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Timestamp: 2019-04-25 17:57:35+00:00

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National Institute of Mental Health, (NIMH), Pilot Explorations of Neurofeedback issues in ADHD, using SmartBrain Technologies, (September, 2008).
We are excited to announce that NIMH, (National Institute of Mental Health), has funded an ADHD research study using the SmartBrain Technology. The principal investigator, L. Eugene Arnold, M.D., M.Ed., Professor Emeritus of Psychiatry, at Ohio State University is an internationally renowned researcher in the treatments of ADHD and will be heading up this study. This study is planned to begin in the fall of 2008.
A Randomized, Double-Blind Clinical Trial of EEG Neurofeedback Treatment for Attention Deficit / Hyperactivity Disorder (ADHD), (2002), A Double Blind, Randomized, Sham Treatment Study for ADHD boys aged 9-11, funded by Johnson and Johnson Consumer Products Companies, Inc., has just been completed, but is not yet published. This research was presented at the ISNR Conference, 2005.
Parents were blinded to study group assignment.
Outcome measures included independent, blinded evaluations by two consulting physicians to establish baseline diagnoses and to assess clinical improvement over the course of treatment for each individual patient.
Clinic staff was not be blinded to study group assignment.
The Contact Control Group, (19 subjects) made the same number of visits to the same clinic as the Experimental Group, (17 subjects) and they took part in an equal number of computer-based sessions and contact hours in an identical room with the same type of equipment. The only difference between the groups was that the Experimental subjects participated in computer-based EEG Biofeedback during their in-clinic sessions while the Control subjects did not. During their in-clinic sessions the Control subjects played a computer game lacking any neurophysiologically contingent feedback signal.
Contact Control Group experienced a 47% study drop out rate.
Experimental Group experienced a 6% study drop out rate.
No significant effects were noted on post study outcome measures for the Contact Control group.
Significant effects (P=<.025) were noted on the post Parent Conners, and post CGI (P=<.001) by both independent blinded physicians.
Child and Adolescent Psychiatric Clinics of North America, Volume 14, (2005).
A comprehensive review of the research on Neurofeedback has been published in a special issue of devoted to Emerging Interventions. In theintroductory chapter, the volume editors assess the degree of scientific support for Neurofeedback using standards developed by the child psychiatry professional organization (AACAP). They conclude that Neurofeedback uniformly shows significant benefit for 70 to 80% of participants, with an effect size for Neurofeedback equivalent to that of stimulants, as measured by computerized tests of attention and impulsivity (continuous performance tests) as well as standardized behavioral rating scales.
Forty-Six patients (aged 8–21 years) diagnosed with ADHD participated in the study. Two groups of 23 patients received the treatment of their (or a parent’s) choice (either stimulant medication or 20 sessions of EEG Biofeedback). None of the participants in either group discontinued treatment during the study.
The results of this study indicated significant improvements (P < 0.05) on the TOVA and several subscales of the Behavioral Assessment System for Children (e.g., hyperactivity, attention problems, and externalizing behaviors).
Comparison with a bona fide treatment for ADHD, (stimulant medication) revealed no difference in the effects of these treatments after 20 sessions.
Similarly, there was no significant difference in the percentage of patients who demonstrated clinical improvement with EEG Biofeedback (83%) and stimulant medication (87%).
Each group was composed of 9 children, 6 of whom were diagnosed with ADHD and 3 of whom were diagnosed with ADHD in combination with a learning disorder.
Patients who received EEG Biofeedback participated in 40 training sessions, (45 minutes each). None of the participants discontinued treatment during the study.
The results of the study revealed that children treated with EEG Biofeedback demonstrated significant increases ( P < 0.05) on measures of intelligence and a reduction in symptoms of inattention on a behavioral rating scale. No adverse effects were reported.
All participants received the following treatments: stimulant medication (dosage titrated based on the results of behavioral measures and the TOVA), a 10-week parenting program with follow-up individualized parental counseling provided as needed, and academic support at school (provided via an individual education plan or 504 accommodation plan).
All patients were given the opportunity to receive EEG Biofeedback as part of their treatment program. Fifty-one families chose to include EEG Biofeedback in their child’s treatment. Forty-nine did not.
All children were treated with stimulant medication, (Ritalin). The average dose of Ritalin administered to the patients of both groups was 25 mg., (typically 10 mg. after breakfast, 10 mg. at lunchtime, and 5 mg. after school). The range of dosages was 15 to 45 mg. per day for both groups.
