Elementary Grade Intervention Approaches to Treat Specific Learning Disabilities, Including Dyslexia Purpose The purpose of this narrative review of the literature is to provide a description of intensive interventions for elementary grade students with dyslexia, students with learning disabilities, and students with intensive reading and writing needs. Method First, we provide a brief overview of response to intervention. Second, ... Tutorial
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Tutorial  |   October 24, 2018
Elementary Grade Intervention Approaches to Treat Specific Learning Disabilities, Including Dyslexia
 
Author Affiliations & Notes
  • Stephanie Al Otaiba
    Southern Methodist University, Dallas, TX
  • Amy Gillespie Rouse
    Southern Methodist University, Dallas, TX
  • Kristi Baker
    Southern Methodist University, Dallas, TX
  • Disclosure: The authors have declared that no competing interests existed at the time of publication.
    Disclosure: The authors have declared that no competing interests existed at the time of publication. ×
  • Correspondence to Stephanie Al Otaiba: salotaiba@smu.edu
  • Editor-in-Chief: Tiffany Hogan
    Editor-in-Chief: Tiffany Hogan×
  • Publisher Note: This article is part of the Clinical Forum: Dyslexia.
    Publisher Note: This article is part of the Clinical Forum: Dyslexia.×
Article Information
School-Based Settings / Language Disorders / Reading & Writing Disorders / Attention, Memory & Executive Functions / Speech, Voice & Prosody / Clinical Forum: Dyslexia / Tutorials
Tutorial   |   October 24, 2018
Elementary Grade Intervention Approaches to Treat Specific Learning Disabilities, Including Dyslexia
Language, Speech, and Hearing Services in Schools, October 2018, Vol. 49, 829-842. doi:10.1044/2018_LSHSS-DYSLC-18-0022
History: Received January 31, 2018 , Revised March 20, 2018 , Accepted April 20, 2018
 
Language, Speech, and Hearing Services in Schools, October 2018, Vol. 49, 829-842. doi:10.1044/2018_LSHSS-DYSLC-18-0022
History: Received January 31, 2018; Revised March 20, 2018; Accepted April 20, 2018

Purpose The purpose of this narrative review of the literature is to provide a description of intensive interventions for elementary grade students with dyslexia, students with learning disabilities, and students with intensive reading and writing needs.

Method First, we provide a brief overview of response to intervention. Second, we explain our theoretical framework for the review. Third, we describe evidence-based interventions, which are divided into predominantly reading or writing interventions. Fourth, we explain data-based individualization for these programs based on a taxonomy of intensity, and we provide an illustrative case study.

Conclusion We conclude by describing a set of links to websites and technical assistance resources that may be helpful for speech-language pathologists, teachers, and other interventionists to stay current with this research base and to lead professional learning communities.

Only about 36% of fourth graders can read on grade level in schools in the United States (National Assessment of Educational Progress (NAEP, 2015). More disturbingly, for minority children (e.g., African American, Hispanic) this rate is much lower (18%–21%). It is also lower (21%) for children living in poverty (i.e., qualify for the National School Lunch Program). A majority (67%) of students with disabilities read below even a basic level (NAEP, 2015). As a consequence of poor reading, students may also face an array of related social, emotional, and behavioral issues, including a higher risk for high school dropout, delinquency (Criminal Justice Initiative, 1997), and future unemployment (National Center for Education Statistics, 2012).
National statistics for student performance in writing are similarly alarming. A majority of students in Grades 4, 8, and 12 in the United States do not demonstrate grade-level writing skills (National Center for Education Statistics [NCES], 2012; Persky, Daane, & Jin, 2003). In the most recent assessment years, only 28% of fourth graders (Persky et al., 2003) and 27% each of eighth and twelfth graders (NCES, 2012) met or exceeded grade-level writing expectations on the NAEP writing assessment. Furthermore, compared to their nondisabled peers, only 7% of fourth-grade students with disabilities and 5% each of eighth- and twelfth-grade students with disabilities performed at or above grade-level expectations on the most recent NAEP writing assessments (NCES, 2012; Persky et al., 2003). These statistics are particularly disconcerting given the writing difficulties many students who struggle with writing or who have disabilities demonstrate.
The purpose of this article is to describe evidence-based reading and writing instruction and interventions that speech-language pathologists (SLPs), teachers, and interventionists can provide to struggling learners. This information is critical to SLPs in light of the American Speech-Language-Hearing Association (ASHA, 2010)  Guidelines for the role of SLPs in schools and the ASHA (2001)  Practice Policy for SLP's role in reading and writing. Specifically, this knowledge about evidence-based interventions can support SLPs as they select programs, collect diagnostic and progress monitoring assessment data, use data to inform intervention decisions, collaborate to improve outcomes for students, and provide leadership and advocacy. We focus on children in the elementary grades who have elevated risk for specific learning disabilities (SLD), who experience difficulty in learning to decode and encode words, who are slow or dysfluent readers, or who have challenges with comprehending or composing written text. Nearly 50% of students who receive special education services do so under the category of SLD, which has been defined under the Individuals With Disabilities Education Act (IDEA, 2004) as a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in the imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations. The SLD category excludes learning problems that are attributable to visual, hearing, motor, or intellectual disabilities. As we describe in the following section in greater depth, IDEA also allowed states and local education agencies to consider whether students respond adequately to intensive interventions as one aspect of identification.
Because many students who qualify for speech-language support also demonstrate significant reading and writing difficulties, the role of the SLP is vital in the selection of effective intensive interventions, determining ways to monitor progress or response, and collaborating to further intensify as needed. Often, the role of reading/writing intervention falls to special education teachers and school specialists. However, because of SLP's specific knowledge of language disorders, ASHA highlights that SLPs should also be involved in the process. Therefore, the role of SLPs includes a spectrum of responsibilities that include involvement in evaluation, decision making, and intervention to support reading and writing needs (ASHA, 2001, 2010).
