ADHD in the Schools

 

The Effects of EEG Neurofeedback and Remedial Reading Program on Oral Reading Fluency and Reading Comprehension of Children with Attention Deficit Hyperactivity Disorder in the Public Schools

By Harry Suffron

Abstract

There is a need in school psychology for research in the school setting which examines the effects of combined interventions verses single intervention with children with attention deficit hyperactivity disorder (ADHD). The study examined the effects of two treatment conditions (combined interventions verses single intervention) on the oral reading fluency and reading comprehension of eighty children with attention deficit hyperactivity disorder (ADHD). Forty children received a combination of neurofeedback and remedial reading program as treatment, and forty children received a remedial reading program as treatment. Children were from two inner city K-8th grade public schools in Phoenix, Arizona with a diverse student population. Test results indicate that treatment conditions had no significant effect upon oral reading fluency, however test results indicate that a combination of neurofeedback and remedial reading program had a significant effect upon reading comprehension. Recommendations were made concerning additional research that needs to be conducted by school psychologists in the school setting.

Children in the public schools who are inattentive, impulsive, and hyperactive are frequently referred by physicians, parents, and teachers for a psychoeducational evaluation. The author has observed that the ratio of referrals of boys to girls is often ten to one, yet there is a paucity of research that explains why there are so many boys with this symptom cluster. Some of these referred children have already received a medical diagnosis of attention deficit hyperactivity disorder (ADHD), while other children may eventually receive such a diagnosis when the psychoeducational evaluation is completed and the parent shares the psychoeducational evaluation with the family physician. This sequence of events may result in the ADHD child being treated with stimulant medications. This form of treatment has been increasing at an alarming rate (Goldstein & Goldstein, 1998), there has been a growing concern over brain toxicity and negative side effects of stimulant medications (Breggin, 1999; Sadiq, 2007), and educators, medical professionals, and psychologists have been developing alternative forms of treatment including cognitive behavior therapy, psychotherapy, family therapy, social skills training, academic skills intervention, and neurotherapy using EEG neurobiofeedback (Amen, 2001; Barkeley, 2007; Swingle, 2008). DuPaul (2007) indicates in a review of interventions with ADHD students that school psychologists need to examine the effects of combined interventions verses single intervention in the school setting. Following a discussion of demographic data and etiology of ADHD, assessment of ADHD, school functioning of children with ADHD, and treatment of children with ADHD, a study will be presented which examines the effects of a combined intervention and a single intervention on the learning of reading skills of children with ADHD in two K-8th grade public schools in Phoenix, Arizona.

Overview of ADHD in Children

The incidence and etiology of children with ADHD will be discussed. The assessment of children with ADHD will be examined through a review of clinical assessment, normative assessment, and neurophysiological assessment. School functioning of children with ADHD will be presented by contrasting behavioral components of the disorder with academic skills components. Treatment of children with ADHD will be discussed in terms of the most common pharmacological, psychological, and neurophysiological approaches.

Demographic Data and Etiology of ADHD

Attention deficit hyperactivity disorder (ADHD) is seen in five percent of children in the elementary school, boys are ten times more likely than girls to have ADHD, and 60 percent of children with ADHD continue to exhibit symptoms of this disorder into adulthood (Carlson, 2004). Santrock (2006) reports that ADHD decreases in only about one third of adolescents. Approximately half of children with ADHD have significant problems with learning or communication (Comer, 2007). The most frequent comorbid disorders are obsessive compulsive disorder, oppositional defiant disorder, and antisocial personality disorder (Goldstein & Goldstein, 1998).

