Exploring Learning Disabilities-Defcits, Delays and Strengths in Dyslexia, Feb 2017

Exploring learning disabilities -
deficits, delays and strengths in

dyslexia
Emeritus Professor Angela Fawcett
University of Swansea
Hermina Hospital, Jakarta

February 2017
Plan of talk
1. What is dyslexia?
2. Our contribution to dyslexia research over 25 years
3. Procedural learning
4. Delayed neural commitment
5. Implications for education
6. The way forward!
Copyright AF and RIN 2016

What is dyslexia-definitions
• Reading performance that is markedly below what is

expected, based on a person's intelligence.’
• “a disorder in children who, despite conventional
classroom experience, fail to attain the language skills of
reading, writing and spelling commensurate with their
intellectual abilities”. World Federation of
Neurology (1968)
• a puzzle….
• a mess…...
• fail for two years before diagnosis possible...
• ‘You taught him to read, so he can’t be dyslexic…”
• Symptom not cause
3
Children with dyslexia…..
• The largest group of children with special educational needs in
mainstream schools –5-10% school population
• Dyslexics have a disorder in one or more areas of learning,
usually defined in terms of learning to read.
• Associated problems with writing, spelling, speech and language,
maths, co-ordination, speed of processing, essay writing,
memory, lower self-esteem, and some will have attention deficit
disorder (ADHD) even social skills.
• There is a 50% chance of dyslexia if one of the parents is dyslexic
• Their problems may be misunderstood - both parents and
teachers may think they are just not trying!
• Brain based differences in processing in dyslexia can explain both
the strengths and weaknesses in this group
Academic Impact

Educational Impact

Deficit Theories of Dyslexia
1. Behaviour Phonologica Double
l Deficit Deficit
Rhythm Visual Attention
Deficit Deficit
2. Cognitive Level
Cross-Modality Automaticity
Deficit Deficit
Procedural
Temporal
Learning
Deficit
3. Brain Level Magnocellular Deficit
Deficit L Hemisphere
Testosterone Language Cerebellar
Hypothesis Deficit
24 candidate
4. Genetic Level
genes… Copyright AF and RIN 2016
Genes and dyslexia
1. Extensive research has been dedicated to trying to unlock the genetic
basis of dyslexia, based on twin and family studies to examine the
impact of genes and the environment
2. Candidate genes include chromosome 1,2,3 6,and 11 (Scerri and
Shulte-Krone, 2010, Pennington et al) with different genes for
reading, phonology etc
3. These genes are all involved in migration during the formation of the
brain in the womb
4. Any changes in the brain are likely to lead to a range of
neurodevelopmental disorders and co-morbidity between these
5. It’s important to remember that a genetic endowment gives a
predisposition for dyslexia, but this need not be expressed
behaviourally, and can be overcome with a supportive environment

Finding the source of ‘pollution’:
Symptom vs Cause
Magno
Reading
Automaticity Phonology
Cerebellum
Dyslexia and Learning:
The Automatisation Deficit Hypothesis
The ‘correct’description of dyslexia is ‘Specific Learning

Difficulties’or ‘{Specific} Learning Disability’
Dyslexia is [some] general deficit in learning

 For some reason it is difficult for dyslexic children to become
‘expert’in a task
 ………………...whether it is a cognitive task or a motor task.
The Automatisation Deficit hypothesis (N & F 1990)

 Dyslexic children have problems making skills automatic and need
therefore to ‘consciously compensate’ even for simple skills

Study 2: Reaction Times and Dyslexia
N&F: QJEP (1994)
SRT: Simple Reaction
Time
SCRT: Selective CRT
Lexical Decision – is it a
word or not?
The deficit increases directly with task complexity

For SRT, no apparent deficit, same as CA, faster than RA
For SCRT, at level of RA controls (though response exactly the same)
For lexical decision, worse than RA controls
 Problems run deeper than language
12 Copyright AF and RIN 2016
Study 3: Procedural learning (1992/2000)
Blending of primitive skills (N&F, EJCP 2000)
70
dyslexic
60 control
(i) Problems with initial blending 50
latency (cs)
(ii) more errors 40
(iii) Slower final performance
30
(iv) slower learning
20
t = 53.9 n–0.07 (dys)
t = 39.4 n–0.14 (cont) 10
[t is time taken, n is number of 0

trials practice] 0 500 1000 1500 2000 2500
SRT CRTs made

The difficulties lie at the Start, the Middle, the End
and the Blend
Performance
Time (Trials)
The ‘square root’ rule:
• The extra time needed for a dyslexic child to master a task is proportional
to the square root of the time a non-dyslexic child takes.
• If it takes 2 hours normally, 4 hours for a dyslexic
• If it takes 10 hours normally, 100 hours for a dyslexic
• Iifif Devast Devastating if generally true - the 1000 hour rule - explains dif
but explains difficulties in remediating reading.