The prevalence of students with specific learning disabilities (SWSLD) varies widely within the United States from 5% to 20%, depending on the criteria for identification. This variability in prevalence rates may be related to confusion about identification criteria. For example, states have not yet adopted a universally accepted definition of dyslexia (cf. Tolson & Krnac, 2015; Youman & Mather, 2015). In some states with dyslexia laws, dyslexia refers to struggling readers and writers generally; in other states, the term dyslexia is reserved for students with a profile that includes struggles with phonemic awareness, rapid naming, spelling, decoding, encoding, and fluency despite having typical intelligence.
Response to Intervention and Multitiered Systems of Support
Since 2004, at which time the IDEA (2004) was reauthorized, states and local education agencies have begun to use models of response to intervention (RTI) or multitiered systems of support (MTSS) to provide early literacy intervention. In general, MTSS models incorporate behavior and social/emotional learning supports and a broader array of academic skills than RTI models, which have mostly been implemented for reading or math. These systems replaced the need to identify SLD by demonstrating a significant discrepancy between IQ and reading or writing ability with the option to identify SLD after demonstrating inadequate response to effective instruction and intensive intervention (e.g., Blachman et al., 2004; L. S. Fuchs & Fuchs, 1998; Torgesen et al., 2001; Vellutino et al., 1996). However, there remains a lack of consistent guidance from a legal and policy perspective; for example, Zirkel and Thomas (2010)  reported considerable variability in state laws and guidelines informing local education agencies about how to implement RTI (see also Miciak, Fletcher, & Stuebing, 2016). Even though there are many RTI models currently being implemented, SLPs may be aware that most models provide three tiers of increasingly intensive intervention, beginning with Tier 1, or the general core language arts instruction. Students move into more intensive tiers based on performance relative to grade-level expectations and benchmarks using screening or progress monitoring assessments (e.g., Gersten et al., 2009; Jimerson, Burns, & VanDer Heyden, 2016). Tier 2 provides small group and more targeted intervention, and Tier 3 is meant to be the most intensive intervention, which may involve special education services, a 504 plan, dyslexia treatment, or speech and language services. Generally, there is an agreement that MTSS includes RTI for academics but also considers whether children have problem behavior or need support in the area of social and emotional learning. What follows is a description of our conceptual framework for interventions, which is a prelude to our description of types of interventions (reading and writing).
Conceptual Framework for Interventions
The primary strand of our conceptual framework in this article will likely be familiar to SLPs—the Simple View of Reading and Writing (Juel, Griffith, & Gough, 1986)—because practitioners can relate it to the development of language and literacy, as well as to individual students' patterns of strengths and weaknesses. The Simple View of Reading and Writing (Gough & Tunmer, 1986; Juel et al., 1986) initially proposed that reading with understanding was the product of two broad sets of skills: code-focused skills such as decoding and spelling and meaning-focused skills such as vocabulary and language comprehension. Thus, a struggling first grader may experience relative strengths in the area of language comprehension and weaknesses, understanding phonemic awareness and decoding within the realm of reading; this pattern could help an SLP collaborate with a team to select an intervention that is generally efficacious to improve the code-focused skill deficit. In the area of writing, the two analogous sets of skills include spelling and ideation, which we have expanded upon (discussed further in the Evidence-Based Writing Interventions section).
Thus, a secondary but related strand within our conceptual framework is the Taxonomy of Intervention Intensity (D. Fuchs, Fuchs, & Malone, 2017). As with the Simple View of Reading and Writing, the Taxonomy of Intervention Intensity is very practitioner friendly, but it addresses the fact that even the most effective interventions will not work for every student; in the vernacular, no one size fits all. In fact, research suggests that a number of students may not respond to generally effective interventions (Al Otaiba & Fuchs, 2002; Lam & McMaster, 2014; Nelson, Benner, & Gonzalez, 2003). Thus, as we will describe in greater detail, the Taxonomy of Intervention Intensity can guide SLPs in the process of how to intensify interventions by increasing their dosage, aligning to the skill deficits and strengths of the student, attending to transfer to other genres and settings, providing behavioral and motivational support, and following a data-based process to guide individualization.
Evidence-Based Reading Interventions
In this section, we describe evidence-based reading interventions for elementary students with intensive reading needs, including struggling readers, students with dyslexia, and SWSLD, based on numerous syntheses (e.g., D. Fuchs, Mock, Morgan & Young, 2003; Gersten et al., 2009; Jimerson et al., 2016; Lonigan & Shanahan, 2009; National Reading Panel [NRP], 2000; Wanzek et al., 2013; Wanzek & Vaughn, 2007; Wanzek, Wexler, Vaughn, & Ciullo, 2010). Evidence-based reading interventions are programs that have been tested empirically to demonstrate there is evidence of their efficacy for struggling readers and SWSLD across multiple research studies, students, and settings. A criteria for the strength of evidence proposed by the What Works Clearinghouse is an effect size (ES) favoring the treatment over a comparison group that is larger than 0.25: small effects, d = 0.2–0.4; medium effects, d = 0.5–0.8; and large effects, d > 0.8. Drawing on the Simple View of Reading and Writing (Gough & Tunmer, 1986; Juel et al., 1986), we include evidence-based interventions within two broad skill areas: code-focused skills (i.e., phonemic awareness, phonics, and fluency) and meaning-focused skills (i.e., vocabulary and comprehension). Some interventions are multicomponent and focus on both sets of skill areas. These skills form the content for interventions; the Taxonomy of Intervention Intensity informs the intensification for delivery of skills.
Code-Focused Reading Skills
Phonemic Awareness and Phonics
Findings from the NRP (2000)  emphasized the effectiveness of explicit and systematic phonemic awareness and phonics instruction and intervention, particularly for students in the primary grades (see also Ehri, Nunes, Stahl, & Willows, 2001). In addition, findings from other meta-analyses and research summaries (Foorman & Torgesen, 2001; Gersten et al., 2009; Swanson, 1999; Torgesen, 2004; Wanzek et al., 2010; Wanzek & Vaughn, 2007) confirm the importance of explicit and systematic, or direct instruction of code-focused skills in a sequence or order of easiest to most difficult skills.
Phonemic awareness involves learning how to manipulate sounds in speech, and difficulty in mastering this skill predicts future reading difficulties (e.g., Adams, 1990; Catts, 1989; Lonigan & Shanahan, 2009; NRP, 2000; Wagner & Torgesen, 1987). It is easiest for children to learn to manipulate larger chunks of language before involving discreet phonemes. Phonics involves understanding how letters represent sounds and how units and morphemes are represented. Both sets of skills are closely related and are challenging for SWSLD.
