Reading difficulty in children: Interventions

INTRODUCTION — Reading is critical to the academic, economic, and social success of children [1]. However, many children complete schooling without achieving more than basic literacy [2]. Pediatric clinicians are well positioned to identify children at risk for reading difficulties and children who have unexpected difficulties in learning to read. Early identification and timely intervention for such children improve long-term outcome.

Interventions for children with reading difficulty will be discussed here. Normal reading development and the epidemiology, etiology, clinical features, and evaluation of reading difficulty are discussed separately. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty" and "Reading difficulty in children: Clinical features and evaluation".)

General issues related to educational interventions for children with learning disability and the evolution of laws related to special education in the United States also are discussed separately. (See "Specific learning disorders in children: Educational management" and "Definitions of specific learning disorder and laws pertaining to learning disorders in the United States".)

TERMINOLOGY — A variety of terms are used to describe reading problems. Different terms may be used in different settings and by different groups (eg, educators, health care providers). Definitions for the terms that are used in this topic review are provided below. A detailed discussion of terminology is provided separately. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Terminology and conceptual framework'.)

●Reading difficulty – "Reading difficulty" is defined from a normative perspective (ie, how a child performs in reading compared with peers or educational expectations) [3]. Reading difficulty has a number of causes, one of which is reading disability.

●Reading disability – Reading disability is best defined as "an unexpected difficulty in learning how to read despite adequate intelligence, instruction, and motivation" [3]. The terms "dyslexia," "developmental dyslexia," "specific reading disability," and "reading disorder" also are used to describe this condition [4], although a more specific definition for "dyslexia" is provided below.

●Dyslexia – The term "dyslexia" is used as a synonym for specific reading disability [5,6]. The International Dyslexia Association defines dyslexia as follows [7,8]:

"Dyslexia is a specific learning disability that is neurologic in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonologic component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede the growth of vocabulary and background knowledge."

This definition also has been adopted by the United States National Institutes of Child Health and Human Development. In the text that follows, "reading disability" is used synonymously with "dyslexia."

OVERVIEW OF APPROACH — Patients with reading disability may require lifelong assistance [9]. The optimal management strategy depends upon the individual's age and circumstances:

●Strategies for preschool children focus on early literacy promotion.

●Strategies for children who are learning to read but who are slightly behind compared with classmates focus on remediation of the underlying problems in phonologic processing [9,10].

●Strategies for children who are learning to read but who are significantly behind classmates or who have disordered patterns in acquisition of reading skills focus on both remediation and compensation (usually through special education interventions).

●Strategies for children who have begun to read focus on increasing sight word vocabulary and reading comprehension.

●Strategies for children in secondary school and beyond focus on accommodation.

Interventions can improve reading in children with normal IQ as well as children and adolescents with intellectual disabilities [11].

Effective intervention programs provide children with systematic instruction in five critical areas [9,12]:

●Phonemic awareness – The ability to focus on and manipulate phonemes (the smallest units of spoken language) in spoken words.

●Phonics – Knowledge of relationships between letters and sounds and spelling-sound correspondence, which allows fluent phonologic decoding.

●Fluency – The ability to read orally with accuracy, speed, and expression.

●Vocabulary – The storage of word meanings.

●Comprehension – The ability to think about and extract the information provided in text while reading (ability to construct meaning from the recognized words) [12].

In addition to systematic and structured training exercises in phonemic awareness and phonics, children with reading difficulty require practice in reading stories aloud [9]. Reading practice allows children with reading disability to use their decoding skills while reading words in context and to experience reading for meaning. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Normal reading development'.)

The evaluation of interventions for reading difficulty has occurred primarily in children beginning to read (eg, in kindergarten and first grade). Phonemic awareness and phonics instruction have been evaluated in a number of randomized or quasi-randomized controlled trials [12-14]. Interventions for older children are not well studied, and there are no firm conclusions regarding the best way to teach fluency, vocabulary, and reading comprehension [15]. Nonetheless, a meta-analysis of studies of reading interventions for children and adolescents with reading difficulty in grades 4 through 12 found a moderate mean effect on reading performance (approximately one-half of one standard deviation for all reading outcome measures and for reading comprehension outcome measures) [16]. The mean effect size was lower for studies that used standardized measures of reading performance and for studies published after 2005, possibly reflecting increased use of standardized measures of reading performance and improved instruction and outcomes in the comparison groups.

