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Interventions to improve mathematical outcomes for children
with dyscalculia (Protocol)

Furlong M, McLoughlin F, McGilloway S, Butterworth B

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This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
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Library 2015, Issue 3

http://www.thecochranelibrary.com

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol)

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

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REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) i

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Interventions to improve mathematical outcomes for children

with dyscalculia

Mairead Furlong1 , Fergal McLoughlin2 , Sinead McGilloway1 , Brian Butterworth3

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1 Department of Psychology, National University of Ireland Maynooth, Maynooth, Ireland. 2 Health Service Executive (HSE) in

Dublin/Mid Leinster, Mullingar, Ireland. 3 Institute of Cognitive Neuroscience, Department of Psychology, University College London,

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London, UK

Contact address: Mairead Furlong, Department of Psychology, National University of Ireland Maynooth, North Campus, John Hume
Building, Maynooth, Co Kildare, Ireland. Mairead.M.Furlong@nuim.ie. mmm_furlong@hotmail.com.

Editorial group: Cochrane Developmental, Psychosocial and Learning Problems Group.

Publication status and date: New, published in Issue 3, 2015.

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Citation: Furlong M, McLoughlin F, McGilloway S, Butterworth B. Interventions to improve mathematical outcomes for children with
dyscalculia. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CDXXXXXX. DOI: 10.1002/14651858.CDXXXXXX.

