Treatment Methods for Dyslexia: To what extent is neurofeedback therapy a more efficient treatment method for improving reading abilities in children with dyslexia, compared to the Orton-Gillingham approach?

Dyslexia is a specific and significant impairment in the development of reading skills that is not solely accounted for by mental age, visual acuity problems, or inadequate schooling. It cannot be cured, but treatment methods exist that can mitigate its symptoms. Based on understanding the nature of dyslexia and relying on existing research, this article aims to compare the effectiveness of two contrasting treatment methods for improving reading abilities in children with dyslexia. Neurofeedback therapy utilizes precise, modern devices to regulate brain behaviour. Contrary, a more traditional, but well-established and more natural Orton-Gillingham approach is used as a teaching approach in educational settings.

1         INTRODUCTION

1.1        DEFINITION AND SYMPTOMS OF DYSLEXIA

Dyslexia, or a specific reading disorder, is a specific and significant impairment in the development of reading skills that is not solely accounted for by mental age, visual acuity problems, or inadequate schooling (World Health Organization, 2011). It is estimated that dyslexia affects from five to seventeen percent of children thus, it represents a major public health problem (Giraud and Habib, 2013).

Even though dyslexia cannot be cured, treatment methods exist that can mitigate its symptoms (Reid, 2005). Treatment usually begins in early years of primary school because that is the time when poor reading skills become most noticeable (Schulte-Körne G., 2010). Reading problems or other dyslexic symptoms, such as difficulty in spelling, may appear sooner however, in pre-school children, the symptoms are less pronounced and hence more likely to be overlooked (Schulte-Körne G., 2010).

1.2        THE NATURE OF DYSLEXIA THROUGH THE MORTON AND FRITH (1995) FRAMEWORK

To understand why certain treatment methods are effective, it is necessary to understand the nature of dyslexia. The Morton and Frith (1995) causal modelling framework contributes to a thorough understanding of dyslexia as it considers biological, cognitive, and behavioural factors that may be associated with a development of dyslexia, while also acknowledging the role of the environment with sociocultural influences (Knight, 2018; Morton and Frith, 1995).

The framework’s biological level is based on genetical and brain imaging research (Frith and Morton, 1995). Evidence from molecular genetics suggests that numerous inherited genes (such as KIAA0319, ROBO1, DYX1C1 and DCDC2) may contribute to the development of dyslexia (DeFries and Fisher, 2002; Fisher and Francks, 2006; Kuerten et al., 2019). Additionally, dyslexia is caused by abnormal brain structure, in particular abnormal magnocellular pathways responsible for the fast visual input transmission from the retina to the occipital and parietal brain regions during reading, and abnormal cerebellum, responsible for reading automatization (Kuerten et al., 2019; Greatrex and Drasdo, 1995; Shastry, 2007). Moreover, Galaburda (2005) emphasized the symmetry of the planum temporale (located within Wernicke’s area in the brain) as a possible cause of dyslexia. Planum temporale in typically developing individuals has a leftward asymmetry with greater size (Bloom et al., 2013). A symmetrical planum temporale, typical for dyslexic individuals, is hence associated with an insufficient amount of brain tissues in the left hemisphere that is heavily involved in language processing (Galaburda, 2005).

Differences in brain structure lead to differences in brain functioning that are described by the cognitive level of the framework (Frith and Morton, 1995). This level suggests that due to abnormal brain structure, dyslexic individuals develop poor phonological processing, or the so-called phonological deficit, (shown as difficulty in manipulating speech sounds and remembering speech sequences), which results in a reading deficit (Kuerten et al., 2019; Frith and Morton, 1995; Ramus et al., 2003; Ramus, 2004).

The framework’s behavioural level explains that behavioural signs of a phonological deficit are associated with abnormal responses in the left hemisphere language system (Démonet et al., 2004; Kuerten et al., 2019). Particularly, during reading tasks, dyslexic brains show increased activation in the left inferior frontal region, and reduced activation in the left parietal-temporal regions and the left inferior temporal-occipital regions, which is not usual in typically developing individuals (Démonet et al., 2004; Hoet et al., 2006; Shaywitz and Shaywitz, 2005).

