Learning Disabilities Research & Practice, 35(3), 150–164


C 2020 The Division for Learning Disabilities of the Council for Exceptional Children

DOI: 10.1111/ldrp.12228

A Multifactorial Model of Dyslexia: Evidence from Executive Functions

and Phonological-based Treatments
Angela Pasqualotto and Paola Venuti
Department of Psychology and Cognitive Science, University of Trento

In this research, we examined the responsiveness to treatment in 49 Italian children with

Dyslexia. In part A, we compare the efficacy of a phonological-based treatment (Ph-T) with a
cognitive training of executive functions (CT). In part B, we investigate whether a sequential
treatment (CT+Ph-T) has a larger remedial effect compared to the pure phonological-based
treatment (Ph-T + Ph-T). Results after 24 hours of treatment showed significant improvements
in the executive functions (EFs) for the sequential group only. Considering reading accuracy,
children benefited significantly from both treatments; however, only the sequential group sig-
nificantly improved in reading speed. Crucially, the reading gains appeared to be related to im-
provements in the EFs, supporting a multifactorial model of this disorder. The aforementioned
findings suggest that the combination of cognitive training of EFs with a phonological-based
treatment can be used effectively in rehabilitating dyslexia.

Even though considerable effort has been expended trying
to identify the proximal cause of dyslexia, no single solu-
tion has been agreed upon to address this disorder. On the
cognitive level, the most compelling explanation is that chil-
dren with developmental dyslexia (DD) have difficulties in
processing the phonological features of words. To date, a
treatment based on a systematic and exhaustive training of
phoneme awareness appears to be the most efficient and
most-studied treatment (Duff et al., 2014; Melby-Lervåg,
Lyster, & Hulme, 2012; Snowling, 2013; Tressoldi, Brem-
bati, Donini, Iozzino, & Vio, 2012; Tucci, Savoia, Bertolo,
Vio, & Tressoldi, 2015; Vellutino, Fletcher, Snowling, &
Scanlon, 2004).
THE PHONOLOGICAL-BASED TREATMENT
According to the theoretical model at the foundation of this
treatment, reading descends from the increasingly automatic
recognition of groups of linguistic units (graphemes and
syllables). Indeed, there is accumulating evidence of a hier-
archical pattern of metalinguistic skills in the development
of phonological awareness, a fundamental predictor of
reading skills (for a review, see Melby-Lervåg et al., 2012).
The phonological-based treatment aims at improving the
ability to quickly recognize and automatically manipulate
phonemes via several tasks (i.e., isolating, blending, seg-
menting, and manipulating larger units such as rime units
[syllables] or smaller linguistic units such as phonemes).
In addition to work on phonological awareness skills, and
on explicit instruction in grapheme-to-phoneme correspon-
dences, training that focuses on rapid identification of larger
linguistic units, and on real words in text passages, seems
to be an effective rehabilitation method for poor reading
fluency (Hintikka, Landerl, Aro, & Lyytinen, 2008; Huemer,
Landerl, Aro, & Lyytinen, 2008; O’Brien, Wolf, Miller,
Lovett, & Morris, 2011; Wolf & Katzir-Cohen, 2001). Gen-
erally, Italian children with DD struggle more with reading
fluency than with accuracy, and it has been proven that they
are usually able to reach adequate ability to recognize or
decode words, whereas reading fluency remains the most
marked problem (De Luca, Borrelli, Judica, Spinelli, &
Zoccolotti, 2002; Spinelli et al., 2009). Indeed, research on
the development of reading speed and accuracy (Landerl,
Wimmer, & Frith 1997; Moll et al., 2014; Tilanus, Segers,
& Verhoeven, 2013; Tressoldi, Stella, & Faggella, 2001;
Wimmer, 1993; Wimmer & Goswami, 1994) clearly reveals
that, in transparent orthographies, the core problem of
individuals with dyslexia is the speed or automatization of
reading processes, and that reading accuracy performance
tends to reach a ceiling in the last years of primary school.
In this regard, O’Brien and colleagues (2011) state that
“explicit training of accuracy precedes the training of speed
for each component process to achieve the ultimate goal of
fluent reading” (p. 113).
TREATMENT EFFECTS

To date, several studies have investigated the effects of phon-

Requests for reprints should be sent to Angela Pasqualotto, Department ics training and phonological awareness training on reading
of Psychology and Cognitive Science, University of Trento. Electronic in- fluency. Despite encouraging results, poor reading fluency
quiries should be sent to a.pasqualotto.1@unitn.it. seems to be resistant to intervention, especially for older