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:
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The objective of this review is to examine the effectiveness of interventions for children with dyscalculia in improving mathematical
performance compared to a control group of no treatment, waiting list, standard schooling, placebo or other treatment.
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BACKGROUND However, the specificity clause has recently been removed in order
to better represent the heterogeneity of the disorder and to im-
prove the clinical utility of DSM diagnoses (Kaufmann 2012; APA
2013). Therefore, dyscalculia is currently understood to involve
Description of the condition
three subtypes: (1) a specific and isolated disorder of mathematics;
Arithmetic is of prime importance in everyday life, and is necessary (2) a mathematics impairment in the context of deficiencies in
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for simple but essential tasks such as counting, reading the clock, other non-numerical cognition (e.g. a general learning disability);
and for budgeting time and money resources. Moreover, numer- and (3) dyscalculia with comorbid disorders (e.g. attention-deficit
ical competency is related to longer-term educational and occu- hyperactivity disorder [ADHD] and dyslexia) (Kaufmann 2012).
pational outcomes, as well as to the economic status of countries Dyscalculia (DC) is as common in girls as in boys, and is a brain-
(Fuchs 2009; Gross 2009). However, research indicates that be- based disorder, with the left parieto-temporal sulcus being of par-
tween 3-6.5% of children fail to achieve competency in basic stan- ticular significance (Molko 2003; Butterworth 2010; Kaufmann
dard mathematics, such as within numerical operations (addition, 2011). Mathematical difficulties appear to have an early onset
subtraction, multiplication and division) and/or within arithmetic (Schopman 1996) and, unless specifically treated, will persist into
reasoning (Hein 2000; Butterworth 2011). Mathematical disor- late adolescence and adulthood (Shalev 2005; Butterworth 2011;
ders, also called dyscalculia, have typically been defined as a spe- Gerber 2012). Impairments in working memory for numerical in-
cific and isolated impairment in numeracy despite normal intelli- formation, visuospatial skills and/or auditory-perceptual abilities
gence and scholastic opportunity (APA 2000; WHO 1992/2007).
Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 1
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
all appear to be implicated in the disorder (Rourke 1997; Rosselli
2006). Comorbidity with ADHD and dyslexia occurs in approxi-
mately one quarter of cases (Ramaa 2002), although comorbidity
with dyslexia appears to produce the most profound impairments
when compared to those with DC alone, or those with DC and
ADHD (Shalev 1997). Moreover, children with dyscalculia often
suffer severe emotional distress because they perform poorly in
school, which can lead to mathematics anxiety and school phobia
(Krinzinger 2006; Kaufmann 2012).
Although the prevalence of DC is comparable to the incidence
of dyslexia, children with DC are often not diagnosed or treated
properly due to a persistent lack of knowledge about the disor-
der (Dowker 2004). This may be linked, in part, to the ‘hidden’
nature of specific DC as teachers and parents may fail to under-
stand that someone with ’normal’ intelligence may suffer from an
isolated disorder of arithmetic skills (Kaufmann 2012). Further-
more, until recently, the study of mathematical difficulties was rel-
atively neglected; for instance, between 1996 and 2005, the ratio
of studies on reading disabilities to mathematic disabilities was 5:
1. This was a dramatic improvement over the ratio of 16:1 in the
prior decade (Gersten 2009). However, in recent years, a growing
interest in child numeracy has led to the development of a range w
of different interventions to treat DC, with a particular emphasis
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on educational interventions that teach specific techniques to im-
prove mathematical competencies (Shalev 2004). Early interven-
tion is critical to prevent a life-course of suffering and secondary
emotional and behavioural problems.
Description of the intervention
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The treatment of children and adolescents with dyscalculia is com-
plex due to the heterogeneity of the disorder and the comorbid
disorders often associated with it (Kaufmann 2012). Ideally, treat-
ment for dyscalculia should address the multiple facets of the disor-
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der while focusing on educational interventions to improve num-
ber perception and arithmetic concepts (Shalev 2004).
Therefore, eligible interventions will include any intervention
(whether educational, psychotherapeutic, pharmacological or
non-invasive brain stimulation) that screened children for dyscal-
culia and measured their mathematical competencies. Compara-
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tors will include standard schooling in mathematics, wait-list con-
trol, placebo-controlled groups, no treatment or other treatment.
Educational interventions that specifically target mathematical
performance typically involve several components including: di-
rect, explicit instruction; use of cognitive heuristics/strategies; stu-
dent verbalisations of their mathematical reasoning; using visual
representations while solving problems; provision of a range and
sequence of examples; repeated practice; and corrective feedback
(Kroesbergen 2003; Gersten 2009). Examples of cognitive strate-
gies include: counting on or back from first summand (e.g. 9 + 3
is solved by counting on 3 from 9); learning complementarity of
addition and subtraction (e.g. a + b = c → c - a = b); estimating
Interventions to improve mathematical outcomes for children with dyscalculia (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
set size; understanding ordinal position (e.g. 5 in 52 means 50
but 5 in 25); and translating between words and digits for quan-
tity (Gersten 2009; Butterworth 2010; Cohen 2013). Neverthe-
less, such interventions may differ from each other with regard
to a number of factors, including: the use of a computer, reme-
dial teaching or peer learning; the size of the groups; the intensity
and duration of the intervention (e.g. ranging from one session of
30 minutes to regular sessions conducted over a 6- or 12-month
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period); the instructional procedures employed;and the age and
grade of students.
Emerging evidence suggests that transcranial electrical stimula-
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tion (TES) may enhance the effectiveness of targeted mathemat-
ics interventions (Cohen 2013). For instance, a small number of
studies have reported improvements in basic numerical skills and
automaticity using TES, including a transfer effect to new mate-
rial, and long-term efficiency in brain functions in the stimulated
brain region (Cohen 2010; Snowball 2013). Results, to date, have
indicated that stimulation needs to be paired with a cognitive-
training intervention and that the timing of stimulation with re-
spect to task performance has important effects (Stagg 2011). TES
involves the delivery of weak electrical currents (e.g.,1-2 mA) via
electrodes, most frequently at the size of 25-35 cm2 , which are
placed on the scalp above the brain area of interest. When the cur-
rent is applied over a short duration (20 min), it passes painlessly
through the scalp and skull and alters spontaneous neural activity
(Fritsch 2010).
Acquisition of non-curricular skills may also be useful for students
with dyscalculia. Examples include arriving prepared for lessons,
meeting deadlines, appropriate school behaviour, following direc-
tions and completing homework assignments. Thus, school/class-
room-based interventions that focus on strengthening these com-
petencies may be helpful in improving arithmetic skills for dyscal-
culic students (Shalev 2004).
Psychotherapy and/or medication may sometimes be necessary
if DC is accompanied by anxiety, depression or ADHD (Shalev
2004;Kaufmann 2012). Little research has examined the effective-
ness of interventions that include pharmacological or psychother-
apeutic components in the treatment of DC. Nevertheless, pre-
liminary evidence indicates that methylphenidate may improve
working memory in children with DC comorbid with ADHD,
although it appears to have little effect on their basic numerical
skills (Grizenko 2006; Rubinsten 2008).
How the intervention might work
This review includes a broad range of intervention strategies in-
volving: targeted mathematics interventions (with or without non-
invasive brain stimulation); classroom-based approaches; pharma-
cology; and psychotherapy. Therefore, a large number of putative
mechanisms are implicated in mediating intervention outcomes.
More detail is provided below.
Mathematics interventions
2
The strategies employed in these interventions (described above)
are believed to develop the physical, visual, and verbal representa-
tions of quantity, i.e. students acquire a sense of the mental num-
ber line (Butterworth 2010; Kaufmann 2012). The mental num-
ber line appears to be of fundamental importance for arithmetical
reasoning and for mental calculation, and extends the semantic
range of the concept of number to a more complex and abstract
level (Kaufmann 2012). In addition, targeted mathematics inter-
duction of disruptive and aggressive behaviour [Wilson 2007]; fol-
lowing directions, staying on task [McGilloway 2012]), which, in
turn, may encourage students to focus their attention on mathe-
matics. Psychotherapy may enable students with DC to develop
effective cognitive and behavioural strategies to address anxieties
about mathematical performance. For instance, the development
of self-efficacy beliefs (e.g. adopting a positive belief that they can
improve their skills with practice) and requesting help from par-

