*3.1. Site Selection*

Penang was selected as the research location for this study. It is an island-state off the northwest coast of Peninsular Malaysia, and is one of the most developed Malaysian states with a population of 1.77 million [77]. This study contributes on the empirical examination and validation of social disorganisation theory by using multiple mediators. Countless aspects present across areas encompassing diverse cultures and neighbourhoods, such as physical and social factors, can be considered.

A survey conducted in Penang, Malaysia, covered a sample of 265 residents (after data cleaning) across a heterogeneous neighbourhood using a systematic sampling method. The study area is in the southeast part of Penang, Malaysia. It is built in on what used to be paddy fields in the mid-1970s, and was quickly converted into the residential neighbourhood that it is now. The location, which consists of landed properties, is a typical medium-class housing area with semi-detached terrace houses. A few condominium blocks and walk-up apartments have been constructed in the last decade at the boundaries of housing estates. This study focused on the landed properties, because they are the predominant types of dwelling in the area. This study used a systematic sampling procedure to select residents at intervals of every fourth unit in the study area.


**2. Genomic for screening and enhancement of SMs**

#### **2.1 Gene editing for metabolites discovery**

Biosynthesis gene clusters (BGCs) are the genes associated with the biosynthesis of secondary metabolites. These BGCs include all genetic information necessary for SMs' biosynthesis, assembly, modification, and regulation of their export and transport [11]. Microorganisms' genome contains variety of cryptic or silent genes that are responsible for the production of secondary metabolites but are not expressed under laboratory conditions. It has been reported that most BGCs remain silent and cannot be fully expressed under standard laboratory conditions. These silent BGCs are potentially significant in the discovery of novel SMs [11–14].

Due to the development of genomic and bioinformatic field, we are able to access extensive sequencing data and genetic information and enable genome mining of relevant BGCs with the potential for valuable SM production [15]. Therefore, biosynthetic biology and genetic engineering tools are now utilized for identification of novel BGCs. In fact, genetic engineering is now widely used and moving beyond traditional tools, which has opened a new era in the detection of novel secondary metabolites [16]. Genetic engineering for the production of SMs can be carried out in heterologous as well as homologous host. In fact, gene manipulation in heterologous host enables the activation of biosynthesis gene clusters (BGCs) obtained from unculturable organisms, whereas gene manipulation in homologous host allows the retention of all natural factors essential for the production of secondary metabolites [17]. While there is no single approach that will work for all genes of interest, a variety of techniques have been developed to induce the expression of these genes.

In fact, several genome techniques have emerged and are utilized in the metabolomic production field, including transcriptional activator-like effector nucleases (TALENs), zinc finger nucleases (ZFNs), and clustered regulatory interspaced short palindromic repeat (CRISPR-Cas9) [18, 19]. Each genome engineering technology has its own advantages and disadvantages (**Table 2**). For instance, ZFNs and TALENs have been successfully utilized in various microbes but still have limitation which includes the difficulty to engineer them [20]. Recently, CRISPR-Cas9 has been reported to be a significant and promising genome editing technology in the discovery and production of SMs [17, 16, 21].

#### *2.1.1 Gene cloning*

Direct cloning of the entire BGCs into the heterologous host is the most general and widely used approach for the activation of silent BGCs. Nowadays, many

#### **Table 2.**

*Different genomic engineering techniques used in Metabolomic.*

new cloning tools have been introduced, including Cas9-assisted targeting of chromosome segments (CATCH), transformation-assisted recombination (TAR), and TAR-CRISPR [22–24]. Basically, gene cloning steps include: determining the suitable heterologous host, cloning of the target BGC, transfer of the BGC into the chosen host, expression in chosen host system, and optimization of production.

**5**

*Enhancement and Identification of Microbial Secondary Metabolites*

Cas9-assisted targeting of chromosome segments (CATCH) is a cloning technique that utilizes the CRISPR-Cas9 gene editing system for direct BGCs cloning into the host. Comparing with traditional cloning tools such as PCR and restricted enzymes, CATCH is predicted to become a useful molecular tool for direct cloning of large gene clusters. Transformation-assisted recombination (TAR) has been used for cloning of large BGCs for about decades. However, the TAR approach is associated with a low cloning efficiency, which means it requires screening of hundreds of colonies to detect few positive clones [22, 24]. To address this challenge, TAR and CRISPR-Cas9 have been coupled resulting in a new approach called TAR-CRISPR [24]. By coupling TAR with CRISPR, a significant increase of the clone efficiency has been reported. Comparing with traditional TAR cloning, the advantages of TAR-CRISPR are that the positive clones could be achieved with secondary screening and lesser manpower and also it does not require a high experience of working with yeast [24]. In fact, the TAR-CRISTAR cloning will allow for the development of BGC cloning and SM production in the future.

Gene refactoring or replacement is useful not only in BGCs' activation but also for novel SMs' discovery. In fact, several silent BGCs have been refactored by replacing the BGC promoter to yield natural products such as secondary metabo-

Another new tool in gene refactoring is multiplexed CRISPR-Cas9- and transformation-associated recombination (TAR)-mediated promoter engineering method (mCRISTAR) [21]. This new tool combines the advantages of the CRISPR-Cas9 system and TAR. It is different than the TAR-CRISPR that was discussed earlier. Comparing with TAR-CRISPR, which is a yeast-based method, basically mCRISTAR uses CRISPR-Cas9 to break the double-stranded in the promoter region of the BGC, and the fragments produced are reassembled by TAR with synthetic gene-cluster-specific promoter cassettes. Another gene refactoring tool that has aided in the faster cloning and refactoring of BGCs is the direct pathway cloning (DiPaC). Direct pathway cloning (DiPaC) depends on PCR amplification and in vitro DNA assembly for biosynthesis gene cluster capture and their expression. DiPaC was recently employed for the capture of biosynthesis gene cluster, which is small in size, followed by their activation and expression of novel natural products [29]. DiPaC was also able to successfully clone mid and large size of BGC [29].