Fluency
Fluency is another code-focused skill identified by the NRP as a necessary skill to address with struggling readers (NRP, 2000). Fluency involves the ability to read connected text smoothly, rapidly, and with minimal errors (Hudson, Lane, & Pullen, 2005; Kuhn & Stahl, 2003). Research has indicated a strong relationship between fluency and reading comprehension with dysfluent readers demonstrating lower comprehension due to spending greater amounts of time sounding out words. (L. S. Fuchs, Fuchs, Hosp, & Jenkins, 2001; Laberge & Samuels, 1974). This skill is challenging for SWSLD and one that should be addressed through explicit and systematic practice.
SLPs need to know that, across the available research and reviews, findings emphasized the importance of building code-focused skills in tandem. First, practitioners provided deliberate scaffolding and modeling of these skills. Then, they supported guided and independent cumulative review and practice. Second, skills were taught along a scope and sequence beginning with manipulating phonemes or sounds in spoken language to learning letters. As students mastered letter–sound correspondence, they began blending and segmenting words to decode and encode. Third, students mapped spellings of parts of words (including morphemes) to read multisyllabic words and began to automatically recognize words with irregular patterns (i.e., sight words). After developing automaticity, they practiced to achieve fluency. Once students read fluently and with prosody, it was easier for them to self-monitor their comprehension.
Meaning-Focused Reading Skills
The NRP (2000)  findings also emphasized the importance of interventions to address meaning-focused skills, which include oral language development, listening, and reading comprehension. These are more traditional targets for SLPs. By oral language development, we mean aspects of language (exclusive of phonology), including (a) semantics or vocabulary, (b) morphology or the study of word formations, (c) syntax or grammar, and (d) pragmatics or language use. As SLPs know, disorders in language development are related to reading and writing difficulties (cf. Soifer, 1999).
Vocabulary Development
Vocabulary development is strongly correlated to reading comprehension; for example, Biemiller (2005)  found a strong and relatively stable correlation of .81 between vocabulary size and reading comprehension across the elementary grades. The NRP (2000)  emphasized the importance of direct and indirect vocabulary instruction. Beck, McKeown, and Kucan (2002)  suggested teachers consider classifying words into three categories or tiers, not to be confused with RTI tiers. Tier 1 words are words within a child's spoken lexicon such as cup, paper, and play. Tier 3 words are very low frequency words or words for specialized content instruction, such as isotope or photosynthesis. Beck and colleagues suggested the more direct instruction focus on Tier 2 words: those high-frequency words that children will encounter in text such as construct, devise, and emerge. They suggested Tier 2 words should be introduced following principles of direct instruction: repeated exposures, modeling of word meanings and word relationships through word webs, direct teaching of synonyms and antonyms, and engaging in discussion to promote word usage.
Listening Comprehension
Another strategy for developing oral language and listening comprehension is shared book reading. Shared book reading can take many forms, but one of the best researched is dialogic reading, which has been found to improve vocabulary and language skills for young children, including students at risk for SLD (e.g., Lonigan & Whitehurst, 1998; Whitehurst et al., 1994). The What Works Clearinghouse (WWC) evaluated rigorous studies of dialogic reading and reported positive effects on oral language (ES = 0.50), but no studies examined effects on listening comprehension. There are several components of dialogic reading practices that should be familiar to SLPs in their work with teachers and parents. First, the adult reader preteaches essential vocabulary. Then, while reading, the adult reader asks questions to engage children, encourage their use of vocabulary, and help them recall information and draw inferences.
Reading Comprehension
In terms of reading comprehension, the NRP (2000)  suggested instruction should develop background knowledge, focus on strategy instruction (e.g., predicting, clarifying, monitoring, summarizing), and incorporate both story grammar for narrative text as well as text structure for expository genres. SLPs may introduce these strategies orally during language therapy. Such instruction may occur before, after, and during reading and should include modeling, guided practice, and independent practice (Mastropieri, Scruggs, Bakken, & Whedon, 1996; Swanson, 1999). Findings from a more recent review of effective comprehension instruction converge; the Institute for Education Sciences (IES) Practice Guide for Comprehension in K-3 (Shanahan et al., 2010) made five primary recommendations for teachers and SLPs. One practice, which had strong evidence, was to teach students how to use evidence-based reading comprehension strategies, including activating background knowledge, questioning, visualization, monitoring, inferencing, and retelling. Two more practices had moderate evidence: teaching students to identify and use text structure, which includes story grammar for narrative and text structures for expository text, and creating an engaging and motivating context in which to teach reading comprehension. The remaining two had only weak evidence to date but include providing guided discussion about the meaning of text and carefully selecting texts that support comprehension development. This particular IES practice guide is notable because the Southwestern Regional Lab created a guide for developing and nurturing professional learning communities with this guide (see Kosanovich & Foorman, 2016). Because SLPs may also be involved in leading professional development for teachers, this type of train-the-trainer material is very helpful. A related guide that focuses on developing language and academic content for English language learners could also be a helpful resource to SLPs (Institute of Education Sciences, 2018b). This second resource has links to videos of practices being implemented in schools.
Specific Intervention Programs
Organizations such as the International Dyslexia Association (IDA, 2018a) currently use the term structured literacy to describe an explicit and systematic instructional approach. However, historically, beginning as early as the 1920s, some in the community have argued that some students with dyslexia learn differently and require explicit and systematic phonetic instructional approaches employing multisensory techniques to develop word reading (e.g., Fernald & Keller, 1921; Monroe, 1932; Orton, 1937). Common characteristics of such approaches include not only explicit and systematic instruction but also emphasis on building connections across the visual, auditory, and kinesthetic/tactile domains. However, to date, there have been few methodologically sound studies from which to determine the effectiveness of multisensory approaches, despite theoretical support and wide-spread adoption of these methods. Most are provided in one-to-one tutoring settings within schools and clinics. The professional development and certification standards to deliver these interventions are considerable (see, e.g., IDA, 2018a); this same link allows navigation to the new Knowledge and Practice Standards, which are recommended for all teachers and the higher-level standards for therapists. A helpful link on the IDA website provides up-to-date information about states with dyslexia legislation or guidance International Dyslexia Association (IDA, 2018b).
