familial nature, which has been confirmed in numerous studies utilizing genetically-sensitive designs with various combinations of relatives—identical and fraternal twins, non-twin siblings, parent-offspring pairs and trios, and nuclear and extended families. The relative risk of having SWRD if at least one family member has SWRD is higher for relatives of individuals with the condition, compared to the risk to unrelated individuals; higher for children in families where at least one relative has SWRD; even higher for families where a first-degree relative (i.e., a parent or a sibling) has SWRD; and higher still for children in families where both parents have SWRD ( Snowling & Melby-Lervåg, 2016 ). Quantitative-genetic studies estimate that 30–80% of the variance in reading, math or spelling outcomes is explained by heritable factors ( Willcutt et al., 2010 ).

Since the 1980s, there have been systematic efforts to identify the sources of structural variation in the genome, i.e., genetic susceptibility loci that can account for the strong heritability and familiality of SWRD ( Figure 4 ). These efforts have yielded the identification of nine regions of the genome thought to harbor genes, or other genetic material, whose variation is associated with the presence of SWRD and individual differences in reading-related processes. Within these regions, a number of candidate genes have been tapped, but no single candidate has been unequivocally replicated as a causal gene for SWRD, and observed effects are small. In addition, multiple other genes located outside of the nine linked regions have been observed to be relevant to the manifestation of SWRD and related difficulties. Currently there are ongoing efforts to interrogate candidate genes for SWRD and connect their structural variation to individual differences in the brain system underlying the acquisition and practice of reading.

There are only a few molecular-genetic studies of SMD and its related processes ( Figure 4 ). Unlike SWRD, no “regions of interest” have been identified. Only one study investigated the associations between known single-nuclear polymorphisms (SNP) and a composite measure of mathematics performance derived from various assessments of SMD-related componential processes and teacher ratings. The study generated a set of SNPs that, when combined, accounted for 2.9% of the phenotypic variance ( Figure 4 shows the genes in which the three most statistically significant SNPs from this set are located). Importantly, when this SNP set was used to study whether the association between the 10-SNP set and mathematical ability differs as a function of characteristics of the home and school, the association was stronger for indicators of mathematical performance in chaotic homes and in the context of negative parenting.

Finally, studies have investigated the pleiotropic (i.e., impacting multiple phenotypes) effects of SWRD candidate genes on SMD, ADHD, and related processes. These effects are seemingly in line with the “generalist genes” hypothesis, asserting the pleiotropic influences of some genes to multiple SLD ( Plomin & Kovas, 2005 ).

Environmental factors are strong predictors of SLD. These factors penetrate all levels of a child’s ecosystem: culture, demonstrated in different literacy and numeracy rates around the world; social strata, captured by social-economic indicators across different cultures; characteristics of schooling, reflected by pedagogies and instructional practices; family literacy environments through the availability of printed materials and the importance ascribed to reading at home; and neighborhood and peer influences. Interactive effects suggest that reading difficulties are magnified when certain genetic and environmental factors co-occur, but there is evidence of neural malleability even in SWDE ( Overvelde & Hulstijn, 2011 ). Neural and genetic factors are best understood as risk factors that variably manifest depending on the home and school environment and child attributes like motivation.

Intervention

Although the content of instruction varies depending on whether reading, math, and/or writing are impaired, general principles of effective intervention apply across SLD i . First, intervention for SLD is explicit ( Seidenberg, 2017 ): Teachers formally present new knowledge and concepts with clear explanations, model skills and strategies, and teach to mastery with cumulative practice with ongoing guidance and feedback. Second, intervention is individualized: Instruction is formatively adjusted in response to systematic progress-monitoring data ( Stecker, Fuchs, & Fuchs, 2005 ). Third, intervention is comprehensive and differentiated, addressing the multiple components underlying proficient skill as well as comorbidity. Comprehensive approaches address the multifaceted nature of SLD and provide more complex interventions that are generally more effective than isolated skills training in reading ( Mathes et al., 2005 ) and math ( L. S. Fuchs et al., 2014 ). For example, children with SLD and ADHD may need educational and pharmacological interventions ( Tamm et al., 2017 ). Anxiety can develop early in children who struggle in school, and internalizing problems must be treated ( Grills, Fletcher, Vaughn, Denton, & Taylor, 2013 ). Differentiation through individualization in the context of a comprehensive intervention also permits adjustments of the focus of an intervention on specific weaknesses.

Fourth, intervention adjusts intensity as needed to ensure success, by increasing instructional time, decreasing group size, and increasing individualization ( L. S. Fuchs, Fuchs, & Malone, 2017 ). Such specialized intervention is typically necessary for students with SLD ( L. S. Fuchs et al., 2015 ). Yet, effective instruction for SLD begins with differentiated general education classroom instruction ( Connor & Morrison, 2016 ), in which intervention is coordinated with rather than supplanting core instruction ( L. S. Fuchs, D. Fuchs, C. Craddock, et al., 2008 ).

In addition, intervention is more effective when provided early in development. For example, intervention for SWRD was twice as effective if delivered in grades 1 or 2 than if started in grade 3 ( Lovett et al., 2017 ). This is underscored by neuroimaging research ( Barquero et al., 2014 ) showing that experience with words and numbers is needed to develop the neural systems that mediate reading and math proficiency. A child with or at risk for SWRD who cannot access print because of a phonological processing problem will not get the reading experience needed to develop the lexical system for whole word processing and immediate access to word meanings. This may be why remedial programs are less effective after second grade; with early intervention, the child at risk for SLD develops automaticity because they have gained the experience with print or numbers essential for fluency. Even with high quality intensive intervention, some children with SLD do not respond adequately, and students with persistent SLD may profit from assistive technology (e.g., computer programs that convert text-to-speech; Wood, Moxley, Tighe, & Wagner, 2018 ).

Finally, interventions for SLD must occur in the context of the academic skill itself. Cognitive interventions that do not involve print or numbers, such as isolated phonological awareness training or working memory training without application to mathematical operations do not improve reading or math skill ( Melby-Lervåg et al., 2016 ). Physical exercises (e.g., cerebellar training), optometric training, special lenses or overlays, and other proposed interventions that do not involve teaching reading or math are ineffective ( Pennington, 2009 ). Pharmacological interventions are effective largely due to their impact on comorbid symptoms, with little evidence of a direct effect on the academic skill ( Tamm et al., 2017 ).

No evaluations of recovery rate from SLD have been performed. Intervention success has been evaluated as closing the age-grade discrepancy, placing children with SLD at an age-appropriate grade level, and maintaining their progress at a rate commensurate with typical development. Meta-analytic studies estimate effect sizes of academic interventions at 0.49 for reading ( Scammacca, Roberts, Vaughn, & Stuebing, 2015 ), 0.53 for math ( Dennis et al., 2016 ), and 0.74 for writing ( Gillespie & Graham, 2014 ).

Implications for Practice and Research

Practitioners should recognize that the psychological and educational scientific evidence base supports specific approaches to the identification and treatment of SLD. In designing SLD evaluations, assessments must be timely to avoid delays in intervention; they must consider comorbidities as well as contextual factors, and data collected in the context of previous efforts to instruct the child. Practitioners should use the resulting assessment data to ensure that intervention programs are evidence-based and reflect explicitness, comprehensiveness, individualization, and intensity. There is little evidence that children with SLD benefit from discovery, exposure, or constructivist instructional approaches.

With respect to research, the most pressing issue is understanding individual differences in development and intervention from neurological, genetic, cognitive, and environmental perspectives. This research will ultimately lead to earlier and more precise identification of children with SLD, and to better interventions and long-term accommodations for the 2–6% of the general population who receive but do not respond to early prevention efforts. More generally, other human conditions may benefit from the examples of progress exemplified by the integrated, interdisciplinary approaches that underlie the progress of the past 50 years in the scientific understanding of SLD.

Acknowledgments

The authors are the Principal Investigators of the currently funded Learning Disabilities Research Centers ( https://www.nichd.nih.gov/research/supported/ldrc ) and Innovation Hubs ( https://www.nichd.nih.gov/research/supported/ldhubs ), the two key NICHD programs supporting research on Specific Learning Disabilities. The preparation of this articles was supported by P20 HD090103 (PI: Compton), P50 HD052117 (PI: Fletcher), P20 HD075443 (PI: Fuchs), P20 HD091005 (PI: Grigorenko), P50 HD052120 (PI: Wagner), and P50 HD27802 (PI: Willcutt). Grantees undertaking such projects are encouraged to express their professional judgment. Therefore, this article does not necessarily reflect the position or policies of the abovementioned agencies, and no official endorsement should be inferred.

i For examples of effective evidence-based interventions see www.evidenceforessa.org , intensiveintervention.org , What Works Clearinghouse, www.meadowscenter.org , www.FCRR.org/literacyroadmap , www.understood.org/en/about/our.../national-center-for-learning-disabilities , https://ies.ed.gov/ncee/edlabs/infographics/pdf/REL_SE_Implementing_evidencebased_literacy_practices_roadmap.pdf , among others.

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The aim of this study, in which one of the qualitative research approaches, the case study design, was used, was to remedy reading problems and develop reading skills in a fourth grade primary school student with sound, syllable and word recognition exercises. The study covers 38 lesson periods in the autumn term of the 2018-2019 academic year. For developing reading skills, the strategies of “prior listening to the paragraph”, “repetitive reading” and “word repetition” were used. For determining reading errors, the “Error Analysis Inventory” was used. Data were obtained by means of observation and document examination. In the study related to determining reading status, it was established that the student had made errors such as repetition, syllabication, omission, addition and failure to notice punctuation marks. Based on the data obtained, first of all, sound, syllable and word recognition exercises were conducted with the student, and then reading exercises were carried out with texts selected to suit the level of the student’s Turkish course books and story books. Analyses were performed by taking audio and video recordings of all exercises. As a result of the intervention, the student’s desire to read increased, he began to read out loud, he began to identify sounds that he previously did not recognise or confused, and improvements in his reading skill were observed.

Keywords: Fluent reading, repetitive reading, reading difficulties, comprehension, reading skills.