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ventions involve the active engagement of students in mathemati- ents and teacher may reduce mathematics anxiety and improve
cal reasoning, which has been shown to be more effective than pas- numerical competencies (Kaufmann 2012). Pharmacotherapy has
sive communication of the subject (Swanson 2000). Students also been shown to improve attention and working memory in chil-

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appear to develop mathematical competency through verbalisa- dren with DC (Rubinsten 2008), which might potentially enhance
tion of mathematical reasoning, dedicated practice, and receiving their mathematical abilities.
detailed corrective feedback. Verbalisation anchors students’ self-
regulation and encourages them to utilise a step-by-step solution
strategy rather than a more random, impulsive approach (Gersten Why it is important to do this review
2009). Repeated practice appears to foster the automatic recall of
Numerical competency is vital to thrive in a modern economy
learned content, thereby lessening the demand on working mem-
and yet very little is known about how to support students who
ory. This demand is especially high in multi-digit calculations with
suffer from dyscalculia. Most research in the field has focused on
carrying, where interim results must be retained and manipulated
(e.g. adding 87 and 45) (Cohen 2013). Ongoing corrective feed-
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back and the collation of detailed knowledge of performance may
also mediate positive outcomes through positive reinforcement of
the development of targeted arithmetic interventions for children
with mathematical difficulties. However, experts in the area also
recommend the provision of medical and psychotherapeutic treat-
ment if required (Kaufmann 2012). Therefore, the current review
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accurate responses and through goal setting (Gersten 2009). Com-
will also include interventions which comprise psychotherapeutic
puter-based interventions may be particularly useful in this respect
or medical elements.
as they can be designed to adapt for different performance profiles
Previous reviews in the field have examined the effectiveness of spe-
and provide intensive training in a stimulating environment. In
cific arithmetic interventions to improve mathematics skills, and
addition, research suggests that the reward-based nature of such
have reported inconsistent results, with effect sizes ranging from
instruction may act on the dopaminergic system that is involved
-0.44 to above 3 (Xin 1999; Kroesbergen 2003; Gersten 2009;
in plasticity (Lisman 2011).
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Slavin 2009; Codding 2011; Fischer 2013). The inconsistent find-

Transcranial electrical stimulation
ings may be due to the heterogeneity of populations, study de-
TES is generally delivered alongside targeted mathematics inter-
signs, and interventions that were included in these reviews. For
ventions, and therefore it may be difficult to disaggregate the
instance, one review included only typically performing students
mediators of change. Nevertheless, research indicates that the ef-
(Slavin 2009), another included only children with specific DC
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fects of TES are protein-synthesis dependent and are accompanied

(Kroesbergen 2003), while the remaining reviews pooled results
by several mechanisms, including the modifications of intracellu-
across those with specific DC and those with mathematical diffi-
lar cyclic adenosine monophosphate (cAMP) and calcium levels,
culties in the context of general cognitive disabilities (Xin 1999;
brain- derived neurotrophic factor, and activation of adenosine
Gersten 2009; Codding 2011). Furthermore, all but one of these
A1 receptors (Márquez-Ruiz 2012). Therefore, these mechanisms
reviews (Gersten 2009) combined effect sizes across a wide range
share some features with long-term potentiation (Castillo 2011).
of study designs, including: randomised controlled trials (RCTs);
Functional magnetic resonance imaging (FMRI) experiments have
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single-case designs; pre-post (non-controlled) studies; and non-

found that TES can alter local and remote brain activation (Keeser
matched controlled studies. Therefore, included studies were of
2011). Magnetic resonance spectroscopy (MRS) studies found
varying quality, with single case designs notable for producing
change in the local concentration of gamma-aminobutyric acid
particularly elevated effect sizes (Busse 1995), while quasi-exper-
(GABA) and glutamate, which are critically involved in learning
iments may also fail to reproduce experimental results unless the
and memory (Stagg 2009).
assignment mechanism is completely known (Glazerman 2003;
Classroom-based, psychotherapeutic and pharmacological in-
Cook 2008). The review by Gersten 2009 only included RCTs
terventions
and treatment versus treatment designs but effect sizes were pooled
Very little research has investigated the efficacy of these interven-
together. This latter review was also the only one which assessed
tions in the treatment of DC (Kaufmann 2012). Putative mech-
selection or attrition bias within included studies; however no sen-
anisms of classroom-based approaches may involve positive rein-
sitivity analyses were undertaken in order to test the robustness of
forcement of desired non-curricular classroom activities (e.g. re-
the results across areas of risk of bias.

