The application of neurofeedback to the management of attention deficit hyperactivity disorders (ADHD).

Attention deficit hyperactivity disorder (ADHD) is one of the conditions for which neuro-feedback has been used. This essay will discuss the application of this psychophysiological technique on children with ADHD. First, ADHD will be introduced and the rationale for the treatment, procedures and characteristics of neuro-feedback, as well as its strength and inadequacies will be covered. Research providing insight into the evaluation of this technique will be presented.

According to the American Psychiatric Association (2000), the persistence of six or more symptoms of inattention and/or hyperactivity/impulsivity for at least six months are the criteria for a diagnosis of ADHD. Due to a number of possible combinations of symptoms, ADHD can present in a wide variety of ways. The checklist for the diagnosis of ADHD is subjective and can be based on evaluations from children, teachers and parents (Swingle, 2008). This results in great uncertainty regarding a judgment of the severity of the condition and even the corresponding treatment. ADHD typically is diagnosed in children by the time they are seven when their function is impaired by hyperactivity and restlessness in school resulting in problems with cooperation and communication (Rathus, 2010). Treatment starts soon after diagnosis but a large majority of those diagnosed with ADHD continue to face problems including depression (Lubar & Lubar, 1999) attention, executive functions and learning (Nigg et al., 2005) as well as alcohol abuse, medical and non-medical drug addiction (Sullivan & Rudnik-Levin, 2001) in adulthood. However, in this essay only children will be considered. While the prevalence of ADHD in school-age children ranges from one to five per cent (Rathus, 2010), the condition is possibly misdiagnosed (Weisler & Sussman, 2007) in that some children who are merely misbehaving, are diagnosed as having ADHD and are medicated to improve their school behaviour (Reddy & De Thomas, 2006).

Stimulants such as Ritalin are the most commonly used medications to treat ADHD. They work by increasing the activity of dopamine and noradrenaline so that the brain areas responsible for executive functions, including executive control, are stimulated (Rathus, 2010). Stimulants improve the symptoms of ADHD including the ability to pay attention and learning performance (Posey et al., 2007).

One of the causes of ADHD (for a review, Nigg, 2006), is thought to be a deficiency of dopamine, a brain chemical, which is an expression of genetic factors on ADHD (Friedel et al., 2007; Thapar, Langley, Owen, & O’Donovan, 2007). Deficiencies in executive functioning may contribute to distractibility and disorganization and other symptoms of ADHD (Nigg, Willcutt, Doyle & Sonuga-Barke, 2005).

Understanding brain functioning helps in assessment and treatment and suggests the pathways to ADHD like executive functioning. Neuro-feedback or brainwave biofeedback is a specialized branch of biofeedback the aim of which is to enable people to regulate electro-physiological processes in the brain, specifically brainwaves (Demos, 2005; Thompson & Thompson, 2003). Information from an electroencephalogram (EEG), which measures brainwaves, is given to people to show their real time cortical activity pattern. This feedback is given in the form of sounds, visual images or other sensory stimulation. People are guided by neurotherapists to modify these patterns towards normalization and optimization of brain activity (Moss & Andrasik, 2008). Theta/beta protocols are a major form of neuro-feedback. Neurotherapists first carry out and analyze EEG brainwaves by measuring cortical activity from different areas of the head. This feedback is used to review the symptoms with clients, and then determine the precise locations of the brain where activities have to be modified by neuro-feedback in order to correct the symptoms (Swingle, 2008). This type of brainwave test is now being considered for ADHD in children and adolescents (‘FDA Permits,’ 2013). Common Attention Deficit Disorder (CADD) is a type of ADHD characterised by a high theta (normally produced by the brain during underactivity) to beta (main brainwaves while awake) ratio or excess theta brainwaves in the sensorimotor cortex of the brain (Swingle, 2002).