Dyslexia: an ontogenetic Causal Chain
(Nicolson, Fawcett and Dean, 2001/7)
Birth 5 years 8 years
Declarative Learning
Balance impairment
Motor skill impairment writing
Cerebellar
impairment Grapheme- READING
Articulatory Phonological phoneme
skill awareness DIFFICULTIES
Cortico- conversion
cerebellar
loop Working'word recognition
Memory module'
orthographic
regularities
Problems in automatising
spelling
skill and knowledge

Procedural & Declarative Memory Systems
(eg. Squire, 1989; Ullman, 2004)
PM
DM PM PM
DM
DM DM PM
Declarative and procedural conspire and compete!

Specific Procedural Learning
Deficit Hypothesis
1. The core difficulties in dyslexia relate to the language-

based component of the procedural learning system
2. The declarative learning system is performing at or above
normal levels
3. Other components of the procedural learning system (and
other neural systems) may (but need not) be affected

Levels of Explanation: Introducing
Neural Systems Level
Genetics 1.Some unknown cause or causes
Biological 2.Cerebellar Deficit, possibly other parts of

PLD esp. IPFC
Neural
Systems 3.Procedural learning system
Cognitive 4.Cognitive Difficulties

• Automaticity deficit
• Phonology, WM, Speed
5.Poor procedural learning

Behavioural • Overemphasis on controlled processing
• Possibility of secondary symptoms

Stages and Timescales of Learning
We found problems at all stages, but where do they come from?

• The study took place in multiple sessions over several
weeks
1. Immediate stage seconds

2. Practice minutes to hours
3. Consolidation overnight
4. Automaticity days

Procedural Learning and the Brain – the
importance of motor learning!
1. Immediate stage many brain regions
2. Practice cerebellum, striatum, motor cortex,
parietal cortex
3. Consolidation divides into 2 routes. Striatal and
cerebellar. With parietal and motor
cortex
4. Automaticity Striatal and cerebellar routes
diverge more. With parietal and
motor cortex
• Cortico-cerebellar circuit Motor adaptation

• Cortico-striatal circuit Motor learning
Copyright Angela Fawcett and Rod
Nicolson 2015
Motor Sequence learning (Needle, 2006)
Correct Sequences in 30 sec
Left hand panel shows that the Right hand panel presents effect
dyslexic Ps learned slower
sizes, combined over speed and
initially, remained slower at
end of session 1, and were accuracy. Note the clear loss
slower at start of next day 21
overnight (consolidation).
Speed and accuracy of word and
pseudoword reading (Brookes, 2007)
1. Stimuli: words (eg. plug), Pseudowords (eg. plig), Irregular (eg. lpug)
2. NB. The dyslexic adults (who are high achieving University students) are
no more accurate given 260 ms than the controls at 100 ms.
1.Recognition of traffic signs (real and
made-up) Brachacki, F & N (1995)
d’ is accuracy of recognition of signs adjusted for guessing

NB. the improvement in performance with experience (slope of line) of the
dyslexic adults is only one third of that for the controls
Development of Learning Disabilities
and co-morbidity
Birth 5 years 8 years
Motor Skill Dyspraxia

Motor
PLS Speech SLI
Language
PLS {Phonology} Dyslexia
Declarative General LD
LS
24 Copyright AF and RIN 2016

