Neurotherapy or Neurofeedback for ADHD
It is widely accepted in Neuroscience research that ADHD is associated with underlying neurophysiological dysfunctions, mostly involving the frontal lobes and central cortex. If these dysfunctions can be rectified then children with ADHD may be able to process information like children without ADHD, enabling them to acquire cognitive skills and coping strategies that children without ADHD acquire normally through the course of growing up.
Neuroscientists have known since the mid 1970s that the EEG (brainwaves) of children with ADHD contained an excess of slow (theta) waves and relatively less of the fast (beta) waves. Hence they have a high theta/beta ratio (Janzen, Graap, Stephanson, Marshall, & et al., 1995; Linden, Habib, & Radojevic, 1996; Lubar, 1985; Lubar, 1991; Lubar, 1995; Lubar & Lubar, 1984; Satterfield, Schell, Backs, & Hidaka, 1984; Steinhausen, Romahn, & Gobel, 1984; Tansey, 1991; Watson, Jacobs, & Herder, 1979). Researchers have been developing techniques to enable children and adults with ADHD to retrain their brainwaves.
What is Neurotherapy
Neurotherapy is also called Neurofeedback training or brainwave (EEG) biofeedback. During typical training, one or two sensors are placed on the scalp and one on each ear lobe. Then, high-tech electronic equipment provides real-time (instantaneous) audio and visual feedback about brainwave activity. The sensors measure the electrical patterns coming from the brain--much like a physician listens to someone's heart from the surface of the chest. No electrical current is put into the brain. The brainwave patterns are relayed to the computer and recorded.
Ordinarily, we cannot influence our brainwave patterns because we lack awareness of them. However, when you can see your brainwaves on a computer screen a few thousandths of a second after they occur, it gives you the ability to influence and change them. The mechanism of action is called operant conditioning. We are literally reconditioning and retraining the brain. At first, the changes are short-lived, but the changes gradually become more enduring. With continuing feedback, coaching, and practice, we can usually retrain healthier brainwave patterns in most people. It is a little like exercising or doing physical therapy with the brain, enhancing cognitive flexibility and control.
Thus, whether the problem stems from ADD/ADHD, Autism, a learning disability, a stroke, head injury, deficits following neurosurgery, uncontrolled epilepsy, cognitive dysfunction associated with aging, depression, anxiety, obsessive-compulsive disorder, or other brain-related conditions, Neurotherapy training offers additional opportunities for rehabilitation through directly retraining the brain.
The exciting thing is that even when a problem is biological in nature, we now have another treatment alternative than just medication. Neurotherapy is also being used increasingly to facilitate peak performance in “normal” individuals and athletes.
Frank H. Duffy, M.D., a Professor and Pediatric Neurologist at Harvard Medical School, stated in an editorial in the January 2000 issue of the journal Clinical Electroencephalography that scholarly literature now suggests that Neurotherapy “should play a major therapeutic role in many difficult areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used” (p. v). “It is a field to be taken seriously by all” (p. vii).
Extract from an article by Professor Corydon Hammond. Physical Medicine & Rehabilitation. University of Utah School of Medicine
Effectiveness of Neurotherapy
There are now numerous research papers in the scientific literature (Click here for Neurotherapy BIBLIOGRAPHY) a list of published papers attesting to the effectiveness of Neurotherapy (EEG biofeedback). These papers, have been published in peer reviewed journals, some of these are reviewed here. There is evidence that Neurotherapy effects are very specific and that brain function is altered as a result of Neurotherapy training. A recent study by Egner and Gruzelier from the Department of Cognitive Neuroscience and Behaviour, Faculty of Medicine, Imperial College London demonstrated these brain changes.
The Neurotherapy treatment developed for ADHD involves patients viewing a computer screen that displays their brainwave activity obtained via EEG sensors on their scalp. Using the visual and auditory feedback provided by the computer, patients learn to reduce slow (theta) waves and increase fast (beta) waves. The process by which this happens is called operant conditioning, and is the mechanism by which we learn most activities in life. After about 20 sessions, the theta/beta ratios start to reduce, and in around 80% of children normalise after 30 to 50 sessions, depending on the severity of symptoms.
