Ann.

of Dyslexia
https://doi.org/10.1007/s11881-018-0157-y

The multiple deficit model of dyslexia: what does it mean

for identification and intervention?

Jeremiah Ring 1 & Jeffrey L. Black

1

Received: 28 June 2017 / Accepted: 16 March 2018

# The International Dyslexia Association 2018

Abstract Research demonstrates that phonological skills provide the basis of reading acqui-
sition and are a primary processing deficit in dyslexia. This consensus has led to the
development of effective methods of reading intervention. However, a single phonological
deficit is not sufficient to account for the heterogeneity of individuals with dyslexia, and recent
research provides evidence that supports a multiple-deficit model of reading disorders. Two
studies are presented that investigate (1) the prevalence of phonological and cognitive pro-
cessing deficit profiles in children with significant reading disability and (2) the effects of those
same phonological and cognitive processing skills on reading development in a sample of
children that received treatment for dyslexia. The results are discussed in the context of
implications for identification and an intervention approach that accommodates multiple
deficits within a comprehensive skills-based reading program.

Keywords Intervention . Multiple deficit model . Phonological processing reading disability

Reading is the foundation of a child’s life-long education, and the consequences of early
reading differences extend well beyond the school years (e.g., McLaughlin, Speirs, &
Shenassa, 2014). Numerous factors can affect reading development, for example, variability
in resources and quality of instruction across schools or home factors such as environmental
stressors, lack of adequate resources, and behavioral or health problems (Fiester & Smith,
2010; Snow, Burns, & Griffin, 1998). Children also differ in pre-reading or emergent literacy
skills that influence reading acquisition such as oral language, knowledge of print concepts, or
phonological sensitivity (Snow, Burns, & Griffin, 1998). In addition, the presence of a learning
disability has a profound impact on a child’s success in school. Recent data from the U.S.
Department of Education reported that 35% of all public school students served in special

* Jeremiah Ring
Jerry.Ring@tsrh.org

1
Luke Waites Center for Dyslexia and Learning Disorders, Texas Scottish Rite Hospital for Children,
2222 Welborn St, Dallas, TX 75219, USA
 Ring J., Black J.L.

education were identified with learning disabilities, a statistic that represents more than 2
million students (National Center for Education Statistics, 2016, Table 204.3). Further, it has
been estimated that as many as 80% of students in special education have a specific difficulty
in reading (Lerner, 1989). A conservative estimate is that specific learning disability in reading,
or developmental dyslexia, affects approximately 7% of the general population (Peterson &
Pennington, 2015). Moreover, rather than simple developmental delay, dyslexia represents a
true deficit in reading acquisition and therefore presents a significant challenge for academic
development (Francis, Shaywitz, Stuebing, Shaywitz, & Fletcher, 1996).
The identification of phonological processing, and phonological awareness in partic-
ular, as an important factor in learning to read and in the specific reading difficulties of
dyslexia reflects general consensus in the reading research literature (National Institutes
of Child Health and Development, 2000). The development of word identification skill
requires understanding the alphabetic principle, that is, that the letters and letter clusters
in written language systematically map to the individual sounds (i.e., phonemes) of
words in spoken language (Liberman, Shankweiler, & Liberman, 1989; Share, 1995).
An awareness of phonemes in words, either implicitly or explicitly, is important for
acquiring alphabetic skills, and longitudinal studies have confirmed that phonological
awareness abilities in preschool correlate with later reading achievement (Torgesen,
Wagner, & Rashotte, 1994). Reading research has also consistently shown that children
with dyslexia have specific difficulties acquiring foundational phonemic awareness and
related phonological skills (Vellutino, Fletcher, Snowling, & Scanlon, 2004). Interven-
tion research demonstrates that the identification of phonological skills as a primary
processing deficit in dyslexia has led to the development of effective reading intervention
methods (e.g., Torgesen, 2005).
Although strong converging evidence supports the importance of phonological awareness
ability for reading development, there are several problems with interpreting this consensus as
reflecting a single causal factor in reading difficulties (van Bergen, van der Leij, & de Jong,
2014). For example, longitudinal family risk studies report that, for some children, weak
phonological abilities in preschool do not necessarily result in subsequent impaired reading,
(e.g., Snowling, Bishop, & Stothard, 2000; Petersen, Pennington, Shriberg, & Boada, 2009).
Alternatively, there are reports of children with relatively strong phonological skills, including
phonological awareness, that still present with significant word reading difficulties (e.g.,
Manis, Seidenberg, Doi, McBride-Chang, & Petersen, 1996; Stanovich, Siegel, & Gottardo,
1997). A single deficit account also has difficulty accommodating comorbidity with other
conditions, such as attention-deficit/hyperactivity disorder (ADHD). Specifically, the incidence
rate of co-occurring dyslexia and ADHD is higher than might be expected if the two conditions
were the result of independent single deficits (e.g., Willcutt et al., 2010). More broadly,
research shows that children with reading difficulties present with a variety of co-occurring
cognitive and language processing deficits (e.g., Morris et al., 1998). For these reasons,
researchers have moved away from a single-deficit model of dyslexia and have adopted a
multifactorial approach to the study of the factors involved in reading disability (Pennington,
2006).
In brief, a multiple-deficit model proposes that the development of any complex
cognitive behavior, such as reading, is the outcome of multiple levels of interacting
factors that may be protective or increase risk of a disorder (see Pennington, 2006,
Fig. 2). The levels of factors begin with genetic influences and their interactions with the
environment that are then expressed in the development of neural structure and function.
The multiple deficit model of dyslexia: what does it mean for...