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case study of a child with reading difficulties

© 2012-2022 Published by Eurasian Society of Educational Research European Journal of Educational Research Online ISSN: 2165-8714

Systematic identification and intervention for reading difficulty: case studies of children with EAL

Affiliation.

  • 1 Department of Psychology, University of Sheffield, UK.
  • PMID: 10840507
  • DOI: 10.1002/(SICI)1099-0909(200001/03)6:1<57::AID-DYS163>3.0.CO;2-W

Literacy underpins education. There is now very widespread concern over standards of literacy for children from multi-cultural backgrounds, who are learning English as a second or subsequent language, and who may have special educational needs. Research evidence suggests that the earlier children's difficulties can be identified, the more effective (and cost-effective) intervention will be, provided that the intervention is tailored to the child's abilities and skills. Nicolson and Fawcett have developed systematic procedures for identifying children at risk for reading difficulty, together with systematic teaching strategies to overcome reading difficulty. In this paper we present case studies of children with EAL (English as an additional language) drawn from a controlled study using computer interventions with secondary school children. Our findings indicate that children with EAL may be more resistant to remediation than some children with learning difficulties. The prognosis is more problematic for children with both EAL and dyslexia.

Publication types

  • Research Support, Non-U.S. Gov't
  • Dyslexia / diagnosis*
  • Dyslexia / therapy*
  • Remedial Teaching / standards
  • Study Protocol
  • Open access
  • Published: 12 March 2024

The short- and longer-term effects of brief behavioral parent training versus care as usual in children with behavioral difficulties: study protocol for a randomized controlled trial

  • Roos S. van Doornik 1 , 2 ,
  • Saskia van der Oord 3 ,
  • Joli Luijckx 4 ,
  • Annabeth P. Groenman 1 , 2 , 5 ,
  • Patty Leijten 5 ,
  • Marjolein Luman 6 , 7 ,
  • Pieter J. Hoekstra 1 , 2 ,
  • Barbara J. van den Hoofdakker 1 , 2 , 8   na1 &
  • Tycho J. Dekkers 1 , 10 , 2 , 7 , 9   na1  

BMC Psychiatry volume  24 , Article number:  203 ( 2024 ) Cite this article

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The access to and uptake of evidence-based behavioral parent training for children with behavioral difficulties (i.e., oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior) are currently limited because of a scarcity of certified therapists and long waiting lists. These problems are in part due to the long and sometimes perceived as rigid nature of most evidence-based programs and result in few families starting behavioral parent training and high dropout rates. Brief and individually tailored parenting interventions may reduce these problems and make behavioral parent training more accessible. This protocol paper describes a two-arm, multi-center, randomized controlled trial on the short- and longer-term effectiveness and cost-effectiveness of a brief, individually tailored behavioral parent training program for children with behavioral difficulties.

Parents of children aged 2–12 years referred to a child mental healthcare center are randomized to (i) three sessions of behavioral parent training with optional booster sessions or (ii) care as usual. To evaluate effectiveness, our primary outcome is the mean severity of five daily ratings by parents of four selected behavioral difficulties. Secondary outcomes include measures of parent and child behavior, well-being, and parent–child interaction. We explore whether child and parent characteristics moderate intervention effects. To evaluate cost-effectiveness, the use and costs of mental healthcare and utilities are measured. Finally, parents’ and therapists’ satisfaction with the brief program are explored. Measurements take place at baseline (T0), one week after the brief parent training, or eight weeks after baseline (in case of care as usual) (T1), and six months (T2) and twelve months (T3) after T1.

The results of this trial could have meaningful societal implications for children with behavioral difficulties and their parents. If we find the brief behavioral parent training to be more (cost-)effective than care as usual, it could be used in clinical practice to make parent training more accessible.

Trial registration

The trial is prospectively registered at ClinicalTrials.gov (NCT05591820) on October 24th, 2022 and updated throughout the trial.

Behavioral difficulties, including oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior, are one of the most common reasons for referral to mental healthcare among children and adolescents [ 1 , 2 ]. When left untreated, problems may exacerbate and put children at risk of adverse outcomes later on in life, such as school dropout, delinquency, substance use and depression [ 3 , 4 ]. Ideally, treatment should prevent this escalation of problems, reduce the need for long and intensive treatments, and lower societal costs [ 5 ]. Behavioral parent training is the first psychosocial treatment of choice for reducing behavioral difficulties in preschool and school aged children [ 6 , 7 , 8 , 9 , 10 , 11 , 12 ]. However, its use in clinical practice is limited by a scarcity of certified therapists, long waiting lists, and the typically long and sometimes perceived as rigid nature of behavioral parent training programs, which may lead to parents not starting or finishing behavioral parent training [ 13 , 14 , 15 ]. To reduce these barriers, this study evaluates a brief and individually tailored behavioral parent training program for children with behavioral difficulties (the “ PAINT-GGZ ” program, developed by the Psychosocial ADHD & disruptive behavior INTerventions [PAINT] consortium). The brief training includes optional booster sessions for families who need additional support [ 16 ].

In behavioral parent training, parents are taught techniques to curtail children’s behavioral difficulties by avoiding or breaking coercive parent–child interactions [ 17 ]. Parenting programs have moderate short-term effects on child conduct problems [ 18 ], oppositional behavior [ 19 , 20 ], inattentive and hyperactive/impulsive behavior [ 21 , 22 ], and parenting [ 23 ]. The longer-term effects of behavioral parent training are less consistent: A meta-analysis on behavioral parent training for children with attention deficit/hyperactivity disorder (ADHD) found mostly sustained effects five months to one year after the intervention [ 24 ], while a meta-analysis on behavioral parent training for children with disruptive behaviors (e.g., tantrums, arguing, rule-breaking) shows a large heterogeneity in results, with some studies showing sustained effects and other studies showing fade-out effects or sleeper effects three years after the intervention [ 25 ]. Overall, the evidence base of behavioral parent training is well-established.

However, a scarcity of certified therapists, long waiting lists, and the typically long and sometimes perceived as rigid nature of behavioral parent training programs undermine the use of parenting interventions in clinical practice. That is, only a minority of families who seek treatment actually receive parent training, because there is a lack of certified therapists who can provide behavioral parent training and waiting lists for parenting interventions are common [ 15 ]. Also, clinicians sometimes do not recommend parent training, but rather redirect children towards medication [ 26 ]. Additionally, behavioral parent training programs are typically long (8 to 12 sessions [ 14 ],) and generally not tailored to the specific behavioral difficulties that parents seek help for [ 27 ]. This is problematic, as behavioral parent training programs are more likely to be effective when their content is tailored to the specific problems parents encounter in daily life [ 14 ]. The perceived rigidity and length of programs may lead to parents not starting or completing behavioral parent training [ 15 , 28 ]. That is, at least 25% of parents who are eligible to participate in scientific studies and qualify for behavioral parent training do not enroll in a parenting program and another 26% terminate the training prematurely [ 13 ]. Brief and individually tailored behavioral parent training programs may reduce these problems, but the few existing brief programs are barely provided and mainly evaluated in prevention settings [ 29 , 30 ]. There is thus an urgent need for evidence-based, brief and individually tailored programs.

To address this need, this randomized controlled trial evaluates the effectiveness of a brief and individually tailored behavioral parent training program with optional booster sessions for children with behavioral difficulties. The program is based on intervention elements that were effective in reducing children’s behavioral difficulties in the broader literature and our earlier work: antecedent techniques (i.e., stimulus control techniques) and consequent techniques (i.e., contingency management techniques) [ 22 , 31 , 32 ]. Antecedent techniques are aimed at changing child behavior by manipulating the antecedents of this behavior (e.g., by setting clear rules and providing structure) and consequent behavioral techniques are aimed at changing child behavior by manipulating their consequences (e.g., by praising desired behavior and ignoring undesired behavior). In a recent microtrial in which we evaluated the efficacy of antecedent and consequent techniques, both sets of techniques were found to reduce behavioral problems of children with ADHD in brief (i.e., two sessions) behavioral parent training, of which antecedent techniques were especially effective in decreasing inattention [ 33 ]. This microtrial also showed that the magnitude of effects of a brief program (i.e., medium-sized effects) was similar to those of traditional, longer programs on reducing child behavioral difficulties [ 23 , 33 , 34 ].

Building upon the findings of our microtrial, the brief behavioral parent training of the present trial consists of two sessions in which antecedent and consequent techniques are combined and a third session aimed at the evaluation and maintenance of applying the learned techniques. To prevent relapse and the possible use of other, more intensive and expensive treatments, parents can receive booster sessions in the first year after the brief training. Similar to the microtrial, the behavioral parent training is individually tailored by letting parents select four target behaviors they want to address in the training and by creating an individually tailored intervention plan based on the functional analysis (see [ 33 ]). A non-randomized pilot study ( N  = 28) preceding the present trial indicated a relatively low dropout rate (14.2%), high treatment feasibility and parent and clinician satisfaction, and a reduction of children’s behavioral difficulties from pre to post intervention [ 35 ].

Objectives and hypotheses

The first objective of this study is to examine the short- and longer-term (i.e., one year) effectiveness of the brief and individually tailored behavioral parent training program with optional booster sessions compared to care as usual (CAU) on daily measured child behavioral difficulties (primary outcome) and on a range of secondary outcomes (see Outcomes). Additionally, we will explore whether a number of general demographic and clinical characteristics, parental attachment, parental psychopathology, parental reward responsivity, and reward and punishment sensitivity of the child moderate the short- and longer-term intervention effects on our primary outcome. The second objective is to investigate the cost-effectiveness of the program compared to CAU. As we assess cost-effectiveness based on measures at baseline and one year after the intervention, we can only draw conclusions about the cost-effectiveness on the longer term.

Based on our earlier work [ 33 , 35 ], we hypothesize that the brief behavioral parent training with booster sessions will be more effective than CAU in reducing children’s behavioral difficulties. Consequently, we expect parents who receive the brief behavioral parent training to use less subsequent care and thus hypothesize the brief training to be more cost-effective than CAU on the longer term.

