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The Role
Of Neurofeedback In The Treatment Of ADHD |
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Neurofeedback – also
known as EEG Biofeedback – is an approach for treating ADHD
that has been studied and practiced for a number of years. In neurofeedback
treatment, individuals are provided with real-time feedback about
their brainwave activity and taught to use that information to modulate
certain aspects of their minds. As a
treatment for ADHD, neurofeedback
is based on findings that measurements of brain activity in many
individuals with ADHD indicate reduced activity in the prefrontal region
and frontal lobes (cortical slowing).
Neurofeedback treatment is designed
to train individuals to increase the production of brainwave patterns
that reduce or eliminate this cortical slowing, and thus reduce or eliminate
many associated ADHD symptoms. For a
more complete discussion of
neurofeedback treatment
for ADHD, go to:
http://www.aapb.org/public/AAPBpEEGbroch.html.
Within
the medical and scientific communities, a diverse range of viewpoints exists
on the utility of neurofeedback treatment for ADHD. At one extreme, there
are prominent researchers who argue that, although neurofeedback treatment
is consistent with current theories about the biological underpinnings
of ADHD, there is a lack of scientific data documenting the efficacy
of this approach. On the other hand,
some neurofeedback researchers
and practitioners argue that published studies clearly establish
the effectiveness of this
treatment.
As
is often the case in such debates, a careful review of the available literature
suggests that a more reasonable position falls somewhere in between
these views. Two controlled studies and numerous, carefully conducted
case studies have reported positive results. Based on this body of prior
work, neurofeedback treatment has been considered a “promising” approach
for which additional study was clearly warranted. This is the conclusion
of Dr. Eugene Arnold in the most comprehensive review of alternative
treatment approaches for ADHD published to date, and most ADHD experts
would agree that additional controlled studies are required to unequivocally
establish the efficacy of neurofeedback treatment for ADHD. (You
can review the article on alternative treatments at:
http://www.attention.com/library/articles/article.jsp?id=113&parentCatId=5&categoryId=33.)
A
recently conducted investigation “The Effects of Stimulant Therapy, EEG Biofeedback
& Parenting Style on the primary symptoms of ADHD” (Monastra et. al.)
represents a significant step in this direction. Preliminary reports of
this research were presented at the CHADD (Children and Adults with Attention
Deficit-Hyperactivity Disorder) national conference in 1999 and the
annual convention of the American Psychological Association (APA) in 2000.
A manuscript describing this study is currently under editorial
review.
As
with many studies of neurofeedback treatment, this investigation was conducted
in an actual clinical setting as opposed to an academic research
setting. Participants were 100
children (83 boys and 17 girls) with
an average age of 10 (range 6-19). Each child was diagnosed with ADHD and
treated at the Family Psychology Clinic, a private outpatient psychological
clinic in upstate
After
each child/teen was diagnosed, his or her parents were informed of a comprehensive
treatment approach that included stimulant medication, parent counseling,
school consultation to establish and monitor a program of academic
support and neurofeedback. Approximately half of the participants
(n=51) opted to include
neurofeedback as part of their child’s treatment.
Because
this study was conducted in a clinic setting where parents paid for treatment
(as opposed to an academic research setting where treatment is often
provided at no charge), it was not possible to randomly assign children
to receive neurofeedback as part of their treatment package. One limitation
associated with non-random assignment is the possibility that children
in the two groups, or their families, may have differed in a systematic
way prior to the beginning of treatment.
If this were found, it would
be difficult to attribute any differences found at the end of treatment
to differences in the treatment they received. Fortunately,
however, this does not
seem to have been true.
Information
presented indicates that the two groups (i.e. children whose treatment
included neurofeedback and those who did not) did not differ in age,
gender composition, IQ, or socioeconomic status. In addition, the representation
of the different ADHD subtypes (i.e. inattentive and combined)
was virtually identical. Finally,
pre-treatment parent and teacher
ratings of ADHD symptoms, scores on the TOVA (a computerized test of sustained
attention that is often used in ADHD evaluations and to monitor the
effects of medication treatment), and results of a QEEG scan were also equivalent.
(Note: A QEEG scan is a technique used to identify the pattern of
cortical under-activity characteristic of ADHD. Recent research indicates
this technique shows considerable promise as an objective procedure
to assist in the diagnosis of ADHD.
For more information on this procedure,
go to
http://www.attention.com/library/articles/s_article.jsp?id=63&keywordId=7.)
