ADD / ADHD in Children & Adults
Review of the Literature Regarding the Efficacy of Neurofeedback in the Treatment of Attention Deficit Hyperactivity Disorder by Lingenfelter JE
This document presents a review of the most recent literature regarding the efficacy of electroencephalographic biofeedback, more commonly known as neurofeedback, in the treatment of attention deficit hyperactivity disorder.
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Electroencephalogram (EEG) biofeedback, also known as neurofeedback, is a promising alternative treatment for patients with attention deficit/hyperactivity disorder (AD/HD) by Friel PN
Alternative Medicine Review, Volume 12, #2, June, 2007, pp146-151
Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder by Monastra VJ, Lynn S, Linden M, Lubar JF, Gruzelier J, LaVaque TJ
Applied Psychophysiology and Biofeedback, Vol. 30, No. 2, June 2005
Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment. This review paper critically examines the empirical evidence, applying the efficacy guidelines jointly established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR). On the basis of these scientific principles, EEG biofeedback was determined to be “probably efficacious” for the treatment of ADHD. Although significant clinical improvement was reported in approximately 75% of the patients in each of the published research studies, additional randomized, controlled group studies are needed in order to provide a better estimate of the percentage of patients with ADHD who will demonstrate such gains in clinical practice.
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Electroencephalographic biofeedback (neurotherapy) as a treatment for attention deficit hyperactivity disorder: rationale and empirical foundation by Monastra VJ
FPI Attention Disorders Clinic, 2102 East Main Street, Endicott, NY 13760, USA. email@example.com
Treatment of attention deficit hyperactivity disorder with neurotherapy by Nash JK
Behavioral Medicine Associates, Inc., MN 55434, USA.
EEG biofeedback: A new treatment option for ADD/ADHD by Alhambra, M. A., Fowler, T. P., & Alhambra, A. A. (1995)
Applied Journal of Neurotherapy, 1(2), 39–43.
Attention Deficit Disorder with or without hyperactivity is a disorder commonly seen inchildren. It is estimated that ADD affects 5-15 percent of school age children (Linden, Habib, & Radojevic, 1993). It was previously thought that children outgrow the disorder, but it is now believed that 70 percent of children do not outgrow the problems associated with ADD (Linden, Habib, & Radojevic, 1993).
The causes of ADD and ADHD have a neurological basis. There is evidence that, in some ADD/ADHD children, there might be decreased levels of metabolism of catecholamine, brain chemicals related to adrenalin (epinephrine) and noradrenalin (norepinephrine) (Lubar, hand-out). Because of this, stimulant medications are often effective treatments for these children, especially in reducing hyperactivity. Children on the medication often show improved attentiveness and decreased impulsivity. However, a significant problem with the pharmacological treatment of ADD children is the statedependent and shortlived effects. For example, the frequently prescribed medication Ritalin (Methylphenidate) lasts only for 3 or 4 hours in the nervous system. As soon as the medication wears off, full blown symptoms of ADD and ADHD appear (Lubar, hand-out). Furthermore, Ritalin has numerous undesirable side-effects such as insomnia, loss of appetite, inhibited growth, and depression.
An ideal treatment is one with long-term results and minimal side effects. EEG biofeedback is a non-pharmacological treatment with such characteristics. The mechanism of how EEG biofeedback could help children with ADD/ADHD is based on the separation of certain brainwave patterns. The EEG frequency range has been divided into six (6) categories: delta: 0.5-4 Hz; theta: 4-8 Hz; alpha: 8-13 Hz; sensorimotor (SMR): 12-15 Hz; beta: 1535 Hz; gamma: 35-50 Hz. Delta and theta are known as slow wave activity and are associated with states such as daydreaming and drowsiness. Alpha is associated with a relaxed state of unfocused attention. Beta is referred to as fast wave activity and is characterized by a state of high alertness, concentration, and focused attention (Linden, Habib, & Radojevic, 1993). Children with ADD and ADHD produce excess theta activity and lower amounts of beta activity (Lubar, 1991). Thus, these children are neurologically inclined to daydream, and less inclined to focus and concentrate. EEG biofeedback training functions to reverse this brain wave abnormality in ADD/ADHD children by inhibiting the amount of theta activities and simultaneously increasing beta activities.
Several studies (Linden, Habib, & Radojevic, 1993; Lubar & Shouse, 1976a, 1976b; Mann, Lubar, Zimmerman, Miller, & Muenchen, 1992; Tansey & Brunner, 1983) provided evidence that EEG biofeedback is abeneficial method for treating the ADD condition. This paper is a report of a series of cases on the effects of EEG biofeedback on children with ADD/ADHD.
EEG-based personalized medicine in ADHD: Individual alpha peak frequency as an endophenotype associated with nonresponse by Arns, M. (2012)
Journal of Neurotherapy.
This review article summarizes some recent developments in psychiatry such as personalized medicine, employing biomarkers and endophenotypes, and developments collectively referred to as neuromodulation with a focus on ADHD. Several neurophysiological subtypes in ADHD and their relation to treatment outcome are reviewed. In older research the existence of an “abnormal EEG” or “paroxysmal EEG” was often reported, most likely explained by the high occurrence of this EEG subtype in autism, as the diagnosis of autism was not coined until 1980. This subgroup might respond best to anticonvulsant treatments, which requires more specific research. A second subgroup is a beta-excess or beta-spindling subgroup. This group responds well to stimulant medication, albeit several studies suggesting that neurophysiologically this might represent a different subgroup. The third subgroup consists of the “impaired vigilance” subgroup with the often-reported excess frontal theta or excess frontal alpha. This subgroup responds well to stimulant medication. Finally, it is proposed that a slow individual alpha peak frequency is an endophenotype related to treatment resistance in ADHD. Future studies should incorporate this endophenotype in clinical trials to further investigate new treatments for this substantial subgroup of patients, such as NIRS-biofeedback, transcranial Doppler sonography biofeedback, hyperbaric oxygen therapy, or medications such as nicotine and piracetam.
