Clinical Reasoning in the Assessment and Intervention Planning for Writing Disorder

Abstract

The incidence of writing disorder is as common as reading disorder, but it is frequently under-identified and rarely targeted for intervention. Increasing clinical understanding on various subtypes of writing disorder through assessment guided by data-driven decision making may alleviate this disparity for students with writing disorders. The purpose of this article is to provide the reader with insight into the clinical reasoning involved in the assessment and intervention planning for a child with a writing disorder. The reader will be guided through the authors’ conceptualization of this case reflecting a recursive problem-solving approach to assessment for intervention.

Keywords

writing disorder adolescence multimodal assessment clinical decision making

Introduction and Framework Overview

Writing disorder (WD) has been referred to as the “forgotten learning disability” (Katusic, Colligan, Weaver, & Barbaresi, 2009), considerably neglected in research in comparison with reading disorder (RD) despite its similar incidence rates (e.g., Mayes & Calhoun, 2006) and its common co-occurrence with RD (Abbott & Berninger, 1993; Katusic et al., 2009). Children with WD are disadvantaged in using writing as a medium to engage in learning and to record what they have learned. Students’ grades decline in the upper elementary and high school years, as writing is relied on more for classroom assessment (Rogers & Graham, 2008). The writing difficulties experienced by children with WD persist into adulthood, even with improved and compensated reading skills (Connelly, Campbell, MacLean, & Barnes, 2006; Harrison, 2009) and are reported to be the most significant area of academic concern for students with a learning disability (LD) in higher education (Connelly et al., 2006). Across professions, writing is an essential skill with written technical reports, visual presentations, memos, emails, and texts required for employment and promotion. The increased demands for writing in the workplace therefore serve as a significant barrier to the employment and career options available to those with WD (Rogers & Graham, 2008). The assessment to intervention process for WD described in this article is situated within a contemporary scientist–practitioner framework (e.g., Huber, 2007) linking theory and research on typical and atypical writing development with data-driven multimodal assessment (Shapiro, 1996) and evidence-informed intervention. Consistent with the process described by Merrell, Ervin, and Gimpel (2006), this approach involves the following steps: (a) problem analysis and development of hypotheses based on the collection of background data including the referral question, interviews, and file reviews; (b) collection of assessment data to test hypotheses; (c) synthesis and interpretation of all assessment data in relation to hypotheses; (d) intervention development; and (e) intervention evaluation. The process is recursive rather than sequential, as hypotheses, interpretation of results, and intervention plans may be revised in light of new or updated information. Consistent with current practices in special education and the ubiquitous response to intervention (RTI) model, the framework also reflects an “assessment for intervention” approach (Berninger, Stage, Smith, & Hildebrand, 2001) where writing skills are targeted based on assessment results, and an ongoing evaluation of the intervention’s effectiveness is conducted to assess the student’s “response.” This framework reflects current cognitive, neurocognitive, and psycholinguistic perspectives on individual differences in writing skills and processes that inform the assessment and intervention process.

