Responsiveness To Intervention in Children With Dyslexia

DYSLEXIA

Published online in Wiley Online Library

(wileyonlinelibrary.com). DOI: 10.1002/dys.1533
■ Responsiveness to Intervention in
Children with Dyslexia
Elisabeth A. T. Tilanus1,2*, Eliane Segers1 and Ludo Verhoeven1
1
Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
2
Marant, Elst, The Netherlands

We examined the responsiveness to a 12-week phonics intervention in 54 s-grade Dutch

children with dyslexia, and compared their reading and spelling gains to a control group of
61 typical readers. The intervention aimed to train grapheme–phoneme correspondences
(GPCs), and word reading and spelling by using phonics instruction. We examined the
accuracy and efficiency of grapheme–phoneme correspondences, decoding words and
pseudowords, as well as the accuracy of spelling words before and after the intervention.
Moreover, responsiveness to intervention was examined by studying to what extent scores
at posttest could directly or indirectly be predicted from precursor measures. Results
showed that the children with dyslexia were significantly behind in all reading and spelling
measures at pretest. During the intervention, the children with dyslexia made more progress
on GPC, (pseudo)word decoding accuracy and efficiency, and spelling accuracy than the
typical reading group. Furthermore, we found a direct effect of the precursor measures rapid
automatized naming, verbal working memory and phoneme deletion on the dyslexic
children’s progress in GPC speed, and indirect effects of rapid automatized naming and
phoneme deletion on word and pseudoword efficiency and word decoding accuracy via
the scores at pretest. Copyright © 2016 John Wiley & Sons, Ltd.
Keywords: dyslexia; primary school; phonics intervention; precursor measures
Learning to read involves learning the alphabetic system and learning about
grapheme–phoneme correspondences (GPCs). To read accurately and fluently,
cognitive processes must be coordinated (National Institute of Child Health and
Human Development, 2000). Mastering and learning how to apply GPC rules is
crucial in learning to read and spell words. The most frequently used, and
uncontroversial effective teaching method for learning these GPCs takes a
declarative approach in explicitly teaching phonics (Devonshire, Morris, & Fluck,
2013; Galuschka, Ise, Krick, & Schulte-Körne, 2014). Phonics instruction
emphasizes the acquisition of GPCs in reading and spelling and aims to help
beginning readers to understand how graphemes are linked to phonemes
(National Reading Panel, US, National Institute of Child Health, and Human
Development, US, 2000, 2000). Systematic phonics instruction is beneficial for
*Correspondence to: Elisabeth A.T. Tilanus, Behavioural Science Institute, Radboud University; P.O. Box 9104,
6500 HE Nijmegen, The Netherlands. E-mail [email protected]
Elisabeth A.T. Tilanus, Eliane Segers, and Ludo Verhoeven, Behavioural Science Institute, Radboud University; P.O. Box 9104,
6500 HE Nijmegen, The Netherlands.E-mail addresses: [email protected], [email protected], [email protected]
Copyright © 2016 John Wiley & Sons, Ltd. DYSLEXIA 22: 214–232 (2016)
Responsiveness to Intervention 215
children regardless of their socio-economic status (McArthur et al., 2012;