Efficacy of neurofeedback treatment in ADHD: The effects on inattention, impulsivity and hyperactivity: A meta-analysis by Arns, M, de Ridder, S, Strehl, U, Breteler, M, & Coenen, A. (2009).
Clinical EEG and Neuroscience, 40(3) 180–189.
Since the first reports of neurofeedback treatment in Attention Deficit Hyperactivity Disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity and hyperactivity. This technique is also used by many practitioners, but the question as to the evidence-based level of this treatment is still unclear. In this study selected research on neurofeedback treatment for ADHD was collected and a meta-analysis was performed.
Both prospective controlled studies and studies employing a pre-and post-design found large effect sizes (ES) for neurofeedback on impulsivity and inattention and a medium ES for hyperactivity. Randomized studies demonstrated a lower ES for hyperactivity suggesting that hyperactivity is probably most sensitive to nonspecific treatment factors.
Due to the inclusion of some very recent and sound methodological studies in this meta-analysis, potential confounding factors such as small studies, lack of randomization in previous studies and a lack of adequate control groups have been addressed, and the clinical effects of neurofeedback in the treatment of ADHD can be regarded as clinically meaningful. Three randomized studies have employed a semi-active control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the AAPB and ISNR guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered “Efficacious and Specific” (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.
Neurotherapy and alert hypnosis in the treatment of attention deficit disorder by Barabasz, A., & Barabasz, M. (1996).
Chapter in S. J. Lynn, I. Kirsch, & J. W. Rhue (Eds.), Casebook of Clinical Hypnosis. Washington, D.C.: American Psychological Association Press, 271–292.
Until recently, treatment has been limited to management through the use of powerful stimulant drugs, such as methylphenidate (Ritalin), and behavior modification. Medication has significant side effects, and even the most elaborate behavior modification programs do not generalize to nontrained behaviors or carry over to the school environment (Gaddes & Edgell, 1994). Cessation of either treatment results in the rapid return of pretreatment symptoms and dysfunction. In contrast to symptom management approaches, neurotherapy (brainwave biofeedback) provides a rehabilitative approach, but may take as many as 40 to 80 sessions. In this chapter, we introduce a new hypnotic-attentional instruction procedure to facilitate normalization of EEG and to accelerate neurotherapy retraining by reducing the number of sessions required by half. We also review the most recent diagnostic considerations, prevalence issues, and traditional treatments.
Treating AD/HD with hypnosis and neurotherapy by Barabasz, A., & Barabasz, M. (2000).
Child Study Journal, 30(1), 25–42.
Traditional diagnosis procedures for Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD) may lead to over-diagnosis and are fraught with complications because the target behavioral symptoms are found in a variety of other disorders. Traditional treatments consisting of powerful side effect laden psychostimulant drugs and/or complex costly behavioral modification programs are at best symptom focused and palliative in nature. Both diagnostic and treatment advances derived from the neurological basis of the disorder are needed, as are habilitative treatment alternatives. This paper presents the procedural details of Instantaneous Neuronal Activation Procedure (INAP) alert hypmosis as an adjunct to neurotherapy in the treatment of ADD. ADD/ADHD diagnostic issues, demographics, traditional treatments, neurological basis, EEG assessment, and implications for the use of hypnosis are reviewed. Recent research demonstrating the efficacy and promise of neurotherapy with and without INAP alert hypnosis is discussed. (Contains 52 references.) (MKA)
Functional magnetic resonance imaging investigation of the efects of neurofeedback training on the neural bases of selective attention and response inhibition in children with attention-deficit/hyperactivity disorder by Beauregard, M., & Levesque, J. (2006).
Applied Psychophysiology & Biofeedback, 31(1), 3–20.
Two functional magnetic resonance imaging (fMRI) experiments were undertaken to measure the effect of neurofeedback training (NFT), in AD/HD children, on the neural substrates of selective attention and response inhibition. Twenty unmedicated AD/HD children participated to these experiments. Fifteen children were randomly assigned to the Experimental (EXP) group whereas the other five children were randomly assigned to the Control (CON) group. Only subjects in the EXP group underwent NFT. EXP subjects were trained to enhance the amplitude of the SMR (12–15 Hz) and beta 1 activity (15–18 Hz), and decrease the amplitude of theta activity (4–7 Hz). Subjects from both groups were scanned one week before the beginning of NFT (Time 1) and 1 week after the end of NFT (Time 2), while they performed a “Counting Stroop” task (Experiment 1) and a Go/No-Go task (Experiment 2). At Time 1, in both groups, the Counting Stroop task was associated with significant activation in the left superior parietal lobule. For the Go/No-Go task, no significant activity was detected in the EXP and CON groups. At Time 2, in both groups, the Counting Stroop task was associated with significant activation of the left superior parietal lobule. This time, however, there were significant loci of activation, in the EXP group, in the right ACC, left caudate nucleus, and left substantia nigra. No such activation loci were seen in CON subjects. For the Go/No-Go task, significant loci of activation were noted, in the EXP group, in the right ventrolateral prefrontal cortex, right ACcd, left thalamus, left caudate nucleus, and left substantia nigra. No significant activation of these brain regions was measured in CON subjects. These results suggest that NFT has the capacity to functionally normalize the brain systems mediating selective attention and response inhibition in AD/HD children.
Followup study of Learning Disabled children treated with Neurofeedback or placebo by Becerra J, Fernndez T, Harmony T, Caballero MI, Garcia F, FernandezBouzas A, Santiago-Rodriguez E, Prado-Alcalá RA. (2006)
Clinical EEG & Neuroscience, 37 (3), 198–203.
This report is a 2-year follow-up to a previous study describing positive behavioral changes and a spurt of EEG maturation with theta/alpha neurofeedback (NFB) training in a group of Learning Disabled (LD) children. In a control paired group, treated with placebo, behavioral changes were not observed and the smaller maturational EEG changes observed were easily explained by increased age.
Two years later, the EEG maturational lag in Control Group children increased, reaching abnormally high theta Relative Power values; the absence of positive behavioral changes continued and the neurological diagnosis remained LD. In contrast, after 2 years EEG maturation did continue in children who belonged to the Experimental Group with previous neurofeedback training; this was accompanied by positive behavioral changes, which were reflected in remission of LD symptoms.
