The Use of EEG Biofeedback for Attention Problems in a School Setting

1
The Use of EEG Biofeedback for Attention Problems
in a School Setting

• Dennis P. Carmody
• Institute for the Study of Child Development

2
Collaborators

• Data Collection
• Mary Jo Sabo, PhD director Biofeedback
  Consultants, Suffern, NY
• Linda Vergara Principal
• Enrico Fermi ES, Yonkers, NY

• Data Analyses
• Ugrad students -
• Diane Radvanski
• Sonia Wadhwani
• Jose Quintela
• Jim Waddington

3
Statement of the Problem

• An estimated 5-7 million school age children are
  diagnosed with ADHD
• Most frequent intervention is stimulant
  medication
• Medication is effective in some, not all cases
• Some children have side effects that prevent
  continued medication

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DSM-IV, part 1

• Diagnostic Criteria
• Either (1) or (2)
• six (or more) of the following symptoms of
  inattention have persisted for at least 6 months
  to a degree that is maladaptive and inconsistent
  with developmental level
• six (or more) of the following symptoms of
  hyperactivity-impulsivity have persisted for at
  least 6 months to a degree that is maladaptive
  and inconsistent with developmental level

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DSM-IV, part 2

• Some hyperactive-impulsive or inattentive
  symptoms that caused impairment were present
  before age 7 years.
• Some impairment from the symptoms is present in
  two or more settings (e.g., at school or work
  and at home).
• There must be clear evidence of clinically
  significant impairment in social, academic, or
  occupational functioning.
• The symptoms do not occur exclusively during the
  course of a Pervasive Developmental Disorder,
   Schizophrenia , or other Psychotic Disorder and
  are not better accounted for by another mental
  disorder (e.g., Mood Disorder, Anxiety Disorder,
  Dissociative Disorder, or a Personality
  Disorder).

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Inattention Examples

• Failure to give close attention to details
• Makes careless mistakes
• Difficulty sustaining attention in tasks or
  applied
• Does not seem to listen when spoken to
• Does not follow instructions or fails to finish
  work
• Has difficulty organizing tasks and activities

• Often avoids or dislikes tasks that requires
  sustained mental effort-school work, homework
• Often loses things such as assignments, pencils,
  books
• Easily distracted
• Forgetful in daily activities

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ExamplesHyperactivity Impulsivity

• Often fidgets with hands or feet or squirms in
  seat
• Often leaves seat in classroom
• Often runs about excessively when inappropriate
• Difficulty playing in activities quietly
• Appears driven by a motor
• Talks excessively

• Blurts out answers before questions have been
  completed
• Difficulty awaiting turn
• Often interrupts or intrudes on others

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Who makes the Dx?

• Primary care physicians
• Developmental pediatricians
• Family practitioners
• Neurologists
• Psychologists
• Psychiatrists

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Historically

• Fidgety Phils
• Brain damage
• Minimal brain damage
• Attention deficit disorder
• ADHD

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Treatment

• Medication
• Behavior modification
• Parent management training
• Cognitive problem-solving skills training

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Medication

• CNS stimulant medications are the most commonly
  used psychotropic drugs to treat the symptoms of
  persons with ADHD. Estimates range from 1.5-5
  million children annually
• Empirical data demonstrate the efficacy of the
  stimulate medications in improving behavioral
  academic and social functioning in 50 percent to
  95 percent of children treated depending on the
  presence of comorbid psychiatric and
  developmental disorders

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How do medications work?

• CNS stimulant medications raise the levels of
  activity, arousal, or alertness of CNS
• These drugs are structurally similar to brain
  catecholamines - dopamine and norepinephrine
• Considered to be sympathomimetic compounds
  because they may mimic the actions of these brain
  neurotransmitters

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Objections to medication American Association
for Health Freedom

• Up to 6 of all school age American boys are now
  believed to take Ritalin for symptoms of ADHD.
• Sufficient data on safety and efficacy of
  long-term use of Ritalin in children are not yet
  available, however suppression of growth (i.e.,
  weight loss, height) has been reported with the
  use of stimulants in children.
• Many symptoms attributed to ADHD often have an
  imbalance in nutrients, or food or chemical
  allergies, poor diet
• Other children are simply very bright, bored by
  the class work, and seeking attention or mental
  stimulation through so-called unruly behavior
• Over-crowded classrooms
• "trouble makers" are subdued with drugs