As the theta/beta ratios reduce and normalise, hyperactivity and impulsivity reduce or disappear, attention span and concentration increase, IQ increases, as do measures of cognitive skills. Many if not most of the undesirable behaviours associated with ADHD also reduce or disappear.
The brain learns to produce certain brainwaves, and consequently acquires the ability to process information more normally. Once acquired, this ability is used in everyday life, and hence constantly reinforced. It's like learning to walk or ride a bike; once learned the skill is retained. There are no negative side effects to Neurotherapy and following training the gains can be expected to be as permanent as any other learned skill (Lubar, 1991; Tansey, 1993).
Typical Neurotherapy training screen
The clinic introduced this DVD driven system in Australia in 2004. The two bars represent the amplitudes of specific brainwaves. The subject uses his mind to control the height of the bars. The DVD plays when the two bars are below the thresholds indicated by the lines. The child is therefore rewarded for being able to control his/her brainwave activity. This technology has been around in more simplified forms since 1967 and is well researched. Through this conditioning process, watching the DVD is dependant on successful suppression of theta activity or whatever other brainwave activity we wish to improve. Any DVD can be used, and this of course improves compliance with Neurotherapy training.
Improvements in theta/beta ratios of ADHD subjects following Neurotherapy have been found to correlate significantly with a number of independent tests as well as parent and teacher reports. Studies and clinical reports from over 1000 clinics worldwide have shown improvement in impulsivity, attention, processing speed and distractibility scores on Continuous Performance Tasks (TOVA). In addition, there were reductions in hyperactivity and impulsivity on behaviour scales, increases in attention and cognitive skills in Individual Achievement Tests scores, and increases in IQ scores
Effect of Neurotherapy on hyperactivity and Attention
While investigating the brainwave patterns of cats during sleep studies in the mid 70s, Sterman discovered that cats could be easily trained, by operant conditioning, to produce SMR (12-15Hz) brainwave activity for food reward. In a later study for NASA, the cats so trained were found to be highly resistant to chemically (Hydrasine jet fuel) induced seizures. This led Sterman to initiate clinical trials aimed at increasing SMR activity through Neurotherapy in epileptic subjects. Both seizure rates and EEG abnormalities were significantly reduced in subjects with epilepsy (Sterman, Macdonald, & Stone, 1974).
Subsequently Lubar and Bahler (1976) published a series of case studies that demonstrated the effectiveness of Neurotherapy SMR training on reducing seizure activity. While doing these studies, Lubar observed that the seizure patients experienced increased attentiveness, focus and concentration. This led him to investigate the effects of Neurotherapy on attention deficits and hyperactivity. Lubar & Shouse (1976) carried out a single case blind crossover (ABAB) study with a child who was on a psychostimulant medication for attention deficits and hyperactivity. Following Neurotherapy training, (SMR enhancement and theta inhibit) the child showed decreased oppositional and out of seat behaviours and increased cooperative behaviours.
The child was then given reversed training (inhibit SMR and increase theta) and the original undesirable behaviours returned. Training was reversed yet again (SMR enhancement and theta inhibit). The child regained all previous losses, school performance and behaviour again improved on all measures. The child was then taken off methylphenidate, and continued to do well. Follow-up over several years showed that the gains were maintained and the child continued to do well.
More studies followed, using more subjects and using the same Neurotherapy ABA blind crossover paradigm. Three of the four subjects in the study showed contingent increases in SMR which were correlated with classroom motor inactivity. The combination of EEG Neurotherapy training with drug treatment resulted in substantial improvements in tested behaviours that exceeded the effects of drugs alone.
In those studies, when medication was withdrawn, the improvements were maintained with SMR training alone. The studies monitored a decrease in undesirable behaviours such as: disruptive motor activities, self stimulation, out of seat behaviours and oppositional behaviours. An increase in desirable behaviours was observed, as was increased attention span and cooperation. Social behaviours such as self initiated approaches to peers or teachers, and sustained interactions with them also improved (Shouse & Lubar, 1978; Shouse & Lubar, 1979).