How can this happen?
1. Many developmental differences arise during the ‘neuronal migration’ stage
when the foetus’ brain is being formed in the mother’s womb.
2. Many factors can lead to small differences in brain organisation - both for
neurons within a brain structure and also for neuronal tracts between
structures
3. Many brain regions are involved at the different stages in learning procedural
skills
4. It is very likely that if some factor leads to structural differences in the
cerebellum, it may also lead to differences in the cortex, the basal ganglia,
and so on.
5. The precise pattern of difficulties shown by a given child will therefore
depend on which brain regions are most adversely affected, but it is likely
that several regions will be affected
6. Therefore differences between disabilities are likely to be of degree rather
than absolute.
7. Hence in developmental disabilities, comorbidity will indeed be the rule rather
than the exception!
What does it mean?
1. For a given child, the specific pattern of declarative and procedural

difficulties and strengths will be unique to that child.
2. We therefore do need to find the way that that child learns best
3. Current educational tools tend to test attainment rather than
potential, and there are very few for non-declarative learning
4. We therefore need to develop a series of tests for the different types
of learning
5. Having done this we need (in principle) to be able to tailor the
learning environment to the child’s learning abilities and disabilities
6. In many cases this will mirror established methods but we need to
update these methods to include our increased understanding of
brain function.

Further Support for PLD
1. Declarative memory in dyslexic children shows learning and
retention better than controls (Ullman, 2013).
2. Metanalysis of serial reaction time studies shows consistent
effect (Lum, Ullman and Conti Ramsden, 2013)
3. Deficit in consolidation of procedural skill automatization in
dyslexia in children and students, greater for procedural
learning of letters than motor sequences (Gabay, Shiff and
Vakil, 2012)
4. Dyslexia as functional co-ordination – automatising nvel synthesis of
procedural learning (Lachmann and Van Leeuwen, 2014)
5. Gabay et al (2015 a, b) show deficits in both probabilistic and
statistical learning in university students with dyslexia
6. Gabay and Holt (2015c) Impaired procedural learning of auditory
categories leads to phonological deficits.
Why Strengths? – delayed
neural commitment …

Ontogeny to Adulthood…
Birth 8 years Adulthood
Declarative Learning
• A major challenge is to identify and

support all dyslexic schoolchildren so
Jackie Hewitt-Main, 2013
that they have every chance of 53% of (2,029) prisoners
swimming or flying rather than sinking at Chelmsford
Copyright AF anddiagnosed
RIN 2016
as having dyslexia
Strength Theories of Dyslexia
1. Behaviour Phonologica Double

l Deficit Deficit
Rhythm Visual Attention
Deficit Deficit
2. Cognitive Level
Cross-Modality Automaticity
Deficit Deficit
Temporal Procedural
Deficit Learning
3. Brain Level Magnocellular
Deficit Deficit
L Hemisphere
Testosterone Language
Hypothesis Cerebellar
24 candidate Deficit
4. Genetic Level
genes… Copyright AF and RIN 2016
Automaticity
1. Effects of automatisation
• Neural commitment – small, dedicated cell assembly
• Encapsulation
• Loss of conscious access
• Stimulus-response ‘habit’
2. Up-side
• Fast
• Efficient
• Takes no conscious capacity, freeing controlled
processing
• Allows new skills to be built on top

Neural Commitment and Bilingualism
1. Monolingual Language Acquisition (Kuhl, 2004)
• At 6 months can distinguish sounds in all human
languages
• At 12 months has specialised onto the phonemes
occurring in their mother tongue
• Neural commitment
2. Bilingual Language Development

• At 6 months can distinguish sounds in all human
languages
• At 12+ months has specialised onto the phonemes
occurring in their mother and father tongues
• At 5-6 years appear to have significant advantages in
executive function (e.g., Bialystok, 2011)
• … and protects against Alzheimers (Bialystok, 2012)
Automaticity – does it have a down-side?
1. Premature Neural Commitment
• Commit to one component only for complex skill
2. Unlearning
• Harder to ‘unlearn’ a habit than to learn it in the first place
3. Loss of declarative access
• Once automatised, no longer available for conscious access
• Can’t integrate that information with other declarative information
4. Over-writing of previous skills
• New skills replace old skills
• May lose the non-language skills that characterise young children
• Exceptional nonverbal memory
• Exceptional spatial skills!?
5. Loss of mental flexibility
• Between stimulus and response there is a space. In that space is our
power to choose our response. In our response lies our growth and our
freedom (Viktor Frankl). Copyright AF and RIN 2016
The Delayed Neural Commitment Hypothesis
1. Dyslexic individuals are relatively slow to automatise skills