EEG biofeedback in the schools: The use of EEG biofeedback to treat ADHD in a school setting by Boyd, W. D., & Campbell, S. E. (1998).
Journal of Neurotherapy, 2(4), 65–71.
Six middle school students diagnosed with attention deficit/hyperactivity disorder were selected for sensorimotor rhthm (SMR) training with EEG biofeedback. The subjects were evaluated following a 72-hour drug-free period with the WISC-III Digit Span subtest and the Test of Variables of Attention (TOVA). Five of the subjects received 20 sessions of EEG biofeedback and one of the subjects received nine sessions of EEG biofeedback. The subjects were evaluated again following a 72-hour drug-free period. Five of the six subjects improved on their combined Digit Span, TOVA Inattention, and TOVA Impulsivity scores. These results supported previous findings that EEG biofeedback can be effective in the treatment of attention deficit/hyperactivity disorder. More importantly, this study demonstrated that EEG biofeedback could be used in an actual school setting. Recommendations for implementing an EEG biofeedback program in the schools were provided.
Improvements in spelling after QEEG-based neurofeedback in dyslexia: A randomized controlled treatment study by Breteler, M. H. M., Arns, M., Peters, S., Giepmans, I., & Verhoeven, L. (2010).
Applied Psychophysiology & Biofeedback, 35(1), 5–11.
Phonological theories of dyslexia assume a specific deficit in representation, storage and recall of phonemes. Various brain imaging techniques, including qEEG, point to the importance of a range of areas, predominantly the left hemispheric temporal areas. This study attempted to reduce reading and spelling deficits in children who are dyslexic by means of neurofeedback training based on neurophysiological differences between the participants and gender and age matched controls. Nineteen children were randomized into an experimental group receiving qEEG based neurofeedback (n = 10) and a control group (n = 9). Both groups also received remedial teaching. The experimental group improved considerably in spelling (Cohen’s d = 3). No improvement was found in reading. An indepth study of the changes in the qEEG power and coherence protocols evidenced no fronto-central changes, which is in line with the absence of reading improvements. A significant increase of alpha coherence was found, which may be an indication that attentional processes account for the improvement in spelling. Consideration of subtypes of dyslexia may refine the results of future studies.
Neurofeedback in residential children and adolescents with mild mental retardation and ADHD behavior by Breteler, R., Pesch, W., Nadorp, M. (2012).
Journal of Neurotherapy
Neurofeedback (NFB) research has reported improved concentration and attention in children with attention deficit/hyperactivity disorder (ADHD) and progress maintained over time. Would that also apply to children with an IQ between 50 and 70 (mild mental retardation [MMR]) and an IQ between 70 and 85 (borderline retardation [BR]) with characteristics of ADHD? To our knowledge this is the first NFB treatment study with long-term follow-up in this particular group. Ten adolescents with MMR and BR and ADHD received 30 sessions of quantitative electroencephalogram (QEEG)-based NFB. QEEG differences with a gender- and age-matched group without mental handicap and ADHD (data provided by BRAINnet) were investigated, at pre- and posttreatment and at 6-month follow-up. Neuropsychological functioning was tested administering the Bourdon-Vos, and the Amsterdam Neuropsychological Testing Program subscales SA DOTS and SSV. Pretreatment eyes-closed EEGs were not statistically different in the children with MMR compared to the controls. With eyes open higher amplitudes were found in the lower frequencies in the children with MMR, normalizing over time. The neuropsychological tests improved for reaction times and errors. On the complex tasks in the SSV a number of errors remained. The subjects perceived an improvement in ADHD and increasingly enjoyed the study. After NFB treatment, attention and concentration in children with MMR and BR have improved. Task span and effort also increased, although impulse control remained weak. This may be explained by a limited working memory capacity. The subjective reports may have been affected by situational factors and should be interpreted with caution. This study is limited by its nonrandomized design.
EEG biofeedback training and attention-deficit/ hyperactivity disorder in an elementary school setting by Carmody, D. P., Radvanski, D. C., Wadhwani, S., Sabo, J. J., & Vergara, L. (2001).
Journal of Neurotherapy, 4(3), 5–27.
Introduction: EEG biofeedback was conducted on site in an elementary school.
Method: An experimental group of eight children ages 8-10 completed 35-47 sessions of EEG biofeedback training over a six-month period. Four participants in the experimental group were diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) and four were not diagnosed with ADHD. Eight children in the waitlist control group were matched to the experimental group on age, grade, teacher, and diagnosis. None of the 16 participants were medicated for ADHD.
Results: Attention abilities as measured by the Test of Variables of Attention showed the experimental group of children with ADHD reduced errors of commission and anticipation, indicating a reduction in impulsivity. Teacher reports using the McCarney Scale indicated improvements in attention but no changes in impulsivity and hyperactivity.
Discussion: Several confounds require exploration before attribution of changes are assigned to neurofeedback. Whether the effects are due to the neurofeedback protocols, attendance at individual sessions away from the classroom, the attention of the technician, or the excitement of a special program cannot be determined with this study. It will be necessary to have a placebo group in order to separate systematically the variables in the training program.
Changes in verbal performance IQ discrepancy scores after left hemisphere frequency control training: A pilot report by Carter, J. L., & Russell, H. L. (1991).
American Journal of Clinical Biofeedback, 4(1), 66–67
The effects of bilateral EEG biofeedback on verbal, visuospatial and creative skills in LD male adolescents by Cunningham, M., & Murphy, P. (1981).
Journal of Learning Disabilities, 14(4), 204–208.
Twenty-four learning disabled adolescent boys with verbal IQ deficiencies were pretested on measures of convergent and creative thinking, assigned to eight weekly, 21-minute sessions of one of two bilateral EEG biofeedback training conditions or a no-training control condition, and post-tested two months after the pretest. The EEG biofeedback training produced baseline effects in the presumably dysfunctional left hemisphere and had an impact on arousal in-task, suggesting remedial potential for the possible hemispheric arousal deficits in learning disabilities. Training the right hemisphere toward higher arousal and the left hemisphere toward lower arousal resulted in a notable improvement in arithmetic.