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 3

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
In addition, all but two of the reviews (Kroesbergen 2003; Gersten OBJECTIVES
2009) included only one outcome measure of mathematics skills
The objective of this review is to examine the effectiveness of in-
whereas the research indicates that students with DC may suffer
terventions for children with dyscalculia in improving mathemat-
from difficulties in basic numerical operations or numerical rea-
ical performance compared to a control group of no treatment,
soning or both (Fuchs 2009). Thus, this review will conduct sep-
waiting list, standard schooling, placebo or other treatment.
arate meta-analyses for basic numerical operations, numerical rea-
soning, and more advanced arithmetic (e.g. algebra). The impact
of interventions on precursor skills to mathematical competency

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(e.g. counting, number conservation) will also be examined. The METHODS
current review is also unique in that it will further assess secondary
outcomes associated with dyscalculia, such as emotional and be-

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havioural problems, adverse outcomes and cost effectiveness. Criteria for considering studies for this review
Moreover, this review will explore the moderating impact of pop-
ulation and intervention characteristics on mathematical perfor-
mance. For instance, evidence suggests that children with DC co- Types of studies
morbid with dyslexia, or in combination with more general cog-
Eligible study designs will include randomised, quasi-randomised
nitive disabilities, are more impaired than those with DC alone
and cluster-randomised controlled trials. Cross-over trials will also
or with DC comorbid with ADHD (Shalev 2004; Fuchs 2009;
be included. We will not include single-case designs, pre-post
Butterworth 2010). In addition, younger participants may de-
studies without a control group, non-matched control groups, or
rive more benefit from interventions than older children (Gersten
2009). Furthermore, research indicates that mathematical diffi-
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culties may be related to low socio-economic status (SES), gender,
and to place of residence (e.g. low income countries) (Royer 2007;
groups matched at post-hoc after results were known. Baseline
equivalence of the analytic sample must be demonstrated, or sta-
tistical controls must be used in the analysis to control for any
between-group differences at baseline. Studies which compare two
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Price 2013). Indeed, such inequity variables may reduce access to
similar treatments (e.g. targeted mathematics interventions) with-
appropriate interventions or education. For instance, many less
out a control group will not be included. We will include studies
developed countries lack teachers with mathematical training at
which compare two different treatments although a separate anal-
second level education, and student participation is low, particu-
ysis will be performed when the comparator is another treatment.
larly among females (Anderson 2009). Preliminary evidence also
Costs or cost-effectiveness studies conducted alongside, or sub-
indicates that children of low SES may derive less benefit from a
sequent to RCTs that meet eligibility criteria, will be included
targeted mathematics intervention than children with higher SES
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(Shemilt 2011).
(Siegler 2008; Wilson 2009).
Intervention characteristics that may potentially affect outcomes
include treatment duration and agent of delivery (e.g. teacher- Types of participants
led, peer-assisted, or computerised programme). Identifying the
We will include students aged 7 to 18 years with all subtypes of
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most effective and resource efficient intervention is important, as

DC, i.e. those with isolated DC with normal intelligence, those
such interventions are more likely to be consistently implemented
with DC in the context of wider cognitive disabilities; and those
(Codding 2011). To date, evidence for the relationship between
with DC comorbid with dyslexia, ADHD, or emotional and be-
effect size and training intensity/duration is mixed: two studies
havioural problems. General intelligence will be defined as ‘nor-
found that shorter interventions were more effective (Kroesbergen
mal’ if students score 85 or above on a validated measure of intel-
2003; Gersten 2009), one favoured longer interventions of more
ligence (e.g. the Wechsler scales; Wechsler 2003). Study authors
than 30 sessions (Codding 2011), whereas another reported no
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will be contacted for further information if the level of general

relationship between effect size and treatment duration (Fischer
intelligence is not specified in the article.
2013). Furthermore, it remains unclear to what extent treat-
In addition, we will include students whose mathematical com-
ment agent affects outcomes: a recent review found no relation-
petencies are at a ‘clinical’ or ‘at risk’ level. In accordance with the
ship (Fischer 2013), two studies reported that interventions de-
literature, a ‘clinical’ level will be defined as scoring below the 10
livered by teachers were more effective than computerised pro- th percentile on a standardised mathematics test and being ‘at risk’
grammes or peer-assisted instruction (Kroesbergen 2003; Slavin
will be defined as scoring below the 25th percentile (Moeller 2012).
2009), whereas another review found that interventions involving
An example of a standardised mathematics test is the Weschsler
both computer and staff instruction produced equivalent results
Individual Achievement Test (WIAT-II, Wechsler 2005).
(Xin 1999).
Children must be aged above 7 years as it is normal for some chil-
dren to experience some level of developmental delay in math-
ematical competencies (Fuchs 2009). However, we will include

