Pavan Madan, MD and Fagie Mandel, MEdDr. Madan and Ms. Mandel have disclosed that they have no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Families of children who struggle with reading often ask child psychiatrists for insight into reading intervention programs. These programs are usually heavily marketed with neuropsychological terms as well as testimonials from families and educators. Many reading intervention programs are expensive, and all are time-consuming, so it is important to understand the elements they involve.
Principles of reading remediation Before delving into individual programs, let’s spend a few minutes reviewing some of the basics. According to the National Reading Panel, led by the National Institute of Child Health and Human Development, reading instruction must include five components to be effective: phonemic awareness (orally identifying the individual sounds that comprise spoken words), decoding (word-level reading that is dependent on understanding the correspondence between letters and sounds), fluency, vocabulary, and text comprehension (www.tinyurl.com/qudjo9l).
Reading occurs on a developmental continuum. That means physical brain development and neurological maturation is required for a child to be able to read; this usually occurs between 5 and 7.5 years of age. For many children, their natural brain development will activate reading acquisition in an environment of literacy instruction. However, this is not the case for all children. It’s often unclear whether early reading difficulties are due to latent development or an underlying disability that requires intensive instruction to overcome.
As with all remediation, early reading intervention is important in order to reduce reinforcement of incorrect practice. The conventional recommendation is for reading intervention to start prior to the end of third grade, because most school systems cease to teach decoding in a systematic manner after that point. However, it is never too late to learn how to read; the International Dyslexia Association (www.dyslexiaida.org) maintains that children and adults of all ages can do so when provided with multisensory, structured instruction.
Given this background, we review several commonly used programs—Arrowsmith, Fast ForWord, Lindamood-Bell, and Orton-Gillingham—and discuss how to evaluate the research claims associated with them.
Arrowsmith Arrowsmith (www.arrowsmithschool.org) is an alternative education program provided through participating schools worldwide, at a cost of about $8000 per child per year. It is designed to be implemented 4 periods a day, 5 days a week, for 3 to 4 years. Teachers must attend 3 weeks of training prior to implementing the program. Though its specific methodologies are not disclosed, Arrowsmith claims to build learning capacity in a vast range of cognitive areas, including reading, writing, math, auditory processing, visual processing, attention, nonverbal functioning, problem solving, communication, memory, and executive functioning. Its exercises are primarily computer based, supported by oral and written exercises. According to Arrowsmith, research on its effectiveness has been in progress since 1997, but no research on Arrowsmith has yet been published in a peer-reviewed journal (Hannan T, Australasian Science 2015;36(9):41).
Fast ForWord Fast ForWord (www.fastforwordhome.com/about) is an internet-based intervention program in a game-like format; it is designed to improve children’s reading and language skills in areas ranging from phonics and grammar to comprehension, processing, and sequencing. Fast ForWord claims that results will occur with regular use (30 minutes a day, 5 days a week) across children with diverse learning needs. Each subscription comes with access to a remote, trained mentor who can personalize the program for the child. A search for research literature on Fast ForWord revealed only a single positive study via fMRI (Temple E et al, PNAS 2003;100(5):2860–2865), while a meta-analysis of 6 studies found no evidence of significant effectiveness (Strong GK et al, J Child Psychol Psychiatry 2011;52(3):224–235).
Lindamood-Bell Lindamood-Bell (www.lindamoodbell.com/category-article/phonological-processing) offers multiple programs to address various learning needs. For example, the “Visualizing and Verbalizing” program teaches visualization skills for language comprehension and big-picture thinking, while the “Seeing Stars” program teaches orthographic processing through “symbol imagery,” defined by Lindamood-Bell as the ability to visualize word parts. Lindamood-Bell’s intervention services can be delivered one on one or in small groups at their learning centers located in the US, UK, and Australia. Remote learning through teleconferencing is also available, with implementation instruction for teachers and tutors via scripted kits.
Lindamood-Bell recommends implementing its programs for 4 hours a day, 5 days a week, for 4 weeks; the learning centers reportedly charge $90 per hour, totaling $7200 for a program. Another website reported that Lindamood-Bell charged $20,000 for 12 weeks of intervention (www.adhd-bipolar-and-beyond.com/lindamoodbell.html).
The Lindamood-Bell website offers three papers supporting its results. Two of them are from the same research group, while the third paper, from an outside entity, was the only one to appear in PubMed. This paper, a peer-reviewed article conducted by independent researchers, found that untimed word reading, untimed pseudoword reading, timed pseudoword reading, and oral reading fluency improved with implementation of the “Seeing Stars” program (Christodoulou JA et al, J Learn Disabil 2017;50(2):115–127). The study did not control for the Hawthorne effect—ie, improvement in cognitive function because of the sheer amount of attention and follow-up provided by the program (McCarney R et al, BMC Med Res Methodol 2007;7(30)). Also, the control group was comprised of children who were on the Lindamood-Bell “waiting list” during the study period. The outcomes of the research would be more meaningful if the control group had received an active control intervention, such as regular sessions with a reading specialist or a tutor.
Orton-Gillingham Orton-Gillingham (www.ortonacademy.org) is a methodology for explicit instruction on sound-symbol connection of the alphabetic principle and morphological awareness using multisensory learning. The structured lessons follow an essential phonics-based scope and sequence that cumulatively builds on prior knowledge and is systematically reviewed.
Orton-Gillingham’s teacher preparation programs require anywhere from 30 to 300 hours of instruction and supervision. Orton-Gillingham programs are generally conducted in small groups by specialists in pull-out and after-school settings, but they can also be held with entire classes. The findings of the National Reading Panel support the Orton-Gillingham approach, but although many reading programs use components of this approach, not all programs are equal.
For example, a multisensory component is critical to the fidelity of the intervention, but many programs that claim to follow the Orton-Gillingham methodology fail to include this. It is also important to ensure incorporation of reading and writing fluency as well as reading comprehension at every level.
Understanding research claims Effective programs must be backed by actual research, not ideology. A given reading intervention may sound promising, but scientific rationales and support are not always as ironclad as a website might boast—research claims often rest on general principles rather than study of the programs themselves. Watch for jargon, look to see if a program’s cited research is actually searchable (eg, in PubMed), and note the balance of research vs marketing. We hope for at least two good peer-reviewed research articles done by different groups. Intervention, whether at school or through an after-school program, should focus on direct reading instruction. Also, engagement is key: No matter the intervention, the child’s own desire to participate will be key to success.
CCPR Verdict: What do we tell parents? All these programs can claim satisfied families. And we can’t rule out a child’s natural development when looking at any program’s purported results. That said, a well-built Orton-Gillingham program will have the most research supporting it. Remember that reading comprehension, not speed, is what matters most. We’ve all had timed tests, but it turns out that merely increasing speed reduces comprehension; the reality is that authentic faster rates of reading are founded upon solid comprehension skills (Rayner K et al, Psychol Sci Public Interest 2016;17(1):4–34). Get your students extra time to read if needed, and do not press for faster reading in and of itself.