National Institute of Child Health and Human Development, 2000) but has shown
to be extremely difficult for children with dyslexia (Lovett, Barron, & Benson,
2000). This can be explained from the fact that difficulties in reading and spelling
in both opaque and transparent orthographies are characterized by impairments
in cognitive processes such as phonological processing, verbal processing speed,
and verbal short term memories (Hachmann, Bogaerts, Szmalec, Woumans,
Duyck, & Job, 2014; Snowling, 2012). In the research so far, most attention has
been paid to phonics intervention effects. These were mainly examined on a
single general reading measure without investigating specific change in skills in
differential reading-related dimensions in outcome variables, such as accuracy
versus speed, GPC knowledge versus words, reading words versus pseudowords
or reading versus spelling. Moreover, the role of precursor measures has mostly
been ignored, leaving open the question of variation in responsiveness to
intervention.
It is widely accepted that in learning to read across orthographies, most
children proceed from a declarative (indirect, explicit, and conscious) decoding
strategy to a procedural (direct, automatic and implicit word recognition)
decoding strategy (Melby-Lervåg, Lyster, & Hulme, 2012; Thomson, Leong, &
Goswami, 2012; Ullman, 2001). Children start out learning the correspondences
between graphemes and phonemes in perspective of acquiring orthographic
representations (Ehri, 2014; Ziegler & Goswami, 2005). The transparency of an
orthography defines the difficulty of orthographic learning (Goswami, 2005;
Hulme & Snowling, 2013; Landerl et al., 2013; Moll et al., 2014), and the degree
to which explicit instructions are needed. Transparent orthographies are
characterized with consistent grapheme–phoneme correspondences (Goswami,
2005; Hulme & Snowling, 2013). For children with dyslexia, the transition from
declarative to procedural decoding processes is a difficult process (Lyon,
Shaywitz, & Shaywitz, 2003). This can be ascribed to poor phonological
awareness, poor rapid naming skills and/or a poor verbal working memory
(Brunswick, Martin, & Rippon, 2012; Johnson, Humphrey, Mellard, Woods, &
Swanson, 2010; Landerl et al., 2013; Tilanus, Segers, & Verhoeven, 2013; Wagner
& Torgesen, 1987). These arrears put the early acquisition of GPC rules and the
accurate and the efficient reading and spelling of words at risk (Elliott &
Grigorenko, 2014; Klicpera & Schabmann, 1993; Wimmer, 1993, 1996). Research
indeed evidenced that children with dyslexia show persistent problems in the
accuracy and speed of word reading and spelling (Devonshire, Morris, & Fluck,
2013; Moats, 2009; Watts & Gardner, 2013).
Snowling and Hulme (2011) reviewed the ingredients needed for successful
interventions for children with dyslexia. They concluded that interventions should
include training in letter sounds, phoneme awareness and linking graphemes and
phonemes through writing and reading from texts at the appropriate level to
reinforce emergent skills. Moreover, successful intervention programmes are
often systematic and well-structured, multi-sensory and they incorporate direct
teaching (Snowling, 2013). For example, a study by Chen and Savage (2014)
indeed showed that the explicit teaching of common complex grapheme-to-
phoneme correspondences improves reading in at-risk readers. Intensive, explicit
phonics instruction is generally seen as the most promising dyslexia intervention
(Watson & Jonston, 2005). In phonics instruction, children are taught to sound
216 E. A. T. Tilanus et al.
and blend sequences of GPCs to read (un)familiar words (de Graaff, Bosman,
Hasselman, & Verhoeven, 2009; Devonshire, Morris, & Fluck, 2013; McGeown
& Medford, 2014; National Institute of Child Health and Human Development,
2000). For example, McArthur, Eve, Jones, and colleagues, (2012) investigated
phonics training for English-speaking poor readers and evidenced a large effect
of phonics training for pseudoword reading accuracy. For word reading fluency
and word reading accuracy, they found a moderate effect. For pseudoword
reading fluency, spelling, letter-sound knowledge and phonological output minor
effects were found. Phonics-based instruction usually leads to superior reading
skills when compared with a non-phonics or non-systematic phonics approach.
This appears to be true for both opaque (Ehri, Nunes, Stahl, & Willows, 2001)
and transparent (de Graaff, Bosman, Hasselman, & Verhoeven, 2009) orthogra-
phies. Despite phonics instruction, a large number of children with dyslexia keep
struggling with word reading and spelling. The ongoing struggling may be due to
the fact that phonics instruction puts a high demand on children’s working
memory (Amtmann, Abbott, & Berninger, 2007; Berninger, Abbott, Nagy, &
Carlisle, 2010). In the research so far researchers evidenced the role of several
cognitive precursor measures in reading and spelling (Landerl et al., 2013; Moll,
Ramus, Bartling, et al., 2014), but the specific change in skills, taking precursor
measures into account, after a phonics intervention for children with dyslexia
has not been demonstrated yet.
In the present study, we investigated the change in skills after a 12-week
phonics intervention program on differential reading and spelling measures in
seven-year-old Dutch children with dyslexia and investigated the responsiveness
for children varying in precursor measures. Two research questions were
addressed in the present study:
(1) What are the changes in GPC accuracy and speed, word and pseudoword
decoding accuracy and efficiency and word spelling accuracy in Dutch children
with dyslexia after a 12-week phonics intervention, compared with a business-
as-usual control group of typical readers?
(2) How do precursor measures directly or indirectly via pretest predict posttest?
Given the fact that the Dutch orthography can be considered transparent, we
expected a substantial change in skills from pretest to posttest on accuracy and
speed of GPCs, as well as on the accuracy and efficiency of pseudoword decoding.
That means that our prediction was that this phonics intervention would help
children in bridging (part of) the gap with their typically reading peers in
declarative GPC knowledge and in applying such knowledge in procedural stages
of pseudoword reading. For decoding and spelling of real words, we expected the
children with dyslexia at least to keep up with their typically reading peers. With
regard to the second question, we investigated to what extent the responsiveness
to the intervention within the group of children with dyslexia would be different
for children varying in the precursor measures rapid automatized naming, verbal
working memory, phoneme manipulation and phoneme deletion. Given the close
relationship between phonological awareness and letter knowledge, we expected
a direct effect of phoneme deletion and manipulation on the growth in GPC
accuracy and speed, and only indirect effects of precursor measures on the
growth of word and pseudoword decoding and spelling skills.
METHOD
Participants
Participants were Dutch second graders with diagnosed developmental dyslexia,
who were referred to a clinic by their parents. In the year 2010, 122 s graders
were diagnosed with developmental dyslexia in this clinic. This group started
treatment throughout second and third grade. In order to have a homogeneous
group in the present study, we selected those children that received their first
treatment session halfway Grade 2. This group consisted of 54 children with
developmental dyslexia (33 boys, 21 girls) with Dutch as first language. Their age
ranged from 7 to 8 years old at pretest, and 45 children had repeated first grade.
All children met the formal criteria of dyslexia in accordance with the definition
of the Dutch Dyslexia Foundation (Stichting Dyslexie Nederland, 2008) and the
DSM-IV (American Psychiatric Association, 2001). According to this definition,
dyslexia is an impairment characterized by persistent problems in learning to read
and/or write words or in the automatization of reading and writing. The level of
reading and/or writing has to be significantly lower than what can expected based
on the educational level and age of the individual.
Out of the list of schools of the children with dyslexia, we randomly selected
one school to function as control group. The control group consisted of 61 typical
readers (36 boys, 25 girls) in second grade with an age between 6 and 8 years old
at pretest, and one child had repeated a class (first grade).
For measures of intelligence, the Wechsler Intelligence Scale for Children III,
Dutch edition (WISC-IIINL) (Kort et al., 1971) was used for children with dyslexia.
This comprehensive intelligence test belongs to the standard diagnostics of
dyslexia. All children with dyslexia in this study had an intelligence ≥85. To control
for intelligence in the typical reading group, we assessed the Raven’s coloured
progressive matrices (Raven, 1995). It would not have been feasible to test the
children of the control group both on dyslexia and intelligence individually by using
the WISC-IIINL during school time, as this would take 3.5 h per child. All children
in the control group showed a standardized average intelligence (M = 6.54,
SD = 2.59).
Reading and Spelling Measures
Grapheme phoneme correspondence