Controlled evaluation of a neurofeedback training of slow cortical potentials in children with ADHD by Drechsler R, Straub M, Doehnert M, Heinrich H, Steinhausen H, Brandeis D. (2007).
Behavioral & Brain Functions, 3, 35.
Background: Although several promising studies on neurofeedback training in Attention Deficit/Hyperactivity Disorder (ADHD) have been performed in recent years, the specificity of positive treatment effects continues to be challenged.
Methods: To evaluate the specificity of a neurofeedback training of slow cortical potentials, a twofold strategy was pursued: First, the efficacy of neurofeedback training was compared to a group training program for children with ADHD. Secondly, the extent of improvements observed in the neurofeedback group in relation to successful regulation of cortical activation was examined. Parents and teachers rated children’s behaviour and executive functions before and after treatment. In addition, children underwent neuropsychological testing before and after training.
Results: According to parents’ and teachers’ ratings, children of the neurofeedback training group improved more than children who had participated in a group therapy program, particularly in attention and cognition related domains. On neuropsychological measures children of both groups showed similar improvements. However, only about half of the neurofeedback group learned to regulate cortical activation during a transfer condition without direct feedback. Behavioural improvements of this subgroup were moderately related to neurofeedback training performance, whereas effective parental support accounted better for some advantages of neurofeedback training compared to group therapy according to parents’ and teachers’ ratings.
Conclusion: There is a specific training effect of neurofeedback of slow cortical potentials due to enhanced cortical control. However, non-specific factors, such as parental support, may also contribute to the positive behavioural effects induced by the neurofeedback training.
EEG activity in females with attentiondeficit/ hyperactivity disorder by Dupuy, E. F., & Clarke, A.(2012).
Although Attention-Deficit/Hyperactivity Disorder (AD/HD) affects millions of females worldwide, our understanding of AD/HD continues to be based heavily on male-dominated research. Significant sex differences reported in the presentation and diagnosis of AD/HD can no longer be ignored; females with AD/HD are different from males with the disorder. Electroencephalography (EEG) is a valuable tool for measuring electro-cortical activity and has been found useful in AD/HD research. Preliminary studies have shown that females with AD/HD have EEG abnormalities different from those found in males with AD/HD. This article reviews the current literature on EEG activity of females with AD/HD and concludes that the lack of comprehensive research draws attention to the necessity for sex-specific EEG research within AD/HD populations.
Learned self-regulation of EEG frequency Components affects attention and event-related brain potentials in humans by Egner, T., & Gruzelier, J. H. (2001).
NeuroReport, 12, 4155–4159.
Learned enhancement of EEG frequency components in the lower beta range by means of biofeedback has been reported to alleviate attention deficit hyperactivity disorder (ADHD) symptoms. In order to elucidate frequency-specific behavioural effects and neurophysiological mediators, this study applied neurofeedback protocols to healthy volunteers, and assessed impact on behavioural and electrocortical attention measures. Operant enhancement of a 12–15 Hz component was associated with reduction in commission errors and improved perceptual sensitivity on a continuous performance task (CPT), while the opposite relation was found for 15–18 Hz enhancement. Both 12–15 Hz and 15–18 Hz enhancement were associated with significant increases in P300 event-related brain potential amplitudes in an auditory oddball task. These relations are interpreted as stemming from band-specific effects on perceptual and motor aspects of attention measures.
EEG biofeedback of low beta band components: Frequency-specific efects on variables of attention and event-related brain potentials by Egner, T., & Gruzelier, J. H. (2004).
Clinical Neurophysiology, 115, 131–139.
Multichannel EEG phase synchrony training and verbally guided attention training for disorders of attention by Fehmi, L. G. (2007).
Chapter in J. R. Evans (Ed.), Handbook of Neurofeedback. Binghampton, NY: Haworth Medical Press, 301–319.
EEG biofeedback, multichannel synchrony training, and attention by Fehmi, L. G. (1978).
Chapter in A. A. Sugarman & R. E. Tarter (Eds.), Expanding Dimensions of Consciousness. New York: Springer. 4
Biofeedback and attention training by Fehmi, L. G., & Selzer, F. A. (1980).
Chapter in S. Boorstein (Ed.), Transpersonal Psychotherapy. Palo Alto: Science and Behavior Books.
EEG and behavioral changes following neurofeedback treatment in learning disabled children by Fernandez, T., Herrera, W., Harmony, T., Diaz-Comas, L., Santiago, E., Sanchez, L., Bosch, J., Fernandez-Bouzas, A., Otero, G., RicardoGarcell, J., Barraza, C., Aubert, E., Galan, L., & Valdes, P. (2003).
Clinical Electroencephalography, 34(3), 145–150.
Neurofeedback (NFB) is an operant conditioning procedure, by which the subject learns to control his/her EEG activity. On one hand, Learning Disabled (LD) children have higher values of theta EEG absolute and relative power than normal children, and on the other hand, it has been shown that minimum alpha absolute power is necessary for adequate performance. Ten LD children were selected with higher than normal ratios of theta to alpha absolute power (theta/alpha). The Test Of Variables of Attention (TOVA) was applied. Children were divided into two groups in order to maintain similar IQ values, TOVA values, socioeconomical status, and gender for each group. In the experimental group, NFB was applied in the region with highest ratio, triggering a sound each time the ratio fell below a threshold value. Noncontingent reinforcement was given to the other group. Twenty half-hour sessions were applied, at a rate of 2 per week. At the end of the 20 sessions, TOVA, WISC and EEG were obtained. There was significant improvement in WISC performance in the experimental group that was not observed in the control group. EEG absolute power decreased in delta, theta, alpha and beta bands in the experimental group. Control children only showed a decrease in relative power in the delta band. All changes observed in the experimental group and not observed in the control group indicate better cognitive performance and the presence of greater EEG maturation in the experimental group, which suggests that changes were due not only to development but also to NFB treatment.
