EEG biofeedback for reading disability
Kirtley E. Thornton, PhDa,*, Dennis P. Carmody, PhDb
Center for Health Psychology, Suite 2A, 2509 Park Avenue, South Plainfield, NJ 07080,
Institute for the Study of Child Development, Department of Pediatrics,
Robert Wood Johnson Medical School, University of Medicine and Dentistry of NJ
› Edited/adapted from a longer article that also discussed traumatic brain injury, by David Dubin, MD
Prevalence and costs
Reading disabilities present major challenges to the educational system. The estimated prevalence rate for learning disabilities is 15% of the student population , with 6.5 million children requiring special education in 2002 . The federal government spent $350 billion over a 20-year period on special education programs , and New York City spends $55,300 per year for each incarcerated youth .
Efficacy research on intervention for students with learning disabilities
Despite the enormity of the social and educational problem, the interventions currently used largely have been unsuccessful in obtaining significant and meaningful results. In 1988, Lyon and Moats  concluded that ‘‘It is difficult, if not impossible, to find any evidence beyond testimonials and anecdotal reports that support the assumptions, treatment methods, and outcomes associated with standard currently available treatments . . . [T]here is overwhelming clinical evidence indicating that current treatments are inadequate for determining what and how to teach learning disabled students.’’
More recently, Birsh  concluded that ‘‘despite the widespread inclusion of multisensory techniques in remedial programs for dyslexic students and a strong belief among practitioners using these techniques that they work, there was little empirical evidence to support the techniques’ theoretical premises.’’
Treatment effects of neurofeedback with reading disability
No outcome research published to date has addressed the efficacy of neurofeedback specifically for reading disability. Several studies of the effect of neurofeedback on attention deficit hyperactivity disorder (ADHD), however, have provided suggestive preliminary evidence that EEG biofeedback can result in improved cognitive function in general.
A case study of a 13-year-old child with ADHD demonstrates the effectiveness of 45 EEG biofeedback sessions ). There was marked improvement in processing speed and processing speed variability, a 19-point IQ increase a 7.5 grade level increase in reading scores and significant behavioral improvements, as indicated by report of parents and patient. Follow-up at 17 months demonstrated that the behavioral and EEG changes were maintained.
With samples of learning disabled subjects and subjects with ADD and ADHD (total sample size n = 155), four independent researchers have demonstrated significant increases in IQ averaging 15 points (one SD) as a result of EEG biofeedback [51–54]. Only one study  used a control group, which did not demonstrate improvements on the IQ measures.
Clinical case examples
Learning disabled case reports
Case examples previously have been reported in peer-reviewed journals [73,74]. This report provides additional information and includes additional subjects. A control group used in the previously reported research did not demonstrate any significant gains as a result of practice effects or the passage of time between first and second testing.
Case 1 involves a 9-year-old girl whose parents reported a history of learning problems. Neither academic records nor formal educational or neuropsycho-logical testing completed were examined to verify the presence of learning disability, however. She improved approximately 1069% in auditory memory (total memory score from 1.8–19.25) and 400% in reading memory (total score from 2.5–14) during the 40 sessions.
Case 2 represents another example of a child with significant history of reading problems. The parents had spent approximately (US) $25,000 in alternate standard treatment programs to improve his reading ability, which resulted in no significant gains.
After treatment his auditory memory functioning increased 589% from baseline by the end of the twenty-fifth session. He also improved on the standardized reading inventory (SRI) from the previous year ’s testing (a standardized reading inventory measure administered by the school system) from a Lexile score of 360 before treatment to 753 after approximately 40 sessions, which is a much larger change than the typical improvement of 75 to 100 Lexiles per year.
His mother reported her impression of increased self-confidence, greater reading fluency, and ability to present information orally in school. There were no grades available for comparison from the resource room to which he was assigned.
