By Marisol Lorenzo
This issue of NASET’s LD Report was written by Marisol Lorenzo. A large population of students between third and fifth grades with autism spectrum disorder and other learning disabilities struggle with reading skills, including comprehension, fluency, and phonemic awareness. Consequently, these children are reading significantly below grade level across all subject areas such as math, science, and social studies, which also affects their communication and writing skills. In addition, they have great difficulty adhering to the state’s content standards. Implementing appropriate instructional strategies and materials becomes a burden for educators due to the unique needs, strengths, and learning styles of each individual child. The purpose of this literature review is to evaluate the effectiveness of different evidence-based practices implemented by teachers to improve the literacy skills of students with disabilities who are reading below grade level.
Abstract
A large population of students between third and fifth grades with autism spectrum disorder and other learning disabilities struggle with reading skills, including comprehension, fluency, and phonemic awareness. Consequently, these children are reading significantly below grade level across all subject areas such as math, science, and social studies, which also affects their communication and writing skills. In addition, they have great difficulty adhering to the state’s content standards. Implementing appropriate instructional strategies and materials becomes a burden for educators due to the unique needs, strengths, and learning styles of each individual child. The purpose of this literature review is to evaluate the effectiveness of different evidence-based practices implemented by teachers to improve the literacy skills of students with disabilities who are reading below grade level.
Keywords: special education, evidence-based practices, reading comprehension, fluency, phonological awareness.
Improving Reading Skills in Students Below Grade Level: A Literature Review
The IEP team should write annual goals that are challenging and at the same time achievable for the students that are reading below grade level (Office of Special Education and Rehabilitative Services, 2015). Teachers must create goals for the Individual Educational Plans (IEP) that will keep the student on grade level whenever possible and suit each student’s specific needs as well. Another essential element in improving these students’ reading skills is combining all the different reading areas when delivering instruction and evidence-based interventions. Zugel (2012) considers that success in creating a complete reading curriculum depends on combining effective teaching strategies with the inclusion of all subsets of reading skills, such as comprehension, vocabulary, fluency and phonemic awareness. As suggested by the National Institute of Child Health and Human Development (2000), the use of a reading curriculum designed to incorporate all the components of reading should be implemented in elementary classroom. Furthermore, research has shown that instruction in oral language, vocabulary, word knowledge, and text structure is a key element in developing good reading comprehension skills (Solari, Denton, Petscher, & Haring, 2018). In reviewing the literature, researchers considered various evidence-based practices to improve reading skills in students with disabilities who are below grade level, while focusing on the following subskills: fluency, comprehension, and phonological awareness.
Reading Comprehension
Headsprout Early Reading consists of 40 animated episodes of 20 minutes each, designed to deliver instruction in comprehension, vocabulary, fluency, phonics and phonemic awareness through an Internet-based curriculum (What Works Clearinghouse, 2009). Headsprout Early Reading is a similar curriculum regarding design and structure; however, it focuses less on decoding than on reading comprehension (Cullen, Alber-Morgan, Schnell, & Wheaton, 2014). Hill and Flores (2015) conducted a study with the purpose of examining Headsprout Early Reading and Headsprout Reading Comprehension as a method of instruction and assessment of early reading skills for students who had poor expressive language skills in writing as well as in communication. Participants were six students with ages between 9 and 14 who had been diagnosed with ASD and other developmental disabilities. Three subjects had African-American origins, three were Caucasians, and one was Hispanic. Monday through Friday for four weeks, the subjects received computer-aided instruction in phonemic awareness, segmenting, blending, phonics, fluency, sight words, and punctuation as part of the Extended School Year program offered by a university where participants were enrolled during summer. One purpose of this study was to ensure maintenance of skills learned through the continuity of the intervention in reading practice and data collection methods to the home school. In addition, the Headsprout Readiness Assessment was used as pre-test and post-test to monitor progress. Outcomes showed that three students made substantial progress with the intervention, while the other three improved focusing skills. Only one participant was able to complete the Headsprout Early Reading and move into the Headsprout Reading Comprehension. Student A scored between the 91% and 99% on 23 lessons ofHeadsprout Early Readingprogram. Student B scored above 80% on the first, third, and sixth lessons, and between 70-79% on the remaining five lessons. Student C scored above 80% in two lessons. Student D scored between 79% and 80% in six lessons. The other two participants failed to read any words during pretest or posttest; however, they improved focusing skills as evidenced in the reduction of timeouts – times the student refused to answer. Student E went from 66% to 9% of timeouts, whereas student F went from 87% to 4% timeouts (Hill & Flores, 2015).