Case study: Improvements in IQ score and maintenance of gains following EEG biofeedback with mildly developmentally delayed twins by Fleischman, M. J., & Othmer, S. (2005).
Journal of Neurotherapy, 9(4), 35–46.
This study reports on the improvements in IQ scores and maintenance of the gains following EEG biofeedback with identical twin girls with mild developmental delay and symptoms suggestive of Attention Deficit Hyperactivity Disorder (ADHD). Full Scale IQ scores increased 22 and 23 points after treatment and were maintained at three follow-up retests over a 52-month period. ADHD symptom checklists completed by their mother showed a similar pattern of improvement and maintenance of gains. The extent of improvement is supported by anecdotal reports of behavioral changes. The results are discussed in the context of other studies of EEG biofeedback also showing improved intelligence following EEG biofeedback.
Neurofeedback training as an educational intervention in a school setting: How the regulation of arousal states can lead to improved attention and behaviour in children with special needs by Foks, M. (2005)
Educational & Child Psychology, 22(3), 6777.
Neurofeedback: An alternative and efcacious treatment for attention deficit hyperactivity disorder by Fox, D. J., Tharp, D. F., & Fox, L. C. (2005).
Applied Psychophysiology & Biofeedback, 30(4), 365–274.
Current research has shown that neurofeedback, or EEG biofeedback as it is sometimes called, is a viable alternative treatment for Attention Deficit Hyperactivity Disorder (ADHD). The aim of this article is to illustrate current treatment modalities(s), compare them to neurofeedback, and present the benefits of utilizing this method of treatment to control and potentially alleviate the symptoms of ADHD. In addition, this article examines the prevalence rates and possible etiology of ADHD, the factors associated with ADHD and brain dysfunction, the current pharmacological treatments of ADHD, Ritalin, and the potential risks and side effects. Behavior modification and cognitive behavioral treatment for ADHD is discussed as well. Lastly, a brief history of the study of neurofeedback, treatment successes and clinical benefits, comparisons to medication, and limitations are presented.
The impact of neurotherapy on college students' cognitive abilities and emotions by Fritson, K. K., Wadkins, T. A., Gerdes, P., & Hof, D. (2007).
Journal of Neurotherapy, 11(4), 1–9.
Background. In past research, several case studies and five controlled-group studies explored the effect of electroencephalographic (EEG) biofeedback on intelligence, attention, and behavior in children diagnosed with attention deficit hyperactivity disorder, but no studies have explored the effects of EEG biofeedback in nonclinical adults on measures of response control, mood, emotional intelligence, and self-efficacy.
Method. Sixteen nonclinical college students were randomly assigned to receive Beta/Sensory Motor Rhythm EEG biofeedback to increase 12 to 15 Hz activity while inhibiting 4 to 7 Hz and 22 to 36 Hz activity. A control group received placebo EEG biofeedback. All participants completed pre- and postmeasures assessing intelligence scores, attention, impulse control, mood, emotional intelligence, and self-efficacy to assess the effect of EEG biofeedback.
Results. Results showed significant improvements in response control but no improvements in attention. Measures of intelligence and emotional functioning did not change after EEG biofeedback.
Conclusions. This study indicates that response control may improve in a few as 20 EEG biofeedback sessions. Implications and shortcomings discussed.
Neurofeedback treatment for attention deficit/hyperactivity disorder in children: A comparison with methylphenidate by Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J. H., & Kaiser, J. (2003).
Applied Psychophysiology and Biofeedback, 28, 112.
Clinical trials have suggested that neurofeedback may be efficient in treating attention-deficit/hyperactivity disorder (ADHD). We compared the effects of a 3-month electroencephalographic feedback program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12–15 Hz) and beta1 activity (15–18 Hz) with stimulant medication. Participants were N = 34 children aged 8–12 years, 22 of which were assigned to the neurofeedback group and 12 to the methylphenidate group according to their parents’ preference. Both neurofeedback and methylphenidate were associated with improvements on all subscales of the Test of Variables of Attention, and on the speed and accuracy measures of the d2 Attention Endurance Test. Furthermore, behaviors related to the disorder were rated as significantly reduced in both groups by both teachers and parents on the IOWA-Conners Behavior Rating Scale. These findings suggest that neurofeedback was efficient in improving some of the behavioral concomitants of ADHD in children whose parents favored a nonpharmacological treatment.
Long term efects after feedback of slow cortical potentials and of theta-beta amplitudes in children with attention-deficit/hyperactivity disorder(ADHD) by Gani C., Birbaumer N. & Strehl U.(2008).
International Journal of Bioelectromagnetism, 10(4), 209–232.
Induced EEG gamma oscillation alignment improves diferentiation between autism and ADHD group responses in a facial categorization task by Gross, E., El-Baz-Ayman A, S., Sokhadze, G, E. (2012).
Journal of Neurotherapy.
Children diagnosed with an autism spectrum disorder (ASD) often lack the ability to recognize and properly respond to emotional stimuli. Emotional deficits also characterize children with attention deficit/hyperactivity disorder (ADHD), in addition to exhibiting limited attention span. These abnormalities may effect a difference in the induced EEG gamma wave burst (35–45 Hz) peaked approximately 300–400 ms following an emotional stimulus. Because induced gamma oscillations are not fixed at a definite point in time poststimulus, analysis of averaged EEG data with traditional methods may result in an attenuated gamma burst power. We used a data alignment technique to improve the averaged data, making it a better representation of the individual induced EEG gamma oscillations. A study was designed to test the response of a subject to emotional stimuli, presented in the form of emotional facial expression images. In a four-part experiment, the subjects were instructed to identify gender in the first two blocks of the test, followed by differentiating between basic emotions in the final two blocks (i.e., anger vs. disgust). EEG data were collected from ASD (n = 10), ADHD (n = 9), and control (n = 11) subjects via a 128-channel EGI system, and processed through a continuous wavelet transform and bandpass filter to isolate the gamma frequencies. A custom MATLAB code was used to align the data from individual trials between 200 and 600 ms poststimulus, EEG site, and condition by maximizing the Pearson product–moment correlation coefficient between trials. The gamma power for the 400-ms window of maximum induced gamma burst was then calculated and compared between subject groups. Condition (anger/disgust recognition, gender recognition) × Alignment × Group (ADHD, ASD, Controls) interaction was significant at most of parietal topographies (e.g., P3-P4, P7-P8). These interactions were better manifested in the aligned data set. Our results show that alignment of the induced gamma oscillations improves sensitivity of this measure in differentiation of EEG responses to emotional facial stimuli in ADHD and ASD.