Study design

In this two-arm multi-center randomized controlled trial, parents of children who experience behavioral difficulties in the home setting and were referred to a child mental healthcare center, are randomly assigned (1:1 ratio) to either (a) three sessions of brief behavioral parent training with optional booster sessions, or (b) CAU, as regularly provided by the involved mental healthcare centers. There are no restrictions regarding the type (e.g., psychoeducation, parent counseling and support, individual child therapy, medication) or duration of CAU, only the brief parent training investigated in this trial is not allowed. Both parents and children in the brief behavioral parent training group are not allowed to receive CAU until the first posttreatment assessment (T1). After that, CAU is allowed and parents can also make use of booster sessions with the therapist who provided the training.

Study setting

To ensure our findings reflect the real-world impact of brief behavioral parent training (i.e., to test effectiveness rather than efficacy), the trial is fully embedded in routine mental healthcare. The participating centers are academic and non-academic youth mental healthcare centers of various sizes. Therapists who provide the brief behavioral parent training have a master’s degree in psychology or child, family and education studies and have had postmaster education in cognitive behavioral therapy (at least 50 h) or have a registered higher vocational education degree as social worker in cognitive behavioral therapy. The therapists are trained in the brief parent training by supervisors qualified in cognitive behavior therapy during a one-day training of seven hours, in which therapists practice the parent training by roleplay and evaluate on their performance. Therapists also receive weekly supervision by these qualified supervisors when providing the brief parent training. Additionally, the supervisors provide feedback to each therapist on the audio-taped first session regarding protocol fidelity, intervention integrity, and the process of providing the training (e.g., engaging parents, didactic skills). There are no in- or exclusion criteria for clinicians in the CAU condition. To prevent contamination of the two research arms, therapists never provide both the brief behavioral parent training and CAU to parents participating in this study and are instructed not to share information about the contents of the brief training.

Stakeholder involvement: parent advisory board

For this trial we have installed a parent advisory board (four members, one of them [co-author JL] represents “ Balans ”, a Dutch association for parents of children with developmental problems). The board is involved in this trial since the grant application. They provided feedback and ideas for the current project and meet biannually in the first and last year of the project and annually in years two, three, and four. In the last year, they will be asked to give their ideas about the interpretation of the results. During the writing of the grant application, the parent advisory board indicated that targeting individual needs is crucial for parents and that booster sessions may be very important and helpful, as some parents may experience relinquishing of their parenting skills after finishing behavioral parent training (e.g., in stressful times). The board also tested the suitability of the measures: they considered the time investment of the questionnaires to be acceptable and indicated to use audiotapes rather than videotapes as observational measurement, as parents may perceive audiotapes as less invasive and interfering with their privacy. The members of the board receive reimbursements for all meetings.

Eligibility criteria

Families eligible for the trial must meet the following inclusion criteria:

The child is aged between 2 and 12 years;

Parents have to identify at least four behavioral difficulties of the child that occur in the home setting and that they want to target in the training, using an adapted version of a list of target behaviors [ 33 , 36 ]. This list contains 29 behaviors that can be targeted in the training, such as hyperactive, impulsive, inattentive, oppositional and defiant behavior. The items are derived from target problems that parents mentioned in previous behavioral parent training groups and concern child behaviors that are commonly targeted in behavioral parent training in clinical practice, confirming ecological validity [ 36 ].

Exclusion criteria are:

The child uses psychotropic medication (currently or in the month before the screening);

The child has at any time received a diagnosis of autism spectrum disorder (ASD) in clinical practice, as (parents of) children with ASD may have different needs and therefore may require different treatments than children with behavioral difficulties without ASD;

The child has a known IQ-score below 70, as (parents of) children with intellectual disabilities may have different needs and therefore may require different treatments than children with behavioral difficulties and typical intellectual abilities;

Parents received behavioral parent training aimed at reducing the behavioral difficulties of the concerned child in the year prior to the start of the study;

It is not a suitable period for the parents and/or the child to participate in the study (e.g., moving, divorce);

The child is not living in the same household as the parent(s) who participate(s) in the trial during at least four weekdays (to ensure that our primary outcome can be reported by the same informant(s) and that parents can apply the intervention plans at home).

Interventions

The parent training program includes the behavioral techniques that were identified as effective for reducing behavioral difficulties (i.e., oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior) in a preceding microtrial [ 33 ] and in the broader literature [ 22 , 23 , 31 , 32 , 34 ]. Importantly, all behavioral techniques are explained to parents and based on a functional analysis, the most suitable techniques are selected and tailored to the specific problem behaviors that parents experience with their child and to the home context. Prior to the brief training, with a researcher parents choose four daily occurring target behaviors from the list of target behaviors (see Primary Outcome) that they prefer to work on in the training [ 33 , 36 , 37 ]. For each of the four behaviors, parents also indicate in which situation the behavior occurs, using the situations that are included in the Home Situation Questionnaire [ 37 ]. The therapist providing the brief training receives a list of the chosen four behaviors in specific situations before the training.

In the first session, parents are briefly educated about supposed underlying mechanisms of behavioral difficulties in children. They learn that children with behavioral difficulties may have problems in executive functioning, such as inhibition or working memory, which may influence the way they process environmental information and exert control over their behavior [ 38 , 39 ]. Parents are taught how they can use antecedent techniques (i.e., setting rules, giving clear instructions, structuring situations, discussing situations in advance) to support their child’s executive functioning and elicit more desirable and prosocial behaviors. Parents are also taught that children with behavioral difficulties may show altered sensitivity to reinforcement and punishment, which may influence how children learn from rewards and negative consequences and the way in which their behavior is shaped by environmental consequences as provided by parents [ 40 , 41 , 42 , 43 , 44 ]. Their altered reinforcement sensitivity may lower the likelihood that children change behavior in response to corrective reactions and result in behaviors that are reward-oriented on the short term [ 40 , 43 ]. The therapist explains that consequent techniques (i.e., reinforcement [e.g., praise], planned ignoring, non-violent discipline techniques [e.g., correction, natural consequences]) are important to deal with these sensitivities, while emphasizing that the majority of the used consequent techniques should concern reinforcement. In their explanations, therapists also stress parents that the psycho-education is based on research involving many children and could therefore not directly apply to the situation of their child. After this psycho-education, the parents and therapist select a first target problem behavior along with the specific situation in which this behavior occurs daily. This behavior is chosen from the four behaviors in specific situations that parents selected beforehand with a researcher to target in the training. Together, the parents and therapist make a functional analysis of the selected behavior and create an individually tailored intervention plan. This plan contains the most suitable of the four antecedent techniques and one consequent technique (i.e., praise). The techniques are selected according to the functional analysis and adapted to the abilities and needs of the child and parents. Parents write down their intervention plan with the therapist and receive a handout with explanations of the techniques. Directly after each session, parents carry out their intervention plan at home the next week.

In the second session, the first plan is evaluated and adapted if necessary. The parents and therapist briefly recapitulate the psycho-education and intervention plan of the first session and discuss a second target problem behavior in the same way as the first problem behavior. They make an individually tailored intervention plan for the second target behavior, which again includes the most suitable techniques of all discussed antecedent and consequent techniques, based on the functional analysis of the second target behavior. Based on the results of our microtrial that antecedent techniques are effective sooner after the training (i.e., immediately) and are more effective in decreasing symptoms of inattention than consequent techniques [ 33 ], the intervention plan of the first session mainly contains antecedent techniques, while the intervention plan of the second session includes both antecedent and consequent techniques. The consequent techniques always include forms of reinforcement (e.g., praise, rewards) and can optionally include ignoring or mild negative consequences. In the third session, the second intervention plan is evaluated and adapted if necessary. Maintenance training is provided by encouraging parents to think about how the techniques can be used for other problems. Furthermore, during this session parents rehearse and practice designing an intervention plan accordingly for possible new behavior problems.

In the optional booster sessions, parents can discuss either the same or new target behaviors and create or adapt an intervention plan with the antecedent and consequent techniques that are taught in the earlier sessions. Parents are stimulated by the therapist to use the steps they have learned in the earlier sessions. Parents implement new or adapted intervention plans directly after the session. Booster sessions are not meant as prolongation of the brief training, but as stand-alone sessions to support parents in refreshing and maintaining to apply the learned techniques. Booster sessions can be combined with any CAU.

Parents in the control arm receive CAU, which in Dutch mental healthcare typically consists of psychoeducation, parent counseling and support, medication, longer behavioral parent training programs, family therapy, support at school, and/or cognitive behavior therapy or other therapy or support for the child.

Treatment fidelity

Intervention fidelity (i.e., the percentage of items covered in each session) is assessed with a fidelity checklist using an adapted version of the procedures of Abikoff and colleagues [ 45 , 46 ]. This implies that all intervention sessions (including the booster sessions) are audiotaped. The audiotapes of 20% randomly selected sessions will be scored on intervention fidelity by independent evaluators. After each session, therapists also have to complete a fidelity checklist in which they are asked which items they covered.

Recruitment

Parents of children with behavioral difficulties who are referred to one of the participating Dutch mental healthcare centers are recruited by clinicians within these centers. After the diagnostic assessment of the child and before any treatment has started, the clinicians involved in the diagnostic assessments inform parents of children who seem eligible about the study and hand out an information letter. Clinicians provide researchers with contact information of parents that have consented to sharing information and are interested in participation. The researchers then further inform parents about the trial through telephone contact. If parents want to participate, the researchers ask both parents, or other legal caretakers of the child, to provide informed consent. By default, parents have 14 days to decide upon participation and ask the researchers any questions. If needed, parents can ask for more time to decide upon participation. Once parents have provided consent, the researchers screen whether families are eligible for the study and inform parents whether they can participate.

Allocation to study arms

Randomization is performed with an online generated randomization schedule [ 47 ], using blocks of six participants for each healthcare center to ensure equal allocations to both arms within and across centers. The randomization schedule is only known and administered by independent researchers who are not involved in the trial in any other way. When participants can be randomized, the independent researchers are informed at which healthcare center the parents are participating and asked to inform the responsible researchers about which condition has been randomly assigned to these parents. Randomization occurs directly after the baseline measurement (T0).

