harnessing individual variability to improve …...proust and the squid. underlying cause will...

Dr.JoannaChristodouloujac765@mail.harvard.edu

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HarnessingIndividualVariabilitytoImproveEducationalOutcomes:

CaseStudiesandInterventions

JoannaA.Christodoulou

MGHInstituteofHealthProfessions

jac765@mail.harvard.edu

Dr.JoannaChristodouloujac765@mail.harvard.edu

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DefiningDyslexia• What is the basis? Neurobiological in origin• What are the main features? Difficulties in accurate and/or

fluent word recognition and by poor spelling and decoding abilities

• Why? Difficulty with the sounds of language (phonology)• What else? Average or higher cognitive skills• What else? Reading comprehension, reduced reading

experience • What else can contribute to reading issues? Exclusion of

cultural, educational, environmental, or other disabilities• Can you tell from a brain scan? No

(Lyon et al., 2003)

LearningDisabilities

ReadingDisabilities

Dyslexia

ContextualizingReadingDifficulties

ReadingComprehensionImpairment

Dr.JoannaChristodouloujac765@mail.harvard.edu

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Whystudywhy?

Wolf, M. (2007). Proust and the Squid.

Underlyingcausewilldetermineprognosis

ManypathstoReadingDifficulty

• Decoding

• Fluency

• Strategiesforcomprehension

• Backgroundknowledge

• Multi-LanguageLearners

• Taskdemands

Goal+Learner+Context

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Fletcher,2007

Spoken&Written LanguageRelationships

Receptive Expressive

Auditory

Visual

Listening Speaking

WritingReading

ModifiedfromDorisJohnson

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SimpleViewofReading

• DecodingxListeningComprehension=ReadingComprehension

• Linkbetweenreadingcomprehensionanddecodingdecreaseovertime

• Linkbetweenreadingcomprehensionandlisteningcomprehensionincreaseovertime

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PROCESSES INVOLVED IN WRITTEN LANGUAGE

Word Identification/Spelling

Orthographic Processing Phonological Processing (Letter Processing) (Sound Processing)

Attention Orthographic/Phonological Association Executive Function Visual Motor/ Memory Oral Motor

Automaticity Fluency

Comprehension/Expression

Syntax Morphology Semantics Discourse Pragmatics Literal Conversation Inferential Narrative Applied Expository

Some Other Factors Affecting Reading/Written Expression Intellectual Functioning Background Experience ESL Features of the Text Educational Opportunity Motivation/Emotional Stage of Reading Pamela Hook, Ph.D., 2010

SingleversusMultipleDeficits

• Cognitivesubtypes

• Equifinality andEquipotentiality

• Multi-variate continuum

• Relativeversusabsoluteperformance

(Pennington,2006)

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MagnocellularCerebellar

Motor Visual

Visual-SpatialAttention

Auditory

Phonology

PhonologicalMemory

PhonologicalAwareness

RhythmicProcessing

RapidTemporalProcessing

Anchoring

PerceptualLearning

ProcessingSpeed?

NamingSpeed

RapidNaming

TheoreticalDeficitFrameworksforDyslexia

SingleWordReadingDifficulty

Level: Neuro

Level: Cognitive

Level:Behavioral

DoubleDeficitHypothesis

(Ramusetal.,2003)

DeficitProfilesAmongAdultswithDyslexia

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Highlights• Generalreadingdifficultieshavemanycauses

• Thesignatureofspecific readingdifficultiesisthattheyare ‘unexpected�

• ThemostreadilyidentifiableSRDisdyslexia,aspecificdifficultywithphonologicalprocessing

• Sourcesofreadingcomprehensionfailurearemulti-facetedandinteractwiththetextcharacteristicsandcontextforreading

• Caveat:labelsareproductsofcultureandtime

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The Reading Brain

(Wolf, 2007)

3CoreReadingBrainNetworks

Posterior:VentralNetwork

AnteriorNetwork

Posterior:DorsalNetwork

Motorproduction,processingunfamiliarwords

Supportsdecodingskills

Supportsword

recognition

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CharacteristicsofDevelopmentalDyslexia

Posterior:VentralNetwork

AnteriorNetwork

Posterior:DorsalNetwork

• Relativelymoreactivationinthefrontal/anteriorsystem

• Relativelyless activationinback/posteriorsystems• Activationofsimilarregionsintherighthemisphere(Brunswick,1999,Paulesu etal.2001;Rumseyetal.,1992,1997;Shaywitz etal.,1998,2002;Simos,Breier,Fletcher,Bergman,&Papanicolaou,2000;Shaywitz etal.,2002;Simos,Papanicolaou,etal.,2000)

Intervention:Brain&BehaviorChanges

• Brainnetworksrecruitedforreadingareadaptableduringdevelopmentandmodifiableinstrugglingreaders

• Plasticityofthereadingbrainacrossreaderages

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Task: Word repetition or sound deletion

(Eden et al., 2004)

Task: Word repetition or sound deletion

Increased activation in parietal and phonological regions

Increased frontal regions

Decreased activation in left of the occipitotemporalcortex (shift from visual to phonological strategies)

(Eden et al., 2004)

DyslexicInterventionGroup

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NewResearch:SummerReading&StrugglingReaders

• Whatisthenatureofsummerreadingoutcomesforyoungstrugglingreaders?