A large number of researches have documented the effect of gene knockout/in on BGC expression or levels of SM production. However, conventional methods of gene editing are time-intensive, while CRISPR-Cas9-based approach allows for much faster and efficient gene editing [30]. The emergence of CRISPR-Cas9 has opened up a new era in gene editing opportunities [31]. Recently, CRISPR gene editing approach has been used to insert promoter in order to activate microor-

Nowadays, CRISPR-Cas9 is used to introduce promoter at multiple BGCs, and at the same time, resulting in the activation of BGCs followed by the production of SMs [32]. Multiplexed site-specific genome engineering (MSGE) was also used for multiple BGCs' editing [33]. MSGE has led to a significant increase in the secondary

While, gene editing approaches provide a significant platform to manipulate the genetic machinery of microbes toward the production of novel, natural secondary

*DOI: http://dx.doi.org/10.5772/intechopen.93489*

*2.1.2 Gene refactoring*

*2.1.3 Gene insertion or deletion*

ganisms' SMs' production [32].

metabolites' production.

lites [25–28].

#### *Enhancement and Identification of Microbial Secondary Metabolites DOI: http://dx.doi.org/10.5772/intechopen.93489*

Cas9-assisted targeting of chromosome segments (CATCH) is a cloning technique that utilizes the CRISPR-Cas9 gene editing system for direct BGCs cloning into the host. Comparing with traditional cloning tools such as PCR and restricted enzymes, CATCH is predicted to become a useful molecular tool for direct cloning of large gene clusters. Transformation-assisted recombination (TAR) has been used for cloning of large BGCs for about decades. However, the TAR approach is associated with a low cloning efficiency, which means it requires screening of hundreds of colonies to detect few positive clones [22, 24]. To address this challenge, TAR and CRISPR-Cas9 have been coupled resulting in a new approach called TAR-CRISPR [24]. By coupling TAR with CRISPR, a significant increase of the clone efficiency has been reported. Comparing with traditional TAR cloning, the advantages of TAR-CRISPR are that the positive clones could be achieved with secondary screening and lesser manpower and also it does not require a high experience of working with yeast [24]. In fact, the TAR-CRISTAR cloning will allow for the development of BGC cloning and SM production in the future.

#### *2.1.2 Gene refactoring*

*Extremophilic Microbes and Metabolites - Diversity, Bioprospecting and Biotechnological...*

It does not require protein engineering steps, very simple to test multiple gRNA

It works by including double-strand breaks in target DNA or singlestrand DNA nicks (Cas9 nickase)

CRISPR consists of single monomeric protein and chimeric RNA

been observed

Easy and very fast procedure

It can cleave methylated DNA in human cells. This aspect is of special concern for plants as this has not been much explored

advantage of CRISPR, and several genes can be edited at same time. Only Cas9 is needed

6 Components crRNA, Cas9 proteins Zn-finger

5 Mutation rate Low mutation rate has

1 Protein

2 Mode of action

4 Structural proteins

7 Length

8 Target

9 Level of experiment

10 Methylated DNA cleavage

11 Multiplexing This is the main

*Different genomic engineering techniques used in Metabolomic.*

of target sequence (bp)

recognition efficiency

engineering steps

**CRISPR/Cas9 Zinc finger**

3 Cloning Not Required Required Required

**nucleases (ZFNs)**

It requires complex steps to test gRNA

It can induce double-strand breaks in target DNA

ZFNs work as dimeric and only protein component is required

High mutation rate has been observed in plants

domains, nonspecific FOKI nuclease domain

20–22 18–24 24–59

High High High

Complicated procedure and need for expertise in protein engineering

Highly difficult to achieve this through ZFNs

**Transcription factorlike effector nucleases (TALENs)**

TALENs need protein engineering steps to test gRNA

Induces DSBs in target DNA

TALENs also work as dimeric and require protein component

Mutation rate is high as compared to CRISPR

Zn-finger domains, nonspecific folk nuclease domain

Relatively easy procedure

marks upon the capacity of TALENs to perform methylated DNA cleavage

Very difficult to obtain multiplexed genes by means of TALENs. Because it needs separate dimeric proteins specific for each target

Unable to do so There are many question

new cloning tools have been introduced, including Cas9-assisted targeting of chromosome segments (CATCH), transformation-assisted recombination (TAR), and TAR-CRISPR [22–24]. Basically, gene cloning steps include: determining the suitable heterologous host, cloning of the target BGC, transfer of the BGC into the chosen host, expression in chosen host system, and optimization of production.

**4**

**Table 2.**

Gene refactoring or replacement is useful not only in BGCs' activation but also for novel SMs' discovery. In fact, several silent BGCs have been refactored by replacing the BGC promoter to yield natural products such as secondary metabolites [25–28].

Another new tool in gene refactoring is multiplexed CRISPR-Cas9- and transformation-associated recombination (TAR)-mediated promoter engineering method (mCRISTAR) [21]. This new tool combines the advantages of the CRISPR-Cas9 system and TAR. It is different than the TAR-CRISPR that was discussed earlier. Comparing with TAR-CRISPR, which is a yeast-based method, basically mCRISTAR uses CRISPR-Cas9 to break the double-stranded in the promoter region of the BGC, and the fragments produced are reassembled by TAR with synthetic gene-cluster-specific promoter cassettes. Another gene refactoring tool that has aided in the faster cloning and refactoring of BGCs is the direct pathway cloning (DiPaC). Direct pathway cloning (DiPaC) depends on PCR amplification and in vitro DNA assembly for biosynthesis gene cluster capture and their expression. DiPaC was recently employed for the capture of biosynthesis gene cluster, which is small in size, followed by their activation and expression of novel natural products [29]. DiPaC was also able to successfully clone mid and large size of BGC [29].


**7. Nanoemulsions for phytopharmaceuticals**

Recently, considerable attention has been focused on the development of novel drug delivery systems for herbal drugs [198]. However some limitations of plant bioactives like instability in highly acidic pH and liver metabolism led to drug levels below therapeutic concentration in the blood resulting in less or no therapeutic effect [199]. Hence, encapsulation of plant extracts or its bioactives would minimize their degradation or presystemic metabolism, and serious side effects due to accumulation of drugs to the non-targeted areas and improves the ease of administration in the pediatric and geriatric patients [200]. Lipid nanoemulsions containing oil from medicinal plants or hydrophobic drugs have been shown to improve drug solubility, reduce side effects of various potent drugs, increase the bioavailability of drugs, and to prolong the pharmacological effects in comparison to conventional formulations such as conventional emulsions [201]. Formulation of nanoemulsions containing phytoactives have been reported.