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 4

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
studies if more than 90 per cent of the students therein are between Electronic searches
7 and 18 years.
We will search the following databases:
Cochrane Library, Cochrane Central Register of Controlled Trials
Types of interventions (CENTRAL)
MEDLINE
We will include any intervention that addresses mathematical per- EMBASE
formance as long as children are screened for dyscalculia and stud- Academic Search Complete

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ies include a measure of mathematical skills at pre- and post-inter- ASSIA (Applied Social Sciences Index and Abstracts)
vention. Studies which do not report a measure of the primary out- CINAHL
come of mathematical skill will not be included in the review. In- Dissertations and Theses Abstracts
terventions will include targeted mathematics interventions, class- ERIC

On
based interventions, non-invasive brain stimulation, pharmaco- metaRegister of Controlled Trials (mRCT)
logical and psychotherapeutic interventions. Proquest Dissertations and Theses,
PsycINFO
Science Citation Index Expanded
Types of outcome measures
Social Science Citation Index
Sociological Abstracts

Primary outcomes Economic sources:

Mathematical skill as measured by:

classification, seriation;
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(i) Precursor arithmetic skills - counting, number conservation,

(ii) Basic numerical operations - addition, subtraction, multipli-

DARE
Econlit
Health Economic Evaluations Database (HEED)
Health Technology Assessments (HTA)
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cation and division; NHS Economic Evaluation Database (NHS EED)
(iii) Numerical reasoning - problem-solving and reasoning from Paediatric Economic Evaluation Database (PEED)
word problems; or No date, publication, geographic or language restrictions will be
(iv) More advanced mathematics - e.g. algebra, calculus. applied to the searches
Medline search strategy
1 Dyscalculia/
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Secondary outcomes 2 Learning Disorders/

Language skills (reading or writing); 3 Developmental Disabilities/
Internalising problems (e.g. anxiety, depression); 4 Intellectual Disability/
Externalising problems (e.g. aggression, defiance); 5 aculculia.ab.
Hyperactivity or attention symptoms; 6 development* dyscalculi*.ab.
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User satisfaction; 7 (learn* n3 (disabilit* or difficult* or problem*)).ab.

Costs and cost-effectiveness data; and 8 (math* n3 (learn* disabilit* or learn* difficult*).ab.
Adverse impact - e.g. increased psychological distress from partic- 9 mld.ab.
ipating in the intervention. 10 (math* n3 (disabilit* or difficult* or disorder* or perform*
Timing of outcomes or competenc* or underachiev* or low perform* or achiev* or
We will conduct separate meta-analyses for outcomes measured at outcome* or operation* or reason* or skill* or educat*)).ab.
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several periods of follow-up: within the first six months, between 11 (numer* n3 (disability* or difficult* or disorder* or perform*
6 to 12 months post-intervention, between 12-24 months post- or competenc* or underachiev* or low perform* or achiev* or
intervention (and longer follow-up points, if such data are avail- outcome* or operation* or reason* or skill* or educat*)).ab.
able). 12 (computation* n3 fluen*).ab.
13 (math* n3 fluen*).ab.
14 (numer* n3 fluen*).ab.
15 Low* numer*.ab.
Search methods for identification of studies 16 mental* retard*.ab.
We will identify studies through key and text word searches of 17 (number* n3 concept*).ab.
electronic databases, as well as searching grey literature (conference 18 or/1-17
papers, unpublished PhD theses, reference lists of other relevant 19 Child/
reviews) and personal communication with experts in the field. 20 Adolescent/

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 5

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
21 child*.ab. Selection of studies
22 adolescen*.ab. Two authors (MF and FM) will independently assess titles and ab-
23 or/19-22 stracts identified through searches in order to determine their po-
24 (math* n3 (train* or intervention* or teach* or instruct* or tential eligibility for inclusion in the review. Any citation deemed
educat*)).ab. potentially relevant by at least one author will be retrieved in full
25 (arithmetic* n3 (train* or intervention* or teach* or instruct* text and, again, will be independently assessed by MF and FM. If
or educat*)).ab. necessary, we will contact study authors to obtain additional infor-
26 (numer* n3 (train* or intervention* or teach* or instruct* or

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mation. We will resolve disagreements by consensus with a third
educat*)).ab. author (SMcG). We will document the specific reasons for exclu-
27 (cognit* n3 (train* or intervention* or teach* or instruct* or sion for each study that might reasonably have been expected to
educat*)).ab. have been included but which did not meet the inclusion criteria.