Disorder Characteristics

The hallmark diagnostic features of WD is impairment (at or below 1.5 SD from the chronological mean) in one or more writing subskills, including spelling, grammar, and punctuation, and the clarity and organization of written expression to the exclusion of intellectual disability, external general factors, neurological, motor, vision, or hearing disorders (American Psychiatric Association [APA], 2013). WD is considered one of several neurodevelopmental disorders of spoken and written language that also includes disorders of speech, sound, language, and reading (Grigorkenko, 2007). Writing has been described as “language by hand” (Berninger, Abbott, Abbott, Graham, & Richards, 2002) and linguistic skills and processes feature prominently in contemporary writing models. Children with a history of speech and/or language disorder are at risk for disorders of written language, including RD and WD (Grigorkenko, 2007). WD has also been reported to be later occurring (11-15 years) in comparison with RD (Grigorkenko, 2007), but this may be due to the fact that reading difficulties tend to be identified sooner and have more prominence in intervention (Berninger, Nielsen, Abbott, Wijsman, & Raskind, 2008). WD is distinct from oral language, however, due to the cognitive demands for integrating and coordinating multiple skills and processes. For example, working memory is taxed far more when writing than when speaking (e.g., Bourdin & Fayol, 2000) as lower order skills involving transcription (e.g., spelling and handwriting) are coordinated with higher order skills involving text generation (e.g., word, sentence, and text-level discourse) in producing text comprehensible to the reader (Berninger & Amtmann, 2003). Higher level executive functions are also required for the multiple stages and recursive nature of the writing process, including planning, revising, problem solving (e.g., Hooper, Swartz, Wakely, de Kruif, & Montgomery, 2002), and strategies for self-regulation (Berninger & Amtmann, 2003; Berninger & Winn, 2006). Due to its reliance on so many different skills and processes at once, writing may be the most cognitively complex task at school (Wendling & Mather, 2009). The incidence of WD is as common as RD, and in some studies, reportedly more common than RD (e.g., Mayes & Calhoun, 2006). Katusic et al. (2009) conducted the first ever epidemiological study on the incidence of WD (based on Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-IV-TR; APA, 2000] diagnostic criteria) and reported cumulative incidence rates between 6.9% and 14.7%, with the incidence rates 2 to 3 times higher in boys than in girls. In the same study, only 25% of affected cases had writing-specific disorder, with most cases co-occurring with RD. Berninger (2009) has developed a research-driven classification system for identifying WD that informs the clinical hypothesis testing and decision making required for assessment, diagnosis, and intervention. Three subtypes of WD are stipulated within this system: dyslexia, dysgraphia, and oral and written language–learning disorder (OWL-LD). Dyslexia is as much a WD as it is an RD (Berninger, 2009), but this fact is often overlooked in clinical practice and special education service delivery with the writing difficulties of children with dyslexia often under-identified and under-targeted for intervention. Writing difficulties experienced by children with dyslexia entail problems primarily at the transcription level in spelling accuracy. Some children may also have difficulties with handwriting fluency and accuracy due to problems converting orthographic codes into motor output (Berninger, 2009). A lack of automaticity at the transcription level constrains cognitive resources, impeding access to resources required to generate coherent and well-organized texts (Berninger & Amtmann, 2003). Children with dyslexia often do not write very much, and what they do write often contains simplistic vocabulary that does not match their oral vocabulary skills usually because they are attempting to use words that they know how to spell. Children with dysgraphia (the classic term for WD) have difficulties primarily in handwriting accuracy and fluency (Berninger, 2009). They may also have spelling difficulties and problems producing legible and correctly aligned written numerals in mathematics (Berninger, 2009). The OWL-LD subtype is characterized by problems with language comprehension and expression. Children with a history of communication disorder, for example, would be expected to fit this profile of WD. Writing problems mainly affect text generation, grammar, and punctuation, and the capacity to produce clear, coherent, and organized texts. Some students may also have spelling problems due to the syntactic underpinnings of spelling development (Scott, 2004). Berninger, Richards, and Abbott (2015) recently reported further support for the validity of each subtype from behavioural and neuroimaging evidence. Each of these subtypes and their characteristics can be deduced via the comprehensive assessment process and the associated clinical reasoning illustrated in the case that follows.