At pretest, GPC ability was examined by Letters Benoemen [letter naming]
(Struiksma, van der Leij, & Vieijra, 1997). In letter naming, the child is shown a card
with 36 graphemes. At posttest, GPC accuracy was examined by the
Grafementoets [grapheme test] (Verhoeven, 1993). In this test, 34 graphemes were
shown at a card. The digraphs /ng/ and /ch/ were excluded in this test. In both
tests, the child has to read the graphemes as accurately and fast as possible. The
accuracy score is the percentage of graphemes read correctly. In both tests,
GPC naming speed is the required reading time per grapheme (in seconds).
Decoding
For decoding ability, we measured both word decoding and pseudoword
decoding. Word decoding was assessed by the Brus Eén Minuut Test [1 min test]
(Brus & Voeten, 1973) in which decoding skills of printed, meaningful words is
measured. The test consists of two parallel test cards: form A and form B. Each
card consists of 116 spaced unconnected words, divided into 4 rows of 29 words.
The child was asked to read as many words of form A or B as possible in 1 min.
Pseudoword decoding was assessed with the Klepel [reading pseudowords] (van
den Bos, Lutje Spelberg, Scheepstra, & de Vries, 1994). The test is comparable
with the decoding test. Here, the child is asked to read as many words as possible
in 2 min. To make both decoding tests comparable, scores on the Brus Eén Minuut
Test were multiplied by two. For both tests, children received form A at pretest
and form B at posttest. For word and pseudoword decoding a distinction was
made in efficiency, calculated by the total number of read words minus the number
of errors, and accuracy, calculated by the percentage of read words correctly.
Spelling
PI-woorddictee [word dictation] (Geelhoed & Reitsma, 1999) is a test for the
investigation of the spelling skills in writing single words. The test consisted of
135 words and was divided into nine blocks. Each block consisted of 15 words.
The words were read aloud in a sentence, the child was asked to write down
the repeated word. The test was discontinued when a child had at least eight
words written incorrectly. The score used for analysis is the total number of
written words correctly. At pretest, children received form A; at posttest, they
received form B.
Precursor Measures
Rapid automatized naming
Rapid automatized naming was measured by a subtask of Continu Benoemen &
Woorden Lezen (CB&WL) [continuous naming and reading words] (van den Bos
& Lutje Spelberg, 2007). Cijfers Benoemen [naming digits] measures the speed of
naming visual presented stimuli. The child is presented with a card with five rows
of digits. A set of five digits is repeated in random order. The child has to name as
fast as possible all digits. The time (in seconds) needed to read all digits was used
for analysis
Verbal working memory