Treatment
Participants
received treatment over the course of 12 months. The different
treatment components are
described below.Stimulant
medication: All participants received treatment with Ritalin throughout
the year. The average daily dose was
25 mg (10 mg in the morning,
10 mg at midday, and 5 mg in the late afternoon) for children in
both groups.
Parent
Counseling: Parents participated in a ten-session parenting class, followed
by individual consultation on an “as needed” basis. The parenting class
was designed to increase parents’ understanding of ADHD and help them increase
the use of systematic reinforcement strategies and positive parental
attention. Information on nutrition, problem solving with teens, and
the educational rights of children with ADHD was also presented. The average
number of clinical contact hours (parenting classes and subsequent individual
consultation) totaled 25 for parents in the neurofeedback group
and 27 for the other
parents.
School
Consultation: At the conclusion of the diagnostic evaluation, parents were
informed about procedures to obtain special educational services for their
children under the appropriate federal regulations. In accordance with
applicable laws, school districts evaluated each child and developed, revised,
and implemented an individualized educational program (IEP) or a plan
of academic support/accommodation (“504 Plan”) for each with the assistance
of the treating clinician. For each
group, the mean number of
on-site consultations
during the treatment year was 3.
Neurofeedback:
For children whose parents elected to include neurofeedback in
their child’s treatment, “attention training” sessions lasting 30 to 40 minutes
were conducted on a weekly basis.
Periodic QEEG scans were used to determine
training effectiveness. Training continued until the patient no longer
exhibited abnormal cortical slowing.
The average number of sessions
required to reach this
criterion was 43.
As
is evident from the above discussion, the overall treatment regimens for the
two groups of children appear to have been virtually identical, except for
the inclusion of neurofeedback treatment in one of the groups. Because the
groups did not differ in systematic ways before treatment began, the researchers
could evaluate whether including neurofeedback training made any
appreciable difference in
the children’s outcomes.
Results
A
comprehensive set of treatment outcome measures was collected on each child
one year after treatment had begun.
These measures included: 1) parent
and teacher ratings of inattentive and hyperactive/impulsive behavior using
the Attention Deficit Disorder Evaluation Scale (ADDES), a widely used standardized
behavior rating scale; 2) the children’s scores on the TOVA; and
3) the children’s Attention Index score, based on a QEEG scan. Each measure
was collected twice: once when participants were still on medication
and a second time after
they had been off medication for an entire week.
The
authors predicted that children in both groups would show behavioral improvements
and “normalized” TOVA results when medication treatment was still
in place, and would not differ from each other in terms of overall results. They also predicted that the improvements
for the neurofeedback group
would be significantly better upon the second outcome assessment, when the
children were no longer receiving medication.
(This prediction was based
on prior research suggesting that neurofeedback training can yield sustained
reductions in ADHD symptoms while medication-induced improvements typically
last only as long as the child is on medication.) Finally, researchers
expected that only children who received neurofeedback would
show normalized Attention
Index scores on the QEEG.
Outcomes
when children were still on medication
As predicted, TOVA scores at the first outcome assessment were well within the normal range for both groups. In contrast to expectations, parent and teacher ratings of ADHD symptoms remained in the clinical range for children who had not received neurofeedback. For participants whose treatment included neurofeedback, however, parent and teacher ratings of ADHD symptoms were all in the normal range and were significantly better than ratings for the other participants. These results are shown below. (Note: Scores below 7 are considered to indicate significant difficulty. The numbers reported represent the average score for each group.) No neurofeedback Neurofeedback included
Parent inattention 4.63 8.59 Parent hyperactivity 6.06 8.65 Teacher inattention 4.96 9.35 Teacher hyperactivity 5.96 9.63 Similar
results were obtained on the outcome measures taken after the children
had been without medication for an entire week. As before, children
whose treatment had not included neurofeedback continued to show significant
ADHD symptoms according to parent and teacher ratings. In addition,
the TOVA results for these participants fell in the clinical range
on 3 of the 4 subscales.
In
contrast, parent and teacher ratings of the neurofeedback group all remained
within the normal range, as did their TOVA results. Furthermore, the
QEEG scan showed that the average Attention Index score for the neurofeedback
group was also within the normal range, indicating that the cortical
slowing characteristic of ADHD that was present at the beginning of treatment
was no longer evident. As expected,
the average Attention Index scores
for participants not receiving neurofeedback continued to indicate
significant cortical
slowing.