Case Presentation

According to the initial referral documents, school file review, interviews with Ethan’s¹ parents, teachers, and with Ethan, writing has always been a challenge. His teachers are concerned with the limited text he produces in the same amount of time as other students and the preponderance of spelling and grammatical errors (e.g., omitting words or forgetting tenses) in what he does produce. Samples of Ethan’s writing were also reviewed. His writing is sometimes difficult to decipher and includes many misspellings and simple vocabulary. Difficulty in deciphering his writing may reflect problems with legibility, a hallmark feature of dysgraphia. Initial background data do not indicate that there is a history of language difficulties or delay and/or co-occurring reading difficulties. There is no indication in his file review or review of prior report cards that Ethan has an RD, although it did state that he sometimes has difficulties following instructions, understanding what is asked on assignments. This information may be indicative of language difficulties. Data will need to be gathered to test this assumption. Ethan has also recently begun to express a dislike for school and has expressed a desire to “drop-out” to his teachers. It seems he is becoming more frustrated and may be reaching a critical point in terms of the value of this assessment and intervention to Ethan’s mental health. Could there be any co-occurring or contributing mental health concerns, such as anxiety or depression? Ethan has just turned 13 and is in Grade 7. He will be entering the last year of middle school next year. His teachers and parents hope that this assessment will shed insight into why writing is so difficult for him and will also inform any intervention approaches that can be implemented prior to his transition to high school in 2 years. Ethan was born at term with a healthy birth weight following an uncomplicated pregnancy and delivery. He met developmental milestones within expected age limits and there is no history of significant illness, injury, or health concerns. There were no early language or communication delays, which may rule out an OWL-LD (subtype). Vision and hearing have both recently been checked, and no difficulties were detected. Ethan lives with his parents and two younger sisters, and family relations are reported to be strong. Ethan’s father was recently laid off from his job as a welder, and there is some financial strain in the family. Ethan’s mother is a preschool teacher. English is the primary language spoken at home. There is a paternal history of dyslexia and a history of learning disorders. Psychosocially, he is described as being in good mental health, although, both parents and his teachers believe that his academic difficulties are taking an emotional toll. Ethan’s marks in language arts over the last 3 years continue to be lower (with C and C− grades) than his performance in math and science (with B+ and B grades), but he recently received his first D in language arts. Despite his academic problems, Ethan is described as a socially competent young man with age-appropriate peer relations and extra-curricular pursuits. There is areported history of some problems learning to read, and a persistent history of difficulties with spelling and writing. Ethan attended learning assistance in grades 2 and 3 to address reading difficulties, which improved with support; however, he has never received a formal assessment, individualized instructional programming, or accommodations. Are there still reading problems? Reports indicated problems developing letter–sound knowledge, sight words, and reading comprehension in relation to peers during the early elementary years, based on criterion-referenced benchmarks. There is nothing else in his previous report cards, or current information from teachers on reading difficulties, although there is some mention of him being a “slow” reader, and also not fully reading or comprehending written instructions. Could Ethan’s writing problems reflect a combined reading–writing disorder? Ethan reportedly avoids writing, and performs markedly better when required to demonstrate his learning orally rather than in writing. Ethan himself reported that writing is the most challenging for him at school and that he finds spelling “tricky.” He says he actually hates writing, even on the computer, and worries about high school and the added expectations to write. He said that he considers himself to be fine at reading, although he said that he does enjoy audio books, or utilizing text-to-talk technology as his eyes get tired. These self-reports do indicate that reading skills may not be consolidated. Vision problems have been ruled out with a recent evaluation. His father indicates that Ethan appears to have low self-esteem and academic self-efficacy, and he is worried about Ethan’s ability to complete high school. Ethan also reportedly has a tendency to avoid novel situations and tasks. In comparison with his literacy skills, math is described as an area of academic strength.

Initial clinical impressions based on the background developmental and educational history have suggested that no general cognitive impairments or intellectual disability exist. There is no history of delay in language or communication, thus initial clinical hypotheses suggest that Ethan’s writing difficulties are likely not due to a language disorder (the OWL-LD subtype). However, there is some history of reading difficulties, which suggest the possibility of a combined reading–writing disorder. Psychosocially, Ethan appears to be more overtly frustrated with his academic difficulties (e.g., his comments that he hates school). His grades have also declined, especially in language arts. At home, the family is experiencing some financial challenges that may be adding to Ethan’s stress in addition to his academic challenges. Based on the analysis of this background data, it is also hypothesized that Ethan is experiencing heightened levels of stress, low academic self-efficacy, and possibly elevated symptoms of anxiety and/or depression.