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Problems with Ritalin

• Abuse
• Schedule II drug
• One of more widely stolen from pharmacies
• Sold on campuses
• Rise in ER visits for overdose
• More popular than other recreational drugs

• SE
• Anemia
• Loss of appetite
• Insomnia
• Reports of Zombie children

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Rise in Ritalin production

• Schedule II production is accountable
• 600 rise in annual production 1990-1997
• Rx rise
• Dx ADHD rises

• Some schools report 30 of boys on Ritalin
• Rise in UK, Canada, Australia

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Note drop in months June, July August
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EEG findings

• In 1938 abnormal brain waves were found in
  children with hyperactivity.
• Research has focused on two goals
• Decrease theta waves associated with day dreaming
  
• Increase beta waves associated with attention
• Many successful case studies have been reported
  under clinical and laboratory conditions.
• Some comparisons of experimental and control
  groups have also yielded evidence of the
  effectiveness of NF

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History of EEG biofeedback

• Human EEG biofeedback used in the 1960s by Joe
  Kamiya at the U of Chicago.
• Early investigations focused on operant
  conditioning of alpha brain waves primarily to
  facilitate deep relaxation and meditation.

• 1970s Joel Lubar used EEG biofeedback to reduce
  hyperactivity in children with no Hx of seizures
• 1980s Eugene Peniston used Alpha/theta NF
  training to to tx alcoholics in VA setting
• 5 year mark 70 remained abstinent

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Sterman and cats

• SMR/beta biofeedback developed from operant
  conditioning of cats' EEG.
• Barry Sterman of UCLA serendipitously discovered
  that when cats were exposed to toxic chemicals
  that usually induce epileptic seizures, reactions
  were modified by BF
• Cats trained in the middle to high frequency
  range (12-20 Hz) from a previous unrelated
  experiment had greater latency to seizure onset,
  and a higher threshold for seizure onset, than
  untrained cats
• These results were replicated in monkeys and
  humans.
• Sterman, M.B. (1977). Sensorimotor EEG operant
  conditioning and experimental and clinical
  effects. Pavlovian J. Biological Science, 12(2),
  65-92.

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Yonkers Project

• Spring 1995 designed a project for on-site NF
  training in a school setting
• Initial design 2 groups
• Group 1 test, tx fall 1995, retest early spring
  and late spring 1996
• Group 2 test, wait fall, test early spring, tx
  spring, retest late spring

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Participants

• 16 -4th, 5th grade children ages 8-10
• 8 ADHD positive, 6 boys, 2 girls
• 8 not ADHD matched age, grade, gender
• Random assignment of 8 (4 ADHD, 4 control) to NF
  and 8 to waitlist
• Approval Bd of Ed School Parents

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NF methods

• Hardware - three electrodes placed on
  participants a ground on right ear reference
  electrode on the left ear the active electrode
  was placed at Cz
• Theta - 2 to 7 Hz frequency band was suppressed
• Beta - 16 to 18 Hz frequency was reinforced for
  the first protocol
• SMR - 12-14 Hz rhythm observed over the
  sensorimotor cortex associated with inhibition
  of motor activity (Chase and Harper, 1971 Howe
  and Sterman, 1972 Sterman, 1977).
• Chase, M.H., and Harper, R.M. (1971).
  Somatomotor and visceromotor correlates of
  operantly conditioned 12-14 c/sec sensorimotor
  cortical activity. Electronencephalogr. Clinical
  Neurophysiology, 31, 85-92.