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28 (educat* n3 intervention*).ab. Studies in other languages for which we cannot obtain translators
29 addition intervention*.ab. will be referred to the editorial base of the CDPLPG.
30 subtraction intervention*.ab.
31 multiplication intervention*.ab.
32 division intervention*.ab. Data extraction and management
33 element* educat*.ab.
Two authors (MF and FM) will extract data independently us-
34 primary educat*.ab.
ing a piloted data extraction form. The authors will extract in-
35 second* educat*.ab.
formation on study design and implementation, setting, sample
36 (comput* n3 (intervention* or program* or instruct*)).ab.
37 digital* n3 intervention*.ab.
38 (school* n3 (intervention* or program* or instruct* or
train*)).ab.
w characteristics, intervention characteristics and outcomes from all
included studies. With regard to costs or cost-effectiveness stud-
ies, MF and FM will independently extract characteristics, such
as: year of study; details of interventions and comparators; study
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39 (classroom*n3 (intervention* or instruct* or train*)).ab.
design; type of economic evaluation; source(s) of resource use;
40 Electric Stimulation/
unit costs; decision making jurisdiction; geographical and organi-
41 transcranial electrical stimulation.ab.
sational setting;analytic perspective; discount rates; and time hori-
42 tes.ab.
zon for both costs and effects. Any differences between review au-
43 non invasive brain stimulation.ab.
thors in data extraction will be resolved by discussion or by arbi-
44 Psychotherapy/
tration with SMcG if agreement cannot be reached.
45 psychotherap*.ab.
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Data will be entered into Review Manager 5.2.11 (RevMan)

46 Pharmacy/
(Review Manager 2012). Where data are not available in the pub-
47 Pharmacology/
lished trial reports, we will contact the authors and ask them to
48 pharmac*.ab.
supply the missing information.
49 methylphenidate.ab.
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50 Clinical Medicine/
51 or/24-50 Assessment of risk of bias in included studies
52 18 and 23 and 51
Review authors (MF and FM) will independently assess the risk of
53 Costs and Cost Analysis/
bias (that is ’high’, ’low’ or ’unclear’) within each included study
54 Econom* or cost* or price* or budget* or resource* or utili?
across the following six domains:
sation.ab.
(1) sequence generation;
55 or/53-54
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(2) allocation concealment;

56 52 and 55
Searching other resources
We will examine the reference lists of included studies and of
reviews in the field in order to find other eligible studies. We will
also contact authors of included studies, as well as experts working
in the area, in order to search for unpublished and ongoing studies.
Data collection and analysis
(3) blinding;
(4) incomplete outcome data;
(5) selective outcome reporting; and
(6) other sources of bias, such as comparability of baseline char-
acteristics between groups and attempts to control for imbalance.
Where judgments differ, additional input will be sought from
SMcG, BB and NH. Missing data on ’risk of bias’ criteria will
be sought from study authors. Judgments will be entered into the
’Risk of bias’ table in RevMan.
In assessing risk of bias in cross-over trials, we will also judge:
• The appropriateness of using a cross-over design

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 6

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • Whether the trial was biased from carry-over effects (e.g.
order or learning effects)
If costs or cost effectiveness studies are included in the re-
view, we will use the ’Drummond checklist’ to critically appraise
the methodological quality of included health economic studies
(Shemilt 2011). MF and FM will assess such quality parameters
independently, with any disagreements being resolved through dis-
If cross-over trials are included, effect sizes should be calculated
from paired analyses using within-participant comparisons. This
evaluates the value of ’measurement on experimental intervention’
(E) minus ’measurement on control intervention’ (C) separately
for each participant. The effect estimate (i.e. mean and standard
error) may be included in a meta-analysis using the generic inverse-
variance method (Higgins 2011). If such paired analyses are not
reported or available, and if we judge there is little likelihood of

ly
cussion. Again, study authors will be contacted for missing infor-
carry-over effects, we will take all measurements from intervention
mation.
E periods and all measurements from intervention C periods and
analyse these as if the trial were a parallel group trial of E versus

On
Measures of treatment effect C. This can lead to a unit of analysis error but is generally judged
as less serious than other unit of analyses errors due to under-
Where outcomes are reported as dichotomous data, we will use the
weighting of the study (Higgins 2011).
risk ratio (RR) with a 95% confidence interval (CI) to summarise
Economic evaluation
results within each study.
Studies will initially be classified according to whether they mea-
Continuous outcomes will be reported, where possible, as mean
sure resource costs or whether or not they calculate an incremental
differences. Where different scales measure the same outcome
cost effectiveness ratio (ICER). An ICER point estimate compares
across studies, standardised mean differences (SMDs) will be used
the costs and consequences of running an intervention relative to
to summarise results within each study. Again, confidence inter-
the costs and consequences of a specified alternative (most com-