The effect of nanoemulsion on intestinal absorption of colchicine was demonstrated *in vivo*. Colchicine nanoemulsion was prepared with isopropyl myristate, eugenol, Tween 80, ethanol and water, with eugenol being the oil phase in the formulation. Result obtained indicated that the intestinal absorption of colchicine was significantly enhanced by the nanoemulsion formulation [202]. Genistein has been shown to possess anticancer activities in different experimental systems, yet the same effects could not be translated in the clinical setting due to its poor bioavailability. Researcher have tried various nano approaches including incorpo‐ ration of genistein into topical nanoemulsion formulations composed of egg lecithin, medium chain triglycerides or octyldodecanol and water by spontaneous emulsification with improved activity [203]. Oil in water nanoemulsion formulation has also demonstrated increased antiinflammatory activity of curcumin [204].


*A Review of Fracturing Technologies Utilized in Shale Gas Resources DOI: http://dx.doi.org/10.5772/intechopen.92366*

to be fractured in new directions. Reusing the existed fractures helps control the cost of re-fracturing. Therefore, another approach for re-fracturing is to add perforations between the existing fractures to create additional fracturing networks as shown in **Figure 4**.


*Edited by Serdar Kucuk*

The robotics is an important part of modern engineering and is related to a group of branches such as electric & electronics, computer, mathematics and mechanism design. The interest in robotics has been steadily increasing during the last decades. This concern has directly impacted the development of the novel theoretical research areas and products. This new book provides information about fundamental topics of serial and parallel manipulators such as kinematics & dynamics modeling, optimization, control algorithms and design strategies. I would like to thank all authors who have contributed the book chapters with their valuable novel ideas and current developments.

Serial and Parallel Robot Manipulators - Kinematics, Dynamics, Control and Optimization

Serial and Parallel

Robot Manipulators

Kinematics, Dynamics,

Control and Optimization

*Edited by Serdar Kucuk*

Photo by iLexx / iStock


5. Design of the analysis

orthography shared commonalities with the models proposed by Frith [43, 44], Ehri [45], and Wolf and her colleagues [46, 47]. The emphasis on developing automaticity through paired reading was based on similar assumptions to the work of Heckelman [48–50] and Laberge and

The techniques used for developing automaticity through combined use of repetitive paired reading and visual tracking in the 3 3 Oral Impress Method, the emphasis on developing writing and spelling automaticity through repetitive phonic analysis using the Seven Vowel Phonic Analysis System, and the emphasis on the development of sequentialisation and working memory skills through use of graded sentence and paragraph dictation passages in the Targeted Analysis, Revisualisation, and Sequential Spelling Programme reflected the author's own contributions. Each of these would appear from the literature to be unique.

It is important to stress that in addition to fluency-based activities, work was also undertaken during therapy sessions with Child 1 in areas of language and comprehension, drawing on the types of exercises suggested by Johnson and Myklebust [56], Harris and Smith [57], Spache [58], Harris and Sipay [59], as well as Moffett [60, 61]. The programme as a whole can thus be described as both fluency-based as well as language and comprehension-based. The two fluency-based areas of intervention (reading, and writing and spelling fluency) were conceptualised as activitybased and hierarchical, while the language and comprehension area was conceptualised as more eclectic, with skills requiring intervention determined both by initial assessment, as well as by clinical teaching. Each area of intervention in therapy was undertaken using simple, low-cost material [62]. In addition, phonically based reading material from the practice's database was made available by email to Child 1's mother to support her reinforcement of the fluency-based

4. Additional children who have used the same materials and methods

difficulties with reading, writing, and spelling, as well as fluency-based difficulties.

Children's problems vary, and no one size fits all. There is, however, sufficient breadth of graded, phonically based material in the database of the author's practice to develop fluency-based programmes for children of different ages and with different pre-test levels of reading, writing, spelling, and sequential spelling skill. These materials have thus also been used by the parents of other children in the author's practice diagnosed as having learning disabilities manifesting in

As a number of additional children have used the same database of materials, as well as similar methods for developing reading, writing, and spelling fluency, an opportunity sample of 19 other children was selected from the files of children with whom similar fluency-based programmes had been implemented during the years 2014, 2015, and 2016. The selection of the sample was purposive. Criteria for inclusion were that each child had been diagnosed with a learning disability affecting reading, writing, and spelling, had fluency-based difficulties, and would be exposed to work in all three areas of intervention of the fluency-based programme

Samuels [51], as well as the approaches described by Topping [52–55].

156 Learning Disabilities - An International Perspective

activities implemented as an integral part of each therapy session.

presented in Table 1.

The design of the analysis was to first establish a sample of children based on similarity in areas of difficulty and similarity in the principles applied in developing the fluency-based areas of their individual programmes [63, 64]. This sample was then grouped in terms of similarities and differences in programme inputs [65], in terms what was actually done in the therapy setting with each child [66].

The children's physical and computer files were first examined on a case by case basis. Difference in programme inputs was then used as a categorisation variable. This enabled certain case studies to be aggregated in terms of similarities in programme interventions received by the children, and certain case studies to be contrasted [67–69] on the basis of differences in programme interventions received by the children.

For purposes of analysis, the results of the initial sample of 20 children were thus partitioned into two groups. Included in the first group were 14 children who had consistent programme implementation involving all 3 areas of intervention in the programme, with regular reinforcement of programme activities from their parents at home. Based on these similarities, the results of these children were then inspected for common trends, and conclusions drawn based on triangulation across case studies.

In the second group were six children on whom one or other systematic variation in programme implementation had taken place. These data were analysed by cross-case analysis, using interpretive ex post facto analysis [70–72].

Overall, it should be noted that both groupings of data were purposive opportunity samples based on evidence drawn from clinical work. This limits generalisability [73, 74]. The analysis was also based on inspection and categorisation of the data as opposed to statistical analysis [75–77], owing to the small numbers of children involved, as well as differences in ages, physical and neurological maturation, date of intake into the practice, number of therapy sessions between pre- and post-testing, and gender within the sample.

There were also differences in initial levels of reading, writing, and spelling ability in the children, as well as variation in demographic variables such as the geographical areas in which the children lived, the schools they attended and how far they had to travel to the author's practice. In addition, there were differences in socio-economic variables such as the types of houses, townhouses, or apartment accommodation in which the children's families lived, whether one or both of their parents worked, and how the families spent their leisure time and holidays. These indicated the need for case study, as opposed to statistical treatment of the data. However, despite age, maturation, demographic, socio-economic, and gender differences, there was a pervasive commonality across the sample as a whole, in that each child has been diagnosed as having a learning disability with difficulties affecting reading, writing, and spelling, as well as fluency-based difficulties. In addition, the individual programmes for each child were based on sufficiently similar principles and used sufficiently similar materials and methods to form the basis for aggregation and case contrast of results.