Neurotherapy and drug therapy in combination for adult ADHD, personality disorder, and seizure by Hansen, L. M., Trudeau, D., & Grace, L. (1996).
Journal of Neurotherapy, 2(1), 6–14.
This is a case report of an adult female patient with ADHD, temporal seizure disorder, and Borderline Personality Disorder treated with 30 weekly sessions of SMR neurofeedback and carbamazepine. Posttreatment measures showed improvements in T.O.V.A., self report, and QEEG. Both neurofeedback and carbamazepine showed the most effect in early treatment. Progress continued after discontinuance of the drug.
Place of electroencephalographic biofeedback for attention-deficit/hyperactivity disorder by Hirshberg, L. M. (2007).
Expert Review of Neurotherapeutics, 7(4), 315–319.
Effects of neurofeedback training on attention in children with intellectual disability by Hong, C., Lee, I. (2012).
Journal of Neurotherapy
This study investigated effects of neurofeedback (NFB) training on attention in children with intellectual disability (ID). Twenty-one children with ID were assigned to an NFB training group (n = 7), to a visual perception (VP) training group (n = 7), or to a no-treatment group (n = 7). Two groups received 36 sessions of NFB or VP training, respectively, over 12 weeks. Children’s Color Trails Test–2, Stroop Color and Word Test, and Digit Span were administered to all participants before and after training. The follow-up study was conducted with both the NFB and VP groups in the same way after 3 months. The EEGs of the NFB group also were measured. The NFB group showed significantly improved scores on the all tests compared to the 2 control groups. The brainwaves of the frontal lobes of the NFB group declined significantly in theta wave amplitude and theta-to-beta ratio. The NFB results were maintained in the follow-up study. Beta/SMR uptraining seemed to be an effective way to enhance attention in children with ID.
Facilitation of performance on an arithmetic task as a result of the application of a biofeedback procedure to suppress alpha wave activity by Jackson, G. M., & Eberly, D. A. (1982).
Biofeedback & SelfRegulation, 7(2), 211–221.
An electroencephalographic (EEG) biofeedback procedure was used in a pilot study to decrease the percent of time in alpha wave activity with five mentally retarded adults while engaged in an arithmetic test. Analysis of intrasubject and intersubject data revealed an overall significant decrease in the number of alpha events and percent of time in alpha wave activity as compared to baseline conditions. Such a decrease indicated facilitated attention by EEG definition. A collateral increase in percent of problems completed correctly and decrease in the number of distractible head-turning responses were noted. An automated method of determining head position was used and shown to be reliable in comparison to a human observer.
Neurofeedback treatment of two children with learning, attention, mood, social, and developmental deficits by Jacobs, E. H. (2005).
Biofeedback & SelfRegulation, 7(2), 211–221.
Background. Neurofeedback is biofeedback training of EEG activity through an operant conditioning process by which the individual is trained to increase or inhibit the brain’s production of electrical activity in specific frequency ranges. Studies have demonstrated efficacy with a variety of disorders, including attention deficit hyperactivity disorder (ADHD), learning problems, and autistic features. This paper describes the application of neurofeedback in a clinical setting with two complex children who manifested multiple diagnoses, including learning disabilities (LD), ADHD, social deficits, mood disorders, and pervasive developmental disorder (PDD). Both boys had adjusted poorly to school, family, and peers.
Methods. Subjects were referred to the author’s clinical practice. They received individualized protocols based on their symptoms and functional impairments. They were administered semi-weekly 20-minute sessions of one-channel neurofeedback training for approximately six months. In both cases symptoms were identified and tracked with a parent rating scale and one case, with the Symptom Assessment-45 Questionnaire (SA-45) also.
Results. Each boy improved in all tracked symptoms without adverse effects. One improved on most measures of the SA-45 with no deterioration on any measure. Functional improvements in academic functioning, home behavior, and peer relationships were indicated.
Conclusions. Neurofeedback was a successful treatment for these two multi-symptomatic and diagnosed boys, whose improvements surpassed the gains made with previous therapies. The advantages of neurofeedback include the relative absence of observable adverse effects, the lack of reliance on medication with its possible side effects and noncompliance, and the possibility of long-term gains without continued intervention.
Effect of Neurofeedback on variables of attention in a large multi-center trial by Kaiser, D. A., & Othmer, S. (2000).
Journal of Neurotherapy, 4(1), 5–15.
Background: Neurofeedback studies have been criticized for including small numbers of subjects. The effect of SMR-beta neuro-feedback training on the Test of Variables of Attention was evaluated in more than 1,000 subjects from thirty-two clinics.
Methods: 1089 subjects (726 children, 324 females, 186 with ADHD or ADD diagnoses) underwent twenty or more sessions of SMR-beta neurofeedback training for attentional and behavioral complaints at thirty-two clinical settings affiliated with EEG Spectrum, Inc. Subjects were evaluated prior to training and at training completion. One hundred and fifty-seven subjects who elected extensive training (forty sessions or more) were tested after both twenty and forty training sessions.
Results: Neurofeedback training produced significant improvement in attentiveness, impulse control, and response variability. Significant clinical improvement in one or more measures was seen in eighty-five percent of those subjects with moderate pre-training deficits.
Conclusions: Neurofeedback training is effective in remediating atten-tional dysfunction. Nevertheless, large-scale studies with greater control (e.g., wait-list designs) are sorely needed.
Neurofeedback protocols for subtypes of attention deficit/ hyperactivity disorder by Kirk, L. (2007)
Chapter in J. R. Evans (Ed.), Handbook of Neurofeedback. Binghampton, NY: Haworth Medical Press, 267– 299.