w
vals of 95% will be used for individual study data and pooled es-
timates throughout. If reported outcomes have insufficient data,
additional information will be requested from the authors. In ad-
dition, it may be possible to calculate effect sizes within contin-
monly chosen to be the status quo). In circumstances where there
is evidence of little variation in resource or cost use between stud-
ies, it may be regarded as legitimate to
vie
present a pooled estimate. Otherwise, we will clearly present the
uous data through reported t-tests, F-tests, exact p-values, and so
distribution of costs (Shemilt 2011). If a decision is made to con-
forth. Due to expected heterogeneity, a random-effects meta-anal-
duct meta-analyses of resource use or
ysis will be employed.
cost data, this will be supported by a thorough critical appraisal of
If several different instruments measure an outcome within in-
the methods used to derive such estimates within the correspond-
cluded studies, we will obtain a mean effect size and standard er-
ing health economics studies, alongside use of 95% confidence
ror for that outcome within the study. This effect estimate will
intervals and statistical methods to investigate and incorporate be-
re

be entered into the generic inverse variance method in RevMan

tween- study heterogeneity (e.g.I² statistic, Chi² test, random-ef-
(Review Manager 2012), using the effect measure of SMD or RR,
fects models). Cost estimates collected from multiple studies will
as appropriate.
be adjusted to a common currency and price year before these data
In multi-arm studies where several experimental (or control)
are pooled. Careful consideration will be given to the jurisdiction,
groups are eligible for inclusion (e.g. three variants of a targeted
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analytic perspective and time horizon for both costs and effects.
mathematics intervention), we will combine groups to create a
If meta-analyses of resource use or cost data are conducted, a nar-
single pair-wise comparison. However, in order to conduct the
rative summary will be included in the Results section to comment
relevant subgroup analyses (as specified below; e.g. one experi-
on the direction and magnitude of results and their precision. Sim-
mental group is teacher led and another is peer-assisted), it may
ilarly, if two or more health economics studies are included in a
be necessary to include each pair-wise comparison separately for
review, but a decision is taken not to pool resource use and/or cost
each experimental group within the study, but with the sample size
data from these studies, this will be stated in the Methods section
Fo

of shared intervention groups divided out approximately evenly

among the comparisons. This latter approach may incur a unit of
analysis error but it still remains a practical means of performing
approximate investigations of heterogeneity (Higgins 2011).
If studies report multiple measures of the same construct at dif-
ferent points in time, we will conduct separate meta-analyses for
outcomes measured at several periods of follow-up: within the first
six months, between 6 to 12 months post-intervention, between
12-24 months post-intervention (and longer follow-up points, if
such data are available). If within any of these periods, measures
are reported more than once, then a single summary effect will be
obtained within that time period.
(Shemilt 2011).
Unit of analysis issues
If cluster-randomised trials are included, data will be controlled for
clustering using the procedures outlined by Higgins 2011 in the
Cochrane Handbook. When outcome measures are dichotomous,
the number of events and number of participants per trial arm
will be divided by the design effect [1 = (1-m) * r], where m is the
average cluster size and r is the intra-cluster correlation coefficient
(ICC). When outcome measures are continuous, the number of

