Cognitive Neuropsychology

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Treatment of irregular word spelling in

developmental surface dysgraphia

Ruth Brunsdon , Max Coltheart & Lyndsey Nickels

To cite this article: Ruth Brunsdon , Max Coltheart & Lyndsey Nickels (2005) Treatment of
irregular word spelling in developmental surface dysgraphia, Cognitive Neuropsychology, 22:2,
213-251, DOI: 10.1080/02643290442000077

To link to this article: https://doi.org/10.1080/02643290442000077

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COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2), 213–251

TREATMENT OF IRREGULAR WORD SPELLING IN

DEVELOPMENTAL SURFACE DYSGRAPHIA

Ruth Brunsdon
Macquarie University and Children’s Hospital at Westmead, Sydney, Australia

Max Coltheart and Lyndsey Nickels

Macquarie University, Sydney, Australia

An increasing number of cognitive neuropsychological treatment studies of acquired dysgraphia have

been published in recent years, but to our knowledge there are no corresponding studies of develop-
mental dysgraphia. This paper reports a cognitive neuropsychological treatment programme
designed for a child with developmental surface dysgraphia. The treatment aim was to improve func-
tioning of the orthographic output lexicon, and so treatment methods targeted irregular word
spelling. Treatment methods were based on previous successful treatments employed in cases of adult
acquired surface dysgraphia (Behrmann, 1987; De Partz, Seron, & Van der Linden, 1992; Weekes &
Coltheart, 1996). Results showed a significant treatment effect for both spelling and reading of irreg-
ular words that was largely stable over time and that generalised partially to spelling of untreated
irregular words. Homophone words were not treated but some aspects of homophone reading and
spelling also improved, though homophone confusion errors remained. Comparison of treatment
effectiveness with and without mnemonics suggested that the mnemonic cue itself was not necessary
to achieve treatment success for irregular word spelling. Analyses revealed that untreated irregular
words whose spellings became correct as a result of treatment generalisation were those whose origi-
nal misspellings were closest to being correct prior to treatment. Results also provided preliminary
evidence that the mechanism underlying treatment generalisation involved improved access to
orthographic representations, resulting in an increased tendency to employ orthography for spelling
attempts and reduced reliance on phoneme to grapheme conversion.

INTRODUCTION has neglected investigation of treatment options

In the field of cognitive neuropsychology, dys-
graphia has received far less research attention
than dyslexia. In addition, most research has
focused on theoretical aspects of dysgraphia and
(e.g., Bub & Kertesz, 1982; Ellis, 1988; Friedman
& Alexander, 1990; Katz & Deser, 1991; Miceli &
Silveri, 1985; Patterson, 1988; Rapcsak, 1997;
Robinson & Weekes, 1995; Roeltgen & Heilman,
1985; Roeltgen & Tucker, 1988; Romani, Ward,

Correspondence should be addressed to Ruth Brunsdon, Rehabilitation Department, Children’s Hospital at Westmead, Locked
Bag 4001, Westmead, NSW 2145, Sydney, Australia (Email: ruthb2@chw.edu.au).
The authors are grateful to Alan Taylor for statistical advice. We are indebted to our client MC and his family for their enthusi-
astic participation throughout the project. Lyndsey Nickels was supported by an Australian Research Council QEII Fellowship and
Max Coltheart by an Australian Research Council Federation Fellowship during the preparation of this paper.
The authors also wish to thank Assistant Professor Argye Hillis and two anonymous reviewers for their very helpful comments
on a previous version of this paper.

© 2005 Psychology Press Ltd 213

http://www.tandf.co.uk/journals/pp/02643294.html DOI:10.1080/02643290442000077
BRUNDSON, COLTHEART, NICKELS
& Olson, 1999; Temple, 1988, 1990; Weekes,
1994). However, a small but growing number of
treatment studies for acquired dysgraphia have been
published (e.g., Beeson, 1999; Beeson, Hirsch, &
Rewega, 2002; Behrmann & Byng, 1992;
Carlomagno & Parlato, 1989; Conway et al., 1998;
De Partz et al., 1992; Hatfield, 1983; Hillis &
Caramazza, 1986; Luzzatti, Colombo, Frustaci, &
Vitolo, 2000; Pound, 1996; Rapp & Kane, 2002;
Seron, Deloche, Moulard, & Rousselle, 1980), but
we are unaware of any published single case treat-
ment studies of developmental dysgraphia. The
current paper reports on the treatment of spelling in
a 12-year-old child with developmental surface
dysgraphia and developmental surface dyslexia, and
is theoretically based on cognitive neuropsychologi-
cal dual-route models of reading and spelling
(Coltheart, 1987; Ellis, 1982; Ellis & Young, 1988;
Patterson & Shewell, 1987).
Cognitive neuropsychological dual-route
models of reading and spelling
Cognitive neuropsychological dual-route models
of reading and spelling (see Figure 1) propose two
main processing routes for spelling to dictation
and reading aloud: the lexical and sublexical pro-
cessing routes.
Spelling
For spelling to dictation (i.e., converting a spoken
stimulus into its written form), the lexical proce-
dure relies on the retrieval of whole-word ortho-
graphic information from the orthographic output
lexicon and allows efficient spelling of familiar
words (both regular and irregular). Skilled readers
first recognise the heard word through activation
of its entry in the phonological input lexicon, and
then access its associated meaning from the
semantic system. Finally, the word’s written form
is retrieved from the orthographic output lexicon
1
There are also several other possible routes that could be employed for spelling to dictation, including: direct route through
lexical phonology and then phoneme-to-grapheme conversion (shown by arrows 1, 9, 11, 7, 8); lexical phonological route via the
semantic system and then grapheme-to-phoneme conversion (shown by arrows 1, 2, 12, 11, 7, 8); lexical route via the semantic
system and then output orthography (shown by arrows 1, 2, 12, 10, 4).
214 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
and is made available for the process of writing via
the graphemic output buffer (see Figure 1, route
shown by arrows 1, 2, 3, 4). The graphemic output
buffer is proposed to store ‘whole-word’ represen-
tations temporarily while the physical process of
writing (or oral spelling) is completed. In contrast,
the sublexical spelling procedure (see Figure 1,
route shown by arrows 5, 6, 7, 8) allows spelling of
unfamiliar words and nonwords, and regularly
spelled familiar words, by applying rule-based
phoneme to grapheme conversion. Some authors
have also proposed a third ‘lexical nonsemantic’
spelling route that links the phonological input
lexicon to the orthographic output lexicon via the
phonological output lexicon bypassing the seman-
tic system (see Figure 1, route shown by arrows 1,
9, 10, 4) (Ellis & Young, 1988; Patterson, 1986).1
Post-graphemic processing includes conversion of
abstract graphemic representations to visual letter
shapes or letter stroke features (often referred to as
allographic conversion) (Goodman & Caramazza,
1986a, 1986b; Rapp & Caramazza, 1997), and
more peripheral writing includes coordination of
motor processes allowing sequences of strokes to
be formed into each written letter (Goodman &
Caramazza, 1986a, 1986b).
Reading
Most theories of reading also make the distinction
between lexical and sublexical processing routes
(Coltheart, 1985, 1987; Coltheart, Curtis, Atkins, &
Haller, 1993; Coltheart, Rastle, Perry, Langdon, &
Ziegler, 2001; Ellis, 1982; Ellis & Young, 1988; but
also see Seidenberg & McClelland, 1989; Plaut,
Seidenberg, McClelland, & Patterson, 1996, for
discussion of alternative theoretical viewpoints).
The lexical reading route relies on visual word recog-
nition through access to an internal store of learned
familiar words (see Figure 1, route 13, 14, 12, 11)
and the sublexical reading procedure involves rule-
based grapheme to phoneme conversion, which
 TREATMENT OF SURFACE DYSGRAPHIA

Figure 1. Cognitive neuropsychological dual-route model of reading and spelling (adapted from Ellis & Young, 1988).

allows the skilled reader to ‘sound-out’ unfamiliar
words and nonwords (see Figure 1, route 16, 17).
As with spelling, some authors also argue for a lex-
ical nonsemantic processing route in reading (e.g.,
Ellis & Young, 1988), which allows for processing
of irregular words without access to their meaning
(see Figure 1, route shown by arrows 13, 15, 11).
Patterns of impairment in dysgraphia
Reported cases of dysgraphia vary enormously in
terms of the nature of the impairment and the
resultant functional spelling difficulties (for a con-
cise summary of the nature of dysgraphia, see
Rapcsak & Beeson, 2000). In brief, cases of both
phonological dysgraphia (specific difficulties with
nonword spelling, in the context of relatively
unimpaired word spelling; e.g., Campbell &
Butterworth, 1985; Iribarren, Jarema, & Lecours,
2001; Marien, Pickut, Engelborghs, Martin, & De
Deyn, 2001; Ogden, 1996; Shallice, 1981;
Snowling, Stackhouse, & Rack, 1986) and surface
dysgraphia (difficulties with irregular word spelling
in the context of relatively intact nonword spelling;
e.g., Behrmann & Bub, 1992; Hanley, Hastie, &
Kay, 1992; Roeltgen & Blaskey, 1992; Temple, 1985,
1986) have been reported. Other cases of dysgraphia
have been reported with specific impairments

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 215

BRUNDSON, COLTHEART, NICKELS
(single or multiple) involving other components of
the spelling system such as the graphemic output
buffer (Bonazzi, 1996; Caramazza, Miceli, Villa,
& Romani, 1987; Piccirilli, Petrillo, & Poli, 1992;
Posteraro, Zinelli, & Mazzucchi, 1988; Rapp &
Kane, 2002; Schiller, Greenhall, Shelton, &
Caramazza, 2001), post-graphemic processes
(Goodman & Caramazza, 1986a; Hanley &
Peters, 2001; Zesiger, Martory, & Mayer, 1997),
or more peripheral aspects of writing such as selec-
tion of motor programmes, motor planning, or
handwriting (Cubelli, Guiducci, & Consolmagno,
2000; Destreri, Farina, Alberoni, Pomati, Nichelli,
& Mariani, 2000; Ellis, Young, & Flude, 1987;
Silveri, Misciagna, Leggio, & Molinari, 1997;
Venneri, Cubelli, & Caffarra, 1994).
Remediation of lexical spelling impairment
This paper will hereafter focus on the treatment
of dysgraphia and specifically treatment pro-
grammes designed to treat lexical spelling impair-
ments. Interested readers are also referred to
Rapcsak and Beeson (2000) and/or Beeson and
Hillis (2001) for a recent overview of published
spelling treatment studies, including those with a
treatment focus on other aspects of spelling. As
there are no known published cognitive neuro-
psychological treatment studies of developmental
dysgraphia, the following review refers solely to
studies of the treatment of acquired lexical dys-
graphia in adults.
Some treatment studies of lexical spelling
impairments have focused on direct remediation of
impaired functions, while others have focused on
the strengthening of compensatory skills. Direct
remediation methods have predominantly aimed to
strengthen representations in the orthographic
output lexicon (or improve access to them) and also
facilitate lexical-semantic connections (Aliminosa,
McCloskey, Goodman-Schulman, & Sokol, 1993;
Beeson, 1999; Beeson et al., 2002; Behrmann,
1987; Carlomagno, Lavarone, & Colombo, 1994;
De Partz et al., 1992; Rapp & Kane, 2002; Weekes
& Coltheart, 1996). Compensatory techniques are
often targeted at sublexical or phonological skills
216 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
in order to support lexical processing, such as
improving the use of phoneme to grapheme con-
version in order to cue whole-word lexical retrieval
(Hillis & Caramazza, 1994; Hillis Trupe, 1986). A
more recent study capitalised on residual oral
spelling skills and employed a compensatory treat-
ment method involving a letter-by-letter oral to
written spelling relay technique (Mortley, Enderby,
& Petheram, 2001). The current treatment study
has a direct remediation methodology so only those
studies reporting direct remediation of lexical
impairments will be reviewed, with a focus on three
studies particularly relevant to the current study
(Behrmann, 1987; De Partz et al., 1992; Weekes &
Coltheart, 1996). Other studies that have employed
subjects with very severe dysgraphia affecting mul-
tiple components of the writing system and/or
groups of aphasia patients with different underlying
impairments (e.g., Aliminosa et al., 1993; Beeson,
1999; Beeson et al., 2002; Carlomagno et al., 1994)
will not be discussed further here.
Behrmann (1987) reports a homophone
spelling treatment study for CCM, a case of
acquired surface dysgraphia without dyslexia.
The treatment aim was to help CCM link homo-
phone words with their meanings and to improve
homophone spelling. During each weekly train-
ing session CCM was required to examine the
spelling of both words in each homophone pair
and to memorise the difference between them.
Each word was presented with a pictorial repre-
sentation of its meaning. Other training activities
included: matching each homophone word to
its corresponding picture; writing each homo-
phone word when given a pictorial cue; and writ-
ing each homophone word to dictation.
Homework practice included a number of forced-
choice activities such as written word to picture
matching, written homophone naming in response
to picture cues, and sentence completion tasks
(e.g., “After Christmas the shops have a big . . .
[sale/sail]”). Behrmann conducted four assess-
ments prior to treatment to establish stable
pretherapy performance; however, each stimulus
homophone word was only given once, so base-
line stability was not established for individual
 TREATMENT OF SURFACE DYSGRAPHIA