The beneficial effects of stimulant medication and EEG Biofeedback indicated that parenting style was a moderating factor in both treatments. The EEG Biofeedback and the non-EEG Biofeedback groups demonstrated significant improvements on behavioral ratings and the TOVA when tested while using medication.
After the medication wash-out period, relapse was noted on behavioral and CPT measures in each of the participants who had not received EEG Biofeedback. Sustained improvement on the QEEG measure was not evident on the QEEG measure once stimulant medication was discontinued in patients who had not received EEG Biofeedback.
There was no indication that the use of stimulant medication yielded any enduring benefits after 3 years (total) of pharmacologic treatment. Although patients who had never been treated with EEG Biofeedback continued to demonstrate positive response on behavioral ratings, the TOVA, and the QEEG when tested with medication, relapse occurred in each of these participants when tested without medication 12, 18, 24, and 36 months after initial evaluation and treatment.
Patients whose treatment included EEG Biofeedback continued to demonstrate significantly improved levels of cortical activation on the QEEG measure and sustained gains on the TOVA and behavioral ratings throughout the 3-year period, even when medications were withdrawn.
Thirty-four (80%) of the patients whose treatment included EEG Biofeedback were able to decrease daily dosage of stimulant by at least 50%. By contrast, none of the patients who did not receive EEG Biofeedback was able to reduce dosage (85% increased dose).
Two EEG Biofeedback protocols were used. Children diagnosed with an inattentive type of ADHD received training designed to increase production of beta 1 activity (and reduce theta) at C3. Children with the hyperactive or impulsive subtype participated in training intended to increase production of SMR and reduce beta 2 (22–30 Hz) at C4. Patients with the combined type of ADHD received both kinds of training. Sessions were conducted three times per week (30–60 minutes) for a 12-week period.
Pretreatment measures included a test of intelligence [WISC-R), computerized tests of attention (TOVA) and behavioral rating scales.
Statistical analysis of pretreatment measures indicated that the groups were comparable before treatment. Post treatment analysis indicated that EEG Biofeedback and Ritalin were associated with significant improvements on computerized tests of attention and behavioral rating scales. The degree of clinical gains noted after EEG Biofeedback was comparable to that associated with stimulant medication. No adverse effects were reported.
75% of patients treated with EEG Biofeedback in controlled group studies responded positively when the treatment was provided in an open trial in which patient choice determined type of treatment (e.g., stimulant medication, EEG Biofeedback, parental counseling).
Follow-up studies also have provided evidence that unlike medication effects (which quickly dissipate when treatment is discontinued), EEG Biofeedback seems to exert a far more enduring effect on the core symptoms of ADHD and associated functional problems.
Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J. H., & Kaiser, J. (2003). Neurofeedback treatment for attention deficit/hyperactivity disorder in children: A comparison with methylphenidate. Applied Psychophysiology and Biofeedback, 28, 1-12.
Linden, M., Habib, T., & Radojevic, V. (1996). A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback & Self-Regulation, 21(1), 35-49.
Monastra, V. J., (2005). Electroencephalographic biofeedback (neurotherapy) as a treatment for attention deficit hyperactivity disorder: Rationale and empirical foundation. Child & Adolescent Psychiatric Clinics of North America, 14(1), 55-82.
Monastra, V. J., Lynn, S., Linden, M., Lubar, J. F., Gruzelier, J., & LaVaque, T. J. (2005). Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Applied Psychophysiology & Biofeedback, 30(2), 95-114.
Monastra, V. J., Monastra, D. M., & George, S. (2002). The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied Psychophysiology & Biofeedback, 27(4), 231-249.
Beauregard, M & Levesque, J, (2006). Functional magnetic resonance imaging investigation of the effects of EEG Neurfeedback training on the neural bases of selective attention and response inhibition in children with attention-deficit/hyperactivity disorder.
This study showed that Neurofeedback with children with ADHD resulted in normalization of brain activation levels in the frontal circuits in the brain that are involved in attention. As shown in pre- and post-Neurofeedback fMRI studies, blood oxygenation levels of 24 ADHD participants normalized with Neurofeedback training, with increased blood oxygenation in the prefrontal cortex bilaterally, and in the anterior portion of the cingulate gyrus. No such changes were seen in non-treatment controls.