Some might argue that any intervention that involves reading and spelling is multisensory, but that term is usually used to describe approaches for students with dyslexia. Given the widespread use of multisensory interventions, SLPs should also be aware of the somewhat limited research about their efficacy. Although there is certainly plenty of anecdotal support for these methods, there is a need for more rigorous studies. For example, Ritchey and Goeke (2006)  reviewed the available studies on the efficacy of multisensory Orton-Gillingham (OG)–based interventions and reported some mixed effects. In three of the 12 studies, the authors found OG was more effective than the “business as usual” instruction with a large mean effect size of 0.82 for word reading and 0.76 for comprehension (Joshi, Dahlgren, & Boulware-Gooden, 2002; Litcher & Roberge, 1979; Stoner, 1991). However, effect sizes could not be determined in some studies; moreover, two studies found OG was less effective than the comparison condition, and one found no significant differences.
In addition, the IES has conducted systematic reviews of the evidence for some specific structured literacy programs with a multisensory approach, including Lindamood Phoneme Sequencing (LIPS; Institute of Education Sciences What Works Clearinghouse, 2010) and the Wilson Reading System (Institute of Education Sciences What works Clearinghouse, 2007; Wilson, 2002). For LIPS, the WWC considered 48 relevant studies but noted that only eight studies included a group design and only two were randomized control trials (Gunn, 1996; Torgesen, Wagner, Rashotte, Herron, & Lindamood, 2010). Torgesen et al. (2010)  reported statistically significant effects of a LIPS small group intervention relative to a basal reading comparison condition on standardized measures of word reading, phonological awareness, and reading comprehension for first graders. However, findings from the Gunn (1996)  study indicate negative effects of LIPS on word reading relative to a basal reading comparison condition.
With regard to the Wilson Reading System, the WWC examined nine studies, but only one included a randomized control trial. In that study, Torgesen et al. (2006)  examined Wilson relative to a basal reading comparison condition and found statistically significant effects favoring Wilson on word reading but not on fluency or comprehension. In a recent single-case design study, Schlesinger and Gray (2017)  directly compared the efficacy of structured language and multisensory approaches. They reported that both approaches showed important treatment effects over baseline; however, there were no significant effects favoring multisensory over a structured literacy approach on letter naming, letter sound production, word reading, or word spelling.
In addition to specific multisensory programs, there are a large number of explicit and systematic interventions that are evidence-based and are commercially available, and many have also been reviewed by IES. All of these programs provide strong phonemic awareness and phonics instruction. None of these programs require the level of training as the IDA-accredited intensive programs, and so they may be feasible for SLPs to recommend in schools as Tier 2 early interventions. For example, some highly scripted programs were designed and field-tested for use by paraprofessionals or volunteers (e.g., Sound Partners; Vadasy, Sanders, & Peyton, 2006), and the curriculum also involves reading connected texts to promote fluency practice. Others have even been designed for classwide peer tutoring (e.g., Peer-Assisted Learning Strategies; D. Fuchs et al., 2011, 2016). For kindergarten, the emphasis is letter–sound correspondence and building decoding and sight word fluency, but for first grade and beyond, students reading connected text and comprehension is also addressed. Other scripted programs have been designed for small group delivery by teachers, whereas one focuses predominantly on code-focused skills (Road to the Code, Blachman, Ball, Black, & Tangel, 2000), two additional programs also include meaning-focused skills (e.g., Early Interventions in Reading, Mathes & Torgesen, 2005; Early Reading Intervention, Simmons & Kame'enui, 2003). In a study of Early Reading Intervention, Coyne et al. (2013)  reported that when kindergarten teachers monitored student mastery and regrouped students to promote more homogeneous small group instruction, effect sizes were even higher. It is also noteworthy that Early Interventions in Reading for first graders has reduced the percentage of children with word reading scores below a standard score of 90 to less than 5% even in high needs schools (Al Otaiba et al., 2014). Other programs are more intensive, focus predominantly on fluency and meaning-focused skills, and are suggested for one-on-one instruction (e.g., Reading Recovery, Clay, 1993). This was designed for highly trained teachers to deliver in a one-on-one format daily for up to 20 weeks; notably the effects of this program were stronger when teachers also provided explicit code-focused instruction (Iversen & Tunmer, 1993).
Common Instructional Characteristics of Evidence-Based Reading Interventions
There are several common characteristics of effective reading instruction across the aforementioned research base of which SLPs should be aware. Consistent with emphasis on structured literacy approaches highlighted by the IDA (2018a), the instructional approaches included explicit instruction, which linked phonics and phonemic awareness to target the critical content that SWSLD need to learn. This instruction was most effective with younger students as prevention than it was with older elementary students as remediation (cf. Ehri et al., 2001; Wanzek & Vaughn, 2007). SLPs, teachers, and other interventionists should seek programs that provide structured, mindfully sequenced, well-organized lessons. SWSLD need daily opportunities to read and practice skills at an appropriate instructional level. Relatedly, SWSLD benefit from intensive intervention that is delivered to small groups of students to provide frequent opportunities to respond and to receive corrective feedback. Although specific comparisons of multisensory interventions to other explicit interventions are lacking, SLPs may collaborate with instructors to incorporate instruction that involves multiple modalities to facilitate connections between letters and sounds, as well as between written and oral language that incorporate visual and auditory cues. We provide more information about incorporating writing to support the kinesthetic or motoric cues in the following section.
Evidence-Based Writing Interventions
In this section, we describe evidence-based interventions for elementary students with intensive writing needs, including SWSLD. It is important that SLPs have knowledge of evidence-based writing interventions that include teaching methods that have been tested and shown to be effective for improving the writing skills and writing quality of struggling writers and SWSLD across multiple research studies, multiple students, and multiple settings. Once again, drawing on the Simple View of Reading and Writing (Juel et al., 1986), we include evidence-based interventions for teaching writing to struggling writers and SWSLD within two broad skill areas: transcription (i.e., handwriting and spelling) and ideation (i.e., sentence construction and composition). Across these skill areas, SLPs will recognize a common theme: Writing instruction should be explicit, systematic, and structured in ways to promote student practice and provide ongoing scaffolding and feedback prior to students practicing writing skills on their own (Graham, 2006; McMaster, Kunkel, Shin, Jung, & Lembke, 2017).