• Whatistheimpactofsummerinterventionforyoungstrugglingreaders?

Collaborators:JohnGabrieli;JackMurtagh;KellyHalverson;AbigailCyr; PamelaHook; T.Guarino;PatriciaChang

SummerTimeAdventuresinReading&Teaching(STARTStudy)

• Participants:– Ages6-9

– Completinggrade1or2

• Recruitedfromcommunity

• RandomizedControlTrial(RCT)– StrugglingReaders

• InterventionGroup

• WaitingControlGroup

(Christodoulouetal.,2017)

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SummerTimeAdventuresinReading&Teaching(STARTStudy)

• TreatmentGroup

• Instruction:4hoursx5daysx6weeks– Providedatnocost

– Minimumof100hours

– Academicsummermonths

– Groupsof3-5children

– Lindamood-Bellteachingstaff

• Program:Lindamood-BellSeeingStars

(Christodoulouetal.,2017)

SeeingStars:SymbolImageryforFluency,Orthography,SightWords,andSpelling

• Orthographicandvisualprocessingtraining,andconsequentlyphonologicaltraining

• Visualize:Letters

SyllablesWords

Connectedtext(Semanticinformation)

• Justasthestarsarepartsofthesky,lettersarepartsofwords

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Lindamood-BellSymbolImageryTest

UntimedWordReading(WRMTWordIdentification)

UntimedPseudowordReading(WRMTWord

Attack)

Stan

dardScoreDifferen

ce(P

ost-

Pre)

SummerSlideintheNo-TreatmentGroupSummerGlideintheTreatmentGroup

TreatmentDyslexicDifference

No-TreatmentDyslexicDifference

(Christodoulouetal.,2017)

Intervention-Difference

NoIntervention-Difference

-15

-10

-5

0

5

10

15

Chan

geScores(Po

st-Pre)

InterventionGroup

Non-InterventionGroup

InterventionEffectsExample:Schoolyearvs.Summer

TypicalInterventionStudyOutcomes

SummerStudyOutcomes

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KeyFindings

• Directevidenceforwideningdifferencesbetweenstudentswithreadingdifficultieswhodoanddonotreceiveintensivesummerreadinginstruction

• Convergencewithstudiesofothervulnerablestudentpopulationsforsummerreadingoutcomes

(Christodoulouetal.,2017)

Implications

• Informourdefinitionofasuccessfulintervention

• Preventionofacademicsummerslide/regression

• Improvementofoutcomes

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NewResearch:SummerReading&SES

• Howdoessocioeconomicstatusrelatetoliteracyskills&responsetosummerreadingintervention?

Collaborators:RachelRomeo(supportedbyNIH5T32DC000038);JohnGabrieli;KellyHalverson; AbigailCyr; JackMurtagh;PatriciaChang;PamelaHook

SocioeconomicStatus(SES)“Anindividual'saccesstoeconomicandsocialresources,

aswellasthebenefitsandsocialstandingthatcomefromtheseresources;oftenmeasuredbyeducationalattainment, income,and/or

occupation.”

• Strongpredictorofacademicachievementandcognitiveskillinchildhood&throughoutlife(Bradley&Corwyn,2002)

• “Achievementgap”growswithage(Lee&Burkam,2002)

• Disproportionateeffectonlanguageandliteracyskills(Nobleetal.,2005;Nobleetal.,2012)

(Romeo,Christodoulou,etal.,2017)

Dr.JoannaChristodouloujac765@mail.harvard.edu

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SES&ReadingDisability• Low-incomestudentshaveadisproportionatelyhigherrateofRDdiagnosis(Shifrer etal.,2010;Fluss etal.,2009)

• StudiesofSES&cognitionaretypicallyconductedon“typicallydeveloping”childrenwithscoresintheaveragerange.

• StudiesofRDaretypicallyconductedonmid-to-high-SESconveniencesamples.

50%oflow-SESchildrenreadbelowabasiclevelvs.21%ofhigher-SESchildren(NAEP,2007)

“Decreasedaccesstoresourcesmayamplifycognitiveriskfactorsforpoordecoding”(Nobleetal.,2006)

(Romeo,Christodoulou,etal.,2017)

SocioeconomicStatus&Language

• Strongpredictorofbrainstructure,withadisproportionateeffectonthecanonical“languageareas”(Raizada etal.,2008;Nobleetal.,2012)

– Todate,thesestudieshavelargelybeendonein“typically”developingreaders

(Nobleetal.,2012)

Dr.JoannaChristodouloujac765@mail.harvard.edu

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ReadingDisability

• Structuralbraindifferencesinclude:– Reducedgreymatterinlefttemporo-parietalcorticalregions(Hoeft etal.,2007;Richlan etal,2012)

– Reducedcerebralwhitematterinthe“readingpathway”(leftarcuatefasciculus) (Vandermosten etal.,2012)

CorticalThickness

pial surface• Shortest distance between

white and pial surfaces.• 1-5mm in healthy subjects

SlidebytheFreesurfer DevelopmentTeamatMGH

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RelationofSEStoCorticalThicknessatPre-Test

(Romeo,Christodoulou,etal.,2017)

SummaryofResults

• DoesthebrainstructureofstudentswithreadingdisabilityvarybySES?– Yes,SESpredictsthethicknessandvolumeofareasincludingkeyreading

andlanguageregions.

