A controlled comparison of EEG-neurofeedback and attention training for children with ADHD.

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A controlled comparison of EEG-neurofeedback and
attention training for children with ADHD.

• Tony Steffert, Annie Frick, Martin Batty, Malcolm
  Hawken, Claire Sturge, Katherine Loveday, John
  Gruzelier.

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Limitations of previous neurofeedback studies

• Rossiter LeVaque (1995)
• Combined neurofeedback with additional
  interventions
• Failed to control for patient-therapist contact
• Linden et al (1996)
• Small sample size difficult to generalise
• Failed to control for patient-therapist contact
• Fuchs et al (2003), Monastra et al (2002)
• Failure to randomly allocate treatment.
• Failed to control for patient-therapist contact
• This has limited the acceptance of neurofeedback
  as a viable alternative

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Project Aim

• To examine the efficacy of neurofeedback in a
  randomised control trial, assessing its
  effectiveness in comparison to another
  computerised intervention. Groups will be
  stratified according to medication status
  (medicated vs. non-medicated)

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Procedure
Subjects randomly allocated
30 Sessions
Neurofeedback No medication. Attention task
No medication. Neurofeedback
Medication. Attention task Medication
Group 1 Group 2 Group 3 Group 4

Pre-Test And QEEG Time 1
Post-Test And QEEG Time 2
N 80
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Assessment Measures

• Test of Variables of Attention (TOVA)
• Attention Network Test (ANT)
• Suffolk Reading Scale (SRS)
• Wide Ranging Aptitude Test Maths (WRAT)
• Eysenck Personality Questionnaire (EPQ)

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Assessment Measures

• Strengths and Difficulties Questionnaire (SDQ)
• Parent Ratings
• Teacher Ratings
• Parenting Alliance Measure (PAM)

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EEG Assessment Measures

• All assessments carried out following a
  medication washout period of 48 hours
• 19-channel qEEG assessment on the Mitsar
• Eyes Open,
• Eyes Closed,
• Listening
• Drawing

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Selection Criteria

• No co-morbid psychiatric or neurological
  conditions
• Subjects receive a DSM IV subtype
• (to inform the training protocol)
• Any subjects with significantly elevated beta
  (compared to Kropotov database) excluded

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Control - Captains Log Computer Attention
Training

• A mental gym
• Increases focused attention and short-term
  memory, while reducing impulsivity using
  specifically designed tasks
• Used in previous research with ADHD children
  (Sandford, 1994 Slate et al, 1998)
• Also successfully used with psychotic patients
  (Bell et al, 2001 Burda et al, 1994) and in
  cognitive rehabilitation programmes with brain
  injured patients (e.g., Stathopoulou Lubar,
  2001)

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Training Protocol

• All subjects receive 30 sessions of Neurofeedback
  or Captains Log training
• Participants in Captains Log group have 5 minute
  eyes open baseline then 6 x 5 minute games per
  session (each game at 2 levels)
• Participants in Neurofeedback group have 5 minute
  eyes open baseline followed by 6 x 5 minute NF
  training per session
• Training protocol in Neurofeedback group
  dependent upon subtype. All training at CZ
  (Beauregard, 2005, Lubar and Lubar,1984)

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Neurofeedback training protocol

• ADHDin 30 sessions inhibit ?/enhance ß1
• (enhance attention)
• ADHDhyp 30 sessions inhibit ?/enhance SMR
• (reduce hyperactive behaviour)
• ADHDcom children 2 protocols
• Sessions 1-15 inhibit ?/enhance SMR
• Sessions 16-30 inhibit ?/enhance ß1
• Rationale inhibit motor activity to reduce
  hyperactive behaviour, while increasing
  attention..

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Assessment Measures

• Attentional Network Task (ANT) Posner et al
  (2002, 2004)
• Measures 3 separate attentional networks
  (alerting, orienting, executive control), based
  on earlier functional studies (e.g. Posner
  Peterson, 1990)

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ANT

• Alerting maintaining an alert state Calculated
  by Mean RT no cue Mean RT double cue.
• Orienting selecting information
• Mean RT centre cue Mean RT spatial cue.
• Executive Attention resolution of conflict
• Mean RT incongruent Mean RT congruent.

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Results

• All data from 23 subjects (11 NF, 12 CL)
• Data analysed using 2 (GROUP) x 3 (TIME) mixed
  ANOVA. Medication status and subtype not included
  as factors in the preliminary analysis
• Any violations in sphericity corrected using
  Greenhouse-Geisser adjustment

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TOVA Omission Errors
Pre test, t ns. Mid test, t -2.55 (d.f 18),
p .024 Post test, t -2.47 (d.f 18), p .024
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Pre test tns. Post test, t2.34 (d.f18), p.017
(2-tailed)
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Strengths and Difficulties (SDQ) Parent Ratings

• Both groups improved equally on the
• Stress and
• Hyperactivity subscales.

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Interpretation

• We demonstrated some advantages for NF in
  improving attention on both computerised measures
• TOVA omissions
• Attention Network Task accuracy.
• This was in comparison with training on a
  Computerised Attention test, a control comparison
  that has not previously been reported on.
• Notwithstanding both groups improved on parent
  ratings of hyperactivity and stress.

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Neurofeedback Session Analysis

• Future work will include analysis of the
  neurofeedback EEG data, both within and between
  sessions
• Neurofeedback learners will be distinguished from
  non-learners
• This differentiation will enable us to determine
  whether learned modulation of the EEG correlates
  with improved performance on the various
  cognitive and behavioural measures

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Methodological Issues

• Threshold settings
•  Reward system
•  Fixed protocols
•  5 minute trials to long
•  Filter settings

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Thanks to
Dr Catherine Loveday The University of
Westminster. Drs Linda and Michael Thompson. Dr
Sturge and colleagues, Northwick Park
Hospital. Dr David Vernon. ADHD Support Group,
Harrow. Silvio Adriovati, Christoph Moehlbrink,
Andrea Oskis, Silvie Rainer, Keri Thornton,
Wallis Levin. All the parents and children who
have taken part in the study.