Transcription
We expanded on Juel et al.'s (1986)  two basic factors (i.e., spelling and ideation) in the Simple View of Reading and Writing to include handwriting with spelling under the heading “transcription.” We felt addressing both spelling and handwriting was important for SLPs to understand, as struggling writers and SWSLD often display difficulties with automatic and fluent letter writing as well as difficulties with spelling (Berninger, Nielsen, Abbott, Wijsman, & Raskind, 2008), both of which can impact writing quality and writing fluency (Graham, Harris, & Hebert, 2011).
Handwriting
Handwriting involves multiple processes and skills a writer must adequately deploy to create legible letters (Datchuk & Kubina, 2013). Furthermore, until handwriting becomes automatic and fluent, it can constrain a writer's ability to focus on other writing processes, including sentence construction, text organization, and the content and meaning conveyed in a text (Graham, 2006; Schlagal, 2013). Because struggling writers and SWSLD frequently struggle with handwriting skills, they often produce texts that are illegible or difficult to read, which can negatively impact how others view and score the quality and content of their writing (Graham et al., 2011).
SLPs should be aware that, across the available research (Datchuk & Kubina, 2013; Graham, 1999; McMaster et al., 2017; Schlesinger & Gray, 2017; Wanzek, Gatlin, Al Otaiba, & Kim, 2017), there were several common features of effective handwriting interventions for struggling writers and SWSLD. First, handwriting interventions included direct instruction in how to form letters, including both instructors modeling how letters were formed and students following verbal (e.g., instructors saying the steps to form each letter or saying the correct positioning of the letter in relation to the lines on the paper) and visual cues (e.g., numbered arrows, dotted lines) to form letters on their own. Introducing students to several letters at a time that shared common features (e.g., h, r, n) but were not easily confused or reversed (i.e., b, d, p) also proved effective. Second, handwriting interventions involved memory retrieval components, such as cover and copy, during which a student examined a properly formed letter and then covered the letter and wrote it from memory. Third, instructors taught students to evaluate their own handwriting, asking them to identify correctly formed letters and correct illegible or improperly formed letters, often creating visual displays (such as graphs) of students' progress. Fourth, handwriting interventions incorporated fluency-building activities. Frequently, instructors asked students to write newly learned letters in words and sentences for a specific time (e.g., 3 min of copying a sentence that contains many of the newly learned letters) to develop fluency. Then, instructors expected students to apply handwriting skills in their own written texts. Fifth, instructors incorporated multisensory activities into handwriting interventions, such as having students skywrite letters or having students trace letters on tactile surfaces (e.g., sand trays, carpet tiles). Sixth, instructors included orthographic coding activities during handwriting interventions. Such activities included students identifying letters that came before or after different letter strings or writing missing letters in various letter sequences.
Direct instruction and modeling of letter formation, combined with memory retrieval, self-evaluation, fluency, and/or orthographic coding activities, led to improvements in students' legibility and writing fluency in the studies reviewed (Datchuk & Kubina, 2013; Graham, 1999; McMaster et al., 2017) and improvements in correct word sequences in one study (Wanzek et al., 2017). Importantly, with all effective handwriting interventions, instructors included time for students to participate in handwriting practice, and handwriting intervention sessions were relatively short, lasting on average less than 30 min (range 10–45 min) per session.
Spelling
Like handwriting, spelling is a complex process involving multiple components and skills. To become competent spellers, students must not only master letter-to-sound relationships but they must also understand letter and syllable spelling patterns and the meaning layer (e.g., Greek and Latin word roots) of spelling (Bear, Invernizzi, Templeton, & Johnston, 2016; Williams, Walker, Vaughn, & Wanzek, 2017). SLPs should be aware that providing effective spelling instruction to struggling writers and SWSLD is important so that transcription becomes automatic, and thus students free up working memory space to focus on other writing processes. In addition, with accurate spelling skills, students are better able to convey their intent in writing, as even one misspelled word can change the meaning of a composition and affect how a reader views the quality of that composition (Graham, Harris, & Fink Chorzempa, 2002). SLPs should also recognize that different types of spelling interventions will be more or less appropriate given the type of words a student is expected to learn. For example, students need understanding of the patterns within English orthography, but they also need strategies for memorizing irregular words that do not follow these patterns.
Research and research reviews on spelling instruction for struggling writers and SWSLD (Berninger et al., 2000; McLaughlin, Weber, & Derby, 2013; McMaster et al., 2017; Schlesinger & Gray, 2017; Wanzek et al., 2017; Williams et al., 2017) indicated several effective interventions. First, spelling interventions involved direct and systematic instruction in letter–sound correspondences, the spelling of syllable patterns, the spelling of morphemes, and the spelling of irregular words. Second, spelling interventions involved teaching students to self-correct spelling errors. One common method, cover–copy–compare, involved a student looking at a spelling word, covering the word, copying it from memory, and then comparing his or her written response to the correctly written word. Teaching students to self-correct allowed for immediate corrective feedback on spelling, thus reducing the creation of error patterns. Third, instructors taught students strategies for studying their spelling words and for self-monitoring their learning. Study strategies included word sorts, word hunts, flashcards, and peer practice with spelling words; these strategies allowed students to determine which words they could spell easily and which words required more practice. Fourth, to support fluency as well as the generalization and maintenance of what they had learned, instructors had students apply newly learned spelling skills in sentence writing and in their own written compositions. Typically, these activities began with single word dictation, followed by sentence dictation, and then application of spelling skills in written compositions. Fifth, instructors employed multisensory activities during spelling interventions; such activities included having students trace three-dimensional letters with their fingers while saying the letters aloud to spell a given word or asking students to use mirrors to watch how their mouths moved when producing letters and sounds.