Further interactions at the neural level have subsequent impacts on the development of
cognitive functions that, in turn, influence observable behavior. The interactivity of
factors within and between levels of analysis affects the contribution of any one factor
on the outcome, with the result that symptom presentation at the behavioral level is a
result of multiple sources of variability in development. Applied to dyslexia, the
multiple-deficit model proposes that developing the condition can result from the pres-
ence of additional risk factors beyond compromised phonological awareness. Risk
factors that might influence reading disability include such candidates as verbal reason-
ing, working memory, and rapid automatic naming (e.g., Willcutt et al., 2010).
A recent study examined the efficacy of the multiple-deficit account versus a single-
deficit model of dyslexia in explaining cognitive profiles in a population-based sample of
children participating in twin studies of reading (Pennington et al., 2012). Data were
collected on phonological awareness, language skills, processing speed/rapid naming
abilities, and reading accuracy. Two methods of defining deficits for all measures were
then used to identify deficit profiles for each participant. The first method was a cut-off
criterion of less than the tenth percentile relative to a typical reader sample. The second
method used regression analyses to identify the best fitting model of predictors for each
individual in the sample. The advantage of the latter method is rather than simply
indicating the presence of a deficit, the regression model identified the relative impor-
tance of a deficit for individual reading performance. The analyses found agreement
between the two identification methods for about 46% of the sample. More importantly,
deficit profiles from both methods were consistent with a Bhybrid^ model that could
accommodate both single- and multiple-deficit cases.
Although important for understanding the etiology of reading disability, the implica-
tions of a multiple deficit model are less clear for making decisions about how to
approach intervention. On the surface, adopting a multiple-deficit view of dyslexia is
consistent with the goal of cognitive profiling models to provide interventions focused
on individual needs (e.g., Reynolds & Shaywitz, 2009). The reading intervention liter-
ature to date, however, provides equivocal evidence that treatment approaches that target
specific cognitive deficits have a substantive impact on reading outcomes beyond skill-
based reading instruction (Burns et al., 2016; Kearns & Fuchs, 2013). Furthermore,
recent meta-analyses indicate that cognitive factors are not strong predictors of reading
intervention outcomes after accounting for baseline status on academic measures of
reading (Steubing et al., 2015).
The research reported in this paper therefore had two aims. The first study extended the
individual case-study analyses of the multiple-deficit model of dyslexia reported in Pennington
et al. (2012) to a sample of children referred for diagnostic assessment at a hospital-based
learning disabilities clinic. The goal was to identify subgroups of individual patterns of risk
factors in children with and without significant word reading deficits and with or without
attention-deficit hyperactivity disorder (ADHD). The criterion cut-off and regression-based
methods were also used in this study to illustrate that a cut-off approach for identification,
although technically simple to implement in practice, provides a poor description of the risk
factors related to reading disability. It was expected that the distribution of profiles supporting
a hybrid multiple-deficit model would be similar to the population-based estimates of
Pennington et al. (2012). A second study then examined the effects of the same candidate
risk factors on treatment response with a sample of children that were treated for dyslexia at the
same hospital clinic. The results were expected to show that phonological awareness and rapid
 Ring J., Black J.L.

automatic naming would be the strongest predictors of post-intervention reading (e.g.,

Torgesen et al., 2001).

Study 1

Participants

All participants were recruited from medical records of patients evaluated at a learning
disabilities center between 2004 and 2014. A total of 2653 patients had sufficient assessment
data to meet initial inclusion criteria for participation. All patients that received non-traditional
schooling (e.g., home school) were then excluded to prevent potential confounding of poor test
performance with inadequate instruction. Patients were also excluded if they had co-occurring
diagnoses that may have interfered with test performance (e.g., hearing or visual impairment).
The remaining 1621 eligible patients were then assigned to a Typical Reader group (n = 901) if
word reading accuracy scores were within the normal range (i.e., > 90 standard score) or a
Reading Deficit group (n = 215) if reading scores were equal to or less than 80 standard score.
Table 1 presents descriptive statistics and demographics summary for both reading groups.

Procedure

All participants were assessed for academic difficulties at the hospital’s learning disabilities
clinic. The clinic’s evaluation services were available at no charge to students aged 6 to 14 years
whose primary language was English. Approximately 7% of patients were evaluated at the
Center during the recruitment period qualified for Special Education services.
Psychoeducational testing was completed by a licensed psychologist, educational diagnostician,
or speech-language pathologist. Differential diagnoses were formed from existing academic
performance data and parent and child interviews concerning the patient’s medical, behavioral,
and family history. The instruments used for each patient’s clinic evaluation were selected on the
basis of the differential diagnoses; patient records were only considered for inclusion in this
study if they had a complete test battery data from their evaluation. All diagnoses were formed
with consensus from an attending developmental-behavioral pediatrician at the hospital clinic.

Table 1 Participant characteristics by reading group

Measure Reading group η2

Typical reader Reading deficit

Age (years) 8.5 (1.5) 9.4 (1.8) .06

Full-scale IQ 99.3 (9.4) 88.3 (8.4) .18
Word reading 98.7 (5.9) 74.2 (5.7) .73
Socioeconomic statusa 45.5 (9.1) 39.2 (9.9) .07
Gender (% female) 46 33
Ethnicity (% minority) 14 28
ADHD (% with diagnosis) 34 38

Typical reader n = 901; reading deficit n = 215. Standard deviation in parentheses. All group comparisons p < .01
except ADHD diagnosis
a
Hollingshead (1975)
The multiple deficit model of dyslexia: what does it mean for...

Measures

The phonological and cognitive processing constructs investigated in this study, phono-
logical awareness, rapid naming, working memory, and verbal aptitude were selected on
the basis of evidence of relationships with reading ability (e.g., Fletcher, Lyon, Fuchs, &
Barnes, 2007). Phonological awareness (PA) and rapid serial naming (RAN) were
measured with the Comprehensive Test of Phonological Processing (CTOPP; Wagner,
Torgeson, & Rashotte, 1999). Reported reliability estimates (coefficient alpha) were .92
for phonological awareness and .93 for rapid automatic naming. General cognitive
aptitude was evaluated with the Wechsler Intelligence Scale for Children Fourth Edition
(WISC-IV; Psychological Corporation, 2003). The Working Memory (WM) and Verbal
Comprehension (VERB) indices were used in the analyses. The WISC-IV manual reports
average split-half reliabilities for those measures of .94 and .92, respectively. The
outcome measure of word reading accuracy was from the Wechsler Individual Achieve-
ment Test Second Edition (WIAT-II; Psychological Corporation, 2001). Split-half reli-
ability of .92 was reported for the Word Identification subtest. The SNAP-IV Rating
Scale for children (Swanson, 1992) was used to assess attention. The scale has coeffi-
cients alpha of .94 (parent scale) and .96 (teacher scale) (Bussing et al., 2008).