treated words.2 Treatment resulted in an im-
provement in overall homophone spelling (from
a total of 49% correct responses at pretest to 67%
at post-test); however, there was not a reduction
in the number of homophone confusions.3 In
contrast, there was a significant decrease—from
36% (35/70) to 18% (8/45)—in the number of
nonword errors. In sum, it seems that treatment
resulted in an improvement in spelling of homo-
phone words but not in assigning each homo-
phone to the correct semantic context. There was
no generalisation to untreated homophone pairs
(though only 20 untreated homophone words
were evaluated) but generalisation to a list of
untreated irregular words was apparent.
Behrmann (1987) postulates that untreated hom-
ophone spelling failed to improve because homo-
phones require word-specific training so, unlike
irregular words, do not benefit as a result of gen-
eral improvements in lexical processing. Finally, a
group of 68 untreated homophone words that
were written correctly pretreatment were evalu-
ated post-treatment and the total number spelled
correct actually decreased from 100% to 85%.
Given that each homophone word was only
administered once pretreatment, this may simply
represent regression to the mean. The statistical
phenomenon of regression to the mean refers to
the tendency for lower pretest scores to be higher
on post-test and higher pretest scores to be lower
on the post-test. That is, the tendency for scores
at the extremes to revert toward mean levels upon
repeated testing (Heiman, 2001; Kazdin, 1982;
Shaughnessy & Zechmeister, 1990). Regression
to the mean effects are not often evaluated in
treatment studies, but in fact should be carefully
considered when evaluating treatment outcome,
particularly when selection of items is not ran-
dom and is based on extremes of performance. In
treatment studies target items are most often
selected on the basis of incorrect responses at
baseline (i.e., the lower extreme of performance),
and thus regression to the mean must be consid-
ered as a possible factor in any increase in perfor-
mance on subsequent assessments. It is therefore
important for researchers to statistically separate
those improvements related directly to treatment
from those resulting from regression to the mean.
Weekes and Coltheart (1996) employed a sim-
ilar technique to Behrmann (1987) for treatment
of NW’s difficulties with homophone spelling.
NW had acquired his surface dysgraphia following
a traumatic brain injury. During treatment, words
were always presented in their homophone pairs
and with a pictorial mnemonic. NW was asked to
examine the spelling of each word in the homo-
phone pair, to notice the differences in their
spelling, and to associate the mnemonic cue with
the appropriate spelling. Treatment results indi-
cated overall improvement in homophone spelling
of target words (29% → 74%) but no generalisa-
tion to spelling of untreated homophone words,
replicating the findings of Behrmann (1987).
Weekes and Coltheart do not discuss the nature of
spelling errors at baseline or change in error type
with treatment.
De Partz et al. (1992) targeted high-frequency
word spelling in their treatment of LP, a French-
speaking patient with acquired surface dysgraphia.
For lexical treatment LP was first familiarised
with a general visual imagery technique, then an
imagery strategy was used to reteach the writing of
words. The target set of words consisted predomi-
nantly of words spelled incorrectly by LP from a
list of high-frequency written words. For each tar-
get word a mnemonic was devised that was both
semantically related to the word and also linked
specifically to misspelt letters. For example, the

2
Berhmann (1987) assessed a total of 138 homophone words (69 pairs) prior to treatment. However, only 34 words were given
at pretest one, 35 at pretest two, 34 at pretest 3, and 35 at pretest 4—with 50%, 46%, 59%, and 43% correct responses respectively.
Behrmann argues that because performance was stable over the four assessments a stable baseline was established. However, each
individual homophone word was only assessed once prior to treatment, so word-specific effects were not measured at baseline.
3
The overall proportion of homophone confusion errors increased from 57% to 82% but absolute number barely changed (i.e., a
change from 40/70 errors at pretest to 37/45 at post-test).

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 217

BRUNDSON, COLTHEART, NICKELS
mnemonic devised for a misspelling of pathologie
as patologie was a drawing of a hospital bed (i.e., a
semantically related cue) and was incorporated into
the letter h (i.e., the defective letter) on the training
card. In each therapy session LP was required to
copy the word with the drawing, reproduce the
written word and drawing from memory after a
delay of 10 seconds, and finally reproduce the writ-
ten word and drawing in response to the spoken
word. Treatment resulted in a dramatic improve-
ment in trained words (0% → 91%) and also a
smaller but significant improvement in untrained
words (0% → 30%). De Partz et al. also used the
Beauvois and Derouesne (1981) list of irregular,
regular, and ambiguous words as a control list that
was not treated and there was no generalisation of
treatment to this control list.4 It is important to
note that these generalisation results cannot be
directly compared with those of Behrmann (1987)
or Weekes and Coltheart (1996) as the target
words were not restricted to homophones but were
simply a mixed list of high-frequency written
words. De Partz et al. (1992) conducted a second
treatment study that contrasted the effectiveness of
the mnemonic cue with a purely didactic verbal
relearning technique (simple copying of the word
with no mnemonic). Results indicated a significant
therapy advantage for the imagery technique.
Generalisation of treatment effects
to untreated stimuli
The finding of treatment generalisation to un-
treated items in cognitive neuropsychological treat-
ment studies is now well established. Lexical
treatment studies of acquired dysgraphia that have
employed treatment methods focused on homo-
phone spelling have demonstrated treatment gener-
alisation to spelling of untreated irregular words
(Behrmann, 1987), but no treatment generalisation
to spelling of untreated homophones (Behrmann,
1987; Weekes & Coltheart, 1996). There is a similar
trend in results for surface dyslexia. Coltheart and
4
This discrepancy may have related to differences in frequency between the two lists as LP’s spelling was significantly affected by
word frequency in pretreatment testing (it is not clearly indicated whether the untrained word list and the control lists were matched).
218 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
Byng (1989) and Weekes and Coltheart (1996),
whose treatments focused on irregular word read-
ing, found generalisation to the reading of
untreated irregular words. Scott and Byng (1989)
focused on the treatment of homophone reading,
and results indicated mixed generalisation results
with improvement of untreated items on one task, a
forced-choice sentence discrimination task, but not
on the more difficult homophone definition task.
In sum, results of lexical treatment studies pro-
vide evidence that treatment generalisation can
occur for untreated irregular words in both reading
and spelling. In contrast, results suggest that
untreated homophone words do not consistently
benefit from treatment generalisation.
The reason for treatment generalisation has not
been unequivocally established. Weekes and
Coltheart (1996), while discussing generalisation
in surface dyslexia treatment, propose two effects
from item specific training. They propose that:
one must be word-specific (since treated words
benefit more than untreated words) and the other
must be more general (since untreated words
benefit). The specific effect we take to be . . .
restoration of the ability to use local word-repre-
sentations in the visual word recognition system;
restoration that occurs only for words that are
part of the treatment programme. We speculate
that the general effect has to do with the general
procedure by which entries in the visual word
recognition system are accessed; if this procedure
is damaged in these patients, and if treatment
improves how well the procedure works, all
words, not just treated words will benefit (p. 305).
The same could be argued to account for findings
of generalisation in treatment of surface dysgraphia.
That is, improvements in spelling of untreated
irregular words could simply represent treatment
effects on the general process by which entries in the
orthographic output lexicon are retrieved. So, in
addition to individual word restoration, general
retrieval from the orthographic output lexicon is

improved, so both treated words and untreated
words benefit, but treated words more so. With
regard to homophones, Behrmann (1987) speculates
that they require word-specific training so do not
benefit from this more general effect on the ortho-
graphic output lexicon.
Weekes and Coltheart (1996) have proposed
that, in treatment of acquired reading impairments,
some untreated irregular words may benefit more
than others, depending on their level of pretreat-
ment activation and whether the words were avail-
able to the patient premorbidly or not.5 More
specifically, they have proposed that generalisation
occurs for those words with premorbidly available
orthographic representation whose entries (or
access to them) have been degraded. In contrast,
generalisation will not occur for lower-frequency
words that were not premorbidly available to the
patient. Therefore, in simple terms, one might the-
orise that those words with orthographic entries
that are relatively inaccessible or degraded may
be more susceptible to generalisation than words
whose orthographic entries are completely absent.
Although treatment generalisation effects have
been clearly documented in previous studies,
researchers have failed to investigate possible
underlying mechanisms in any detail. In contrast,
the current treatment study was carefully designed
to enable detailed exploration of the reasons why
treatment generalisation occurs. That is, the cur-
rent study investigated which factors or variables
predict treatment generalisation through analyses
of differences between those untreated words that
improved and those that did not.
This study evaluated a lexical treatment pro-
gramme designed for MC, a child with develop-
mental surface dyslexia and dysgraphia, and was
theoretically based on cognitive neuropsychologi-
cal dual-route theories of spelling. The aim of
treatment was to improve the functioning of the
orthographic output lexicon and targeted irregular
word spelling. Treatment design enabled an objec-
tive assessment of treatment efficacy, stability of
5
For their case study of NW, premorbidly available words were irregular words that NW could define when presented in spoken
form (and were therefore presumed to have been readable by him prior to his acquired brain injury) and premorbidly unavailable
words were low-frequency irregular words that he could not define when presented aurally.
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
treatment effects over time, generalisation of treat-
ment to spelling of untreated stimuli (irregular and
homophone words), and also generalisation of
treatment to reading performance.
CASE HISTORY
MC, a 12-year-old boy, was in his first year of high
school at the time of treatment. He was referred by
his mother for assessment and intervention. There
had been concerns about his progress in reading
and spelling since early primary school, and as a
result MC received extra assistance (both through
school and privately organised tuition) in Years 3,
4, and 5 of primary school. Detailed developmen-
tal history revealed no prenatal or postnatal risk
factors and early developmental milestones were
within normal limits (if not a little advanced).
There was no history of neurological damage or
dysfunction. Intellectual assessment conducted at
age 7 years indicated superior intellectual skills.
There were also no concerns regarding general
cognitive, language, or behavioural development
other than MC’s specific difficulties with reading
and spelling. The following excerpt from a letter
written by MC’s school teacher illustrates this well.
I have found [MC] to be a perceptive, intelligent
student who possesses excellent oral skills. He
organises his thoughts and opinions effectively
and expresses himself in a clear and confident
manner. He is able to listen to presentations
and summarise main points [and] he also pos-
sesses an excellent general knowledge of current
affairs issues. [He] is, however . . . currently
reading at a level below his chronological age.
Furthermore, he finds it extremely difficult
expressing himself on paper. Despite his best
efforts, [MC] cannot spell most common words
correctly.
Recent intellectual assessment using the
WISC-III (Wechsler, 1991) revealed skills in the
219
BRUNDSON, COLTHEART, NICKELS

Table 1. Intellectual assessment resultsa

Scaled score Scaled Score Standard score

Information 12 Picture Completion 12 VIQ 106

Similarities 15 Coding 4 PIQ 116
Arithmetic 5 Picture Arrangement 17 FSIQ 112
Vocabulary 11 Block Design 16
Comprehension 12 Object Assembly 13
Digit Span 7 Symbol Search 4
a
Wechsler Intelligence Scale for Children–3rd revision (Wechsler, 1991).

above-average range, though MC’s pattern of sub- Single letter processing

test weaknesses suggested specific difficulties with
MC was able to name (26/26) and sound (24/26)
working memory (see Table 1). On an initial
single letters (errors: e → /i:/, u → /jə/). He was
screening of academic skills (Wide Range
also able to write letters when provided with their
Achievement Test-Revision 3) (Wilkinson, 1993)
names (26/26) or their sounds (26/26).
MC achieved standard scores of 90 for word read-
ing, 75 for word spelling, and 90 for arithmetic.
Of most interest, however, was the striking nature Visual lexical decision
of MC’s errors on the spelling subtest (e.g.,
circle → circel, reasonable → resanerball, surprise → Visual lexical decision was assessed using the
serpries, explain → exsplaen). Nearly all of his errors visual lexical decision task from PALPA (subtest
were phonologically plausible nonword responses, number 27, Kay, Lesser, & Coltheart, 1992). This
which immediately suggested the possibility of task contains an equal number of exception words,
surface dysgraphia with or without dyslexia (read- regular words, pseudohomophones (e.g., wich)
ing errors on this word set were less conclusive).
These preliminary test results and review of MC’s
prose writing prompted further investigation of
reading and spelling skills. Two samples of prose
writing taken from MC’s school exercise books are
shown in Figures 2 and 3 and illustrate other
interesting aspects of MC’s written output includ-
ing incorrect use and/or absence of punctuation
and capitalisation.

FURTHER ASSESSMENT AND

FUNCTIONAL LOCALISATION OF
IMPAIRMENT

Pretreatment testing included assessment of read-

ing, spelling, and phonological skills and also
included a screen of picture naming and semantics.
Assessment results (described below) revealed a
pattern confirming a diagnosis of developmental
surface dyslexia and dysgraphia. Figure 2. Sample of MC’s pretreatment prose writing.