Assessment Results and Interpretation

Cognitive Functioning

Ethan achieved scores within the average range on the primary composites of the Wechsler Intelligence Scale for Children-5th Edition (WSC-V; PsychCorp, 2014; verbal comprehension, visual spatial, and fluid reasoning), an overall score below average on the working memory composite (18th percentile) and a well below average score on the processing speed composite (2nd percentile) achieving scaled scores of 4 and 5 on the coding and symbol search subtests, respectively. Ethan’s overall cognitive ability as reflected in the full scale score, a composite of his performance across all the primary domains assessed by the WISC-V, was assessed at the 23rd percentile. As there was some history of problems learning to read, the tasks within the naming speed index were also administered due to their predictive utility in identifying reading disabilities. Naming speed is a new secondary index on the WISC-V comprised of naming speed literacy (NSL; naming a series of numbers and letters as quickly as possible) and naming speed quantity (NSQ; naming the quantity of squares inside a series of boxes as quickly as possible). Ethan achieved an overall index score at the 3rd percentile, and there was a statistically and clinically significant difference between his performance on the NSL compared with the NSQ tasks, that is quite rare, occurring in only .9% of the overall WISC-V standardization sample. These results indicate a particular processing deficit in the automaticity with which Ethan can retrieve letter names in memory, a process that is particularly sensitive to reading and written expression skills, and a deficit that is predictive of reading disabilities. This data provide the first evidence on the possible co-occurrence of reading problems along with writing difficulties; thus, Ethan’s profile may more clearly fit that of the dyslexic writer. Graphomotor and working memory difficulties were also evident. The fact that Ethan’s language comprehension skills are on par with his peers tends to rule out the OWL-LD subtype, although further language assessment will be conducted to augment this hypothesis. Given the graphomotor difficulties, dysgraphia cannot be ruled out yet, but the evidence from the naming speed index does lead to a greater possibility of a combined writing and RD (dyslexia), rather than a writing-specific (dysgraphic) disorder.

Academic Functioning

Consistent with referral concerns, Ethan’s overall written expression skills were assessed below age-expectations at the 6th percentile on the Wechsler Individual Achievement Test-3rd Edition; (WIAT-III; PsychCorp, 2009). He completed several writing tasks. Spelling was assessed by a dictated spelling task of increasingly more difficult word spellings. Ethan achieved a score well below age-expectations on this task at the 4th percentile. Ethan also wrote sentences (sentence composition) by either combining two or three sentences into one sentence (sentence combining) or by constructing his own sentence using a target word (sentence building). Although his overall performance was within the average range at the 27th percentile, he experienced more difficulty constructing sentences than combining them. Finally, Ethan wrote an essay and was evaluated on the quality of the essay based on word count, organization, and theme development. Mechanics and grammar were scored separately and did not factor into the overall score. Ethan’s overall score on the quality of the essay was below age-expectations at the 10th percentile, as were his scores across mechanics (spelling and grammar) and word count at the 5th and 8th percentile, respectively. During the assessment, Ethan commented, “I hate writing, I’m a terrible writer” and that “I have no idea how to write an essay.” When queried further about his comments, Ethan replied, “I’ve never learned how to write an essay . . . I have no idea where to start—I know my spelling is going to suck and you probably won’t be able to read it anyway.” These comments reflect a negative self-efficacy in relation to writing tasks, as well as some evidence that he might not have been explicitly taught how to compose an essay. The assessment data indicate that Ethan is experiencing difficulties with transcription (handwriting fluency and spelling) that are affecting the text generation and the quality of the writing he produces. Cognitive data also suggest working memory deficits, which compound writing difficulties, as transcription and text generation are coordinated in working memory. The fact that his language skills are well-developed rules out the OWL-LD subtype, but not the dyslexic and dysgraphic subtype of WD each involving handwriting fluency and spelling problems. Despite his comments that his writing would be difficult to read, the essay was legible, but difficult to decipher in places due to spelling and grammatical errors. For example, “carry” was spelled “cary”; “tired” was spelled “tiered”; and one reversal, “different” spelled “bifferent.” He also omitted some articles (“a”) and verbs from sentences. The fact that the essay was legible may rule out the dysgraphic profile. The data confirm a WD featuring spelling and grammatical problems and possible difficulties in handwriting fluency based on the low score achieved on word count. Further assessment of writing fluency and spelling will be important to confirm this hypothesis.