Management of reading disability may involve educators, psychologists, and pediatric clinicians [17]. Interventions usually are provided by educators within the school system and/or, depending upon caregiver resources, by private tutors. The information below is provided to help pediatric health care clinicians understand the components of effective intervention so that they can help the caregivers make sure the child receives appropriate interventions.

EARLY LITERACY PROMOTION

Precursor skills — Early or precursor literacy skills that correlate with subsequent literacy achievement include [18]:

●Knowledge of the names and sounds associated with letters (alphabet knowledge)

●Ability to detect, manipulate, or analyze the auditory aspects of spoken language independent of meaning (phonologic awareness)

●Rapid automatic naming of letters and digits

●Rapid automatic naming of objects or colors

●Writing one's name

●Ability to remember spoken information for a short period of time (phonologic memory)

Practices that promote early literacy skills — Instructional practices that promote early literacy skills include code-focused interventions (ie, increasing phonologic awareness), language enhancement interventions, shared reading, caregiver-home programs, and preschool and kindergarten programs [18].

●Code-focused interventions – Code-focused interventions teach children the relationship between written letters and word sounds (ie, to "crack the alphabet code"). Nearly all code-based interventions emphasize phonologic awareness, either in isolation or in combination with other code-focused instruction.

●Language enhancement – Language-enhancement interventions are instructional efforts aimed at improving language development in young children. Such interventions enhance a wide range of measures of oral language, including expressive and receptive language skills, phonemic awareness, and verbal intelligence [18].

●Shared reading – Shared-reading interventions involve reading one-on-one to children with varying degrees of child-reader interaction. Shared reading appears to improve oral language skills and print knowledge, particularly when it takes place frequently and is interactive [18,19]. Frequent shared reading also is associated with fewer subsequent childhood emotional and behavior problems [20]. Shared reading by itself does not appear to promote improvement in conventional literacy skills (ie, oral reading fluency, reading comprehension, writing, and spelling) [18].

●Caregiver-home programs – Caregiver-home programs are interventions through which the caregiver promotes literacy in the home setting, typically through caregiver-child shared reading. Well-known national efforts include Reach Out and Read (ROR) and Reading is Fundamental. Caregiver-home programs help to promote oral language skills and cognitive abilities in young children [18].

●Preschool and kindergarten programs – Preschool and kindergarten programs have the largest impact on measures of readiness, a composite of early literacy predictors including alphabet knowledge, print concepts, vocabulary, memory, and phonologic awareness [18].

●Identification of and intervention for at-risk prereaders – Asking about a family history of reading difficulty, asking about exposure to books and reading at home, and monitoring prereading skills may identify children at increased risk for reading difficulty [21-24]. (See "Reading difficulty in children: Normal reading development and etiology of reading difficulty", section on 'Risk factors' and "Reading difficulty in children: Clinical features and evaluation", section on 'Preschooler at risk'.)

At-risk children can be referred for intervention before starting school, when interventions for reading difficulty are most effective [21]. (See 'Precursor skills' above.)

Reach Out and Read — ROR is a literacy promotion program in which clinicians give children a developmentally and culturally appropriate book, emphasize the importance of reading, and model reading to the child at each well-child visit between six months and five years [25]. The American Academy of Pediatrics recommends that regular literacy promotion begin during infancy and continue until entry into school and supports the regular provision of books at well-child visits for vulnerable populations [26].

No existing research has evaluated the effect of ROR on early reading skills (eg, print knowledge, phonologic awareness) or beyond entry into kindergarten [27]. However, randomized, quasi-experimental, and observational studies indicate that ROR affects caregivers' reading frequency, behaviors, and attitudes and improves language development in young, high-risk children [25,27-34]. As an example, in a nationally representative sample of 1647 subjects, ROR was associated with a variety of positive reading promotion behaviors, including reading aloud before bedtime (odds ratio [OR] 1.5), reading aloud ≥3 days per week (OR 1.8), and ownership of 10 or more picture books (OR 1.6) [32].

REMEDIATION

Content areas — In prereaders and beginning readers, reading interventions focus on remediation of reading skills. Basic skills (ie, phonemic awareness, phonics) are emphasized in the early school years, and vocabulary and comprehension as schooling progresses. Older students (grade 4 through high school) benefit from interventions focused at the word and text level, improved knowledge of word meanings and concepts, and reading comprehension strategies [16].