### 6. Results

The pre- and post-test results of the two groups are presented in Tables 2 and 3. Table 2 contains the results of Child 1 and of 13 other children who had been exposed to programme inputs involving focus on language and comprehension, phonological and phonic instruction, reading fluency work, as well as writing and spelling fluency work (i.e. all of the different areas of intervention and components in the fluency-based programme). Table 3 then presents

Developing Automaticity in Children with Learning Disabilities: A Functional Perspective Part Two: Programme… http://dx.doi.org/10.5772/intechopen.72052 159

#### Child 3

However, despite age, maturation, demographic, socio-economic, and gender differences, there was a pervasive commonality across the sample as a whole, in that each child has been diagnosed as having a learning disability with difficulties affecting reading, writing, and spelling, as well as fluency-based difficulties. In addition, the individual programmes for each child were based on sufficiently similar principles and used sufficiently similar materials and

The pre- and post-test results of the two groups are presented in Tables 2 and 3. Table 2 contains the results of Child 1 and of 13 other children who had been exposed to programme inputs involving focus on language and comprehension, phonological and phonic instruction, reading fluency work, as well as writing and spelling fluency work (i.e. all of the different areas of intervention and components in the fluency-based programme). Table 3 then presents

Grade at School: 3 Gender male One word reading Sentence reading One word spelling Sequential spelling Age at pre-test: 8 yrs. 4 mths 7 yrs. 0 mth 7 yrs. 7 mth 7 yrs. 5 mth 7 yrs. 0 mth

Grade at School One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 10 yrs. 8 mths 10 yrs. 1 mth 9 yrs. 10 mth 9 yrs. 7 mth 8 yrs. 10 mth

Grade at School: 4 Gender female One word reading Sentence reading One word spelling Sequential spelling Age at pre-test 9 yrs. 9 mths 9 yrs. 2 mth 9 yrs. 10 mth 9 yrs. 8 mth 7 yrs. 0 mth

Grade at School One word reading Sentence reading One word spelling Sequential spelling Age at post-test 10 yrs. 2 mths 10 yrs. 10 mth 11 yrs. 10 mth 9 yrs. 9 mth 13 yrs. 1 mth

methods to form the basis for aggregation and case contrast of results.

6. Results

Child 1

Child 2

Pre-test date: March 2014 Pre-test age scores

158 Learning Disabilities - An International Perspective

Post-test date: June 2016 Post-test age scores

Number of writing/spelling fluency paragraphs covered: 18

Pre-test date: July 2015 Pre-test age scores

Post-test date Post-test age scores

Number of writing/spelling fluency paragraphs covered: 10

Number of therapy sessions: 84

Number of therapy sessions: 22

Number of reading fluency books covered: 5

Number of reading fluency books covered: 11

Developing Automaticity in Children with Learning Disabilities: A Functional Perspective Part Two: Programme… http://dx.doi.org/10.5772/intechopen.72052 161

#### Child 10

Post-test date: November 2016 Post-test age scores

Number of writing/spelling fluency paragraphs covered: 15

Pre-test date October 2015 Pre-test age scores

Post-test date: August 2016 Post-test age scores

Number of writing/spelling fluency paragraphs covered: 4

Pre-test date: June 2014 Pre-test age scores

Post-test date: November 2016 Post-test age scores

Pre-test date: March 2016 Pre-test age scores

Post-test date: November 2016 Post-test age scores

Number of therapy sessions: 42

Number of therapy sessions: 34

Number of therapy sessions: 78

Number of therapy sessions: 27

Number of reading fluency books covered: 6 Number of fluency paragraphs covered: 8

Number of reading fluency books covered: 9 Number of fluency paragraphs covered: 11

Number of reading fluency books covered: 2

Child 7

Child 8

Child 9

Number of reading fluency books covered: 5

160 Learning Disabilities - An International Perspective

Grade at School: 4 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 10 yrs. 7 mth 10 yrs. 9 mth 9 yrs. 5 mth 8 yrs. 7 mth 8 yrs. 0 mth

Grade at School: 2 Gender male One word reading Sentence reading One word spelling Sequential spelling Age at pre-test: 8 yrs. 11 mth 7 yrs. 7 mth 8 yrs. 3 mth 7 yrs. 3 mth 7 yrs. 3 mth

Grade at School: 3 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 9 yrs. 6 mths 9 yrs. 5 mth 9 yrs. 10 mth 8 yrs. 8 mth 8 yrs. 6 mth

Grade at School: 3 Gender female One word reading Sentence reading One word spelling Sequential spelling Age at pre-test: 9 yrs. 1 mth 6 yr. 10 mth 7 yrs. 2 mth 5 yrs. 6 mth < 6 yrs. 0 mth

Grade at School: 5 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 11 yrs. 7 mth 8 yrs. 11 mth 8 yrs. 0 mth 7 yrs. 7 mth 7 yrs. 11 mth

Grade at School: 4 Gender male One word reading Sentence reading One word spelling Sequential spelling Age at pre-test" 10 yrs. 6 mth 7 yrs. 10 mth 8 yrs. 6 mth 7 yrs. 4 mth 6 yrs. 9 mth

Grade at School: 4 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 11 yrs. 3 mth 10 yrs. 0 mth 8 yrs. 11 mth 8 yrs. 2 mth 7 yrs. 11 mth

Note that in Table 2, the pre- and post-test scores for each child have been highlighted and also accentuated in larger font size to enable case by case visual inspection of the data for each type of assessment test used, as well as profile interpretation across different areas of the assessment.

Table 2. Pre- and post-test results of children who have worked on phonological and phonic skills, reading fluency, as well as writing and spelling fluency.