220 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)


Figure 3. Sample of MC’s pretreatment prose writing.
and nonhomophonic nonwords (e.g., plit).
Although no normal control data exists for 12-
year-olds, comparison with data for a small group
of normal 9–10-year-olds certainly suggests that
MC’s lexical decision skills were below age expec-
tations (see Table 2) and that he made more irreg-
ular (exception word) and pseudohomophonic
word errors than normal.
Table 2. Visual lexical decision (PALPA, subtest number 27)
Test
Total (n ⫽ 60)
Regular words (n ⫽ 15)
Exception words (n ⫽ 15)
Pseudohomophones (n ⫽ 15)
Nonhomophonic nonwords (n ⫽ 15)
TREATMENT OF SURFACE DYSGRAPHIA
Phonological processing
General phonology skills were assessed using
phonological segmentation of initial and final
sounds (PALPA subtests 16 and 17), word rhyme
judgements-auditory version (PALPA subtest
15), the Children’s Test of Nonword Repetition
(CNRep; Gathercole & Baddeley, 1996) and
Phonological Processing (a phonological
segmentation task) from the NEPSY (Korkman,
Kirk, & Kemp, 1997). MC’s performance on the
PALPA segmentation of sounds tasks was error free.
He also performed well on the other phonological
processing tasks, with scores of 58/60 on PALPA
word rhyme judgements, an age-scaled score of 10
on NEPSY phonological processing, and 36/40 on
nonword repetition (CNRep).
Naming and semantics
Semantic knowledge and naming were screened
using spoken word–picture matching, written
word–picture matching, and spoken picture
naming (PALPA subtests 47, 48, and 53). MC’s
performance on all three tasks was virtually error-
free with scores of 40/40, 40/40, and 39/40
respectively.
Reading and spelling of regular and
irregular words
MC was first asked to read aloud and write 30 irreg-
ular and 30 regular words from the Coltheart and
Leahy (1996) word/nonword test (see Appendix A).
He was also required to read and spell a list of 308
monosyllabic irregular words (all with a written
MC age 12 Normal controls age 9 and 10 (n ⫽ 6)
Raw scores Mean (SD) Range
43 55.5 (3.02) 53–59
11 14.7 (0.82) 13–15
9 13.2 (0.75) 12–14
10 13.7 (0.82) 13–15
13 14.0 (1.26) 12–15
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 221
BRUNDSON, COLTHEART, NICKELS
frequency greater than 100). The list was obtained
by removing all homophones, plurals, and past-tense
word variations and words with a written frequency
of ⬍ 100 from an original list of 1396 monosyllabic
irregular words. This original list consisted of all
the monosyllabic words in the CELEX lexical
database (Baayen, Piepenbrock, & van Rijn, 1993)
that are irregular according to the set of grapheme
to phoneme correspondences listed by Rastle and
Coltheart (1999).
Reading
Using the Coltheart and Leahy (1996) stimuli,
reading performance on regular words (25/30,
z ⫽ ⫺1.67) was better than with irregular words
(15/30 correct, z ⫽ ⫺2.41) (see Table 3), though
both fell below an expected level based on MC’s
level of intellectual functioning. Note that the
z-scores were calculated using developmental nor-
mative data provided by Edwards and Hogben
(1999), and indicate MC’s level of performance
relative to other children of his age. Predominant
error type for irregular word reading reflected the
attempted (mostly but not invariably correct)
application of grapheme to phoneme correspon-
dence rules (e.g., bouquet → /bəυkεt/, soul →
/səυl/, also see Appendix A). Regular word read-
ing errors, however, were more visual in nature
(e.g., peril → “pearl”, also see Appendix A).
Table 3. Total number of correct responses on the Coltheart
and Leahy (1996) word and nonword lists (n ⫽ 30)
Task Total correct
Reading
Regular words 25
Irregular words 15
Nonwords 21
Spelling
Regular words 20
Irregular words 12
Nonwords 27
6
Taken from the CELEX (Centre for lexical information) database (Baayen et al., 1993). Log frequency was used for all analyses.
7
Number of orthographic neighbours determined using the definition of Coltheart, Davelaar, Jonasson, and Besner (1977).
222 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
For the longer list of 308 irregular words, MC
read a total of 210 correctly. A regression analysis
including the variables spoken frequency and,
written frequency,6 word length (number of let-
ters), and number of orthographic neighbours7
was conducted to determine which had a signifi-
cant impact on reading accuracy. The analysis
revealed that the only stimulus variables which
made independent contributions to irregular word
reading accuracy were written frequency (Wald
␹2 ⫽ 12.056, p ⫽ .001), and number of ortho-
graphic neighbours (Wald ␹2 ⫽ 5.362, p ⫽ .021).
Irregular words read correctly (when compared to
those read incorrectly) were significantly higher in
written frequency and had more orthographic
neighbours (see Table 4). The predominant error
type involved the attempted application of
grapheme to phoneme correspondence rules,
though a number of visual errors were also evident.
Spelling
Using the Coltheart and Leahy (1996) stimuli, reg-
ular word spelling (20/30) was better than irregular
word spelling (12/30) (refer to Table 3; z-scores
are not provided as developmental normative data
was not available). As with reading, most errors
were phonologically plausible nonword responses
(e.g., choir → quwiyer, colonel → cernal, also see
Appendix A).
For the longer list of irregular words, MC
spelled 120/308 correctly. A regression analysis
including the variables spoken frequency, written
frequency, word length, and number of ortho-
graphic neighbours was again conducted to
z-score
determine which variables had a significant
impact on spelling accuracy. The only stimulus
⫺1.67 variables that made independent contributions to
⫺2.41
⫺1.26
spelling accuracy were number of orthographic
neighbours (Wald ␹2 ⫽ 23.937, p ⫽ .000), written
frequency (Wald ␹2 ⫽ 23.536, p ⫽ .000), and
spoken frequency (Wald ␹2 ⫽ 7.862, p ⫽ .005)
(see Table 4). The predominant error type again
 TREATMENT OF SURFACE DYSGRAPHIA

Table 4. Variables affecting reading and spelling of irregular words at baseline

Number of
orthographic
Length neighboursa,b Spoken frequencyb Written frequencya,b

Reading
Incorrect responses
Mean 4.95 4.41 72.01 1573.52
SD 0.94 3.86 298.13 7041.40
Correct responses
Mean 4.50 6.72 1237.43 16,540.68
SD 0.95 5.24 5287.40 81,696.54
Spelling
Incorrect responses
Mean 4.88 4.65 153.15 2184.37
SD 0.89 4.32 377.46 6097.94
Correct responses
Mean 4.22 8.37 2135.46 28,812.69
SD 0.96 5.16 7145.85 110,888.10
a
Variables that significantly affected reading accuracy.
b
Variables that significantly affected spelling accuracy.

involved the attempted application of phoneme Reading and spelling of homophones

to grapheme rules.
Reading and spelling of nonwords
Reading
MC was asked to read aloud and write 30 non-
words from the Coltheart and Leahy (1996)
word/nonword test. In reading, 21/30 nonwords
were read aloud correctly (z ⫽ ⫺1.26, see Table 3)
(Edwards & Hogben, 1999), with 5 errors reflect-
ing visually similar real-word responses (e.g.,
boril → “boil”, also see Appendix A). Nonword
reading was also assessed using the Graded
Nonword Reading Test (Snowling, Stothard, &
McLean, 1996). On this test MC read 14/20
nonwords correctly, which placed him at the 25th
percentile for his age.
MC was required to read and write 96 homo-
phone words (48 homophone pairs) (see Appendix
B). Forty-two of the homophone words had an
irregular spelling (e.g., queue) and the remainder
had regular spellings (e.g., brake).
Reading of homophones
For assessment of homophone reading, MC was
asked to read the homophone word aloud and then
form a sentence using the target word. He read
aloud a total of 77/96 homophone words
correctly (i.e., pronounced the word correctly),
but for 13 of these correct responses he made a
homophone confusion error when forming the
sentence (e.g., pear → “pairs of them,” tale → “there
is a tail on a dog”) (also see Appendix C).

Spelling Spelling of homophones

In contrast, nonword spelling was almost perfect. For assessment of homophone spelling, MC was
When required to write the 30 nonwords from required to listen to the target word both in isola-
Coltheart and Leahy (1996), MC spelled 27/30 tion and in context (in a sentence) prior to writing
correctly (see Appendix A and Table 3). it. Sixty-six per cent (63/96) of homophonic words

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 223

BRUNDSON, COLTHEART, NICKELS
were misspelled. Nineteen per cent of errors
(12/63) were homophone confusions (i.e., in
response to “maid, the maid cleaned the house”
MC wrote made). Sixty per cent (38/63) of errors
were phonologically plausible nonword errors (i.e.,
in response to “prays, he prays everyday before
going to sleep” MC wrote praes), and 21% of errors
(13/63) consisted of other error responses that
were not phonologically plausible (i.e., eight →
etaght, their → thir) (also see Appendix D).
Summary of pretreatment assessment
In summary, MC’s reading and spelling were char-
acteristic of surface dyslexia and dysgraphia. That is,
sublexical processing was relatively preserved
(although not perfect), as shown by his better per-
formance on regular words and nonwords for both
reading and spelling. In contrast, MC displayed sig-
nificant difficulties with irregular word reading and
spelling, homophone reading comprehension, and
homophone spelling (with frequent homophone
confusion errors), and overall his error pattern was
characterised by a large number of phonologically
acceptable attempts, or regularisation errors. We
acknowledge that MC’s reading impairment did
not represent ‘pure’ surface dyslexia. It is not argued
that sublexical reading processes (i.e., nonword
reading) were entirely normal, only that lexical
reading skills were clearly impaired.8
Functional localisation of impairment
With respect to models of reading and spelling,
MC’s dyslexia and dysgraphia can primarily be
explained by specific difficulties with lexical
orthographic processing. We can determine the
level of impairment more specifically using pre-
treatment assessment results and the theoretical
framework of the dual-route model of reading and
spelling shown in Figure 1.9
8
The terms intact and impaired (when used in reference to MC’s abilities) refer to MC’s performance relative to normal age
expectations.
9
We note that MC’s pattern of impairment can be explained adequately by either the two lexicon or the single lexicon theoreti-
cal viewpoints. Data from the current case was unable to definitively adjudicate between the two theoretical viewpoints, and there-
fore this theoretical debate and relevant analyses are not discussed in the current paper.
224 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
First, intact processes will be discussed. Relatively
good nonword reading suggests a relatively intact
(though not perfect) sublexical reading route (visual
analysis, grapheme to phoneme conversion, phono-
logical output buffer, linked by arrows 16 and 17).
Good nonword spelling to dictation suggests intact
sublexical spelling processes (including auditory
analysis, acoustic to phonological conversion,
grapheme to phoneme conversion, and the
graphemic output buffer, linked by arrows 5, 6, 7,
and 8). Intact expressive language and comprehen-
sion of spoken language suggests intact language
processing routes and semantics (including the
phonological input and output lexicons, and
semantic system, linked by arrows 1, 2, 12, 11, and
arrow 9).
Reading
MC’s lexical reading impairment can therefore be
explained by specific difficulties with lexical
orthographic processes. MC had difficulty with
visual lexical decision (see Table 2), which sug-
gested difficulties with access to and/or entries in
the orthographic input lexicon. So when unable to
access the entry for an irregular word in input
orthography MC was forced to rely on grapheme
to phoneme correspondences (shown by arrows 16
and 17, Figure 1), leading to regularisation errors.
This was apparent with irregular word reading
tasks (especially the longer list of irregular words),
on which MC made a large number of phono-
logically plausible nonword responses. Can we be
more specific regarding MC’s theoretical level of
impairment in reading and, in particular, can we
determine whether MC also had additional
deficits affecting connections from orthographic
lexicon to semantic system (as shown by arrow
14)? We will argue that MC’s connections
between orthography and semantics were not fully
developed.

MC was able to read aloud correctly a small
number of irregular homophone words, which
suggested that he was able to access their entries in
the orthographic input lexicon and was not relying
on sublexical grapheme to phoneme conversion
for pronunciation. However, even with these irreg-
ular homophone words he still made homophone
confusion errors (e.g., MC was able to read the
word queue correctly but provided the wrong
semantic context “the actor needed a cue,” see
Table 5 for other examples). This suggested that
for some words MC was able to access their ortho-
graphic entries but that connections from these to
semantics were faulty, forcing MC to use the
direct route to the phonological output lexicon but
preventing word-specific semantic activation
(route shown by arrows 13, 15, 11, Figure 1).
Homophone confusion errors with irregularly
spelled homophones are rarely investigated or
reported in developmental cases. One exception,
however, is a developmental case (CD) reported by
Coltheart, Masterson, Byng, Prior, and Riddoch
(1983) who also made a small number of such
errors in reading. So, in summary for MC’s read-
ing, it seems that impairments were evident both
at the level of representations in the orthographic
Table 5. Reading and spelling of irregular homophones (examples from baseline
1 and 2)
(a) Reading
Target Read correctly
Queue Yes
Pear Yes
Whole Yes
Their Yes
Steak Yes
(b) Spelling
Target Context provided
Bred ‘They bred the cattle carefully . . . ’
Bare ‘The desert landscape was bare’
Pair ‘He wore a pair of black shoes’
Lock ‘The gate had a lock’
Quay ‘The boat sailed into the quay’
Their ‘They were washing their clothes’
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
input lexicon or access to them, as well as in their
connections to semantics.
Spelling
MC’s spelling to dictation performance can also
be explained by difficulties with orthographic pro-
cesses. However, it is more difficult to determine
his exact level of impairment in this area than it is
for reading.
MC’s homophone spelling, akin to reading,
revealed an interesting pattern of responses. For
some homophones, MC produced a homophone
confusion response, which had an irregular spelling
and which he spelled correctly (e.g., when provided
with the context “they bred the cattle carefully” he
produced the homophone confusion bread, but
spelled it correctly despite it being an irregular
word; see Table 5 for more examples). This sug-
gested that he was able to successfully access the
response word’s representation in the orthographic
output lexicon and write the word, but was unable
to access the stimulus word’s orthographic output
representation correctly from semantics. So, refer-
ring to Figure 1, we assume, based on his intact
auditory comprehension skills, that when asked to
Homophone confusion:
Definition provided by MC
“the actor needed a cue”
“socks . . . pairs of them”
“there is a hole in the ground”
“there is a ball”
“I stuck a stake into the ground”
Homophone confusion:
MC’s written response
bread
bear
pear
loch
key
there
225
BRUNDSON, COLTHEART, NICKELS