According to Gately (2008), skills like highlighting key details, working memory, and independence in children with autism can be enhanced by the usage of graphic organizers, graphics, visual maps, and structure mapping. A study was carried out by Bethune and Wood (2013) to evaluate the effects of graphic organizers on the accuracy of wh-questions answered after reading a short story. Subjects were three children with ASD who studied in an elementary school and had de?cits in reading comprehension. The study was conducted in a public elementary school in an urban area of the southeastern United States. Due to the small sample of participants taken from a special needs’ population, the experimental design used was a delayed multiple baseline across participants. In addition, the design was divided in three phases: baseline, intervention, and maintenance. During the baseline phase, students had to complete two probes identifying and answering wh-questions. The intervention used during the second phase was graphic organizers. The generalization and maintenance data were collected as percent of wh-questions answered accurately during the participants’ regular reading instruction hours. The interventions took place in each student’s classroom, at their own desk or at a designated reading instruction table. The main goal was to stop the intervention when the student was able to answer seven out of eight comprehension questions accurately in three sessions, obtaining five data points per phase. Outcomes indicated generalization and maintenance of skills gained through the graphic organizers on the accuracy of wh-questions interventions. In the maintenance phase, the three participants averaged 7.6, 7.25, and 7.0 correct answers to wh-questions per probe respectively. Also, students averaged 7.8, 7.5, and 7.3 correct words sorted onto the graphic organizers respectively (Bethune & Wood, 2013).
When teachers incorporate informational texts into science instruction, it is useful to encourage children to establish connections between the new content they are learning with the background information they already have about the topic, which will assist them in challenging the way they think and finding new methods for applying their knowledge (Vick, 2016). Ritchey, Palombo, Silverman, and Speece (2017) implemented a study using a reading-comprehension intervention – PLUG-IN –using informational science texts for fifth graders. As suggested by the name of this intervention, it teaches strategies to preview the passage; link it to background information; use fix-up strategies; generate questions; restate the main ideas in their own words; and finally answer a set of comprehension questions. The subjects that participated in this experiment were 46 fifth graders with deficits in one or more areas of reading, coming from elementary schools in the Mid-Atlantic region of the United States. One student was identified as having a learning disability in math, and one had a learning disability in writing. Three participants had Individual Educational Plans, while two had 504 Plan. Furthermore, four students were English Language Learners. Participants were assigned to an intervention or no treatment control condition. The intervention was implemented in instructional cycles of four days each. Explicit instruction was delivered in the first day, targeting comprehension and vocabulary of short passages or selections. Additional modeling on independent practice with short texts and books was implemented the second day. More independent practice was introduced the third day, when participants received scaffolding from the tutors. Finally, in the fourth day students guided one another on applying reading strategies to analyze biographical texts. Outcomes yielded statistically significant effects favoring the intervention and its effectiveness as short-term interventions within a Response to Intervention framework. Hedge’s g with covariate adjusted mean scores was used to determine the effect sizes. The effect size for the Assessment of Strategy Knowledge and Use for Information Test (ASKIT) was 0.724. The effect sizes for the Qualitative Reading Inventory–Fifth Edition comprehension test (QRI-5) were moderate. The results from the Wechsler Individual Achievement Test (WIAT) indicated an effect size of ?0.037. Similarly, results from the Test of Sentence Reading Efficiency and Comprehension (TOSREC) yielded an effect size of 0.155 (Ritchey, Palombo, Silverman, & Speece, 2017).