These effective spelling interventions (i.e., direct and systematic instruction, self-correction, self-study strategies, and fluency activities) resulted in improved spelling and, in some studies, improved writing quality, writing fluency, and word reading skills (Berninger et al., 2000; McLaughlin et al., 2013; McMaster et al., 2017; Williams et al., 2017). Importantly, SLPs should note that, across effective spelling interventions, instructors provided distributed spelling practice over time and limited the number of words students were required to learn at one time.
Ideation
We felt it was important for SLPs to know how to address both sentence-level skills and composition skills when considering ideation. This is important because research shows that struggling writers and SWSLD struggle with both the cognitive demands imposed by sentence construction (Datchuk & Kubina, 2013; Saddler, 2013) and with understanding and enacting the skills needed to carry out the writing (i.e., composition) process (Lienemann & Reid, 2008; MacArthur & Graham, 2016).
Sentence Construction
Writers must consider lexical, syntactical, grammatical, mechanical (e.g., punctuation), and rhetorical choices for each sentence they construct (Fayol, 2016); because this process is so complex and cognitively demanding, researchers contend that composing a sentence is akin to the process required to plan and organize an entire composition (Furey, Marcotte, Wells, & Hintze, 2017; Saddler, 2013). Because struggling writers and SWSLD typically lack the linguistic skills required to produce complete, interesting, and varied sentences, their compositions are often less coherent and less complex, which negatively impacts overall writing quality (Saddler, Behforooz, & Asaro, 2008). Therefore, it is important to improve the sentence construction skills of struggling writers and SWSLD not only to increase their writing fluency but also to improve the quality of their written compositions (Datchuk & Kubina, 2013; Saddler et al., 2008).
Across the available research and research reviews of sentence construction interventions for struggling writers and SWSLD (Datchuk & Kubina, 2013; Furey et al., 2017), there were several common effective practices for SLPs to understand. First, sentence construction interventions included direct instruction (modeling, guided practice, and independent practice) in how to develop and write simple and complex sentences. Often, instructors used picture–word prompts; each of these prompts included an illustration along with several related words that students should include in their sentence to describe the illustration. Using these prompts allowed students to focus on sentence-level skills without having to come up with writing content on their own. Second, instructors used sentence-combining activities during sentence construction interventions. With sentence combining, students learned to combine simple, or kernel, sentences into more complex sentences using sentence cues (e.g., underlined parts of each kernel that should be retained in the combined sentence) and connector words (e.g., conjunctions). Through sentence combining, students learned to consider different syntactical options and to choose to write the combined sentence that best conveyed the meaning they intended. After direct instruction in how to combine sentences, instructors often paired students to complete sentence-combining activities, so that peers could provide feedback on the sentences their partners created. Third, sentence construction interventions included teaching of grammar skills within authentic contexts. During authentic grammar instruction, students applied learned grammar skills to writing (rather than learning them through workbook-type activities that were disconnected from writing connected text). Frequently, instructors incorporated grammar instruction (e.g., subject–verb agreement, parts of speech, capitalization, and punctuation) into their direct instruction in simple and complex sentences or into their sentence-combining instruction. Fourth, instructors used strategy instruction to teach students mnemonics (e.g., F-SPEED: Framed-Subject Predicate Evaluate Expand Describe; Furey et al., 2017) for remembering steps in creating complete and interesting sentences.
The aforementioned sentence construction interventions (i.e., direct instruction in simple and complex sentences, sentence combining, authentic grammar instruction, and strategy instruction) led to improved sentence construction skills (i.e., production of complete sentences production of complex sentences, correct word sequences in sentences) as well as to improvements in writing fluency and writing quality (in some studies) for struggling writers and SWSLD. Importantly, across interventions, instructors provided opportunities for students to apply sentence construction skills in their own writing and to get feedback on their performance from the instructor and/or peers.
Composition
With fluent transcription and sentence construction skills, writers can focus on the higher-order processes involved in composing quality compositions. Skilled writers devote time to planning what they will write as well as revising and editing their texts; they have strategies for carrying out each of these writing processes (Graham & Harris, 2000; Lienemann & Reid, 2008). Skilled writers consider not only what they know about a topic but also consider how to convey their message to an intended audience, which elements are important for their chosen writing genre, and which text structures they should use to express their ideas (Flower & Hayes, 1981; Graham, 2006; Scardamalia & Bereiter, 1987). In contrast, as SLPs have likely experienced, many struggling writers and SWSLD lack the skills, strategies, and writing knowledge necessary to produce quality texts (Graham, 2006; MacArthur & Graham, 2016). Thus, they require targeted interventions to address each of these areas of weakness.
Reviews of research on composition interventions for struggling writers and SWSLD (Gersten & Baker, 2001; Gillespie & Graham, 2014; McMaster et al., 2017) indicated several common effective practices of which SLPs should be aware. First, composition interventions involved using a process writing approach. With process writing, instructors taught students to follow the writing process (i.e., plan, draft, edit, revise, publish), asked students to write for authentic audiences and purposes, allowed sustained time for students to write, allowed students opportunities to write collaboratively with peers, and delivered mini-lessons to address students' writing skills as the need arose (Graham & Sandmel, 2011). Second, during composition interventions, instructors provided direct instruction in strategies for carrying out the writing process, such as strategies for planning, writing for different genres, editing, and revising texts. Often, instructors provided students mnemonics (e.g., SPACE: Setting Purpose Action Conclusion Emotions; Harris, Graham, Mason, & Friedlander, 2008) for remembering steps of each writing strategy. Third, composition interventions involved self-regulated strategy development (SRSD; see Harris, 1982; Harris et al., 2008; Harris & Graham, 1992). SRSD involved explicit instruction in writing strategies combined with instruction in the self-regulation strategies needed to carry out those writing strategies. In addition, with SRSD, instructors provided the background knowledge and writing knowledge (e.g., common vocabulary used to talk about a specific writing genre, elements of specific genres, strong and weak examples of the types of texts students are learning about) students needed to use the writing strategies. SRSD instruction was presented through six flexible stages and driven by student progress in each stage (see Harris et al., 2008, and thinkSRSD, 2018, for further information about SRSD). Fourth, instructors provided frequent writing feedback during composition interventions. Instructors conducted writing conferences with students, providing feedback on overall writing quality and specific elements students included (or neglected) in their writing. Often, instructors set a goal with each student (e.g., add three more descriptive details, take out all uses of passive voice) and followed up on the goal at the next conference. Instructors also taught students how to provide writing feedback to their peers and paired students for peer writing conferences.