Data analyses

The analyses for this study adopted an individual case-level rather than group-level approach
to the investigation of factors related to significant reading difficulties. Following the proce-
dure of Pennington et al. (2012, pp. 216–17), two methods were used to identify sub-groups of
patients with different cognitive profiles. The first identification method was a simple count of
the number of individuals with a criterion-defined deficit in phonological and/or cognitive
abilities. In a direct replication of Pennington et al. (2012), the same Bcut-off^ decision
criterion of the 10th percentile (i.e., ≤ 80 standard score) was used to determine significant
deficits in both word reading achievement and the four predictor variables in this study. The
selection of such a restrictive criterion also had the effect of yielding a sample of participants
with reading skills in the lowest 10% of the population, a proportion that approximates some
estimates of the prevalence of dyslexia (e.g., Elliott & Grigorenko, 2014).
Participants were grouped according to which predictor(s) were below the cut-off criterion.
Cases with multiple predictors meeting that deficit criterion were aggregated into two groups
depending on whether their profile included a phonological awareness deficit (Phonological
Core) or did not include a phonological awareness deficit (Multiple Deficit). Any participants
with no significant deficits, that is, all their predictor scores were above an 80 standard score,
were assigned to a BNo Deficit^ group. Cross-tabulation and Pearson’s chi-square test for
independence was then used for comparisons of the cut-off criterion-based deficit profiles in
the Typical Reader and Reading Deficit groups.
The cut-off method identifies whether an individual with a significant word reading
difficulty has co-occurring deficits in other phonological or cognitive domains. The method
does not indicate whether the co-occurring deficit(s) are important predictors of an individual’s
word reading ability. A second issue concerns the presence of mild deficits, defined in this
study as skills between 80 and 90 standard score, in one or more of the predictors. Such
individuals would be considered to have no significant deficit(s), yet those compromised skills
may still be related to their difficulty with word-level reading. A second profiling method used
 Ring J., Black J.L.

statistical modeling to address these issues and identify the phonological and/or cognitive
variable(s) that predicted word reading ability in the Reading Deficit group (Pennington et al.,
2012). The best-fitting model of such analyses, however, only applies to the entire group and
may overlook subgroups of participants who share similar patterns of significant risk factors
that differ from the overall group model. The group-level regression analyses, therefore, were
of interest only as a means to identify the best combination of predictors of word reading for
each individual in the sample.
A linear regression approach for this study was complicated by potential dependencies in
the data due to the hierarchical nature of the sample. For example, referral biases or changes in
clinic admission criteria could result in patients in one year having systematically different
measured abilities compared to patients from the previous year. One method for accounting for
data dependencies in analyses is to use multilevel regression modeling (MLM), an approach
that would separate the variance in word reading attributed to cohort differences from variance
in word reading related to individual characteristics (Peugh, 2010). Similarly, many patients
were nested within schools or school districts which suggests a second clustering variable in
the multilevel model. A MLM analysis controlling for variance across schools, however,
proved unsuitable for these data because the sample was drawn from 355 separate school
districts/schools, of which 47% were represented by one patient, which would overestimate
school effects (Clarke, 2008).
A multilevel regression approach was therefore adopted for the analyses of word
reading ability with individual characteristics (i.e., Level 1 predictors) clustered within
recruitment cohorts (i.e., Level 2). Schools were not added as a second Level 2 cluster
variable because inclusion would have required significant loss of participants. A
likelihood ratio test, χ2(1; N = 1621) = 107.5, p < .0001, and intraclass correlation of
.34 indicated significant variance in reading skills across the cohorts in the sample,
confirming the appropriateness of the MLM approach (Hayes, 2006). The combination of
four predictors in this study resulted in 16 multilevel regression models of word reading
ability (see Appendix for model specification). The entire eligible sample (n = 1621) was
used to obtain stable parameter estimates for each model across the full range of reading
and predictor abilities. In contrast to Pennington et al. (2012), however, the group-level
results of each model were not of interest in this study; rather, the models were only used
to obtain standardized residual errors for each participant. An individual, regression-
based predictor profile was then identified as the one model from the full set of
multilevel analyses that resulted in the smallest standardized residual error for each
participant. The same deficit category labels from the criterion-defined method were
applied to the regression-based profiles. Participants whose reading scores were best
predicted by a model with only cohort as a predictor (i.e., baseline model) were assigned
to a No Deficit category. Cross-tabulation and Cohen’s kappa coefficient were used to
assess agreement of the criterion- and regression-defined methods in the Reading Deficit
sample.

Results

The analyses of deficit profiles are presented in three sections: (a) comparison of
criterion cut-off deficit profiles for the Typical Reader and Reading Deficit groups,
(b) regression-based profiles in the Reading Deficit group and agreement with the
The multiple deficit model of dyslexia: what does it mean for...

criterion-based definition, and (c) effects of age and ADHD diagnosis on the distri-
butions of risk factors for each method.

Criterion-defined deficit profiles by reader group

Deficit profiles of the two reader groups are shown in Table 2. The distribution of profiles was
significantly different between the two groups of participants, χ2(6, N = 1116) = 294.9,
p < .0001.

Regression-based predictor profiles in reading deficit sample

The group-level analyses of multilevel regression models were conducted to identify

which particular combination of predictors best predicts an individual’s word reading
ability. The numbers of individuals with each regression-based predictor pattern are cross
tabulated with the criterion-based deficit definitions in Table 3 for comparison of
agreement between the two methods. The No Deficit category for the regression-based
definition indicates an intercept-only best-fitting regression model, that is, a participant’s
reading level was best predicted by an estimated grand mean. The column labels indicate
the regression models that returned the smallest standardized residual error, that is, the
best fitting combination of predictors for an individual. The last row of the table
indicates the numbers of participants within each of those profile subgroups. Examina-
tion of the values along the diagonal in the table indicated fair but statistically significant
agreement in approximately 47% of the cases (κ = .36, p < .0001).

Age and attention effects

Multilevel regression models and Pearson chi-square tests of independence were used to test
age and ADHD diagnosis effects within the Reading Deficit sample. The regression model
found moderate but significant effects of age on reading accuracy standard scores, γ10 = − .45,
t(1,212) = − 2.1, p = .04, r2LMM(m)1 = .02. The sample was then split at the median age for chi-
square analysis of deficit patterns. The analysis found no reliable effects of age on observed
profile distributions for either criterion-, χ2(6, N = 215) = 7.6, p = .27, or regression-based
definitions, χ2(6, N = 215) = 4.7, p = .58. A multilevel regression analyses of contrast-coded
ADHD diagnosis found no effects on reading ability, γ10 = .31, t(1,213) < 1, p = .44,
r2LMM(m) = .00. Cross-tabulation of ADHD diagnosis also showed no effects on distributions
of the criterion-, χ2(6, N = 215) = 9.5, p = .15, or regression-based definitions, χ2(6, N =
215) = 7.6, p = .27.

