Literacy Skills Improvement and Early Diagnosis of Specific Learning Disorders (SLD) Using a New Phono Syllabic Program

Specific learning disorders (SLDs) are neurodevelopmental disorders characterized by deficits in specific domains of reading (dyslexia), writing (dysorthographia/dysgraphia), or calculation (dyscalculia), in a relevant but defined way that leaves general intellectual functions intact. They have a neurobiological and genetic basis but are not related to neurological damage nor to significant socio-cultural disadvantages. However, SLDs can compromise personality development, social adaptation, and be associated with psychopathological disorders, both externalizing, i.e., oppositional, or defiant behaviour, and internalizing, i.e., anxious, and/or depressive traits, which can further impair a student's adaptation. In Italy, SLDs affect 3.5% of the school population; in Friuli Venezia Giulia (FVG), 3.1% of students are diagnosed with SLDs. Screening and early diagnosis play an important positive role in determining the evolution of the disorder and the overall emotional and cognitive development of children with SLDs. Diagnosis of disorders in reading and writing skills can only be made from the end of second grade in primary school. Italian and regional FVG regulations promote early identification of children with SLDs at school where, however, SLDs are often confused with learning difficulties, which affect approximately 20% of children and for which adequate reinforcement and targeted teaching methods are considered sufficient to improve reading and writing skills. This results in a high percentage of inappropriate referrals to the National Health Service (SSN) for SLD evaluation (40% false positives in 2023), leading to a lengthening of waiting times for a definitive SLD diagnosis.

The Guidelines of the Istituto Superiore di Sanità (ISS) recommend, as priority actions in first-grade primary school, phonological-metaphonological interventions to explicitly promote grapheme-phoneme association strategies for reading and writing. The literature supports these recommendations. Numerous studies have highlighted the essential role of Phonological Skills, demonstrating how systematic phonological methods are more helpful for children learning to read than all other methods and should therefore be implemented in schools. Furthermore, phonological skills also improve writing skills. This is further supported by evidence from the field of neuropsychology and from neuroscience using neuroimaging techniques. Dehaene has shown that a child learning to read needs to use the phonological pathway, which allows them to read a word by transcoding individual graphemes into their corresponding phonemes, thereby highlighting the neural circuits involved in grapheme-phoneme correspondence. On the contrary, having to pay attention to the overall shape of the word hinders the acquisition of the alphabetic code by directing brain activity towards an inadequate circuit.

The Alfabeto program is a rigorous, structured phono-syllabic approach that has been shown to be sustainable and effective in improving the reading and writing skills of all children in a quasi-experimental before-and-after study with a control group, conducted in first-grade classes during the 2019/2020 school year.

This randomized controlled trial aims to demonstrate that the Alfabeto program is superior for the acquisition of both reading and writing skills for all children, including those with learning difficulties or SLDs, compared to other teaching methods. If, as we expect, the program benefits all children, not only those with SLDs, the implementation of this method in a primary school setting should guarantee a reduction in inappropriate referrals for psychological evaluation and, consequently, in assessment waiting lists, thereby enabling true, accurate early detection of children with SLDs.

All FVG schools will be asked by the Regional School Office (USR) to join the project. School representatives will be invited to participate in a webinar to present the study and receive SLD training from specialized personnel. During the same period, family paediatricians will also be informed of the study's contents and objectives.

First-grade classes of schools that have accepted to take part in the project will be recruited. The randomization will be by class; therefore, all the children of the enrolled class, who do not have any of the exclusion criteria, will be assigned to a reading and writing learning method specified as follows:

• control group (CG) will comply with any of the standard methods used in Italian schools to teach reading and writing in first grade (synthetic: alphabetic method, focused on the single sound; phono-syllabic, starting from the single sounds to arrive to syllables; analytical: starting from the whole word; analytical-synthetic: starting from the entire word and then moving to the single letter or vice versa). In second grade, they will follow the teacher-chosen standard program.
• Experimental group (EG) will follow the Alfabeto reading and writing method in first grade, and will continue with the same method also in second grade.

Alfabeto is a structured phono-syllabic program, developed by SApIE Association (Society for Learning and Education informed by Evidence) starting from the working material of Dr. Ventriglia. It is:

• Phonological: based on the phonological and meta-phonological dimensions;
• Syllabic: open syllables [i.e., Consonant-Vowel groups (CV)] are central to the methodology;
• Generative: Once the ability to read CVs has been acquired, reading is extended to all types of compound forms.
• Structured: it progresses according to a precise order of phonological difficulty, and full words or parts of them are never presented to children before they can decode them analytically; therefore, children master the mechanics of reading gradually.
• Explicit: the program is composed of 5 units, each divided into 2-hour work sessions with clear didactic objectives, exercises, and games. The program is carried out in compliance with the principles of cognitive load theory, which require that no distracting stimuli, particularly graphic ones, be used. (19)
• Playful: the program requires teachers to convey a sense of play, fun, and passion for the pronunciation of sounds to make children feel that phono-syllabic learning can be fun. Mistakes are part of the process; teachers themselves will play making mistakes, asking children to correct them.