Phonemic awareness — We recommend instruction in phonemic awareness as the major focus of reading remediation for young children with reading difficulty or reading disability [10,12,35-40]. Phonemic awareness helps children understand the way letters are used to represent sounds [41].

Instruction in phonemic awareness includes [12,13]:

●Phoneme isolation ("Tell me the first sound in 'paste.'")

●Phoneme identity ("Tell me the sound that is the same in 'bike,' 'boy,' and 'bell.'")

●Phoneme categorization ("Which word does not belong: 'bus,' 'bun,' 'rug'?")

●Phoneme blending ("What word is /s/ /k/ /u/ /l/?" [school])

●Phoneme segmentation ("How many sounds are there in 'ship'?")

●Phoneme deletion ("What is 'smile' without the /s/?")

Phonemic awareness instruction is helpful to young readers who are at risk, reading disabled, or progressing normally but is most helpful to those who are at risk [12]. There are few data on the effect of phonemic awareness training programs for children beyond the second grade.

In a meta-analysis of experimental studies of phonemic awareness instruction compared with alternative approaches, phonemic awareness instruction had a large effect in improving phonemic awareness in readers who were at risk, reading disabled, or progressing normally and a moderate effect on reading outcomes [12]. At follow-up, phonemic awareness instruction had a large effect on reading development in at-risk readers and a small to moderate effect on reading development in children with reading disability. Another meta-analysis supports the long-term effects of interventions targeting phonemic awareness [42]. In addition to improvements in reading ability, in a functional magnetic resonance imaging study, phonemic awareness instruction was associated with changes in brain function specific to language processing to resemble the patterns in normal readers [43].

Effective elements of phonemic awareness interventions include [9,10,12,15,40]:

●Teaching children to manipulate phonemes with letters (rather than limiting manipulation to sounds); this allows children to apply the skills to reading and writing

●Focusing the instruction on one or two types of phoneme manipulation

●Teaching children in small groups

●Providing systematic instruction and teaching children how to apply phonemic awareness skills in reading and writing tasks

●A multisensory approach (eg, asking the children to write letters in the air, trace letters on paper, etc)

Phonics — Systematic (ie, planned and sequential) phonics instruction stresses the acquisition of skills in letter-sound correspondence and the use of these skills to read and spell words [10,12]. Explicit, systematic phonics instruction is critical for children beginning to read and those with reading difficulty.

Systematic phonics instruction is effective in improving reading skills. The effect varies with age/grade level and is generally greater in children who are at risk and those with mild reading disability than in those who are more severely affected [12,13]

In meta-analyses of experimental, randomized, and quasi-randomized studies, systematic phonics instruction had a moderate to large effect in improving general literacy/reading performance for kindergarten and first-grade children at risk of reading problems [12], and a small to moderate effect for children and adolescents with reading disability [12,13]. Systematic phonics instruction was more effective in improving general literacy for normal readers during first grade than afterward. In another meta-analysis of randomized and quasi-randomized trials, phonics interventions (alone or combined with one other literacy-related skill intervention) had a small to large effect in improving accuracy of and reading fluency compared with no training or nonliteracy training interventions in poor readers [14].

Fluency — Fluency is the ability to read orally with accuracy, speed, and expression. It requires well-developed word-recognition skills and is a critical factor in reading comprehension [12,44,45]. We recommend repeated oral reading practice as the most effective method to build reading fluency [6,12]. Other terms for repeated oral reading practice include guided-repeated oral reading, paired reading, shared reading, assisted reading, student-adult reading, chorale reading, tape-assisted reading, and partner reading [6,12].

In repeated oral reading, the child reads aloud repeatedly to a teacher, an adult, or a peer and receives feedback. Guided oral reading has a clear and positive impact on word recognition, fluency, and comprehension at many grade levels [9,12].

In a meta-analysis of experimental studies, guided oral reading had moderate effects on reading accuracy and small to moderate effects on reading fluency and reading comprehension [12]. Guided oral reading was beneficial for children without reading impairment through at least grade 4 and for children with various reading problems through high school. It appears to be effective under a variety of conditions and with minimal special training or materials.

Vocabulary — Vocabulary building is an important aspect of reading comprehension. However, methods of vocabulary instruction are not well standardized, and there are few studies that evaluate the effectiveness of various strategies, particularly using standardized measures [16].