Verbal working memory was measured using the digit span task from the WISC-
IIINL (Kort, et al., 2005). The test consisted of two parts. First, children were asked
to repeat an auditory set of digits, starting with two items with two digits, and
increasing to a maximum of nine digits. In the first part of the test, the child was
asked to repeat the digits in the same order. In the second part, they were asked
to name the digits in the reversed order. The raw score is converted into a
standardized score, which was used for analysis.
Phonological Awareness
Phonological awareness was measured by two tests of DSTNL: Letterverwisseling
[phoneme manipulation] and Klanksplitsing [phoneme deletion] (Kort et al.,
2005). In phoneme manipulation, the child was asked to change the initials of
two words (e.g., changing the first sounds of Michael Jackson makes Jichael
Mackson). The number of full correct transitions of the words was used for
analysis (maximum score is 11). In phoneme deletion, a child was asked to
produce the word that remained when a particular sound or syllable was omitted.
In the first item, a syllable had to be omitted; in the final 11 items, a sound had to be
omitted. The maximum score on this task is 12. These tests could only be
interpreted in terms of accuracy. To make the tests comparable, scores were
divided by the total number of test items and multiplied by 10.
Procedure and Intervention
Both groups were tested twice. Pretesting was performed between August and
December. Between January and March, the phonics intervention started for the
children with dyslexia. The intervention was conducted by 32 certified
MSc-graduated clinicians, at one clinic, who all completed an elaborate training
at the clinic in order to deliver the intervention program. The training included
a session with a child that was videotaped and evaluated afterwards. This was
supervised by a certified clinical psychologist. The continuity of quality was guaran-
teed by four training sessions a year. Each child worked with one clinician
throughout the intervention. The typical reading group did not receive the
intervention and followed regular education. After 12 weeks, all children received
the posttest, consisting of the GPC, decoding and spelling tests again.
This intervention is based on the standardized Dutch Protocol Dyslexia
Diagnostics and Treatment (Blomert, 2006). The main goal is to achieve a
functional level of technical reading and spelling. The present intervention used
the same steps as in regular phonics intervention but adds symbolic scaffolds.
Symbolic scaffolds were added to simplify the structure of GPCs and to help the
child to read and spell the word adequately and to check their pronunciation
and spelling.
Even though Dutch is a transparent orthography, there are rules and
exceptions that have to be learned to be able to read polysyllabic words. A good
foundation is necessary to build this knowledge on. During the phonics
intervention, we therefore primarily focused on reading and spelling monosyllabic
words to make sure the GPCs in words can be read and written accurately by
using symbolic scaffolds. A next step would be to extend the intervention with
polysyllabic words.
The phonics intervention program in the present study consisted of a period of
12 weeks. Each week, the child had a 45 min session with a clinician. Each session
was characterized by a strong interactive process between the clinician and the
child. All sessions were built up the same way. In the first 5 min, the child and
the clinician retrieved knowledge of the previous session: what did we learn and
what characterized the learned GPC, what was difficult and where do we need
to focus on? In the next 10 min, a new GPC was introduced by the clinician in
an interactive way, building on previous knowledge and explaining what is new
and special of the presented GPC. Each new GPC was presented on a mnemonic
card. For example, the grapheme /eu/ was presented on a mnemonic card on
which a ‘reus’ [giant] is drawn. In the ‘neus’ [nose] of the ‘reus’ [giant], the /eu/
is placed as a mnemonic. After this focus on GPC, the next phase in each session
was on reading and spelling words.
First, guided exercise took place (10 min), using a mnemonic card on which five
steps are described ((1) repetition of the auditory offered word; (2) splitting the
word into phonemes; (3) linking a symbolic scaffold to each phoneme and write
each symbolic scaffold on the paper; (4) Writing the accurate graphemes below
each symbolic scaffold; (5) Check the mapping between the phoneme, the
symbolic scaffold and the written grapheme). During this guided exercise, the child
learned to spell the specific GPC in words and learned to read the written words.
For example, before writing the word ‘boom’ [tree], the first step is to repeat this
word as it is read by the clinician, followed by dividing the word into phonemes /b/
/oo/ /m/. Next, for each phoneme, the grapheme is visualized in symbolic scaffolds
(in this case: < ___ <) and written down as ‘b’ ‘oo’ ‘m’. Finally, a conscious check
takes place by verifying the correspondence between the graphemes and the sym-
bolic scaffolds (is the homogeneous digraph, which sounds long, also represented
as a long visualized symbolic scaffold). The child learns to recognize differences
between ‘boom’ [tree] and ‘bom’ [bomb] by using these symbolic scaffolds.
After this guided exercise, the accent shifted from spelling words to reading by
naming graphemes and/or words using flashcards (5 min). Each week, a maximum
of 15 word flashcards were presented or all grapheme flashcards; depending on
the level of the child. Each flashcard represents a grapheme or a word. Children
were asked to name as accurately, and later as quickly as possible, each represen-