The etiology of attention deficit hyperactivity disorder (ADHD) involves multiple factors. Barkeley (2007) is critical of professionals who maintain the false belief that ADHD and its related disruptive behavior and academic deficits are due to faulty contingencies of reinforcement in natural ecologies at home and at school. His review of the literature suggests that the etiology of ADHD includes pre, peri, and post-natal biological hazards to the developing brain, genetic traits, and brain physiology that affects self regulation and executive functioning. In a review of neurophysiological research on the etiology of ADHD, Swanson et. al. (2007) report that research indicates the following conclusions regarding the etiology of ADHD: 1) brain imaging studies clearly indicates the presence of abnormalities in structure (smaller size) and function (hypoactivation) of critical brain regions related to dopamine, 2) molecular genetics studies indicates the presence of associations with dopamine genes (DRD4 and DAT), and 3) studies of environmental effects suggests an increased risk for ADHD is related to the multiple factors of maternal smoking during pregnancy, premature birth or low birth weight, and exposure to low levels of lead. Swanson et. al.(2007, p. 43) report the following major findings concerning regional differences:

  • The caudate nucleus and globus pallidus, which both contain a high density of DA receptors, are smaller in the ADHD  groups than in the control groups.
  • ADHD groups have larger posterior regions (eg., occipital lobes) and smaller anterior brain regions (eg., right frontal white matter).
  • Areas involved in coordinating activities of multiple brain regions have specific subregions (e.g., the rostrum and splenium of the corpus callosum and cerebellum vermis lobules VIII-X) that are smaller in ADHD groups than in control groups.

    Additional studies report on the structure of the corpus callosum with children with ADHD. Giedd et. al. (1995) used quantitative neuroanatomic imaging to examine the corpus callosum of 18 boys with ADHD and 18 matched normal boys. Two anterior regions, the rostrum and the rostral body, were found to have significantly smaller areas in the ADHD group. Antshel et. al. (2005) examined the corpus callosum of 60 children with velocardiofacial syndrome (VCFS), a neurological disorder caused by a microdeletion on chromosome 22q11.2 that predisposes affected individuals to psychiatric conditions and learning disabilities. Half of the children in this sample had VCFS and comorbid ADHD. Results of the study indicate that the children with VCFS and comorbid ADHD had smaller callosal, splenium, and genu areas than children with VCFS alone. 52 gender matched control participants were found to have larger total callosal and subregion areas except for the genu.

    Catecholomine dysfunction is thought to be an etiological factor (Vermont Department of Health, 2008), studies implicate dopamine and norepinephrine, and prescribed medication is directed at these neurotransmitters. Use of methylphenidate (Ritalin) causes an increase in extracellular dopamine in the human brain, while use of atomoxetine (Strattera) blocks the norepinephrine transporter while increasing norepinephrine concentration in the synapse.

    There appears to be an association between otitis media and attention deficit hyperactivity disorder (ADHD) in children. In a study of 22 hyperactive children with learning disorders and 772 normal children, ages 7 to 13, a significantly higher percentage (54%) of hyperactive children had more than 6 episodes of otitis media than was found in the normal group of children (15%) (Hersher, 1978). Thirty-six percent of hyperactive children had more than ten episodes compared to five percent in the normal group. Hagerman & Falkenstein (1987) indicate that a study of 45 children (29 boys, 16 girls, mean age = 9.5 years) with learning disabilities and 21 children with ADHD (17 boys, 4 girls, mean age = 8.5 years) in a child development clinic found that children with ADHD had significantly more complaints of earaches during the preceding three months as well as significantly more ear infections during the preceding year. No between group differences were found.

    A review of the literature found that "psychosocial stressors are not thought to cause ADHD" (Vermont Department of Health, 2008, p. 16), however psychosocial stressors appear to have a relationship to children who have both ADHD and co-morbid disorders. There are higher levels of stress and psychosocial adversity in children with ADHD and co-morbid mood disorders or anxiety than in children with ADHD alone. Children with ADHD and no co-morbid disorders had levels of psychosocial stress which were no different than controls.

    Assessment of ADHD

    Three types of assessment, clinical, normative, and neurophysiological, will be discussed. Clinical assessment utilizes the Diagnostic and Statistical Manual IV-TR (DSM IV-TR) of the American Psychiatric Association. Normative assessment occurs during a psychoeducational evaluation which utilizes an ecological assessment model. Psychophysiological assessment includes the use of EEG electrobiofeedback and brain imaging methods.