Case 3 involved a 17-year-old subject with reading disability. After 20 sessions he increased his comprehension score (on the Burns Roe Reading Passages) from 45% to 90% (on alternate versions –eighth grade level) and from 20% to 70% (on tenth grade level). His performance on alternate versions of the Cognisys Story Recall Test had increased by 3 SD. On the Wechsler Individual Achievement Test reading comprehension subtest he attained a standard score of 99 for age and grade level.
Comparisons of effectiveness of interventions
For reading disability, the current programs show improvements that range from 0 to +0.40 SD on verbal skill measures, +0.60 to +1 SD for ‘‘standard’’ EEG biofeedback on attention and IQ measures, compared with the +3 to +3.3 SD changes for the EEG biofeedback (reading and auditory memory).
Our society has spent billions of dollars on efforts to remediate the cognitive and behavioral dysfunction in individuals with learning disabilities and TBI through various cognitive-based strategies.
The evidence accumulated to date indicates that few of these intervention efforts demonstrate efficacy. When change is measured for the more traditional approaches, the change scores typically result in improvements in the +0.00 SD to +0.50 SD range, often after lengthy intervention periods. Research completed to date and clinical reports show greater improvements with EEG biofeedback with these two groups.
The application of neurofeedback with reading disability is relatively recent. Although no published studies have assessed the efficacy of neurofeedback for subjects specifically diagnosed with reading disability, many studies have assessed the effectiveness of EEG with the ADHD population, which is known to have a high rate of co-morbidity for learning disabilities.
These findings suggest the possibility that neurofeedback specifically aimed at remediating reading disability would be effective. Clinical experience, as evidenced by the case examples, provides strong initial support for this suggestion. In particular, there is reason to believe that assessment and training under task conditions are likely to be fruitful.
Given the significance of the problems and the absence of proven alternatives for remediating reading disability, efforts to complete the needed research seem warranted. Given the absence of proven alternatives, clinical use of this intervention also seems to be warranted.
 Learning Disability Association of America. Available at: www.ldanatl.org. Accessed January 2004.
 Individuals with Disabilities Education Act—Data; Data Tables for OSEP State Reported Data IDEA Part B Child Count (2002). Available at: http://www.ideadata.org/arc_toc4.asp#partbCC. Accessed September 3, 2004.
 Winter C. Learning disabilities, crime, delinquency, and special education placement. Adoles- cence 1997;32:451 – 62.
 Wood R. The trillion-dollar sham in federal remedial education, NRRF Director of Statistical Research, The National Right to Read Foundation. Available at: http://www.nrrf.org/essay_ Trillion_ 116.html. Accessed September 3, 2004.
 Galaburda AM, Geschwind N, Sherman GF, Rosen GD, Aboitiz F. Developmental dyslexia: four consecutive patients with cortical anomalies. Ann Neurol 1985;18:222 – 33.
 Temple E, Deutsch GK, Poldrak RA, Miller SL, Tallal P, Merzenich MM, et al. Neural deficits in children with dyslexia ameliorated by behavioral remediation: evidence from functional MRI. Proc Natl Acad Sci U S A 2003;100(5):2860 – 5.
 McCandliss BD, Noble KG. The development of reading impairment: a cognitive neuroscience model. Ment Retard Dev Disabil Res Rev 2003;9:196 – 205.
 Paulesu E, Frith U, Snowling M, Gallagher A, Morton J, Frackowiak RSJ, et al. Is develop- mental dyslexia a disconnection syndrome? Evidence from PET scanning. Brain 1996;119: 143 – 57.
 Rumsey JM, Horwitz B, Donohue BC, Nace K, Maisog JM, Andreason P. Phonological and orthographic components of word recognition: a PET-rCBF study. Brain 1997;120:739 – 59.
 Rumsey JM, Nace K, Donohue B, Wise D, Maisog JM, Andreason P. A positron emission tomographic study of impaired word recognition and phonological processing in dyslexic men. Arch Neurol 1997;54:562 – 73.
 Shaywitz SE, Shaywitz BA, Pugh KR, Fulbright RK, Constable RT, Mencl WE, et al. Functional disruption in the organization of the brain for reading in dyslexia. Proc Natl Acad Sci U S A 1998;95:2636 – 41.