readers (Duff et al., 2014; Duff & Clarke, 2011; Snowling,
2013). For example, Torgesen and colleagues (2001) eval-
uated the effects of two one-to-one treatments that lasted
8 weeks, for a total of 67 hours. These intensive train-
ing programs, which combined phonics and phonological
awareness instruction, did not show significant differences
in their efficacy. Both were able to improve reading accuracy
(at follow-up 2 years later, 70 percent of children were able
to read within the average range), but these improvements
did not extend to fluency. Similar results were found in a
large Cochrane review (McArthur et al., 2012) meant to
analyze the effects of phonics training on English-speaking
children’s reading skills. Despite the fact that phonics-based
treatments seem to lead to better reading skills in compari-
son with other approaches, they show large effects only on
nonword reading accuracy, with moderate effects on word
reading accuracy. The positive effects on reading fluency
were small and inconsistent (results in nonword reading
fluency, measured only in one study, were in a negative
direction), and did not reach a statistically significant level.
In this regard, Lyon and Moats (1997) state that “Improve-
ments in decoding and word-reading accuracy have been far
easier to obtain than improvements in reading fluency and
automaticity” (p. 579). Nevertheless, the National Reading
Panel (NRP 2000) reported that phoneme awareness instruc-
tion was able to explain only 6.5 percent (10 percent adding
letter knowledge) of the variance in reading outcomes (both
accuracy and fluency), indicating that definitive and uni-
versally accepted results on phonological-based treatment
have not yet been demonstrated. Besides, a large portion of
students with dyslexia, even after years of treatment, strug-
gle not only with reading fluency but also with accuracy,
showing no effects or minimal effects at the end of the inter-
vention. The issue relating to the “nonresponders” or “poor
responders,” meaning children whose reading problems are
severe and persistent, is that their response, even to effective
and well-implemented intervention, is poor (Snowling &
Hulme, 2011). Hence, these results seem to call for the
dismissal of the simplistic single-deficit model of this dis-
order. In the last few years, in fact, there has been growing
evidence supporting a multifactorial model of dyslexia: The
neurocognitive developmental dysfunctions in this disorder
may not be limited to linguistic deficits, but rather may also
involve a more multifocal network in which the combination
of different impairments in the executive system domain
leads to the resulting difficulties in reading acquisition and
automatization (e.g., Menghini et al., 2010; Moll et al.,
2014; Peterson & Pennington, 2012; Varvara, Varuzza,
Sorrentino, Vicari, & Menghini, 2014). It has, in fact, been
demonstrated that deficits in several determinants (e.g.,
phonological, visual, and executive domains) could underlie
DD, as highlighted by longitudinal cohort studies spanning a
large array of cognitive abilities (Carroll, Solity, & Shapiro,
2016; Franceschini, Gori, Ruffino, Pedrolli, & Facoetti,
2012; Gori, Seitz, Ronconi, Franceschini, & Facoetti, 2016;
Schatschneider, Fletcher, Francis, Carlson, & Foorman,
2004). For these reasons, even though phonological-based
interventions seem important for an effective remediation
of dyslexia, they do not seem to be sufficient (Duff &
Clarke, 2011).
LEARNING DISABILITIES RESEARCH 151
A NEW PROPOSAL FOR INTERVENTION
In recent years, the field has debated whether training execu-
tive functions (EFs) may result in greater reading abilities
in school-aged children with or without dyslexia. Indeed,
several executive aspects have been related to reading pro-
ficiency. Among these, efficient mechanisms of attentional
control appear to be essential for scanning the spotlight of
attention over the letters of a text, while inhibiting the pro-
cessing of close phonological or orthographic competitors,
and flexibly moving from one line to the other (Franceschini
et al., 2012; Grainger, Dufau, & Ziegler, 2016; Vidyasagar
& Pammer, 2010). Reading acquisition requires an efficient
working memory updating for sounding out syllables and
phonemes as decoding proceeds, and for temporarily storing
new words as sentences unfold (Baddeley, 2003; Gathercole,
Willis, Baddeley, & Emslie, 1994). Furthermore, this highly
complex neurocognitive process seems to depend on other
aspects of executive functions such as cognitive flexibility
(e.g., for building cross-modal connections and switching
between the multiple dimensions of written content) and
planning (e.g., for reading comprehension) (Blair & Razza,
2007; Colè, Duncan, & Blaye, 2014).
In addition, empirical findings suggested that children
with learning disabilities might benefit from early inter-
vention programs focusing on training EFs. For example,
Franceschini and colleagues have highlighted how Italian
(2013) and English-speaking children (2017) with DD, a
specific reading disability, may benefit from training of ex-
ecutive attention through an action video game (see Łu-
niewska et al., 2018). Another example comes from work-
ing memory training (Blakey & Carroll, 2015; Karbach &
Verhaeghen, 2014), although meta-analytic confirmation is
lacking (Melby-Lervåg & Hulme, 2013). Melby-Lervåg and
colleagues did not find convincing evidence of generaliza-
tion of WM training to other cognitive skills, but only near
transfer to other working memory and attentional tasks.
Despite the fact that evidence for a positive answer is
starting to emerge, as a few types of training schemes have
indeed been suggested to increase reading speed and/or read-
ing accuracy, several of the previous studies present some
limitations. Not all the studies used random assignment, and
some included pre- and postintervention measures and an
active control group, resulting in potential confounds related
to motivation or expectations (e.g., placebo or Hawthorne ef-
fects). In addition, most of the existing computerized train-
ing has tended to focus on the training of single functions,
thus ignoring the heterogeneity of many neurodevelopmen-
tal disorders, dyslexia in primis. Moreover, EFs should be
considered as a multidimensional system, and it could be
reasonable to include more than one EF in the intervention
programs.
In sum, despite the fact that many cognitive training
companies advertise their products as extremely effective
for a wide set of cognitive and emotional functions, there is
a glaring lack of evidence that computerized training is able
to consistently improve EFs, or that these improvements
generalize to other, untrained domains (i.e., reading and
writing). In an effort to overcome scientific inconsisten-
cies and disagreements, this study aims to analyze new
152 PASQUALOTTO AND VENUTI: DYSLEXIA: EFs AND PHONOLOGICAL-BASED TREATMENTS

FIGURE 1 The flowchart of the present study. Following randomization, children were exposed to 12 hours of their assigned treatment (Cognitive Training
vs. Phonological-based treatment), and then all children received 12 hours of the phonological-based treatment. Children were pretested (T1), tested at the end
of the initial 12 hours of treatment (T2), and again following the second 12 hours of treatment (T3) on measures of literacy skills, phonological awareness, and
executive function tasks. All the tests were administered 1 week before treatment (T1) and within 10 days after treatment.

evidence-based treatment methodologies based on a multi- Part B: Investigating Whether a Sequential

factorial, probabilistic, model of dyslexia. Specifically, the
main objective is to compare a phonological-based reading
treatment with a training program of the executive functions
(EFs) and to explore whether an intervention, one in which
the phonological-based treatment follows EF training, has a
larger remedial effect on reading skills in children with DD
than a purely phonological-based reading treatment.
AIMS AND HYPOTHESIS
The study has two phases, Part A and Part B.
Part A: Comparing Different Interventions for
Dyslexia: A Phonological-based Treatment (Ph-T)
and a Cognitive Training of EFs
Treatment (CT Followed by Phonological-based
Treatment [Ph-T]) Has a More Substantial
Remedial Effect on Reading Skills in
Comparisons with the Purely Phonological-based
Treatment (Ph-T Followed by Ph-T)
Although we expected substantial changes in reading skills
for both treatments, our prediction is that only the sequen-
tial group (i.e., the group that underwent 12 hours of cogni-
tive training prior to 12 hours of phonological-based treat-
ment) will improve in terms of both reading accuracy and
speed. Specifically, we hypothesized that these gains could
be related to improvements in the executive functions, par-
ticularly with visuospatial attentional skills. In Figure 1, the
study plan of the study is represented as a flowchart.
METHOD

Significant improvements in the EFs measures were ex- Participants

pected in the Cognitive training of EFs (CT) group only.
The cognitive training of EFs was a computer-based train-
ing program (Brain-HQ) that focused on working memory,
attention, speed of visual stimuli processing, problem solv-
ing, and inhibition. To our knowledge, no previous study
has been implemented using Brain-HQ with struggling read-
ers or, more broadly, to target reading speed and accuracy.
Regarding the improvement in reading skills, we expected
larger gains for the group who underwent the phonological-
based treatment.
The study design was composed of two groups of children
with DD. Participants were patients of the Observation,
Diagnosis and Education Lab (ODFLab) at the University
of Trento (Italy). The diagnosis of DD was determined by
a group of expert clinical psychologists according to the
ICD-10 (International statistical classification of diseases
and related health problems: Tenth revision; World Health
Organization, 2004) and DSM-IV (Diagnostic and statis-
tical manual of mental disorders 4th ed., Text Revision;