Computerassisted cognitive training for ADHD: A case study by Kotwal, D. B., Burns, W. J., & Montgomery, D. D. (1996).
Behavior Modification, 20(1), 85–96.
A computer-assisted cognitive training program was used to treat a 13-year-old Caucasian male with attention deficit hyperactivity disorder. The subject was administered a cognitive training computer program, Captain’s Log, for 35 sessions. Pre/post differences on the Conners Parent Rating Scale revealed a decrease on all subscales. The scores on the Conners Teacher Rating Scale were less conclusive. Electrophysiological testing on the A620 EEG/Neurofeedback revealed a reduction in EMG, theta, and beta wave amplitudes. However, the theta/beta ratio increased. A 7-month follow-up revealed that most of the acquired gains were maintained, but at a slightly lower level.
Changes in EEG spectograms, event-related potentials and event-related desynchronization induced by relative beta training in ADHD children by Kropotov, J. D., Grin-Yatsenko, V. A., Ponomarev, V. A., Chutko, L. S., Yakovenko, E. A., & Nikishena, I. S. (2007).
Journal of Neurotherapy, 11(2), 3–11.
Background. During the last three decades EEG-based biofeedback (neurofeed-back) was used as an alternative treatment for reducing symptoms of ADHD. The goal of this study was to objectively assess the efficacy of biofeedback training by comparing spectrograms, ERPs and ERDs, measured before and after 20 sessions of neurotherapy in a group of ADHD children.
Method. Electroencephalogram (EEG), Event related potentials (ERPs) and event related synchronisation/desynchronisation (ERD/ERS) were recorded and computed in auditory GO/ NOGO task before and after 15–22 sessions of EEG biofeedback. Eighty-six ADHD children participated in the study. Each session consisted of 30 min of relative beta training. The patients were divided into two groups (good performers and poor performers) depending on their ability to elevate beta activity during sessions.
Results. Amplitude of late positive components of evoked potentials in response to NOGO stimuli increased, and event-related synchronisation in alpha frequency band measured at central areas decreased after the whole set of sessions of neurofeedback training in the group of good performers but did not change for the poor performers group. Evoked potential differences between post- and pre-treatment conditions for good performers were distributed over frontal-central areas, reflecting activation of frontal cortical areas associated with beta training.
Conclusion. Relative beta training with electrodes located above the frontal areas was associated with an increase of the late positive NOGO component. This activation likely indicates recovery of normal functioning of the executive system.
ERPs correlates of EEG relative beta training in ADHD children by Kropotov, J. D., Grin-Yatsenko, V. A., Ponomarev, V. A., Chutko, L. S., Yakovenko, E. A., Nildshena, I. S. (2005).
International Journal of Psychophysiology, 55(1), 23–34.
EEG asymmetry analysis of the left and right brain activities during simple versus complex arithmetic learning by Kwon, H., Cho, J., Lee, E. (2009).
Journal of Neurotherapy, 13(2), 109–116.
Introduction. Repeated practice of simple arithmetic such as addition, subtraction, and multiplication has been widely used for effective math education. Brain activity patterns during simple and complex arithmetic calculation have been explored by several research groups using magnetic resonance images (MRI) and functional MRI (fMRI), and some have reported that the balanced whole brain (both left and right brain) activities during simple arithmetic in contrast to the predominant left brain activities during complex arithmetic.
Methods. In this work, we have identified the characteristic brainwaves and asymmetric activation patterns of the left and right brain during the process of simple and complex arithmetic by measuring theta, alpha, Sensory Motor Response (SMR), and beta brainwaves of 24 participants from the location FP1 (left brain) and FP2 (right brain) using EEG.
Results. Simple statistics analysis showed the significantly different beta activities from the left brain during complex arithmetic compared to simple arithmetic process, and through the asymmetry analysis of the left and right brain activities, less symmetrical brain activation during complex calculation, that is, specifically higher SMR, and beta brainwaves in the left hemisphere more than right hemisphere was identified, which is consistent with recent fMRI findings.
Conclusion. The results imply that simple arithmetic process may improve the whole brain activities in a balanced way while complex arithmetic induce unbalanced activities of the left and right brain.
Neurofeedback for children with ADHD: A comparison of SCP and theta/beta protocols by Leins, U., Goth, G., Hinterberger, T., Klinger, C., Rumpf, N., & Strehl, U. (2007).
Applied Psychophysiology & Biofeedback, 32(2), 73–88.
Behavioral and cognitive improvements in children with ADHD have been consistently reported after neurofeedback-treatment. However, neurofeedback has not been commonly accepted as a treatment for ADHD. This study addresses previous methodological shortcomings while comparing a neurofeedback-training of Theta-Beta frequencies and training of slow cortical potentials (SCPs). The study aimed at answering (a) whether patients were able to demonstrate learning of cortical self-regulation, (b) if treatment leads to an improvement in cognition and behavior and (c) if the two experimental groups differ in cognitive and behavioral outcome variables. SCP participants were trained to produce positive and negative SCP-shifts while the Theta/Beta participants were trained to suppress Theta (4–8 Hz) while increasing Beta (12–20 Hz). Participants were blind to group assignment. Assessment included potentially confounding variables. Each group was comprised of 19 children with ADHD (aged 8–13 years). The treatment procedure consisted of three phases of 10 sessions each. Both groups were able to intentionally regulate cortical activity and improved in attention and IQ. Parents and teachers reported significant behavioral and cognitive improvements. Clinical effects for both groups remained stable six months after treatment. Groups did not differ in behavioural or cognitive outcome.
Effect of neurofeedback training on the neural substrates of selective attention in children with attention–deficit/hyperactivity disorder: a functional magnetic resonance imaging study by Levesque, J., Beauregard, M., & Mensour, B. (2006).
Neuroscience Letters, 394(3), 216–221.