2. They therefore show ‘delayed neural commitment’
3. This occurs in most skills, especially language-based ones
4. While generally DNC is associated with slower and more effortful
processing, it can endow advantages, especially in circumstances
where it is useful to maintain earlier skills, or valuable to combine two
different skills which do not normally occur within the same ‘time
window’
5. DNC can therefore lead to two crucial advantages:
• Retention of access to pre-linguistic skills
• Combination of knowledge from two different domains

Evidence for the DNC Hypothesis
1. Neural commitment is the primary mechanism for language

specialisation in infants [Kuhl, 2004]
2. Reading delay, especially the transition from logographic to alphabetic,
and then the transition from alphabetic to orthographic (VWFA may
never develop fully)
3. Automatisation deficit etc. [Nicolson and Fawcett studies]. Statistical,
procedural, implicit learning weaknesses (Hedenius et al, 2013;
Menghini et al., 2010; Vicari et al., 2005)
4. No sensitivity to speech sounds at birth (hence no learning in womb)
[Lyytinen et al., 2010; Molfese, 2000]
5. For some children, primitive reflexes not unlearned [McPhillips et al,
2000]
6. Delay in speech milestones and in some cases motor milestones
[Lyytinen et al., 2004; Viholainen et al., 2002]
Sources of Potential Advantage under DNC
1. Declarative specialisation
2. Extended sensitive periods allow extended learning period into late
adolescence and adulthood
3. Reduced commitment / compartmentalisation allows greater cognitive
processing and flexibility
4. More cross-talk between different brain regions and senses etc. allows
more integrative processing
5. More speculative..
• Less ‘pruning’ of primitive capabilities
• Greater scope for ‘post-operational thinking’ (problem finding, fuzzy
logic..)

Succeeding in School

Reading activities and sub-skills
Writing

Coordinating
Positive Dyslexia: Sinking
Fluent
Reading
Reading reading failure

Skill
Executive
function
Not ready to learn to

Speech / read
Language
3 5 7 years Copyright AF and RIN 2016

Executive Functions
“Executive functions (EFs; e. g., reasoning, working memory, self-

control) can be improved. Good news indeed, since EFs are critical for
school and job success and for mental and physical health.
Here I address what can be learned from the research thus far, including
that EFs need to be progressively challenged as children improve and
that repeated practice is key.
Children devote time and effort to activities they love; therefore, EF
interventions might use children's motivation to advantage.
Focusing narrowly on EFs or aerobic activity alone appears not to be as
efficacious in improving EFs as also addressing children's emotional,
social, and character development (as do martial arts, yoga, and
curricula shown to improve EFs).
Children with poorer EFs benefit more from training; hence, training
might provide them an opportunity to "catch up" with their peers and not
be left behind.”
Diamond (2012)
Delaying Formal Reading Instruction
1. There is no doubt that reading achievement in the UK and

USA is poor. In the 2012 PISA assessments the UK and
USA came lowest of the English-speaking countries
2. The Scandinavian countries have traditionally (a)
achieved much better reading than the English-speaking
countries and (b) delayed the start of formal reading
instruction to 7 years, using the years 5-7 to build
confidence, citizenship, classroom readiness and
executive function skills
3. But the US reading researchers argue that one can’t
generalise across cultures or languages
4. Could delaying formal reading instruction actually lead to
a deficit that can’t be caught up later?
New Zealand Study:
Suggate, Schaughency & Reece, 2013
• Compared 283 children in Steiner
schools (RIA 7 years) with those in
state schools (RIA 5 years).
• The Steiner children lagged
behind in reading at 8 years (of
course), but by 11 years had
caught up in reading and were
slightly ahead in comprehension.
• Personal Communication, thanks
to Sebastian Suggate …
• Unlike most studies where those
who are already doing well get
further ahead, the effect was
beneficial primarily for the lower
achievers!
• More haste, less speed
Adopting a neuroconstructivist approach
(cf Karmiloff-Smith,2013)
Understanding the dynamics of developmental trajectories, that
outcomes for a child reflect both genes and the environment
1. Using early intervention in children at genetic risk to prevent
the expression of the phenotype, changing the trajectory,
working with developing skills over time
2. Ensuring children are ready to learn and anticipating progress
from stage to stage with explicit input to develop language and
executive skills
3. Adopting an appropriate and different approach for the pre-
school, primary and secondary child building on plasticity
4. At least a 2 pronged attack - preventing the development of
procedural learning deficits, building automaticity and
remediating deficits which have already developed
5. Building in success, fun and raising self esteem at all stages
Prevention – what works for the at risk
pre-school child?
Building on experimental evidence from family studies
i) Train grapheme phoneme linkage – 3 hrs with
Graphogame (Lyttinen, 2012) and emergent literacy
ii) Protective factors Vocabulary and resilience through
wider interests (Muter and Snowling (2007)
iii) ‘fun’ impacts as much as reading to your child
iv) Train executive skills – listening, memory, attention,
inhibition, readiness to learn
v) Lexipal – colourful computerised screener and
intervention tool for Indonesia
Elements - Explicit, structured systematic, concrete, fun
Large scale screening and support at 5
Numbers at risk before and after HOL
100
80
60
Pre
40 Post
20
0
High Risk Low Risk No Risk
Screening with DEST (Nicolson and Fawcett, 2004) 12 weeks support