In 1981 Lubar and Deering, a pediatric neurologist, collaborated in the publication of a book which reported and reviewed research and clinical experience to date, in the use of beta/SMR Neurotherapy with theta inhibition to reduce hyperactivity and improve attentiveness (Lubar & Deering, 1981).
To investigate whether Neurotherapy improved school performance, Lubar and Lubar (1984) conducted an experiment with 6 10-19 year old males with ADHD, who received EEG Neurotherapy for either increasing 12-15 Hz Sensorimotor Rhythm (SMR) or 16-20 Hz beta activity. In this study, treatment was combined with academic training, including reading, arithmetic and spatial tasks to improve attention.
At the end of the experiment, all children had successfully increased their SMR or beta waves, and decreased slow wave activity in their EEG and muscle activity, as determined by a frequency analysis of their brainwaves. All subjects demonstrated considerable improvement in their schoolwork in terms of grades or achievement test scores on the Metropolitan Achievement Test, Peabody, Stanford Achievement test and California Achievement test. None of the subjects required medications for hyperactivity after the study was finished. Individual results presented in case studies for each subject indicate that EEG Neurotherapy training, if applied comprehensively, can be highly effective in helping to remediate children who are experiencing attention deficit disorders and difficulties with academic tasks (Lubar & Lubar, 1984). This study paved the way for the investigation of the effect of Neurotherapy on Learning Difficulties.
Neurotherapy and Learning Difficulties
Specific Learning Difficulties may well have their basis in minor neurological deficits. Using as few as 8 EEG variables, identification of learning disabled children could be correctly made in 75 percent of cases. By using a larger number of indicators, some 95 percent of learning disabled children could be correctly identified strictly on the basis of their EEG. The best predictor of learning difficulty was excessive 4 to 8 Hz activity in the frontal-temporal locations. Over a period of two years Neurotherapy enhancement of beta activity was found to be successful in remediation of learning difficulties in most of the group of 37 children with who participated in the studies. Again the children showed a significant improvement in metropolitan achievement test scores as compared to controls (Lubar, 1989).
In three separate experiments, Lubar and colleagues assessed the effectiveness of Neurotherapy treatment for 42 children with ADHD and adolescents, aged 8-19 years, on both objective and subjective measures. In the first experiment, using 19 subjects, those who successfully decreased theta activity showed significant improvement in the Test of Variables of Attention (TOVA). In the second experiment, using 13 subjects, significant improvement in parent evaluations on the Attention Deficit Disorders Evaluation Scale (ADDES) was obtained following Neurotherapy training. In the last experiment, significant increases in Wechsler Intelligence Scale for Children--Revised (WISC-R) scores were obtained following Neurotherapy training. The findings of these three studies indicate that Neurotherapy training can be an appropriate and efficacious treatment for children with ADHD, as it effectively increased their cognitive skills, and decreased attention deficits (Lubar, Swartwood, Swartwood, & O'Donnell, 1995b).
Lubar and his colleagues demonstrated that many individuals could learn to decrease the microvolt level of theta over 40 sessions. Of the 12 subjects who successfully reduced microvolt levels of theta during Neurotherapy, it was found that even though the training took place in locations between FZ and PZ, the training effect had generalised to most other cortical areas, and many of the differences were highly significant. In the same study, it was illustrated graphically that 7 individuals who could not learn to decrease their microvolt levels of theta over time showed absolutely no effect of any significance in the EEG following Neurotherapy at any of the 19 EEG placement sites effect (Lubar, Swartwood, & Timmerman, 1995a).
This study shows that in those subjects where Neurotherapy learning has not taken place (no decrease in theta at training site), then the QEEG does not show any changes, indicating that Neurotherapy is linked directly to changes in cortical functioning and is not a placebo effect (Lubar et al., 1995a). This study suggests that Neurotherapy at frontal and central regions may influence cortical resonant loops originating in the frontal and central regions which have linked to regional and global resonances causing other areas to shift as well (Lubar, 1997).