tation. Guided exercise (clinician reads out aloud, reading aloud together, child
reads aloud) took place to practice the graphemes or words on the flashcards.
The focus was primarily on the recognition of the structure of the words and/or
on the characteristics of graphemes that has to be learned.
In the final stage of the treatment session, the child and the clinician read a text
by using a reading strategy (repeated reading, modelling, phrase drill error, success
experiences) (15 min). In this stage, the focus was on reading both monosyllabic
and polysyllabic words. The texts were chosen by the clinician to make sure that
the child read at an appropriate text level including words with graphemes of the
present and previous week. Depending on the success of the child during the
treatment, the clinician decided how much help is offered to the child to read
the text, for example, by highlighting some (monosyllabic) words or by clarifying
the structure of the word by placing symbolic scaffolds.
During the intervention, different mnemonic cards were used. The mnemonic
card with the sound schedule (Figure 1) was introduced at the first treatment
session. In this session, children learn that the Dutch alphabet consists of 26 letters
and that a combination of these letters is associated with phonemes. Next,
children learn to categorize, as they (often) already learned at school. For
example, children learn that the phonemes /aa/, /ee/, /oo/ and /uu/ sound long
and therefore are called long vowels. The phonemes /a/, /e/, /i/, /o/ and /u/ sound
short and are called short vowels. In the second session, the main goal was to
introduce the symbolic scaffolds. In this session, children learn to link meaningful
symbolic scaffolds to each category. The addition of the symbolic scaffolds
simplifies the complexity of Dutch GPC categories.
Data of every treatment session was weekly documented in an online database,
which was evaluated by the team of responsible certified psychologists, and
feedback was given to the clinicians executing the intervention. The continuity
of the intervention was ensured by home and school exercises each week. Parents
and teachers were expected to practice with the child four times a week during
Figure 1. Sound schedule (visual mnemonics for orthographic units): Categorization and symbolic
scaffolding of Dutch grapheme–phoneme correspondences (GPCs).
20 min on reading and two times a week 10 min on spelling (i.e. a total of 100 min
per week). Parents and teachers were informed by special parent-written manuals
and explanations for each exercise. Parents and teachers informed the clinician
weekly by describing the progress of the home exercises in online logbooks. If
the home exercises were not performed, the intervention could be ended directly
in order to be ensured of the continuity and fidelity of the intervention. This was
not the case in the present study.
RESULTS
Before evaluating the change in skills after the intervention (pretest versus
posttest scores), we first compared the children with dyslexia with the typical
reading group at pretest. Differences in precursor measures, GPC, decoding and
spelling skills between typical readers and children with dyslexia were investigated
with independent samples two-tailed t-tests. As presented in Table 1, indeed all
children with dyslexia were behind typical readers on all measures at pretest
(p < .01) with large effect sizes, with the exception of phoneme deletion
(p = .130). All children with dyslexia were also behind typical readers on
Table 1. Descriptive statistics on precursor measures, GPC, decoding and spelling for typical readers
and children with dyslexia
Typical Readers Children with dyslexia
n M (SD) n M (SD) t d
Precursor Measures
Rapid automatized naming Digits 61 35.75 (7.07) 53 42.51 (11.80) 3.64*** 0.70
Verbal working memory Repeating digits 61 9.97 (2.70) 53 7.57 (2.41) 4.96*** 0.94
Phonological awareness Phoneme 61 2.92 (3.39) 53 0.63 (1.54) 4.73*** 0.87
manipulation
Phoneme deletion 61 6.23 (2.42) 54 5.56 (2.30) 1.53
GPC accuracy
Pretest Letter naming 61 96.58 (5.28) 54 92.90 (5.85) 3.55** 0.67
Posttest Letter naming 58 97.21 (3.55) 49 98.98 (2.13) 3.18** 0.65
GPC speed
Pretest Letter naming 61 1.00 (0.29) 34 1.33 (0.50) 3.52** 1.03
Posttest Letter naming 58 0.97 (0.22) 48 0.82 (0.23) 3.41** 0.67
Decoding accuracy
Pretest Words 61 88.90 (11.03) 52 79.92 (14.06) 3.80** 0.72
Pseudowords 61 59.17 (16.60) 54 47.46 (17.02) 3.40** 0.64
Posttest Words 58 91.48 (8.05) 51 85.55 (9.12) 3.61** 0.70
Pseudowords 58 58.24 (17.55) 51 57.96 (15.46) 0.09
Decoding efficiency
Pretest Words 61 71.87 (34.31) 54 33.52 (15.67) 7.85** 1.63
Pseudowords 61 29.44 (17.11) 54 12.13 (6.10) 7.39** 1.69
Posttest Words 58 84.48 (29.35) 52 46.12 (22.72) 7.71** 1.50
Pseudowords 58 30.81 (14.50) 52 17.33 (9.64) 5.80** 1.16
Spelling
Pretest Word dictation 61 32.70 (19.10) 54 23.57 (12.02) 3.11** 0.61
Posttest Word dictation 58 47.28 (19.87) 51 42.24 (11.68) 1.64
*p < .05
**p < .01
***p < .001
GPC, grapheme-phoneme correspondence.
respectively GPC, decoding and spelling. For each measure, Table 1 presents
descriptive statistics at pretest and at posttest. Precursor measures were only
tested once, at pretest.
Next, we investigated the change in skills after the intervention by conducting
several general linear model repeated measure analyses, taking the multivariate
approach, exploring differences between typical readers and children with dyslexia
over time on GPCs accuracy and speed, decoding (efficiency and accuracy, words
and pseudowords) and spelling. Group (typical readers versus children with
dyslexia) was the between subjects factor each time. Results of these repeated
measures are presented in Table 2. For each measure (GPC, decoding and
spelling), results are further explored when there were significant interactions.
Change in Skills on GPCs