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 7

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
participants per trial arm will be divided by the design effect, with
the mean values unchanged. To determine the ICC, authors will
use estimates in the primary trials on a study-by-study basis. If
these values are not reported, the authors will use external estimates
of the ICC that are appropriate to each trial context and average
cluster size.
As noted above, a unit of analysis error may occur when conducting
subgroup analyses if more than one pair-wise comparison from the
same study is entered into meta-analysis. Such subgroup analyses
will be interpreted with caution.
In addition, there may be a unit of analysis error if a paired anal-
ysis is not reported within cross-over trials. A common approach
to incorporating cross-over trials in a meta-analysis is to take all
measurements from intervention E periods and all measurements
from intervention C periods and analyse these as if the trial were a
parallel group trial of E versus C. This method may under-weight
the study but some view this type of unit-of-analysis error is less
serious than other types of unit-of-analysis errors (Higgins 2011).
Dealing with missing data
We will assess missing data and dropouts for each included study
and report the number of participants who were included in the
w ical and psychotherapeutic interventions. A separate meta-analysis
vie
final analysis as a proportion of all randomised participants in each
study. We will provide reasons, where known, for missing data in
the ’Risk of bias’ section, as well as details of investigators’ use
of intention-to-treat analysis (where applicable). Authors will be
contacted to supply missing data. If missing data are not available
in studies, a sensitivity analysis will be conducted to assess potential
bias in the analysis.
re
Assessment of heterogeneity
We will assess clinical heterogeneity by comparing the distribution
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of important factors such as participant demographics, type of in-
tervention and control comparators, quality of trials (randomisa-
tion, blinding, losses to follow-up) and outcomes measured across
studies. Statistical heterogeneity will be assessed visually and by
examining the I² statistic, a quantity which describes the approxi-
mate proportion of variation in point estimates that is due to het-
Fo
erogeneity rather than sampling error. With the I² statistic, 30%
to 60% may be interpreted as moderate heterogeneity; 50% to
90% as substantial heterogeneity; and 75% to 100% as consid-
erable heterogeneity. This will be supplemented by the Chi² test,
where a P value < 0.05 indicates heterogeneity of treatment effects.
Sensitivity and subgroup analyses will also be used to investigate
any possible sources of heterogeneity.
For the economic evaluations, careful attention will be given to
whether the metric in question has equivalent meaning across stud-
ies before data are pooled (Shemilt 2011). Cost estimates collected
from multiple studies will be adjusted to a common currency us-
ing purchasing power parity and price year before these data are
Interventions to improve mathematical outcomes for children with dyscalculia (Protocol)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
pooled. Between-study heterogeneity will be assessed using the
Chi² test, the I²statistic and random-effects models.
Assessment of reporting biases
Funnel plots will be drawn, where possible, to investigate any re-
lationship between effect size and standard error. Such a relation-
ship could be due to publication or related biases, or due to sys-
ly
tematic differences between small and large studies. Where such a
relationship is identified, the experimental diversity of the studies
will be further examined as a possible explanation (Egger 1997).
On
Data synthesis
We will perform meta-analysis where studies have sufficiently sim-
ilar participants, interventions, comparators and outcome mea-
sures. We will analyse outcome data separately for the various cat-
egories of intervention: targeted mathematics intervention, class-
based intervention, non-invasive brain stimulation, pharmacolog-
will be conducted where an intervention represents a combination
of these categories. Where a comparator is another intervention,
we will conduct a separate meta-analysis. In addition, separate
meta-analyses will be performed for each type of mathematical
skill noted in the primary outcome (i.e. precursor arithmetic skills,
basic numerical operations, numerical reasoning, advanced math-
ematics such as algebra and calculus). Furthermore, as noted ear-
lier, separate meta-analyses will be conducted for outcomes mea-
sured at different time points.
In carrying out meta-analysis, the weight given to each study is the
inverse of the variance so that more weight will be given to more
precise estimates (from larger studies with more events).
Subgroup analysis and investigation of heterogeneity
If sufficient studies are found or if information is available, we will
examine the following subgroups:
• Effect of child’s age on outcomes (i.e. compare children
aged between 7-12 years with those between 13-18 years)
• Effect of subtype of DC on outcomes (i.e. compare isolated
DC, DC with general cognitive impairments, and DC comorbid
with ADHD, dyslexia and emotional and behavioural problems)
• Efffect of treatment agent on outcomes (i.e. compare
teacher led, peer-assisted, computerised programme, and teacher
in combination with computer programme)
• Effect of treatment duration on outcomes (i.e. compare
interventions comprising 0-10 hours versus those with 10-20
hours, 20-30 hours or more than 30 hours)
• Effect of inequity variables on outcomes (i.e. compare
outcomes for gender, socioeconomic status, and comparison of
low-, middle- and high-income countries)
8
Sensitivity analysis
Sensitivity analyses will be performed to evaluate the robustness of
the results across various components of methodological quality,
including:
• Removing quasi-randomised, cluster randomised, and cross
over trials
• Removing studies without blind assessment of outcomes
• Exclusion of studies with attrition rates larger than 20% or
which did not conduct an intention-to-treat analysis
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ACKNOWLEDGEMENTS
We would like to convey a special note of thanks to Professor
Sandra Jo Wilson (Editor of Campbell’s Education Coordinating
Group) for her helpful suggestions and advice in writing this pro-
tocol. We also thank Sean Grant (former managing editor) and
Carlton Fong (managing editor) for their support. In addition, we
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and managing editor (Joanne Wilson) of the Cochrane DPLPG
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∗
Indicates the major publication for the study

CONTRIBUTIONS OF AUTHORS
Mairead Furlong (MF) wrote the text of the protocol, with feedback from the rest of the review team (Fergal McLoughlin [FM], Sinead
McGilloway [SMcG], Brian Butterworth [BB] and Noirin Hayes [NH]). All team members were involved in developing the search
strategy, and will liaise with the information retrieval specialist at Campbell in searching for studies. MF and FM will independently
select trials and extract data from them, with SMcG arbitrating in the event of a dispute. MF will conduct the analysis, with all members
of the team being involved in interpretation. MF will draft the text of the final review, with input from all of the team. MF will be
responsible for keeping the review up to date.

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 11

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 DECLARATIONS OF INTEREST
Professor Butterworth’s research resides primarily in the investigation of the neural basis of mathematical cognition. However, he has
recently been involved in the development of two digital interventions for dyscalculia. These are called Dots2Track and Dots2Digits and
are designed to help the learner discern the relationship between the numerosity in a dot pattern and its representation as a digit, and
on a number line (Butterworth 2010). The other four authors have no known conflicts of interest to report.

ly
SOURCES OF SUPPORT

Internal sources

On
• Department of Psychology, National University of Ireland Maynooth, Ireland.

External sources
• No sources of support supplied

w
vie
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Fo

Interventions to improve mathematical outcomes for children with dyscalculia (Protocol) 12

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