1. Neurofeedback treatment of ADHD Brendan Reid Luke Mueller Bryan Clark Adrian Scott

2. Outline ● What is ADHD? ● Physiology and Neurofeedback Procedures ● 2 Efficacy Studies ● Criticism of Neurofeedback for ADHD treatment

3. 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

4. Timeline NamesDrugs

5. 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)

6. “Dr. Quack’s 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

7. 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 computers…to carry out neurometric analysis right in the schools”

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Two Efficacy Studies ● Monastra et al. (2002) study ● Fuchs et al. (2003) study

17. 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

18. 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

19. 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

20. Monastra: Results

21. 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)

22. 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

23. 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

24. Fuchs: Results ● No difference between groups pre-treatment ● After treatment, both groups showed similar improvements on all tests

25. 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

26. Criticism: “Hunters in a Farmer’s 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

27. Hunters in a Farmer’s 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

28. 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?

29. 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

30. 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

31. 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

32. 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

33. 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.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/