Summary and
Implications
These
results provide compelling evidence that incorporating neurofeedback into
a comprehensive treatment approach for ADHD can yield important benefits. As discussed above, only the participants
whose treatment included
attention training via neurofeedback showed behavioral improvement upon
follow up, and these benefits were evident even after medication was discontinued.
These children were doing substantially better—according to both
parents and teachers—than participants who had not received neurofeedback. In addition, the pattern of cortical
slowing that is found in
many individuals with ADHD, and which is specifically targeted by neurofeedback,
was no longer evident. This suggests
that the gains associated
with neurofeedback training cannot be attributed to the placebo
effect, but instead
reflect meaningful changes in EEG activity.
This
is a very impressive set of findings.
As with any study, however, it is
important to recognize its inherent limitations. First, it is surprising
that no significant gains in parent and teacher ratings were obtained
for the non-neurofeedback group, even when medication treatment was still
in place. Recently published results
from the MTA study document substantial
benefits from medication treatment alone, and in combination with
behavioral interventions, over a 14-month period. Based on these results,
as well as results from other studies, improved symptom ratings from
parents and teachers would have been anticipated. Because the same treatments
were delivered to participants who also received neurofeedback, this
does not call into question the incremental gains associated with neurofeedback. However, it does raise the question of
whether such incremental
gains would have been detected if the benefits provided by the
other intervention
components were as expected.
Several other cautions need to be noted. Because random assignment to treatment conditions was not feasible, one cannot rule out the possibility that parents who opted to include neurofeedback in their child’s treatment were a more highly motivated group of parents, and this is why their children did better. After all, this was a time-consuming and expensive addition. The fact that there was no differential attendance in parent counseling sessions between the two groups mitigates these concerns, however. In addition, the EEG changes revealed by the QEEG scan make it unlikely that enhanced parent motivation alone could explain the differential treatment results. This is because these better results were associated with documented changes in neurophysiological processes known to be associated with ADHD, and it seems implausible that parents’ motivation, or other extraneous factors , could have produced such changes.
Finally,
it is important to emphasize that neurofeedback was delivered as part
of a comprehensive treatment plan that included three other components. There
is thus no basis for determining whether neurofeedback alone would have
yielded positive results. And,
although gains were sustained beyond the
active use of medication, it is unclear whether these gains would persist
without ongoing intervention. These
issues would be important to
address in subsequent
research.
These
cautions notwithstanding, this is an important study that makes a significant
contribution to establishing a clear place for attention training
using neurofeedback in the treatment of ADHD.
One hopes that subsequent
studies building on this impressive piece of work, and which incorporate
important controls such as random assignment that were not
possible in this
investigation, will soon be forthcoming.
TEACHING
ATTENTION SKILLS TO CHILDREN WITH ADHD
In
a prior issue of Attention Research Update, I reviewed the results of an interesting
study in which children with ADHD received an intervention designed
to teach them how to improve their ability to sustain attention.
(http://www.attention.com/library/articles/article.jsp?id=59&parentCatId=5&categoryId=33.)
This
was one of very few studies to test whether systematic procedures to directly
train attention skills in children with ADHD (other than attention training
via neurofeedback) could be successful.
Results from this study
appeared to be promising.
A
second investigation of this topic was published in the November 99 issue of
the Journal of Learning Disabilities (Semrud-Clikeman, M., An Intervention
Approach For Children With Teacher- And Parent-Identified Attentional
Difficulties. Journal of Learning Disabilities, 32, 581-590). Participants
in this study were 33 children in grades 2 through 6 who were diagnosed
with ADHD, and 21 matched comparison children. Teachers nominated children
to participate in the study, based on their difficulty completing assignments
and paying attention in class. (Note:
Efforts were made to screen
out children who had other diagnoses in addition to ADHD, so this was
not a truly
representative group of ADHD children.)
Parents were informed about a program to teach their child better attention skills. Those parents expressing interest in the program were contacted so that an ADHD evaluation for their child could be completed. Interestingly, of the 33 children identified with ADHD in this study, only 50% had been previously diagnosed and very few were receiving any treatment. Although this is not the focus of the study, these data highlight the unfortunate fact that many children who struggle with ADHD are never formally identified and receive little appropriate assistance.
