**16. Main trends in this case study**

In the case study presented in this chapter, firm classification of type of learning disability was made at the end of Child H's primary school years, based on triangulation of evidence collected by use of different methods over time [84, 85], within a model of inference based on a process of incremental validity [17, 83]. Diagnosis was then linked to concessions to compensate for those areas of difficulty which have been demonstrated to be resistant to particular forms of treatment, as well as to ongoing treatment and learning support in particular areas of the high school curriculum.

Firm diagnosis was made possible by both longitudinal assessments using psychometric testing, as well as analysis of Child H's response to particular types of treatment intervention. These focused on a number of areas of difficulty identified by Child H's parents, including the following:


These areas indicated the need for multivariate assessment as well as multivariate treatment, which was provided by the following:


Child H's difficulties were initially described functionally, as the basis for developing his treatment programme. This was implemented using formats which enabled focus on a number of treatment areas side by side using graded electronic materials which included.


Child H's treatment was thus multivariate and was implemented through weekly sessions with support from Child H's parents, who received illustrated electronic parent implementer manuals as well as weekly emails with supporting electronic materials for implementation at home. This enabled focus on the skills required to support Child H's work at school, as well as the classroom and homework tasks provided as part of his programme at school. It also enabled firm diagnosis of dyslexia, dysgraphia or dyscalculia to be made at the end of Child H's primary schooling career, based on evidence of his response to the classroom work included in his school programme, evidence of his scholastic attainments, as well as evidence of the development of his abilities in cognitive processing which took place side by side with the treatment interventions described in this chapter.

Detail in the case study has been provided with the aim of providing the reader with an idea of the different types of fluency-based methods and materials used in working with Child H over a number of years, as well as the way in which longitudinal progress evaluation has been combined with psychometric testing conducted at different points over Child H's primary schooling. This has enabled skill development to the stage where Child H has successfully made the transition to high school. It has also enabled firm diagnosis of dyslexia with the aim of motivating for a number of concessions.

The application for concessions has been successful at this point in Child H's schooling. He is confident in his abilities, coping well with his high school programme and excelling at sport. He also has a talent for maths, a talent for transactional writing in English and a love of poetry.

#### **17. Summary and evaluation: can this case study be replicated?**

Despite the limitations implicit in the analysis of single cases, a number of aspects of this single case (N = 1) design can be generalised, and are replicable by others.

#### **17.1 Model of assessment**

The model for response to intervention classification of learning disabilities described in this case study is multimethod, based on summative assessment linked to progress evaluation of longitudinal interventions conducted across a number of areas of functional difficulty. While the assessments conducted with Child H have utilised the types of psychometric instruments commonly used in our country to provide indicators of underlying learning disabilities [6], the methods used and the types of evidence used for classification can be replicated.

For readers interested in assessment, there would also be good reason to do so. One reason is that use of repeated measurement linked to qualitative evidence collected at different data points over time would be likely to increase the likelihood of valid classification. The detail provided in this chapter would also indicate that a response to intervention approach to classification provides firm evidence that dyslexia is a type of learning disability which is likely to affect children throughout their schooling, for which concessions are not only advisable, but necessary.

This argument has been advanced by a number of other researchers and clinicians working internationally [20–22].

#### **18. Methods of treatment**

For readers interested in methods of treatment, this chapter has presented a longitudinal timeline documenting an approach to treatment which is essentially multivariate and eclectic, based on the combination of a number of treatment methods. The central focus of treatment has lain on the development of fluency in reading, writing and spelling based on the neuropsychological theories of automaticity proposed by Luria [1, 2] as well as the work on oral impress methods and paired reading first described by Heckelman [135–137] and then successfully implemented by others in the field [138–147].

A number of the treatment methods reflect the types of phonically based described by the body of researchers and clinicians who work from the standpoint that dyslexia is a severe difficulty with phonological processing [121, 148–153]. Other treatment methods are based on my previous work in the development of spatial perception using Piaget's theories [154–159] and focus on developing working memory for individual words and words in sequence using eidetic imagery [160, 161]. These methods use phonic analysis combined with VAKT and revisualisation-based techniques similar to those described by Fernald [27], as well as by others who have found it necessary to adapt other techniques in working with children [162–165].