spell a homophone (e.g., “bred”) after hearing the
semantic context in a sentence (e.g., “they bred the
cattle carefully”), MC was able to access the seman-
tic system normally (route shown by arrows 1 and
2).10 We also know he was able to retrieve the cor-
rect spelling of the homophone confusion response
from the orthographic output lexicon because he
correctly wrote bread, which has an irregular
spelling.11 The homophone confusion must there-
fore arise from MC’s inability to access output
orthography directly from semantics. He is instead
forced to access the orthographic representation of
the word via the phonological output lexicon
(shown by arrows 12 and 10), which gives rise to
the homophone confusion. This suggests impair-
ment in connections between the semantic system
and orthographic output lexicon (shown by arrow 3
in Figure 1).
MC’s irregular word spelling performance (i.e.,
his spelling of irregular words that are not homo-
phones) suggests additional deficits. MC made a
large number of phonologically plausible nonword
errors when spelling irregular words to dictation.
His phonologically plausible nonword spelling
errors most probably resulted from him relying on
the processing route through the phonological lex-
icons and semantic system and then sublexical
phoneme to grapheme correspondences (shown by
arrows 1, 2, 12, 11, 7, 8). He would be forced to
employ this compensatory strategy if entries within
the output lexicon were poorly formed and/or if
unable to access the orthographic output lexicon
from semantics (arrow 3) and the phonological
output lexicon (arrow 10). In summary, using evi-
dence from both irregular and homophone words,
it is proposed that MC’s spelling impairments
resulted from deficits in semantic to orthography
connections (shown by arrow 3) and deficits either
at the level of entries in the orthographic output
lexicon or access to those entries from the phono-
logical output lexicon (shown by arrow 10).
It is important to note that we do not propose
that affected components of the reading and
spelling system are abolished. For MC, a develop-
mental case, we would propose that entries in the
orthographic lexicons and/or access to them were
poorly formed, immature, or unreliable. It is
important to note, however, that MC could read
and spell some irregular words correctly. He could
also read and spell some homophones correctly
and access their correct semantic representation.
So, he did have some complete entries in his
orthographic lexicons and he could access them
and retrieve correct semantic information consis-
tently for some words; however, he certainly had
not reached a normal level of efficiency in func-
tioning for his age.
TREATMENT OF THE SPELLING
IMPAIRMENT
General treatment aims
Treatment was focused on spelling, as this was
perceived by MC and his family to be the major
functional difficulty. His family were very aware
of MC’s poor irregular word spelling as it was evi-
dent in his written work, even with very high-
frequency words. Assessment results suggested
that MC’s spelling difficulties resulted from
impairments in access to output orthography and
most probably additional deficits in actual word
representations in the orthographic output

10
Although semantic knowledge was not assessed for target words at an individual word level, the authors feel confident that
words were semantically represented and that access to these from spoken language was intact, especially given the target words’ high
written and spoken frequency. MC had normal language and semantics (as tested using PALPA 47, 48, and 53 and standard VIQ
assessment). He had no history of developmental language or semantic difficulties and no reported current difficulties in these areas.
In fact, he was described by his school teacher as highly articulate and intelligent, with good listening skills, good spoken expression
and good general knowledge (as quoted on p. 219).
11
It is interesting to note that MC’s homophone confusion responses that were correctly spelled irregular words did not simply
reflect a tendency for him to produce the higher-frequency homophone of the homophone pair. Some of these responses were the
lower-frequency member of the homophone pair.

226 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)


lexicon. Therefore, treatment focused on irregular
word spelling and aimed to add new ‘whole irreg-
ular word’ entries in his output lexicon. Because
MC’s semantic representations of target irregular
words were presumed intact, it was also hoped
that treatment would facilitate his ability to access
output orthography directly from semantics. It
was anticipated that a focus on irregular word
spelling would result in the best functional out-
come for MC (when compared to a focus on
homophone spelling).
The treatment study was also carefully designed
to enable detailed post hoc investigation of the
mechanisms underlying treatment generalisation
to untreated stimuli, which to our knowledge has
not been investigated in such detail previously. In
addition, treatment design enabled evaluation of
the efficacy of employing mnemonics in lexical
treatment studies.
In summary, the treatment study aimed to:
1. Improve MC’s irregular word spelling.
2. Determine factors underlying treatment
generalisation to untreated items.
3. Determine the contribution of the specific
mnemonic cue to the effectiveness of treatment.
Target stimuli
Two baseline assessments of reading and spelling
were conducted using 308 irregular words (the
same list that was used for assessment of irregular
word reading and spelling above). The 222 target
stimuli were then selected. They included all
those words for which MC’s spelling response
was incorrect on at least one of two baselines.
The 222 target irregular words were then divided
into three sets of 74 words (Sets 1, 2 and 3). The
sets were matched as closely as possible on writ-
ten frequency (Kruskal Wallis ␹2 ⫽ 0.69, p ⫽ .71),
spoken frequency (␹2 ⫽ 2.05, p ⫽ .36), length
(␹2 ⫽ 3.93, p ⫽ .14), and number of orthographic
neighbours. Although the word sets did differ
significantly in terms of number of orthographic
12
Word set 2 (mean 5.74, SD 4.23), had a higher mean number of orthographic neighbours than Sets 1 (mean 4.05, SD 4.23)
and 3 (mean 4.9, SD 4.3).
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
neighbours12 (␹2 ⫽ 7.71, p ⫽ .021), all further
analyses comparing word sets 1, 2, and 3 con-
trolled for this difference. The words sets were
also matched according to the total number of
words read and spelled incorrectly on both base-
lines and the total number that were incorrect on
just one baseline (also matched for the number
incorrect on only the first baseline and only the
second baseline). Word set 4 consisted of 86
words that were spelled consistently correctly
over two baselines.
Baseline assessments
MC’s performance on the 222 target irregular
words did not vary across pretest assessments for
spelling (overall, McNemar ␹2 ⫽ 1.82, p ⫽ .178;
Set 1, p ⫽ .481; Set 2, p ⫽ .648; Set 3, p ⫽ .481)
(see B1 vs. B2 in Figure 5) or reading (overall,
McNemar ␹2 ⫽ 2.327, p ⫽ .127; Set 1, p ⫽ .804;
Set 2, p ⫽ .481; Set 3, p ⫽ .238) (see B1 vs. B2 in
Figure 7). There was no change in total correct for
Set 4 spelling (see B1 vs. B2 in Figure 6).
Two baseline assessments were also conducted
for reading and spelling of the 48 homophone
pairs (as described in assessment section above).
Spelling performance was recorded in terms of
total errors, total homophone confusion errors
(total HCE), total phonologically plausible non-
word errors (total PPNE), and total other errors
(total OE). Other errors were those spelling
attempts that were nonwords but not phonologi-
cally plausible (see Appendix D for error exam-
ples). Homophone spelling was consistent across
baselines for total errors (McNemar, p ⫽ 1.0),
total PPNE (p ⫽ .359), total OE (p ⫽ .388) but
not for total HC errors (p ⫽ .039) (see B1 vs. B2
in Figure 8). MC made significantly more HCE
errors on the second baseline.
Homophone reading performance (see Figure 9)
was recorded in terms of total errors in reading
aloud and total homophone confusion errors (total
HCE). MC’s homophone reading performance
227
BRUNDSON, COLTHEART, NICKELS

was consistent across baseline assessments (total
correct, McNemar, p ⫽ 1.0; total HCE, p ⫽ .424).
Treatment design
Overall treatment design is shown in Table 6.
Treatment was conducted over a period of 1
month and focused on each irregular word set in
turn. There were three training sessions, one for
each word set (see italics, Table 6). There were
seven assessments—two baseline assessments,
three post-treatment assessments (post-treatment
phase 1, 2, and 3), and two follow-up assessments
(2 months and 4 months post-treatment). Each
included assessment of both reading and spelling
of all homophone and irregular words (with the
exception of the post-treatment phase 1 and the
second follow-up assessment, when only spelling
was assessed). Assessments were conducted over
two testing sessions to avoid repetition of stimuli
(that is, assessment of reading and spelling of the
irregular word set was conducted on separate days,
as was assessment of reading and spelling of the
homophone word set).
Treatment method
As mentioned above, there were three treatment
phases with each phase targeting a different set of
irregular words. Target words for training session
1 were Set 1 words, for training session 2 were Set
2 words, and for training session 3 were Set 3
words.
Stimuli
All stimuli consisted of flash cards containing
the target word written in lower case (size 48
arial font). Set 2 words were also assigned a
mnemonic cue (a semantically related picture
cue; see Figure 4). Mnemonic cues were devised
by the first author and drawn beside the target
word on each flash card. Only Set 2 words were
assigned a mnemonic and, aside from this, treat-
ment method and training sessions were identi-
cal for all word sets.
Training sessions
Training sessions were conducted by the first
author. Only one training session was conducted
for each word set. In the training sessions each tar-
get word was trained in turn and was trained only
once. For each target word MC was shown a flash
card displaying the correct spelling. He was first
asked to copy the word (the word was also read
aloud by the first author). The word was then
removed from view and MC was asked to write
the word again after a 10-second delay. If his

Table 6. Treatment design

Testing session Date Testing Tasks

1 1/3/01 Baseline 1 Irregular word spelling and homophone reading

2 10/4/01 Baseline 1 cont Irregular word reading and homophone spelling
3 13/4/01 Baseline 2 Irregular word spelling and homophone reading
4 18/4/01 Baseline 2 cont Irregular word reading and homophone spelling
5 30/4/01 Word Set 1 training Session Irregular word spelling
6 10/5/01 Post-treatment 1 testing Irregular word spelling and homophone spelling
7 14/5/01 Word Set 2 training session Irregular word spelling
8 26/5/01 Post-treatment 2 testing Irregular word spelling and homophone reading
9 27/5/01 Post-treatment 2 testing cont Irregular word reading and homophone spelling
10 27/5/01 Word Set 3 training session Irregular word spelling
11 12/6/01 Post-treatment 3 testing Irregular word spelling and homophone reading
12 13/6/01 Post-treatment 3 testing cont Irregular word reading and homophone spelling
13 20/8/01 Follow-up 1 (2 mths post-treatment) Irregular word spelling and homophone reading
14 21/8/01 Follow-up 1 cont Irregular word reading and homophone spelling
15 23/10/01 Follow-up 2 (4 mths post-treatment) Irregular word spelling and homophone spelling

228 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)