A national panel of experts in reading and education, reading teachers, and caregivers concluded that [12]:

●Vocabulary can be learned incidentally in the context of storybook reading or from listening to the reading of others.

●Repeated exposure to vocabulary items is important, particularly exposure in contexts outside the classroom.

●Vocabulary instruction before reading a passage that contains the vocabulary words facilitates vocabulary acquisition and comprehension.

●Active engagement in learning tasks facilitates vocabulary acquisition.

●Vocabulary learning is optimized by using multiple methods of instruction.

Comprehension — Interventions for teaching reading comprehension are not well established [6]. The most effective methods appear to involve teaching vocabulary and strategies that encourage active interaction between the reader and the text [12,15]. Multicomponent reading interventions typically include instruction in reading comprehension [16].

A systematic review identified the following effective strategies for teaching reading comprehension [12]:

●Comprehension monitoring, in which the reader learns how to monitor their understanding during reading and to manage problems in understanding as they arise.

●Cooperative learning, in which readers work together to learn reading comprehension.

●Graphic and semantic organizers that allow the reader to write or draw the meanings and relationships of the ideas that underlie the words in the text.

●Story structure, from which the reader learns to ask and answer who, what, where, when, and why questions about the plot and, in some cases, maps out the time line, characters, and events.

●Question answering, in which the reader answers questions posed by the teacher.

●Question generation, in which the reader asks themself questions about the text (who? what? when? where? why? how? what will happen next?).

●Summarization, in which the reader attempts to identify and write the main or most important ideas that integrate or unite the other ideas or meanings of the text into a coherent whole.

Intensity — Students with reading difficulty require "intensive" instruction. Although "intensive" is not always defined clearly [46], interventions with greater intensity appear to be more effective [13]. In a meta-analysis, intensive reading interventions (defined by ≥100 sessions) had a small to moderate effect on improving reading performance in students with or at risk for reading difficulties in kindergarten through third grade [47]. Intensive reading interventions also may be associated with cortical brain growth [48].

Intensive instruction can consist of three to five sessions weekly, lasting 30 to 60 minutes each, occurring in a small group setting (ie, three students or less), and provided over the course of several weeks to a year. More severely disabled readers may need intensive instruction over the course of years. The intensity of instruction can be increased by increasing the number of sessions per week, increasing the duration of the sessions, and by reducing the number of sound-symbol correspondences that are taught each week. Low-intensity supplemental tutoring for a few minutes two or three times per week, or instruction provided in groups of 6 to 10, are not likely to result in an adequate response and may not be cost effective in the long run [49,50].

Intervention programs — The Orton-Gillingham approach to reading intervention has been used since the 1930s. It is a multisensory, sequential, phonics-based system that teaches the basics of word formation before whole meanings. It emphasizes visual and auditory feedback for sounds and tactile-kinesthetic input for letter formation [15]. Several treatment programs that are based on the Orton-Gillingham techniques are commercially available, although few have been tested in methodologically sound studies [15,51]. Examples of commercially available programs include: the Wilson method, Project Read, Alphabetic Phonics, the Herman method, the Slingerland method, Language!, and the Spalding method [15,51].

ACCOMMODATION — For students in secondary school, college, and beyond, we suggest educational accommodations, including [9,52]:

●Extra time for reading and test-taking

●Recording classroom lectures

●The use of note-takers or a note service

●Access to syllabi and lecture notes

●The use of tutors to "talk through" and review the content of reading material

●The use of live readers or audiobooks (available from Learning Ally)

●The use of a word processor and spell-checker

●Opportunity to take tests in alternate formats (eg, orally, short essays) and/or in a separate quiet room

●Relaxation of the requirement to study a second language

UNPROVEN THERAPIES — A number of unconventional therapies have been proposed as treatment for reading disability, including optometric training, pharmacotherapy for vestibular dysfunction, chiropractic manipulation, dietary supplementation, specialized fonts [53-55], video games [56], and music education [6,57]. Such interventions are not supported by high-quality empiric evidence [57-63].