The methods used are thus eclectic and based on use of combinations of graded reading, writing and spelling fluency activities, as well as use of methods targeting rapid naming and rapid reading and recall of words. They would accord with the types of multivariate curricular strategies suggested by Wolf and her colleagues [133–134]. They would also accord with the recommendations made by those researchers and clinicians who have suggested the value of linking the development of both skills and automaticity in reading, writing and spelling [107, 166–171].

At the same time, the methods used with Child H for developing writing and spelling fluency would appear to be unique in the literature. These are based on use of phonological referencing [106] as well modifications of the analytical techniques for teaching how words work based on seven vowels pioneered by Caroline [172]. As used in my practice, the seven vowel system applied in analysing and mapping the letter combinations used to represent vowels in English orthography is based on metacognitive strategies that have been logical to a number of children with severe learning difficulties [5]. What has been effective in enabling these children to code

from what you write to what you say, and to recode from what you say to what you write have also been logical in terms of research indicating evidence of a universal phonological principle, which would apply to learning to read the orthographies used in all languages, including pictographic written languages [173–176].

These methods may be of interest to others as use of a seven vowel as opposed to five vowel system enables direct coding and mapping of the letters used in written English to the sounds made in spoken English, with few exceptions. It also provides a basis for combining phonic analysis and revisualisation in developing working memory for individual words as well as words in sequence, as described in previous publications [6], and in this case study.

Overall, however, those readers who know the field well are likely to see the methods described in this case study as multivariate, eclectic and derivative of the pioneering work of Gates [25, 177], Monroe [178, 179], Orton and Gillingham [180, 181], Durrell [26] and Fernald [27] in stressing the importance of assessing and linking treatment of both phonological and visual aspects of reading disability to the development of working memory. In addition, they are derivative of the many other researchers and clinicians who have stressed the importance of linking the teaching of reading, writing and spelling with the development of working memory, whose contributions are acknowledged in the reference list.

As the practice materials are phonically based and made available for use electronically, the methods described in this case study can be and have been successfully worked with and adapted by parents, teachers and therapists through use of the types of activities described in our detailed manuals [8, 105]. They can also be replicated as the methods and materials described in this case study are available for implementation at low cost by others.

#### **19. Aggregation with the results of other case studies**

Children's problems vary, and no one size fits all. While this N = 1 case study would support this standpoint, there is also the potential of aggregation of N = 1 case studies with others. For readers with an interest in aggregative case survey research, one way to implement this type of clinically based aggregation is to use classificatory variables for purposes of grouping, comparison and contrast. This is being done in the author's practice on an ongoing basis as follows.

There is sufficient breadth of graded, phonically based material in the practice's data base to develop fluency-based programmes for children of different ages and with different pre-test levels of reading, writing, spelling and sequential spelling skill. Besides Child H, these materials have been used by the parents of a number of other children diagnosed as having learning disabilities manifesting in difficulties with reading, writing and spelling, as well as fluency-based difficulties.

As a number of additional children have used the same data base of materials as well as similar methods for developing reading, writing and spelling fluency, the case aggregative techniques described in a previous publication provide a basis for ongoing aggregation [6]. This used categorical variables to contrast the results of an opportunity sample of 20 children selected from the files of children with whom similar fluency-based programmes had been implemented over a three-year period with the results of other children exposed to differing types of fluency-based programme implementation.

*Multivariate Treatment of Dyslexia, Dysgraphia and Dyscalculia DOI: http://dx.doi.org/10.5772/intechopen.110287*

Criteria for inclusion were that each of the 20 children had been diagnosed with a learning disability affecting reading, writing, and spelling, and also had fluency-based difficulties. Each child was also exposed to work in all three areas of intervention (reading, writing and spelling) of the fluency-based programmes described in this current chapter. Based on case contrast analysis with the results of 6 children on whom systematic variation in one or more area of programme implementation had occurred over the three-year period, a number of implementation variables were found to be likely to affect the successful implementation of our fluency-based work.