American Psychiatric Association, 2000) inclusion and
exclusion criteria. Inclusion criteria for this study were (1)
a delay of at least –1.8 standard deviation (SD) below the
normative threshold in one or more of the three reading
tests used (i.e., word, nonword, and text); (2) the presence of
reading impairment not explained by cognitive, sensory, or
neurological deficits; and (3) the absence of psychopatho-
logical disorders and/or other developmental disorders (e.g.,
ADHD). The cognitive profile of each participant was
evaluated with the Wechsler Intelligence Scale for Children
(WISC-IV; Wechsler, 2003). The reading performances
were assessed using the word and nonword subtests of
the DDE-2 (Battery for the Assessment of Developmental
Dyslexia and Dysorthographia; Sartori, Job, & Tressoldi,
1995) and the MT text reading test (MT Reading Accuracy
and Speed; Cornoldi and Colpo, 1998). These two tests
analyze the speed and accuracy in reading isolated (word
and nonword) and nonisolated stimuli (text), respectively. In
addition, each diagnosis was discussed by licensed psychol-
ogists taking into consideration the impact of this condition
on children’s everyday lives (i.e., current schooling).
The University of Trento ethics committee approved the
research protocol and, thus, the entire research was carried
out in accordance with the principles of the Declaration of
Helsinki. After written consent was obtained, an automated
system took the details of the new participant and randomly
assigned them to one of the two experimental groups: the
cognitive training (CT) or the phonological-based treatment
(Ph-T). Three children (n = 2 for the CT group; n = 1 for the
Ph-T group) dropped out of the study because they could not
keep up with the schedule of the study. Therefore, the final
sample consisted of 49 subjects (n = 25 for the CT group;
n = 24 for the Ph-T group), including 19 females (38.77
percent) and 30 males (61.22 percent). These percentages
are consistent with a higher prevalence of this disorder be-
ing observed in males compared to females (Jiménez et al.,
2011; Quinn & Wagner, 2015). All children were native Ital-
ian speakers with 2 years of literacy instruction. The mean
age was 8.95 (SD = 1.20) years, and the majority of the par-
ticipants were third- (n = 25; 55.50 percent) and second-
(n = 13; 26.53 percent) grade students. No significant dif-
ferences were found between the two groups, either for de-
mographic characteristics (i.e., socioeconomic status [SES])
or for literacy scores at T1.
Measures
Reading and executive functioning of all children were
tested at baseline (T1), and at two other assessment points
(T2–T3). All of the tests were administered individually, 1
week before treatment (T1) and within 10 days after treat-
ment, by expert clinical psychologists who were blind to
group allocation. Testing was conducted in a quiet room,
and generally, each child was evaluated by the same clini-
cian in one or two sessions lasting approximately 1.5 hours.
An additional session of approximately 2 hours was per-
formed at baseline to assess IQ. The total number of ses-
sions, as well as the duration of each assessment session and
the number of breaks, was carefully calibrated on the ba-
LEARNING DISABILITIES RESEARCH 153
sis of each child’s capacities and emotional well-being. The
literacy skills assessment battery consisted of standardized
reading, writing, comprehension, and phonemic awareness
tasks (Cornoldi & Colpo, 1998; Sartori et al., 1995). These
measures are considered the gold-standard tools for the as-
sessment of decoding skills for the Italian population, as sug-
gested by the Consensus Conference for Learning Disorders
(Lorusso et al., 2014), and show a good test–retest reliabil-
ity (Spearman’s Rho ranging between .56 and .97), as well
as adequate construct validity (Spearman’s Rho ranging be-
tween .24 and .39). In addition to the reading assessment,
multiple other measures were given—a standardized neu-
ropsychological protocol assessing attention (Modified Bell
Test; Biancardi & Stoppa, 1997), working memory (Digit
span and visuospatial span of the Battery for Visuospatial
Memory Assessment: BVS-Corsi; Pazzaglia, Mammarella,
Toso, & Cornoldi, 2008), auditory attention (Test of Auditory
Attention: TAU; Marzocchi, Re, & Cornoldi, 2010), inhibi-
tion (Frogs Test; Marzocchi et al., 2010), verbal fluency (sub-
test of the Neuropsychological Assessment Battery: BVN;
Bisiacchi et al., 2005), and planning (Tower of London: TOL;
Sannio Fancello, Vio, & Cianchetti, 2006) tasks was used.
The psychometric characteristics of the neuropsychological
tests were considered completely adequate, because they all
obtained good reliability and concurrent and predictive va-
lidity coefficients (e.g., reliability coefficients ranging be-
tween 0.60 and 0.91, and construct validity coefficients rang-
ing between 0.21 and 0.35). The raw data were converted to
z-scores according to age and/or schooling (with the excep-
tion of phonological awareness, expressed in percentile). The
reliability indices and the correlation coefficient among the
variables at T1 are reported in Table 2.
Procedure
In the first part of the study (Part A), the cognitive training
(CT) group underwent a 5 weeks training of EFs, whereas
the phonological-based treatment group completed an 8-
weeks phonological-based intervention. The total amount of
training hours was the same for each treatment (12 hours),
but they differed in terms of duration and frequency of train-
ing sessions. Children in the CT group were asked to train
with the cognitive training software (Brain-HQ) for approx-
imately 30 minutes, 5 times per week. The first training ses-
sion (30 minutes) was not counted as part of the training,
because it was aimed at the explanation of the training pro-
tocol and the functioning of the website. Except for the first
training session, and an additional one in the middle of the
training period that was performed at the clinic, under the su-
pervision of expert clinicians, the participants played alone
at home. Parents were instructed to help children at keeping
the training time limit through a timer. During each train-
ing session, practice time was recorded through the software
and, on average, the amount of practice time for each session
corresponded to 30.67 minutes (SD = 2.35). On the other
hand, the phonological-based treatment was carried out in
eight individual sessions that lasted 1 hour and a half each.
All the treatment sessions were performed on a weekly basis
154 PASQUALOTTO AND VENUTI: DYSLEXIA: EFs AND PHONOLOGICAL-BASED TREATMENTS
in a quiet room of the clinic. It is important to note that, for
each child, treatment was delivered on a one-to-one basis.
Both the Cognitive Training and the Phonological-based
training were carried out by expert clinical psychologists
with at least 5 years of experience in implementing EF train-
ing through paper-and-pencils materials and phonological-
based treatment for children with dyslexia. The treatments
were implemented by the same clinicians in close collabora-
tion, observation, and supervision with the first author every
week. In addition, the experimenter provided a manual of
the training protocols for both interventions to ensure con-
sistency of delivery and adherence to active ingredients of
the treatments.
In part B of the study, both groups, after the second as-
sessment point (T2), completed an additional 8 weeks of
phonological-based intervention, followed by the last assess-
ment point (T3). The two interventions are described in the
following paragraphs.
Phonological-based Reading Treatment
Several types of linguistic treatment of dyslexia exist, as
reported by the National Reading Panel (2000) review.
To date, however, the phonological-based treatment—based
on a systematic and exhaustive instruction in learning
letter-sound correspondences and in manipulating sounds to
form words—appears to be the most efficient (Bogdanow-
icz, Krasowicz-Kupis, & Wiejak, 2016; Duff et al., 2014;
Galuschka, Ise, Krick, & Schulte-Körne, 2014; Snowling,
2013). Our phonological-based reading treatment relies on
the guidelines provided by the Consensus Conference pro-
moted by the Italian National Institute of Health (Lorusso
et al., 2014). Furthermore, it has to be emphasized that a
similar treatment has been demonstrated to be effective for
Italian-speaking children with DD in previous studies (Al-
lamandri et al., 2007; Bonacina, Cancer, Lanzi, Lorusso, &
Antonietti, 2015; Lorusso, Facoetti, & Bakker, 2011; Mo-
gentale & Chiesa, 2009; Tressoldi et al., 2012; Tressoldi &
Vio, 2008; Tucci et al., 2015). The phonological-based treat-
ment is aimed at ameliorating the reading process, both in
accuracy and in speed, facilitating the fast recognition of
syllables or other phonological units (e.g., phonemes) that
constitute the key subcomponents of words (a sublexical ap-
proach). This critical aim can be reached through a progres-
sive reduction of the use of the grapheme-to-phoneme con-
version mechanism while recognizing “on sight” groups of
linguistically relevant units that are increasingly complex. In
addition, this treatment aimed not only at reaching the best
reading accuracy possible, but also at addressing dysfluent
reading, a disability that, for Italian children with dyslexia,
is usually the main problem (e.g., Spinelli et al., 2009; Zoc-
colotti, De Luca, Marinelli, & Spinelli, 2014).
In this study, most of the activities of the phonological-
based reading treatment were structured using the materi-
als included in widely used manuals (Brignola, Perrotta, &
Tigoli, 2012; Cazzaniga, Re, Cornoldi, Poli, & Tressoldi,
2007; Gagliardini, 2011; Perrotta & Brignola, 2014). Fur-
thermore, we developed additional paper-and-pencils mate-
rials or other game-like activities in order to provide training
in specific aspects of interest.
Generally, our children with dyslexia mastered basic
reading precursors (i.e., letter knowledge) and seemed able
to identify single graphemes satisfactorily. Therefore, our
phonological-based treatment was based on the systematic
instruction of letter sound-correspondences and the use of
decoding strategies in order to obtain improvements in read-
ing and writing skills (Galuschka et al., 2014) starting two-
letter grapheme sounding and long vowel sounding. Af-
ter each child was considered proficient by the clinician in
grapheme-to-phoneme sounding for all target graphemes, a
revision of grapheme sounding was carried out adding new
stimuli (e.g., new two-letter grapheme sounding, three-letter
grapheme sounding, etc.). The revision of the difficulty of
the graphemes was usually made weekly. In addition to de-
coding training, this treatment focused on phonemic aware-
ness training. Indeed, a sublexical strategy, used to train
grapheme–phoneme conversions and reestablish knowledge
of grapheme–phoneme correspondences, was intertwined
with a phoneme-blending and grapheme-parsing approach.
For example, a list composed of two or three grapheme
nonwords was presented to the child. For each nonword,
the participant was required to circle each grapheme, sound
the phoneme for each grapheme serially, and combine the
phonemes in order to pronounce the whole nonword. The
same activity was done with each word presented orally, ask-
ing the child to segment it into its different phonemes. More
complex tasks, such as spoonerism (the child is asked to
swap the initial phonemes of two words presented orally),
were added only for the participants who mastered the pre-
vious ones. A number of teaching aids (e.g., using con-
crete objects—for example, blocks—to represent sounds)
and rewards were used to make the activities intrinsically
motivating.
For the participants who underwent the additional 12
hours of phonological-based training, we decided to focus
on the rapid (and accurate) reading of increasingly larger lin-
guistic units (e.g., starting with simple bisyllabic words). Al-
though at the beginning of the treatment, single reading units
or lists were preferred, complete texts were preferred in the
last part of the intervention. Some researchers supported the
idea that is better to train words in context, rather than train-
ing words in isolation, because it leads to greater generaliz-
ability (LeVasseur, Macaruso, & Shankweiler, 2008; Martin-
Chang & Levy, 2005; Tressoldi et al., 2012).
In our phonological-based treatment, the levels of diffi-
culty of all the activities were defined on the basis of the
specific reading profile of the child. In that sense, all chil-
dren were trained using the full range of exercises, but the
speed of presentation or the type of orthographic difficulty
of the stimuli in the exercises was dependent upon the read-
ing level of each participant.
In general, all the training sessions were organized fol-
lowing a precise structure: after an initial part in which
the child and the psychologist had the possibility to
talk and about the main events of the week (maximum
10–15 minutes), the child received an explanation of the type
of activities he/she was going to carry out with the help of the
clinicians. This initial part was particularly important due to