During shared reading, a story is read aloud by the teacher while students listen and interact with the reader; this practice is a more interactive way to access literature that is age-appropriate for young readers (Hudson & Test, 2011). The purpose of a research study conducted by Alison, Root, Browder, and Wood (2017) was to examine the effectiveness of e-text shared story reading combined with vocabulary and comprehension prompts, using narrative texts aligned with the participants’ grade. The subjects participating in this experiment were three elementary students of diverse ethnic backgrounds who had been identified as having autism and were English-language learners as well. The intervention took place in a separate classroom from a school located in the southeastern United States. Each session lasted 30 minutes and was delivered one-to-one during daily literacy centers, while the other participants rotated during the 90 minutes of literacy blocks. An iPad was utilized to create and display all the materials in this intervention. The design used in this study was single-case multiple probe across participants. The independent variables measured the correct matching of WH words with definitions and examples, and the amount of comprehension question answered correctly. Outcomes indicated that students can benefit from the use of shared story reading combined with technological support to answer WH questions, and to identify the definitions and rules of WH comprehension questions. Regarding the number of independent correct WH words matching during the intervention phase, the subjects averaged 7.9, 9.6, and 8.4 respectively. They met mastery criteria after around eleven sessions and maintained the skills postintervention after five and eight sessions approximately. Regarding correct answers to comprehension questions during the intervention phase, participants averaged 4.1, 3.9, and 4.2. The students reached mastery criteria in around eight weeks (Alison, Root, Browder, & Wood, 2017).
Rivera, Spooner, Wood, and Hicks (2013) conducted a study to evaluate how two students with moderate intellectual disability, as well as being English Language Learners, would benefit from the use of a multimedia shared story reading program to acquire new vocabulary in English language. Participates were two Mexican-American students in third grade from a separate especial education setting where they received instruction in English language.
The design used in this study was a single subject alternating treatment with an initial baseline. During the baseline, the teacher presented vocabulary words from the pre-assessment in English and Spanish. During the Multimedia Shared Stories intervention, participants were given the opportunity to predict the plot of the story; also, vocabulary already previewed in the baseline and pre-teaching phases was now introduced. Intervention was implemented in both languages, English and Spanish, following the same steps and strategies. Intervention was implemented for two weeks, around seven to eleven minutes per session. In order to measure generalization, a pre-test and post-test was administered using 15 different words learned in the intervention phase. Moreover, data was collected for five weeks after the intervention was over for maintenance. Outcomes yielded that multimedia shared stories were a practical supplement for literacy instruction, though they did not have a great effect on vocabulary generalization and maintenance over time. Regarding English intervention for correct words identification, the two participants scored means of 13.6, and 18.1 respectively. In relation with the Spanish intervention, students scored 7.8 and 3.4 respectively. As per generalization, results indicated a mean growth of 65%, and 30% between pre-test and post-test for each child respectively (Rivera, Spooner, Wood, & Hicks, 2013).
Fluency
What Works Clearinghouse (2014) describes the Repeated Reading intervention as an academic practice to help students with reading fluency skills below grade level, but that have gained knowledge of initial word reading. Listening Passage Preview is another intervention used for increasing reading fluency where students listen to a short word passage written at their instructional level before reading it orally (Skinner, Cooper, & Cole, 1997). The effectiveness of listening passage preview (LPR) and repeated readings (RR) on oral reading ?uency in children on the autism spectrum was examined by the researchers Reisener, Lancaster, McMullin, and Ho (2014). Participants were four third graders coming from a Southeastern rural school. These students were diagnosed with autism and had deficits with their overall reading abilities. The researchers utilized a single-subject withdrawal design to evaluate the effectiveness of the two reading interventions. Also, the LPP and RR interventions were counter balanced. Outcomes showed that all participants increased their overall oral reading ?uency with the repeated reading and listening passage preview interventions. The participants’ mean scores in oral reading fluency as measured by words correct per minute during the listening passage preview condition were 110.7, 75.1, 44.0, and 60.5. Students’ mean scores during the repeated reading condition were 120.0, 97.2, 60.6, and 83.0. Both interventions produced greater mean scores as compared with baseline or withdrawal phase (Reisener, Lancaster, McMullin, & Ho, 2014).
The purpose of a research study performed by Begeny, Krouse, Ross, and Mitchell (2009) was to show the effectiveness of three reading interventions used to improve reading fluency: repeated reading, listening passage preview, and listening only. Participants were four second-grade students from a rural school in the Southeast with average to below average reading skills, who needed additional support in reading practice. Their ethnic backgrounds were one Caucasian, two African Americans, and one Hispanic. The researchers used an alternating-treatments design to evaluate the intervention and control conditions. Participants were grouped together and received interventions simultaneously. Outcomes yielded that repeated reading intervention, followed by listening passage preview, is a most effective intervention to aid students with fluency difficulties. The average score across all students for each intervention indicated immediate gains for all the four students. Average scores across all students for control condition, listening passage preview, repeated reading, and listening only were 65.25, 88.69, 98.19, and 84.13 respectively. Also, generalization and maintenance of intervention were evidenced after completion of the program, as evidenced by retention gains of 75.00, 92.56, 96.69, and 83.63 across each intervention implementation (Begeny, Krouse, Ross, & Mitchell, 2009).