"Irlen syndrome" is a proposed perceptual disorder that causes distortions when viewing text and contributes to reading difficulty. It is treated with colored lenses (Irlen lenses) or plastic overlays (Irlen overlays). Both the disorder and the intervention are controversial [64]. A randomized trial found no benefit to the use of colored overlays in schoolchildren with reading difficulty (the majority of whom had been diagnosed with Irlen syndrome by an Irlen diagnostician) [62]. Two systematic reviews also concluded that colored lenses or overlays are not helpful in improving reading performance [13,65]. We do not recommend colored lenses or overlays to treat reading difficulty in children.

OUTCOME — Children who have reading difficulty that resolves during kindergarten typically become normal readers [66,67]. In contrast, reading disability persists throughout life; it is not a transient "developmental lag" [68-75]. Many children with reading disability become proficient in reading a set of words that recur in their areas of interest [9]. They also may be able to decode unfamiliar words accurately but not fluently or automatically [6,9,68,73,76]. Even after acquiring decoding skills, reading tends to be slow and laborious.

Longitudinal studies demonstrate that although the reading scores of children with reading disability improve as they get older, a gap remains between them and children without reading disability [68,73,77,78]. Over time, poor readers and good readers tend to maintain their relative positions along the spectrum of reading ability [77]. Children with persistent deficits in fundamental reading skills have lower academic performance overall [68].

Among at-risk children in kindergarten and first grade and children in the second through sixth grades, the following characteristics are associated with poor outcome in reading and spelling [15,72,79]:

●Poor rapid naming

●Poor verbal ability

●Poor attention or behavior overall

●Poor fluency

●Poor response to intervention (see "Specific learning disorders in children: Educational management", section on 'Response to intervention services')

Children with reading disability are at risk for secondary social, emotional, and behavioral problems, reporting higher rates of anxiety, depression, and somatic complaints than children without reading disability [80-82]. They also are less likely to graduate from high school and therefore are at greater risk for unemployment, underemployment, and incarceration [83]. Poor reading achievement has been associated with antisocial behavior, but the relationship is complex [84].

RESOURCES — The following resources may provide additional information for caregivers and clinicians:

●"Overcoming Dyslexia" by Sally Shaywitz, MD (2003)

●LD OnLine

●Eunice Kennedy Shriver National Institute of Child Health and Human Development

●International Dyslexia Association

●Reading Rockets for kindergarten through third grade students

●The Federation for Children with Special Needs

●The Florida Center for Reading Research

●Learning Ally – Support for Dyslexia and Learning Disabilities

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Dyslexia (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Approach – Patients with reading disability may require lifelong assistance. The optimal management strategy depends upon the individual's age and circumstances. (See 'Overview of approach' above.)

•Strategies for preschool children focus on early literacy promotion.

•Strategies for children who are learning to read but are slightly behind compared with classmates focus on remediation.

•Strategies for children who are learning to read but who are significantly behind classmates or who have disordered patterns in acquisition of reading skills focus on both remediation and compensation (usually through special education interventions).

•Strategies for children who have begun to read focus on increasing sight word vocabulary and reading comprehension.

•Strategies for children in secondary school and beyond focus on accommodation.

●Early literacy promotion – Instructional practices that promote early literacy skills include code-focused interventions (ie, increasing phonologic awareness), language enhancement interventions, shared reading, caregiver-home programs, and preschool and kindergarten programs. (See 'Early literacy promotion' above.)

●Phonemic awareness and phonics – Instruction in phonologic processing is the major focus of reading remediation. Direct and systematic phonemic awareness and phonics instruction are beneficial for children with limited exposure to reading before school entry, as well as for those with reading disability. (See 'Phonemic awareness' above.)

We recommend systematic instruction in phonemic awareness and phonics for young children with reading difficulty or reading disability (Grade 1A). (See 'Phonemic awareness' above and 'Phonics' above.)

●Fluency – We recommend repeated oral reading practice to improve fluency in children with reading disability (Grade 1A). (See 'Fluency' above.)

●Vocabulary and comprehension – Instruction strategies that require active engagement of the student facilitate acquisition of vocabulary and reading comprehension skills. (See 'Vocabulary' above and 'Comprehension' above.)

●Educational accommodations – We suggest educational accommodations for children with reading disability in secondary school and beyond (eg, extra time, audiobooks) (Grade 2C). (See 'Accommodation' above.)

●Unproven therapies – Interventions such as optometric training, treatment of vestibular dysfunction, chiropractic manipulation, colored lenses or overlays, dietary supplementation, specialized font, video games, and music education are not supported by high-quality evidence. (See 'Unproven therapies' above.)