Discussion

The purpose of Study 1 was to examine profiles of risk factors in a sample of children referred
for diagnostic services in a learning disabilities clinic. The analyses of criterion-defined deficits

1
Marginal R2 for linear mixed models. See Nakagawa and Schielzeth (2013). Eq. 26.
 Ring J., Black J.L.

Table 2 Criterion-defined deficit profiles by reading group

Group Deficit profile

No deficit PA RAN WM VERB PA core Multiple

Typical Readers 0.76 0.05 0.08 0.08 0.01 0.02 0.01

Reading Deficit 0.28 0.09 0.14 0.10 0.01 0.23 0.14

Tabled values indicate proportion of each sample

PA phonological awareness, RAN rapid naming, WM working memory, VERB verbal comprehension

(< 80 standard score) found significant differences in observed cognitive profiles of typical
readers and the sample with a pronounced reading deficit (see Table 2). The majority of typical
readers presented with no significant deficits in any of the predictor variables, although modest
numbers of typical readers still presented with significant single deficits in phonological
awareness (n = 43), rapid naming (n = 72), and working memory (n = 71). The reading deficit
sample, in contrast, showed a different pattern with approximately one third of the participants
showing single deficits in phonological awareness, rapid naming and, to a lesser extent,
working memory, and verbal ability. Additionally, more patients with a reading deficit
presented with multiple deficits, primarily phonological awareness in combination with other
risk factors. However, it is notable that for a large number of the reading deficit sample (28%),
none of the four cognitive skills used for defining profiles were low enough to meet the
criterion definition of a Bdeficit.^
The statistical modeling used to identify which predictor(s) were related to an
individual’s reading ability in this study resulted in profiles similar to the criterion-
defined method (see Table 3). The computed agreement between two definition methods
was statistically significant and of similar magnitude (47%) to that observed in the
Pennington et al. (2012, Tables 6 and 8) study. The most evident difference between
the two methods in this study was that the regression approach reduced the number of
participants without significant phonological or cognitive deficits (i.e., No Deficit cate-
gory). This result suggests that Bmild^ deficits (i.e., > 80 standard score) have effects on
reading ability although they are not identified by the criterion-cut-off method. Compar-
ison of the column and row totals in Table 3, specifically the decrease in single-deficit

Table 3 Cross-tabulation of criterion- and regression-based deficit profiles

Regression-based profiles

Criterion-based No deficit PA RAN WM VERB PA core Multiple Total

No deficit 10 10 5 0 8 16 12 61
PA 0 6 0 1 0 12 0 19
RAN 0 0 8 0 0 9 13 30
WM 1 0 0 6 1 7 6 21
VERB 0 0 0 0 3 0 0 3
PA core 1 0 0 2 1 42 4 50
Multiple 0 1 0 0 1 3 26 31
Total 12 17 13 9 14 89 61 215

Tabled values indicate the number of individuals within each profile category
The multiple deficit model of dyslexia: what does it mean for...

cases, also show that in many cases, a single-deficit is part of a complex profile of other
phonological and/or cognitive skills that affect reading ability.
Supplemental analyses of the Reading Deficit group found that age was reliably related to
reading scores. Average norm-referenced standard scores were lower in older participants;
however, age did not affect the distribution of deficit profiles. A second individual character-
istic investigated was attention, often associated with underachievement in reading (Frazier,
Youngstrom, Glutting, & Watkins, 2007). A second set of analyses showed no reliable effect of
ADHD diagnoses on reading ability or deficit profiles defined either by the criterion cut-off or
regression models.

Study 2

Study 1 demonstrated that children with a significant reading difficulty present with a
variety of phonological and cognitive deficit profiles. The purpose of Study 2 was to
examine the relation of the same four predictors with treatment outcomes.

Participants

A sample of 89 participants was recruited from nine successive cohorts of patients who
received reading intervention services at the hospital’s learning disabilities clinic. As in Study
1, all patients were evaluated by a psychologist, speech-language pathologist, or educational
diagnostician in the hospital’s learning disabilities clinic. Diagnoses of developmental dys-
lexia were formed with the consensus of an attending developmental-behavioral pediatrician
from the data collected in the clinic assessment and the patient’s history. The sample was
48% female, 34% of minority ethnicity, and 52% from home schooling environments.
Approximately 15% of the sample that attended public schools qualified for special educa-
tion services. Clinical assessment determined that 32% of the sample had attention-deficit
disorder. One participant in Study 2 was also included in the Study 1 sample. All other Study
2 participants were either home-schooled, missing the necessary data from their initial clinic
assessment, or their reading scores were above the 80 standard score cut-off criterion used in
Study 1. Participant characteristics and phonological and cognitive predictor status at baseline
are shown in Table 4.

Table 4 Participant characteristics at baseline

Measure Mean SD Min Max

Age (years) 9.61 1.69 6.6 13.3

Full-scale IQ 99.93 9.83 73 122
Word identification 82.82 11.74 45 112
Reading comprehension 83.78 11.51 55 108
Socioeconomic status 44.40 10.19 22 66
Phonological awareness 88.15 10.37 64 112
Rapid naming 84.53 12.74 52 109
Working memorya 90.94 10.59 56 120
Verbal aptitude 100.40 9.98 81 129

Minimum and maximum values indicate range of scores

a
n = 58
 Ring J., Black J.L.

Procedure

Patients were referred for intervention services at the hospital if they had inadequate access to
appropriate reading instruction at home or school. Participants receiving home-school educa-
tion were eligible for this study because the content and fidelity of their reading instruction
were controlled by the intervention therapists. Participants were included in this study if they
completed the 2-year intervention and had data from their clinical assessment on phonological
processing and cognitive aptitude for use in analyses. Patients with cognitive assessments by
outside providers (e.g., school evaluation) were excluded. The final sample represented 61% of
patients treated during the recruitment period.
The hospital’s intervention program does not continuously enroll patients during the
academic year; classes are formed only at the beginning of the school year. The result is
that patients evaluated during a school year often have to wait until the following school
year to begin the intervention. The average interval between initial diagnosis and
enrollment for participants was approximately 9 months. Phonological processing and
reading skills were assessed by the clinic’s diagnostic staff prior to the onset of inter-
vention. The same test battery was then used to assess treatment response at the end of
the intervention. The measures used for this study included the assessment of cognitive
aptitude at the initial clinical evaluation and phonological processing and reading vari-
ables from the intervention period.

Measures

The same measures used in Study 1 were used for this study. Data from patients with cognitive
assessments from other Wechsler intelligence scales for children was included in this sample
(n = 51). The Verbal IQ composite was used to estimate verbal abilities for those participants.
The other Wechsler scales did not have a working memory composite comparable to the
WISC-IV; however, 20 participants had complete data from the Digit Span subscale which was
used as a proxy measure of working memory. There were no significant differences from the
WISC-IV scores in either verbal intelligence, F(1,87) < 1, p = .39, or working memory,
F(1,56) = 2.6, p = .11. The Reading Comprehension subtest of the WIAT-II (Psychological
Corporation, 2001) was added for additional analysis of treatment outcomes. The reading
comprehension subtest required participants to read short passages and respond to orally
presented comprehension probes. The measure has an average reported test-retest reliability
of .94.