The Writing Fluency Task from the Woodcock-Johnson Tests of Achievement (WJ-III; Woodcock, McGrew, & Mather, 2001) was administered to provide more data in support of fluency problems contributing to Ethan’s writing difficulties (as assessed by word count on the WIAT-III essay task). This task required Ethan to write a simple sentence based on a picture under timed conditions. He achieved a standard score below age-expectations at the 7th percentile on this task. Considered together with the processing speed scores from the WISC-V, the word count score from the WIAT-III, observational data that Ethan tends to not write very much during in-class writing times compared with other students, this data provide evidence consistent with handwriting fluency problems. The Spelling of Sounds subtest from the WJ-III was also administered to assess Ethan’s knowledge of sound–letter connections. This subtest provides important information on Ethan’s graphophomemic processing that may be affecting spelling, and thus, his transcription skills in writing. Ethan achieved a score below age-expectations at the 5th percentile.

Oral language skills were assessed well within age-expectations at the 61st percentile. Ethan completed several tasks on the WIAT-III assessing receptive and expressive vocabulary and language processing skills. His performance across the tasks assessing listening comprehension and oral expression were both within the average range for his age. These findings considered together with the results from the WISC-V verbal subtests and the quality scores achieved on the essay on the WIAT-III suggest that the OWL-LD subtype can be ruled out in Ethan’s case. A language disorder is not co-occurring with a WD, but the question remains: Are there combined reading difficulties?

Ethan’s overall reading skills were assessed well below age-expectations at the 9th and the 8th percentile, respectively, as reflected in both the total reading and reading comprehension and fluency composites of the WIAT-III. These results are consistent with a reported early history of difficulties developing reading skills and also indicate that Ethan’s reading skills fall within a degree of impairment that has gone undetected. Specifically, Ethan’s decoding skills (letter–sound knowledge in reading isolated non-words) and word reading fluency (a combination of accuracy and reading rate in reading passages) all fell well below age-expectations. The particular profile of assessed word-level reading skills deficits and spelling problems are indicative of dyslexia and provide strong data in support of a combined reading and WD. Processing deficits in accessing name codes in memory (naming speed for letters and digits as assessed on the WISC-V), a predictor for reading disabilities, were also found. Ethan’s writing skills are consistent with the profile of dyslexia, with persistent word-level difficulties in reading (i.e., decoding and fluency) and spelling affecting his writing achievement.

In contrast to reading skills, Ethan’s math skills were assessed well within age-expectations at the 50th percentile, consistent with parental and school reports. He computed increasingly more difficult math problems by hand with paper and pencil (numerical operations) and used math concepts and operations to solve practical questions (problem solving) well within the level expected for his age. Ethan commented during the completion of these tasks how much he enjoys math. Math fluency skills were also assessed within age-expectations at the 30th percentile across timed basic addition, subtraction, and multiplication computation tasks. There was no indication of problems with the legibility of written numerals or aligning numerals for computation, ruling out dysgraphia.

Behaviour and Social Emotional Functioning

Assessment of behaviour and social emotional functioning was conducted with the Behavior Assessment System for Children-2nd Edition (BASC-2; Reynolds & Kamphaus, 2004), an integrated system for the differential identification of a variety of emotional and behavioural disorders of children, including depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD), consistent with diagnostic criteria. Parent, teacher, and self-report forms were completed, and validity indices across raters were within acceptable limits. Elevated ratings for problems with anxiety (within the “at risk” range) were indicated across all raters. Ethan’s teacher also noted ratings within the “at risk” range for school problems and learning. Ethan also reported elevated ratings within the “at risk” range for items assessing sense of inadequacy within the Personal Adjustment Scale. For example, he noted “true” that most things are harder for him than for others, that he “never” quite reaches his goals, and that he is “disappointed with his grades.” This data confirm the observations by teachers and parents that Ethan’s learning difficulties are having an impact on his social emotional functioning. The elevated symptoms of anxiety are likely due in part to the financial stressors at home, but also may be related to Ethan’s learning difficulties and his increasing frustration with the writing demands of schoolwork.