Block randomization to either CG or EG will be performed by the SCR of Clinical Epidemiology and Public Health Research Unit using a computerized electronic random number generator.

Blocks will be single schools or school areas, so that first-grade classes within the same school or area will be paired and balanced by demographic and socio-cultural background. Given the experimental nature of the intervention, it will not be possible to ensure blindness.

Before the start of the school year, participating schools will be notified of the class assignment to EG or GC, and EG teachers will complete a 2-hour online synchronous training course on the Alfabeto program led by Dr. Ventriglia. She will also support EG teachers throughout the school year, both in the first and second grades, through monthly 2-hour synchronous online meetings.

EG teachers will receive the Teacher's Book to guide them step by step in applying the Alfabeto program, and EG children will receive the Child's Book, both in the first and second grades.

Parents of enrolled children will be adequately informed about the study at the beginning of the school year. They will be asked to sign informed consent for the administration of the validated tests used in the study, and a specific consent to privacy for the acquisition and storage of data collected through the study. Parents will also be asked to complete a questionnaire about the child and family (language spoken at home, age, parents' work and education, child's health problems, disability certification).

EG or CG teaching will start in September 2025 (start of first grade: T0) and will end in June 2027 (end of second grade: T2). At T0:

1. A progressive ID number will be assigned to each child to ensure maximum confidentiality of data collected and analysed;
2. Scores will be collected from the prerequisite tests administered to each child who meets the inclusion criteria, regardless of the allocation group. The tests administered online or on-site by research fellows or university students assigned to the project will be: the PRCR-2 Battery Quick Colour Naming and Letter recognition test and the Spontaneous writing test;
3. Schools will be asked to fill in a questionnaire on the economic and social characteristics of the area in which the school is situated and of the families of the pupils who attend it, as well as on the procedures implemented for the identification and management of SLD children. Teachers will be asked to describe the methods they have used to teach reading and writing over the years, as well as their knowledge of SLDs, including the support they provide and the actions they take. Information will be collected on which textbook has been chosen for the first three years of primary school.

At T1:

1. Scores for the following tests will be collected for each child, regardless of the allocation group: New Reading Tests MT for school - speed of reading, Lexical decision test (DLC), Integrated Stella - Apolito word dictation, and the METAFONO test. The DLC, METAFONO test and the word dictation will be administered collectively by the teachers while the MT test will be administered individually online or on-site by research fellows or university students assigned to the project. Children with scores that classify them as at risk for SLDs in at least one of the above tests will be considered 'T1 presumed SLD'.
2. Scores for the following questionnaire will be collected for each child, regardless of the allocation group: SDQ-I (Strengths and Difficulties Questionnaire) filled in by the class teacher/s.

At T2:

1. The same tests performed at T1, with the same parameters but specific for the second grade, plus the collective BVSCO writing speed test, will be administered. Children with a score that classifies them as at risk for SLDs ' in at least one of the above tests will be considered 'T2 presumed SLD'.
2. The same SDQ-I, filled in by the class teacher/s, will also be collected. 'T2 presumed SLD' children will be sent to IRCCS Burlo Garofolo for SLD evaluation, as per the ISS Guideline. The evaluation visit, booked through the hospital's booking centre (CUP) with a specific research code and free of charge for participating families, will consist of a first psychological visit carried out by qualified research fellows assigned to the project online or in person at the Child Neurology and Psychiatry Department of IRCCS Burlo Garofolo. This set-up will ensure that SLD evaluation is delivered to 'T2 presumed SLD' children in a timely and manageable manner.

All SLD diagnoses will be documented and registered in a medical report inserted into the regional clinical system (G2). The medical report, including the functional profile and the impaired abilities, will be delivered to families and, through them to schools, after confirmation and countersignature by the authorized neuropsychiatrist/psychologist of the Child Neurology and Psychiatry Department.

Non-SLD children will be provided with tools to improve their reading and writing skills. SLD-confirmed children will enter the standard of care pathway, and all subsequent visits will be managed and paid through the (SSN) according to standard practices, including the payment of the 'ticket' by families that are not entitled to specific exemptions.

Inclusion criteria include parental informed consent; exclusion criteria include children receiving individualized instruction with a dedicated support teacher (Law 104). Schools must provide instruction in Italian and include first-grade classes with different teachers. Montessori, Waldorf, adult education, and multi-grade classes are excluded.