Neurotherapy (Neurofeedback) for ADHD and Learning Difficulies

Frontal lobe
Frontal lobe

It is widely accepted in Neuroscience research that ADHD is associated with underlying neurophysiological dysfunctions, mostly involving the frontal lobes. When these dysfunctions are rectified, children with ADHD can 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 and clinicians have developed techniques to push the brain's Neuroplasticity towards normal to enable children and adults with ADHD to retrain their brainwaves and consequently improve or normalise their behaviours.

What is Neurotherapy

Neurotherapy is also called Neurofeedback training or brainwave (EEG) biofeedback. During typical training, a sensor is placed on the scalp and one on each ear lobe. Then, high-tech electroencephalographic equipment and software provide real-time (instantaneous) audio and visual feedback about brainwave activity. The sensors measure the electrical patterns coming from the brain, in a similar way that a GP may listen to your heart with a stethoscope. Neurotherapy is not invasive, as no electricity is put into the brain, instead the brainwaves are picked up by the sensors and relayed to the computer where it is analysed, displayed as EEG traces and bar graphs as well used to drive a video or games..

Neurotherapy session
Neurotherapy session

We cannot usually directly influence our brainwave patterns because we lack awareness of them. However, when we can see your brainwaves represented on a computer screen as they occur, it gives us the ability to influence and change them. We are literally reconditioning and retraining the brain by a process known as operant conditioning. At first, the changes are short-lived, but the changes gradually become more lasting. With continuing feedback, coaching, and practice, most people can retrain their brainwaves in this way. It is a little like exercising or doing physical therapy. During a Neurotherapy session, we push the plasticity of synapses in brain cells to function better, enhancing cognitive flexibility and control and improving focus and behaviour control.

Thus, whether the problem stems from ADHD, Autism, a learning disability, a stroke, head injury, deficits following neurosurgery, uncontrolled epilepsy, cognitive dysfunction associated with ageing, depression, anxiety, obsessive-compulsive disorder, or other brain-related conditions, Neurotherapy training offers additional opportunities for rehabilitation through directly retraining the brain patterns that are dysfunctional in these disorders. Click here for a comprehensive list of scientific research.

The exciting thing is that even when a problem is biological in nature, Neurotherapy offers a viable treatment alternative than just medication. Neurotherapy is also being used increasingly to facilitate peak performance in “normally functioning” 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).

Effectiveness of Neurotherapy for ADHD and Learning Difficulties

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. Dr. Jacques Duff's PhD study at the Brain Sciences Institute investigated the brain electrical activity of boys with ADHD following Neurotherapy. 

In this figure, the graph illustrates activation in the right frontal lobe pre- and post-Neurotherapy in the CPT-AX task executed by 17 boys with ADHD. The dashed horizontal line represents a baseline task and is set to zero for both conditions. The computer administered CPT-AX task required the boys to press a button when they saw the letter X, only if the letter before it was an A. The vertical lines represent the time points at which: the letter A is presented (A), the letter A disappears and the blanking interval commences () and the letter X appears (X). The horizontal blue and red lines represent changes in latency (delay).  A reduction in latency is interpreted as increased excitation and a speeding up of brain processes, while an increase in latency can be interpreted as less excitation or a slowing down of processes.

Functional Brain changes following neurotherapy
Frontal lobe functional changes

The graph shows that before Neurotherapy there was minimal reduction in latency (no excitation or brain engagement) throughout the CTP-AX task at this right pre-frontal site, whereas following Neurotherapy, there was a large transient reduction in latency on the appearance of the X, suggesting increased excitation and brain involvement. Neurotherapy speeded up the frontal lobe processes necessary for rapidly recognising and processing of the target X. The 17 boys with ADHD all improved their behaviours and TOVA scores. All were able to come off stimulant medication and function normally. 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.

According to the research, 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 ratio reduces and normalises, 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).

Neurotherapy training screen
Neurotherapy training screen

The Behavioural Neurotherapy Clinic introduced this DVD-based neurofeedback reward 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. There are many other such training screens. The person is rewarded for controlling his/her brainwave activity. Through this conditioning process, the DVD only plays on successful suppression of slow brainwave activity or whatever other brainwave activity we wish to improve. Parents are encouraged to use a DVD that the child likes, so as to improve 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 thousands of 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

Early Neurotherapy Studies 

Professor Barry Sterman
Prof. Barry Sterman

While investigating the brainwave patterns of cats during sleep studies in the late 1960s in the EEG Lab at UCLA, Professor Barry 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 induced seizures (from Hydrazine jet fuel). This led Sterman to initiate clinical trials aimed at increasing SMR brainwave activity through Neurotherapy in epileptic subjects. Both seizure rates and EEG abnormalities were significantly reduced in subjects with epilepsy (Sterman, Macdonald, & Stone, 1974). Sterman went on to publish over a dozen studies on Neurotherapy for seizure disorders and ADHD.

Subsequently Professor Joel Lubar at Tennessee University published a series of case studies that demonstrated the effectiveness of Neurotherapy SMR training on reducing seizure activity (Lubar and Bahler, 1976). 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. More studies followed, using more subjects and using the same blind crossover paradigm. Seventy five percent of the subjects  showed contingent increases in SMR which were correlated with a reduction in classroom hyperactivity. 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).

Professor Joel Lubar
Prof. Joel Lubar 

In 1981 Lubar and Deering, a paediatric 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 Neurotherapy for either increasing 12-15 Hz Sensorimotor Rhythm (SMR) or 16-20 Hz beta activity. 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 QEEG 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 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 (WISC) 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 and learning difficulties, as it effectively increased their cognitive skills, and decreased attention deficits (Lubar, Swartwood, Swartwood, & O'Donnell, 1995b)

Learning Difficulties
Learning Difficulties

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).

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.

Medication for ADHD
Medication for ADHD

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 stimulant medication without side effects (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).

Click here for an up to date neurotherapy bibliography