In addition to obtaining behavioral and neuropsychological measures, functional magnetic resonance imaging (fMRI) was conducted on each participant pre- and post-treatment during completion of the Counting Stroop Task and the Go/No Go Task.
As anticipated, children who received EEG Biofeedback demonstrated significant improvement on behavioral and neuropsychological tests of attention.
The children who had received EEG Biofeedback demonstrated significant activation of the right anterior cingulated cortex, the left caudate nucleus, and in the lateral prefrontal cortex (bilaterally) in comparison to pretreatment findings. No such change in activation was noted in the control group.
Berkley Medical Journal, Issues 2002, by Gordon Kwan. Play Attention! Can custom-made video games help kids with Attention Deficit Disorder.
For children with Attention Deficit Hyperactivity Disorder (ADHD), life can feel like a never-ending video game. They are wired–restless, impulsive, and easily distracted. Their minds are constantly bombarded with different elements of reality that compete for their attention.
So far, the most popular treatment for ADHD has been Ritalin, a rapid-acting stimulant for adults that has the opposite effect in children, calming the jitters associated with the disorder. According to the National Institute of Mental Health, about three percent of American school children take stimulants like Ritalin regularly. However current research suggests a surprising new strategy for treating this disorder: video games linked to brain-wave biofeedback that can help kids with ADHD train their minds to tune in and settle down.
It is difficult for a child with ADHD to learn how to self-regulate and know what it feels like to concentrate. Biofeedback teaches patients to control normally involuntary body functions such as heart rate by providing real-time monitoring of such responses. More than 15 years of studies show that with the aid of a computer display and an EEG sensor attached to the scalp, ADHD patients can learn to modulate brain waves associated with focusing. Increasing the strength of high-frequency beta waves and decreasing the strength of low-frequency theta waves, for example, creates a more attentive state of mind. With enough training, changes become automatic and lead to improvements in grades, sociability, and organizational skills.
Despite its proven success, the technique has not become a mainstream treatment for several good reasons. First, unlike drug therapy, which can have immediate results, a typical course of biofeedback treatment takes a series of about 40 one-hour sessions over a span of several months before benefits become apparent. Second, it is more expensive than drugs. Costs range from $3,000 to $4,000 for these treatments, so insurance companies tend to pick the less expensive option. Finally, biofeedback training requires the very kind of prolonged concentration that patients with ADHD struggle to attain.
Alan Pope, a behavioral scientist at NASA Langley Research Center in Hampton, Virginia, came up with a more engaging approach through work with NASA flight simulators. He was determining the degree of interaction with cockpit controls necessary to help pilots stay attentive during routine flights. In an experiment, he linked the level of automation in the cockpit to the pilots’ brain-wave signals, so that some controls switched from autopilot to manual when the pilot started to lose focus. He found that with practice the pilots could begin to adjust the controls to the level of automation that felt most comfortable by regulating their own brain waves.
Pope applied his findings to help ADHD patients stay focused by rewarding an attentive state of mind. He realized, however, that the simple displays that were already part of biofeedback treatment may not be enough to hold the interest of restless youngsters. He then chose several common video games and linked the biofeedback signal from the player’s brain waves to the handheld controller that guides the games’ actions. “In one auto-racing game, a car’s maximum speed increases if the player’s ratio of beta to theta waves improves. The same sort of feedback also controls the steering,” Pope says.
In the test, six Sony PlayStation games were used with 22 boys and girls between the ages of nine and thirteen who had ADHD. Half the group received traditional biofeedback training; the other half played the modified video games. After 40 one-hour sessions, both groups showed substantial improvements in everyday brain-wave patterns as well as in tests of measuring attention span, impulsiveness, and hyperactivity. Parents in both groups also reported that their children were doing better in school.
The difference between the two groups was motivation. “In the video-game group, there were fewer no-shows and no dropouts,” according to Pope. The parents were more satisfied with the results of the training, and the kids seemed to have more fun.
Since children are more motivated toward video-game biofeedback and may already be familiar with video games, they will not need one-on-one coaching to master the technique. As a result, the cost of the treatment should be reduced and maybe even permit “do-it-yourself” biofeedback. One North Carolina company markets their system as a fun bike helmet and game-like video exercises that work on almost any computer. The helmet is lined with sensors that monitor the child’s brain waves, and the child actually controls the computer video exercises by mind alone. Parents should not expect regular video games to help their children. The wrong kinds of video games might actually hurt children with attention disorders.