Figure 4. Examples of mnemonic cues employed for
irregular words.
response was incorrect he was shown the flash card
again for a few seconds. Finally, he was required to
write the word to dictation. Again, he was shown
the flash card containing the correct spelling if his
response was still incorrect.
Home practice
In between training sessions MC was required to
conduct home practice. Detailed instructions were
provided for his parents, who supervised all home
practice sessions. Home practice was discontinued
when MC spelled at least 90% of the words
correctly for 2 consecutive days. Duration of
treatment was 8 days for Set 1, 6 days for Set 2,
and 7 days for Set 3. For each word (once a day
13
For example, for irregular word spelling (see Figure 5) baseline one is employed for all comparisons and for homophone
reading (see Figure 9) baseline two is used for total error comparisons and baseline one is used for total homophone confusion error
comparisons.
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
in a different order) MC’s parents were instructed
to:
1. Read aloud the word and ask MC to write
the word down.
2. Tell MC whether his response was correct
or incorrect.
3. If incorrect, show MC the corresponding
flash card with the correct spelling. Show him for
5 seconds and then ask him to rewrite the word
from memory. Provide no further help if his second
attempt was also incorrect.
4. Move on to the next word.
RESULTS
All comparisons between baseline and post-
treatment results employ the highest baseline
result for establishing improvements in total cor-
rect or increase in error responses and the lowest
baseline for establishing a reduction in errors.13
Irregular word spelling
General treatment results
Results for irregular word spelling are shown in
Figure 5. There was a significant increase in the
total number of irregular words spelled correctly
from pretreatment baseline (33/222 at B1)
to post-treatment phase 3 (149/222) (overall,
McNemar ␹2 ⫽ 148.30, p ⫽ .000; Set 1, p ⫽ .000;
Set 2, p ⫽ .000; Set 3, p ⫽ .000). As expected all
individual word sets improved dramatically after
they were specifically targeted for spelling treat-
ment. That is, Set 1 words improved after treat-
ment phase 1 when compared to baseline
(McNemar ␹2 ⫽ 57.02, p ⫽ .000), Set 2 improved
after treatment phase 2 when compared to post-
treatment phase 1 (McNemar ␹2 ⫽ 40.20,
p ⫽ .000), and Set 3 words improved after treat-
ment phase 3 when compared to post-treatment
phase 2 (McNemar ␹2 ⫽ 39.02, p ⫽ .000).
229
BRUNDSON, COLTHEART, NICKELS
Figure 5. Percentage correct for irregular word spelling at
baseline, during treatment and at post-tests.
At 2 months post-treatment (follow-up 1) a
total of 134/222 words were spelled correctly indi-
cating a significant decline from post-treatment
phase 3 (overall, McNemar ␹2 ⫽ 41.07, p ⫽ .000;
Set 1, p ⫽ .004; Set 2, p ⫽ .004; Set 3, p ⫽ .000),
though this still represented a significant improve-
ment when compared to pretreatment baseline
performance (overall, McNemar ␹2 ⫽ 93.458,
p ⫽ .000; Set 1, p ⫽ .000; Set 2, p ⫽ .000; Set 3,
p ⫽ .000). There was no difference between
the three word sets in degree of decline from
14
GEE is an approach to the analysis of correlated response data, which is particularly useful when the responses are binary. It
takes account of the correlations between observations and uses them when calculating both parameter estimates and their standard
errors. Interested readers can refer to Hanley, Negassa, Edwardes, and Forrester (2003) for more information.
15
This regression to the mean effect was calculated by determining the percentage of correct responses at baseline 1 (from all
word sets) that were incorrect at baseline 2.
230 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
post-treatment to assessment at follow-up 1
(Generalised Estimating Equation [GEE] analysis,
␹2 ⫽ 3.15, p ⫽ .21).14 No further decline was evi-
dent at 4 months post-treatment (follow-up 2)
(overall, McNemar ␹2 ⫽ .078, p ⫽ .78; Set 1,
p ⫽ 1.0; Set 2, p ⫽ .424; Set 3, p ⫽ 1.0).
Post hoc analyses were conducted to investigate
possible reasons for the decline in performance
between post-treatment phase 3 and the first
follow-up assessment. A logistic regression analy-
sis was conducted to determine which variables
were significant in differentiating between words
that changed from correct to incorrect and words
that remained correct. Target words for the analy-
sis were responses for word sets 1–3 at the post-
treatment 3 assessment. Variables investigated
included word frequency, spoken frequency, length
(number of letters), and number of orthographic
neighbours. The only variable that made a signifi-
cant independent contribution was number of let-
ters, with longer words more likely to drop off
with time (Wald ␹2 ⫽ 7.162, p ⫽ .007), though
number of orthographic neighbours did also
approach significance (Wald ␹2 ⫽ 3.03, p ⫽ .082)
(those words with fewer orthographic neighbours
were more likely to drop off with time).
Total number of words spelled correctly in Set
4 (i.e., words that were consistently correct pre-
treatment) was significantly lower post-treatment,
as measured at post-treatment phase 3 and follow-
up 1 assessments, when compared to baseline two
(PT3: McNemar, p ⫽ .000; follow-up 1: p ⫽ .031)
(see Figure 6). Accuracy declined from 100% at
baseline to 86% at post-treatment phase 3 and
93% at follow-up. However, this degree of change
(i.e., 14% and 7% respectively) was no greater than
a regression to the mean effect as measured over
baseline (i.e., a regression to the mean effect of
28%)15 and thus will not be discussed further.

Figure 6. Percentage correct for irregular word Set 4
(irregular words that were spelled correctly on both baselines
and were never treated) at baseline and post-treatment.
Generalisation to untreated words
Significant generalisation (of treatment effects) to
untreated irregular words was also apparent. After
treatment phase 1 (which targeted Set 1 words
only) the number of words spelled correctly for
the untreated Set 2 improved significantly when
compared to baseline 1 (McNemar, p ⫽ .023).
Although Set 3 words had not significantly
improved following treatment phase 1 (p ⫽ .383),
generalisation was evident after treatment phase 2
(i.e., improvement occurred before Set 3 words
were trained) (p ⫽ .000).
It was important to demonstrate that this effect
was not a result of regression to the mean but a true
treatment generalisation effect. We examined the
extent of variability across baseline testing in order
to predict the size of the likely effects of regression
to the mean: Of all those words incorrect at the first
baseline, 11.7% were correct at the second baseline
(i.e., a regression to the mean effect of 11.7% prior
16
Given that the improvements in spelling of untreated irregular words was significantly greater than regression to the mean
effects, we can conclude that the larger improvement evident in spelling of treated irregular words following treatment was also
significantly greater than any regression to the mean effect.
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
to the commencement of treatment). In contrast,
after treatment phase 1, untreated words from sets 2
and 3 that were spelled incorrectly on the second
baseline improved, with 21.1% becoming correct.
This represented a significantly larger proportion of
words than the 11.7% regression to the mean effect
(␹2 ⫽ 4.58, p ⫽ .032). Therefore, we argue that at
least part of the improvement in untreated words
was a true treatment generalisation effect. Similarly,
for Set 3, 27.6% of words that were wrong after
treatment phase 1 became correct after treatment
phase 2 (again significantly more than the 11.7
regression to the mean effect, ␹2 ⫽ 7.487, p ⫽ .006),
even though they had not yet received any treat-
ment. Again, this indicates that improvements in
spelling of untreated words cannot be explained
entirely by regression to the mean but in fact reflects
(at least in part) a treatment generalisation effect.16
Post hoc analyses were conducted to investigate
possible predictors of generalisation. The analyses
conducted compared characteristics of those
untreated words that improved prior to their treat-
ment (i.e., those affected by treatment generalisa-
tion) and those that didn’t improve. Target words
for the analysis included error responses for word
sets 2 and 3, taken from the second baseline assess-
ment. A logistic regression analysis was used to
determine which variables significantly differenti-
ated between untreated words that improved with
generalisation and those that didn’t. The dependent
variable ‘generalisation’ was a binary outcome vari-
able. Predictor variables included were written word
frequency, spoken word frequency, length (number
of letters), number of orthographic neighbours, and
a binary variable ‘error vs. stimulus length,’ which
represented whether the error response was the
same length as the stimulus. It was also considered
that generalisation could possibly depend on how
close the error response was to being correct prior to
treatment. It was hypothesised that those words
whose error responses were closer or more similar to
the correct response prior to treatment may respond
231
BRUNDSON, COLTHEART, NICKELS
to treatment generalisation more readily. To investi-
gate this possibility, five variables representing a
series of ‘match’ values were also included in the
analyses. These match variables essentially repre-
sent a measure of how similar an error response is to
the correct stimulus (i.e., how closely the error
matches the correct spelling) in five different ways
according to different coding schemes. The five
different coding schemes and their match values
will be referred to as match 1, match 2, match 3,
match 4, and match 5, where the match value is
based on the measure of overlap between the stimu-
lus and error response divided by the number of let-
ters in the stimulus (resulting in a match value
between 0 and 1). An in-depth review of coding
schemes is beyond the scope of this paper; however,
a brief description of each match variable employed
in the current study will follow (for match values
1–4 also refer to Table 7).17
Match 1. The variable match 1 is based on a
simple comparison of letters according to absolute
letter position, in which the stimulus and error
response are aligned according to the leftmost letter.
Match 2 and 3. Match 2 and 3 are ‘vowel-
centred’ schemes in which the stimulus and error
response are aligned using the first vowel as an
anchor. Match 2 and 3 use slightly different meth-
ods for aligning the surrounding consonants. For
match 2, surrounding consonants are assigned
positions from left to right. Consonants preceding
the vowel are assigned to slots until a vowel is
reached; this is then assigned to a designated
Table 7. Match variable 1–4 for stimulus “STRAP” and error response SPAT
Matching scheme S T R A
1 S* P A T 1/5
2 S* P A*
3 S P A*
4 S* P A*
17
For a discussion of the various orthographic coding schemes, see Davis (1999, pp. 77–81). We thank Colin Davis for making
available to us his program for calculating these various kinds of match values.
232 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
vowel slot with the remaining consonants assigned
from left to right. For match 3, surrounding con-
sonants are assigned positions from right to left
surrounding the vowel.
Match 4. For match 4, the position of each letter
is coded relative to the first and last letters and the
middle letters are then compared for similarity (so,
in a way, the first half of the word is coded accord-
ing to absolute letter position, while the second
half is coded relative to the final letter).
Match 5. This is a form of spatial coding devised
by Davis (1999), in which the comparison between
stimulus and error response is based on the spatial
pattern of activity across the stimuli within the
SOLAR computational model of reading rather
than direct comparison of letters according to letter
position. Briefly, in this scheme words are not
anchored according to letter position; letter order is
coded by relative activation of letters and resultant
spatial patterns of activation are position-invariant.
This enables recognition of similarity between a
stimulus and response when letters are transposed
(or when the correct letters are employed but in the
wrong order (e.g., “weight”–wiehgt). For the current
analyses, the default parameters employed for
match 5 placed slightly more weight on exterior let-
ters. For the above examples of target and error
response (i.e., “strap”–spat) this coding scheme
results in a match value of 0.41.
For a comparison of match values 1–5 for a
sample of MC’s actual spelling error responses,
refer to Table 8.
P (Stimulus) Overlaps * Match value
.2
T 2/5 .4
T 1/5 .2
T 2/5 .4
 TREATMENT OF SURFACE DYSGRAPHIA

Table 8. Match values for a selection of MC’s spelling Because of the significant correlation between
errors the match variables, additional regression analyses
Error were conducted for each match variable in turn
Stimulus response 1 2 3 4 5 (with word characteristics and ‘error vs. stimulus’
Yield Yiald .80 .80 .80 .80 .84 length also included in the analysis) to examine
Phase Faes .20 .40 .40 .00 .44 the difference in their predictive powers when
Clerk Clarc .60 .40 .40 .60 .58 included alone. In this analysis, match 1, 3, 4, and
Pearl Perl .40 .60 .60 .80 .76 5 were all significant predictors of generalisation
Ward Word .75 .25 .50 .75 .80
(match 1, p ⫽ .038; match 3, p ⫽ .048; match 4,
Heart Hart .20 .20 .40 .60 .77
Built Biult .60 .60 .60 .60 .89 p ⫽ .016; match 5, p ⫽ .022). Finally, regression
Path Parth .50 .50 1.0 1.0 .90 analyses were conducted for pairs of match vari-
ables to determine whether any individual match
variable could predict generalisation independent
of the other (word characteristic variables were also
Analyses investigating the nature of generalisation
included as predictor variables). Match 4 was a sig-
First, point-biserial correlation analyses were con- nificant predictor of generalisation independent of
ducted to investigate the intercorrelation between match 2 (p ⫽ .043), with a trend for prediction
the match variables, the ‘error vs. stimulus length’ independent of match 1 (p ⫽ .089). Match 5 also
variable, the word characteristic variables (spoken approached significance for prediction of generali-
frequency, written frequency, number of ortho- sation independent of match 2 (p ⫽ .055). No
graphic neighbours, word length), and also the other comparisons between pairs of match vari-
binary outcome variable ‘generalisation.’ All of the ables were significant.
match variables were highly correlated with each Finally, a backwards logistic regression was con-
other (correlations ranged from .508 to .832). ducted to determine the best model of prediction for
Match variables 3, 4, and 5 were significantly cor- generalisation. All of the match variables and word
related with number of orthographic neighbours characteristic variables were included as predictors.
and match 4 was also significantly correlated with The best model for predicting generalisation con-
word length. None of the match variables were sisted of match 4 (Wald ␹2 ⫽ 7.235, p ⫽ .007), and
significantly correlated with word frequency. The written frequency (Wald ␹2 ⫽ 4.678, p ⫽ .031). As
variable ‘error vs. stimulus’ length was significantly the degree of match between the error responses and
correlated with match 1, written frequency, and stimuli increased (where the position of each letter
word length. All of the word characteristic vari- was coded relative to the first and last letters) and
ables were highly correlated with each other. The written frequency increased, the likelihood of
variable of interest, ‘generalisation,’ was signifi- improvement with generalisation also increased.
cantly correlated with the match variables 1, 3, 4, In summary, results suggest that match variables
and 5 (correlations ranged from .189 to .242) as 1, 3, 4, and 5 are all strong predictors of generalisa-
well as spoken frequency, written frequency, and tion. However, match 4 is consistently the strongest
number of orthographic neighbours. or best predictor of generalisation, and the best
Then, a logistic regression analysis including model for prediction includes both match 4 and
word frequency, spoken frequency, length and written frequency. Mean match values (at baseline
number of orthographic neighbours, ‘error vs. 2) for those words that improved prior to treatment
stimulus’ length, and the match variables was con- and those that didn’t are shown in Table 9.
ducted. Results indicated that no stimulus variable
made a significant contribution that was indepen-
Analyses of how errors changed during treatment
dent of the other variables. This was not a surpris-
ing result given the high degree of correlation Analyses were also conducted to investigate the
between predictor variables. nature of changes in error characteristics for