small group for 1 hr weekly in 3 20 minute sessions.
Total children assessed both at pre-test and post-test 599.
Incidence of high risk reduced from 10.9% to 5.0%
Incidence of low (or high) risk reduced from 24.2% to 8.5%
What works for children who are failing?
1. This may depend on the language – for irregular English we definitely need
accuracy and phonics, but for regular languages we need fluency!
2. Phonics meta-analysis (Galuscha et al, 2014), Rime Graphogame combining
English and music training (Goswami’s group, 2013)
3. Assistive listening devices improve language processing and music as an aid
to statistical learning (Kraus’s group 2013, 2014)
4. Train Executive function– memory, attention, and categorisation cf. Facoetti
Rabbits study with sequences – make it fun! Use feedback. Try scaffolding
for extra effectiveness.
5. Train non-linguistic components of procedural learning, matching rhythms
with spatial representations, with length, width and varying exposure Kujala
et al, 2001.
6. Extra wide letter spacing to improve speed and accuracy of reading (Zorzi et
al 2012)
7. Keys to success- understanding, recognition of difficulties and amount of
hard work needed, perseverance and determination!
Theoretical and applied conclusions
1. There is growing evidence of impairments in procedural

learning for dyslexic children across the age range
2. Impairments are in place before children even reach
school, in statistical learning in language and vision
3. To reduce these we need to assess strengths and
weakness and provide consistent conditions for learning
with explicit feedback and constant mapping before
children fail – focusing on executive skills
4. For older children a range of approaches harnessing new
technologies, building on strengths for positive outcomes
and the expression of their full potential
More research needed - there is much to be done!
References
Nicolson R.I and Fawcett, A.J (2105 submitted) Development of Dyslexia: The Delayed Neural
Commitment framework, Annals of Dyslexia
Nicolson, R.I and Fawcett, A.J. (2011) Dyslexia, dysgraphia and procedural learning. Cortex, 47,
117-127
Nicolson, R. I, Fawcett, A. J, Brookes, R. L. and Needle J. (2010). Procedural learning and
dyslexia. Dyslexia, 16, 194-212
Nicolson, R. I. and Fawcett, A. J. (2007). Procedural learning difficulties: reuniting the developmental
disorders? Trends in Neurosciences, 30 (4), 135-141.
Crispiani P and Palmieri, E (2015) Improving the fluidity of whole word reading with a dynamic
co‐ordinated movement approach Asia Pacific Journal of Developmental Differences Vol. 2, No.
2, July 2015, pp 158 ‐ 183
DOI: 10.3850/S2345734115000277
Gabay, Y., Schiff, R., & Vakil, E. (2012). Dissociation between the procedural learning of letter
names and motor sequences in developmental dyslexia. Neuropsychologia, 50(10), 2435-2441.
Gabay, Y, Thiessen, E D Holt L (2015) Impaired Statistical Learning in Developmental Dyslexia.
Journal of speech, language, and hearing research : 58 3, 934-45
Gabay, Y. Schiff, R, Vakil, Eli. (2015) Attentional Requirements During Acquisition and Consolidation
of a Skill in Normal Readers and Developmental Dyslexics NEUROPSYCHOLOGY, 26, 6, 744-757
Gabay, Y, Holt, L (2015) Incidental learning of sound categories is impaired in developmental
dyslexia Cortex, 73, 131-143
Hedenius, Ullman, M T. Alm,P Jennische,M Persson, J (2013) Enhanced Recognition Memory
after Incidental Encoding in Children with Developmental Dyslexia PLOS ONE, 8, 5 63998