Synthesis of Assessment Results and Diagnosis

The degree of impairment in Ethan’s decoding accuracy and fluency is significant and surprising. The fact that these difficulties have gone undetected for so long attests to Ethan’s strong compensatory strategies, which will have required substantial cognitive effort to sustain over the elementary and middle school years. He appears to have compensated, and somehow worked around his significant reading difficulties, but writing is much more difficult to compensate and provides a tangible record of Ethan’s written language disorder. He also fits the age range when most WDs are identified (11-15 years) as writing is relied on more in school to demonstrate learning. Ethan’s increasing frustration with school is expected, given the assessed literacy difficulties and combined reading and WD. The elevated symptoms of anxiety at home and at school suggest a secondary social emotional impact of his learning difficulties. Based on the present assessment, Ethan’s profile is consistent with Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) diagnostic criteria for specific learning disorder with moderate impairment in reading (315.00) for word reading accuracy and reading rate or fluency and with moderate impairment in written expression (315.2) for spelling accuracy and clarity and organization of ideas in writing. There is a substantial and quantifiable difference of more than 1.5 standard deviations between his assessed performance within these areas compared with the mean for same-age peers. The data suggest a combined reading–writing disorder (dyslexia) with primary impairment at the word level for decoding and spelling rather than a writing-specific disorder (dysgraphia) or a combined OWL-LD. An intervention aimed at developing Ethan’s transcription and text generation skills in tandem fit his specific profile of WD.

Intervention Plan

Ethan’s writing difficulties reflect impairments affecting lower level transcription skills and higher level clarity and organization in text generation. Ethan’s self-efficacy and motivation for writing are also extremely low. Ethan’s case presents a good fit to an intervention designed to increase his knowledge and skills in the processes and products of writing (Harris & Graham, 2013; Harris, Graham, Brindle, & Sandmel, 2009; Troia & Graham, 2003) in addition to addressing his attitudes about writing and his regulation of the writing process. The self-regulated strategy development model (SRSD; Harris & Graham, 1996; Mason, Harris, & Graham, 2011) provides the framework for systematic and collaborative writing instruction grounded in consideration of how writing skills develop in typically achieving students and students with writing difficulties and WDs (Harris & Graham, 2013). Using group or individualized delivery, teachers explicitly outline the steps and strategies in the writing process, including planning and organization, sentence construction, summary, revision, and editing (Graham & Perin, 2007; Mason, Kubina, & Taft, 2011). Interventionists also help students to develop and apply positive self-statements about writing (see Project Write website at Vanderbilt University, for more information on SRSD, including lesson plans at http://kc.vanderbilt.edu/projectwrite/tree-support.html).

Mnemonic tools and graphic organizers provide executive strategies to help regulate the cognitive processes in writing (Berninger & Amtmann, 2003), and the SRSD framework is well-validated with the largest treatment effects compared with other writing interventions (Graham & Perin, 2007). For students with learning disabilities in kindergarten through 12th grade, SRSD has been identified as the most effective method of writing strategy instruction (Gillespie & Graham, 2014). When determining the fit between Ethan, the intervention, and those supporting the intervention, we considered the numerous strong points of the SRSD. The first strength is its wide applicability. The SRSD approach can be applied to help students learn how to write within different genres (i.e., informational writing, persuasive writing, and narrative and creative expression) or to master processes like researching, planning, summarizing, composing, and revising (Graham & MacArthur, 1988; Harris, Graham, & Mason, 2003; Mason, Harris, & Graham, 2011). SRSD can also be embedded with specific accommodations like assistive technology, graphic organization software, screen readers, or speech-to-text. This intervention model is also flexible, customizable, and intuitive to grasp for teachers, support staff, and parents.