    The American Psychiatric Association has published clinical assessment classification systems for mental disorders that have been periodically revised based upon data from clinical practice and research. Moon (2004) reports that that the American Psychiatric Association published the first edition of the Diagnostic and Statistical Manual (DSM I) in 1952, and this author indicates that subsequent editions include DSM II, DSM III, DSM III-R, DSM IV, and DSM IV-TR. DSM I, which reported symptom clusters for 106 disorders in three areas (organic brain syndromes, functional disorders, mental deficiency), contained only one disorder, adjustment reaction of childhood/adolescence, that applied to children. This is in contrast with DSM II which included 11 diagnostic categories and symptom clusters for 185 disorders, including hyperkinetic reaction of childhood. Nagliari and Goldstein (2007) report that hyperkinetic reaction of childhood is characterized by overactivity, restlessness, distractibility, and short attention span. These symptoms were previously viewed as pertaining to children with minimal brain dysfunction (MBD) due to a theory that such children had a minimal degree of brain injury (Goldstein & Goldstein, 1998). Children with MBD exhibited symptoms that were similar to those of brain damaged soldiers from the two world wars, thus it was believed that some form of brain injury was part of the etiology of these symptoms.

    Moon (2004) indicates that DSM III had improved reliability, was based on new research in psychopathology, and contained a multiaxial system of assessment. Symptom clusters for 265 disorders were contained in DSM III. The following two childhood disorders of inattention were included in DSM III: 1) attention deficit with hyperactivity, and 2) attention deficit without hyperactivity (Goldstein & Goldstein, 1998). DSM III-R, an update, was published in 1987, and it included categories that were renamed, significant changes in diagnostic criteria, and symptom clusters for 297 disorders. The two childhood disorders of inattention of DSM III were combined into one disorder, attention deficit hyperactivity disorder (ADHD), in DSM III-R. Webb and Latimer (1993) report that ADHD diagnostic criteria include fourteen behaviors that may be found in children. In order to diagnose ADHD, at least eight of the behaviors must be present, onset must occur prior to age seven, and the behaviors must be present for at least six months.

    According to Moon (2004), DSM IV was published in 1994, included a multiaxial system, provided symptom clusters for 365 disorders, and included the following detailed information for each disorder: 1) essential and associated features, 2) presence, course, and familial pattern, 3) differential diagnosis, and 4) age, gender, and culture. It contained A to E diagnostic criteria for attention deficit hyperactivity disorder. DSM IV-TR was published in 2000 in order to correct factual errors and make changes based upon recent research (American Psychiatric Association, 2000). It lists the following diagnostic codes for four types of ADHD:

  • attention deficit hyperactivity disorder, combined type (314.01)
  • attention deficit disorder, predominantly inattentive type (314.00)
  • attention deficit hyperactivity disorder, predominantly hyperactive-impulsive type (314.01)
  • attention deficit hyperactivity disorder not otherwise specified  (314.9)
  • The fourth type of disorder above is often listed in medical reports as attention deficit hyperactivity disorder NOS. DSM IV-TR retains the multiaxial system that provides assessment information on five axis as follows:

    Axis I:     clinical disorders

    other conditions that may be the focus of clinical attention

    Axis II:    personality disorders

    mental retardation

    Axis III:   general medical conditions

    Axis IV:   psychosocial and environmental problems

    Axis V:    global assessment of functioning

    It is apparent that clinical assessment of children with ADHD involves a multiaxial system which considers factors in five categories. This permits the identification of co-morbid disorders and medical conditions that may be present with the ADHD.

    Normative assessment of children with ADHD utilizes an ecological assessment model that assesses the child in the home and school environments. This model includes the use of normative tests, behavioral observation, and the options of curriculum based assessment and clinical assessment with DSM IV-TR. (Goldstein & Goldstein, 1998; American Psychiatric Association, 2000; Jitendra et. al., 2007; Kern et. al., 2007 ).

    Normative tests include academic skills tests, auditory perception tests, cognitive ability tests, perceptual-motor tests, personality tests, and speech/language tests. Personality tests which consist of both parent rating scales and teacher rating scales include the following: Conners Parent Rating Scale, Conners Teacher Rating Scale, Disruptive Behavior Disorders Parent Rating Scale, Disruptive Behavior Disorders Teacher Rating Scale, and ADHD Rating Scale-IV (Home & School Forms)( Jitendra et. al., 2007; Kern et. al., 2007). The results of the ecological assessment are written in a psychoeducational evaluation report for the benefit of parents, school staff, and other professionals such as physicians and private therapists.