These variables were as follows:


Despite the many limitations and threats to validity implicit in aggregative case survey analysis, these results indicate the potential of using categorical variables for purposes of classification and contrast, as a basis for identifying central trends in multimethod data drawn from clinical work with children, and relating these to outcomes. The central trends reported above are of interest as each of the treatment variables applied in the types of fluency-based programmes used in working with Child H, in the case study presented in this chapter. Consistent implementation has also taken place. Consistent support from Child H's parents has been present over the entire period of programme implementation. The evidence of outcomes has also been positive.

#### **20. Notes**

Note 1. This has been described in a previous chapter which can be accessed *via* the following link:

http://mts.intechopen.com/articles/show/title/dyslexia-dysgraphia-and-dyscalc ulia-a-response-to-intervention-approach-to-classification

Note 2. The ICD-10 (International Statistical Classification of Diseases and Related Health Problems – Tenth Revision) is a diagnostic coding standard owned and maintained by the World Health Organisation (WHO) [182]. The coding standard has been adopted by the National Health Information System of South Africa (NHISSA), and forms part of the health information strategy of the South African National Department of Health (NDOH). The standard serves as the diagnostic coding standard of choice in both the public and private healthcare sectors in South Africa for morbidity coding under Regulation 5(f) of the Medical Schemes Act 131 of 1998 [183].

Note 3. Rob Stark, of the Centre for Therapeutic Excellence https://www. centrefortherapy.co.za

Note 4. The multivariate approach to assessment and treatment used in the practice has been described in a previous two part publication which can be accessed via the following links.

https://www.intechopen.com/books/learning-disabilities-an-internationalperspective/developing-automaticity-in-children-with-learning-disabilities-afunctional-perspective-part-one-the

http://www.intechopen.com/articles/show/title/developing-automaticity-inchildren-with-learning-disabilities-a-functional-perspective-part-two-pro

Note 5. Child H was educated in a government-funded primary school in the northern suburbs of Johannesburg, which are areas where parents usually lie in higher socio-economic bracket than parents in other residential areas, or the reason that as the city evolved, the eastern, western and southern suburbs were closer to the dust, pollution as well as the physical danger of underground blasting in the gold mines. As commercial gold mining has been phased out as the underlying gold-bearing reef has been exhausted, wealth distinctions affecting residential areas have become more blurred. As a result, the children in the author's practice come from a wide catchment area, with many parents travelling from the eastern, southern and western suburbs, and some parents travelling as much as 600 kilometres from out of town on a weekend to bring their children for assessment or to educational therapy sessions. Similarly, the referral and schooling network in the practice covers a wide geographical area. This is possible with the advent of email and cell phones, and this has been enabled by the fact that our reading, writing and spelling fluency materials and manuals are electronic.

Note 6. These were developed in the classroom in 1978 and 1979, while the author was working at Crossroads Remedial Centre and then at Norwood Remedial School. The initial research results were analysed in early 1979 and reported in mid-1979 [87], prior to the author joining the University of the Witwatersrand, Johannesburg. The Phonic Inventories were then implemented as one of the instruments used in research conducted at Japari Remedial Centre, Parktown, Johannesburg. The results were reported between 2005 and 2011 [89, 90, 98, 184, 185].

Note 7. In working with Child H and other children in the practice, my aim has been to link instructional activities to the child's cognitive style, which is defined as the ways in which each child thinks, perceives and remembers information. Child H's cognitive style was determined by listing areas of strength and areas of weakness from a number of indicators of how he processed information (e.g. areas of strength and areas of weakness in his cognitive and achievement test profiles) [186, 187]. Following Piaget [188], these indicators were then combined with observation of the successful strategies employed by Child H as well as errors made in working on activities involving use of perception, language, thinking and working memory. Areas of weakness and errors made then formed the targets for instruction, using methods based on Child H's strengths and the learning strategies he found to be effective in writing and spelling individual words and words in sequence. These were determined through action research based on observation, followed by evaluation and replanning.