Discomfort due to excessive underactivity prompts CADD children to be hyperkinetic to stimulate the brain (Swingle, 2008). Swingle (2008) treated this condition successfully with frequency band training as follows. The protocol was set to inhibit theta and promote beta. When the brain was in the desired state, in order to show the trainee the pattern of their brain activity, the feedback given was a moving balloon that appeared on the computer screen. The trainee experienced and practiced the conditions that kept the balloon moving. The learning process was achieved during sessions of neuro-feedback with difficulty levels being adjusted according to the performance of the trainee. This entailed making it more difficult to keep the balloon being used as feedback moving, thereby training an ability to regulate brain activities.

As well as EEG frequency training, a common neuro-feedback process for ADHD is slow cortical potentials (SCPs); these are event-related changes of cortical activity (Birbaumer, Elbert, Canavan, & Rockstroh, 1990). The training is similar to the learning process used with theta/beta protocols, in that it involves regulation of central negativity (related to cognitive preparation and elevated cortical activation), and central positivity (related to decreased cortical activation) in the sensorimotor cortex (Hinterberger et al., 2003). In Drechsler et al.’s (2007) experiment, children were prompted by colour cues to regulate SCPs with the action of cartoon figures providing positive reinforcement for correct changes allowing the person to reach the required threshold. The specific aspect of SCPs that contributed to positive results was found to be enriched cortical control. Leins et al. (2007) reported on groups receiving either SCPs or theta/beta protocols. Their results showed no significant difference between the two groups in terms of positive behavioral and cognitive changes including attention, IQ and cortical activity regulating ability after intervention and at a six-month follow-up.

Because of a wide range of ADHD conditions and corresponding neuro-feedback treatment variations, common phenomena of the technique used with children manifesting ADHD will be investigated. Apart from neurotherapy sessions, home treatments are prescribed to cultivate progressive changes in brainwave activity. Visual stimulation including repetitive flashes is used to stimulate the brain to produce brainwaves at the same frequency (Collura, 2002). This is to suppress theta amplitudes to allow a higher level of attention. Subliminal sounds at different frequencies help suppress slow amplitudes and therefore increase concentration, so listening to CDs is also prescribed (Swingle, 2008). These tools are beneficial to children when they need to carry out activities that require concentration at home like doing homework and reading, resulting in an improvement in academic performance.

The role of practitioners is strongly emphasized. Neurotherapists have to justify particular settings for individual clients according to evidence in the literature because there is so much variation in EEG protocols in terms of brainwave bandwidths and threshold adoption (Moss & Andrasik, 2008). Neurotherapy is not universal; for example, conventional treatment to help an anxious person calm down may have totally the opposite effect in some patients (Thomas & Sattlberger, 1997). The distinguishing feature of one type of ADHD is high levels of alpha brainwaves in the frontal area; however, anxious patients can have similar symptoms and brain patterns but with high alpha waves in other areas (Swingle, 2008). Thus, practitioners have to be cautious about differences in brain amplitudes for various conditions.

Brainwave biofeedback should be a major part of a comprehensive treatment plan instead of an independent intervention. To achieve long-term satisfying results from neurotherapy, family problems have to be dealt with (Swingle, 2008) as a favourable environment may facilitate the positive training effects of neuro-feedback in routine daily activities. For example, parental support was found to correlate well with some behavioral improvements (Drechsler et al., 2007). Parenting style had a moderating effect on behavioral measures, in terms of improved attention and reduction in impulsivity and hyperactivity (Monastra, Monastra & George, 2002). The benefits of a parenting programme on neurofeedback were demonstrated (Monastra et al., 2005). A comprehensive approach can include parent counselling, family therapy, and psychotherapy to aid self-image, thoughts and emotions.

Neurofeedback for ADHD is based the evidence of ample research. Yucha & Montgomery (2008) considered neurofeedback treatment for ADHD as ‘Efficacious’ (Level 4). This rating was accepted by the Association for Applied Psychophysiology and Biofeedback (AAPB). According to the guidelines developed by AAPB and the Society for Neuronal Regulation on efficacy levels of one to five, research evidence on level 4 treatment attains high standards including research settings, comparison with appropriate control groups, inclusion criteria of the population, validated and clearly specified outcome measures, data analysis, clearly defined diagnostic and treatment variables and procedures, and other details (Moss & Gunkelman, 2002).