    Neurophysiological assessment includes the use of QEEG brainmapping, brain SPECT imaging, and EEG neurobiofeedback during neurotherapy. Each of the three assessment methods will be described. Research studies will also be reported.

    During QEEG (Quantitative Electroencephalogram) brainmapping, a cap with nineteen sensors is placed on the surface of the head, and brainwave activity is recorded over those nineteen areas. The child's brainmap is compared to a normative database in order to determine if the child's symptoms are neurologically based or simply behavioral (The Drake Institute, 2008a). This type of computerized technology evaluates the way the brain functions rather than assessing the structure of the brain. The brain wave patterns of the child are compared to profiles found in a variety of disorders including ADHD, learning disability, and depression (QEEG Brainmapping Clinic, 2007).

    While CT scans and MRIs look at structure, QEEQ brainmapping looks at metabolism and function. This assessment uses software programs and a normative database which allow subject to data base comparisons in order to show the location and extent of brain dysfunction. Generalized or focal cerebral dysfunction is displayed in colored brain maps or graphs. QEEG is described as an effective tool for differentiating between organic and functional brain disorders. It is able to differentiate between physiological and functional causes of depression and hyperactivity (Learning Discoveries Psychological Services, 2008).

    Monastra et. al (1999) report that QEEG spectral analysis of the electrophysiological output at a single, midline prefrontal location of the brain, the vertex, was conducted in 482 subjects, ages 6 to 30 years old, to test the hypothesis that cortical slowing in the prefrontal region can be used as the basis for differentiating patients with attention deficit hyperactivity disorder (ADHD) from nonclinical control groups. Based upon the results of a standardized clinical interview, behavior rating scales, and a continuous performance test, subjects were classified into three groups (ADHD, inattentive; ADHD, combined; control). The authors report that assessment results indicate significant maturational effects in cortical arousal in the prefrontal cortex as well as evidence of cortical slowing in both ADHD groups, regardless of age or sex. They indicate that assessment results are consistent with the results of neurological assessment procedures (PET, SPECT, MRI) as well as emerging neuropsychologically based models which associate ADHD with prefrontal cortical functioning. This study suggests that quantitative electroencephography assessment procedures are a relatively nonintrusive and inexpensive methodology that provides information about cortical processes that are difficult to obtain from neuroimaging scans (eg., degree of coherence and symmetry in activity between different cortical regions).

    A factor analytic study is reported which involved 100 boys with ADHD (inattentive type) and 40 boys who were age matched controls. Subjects were assessed with an electroencephalograph (EEG) that measured brain wave activity of 21 sites during an eye closed resting condition. The following four types of brain waves were measured: delta, theta, alpha, and beta. Two distinct EEG clusters of children with the inattentive type of ADHD were identified. These were characterized by: 1) increased high amplitude theta with deficiencies of delta and beta activities, and 2) increased slow wave and deficiencies of fast wave activity. These two subtypes consist of a cortically hypoaroused group and a group typified by a maturational lag in central nervous system development. This research study indicates that there are central nervous system abnormalities which are underlying the inattentive type of ADHD (Clark et. al., 2002).

    In contrast with QEEG assessment, brain SPECT imaging refers to single photon emission tomography, a nuculear medicine technology, that evaluates blood flow and activity patterns of the brain. Amen, Paldi, and Thisted (1993) performed brain SPECT imaging on 54 medication free children and adolescents from a psychiatric outpatient clinic who had a DSM III-R diagnosis of attention deficit hyperactivity disorder as well as a score of greater than 18 on the short form of the Conners Parent Rating Scale. The authors also performed brain SPECT imaging on 18 medication free children and adolescents from a psychiatric outpatient clinic. Single photon emission computer tomography (SPECT) gives a three dimensional picture of cerebral blood flow and indirectly measures metabolic activity in deep structures of the brain. 65% of the ADHD children and adolescents had significant (p<.0001) prefrontal cortex deactivation in response to an intellectual challenge as compared to 5% of the non ADHD children and adolescents. 22% of the ADHD children and adolescents had decreased prefrontal lobe activity at rest that could account for their ADHD symptoms. This study supports the finding of other researchers regarding decreased prefrontal lobe activity in children and adolescents with ADHD. Brain SPECT imaging appears to be a valid assessment tool to identify the neurophysiological etiology of symptoms of ADHD in children and adolescents.