Parents in the brief behavioral parent training arm receive three sessions of behavioral parent training. The first two sessions take 120 min each and are planned one or two weeks apart. The third session takes 60 min and is planned one week after the second session. To take parents’ and therapists’ availability into account, some flexibility in planning is allowed as long as all three sessions are planned within six weeks with at least one week between two consecutive sessions. After the third session, parents wishing to receive additional support can receive CAU and/or booster sessions. The booster sessions take 60 min each and can be provided maximally once every four weeks up to one year after the last session of the brief behavioral parent training program. Booster sessions can be suggested by the therapist who provided the brief behavioral parent training or by other involved clinicians, or requested by parents themselves.

The trial contains four measurement occasions, see Fig.  1 for the participant timeline. T0 takes place after parents provide consent and are found eligible for participation, before randomization. The first posttreatment measurement (T1) takes place one week after the third session for parents in the brief behavioral parent training arm and eight weeks after T0 for parents in the CAU arm. The second posttreatment measurement (T2) takes place six months after T1 and the third posttreatment measurement (T3) takes place twelve months after T1. Participation in the trial therefore takes approximately 14 months in total. The care families receive at the child mental healthcare center may terminate sooner if they do not need or want care anymore.

figure 1

Participant Timeline

The outcomes are measured with questionnaires, audiotapes, and short daily phone calls. Completing the questionnaires (including those measuring moderator variables) takes 30 to 45 min per measurement occasion, making the audiotapes takes about 30 min per measurement occasion (i.e., two recordings of 15 min each), and making the phone calls takes two to three minutes each. Furthermore, parents in the behavioral parent training arm fill out the ECBI-I questionnaire at the beginning of and two weeks after each booster session, which takes a couple of minutes.

Demographic information and clinical characteristics

Parents will provide information on children’s age and gender, on their own and children’s ethnicity, educational background, and household composition, and on children’s previous and ongoing pharmacological and non-pharmacological treatments, medical conditions, and clinical diagnoses (e.g., ADHD, oppositional defiant disorder [ODD], conduct disorder [CD]).

Primary outcome

Individually determined daily ratings of behavioral difficulties.

The primary outcome is the mean severity of parents’ daily ratings of four selected target behaviors in specific home situations. On the adapted version of the list of target behaviors [ 33 , 36 ], parents indicate whether the 29 behaviors occur daily ( yes/no ). For the behaviors scored as yes, parents rate the severity on a 5-point Likert scale ranging from 1 ( not severe ) to 5 ( extremely severe ). Behaviors scored as no are coded 0. With a researcher, parents choose four daily occurring target behaviors from this list that they prefer to work on in the training. Parents also indicate in which situation these behaviors occur, using the situations that are included in the Home Situation Questionnaire [ 37 ].

For each measurement occasion, during preferably five but at least four consecutive weekdays, short daily phone calls with parents are made to evaluate whether the four selected target behaviors occurred in the past 24 h in the selected situation ( yes/no ). Items scored as no are rated 0 and items scored as yes are rated on a 5-point Likert scale ranging from 1 ( not severe ) to 5 ( extremely severe ). This outcome is measured at all timepoints (T0-T3). For each timepoint, the average score of all four behaviors on all weekdays is used as outcome measure.

Secondary outcomes

Parent-reported behavioral difficulties.

Children's behavioral difficulties are assessed with the Intensity scale of the Eyberg Child Behavior Inventory (ECBI-I) [ 48 ]. The Intensity scale consists of 36-items for parents of children aged 2 to 16 and measures the frequency of specific problem behavior on a 7-point Likert scale from 1 ( never ) to 7 ( always ). The convergent and divergent validity and the reliability of the ECBI-I are well established [ 49 ]. This outcome is measured at all timepoints, and at the beginning of and two weeks after each booster session for parents who receive the brief behavioral parent training.

Child well-being

Child well-being is assessed with the Health-Related Quality of Life Questionnaire (KINDL-R) [ 50 ]. Parents rate their children's quality of life on 20 items regarding emotional well-being, self-esteem, family functioning, social contacts, and school, of which the total score will be used. Parents rate the items on a Likert scale ranging from 1 ( never ) to 5 ( all the time ). The KINDL-R has revealed sufficient internal consistency (α = 0.82) [ 51 ]. This outcome is measured at all timepoints.

Parenting behaviors

Parenting behaviors are assessed with the Alabama Parenting Questionnaire (APQ; [ 52 ]). The APQ is a 42-item parent-report measure assessing five categories of parenting practices (involvement, positive parenting, poor monitoring/supervision, inconsistent discipline, and corporal punishment), of which the total score will be used. Parents rate their parenting on a 5-point scale ranging from 1 ( never ) to 5 ( always ), with higher scores representing higher levels of the particular parenting category. The reliability and validity of the APQ are well established [ 52 ]. This outcome is measured at all timepoints.

Observed parent and child behaviors

To include an observational measurement of parent and child behaviors, parents are asked to audio record their mealtime routines for at least 15 min on two different weekdays. Mealtimes are notoriously busy times in family lives and thus well suited as a setting for an ecologically valid measure. The recordings of mealtime routines are a masked measure (i.e., assessors are not aware of the intervention condition), based on the method that was used by Herbert et al. [ 53 ]. Using the recordings, the following behaviors will be scored with a global coding system: parental behavior (both supportive and non-supportive parenting), child misbehavior, and emotional talk. A subsample of recordings will be double coded until sufficient interrater reliability is established. This outcome is measured at all timepoints except T2, to minimize the burden for families.

Parenting stress

Parenting stress is assessed with the Parental Stress Scale (PSS; [ 54 ]). The PSS is an 18-item parent report scale that measures positive (e.g., emotional benefits) and negative (e.g., restrictions) aspects of parenting, of which the total score will be used. Parents have to agree or disagree with statements concerning parenting on a 5-point scale ranging from 1 ( strongly disagree ) to 5 ( strongly agree ). The adequate reliability (α = 0.83) and validity of the PSS have been demonstrated [ 54 ]. This outcome is measured at all timepoints.

Parenting self-efficacy

Parenting self-efficacy is measured with the subscale Efficacy of the Parenting Sense of Competence Scale (PSOC; [ 55 ]). On the eight items of this subscale, parents rate their capability level and problem-solving ability regarding their parental role on a 6-point scale, ranging from 1 ( strongly disagree ) to 6 ( strongly agree ). The internal consistency (α = 0.76) of the subscale Efficacy has been established [ 55 ]. This outcome is measured at all timepoints.

Quality of the parent–child relationship

The quality of the parent–child relationship is measured with the parent version of the Parent–Child Interaction Questionnaire-Revised (PACHIQ-R; [ 56 ]). On 21 items, parents rate their relationship with their child on a 5-point scale, ranging from 1 ( strongly disagree ) to 5 ( strongly agree ), of which the total score will be used. The PACHIQ-R has been demonstrated to have high internal consistency (ranging between α = 0.79 and α = 0.93) [ 56 ]. This outcome is measured at all timepoints.

Utilities, also called preferred health states, are assessed using quality-adjusted life years (QALYs). QALYs range between 0 and 1, where 0 represents death and 1 perfect health. QALYs are calculated based on the EuroQol-5D-5L (EQ-5D) questionnaire [ 57 , 58 ], which parents fill out about their child. The EuroQol-5D-5L measures the child’s health with five items (mobility, self-care, daily activities, pain, and anxiety/depression) on 5-level categorical scales. EQ-5D responses will be transferred into QALYs based on the Dutch EQ-5D-5L tariff for adults [ 59 ], as a tariff for Dutch children is not yet available. The content and face validity of the EuroQol-5D-5L are well established [ 58 ]. This outcome is measured at T0 and T3.

Use of healthcare

Use of mental healthcare within the organization where the child is treated is measured by drawing up an inventory (based on patient records) of the type of care (brief behavioral parent training, booster sessions, CAU) that is used and the duration (in minutes) of this care between T0 and T3 in both arms. The broader use of healthcare within and outside the mental healthcare centers is assessed with the Vragenlijst Intensieve Jeugdzorg , a Dutch questionnaire on intensive youth care [ 60 ]. This questionnaire assesses the use of a wide variety of healthcare (e.g., contact with general practitioner or medical professionals, use of social services or (alternative) medicines), along with the child’s use of education, contact with judicial authorities, and losses in the productivity of parents. Parents complete this questionnaire about the use and intensity of healthcare of both the child and themselves in the past three months. This outcome is measured at T0 and T3. Both measures of healthcare use (i.e., inventory of care and questionnaire) will be combined to obtain a complete image of all used care.

Costs of healthcare

Healthcare costs are estimated from a societal perspective [ 5 ]. Costs of mental healthcare are estimated by multiplying the used care by the reference prices provided in the Cost Manual of the Dutch National Health Care Institute. Costs of medication are estimated by using prices provided by the Dutch National Health Care Institute [ 61 ]. Costs in other sectors (e.g., education, justice) are estimated by using reference prices provided in the Manual Intersectoral Costs and Benefits [ 62 ]. All costs are estimated after families’ participation in the study, when their healthcare use is fully measured.

Candidate moderators

In addition to the general demographic and clinical characteristics and some baseline characteristics such as the severity of behavioral problems, the following variables are included to explore whether they moderate the short- (T1) and longer-term (T2, T3) intervention effects: parental attachment as measured with the 12-item version of the Revised Experiences in Close Relationship questionnaire (ECR-R; [ 63 , 64 ]),parental psychopathology as measured with the 25 items of the Strengths and Difficulties Questionnaire (SDQ) for adults [ 65 ], parental reward responsivity as measured with the 8-item Reward Responsiveness (RR) questionnaire [ 66 ], and child reward responsivity and punishment sensitivity as measured with the Punishment Sensitivity and Reward Responsivity subscales (combined 22 items) of the Sensitivity to Punishment and Sensitivity to Reward Questionnaire for Children (SPSRQ-C; [ 67 ]). All candidate moderators are measured at T0 only and reported by parents.