 Simos PG, Breier JI, Fletcher JM, Foorman BR, Bergman E, Fishbeck K, et al. Brain activation profiles in dyslexic children during non-word reading: a magnetic source imaging study. Neurosci Lett 2000;290:61 – 5.
 Simos PG, Fletcher JM, Foorman BR, Francis DJ, Castillo EM, Davis RN, et al. Brain activation profiles during the early stages of reading acquisition. J Child Neurol 2002;17:159 – 63.
 Shaywitz BA, Shaywitz SE, Pugh KR, Mencl WE, Fulbright RK, Skudlarski P, et al. Disruption of posterior brain systems for reading in children with developmental dyslexia. Biol Psychiatry 2002;52:101 – 10.
 Shaywitz SE, Shaywitz BA, Fulbright RK, Skudlarski P, Mencl WE, Constable RT, et al. Neural systems for compensation and persistence: young adult outcome of childhood reading disability. Biol Psychiatry 2003;54:25 – 33.
 Watts R, Liston C, Niogi S, Ulug˘ AM. Fiber tracking using magnetic resonance diffusion tensor imaging and its applications to human brain development. Ment Retard Dev Disabil Res Rev 2003;9:168 – 77.
 Klingberg T, Hedehus M, Temple E, Salz T, Gabrieli JD, Moseley ME, et al. Microstructure of temporo-parietal white matter as a basis for reading ability: evidence from diffusion tensor magnetic resonance imaging. Neuron 2000;25:493 – 500.
 Horwitz B, Rumsey JM, Donohue BC. Functional connectivity of the angular gyrus in normal reading and dyslexia. Proc Natl Acad Sci U S A 1998;95:8939 – 44.
 Lyon GR, Moats LC. Critical issues in the instruction of learning disabled. J Consult Clin Psychol 1988;56:830 – 5.
 Birsh J. Multisensory teaching of basic language skills. Baltimore7 Brookes; 1999.
 Oakland T, Black JL, Stanford G, Nussbaum NL, Balise RR. An evaluation of the dyslexia training program: a multisensory method for promoting reading in students with reading disabilities. J Learn Disabil 1998;31(2):140 – 50.
 Lindamood-Bell. Available at: www.Lindamood-Bell.com. Accessed October 12, 2004.
 FastForWord. Available at: www.Scientificlearning.com. Accessed October 12, 2004.
 Simos PG, Breier JI. Age-related changes in regional brain activation during phonological decoding and printed word recognition. Dev Neuropsychol 2001;19(2):191 – 210.
 Brain Injury Association of America. Available at: www.biausa.org. Accessed.
 Thatcher RW. EEG operant conditioning (biofeedback) and traumatic brain injury. Clin Electroencephalogr 2000;31:38 – 44.
 Thatcher RW, Biver C, McAlaster R, Camacho M, Salazar A. Biophysical linkage between MRI and EEG amplitude in closed head injury. Neuroimage 1998;7:352 – 67.
 Benedict RHG. The effectiveness of cognitive remediation strategies for victims of traumatic head injury: a review of the literature. Clin Psychol Rev 1989;9:605 – 26.
 Glisky EL, Schacter D. Remediation of organic memory disorders: current status and future prospects. J Head Trauma Rehabil 1986;1(3):54 – 63.
 McKinlay WW. Achieving generalization of memory training. Brain Inj 1992;6(2):107 – 12.  Freeman MR, Mittenberg W, Dicowden M, Bat-Ami M. Executive and compensatory memory retraining in traumatic brain injury. Brain Inj 1992;6(1):65 – 70.
 Carney N, Chesnut RM, Maynard H, Mann NC, Patterson P, Helfand M. Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: a systematic review. J Head
Trauma Rehabil 1999;14(3):277 – 307.
 Cicerone K, Dahlberg C, Kalmar K, Langenbahn D, Malec J, Bergquist F, et al. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000;81:1596 – 615.