Intervention

Participants received instruction from a comprehensive curriculum designed for students with
dyslexia (Avrit et al., 2006; Ring, Avrit, & Black, 2017). The daily lessons were approximately
1 h in duration and provided in small groups of two to four students. The curriculum was
delivered over two academic years and totaled 230 h of instruction.
The curriculum content was developed in response to evidence-based practices for teaching
reading (National Institutes of Child Health and Development, 2000). Phonemic awareness
instruction explicitly taught spelling-sound patterns and manipulation of sounds in analytic
spelling and reading exercises (e.g., Wise & Olson, 1995). The phonics component was
derived from established Orton Gillingham procedures for teaching the structure of written
The multiple deficit model of dyslexia: what does it mean for...

language (e.g., Beckham & Biddle, 1987). Approximately 35% of the lesson time was devoted
to direct instruction of phonological skills (25% for phonics and 10% for phonological
awareness). Spelling instruction accounted for 17% of lesson time.
Reading rate and fluency practice adopted the repeated oral reading model but was
designed to develop automatic recognition of orthographic units (i.e., letter clusters) within
words rather than full text (e.g., Berends & Reitsma, 2007). Reading rate and fluency practice
totaled 18% of instruction time. The curriculum used a multiple-strategy approach for vocab-
ulary and reading comprehension instruction that combined methods that have the support of
scientific evidence (e.g., cooperative learning, summarization, comprehension monitoring;
Vaughn & Klingner, 1999). Reading comprehension (20%) and vocabulary (10%) instruction
comprised the remaining instruction time.
Fidelity of curriculum implementation was ensured by the extensive training of
instructors at the hospital. All instructors were Certified Academic Language Therapists
(CALT), a certification that required a minimum of 200 instructional hours in a struc-
tured Orton Gillingham-based program and a minimum of 700 supervised clinical hours
working with children with dyslexia. All CALTs on the education staff had a minimum
of 2 years experience working with the intervention curriculum before data collection.
The hospital also serves as an accredited dyslexia therapist training center. As a result, all
staff CALTs had to provide model intervention practices including strict adherence to the
curriculum for classroom observations by teachers in the training program. Additionally,
all students were present for the majority of lessons as a result of an enforced attendance
policy of 90% of class days.

Data analysis

Participants in this study were clustered in both cohorts and classrooms, suggesting a similar
hierarchical structure as in Study 1. However, the number of cohorts (9) is below the minimum
sample size recommended for Level 2 variables in a multilevel analysis (Maas & Hox, 2005).
Similarly, the number of classrooms or therapists (4) is also less than the recommended Level 2
sample size. Moreover, students in the Dyslexia Lab were frequently assigned to different
classes in their second year of intervention, further complicating model specification. For these
reasons, an alternative to multilevel modeling was adopted that used a fixed effects ANCOVA
regression approach to remove any variance between cohorts (McNeish & Stapleton, 2016).
First, eight contrast-coded predictors were created to account for all variance in outcome
measures due to the nine cohorts in the sample. The analyses then used ordinary least squares
estimation for regression modeling of the contrast-coded cohort predictors as blocking vari-
ables and the predictors of interest.
The first set of regression analyses examined the individual relationship of each
phonological or cognitive processing predictor with baseline levels of word reading
and reading comprehension. The predictor variables were assessed separately in a model
that also included participant age, a covariate added to control for the wide age range in
the sample. Effects of each predictor on post-intervention word reading accuracy and
reading comprehension outcomes were then assessed in four additional regression
models that predicted posttest status as a function of age, the respective baseline
performance, and one of the four predictors. Baseline performance was added to the
latter set of analyses to assess whether the predictors provided any additional information
about outcome status beyond that provided by initial reading status. The predictors in
 Ring J., Black J.L.

this study were modestly correlated (rs range from .1 to .27); therefore, adjusted
significance levels were used to maintain a False Discovery Rate (FDR) of .05 for each
set of regression analyses (Benjamini & Hochberg, 1995).
The unique effects of each predictor, independent of all other predictors, were then
examined for both word reading accuracy and comprehension with simultaneous multiple
regression analyses. The model for post-intervention word reading accuracy included
age, baseline reading status, and any significant predictors from the set of individual
analyses of word reading outcome. The model for reading comprehension included age,
baseline comprehension status, and all reliable predictors from the individual analyses of
comprehension at the end of treatment. Word reading was added to the model of
comprehension outcomes to assess effects of the other predictors that were independent
of basic word reading ability.
The effects of an ADHD diagnosis on observed word reading and reading compre-
hension was first assessed with repeated-measures ANCOVA models controlling for
age and variation due to cohorts. The series of individual and simultaneous regression
models were then re-analyzed with ADHD status included as a contrast-coded
predictor.

Results

A 2 × 9 (Test[Baseline, Posttest] × Cohort[Year 1, …, Year 9]) repeated-measures

ANCOVA with age as a covariate indicated significant intervention gains in both word
reading accuracy (MPRE = 82.8 to MPOST = 92.1), F(1,79) = 89.98, p < .0001, η2 = .53, and
reading comprehension (M PRE = 83.7 to M POST = 94.6), F(1,75) = 72.38, p < .0001,
η2 = .49. The results from the regression analyses of the four predictor variables on
baseline and post-intervention word reading accuracy and comprehension are summa-
rized in Table 5. The squared semi-partial correlation (sr2) indicates the amount of
variance in the outcome measure attributed to each predictor independent of all other
variables in the model. The analyses also indicated reliable effects of age in all models of
baseline word reading accuracy and reading comprehension (all p < .05). The analyses of

Table 5 Separate prediction models of baseline and post-intervention reading

Predictor measure Word reading accuracy Reading comprehension

Baseline Post-test Baseline Post-test

B sr2 B sr2 B sr2 B sr2

Phonological awareness .26 .06* .19 .03* .22 .04 .22 .04*
Rapid naming .43 .16* .11 .01 .27 .06* .14 .01
Working memorya − .06 .00 − .03 .00 .16 .02 − .06 .01
Verbal aptitude .26 .05* .09 .00 .41 .13* .19 .03†

B standardized regression coefficient, sr2 squared semi-partial correlation. Tabled significance values indicate
adjusted α-levels
*p < .05
†
p < .05 but not significant with adjusted α-level
a
n = 58
The multiple deficit model of dyslexia: what does it mean for...

post-intervention word reading and reading comprehension showed significant effects of

the respective baseline levels (all p < .01). Age was not a significant factor in any
analyses of post-intervention status.