Several studies have demonstrated the effectiveness of Neurotherapy in normalising the theta/beta ratios in the EEG and in producing improvements in academic performance, attention deficits, IQ scores, parent and teacher behavioural ratings and schoolwork, in terms of grades and achievement test scores (Linden et al., 1996; Lubar, 1991; Lubar, 1995; Lubar et al., 1995b; Lubar & Lubar, 1984; Tansey, 1985).
For example, Tansey (1991) trained 24 children with attention deficits and learning disabilities to increase SMR and inhibit theta activation over the central and sensorimotor cortex. Following Neurotherapy the subjects showed a normalisation in brainwave signatures. More significantly, 22 of the 24 subjects manifested increases in full scale IQ scores on the WISC-R of at least 15 points, with the remaining 2 obtaining an increase of 13 and 14 points. These results are consistent with an increase in bi-hemispheric skills (complementary verbal-expressive and visual-motor abilities). These are the very skills that are prerequisite to a successful learning posture; they are also necessary for the acquisition of reading and for integration of higher-order learning (Tansey, 1990; Tansey, 1991).
Linden and colleagues confirmed these findings in a controlled study that investigated the effects of Neurotherapy on cognition and behaviour with 18 children with ADHD, aged 5-15 years. Training consisted of enhancing beta activity and suppressing theta activity. The Neurotherapy group demonstrated increases on the Kaufman Brief Intelligence Test and reduced inattentive behaviours on the Behaviour Rating Scale, compared to the controls who received no Neurotherapy (Linden et al., 1996).
Comparison of Neurotherapy to medication.
The neurobiological causes of ADHD suggest that the primary focus of treatment should address the core issue, namely promote the remediation of the neurophysiological dysregulation. Medication and Neurotherapy are two treatment methods that directly address the neurological dysregulation, but from two different approaches. While medication attempts to redress neurotransmitter (chemical) imbalance, Neurotherapy attempts to challenge the brain to self regulate and redress the imbalance.
A study by Rossiter and La Vague compared the effects of Neurotherapy to stimulant medication in reducing ADHD symptoms. The study compared the effects of a medical treatment program to 20 sessions of Neurotherapy. The Neurotherapy group of 23 subjects was matched with a stimulant group, also of 23 subjects, by age, IQ, gender and diagnosis. The Test of Variables of Attention (TOVA) was administered pre and post treatment. Both groups improved significantly on TOVA measures of inattention, impulsivity, information processing, and variability, and did not differ from each other on TOVA change scores. The results indicate that Neurotherapy is an effective alternative to stimulants and may be the treatment of choice when medication is ineffective, has side effects, or when compliance to medication is a problem (Rossiter & La Vaque, 1995).
Lubar and colleagues measured the QEEG of 23 individuals with ADHD. They examined theta/beta ratios, both with and without medication and found no significant effect of the medication on the theta/beta ratios in the QEEG at all 19 sites evaluated. The researchers concluded that Methylphenidate had very little effect on the cortical EEG (Lubar et al., 1995a). Methylphenidate and some of the other medication that are used to enhance attention produce state dependent learning. This means that the medication works while it is in the system but that there is virtually no long-term carryover to the non-dependent state. On the other hand Neurotherapy works not only while doing training, but has a carryover effect that lasts for a very long time, perhaps even the whole lifetime (Lubar, 1997).
Clinical trials have suggested that Neurotherapy may be efficient in treating attention deficit/hyperactivity disorder (ADHD). Fuchs from Eberhard-Karls-University of Tubingen, Germany, and colleagues from Italy and the United Kingdom compared the effects of a 3-month Neurotherapy program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12–15 Hz) and beta1 activity (15–18 Hz) with stimulant medication. Participants were 34 children aged 8–12 years, 22 of which were assigned to the Neurotherapy group and 12 to the methylphenidate group according to their parents’ preference. Both Neurotherapy and methylphenidate were associated with improvements on all subscales of the Test of Variables of Attention and on the speed and accuracy measures of the d2 Attention Endurance Test. Furthermore, behaviours related to the disorder were rated as significantly reduced in both groups by both teachers and parents on the IOWA-Conners Behaviour Rating Scale. These findings suggest that Neurotherapy was efficient in improving some of the behavioural concomitants of ADHD in children whose parents favoured a non-pharmacological treatment.