References 2
1 Franceschini, S., Gori,S Ruffino,M Viola, S Molteni, M and Facoetti, (2013) A. Action Video
Games Make Dyslexic Children Read Better. Current Biology 23, 462–466
2 Hornickel J, Zecker S, Bradlow A, Kraus N. (2012)Assistive listening devices drive neuroplasticity
in children with dyslexia. Proceedings of the National Academy of Sciences. 109(41): 16731–16736
3 Kraus N, Slater J, Thompson E, Hornickel J, Strait D, Nicol T and White-Schwoch T (2014)Music
enrichment programs improve the neural encoding of speech in at-risk children. Journal of
Neuroscience. 34(36): 11913-11918
4 T. Kujala*†, K. Karma‡, R. Ceponiene*, S. Belitz*, P. Turkkila‡, M. Tervaniemi*, and R. Näätänen. (2001) Plastic neural changes
and reading improvement caused by audiovisual training in reading-impaired children. PNAS. 98.
1091-6490
5 Lachmann, T and van Leeuwen, C. (2014) Reading as functional coordination: not
recycling but a novel synthesis. FRONTIERS IN PSYCHOLOGY, 5, 1046
6 Lum, J. A. G., Ullman, M T. and Conti-Ramsden, G (2013) Procedural learning is impaired in
dyslexia: Evidence from a meta-analysis of serial reaction time studies. RESEARCH IN
DEVELOPMENTAL DISABILITIES, 34, 10, 3460-3476
7 Ullman, M T. and Pullman, M Y. (2015) A compensatory role for declarative memory in
neurodevelopmental disorders NEUROSCIENCE AND BIOBEHAVIORAL REVIEWS, 51, 205-
222
8 Zorzi, M, Barbiero, C., Facoetti, A, Lonciari, I., Carrozzi, M Montico, M., Bravar, M George, F.,
Pech-Georgel, C and Ziegler. J (2012) Extra-large letter spacing improves reading in dyslexia. PNAS
109 (28) 11455-11459

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Exploring learning disabilities -

deficits, delays and strengths in

Hermina Hospital, Jakarta

Copyright AF and RIN 2016

• Reading performance that is markedly below what is

Copyright AF and RIN 2016

Copyright AF and RIN 2016

Copyright AF and RIN 2016

The ‘correct’description of dyslexia is ‘Specific Learning

Dyslexia is [some] general deficit in learning

The Automatisation Deficit hypothesis (N & F 1990)

Copyright AF and RIN 2016

The deficit increases directly with task complexity

(i) Problems with initial blending 50

[t is time taken, n is number of 0

Copyright AF and RIN 2016

Copyright AF and RIN 2016

Motor skill impairment writing

Copyright AF and RIN 2016

Declarative and procedural conspire and compete!

1. The core difficulties in dyslexia relate to the language-

Copyright AF and RIN 2016

Biological 2.Cerebellar Deficit, possibly other parts of

Cognitive 4.Cognitive Difficulties

5.Poor procedural learning

Copyright AF and RIN 2016

We found problems at all stages, but where do they come from?

1. Immediate stage seconds

Copyright AF and RIN 2016

• Cortico-cerebellar circuit Motor adaptation

d’ is accuracy of recognition of signs adjusted for guessing

Motor Skill Dyspraxia

24 Copyright AF and RIN 2016

1. For a given child, the specific pattern of declarative and procedural

Copyright AF and RIN 2016

Copyright AF and RIN 2016

• A major challenge is to identify and

1. Behaviour Phonologica Double

Copyright AF and RIN 2016

2. Bilingual Language Development

1. Dyslexic individuals are relatively slow to automatise skills

Copyright AF and RIN 2016

1. Neural commitment is the primary mechanism for language

Copyright AF and RIN 2016

Copyright AF and RIN 2016

Copyright AF and RIN 2016

Reading reading failure

Not ready to learn to

3 5 7 years Copyright AF and RIN 2016

“Executive functions (EFs; e. g., reasoning, working memory, self-

1. There is no doubt that reading achievement in the UK and

Screening with DEST (Nicolson and Fawcett, 2004) 12 weeks support

1. There is growing evidence of impairments in procedural

Copyright AF and RIN 2016

Copyright AF and RIN 2016

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