Parent and therapist satisfaction

Parents’ satisfaction with the brief behavioral parent training.

Satisfaction with the brief behavioral parent training of parents who received the intervention are measured in two ways. First, parents are asked to fill out a self-developed satisfaction questionnaire, which is based on questions of the Parent Satisfaction Questionnaire [ 68 ], the Therapy Attitude Inventory [ 69 ], and the satisfaction questionnaire that was used in Breider et al. [ 70 ]. Parents who received the brief behavioral parent training answer 13 questions about their satisfaction with the brief behavioral parent training at T1 and three questions about their satisfaction with the booster sessions (if used) at T3 on a 5-point scale ranging from 1 ( strongly disagree ) to 5 ( strongly agree ). Parents also grade the brief behavioral parent training generally between 1 ( very bad ) and 10 ( excellent ). Second, one or multiple focus group(s) will be organized with a small number of parents. In the focus group(s), the new program will be qualitatively evaluated and information about feasibility and barriers and facilitators for the implementation of the training in clinical settings will be gathered. The focus group(s) will be held after the inclusion of parents is finished, which is anticipated to be at the beginning of 2025.

Therapists’ satisfaction with the brief behavioral parent training

Therapists' satisfaction and opinion about the intervention are measured in two ways. First, therapists will be asked to fill in a self-developed satisfaction questionnaire, which is based on questions of the Parent Satisfaction Questionnaire [ 68 ], the Therapy Attitude Inventory [ 69 ], and the satisfaction questionnaire that was used in Breider et al. [ 70 ]. Therapists have to answer seven questions on a 5-point scale ranging from 1 ( strongly disagree ) to 5 ( strongly agree ) and give the brief behavioral parent training a general grade between 1 ( very bad ) and 10 ( excellent ). Second, one or multiple focus group(s) will be organized with a selection of therapists from different healthcare centers who provided the brief parent training and range in years of work experience and to how many families they have provided the brief behavioral parent training. In the focus group(s), important barriers and facilitators for the implementation of the program will be identified. Both outcomes will be measured after the trial is finished, which is anticipated to be at the beginning of 2026.

Adverse reactions

Adverse reactions are measured with a self-developed questionnaire. These reactions involve negative experiences of parents and/or children that are, according to parents, related to the care they received either in the brief parent training treatment arm or in the CAU arm. The questionnaire consists of six questions that ask parents whether they experience a decline in their trust in healthcare, (anxiety of) negative reactions from others (i.e., stigma), mental health issues, difficulties in relationships and activities, or any other difficulties or concerns that could be related to the care they received during the trial. For each question that applies to them, we ask parents to shortly elaborate on their experiences and indicate when these experiences happened. These answer options are based on the Medical and Psychological Events and Difficulties (MAPED) questionnaire that was used in the Online Parent Training for The Initial Management of ADHD referrals (OPTIMA) trial [ 71 ]. This outcome is measured at T3.

Sample size calculation

Based on our previous study that found medium-sized short term effects on daily ratings of behavioral difficulties compared to waitlist (range of Cohen’s d  = 0.35 to d  = 0.66, [ 33 ]) and studies showing medium-sized parenting intervention effects on behavioral difficulties using parent-report rating scales [ 19 , 20 , 25 , 36 , 72 ], we estimate the effect of our brief behavioral parent training program as compared to CAU to be at least small ( d  = 0.25).

A power analysis has been performed using G*Power software [ 73 ]. Based on an effect size of d  = 0.25 ( f  = 0.125), two groups and three repeated measures (T0, T1, T2 for short term effectiveness), with r  = 0.60 between-measurement relation, a power of 0.80 and α = 0.05, we need at least 42 participants per group, resulting in a total of 84 participants. Given that the data are clustered, we increased the sample size with 10% [ 74 ], resulting in a total of 93 participants. This is in line with the number of participants in similar studies comparing behavioral treatments to CAU (e.g., [ 36 ]).

Statistical analysis

Data will be analyzed on an intention-to-treat basis. To examine the effects of the intervention on the primary and secondary outcomes, we will conduct multilevel analyses (mixed modeling), taking missing data into account [ 75 ]. Depending on the fit of the models, up to four hierarchical levels will be distinguished: outcomes (level 1), nested within children (level 2), nested within therapists (level 3), nested within healthcare centers (level 4). Random intercepts at the subject level, therapist level and healthcare center level will be included only if the Likelihood Ratio Test shows a significant improvement of the model fit. Time will be included as short-term (T1) and longer-term (T2, T3) within-subjects factors and condition (brief parent training vs. CAU) as between-subjects factor. The interaction between time and condition will be examined to interpret changes over time between conditions. To examine whether the candidate moderator variables moderate the intervention effects, these variables will also be added as interaction effects to the multilevel analyses.

To assess the cost-effectiveness of the brief behavioral parent training compared to CAU, we will calculate the Incremental Cost Effectiveness Ratio (ICER) from a societal perspective. We will perform both a cost-utility analysis (based on QALYs) and cost-effectiveness analyses (based on the daily ratings of behavioral difficulties and based on ECBI-I scores). An ICER is calculated by dividing the difference in the total costs by the difference in the total effect (either QALYs or the daily ratings of behavioral difficulties and ECBI-I scores, respectively). In these analyses, the costs of healthcare will be used and interpolated to the previous 12 months. We will compare each ICER based on relevant willingness to pay thresholds. Bootstrapping will be used to calculate the reliability of our estimates.

Trial duration

October 2022 – December 2026.

Data management

Digital data, both raw and processed data are stored at a study specific secured folder within the network of Accare, the institution at which the research is carried out. This study specific folder can only be accessed by authorized personnel, who are involved in this study. All questionnaire data and processed audio files are stored in one, pseudonymized file, that is accompanied by a 'readme' text file that contains a code book explaining the meaning of all variables. A separate logbook-file will be created documenting all decisions that are made during the process from raw to processed data. Raw data containing identifiable information is kept strictly separate from the processed data and can only be accessed by two of the supervisors (BJvdH, TJD), research assistants and PhD candidate (RSvD). After the research project will be completed (i.e., data collection, data analysis and publishing of research articles), all digital data will be transferred to a study specific folder for long-term storage. The folder can only be accessed by authorized personnel. All research data will be stored for at least 15 years after the data collection has been completed. Upon request, the processed, pseudonymized data will be available for fellow researchers and made available (restricted access) for use in future research projects, to which all participants have consented before enrolling in the study. Requests for re-use of data will be evaluated to check whether the research question falls within the scope of the informed consent.

Ethics and dissemination

This study has been granted a non-WMO statement from the Medical Ethics Review Committee (METc) of the University Medical Center Groningen, meaning that the study does not meet the conditions of the Medical Research Involving Human Subjects Act. Ethics approval has been obtained from the Scientific and Ethical Review Board (VCWE) of the Vrije Universiteit (VU) Amsterdam (VCWE-2022–124). Approval to participate in this study has been obtained from all research partners. The results of this study will be submitted for publication in peer-reviewed journals. In addition, findings will be presented at scientific conferences and shared with stakeholders (e.g., parents, clinicians), for instance on our website ( https://www.paint-studies.nl/ ) and social media channels. Regarding clinical practice, findings will be shared with parents and mental healthcare institutions, partly in collaboration with Balans (e.g., vlogs, flyers, presentations, newsletters). If the brief behavioral parent training with booster sessions is more effective than CAU in reducing children’s behavioral difficulties, the brief training can be implemented in clinical practice.

This study protocol describes a multi-center randomized controlled trial investigating the short- and longer-term effectiveness and the cost-effectiveness of a brief, individually tailored behavioral parent training program that aims to reduce children’s behavioral difficulties. Although behavioral parent training is an evidence-based psychosocial treatment for reducing children’s behavioral difficulties, few families currently receive the intervention. This may be due to, among other reasons, a shortage of certified therapists, long waiting lists, and a perceived rigidity and length of behavioral parent training programs. Brief and individually tailored parenting interventions may reduce these problems and could therefore be a promising way to make behavioral parent training more accessible for parents.

We anticipate multiple challenges that the trial could face. For instance, clinicians’ policies and attitudes towards parent training may complicate the enrollment of eligible families in clinical practice [ 26 ]. Clinicians might be used to their work routines and experience resistance or difficulty getting acquainted with the trial, for instance because they do not feel sufficiently knowledgeable about the contents and effects of the brief behavioral parent training or feel uncertain about the procedures and administration that come with families’ participation in the trial, or because families may express hesitation about participating in a trial. As a result, clinicians may not refer eligible families or (intuitively) recommend usual care (e.g., other parent training programs or parent support, child treatments, medication) rather than the trial. We aim to tackle this hindrance by making clinicians aware that participation in this trial is in line with the stepped-care approach as delineated in international and Dutch treatment guidelines for children with ADHD and for children with disruptive behavior disorders, which suggest offering non-pharmacological treatment that includes psycho-education and practical advices, such as the brief behavioral parent training, before starting more intensive treatment or medication [ 6 , 8 , 10 , 12 ].

Other challenges concern potential hindrances for parents to participate. For instance, parents might find it difficult to complete all measurements during four occasions over an extended period of time (i.e., approximately 14 months). For several reasons, it can be difficult to stay dedicated to participate (e.g., motivational issues, time constraints). Besides, parents presumably take part in the trial hoping to receive the brief parent training and might therefore be disappointed when they are randomized into the CAU arm, which can cause their motivation for participation to decline. This might make parents who receive CAU more likely to drop out of the study. We anticipate this challenge by keeping parents involved in the measurements through frequent reminders, expressing the value of parents’ participation and thanking parents after each completed measurement. We also offer parents who consider quitting the study options to reduce the burden of the measurements (e.g., four instead of five daily phone calls, making less or no audio recordings) to possibly keep them involved for a longer period of time.

The results of the trial could have meaningful societal implications for children with behavioral difficulties and their parents. If we find the brief behavioral parent training to be more (cost-)effective than CAU, the treatment could be used in clinical practice to make parent training more accessible.