    Amen (2001) reports that brain SPECT imaging has identified the following six subtypes of ADD: classic ADD (inattentive, impulsive, hyperactive), inattentive ADD (inattentive, slow moving, low in motivation), overfocused ADD (difficulty in shifting attention, obsessive, worry excessively), temporal lobe ADD (inattention, irritable, aggressive, impulsive), limbic ADD (inattentive, chronic low grade depression, negative attitude), and ring of fire ADD (inattentive, angry, irritable, oppositional, cyclic moodiness).

    Swingle (2008) indicates that EEG neurofeedback assessment of children with attention deficit hyperactivity disorder (ADHD) during neurotherapy typically indicates excesses of slow frequency (theta) amplitude over much of the brain, excessive alpha amplitude in the frontal areas of the brain, excessive beta amplitude over much of the brain, inequality of brain activity between the frontal lobes, and a deficiency of theta amplitude in the back of the brain. EEG neurofeedback assessment during neurotherapy, brain SPECT imaging, and QEEG brainmapping are three promising neurophysiological assessment methods which should be of interest to school psychologists since the National Association of School Psychologists (NASP) has indicated a need for a "psycho-medical evaluation that matches our growing awareness of the complexity that goes by the simple name of ADHD" (QEEG Brainmapping Clinic, 2007, p. 3).

    School Functioning of Children with ADHD

    DuPaul (2007) reports that children with ADHD score between 10 and 30 points lower than non-ADHD children on norm referenced standardized achievement tests, 20 to 30 percent of students with ADHD have a specific learning disability (reading, math, or writing), and students with ADHD are at higher risk for grade retention, placement in special education classrooms, and dropping out from high school. The author indicates that the number and scope of school based interventions over the past several decades, including studies of behavior management, instructional design, and home/school collaboration, pales in comparison to the extensive research on stimulant medication.

    Children with ADHD are characteristically disruptive of their own education as well as disruptive of the education of other children in the classroom. Carlson (2004, p. 558) observes that children with ADHD "have difficulty withholding a response, act without reflecting, often show reckless and impetuous behavior, and let interfering activities intrude into ongoing tasks." This is in contrast with Santrock (2006, p. 299) who notes that "elementary school teachers typically report that the child with ADHD has difficulty working independently, completing seatwork, and organizing work."

    Wilcutt et. al. (2005) reports that tests of component reading and language skills, executive functions, and processing speed were administered to 113 children with attention deficit hyperactivity disorder (ADHD), 109 children with reading disability (RD), 64 children with both ADHD and RD, and 151 children who did not have any disorders (non ADHD/RD). Slow and variable processing speed was found in the three clinical groups. Children with ADHD had weaknesses on response inhibition tests and were impaired on some tests of component reading skills and verbal working memory. Children with RD had pronounced deficits on all tests of component reading skills and language skills, as well as significant weaknesses on tests of verbal working memory and response inhibition. Children with comorbid ADHD and RD had the combination of deficits of the ADHD and RD groups of children. This study highlights the need for remedial reading instruction for children with special needs.

    Treatment of Children with ADHD

    Barkeley (2007) is critical of professionals who routinely prescribe medication for the treatment of ADHD or implement psychological interventions without efforts to study side effects and adverse events which are caused by treatment efforts. He advocates impairment focused treatment which focuses on impairments in major life activities. An example of this form of treatment is to train parents to do reading tutoring and math videogames with ADHD children and adolescents.