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Procedure - NF

• Beta threshold was set above which a high pitched
  tone would be heard sixty to seventy-five percent
  of the time - reinforcement
• Theta threshold was set below which a low-pitched
  tone would be heard seventy-five to eighty-five
  percent of the time - suppression
• When reinforcement and suppression task criteria
  were simultaneously met, the participant received
  preferred visual feedback and auditory feedback
  tones
• When criteria were not simultaneously met,
  feedback would cease

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Procedure

• Sampling rate 512 Hz
• Means recorded over 3 minute sampling periods
• 30-minute session
• 2-3X weekly
• Goal of 40 sessions
• Actual 37 55 sessions

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Ancillary Tests

• McCarney Scale - Teachers version to be
  completed weekly
• TOVA Test of Variables of Attention
• 22 minute CPT visual modality
• participants viewed a computer monitor and
  pressed a thumbswitch whenever a square figure
  appeared in the top portion of a rectangle.
  Participants were to inhibit the switch press
  when the square figure appeared in the lower half
  of the field.
• Yields measures of inattention, impulsivity,
  anticipation

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Change in training protocol

• Participants in the ADHD-positive group showed
  signs of overstimulation
• More aggressive, expressed more anger, agitated
  in classroom by self-report or observations by
  staff
• 16-18 Hz beta band changed to 13-15 SMR band for
  4 participants
• Switch occurred between sessions 13 35
  depending on the child

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Findings

• Performance
• McCarney Scores
• TOVA scores
• Brainwaves
• Theta changes
• Beta changes
• Theta/Beta ratio
• SMR changes
• EEG Biofeedback training and attention-deficit/hyp
  eractivity disorder in an elementary school
  setting. Carmody DP, Radvanski, DC, Wadhwani S,
  Sabo MJ, Vergara L. Journal of Neurotherapy.
  4(3), 2001.

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McCarney Scale results

• Analyses by ANOVA, Friedman
• Inattention scores improvements in Exp group
  not control group no change Jan Mar but sig
  changes Mar Jun
• No changes either group for Impulsivity
• No changes either group Hyperactivity

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Reduction in Anticipation Score on TOVA
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Reduction in Commission Errors on TOVA
31
Example of theta amplitudes over sessions
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Changes in brainwaves

• In contrast, among the four participants with the
  highest intercept values, two showed significant
  negative slopes and two showed no change.
• Two children with the highest SMR intercepts had
  significant decreases in amplitude over sessions,
  while the two with the lowest initial SMR
  intercepts significantly increased the amplitude
  of SMR brainwaves.

• From initial 5 sessions to last 5 sessions
• Theta
• two reduced amplitude
• three increased
• three showed no change.
• Beta -
• three increased amplitude
• three decreased amplitude
• two showed no change
• Of the four participants with the lowest levels
  of beta activity, all showed significant positive
  slopes

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Continuation of program

• 1996-97 16 more children involved in NF study
• 32 48 sessions per child 660 sessions 330
  hours
• Linear regression analyses
• Theta 25 decreased 35 no change 40
  increased
• Beta 21 decreased 47 no change 32 increased
• SMR 33 decreased 17 no change 50 increased
• Participants with the lowest initial amplitudes
  had significant increases over session, while the
  participants with significant decreases in
  amplitudes tended to have the highest initial
  levels of beta.
• Neurofeedback Training and Attention Disorders in
  an Elementary School Setting, Dennis P. Carmody,
  Jose Quintela, Diane C. Radvanski, Mary Jo Sabo
  and Jim Giorgi Journal of Neurotherapy, 3 (4),
  1999.

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Expansion to other schools

• 27 Westchester County, NY elementary school
  children 1st through 5th grades
• Most were without diagnoses
• Referred by teachers due to attention problems
• A technician from Biofeedback Consultants
  Incorporated conducted training

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Limitations

• Teachers reported the completion of McCarney
  weekly forms to be a burden
• Brainwave changes were not uniform over
  participants
• Participants with ADHD and in Exp group were
  identifiable by staff
• Presence of comorbid conditions disorders such
  as anxiety, depression, conduct disorders

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Explanations

• Individualized training and attention by
  technician
• Removal from standard classroom to a one-on-one
  or two-on-one setting
• Changes in the video game
• Effects of controlling the video game with
  brainwaves

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Further research

• Need to conduct placebo control study to isolate
  the four variables
• Daniel Amen has identified several subtypes of
  ADHD based on SPECT imaging studies
• NF may have differential effects based on
  subtypes
• Brain SPECT Imaging and ADD in Understanding,
  Diagnosing, and Treating AD/HD in Children and
  Adolescents An Integrative Approach. Eds
  Incorvaia, JA, Mark-Goldstein BS, and Tessmer D.
  Jason Aronson, Inc, Northvale, New Jersey, 1999,
  183-196.