12 Lubar, J. F., 1991; 13 Monastra, V. J., Lynn, S., Linden, M., Lubar, J. F., Gruzelier, J., & La Vaque, T. J., 2005; 14 Gruzelier, J., & Egner, T., 2005 Introduction Studies on neurofeedback (NF) have consistently noted improvements in school performance; positive outcomes on cognitive and academic measures have been reported 1, 2. Research demonstrates that NF is most efficacious for ameliorating symptoms of inattention 3, 4 . Studies indicate that inattention is associated with reduced processing speed on school-related tasks 5 and impaired processing of visual information 6 . Willcutt and Pennington 7 found that the relationship between ADHD and reading disorders (RD) is correlated with symptoms of inattention. Sexton, Gelhorn, Bell, and Classi 8 suggest that ADHD and reading disorders (RD) are not just comorbid conditions but are, indeed, co-occurring conditions. The American Academy of Pediatrics recently elevated biofeedback (including neurofeedback) to their highest level of support (Level 1: Best Support) as an evidenced-based psychosocial intervention for attention and hyperactivity 9 . However, there remains a dearth of research that exams the use of NF to directly address academic achievement; the literature deals primarily with symptoms of attention and hyperactivity/impulsivity. Some of the findings of the first study to investigate the impact of 40 qEEG- guided NF sessions on measures of reading achievement 10 are presented here. Pre- and post-intervention quantitative electroencephalographic (qEEG) data are provided, especially as such information has been shown to be sensitive to distinguishing individuals with ADD/ADHD from others 11 . The role of theta/beta ratio reduction, particularly as it applies to the decrease in symptoms of inattention to improve reading achievement is discussed. Pre- and Posttest improvements in reading achievement are provided. 1 Linden, Habib, & Radojevic, 1996; 2 Lubar & Shouse, 1976; 3 Arns, de Ridder, Strehl, Breteler, & Coenen, 2009; 4 La Marca, 2011; 5 Weiler, Bernstein, Bellinger, & Waber, 2000; 6 Swanson, Posner, Potkin, & Bonforte, 1991; 7 Willcutt and Pennington, 2000; 8 Sexton, Gelhorn, Bell, and Classi , 2012; 9 The American Academy of Pediatrics, 2012; 10 La Marca, 2013; 11 Monastra, V. J., Lubar, J. F., Linden, M., VanDeusen, P., Green, G., Wing, W., . . . Fenger, T. N. (1999) qEEG, Theta/Beta Ratios, and ADHD Inattentive Subtype: Neurofeedback and Reading Achievement Jeff La Marca, Ph.D. Candidate — Graduate School of Education, University of California, Riverside Michael Linden, Ph.D. — Linden Attention Learning Center, San Juan Capistrano, CA For Further Information Please contact: Jeff La Marca: jlama001@ucr.edu Dr. Michael Linden: drlinden@lindenalc.com Implications/Future Research The results of the theta/beta ratio comparisons done in this study at baseline indicate that ratios are higher when beta (15 to 18 Hz), rather than beta (16 to 20Hz), is considered. Thus, Gruzelier’s and Egner’s suggestion 14 that this frequency band may have more saliency when enhancement of attention is a treatment goal appears to have merit. The qEEG-guided protocols used during the neurofeedback sessions provided all participants with enhancement of two bandwidths, beta (15 to 18 Hz) and SMR (12 to 15 Hz). Following 40 sessions of neurofeedback, the mean results for participants (as a group) showed positive gains on the IVA+Plus. All participants displayed increases on the GORT-5 measure of reading comprehension, four of the five participants displayed gains in Fluency, as well as on the Oral Reading Index. At the same time, the Rate score remained relatively static although Accuracy increased. This suggests that the intervention resulted in participants’ active engagement with text (with little or no change in rate) while, at the same time improved accuracy and increased reading comprehension scores were observed. Further research is required to confirm the findings of this study. 14 Gruzelier, J., & Egner, T., 2005; Screening Prior to the commencement of the study, the Conners 3AI rating scales were completed by parents and teachers. Ratings by a parent and/or a teacher had to exceed the test’s cutoff (T-score ≥ 61) for an attention deficit (Table 2). Participants were administered the WASI-II; a FSIQ ≥ 80 was used as the cutoff. On the IVA+Plus, participants had to have scores, as described in the IVA+Plus Interpretive Flowchart, that supported a diagnosis of an attention deficit. Method Five participants were selected from a single public elementary school located in southern California. The sample included an ethnically diverse group of students consisting of four boys and one girl, all between the ages of nine and ten (Table 1). The participants were selected from a larger pool of potential candidates (n ≈ 15) that included school-referred students in grades 3 to 5, all of whom had profiles that were suggestive of an attention deficit. Screening