In accordance with Table 2, we investigated the change in skills on GPCs and used
Time (pretest versus posttest) and Test (GPC accuracy versus GPC speed) as
within subjects factor. We found main effects of Time and Test. There was no
main effect of Group. We found interactions between Time*Group, Test*Group,
and Time*Test. Also a Time*Test*Group interaction effect was found. To further
disentangle the Time*Test*Group interaction, we conducted separate analyses for
Table 2. Results of the GLM Repeated Measure analyses exploring differences between typical
readers and children with dyslexia over time on GPC, decoding and spelling
F(df) p η2p
GPC Time 40.41 (1,88) <.001 .32
Test 97009.38 (1,88) <.001 .10
Group 1.69 (1,88) .20 .02
Time*Group 25.76 (1,88) <.001 .23
Test*Group 5.66 (1,88) .02 .06
Time*Test 8.92 (1,88) .004 .09
Time*Test*Group 49.98 (1,88) <.001 .36
GPC accuracy Time 33.49 (1,105) <.001 .24
Group 4.09 (1,105) .05 .04
Time*Group 32.35 (1,105) <.001 .24
GPC speed Time 36.36 (1,88) <.001 .29
Group 5.75 (1,88) .02 .06
Time*Group 33.62 (1,88) <.001 .28
Decoding Time 62.38 (1,105) <.001 .73
Test 563.44 (1,105) <.001 .84
Word 1718.95 (1,105) <.001 .94
Group 45.00 (1,105) <.001 .30
Time*Group 10.41 (1,105) <.001 .09
Test*Group 68.46 (1,105) <.001 .40
Word*Group 62.90 (1,105) <.001 .38
Time*Test 5.45 (1,105) .021 .05
Time*Word 10.77 (1,105) .001 .09
Test*Word 7.09 (1,105) .009 .06
Time*Test*Word 40.28 (1,105) <.001 .28
Test*Word*Group 36.59 (1,105) .000 .26
Time*Word*Group 7.57 (1,105) .007 .07
Time*Test*Group 7.55 (1,105) .007 .07
Time*Test*Word*Group 2.69 (1,105) .104 .03
Word decoding accuracy Time 15.41 (1,105) <.001 .13
Group 19.40 (1,105) <.001 .16
Time*Group 2.81 (1,105) .097 .03
Pseudo word decoding accuracy Time 11.55 (1,107) .001 .10
Group 5.03 (1,107) .027 .05
Time*Group 14.13 (1,107) <.001 .12
Word decoding efficiency Time 103.29 (1,108) <.001 .49
Group 62.16 (1,108) <.001 .37
Time*Group 0.13 (1,108) .719 .00
Pseudo word decoding efficiency Time 28.03 (1,108) <.001 .21
Group 44.93 (1,108) <.001 .29
Time*Group 11.18 (1,108) .001 .09
Spelling Time 234.46 (1,107) <.001 .69
Group 6.50 (1,107) .012 .06
Time*Group 4.54 (1,107) .04 .04
GPC, grapheme-phoneme correspondence.
GPC accuracy and GPC speed, with Time (pretest versus posttest) as the within
subjects factor.
For GPC accuracy, we found main effects of Time, and Group, as well as an
interaction between Time*Group. At pretest, the typical readers outperformed
the children with dyslexia t(113) = 3.55, p = .001, d = 0.67, at posttest, this
effect was reversed, with the children with dyslexia having higher scores than the
typical readers, t(95.35) = 3.18, p = .002, d = 0.65. The children with dyslexia
showed a significant growth t(48) = 6.57, p < .001, d = 1.90, the typical readers
did not (p = .95).
For GPC speed, a similar pattern emerged. We found main effects of Time, and
Group, as well as an interaction between Time*Group. Children with dyslexia
were behind typical readers in GPC speed at pretest t(46.47) = 3.52, p = .001,
d = 1.03, but faster in naming GPCs at posttest t(104) = 3.41, p = .001, d = 0.67.
Figure 2(a) and 2(b) illustrate these findings.
Figure 2. Mean scores of GPC accuracy (a) and speed (b), pseudoword decoding accuracy (c), effi-
ciency (d) and spelling (e) for children with dyslexia and typical readers.
Change in Skills on Decoding
To investigate the change in skills after the intervention on decoding skills, we used
Time (pretest vs posttest), Test (accuracy vs efficiency) and Word (words vs
pseudowords) as within subjects factors. We found main effects of Time, Test,
Word and Group. Also, interactions between Time*Group, Test*Group and
Word*Group were found. Interactions were also found for Time*Test,
Time*Word, Test*Word, Time*Test*Word, Test*Word*Group,
Time*Word*Group and Time*Test*Group. There was no interaction effect
between Time*Test*Word*Group. To further disentangle the Time*Test*Word
and Time*Test*Group interaction, we conducted separate analyses for word
and pseudoword decoding accuracy and efficiency.
For word decoding accuracy, we found main effects for Time and Group. There
was no interaction between Time*Group; both groups showed similar
progression. Next, for pseudoword decoding accuracy, we found main effects of
Time and Group, as well as an interaction between Time*Group. The interaction
in pseudoword decoding accuracy could be explained by the progression of
children with dyslexia, t(89.223) = 3.68, p < .001, d = 0.78). Typical readers did
not show a significant progression (p = .752). In other words, the children with
dyslexia were catching up.
For word decoding efficiency, we found main effects of Time and Group. There
was no interaction between Time*Group. For pseudoword decoding efficiency,
we found main effects of Time and Group, as well as an interaction between
Time*Group. Differences in progression between both groups were significant
t(107.82) = 3.36, p = .001, d = 0.65, in advantage for children with dyslexia.
For pseudoword decoding accuracy and efficiency interesting results were
found. Figure 2(c) and (d) illustrate the interaction effects.
Change in Skills on Spelling
Finally, for spelling, we found main effects of Time and Group and an interaction
between Time*Group. Children with dyslexia were behind typical readers at
pretest t(102.51) = 3.11, p = .002, d = 0.61. At posttest, the two groups did
not differ anymore (p = .105). Figure 2(e) illustrates this finding.
Responsiveness to Intervention
With respect to the second research question, we investigated the responsiveness
to intervention within the group of children with dyslexia. We investigated how
precursor measures directly and indirectly via pretest predicted posttest. We
used the Process add-on in SPSS (Hayes, 2013), and performed mediation analyses.
The precursors rapid automatized naming, verbal working memory, phoneme
manipulation and phoneme deletion were the independent variables, the pretest
score on GPC accuracy and speed, word and pseudoword decoding accuracy
and efficiency and spelling accuracy was the mediator each time, and the posttest
score on these measures was the dependent variable, respectively. Class repeating
was added as covariate. Each model was run five times, with four independent
variables as covariate, to be able to estimate the effects. Bootstrapping was set
at 5000 cycles, as recommended by Hayes (2013). In mediation models, the total
effect of an independent variable on the dependent variable is the addition of the

