Neurofeedback treatment of ADHD

Brendan Reid
Luke Mueller
Bryan Clark
Adrian Scott
Outline
What is ADHD?
Physiology and Neurofeedback Procedures
2 Efficacy Studies
Criticism of Neurofeedback for ADHD treatment


What is ADHD
A medical condition caused by genetic factors
that result in certain neurological differences
Behavioral Characteristics
1. Problems with attention
2. Lack of Impulse Control
3. Motor Restlessness
4. Boredom
Classifications
>Inattentive
>Impulsive-Hyperactive

Timeline
Names Drugs
Is ADHD on the Rise?
Market flooded with new drugs
Number of legitimate cases has remained steady
5% in adults
3% in children
Misdiagnosis
Drug exposure in-utero
Fetal Alcohol Syndrome(FAS)
Expectant Mothers:
~5% report using illicit drugs*
>20% report using alcohol*
*Source: National Institute of Drug Abuse (NIDA)

Dr. Quacks Machine
Development of Neurofeedback Therapy for ADHD (I)
Dr. Barry Sternan
Commisioned by U.S. Navy
Training experiments on cats
D.A. Quirk
Showed interesting neurofeedback results with
prisoners
First to test effectiveness at treating ADHD, as well as
neurological disorders
Depression
Autism
Stroke
Neurometric Analysis
Development of Neurofeedback Therapy for ADHD
(II)
Able to distinguish Learning Disabled from non-
Learning Disabled children based on EEG
differences
97% successful diagnosis?
High Hopes
Should be possible to use home computersto
carry out neurometric analysis right in the schools
Brain waves and their functions
Delta: 0.1-3 Hz
Deep sleep, lucid dreaming, increased immune functions, hypnosis
Theta: 3-8 Hz
Deep relaxation, meditation, increased memory, focus, creativity, lucid
dreaming
Alpha: 8-12 Hz
Light relaxation, super learning, positive thinking
Low Beta: 12-15 Hz
Relaxed focus, improved attentive abilities
Midrange Beta: 15-18 Hz
Increased mental ability, focus, alertness, and IQ
High Beta: above 18Hz
Fully awake, normal state of alertness, stress and anxiety
Gamma: 40 Hz
Associated with information-rich task processing and high-level
information processing
Brainwaves in ADHD children
Lubar suggested that children with hyperactivity
+ an attention deficit have:
Less beta activity above 14 Hz
Excessive theta (4-8 Hz) activity
Suggests that these children are
less able to shift from resting states
(theta/alpha dominant) to excited
states (beta dominant)
Brainwaves in ADHD children
A case study of 6 such patients showed that
SMR (12-15 Hz) training followed by beta
training with theta inhibition produced significant
and sustained improvements in school
performance and psychometric measures
Letter grades improves, and SMR and beta
production improved with decreases in theta
What areas/systems are affected in
ADHD patients?
Frontal lobe
Attention to tasks
Focus concentration
Make good decisions
Plan ahead
Learn and remember what we have learned
Behave appropriately in situations
What areas/systems are affected in
ADHD patients?
Limbic system
Base of our emotions
If over-activated, a person might have wide mood
swings or quick temper outbursts
Might also be over-aroused: quick to startle,
touching everything around, hyper vigilant
What areas/systems are affected in
ADHD patients?
The Reticular Activating System
Connected at its base to the spinal cord
Receives information projected directly from the
ascending sensory tracts
Brainstem reticular formation runs all the way up to
the mid-brain
Serves as a point of convergence for signals from
the external world and from interior environment
What areas/systems are affected in
ADHD patients?
Functional imaging techniques have pointed to
3 areas related to the basal ganglia
Prefrontal cortex
Caudate nucleus
Globus palladus
Problems with the circuit between these three
regions may be the underlying mechanism that
causes ADHD symptoms
EEG Biofeedback procedure
One or more sensors are put on the scalp and
one on an earlobe
No pain
Non-invasive
Computer translates brainwaves into controls
for a video game
Practice can allow the child to gain an
increased control over their brainwaves
Number of sessions varies
Can take from 40-60 sessions to eliminate
ADD, may need more than 60 for ADHD
Two Efficacy Studies
Monastra et al. (2002) study
Fuchs et al. (2003) study
Monastra et al (2002)
100 subjects (mean age = 10) were diagnosed
with ADHD using multiple tests
All subjects were given stimulant therapy,
parental counseling, and school consultation
51 of the subjects were administered
neurofeedback
Subjects were tested after 1 year, then taken off
Ritalin for 1week and retested
Monastra: Detail of neurofeedback
training
30-40 minute weekly sessions
point given for each .5 seconds of improved
arousal
20 points could be exchanged for a $15 reward
Children were given training until their cortical
slowing was within 1 SD of same-age peers
Monastra Results
Tested after 1 year of medication with Ritalin,
then 1 week later after no Ritalin
Non-neurofeedback group showed little
improvement over their initial scores while on
Ritalin, no improvement after the wash-out period;
all still classified as ADHD
Neurofeedback group showed significant
improvement; most were no longer classified as
ADHD
Of the neurofeedback group, the only subgroup that
still tested as ADHD were subjects who received
non-systematic parenting
Monastra: Results
Fuchs et al. (2003)
34 children (mean age=9.8) diagnosed with
ADHD but not previously treated
Treatment based on parent's choice
22 given neurofeedback (no Ritalin)
12 given Ritalin
Typically 3 10-mg doses, only on school days
Treatment lasted for 12 weeks
One subject in the Ritalin group dropped out
because of excessive side effects (tics)
Fuchs: Detail of Neurofeedback
Training
Neurofeedback training to increase 12-18 Hz
activity, decrease 4-7 Hz and 22-30 Hz
Children of the hyperactive subtype were trained in
SMR (12-15 Hz)
Children of the inattentive subtype were trained in
beta1 (15-18) Hz activity
Children of the combined subtype were trained for
half the sessions in SMR, half the sessions in beta1
Fuchs: Detail of Neurofeedback
Training
SMR is associated with inhibition of the
thalamo-cortical loop
Hyperactivity is thought to be caused by
overresonsiveness in the right hemisphere, so
suppressing activity would lead to an decrease in
hyperactivity
Attentional deficits may be caused by a
predominance of theta and lack of beta activity
in the left hemisphere
Fuchs: Results
No difference between groups pre-treatment
After treatment, both groups showed similar
improvements on all tests
Problems with Neurofeedback
time and money (at least 40 sessions, up to
$100 each)
insurance doesn't cover neurofeedback
requires patient to be motivated, bored patients
not as successful
age: too young vs too old (somewhat individual)
*ability to make EEG changes*
Unreliable success rate (~50% --> ~90%),
uncertainty of effectiveness until late in
treatment
Criticism: Hunters in a Farmers World
(Genetic basis of ADHD)
cultural evolution v.s. biological evolution
AD/HD may not have always been a disorder
(University of California, Irvine)
Attention-Deficit/Hyperactivity Disorder (AD/HD)
first appeared 10,000 to 40,000 years ago
speculation that early humans with AD/HD had
traits such as novelty-seeking, increased
aggression and perseverance
traits have been associated with the DRD4 7R
gene
Hunters in a Farmers World (cont.)
"survival of the fittest" scenario
ever-increasing number of people with AD/HD
more aggressive, inquisitive, and willing to take
risks meant a higher probability for mate
selection and perhaps multiple sex partners
spreading of the gene and its associated
AD/HD behaviors through the population.
Primitive hunters with this gene would have
been more successful and would have been
better providers for their families and tribes
Criticism: Incomplete Knowledge
Incomplete understanding of underlying
mechanisms of brain wave production
Is it wise to alter these mechanism by using
their byproduct? Self directed alteration and
morality.
Are unknown or intractable side effects in
action?
Placebo effect (up to 50%)
Reproducible results: Umbrella Diagnosis
Symptoms: cause or effect?