After participating in effective composition interventions (i.e., process writing, strategy instruction, SRSD, and writing feedback), struggling writers and SWSLD demonstrated increases in writing quality as well as increases in the number of genre elements present in their texts and in the length of their texts in some studies (Gersten & Baker, 2001; Gillespie & Graham, 2014; McMaster et al., 2017). Like the other writing interventions described in this article, all composition interventions involved explicit instruction, instructor modeling, opportunities for students to receive feedback on their writing during guided practice, and opportunities for students to apply newly learned skills and strategies in their own writing.
Common Instructional Characteristics of Evidence-Based Writing Interventions
Importantly, all of the aforementioned evidence-based writing interventions that address transcription and ideation difficulties for struggling writers and SWSLD shared common characteristics that are important for classroom or small-group, intensive implementation. The interventions also included elements of structured literacy and multisensory instruction, both of which have been emphasized by IDA (2018a) .
Regardless of the type of writing intervention used or the type of writing skill of focus, writing instruction for struggling writers and SWSLD should be explicit, direct, and systematic (Berninger et al., 2000; Datchuk & Kubina, 2013; McMaster et al., 2017). SLPs, teachers, and other interventionists should model writing skills and strategies extensively, with the goal of making the writing process and the “hidden” strategies (e.g., generating ideas for writing, planning and brainstorming) that skilled writers use transparent. Struggling writers and SWSLD also need multiple opportunities for guided practice before they are expected to apply newly learned writing skills and strategies independently. Furthermore, writing skills and strategies should be taught within an authentic context, and students should be expected to learn and apply those skills and strategies in connected text and ultimately be held accountable for using them in their own writing (Berninger et al., 2000; Datchuk & Kubina, 2013; Graham, 2006; Troia, 2013). Instructors should also help students learn writing skills through multiple modalities, making connections between visual, auditory, and kinesthetic cues for written language as well as gross and fine motor movements (Berninger et al., 2000; Wolf, Abbott, & Berninger, 2017).
Taxonomy of Intensive Intervention
The Taxonomy of Intervention Intensity proposed by D. Fuchs et al. (2017)  informs what SLPs, teachers, and other interventionists might consider as they collaborate to adapt standard programs and provide data-based individualization. For illustrative purposes, we provide a case study of a fourth-grade SWSLD, Tommy, who did not respond to a Tier 2 small group multicomponent intervention, showing how this Taxonomy of Intervention Intensity could be used to intensify his intervention, monitor his response, and use data to improve the intervention formatively.
During the fall semester, Tommy received an evidence-based multicomponent intervention 5 days a week for 30 min a day provided by a well-trained reading specialist at his school. The program followed a scope and sequence that included about 15 min of word study, 5 min of vocabulary, and 10 min of comprehension instruction; but after about 20 weeks, the word study was reduced to only 5 min with extra time devoted to comprehension. As a student identified with a speech-language disorder, he also received speech and language services once a week from the school's SLP.
Despite these supports, the interventionist noted that, after 2 months, Tommy could not keep up with his group, his reading was very dysfluent, and he lacked the ability to decode many simple vowel patterns. His progress monitoring data indicated that he read in the bottom quartile of words correct per minute, and he was not able to answer basic or inferential comprehension questions. Tommy was beginning to act out during intervention to avoid his peers realizing he could not read the text; his lack of motivation was obvious when he would say things such as “You can't make me read that!” or “I'm too tired today.”
In an RTI meeting, the principal asked both the upper elementary SLP Mrs. Garcia and the reading specialist Ms. Evans to collaborate to build a plan to intensify Tommy's intervention using the Taxonomy of Intervention Intensity. In the first or setup phase, Mrs. Garcia and Ms. Evans examined six dimensions of the Taxonomy of Intervention Intensity. First, they considered the “strength” of the program for students like Tommy. They logged on to the Institute of Education Sciences What Works Clearinghouse (2018)  website and the National Center for Intensive Intervention (NCII; 2018b) tools chart to learn what effect sizes for the intervention were reported for SWSLD and found both resources suggested effects ranged from 0.40 to 0.60 on comprehension. This suggests the intervention was generally strong for students like Tommy.
In the second step, Mrs. Garcia and Ms. Evans both examined the “dosage,” including the group size, number of minutes per day, and sessions per week to evaluate Tommy's opportunities to respond and to receive corrective feedback. Both of the educators were satisfied that Tommy was receiving the recommended dosage.
The third step was to examine the “alignment” or how well the intervention addressed Tommy's reading deficits but also covered fourth-grade standards. Mrs. Garcia and Ms. Evans closely examined Tommy's most recent comprehensive evaluation and decided to readminister a phonics inventory, a test of word fluency, and an oral reading fluency measure. These data confirmed he was reading at only a first-grade level and was unable to consistently decode words with a consonant–vowel–consonant–e or vowel team patterns. His sight word lexicon was also very limited. However, the readability for the intervention materials was at a third-grade reading level, which was not well aligned with his instructional reading level. Furthermore, the amount and type of word study were not adequate to help him catch up to grade level.
Their fourth step was to evaluate “attention to transfer” or the degree to which the intervention supported Tommy in making connections from the skills taught in the lessons with reading other texts, such as informational text. They realized that there was a big divide between the intervention materials and they included little to no explicit instruction for how to use the comprehension strategies when reading social studies and science content texts.
Their fifth step was to examine the “comprehensiveness” of the intervention; in other words, to what extent were the explicit and systematic principles applied? Did the program provide clear and simply worded explanations, model strategies for decoding and comprehending, support Tommy's limited background knowledge, fade supports and increase independent practice, and incorporate specific feedback as well as cumulative review of the skills taught? Mrs. Garcia and Ms. Evans sampled four lessons and noted that the program was very comprehensive.
Their final step of the setup phase was to consider “behavior support.” The team had noted Tommy was frequently off task and lacked motivation. So, both the SLP and the reading specialist considered whether the program provided supports for self-regulation, self-monitoring, as well as praise for effort. After collaborating, they judged that Tommy would need more behavior supports in both his speech and reading pullout sessions.