direct effect and the indirect effect. The indirect effect is the product of the effect
of the independent variable on the mediator and the effect of the mediator on the
dependent variable. An indirect effect a and b may be significant, even when a or b
in itself are not (Hayes, 2013).
The R2 of the models was .07n.s. for GPC accuracy, .50* for GPC speed, .29* for
word decoding accuracy, .68*** for word decoding efficiency, .08n.s for pseudoword
decoding accuracy, .65*** for pseudoword decoding efficiency and .39** for spelling.
Figure 3 depicts the models with a significant total R2. For word and pseudoword
Figure 3. Model for the prediction of the precursor measures rapid automatized naming (RAN), ver-
bal working memory (VWM), phoneme manipulation (PM) and phoneme deletion (PD) on posttest
scores on (a) GPC speed, (b) word decoding accuracy, (c) word decoding efficiency, (d) pseudoword
decoding efficiency and (e) spelling. Significant coefficients are reported.
decoding efficiency and word decoding accuracy, rapid automatized naming and
phoneme deletion impacted posttest indirectly via pretest. Indirect effects of
precursor measures were also found for spelling. Only for GPC speed direct effects
of precursor measures were found. All precursor measures (rapid automatized
naming, verbal working memory, phoneme deletion and phoneme manipulation)
impacted posttest outcomes directly.
DISCUSSION
The main goal of the present study was to compare change in skills of children
with dyslexia after a phonics intervention to a typical reading control group and
to investigate variation in responsiveness to intervention in the children with
dyslexia. The change in skills after the intervention was investigated by
distinguishing these changes on both accuracy and speed of GPCs, accuracy and
efficiency of word and pseudoword decoding and accuracy of spelling. The
responsiveness to intervention was examined by taking into account the dyslexic
children’s variation in rapid automatized naming, verbal working memory,
phoneme manipulation and phoneme deletion by the start of the intervention.
In light of the first research question in this study, “what are the changes in GPC
accuracy and speed, word and pseudoword decoding accuracy and efficiency and
word spelling accuracy in Dutch children with dyslexia after a 12-week phonics
intervention, compared to a business-as-usual control group of typical readers?”,
we found, as expected, positive changes in skills after the intervention on both
GPC accuracy and speed. In the present study, the children with dyslexia scored
even higher on GPC accuracy and speed than the typical group at posttest. Suggate
(2010) suggested that phonics interventions are particularly effective for GPC
learning in the early stages of reading acquisition. However, it is interesting to note
that the group of children with dyslexia in our study even outperformed their
typically reading peers, which could possibly be explained by the reduce of the
overload on children’s verbal working memory by simplifying the complexity of
Dutch GPCs, and the heavy focus on both accuracy and speed of GPC during
the intervention.
Second, we evidenced increased accuracy and efficiency for both word and
pseudoword reading. For pseudoword reading accuracy and efficiency, the
children with dyslexia showed more progress than the typical readers during the
12 week intervention period. For accuracy, this is not an unexpected finding,
because the emphasis of the intervention is on the indirect, declarative route of
reading. More interestingly, children with dyslexia also showed more progression
on pseudoword reading efficiency. Moreover, we found that the children with
dyslexia showed equal progression in accuracy and efficiency of word decoding,
showing that the change in skills after the intervention for children with dyslexia
was similar as for their typically reading peers. Differences in our findings between
words and pseudowords can be interpreted in terms of differential reading
problems children may be confronted with as predicted from the dual-route
model (Coltheart, Rastle, Perry, Langdon, & Ziegler, 2001; Castles, 2006).
According to this model, reading problems can be attributed to problems in the
application of grapheme–phoneme converting rules in pseudoword decoding, on
the one hand, and in the activating frequently encountered written words from
the mental lexicon, on the other hand. The first type of problems may refer to a
deficit in assembling phonology associated with the indirect route of word
identification; the second type to problems with addressed phonology associated
with the direct route of word identification. The present study makes clear that
children with dyslexia are able to show greater change in skills compared with
typically reading peers in acquiring GPC knowledge and in spelling and can keep
up with typical readers in developing lexical representations (cf. Ullman, 2001).
The increased GPC knowledge seems to enable children with dyslexia to
accurately and fast decode constituent graphemes in pseudowords. No longer
the word is read aloud letter by letter. For example, the pseudoword ‘taaf’ is no
longer read aloud as /t/ /a/ /a/ /f/ but is recognized as < ___ <, (/t/ /aa/ /f/) by using
meaningful symbolic scaffolds. Instead of naming four letters, only three GPCs
have to be decoded, resulting in more efficient reading. Accordingly, the teaching
of common complex grapheme-to-phoneme correspondence rules appears to
improve the indirect route of decoding that forms the basis of efficient visual word
identification (Chen & Savage, 2014).
The final research question addressed “How do precursor measures directly or
indirectly via pretest predict posttest?”. Only for GPC speed, we found an impact
(direct effect) of precursor measures on posttest. In line with the study of Moll,
Ramus, Bartling, and colleagues (2014) who evidenced rapid automatized naming
as the best predictor of reading speed, rapid automatized naming, verbal working
memory and phoneme deletion turned out to significantly predict the progress in
GPC speed. Apparently, the progress in GPC speed can be seen as at least partly
dependent on children’s prior abilities. For all other measures, the precursor
measures had no direct influence on intervention outcomes. Rapid automatized
naming and phoneme deletion did indirectly predict posttest scores on the
efficiency of word and pseudoword reading, as well as the accuracy of word
reading. We had expected that verbal working memory and phoneme
manipulation would show a similar effect, but we now speculate that the
intervention was such that the load on children’s working memory was reduced,
and the generally low scores of the children with dyslexia at pretest on phoneme
manipulation would probably explain that phoneme manipulation did not predict
the posttest.
The present findings show that our phonics intervention may help children to
reduce reading and spelling problems in the early stage of acquisition. This