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 233

BRUNDSON, COLTHEART, NICKELS
Table 9. Match values for irregular words (spelling) that
improve prior to treatment and those that do not
Match
1 2 3 4 5
Words that improve
Mean 0.62 0.67 0.75 0.69 0.77
SD 0.19 0.19 0.18 0.22 0.15
Words that do not improve
Mean 0.53 0.59 0.64 0.56 0.68
SD 0.21 0.23 0.25 0.26 0.19
untreated words during treatment. This interest
arose from an observation that error responses for
some words appeared to gradually change and
improve in orthographic accuracy as a result of
treatment generalisation but prior to becoming
totally correct. For example, the stimulus word
“tough” (from treatment set 3) was an untreated
word that benefited from treatment generalisa-
tion. However, there appeared to be a gradual
increase in the use of orthography from baseline 2
(taf ), to post-treatment phase 1 (taugh), prior to
the correct response at post-treatment phase 2
(tough) (also see Appendix E). This raised the pos-
sibility that treatment generalisation might actu-
ally result in a gradual improvement in spelling of
untreated words, rather than a sudden all-or-none
change from incorrect to totally correct. This pos-
sibility was formally investigated in more detail
and is discussed below.
The analyses focused only on words from Set 3,
those words treated last. Limiting the focus to Set
3 words enabled an examination of error charac-
teristics at four points prior to their treatment (i.e.,
at baseline 1, at baseline 2, after treatment phase 1
and after treatment phase 2: B1, B2, PT1, PT2).
This provided an opportunity to analyse how the
misspellings of words changed during treatment
rather than simply focusing on the identification
of which words benefited most from treatment
generalisation. The analyses were conducted in
two stages (described below).
Comparison of error characteristics at baseline 2 and
post treatment phase 1. The data used for the first
234 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
set of analyses included all error responses (from
Set 3) made at baseline 2 and post-treatment
phase 1, for those words that were correct prior to
treatment (i.e., were correct after treatment phase
2). We were interested in determining whether
their misspellings were closer to being correct after
treatment phase 1 when compared to baseline.
Results indicated that there was a significant
increase in match 2 (Mann Whitney, p ⫽ .016),
match 3 (p ⫽ .009), and match 5 (p ⫽ .015) values
between baseline 2 and post-treatment phase 1.
This suggests that the nature of the error
responses was changing and that misspellings of
words were improving with treatment generalisa-
tion prior to becoming totally correct. Interestingly,
it was the two vowel-centred match schemes
(match 2 and 3) that improved significantly,
possibly suggesting a gradual improvement in
interior vowel patterns during treatment. The
analyses below further examine the role of match
schemes 2 and 3 in error change.
Examination of error characteristics at four testing
points during treatment. The second analyses
examined a smaller subset of words in more detail
to allow specific examination of gradual changes in
error responses for untreated words during treat-
ment, with a focus on match schemes 2 and 3. The
stimuli for these analyses were those Set 3 words
that were consistently incorrect at baseline 1, base-
line 2, and post-treatment phase 1 (B1, B2, PT1).
These target stimuli were divided into two groups
for the analyses: words that benefited from gener-
alisation (i.e., incorrect at B1, B2, and PT1 but
correct at PT2, N ⫽ 10; see Appendix E) and
words that failed to benefit from generalisation
(incorrect at B1, B2, PT1, and PT2, N ⫽ 37).
Mean match values for coding schemes 2 and 3
were calculated for both groups for words at each
testing point.
Analyses revealed a very strong trend for an
increase in match 2 (Wilcoxon, p ⫽ .066) and 3
(p ⫽ .066) values between baseline 2 and post-
treatment phase 1 for words that benefited from
treatment generalisation (i.e., were correct at
post treatment phase 2). In contrast, there was no
significant increase in match 2 (p ⫽ .688) or match
 TREATMENT OF SURFACE DYSGRAPHIA

3 (p ⫽ .478) values from B2 and PT1 for errors
that failed to benefit from treatment generalisa-
tion (i.e., remained incorrect at PT2). This sup-
ports the observation that errors gradually increase
in degree of correctness (e.g., “tough” → taf →
taugh example described above) as a result of treat-
ment generalisation and that this improvement
predominantly involves interior letters.18
Finally, analyses were conducted to determine
whether the misspellings of words that do not ben-
efit from generalisation (those misspelled at post-
treatment phase 2) ever increase in accuracy. The
match values for this group of words did actually
eventually improve between post-treatment phase
1 and 2 (but still prior to being targeted for treat-
ment) (match 2, p ⫽ .025; match 3, p ⫽ .04). So,
even those words that did not become correct as
a result of treatment generalisation did actually
show a treatment generalisation effect. Again it
was interior letters that appeared to improve most.
had received spelling treatment, improved signifi-
cantly when compared to pretreatment (baseline
2) (Set 1, McNemar ␹2 ⫽ 12.90, p ⫽ .000; Set 2,
p ⫽ .000). In contrast, reading of irregular words
for Set 3 (untreated at this stage) did not signifi-
cantly improve, suggesting no treatment generali-
sation to reading of untreated words (McNemar,
p ⫽ .302). Reading of Set 3 words, however, did
improve after treatment phase 3 when compared
to baseline and post-treatment phase 2 (baseline,
McNemar p ⫽ .000; PT2, p ⫽ .000).
Homophone spelling
Results for homophone spelling are shown in
Figure 8.

Irregular word reading

Results for irregular word reading are shown in
Figure 7. Irregular word reading was assessed at
baseline 1 and 2, after treatment phase 2 and 3,
and at 2 months post-treatment (follow-up 1).
There was a significant increase from baseline
(baseline 2) to post-treatment phase 3 in the total
number of irregular words read correctly (overall,
McNemar ␹2 ⫽ 58.53, p ⫽ .000; Set 1, p ⫽ .000;
Set 2, p ⫽ .000; Set 3, p ⫽ .000). At 2 months
post-treatment (follow-up 1) this improvement
was maintained, with no significant change in
total correct from post-treatment phase 3 to the
first follow-up assessment (overall, McNemar
p ⫽ .210; Set 1, p ⫽ 1.0; Set 2, p ⫽ .250; Set 3,
p ⫽ .727). At assessment post-treatment phase Figure 7. Percentage correct for irregular word reading at
two, reading of both Set 1 and Set 2 words, which baseline, during treatment, and at post tests.

18
It is important to note that neither group of words significantly changed in match values from baseline 1 to baseline 2 (match
2, p ⫽ .688; match 3, p ⫽ .478). So, there were no changes in error characteristics during baseline and therefore any changes that
occurred during treatment were due to treatment generalisation effects.

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 235

BRUNDSON, COLTHEART, NICKELS
Total errors
The total number of homophone spelling errors
was reduced during treatment, with significantly
fewer errors evident after treatment phase 3 than
at baseline 2 (McNemar p ⫽ .031), suggesting
treatment generalisation to homophone spelling.
This treatment effect was maintained at 2 and 4
months post-treatment, when compared to Post-
treatment 3 (follow-up 1, McNemar ␹2 ⫽ 0.30,
p ⫽ .584; follow-up 2, p ⫽ 1.0). Interestingly, the
predominant change occurred after treatment phase
two and the use of mnemonics, with the difference
between post-treatment phase 1 and 2 for total
correct approaching significance (p ⫽ .053).
Homophone confusion errors
As mentioned above, total homophone confusion
errors (HCE) for spelling increased between
Figure 8. Percentage of responses that were errors for
homophone spelling at baseline, during treatment,
and at post-tests.
236 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
initial baselines. No further significant changes
were evident during treatment or at follow-up,
when compared to baseline 2 (PT1, McNemar
p ⫽ .804; PT2, p ⫽ .607; PT3, p ⫽ .804; follow-up
1, p ⫽ .629; follow-up 2, p ⫽ 1.0). When com-
pared to baseline 1, the total homophone confu-
sion errors post-treatment 3 was significantly
higher (p ⫽ .041) (NB. no other comparisons were
significant), though this result is difficult to
interpret in the context of unstable baselines.
Phonologically plausible nonword errors
The total number of phonologically plausible non-
word errors (PPNE) was reduced during treat-
ment, with significantly fewer errors after
treatment phase 3 than at baseline 2 (McNemar
␹2 ⫽ 16.7, p ⫽ .000), suggesting a change in the
nature of errors made as a result of treatment.
There was a significant decrease in PPNE
between baseline 2 and post-treatment phase 1
(p ⫽ .023), between post-treatment phases 1 and 3
(p ⫽ .019), but not between treatment phases 1
and 2 (p ⫽ .541). This treatment effect was main-
tained over time with no change between the end
of treatment and the two follow-up assessments
(follow-up 1, p ⫽ 1.0; follow-up 2, p ⫽ 1.0).
Other errors
The total number of other errors (OE) increased
significantly after treatment phase 1 when com-
pared to baseline 1 (McNemar, p ⫽ .012) but there
were no further significant changes during treat-
ment or at follow-up. These errors were responses
that were incorrect and were not phonologically
plausible (see Appendix D for examples).
Post hoc analyses were conducted to compare
the nature of homophone spelling errors before
and after treatment. This analysis included all
homophone error responses (both nonword errors
and homophone confusion word errors) and was
conducted to investigate whether error responses
moved closer to the target with treatment. In other
words, even though the responses were still incor-
rect after treatment, were they closer to being

correct as a result of the irregular word spelling
treatment. The degree of match (using the match
variables described previously) between error
responses and the correct spellings were calculated
for errors at baseline 2 and the first follow-up
assessment and then compared.
First, at baseline (baseline 2), there was not a
significant interaction between error type and
match values for coding schemes overall (match 1,
Kruskal Wallis ␹2 ⫽ 4.719, p ⫽ .094; match 2,
p ⫽ .339; match 3, p ⫽ .411; match 4, p ⫽ .259;
match 5, p ⫽ .060). This indicated that the match
variables did not distinguish significantly between
the three error response classifications (e.g., HCE,
PPNE, and OE) in homophone spelling. In other
words, HCE, PPNE, and OE were similar in how
closely they matched the stimulus word (or correct
response).
A simple overall comparison of the errors made
at baseline with those made at follow-up assess-
ment indicated that there were significantly fewer
phonologically plausible (p ⫽ .000) and signifi-
cantly more other (p ⫽ .001) errors at follow-up
(see Table 10). There was no difference according
to stimulus regularity (p ⫽ .096), number of HCE
(p ⫽ .568), or any match values (match 1: p ⫽ .202,
match 2: p ⫽ .447; match 3 p ⫽ .418; match 4,
p ⫽ .154; match 5, p ⫽ .407).
A regression analysis was then conducted to
further investigate differences between the errors
at baseline and those at follow-up (i.e., to deter-
mine what was different about the errors after
treatment). Predictor variables included match
values 1–5, error type (i.e., PPNE, HCE, or OE),
whether the stimulus was irregular or regular, and
Table 10. Total number of homophone errors at baseline 2
and follow-up assessment
Errors Baseline Follow-up
Total HCE 20 18
Total PPNE 33 9 changed from incorrect to correct), 77% (10/13)
Total OE 9 21
Total errors 62 48
HCE: homophone confusion errors; PPNE: phonologically
plausible nonword errors; OE: other errors.
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
whether the error response was the same length as
the stimulus. The binary outcome variable repre-
sented time of testing (baseline vs. post-treatment)
for all error responses. Results indicated that error
type was the only variable that differentiated sig-
nificantly between errors made before treatment
and those made post-treatment. Errors at follow-
up were less likely to be phonologically plausible
(Wald ␹2 ⫽ 7.4, p ⫽ .006), than at baseline. There
was also a trend for errors at follow-up to be more
likely to be ‘other’ errors (Wald ␹2 ⫽ 3.246,
p ⫽ .072), consistent with results reported above
(again see Table 10).
Finally, a regression analysis was conducted to
investigate the difference between errors at base-
line that were correct at follow-up (N ⫽ 17) and
those that were not (N ⫽ 45) (i.e., to determine
differences between those untreated homophone
words that improved and those that didn’t). The
same predictor variables were included. Results
indicated that no variable was able to predict
improvement in homophone words over and
above the other variables included; however the
power of the analyses is limited due to the small
number of homophone errors that improved
(N ⫽ 17).
Homophone reading
Results for homophone reading are shown in
Figure 9.
Total words read correctly
The total number of homophone reading errors
decreased during treatment, with significantly
fewer read incorrectly at post-treatment phase 3
and follow-up 1 assessments when compared to
baseline 2 (PT3, p ⫽ .035; post follow-up 1,
p ⫽ .002), suggesting some treatment generalisa-
tion to homophone reading. It is interesting to
note that, of those words that improved (i.e.,
were irregular homophonic words. Results indi-
cated a significant increase in the total number of
homophone words read correctly during treatment
but, as with spelling, there was no consistent
237
BRUNDSON, COLTHEART, NICKELS
Figure 9. Percentage of responses that were errors for
homophone reading performance at baseline, during
treatment, and at post-tests.
change in the number of homophone confusion
errors.
Homophone confusion errors
The total number of homophone confusion errors
(made with those words read correctly) decreased
significantly following treatment phase 3 when
compared to baseline 2 (binomial p ⫽ .035) but
not baseline 1 (p ⫽ .118), but this decline was
transitory and errors had increased by follow-up 1
(p ⫽ .000) back to baseline level (B2, p ⫽ .210; B1,
p ⫽ .063).
Mnemonics
The efficacy of employing mnemonics in lexical
spelling treatment was evaluated according to effi-
ciency of treatment (speed at which target word
spelling improved) and stability of treatment (how
resistant the words were to decline following treat-
ment). Note: As mentioned in the Method
section, mnemonics were used for treatment of
238 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
Set 2 irregular words but not for treatment of
words in Set 1 or Set 3.
There was no significant difference between
the word sets in terms of duration of treatment
required to reach ceiling (i.e., efficiency of treat-
ment). Duration of treatment for Set 1 was 8 days,
for Set 2 it was 6 days, and for Set 3 it was 7 days.
There was also no difference between the three
word sets in degree of decline from post-treatment
to assessment at follow-up 1 (Generalised
Estimating Equation [GEE] analysis, ␹2 ⫽ 3.15,
p ⫽ .21). The only relevant change was a reduction
of errors in homophone spelling, which predomi-
nantly occurred after treatment of Set 2 (and the
use of mnemonics), but this change only
approached significance (p ⫽ .053). Thus there was
no consistent evidence that the use of mnemonics
contributed to the efficacy of treatment.
Overview of results
1. The treatment method used in this case of
developmental surface dysgraphia was highly effi-
cacious, since spelling of treated words improved
significantly as a direct result of treatment.
2. Although there was some reduction in total
words spelled correctly at 2 months post-
treatment (indicating some loss of accuracy with
time), spelling of treated words remained signifi-
cantly improved at 4 months post cessation of
treatment when compared to baseline.
3. The treatment method employed resulted in
a significant generalisation effect, since spelling of
untreated words also improved with treatment,
though not as dramatically as spelling of treated
words.
4. Untreated words whose spellings became
correct as a result of treatment generalisation (as
compared to untreated words whose spellings
remained incorrect) were those whose errors were
closer to being correct prior to treatment and
those with a higher word frequency. The degree of
correctness (or degree of match to the correct
spelling) was best characterised by a coding
scheme that placed relatively more weight on exte-
rior letters than interior letters.