Brain-wave biofeedback alone may not be a substitute for drug therapy. Professor Stephen Hinshaw, an expert in the field of child clinical psychology at UC Berkeley, gives a reserved opinion about biofeedback treatment. “Biofeedback is a promising potential alternative, but unfortunately the kinds of really well-controlled studies that might support its clinical benefits have yet to be performed.” The two treatments have complementary aspects that make them effective as adjuncts. A dose of Ritalin, for example, acts quickly but only for a few hours, and most patients take it only on school days. Brain-wave regulation takes a long time to learn but has the potential for longer-lasting effects.
Researchers and clinicians are realizing that ADHD is not easily outgrown. Most doctors support an approach that combines good nutrition, sleep, exercise, and learning strategies as well as biofeedback and drug therapy. The possibilities for brain-wave biofeedback are very promising since its benefits could last a lifetime. Video game biofeedback therapy may provide a more tolerable and long-lasting form of treatment for children through a medium they are more likely to enjoy.
Effectiveness of Video Game EEG Neurofeedback on ADHD. (2000). NASA and Eastern Virginia Medical School conducted a research study to determine the effectiveness of video game EEG Neurofeedback on ADHD. In one research group kids received standard EEG Neurofeedback for the treatment of ADHD. In the other research group, kids played brain wave enabled video games. Both the video game and standard EEG Neurofeedback groups improved significantly on most main ADHD outcome measures. No significant difference in treatment change was seen in group comparisons. Parents’ appraisal of treatment effect on ADHD was more positive for the video game group. The treatment was rated significantly more enjoyable by both parents and children. Trends on pre-post Brain Maps indicate that the video game training may have advantages in creating more positive EEG effect in the therapeutic direction.
Epilepsy and Seizure Disorders- Substantial validation research has also been completed on neurofeedback for epilepsy or seizure disorder.
Several controlled studies have been completed, including three condition reversal studies. Several other open trials or case series have also been reported. A recent meta-analysis (combining results of numerous separate studies) indicated that 82% of patients demonstrated greater than 30% reduction in seizures, with an average greater than 50% reduction.
This outcome is all the more significant in that most of the participants included in these studies did not improve with standard medical care; for many, neurofeedback was the only alternative to surgery. Recent clinical experience has shown significantly improved outcomes using neurofeedback which is individually targeted at abnormalities in the degree of co-activation of different brain sites, as guided by coherence findings in the QEEG.
Anxiety and Neurofeedback- Research on neurofeedback for anxiety is less well developed than for ADHD and epilepsy.
Multiple small studies on generalized anxiety disorder, obsessive-compulsive disorder, phobic anxiety, and post-traumatic stress disorder have been published, with several controlled trials. Overall results show significant reduction in anxiety with neurofeedback, although several of the studies involved many fewer sessions than is used in clinical settings. Clinical trials with QEEG guided neurofeedback appear to show stronger benefit. With depression, several case studies have been published providing preliminary evidence of efficacy with major depression. A published open case series also suggests that QEEG guided neurofeedback training may have a larger effect size.
Substance Abuse- In research with adults with substance use disorder (PSUD) multiple random controlled trials (RCT’s) as well as uncontrolled studies have shown protocol specific changes in the EEG.
Improvements on measures of depression (self-rating), attention (using computerized tests of attention) and stress (physiological) have been noted. Several long-term follow-up studies showed a significant reduction in the one year abstinence/recidivism rate for those treated with neurofeedback compared to controls. Given that neurofeedback is medication free and has been shown to be effective with ADHD, a condition frequently also found with PSUD, neurofeedback appears to have particular value for these (PSUD with ADHD) patients where the risk of medication abuse is high.
Traumatic Brain Injury -Reviews of the literature on treatment for traumatic brain injury (TBI) and reading disabilities (RD) indicate that very few of the commonly used interventions have shown efficacy in formal research, and that the effect size of these techniques is usually quite small.
By contrast, preliminary research suggests that neurofeedback shows efficacy in the treatment of both of these conditions with a lare effect size. Several open case series and controlled studies (including one RCT) have shown significant benefits for neurofeedback with TBI primarily in adults, with improvements on measures of attention, executive function, cognitive flexibility, problem solving, information processing, verbal fluency, and depression, as well as in the EEG. Cessation and reduction of medication has also been reported as well as return to productive work. For RD, no formal studies have been published to date, although several studies of the effect of neurofeedback on ADHD have provided suggestive preliminary evidence of improved cognitive function.