Simultaneous multiple regression analyses

Reliable predictors from the separate regression models in Table 5, including those that
were marginally significant with the adjusted alpha-level, were then analyzed to assess
the effect of each predictor on word reading and comprehension outcomes after control-
ling for the effects of the other predictors in the model. The results in Table 5 indicated
that phonological awareness and rapid naming were reliable predictors of both word
reading accuracy and reading comprehension at baseline. However, for the age range in
this sample, the average correlation of word reading and reading comprehension in the
WIAT normative sample was .69 (Psychological Corporation, 2001). The regression
analysis of comprehension outcomes therefore included concurrent word reading to
assess unique contributions of the predictors to comprehension outcomes that were
independent of basic reading ability. Results for word reading and reading comprehen-
sion outcomes are summarized separately in Table 6.

Attention and intervention response

Separate 2 × 2 × 9 (Time[Baseline, Posttest] × ADHD[Diagnosis, No Diagnosis] ×

Cohort[Year 1, …, Year 9]) repeated-measures ANCOVAs indicated no relation of
ADHD diagnosis on word reading or comprehension treatment outcomes. Re-analysis
of the regression models in Table 5 with ADHD status included as a contrast-coded
predictor also found no significant effects of ADHD on word reading accuracy at either
baseline or post-treatment. However, the analyses did suggest a significant group differ-
ences in baseline comprehension ability. A post hoc 2 × 9 ADHD[Diagnosis, No Diag-
nosis] × Cohort[Year 1, …, Year 9]) ANOVA confirmed that participants with attention
issues had lower average reading comprehension (MADHD = 79.12 vs. MNO ADHD =
86.05), F(1, 67) = 4.8, p = .03, η2 = .07. The previously reported repeated-measures
ANOVA indicated that those baseline differences were not present at posttest. The

Table 6 Simultaneous prediction of post-intervention reading ability

Word reading Comprehension

Predictor B sr2 Predictor B sr2

Baseline .49 .15** Baseline .25 .03*

Phonological awareness .18 .02* Word reading .28 .03*
Rapid naming .08 .00 Phonological awareness .20 .03*
Verbal aptitude .06 .00 Rapid naming .09 .00
Verbal aptitude .18 .02†

Baseline refers to pre-intervention word reading or reading comprehension levels

B standardized regression coefficient, sr2 squared semi-partial correlation
*p < .05; **p < .01
†
p = .05 but not significant with adjusted α-level
 Ring J., Black J.L.

presence of ADHD as a predictor did not change the pattern of results in any of the
simultaneous regression models reported in Table 6.

Discussion

The data in Table 5 showed that phonological awareness, rapid naming, and verbal aptitude
were marginally significant predictors of baseline reading. Rapid naming and verbal aptitude
were also related to baseline comprehension. The analyses also suggest that phonological
awareness accounted for some of the variance in comprehension although that result was not
statistically significant. The baseline results replicate the outcomes of Study 1 and are similar
to other reports of phonological and cognitive skills related to reading difficulty (e.g., Morris
et al., 1998). In contrast to both previous research and the data in Study 1, working memory
had no relationship with reading ability in these analyses. The observed effect size suggests
that the latter result may not be just an artifact of the smaller sample of participants in Study 2.
It should be noted, however, that working memory was only assessed by digit span in
approximately one third of the sample. Those tasks may not be sufficiently sensitive to relevant
working memory span differences to detect reliable correlations with reading performance
(c.f., Gathercole, Alloway, Willis, & Adams, 2006).
The relationship of phonological awareness and rapid naming with post-intervention
reading status differed in important ways from baseline predictions. Phonological awareness
was a reliable predictor of both word reading accuracy and reading comprehension after
treatment, results previously found in intervention studies (e.g., Mathes et al., 2005; c.f.,
Torgesen et al., 2001). The effect of rapid naming at post-test, however, was significantly
reduced and no longer a reliable predictor of word reading. This unexpected outcome may
result from the untimed nature of the skill tested, or alternatively, the inclusion of baseline
reading in the regression model captured shared variance in post-intervention reading. In
addition, the significance of rapid naming for reading comprehension outcomes must also be
interpreted in the context of the relation to word reading. The analysis summarized in Table 6
suggested that the effects of rapid naming were mediated through concurrent word reading
ability, although phonological awareness continued to be a significant predictor of compre-
hension outcomes.
The effect of initial levels of verbal aptitude on reading in this study was also consistent
with reported research. Specifically, the correlation of baseline verbal aptitude with reading
accuracy and comprehension likely reflects the connection of reading with vocabulary devel-
opment (e.g., Cunningham & Stanovich, 2001). That relationship was not expressed in word
reading after treatment, although verbal abilities were a marginally significant predictor of
gains in reading comprehension (Torgesen et al., 2001; Wise, Ring, & Olson, 1999). Partic-
ipants with higher verbal aptitude showed larger gains in comprehension, though the effect
was reduced after accounting for basic reading ability.

General discussion

Although research consensus finds that phonological processing problems are primary to the
reading disorder, children with dyslexia present with a variety of co-occurring cognitive and
language processing deficits (e.g., Morris et al., 1998; Vellutino et al., 2004). Moreover, a
single phonological deficit does not account for all the observed performance variability in
The multiple deficit model of dyslexia: what does it mean for...

individuals with dyslexia (Boada, Wilcutt, & Pennington, 2012). The phenotypic expression of
the condition, therefore, may be better described as reflecting variation in cognitive abilities
around a Bphonological core^ deficit (Stanovich, 1988). As a result, a multifactorial approach
provides a better model for the study of the risk factors associated with reading disability
(Pennington, 2006). Recent research has since provided converging evidence that supports a
multiple deficit model of reading disorders (McGrath et al., 2011; Menghini et al., 2010).
The goal of Study 1 was to add to that literature and examine individual profiles of
phonological and cognitive processing deficits associated with significant reading difficulty.
Direct comparison of the deficit patterns in this clinically referred sample and the population-
based sample of Pennington et al. (2012) was complicated by the different predictor variables
and deficit categories used in the two studies. However, in general, the results in Study 1 and
the correlation of the two methods used to define those phonological and cognitive processing
profiles were similar to the results reported by Pennington et al. (2012). Specifically, the
outcomes of this study supported the conclusion that a multiple-deficit model, one that can
allow for single-deficit cases, provides a better description of the profiles of risk factors
associated with significant reading problems. Moreover, although there were a non-trivial
number of participants without significant phonological awareness deficits, the majority had
phonological-core deficit profiles, particularly if rapid naming was included as a phonological
processing skill (e.g., Wagner, Torgeson, & Rashotte, 1999). Finally, patient age and the
presence of comorbid ADHD were analyzed as additional risk factors but showed no effects
on the observed pattern of results.