Quotient; EQ-5D-5L: EuroQol-5 Dimension 5-Level; KINDL-R: Health-Related Quality of Life Questionnaire (German abbreviation); MAPED: Medical and Psychological Events and Difficulties; METc: Medical Ethics Review Committee; ODD: Oppositional Defiant Disorder; PACHIQ-R: Parent–Child Interaction Questionnaire-Revised; PSOC: Parenting Sense of Competence Scale; PSS: Parental Stress Scale; QALYs: quality-adjusted life years; RR: Reward Responsiveness Questionnaire; SDQ: Strengths and Difficulties Questionnaire; SPSRQ-C: Sensitivity to Punishment and Sensitivity to Reward Questionnaire for Children; VCWE: Scientific and Ethical Review Board; V31, U: Vrije Universiteit Amsterdam.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Alabama Parenting Questionnaire

Autism Spectrum Disorder

Care as usual

Conduct Disorder

Eyberg Child Behavior Inventory Intensity scale

Experiences in Close Relationship Questionnaire Revised

EuroQol-5 Dimension 5-Level

Incremental Cost Effectiveness Ratio

Intelligence Quotient

Health-Related Quality of Life Questionnaire (German abbreviation)

Medical and Psychological Events and Difficulties

Medical Ethics Review Committee

Oppositional Defiant Disorder

Parent-Child Interaction Questionnaire-Revised

Parenting Sense of Competence Scale

Parental Stress Scale

Quality-adjusted life years

Reward Responsiveness Questionnaire

Strengths and Difficulties Questionnaire

Sensitivity to Punishment and Sensitivity to Reward Questionnaire for Children

Scientific and Ethical Review Board

Vrije Universiteit Amsterdam

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Acknowledgements

We would like to express our gratitude to Tess Praamstra and Nienke Markensteijn, two research assistants who have made a major contribution in preparing the practical aspects for the data collection (e.g., thinking along in the logistics of the data collection, preparing the questionnaires for and phone calls to parents) and are actively involved in the execution of the data collection. We would also like to express our gratitude to Marjan Houwing, a research assistant who has set up a database in preparation of the data collection and manages the randomization of participants. We would furthermore like to express our gratitude to the parent advisory board for their involvement in the project.

This randomized controlled trial is funded by ZonMw (dossier number 60–63600-98–1151, third cash flow) in the Dutch subsidy round “ Klinisch toegepast onderzoek in de geestelijke gezondheidszorg ronde 2 ”. The funding source was not involved in the design of this trial and will not be involved in the conduct (data collection, analyses, interpretation of results) and reporting (decision to submit results, manuscript writing, dissemination of results, implementation) of the trial.

Author information

Barbara J. van den Hoofdakker and Tycho J. Dekkers contributed equally to this work.

Authors and Affiliations

Accare Child Study Center, Groningen, The Netherlands

Roos S. van Doornik, Annabeth P. Groenman, Pieter J. Hoekstra, Barbara J. van den Hoofdakker & Tycho J. Dekkers

Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

Clinical Psychology, KU Leuven, Louvain, Belgium

Saskia van der Oord

Balans, National Parent Association, Bunnik, The Netherlands

Joli Luijckx

Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, The Netherlands

Annabeth P. Groenman & Patty Leijten

Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

Marjolein Luman

Department of Complex Behavioral Disorders and Forensic Youth Psychiatry, Levvel, Amsterdam, The Netherlands

Marjolein Luman & Tycho J. Dekkers

Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands

Barbara J. van den Hoofdakker

Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center (AUMC), Amsterdam, The Netherlands

Tycho J. Dekkers

Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands

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Contributions

BJvdH, SvdO, APG, PJH, ML, PL, JL, and TJD prepared the grant application to obtain funding for the trial. RSvD prepared the body, figure, references and formatting of the present manuscript. BJvdH, SvdO, and TJD supervised RSvD in preparing the trial and writing the manuscript. BJvdH, SvdO, TJD, APG, PL, ML, and PJH contributed to preparing the body of the manuscript. JL reviewed the contents of the manuscript on behalf of the parent advisory board.

Corresponding author

Correspondence to Roos S. van Doornik .

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Ethics approval and consent to participate.

The Medical Ethics Review Committee (METc) of the University Medical Center Groningen has granted this trial a non-WMO statement on April 21st, 2022, meaning that the study does not meet the conditions of the Medical Research Involving Human Subjects Act. The Scientific and Ethical Review Board (VCWE) of the Vrije Universiteit (VU) Amsterdam, the Netherlands, has given approval for this trial on September 20th, 2022 (VCWE-2022–124). All research partners have given consent to collaborate in this trial. Before deciding upon participation, legal caretakes are informed about the study in detail, both through an information letter and through telephone calls with a researcher. All parents provide written informed consent during the recruitment.

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Not applicable.

Competing interests

BJvdH and SvdO were involved in the development and evaluation of several Dutch parent and teacher training programs, among which the brief behavioral parent training that is being investigated in this trial, and are both involved in the training and supervision of therapists who deliver the brief behavioral parent training. BJvdH, SvdO and TJD also provide the brief behavioral parent training to participants themselves. ML has co-developed teacher training programs and other behavioral treatments. BJvdH, SvdO and ML have been advisors of Dutch ADHD guideline groups and BJvdH and SvdO are also members of the European ADHD Guidelines Group (EAGG). SvdO is on the higher health council in Belgium, an advisory committee about ADHD to the minister of health in Belgium and is on the board of trustees of “ Zit Stil ”; the ADHD advocacy organization in Flanders. BJvdH is an advisor of the Dutch Knowledge Centre for Child and Adolescent Psychiatry. BJvdH, SvdO, ML, PL, APG, PJH and TJD have received research grants from ZonMw. SvdO has also received several research grants from FWO (Flanders Research Foundation). JL is member of the parent advisory board that is involved in this trial. RSvD, APG, PL and PJH have no non-financial conflict of interest.

BJvdH receives royalties as one of the editors of “ Sociaal Onhandig ” (published by Van Gorcum), a Dutch book for parents that can be used in parent training. SvdO declares a financial honorarium and reimbursement for travel expenses from MEDICE for being a speaker on non-pharmacological treatments of ADHD. The other authors have no financial conflict of interest.

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van Doornik, R.S., van der Oord, S., Luijckx, J. et al. The short- and longer-term effects of brief behavioral parent training versus care as usual in children with behavioral difficulties: study protocol for a randomized controlled trial. BMC Psychiatry 24 , 203 (2024). https://doi.org/10.1186/s12888-024-05649-8

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  • Behavioral difficulties
  • Behavioral parent training
  • Individually tailored
  • Psychosocial intervention
  • Randomized controlled trial
  • Effectiveness
  • Cost-effectiveness

BMC Psychiatry

ISSN: 1471-244X

case study of a child with reading difficulties

The Philippines economy in 2024: Stronger for longer?

The Philippines ended 2023 on a high note, being the fastest growing economy across Southeast Asia with a growth rate of 5.6 percent—just shy of the government's target of 6.0 to 7.0 percent. 1 “National accounts,” Philippine Statistics Authority, January 31, 2024; "Philippine economic updates,” Bangko Sentral ng Pilipinas, November 16, 2023. Should projections hold, the Philippines is expected to, once again, show significant growth in 2024, demonstrating its resilience despite various global economic pressures (Exhibit 1). 2 “Economic forecast 2024,” International Monetary Fund, November 1, 2023; McKinsey analysis.

The growth in the Philippine economy in 2023 was driven by a resumption in commercial activities, public infrastructure spending, and growth in digital financial services. Most sectors grew, with transportation and storage (13 percent), construction (9 percent), and financial services (9 percent), performing the best (Exhibit 2). 3 “National accounts,” Philippine Statistics Authority, January 31, 2024. While the country's trade deficit narrowed in 2023, it remains elevated at $52 billion due to slowing global demand and geopolitical uncertainties. 4 “Highlights of the Philippine export and import statistics,” Philippine Statistics Authority, January 28, 2024. Looking ahead to 2024, the current economic forecast for the Philippines projects a GDP growth of between 5 and 6 percent.

Inflation rates are expected to temper between 3.2 and 3.6 percent in 2024 after ending 2023 at 6.0 percent, above the 2.0 to 4.0 percent target range set by the government. 5 “Nomura downgrades Philippine 2024 growth forecast,” Nomura, September 11, 2023; “IMF raises Philippine growth rate forecast,” International Monetary Fund, July 16, 2023.

For the purposes of this article, most of the statistics used for our analysis have come from a common thread of sources. These include the Central Bank of the Philippines (Bangko Sentral ng Pilipinas); the Department of Energy Philippines; the IT and Business Process Association of the Philippines (IBPAP); and the Philippines Statistics Authority.

The state of the Philippine economy across seven major sectors and themes

In the article, we explore the 2024 outlook for seven key sectors and themes, what may affect each of them in the coming year, and what could potentially unlock continued growth.

Financial services

The recovery of the financial services sector appears on track as year-on-year growth rates stabilize. 6 Philippines Statistics Authority, November 2023; McKinsey in partnership with Oxford Economics, November 2023. In 2024, this sector will likely continue to grow, though at a slower pace of about 5 percent.

Financial inclusion and digitalization are contributing to growth in this sector in 2024, even if new challenges emerge. Various factors are expected to impact this sector:

  • Inclusive finance: Bangko Sentral ng Pilipinas continues to invest in financial inclusion initiatives. For example, basic deposit accounts (BDAs) reached $22 million in 2023 and banking penetration improved, with the proportion of adults with formal bank accounts increasing from 29 percent in 2019 to 56 percent in 2021. 7 “Financial inclusion dashboard: First quarter 2023,” Bangko Sentral ng Pilipinas, February 6, 2024.
  • Digital adoption: Digital channels are expected to continue to grow, with data showing that 60 percent of adults who have a mobile phone and internet access have done a digital financial transaction. 8 “Financial inclusion dashboard: First quarter 2023,” Bangko Sentral ng Pilipinas, February 6, 2024. Businesses in this sector, however, will need to remain vigilant in navigating cybersecurity and fraud risks.
  • Unsecured lending growth: Growth in unsecured lending is expected to continue, but at a slower pace than the past two to three years. For example, unsecured retail lending for the banking system alone grew by 27 percent annually from 2020 to 2022. 9 “Loan accounts: As of first quarter 2023,” Bangko Sentral ng Pilipinas, February 6, 2024; "Global banking pools,” McKinsey, November 2023. Businesses in this field are, however, expected to recalibrate their risk profiling models as segments with high nonperforming loans emerge.
  • High interest rates: Key interest rates are expected to decline in the second half of 2024, creating more accommodating borrowing conditions that could boost wholesale and corporate loans.