Implementation

In this case, the school psychologist collaborated with Ethan’s learning assistance teacher, his language arts teacher, and his parents to design an intervention that could be embedded within his class writing projects. Two strategies were paired to scaffold both the writing process (POW; Pick my idea, Organize my notes, Write and say more) and genre expectations (TREE; Topic, Reasons, Explain, Ending) outlined by Mason and colleagues (2011). The instructional approach is recursive, and interventionists may present material in forward sequence, or may review important stages, as needed. After collaborating with the school psychologist to develop the instructional and assessment design, the learning assistance teacher will be working with a group of four students (including Ethan), all identified as requiring support in writing. A checklist was also collaboratively developed by the learning assistance teacher and the school psychologist to evaluate treatment fidelity. Each session will end with the completion of the checklist by the learning assistance teacher, and notes and observations will be added informing any need to diverge from the delivery of the instruction as intended. The intervention included the following steps:

Develop background knowledge. Evaluate prior knowledge about lesson content, introduce the POW, and TREE strategies.

Discuss it. Engage in conversation about the practices of good writers and features of good writing. Discuss the purpose of the POW and TREE strategies.

Model it. Model how to use the strategies and the process of completing a project from start to finish using POW and TREE.

Memorize it. Using the tools and mnemonic aids, help Ethan to memorize the POW and TREE strategies and the purpose of each part.

Support it. Provide direct, explicit instruction in use of the strategies and self-regulatory processes in the intervention material, gradually fading support as Ethan masters the components.

Independent performance. Work toward having Ethan use the POW and TREE strategies to complete projects from start to finish without teacher support.

This SRSD intervention will span 12 weeks, in weekly 45-min sessions with the learning assistance teacher, although research suggests the intervention can be delivered in six to nine sessions (e.g., Milford & Harrison, 2010) with comparable treatment efficacy (e.g., Harris & Graham, 1999). Evaluation will be based on three baseline probes and 12 intervention probes (i.e., short paragraphs written during SRSD instruction) scored across textual elements produced in each prompt (TREE) based on the rubric used by Hoover, Kubina, and Mason (2012) in their study using POW and TREE with adolescents. Correct–incorrect word sequences (CIWS) will also recorded (see Hosp, Hosp, & Howell, 2006) to investigate the accuracy of spelling, punctuation, capitalization, grammar, and semantics. Scoring of each prompt takes less than 10 min, and the learning assistance teacher will graph results with Ethan on a weekly basis. Ethan’s mother will review the mnemonics and help Ethan to memorize and review the POW and TREE stages over the weekends. Ethan’s language arts teacher will review the strategy components and their relation to writing activities within the classroom. A card will also be laminated with the mnemonics and their respective activities for Ethan’s easy reference at his desk and a copy will also be uploaded to his smart phone.

Conclusion

The present case has highlighted a multimodal assessment approach to inform intervention for WD situated within a contemporary scientist–practitioner framework (e.g., Huber, 2007). Embedded within the clinical decision-making process, this framework guides the recursive and iterative activities from referral question, initial hypotheses, collection of assessment data, interpretation, syntheses, and intervention planning and implementation. At each step, this process is informed by clinical acumen, sensitivity to the client’s milieu, and an in-depth knowledge on current theory and research relevant to the particular case, the presenting problem, and to specific interventions. Ethan’s particular case reflected a combined reading and WD, rather than a dysgraphic or OWL disorder, based on Berninger’s (2009) classification. The RD and its severity had gone undetected in Ethan’s developmental history, and he was experiencing secondary internalizing behavioural difficulties. Intervention targeting transcription and text generation via an explicit structure provided for writing—modeled and scaffolded within the context of the SRSD framework—linked the disorder to current theory and research on effective intervention to be implemented within the school context.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Gina L. Harrison is an associate professor and registered psychologist in the Department of Educational Psychology and Leadership Studies at the University of Victoria. She teaches graduate and undergraduate courses in assessment and intervention for special educators and pre-service teachers. Her research focuses on the cognitive, neurocognitive, and linguistic underpinnings of written language disorders to inform assessment and intervention.

Kelly L. McManus completed her MA in educational psychology in 2014. Her thesis examined the role of talk-to-text technology embedded within the framework of self-regulated strategy development (SRSD) intervention for university students with learning disabilities. She is currently an instructor within the Learning Strategies Program at the University of Victoria that provides instructional support to students with learning disabilities on campus.

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