 Salazar AM, Warden DL, Schwab K, Spector J, Braverman S, Walter J, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial for the Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA 2000;283(23):3075 – 81.
 Thatcher RW, Cantor DS, McAlaster R, Geisler F, Krause P. Comprehensive predictions of outcome in closed head-injured patients: the development of prognostic equations. Ann N Y Acad Sci 1991;620:82 – 101.
 Randolph C, Miller MH. EEG and cognitive performance following closed head injury. Neuropsychobiology 1988;20:43 – 50.
 Tabano MT, Cameroni M, Gallozzi G, Loizzoa A, Palazzinob G, Pezzinib G. EEG Spectral analysis after minor head injury in man. Electroencephalography and Clinical Neurophysiology 1988;70:185 – 9.
 Trudeau DL, Anderson J, Hansen L M, Shagalov DN, Schmoller J, Nugent S, et al. Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion. J Neuropsychiatry Clin Neurosci 1998;10(3):308 – 13.
 Hughes JR, John ER. Conventional and quantitative electroencephalography in psychiatry. J Neuropsychiatry Clin Neurosci 1999;11(2):190 – 208.
 Basar-Eroglu C, Struber D, Schurmann M, Stadler M, Basar E. Gamma-band responses in the brain: a short review of the psychophysiological correlates and functional significance. Int J Psychophysiol 1996;24(1–2):110 – 2.
 Sheer DE. Electrophysiological studies in learning disabilities. In: Eichenwald H, Talbot A, editors. The learning disabled child. Austin7 University of Texas Press; 1974.
 DeFrance J, Sheer DE. Focused arousal, 40 Hz EEG and motor programming. In: Giannitrapani D, Murri L, editors. The EEG of mental activities. Basel7 Karger; 1988. p. 153 – 69.
 Miltner WHR, Braun C, Arhnold M, Witte H, Taub E. Coherences of gamma-band EEG activity as a basis for associative learning. Nature 1999;397:434 – 6.
 McEvoy LK, Smith ME, Gevins A. Test-retest reliability of cognitive EEG. Clin Neurophysiol 2000;111:457 – 63.
 Thornton K. Exploratory investigation into mild brain injury and discriminant analysis with high frequency bands (32–64 Hz). Brain Inj 1999;13(7):477 – 88.
 Thornton K. Exploratory analysis: mild head injury, discriminant analysis with high frequency bands (32–64 Hz) under attentional activation conditions and does time heal? Journal of Neurotherapy 1999;3(3):1 – 10.
 Thornton K. Electrophysiology of the reasons the brain-damaged subject can’t recall what they hear. Arch Clin Neuropsychol 2002;17:1 – 17.
 Thornton K. Electrophysiology of auditory memory of paragraphs. Journal of Neurotherapy 2000;4(3):45 – 73.
 Lloyd D. Virtual lesions and the not-so-modular brain. Journal of the International Neurospychological Society 2000;6:627 – 35.
 Rossiter R. Neurofeedback for AD/HD: a ratio feedback case study and tutorial. Journal of Neurotherapy 2002;6(3):9 – 37.
 Linden M, Habib T, Radojevic V. A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback Self Regul 1996;21(1):35 – 49.
 Tansey M. Wechsler (WISC-R) changes following treatment of learning disabilities via EEG biofeedback training in a private practice setting. Aust J Psychol 1991;43:147 – 53.
 Othmer S, Othmer SF. EEG biofeedback training for hyperactivity, attention deficit disorder, specific learning disability, and other disorders. Encino (CA)7 EEG Spectrum; 1992.
 Thompson L, Thompson M. Neurofeedback combined with training in metacognitive strategies: effectiveness in students with ADD. Appl Psychophysiol Biofeedback 1998;23(4):243 – 63.
 Sheer DE. Focused arousal and 40 Hz EEG. In: Knights RM, Bakker DJ, editors. The
neurophysiology of learning disorders. Baltimore7 University Park Press; 1976.