#### Child A: worked in only one of the fluency areas of the programme (reading fluency) owing to need to focus on phonological and phonic difficulties

Number of therapy sessions: 24

Number of reading fluency books covered: 10

Number of writing/spelling fluency paragraphs covered: 0

#### Child B: worked in only one of the fluency areas of the programme (reading fluency) owing to need to focus on phonological and phonic difficulties, as well as persistent letter reversals in writing

Number of therapy sessions: 41

Grade at School: 5 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 9 yrs. 1mth 9 yrs. 1 mth 9 yrs. 5 mth 7 yrs. 6 mth 7 yrs. 0 mth

Grade at School: 1 Gender male One word reading Sentence reading One word spelling Sequential spelling Age at pre-test: 7 yrs. 4 mth 6 yrs. 6 mth 6 yrs. 9 mth 6 yrs. 8 mth < 6 yrs. 0 mth

Grade at School: 2 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 8 yrs. 4 mth 8 yrs. 7 mth 9 yrs. 2 mth 9 yrs. 7 mth 8 yrs. 6 mth

Note that in Table 2, the pre- and post-test scores for each child have been highlighted and also accentuated in larger font size to enable case by case visual inspection of the data for each type of assessment test used, as well as profile

Table 2. Pre- and post-test results of children who have worked on phonological and phonic skills, reading fluency, as

Child A: worked in only one of the fluency areas of the programme (reading fluency) owing to need to focus on

Grade at School: 1 Gender male One word reading Sentence reading One word spelling Sequential spelling Age at pre-test: 6 yrs. 8 mth 6 yrs. 4 mth 5 yrs. 6 mth 6 yrs. 1 mth < 6 yrs. 0 mth

Grade at School: 1 One word reading Sentence reading One word spelling Sequential Spelling Age at post-test: 7 yrs. 2 mth 8 yrs. 2 mth 8 yrs. 3 mth 7 yrs. 9 mth < 6 yrs. 0 mth

Child B: worked in only one of the fluency areas of the programme (reading fluency) owing to need to focus on

Grade at School: 2 Gender male One word reading Sentence reading One word spelling Sequential Spelling Age at pre-test: 7 yrs. 6 mth 7 yrs. 4 mth 7 yrs. 2 mth 5 yrs. 5 mth < 6 yrs. 0 mth

phonological and phonic difficulties, as well as persistent letter reversals in writing

Number of therapy sessions: 26

Number of therapy sessions: 29

well as writing and spelling fluency.

phonological and phonic difficulties

Number of therapy sessions: 24

Number of reading fluency books covered: 10

Number of reading fluency books covered: 4 Number of fluency paragraphs covered: 17

interpretation across different areas of the assessment.

Pre-test date: June 2016 Pre-test age scores

Post-test date: November 2016 Post-test age scores

Number of writing/spelling fluency paragraphs covered: 0

Pre-test date: December 2015 Pre-test age scores

Child 14

Number of reading fluency books covered: 9 Number of fluency paragraphs covered: 7

162 Learning Disabilities - An International Perspective

Pre-test date: October 2015 Pre-test age scores

Post-test date: November 2016 Post-test age scores

Number of reading fluency books covered: 3

Number of writing/spelling fluency paragraphs covered: 0

Child C: worked only during therapy sessions as parent was unwilling to work on fluency materials with child at home

Number of therapy sessions: 45

Number of reading fluency books covered: 3 (working with therapist only) Number of writing/spelling fluency paragraphs covered: 20

Child D: slow learning child who has worked well during therapy sessions but inconsistently on reading fluency materials, due to divorce in family, and mother's unwillingness to support the programme with work on reading fluency materials at home

Number of therapy sessions: 74

Number of reading fluency books covered: 3 (working with therapist only)

Number of writing/spelling fluency paragraphs covered: 68

#### Child E: worked in both of the fluency areas of the programme (reading fluency, and writing/spelling fluency using analytical phonics linked to sequential spelling), but not on basic phonic skills and phonic workbooks

Number of reading fluency books covered: 9

Number of fluency paragraphs covered: 14

Child F: slow learning child who has worked on reading fluency but has not yet had consistent intervention in the writing/sequential spelling area of the programme, owing to the need to focus on developing phonological, phonic and language skills

Note that in Table 3, the pre- and post-test scores for each child have been highlighted and also accentuated in larger font size to enable case by case visual inspection of the data for each type of assessment test used, as well as profile interpretation across different areas of the assessment.

Table 3. Case contrasts (pre- and post-test results of children where systematic variations in implementation of the fluency-based programme have occurred).

six case contrasts (the results of six children on whom systematic variation in one or more area of programme implementation has occurred over the past 3 years).

The results presented in Table 2 indicate a number of common trends indicating improvements made by these children in all areas pre- and post-tested. The results presented in Table 3, in contrast, indicate improvements in certain areas of functioning but not in others.

These trends and counter-trends in the data will be discussed in the section following, by linking particular groupings of results to particular intervention areas in the fluency-based programme. The discussion will be structured by first focusing on common trends in the results of the main body of case studies (i.e. the 14 children for whom convergent implementation of our programme has taken place). Divergences will then be highlighted, by focusing on the counter-trends evident in the six case contrasts (i.e. the six children where divergent implementation of the programme has occurred).

### 7. Discussion

There are limitations in interpretive analysis of case studies, as well as ex post facto analysis of evidence. Claims made on the basis of these types of evidence are limited, and essentially descriptive and exploratory.

Nevertheless, despite the cautions applying to both opportunity sampling and generalisability, a number of trends in the main body of case studies can be highlighted.

#### 7.1. The main body of case studies

It will be evident from Table 2 that each of the 14 children exposed to all areas of intervention in the programme has made gains in each of the 4 areas tested. However, some of the children have made greater and quicker progress than others. Some children have also required more input in terms of therapy sessions than others, indicating that in many cases, the gains made have been hard to achieve.

For this reason, gains made by these children relative to programme input variables as well as number of therapy sessions are summarised in Table 4.

As programme inputs have been similar for all these children, progress made relative to number of therapy sessions has been used to further partition the data, so as to highlight trends in response to the programme.

#### 7.1.1. Children responding rapidly to treatment

A number of the children have responded rapidly to intervention in the reading fluency area of the programme (Child 1, Child 4, Child 7, Child 10, Child 11, Child 12, and Child 14) indicated by number of therapy sessions conducted and number of reading fluency books covered. These children all commenced the programme with deficits in one word reading and sentence reading, and have all achieved reading scores within 6 months of chronological age at time of post-testing. The evaluation reports from the children's parents indicate that there have been observable differences in reading fluency, and improvement in the following problems with problems with reading accuracy and fluency which were evident prior to commencement of the programme, in the following areas:

• Word-by-word reading;

six case contrasts (the results of six children on whom systematic variation in one or more area

Table 3. Case contrasts (pre- and post-test results of children where systematic variations in implementation of the

Note that in Table 3, the pre- and post-test scores for each child have been highlighted and also accentuated in larger font size to enable case by case visual inspection of the data for each type of assessment test used, as well as profile

Child F: slow learning child who has worked on reading fluency but has not yet had consistent intervention in the writing/sequential spelling area of the programme, owing to the need to focus on developing phonological, phonic