Note 8. In terms of ICD DSM IV diagnosis [189], assessment of reading difficulties would normally be conducted on Axis IV, which would aim to identify psychosocial stressors, as well as psychosocial and environmental problems affecting reading ability on a functional level. Reading difficulties would then be classified under reading disorders, corresponding to ICD-10 code F81.0 and DSM-IV code 315.00, as follows:

A. Reading achievement, as measured by individually administered standardised tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence and age-appropriate education.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills.

C. If a sensory deficit is present, the reading difficulties are in excess of those usually associated with it.

If a general medical (e.g. neurological) condition or sensory deficit is present, Axis III on the ICD DSM IV would also be used for classification purposes. This axis aims to identify underlying medical or neurological conditions which may influence reading ability (e.g. attentional or concentration difficulties, especially those associated with cortical immaturity, or slow myelinisation associated with poor connectivity).

Note 9. The diagnostic criteria corresponding to ICD-10 code F81.2 and DSM-IV code 315.2 for 315.2 a disorder of written expression are as follows:

A. Writing skills, as measured by individually administered standardised tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence and age-appropriate education.

B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organised paragraphs).

C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

As with Code 315.00, if a general medical (e.g. neurological) condition or sensory deficit is present, the condition would then be coded.

Note 10: This was done through use of standard scores linked to age equivalents.

Note 11: At time of writing this chapter there are between eight and nine thousand items in the practice's data base. These are graded, and test-based. As all of the materials are electronic, they can be sent out by email. This enables implementation of multivariate programmes based on use of our methods and materials both locally and internationally.

Note 12: Based on a points reward system suggested to me by Alex Bannatyne in 1977.

Note 13. Based on the author's work with Errol van der Merwe in developing three dimensional spatial perception working with engineering students at the University of the Witwatersrand over a 20-year period [155, 156, 158, 159, 188, 190–195], as well as work done over a 10-year period with children at Japari Remedial School, Johannesburg. This involved implementation of instructional procedures based on use of eidetic imagery in visualising and revisualising words [161, 196–198].

Note 14. The possibilities of using eidetic imagery in developing working memory for words are indicated by the author's clinical work using the Targeted Revisualisation and Sequential Spelling Programme with a number of children with reading, writing and spelling difficulties [5, 6], as well as by research done by Ravenscroft [161]. Ravenscroft used a mental imagery questionnaire based on procedures for visualising and revisualising words with a sample of 92 children at Japari Remedial Centre, each of whom had been diagnosed as having a learning disability. About 76% of children in the sample (70 out of the 92 children tested) were able to use eidetic imagery to visualise and revisualise words. Ravenscroft's research thus indicated the potential value of using revisualisation techniques in working with children with learning disabilities, as well as the high incidence of spatial competence in children with reading, writing and spelling difficulties. This provided support to my

own clinical work which has focused on combining phonological referencing, phonic analysis and revisualisation techniques in developing working memory for words, and sequential working memory for words [8, 105].

Note 15: It is important to note that my work has involved adaptation use of Fernald's techniques. Ravenscroft's research indicated that three out of four children in a sample of 92 children at Japari were able to use eidetic imagery for purposes of recalling words. At the same time, one out of four children in the sample was not high visualisers. For this reason, both visual imagery and other forms of mental imagery (e.g. reauditorisation or use of kinetic or tactile imagery) would need to be used in developing working memory for words.

At the same time, there were also indications from Ravenscroft's data that eidetic imagery was trainable. As Kasdon has pointed out, this is also implicit in the stages involved in Fernald's procedures. As Fernald has suggested [27], what is important is to develop the ability to look at the word and say it, to close one's eyes and use mental imagery to recall the word, then to say the word while holding the word in the mind with one's eyes shut (thus linking spoken language and mental image) and then to spell the word with one's eyes shut. It would also be important to test working memory through writing the word.

Following Fernald's suggestions, working memory for words as well as writing and spelling fluency would need to be developed in stages. It is also clear from Fernald's account (e.g. page 147), that visual imagery was not present with all the children she worked with at the start, but in a number of children developed through training. Individual children also adapted to the techniques in their own ways.