 Sheer DE. Focused arousal, 40 Hz EEG and dysfunction. In: Elbert J, Rockstrogh B,
Lutzenberger W, Birbaumer N, editors. Self regulation of the brain and behavior. Berlin7
 Sheer DE. Biofeedback training of 40 Hz EEG, and behavior. In: Kamiya J, Barber TX, Miller NE, Shapiro D, Stoya J, editors. Biofeedback and self-control, 1976/1977: an annual review. Chicago7 Aldine; 1977. p. 435.
 Bird BL, Newton FA, Sheer DE, Ford MR. Biofeedback training of 40 Hz EEG in humans. Biofeedback Self Regul 1978;3(1):1 – 12.
 Byers AP. Neurofeedback therapy for a mild head injury. Journal of Neurotherapy 1995;1(1): 22 – 37.
 Hoffman DA, Stockdale S, Hicks LL. Diagnosis and treatment of head injury. Journal of Neurotherapy 1995;1(1):14 – 21.
 Hoffman DA, Stockdale S, Van Egren L. Symptom changes in the treatment of mild traumatic brain injury. Clin Electroencephalogr 1996;27(3):164.
 Hoffman DA, Stockdale S, Van Egren L. EEG neurofeedback in the treatment of mild traumatic brain injury. Clin Electroencephalogr 1996;27(2):6.
 Keller I. Neurofeedback therapy of attention deficits in patients with traumatic brain injury. Journal of Neurotherapy 2001;5(1/2):19 – 33.
 Marker T. COGPACK: Programmpaket fqr neuropsychologicschen rehabilitation. Ladenburg, Germany: 1996.
 Siegmund K. Neurosoft: ein integriertes therapliesystem. Burladingen, Germany: 1999.
 Walker JE, Norman CA, Weber RK. Impact of qEEG-guided coherence training for patients with a mild closed head injury. Journal of Neurotherapy 2002;6(2):31 – 45.
 Tinius TP, Tinius KA. Changes after EEG biofeedback and cognitive retraining in adults with mild traumatic brain injury and attention deficit hyperactivity disorder. Journal of Neurotherapy 2000;4(2):27 – 44.
 Sandford JA, Turner A, Browne RJ. Captain’s log cognitive training system (computer program). Richmond (VA)7 Braintrain, Inc.; 1993.
 Sandford JA, Turner A. Alphabet bingo (computer program). Richmond (VA)7 Braintrain, Inc.; 1996.
 Sandford JA, Turner A. Intermediate visual and auditory continuous performance test. Richmond (VA)7 Braintrain, Inc.; 1995.
 Schoenberger NE, Shif SC, Esty ML, Ochs L, Matheis RJ. Flexyx neurotherapy system in the treatment of traumatic brain injury: an initial evaluation. J Head Trauma Rehabil 2001;16(3): 260 – 74.
 Ochs L. EEG-driven stimulation and heterogeneous head injured patients: extended findings. Presented at the Berrol Head Injury Conference. Las Vegas, 1994.
 Thornton K. Rehabilitation of memory functioning with EEG biofeedback. NeuroRehabilitation 2002;17(1):69 – 81.
 Thornton K. Rehabilitation of memory functioning in brain injured subjects with EEG bio- feedback. J Head Trauma Rehabil 2000;15(6):1285 – 96.
 Orlando PC, Rivera RO. EEG: biofeedback for elementary students with identified learning problems. Journal of Neurotherapy, in press.
 Kaiser D, Othmer S. Effect of neurofeedback on variables of attention in a large multi-center trial. Journal of Neurotherapy 2000;4(1):5 – 17.
 Cicerone K, Smith LC, Ellmo W, Mangel HR, Nelson P, Chase RF, et al. Neuropsychological rehabilitation of mild traumatic brain injury. Brain Injury 1996;10(4):277 – 86. K.E. Thornton, D.P. Carmody / Child Adolesc Psychiatric Clin N Am 14 (2005) 137–162