statement should be taken with caution though, as we did not have a control
group of children with dyslexia who did not receive an intervention. However,
it is interesting to note that within this 12-week period, the children who received
the intervention not only showed better declarative knowledge of GPC rules but
also in greater ability in procedural decoding strategies than a typical reading con-
trol group. Structures of words can quickly be recognized by the use of symbolic
scaffolds. In this way, the complexity of the language is reduced leading to less load
in order memory. This is in line with existing literature in which language learning
is primarily seen as a statistical process. If language is regarded as a well-structured
environment, the learning draws on the general cognitive ability to perceive and
identify systematic structures (Frost, 2012a, 2012b). Proficient readers implicitly
develop differential sensitivities to the statistical properties of their own language
(Plaut & Gonnerman, 2000). For children with dyslexia, this is not a seamless
process. The phonics intervention enables children to oversee structures in words
and pseudowords easier, which may explain the positive changes in skills over time
after the present intervention.
A limitation of the present study could be whether class repeating influenced
our results. We therefore added class repeating as covariate. For word decoding
efficiency and accuracy as well as on GPC speed, class repeating showed an
indirect effect on posttest. This indicates that children who had repeated a class
had higher scores at pretest and as a result also higher scores at posttest. Other
limitations in the present study were the lack of a second control group, in which
children with dyslexia who did not receive the intervention are included and the
fact that we could not control for socio-economic status of the children. It should
be noted though that the distribution of socio-economic status in the Netherlands
in children with or without dyslexia is highly comparable (van Bergen, de Jong,
Regtvoort, Oort, van Otterloo, & van der Leij, 2011). An important question that
remains is what the long-term perspective of the present phonics intervention
looks like. Tops, Callens, Lammertyn, van Hees, and Brysbaert (2012) found that
adult Dutch dyslexics were not capable to compensate entirely for their
phonological deficit and that their reading and spelling tended to remain deficient
in adulthood. However, no attempt has been made yet to examine sustained
phonics intervention effects over time.
A final relevant issue is to what extent the changes in skills of the present study
can be generalized to children with dyslexia reading other orthographies. This
question could not be addressed in the present analysis and needs to be addressed
by further research. The changes in skills in the present intervention are based on
Dutch children. The transparency of this orthography limits the generalization of
the effects of the intervention into other orthographies (Ehri, 2014; Ziegler &
Goswami, 2005; Hulme & Snowling, 2013). GPC learning in an opaque
orthography is much more complicated, and some argued that early grapheme–
phoneme-based phonics programmes cannot be very effective in English
(Dombey, 2006). However, Johnston, McGeown, and Watson (2012) argued that
despite English being an opaque orthography, children are not impaired when
taught by an approach to reading that is common to transparent orthographies.
As a case in point, Chen and Savage (2014) found that the application of a
simplicity principle in English phonics instruction may help children in acquiring
grapheme-to-phoneme conversion rules and in applying such rules in elementary
word reading. Therefore, it is interesting to find out to what extent such a phonics
intervention in non-transparent orthographies show the same results as in Dutch.
The present study examined the responsiveness to intervention and showed
that in Dutch children with dyslexia, the use of our phonics intervention ensures
that children become more capable in acquiring basic GPC rules and in applying
these rules in word decoding. They reached an acceptable level of reading
accuracy and improved their reading speed, although their speed of reading still
remained slow. This finding is in line with the observation that in transparent
languages, the main reading difficulty tends to centre around reading fluency rather
than accurate word reading (Elliott & Grigorenko, 2014). It is also fully
commensurate with the view of Wolf, Miller, and Donnelly (2000) in which is
stated that explicit training of accuracy preceded the training of speed for each
component process to achieve the ultimate goal of fluent reading. It should be
noted that the present intervention puts a high demand on follow-up steps to
be taken in practice. After the phonics intervention, treatment should focus on
the transition to fluency by stimulation the direct word recognition using repeated
exposure to invoke implicit learning. For teachers and clinicians, these findings
imply that after the phonics intervention, remediation of children with dyslexia
should also include frequent exposure of texts in order to be able to reduce their
arrears. Encouraging children’s motivation to read precedes this all (Chen &
Savage, 2014).
In the present study, we attempted to provide insight in the variation in
responsiveness to a phonics intervention and to increase the knowledge about a
successful intervention program for children with dyslexia who were still
struggling after regular intervention in their schools. Substantial changes in skills
were found on accuracy and speed of GPC rules, accuracy and efficiency of
pseudowords and accuracy of word spelling. For word decoding, the children with
dyslexia were found to keep up with typical readers. This study thus shows that
Dutch children with dyslexia improve their declarative knowledge, by internalizing
GPCs as well as improve their procedural knowledge by applying this knowledge
in word decoding. The change in (pseudo)word reading skills after the
intervention were not directly influenced by pretest precursor measures, showing
the approach to work for the group as a whole.
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DYSLEXIA

Published online in Wiley Online Library

We examined the responsiveness to a 12-week phonics intervention in 54 s-grade Dutch

Keywords: dyslexia; primary school; phonics intervention; precursor measures

children regardless of their socio-economic status (McArthur et al., 2012;

Reading and Spelling Measures

Grapheme phoneme correspondence

Verbal working memory

Procedure and Intervention

Change in Skills on GPCs

GPC, grapheme-phoneme correspondence.

Change in Skills on Decoding

Change in Skills on Spelling

effect of an independent variable on the dependent variable is the addition of the

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