    A review of the literature by Breggin (1999) indicates that the use of methylphenidate, dextroamphetamine, and methamphetamine in the treatment of children and adolescents with attention deficit hyperactive disorder involves great risks. The author indicates that the drugs produce a continuum of central nervous system toxicity that begins with mild symptoms (increased energy, hyper-alertness, overfocusing on rote activities) and progresses toward severe symptoms (obsessive-compulsive or perseverative activities, insomnia, agitation, hypomania, mania, and sometimes seizures). The drugs cause the individual to feel apathetic, exhibit social withdrawal and depressed mood, and act docile. Physical withdrawal, including rebound and dependence, are produced by the drugs. Furthermore, the author reports that there is little evidence that that stimulant medications lead to improvement in academic skills and social skills. The author indicates that some clinicians and researchers do not recognize adverse drug reactions in children and adolescents. They instead make the mistake of labeling drug related behaviors as symptoms of co-morbid mental disorders.

    Sadiq (2007) warns against the use of stimulant medications in the treatment of ADHD and their adverse reactions. He suggests that their use violates the Hippocratic oath of "primum non nocere" (first do no harm). He advocates the wisdom of "vis medicatrix" (the healing power of nature) and the use of the following integrative treatments for ADHD in a multi-modal treatment plan: individualized diet, omega 3 (DHA.EPA), probiotics, vitamins, botanicals, aromatherapy, mind-body medicine, chelation treatment with calcium EDTA, EEG neurofeedback massage, chiropractic manipulation, lifestyle changes, yoga, meditation, music therapy, and homeopathy.

    An increasing number of authors report the use of biofeedback in treatment. Amen (2007) reports that the Amen Clinic's ADD brain enhancement program uses EEG neurofeedback as well as supplementary strategies (parenting and family strategies, school strategies, bedtime and sleep strategies) for the treatment of ADD in children and adolescents. The author's approach is an integration of neurophysiological assessment, clinical interviewing, and programming of holistic interventions for the benefit of the child, adolescent, and family. This is in contrast with Butnik (2005) who reports research studies with adolescents and adults that use a form of brain wave training that is known as neurofeedback or electroencephalogram (EEG) biofeedback. He indicates that many research studies demonstrate that adolescents and adults with attention deficit hyperactivity disorder, as compared to matched peers, have excessive slow wave activity and reduced fast wave activity. In most cases clients are trained to reduce slow wave activity and increase fast wave activity. The author reports that research indicates that neurofeedback outcomes compare favorably to outcomes using stimulant medication, neurofeedback is a safe form of intervention and does not produce adverse reactions similar to the side effects of stimulant medication, and neurofeedback causes individuals to become more attentive to being attentive.

    One author notes that "neurofeedback is safe and can lead to long term improvement, unlike the drugs, because neurofeedback uses a learning process that strengthens and develops the synaptic connections of the brain" (The Drake Institute, 2008b, p. 1). Swingle (2008) reports that neurofeedback is a self regulatory treatment to normalize and optimize brain functioning. The activity of the brain is monitored electronically using electrodes placed on the scalp. In the treatment of attention deficit hyperactivity disorder with this method, the child may hear a tone when the brain is producing the target brainwave pattern, or the child may see an image on a computer monitor move more quickly when brainwaves related to poor focus became weaker. The author recommends the following three interventions which compliment the use of neurotherapy: 1) psychotherapy for intrapsychic conflicts, 2) family therapy for treatment of family stress related symptoms, and 3) medical consultation which is needed due to the adverse effects of medication, including central nervous system stimulants which are used to treat ADHD.

    Orlando and Rivera (2004) report a research study whose goal was to determine whether basic reading skills (eg, oral reading), reading comprehension, reading composite score, and IQ scores of 6th, 7th, and 8th grade students in a school setting could be increased using neurofeedback. The sample of students included students with attention deficit hyperactivity disorder and learning disabilities. Students in the treatment group (12 students, mean age = 11.27 years) and control group (14 students, mean age = 13.14 years) had either IEPs or 504 Accommodation Plans. The treatment group subjects received weekly 30 to 40 minute sessions of neurofeedback training over a seven month period. Results indicate that neurofeedback produced significant gains in basic reading skills (p<.01), reading comprehension (p=.01), and reading composite score (p<.01). There were significant interactions between Verbal IQ and time (p<.01) and Full Scale IQ and time (p<.01). This study indicates that neurofeedback is an effective intervention for increasing reading skills and intelligence quotients in a school setting with special needs students.