5. A close examination of error characteristics
during treatment revealed that untreated words
improved gradually as a result of treatment gener-
alisation and that this improvement predominantly
involved interior letters. Even those untreated
words that did not become correct prior to their
treatment showed some improvements in spelling.
6. There was no evidence that the use of
mnemonics contributed to the efficacy of treatment.
7. Although reading was not specifically treated,
those words whose spelling had been treated also
showed an improvement in reading accuracy.
8. The total number of error responses made in
homophone reading and spelling was also signifi-
cantly reduced, but the number of homophone
confusions did not change. However, there was a
significant reduction in phonologically plausible
spelling errors and an increase in other errors (i.e.,
orthographically based spelling attempts) during
treatment.
9. In addition, a close examination of error
characteristics (from both irregular word and hom-
ophone word spelling) provided preliminary evi-
dence that the mechanism underlying treatment
generalisation involved a general improvement
(that was not word-specific) in the ability to access
and use output orthography for spelling attempts.
DISCUSSION
The current study adds to the small number of
cognitive neuropsychological case studies report-
ing successful treatment of surface dysgraphia, and
is the first study we are aware of to focus on the
cognitive neuropsychological treatment of devel-
opmental surface dysgraphia. The results have
implications for current theoretical proposals
about lexical processes in reading and spelling, as
well as clinical methods used for treatment of
surface dysgraphia.
Theoretical implications
The current results provide support for a number
of theoretical proposals, including the following.
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
1. Weekes and Coltheart’s (1996) proposal
that two treatment effects can occur as a result of
item-specific training: a word-specific treatment
effect and a more general treatment effect impact-
ing on access to orthography.
2. Behrmann’s (1987) speculation that homo-
phone comprehension difficulties require item-
specific training and that homophone
comprehension does not improve as a result of
general improvements in orthographic processing.
3. Weekes and Coltheart’s (1996) prediction
that some untreated irregular words may benefit
more than others depending on their level of pre-
treatment representation.
4. The empirical proposal that exterior letters are
particularly important for orthographic processing
(Humphreys, Evett, & Quinlan, 1990; Jordan, 1990;
Perea, 1998).
5. The theoretical proposal that a direct nonse-
mantic route is required in models of normal read-
ing and spelling.
Each of these proposals will be discussed in
turn. Orthographic processing difficulties can
result from two different levels of impairment;
from word-specific impairment or from a general
impairment or inefficiency in access to stored lexi-
cal representations. The current study adds weight
to previous research findings that treatment
focused on improving orthography (in this case
irregular word spelling) can benefit both forms of
impairment. This is consistent with Weekes and
Coltheart’s (1996) proposal that two treatment
mechanisms arise from item-specific training: a
word-specific effect (which results in improve-
ment for target words) and a more general effect
on access to orthography (which results in gener-
alisation to untreated irregular words). This expla-
nation makes sense for cases of acquired
dysgraphia, but can it be applied to MC, a devel-
opmental case? Adults with acquired dysgraphia
will have had a normal store of lexical representa-
tions prior to their injury (assuming they were lit-
erate) and thus can benefit from treatments that
improve general access to those orthographic
representations that remain relatively intact. But
can a child with long-standing poor or unreliable
239
BRUNDSON, COLTHEART, NICKELS
access to orthography actually form adequate
word-specific representations that would then
enable them to benefit from generalised improve-
ments in access to orthography? We would argue
in the affirmative, for the following reason. It is
conceivable that a child with poor access to
orthography could gradually build up correct (or
partially correct) representations of individual
words via multiple exposures to the correct
spelling, though presumably the formation of
orthographic representations would be delayed.
The child could then continue to have difficulty
accessing (or retrieving) these representations
(resulting in ongoing severe reading and spelling
difficulties) but would show significant improve-
ments as a result of treatment generalisation, as
seen in the current case MC. For MC, significant
treatment generalisation did occur, which provides
additional evidence that MC had a developmental
impairment in general access to orthography and
not just impairment at the level of orthographic
representation.19
The current results also provide strong support
for Behrmann’s (1987) speculation that homo-
phones require word-specific training (presumably
in orthography-semantic association) so, unlike
irregular words, do not benefit from a general
orthographic treatment effect. In the current
study, the benefits of treatment generalisation did
not extend to orthography-semantic connections
for untreated homophones. Although homophone
spelling improved, the improvement was only evi-
dent in the total number of homophone stimuli
spelled correctly. There was no reduction in the
number of homophone confusion errors.
Of most interest, in the current study, were the
results of the novel investigation into mechanisms
underlying treatment generalisation, analyses that
have been lacking in previous research. Weekes
and Coltheart (1996) propose that some untreated
irregular words may benefit more than others,
19
This is based on the assumption that the generalisation effects in the current study were due to improvements in orthographic
processing. An anonymous reviewer made the valid point that generalisation effects can occur following improvement in other
aspects of the spelling system, such as the graphemic buffer. However, in the current case, this would be unlikely as no such other
impairments were detected in assessment.
240 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
depending on their level of pretreatment represen-
tation. More specifically, words with partial repre-
sentation prior to treatment will benefit more than
those with little or no orthographic representation
(Weekes & Coltheart, 1996). In order to investi-
gate this proposal the current study analysed the
characteristics of untreated words that improved
as a result of treatment generalisation and exam-
ined how they differed from those untreated words
that didn’t improve. Pretreatment representation
was measured using the degree of match (or simi-
larity) between the error response and correct
spelling prior to treatment. In addition, an attempt
was made to investigate the actual mechanism
underlying treatment generalisation through analy-
ses of changes in error characteristics as a result of
treatment. Overall and in combination, the results
of these investigations provide some support for
the proposals of Weekes and Coltheart (1996).
First, the current results indicate that, in general,
untreated irregular words whose errors are closer to
being correct prior to treatment (i.e., have a closer
match to the correct spelling) are more likely to
improve as a result of treatment generalisation.
However, the coding schemes and match values
employed in the analyses did not distinguish
between error type prior to treatment; that is, both
phonologically plausible nonword spelling errors
and nonphonological spelling errors (which often
contained partial orthographic information) had
similar match values. This is because both phono-
logically and orthographically based errors can be
highly similar to the correct response (e.g., phono-
logical attempts: soul → sowl, won → wun; non-
phonological orthographic attempts: eight →
etaght, their → thir). In addition, phonologically
plausible nonword errors are also often ortho-
graphically similar to the correct response, so there
may have also been some overlap between error
classifications. Therefore, all we can conclude
from this finding is that untreated irregular words

that improve with treatment generalisation have a
closer match to the correct spelling prior to treat-
ment. This does not provide definitive support for
a proposal that these words have partial ortho-
graphic representations prior to treatment.
However, investigation into changes in error char-
acteristics during treatment provided some evi-
dence for an underlying treatment mechanism of
an improved ability to access and use orthographic
representations for spelling attempts. Observation
of untreated irregular words that improved over
multiple testing points during treatment revealed
that many showed gradual improvement in degree
of similarity to target orthography. In addition, for
homophone spelling (all untreated) there was a
reduction in phonologically plausible nonword
errors, which is consistent with incomplete but
improved access to representations in orthography
resulting in less reliance on sublexical processing.
There was also a co-occurring increase in the num-
ber of ‘other’ errors, which essentially reflected an
increase in attempts that were not phonologically
plausible but more often represented incomplete
orthographically mediated attempts.
In the current study, extensive analyses were
conducted to determine the best predictors of
treatment generalisation. The main focus of the
analyses were the coding schemes (and match val-
ues) to determine not only whether degree of pre-
treatment ‘correctness’ could predict generalisation
(as discussed above), but also whether one method
of coding ‘correctness’ was superior to another.
Overall, the results suggest that the best way to
determine how correct an error response is prior to
treatment, in order to predict treatment generali-
sation, is to use a coding method where the posi-
tion of each letter is coded relative to the first and
last letters—that is, a coding method that places
relatively more weight on exterior letters. The best
statistical model for predicting generalisation for
untreated irregular words included this particular
method of coding combined with written fre-
quency. However, given the very high correlation
between all of the coding methods employed
(match variables), the authors would hesitate to
argue definitively that one matching method was
significantly superior to the others. It would seem
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
TREATMENT OF SURFACE DYSGRAPHIA
reasonable, however, given the consistent findings
of various analyses, to suggest that some matching
methods (or coding schemes) may be better than
others for predicting which untreated words will
improve with treatment. In the current study,
matching methods for coding schemes 4 and 5
(which both emphasised the exterior letters)
seemed consistently superior for predicting which
untreated irregular words would benefit from
treatment generalisation. A post hoc examination
of the nature of MC’s actual error responses for
untreated words was also highly consistent with
this finding, particularly for the relative impor-
tance of exterior letter positions. For those irregular
words that improved with treatment generalisa-
tion, a large proportion of the errors at baseline
(75%) contained correct letters in the first and last
letter position. In contrast, for those untreated
words that failed to improve, less than half of the
error responses (46%) contained correct first and
last letters. For interior letters, this effect was not
present: Interior letters were correct in 15% of
untreated words that improved and 9% of untreated
words that did not improve. This finding makes
theoretical sense as previous research has also indi-
cated the importance of exterior letters (over inter-
nal letter positions) in orthographic processing
(Humphreys et al., 1990; Jordan, 1990; Perea,
1998). Most previous studies have investigated
letter position effects in visual word recognition, but
the current results provide some preliminary
evidence that exterior letters may also be important
in spelling.
It is interesting to consider how the results for
predicting which untreated words will benefit most
from generalisation (as just discussed) relate to
results describing the nature of error change during
treatment. That is, can we speculate not only
about which words will improve but also about
how they will improve? As discussed above, error
responses with a closer match (particularly involv-
ing exterior letter positions) to the correct response
will benefit most from treatment generalisation. So
at baseline, those words with correct initial and final
letter positions are more likely to become correct
as a result of treatment generalisation (many of
these words would therefore have errors affecting
241
BRUNDSON, COLTHEART, NICKELS
interior letter positions). Interestingly, an examina-
tion of how error responses change during treat-
ment (prior to becoming correct) indicated a
highly significant change in vowel-centred match
schemes (match 2 and 3), possibly indicating a
gradual improvement in interior vowel patterns
during treatment. This was apparent for both
words that became correct as a result of treatment
generalisation and those that didn’t, though the
latter took longer to respond to treatment generali-
sation effects.
Finally, in regard to theoretical implications,
homophone confusions with irregularly spelled
homophones are rarely investigated or reported in
cases of surface dyslexia and more particularly in
developmental surface dyslexia. As Coltheart et al.
(1983) discuss, these errors are of theoretical
importance as they provide additional evidence
for the existence of the direct nonsemantic route
in reading connecting the orthographic input
lexicon to the phonological output lexicon. When
an irregular homophone is read aloud correctly but
a homophone confusion is made in comprehen-
sion (e.g., reading the word ‘queue’ correctly but
providing the wrong definition “the actor needed a
cue,” see Table 5 for other examples) the theoreti-
cal explanation must be as follows. The correct
word entry is successfully accessed in the ortho-
graphic input lexicon but word-specific communi-
cation with the semantic system fails. As a result,
output phonology is obtained via the direct route
linking the orthographic input lexicon to the
phonological output lexicon, which prevents
word-specific semantic activation (route shown by
arrows 13, 15, 11, Figure 1), giving rise to the
homophone confusion error. Documentation of
multiple examples of such errors in the current
developmental case, in addition to the case of
Coltheart et al. (1983), requires current models of
reading and spelling to include not only the
lexical-semantic and sublexical reading routes, but
also the third nonsemantic reading route.
Clinical implications
The current results also have clinical implications
for management of dysgraphia, particularly
242 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
developmental dysgraphia. Results suggest the
following.
1. Carefully designed theoretically based treat-
ment methods for developmental dysgraphia can
be highly efficacious.
2. Lexical treatment of developmental surface
dysgraphia can result in dramatic improvements in
target word spelling but also significant improve-
ments in spelling of other untreated words.
3. Further improvements in efficiency of treat-
ment may be achieved by targeting particular sub-
sets of words, specifically those that are less likely
to benefit from treatment generalisation.
4. Lexical spelling treatment methods can
result in substantial improvements in reading of
target words.
5. It must not be assumed that mnemonics
always increase efficacy in treatment of irregular
word spelling in developmental dysgraphia.
Each of these clinical implications will be dis-
cussed briefly. The theoretically based lexical treat-
ment method used in the current study was highly
successful in improving irregular word spelling in a
child with long-standing delays in the development
of orthographic word reading and spelling. The
treatment improvements were dramatic, occurred
rapidly, and were also maintained over time. This
study shows that treatments previously used success-
fully in cases of adult-acquired surface dysgraphia
can be very effective for treatment of developmental
surface dysgraphia. It is hoped that this case study
will encourage further research into treatment of
childhood reading and spelling disorders (a research
area that remains extremely limited), especially given
the potentially dramatic benefits for the child.
The lexical treatment methods used in the cur-
rent study not only resulted in dramatic improve-
ments in the specific words chosen for treatment
but also resulted in better spelling of other
untreated words. Essentially, clinically, this implies
that the benefits of treatment can reach well beyond
the small set of target words and that treatment
focused on single words can also benefit other
words in the system that are not fully developed.
In addition, the current results suggest that it
may be possible to predict, prior to treatment,