Grade at School: 2 Gender male One word reading Sentence reading One word spelling Sequential spelling Age at pre-test: 10 yrs. 0 mth 7 yrs. 7 mth 8 yrs. 6 mth 7 yrs. 8 mth 6 yrs. 0 mth

Grade at School: 5 One word reading Sentence reading One word spelling Sequential spelling Age at post-test: 13 yrs. 0 mth 11 yrs. 8 mth 10 yrs. 1 mth 9 yrs. 7 mth 7 yrs. 8 mth

The results presented in Table 2 indicate a number of common trends indicating improvements made by these children in all areas pre- and post-tested. The results presented in Table 3,

These trends and counter-trends in the data will be discussed in the section following, by linking particular groupings of results to particular intervention areas in the fluency-based programme. The discussion will be structured by first focusing on common trends in the results of the main body of case studies (i.e. the 14 children for whom convergent implementation of our programme has taken place). Divergences will then be highlighted, by focusing on the counter-trends evident in the six case contrasts (i.e. the six children where divergent

There are limitations in interpretive analysis of case studies, as well as ex post facto analysis of evidence. Claims made on the basis of these types of evidence are limited, and essentially

Nevertheless, despite the cautions applying to both opportunity sampling and generalisability,

a number of trends in the main body of case studies can be highlighted.

in contrast, indicate improvements in certain areas of functioning but not in others.

of programme implementation has occurred over the past 3 years).

implementation of the programme has occurred).

7. Discussion

and language skills

Number of therapy sessions: 97

Number of reading fluency books covered: 7 Number of fluency paragraphs covered: 6

fluency-based programme have occurred).

Pre-test date: November 2013 Pre-test age scores

164 Learning Disabilities - An International Perspective

Post-test date: December 2016 Post-test age scores

interpretation across different areas of the assessment.

descriptive and exploratory.

Child 2, Child 11, and Child 14 have also responded to the writing and spelling fluency methods used in the programme rapidly, achieving spelling, and sequential spelling scores either above or at level of within 6 months of chronological age at time of post-testing. Each of these children has also done well in their written work presented at school, as indicated by analysis of their school books and their school reports.

Table 4. Analysis of programme inputs and outputs (main body of case studies).

each child. Number of months spent in therapy is an indicator of the severity of each child's learning disability. Child 4, Child 7, Child 10, and Child 12, in contrast, have responded well to the reading fluency area of intervention in the programme, but require additional time on task and additional work in writing and spelling areas of the programme. These needs are corroborated by analysis of their school books as well as their school reports.

#### 7.1.2. Children responding less rapidly to treatment

Child 1, Child 3, Child 5, Child 6, and Child 8 have all been involved in working with all areas of the programme for some time, as indicated by the number of therapy sessions and the number of reading fluency books on which they have worked. These children have all made progress, but require further work.

Child 1 left the programme in June 2016 as it was felt that his parents were at that point able to address his continuing difficulties with writing and spelling themselves. Child 3, Child 5, Child 6, and Child 8 will be continuing with the programme in 2017.

#### 7.1.3. Gains made in response to teaching both basic skills and fluency

Where focus has been placed in the programme on teaching both basic skills and training fluency, gains have been made in one word reading, sentence reading, one word spelling, and sequential spelling as measured by tests of dictation. While certain children have responded more rapidly to treatment than others, gains have been made by all children, indicating that both basic skills and fluency are trainable, in both reading and in writing and spelling.

The gains made on psychometric tests have been corroborated by qualitative evidence from parent evaluation questionnaires as well as the children's school reports. All children in the main body of case studies have made progress at school, and their parents have also evaluated the programme positively. Child 1, for example, passed the year well, 8 months after entering the programme. His mother's progress evaluation form also indicated many areas of gain, relative to his fluency skills when he commenced the programme. This is presented as Appendix 1 at the end of this chapter, together with a copy of the evaluation form itself as Appendix 2, should others wish to use it.

#### 7.1.4. Conclusions

Programme inputs

Phonic

Reading

Writing and spelling

Language and

Parent support at

Word reading

Sentence reading

Word spelling

Sequential spelling

Parent fluency rating

gains

gains

22 mths in 27 mths ♦

gains

gains

gains

27 mths in 27 mths 26 mths in 27

mths

home

11 bks in 27 mths 37 mths in 27

mths

comprehension

fluency

fluency

workbooks

Child

◊

◊◊

 ◊

1

Child

◊

◊◊

 ◊

5 bks in 5 mths

 20 mths in 5

24 mths in 5 mths 1 mth in 5 mths 73 mths in 5 mths ♦

mths

2

Child

◊

◊◊

 ◊

8 bks in 24 mths

 40 mths in 24

31 mths in 24 mths 28 mths in 24

mths

42 mths in 24 mths ♦

166 Learning Disabilities - An International Perspective

mths

3

Child

◊

◊◊

 ◊

6 bks in 8 mths

 25 mths in

32 mths in 8 mths 4 mths in

8 mths

15 mths in 8 mths ♦

> 8 mths

4

Child

◊

◊◊

 ◊

9 bks in 31 mths

 50 mths in 31

30 mths in 31 mths 24 mths in 31

mths

23 mths in 31 mths ♦

mths

5

Child

◊

◊◊

 ◊

5 bks in 12 mths

 36 mths in 12

14 mths in 12 mths 3 mths in 12

mths

12 mths in 12 mths ♦

mths

6

Child

◊

◊◊

 ◊

2 bks in 10 mths

 22 mths in 10

19 mths in 10 mths 17 mths in 10

mths

15 mths in 10 mths ♦

mths

7

Child

◊

◊◊

 ◊

9 bks in 29 mths

 25 mths in 29

10 mths in 29 mths 25 mths in 29

mths

23 mths in 15 mths ♦

mths

8

Child

◊

◊◊

 ◊

6 bks in 8 mths

 26 mths in

5 mths In 8 mths 8 mths in

8 mths

14 mths in 8 mths ♦

> 8 mths

9

Child

◊

◊◊

 ◊

3 bks in 4 mths

 8 mths in 4

19 mths in 4 mths 5 mths in 4

mths

30 mths in 4 mths ♦

mths

10

Child

◊

◊◊

 ◊

4 bks in 13 mths

 18 mths in 13

15 mths in 13 mths 15 mths in 13

mths

28 mths in 13 mths ♦

mths

11

Child

◊

◊◊

 ◊

4 bks in 5 mths

 20 mths in 5

19 mths in 5 mths 33 mths in 5

mths

34 mths in 5 mths ♦

mths

12

Child

◊

◊◊

 ◊

9 bks in 7 mths

 7 mths in 7

17 mths in 7 mths 12 mths in 7

mths

12 mths in 7 mths ♦

mths

13

Child

◊

◊◊

 ◊

4 bks in 13 mths

 programme implemented with each child. Programme outputs are quantified in terms of gains made by the child in each area of

 25 mths in 13

29 mths in 13 mths 35 mths in 13

mths

 of improvements

 in fluency is an additional indicator of gains made by

39 mths in 13 mths ♦

mths

14

Note that programme inputs in Table 4 refer to the different areas of the fluency-based

assessment (expressed as gain scores in months relative to the period of time in months spent in therapy between pre- and post-testing). Parents'rating

each child. Number of months spent in therapy is an indicator of the severity of each child's learning disability.