    Purpose of the Study

    There is a need in school psychology to provide interventions to remediate reading skills in students with attention deficit hyperactivity disorder since 20 to 30 percent of students with ADHD have specific learning disabilities (DuPaul, 2007). Neurotherapy (Orlando & Rivera, 2004), reading fluency development lesson (Opitz & Rasinski, 1998), and Soar to Success Reading Intervention Program (Cooper, Boschken, McWilliams, & Pistochini, 2001) are three research based interventions that have been found to be effective in helping students acquire reading skills. There is also a need in school psychology for research in the public schools which examines the effects of combined interventions verses single intervention with children with attention deficit hyperactivity disorder (ADHD). This study will examine the effects of combined interventions verses single intervention on the oral reading fluency and reading comprehension of eighty children with ADHD in two K-8th grade public schools. The hypothesis is that the children with ADHD in the treatment group who receive a combination of remedial reading program and EEG neurobiofeedback will learn differently than children with ADHD in the treatment group who receive a remedial reading program.

    Method Subjects

    80 children with a DSM IV-TR diagnosis of ADHD in grades 3rd through 7th in two large schools in Phoenix, Arizona participated in the study. All children in the study had a special education placement in a resource room with a special education teacher due to an eligibility of Other Health Impairment (ADHD) and/or Specific Learning Disability. Fifty percent of the students were Hispanic and fifty percent of the students were caucasion. Eighty percent of the students were boys, and twenty percent of the students were girls. A table of random numbers was used to assign children to two treatment groups.

    Measures

    Form A of the Gray Oral Reading Tests (4th ed.) (Wiederholt & Bryant, 2001), a normative test of academic skills, will be administered to subjects of the two treatment groups by school psychologists and teachers at the beginning of the seven month intervention period. Form B of the same test will be administered to subjects of the two treatment groups by school psychologists and teachers at the end of the seven month intervention period. Form A and Form B are alternate forms of the same test with similar validity and reliability. This test provides age norm standard scores (mean average= 100) for oral reading fluency and reading comprehension. Oral reading fluency is a combined measure of reading rate and reading accuracy.

    Procedures

    Forty children will be assessed with QEEG brainmapping and will receive the combined treatment condition (remedial reading program and neurotherapy) and forty children will receive the single treatment condition of remedial reading program. Neurotherapy will utilize neurofeedback protocols for 30 to 40 minutes per week per child as reported by Orlando and Rivera (2004, p.10) as follows: "protocols were chosen by following the QEEG map and by using clinical judgments in conjunction with the equipments' statistics, consultation with teachers as well as parents, and the psychoeducational evaluations." Children in both treatment conditions will receive treatment during a seven month period. The remedial reading program will utilize the fluency development lesson (Opatz & Rasinski, 1998) for oral reading instruction and the Soar to Success program for reading comprehension instruction (Cooper, Boschken, McWilliams, & Pistochini, 2001) for forty minutes daily in a special education resource room. Each of the reading skills treatment components will now be described.

    The fluency development lesson involves the following components: 1) modeling of oral reading by the teacher, 2) discussion of oral reading strategies used during the modeling, 3) repeated choral reading of the printed text by the class, 4) guided practice or oral reading by pairs of students,5) independent practice of oral reading by pairs of students as the whole class watches, 6) selection of three words from printed text for use in spelling and writing, 7) independent practice of oral reading at home, and 8) choral reading of printed text on the next day by the whole class (Opatz & Rasinski, 19989). A high level of oral reading fluency is needed for a student to be able to comprehend what he is reading. If it is not at a high level, one at which he can decode at least 90 percent of words, the student is so involved in attempting to decode unfamiliar words that he is not able to use reading strategies to comprehend the meaning of printed text.

    Cooper, J., Boschken, I., McWilliams, J., & Pistochini, L. (2001) indicate that the Soar to Success program for the teaching of reading comprehension skills is based upon the reciprocal teaching model of Palinscar and Brown, an instructional model with a strong research basis. The program teaches word comprehension and passage comprehension skills for grades 3rd through 8th. Reading content at each grade level is at an instructional reading level and not at a frustration reading level. The program encourages active learning on the part of the student since the student is placed in the role of both student and teacher as he progresses through the program. Instruction occurs in large groups and small groups. The program has been found to be successful for regular education students, English language learners, and special education students.