– ThisextendstraditionalSESbrainstructureresultstoaclinicalpopulation(withdeficitsintheneurocognitiveareasmostaffectedbySES).

(Romeo,Christodoulou,etal.,2017)

Dr.JoannaChristodouloujac765@mail.harvard.edu

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DifferencesBetweenChildrenWhoRespondedMoreorLesstoIntervention

• LowerSESandlowerreadingpredictedgreaterimprovement(controllingforpre-test)

(Romeo,Christodoulou,etal.,2017)

DifferencesBetweenChildrenWhoRespondedMoreorLesstoIntervention

• Nosignificantdifferencesinthicknesschangesbetweentheinterventionandwaitingcontrolgroups,*only*withininterventiongroup

• Respondersexhibitedsignificantlygreaterthickeningthannon-responders

• Leftmiddletemporalcluster

– responders’corticesthickened (1%gain)– non-responders’corticesthinned (0.37%loss)– waitingcontrolgrouponaveragethinned(0.26%loss)

(Romeo,Christodoulou,etal.,2017)

Dr.JoannaChristodouloujac765@mail.harvard.edu

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SummaryofResults

• ArethereSES-relateddifferencesinchildren’sresponsetoreadinginterventionatthelevelofbehaviorand/orbrain?– Yes,morelower-SESchildrenexhibitedimprovementthanhigher-SESpeers,evenwhencontrollingforinitialscores.

– Lower-SESchildrenalsoexhibitedgreatercorticalthicknessgrowthinanauditoryprocessingareanearWernicke’sarea.

– Thissuggeststhatintensivereadinginterventionmightbeevenmoreeffectivefortheseduallyat-riskchildren(especiallyinthesummer).

(Romeo,Christodoulou,etal.,2017)

SummaryofFindings

• NoveldemonstrationthatamongagroupofchildrenwithRD,higherSESwasassociatedwiththickercortexinmultipleneocorticalregionsassociatedwithlanguageandreading

• Despitenooverallcorticaldifferencesbetweeninterventionvs non,childrenwhorespondedtointerventionexhibitedpre-to-postthickeningofcorticalareas

• Childrenfromlower-SESfamiliesandchildrenwithmoresevereRDweremorelikelytobenefitfromintervention,bothbehaviorallyandneurally.

Dr.JoannaChristodouloujac765@mail.harvard.edu

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PredictingReadingOutcomeswithNeuroimaging

• 25childrenwithdyslexia• 20typicalreaders

• Predictreadingovertime:age14à16.5

• fMRIRhymetask

(Hoeft et al., 2010, PNAS)

baitgate

pricemiss

PredictingReadingOutcomeswithNeuroimaging

• Neuroimaging(70-90%)vs.Behavioral(@chance,50%)

– Greateractivationattime1intherightfrontalregionpredicted

readingimprovement2.5yearslater

• MoreactivationofRightIFGattime1predictedbetterreading

outcomes

(Hoeft et al., 2010, PNAS)

Dr.JoannaChristodouloujac765@mail.harvard.edu

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ContributionsofNeuroscience

• Brainimagingcancurrently:– Continuetoinformourunderstandingofbrainplasticityinresponsetointervention

– Revealmechanismsunderlyingbehavioraltrajectories

– Demonstratebraincorrelatesforbehavioralchanges

• Brainimaginghasthepotentialto:– Anticipatewhowillbenefitfromwhichintervention

– Identifybehavioralandbraincharacteristicspredictingresponsetointervention

ParticipantsandtheirfamiliesNationalInstitutesofHealth/NationalInstituteofChildHealthandHuman

DevelopmentFacultyResearchFellowship,MGHInstituteofHealthProfessions

ThePeterandElizabethC.TowerFoundationGeorgeE.BurchFellowship,SmithsonianInstitutionWilliamF.MiltonFund,HarvardMedicalSchool

PrivateDonors

Acknowledgements

Contact:jac765@mail.harvard.edu

Dr.JoannaChristodouloujac765@mail.harvard.edu

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Wherecanyoulearnmore?

• BEAMwebsite:www.mghihp.edu/BEAM

• http://scholar.harvard.edu/joanna/pages/resources

• InternationalDyslexiaAssociation:www.eida.org

• MAIDABranch:www.ma.dyslexiaida.org

• www.Understood.org

JoinourresearchattheBEAMLab

• Emailus:BEAMstudies@gmail.com

• FindusonFaceBook:www.facebook.com/BEAMChristodoulou

• Enrollinourstudies:http://bit.ly/BEAMstudies