2007 EEG biofeedback in the treat of ADHD JAltMed.pdf

Alternative Medicine Review Volume 12, Number 2 2007

Review Article

EEG Biofeedback in the

Treatment of Attention Deicit/

Hyperactivity Disorder

Patrick N. Friel, BS

Abstract

Electroencephalogram (EEG) biofeedback, also known as

neurofeedback, is a promising alternative treatment for

patients with attention deicit/hyperactivity disorder (AD/HD).

EEG biofeedback therapy rewards scalp EEG frequencies

that are associated with relaxed attention, and suppresses

frequencies associated with under- or over-arousal. In large-

scale clinical trials, the eficacy of EEG biofeedback for

AD/HD is comparable to that of stimulant medications.

Many different EEG biofeedback protocols for AD/HD are

available. Single-channel protocols developed by Lubar and

interhemispheric protocols developed by the Othmers are

widely practiced and supported by large-scale clinical studies.

(Altern Med Rev 2007;12(2):146-151)

which is supported by extensive peer-reviewed litera-

ture, including large-scale controlled clinical trials. 1,4

he purpose of this review is to summarize the evidence

supporting the use of EEG biofeedback for treatment of

AD/HD.

Background

he standard scalp EEG is recorded at 19 sites.

Scalp EEG frequencies are broadly associated with vari-

ous mental states, as shown in Table 1. With modern

computerized systems, experts can map scalp EEG

quantitatively by using spectral analysis. Quantitative

electroencephalography (QEEG) studies demonstrate

deviations from normal patterns in many neuropsychi-

atric conditions, including AD/HD. 5

Clinical EEG biofeedback originated with the

observation by Sterman that cats conditioned to pro-

duce a speciic EEG frequency (SMR; sensory-motor

rhythm; 12-15 hz) exhibited an elevated seizure thresh-

old when exposed to the convulsant agent methylhy-

drazine. 6 Subsequent studies by Sterman and others,

conducted from the 1970s onward, demonstrated that

approximately 80 percent of patients with medically

intractable epilepsy experience a clinically signiicant

(>50%) reduction in seizure frequency after a course of

EEG biofeedback that rewards the SMR frequency. 7

Introduction

Attention deicit/hyperactivity disorder (AD/

HD) afects approximately 3-5 percent of school-age

children in the United States, and a majority of children

diagnosed with AD/HD are treated with medications,

primarily stimulants. 1 It is estimated that 10 percent

of 10-year old boys in the United States are currently

being treated with prescription stimulants. 2 Concerns

about the cardiovascular toxicity of amphetamine and

methylphenidate 2 cause many patients and their fami-

lies to seek alternative therapies. Well-established al-

ternative therapies include dietary modiications and

the administration of supplements, including vitamins,

minerals, phytonutrients, amino acids, essential fatty ac-

ids, phospholipids, and probiotics. 3 Another alternative

to drug therapy for AD/HD is electroencephalogram

(EEG) biofeedback, also known as neurofeedback,

Patrick N. Friel, BS – Forensic toxicologist; special interests in gas

chromatography-mass spectrometry, liquid chromatography-mass spectrometry,

and the pharmacokinetics/pharmacodynamics of alcohol; trained in EEG

biofeedback at the EEG Institute in Woodland Hills, CA.

Correspondence address: Washington State Toxicology Laboratory, Forensic

Laboratory Services Bureau Suite 360, 2203 Airport Way South, Seattle, WA

98134.

Email: Pat.Friel@wsp.wa.gov

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Alternative Medicine Review Volume 12, Number 2 2007

Review Article

Table 1. EEG Rhythms and Associated Mental States

EEG Rhythm Frequency

(hz)

Associated Mental States

Delta

1 - 4

Sleep; dominant in infants

Theta

3 - 7

Drowsiness; “tuned-out;” inner-directed insights

Alpha

8 - 12

Alertness; meditation, dominant when eyes closed

SMR

12 - 15

Mental ly alert; physically relaxed

Beta

13 - 21

Focused; sustained attention; problem solving

High Beta

20 - 32

Intensity; anxiety; hypervigilance

Gamma

38 - 42

Important in learning

Patients with AD/HD exhibit characteristic

surface EEG disturbances. 4 Speciically, 85-90 percent

of patients with AD/HD display signs of cortical “hy-

poarousal,” quantitatively described as elevated relative

theta power, reduced relative alpha and beta power, and

elevated theta/alpha and theta/beta power ratios (Ta-

ble 1). hese patterns are typically observed over frontal

and central midline brain regions. A smaller subgroup

of AD/HD patients exhibits an EEG pattern suggestive

of “hyperarousal,” with greater relative beta activity, de-

creased relative alpha activity, and decreased theta/beta

power ratios difusely across multiple cortical recording

sites. he hyperaroused group tends to respond poorly

to stimulant medications.