the fact that it enabled the psychologist to establish and then
reinforce the clinical alliance with the child. The decoding
training was then divided into two parts of 15–20 minutes
each, intertwined by a 20-minute training period focused on
phonological awareness skills. Particularly, for the last type
of training, a series of game-like activities was used in order
to make the training more entertaining and motivating. For
this reason, most of the children did not need to take a break,
but if they did, the break never lasted more than 5–10 min-
utes. In only one case, the clinician noticed that the child was
too tired, and she decided to reschedule the training session,
postponing it to the following day.
Finally, it is important to note that a clear manual of the
procedures was developed before the start of the study, to
ensure consistency of delivery and adherence to the active
ingredients of the treatment. In addition, for each session of
the phonological-based training, the clinician was requested
to fill out a checklist of the different training components and
record protocol deviations (i.e., dose and treatment content).
Cognitive Training
We decided to use Brain-HQ, an online cognitive training
system developed by the neuroscientist Michael Merzenich
and his team (2013). Brain-HQ consists of several short
mini-games (average duration: 5 minutes) that are de-
signed to train EFs through repeated practice. Numerous
studies, published on Posit Science, have investigated its
functionality for adults (https://www.brainhq.com/world-
class-science); but to our knowledge, there are no empir-
ical studies of its effect on reading accuracy and fluency.
Intensive training, however, can lead to an improvement in
the trained abilities and, possibly, to a more automatic and
straightforward application of the abilities involved in other
tasks, such as reading (Diamond & Ling, 2016). Therefore,
at least in the trained tasks, response times should dimin-
ish, and performance should improve. This might contribute
to creating, in trainees, a higher sense of self-efficacy that
is known to be crucial for the motivation to learn. This
kind of training is inexpensive to deliver in comparison
with traditional clinical interventions, considering that it re-
quires only an Internet-connected computer. Training ses-
sions (two clinic-based, the remnants home-based) were in-
dividual and were managed by the same clinician. To check
treatment fidelity, parents or tutors were requested to monitor
the amount of daily training with the help of a chronometer,
and to refer this information to the clinician by phone, email,
or direct contact. The clinicians provided a manual with the
type and amount of daily exercises that the child was sup-
posed to follow, one in which both the parents and the chil-
dren would be able to find a space where they could write
notes and feedback on the training. In addition, the clini-
cians monitored the training (e.g., time spent training each
day for each participant) at the end of each week through
a dedicated page of Brain-HQ software. Doing so enabled
the experimenters to monitor the correct implementation of
their recommendations, support parents, and motivate par-
ticipants to continue the treatment.
LEARNING DISABILITIES RESEARCH 155
With regard to the training battery, it is important to
specify that Brain-HQ consists of 29 online exercises, or-
ganized into six categories that are often overlapping: Atten-
tion, Brain Speed, Memory, People Skills, Intelligence, and
Navigation. From this pool of exercises, we opted for a sub-
set that best met our research interests to create a 5-week
training protocol. Specifically, three exercises for each week
were selected to train the different executive functions ho-
mogeneously (for a total of 12 types of exercises). The last
week of training consisted in repeating three exercises that
had already been performed but were considered particularly
meaningful. In particular, these exercises were selected from
five main domains of Brain-HQ (i.e., Attention, Brain Speed,
Memory, Intelligence, and Navigation); no exercise was se-
lected from the social skills domain (i.e., People Skills). In
conclusion, the trained cognitive functions were (1) selec-
tive, sustained, and divided attention, both in auditory and vi-
sual modality; (2) speed of visual stimuli processing; (3) fine
discrimination and processing of auditory stimuli; (4) audi-
tory and visuospatial working memory; (5) problem solving;
and (6) inhibition.
We tried to select engaging mini-games, with the aim
of making the training sessions as pleasant as possible.
Moreover, we matched the exercises in order to avoid an
imbalance within each session. In other words, particu-
larly demanding and tedious exercises were not performed
consecutively.
A short and schematic presentation of the training proto-
col with the main characteristics of each exercise is provided
in Table 1.
Statistical Analyses
Training Effects on Literacy Skills
In order to investigate differential training effects on read-
ing skills, and on other literacy skills, a series of Analyses
of Covariance (ANCOVA) were conducted. In each model,
Time (T1 vs. T2) was inserted as a within-subject factor, and
Group (CT vs Ph-T) as a between-subject factor. In order
to exclude possible confounding effects, chronological age
and IQ scores (Raven’s CPM) at T1 and Sex were entered
as covariates. Specifically, the Time:Group interaction was
our primary effect of interest. We further investigated signif-
icances by means of post hoc analyses.
Reading skills and other literacy skills were measured by
means of two z-scores:
- Total Reading Speed: that is, average of speed scores
in word, nonword, and text reading;
- Total Reading Accuracy: that is average of accuracy
scores in word, nonword, and text reading.
Speed and accuracy of reading were assessed using dif-
ferent instruments: the word and nonword tasks of the “Bat-
tery for the Assessment of Developmental Dyslexia and
Dysorthographia” [DDE-2] (Sartori et al., 1995) and the
text reading task, developed by the MT Group (Cornoldi &
Colpo, 1998). In conclusion, two separate ANCOVAs were
156 PASQUALOTTO AND VENUTI: DYSLEXIA: EFs AND PHONOLOGICAL-BASED TREATMENTS