    Data Analysis

    An independent t test will be used to examine the pre and post test data of the two treatment groups (Green and Salkind, 2005).

    Results

    Oral Reading Fluency

    An independent samples t test was conducted to evaluate the hypothesis that children with ADHD who received combined interventions (neurobiofeedback and remedial reading program) would perform significantly different on a measure of oral reading fluency than children with ADHD who received a single intervention (remedial reading program). The test was non significant, t(47.62) =.187, p = .85, and the mean of the combined interventions group (M = 23.18, SD = 5.62) was similar to the mean of the single intervention group (M = 23.00, SD = 1.88). This suggests that the results were counter to the research hypothesis. The 95% confidence interval for the difference in means was not wide, ranging from -1.71 to 2.06.

    Reading Comprehension

    An independent samples t test was conducted to evaluate the hypothesis that children with ADHD who received combined interventions would perform significantly different on a measure of reading comprehension than children with ADHD who received a single intervention. The test was significant, t (78) = 21.35, p < .01, and the mean of the combined interventions group (M = 23.95, SD = 4.58) was higher than the mean of the single intervention group (M = 5.63, SD + 2.91). This indicates that the results support the research hypothesis. The 95% confidence interval for the difference in means was not wide, ranging from 16.61 to 20.03

    Conclusions

    The combined treatment condition of neurofeedback and remedial reading program had a significant effect on the acquisition of reading comprehension, however it did not have a significant effect on the acquisition of oral reading fluency. Limitations of the study include the small sample size, small percentage of females in the sample, and lack of a control group that did not receive any treatment. It is recommended that the following types of research be implemented in the school setting in order to examine the effects of neurofeedback on symptoms of ADHD and reading skills as well as the effects of cross lateral movements on the corpus callosum of children with ADHD.

    Miller (2007) examined the effects of neurofeedback with music therapy protocols on symptoms of ADHD of 38 children in a Philadelphia Office of Mental Health multi site study. The treatment protocol consisted of a theta/beta brainwave variation which incorporated brain triggered musical tones assigned to theta amplitude in key with background musical selections. Children who received this protocol, in comparison to children in a control group and treatment group with a traditional neurofeedback protocol, had significant effects on the NEPSY audio subtest, ADHD index of the Conners Parent Rating Scale, and cognitive subscale of the Conners Parent Survey.

    Swingle (2008, p. 84) reports on the use of neurotherapy with light and sound in the treatment of reading skills:

                  Many complimentary treatments are used in neurotherapy.  All stimulation
                  influences the brain.  Sounds for example affect the brain in ways that we
                  can monitor on the EEG.  Similarily, light, electrical stimulation, vibration,
                  and visual images with different content, such as pleasing or repulsive
                  photographs, all can spark activity in specific brain areas.  Audiovisual
                  devices that stimulate with light and sound in specific wave lengths are
                  particularly effective for children with reading problems.

    Myomancy Editor (2008, p. 1) indicates that the corpus callosum, which has been found to be smaller in children with ADHD, can be strengthened with cross lateral movements:

    It has been found that the corpus callosum was larger in professional musicians than in non-musicians. Playing instruments involves a lot of cross hemisphere processing to keep both hand's movements in time with each other. This suggests that by regular practice the corpus callosum can be strengthened.

    The Dore Program, Interactive Methronome, and primitive reflex based treatments such as INPP all involve cross lateral movements designed to train this area of the brain.

    Applied research in school psychology needs to integrate findings from neurophysiology with an open mind which searches for underlying causes of surface behavior in children. As Oliver Windell Holmes wrote, "A mind stretched to a new idea never goes back to its original dimensions" (Zimmerman & Hutchins, 2003, p. 129).

    Appendices

    The Examiner Record Booklet of the Gray Oral Reading Tests (4th ed.) consists of fourteen stories in increasing readability which are read orally by subjects. Each story has five comprehension questions that the subject must answer orally when they are read out loud by the examiner.

    References

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