Research to practice

The agreement of the two identification methods in this study of 47%, while statistically
significant, suggests that the criterion cut-off approach under-identified the risk factors asso-
ciated with significant reading difficulties for more than one half of the sample. For example,
the data in Table 3 indicated that a large proportion of the sample did not present with
significant criterion-defined deficits in any of the risk factors. In contrast, the statistical
modeling approach showed that reading ability was associated with one or more milder
deficits in risk factors for many of those participants. Moreover, the analyses also indicated
that many patients who were initially identified with a single risk factor actually had multiple
risk factors that were related to their reading ability.
The poor sensitivity of the cut-off criterion method might be attributed in part to the rather
conservative criterion used to identify a skill deficit in this study. Reading and associated
phonological or cognitive abilities, however, are normally distributed in the population and the
adoption of a cut point along that continuum of ability represents a somewhat arbitrary
decision (Fletcher, Lyon, Fuchs, & Barnes, 2007). An interesting question for practice
concerns how the sensitivity of the criterion-based method might change with different cut-
off points for associated risk factors. A post hoc analysis that still defined a reading deficit at
the lowest 10th percentile but used a one standard deviation cut-off criterion (i.e., 85 standard
score) for the predictors of reading found that the agreement between the two methods
increased from 47 to 63%. The adoption of the less restrictive criterion for the predictors of
the reading deficit thus provided a more accurate identification of associated risk profiles. It is
worth noting, however, that using an even less restrictive cut-off point of 90 standard score did
not improve the observed agreement of the criterion- and regression-based methods, a result
that implies an upper limit to the sensitivity of a criterion-based method.
 Ring J., Black J.L.

The results of Study 1 suggest important consequences for the identification of reading
disability and subsequent referral for remedial services. Specifically, identification methods
that rely on the presence of phonological awareness deficits in addition to significant reading
difficulties as qualifying criteria would miss a large number of children. The data presented
in Pennington et al. (2012) showed that approximately one half of their samples would not
meet that criterion for services. Based on the distributions shown in Table 2, approximately
40% of the sample in Study 1 would not be eligible for remedial reading services.
Furthermore, even if a more lenient requirement was adopted as simply being below average
in phonological awareness (i.e., ≤ 90 standard score), approximately 26% of the Reading
Deficit sample would still not receive instruction appropriate for their reading difficulties.
The practical implications of the multiple deficit model for decisions about the focus of
reading intervention are not as clear. A multiple-deficit view of reading disability may be
interpreted as consistent with the goals of using cognitive profiles to identify the Bvaried root
causes of reading difficulties and then provide specific interventions that are targeted to each
student’s individual needs^ (Reynolds & Shaywitz, 2009). More precisely, the cognitive
assessment approach proposes that comprehensive assessment of neuropsychological process-
es (e.g., intelligence) identifies a pattern of cognitive strengths and weaknesses that can inform
the development and implementation of individualized instruction (e.g., Fiorello, Hale, &
Snyder, 2006). There is some evidence that at least some neuropsychological deficits (e.g.,
working memory) can be improved with targeted instruction, at least in the short-term
(Klingberg et al., 2005; c.f., Melby-Lerv g, Redick, & Hulme, 2016). The reading intervention
literature, however, provides little evidence that cognitive interventions have an effect on
reading outcomes (Burns et al., 2016; Kearns & Fuchs, 2013).
The purpose of Study 2 was to examine how the phonological and cognitive and processing
skills evaluated in Study 1 impacted the outcomes of intervention for reading disability. The
results were variable and depended in part on how reading development was measured. For
example, phonological awareness was the only reliable predictor of gains in word reading
accuracy, a common finding in the intervention literature (e.g., Vellutino et al., 2004). Reading
comprehension presented a more complicated picture where phonological awareness, rapid
naming, and verbal aptitude were initially all significant predictors of post-intervention status.
After controlling for the correlation of concurrent reading ability with all three predictors,
phonological awareness and verbal aptitude still accounted for unique variance in comprehen-
sion outcomes. It should be noted that, although marginally significant, neither variable
predicted much variance in post-intervention reading (see Table 6). Rather, the strongest
predictors of post-intervention reading status were baseline levels of those same reading skills,
a result that corresponds with other research investigating cognitive profiles and treatment
response (Burns et al., 2016; Steubing et al., 2015).
The latter outcome raises a practical question why phonological and cognitive and
processing skills that are significantly correlated with concurrent reading abilities prove
such modest predictors of treatment outcome. One explanation may be that the interven-
tion itself moderates the effects of individual characteristics on treatment response. For
example, a comprehensive curriculum that includes specific instruction in all areas
critical to reading success (e.g., phonological awareness) will directly address any pre-
intervention deficits, thus reducing any relationship of initial status to outcomes. A
second moderating effect may be the diagnostic and prescriptive teaching model imple-
mented by the academic language therapists in this study and typical of the Orton
Gillingham approach (Uhry & Clark, 2005). In the classroom, the teacher or therapist
The multiple deficit model of dyslexia: what does it mean for...

monitors student progress, either formally or informally, and uses that information to
plan the daily lesson. The diagnostic process also involves assessing students’ daily
difficulties and making accommodations in instructional delivery or behavioral feedback.
For example, reading disability and ADHD have a high co-occurrence rate and comorbid
ADHD problems can adversely affect reading achievement (e.g., Alexander & Slinger-
Constant, 2004). However, attention was not a significant factor in treatment outcomes in
this study, largely because in a small-group setting, the therapist was able to actively
manage the learning environment for the students and re-direct inattentive students to
lesson activities.
Returning to the question of student profiles and intervention decisions, this study suggests
that the deficits that matter are in component reading skills and relevant behavioral issues
(Fletcher & Miciak, 2017). Significant phonological awareness and decoding deficits recom-
mend combined phonological awareness and phonics instruction (National Institutes of Child
Health and Development, 2000). Word identification difficulties in the absence of phonolog-
ical deficits suggest more advanced word study including morpho-phonological analysis and
spelling (e.g., Moats, 2005). Rate exercises in activities such as repeated readings can address
reading fluency deficits (Chard, Vaughn, & Tyler, 2002). Significant reading comprehension
deficits would require direct instruction in vocabulary development and strategy training (e.g.,
Vaughn & Klingner, 1999). Finally, extensive opportunities to read authentic text engage all
components with beneficial effects on reading achievement (Mol & Bus, 2011). A well-trained
therapist using diagnostic teaching methods and a comprehensive curriculum can vary the
relative emphasis of each of these components within daily lessons to meet individual
academic needs. Furthermore, behavioral or cognitive (e.g., working memory) issues that
may affect student progress can be accommodated within such an individualized intervention
approach.

Limitations

This research must be interpreted in the context of important methodological limitations.