Phonological Awareness
Mulé, Volpe, Fefer, Leslie, and Luiselli (2015) compared traditional drill and practice (TDP) and incremental rehearsal (IR) -?ashcard drill techniques for teaching sight words to students – to evaluate their effectiveness with the autism population. With the TPD, first the teacher presents flashcards with printed words and models its accurate pronunciation, then the student reads the words aloud (Joseph, 2007). On the other hand, the IR provides repetition through interspersing unknown words with previously learned ones, each new item one at a time (MacQuarrie, Tucker, Burns, & Hartman, 2002). The participant was a second-grade student, educated in a separate classroom, who was diagnosed with ASD. The researchers utilized an adaptive alternating treatments design. The study was conducted in the participant’s classroom comprised of a special education teacher, two paraprofessionals, and four other peers. Sessions took place at a table located in the classroom while the other students and teachers were engaged in different activities. As per results, the participant was able to retain 52 words (2.48 words per day) from the traditional drill and practice condition, and 41 words (1.95 words per day) from the incremental rehearsal condition. Generalization and maintenance outcomes indicated that both interventions helped increase sight-word recognition in students with autism. The maintenance assessment data indicated that the participant maintained 38 words from traditional drill and practice condition, and 24 words from the incremental rehearsal condition (Mulé, Volpe, Fefer, Leslie, & Luiselli, 2015).
As stated by researchers Akechi, Senju, Kikuchi, Tojo, Osanai, and Hasegawa (2011), children with autism do not follow the speaker’s eye gaze when learning the meaning of new words by connecting the word with its corresponding object. The purpose of a research study conducted by McGregor, Rost, Arenas, Farris-Trimble, and Stiles (2013) was to evaluate the importance eye gaze to attach meaning to words in the extra-linguistic context for children with autism spectrum disorder. Subjects were 73 students treated according to ethics approved by the University of Iowa IRB; 30 had been diagnosed with autism, while 43 were typically developing children. The intervention utilized in this study was word recognition and mapping task. Participants had to look at pictures of three objects on a computer screen and click on one of those objects as soon as it was named by a woman sitting behind the objects. Outcomes indicated that students with autism spectrum disorder are as skilled as typical readers in monitoring speaker’s eye gaze and using it as a clue to identify the meaning of unknown words. Regarding word recognition, results showed an accuracy between 95% and 100% across groups and conditions. Accuracy of students with autism was not significantly different from typically developing students (ps > .32). With respect to the word mapping, both groups scored significantly high. Students with autism scored t = 3.55, df = 29, p = .001; typically developing students scored t = 4.38, df = 42, p < .0001 (McGregor, Rost, Arenas, Farris-Trimble, & Stiles, 2013).
Children with autism have difficulty understanding metalinguistic information conveyed through eye-gaze, thus affecting their skills to use arbitrary cues to make inferences (Ames, & Jarrold, 2007). Akechi, Kikuchi, Tojo, Osanai, and Hasegawa (2013) conducted a study to investigate whether children’s performance improve when another person’s cue, like pointing, is added to the speaker’s eye gaze. Participants were 18 children with autism and 18 typically developing children aged between six and eleven years old. An integrated Tobii 2150 Eye Tracker was used to present stimuli and collect gaze direction data. In this experiment, a pointing hand was presented with the speaker’s gaze to determine the effects of combining pointing and gaze to improve referential word mapping. In the familiar trial, a speaker face was presented with two random, numbered objects, then participants were prompted to identify one object by calling out its number. Later, in the test trials, a pointing hand was added to the speaker’s face gaze. The experiment demonstrated that adding pointing to gaze duration on the object improves referential word mapping in children with ASD. In the follow-in condition, the percentage of children who selected the target object accurately was similar between the group of students with autism (94.04%) and the group of typically developing students (100%). Similarly, the percent of accurate responses in the discrepant condition was 100% for each group, with 18 correct items out of 18 (Akechi, Kikuchi, Tojo, Osanai, & Hasegawa, 2013).
