Neurofeedback: Another

Treatment for ADHD

In just the last 20 years, Attention Deficit & Hyperactive Disorder, (ADHD) has

become America’s “leading childhood psychiatric disorder. Approximately 2% to 6% of school-age children are diagnosed with ADHD (Raz 2004).   According to Barkley (1998) the number of children affected by ADHD can vary from 1% to 20 %, depending on how one chooses to define it, the population studies, the geographic locale of the survey, etc. ADHD is characterized by the inability to self-regulate focused attention. Children with hyperactivity are impulsive and behaviorally disinherited. The condition is developmentally disabling which, if left uncontrolled persists into adolescence and adulthood (Edwards, 1995).

Frontal Lobe and ADHD

Research indicates a neurological basis for ADHD, specifically, frontal lobe dysfunction. Frontal lobe functions are executive in nature and are involved in developing plans and organizing resources. They also are critical in mediating inhibitory behaviors such as controlling motor behavior and inhibiting attentional focus on distracter or irrelevant stimuli. The evidence suggesting right frontal lobe dysfunction as the basis of attention deficit disorders is considerable (Chelune, Ferguson, Koon & Dickey, 1986; Gualteri & Hicks, 1985; Hynd, et.al 1990; Lou,et.al., 1989).

There has been increasing interest in the relationship between prefrontal cortex functioning and the ADHD. Children with frontal lobe lesions show impulsive hyperactive behavior (Grattan and Eslinger, 1991), and adolescents with ADHD show decreased anterior frontal lobe activity on positron emission tomography (Zametkin et al., 1993). Performance on neuropsychological tests purported to test frontal cortex functioning is deficient in children with ADHD (Barkley et al., 1992). In study examined frontal lobe functioning in adolescents with ADHD Schandler (2001) found a presence and magnitude reflect frontal lobe dysfunction in children with ADHD ages between 12 and 17. The results of the study conducted by Fredericksen et. al. (2002) was consistent with previous reports of reduced frontal lobe volumes associated with ADHD.  Schmidt’s study (1999) shows that boys with ADHD exhibited a less right-lateralized frontal activation pattern than normal control boys. Halperin (2006) found that the brain activation gradients in ventrolateral prefrontal cortex of ADHD adolescents. Recent research using advanced neuroimaging morphological procedures has shown that ADHD children fail to show the normal right-greater-than-left asymmetry in the mass of the frontal lobes (Hynd, Hem, Voeller & Marshall, 1991). Consistent with this finding, computerized quantitative electroencephalographic (EEG) analysis shows significantly greater slow wave (theta) activity and significantly less fast wave (beta) activity predominantly in the frontal regions for ADHD boys and girls when compared to age-and-sex-matched normal (Mann, et.al.,1992).

Neurofeedback Training for ADHD

The neurofeedback Training, also known as EEG Biofeedback or Neurotherapy, uses an electroencephalograph (EEG), a device that detects and records the electrical activity in the brain, called brainwaves. An EEG can detect brainwaves and discern whether they are strong or weak (amplitude) or fast or slow (frequency). Scientists commonly identify brainwaves in four categories:-

Beta, the fastest brainwaves, 14-32 hertz, focused on day-to-day activities and on attentiveness & thinking activities.

Alpha, a slower brainwave, ranging from 8 to 12 hertz.  This rhythm is characteristic of a relaxed yet alert state of awareness.

Theta, the next slower waves range from 4 to 8 hertz. This rhythm is often associated with dreamlike imagery, sleepiness and deep relaxation.

Delta, the slowest waves, from 0 to 4 hertz, predominates during dreamless sleep.

EEG accepts the neurological basis of the ADHD (i.e. frontal lobe dysfunction).  Recognizing that the ADHD patients produce more theta waves activity and less beta waves activity, compared to non ADHD patients (Barabasz et al, 1993; Mann et al, 1992). The goal of EEG training is to alter these abnormal brain waves by decreasing theta waves, while simultaneously increasing beta waves. Proponents of this technique believe that bringing theta and beta brainwave closer to healthier patterns leads to a reduction of ADHD symptoms.The EEG monitors and records the different brainwaves of the patient, who learns how to increase or reduce certain types of brainwaves.  EEG training is intended to teach patients to normalize their brainwave responses to stimuli.

In EEG neurofeedback training, the therapist explains to the patient the connection between what is happening in his/her cortex and what is recorded on the EEG. Then, the therapist helps the patient to learn how to gain control over his/her brain waves. The therapist places the EEG electrodes on the head detect the different types of brainwaves produced by the patient and send the information to a data recorder. Every time the desired brainwave is identified, the neurofeedback apparatus sends a signal to the patient – auditory or visual feedback – to encourage the production of similar brainwaves. The auditory or visual feedbacks vary from simple sounds to elaborate computer graphics made to resemble video games where generating the wanted brainwave adds excitement to the action and brings some kind of rewards. Neurofeedback training typically takes 30-40 sessions depending on the severity of the disorder and other comorbid symptoms present. The first six sessions are completed as quickly as possible and then the frequency of training reduces to two or three times per week. With regular attendance, total training can be completed in four to six months. Each training session lasts approximately 30-45 minutes.

The procedure is based on an early study by Sterman and Friar (1972), who discovered that brainwave feedback made it possible to learn to inhibit epileptic seizures by enhancing low beta (12-16) which is referred to as sensory motor rhythm (SMR). As in current neurofeedback protocols for ADHD, Sterman and Friar’s patients were also trained to simultaneously minimize theta. The first preliminary case study application of this procedure to hyperkinetic children was by Lubar and Shouse (1977). The effects of neurofeedback appear to provide a change in performance without continual external intervention. Chartier and Kelly (1991) reviewed the effects of neurofeedback for ADHD on over 200 children treated by Dr. Joel Lubar at the University of Tennessee, Dr. John Carter at the University of Texas and Dr. Michael Tansey of Sommerville, New Jersey. Chartier and Kelly found neurofeedback training to provide significant and sometimes “dramatic” clinical improvements in children with attention deficit disorder. Parents and teachers of children who receive EEG neurofeedback training have reported dramatic behavioral improvements such as:  finishing tasks, listening better, less impulsivity, greater motivation and focus, and higher self esteem. In some cases, medications are completely discontinued and in others they have been considerably reduced.

Although the review suggests that EEG neurofeedback approach is an effective intervention for addressing behavioral, listening, impulsivity, and attention problems in patients with ADHD, more research are needed to delineate optimal information for training sessions and follow up procedures Presently, limitations of neurofeedback include: 1) the need for additional controlled experimental studies demonstrating effects which are independent of developmental maturation and the potentially confounding effect of the therapists and parents’ attention during the course of treatments; and 2) the large number of sessions (up to 80; 6-8 months) required for permanent clinical and academic changes to occur.  While the field awaits additional research, however, the current EEG training  could be used either separately or can be combined with one or more than one of other traditional treatment approaches in order to eliminate or reduce some the possible drawbacks.

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By: Dr. Kamal SeSalem

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