Supportive frameworks have a pivotal role to play in unlocking growth in this sector to meet the ever-increasing demand from the financially underserved. For example, financial literacy programs and easier-to-access accounts—such as BDAs—are some measures that can help widen market access to financial services. Continued efforts are being made to build an open finance framework that could serve the needs of the unbanked population, as well as a unified credit scoring mechanism to increase the ability of historically under-financed segments, such as small and medium-sized enterprises (SMEs), to access formal credit. 10 “BSP launches credit scoring model,” Bangko Sentral ng Pilipinas, April 26, 2023.

Energy and Power

The outlook for the energy sector seems positive, with the potential to grow by 7 percent in 2024 as the country focuses on renewable energy generation. 11 McKinsey analysis based on input from industry experts. Currently, stakeholders are focused on increasing energy security, particularly on importing liquefied natural gas (LNG) to meet power plants’ requirements as production in one of the country’s main sources of natural gas, the Malampaya gas field, declines. 12 Myrna M. Velasco, “Malampaya gas field prod’n declines steeply in 2021,” Manila Bulletin , July 9, 2022. High global inflation and the fact that the Philippines is a net fuel importer are impacting electricity prices and the build-out of planned renewable energy projects. Recent regulatory moves to remove foreign ownership limits on exploration, development, and utilization of renewable energy resources could possibly accelerate growth in the country’s energy and power sector. 13 “RA 11659,” Department of Energy Philippines, June 8, 2023.

Gas, renewables, and transmission are potential growth drivers for the sector. Upgrading power grids so that they become more flexible and better able to cope with the intermittent electricity supply that comes with renewables will be critical as the sector pivots toward renewable energy. A recent coal moratorium may position natural gas as a transition fuel—this could stimulate exploration and production investments for new, indigenous natural gas fields, gas pipeline infrastructure, and LNG import terminal projects. 14 Philippine energy plan 2020–2040, Department of Energy Philippines, June 10, 2022; Power development plan 2020–2040 , Department of Energy Philippines, 2021. The increasing momentum of green energy auctions could facilitate the development of renewables at scale, as the country targets 35 percent share of renewables by 2030. 15 Power development plan 2020–2040 , 2022.

Growth in the healthcare industry may slow to 2.8 percent in 2024, while pharmaceuticals manufacturing is expected to rebound with 5.2 percent growth in 2024. 16 McKinsey analysis in partnership with Oxford Economics.

Healthcare demand could grow, although the quality of care may be strained as the health worker shortage is projected to increase over the next five years. 17 McKinsey analysis. The supply-and-demand gap in nursing alone is forecast to reach a shortage of approximately 90,000 nurses by 2028. 18 McKinsey analysis. Another compounding factor straining healthcare is the higher than anticipated benefit utilization and rising healthcare costs, which, while helping to meet people's healthcare budgets, may continue to drive down profitability for health insurers.

Meanwhile, pharmaceutical companies are feeling varying effects of people becoming increasingly health conscious. Consumers are using more over the counter (OTC) medication and placing more beneficial value on organic health products, such as vitamins and supplements made from natural ingredients, which could impact demand for prescription drugs. 19 “Consumer health in the Philippines 2023,” Euromonitor, October 2023.

Businesses operating in this field may end up benefiting from universal healthcare policies. If initiatives are implemented that integrate healthcare systems, rationalize copayments, attract and retain talent, and incentivize investments, they could potentially help to strengthen healthcare provision and quality.

Businesses may also need to navigate an increasingly complex landscape of diverse health needs, digitization, and price controls. Digital and data transformations are being seen to facilitate improvements in healthcare delivery and access, with leading digital health apps getting more than one million downloads. 20 Google Play Store, September 27, 2023. Digitization may create an opportunity to develop healthcare ecosystems that unify touchpoints along the patient journey and provide offline-to-online care, as well as potentially realizing cost efficiencies.

Consumer and retail

Growth in the retail and wholesale trade and consumer goods sectors is projected to remain stable in 2024, at 4 percent and 5 percent, respectively.

Inflation, however, continues to put consumers under pressure. While inflation rates may fall—predicted to reach 4 percent in 2024—commodity prices may still remain elevated in the near term, a top concern for Filipinos. 21 “IMF raises Philippine growth forecast,” July 26, 2023; “Nomura downgrades Philippines 2024 growth forecast,” September 11, 2023. In response to challenging economic conditions, 92 percent of consumers have changed their shopping behaviors, and approximately 50 percent indicate that they are switching brands or retail providers in seek of promotions and better prices. 22 “Philippines consumer pulse survey, 2023,” McKinsey, November 2023.

Online shopping has become entrenched in Filipino consumers, as they find that they get access to a wider range of products, can compare prices more easily, and can shop with more convenience. For example, a McKinsey Philippines consumer sentiment survey in 2023 found that 80 percent of respondents, on average, use online and omnichannel to purchase footwear, toys, baby supplies, apparel, and accessories. To capture the opportunity that this shift in Filipino consumer preferences brings and to unlock growth in this sector, retail organizations could turn to omnichannel strategies to seamlessly integrate online and offline channels. Businesses may need to explore investments that increase resilience across the supply chain, alongside researching and developing new products that serve emerging consumer preferences, such as that for natural ingredients and sustainable sources.

Manufacturing

Manufacturing is a key contributor to the Philippine economy, contributing approximately 19 percent of GDP in 2022, employing about 7 percent of the country’s labor force, and growing in line with GDP at approximately 6 percent between 2023 and 2024. 23 McKinsey analysis based on input from industry experts.

Some changes could be seen in 2024 that might affect the sector moving forward. The focus toward building resilient supply chains and increasing self-sufficiency is growing. The Philippines also is likely to benefit from increasing regional trade, as well as the emerging trend of nearshoring or onshoring as countries seek to make their supply chains more resilient. With semiconductors driving approximately 45 percent of Philippine exports, the transfer of knowledge and technology, as well as the development of STEM capabilities, could help attract investments into the sector and increase the relevance of the country as a manufacturing hub. 24 McKinsey analysis based on input from industry experts.

To secure growth, public and private sector support could bolster investments in R&D and upskill the labor force. In addition, strategies to attract investment may be integral to the further development of supply chain infrastructure and manufacturing bases. Government programs to enable digital transformation and R&D, along with a strategic approach to upskilling the labor force, could help boost industry innovation in line with Industry 4.0 demand. 25 Industry 4.0 is also referred to as the Fourth Industrial Revolution. Priority products to which manufacturing industries could pivot include more complex, higher value chain electronic components in the semiconductor segment; generic OTC drugs and nature-based pharmaceuticals in the pharmaceutical sector; and, for green industries, products such as EVs, batteries, solar panels, and biomass production.

Information technology business process outsourcing

The information technology business process outsourcing (IT-BPO) sector is on track to reach its long-term targets, with $38 billion in forecast revenues in 2024. 26 Khriscielle Yalao, “WHF flexibility key to achieving growth targets—IBPAP,” Manila Bulletin , January 23, 2024. Emerging innovations in service delivery and work models are being observed, which could drive further growth in the sector.

The industry continues to outperform headcount and revenue targets, shaping its position as a country leader for employment and services. 27 McKinsey analysis based in input from industry experts. Demand from global companies for offshoring is expected to increase, due to cost containment strategies and preference for Philippine IT-BPO providers. New work setups continue to emerge, ranging from remote-first to office-first, which could translate to potential net benefits. These include a 10 to 30 percent increase in employee retention; a three- to four-hour reduction in commute times; an increase in enabled talent of 350,000; and a potential reduction in greenhouse gas emissions of 1.4 to 1.5 million tons of CO 2 per year. 28 McKinsey analysis based in input from industry experts. It is becoming increasingly more important that the IT-BPO sector adapts to new technologies as businesses begin to harness automation and generative AI (gen AI) to unlock productivity.

Talent and technology are clear areas where growth in this sector can be unlocked. The growing complexity of offshoring requirements necessitates building a proper talent hub to help bridge employee gaps and better match local talent to employers’ needs. Businesses in the industry could explore developing facilities and digital infrastructure to enable industry expansion outside the metros, especially in future “digital cities” nationwide. Introducing new service areas could capture latent demand from existing clients with evolving needs as well as unserved clients. BPO centers could explore the potential of offering higher-value services by cultivating technology-focused capabilities, such as using gen AI to unlock revenue, deliver sales excellence, and reduce general administrative costs.

Sustainability

The Philippines is considered to be the fourth most vulnerable country to climate change in the world as, due to its geographic location, the country has a higher risk of exposure to natural disasters, such as rising sea levels. 29 “The Philippines has been ranked the fourth most vulnerable country to climate change,” Global Climate Risk Index, January 2021. Approximately $3.2 billion, on average, in economic loss could occur annually because of natural disasters over the next five decades, translating to up to 7 to 8 percent of the country’s nominal GDP. 30 “The Philippines has been ranked the fourth most vulnerable country to climate change,” Global Climate Risk Index, January 2021.

The Philippines could capitalize on five green growth opportunities to operate in global value chains and catalyze growth for the nation:

  • Renewable energy: The country could aim to generate 50 percent of its energy from renewables by 2040, building on its high renewable energy potential and the declining cost of producing renewable energy.
  • Solar photovoltaic (PV) manufacturing: More than a twofold increase in annual output from 2023 to 2030 could be achieved, enabled by lower production costs.
  • Battery production: The Philippines could aim for a $1.5 billion domestic market by 2030, capitalizing on its vast nickel reserves (the second largest globally). 31 “MineSpans,” McKinsey, November 2023.
  • Electric mobility: Electric vehicles could account for 15 percent of the country’s vehicle sales by 2030 (from less than 1 percent currently), driven by incentives, local distribution, and charging infrastructure. 32 McKinsey analysis based on input from industry experts.
  • Nature-based solutions: The country’s largely untapped total abatement potential could reach up to 200 to 300 metric tons of CO 2 , enabled by its biodiversity and strong demand.