Lastly, the framework suggests that also environmental factors, for example orthography and teaching methods, have a strong impact on the acquisition of grapheme-phoneme knowledge, i.e., knowledge about the connection between letters and sounds (Frith and Morton, 1995). For example, the type of orthography may influence the developmental progress of children who are learning to read (Vellutino et al., 2004). Languages with opaque orthographies, i.e., languages with no consistent relationship between graphemes and phonemes, like English, present a significantly greater challenge to many beginning learners than languages with transparent orthographies, i.e., languages with consistent relationship between graphemes and phonemes, like Italian or German (Kuerten et al., 2019; Morton and Frith, 1995). Additionally teaching methods play an important role in supporting the development of phonological skills (Kuerten et al., 2019; Morton and Frith, 1995).

2         TREATMENT

2.1        NEUROFEEDBACK THERAPY AND ORTON-GILLINGHAM APPROACH

Based on the Morton and Frith (1995) framework, this article will present two treatment methods, each associated with a different level of the framework. The first method, neurofeedback therapy, is a non-invasive, pain-free approach for treating dyslexia, which was pioneered in the 1960s (Othmer, 2020; Suruchi, 2021). It is associated with the biological level of the Frith and Morton framework, as it is based on the principles of neuroplasticity (the brain’s ability to change and adapt) and operant conditioning (rewarding and hence reinforcing favourable activity) (Coben et al., 2015; Morton and Frith, 1995; Othmer, 2020; Suruchi, 2021).

First, sensors are placed on the head to record brain activity (Suruchi, 2021). Then, a software program is used to analyse obtained recordings and provide a visual (e.g. graphics on a screen) or auditory (e.g. music) feedback to the brain to reinforce desirable patterns of activity and inhibit dysfunctional activity (Suruchi, 2021; Antonietti et al., 2021). Over time, these sensory rewards and inhibitions help the brain to establish healthy functioning (Suruchi, 2021). Neurofeedback therapy is based on a thorough understanding of the dyslexic brain and has been gaining more attention because of its ability to precisely target neurobiological functioning while considering individual needs (Coben et al., 2022; Kawato et al., 2017; Niv, 2013). The therapy consists of one-on-one sessions and usually takes place in an office or a clinic, where it is provided by trained staff like psychologists, psychiatrists, or social workers (Suruchi, 2021).

Contrary to a more modern and precise neurofeedback therapy, there exists a more traditional, but well-established treatment method, the Orton Gillingham approach (Austin et al., 2021; Rose and Zirkel, 2007; Goeke and Ritchie, 2006). This approach, introduced in the 1930s, is one of the oldest approaches to instruct those having reading problems (Austin et al., 2021; Rose and Zirkel, 2007; Goeke and Ritchie, 2006). It is a learning process that focuses on letters and sounds while being multisensory (involving different senses) and personalized (tailored to students’ needs) to make a learning process more natural for a student (Austin et al., 2021; Ganschow et al., 1991; Peavler and Rooney, 2019). For example, when children learn about new letters, a teacher may ask students to play with sticks from the forest and make different letters with them (Peavler and Rooney, 2019).

Instruction based on the Orton-Gillingham approach can be given to individuals or groups of students and is available by teachers or reading specialists in educational settings (Goeke and Ritchey, 2006; Peavler and Rooney, 2019). As a teaching approach, the Orton-Gillingham approach is associated with the environmental level of the Morton and Frith framework (Morton and Frith, 1995; Peavler and Rooney, 2019).

Even though the Orton-Gillingham approach has been regarded as beneficial by teachers and parents, there has been criticism pointing to a lack of adequate research which would prove its efficacy (Chia Kok Hwee and Houghton, 2011; Goeke and Ritchey, 2006). The Orton-Gillingham approach is adjustable, open to each teacher’s judgement in what would be best for students, not a program that would always follow one specific repeatable procedure, hence it may be hard to study it scientifically (Austin et al., 2021; Ganschow et al., 1991; Peavler and Rooney, 2019).