Table 4.

Analysis of programme

 inputs and outputs (main body of case studies).

Programme outputs

> Overall, analysis of the main body of case studies would suggest that consistent involvement in fluency-based work is associated with gains in psychometric test scores as well as positive changes in performance at school in all 14 cases presented. On the basis of observable improvement, the parents of all 14 children have evaluated their progress positively.

> It is important to stress that all 14 children in the main body of case studies have not only been involved in all areas of intervention in the fluency-based programme, but have also had consistent input both from the therapist and from the child's parents in support of particular components within the programme at home. Fluency in reading has been addressed both in therapy sessions and at home by repetitive paired reading methods, in which paragraphs read are repeated with the order of the person reading being rotated. It has also been addressed

through simultaneous focus on visual tracking. This type of intervention has led to observable effects which have sometimes been achieved quickly, but in the majority of cases have required considerable focus and application. To provide the necessary time on task, the involvement of both therapist and parent has been essential.

Fluency in writing and spelling has been addressed through a variety of methods involving not only training in phonics and basic skills in writing and copying, but also by teaching the child how to analyse words based on phonic analysis of how words work, and then using these skills as the basis for training of working memory for words in sequence. This type of intervention has led to effects which have sometimes been achieved quickly, but in the majority of cases have required considerable time on task.

In developing individual programmes for each of the 14 children, the processes of reading, writing, spelling, and comprehension have been conceptualised as linked on a functional level, with basic phonological and phonic skills initially being taught as a foundation for use in the processes of reading, writing, spelling, and comprehension. The use of repetitive paired reading has then formed the basis for developing reading fluency, while at the same time a seven vowel phonic analysis system has been introduced to provide a metacognitive basis for developing fluency in writing and spelling.

In each case where this type of linked intervention across areas and components has taken place, there has been steady and even progress. There has also been evidence of a backwash effect from application of the methods used in teaching phonic analysis into both proficiency in one word reading ability as well as fluency in reading sequentially, as well as reciprocal effects from use of reading fluency methods into competencies in writing and spelling (and vice versa). The indications would thus be that there is commonality of influence across the different areas of the fluency-based intervention programme described in this chapter.

Following Luria [78–80], the reason for commonality of influence across the different areas and components in the programme would be that the various language, reading, writing, and spelling interventions are dependent on the mediation of speech processes. They would thus be dependent on the development of both phonological and phonic abilities, which would need to be the core skills taught in the language and reading comprehension, the reading fluency, as well as the writing and spelling fluency areas of intervention in the programme, as well as across different components within each of these areas, on a functional level.

In terms of more recent literature, commonality of influence could also be cited as evidence of a common linguistic awareness manifesting in phonological, orthographic, and morphological awareness as suggested by Berninger et al. [81], and of a universal phonic principle manifesting across different orthographies as suggested by Perfetti et al. [82]. Difficulties in developing linguistic awareness and the universal phonic principle would have been assisted, as suggested by McCutchen [83], by introducing metacognitive strategies such as the Seven Vowel Phonic Analysis System in each of the 14 children's individual programmes. Greater metacognitive control, as opposed to simply increasing encapsulated automaticity, would then have accounted for the backwash effects as well as the steady progress across different areas of the fluency-based programme observed in therapy.

#### 7.2. Case contrast analysis

through simultaneous focus on visual tracking. This type of intervention has led to observable effects which have sometimes been achieved quickly, but in the majority of cases have required considerable focus and application. To provide the necessary time on task, the involvement of

Fluency in writing and spelling has been addressed through a variety of methods involving not only training in phonics and basic skills in writing and copying, but also by teaching the child how to analyse words based on phonic analysis of how words work, and then using these skills as the basis for training of working memory for words in sequence. This type of intervention has led to effects which have sometimes been achieved quickly, but in the majority

In developing individual programmes for each of the 14 children, the processes of reading, writing, spelling, and comprehension have been conceptualised as linked on a functional level, with basic phonological and phonic skills initially being taught as a foundation for use in the processes of reading, writing, spelling, and comprehension. The use of repetitive paired reading has then formed the basis for developing reading fluency, while at the same time a seven vowel phonic analysis system has been introduced to provide a metacognitive basis for devel-

In each case where this type of linked intervention across areas and components has taken place, there has been steady and even progress. There has also been evidence of a backwash effect from application of the methods used in teaching phonic analysis into both proficiency in one word reading ability as well as fluency in reading sequentially, as well as reciprocal effects from use of reading fluency methods into competencies in writing and spelling (and vice versa). The indications would thus be that there is commonality of influence across the different areas of the fluency-based intervention programme described

Following Luria [78–80], the reason for commonality of influence across the different areas and components in the programme would be that the various language, reading, writing, and spelling interventions are dependent on the mediation of speech processes. They would thus be dependent on the development of both phonological and phonic abilities, which would need to be the core skills taught in the language and reading comprehension, the reading fluency, as well as the writing and spelling fluency areas of intervention in the programme, as well as across different components within each of these areas, on a func-

In terms of more recent literature, commonality of influence could also be cited as evidence of a common linguistic awareness manifesting in phonological, orthographic, and morphological awareness as suggested by Berninger et al. [81], and of a universal phonic principle manifesting across different orthographies as suggested by Perfetti et al. [82]. Difficulties in developing linguistic awareness and the universal phonic principle would have been assisted, as suggested by McCutchen [83], by introducing metacognitive strategies such as the Seven Vowel Phonic

both therapist and parent has been essential.