TABLE 1
Training Protocol with Brain-HQ. Description of the Selected Exercises and their Functionality

Task Trained Functions

Week 1
Divided Attention Observe two figures and decide as fast and accurately as possible whether they are Divided attention,
equal or not on the basis of a particular criterion (e.g., shape and color). As the Cognitive flexibility,
participant improves, the figures flash by more quickly and, in addition, the Inhibition of irrelevant
categories double up (e.g., match by color and shape). information.
Hawk Eye Identify the target bird (the only one that slightly differs from the others) as it Visual speed and
appears briefly on screen (in the periphery of the visual field). As the participant precision; UFOV
improves, the stimuli become more similar, whereas their distance from the (Useful field of view).
center increases. Moreover, the backgrounds get more and more complex.
Optic flow Make rapid visual discriminations of the target shape (i.e., on a sign) and, at the Visual attention; Rapid
same time, stay alert to potential hazards in the periphery of the screen. As the detection and
participant improves, the targets become more similar and the number/type of identification of visual
hazards increase. The navigation becomes more complex (night and/or bad stimuli; Inhibition.
weather), whereas the speed of presentation of the stimuli increases.
Week 2
Double Decision Decide which of two cars has just been flashed in the middle of the screen, while Visual processing speed;
noticing where a Route 66 road sign appears in the periphery. As the participant UFOV
improves, the number of distractors, their similarity, and their distance from the
screen increase. Furthermore, the complexity of the background grows.
Sound Sweeps Listen to two sounds that change in frequency (“sweep”) and identify their Auditory processing
direction (up or down). As the participant improves, sound frequencies vary and speed; Auditory
the space between the two sweeps shortens. attention.
Juggle Factor Reconstruct a sequence of numbers (that appear briefly in the middle of circles) in Visual attention; Rapid
the correct locations. For this exercise, the participant is asked to remember not detection and
only the correct order but also the right locations. As the participant improves, identification of visual
the object trajectories become more complex, whereas the number of targets stimuli.
and distractors increases. In addition, the order presentation changes from
forward to backward to random.
Week 3
Target Tracker Track target objects as they move around the screen (Multiple object Visuospatial attention.
tracker—MOT task). As the participant improves, the number of objects and
their visual complexity increases, whereas they move faster, for longer amounts
of time, and over larger areas. Furthermore, the complexity of the background
grows.
Scene Crasher Pay attention and memorize the details of the scene that will soon disappear; after Visual working memory;
they reappear, identify the added item (delayed-recognition span task). As the scanning abilities.
participant improves, the contrast between the background and the stimuli
reduces, the scene presentation shortens, and the display area increases.
Eye for Detail Pay attention, remember, and then identify some images that briefly flash, one at Visual processing speed;
time, in different positions on screen. As the participant improves, the number Visual working
of objects increases (i.e., the targets move from 3 to 5), and they become more memory.
similar. In addition, they appear over larger areas and with more complex
trajectory.
Week 4
Freeze Frame Press the response key only when you see distractors (reinforced answers), Tonic and phasic
whereas you have to hold back on giving the answer when you see a target alertness; Motor
(“Go/no-go task”). As the participant improves, distractors become more inhibition.
similar to the target, the stimulus category changes, and the images appear more
quickly.
Card Shark Remember the sequence of visual information (the cards are added one at time Auditory processing
and then turned over) and decide if the current card is the same presented speed; Auditory
n-times before it (“n-back” task). As the participant improves, the number of attention.
cards and their complexity (suit, number) in the sequence to remember increase,
whereas the presentation time decreases.
Syllable Stack Listen to a series of syllables, and then repeat them in order (“serial Auditory attention; Rapid
memory-span” task). As the participant improves, the number of syllables detection and
increases, whereas their frequencies decrease. Moreover, they become more identification of visual
similar, and they are pronounced by different voices. stimuli.
Week 5 Repetition of the following exercises: Target Tracker; Freeze Frame; Optic flow