With both methods having their unique characteristics, the aim of this article therefore is to compare the two methods and derive an answer to the question, to what extent is the more modern and precise neurofeedback therapy a more efficient treatment method for improving reading abilities in children with dyslexia, compared to the more traditional, but well-established and seemingly more natural Orton-Gillingham approach.

2.2 EVIDENCE

Although research is limited, there exists evidence for both neurofeedback therapy and Orton-Gillingham approach. Existing evidence mostly focuses on children aged from eight to fourteen years.

To begin with neurofeedback, there are multiple experiments that have shown the efficacy of this treatment method in treating dyslexia. This article will present two such experiments, the first of which was conducted by Abbasi Fashami et al. (2021), and the second one by Ali Nazari et al. (2011). They both aimed to investigate the effectiveness of neurofeedback in improving reading performance in dyslexic students. The first experiment included 24 male Iranian participants between eight and twelve years of age (mean age ten years), while the second experiment included six male participants between eight and ten years of age (mean age nine years). Participants in both experiments had to be healthy, of at least average intelligence, and display poor reading abilities. Each participant was randomly assigned to an experimental or a control group. For several weeks, multiple times per week, the experimental groups received from 20 to 30 neurofeedback treatment sessions, while the control groups received no treatment. Reading performance was assessed with standardized tests before and after the intervention period, and results showed that with neurofeedback therapy, reading abilities of the experimental groups significantly improved.

In both experiments, the modern neurofeedback devices’ ability to target specific brain functions enabled strict control of the procedure and hence contributed to a higher internal validity. However, as the health clinic was still a real-life setting, and the participants were only controlled during neurofeedback sessions in their day, extraneous variables could have influenced the results. Therefore, even though internal validity increased, it was not high enough to confirm with complete certainty that results occurred solely due to the neurofeedback therapy.

In both experiments, a limitation preventing generalizability of results to a wider population were samples that were unrepresentative due to their small size and inclusion of only male participants. The sample having included only Iranian participants is also a limitation, though a negligible one. That is because, as explained by Vellutino et al. (2004), environmental factors, such as the type of orthography, indeed influence the progress of children who are learning to read, but on the other hand, biological explanation of dyslexia’s nature suggests that dyslexic brains show similar functional abnormalities regardless of one’s cultural background (Frith and Morton, 1995; Suruchi, 2021). Hence, the effect of a neurofeedback therapy, which always follows the same procedure (although personalized to some degree), can be expected to be similar cross-culturally (Frith and Morton, 1995; Suruchi, 2021).

It is, though, an advantage that both presented experiments had strict inclusion criteria and included at least one experimental and one control group, increasing the chance that the improvements occurred due to the therapy. Despite limitations, research still suggests that neurofeedback therapy is a highly effective treatment method for improving reading abilities of children with dyslexia.

Conducted were also experiments that showed the efficacy of the Orton-Gillingham approach as treatment for dyslexia. This article will present two such experiments, the first of which was conducted by Chia Kok Hwee and Houghton (2011), and the second one by Lim and Oei (2015). They both aimed to investigate the effectiveness of the Orton-Gillingham approach on reading abilities of dyslexic children. The first experiment included 77 dyslexic Singaporean children aged from six to eight years (mean age seven years), and the second experiment included 39 dyslexic Singaporean children aged between six and fourteen years (mean age nine years). All participants had to be healthy, of at least an average intelligence, and display poor reading abilities. Each participant was randomly assigned to either an experimental or a control group. For several weeks, multiple times per week, participants attended one-hour long Orton-Gillingham instruction sessions that took place in learning centres. Standardized tests for reading abilities were administered to participants before and after the intervention. Results showed that with Orton-Gillingham treatment, the students improved significantly in reading.