168 Learning Disabilities - An International Perspective

of cases have required considerable time on task.

oping fluency in writing and spelling.

in this chapter.

tional level.

In addition to the 14 children in the main body of case studies, 6 case studies have been presented in Table 3 for purposes of case contrast. These are children for whom there has been one or other systematic variation in programme implementation (differences in programme inputs in terms of areas of the programme covered, or differences in parental support at home).

To enable case contrast, gains made by these children relative to programme input variables and number of therapy sessions are summarised in Table 5.

It will be evident from Table 5 that there are differences in terms of programme input indicating that differences in the areas of intervention in the programmes implemented with each child. There has also been uneven progress in terms of the output variables, indicating that each of the six children has not made steady and even progress in terms of gains made on the four assessment tests used to monitor progress made in response to therapy. This would also indicate that that the following variables affected successful implementation of the fluencybased intervention programme with these children.

#### 7.2.1. Parental support

Whereas each of the 14 children in the main body of case studies has been exposed to regular parental support involving exposure to repetitive paired reading on the reading fluency ebooks, and have also produced evidence of gains in reading fluency, both Child C and Child D in the contrast group have not had consistent input from their parents at home.

Gains have been made by both children, but their case files indicate that less ground has been covered and that gains would have been greater, had parental support been more consistent.

#### 7.2.2. Exposure to all three areas of intervention in the programme

Whereas each of the 14 children in the main body of case studies has been exposed to all areas of intervention in the fluency-based programme, and have produced evidence of gains in all four sides of the assessment, both Child A and Child B have had difficulties at the phonological and phonic level which have required particular attention. They have thus been exposed to work on language and comprehension, auditory processing, phonological awareness and

Table 5. Analysis of programme inputs and outputs (case contrasts).

severity of each child's learning disability. phonics as well as consistent work on reading fluency ebooks, and have also had work on basic skills in writing and spelling.

However, neither Child A nor Child B has yet worked on the writing and spelling fluency area of the programme. The assessment data on both children also indicates that neither Child A or Child B has made gains in sequential spelling skills, suggesting that gains in sequential writing and dictation skills are associated with exposure to the writing and spelling fluency area of the programme.

This may seem a trivial and self-evident conclusion. It is an important one, nevertheless, for the reason that all children in the author's practice have been diagnosed as learning disabled against the DSM IV criteria. Certain children can also be described as resistant to treatment, as they have had previous interventions which have not been effective. As both Child A and Child B have had multiple difficulties and can also be described as treatment resistant children, evidence of improvement as well as lack of evidence of improvement would be important indicators.

#### 7.2.3. Consistent exposure to basic phonological and phonic instruction

Whereas all of the 14 children in the main body of case studies have been exposed to all 3 areas of intervention in the fluency-based programme and have produced evidence of gains in all 4 tests used in assessment, Child E was exposed to the language and reading fluency areas and the writing and spelling fluency area of the programme. However, he was not exposed to consistent basic phonological and phonic instruction, as provided by instruction targeting the particular types of errors made on the Phonic Inventories, as well as exposure to reading skill activity books and phonic workbooks.

Child E has not made gains in spelling skills, suggesting that gains in spelling are associated with exposure to basic phonic instruction. The gains made in sequential spelling, in contrast, would appear to be associated with involvement with the sequencing, and the working memory skills taught in the writing and spelling fluency area of the programme.

It is thus important to stress that phonological and phonic abilities would appear to be the core and foundational skills essential to progress in both the reading fluency and the writing and spelling intervention areas of the programme. The evidence from analysis of Child E's results would indicate that phonological and phonic abilities should remain the focus of intervention, even where children are older, or where there are time constraints affecting programme implementation.

### 7.2.4. Use of the programme with slow learning children

Programme

Phonic

Reading

Writing and

Language and

Parent

Word

Sentence

Word

Sequential

Parent fluency

rating gains

reinforcement

home

 at

reading

reading

spelling

spelling gains

gains

gains

gains

comprehension

workbooks

Child

◊

 ◊

◊

10 bks in 5 mths

 20 mths in

33 mths in 5

20 mths in 5

0 mths in 5

♦

170 Learning Disabilities - An International Perspective

mths

mths

mths

5 mths

A

Child

◊

 ◊

◊

3 bks in 11 mths

 14 mths in

21 mths in 11

26 mths in

0 mths in 11

♦

11 mths

mths

11 mths

mths

B

Child

◊

◊◊

 ◊

3 bks in 20 mths

 4 mths in

5 mths in 20

4 mths in 20

9 mths in 20

Working with

therapist only

20 mths

mths

mths

mths

C

Child

◊

◊◊

 ◊

3 bks in 28 mths

 24 mths in

12 mths in 28

13 mths in

24 mths in 28

Working with

therapist only

mths

28 mths

28 mths

mths

D

Child

◊◊

 ◊ ◊

7 bks in 37 mths

 37 mths in

17 mths in 37

23 mths in

20 mths in 37

♦

mths

37 mths

37 mths

fluency-based

 (expressed as gain scores in months relative to the period of time in months spent in therapy between pre- and

 programme

implemented

 with each child. Programme

 outputs are quantified in

mths

9 bksin 8 mths

 21 mths in

24 mths in

12 mths in

♦

8 mths

8 mths

8 mths

8 mths

E

Child

◊

 ◊

F

Note that programme

terms of gains made by the child in each area of assessment

post-testing).

severity of each child's learning disability.

Table 5.

Analysis of programme

 inputs and outputs (case contrasts).

 Parents' rating of

improvements

 in fluency is an additional indicator of gains made by each child. Number of months spent in therapy is an indicator of the

 inputs in Table 5 refer to the different areas of the

fluency

spelling Fluency

 inputs

Programme

 outputs

> Both Child D and Child F are slow learning children. Each child has made progress on all four sides of the assessment, but each child has required a large number of therapy sessions to support the gains made, suggesting that slow learning children can benefit from exposure to the language, reading fluency, and writing fluency areas of the programme, but require greater support to do so.

Lerner<sup>4</sup> has suggested that it is important to bear in mind that slow learning children learn, but that this is at a slower rate than many other children. This observation would be corroborated by the author's experience, as well as the experience of other teachers and therapists who have worked with the materials and methods used in the programme.

It has also been the author's observation that certain of the children who have been treated in the practice make gains and can "bank" the skills learned and integrities developed. In other children, deterioration takes place in the absence of repetition, indicating difficulties in long-term memory processes and needs for ongoing work to maintain and consolidate gains made.