The importance of integrating all components of reading – comprehension, vocabulary, fluency, phonics, and phonemic awareness – when implementing instruction for students reading significantly below grade level, is evidenced throughout the literature review. This goal can be achieved by utilizing a diverse number of evidenced-base practices. The studies reviewed in the in the literature indicated that combining comprehension, vocabulary, fluency, phonics and phonemic awareness through an Internet-based curriculum can improve early reading skills in students with poor expressive language skills in writing as well as in communication. Also, previewing, linking to background information, using fix-up strategies, generating questions, restating main ideas, and answering comprehension questions are useful strategies to understand informational texts in science instruction. Furthermore, shared reading using an iPad facilitates the development of communication skills and acquisition of new vocabulary while analyzing a story and interacting with the teacher. All these practices incorporate several components of reading to promote the development of good literacy skills.
References
Akechi, H., Senju, A., Kikuchi, Y., Tojo, Y., Osanai, H., & Hasegawa, T. (2011). Do children with ASD use referential gaze to learn the name of an object? An eye-tracking study. Research in Autism Spectrum Disorders, 5(3), 1230-1242. doi:http: //dx. doi.org. ezproxy.fiu. edu/ 10.1016/j.rasd.2011.01.013
Akechi, H., Kikuchi, Y., Tojo, Y., Osanai, H., & Hasegawa, T. (2013). Brief report: Pointing cues facilitate word learning in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(1), 230-235. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1007/ s10803-012-1555-3
Alison, C., Root, J. R., Browder, D. M., & Wood, L. (2017). Technology-based shared story reading for students with autism who are English-language learners. Journal of Special Education Technology, 32(2), 91-101.doi:http://dx.doi.org.ezproxy.fiu.edu/ 10.1177/ 0162643417690606
Begeny, J. C., Krouse, H. E., Ross, S. G., & Mitchell, R. C. (2009). Increasing elementary-aged students’ reading fluency with small-group interventions: A comparison of repeated reading, listening passage preview, and listening only strategies. Journal of Behavioral Education, 18(3), 211-228. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1007/s10864-009-9090-9
Bethune, K. S., & Wood, C. L. (2013). Effects of wh-question graphic organizers on reading comprehension skills of students with autism spectrum disorders. Education and Training in Autism and Developmental Disabilities, 48(2), 236-244.
Cullen, J. M., Alber-Morgan, S., Schnell, S. T., & Wheaton, J. E. (2014). Improving reading skills of students with disabilities using Headsprout comprehension. Remedial and Special Education, 35(6), 356-365. doi:http://dx.doi.org.ezproxy.fiu.edu/ 10.1177/0741932514534075
Gately, S. E. (2008). Facilitating reading comprehension for students on the autism spectrum. TEACHING Exceptional Children, 40(3), 40-45.
“Headsprout early reading” TM]. what works clearinghouse intervention report. (2009). What Works Clearinghouse, P.O. Box 2393, Princeton, NJ 08543-2393. Retrieved from ERIC
Hill, D. A., & Flores, M. M. (2015). A preliminary investigation of the benefits of computer-aided instruction in reading decoding for students with autism spectrum disorder and other developmental disabilities. Journal of the American Academy of Special Education Professionals, 1-11.
Hudson, M. E., & Test, D. W. (2011). Evaluating the evidence base of shared story reading to promote literacy for students with extensive support needs. Research and Practice for Persons with Severe Disabilities (RPSD), 36(1-2), 34-45.
Joseph, L. M. (2007). Getting the “most bang for your buck”: Comparison of the effectiveness and efficiency of phonic and whole word reading techniques during repeated reading lessons. Journal of Applied School Psychology, 24(1), 69-90. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1300/J370v24n01_04
MacQuarrie, L. L., Tucker, J. A., Burns, M. K., & Hartman, B. (2002). Comparison of retention rates using traditional, drill sandwich, and incremental rehearsal, flash card methods. School Psychology Review, 31(4), 584.