The presented experiments appear to have been precise due to their strict inclusion criteria for participants. It is an advantage that reading abilities were assessed using standardized reading tests, many of which were adapted for an appropriate age group of participants, contributing to reliability of results. Mostly, no specific details were given about the setting, but considering that the treatment was given by trained teachers to mostly groups of students in a form of classes, the studies can be trusted to reflect real-life situations to a great extent.

Still, the Orton-Gillingham approach is adjustable to teachers’ judgement and an education system’s practices. The utilization of this approach in teaching is not exactly predetermined, but only relies on guidelines, and there exists no recognized procedure that would enable control of the Orton-Gillingham instruction sessions. Consequently, the treatment that children receive varies. In this way, children can receive treatment that is tailored to them, but on the other side, the latter also suggests that it is not possible to generalize the results of presented experiments to a wider population of dyslexic children.

Even though samples in both experiments reflected the approximate gender ratio of individuals diagnosed with dyslexia in Singapore, the samples were relatively small, additionally limiting generalization. Furthermore, no control group was established, which lowered internal validity of the experiments as it cannot be known with certainty whether the Orton-Gillingham instruction was the independent variable that influenced reading abilities. However, the absence of control group could have been justified from an ethical perspective. Have those children been prevented to obtain remediation for their reading difficulties, there could have been negative long-term consequences on the development of their literacy skills.

Despite limitations, significant improvements in experimental groups in both experiments suggest that the Orton-Gillingham approach is highly effective for improving reading abilities in dyslexic children.

3         DISCUSSION

After taking into consideration all the evidence on the efficacy of the Orton-Gillingham approach and neurofeedback therapy, both have been shown as significantly effective in improving reading abilities in children with dyslexia. Still, research in both fields is limited.

Participation in presented experiments on both treatment methods was conditional on meeting strict inclusion criteria in terms of reading abilities, intelligence, and medical history, which, together with the use of standardized tests for reading abilities, suggests that the experiments’ designs were well though-out and results hence reliable. Experiments from both fields were characterized by several common methodological weaknesses, especially samples that were unrepresentative and prevented generalization of results due to their relatively small size and inclusion of participants of only one gender and/or from a specific culture. Despite these similarities, there are also notable distinctions between the two treatment methods.

Compared to the studies on neurofeedback therapy, the ones on the Orton-Gillingham approach lacked control groups that would confirm that the improvements occurred only due to the treatment. Still, they were characterized by higher ecological validity as treatment was given by trained teachers and presumably in real-life educational settings that were more natural to children. Even though research on both methods often included culturally biased samples, the latter seemed to be problematic only for the Orton-Gillingham approach which depends much on cultural factors such as each orthography and education system’s own practices applied in the classroom, while the neurofeedback therapy (although also personalized to some degree) follows the same procedure no matter in which cultural setting or to whom it is given. Even though internal validity of experiments on neurofeedback therapy was increased for some degree due to the presence of control groups, their ecological validity was still not particularly low as also those experiments were conducted in real-life environments. The therapy was administered using modern devices capable of precise measurements and targeting specific brain functions. This feature allowed for strict control, at least during treatment sessions, and is considered one of the strongest advantages of neurofeedback therapy over the Orton-Gillingham approach from a scientific research perspective.

Future research could investigate whether factors such as a culture’s literacy values could influence the efficacy of the treatment. Additionally, further studies on the Orton-Gillingham approach could also address the question if the efficacy of the Orton-Gillingham instruction varies depending on whether a student is being taught individually or in a group.

In conclusion, given the unique benefits of both treatment methods, future research should explore not only their separate evaluations but also investigate whether the combined use of both methods could lead to even greater improvements in students’ reading abilities. Still, neurofeedback therapy, targeting brain functions more specifically and being more controlled and less culturally conditioned, seems to be a more effective treatment method for improving reading abilities in children with dyslexia compared to the Orton-Gillingham approach for the time being. Also the Orton-Gillingham approach has shown to have great potential as a treatment method and might be more effective in reality, but more research is required to confirm or refute this possibility in the future.

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