Criticism: Afterwards
Potentially permanent changes (side effects
may be more intractable, like loss of creativity)
Personality changes
Standardization of behavior
Long term effects relatively unstudied
Technology advancement and future uses
Neuroscience conference on
Neurofeedback (UCLA, 2005)
Widespread support from clinical practitioners
Skepticism from researchers
Scale Chauvinism
Unconvinced vs Under-funded
Neurofeedback as alternatives to Psycho-
stimulants
Double blind studies and Placebo effect

Neurofeedback, ADHD, and Altered
States of Consciousness
If states of consciousness are dependent on
brain activity, then the mental states of an
untreated ADHD patient are different from their
treated mental states (since there is a change
in EEG readings)
ADHD has effects on dopamine,
norepinepherine, acetylcholine

References
Masterpasqua, Frank and Kathryn Healey. Neurofeedback in Psychological Practice.
Professional Psychology: Research and Practice. 2003, Vol. 34, No. 6, 652-656.
Fuchs, Thomas et al. Neurofeedback for Attention-Deficit/Hyperactivity Disorder in
Children: A Comparison With Methylphenidate. Applied Psychophysiology and
Biofeedback, Vol. 28, No. 1, March 2003.
Monastra, Vincent, Donna Monastra, and Susan George. The effects of Stimulant
Therapy, EEG Biofeedback, and Parenting Style on the Primary Symptoms of
Attention-Deficit/Hyperactivity Disorder. Applied Psychophysiology and Biofeedback,
Vol. 27, No. 4, Dec. 2002.
http://www.drbiofeedback.com/sections/biofeedback/howisbioperformed.html
http://www.newideas.net/attention_deficit/neurology.htm
http://brain.web-us.com/brainwavesfunction.htm

References (cont.)
Lubar Joel F. (1985) EEG Biofeedback and Learning Disabilities Theory Into
Practice, 24(2) 106-111.
(2003) "The History of ADHD and Attention Deficit Disorder" May 20, 2005.
http://www.add-adhd-help-center.com/newsletters/newsletter_15july03.htm
Bate P (2004) Brief History of EEG Biofeedback May 20, 2005
http://www.adhd-biofeedback.com/eeghist.html
http://www.add-adhd.org/ADHD_attention-deficit.html
http://www.adhd.com.au/Neuro.html
http://www.attention.com/start/New_Abstracts.pdf
http://www.eegspectrum.com/Applications/ADHD-ADD/EfficacySMR-BetaIntro2/