Source: https://www.brainhq.com/why-brainhq/about-the-brainhq-exercises.
 TABLE 2
Pearson Correlations among the Neuropsychological Variables at T1. For Each Variable, the Reliability Indices are Specified. See footnotes for significance level

Pearson CORRELATION
Reliability
Standardized Test Measures Coefficient 1 2 3 4 5 6 7 8 9
DDE-2, “Battery for the Assessment of 1. Total Reading .76 –
Developmental Dyslexia and Accuracy
Dysorthographia”;
Sartori, Job, & Tressoldi, 1995; MT Text
Reading Battery, Cornoldi et al., 1981
DDE-2, “Battery for the Assessment of 2. Total Reading .87 .18 –
Developmental Dyslexia and Speed
Dysorthographia”;
Sartori, Job, & Tressoldi, 1995; MT Text
Reading Battery, Cornoldi et al., 1981
∗
Modified Bell Test; Biancardi & Stoppa, 3. Visuospatial .62 .11 .21 –
1997 attention
BVS-Corsi, the battery for visuospatial 4. Digit span .60 .15 .08 –
memory assessment;
Pazzaglia, Mammarella, Toso, & Cornoldi,
2008
BVS-Corsi, the battery for visuospatial 5. Spatial span .74 .02 .11 –
memory assessment;
Pazzaglia, Mammarella, Toso, & Cornoldi,
2008
TAU, Test of Auditory 6. Auditory Attention .49 .14 .1 .11 .15 .02 –
Attention; BIA—Italian Battery for
ADHD;
Marzocchi et al., 2010
BVN, Neuropsychological Assessment 7. Verbal Fluency .39 .06 .07 .09 .15 .16 .11 –
Battery;
Bisiacchi, Cendron, Gugliotta, Tressoldi, &
Vio, 2005
∗
Frogs test; BIA—Italian Battery for ADHD; 8. Inhibition .41 .17 .16 .27 .06 .05 .14 .06 –
Marzocchi et al., 2010
TOL, Tower of London; Sannio Fancello, 9. Planning .57 .13 .08 .1 .12 .17 .06 .09 .07 –
Vio, & Cianchetti, 2006
∗∗ Correlation is significant at the 0.01 level (two-tailed).
∗ Correlation is significant at the 0.01 level (two-tailed).
LEARNING DISABILITIES RESEARCH
157
158 PASQUALOTTO AND VENUTI: DYSLEXIA: EFs AND PHONOLOGICAL-BASED TREATMENTS
performed. No correction for multiple comparisons was
applied.
Training Effects on Executive Functions
By contrast, the training-related changes of the executive
functions were analyzed by means of a two-way mixed de-
sign (MANCOVA) with IQ and Age as covariates, Time (T1
– T2) as a within-subject factor, and Group (CT vs. Ph-T)
as a between-subject factor. The seven EF tasks (Bell–TAU–
Frogs–Digit span–Visuospatial span–Verbal Fluency–TOL)
were inserted in the model as dependent variables. One z-
score for each EFs test was taken into consideration. There-
fore, for the tests that produced two scores, the average of the
two was considered (e.g., digit span forward and backward).
Similar analyses, except for the time points considered
(T1 and T3), were run to evaluate group differences be-
tween the sequential treatment (CT + Ph-T) and the pure
phonological-based treatment (Ph-T + Ph-T). Only signifi-
cant results were reported.
3) The link between improvements in Reading and Executive
Functions.
To explore the predictive relationships between EF gains
and reading improvements after 24 hours of treatment, two
multiple regression analyses were computed for each Total
Reading Score (i.e., delta score between T1 and T3 in read-
ing speed and accuracy). In the first two-step fixed-entry
regression, the dependent variables were the delta scores
(differences between the last assessment time point and the
baseline) of the performances in Total Reading Accuracy
and Total Reading Speed. Predictors included age, IQ, and
sex for block 1, and the reading variable at T1 for block
2. Additionally, two further stepwise regressions were per-
formed using the standardized residuals of the previous re-
gression models as dependent variables and the improve-
ments in the EFs test as predictors. The delta scores of the
EFs tests were indexed by calculating the mean between the
delta scores (T3 – T1) in each of the seven executive func-
tions tests.
RESULTS
Part A (T1–T2)
Literacy Skills
Reading. The ANCOVA of Total Reading Accuracy
showed significant main effects for Time [F(1, 43) = 6.078,
η2 p = .037, p = .029] and Time × Group interaction [F(1,
43) = 4.792, η2 p = .031, p = .033]. Post hoc analysis showed
that the Ph-T group only achieved statistical improvement
after intervention (p < .001). By contrast, the Total Read-
ing Speed model showed a significant main effect for Time
[F(1, 43) = 15.347, η2 p = .107, p = .001], but no significant
Time × Group interaction [F(1, 43) = 2.941, η2 p = .092,
p = .078].
Executive Functions
Repeated-measures MANCOVA was conducted to test treat-
ment effect on EFs. The results showed that there was a sig-
nificant difference between CT and Ph-T groups on the ex-
ecutive functioning over time [Time × Group F(7, 43) =
8.434, η2 p = .352, p < .001]. Specifically, univariate tests
indicated that there was a significant effect of the CT on
specific EFs tests: Bell [F(1, 43) = 7.141, η2 p = .276, p <
.001], Digit span [F(1, 43) = 3.434, η2 p = .072, p = .028],
and Visuospatial span [F(1, 43) = 2.521, η2 p = .053, p =
.035]. Conversely, no significant differences (Time × Group
interaction) between the two groups were found in other
EFs tests.
Part B (T1–T3)
After the last 12 hours of phonological-based treatment, we
analyzed the differential effects of the two interventions, tak-
ing into consideration the baseline (T1) and the last posttest
assessment (T3).
Literacy Skills
Reading. After an additional 12 hours of intervention,
only a significant main effect of Time [F(1, 43) = 23.325,
η2 p = .178, p < .001] was found for Total Reading Accuracy,
highlighting gains in both groups, but no significant differ-
ences between treatments. By contrast, a significant Time
effect and Time × Group interaction for the Total Reading
Speed [Time: F(1, 43) = 17.624, η2 p = .152, p < .001; In-
teraction: F(1, 43) = 13.209, η2 p = .148, p < .001] were
found. Post hoc comparisons showed that children in the se-
quential group (CT + Ph-T) improved in reading fluency
(p < .001), whereas the pure phonological-based group (Ph-
T + Ph-T) only showed a trend (p = .083). See Figure 2
and 3 for details.
Executive Functions
The results of the repeated-measure MANCOVA confirmed
that children of the sequential group retained their read-
ing advantage in the overall executive functioning, as sug-
gested by a significant Time × Group interaction, F(7, 47)
= 9.174, η2 p = .371, p < .001. Interestingly, univariate tests
revealed significant intervention effects not only for the Bell
task [F(1, 43) = 15.372, η2 p = .371, p < .001], Digit span
[F(1, 43) = 8.518, η2 p = .547, p < .001], and Visuospa-
tial span [F(1, 43) = 7.554, η2 p = .251, p = .007], but
also for the Verbal Fluency task [F(1, 43) = 4.613, η2 p =
.312, p = .033]. By contrast, only a main effect of Time was
showed for the TAU and Frogs tasks [F(1, 43) = 11.941, η2 p
= .321, p < .001; F(1, 43) = 8.903, η2 p = .352, p < .001,
respectively], whereas no significant effects were found for
the Tower of London (TOL) [Time: F(1, 43) = 0.068, η2 p =
.001, p = .421].
The treatment-related changes are summarized in Table 3.
 LEARNING DISABILITIES RESEARCH 159