Lubar et al developed EEG biofeedback pro-

tocols to inhibit cortical slowing and reward higher

frequencies in hypoaroused patients, with the goal of

normalizing EEG activity in regions thought to be re-

sponsible for attention and behavioral control. 4

Modern EEG biofeedback systems, sold by a

number of manufacturers, consist of a set of EEG sen-

sors and a signal transducer/ampliier, connected to a

computer or computers with software capable of ana-

lyzing the EEG signals, performing various transforma-

tions, displaying relevant signals to the patient, and

providing rewards or inhibitions in the form of visual

and/or audio feedback. he client learns to enhance

desirable EEG frequencies and suppress undesirable

frequencies at the selected scalp location(s) by being

rewarded (e.g., by progress in a video game) for increas-

ing desirable frequencies and/or reducing undesir-

able frequencies. Scalp electrode placements along the

sensory-motor strip (C3 and C4) and temporal lobes

(T3 and T4) are widely used. A typical neurofeedback

coniguration involves the patient seated in a reclining

chair, watching one video display that provides video

and audio feedback, while the therapist monitors a sec-

ond video display that provides detailed, real-time data

on the patient’s EEG during the session.

A typical course of EEG biofeedback therapy

involves at least 20 half-hour sessions, administered

over a 6- to 12-week period. Although rates of prog-

ress vary from patient to patient, signiicant beneit is

often observed within the irst few weeks of therapy. Ac-

creditation for EEG biofeedback practitioners is avail-

able through the Biofeedback Certiication Institute of

America.

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Alternative Medicine Review Volume 12, Number 2 2007

EEG Biofeedback: AD/HD

Clinical Trials

A recent review discusses the evidence sup-

porting EEG biofeedback for AD/HD, collected in

case studies and controlled-group trials. 4 he studies

reviewed all employed single-channel neurofeedback,

based on the original work of Lubar et al. Case series

demonstrating favorable outcomes with EEG biofeed-

back for AD/HD include one group of 111 8 and an-

other of 186 9 subjects. In the case series of 111 patients,

who were treated with 40 sessions of neurofeedback,

hompson and hompson reported improvements in

quantitative EEG and performance in a continuous per-

formance task, as well as a mean gain in full-scale IQ

of 12 points after neurofeedback. 8 Kaiser and Othmer

reported a series of 1,089 patients, 186 with AD/HD. 9

hey described signiicant improvement in measures of

attentiveness and impulse control using a test of vari-

ables of attention (TOVA).

Five controlled-group studies that appeared in

peer-reviewed journals between 1995 and 2003 were

also reviewed. Rossiter and LaVaque compared the ef-

fects of 20 sessions of EEG biofeedback with the efects

of stimulant medication in 46 subjects with AD/HD

ages 8-21 years, who were divided into two matched

groups. 10 In this study, patients receiving EEG biofeed-

back demonstrated signiicant improvement in several

psychometric test scores. here was no signiicant dif-

ference in response rates for patients treated with EEG

biofeedback (83%) and medication (87%).

Linden et al studied 18 children (ages 5-15

years) with AD/HD who were randomly assigned to a

“waiting list” or an EEG biofeedback treatment group. 11

Patients treated with EEG biofeedback demonstrated a

signiicant increase in IQ (9 points) when compared to

the control group, and signiicantly reduced inattentive

behaviors, as rated by parents.

Another randomized, waiting-list trial, involv-

ing 16 children (ages 8-10 years) with AD/HD, was

conducted by Carmody et al. 12 Patients treated with

EEG biofeedback exhibited reduced impulsivity on psy-

chometric testing and were rated more attentive by their

teachers. However, follow-up QEEG testing did not

demonstrate consistent patterns of electrophysiological

improvement after EEG biofeedback.

he largest published controlled trial of EEG

biofeedback for AD/HD was conducted by Monastra et

al. 13 A group of 100 patients (ages 6-19 years) was divid-

ed into two groups; one received methylphenidate and

the other received methylphenidate plus EEG biofeed-

back. After one year of therapy, post-treatment assess-

ments were conducted while patients continued to take

methylphenidate, and then after a one-week medication

washout. he EEG biofeedback-plus-medication group

received an average of 43 sessions, which were designed

to reduce cortical slowing to within one standard devia-

tion of age peers. Statistical analysis demonstrated an

independent beneicial efect of EEG biofeedback, with

greater improvement in attention and less hyperactive

behavior, reported by parents and teachers, in patients

treated with both methylphenidate and EEG biofeed-

back. After medication washout, sustained improve-

ment, as reported by parents and teachers, was seen only

in the group that had been treated with methylphenidate

and EEG biofeedback. Children whose parents followed

the strategies taught in a concurrent parenting program

had fewer attentional and behavioral problems at home,

regardless of which treatment they received.

