Neurofeedback and ADD

 Kim Trask

What is ADD?

 

            ADD is an acronym for Attention Deficit Disorder (this can also be known as ADHD [Attention Deficit Hyperactivity Disorder]).  “Attention-deficit/hyperactivity disorder is characterized by an age-inappropriate level of inattention, with or without impulsivity and overactivity, that occurs across settings, causes functional impairment and cannot be attributed to another disorder” (Mercugliano 831).  This is one of the most common psychiatric disorders amongst children today.  According to Linder, Habib, and Radojevic (1996), ADD affects between 5% and 15% of children. 

            DSM-IV CRITERIA FOR ADHD

A.     Either 1 or 2 (or both):

1.      Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention

a.       often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

b.      often has difficulty sustaining attention in tasks or play activities

c.       often does not seem to listen when spoken to directly

d.      often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

e.       often has difficulty organizing tasks and activities

f.        often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

g.       often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

h.       is often easily distracted by extraneous stimuli

i.         is often forgetful in daily activities

2.      Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

a.       often fidgets with hands or feet or squirms in seat

b.      often leaves seat in classroom or in other situations in which remaining seated is expected

c.       often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

d.      often has difficulty playing or engaging in leisure activities quietly

e.       is often on the go or gotten acts as if driven by a motor

f.        often talks excessively

Impulsivity

g.       often blurts out answers before the question has been completed

h.       often has difficulty awaiting turn

i.         often interrupts or intrudes on others (e.g., butts into conversations or games)

Additional Criteria:

B.     Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7.

C.     Some impairment from symptoms is present in two or more settings (e.g., school or work and at home).

D.     There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E.      The symptoms do not occur exclusively during the course of pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder) (Mercugliano 833).

 

Some of the effects of ADD can be:

·        Trouble sitting still

·        Trouble inhibiting behavior

·        Being mostly inattentive                                                

·        Difficulties paying attention and keeping on task

(http://www.add-adhd.org/ADHD_attention-deficit.html)

·        Poor peer relationships

·        Below average performance in school

·        Hardships with parenting

(http://www.biof.com/linden.html)

      It is believed that there are genetic and physiological factors that can lead to ADD.  This is supported by the fact that “70% of children do not outgrow the attention and learning problems associated with ADD… Incidence rates are much greater among family members” (Linden, Habib, & Radojevic, 1996, 36). 

What are treatments for ADD?

There are many different treatments for ADD.  Stimulants are a common way of suppressing ADD.  Drugs such as Ritalin, Dexedrine, and Aderall are often prescribed for people diagnosed with ADD.  There has been a large increase (248%) in the amount of stimulants being prescribed in the ten-year period between 1971 and 1981 (Tan & Schneider, 1997).  One of the drawbacks using stimulants to treat ADD is that they can become addictive.  Young children cannot become dependent on their prescriptions (http://www.add.org/content/treatment/meds1.htm).  These drugs are often effective in most people.

However, there are some cases in which stimulants do not work.  In these cases tricyclic antidepressants or antihistamines may be used to treat ADD.  Clonidine is an example of a treatment that had been prescribed when stimulants have failed to produce the expected results (http://www.add.org/content/treatment/meds1.htm).  Other medications are: Norpramin, Tofranil, Catapres, Tenex, Prozac, and Wellbutrin (Tan & Schneider, 1997).

The preceding treatments have some side effects that should be anticipated.  These can be any of the following:

·        Weight loss

·        Loss of appetite

·        Inhibited growth

·        Insomnia

(http://www.add.org/content/treatment/meds1.htm)

These can be anticipated and avoided by altering the dosage of the medication.  These side effects often disappear after the first six months of treatment (Tan & Schneider, 1997).

            There is an alternative (“non-medication”) way of treating ADD: Neurofeedback.

What is neurofeedback?