Attention Deficit Hyperactivity Disorder (AD/HD) is a neurodevelopmental disorder mainly characterized by impairments in cognitive functions. Functional neuroimaging studies carried out in individuals with AD/HD have shown abnormal functioning of the anterior cingulate cortex (ACC) during tasks involving selective attention. In other respects, there is mounting evidence that neurofeedback training (NFT) can significantly improve cognitive functioning in AD/HD children. In this context, the present functional magnetic resonance imaging (fMRI) study was conducted to measure the effect of NFT on the neural substrates of selective attention in children with AD/HD. Twenty AD/HD children—not taking any psychostimulant and without co-morbidity-participated to the study. Fifteen children were randomly assigned to the Experimental (EXP) group (NFT), whereas the other five children were assigned to the Control (CON) group (no NFT). Subjects from both groups were scanned 1 week before the beginning of the NFT (Time 1) and 1 week after the end of this training (Time 2), while they performed a Counting Stroop task. At Time 1, for both groups, the Counting Stroop task was associated with significant loci of activation in the left superior parietal lobule. No activation was noted in the ACC. At Time 2, for both groups, the Counting Stroop task was still associated with significant activation of the left superior parietal lobule. This time, however, for the EXP group only there was a significant activation of the right ACC. These results suggest that in AD/HD children, NFT has the capacity to normalize the functioning of the ACC, the key neural substrate of selective attention.
A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities by Linden, M., Habib, T., & Radojevic, V. (1996).
Biofeedback & Self-Regulation, 21(1), 35–49.
Eighteen children with ADD/ADHD, some of whom were also LD, ranging in ages from 5 through 15 were randomly assigned to one of two conditions. The experimental condition consisted of 40 45-minute sessions of training in enhancing beta activity and suppressing theta activity, spaced over 6 months. The control condition, waiting list group, received no EEG biofeedback. No other psychological treatment or medication was administered to any subjects. All subjects were measured at pretreatment and at posttreatment on an IQ test and parent behavior rating scales for inattention, hyperactivity, and aggressive/defiant (oppositional) behaviors. At posttreatment the experimental group demonstrated a significant increase (mean of 9 points) on the K-Bit IQ Composite as compared to the control group (p<.05). The experimental group also significantly reduced inattentive behaviors as rated by parents (p<.05). The significant improvements in intellectual functioning and attentive behaviors might be explained as a result of the attentional enhancement affected by EEG biofeedback training. Further research utilizing improved data collection and analysis, more stringent control groups, and larger sample sizes are needed to support and replicate these findings.
Clinical utility of EEG in attention deficit hyperactivity disorder by Loo, S., & Barkley, R. (2005).
Applied Neuropsychology, 12(2), 64–76.
Electrophysiological measures were among the first to be used to study brain processes in children with attention deficit hyperactivity disorder (ADHD; Diagnostic and Statistical Manual of Mental Disorders [4th ed.], American Psychiatric Association, 1994) and have been used as such for over 30 years (see Hastings & Barkley, 1978, for an early review). More recently, electroencephalography (EEG) has been used both in research to describe and quantify the underlying neurophysiology of ADHD, but also clinically in the assessment, diagnosis, and treatment of ADHD. This review will first provide a brief overview of EEG and then present some of the research findings of EEG correlates in ADHD. Then, the utility of EEG in making an ADHD diagnosis and predicting stimulant response will be examined. Finally, and more controversially, we will review the results of the most recent studies on EEG biofeedback (neurofeedback) as a treatment for ADHD and the issues that remain to be addressed in the research examining the efficacy this therapeutic approach.
EEG biofeedback and learning disabilities by Lubar, J. F. (1985).
Theory into Practice, 26, 106–111.
Neurofeedback for the management of attentiondeficit/hyperactivity disorders by Lubar, J. F. (1995).
Chapter in M. S. Schwartz (Ed.), Biofeedback: A Practitioner’s Guide. New York, Guilford, 493–522.
describe a relatively new . . . adjunctive procedure called EEG neurofeedback training (neurofeedback) for treatment and long-term management of [attention deficit hyperactivity disorder (ADHD)] / covers the description of ADHD, its characteristics, a brief historical review, and a description of some of the existing therapies for this disorder / present a detailed description of the EEG characteristics of ADHD, along with the rationale for developing a data base from EEG measures including both age-related and intelligence-related considerations / discuss the rationale for neurofeedback including the criteria for an effective intervention with specific individuals / describe the details of instrumentation and treatment protocols that should be used for this type of training and how they vary as a function of age, intelligence, and severity of the disorder / [discuss] pre- and posttreatment measurement used to determine the effectiveness of neurofeedback focuses on the integration of neurofeedback with other therapies, including the use of medications, family therapy, individual therapy, and parent support groups / outline future directions that need to be considered for the further development of neurofeedback training
Neurofeedback for the management of attentiondeficit / hyperactivity disorders by Lubar, J. F. (2003).
Chapter in M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A Practitioner’s Guide (Third Edition New York, Guilford), 409–437.
Electroencephalographic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting by Lubar, J. O., & Lubar, J. F. (1984).
Biofeedback & Self-Regulation, 9, 1–23.
Six children were provided with long-term biofeedback and academic treatment for attention deficit disorders. Their symptoms were primarily specific learning disabilities, and, in some cases, there were varying degrees of hyperkinesis. The training consisted of two sessions per week for 10 to 27 months, with a gradual phase-out. Feedback was provided for either increasing 12-to 15-Hz SMR or 16- to 20-Hz beta activity. Inhibit circuits were employed for blocking the SMR or beta when either gross movement, excessive EMG, or theta (4–8 Hz) activity was present. Treatment also consisted of combining the biofeedback with academic training, including reading, arithmetic, and spatial tasks to improve their attention. All children increased SMR or beta and decreased slow EEG and EMG activity. Changes could be seen in their power spectra after training in terms of increased beta and decreased slow activity. All six children demonstrated considerable improvement in their schoolwork in terms of grades or achievement test scores. None of the children are currently on any medications for hyperkinetic behavior. The results indicate that EEG biofeedback training, if applied comprehensively, can be highly effective in helping to remediate children who are experiencing attention deficit disorders.