Although more research needs to be completed, especially further follow-up studies assessing the maintenance of gains over time, clearly there is at the present time substantial research support for this intervention.
NASA Research: Counter-Response Training via Physiological Self-Regulation During Flight Simulation, (1997).
A new NASA training concept and technology is aimed at training pilots to maintain physiological equilibrium under emergency circumstances in an airplane cockpit.
NASA is working to adapt this concept to a full-scale cockpit simulator in future research and into a training approach for civilian and military professional pilots to reduce flight hazards resulting from impairment of pilot responses in aviation emergencies.
Excessive sympathetic autonomic nervous system (ANS) arousal can interfere with task performance of pilots during flight emergencies. Regular biofeedback training is hard to apply to this problem, because it is very situation-specific and biofeedback signals may distract the pilot from attention to flight tasks. NASA LaRC and Eastern Virginia Medical School developed a Stress Counter-Response Training method where biofeedback is integrated directly into ordinary flight tasks. Training aims at limiting deviations from optimal arousal levels through feedback during repeated stressful events in simulated flight.
With increased sophistication in technology, human performance has increasingly become a limiting factor in aviation safety. Both inattention and stress overload play a substantial role in impairing pilot performance and producing flight hazards. Biofeedback training can foreseeably help reduce the occurrence of these “hazardous states of awareness” by teaching pilots to maintain the necessary physiological conditions for good cognitive and psychomotor performance under the circumstances which are most likely to produce inattention or dysfunctional stress.
Pope, A. T., and Bogart, E. H. Identification of Hazardous Awareness States in Monitoring Environments. SAE Technical Paper No. 921136, SAE 1992 Transactions: Journal of Aerospace, Section 1 – Volume 101, 1993, pp. 449-457.
• Stressful events occur infrequently and between their occurrences the physiological functioning and performance of pilots may be normal.
• Regular biofeedback training is not appropriate.
• The problem is very situation-specific and hard to generate except in a flight simulator.
• In flight simulation of high-threat situations it is hard to add biofeedback task to the excessive cognitive demands on the pilot.
Progress in Efficacy Studies of EEG Biofeedback for ADHD. Roger deBeus, Ph.D., Eastern Virginia Medical School. Annual Meeting of the American Psychiatric Association Toronto, May 2006. deBeus et. al., is the first randomized controlled trial using a double-blind paradigm that incorporates a “sham” EEG Biofeedback treatment.
Fifty percent of the children were diagnosed with an inattentive type of ADHD; 50% with the combined type. Co-morbid conditions (oppositional-defiant disorder, conduct disorder, depression, social phobia, and obsessive-compulsive disorder) also were present in 46% of the children.
Participants were randomly assigned to either a bona fide EEG Biofeedback treatment (theta suppression, beta or SMR enhancement) or a “”sham” EEG Biofeedback condition in which rewards (e.g., movement on a Sony PlayStation game) were provided randomly. A total of 40 sessions were conducted.
Because a Sony PlayStation interface was used, neither the participants nor the therapist was aware of treatment condition (ie, bona fide versus sham EEG Biofeedback). Monitoring of EEG activity was conducted in both types of treatment. Twenty-eight of the children (equally represented in the two groups) were being treated with stimulant medications during their participation in treatment.
Statistical comparisons between the two groups revealed that the participants who received bona fide EEG Biofeedback were rated as demonstrating significantly less hyperactivity at home and school, improved attention at home, less anxiety, less depression and fewer complaints of minor physical problems at home, better adaptability to change, improved ability to work with others, and improved peer interactions, organizational skills, study habits, and a better attitude toward school (P < 0.01).
On computerized tests of attention, the children who had received bona fide EEG Biofeedback demonstrated significantly better scores than age-matched peers diagnosed with ADHD who received sham EEG Biofeedback (P < 0.01).
Demonstration of improvements in cortical arousal (reduced theta, increased beta or SMR) was evident only in the bona fide EEG Biofeedback groups (P < 0.01). Within this group, approximately one third of the patients were able to reduce dosage of medication.
ADD/ADHD, Learning and Development Disabilities, and Academic Cognitive Enhancement.
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