McGregor, K. K., Rost, G., Arenas, R., Farris-Trimble, A., & Stiles, D. (2013). Children with ASD can use gaze in support of word recognition and learning. Journal of Child Psychology and Psychiatry, 54(7), 745-753. doi:dx.doi.org.ezproxy. fiu.edu /10.1111/jcpp.12073
Mulé, C. M., Volpe, R. J., Fefer, S., Leslie, L. K., & Luiselli, J. (2015). Comparative effectiveness of two sight-word reading interventions for a student with autism spectrum disorder. Journal of Behavioral Education, 24(3),304-316. doi:http://dx.doi.org.ezproxy. fiu.edu/10.1007/s10864-015-9220-5
National Institute of Child Health and Human Development. (2000). Report of the National Reading Panel. Teaching children to read: An evidence?based assessment of the scientific research literature on reading and its implications for reading instruction (NIH Publication No. 00?4769). Washington, DC: U.S. Government Printing Office.
Reisener, C. D., Lancaster, A. L., McMullin, W. A., & Ho, T. (2014). A preliminary investigation of evidence-based interventions to increase oral reading fluency in children with autism. Journal of Applied School Psychology, 30(1), 50-67.doi:http:// dx.doi.org.ezproxy.fiu.edu/10.1080/ 15377903.2013.869785
Ritchey, K. D., Palombo, K., Silverman, R. D., & Speece, D. L. (2017). Effects of an informational text reading comprehension intervention for fifth-grade students. Learning Disability Quarterly, 40(2), 68-80. doi:http://dx.doi.org. ezproxy.fiu.edu/ 10.1177/ 0731948716682689
Rivera, C. J., Spooner, F., Wood, C. L., & Hicks, S. C. (2013). Multimedia Shared Stories for Diverse Learners with Moderate Intellectual Disability. Journal of Special Education Technology, 28(4), 53–68.
Skinner, C. H., Cooper, L., & Cole, C. L. (1997). The effects of oral presentation previewing rates on reading performance. Journal of Applied Behavior Analysis, 30(2), 331-33.
Solari, E. J., Denton, C. A., Petscher, Y., & Haring, C. (2018). Examining the effects and feasibility of a teacher-implemented tier 1 and tier 2 intervention in word reading, fluency, and comprehension. Journal of Research on Educational Effectiveness, 11(2), 163-191.
U.S. Department of Education, Institute of Education Sciences, What Works Clearinghouse. (2014, May). Students with Learning Disabilities intervention report: Repeated Reading. Retrieved from whatworks.ed.gov
U.S. Department of Education, Office of Special Education and Rehabilitative Services. (2015, November 16). Guidance on FAPE. Retrieved from https://www2.ed.gov/policy/ speced/guid/idea/memosdcltrs/guidance-on-fape-11-17-2015.pdf
Zugel, K. (2012). Success for students with diverse reading abilities through the use of supplemental reading curriculum. TESOL Quarterly: A Journal for Teachers of English to Speakers of Other Languages and of Standard English as a Second Dialect, 46(1), 199-209. doi:http://dx.doi.org.ezproxy.fiu.edu/10.1002/tesq.11
About the Author
Marisol Lorenzo was born in Cuba in 1976. After finishing high school, the author enrolled for the English Language major at the University of Havana and graduated with a bachelor’s degree in 2002. In 2013, Marisol Lorenzo moved to the United Stated, where new professional opportunities opened for her. She was offered a position as paraprofessional to work with students with autism, and her career as interpreter and translator made a twist. Now she works as a special education teacher at Gloria Floyd Elementary school, and she is earning a master’s degree in special education at FIU. Since she works with students who have autism spectrum disorder, she has focused most of her research on improving students’ behavior and academic achievements in the classroom. Likewise, home practice is a related topic that highly interests her because enhancing implementation of parental training outside the school environment is an effective way to ensure that skills students have learned are transferred to their home environment. The author has conducted literature reviews to investigate home and classroom evidence-based practices to help families cope with the stress of raising children with autism. Her literature review “Parents Coping with Autism Spectrum Disorder: A Literature Review” was recently published by the National Association of Special Education Teachers (NASET). Mrs. Lorenzo currently lives with her husband and son in a suburban area of Miami. Her family is her greatest responsibility and, at the same time, her greatest reward.
Download this Issue
To Download a PDF file version of this Issue of the NASET LD Report –CLICK HERE