First, the correlation of a predictor with a reading disability does not necessarily imply a
causal role in the reading deficit. The performance on any predictor measure (e.g.,
vocabulary) may be a consequence rather than a cause of the reading deficit. Second,
the set of predictors used in these studies was limited and did not include additional
important constructs related to reading ability (orthographic processing, morphological
awareness, non-symbolic processing speed, etc.) or component reading skills (e.g.,
phonological decoding). The four predictors in Study 1 accounted for 42% of the
variance in reading skills, suggesting that there was substantial unexplained variance in
the analysis. Third, because word reading accuracy is the defining characteristic of
dyslexia and therefore the focus of analyses in Study 1, the results likely underestimated
the relative importance of cognitive predictors to more complex elements of reading.
Furthermore, the decision criterion of the 10th percentile on one measure of reading
ability represents an arbitrary cut-point with the result that approximately one third of the
eligible sample was excluded from analysis.
Children with reading disability are also distinguished by relative difficulties with
phonological decoding (Rack, Snowling, & Olson, 1992). The inclusion of such a second
measure of reading ability would likely identify larger numbers of participants for
 Ring J., Black J.L.

analyses. Additionally, the implications for identification assumed service delivery that
did not completely rely on a Response to Intervention (RtI) tiered model but rather
directly referred students in need for intensive intervention (Vaughn, Denton, & Fletcher,
2010). A fully implemented tiered intervention model would likely catch some of those
struggling students who do not have noticeable phonological difficulties, although this
would occur with a cost in terms of lost time before initiating an appropriate intensive
intervention. Finally, metropolitan public school districts were over-sampled in Study 1
and, because school effects were not removed in the analysis for methodological reasons,
this may affect generalizability of the results beyond urban and suburban school
environments.
The pattern of treatment effects reported from Study 2 may be dependent, in part, on a
highly controlled small class environment. Some risk factors (e.g., ADHD) may exert greater
effects on treatment response in less controlled classrooms. The analyses in Study 2 were not
completely comparable to results of Study 1 because the intervention sample’s reading ability
was not as severely compromised as the Reading Deficit sample in Study 1. The predictors
showed adequate variance (see Table 4) and normality for regression analyses, so the modest
results cannot be fully attributed to statistical artifact. It is possible that the effects of cognitive
predictors may change in more severely affected individuals; however, the number of partic-
ipants with comparable word reading deficits in the intervention sample (n = 34) provided
insufficient statistical power to test that hypotheses.

Summary and future directions

The reported research provides additional empirical support for the multiple deficit
model of reading disability (Pennington et al., 2012). Moreover, the majority of partic-
ipants presented with a phonological core deficit profile, that is, phonological processing
deficits either in isolation or with other cognitive deficits (Morris et al., 1998). It is
important to note that these results also showed that phonological awareness, though
sufficient in many cases, is not necessary for a reading disability. It may be argued that a
reading disability without phonological awareness deficits is not dyslexia, which is itself
an important discussion beyond the scope of this research (Elliott & Grigorenko, 2014).
A careful reading of the consensus definition of dyslexia, however, accommodates this
interpretation of the condition. Specifically, the definition states that the reading diffi-
culties in dyslexia B…typically [emphasis added] result from a deficit in the phonological
component of language that is unexpected in relation to other cognitive abilities and the
provision of effective classroom instruction.^ (Lyon, Shaywitz, & Shaywitz, 2003, p. 2).
The results of this study agree with that definition; the typical participant with significant
reading difficulties had some kind of phonological processing deficit. However, many
participants presented with profiles of risk factors that did not include significant
phonological awareness problems. The implication for practice is that more students
would receive academic intervention appropriate for their reading difficulties with a
broader definition of the conditions associated with reading disability.
A multiple deficit model of dyslexia provides less guidance for the design of academic
interventions. Cognitive variables are not very effective predictors of reading achievement
after intervention relative to baseline status on those same reading skills (Steubing et al.,
2015). Moreover, research that has applied cognitive profiling and targeted cognitive
The multiple deficit model of dyslexia: what does it mean for...

interventions for academic difficulties have produced equivocal results (Burns et al., 2016;
Kearns & Fuchs, 2013). Although the mixed results suggest areas of future research, at this
time, the intervention literature most clearly recommends comprehensive phonics-based
reading instruction for children who are struggling to read (National Institutes of Child
Health and Development, 2000). The principle of best practices would recommend accom-
modating individual differences due to cognitive weaknesses within the context of a com-
prehensive, skill-based reading program rather than targeting those weaknesses with specific
intervention (Kearns & Fuchs, 2013). The patterns of strengths and weaknesses in reading
processes rather than cognitive function, therefore, would prove more useful for intervention
design (Fletcher & Miciak, 2017).
The limitations of this study suggest several directions for additional research.
First, although impaired word reading accuracy is a signature of reading disability,
children with the condition are typically also impaired in phonological decoding. The
inclusion of such an additional measure for identification would likely expand the
number of students eligible for appropriate intervention. The pattern of relevant
deficits would also likely depend on the measure(s) that identify a reading disability.
Furthermore, a more fully specified model of reading and/or decoding accuracy that
includes additional components (e.g., orthographic processing) can better define the
complex relation between risk factors and behavioral outcomes. A more applied
direction could examine the moderating effects of intervention in prospective studies
that systematically vary treatment components and also quantify therapist-student
interactions. A program of these types of studies would represent a step forward
toward understanding what intervention components and practices work best for
specific types of students (Shaywitz, Morris, & Shaywitz, 2008).

Appendix

Table 7 Multilevel-regression models used for individual prediction in Study 1

Description Regression model

Baseline Yij = γ00 + u0j

Single predictor Yij = γ00 + γ10PAij + u0j
Yij = γ00 + γ10RANij + u0j
Yij = γ00 + γ10WMij + u0j
Yij = γ00 + γ10VERBij + u0j
Phonological-core predictor Yij = γ00 + γ10PAij + γ20RANij + u0j
Yij = γ00 + γ10PAij + γ20WMij + u0j
Yij = γ00 + γ10PAij + γ20VERBij + u0j
Yij = γ00 + γ10PAij + γ20RANij + γ30WMij + u0j
Yij = γ00 + γ10PAij + γ20RANij + γ30VERBij + u0j
Yij = γ00 + γ10PAij + γ20WMij + γ30VERBij + u0j
Yij = γ00 + γ10PAij + γ20RANij + γ30WMij + γ40VERBij + u0j
Multiple predictor Yij = γ00 + γ10RANij + γ20WMij + u0j
Yij = γ00 + γ10RANij + γ20VERBij + u0j
Yij = γ00 + γ10WMij + γ20VERBij + u0j
Yij = γ00 + γ10RANij + γ20WMij + γ30VERBij + u0j

The baseline model includes both a fixed γ00 and random u0j component
 Ring J., Black J.L.

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