procedures were used to eliminate students who did not meet this study’s criteria. Table 1: Participant Demographics Student Age (years) Gender Grade Ethnicity Existing Diagnosis Family History ADD/ADHD Teacher Referral Mildred 9.58 F 4 Hispanic No Yes Yes Dudley 10.63 M 4 Black Yes No Yes Nimrod 9.37 M 4 Vietnamese No No Yes Webster 10.66 M 4 White No Yes Yes Egbert 9.98 M 4 Hispanic Yes No Yes Note. Age calculated as of March 2013 Table 2: Screening Results Student Connors 3AI-P Connors 3AI-T WASI-II FSIQ IVA+Plus Supported ADD/ADHD Diagnosis? Mildred ≥ 90 ≥ 90 102 Yes Dudley ≥ 90 ≥ 90 101 Yes Nimrod 45 ≥ 90 90 Yes Webster ≥ 90 ≥ 90 107 Yes Egbert ≥ 90 ≥ 90 105 Yes Note. Values in bold indicate that data met inclusionary criteria for participation in study. Baseline Theta/Beta Ratios This study used a multiple-baseline-across-participants single-case design. During the baseline phase, various measures were monitored, including EEG. Readings were acquired by placing the active electrode at Cz as this site is considered optimal (along with frontal regions) for theta/beta reduction training 12 . Reference and ground were placed at A1 and A2, respectively. Theta was defined as 4 to 8 Hz. As part of this process, the decision was made to monitor two subsets of the beta bandwidth (15 to 18 Hz and 16 to 20 Hz) to investigate which might be optimal for training. Some studies have examined 16 to 20 Hz 13 , while others have considered 15 to 18 Hz 14 . 0.00 5.00 10.00 15.00 20.00 25.00 Mildred Dudley Nimrod Webster Egbert Figure 1: Theta/Beta Ratio Comparison T/B (15 to 18 Hz) T/B (16 to 20 Hz) Table 3: qEEG Pre- and Posttest Theta/Beta Ratios Eyes Closed Pretest Posttest Mildred 5.97 5.77 Dudley 3.88 4.29 Nimrod 1.97 1.52 Webster 4.40 3.65 Egbert 2.00 1.92 Note. Posttest results in bold indicate change in the desired direction. The qEEG report provided information on theta/beta power ratios calculated as (theta) 2 / (beta) 2 . Theta was defined as (4 to 8 Hz) and beta as (13 to 21 Hz). Reading Comprehension and Fluency The Gray Test of Oral Reading – Fifth Edition (GORT-5) consists of several measures: Fluency, which is derived from Rate (reading speed) and Accuracy; and Reading Comprehension. An Oral Reading Index (ORI) is derived from the Fluency and Comprehension scores. While participants’ rate remained relatively static, four of the five participants exhibited increases in accuracy (Table 5). Similarly, the same students who had increases in accuracy also showed improvements in their Fluency scores. All five participants had improvements in their Comprehension scores. Four students made gains in their ORI with one participant’s scores exhibiting a slight decrease. Table 5: GORT-5 Pre- and Posttest Results Oral Reading Index a Rate b Accuracy b Fluency b Comprehension b Participant Pre Post Pre Post Pre Post Pre Post Pre Post Mildred 81 89 7 8 6 7 6 7 7 9 Dudley 73 86 5 6 4 8 4 7 6 8 Nimrod 78 89 8 7 6 9 7 8 5 8 Webster 97 105 10 9 9 11 9 10 10 12 Egbert 86 84 9 8 10 8 9 6 6 8 Mean 83.00 90.60 7.80 7.60 7.00 8.60 7.00 7.60 6.80 9.00 SD 9.14 8.32 1.92 1.14 2.45 1.52 2.12 1.52 1.92 1.73 Note. Posttest results in bold indicate change in the desired direction. a Standard Scores. b Scaled Scores (range = 1 to 20, mean = 10, SD = 3). IVA+Plus Results All participants, with the exception of Dudley, demonstrated gains on all major indices following 40 sessions of neurofeedback (Table 4). At posttest, the algorithms used by the IVA+Plus Interpretive Flowchart no longer suggested a diagnosis of ADD/ADHD for two students, Nimrod and Webster, while a diagnosis continued to be suggested for Mildred and Egbert (Dudley’s also suggested a diagnosis). Table 4: IVA+Plus Pre- and Posttest Standard Scores Participant Group Subtest Mildred Dudley a Nimrod Webster Egbert Mean SD FS-RCQ Pre 106 19 79 91 68 72.60 33.13 Post 109 63 90 97 80 87.80 17.43 FS-AQ Pre 61 59 99 83 54 71.20 19.11 Post 77 32 103 95 90 79.40 28.13 C-SA Pre 42 28 91 84 48 58.60 27.47 Post 70 7 96 87 82 68.40 35.59 Supports Pre Yes Yes Yes Yes Yes Diagnosis? Post Yes Yes No No Yes Note. Posttest results in bold indicate change in the desired direction. FS-RCQ = Full Scale Response Control Quotient (RCQ); FS-AQ = Full Scale Attention Quotient (AQ); C- SA = Combined Sustained Attention a Analysis of Dudley’s posttest results must be interpreted with caution due to extreme variability in his performance on subtest measures (not provided here) that suggest motivation issues negatively influenced results. qEEG Results Pre- and posttest qEEG theta/beta (eyes closed) power ratios exhibited changes in the desired direction for all participants except for Dudley (Table 3). Posttest power ratios were calculated by dividing the amplitude (μV) of theta squared by the amplitude of beta squared (theta 2 /beta 2 ). 12 Lubar, 1991; 13 Monastra, V. J., Lynn, S., Linden, M., Lubar, J. F., Gruzelier, J., & La Vaque, T. J., 2005; 14 Gruzelier, J., & Egner, T., 2005