Neurofeedback is “designed to help [people] correct problems in brain function such as ADD” (http://www.eegspectrum.com/school/anders98.htm).  This process is supposed to teach ADD patients how to control their brain waves.  This procedure yields permanent results.  As opposed to the medications, which can only temporarily relieve the person from the characteristic symptoms of ADD.  The problems are only suppressed until the medication wears off.  However, once a person is taught to control their brain waves, they have control over them indefinitely. 

What actually happens during neurofeedback?

“Sensors are attached to the scalp and ear using conductive paste.  These sensors measure frequencies and amplitudes produced by the brain.  The computer then converts this information into visual and auditory feedback.  This way the person can begin to experience how their brain is reacting during different situations, and learn how to change their brain wave patterns.  By continuously practicing, the individual learns to change and control their brain patterns” (http://webideas.com/biofeedback/research/minevich.htm).

During this process, patients are believed to increase the amplitude of their beta waves (12-20 Hz).  These types of brain waves are associated with concentration and attention.  Patients also decrease the amplitude of their theta waves (4-8 Hz) during the neurofeedback process.  These are linked to inattentive behaviors.  Various researchers have defined the waves differently, so the previous values encompass all of them (http://webideas.com/biofeedback/research/minevich.htm). 

In the study done by Linder, Habib, and Radojevic (1996), the following method was used.  “The EEG biofeedback sessions were 45 minutes in length and consisted of electrode attachment and 3 10-minute EEG biofeedback segments: (1) standard training (biofeedback with eyes open while attending to visual and auditory feedback), (2) a reading task (biofeedback during reading age appropriate books), and (3) an auditory listening task (biofeedback while an assistant read age appropriate material to them).  During the reading and listening sessions, if the subject stopped receiving feedback rewards (points or tones) the task was temporarily stopped and the subject was instructed to concentrate until the rewards began, and then continue reading or listening…At the conclusion of each training day, the subjects were given small rewards (e.g., baseball cards, stickers), which were provided based on their levels of cooperation, effort, and performance” (40).

Who can benefit from it?

            According to Joel F. Lubar, Ph. D., one of the primary researchers of neurofeedback, almost all people diagnosed with ADD or ADHD can benefit from neurofeedback.  There are however some restrictions.  The patient must be between the ages or 7 and 45.  The candidate for therapy can be of any intelligence.  The person cannot be experiencing any of the following:

• Mental Retardation Childhood Psychosis
• Severe depression
• Bipolar illness
• Seizure disorder (where medications inhibit learning)
• Hyperkinesis
• Learning disabilities (without ADD or ADHD)

(http://www.selfgrowth.com/articles/lubar.html)

What is it supposed to do?

Neurofeedback is supposed to allow a person to control their beta and theta activity.  This will allow for them to focus on learning; therefore, school grades will improve.  This will also bring about higher scores on standardized tests (to measure intelligence).  There should also be a dramatic improvement in behavior.  This will facilitate the betterment of relationships with peers.  Job performance will reach the standard, if not surpass it.  The patient will being to realize that he/she has a greater potential than previously believed and will begin to strive to reach it.  The scores of Parent-Teacher ratings will begin to improve after the therapy.  Combined these will improve the patient’s self-esteem (http://www.selfgrowth.com/articles/lubar.html).

How well does it work?

There have been numerous studies on the effectiveness of neurofeedback in the treatment of ADD.  In 1995, Lubar, Swartwood, Swartwood, and O’Donnell did a study involving 23 subjects who ranged from ages eight to nineteen.  The study was conducted over a two to three month period in the summer.  The goal was to have each patient go through forty sessions of neurofeedback (each session was one hour of training).  The study was divided into three parts.  Part one had 19 participants; it’s objective was to determine the effect of neurofeedback on a continuous performance task (T.O.V.A.).  There were significant changes in the T.O.V.A. performance after the neurotherapy.  “The effects of neurofeedback appear to provide a change in performance without continual external intervention” (Lubar, Swartwood, Swartwood, & O’Donnell, 1995, 91).  In comparison to pharmacological treatments, which only last as long as the drug is in the patient’s system.