Fuchs et al compared EEG biofeedback with

stimulant medication in 34 children (ages 8-12 years)

with AD/HD. 14 Treatment assignment was based on

parental preference, and the two treatment groups were

similar in pre-treatment measures of intelligence and

severity of AD/HD. he EEG biofeedback group re-

ceived 36 sessions over 12 weeks. Signiicant improve-

ment in psychometric and behavioral test results, and

in parent and teacher reports, were found in both treat-

ment groups. he authors concluded that EEG bio-

feedback was eicient in improving some behavioral

concomitants of AD/HD in children whose parents

favored a nonpharmacological treatment.

A recent paper by Levesque et al evaluated the

impact of EEG biofeedback on brain function in AD/

HD by using brain functional magnetic resonance im-

aging (fMRI) in conjunction with psychometric tests. 15

After EEG biofeedback therapy, children with AD/HD

exhibited improved attentional performance, as well

as distinctive activation of the right anterior cingulate

cortex on fMRI, which were not observed in untreated

control subjects.

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Alternative Medicine Review Volume 12, Number 2 2007

Review Article

In summary, controlled studies demonstrate

that the eicacies of EEG biofeedback and stimulant

medication are comparable in the treatment of AD/

HD.

simultaneously encourage increased left hemispheric

frequency and decreased right hemispheric frequency,

while also supporting left hemisphere-right hemisphere

integration. Interhemispheric EEG biofeedback has

become the Othmers’ method of choice for improving

functional brain stability. Case study data indicate inter-

hemispheric EEG biofeedback is comparable to single-

channel EEG biofeedback in eicacy for treatment of

AD/HD. 17

Protocol Choice

EEG biofeedback is a relatively new treatment

modality, and the novice is confronted with a wide array

of protocols to choose from. Although newer protocols

may ofer comparable or even better outcomes than the

approaches used in the clinical trials described in the

previous section, evidence to support the newer proto-

cols tends to be more anecdotal.

Low Energy Neurofeedback

A low energy neurofeedback system is another

EEG biofeedback variation that employs direct weak

electromagnetic stimulation at the sensor sites, instead

of the customary visual and auditory feedback employed

in other EEG biofeedback modes. At this time, no pub-

lished research studies are available to evaluate this ap-

proach for treatment of AD/HD.

Quantitative Electroencephalographic

Analysis

One important question is whether pre-treat-

ment QEEG is necessary and beneicial in guiding EEG

biofeedback treatment. Of the ive controlled-group

studies discussed in the previous section, only one used

QEEG improvement as a treatment endpoint. One

other study found no consistent change in QEEG after

EEG biofeedback, and the remaining three studies did

not report QEEG data. Since the studies all found sig-

niicant improvement for AD/HD with EEG biofeed-

back, independent of QEEG use, the case for QEEG

is not compelling; furthermore, QEEG is relatively ex-

pensive. Avoiding QEEG testing can reduce the cost of

EEG biofeedback. On the other hand, some of the lead-

ing experts in EEG biofeedback who routinely perform

QEEG report excellent treatment outcomes.

Hemoencephalography

Hemoencephalography, the newest outgrowth

of neurofeedback, employs near-infrared sensors to

monitor cerebral blood low and guide feedback to the

patient. 18 Prefrontal sensor placement sites have been

used in limited published studies of hemoencephalog-

raphy to treat AD/HD. Because hemoencephalography

has a direct impact on cerebral blood low, it is contra-

indicated in patients with cerebrovascular disorders.

Choosing a Protocol and Practitioner

he data available do not allow a head-to-head

comparison of standard single-channel EEG biofeed-

back and newer protocols. Selection of a neurofeedback

practitioner should be based on level of experience and

training, accreditation, the fraction of the therapist’s

practice devoted to neurofeedback, positive reports

from clients, and the therapist’s speciic experience in

treating AD/HD.

Interhemispheric EEG Biofeedback

Interhemispheric EEG biofeedback was devel-

oped by the Othmers at he EEG Institute, based on

re-evaluation of the original methods used in the con-

trolled studies described earlier. 16,17 In their clinical work

using single-channel EEG biofeedback, the most com-

mon EEG disturbances encountered in patients were

left hemispheric hypoarousal and right hemispheric

hyperarousal. Single-channel EEG biofeedback aims to

increase EEG frequencies in areas of hypoarousal and/

or decrease them in areas of hyperarousal. he Oth-

mers developed a new paradigm in which instability

of state, as well as hypo- or hyperarousal, is addressed.