FIGURE 2 Reading performance at pretest, after 12 hours and at the end of the 24 hours of treatment. The Total Reading Accuracy (standardized score) is
showed before (T1), after 12 hours (T2), and at the end of the 24 hours of treatment (T3) in the Phonological-based and CT/Integrated group (a). Training
effects (T1–T2–T3) of the Phonological-based group (Ph-T), and CT/Integrated group on Total Reading Speed (standardized score) (b). The two groups did
not differ at the baseline in all the reading measurements. Error bars represent the standard errors.

FIGURE 3 Improvements (T3–T1) in word, nonword, and text reading tasks. Improvements in Accuracy (a), expressed in the number of errors, and in Fluency
(b), expressed in syll/sec, reached by the two treatments in word, nonword, and text reading. Error bars represent the SE.

The Link Between Improvements in Reading and
Executive Functions
Both the two-step fixed-entry regressions (Total Reading
Accuracy and Total Reading Speed delta scores) were found
significant. Specifically, the level of the reading variable
at T1, entered last, accounted for a significant quote of
variance for the amount of gain in Total Reading Accuracy
(β = –.282, F(1, 47) = 4.02, R2 = .189, p = .031) and Total
Reading Fluency (β = .329, F(1, 47) = 5.78, R2 = .283,
p = .019). These results seem to suggest that children with
the poorest initial reading skills (both accuracy and speed)
are those who gain the most at the end of the treatments.
Therefore, higher reading improvement might be associated
with low initial reading abilities.
Two further stepwise regressions were computed in or-
der to explore the link between improvements (T1–T3) in
Reading and Executive Functions. Only the improvements
in the Bell’s task and the Frogs test accounted for a signif-
icant quote of the variance (13.9 percent) of Total Reading
accuracy changes (R2 = .139, p < .001). In the second re-
gression model, which took into consideration the improve-
ments in Total Reading Fluency, only the gains in the Bell’s
task and the Digit span accounted for 19.6 percent of the
160 PASQUALOTTO AND VENUTI: DYSLEXIA: EFs AND PHONOLOGICAL-BASED TREATMENTS

TABLE 3
Summary of the Mean Values and Standard Deviations of the Reading and Executive Functions Performance at the Three Assessment Time
Points for the Two Groups. Effect Sizes (Cohen’s d) for T3 Analysis are Presented in the Right Column

T1 T2 T3
Literacy Skills Mean SD Mean SD Mean SD Effect Size
Total Reading Accuracy CT −2.30 1.53 −2.10 1.12 −1.47 1.05 .33
Ph-T −2.32 1.49 −1.46 1.33 −1.37 1.37
Total Reading Speed CT −3.61 1.97 −3.04 1.96 −2.41 1.83 .42
Ph-T −3.64 1.66 −3.18 1.73 −3.05 1.70

Executive Functions
Bell task (Visuospatial CT −0.86 1.09 −0.17 1.08 0.32 0.97 .78
attention) Ph-T −0.75 1.17 −0.71 1.11 −0.53 1.34
TAU (Auditory attention) CT −0.92 1.30 −0.41 1.32 −0.29 0.69 .15
Ph-T −0.98 1.22 −0,57 1.39 −0.18 1.54
Frogs (Auditory attention CT −0.28 0.79 −0.16 0.77 0.48 0.45 .21
+ Response inhibition) Ph-T −0.36 0.84 −0.23 0.96 0.23 1.05
Digit Span CT −0.94 0.86 −0.35 0.74 −0.32 0.82 .35
Ph-T −0.85 1.03 −0.79 0.86 −0.77 0.94
Visuospatial Span CT −0.34 0.78 0.03 0.56 0.04 0.71 .17
Ph-T −0,26 0.91 −0.09 0.97 −0.06 1.09
Verbal Fluency CT −0.46 1.01 −0.26 1.07 0.23 1.12 .1
Ph-T −0.39 1.05 −0.31 1.14 0.07 1.48
Planning CT 0.01 1.30 0.24 1.08 0.37 0.94 .14
Ph-T 0.06 1.12 0.21 1.04 0.33 1.17

Note. It has to be noted that when all the time points are considered (T1, T2, and T3), the CT group refers to the sequential treatment (Ct + Ph-T), whereas the
Ph-T refers to the pure phonological-based treatment (Ph-T + Ph-T).