The highest level – “Efficacious and Specific” (Level 5) – requires the fulfillment of all the level 4 criteria and that ‘the investigational treatment has been shown to be statistically superior to credible sham therapy, pills, or alternative bona fide treatment in at least two independent research settings (Moss & Gunkelman, 2002)’. A meta-analysis reached the conclusion that brainwave biofeedback could be upgraded to level 5 with a large effect size (ES) for inattention and impulsivity and a medium ES for hyperactivity (Arns, de Ridder, Strehl, Breteler, & Coenen, 2009).

Despite well-recognized empirical support, there are ethical and methodological challenges around research on neurofeedback for ADHD. Proper controls are used to investigate whether the changes in outcome variables are related to the intervention or

non-specific factors such as maturation and changes in parenting. These are difficult to establish for ethical or methodological reasons; for example, both the waiting list and the intermittent placebo feedback control lead to ethical concerns especially with children (Drechsler et al., 2007). Sham therapy controls can easily break the double-blind condition (Moss & Andrasik, 2008). The problem of semi-active controls involving alternative treatment is that, for example, cognitive training can

have positive effects on ADHD symptoms (Klingberg et al., 2005; Toplak, Connors, Shuster, Knezevic, & Parks, 2008).

Validation of neurofeedback has been obtained from medical and psychological professional bodies. The devices used are registered with the US Federal Drug Administration (FDA) which compiles the regulations for medical devices (Swingle, 2008). The Biofeedback Certification Institute of America has implemented professional standards and guidelines for practitioners. The practitioners take examinations for qualifying certification in essential knowledge and skills of biofeedback including neurofeedback (Moss & Andrasik, 2008).

In terms of efficacy and validation for ADHD, neurofeedback has advantages over medication and other interventions that are not strictly evaluated in terms of efficacy and are not continuously monitored. For example, some medications are prescribed off-label (for medical conditions not indicated by FDA and thus no strict clinical trials available) (Moss & Andrasik, 2008). Guanfacine and guanfacine extended release are off-label medicines for ADHD. However, their adverse effects include sedation with the side effects of some decrease in blood pressure and heart rate (Posey & McDougle, 2007).

In terms of results, while stimulants can improve symptoms, it is common that improvement of symptoms revert when medication is terminated (Arns et al., 2009; Swingle, 2008). No long-term effect was observed with continued medication even if the dosage was increased (Molina et al., 2009). Although neurotherapy is a learning process that takes more time, its effects on ADHD children is longer lasting than medications and relapses are not common, thus treatments are less costly in the long run (Swingle, 2008). The outcomes of neurofeedback are equivalent to that of stimulants (Rossiter, 2004). Persistence in developing the skills to regulate brainwaves, resulting in improvements in behaviour and symptoms by neurofeedback were found in a two-year follow-up (Gani, Birbaumer, & Strehl, 2008). Monastra et al. (2002) reported that after stopping stimulants, the group originally receiving both neurofeedback and stimulants showed stable improvements compared with participants in the stimulant alone group. Besides, there are concerns about the long-term negative effect of stimulant medications (Breggin, 1998; Jensen et al.,1999). Behavioural approaches like neurofeedback with ADHD children, for which there have been no negative reports, should be a safer, more widely accepted and adopted choice (Duffy, 2000). Moss & Andrasik (2008) concluded that neurofeedback has the characteristics of alternative medicine that the public prefer: it allows a more active role in the individual’s own health care, a holistic emphasis on body, mind and spirit, it is non-invasive and encourages the body’s self-healing response (Moss, 2003). In view of the increasing prevalence of chronic conditions, self-care is an essential alternative medicine (Gordon, 1996).

This essay has discussed the management of ADHD using neurofeedback – mainly by theta/beta protocol and SCPs. Learning how to self-regulate brain activity, takes time and effort before the ability is fully acquired, but ultimately, is not likely to be lost. The best way to attain and maintain the effects is by forming a holistic approach with supporting psychological interventions like counselling. However, given that the acquired skills and ability of brainwave regulation can bring continuous benefits and is safe in terms of side-effects and rigorous regulation, neurofeedback is an ideal alternative managing long-term conditions such as ADHD.

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