which words will benefit most from treatment
generalisation by examining the nature of errors at
baseline. This may therefore allow increased effi-
ciency in treatment by allowing the separation of
target words into two groups prior to treatment.
The first group would contain those words least
likely to benefit from treatment generalisation,
that is, those words with a low written frequency
and with spelling errors that are not close to being
correct prior to treatment (i.e., spelling errors that
do not have a high degree of match with the cor-
rect spelling). These errors would be targeted for
word-specific treatment. The second group would
contain those words most likely to benefit from
treatment generalisation, those words with a high
written frequency and with spelling errors that are
close to being correct prior to treatment. These
words could be deliberately excluded from the
treatment group as we might predict that they
would improve during treatment as a result of
treatment generalisation. This proposal, that treat-
ment planning could potentially maximise effi-
ciency of treatment, requires further investigation
and research, however.
Treatment of irregular word spelling in the cur-
rent case also resulted in significant improvement
in reading of treated words. The improvement in
reading of treated words is not an unexpected
finding as, although treatment focused on output
orthography and spelling, the treatment method
also involved constant visual exposure to target
words. In clinical terms this result implies that in
developmental dysgraphia and dyslexia treatment
targeted at spelling is also likely to benefit reading.
Mnemonics are commonly used as a treatment
tool in treatment of surface dyslexia and dys-
graphia and are also employed for teaching begin-
ner readers early in primary school. However, the
efficacy of mnemonics is not often empirically
evaluated (Behrmann, 1987; Byng & Coltheart,
1986; Coltheart & Byng, 1989; Weekes &
Coltheart, 1996). De Partz et al. (1992) evaluated
the efficacy of mnemonics (compared to writing
to dictation and simple copying of the word with
no mnemonic) in their treatment of spelling in
an adult, LP, with acquired dysgraphia, which
targeted high-frequency words. They found a
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (0)
TREATMENT OF SURFACE DYSGRAPHIA
significant therapy advantage for the mnemonic
technique. It is important to note that LP report-
edly had semantic deficits. In contrast, a recent
treatment study focused on improving visual word
recognition in developmental dyslexia (also
focused on high-frequency words) questions the
efficacy of mnemonics when compared to ‘word-
only’ treatment methods (Brunsdon, Hannan,
Coltheart, & Nickels, 2002). In the current study,
mnemonics were used for treatment stage two
(word Set 2 only) and, in general, results suggested
no additional benefit from use of mnemonics.
Neither of these developmental cases benefited
from mnemonics and neither presented with
semantic deficits. Overall, it would be reasonable
to suspect that the use of mnemonics may be
beneficial when the treatment aim is specifically to
train orthography-semantic connections, as in
specific homophone reading and spelling treat-
ment programmes, where the individual demon-
strates impaired access to semantic information for
target words (though, even in this instance, a ver-
bally mediated orthography-semantic association
treatment may be equally effective). In contrast,
mnemonics may not offer any treatment advan-
tage when treatment simply targets irregular word
reading or spelling, when the individual already
knows the meaning of target words.
Finally, with regard to clinical implications,
surface dyslexia and dysgraphia are still commonly
overlooked or misdiagnosed in children. MC’s
case provides a typical example of this. His reading
and spelling difficulties were apparent from early
in primary school. He had undergone numerous
reading assessments and as a result received extra
reading tuition during primary school. Despite
this, the exact nature of his reading and spelling
disorder was not precisely diagnosed until the cur-
rent investigation, when MC was 12 years old and
in high school. Although it is certainly never too
late to begin treatment, appropriate treatment ear-
lier in primary school would obviously be better. It
is hoped that the current case will provide a timely
reminder of the importance of theoretically based
assessment early in primary school for identifica-
tion and then treatment of lexical spelling (and
reading) disorders.
243
BRUNDSON, COLTHEART, NICKELS
Theoretically based assessment and diagnosis is
fundamental to treatment planning and design. To
devise a successful treatment programme targeted
at a particular impairment, the fundamental
requirement is to first determine the nature of that
impairment. Although the treatment design
(including the intensive nature of treatment and
repeated exposure to target stimuli) is important, if
treatment is not targeted specifically at the impair-
ment, success is likely to be limited. The current
case MC had undergone numerous special educa-
tion programmes, including some periods of inten-
sive daily training. However, given that his surface
dyslexia and dysgraphia had not previously been
diagnosed it must be suspected that treatment was
not targeted appropriately at irregular words.
Final comments
In summary, the current study demonstrates suc-
cessful application of cognitive neuropsychological
theories and methods to the assessment and reme-
diation of developmental spelling difficulties.
Treatment was highly successful and resulted in a
dramatic improvement in spelling and reading of
irregular words that was stable over time.
Treatment also generalised to spelling of untreated
irregular words. Novel analyses indicate that
untreated words that improved were closer to being
correct prior to treatment than untreated words
that failed to improve. Results also suggest that,
prior to treatment, it may actually be possible to
predict which words will benefit most from treat-
ment generalisation. There is also preliminary evi-
dence that the actual mechanism underlying
treatment generalisation involves improved access
to orthographic representations, resulting in an
increased tendency to attempt to employ ortho-
graphic knowledge and a reduced tendency to rely
entirely on phoneme to grapheme conversion.
Results have both theoretical and clinical implica-
tions and raise a number of interesting proposals
worthy of future research.
Manuscript received 8 April 2003
Revised manuscript received 3 October 2003
Revised manuscript accepted 16 February 2004
PrEview proof published online 15 December 2004
244 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)
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247
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APPENDIX A

MC’s errors for irregular, regular, and nonword reading and spelling (using the Coltheart &
Leahy, 1996, word and nonword lists)
Regular words Reading response Spelling response Irregular words Reading response Spelling response

1. bed ✓ ✓ 16. head ✓ haed

2. brandy ✓ ✓ 17. iron ✓ iorne
3. chance “change” carns 18. island ✓ ✓
4. check ✓ ✓ 19. lose /ləυz/ lowes
5. chicken ✓ ✓ 20. meringue “merging” merrag
6. context ✓ contexs 21. pint /pnt/ pient
7. cord ✓ corwd 22. pretty /prεti:/ pritte
8. curb ✓ cerb 23. routine /raυtn/ rooten
9. drop ✓ ✓ 24. shoe ✓ ✓
10. flannel /flntεl/ ✓ 25. soul /səυl/ ✓
11. free ✓ ✓ 26. sure /ʃu::/ shore
12. hand ✓ ✓ 27. tomb /tɒmb/ ✓
13. life ✓ ✓ 28. wolf ✓ ✓
14. long ✓ ✓ 29. work ✓ werk
15. luck ✓ ✓ 30. yacht /jtʃt/ yote
16. market ✓ ✓
17. marsh ✓ ✓ Nonwords Reading response Spelling response
18. middle ✓ ✓
19. mist ✓ ✓ 1. aspy /sfiə/ ✓
20. navy ✓ navey 2. baft ✓ ✓
21. need ✓ ✓ 3. bick “bike” ✓
22. nerve /n:vi:/ nerv 4. bleaner /bεnə/ ✓ (blener)
23. peril “pearl” peral 5. boril “boil” ✓ (boral)
24. plant ✓ ✓ 6. borp ✓ ✓
25. pump ✓ pamp 7. brennet /brεnt/ ✓ (brenet)
26. stench ✓ staench 8. brinth ✓ ✓
27. tail ✓ ✓ 9. crat ✓ ✓
28. take ✓ ✓ 10. delk ✓ ✓ (delck)
29. weasel /wɒzli:/ ✓ 11. doash ✓ ✓(dowsh)
30. wedding ✓ weding 12. drick ✓ ✓
13. farl ✓ ✓ ( farll )
14. framp ✓ ✓
Irregular words Reading response Spelling response
15. ganten ✓ ✓
1. blood /blυd/ ✓ 16. gop ✓ ✓
2. bouquet /bəυkεt/ bowckay 17. grenty “gentle” granty
3. bowl ✓ ✓ 18. gurve “gravy” ✓ ( girv)
4. break ✓ braek 19. hest ✓ ✓
5. brooch ✓ browtch 20. norf ✓ ✓
6. ceiling ✓ cilling 21. peef /pəf/ ✓
7. choir “chore” quwiyer 22. peng “peg” pag
8. colonel /kɒləυnel/ cernal 23. pite ✓ ✓(piet)
9. come ✓ ✓ 24. pofe ✓ ✓(powf )
10. cough “caught” cofe 25. rint ✓ ✓
11. eye ✓ ✓ 26. seldent ✓ ✓(selldent)
12. friend ✓ ✓ 27. spatch ✓ ✓
13. gauge /g:rd/ gaeg 28. stendle ✓ ✓ (stendell)
14. give ✓ ✓ 29. tapple ✓ ✓ (tapell )
15. good ✓ ✓ 30. trope ✓ trop

248 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)

 TREATMENT OF SURFACE DYSGRAPHIA

APPENDIX B

Homophone stimuli
Irregular Regular Irregular Regular Irregular Regular

key ring sure shore one plane

quay wring bear bare won plain
loch lock heard herd aisle seen
stalk stork none nun isle scene
pear pair bread bred where missed
break brake waste waist wear mist
bury berry raise rays whole hole
seize sees soul sole knead
suite sweet queue cue need
son sun earn urn tax
prays praise two male tacks
build billed to mail sail
know no their fair sale
some sum there fare tail
steak stake would ate tale
heir air wood eight maid
great grate watt hire made
what higher cruise

APPENDIX C

Homophone confusion errors in reading at baseline 1

Target word Read aloud correctly? Spoken definition provided by MC

wring yes “the telephone rings”

pear yes “socks. . . . pairs of them”
mist yes “I missed the ball”
brake yes “I break the vase”
tale yes “there is a tail on a dog”
prays yes “a cat preys on a bird”
steak yes “I stuck a stake in the ground”
mail yes “the male toilet”
male yes “the mail came. . . . was delivered”
their yes “there is the ball”
whole yes “there is a hole in the ground”
queue yes “the actor needed a cue”
crews yes “a boat cruise. . . . a cruise ship”

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 249

BRUNDSON, COLTHEART, NICKELS

APPENDIX D

Homophone errors in spelling at baseline 1

Target Homophone Phonologically plausible Other
homophone MC’s written response confusion errors nonword errors errors

quay key 1
loch lock 1
stalk stork 1
wring ring 1
whole hole 1
knead need 1
scene seen 1
hire higher 1
maid made 1
fare fair 1
sum some 1
heard herd 1
pear pare 1
missed mistd 1
tax taxs 1
brake braek 1
break braek 1
sail sayal 1
tale taile 1
tail taile 1
bury berrey 1
berry berrey 1
prays praes 1
Praise praes 1
steak staek 1
stake staek 1
mail maile 1
male maeal 1
heir airr 1
there thair 1
watt whot 1
grate graet 1
great graet 1
sure shor 1
shore shor 1
bear bair 1
bare bair 1
build biuld 1
won wun 1
waist waest 1
raise raes 1
rays raes 1
soul sowl 1
sole sowl 1
cruise croos 1
crews croos 1
aisle ieal 1
earn ern 1

250 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2)

 TREATMENT OF SURFACE DYSGRAPHIA

APPENDIX D (continued)

Homophone errors in spelling at baseline 1

Target Homophone Phonologically plausible Other
homophone MC’s written response confusion errors nonword errors errors

where whair 1
wear whair 1
tacks taxes 1
seize sesy 1
sweet swety 1
suite swets 1
plain plan 1
higher highter 1
eight etaght 1
their thir 1
none nune 1
queue qu 1
cue qu 1
isle lias 1
bred breaed 1

Phonologically plausible nonword errors refer to those errors for which MC employed plausible sound to letter conversion in his
spelling response (this classification was not restricted to the most common phoneme to grapheme rules).

APPENDIX E

Irregular word responses (from Set 3): Those responses that are incorrect at baseline 1,
baseline 2, and after treatment of Set 1 words but are correct after treatment of Set 2 words
Target irregular word At baseline 1 At baseline 2 Post-treatment 1

want wont wont wont

kind ciend cind cind
move more moov morve*
range rang rang raeng
staff starf starf starf
rise ries riess ries
clothes cloths clows clouthes*
tough taph taf taugh*
draft drarft drarft drarft
soup soop soop soupe*

*Untreated words with gradual increase in orthographic knowledge with treatment generalisation (Note: All of these untreated
words were spelled correctly at the next assessment).

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (2) 251