variance (R2 = .196, p < .001) in Total Reading Speed
changes. These results support the idea of the involvement of
the EFs performance in the prediction of the improvements
in speed and accuracy in reading.
DISCUSSION
The primary aim of this article was to take a step forward in
identifying effective treatments for children with dyslexia.
In this study, in fact, we developed a training program that
combined phonological-based intervention and training of
the EFs, showing that children who participated in both types
of intervention improved the most. Indeed, after 24 hours of
sequential training, children with dyslexia progressed in vi-
suospatial attention and working memory at posttest (T3),
whereas no significant improvements in EFs were observed
in the pure phonological-based treatment. In fact, despite the
short duration of the treatment program, the integration of
the cognitive training and the phonological-based treatment
resulted in significant gains in both reading accuracy and
speed.
Specifically, children of the sequential group posted
higher improvements in reading fluency than expected in 1
year of development without specialized interventions. This
finding is particularly important, because, in the context
of transparent orthographies, the core symptom of stu-
dents with dyslexia is the lack of fluent reading (Tressoldi
et al., 2001; Tressoldi & Vio, 2008; Zoccolotti et al., 2014;
Zoccolotti et al., 1999). Without a specific and systematic
intervention, the expected improvement per grade of these
students is around half the increment observed in typically
reading children. In addition, an effortless, flowing reading
is at the base of other higher level components such as
text comprehension (Fuchs, Fuchs, Hosp, & Jenkins, 2001;
Jenkins, Fuchs, Van den Broek, Espin, & Deno, 2003;
Klauda & Guthrie, 2008; Raghubar, Barnes, & Hecht,
2010).
Indeed, the automaticity with which a reader is able to
decode words is almost as crucial as word reading accuracy,
constituting a fundamental goal for effective remediation of
dyslexia. Furthermore, the gains in reading fluency can be
fully appreciated by considering that the sequential train-
ing improved not only nonword reading, which represents
the sub-lexical route functioning, but also word text reading,
which, in addition, represents the ability to rapidly recog-
nize words via the lexical route (Coltheart, 1981; Coltheart,
Rastle, Perry, Langdon, & Ziegler, 2001). Nonwords have
no representation in the lexicon and, thus, need to be read
using the grapheme-to-phoneme correspondence rules; by
contrast, well-learned words that have a visual representa-
tion in the lexicon can be read directly. In both cases, words
are not read as wholes, but rather are processed as letters
or larger units in a sequence or in parallel (Dehaene et al.,
2010; Pelli & Tillman, 2007). In this regard, Vidyasagar and
Pammer (2010) propose that “attentional mechanisms con-
trolled by the dorsal visual stream help in serial scanning
of letters and any deficits in this process will cause a cas-
cade of effects, including impairments in visual processing
of graphemes, their translation into phonemes and the devel-
opment of phonemic awareness” (p. 57).

In this study, exploratory results of the regression anal-
yses seem to suggest a link among these abilities: im-
provements in visuospatial attention and verbal memory ap-
peared to be associated with improvements in reading speed,
whereas improvements in visuospatial attention, auditory at-
tention, and response inhibition seem to be related to im-
provements in reading accuracy. These data are in line with a
multifactorial view of dyslexia (e.g., Menghini et al., 2010;
Peterson & Pennington, 2012). Hence, beyond phonologi-
cal awareness, other cognitive processes, such as EFs, are
needed to account for all the components of reading. It must
be noted, however, that further studies, with larger sam-
ple sizes, are required in order to meaningfully investigate
whether improvements in EFs mediate the improvement in
reading fluency and accuracy.
To date, little is known about the transfer between train-
ing effects in specific EFs and untrained academic skills,
such as reading, even though the degree to which improve-
ment in one or more EFs tasks extends to learning represents
an issue of great importance for education and rehabilitation
policies (Bierman and Torres, 2016; Traverso, Viterbori,
& Usai, 2019). In addition, the recognition of the role of
other cognitive factors in reading does not negate the role
of the phonological deficit in the etiology of this disorder,
but rather provides the opportunity to develop and validate
innovative intervention programs. It has to be highlighted
that the two types of interventions (i.e., phonological-based
and training of EFs) should not be seen as conflicting,
but rather as complementary: to date, cognitive train-
ing alone could not be considered enough to remediate
reading.
In conclusion, the treatment effects can be regarded as
satisfactory for both interventions, even though the sequen-
tial group obtained the most positive effects thanks to the
combination of the two methods, a combination that helped
children with dyslexia maximize their chance of enhancing
their reading skills. At this point, progress in this field offers
the hope of providing evidence-based interventions that
are tailored to the specific cognitive and reading profile of
each student with dyslexia. For these reasons, researchers
now need to focus on disentangling how to personalize
programs, and on specifying the type of implementation re-
quired (i.e., clinic-based vs. home-based; computerized vs.
non-computerized). The results of this study seem to sup-
port the possibility of obtaining satisfactory improvements
in reading accuracy and fluency through the combination
of home-based and clinic-based approaches (sequential
treatment), highlighting the possibility of making treatments
accessible to more children with dyslexia in need of less
expensive and less time-consuming intervention. In sum,
because the opportunity of applying home-based treatments
seems extremely promising, researchers should control for
treatment environment as a potential influencing factor.
Limitations and Further Research
Although the results of the study give clear indications on the
necessity of individualizing treatment programs to the spe-
cific cognitive profile of the child, several limitations should
LEARNING DISABILITIES RESEARCH 161
be taken into consideration. First, the present study presents
a small sample size. Second, the results did not include a pas-
sive control group and regard only efficacy in the short-term
for ethical reasons. Indeed, it is important to give the oppor-
tunity to every child with dyslexia to undergo a proper inter-
vention. Given the promising results of the study, follow-up
testing is required in order to confirm the long-term validity
and its generalizability to other important aspects of life such
as academic functioning. Thus, a follow-up will be planned
in order to understand whether reading interventions result
in long-term gains, and individual features will be measured
to investigate how they relate to intervention outcomes.
The main challenge for the remediation of this disorder
is not only to find the most effective remediation programs,
but also to precisely select a personalized program for each
child with dyslexia.
In sum, further research seems to be necessary to validate
the effectiveness of the integration of a phonological-based
approach with a training of EFs. More specifically, it would
be crucial to study the role in reading improvement of
increasing different cognitive functions that were shown to
be fundamentally related to the appropriate development of
reading in childhood. Although the hypothesis of a positive
effect of training of EFs on the impaired reading skills of
children with dyslexia is supported by the results of this
study, further comparative studies of reading interventions
from different countries would help shed some light on the
role of cognitive training in reading enhancement.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the valuable assistance
of Dr. Veronica Tranquillini and the entire ODFlab team of
clinicians. We are also grateful for the cooperation of the
parents and children who participated in the study. Finally,
we thank Dr. Isotta Landi and Dr. Teresa Del Bianco for the
useful suggestions and the students that helped us in the data
collection process.
NOTE
1. A Cochrane Review is a systematic review of re-
search in health care and health policy that is pub-
lished in the Cochrane Database of Systematic Re-
views and it base its findings on the results of studies
that meet high quality criteria (for additional infor-
mation, see Cochrane Handbook for Systematic Re-
views of Interventions).
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164 PASQUALOTTO AND VENUTI: DYSLEXIA: EFs AND PHONOLOGICAL-BASED TREATMENTS

About the Authors

Angela Pasqualotto is a clinical psychologist and a postdoc research fellow at the University of Trento (Italy). Her research
focuses on the psychological aspects of the interaction between children and technology, with an emphasis on the design and
the evaluation of innovative tools for students with special needs.

Paola Venuti is head of the Observation, Diagnosis and Education Lab (ODFLab) and the Director of the Department of
Psychology and Cognitive Science at the University of Trento. The ODFLab is devoted to the study of emotional and cognitive
development in neurotypical individuals and in individuals with special needs.