Part two had 13 participants; it’s objective was to determine the effect of neurofeedback on behavior ratings.  The behavior was assessed by parents using the McCarney Attention Deficit Disorder Evaluation Scale (ADDES).  ADDES measures the patient’s inattention, impulsivity, and hyperactivity.  The results from this part showed an improvement whether or not the patient showed EEG changes.  However, “parents often tend to overemphasize positive gains that are [a result of treatment]” (Lubar, Swartwood, Swartwood, & O’Donnell, 1995, 93).  For this type of assessment, a parent would not be the one to do the evaluation, strictly for reasons like this.

            Part three had 10 participants; it’s objective was to determine effects of neurofeedback on IQ scores.  All subjects made significant improvements on the IQ scores.  This data is valid because of the time span (more than six months) between the test and retest (Lubar, Swartwood, Swartwood, & O’Donnell, 1995).

            Linden, Habib, and Radojevic conducted another study in 1996.  This study consisted of 18 children aged five through fifteen.  They were split into an experimental and waiting list control group.  The experimental group was given forty 45-minute sessions of neurofeedback training.  The goal was to increase beta activity and decrease theta activity.

            The results from this study led the researchers to believe that the participants’ beta activity increased and theta activity decreased.  There was an average increase in IQ of nine points in the experimental group.  Inattentive behaviors decreased as a result of the neurofeedback training.  As in Lubar, Swartwood, Swartwood, and O’Donnell (1995), there was not a significant difference in the two groups aggressive/defiant behaviors.

            On of the problems with this study was that the EEG data from each subject could not be compared to each other’s data.  There were software restrictions and revisions; therefore, the threshold settings were inconsistent.  Another problem was that the subjects were rewarded for their improvement (Linden, Habib, & Radojevic, 1996).  So the subjects’ behavior may be a result of being rewarded, not a result of the neurofeedback training sessions. 

            None of the studies involving the effect of neurofeedback on ADD have been large enough or controlled enough to say that this is a very effective way of treating ADD.  However, in all the studies, the patients’, who underwent neurofeedback therapy, conditions were improved.  But there needs to be more research in which the controls are better and the groups are large enough to draw valid conclusions.

 

Works Consulted (these will be very helpful)

Baumgaertel, Anna.  (1999).  Alternative and Controversial Treatments for Attention-Deficit Hyperactivity Disorder.  The Pediatrics Clinics of North America, 46:5, 977-990.

Linden, Michael; Habib, Thomas; & Radojevic, Vesna.  (1996).  A Controlled Study of the Effects of EEG Biofeedback on the Cognition and Behavior of Children with Attention Deficit Disorder and Learning Disabilities.  Biofeedback and Self-Regulation, 21:1. 35-48.

Lubar, Joel F.  (1991).  Discourse on the Development of EEG Diagnostics and Biofeedback for Attention-Deficit/Hyperactivity Disorders.  Biofeedback and Self-Regulation, 16:3, 201-223.

Lubar, Joel F., Swartwood, Michie Odle, Swartwood, Jeffrey N., & O’Donnell, Phyllis H.  (1995).  Evaluation of Effectiveness of EEG Neurofeedback Training for ADHD in a Clinical Setting as Measured by Changed in T.O.V.A. Scores, Behavioral Ratings, and WISC-R Performance.  Biofeedback and Self-Regulation, 20:1, 83-98.

Mercugliano, Marianne.  (1999).  What is Attention-Deficit/Hyperactivity Disorder?  The Pediatric Clinics of North America, 46:5, 831-843.

Nash, John K.  (2000).  Treatment of Attention Deficit Hyperactivity Disorder with Neurotherapy.  Clinical Electroencephalography, 31:1, 30-36.

Tan, Grace; & Schneider, Steven C.  (1997).  Attention-Deficit Hyperactivity Disorder Pharmacology and Beyond.  Postgraduate Medicine, 101:5, 210-216.