The Philippine economy: Three scenarios for growth

Having grown faster than other economies in Southeast Asia in 2023 to end the year with 5.6 percent growth, the Philippines can expect a similarly healthy growth outlook for 2024. Based on our analysis, there are three potential scenarios for the country’s growth. 33 McKinsey analysis in partnership with Oxford Economics.

Slower growth: The first scenario projects GDP growth of 4.8 percent if there are challenging conditions—such as declining trade and accelerated inflation—which could keep key policy rates high at about 6.5 percent and dampen private consumption, leading to slower long-term growth.

Soft landing: The second scenario projects GDP growth of 5.2 percent if inflation moderates and global conditions turn out to be largely favorable due to a stable investment environment and regional trade demand.

Accelerated growth: In the third scenario, GDP growth is projected to reach 6.1 percent if inflation slows and public policies accommodate aspects such as loosening key policy rates and offering incentive programs to boost productivity.

Focusing on factors that could unlock growth in its seven critical sectors and themes, while adapting to the macro-economic scenario that plays out, would allow the Philippines to materialize its growth potential in 2024 and take steps towards achieving longer-term, sustainable economic growth.

Jon Canto is a partner in McKinsey’s Manila office, where Frauke Renz is an associate partner, and Vicah Villanueva is a consultant.

The authors wish to thank Charlene Chua, Charlie del Rosario, Ryan delos Reyes, Debadrita Dhara, Evelyn C. Fong, Krzysztof Kwiatkowski, Frances Lee, Aaron Ong, and Liane Tan for their contributions to this article.

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Nearly 130,000 children exposed to lead-tainted drinking water in Chicago

Study says the 19% of kids using unfiltered tap water have about twice as much lead in their blood as they would otherwise

About 129,000 Chicago children under the age of six are exposed to poisonous lead in their household drinking water because of lead pipes, according to a study published on Monday.

The study used artificial intelligence to analyse 38,000 home water tests conducted for the city of Chicago, along with neighborhood demographics, state blood samples and numerous other factors.

It found that Black and Latino residents are more likely to have lead-contaminated water because of lead pipes. And it estimated that the 19% of Chicago children who use unfiltered tap water as their primary drinking source have about twice as much lead in their blood as they would otherwise.

“These findings indicate that childhood lead exposure is widespread in Chicago, and racial inequities are present in both testing rates and exposure levels,” said the study, published by the Johns Hopkins Bloomberg School of Health in Jama Pediatrics. “We estimated that more than two-thirds of children are exposed to lead-contaminated drinking water.”

The federal government has said that there is no safe level of lead in drinking water. Studies have shown that even small amounts of the highly poisonous metal can affect childhood brain development and contribute to preterm births, heart problems and kidney disease. Yet Chicago still has 400,000 homes served by potentially water-contaminating lead service lines – more than any other US city.

“I think residents have reason to be concerned,” said public health professor Benjamin Huynh, who authored the study with Elizabeth Chin and Mathew Kiang. “I think this should be a call to get your water tested for lead, see what the results are, then make your decisions accordingly.”

Huynh said the idea to conduct the research came after seeing the Guardian’s analysis of 24,000 city water tests, which found one-third of home water tests had more lead than the federal limit for bottled drinking water, which is 5 parts per billion (ppb).

The Johns Hopkins study used a more stringent measure, and flagged as concerning any home tests that detected more than 1ppb. Huynh said this was based on the fact that no level of lead consumption is considered safe and lead service lines can often create spikes in lead levels that go undetected, especially after they are disturbed by nearby construction. Similarly, the American Academy of Pediatrics has called for state and local governments to limit the lead in school drinking fountains to no more than 1ppb.

The US Environmental Protection Agency (EPA) has a municipal “action level” of 15ppb, meaning that cities are only required to notify the public when at least 10% of a small sample of homes tested are above that amount.

By this measure, Chicago is in compliance.

“Nothing is more important than the health and safety of Chicago’s residents and, particularly, our children,” city spokesperson Megan Vidis said in an emailed statement. “Chicago’s water continues to meet and exceed all standards set by the US Environmental Protection Agency.”

She said that “the city has introduced five programs to remove Chicago’s 400,000 lead service lines and offers free water testing to any resident”.

While the EPA is proposing to require most cities around the nation to remove all lead service lines within 10 years, it is giving Chicago 40 years to do so because of the large number of unreplaced pipes in the city.

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“If we’re looking at 40 more years of contaminated drinking water, what does that mean for the children?” Huynh said. “What can we do about that in the meantime?”

Chakena Perry, Chicago water advocate for the Natural Resources Defense Council, called for the city to distribute water filters to families with lead service lines and do everything possible to speed up the work to remove them.

“Clean drinking water is something that everyone deserves no matter their zip code or their life circumstances,” said Perry.

The city’s newly elected mayor, Brandon Johnson, has vowed to replace 40,000 lead lines by 2027.

But the study authors and other experts say this is not enough.

“With 400,000 lead service lines, Chicago officials need to be way more aggressive in protecting their children and the population in general,” said water safety engineer Elin Betanzo, who was one of the first to flag Flint’s lead water issues . “There’s really no reason for anybody to be drinking lead in their water.”

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  1. PDF Reading Difficulty and its Remediation: A Case Study

    elementary education onwards. In this respect, it is essential that the fundamental reasons for difficulties experienced in reading by children are determined and that suitable strategies are used. Reading is to derive sense from the text. So, the difficulty in reading comprehension is rooted in the lack of deriving sense from the text.

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  3. Helping children with reading difficulties: some things we ...

    Sixteen per cent of children struggle to learn to read to some extent, and 5% of children have significant, severe, and persistent problems. 2 The impact of these children's reading difficulties ...

  4. Full article: Children's reading difficulties, language, and

    The implication of this for children with reading difficulties is neatly captured by Stanovich's (Citation 1986) description of the Matthew effect—the richer get richer and the poor get poorer. Low levels of spoken language set the scene for reading difficulties, which in turn lead to greater differences in spoken language, relative to ...

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    Early case studies of reading difficulties identified their familial nature, which has been confirmed in numerous studies utilizing genetically-sensitive designs with various combinations of relatives—identical and fraternal twins, non-twin siblings, parent-offspring pairs and trios, and nuclear and extended families.

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    Additional support for pupils with reading difficulties - a case study. The importance of reading competence has been increasingly acknowledged in the Swedish educational system, not least through the demands for higher standards in reading in all subjects stated in the national curriculum. Still, in the school year 2018/19, approximately 7% ...

  13. PDF A Case Study of A Child With Special Need/Learning Difficulty

    The study has been conducted to investigate the levels and kind of difficulty the child/student is facing in learning things in or outside the classroom. It also examines the relationship between the school and home environment of the student with special needs who is facing difficulty in learning i.e. reading, writing listening or speaking.

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    In this study, it was aimed to remediate the reading difficulties of a fifth-grade student having no physical or mental problem but experiencing reading difficulties and to develop his skills of reading fluency. For this purpose, the repeated reading, paired reading, and word repetition techniques were used in the research process.

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    the study. Likewise, many techniques for tapping these sources have been found useful. Observations, interviews, home visits, and ex-aminations are a few of the numerous ones possible of successful use in the study. The case study method in understanding children can be applied to any type of school situation, but the small rural school is ...

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    We report a single-case intervention study of Alan, a child aged 10;04, who presented with spelling difficulty but good reading skills. Assessment of the potential cognitive functions underlying the spelling difficulty explored phonological abilities, visual memory and letter report. We also assessed print exposure and verbal memory.

  18. Exploring the phonological profiles of children with reading

    The current study extends this work by exploring individual differences in phonological ability using a multiple case study approach. A heterogeneous sample of 56 children (M age = 9 years) with reading difficulties completed a battery of tasks measuring literacy, phonological processing, expressive vocabulary and general ability.

  19. Exploring the phonological profiles of children with reading

    The multiple case study reported here addresses these issues by exploring individual differences in the phonological profiles of 56 children with reading impairments, focusing on the aspects of phonological processing that are most consistently associ-ated with reading difficulties (PA, PM and RAN: Wagner et al., 1987).

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    CASE STUDY A 10-year-old boy with learning disabilities and speech and language difficulties due to birth trauma These case studies, each submitted by a Certified HANDLE® Practitioner, demonstrate outcomes ... reading problems persisted. Sensation of the body in space, called propriocep-tion, is also supported by the vestibular system.

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    Study design. In this two-arm multi-center randomized controlled trial, parents of children who experience behavioral difficulties in the home setting and were referred to a child mental healthcare center, are randomly assigned (1:1 ratio) to either (a) three sessions of brief behavioral parent training with optional booster sessions, or (b) CAU, as regularly provided by the involved mental ...

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    Despite the challenges, there are ongoing efforts to improve support systems for families. The age of diagnosis for autism has been decreasing, while awareness and services available have been increasing (Montiel-Nava et al., 2020).Autistic children in Argentina are often offered psychodynamic therapy and have access to speech, occupational and behavioural therapy - although as children ...

  26. The Philippines economy in 2024

    The Philippines ended 2023 on a high note, being the fastest growing economy across Southeast Asia with a growth rate of 5.6 percent—just shy of the government's target of 6.0 to 7.0 percent. 1 "National accounts," Philippine Statistics Authority, January 31, 2024; "Philippine economic updates," Bangko Sentral ng Pilipinas, November 16, 2023. ...

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    Research design and participants. This case-control study was conducted in June 2022, with 3512 students from three primary schools in Shenzhen (846, 629, 612, 443, 551 and 431 students from grades 1 to 6, respectively) recruited through random cluster sampling for a questionnaire survey, myopia screening and ocular biometric parameters measurement.

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