This has been the principle followed in my own work. As Kasdon has observed [162], the stages involved in using Fernald's techniques are not purely based on use of a kinesthetic method, but involve the development of a process of recall based on the child's particular use of mental imagery. The processes involved would be likely to vary from child to child. This is clear from the cases described by Fernald, and was the principle adopted in Kasdon's work at the Ferkauf clinic at Yeshiva University, as well as the principle adopted in working with Child H. This involved use of Fernald's techniques as a framework, which was then adapted to fit Child H's cognitive style and his individual ways of learning.

Note 16. Use of a format system enabled work to be conducted with Child H in a number of areas, and supported by work done at home. The format system was also used as the basis for the work done with other children online during COVID [8].

Note 17. Learning the spelling of words using occlusion involved a technique in which a word was written on the left hand side of the page, looked at and then covered with the hand while being written in the middle of the page. Both hands would then be lifted, and the words checked for consistency and accuracy. Both words would then be covered with the hand while the child tested him or herself by writing the word for the their time on the right hand of the page. Both hands would then be lifted, and the word marked by the child as correct or incorrect.

Note 18. As in the clinical work described by both Fernald and Kasdon, test information was combined with use of observation of the strategies used by Child H in remembering words. In working with Child H, grade and age scores from the Durrell tests of visual memory for words and phonic spelling of words were used as indicators of competence in using visual and auditory memory for recalling words. These were interpreted in conjunction with observation of the processes Child H used for revisualising words, and then writing these words from memory. Once the revisualisation process was well established, this was then extended into rapid reading of words combined with work on recall of words read rapidly using an electronic tachistoscope.

Note 19. In terms of ICD DSM IV diagnosis, there was evidence that Child H had reading difficulties which has continued over a number of years. This implied diagnosis on Axis IV, which would aim to identify psychosocial stressors, as well as psychosocial and environmental problems affecting reading ability on a functional level. This could then be classified as either ICD 10 Code F 81.3 relating to a continuing and long-term reading disorder, or ICD 10 Code Z 73.3 (stress not elsewhere classified).

Note 20. The diagnostic criteria corresponding to ICD-10 code F81.2 and DSM-IV code 315.2 for 315.2 a disorder of written expression also still applied, based on assessment of Child H's writing and spelling skills, as measured by individually administered standardised tests (or functional assessments of writing skills) are substantially below those expected given Child H's chronological age, measured intelligence, and age-appropriate educational reports from his school.

Note 21. The three levels of the Phonic Inventories focus on use of consonant blends in words based on short vowel sounds, use of vowel digraphs and use of morphological endings in polysyllabic and compound words based on short vowel sounds.

Note 22. The diagnosis of dyslexia linked to the ICD 10 diagnostic criteria was made by Robert Stark, of the Centre for Therapeutic Excellence. This was based on analysis of psychometric test data, combined with longitudinal analysis of school reports. In addition, Child H's response to intervention over the same period provided clear evidence of the need for concessions in reading, spelling and rate of work.

Note 23. A number of children in the practice have been using tachistoscopic methods for development of rapid reading as well as working memory for words. The response to use of these methods has been very positive. Child H, for example, reports that work on the tachistoscope has contributed to better processing of written material as well as more rapid cognitive processing more generally. Similar comments have been made by other adolescent boys and girls in the practice, indicating the potential of tachistoscopic work to address rapid reading of words as well as working memory for words read quickly.

Note 24. A level of literacy is defined as attainment of reading, writing and spelling age scores of between 12 and 13 years on achievement tests.

Note 25. Based on Child H's verbal and written evaluation comments.

Note 26. Robert Stark, of the Centre for Therapeutic Excellence., https://www. centrefortherapy.co.za

Note 27. The WISC, WISC-R, WISC IV and WISC V all use identical symbols and presentation formats in the coding subtest. The implementation procedures and timing of the test have also remained unchanged through all the different restandardisations of the WISC.

*Recent Advances in the Study of Dyslexia*