Attention
training was conducted in after-school groups of 4 to 5 children that
met twice a week for 60 minutes each time over an 18-week period. The attention
training system used was based on the Attention Process Training model
(APT), developed for adults over a decade ago. This system is based on
the idea that there are different components to attention: lower level components
such as being able to focus and sustain attention over time and higher
level components that involve the ability to allocate attention
between different tasks.
The
training program utilized both visual and auditory attention tasks. The visual
attention tasks required children to find a target stimulus embedded in
an array of distracters. Tasks were
relatively simple at first (i.e. the child
was required to find one type of figure among widely spaced figures ranging
from somewhat similar to widely dissimilar) and became increasingly difficult
(i.e. the child had to find a selected number of figures from among
many closely spaced figures as quickly as possible). For the auditory task,
children were required to count the number of times particular targets could
be heard on a cassette tape. The
easier tasks required children to keep
track of how often they were presented with a particular letter from among
a group of dissimilar options. In the
more difficult tasks, children had
to count the instances of words beginning with particular sounds. These are
the kinds of repetitive, uninteresting tasks that children with ADHD
typically have great
difficulty performing accurately.
During each session, children reviewed their performance (i.e. speed and accuracy) from prior sessions and were required to set goals for their performance that day. In addition, the group discussed strategies to help each child meet his or her goals. Children attempted the task using the strategy they had selected, and then evaluated the effectiveness of the strategy based on their performance. When this evaluation indicated the strategy was not effective, the group leader helped the child revise the initial strategy and he or she would try again. Thus, the basis on which better attention skills were trained included repetitive practice in attention tasks, reviewing prior performance and setting new performance goals, and developing, monitoring, and, if necessary, revising strategies to achieve one’s performance goals. This active problem-solving approach is one that can be applied to a wide range of academic and behavioral objectives, not just the attention tasks that were the focus of this study.
Only 21 of the participants with ADHD received the intervention described above. The remaining children were unable to take part because of after-school scheduling conflicts. Prior to beginning the intervention, all 33 ADHD children and the 21 non-ADHD comparison subjects completed a test of visual and auditory attention that was different from those tasks used in the attention-training paradigm.
After
the 18-week attention training intervention was completed, all children
were given the visual and auditory attention tests a second time. To
determine whether the attention-training program was successful, the authors
compared the pre- and post-training performance of 3 groups: ADHD children
who received the intervention (i.e. ADHD intervention group); ADHD children
who did not receive the intervention (i.e. ADHD control group); and
non-ADHD comparison
children (non-ADHD control group).
RESULTS
As
expected, pre-test results indicated that children in both ADHD groups performed
more poorly on the visual and auditory attention tests than the non-ADHD
comparison children. The ADHD groups
did not differ from one another,
however, suggesting that their attention skills were equivalently impaired
prior to the training program. In
addition, parent and teacher ratings
of attention problems for children in these groups were equivalent
prior to the start of
training.
At
the post-test assessment, the ADHD control group continued to show poorer performance
on both attention tasks than the non-ADHD control group. Children
who received the attention-training program scored as well as the non-ADHD
subjects and significantly better than the children in the ADHD control
group. In fact, on the auditory
attention task, children in the ADHD
intervention group had slightly higher average scores, although this
difference was not
statistically significant.
Post-test behavior
ratings from parents and teachers were not obtained.
SUMMARY
AND IMPLICATIONS
Results
from this study indicate that children with ADHD can perform as well as
non-ADHD children on visual and auditory attention tasks following training
in sustained attention and problem-solving skills. This is the second
study published in recent years suggesting the potential benefits of
direct attention training
for children with ADHD.
These
are encouraging results, but there are limitations to this study that the
author notes are important to consider.
First, because the sample did not
include any children with diagnoses in addition to ADHD, as is true for many
children with ADHD, this was not truly representative of the overall ADHD
population. Therefore, it cannot be
determined whether similarly positive
results would have been obtained for children with ADHD and co-occurring
problems. Second, there were very few
females included in the study,
making it unclear whether the beneficial impact of the training
program would generalize
to girls as well.
The most important limitation is the absence of any post-test assessment of children’s actual behavior and performance in the classroom. Although it is encouraging that children who received the training performed better on specific tests of attention, it is essential to know whether the training also had positive impact on classroom behavior and academic performance. It is certainly possible that it did, but it is also possible that there was no change in these more important outcomes. It would thus be very important to repeat this study to determine whether the attention-training paradigm used actually results in classroom gains. |
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