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
Electroencephalogram (EEG) biofeedback, also known as neurofeedback, is a promising alternative treatment for patients with attention deficit/hyperactivity disorder (AD/HD) by Friel PN
Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder by Monastra VJ, Lynn S, Linden M, Lubar JF, Gruzelier J, LaVaque TJ
Electroencephalographic biofeedback (neurotherapy) as a treatment for attention deficit hyperactivity disorder: rationale and empirical foundation by Monastra VJ
Treatment of attention deficit hyperactivity disorder with neurotherapy by Nash JK
EEG biofeedback: A new treatment option for ADD/ADHD by Alhambra, M. A., Fowler, T. P., & Alhambra, A. A. (1995)
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 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)
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).
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).
Treating AD/HD with hypnosis and neurotherapy by Barabasz, A., & Barabasz, M. (2000).
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).
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)
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).
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).
Neurofeedback in residential children and adolescents with mild mental retardation and ADHD behavior by Breteler, R., Pesch, W., Nadorp, M. (2012).
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).
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).
The effects of bilateral EEG biofeedback on verbal, visuospatial and creative skills in LD male adolescents by Cunningham, M., & Murphy, P. (1981).
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).
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).
Learned self-regulation of EEG frequency Components affects attention and event-related brain potentials in humans by Egner, T., & Gruzelier, J. H. (2001).
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).
Multichannel EEG phase synchrony training and verbally guided attention training for disorders of attention by Fehmi, L. G. (2007).
EEG biofeedback, multichannel synchrony training, and attention by Fehmi, L. G. (1978).
Biofeedback and attention training by Fehmi, L. G., & Selzer, F. A. (1980).
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).
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).
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)
Neurofeedback: An alternative and efcacious treatment for attention deficit hyperactivity disorder by Fox, D. J., Tharp, D. F., & Fox, L. C. (2005).
The impact of neurotherapy on college students' cognitive abilities and emotions by Fritson, K. K., Wadkins, T. A., Gerdes, P., & Hof, D. (2007).
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.
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).
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).
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).
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).
Neurofeedback treatment of two children with learning, attention, mood, social, and developmental deficits by Jacobs, E. H. (2005).
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).
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)
Computerassisted cognitive training for ADHD: A case study by Kotwal, D. B., Burns, W. J., & Montgomery, D. D. (1996).
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).
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).
EEG asymmetry analysis of the left and right brain activities during simple versus complex arithmetic learning by Kwon, H., Cho, J., Lee, E. (2009).
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).
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).
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).
Clinical utility of EEG in attention deficit hyperactivity disorder by Loo, S., & Barkley, R. (2005).
EEG biofeedback and learning disabilities by Lubar, J. F. (1985).
Neurofeedback for the management of attentiondeficit/hyperactivity disorders by Lubar, J. F. (1995).
Neurofeedback for the management of attentiondeficit / hyperactivity disorders by Lubar, J. F. (2003).
Electroencephalographic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting by Lubar, J. O., & Lubar, J. F. (1984).