Interhemispheric EEG biofeedback can be employed to

Contraindications

Case and controlled group studies did not

include patients under age six years, or subjects with

developmental delay or other signiicant medical, neu-

rological, or psychiatric disease. Patients from families

with signiicant marital discord that could interfere

with participation in the treatment process were also

excluded from the studies.

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Alternative Medicine Review Volume 12, Number 2 2007

EEG Biofeedback: AD/HD

Adverse Efects

here is a potential for increased irritability,

moodiness, and hyperactivity when stimulant medica-

tion and EEG biofeedback are combined. his can oc-

cur along with improvement in cortical activation, indi-

cating the stimulant dosage might need to be reduced

or eliminated. Occasionally, patients report transitory

headaches, tiredness, and/or dizziness after treatment.

he original work by Sterman clearly demonstrated

that EEG biofeedback has the potential to decrease or

increase seizure threshold, depending on the frequen-

cies and sensor locations used. 7 Patients with a history

of epilepsy should only receive neurofeedback from

practitioners who are well versed in EEG biofeedback

therapy for seizure disorders.

Use of EEG Biofeedback for other

Disorders

Experienced practitioners treat a range of neu-

ropsychiatric problems with EEG biofeedback. he

strongest evidence-based justiication for EEG biofeed-

back therapy exists for AD/HD and epilepsy. 7,22-25 A

growing body of evidence supports the use of EEG bio-

feedback in the treatment of mood disorders. 26 A num-

ber of other conditions have been reported to respond

to EEG biofeedback, including migraine, ibromyalgia,

chemical dependency, and syndromes secondary to

traumatic brain injury. EEG biofeedback protocols have

also been developed to improve “peak performance” in

healthy individuals. For example, conservatory students

experienced improvements in artistic aspects of music

performance equivalent to two class grades after EEG

biofeedback. 27

Potential Synergies

EEG biofeedback therapy for AD/HD results

in signiicant improvement in cognitive functioning for

75-85 percent of patients. It is possible faster and better

outcomes might be achieved by combining other alter-

native therapies with EEG biofeedback. According to

Schnoll et al, dietary modiication plays a major part in

the treatment of AD/HD and should be considered as

part of the overall treatment protocol when EEG bio-

feedback therapy is employed. 19 hey also reviewed re-

search demonstrating that patients with AD/HD and

food sensitivities have changes in brain electrical activ-

ity after exposure to ofending foods, suggesting that re-

moving foods the patient is sensitive to could accelerate

response to EEG biofeedback.

Another example of a potential synergy be-

tween EEG biofeedback and alternative therapies con-

cerns omega-3 fatty acid supplements, which are incor-

porated into neuronal membranes and have stabilizing

efects on mood and other aspects of mental function-

ing. 20 Although it is possible omega-3 fatty acid therapy

could “prime” the brain to respond to EEG biofeedback-

augmented stabilization, no clinical research has been

conducted to conirm such a hypothesis. Anecdotal

evidence, however, from practitioners who prescribe

dietary modiication and nutritional supplements along

with EEG biofeedback is impressive. 21 Further research

on combined approaches is warranted.

Conclusions

EEG biofeedback is a well-established, non-

drug treatment modality for AD/HD, with proven ei-

cacy and minimal adverse efects. 4,22 In seeking to engage

neuronal plasticity for patient beneit, EEG biofeedback

ofers an optimistic, non-reductionist approach to neu-

ropsychiatric problems. Although integrative treatment

of AD/HD, including dietary modiication, nutritional

supplements, and EEG biofeedback, may ofer patients

the best chance for a favorable outcome, research on

combining these therapies has not yet been conducted.

Disclaimer

his paper relects the author’s opinions, which

are not endorsed by the Forensic Laboratory Services

Bureau of the Washington State Patrol.

References

Fox DJ, harp DF, Fox LC. Neurofeedback: an

alternative and eicacious treatment for attention

deicit hyperactivity disorder. Appl Psychophysiol

Biofeedback 2005;30:365-373.

Nissen SE. ADHD drugs and cardiovascular risk. N

Engl J Med 2006;354:1445-1448.

Harding KL, Judah RD, Gant C. Outcome-based

comparison of Ritalin versus food-supplement treated

children with AD/HD. Altern Med Rev 2003;8:319-

330.

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