Taken together, these six steps within the setup phase led Mrs. Garcia and Ms. Evans to develop an intensification plan for “individualization.” They planned to use data-based individualization (D. Fuchs, Fuchs, & Vaughn, 2014; Lemons, Kearns, & Davidson, 2014; Stecker, Fuchs, & Fuchs, 2005) as their platform. After revisiting the National Center on Intensive Intervention website (NCII 2018a)  Mrs. Garcia and Ms. Evans selected the Dynamic Indicators of Basic Literacy (Good & Kaminski, 2002), a second grade–level oral reading fluency measure, to track his RTI every other week. They set up a shared Excel spreadsheet to evaluate whether his progress was commensurate with the end-of-year goal by checking each month to see if his rate of improvement was as steep as his goal line. For intervention, they decided that the program appeared strong and was comprehensive, but that Tommy should be regrouped in a smaller group of students with similar skills to an earlier stage in the intervention with simpler text. To improve the alignment of the intervention with his skills, after consulting the Center on Instruction's review titled “Why Teach Spelling?” (Reed, 2012), Mrs. Garcia and Ms. Evans added a word study intervention that involved spelling to develop more accurate word reading. They also boosted grade-level comprehension through e-books that allowed Tommy to preview and review with a graphic organizer and listen to social studies and science text. They decided that Tommy would benefit from an additional one-on-one speech session to further support the language deficits affecting his reading and writing. During reading instruction, Ms. Evans increased the behavioral supports by adding a fluency game that provided more practice and motivation for Tommy to beat his own best time with a self-graphing component to help him see his effort paying off. To promote transfer for reading informational text during social studies and science, Mrs. Garcia reviewed the Office of Special Education–funded technical assistance website for Positive Behavior Interventions & Supports (2018)  and developed a daily report card/checklist to help Tommy self-monitor his use of word reading and comprehension strategies during intervention and speech.
Next, during the implementation stage, Mrs. Garcia and Ms. Evans executed the plan. They met with Tommy together to discuss the changes that would be occurring in both classes. At the end of the month, they evaluated Tommy's progress monitoring. In their meeting, Tommy proudly showed them his improvements on the fluency game scores on his own progress-monitoring graph. He also told them his plan for the upcoming science fair. Mrs. Garcia and Ms. Evans determined that he had mastered the phonics patterns and so changed the word study elements to include patterns he did not know. In child-friendly terms, they told him it was time to “level up” just as he did when playing computer games. Within 2 months, they conducted a second brief review and saw that his progress was accelerating and he appeared likely to meet his end-of-year goal.
We hope this case study shows how SLPs and other educators can work together to use the Taxonomy of Intervention Intensity in order to increase the intensity of intervention and improve outcomes. In the next section, we provide more resources for evidence-based tools, similar to the IES WWC Practice Guides, and websites like the PBIS and NCII, which we mentioned within this case study.
Resources for Intensification
There are many evidence-based websites that provide technical assistance resources that may be helpful for SLPs to stay current with the research and that are useful for guiding professional learning communities to help general educators as well as special educators and dyslexia specialists. We emphasize that the intensification taxonomy is a process of taking one step at a time and involving a team with a common child-focused and problem-solving mindset.
The NCII (2018a), American Institutes for Research, provides resources and tools for providing intensive intervention and for monitoring RTI. Particularly helpful are the reviews describing the reliability and validity of a variety of universal screeners and progress monitoring tools (NCII, 2018b).
The IES (2018a)  provides practice guides for implementing educational practices and conducts reviews of programs to determine the research base of effectiveness. IES has tasked 10 regional educational laboratories to disseminate findings and provide technical assistance to improve reading outcomes (e.g., Foorman et al., 2016).
The IRIS Center (2018), funded by the Office of Special Education Programs, offers training modules on RTI, reading, writing, math, behavior, individualization, English language learners, and assessment. For example, IRIS offers case studies on students who struggle with written expression skills (Lienemann, Reid, & the IRIS Center, 2009). Each case study presents a short vignette about a student struggling with a particular writing skill and typically displays a sample of that student's writing.
TeachingLD (2018a), a project of the Division for Learning Disabilities, which is part of the Council for Exceptional Children, features Current Practice Alerts, highlighting evidence-based academic interventions for SWSLD. One example of an alert is Fluency Instruction (2008), which describes the practice and research behind it. Furthermore, educators can access a wealth of online tutorials (TeachingLD, 2018b).
The International Dyslexia Association (IDA, 2018d) has a website that offers resources for families and educational professionals including the fact sheets (IDA, 2018d) that provide foundational understanding about dyslexia. Moreover, the website provides a link to dyslexia laws for each state (IDA, 2018c).
The RTI Action Network (2018a), sponsored by the National Center for Learning Disabilities, is a website that offers a variety of resources about RTI. For example, SLPs can link to pages within the website to initially develop the plan for implementing RTI in their schools (2018b).
Understood: For Learning and Attention Issues (2018)  is a website that primarily targets parents and families of children with high-incidence disabilities. In addition, SLPs and educators will find resources to communicate with parents of SWSLD.
Conclusion
Our purpose in writing this narrative review was to describe intensive reading and writing interventions for elementary grade students with dyslexia, SWSLD, and students with intensive reading and writing needs. Across these interventions, SLPs, teachers, and interventionists will notice common characteristics of effective reading and writing instruction include (a) explicit and systematic instruction, (b) extensive modeling and daily practice opportunities, (c) frequent and timely feedback, and (d) use of multiple modalities for practice and retention of skills. This was not an exhaustive review of the research. Rather, our intention was to inform readers and to empower them with tools and resources to guide them in selecting interventions, but more broadly to guide RTI and MTSS implementation and to inform professional development efforts. These resources may be helpful to SLPs, teachers, and interventionists both for self-study and for use within professional learning communities.
Acknowledgments
The research reported here was supported by the Institute of Education Sciences, U.S. Department of Education, through Grant R324A160132 to Stephanie Al Otaiba at Southern Methodist University. The opinions expressed are those of the authors and do not represent views of the Institute or the U.S. Department of Education.
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