The Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part II. Replication

This study replicated T. R. Rossiter and T. J. La Vaque (1995) with a larger sample, expanded age range, and improved statistical analysis. Thirty-one AD/HD patients who chose stimulant drug (MED) treatment were matched with 31 patients who chose a neurofeedback (EEG) treatment program. EEG patients received either office (n = 14) or home (n = 17) neurofeedback. Stimulants for MED patients were titrated using the Test of Variables of Attention (TOVA). EEG (effect size [ES] = 1.01–1.71) and MED (ES = 0.80–1.80) groups showed statistically and clinically significant improvement on TOVA measures of attention, impulse control, processing speed, and variability in attention. The EEG group demonstrated statistically and clinically significant improvement on behavioral measures (Behavior Assessment System for Children, ES = 1.16–1.78, and Brown Attention Deficit Disorder Scales, ES = 1.59). TOVA gain scores for the EEG and MED groups were not significantly different. More importantly, confidence interval and nonequivalence null hypothesis testing confirmed that the neurofeedback program produced patient outcomes equivalent to those obtained with stimulant drugs. An effectiveness research design places some limitations on the conclusions that can be drawn.     

Neurofeedback training for a patient with thalamic and cortical infarctions

One year after a left posterior and thalamic stroke, a 52-year-old male participant was treated with 14 weeks of theta reduction neurofeedback training. Imaging studies revealed left temporal, parietal, occipital, and bilateral thalamic infarctions along the distribution of the posterior cerebral artery. Neuropsychological testing demonstrated severe verbal memory, naming, visual tracking, and fine motor deficits. Additionally, alexia without agraphia was present. A pretraining quantitative electroencephalograph (QEEG) found alpha attenuation, lack of alpha reactivity to eye opening, and excessive theta activity from the left posterior head region. Neurofeedback training to inhibit 4–8 Hz theta activity was conducted for 42 sessions from left hemisphere sites. Over the course of the training, significant reductions in theta amplitude occurred from the training sites as assessed from the postsession baseline periods. Posttraining, a relative normalization of the QEEG was observed from the left posterior head region.     

Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison with methylphenidate

Clinical trials have suggested that neurofeedback may be efficient in treating attention-deficit/hyperactivity disorder (ADHD). We compared the effects of a 3-month electroencephalographic feedback program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12–15 Hz) and beta1 activity (15–18 Hz) with stimulant medication. Participants were N = 34 children aged 8–12 years, 22 of which were assigned to the neurofeedback group and 12 to the methylphenidate group according to their parents' preference. Both neurofeedback and methylphenidate were associated with improvements on all subscales of the Test of Variables of Attention, and on the speed and accuracy measures of the d2 Attention Endurance Test. Furthermore, behaviors related to the disorder were rated as significantly reduced in both groups by both teachers and parents on the IOWA-Conners Behavior Rating Scale. These findings suggest that neurofeedback was efficient in improving some of the behavioral concomitants of ADHD in children whose parents favored a nonpharmacological treatment.     

Changes in EEG Rhythms and Spike Activity of Brainstem Dopaminergic Neurons Induced by Neurofeedback Sessions in Cats

We examined the dynamics of the ratios of spectral power densities (SPDs) of the alpha vs theta rhythms (α/θ ratio). of EEG and of the spiking frequency of supposedly dopaminergic (DA) neurons of the ventral tegmentum in the course of neurofeedback sessions directed toward changes in the EEG characteristics. Trainings were performed using techniques analogous to that used in neurofeedback sessions in humans. The level of the noise acoustic signal presented to the animal decreased with increase in the α/θ ratio in the occipital leads. In the control realizations, there were no dependences between the intensity of the acoustic signal and modulation of the current EEG. It was found that the animals learned, in a conditioned-reflex mode, to correlate changes in the intensity of the sound signal and power of the EEG rhythms and to control the latter; a high sound intensity was probably considered a factor of discomfort. The α/θ ratio in the course of neurofeedback sessions changed due to some increase in the SPD of the alpha EEG component and a noticeable drop in the SPD of theta oscillations. In a parallel manner with such modifications, augmentation of the spike activity of DA neurons was observed. Probable mechanisms of the involvement of the cerebral DA system in the formation of the effects of neurofeedback sessions are discussed.     

The Effects of QEEG-Informed Neurofeedback in ADHD: An Open-Label Pilot Study

In ADHD several EEG biomarkers have been described before, with relevance to treatment outcome to stimulant medication. This pilot-study aimed at personalizing neurofeedback treatment to these specific sub-groups to investigate if such an approach leads to improved clinical outcomes. Furthermore, pre- and post-treatment EEG and ERP changes were investigated in a sub-group to study the neurophysiological effects of neurofeedback. Twenty-one patients with ADHD were treated with QEEG-informed neurofeedback and post-treatment effects on inattention (ATT), hyperactivity/impulsivity (HI) and comorbid depressive symptoms were investigated. There was a significant improvement for both ATT, HI and comorbid depressive complaints after QEEG-informed neurofeedback. The effect size for ATT was 1.78 and for HI was 1.22. Furthermore, anterior individual alpha peak frequency (iAPF) demonstrated a strong relation to improvement on comorbid depressive complaints. Pre- and post-treatment effects for the SMR neurofeedback sub-group exhibited increased N200 and P300 amplitudes and decreased SMR EEG power post-treatment. This pilot study is the first study demonstrating that it is possible to select neurofeedback protocols based on individual EEG biomarkers and suggests this results in improved treatment outcome specifically for ATT, however these results should be replicated in further controlled studies. A slow anterior iAPF at baseline predicts poor treatment response on comorbid depressive complaints in line with studies in depression. The effects of SMR neurofeedback resulted in specific ERP and EEG changes.     

Modulation of attention in healthy children using a course of EEG-feedback sessions

We studied changes in the power spectra of EEG in the course of sessions of feedback by EEG characteristics (neurofeedback sessions) and estimated the effects of neurofeedback on psychological and EEG correlates of voluntary attention. Indices of the latter were estimated using Bourdon’s test (a correcture test) and Schulte’s tables. Twenty-nine reasonably healthy 10-to 13-year-old children took part in the study; they were divided into two groups, an experimental group (n = 12) and a control group (n = 15). The results obtained support the statement on noticeable changes in the functional state of the brain both immediately in the course of a neurofeedback session and after a course of such trainings. Changes in the ratios of the spectral powers of the beta₁ vs theta rhythms and the low-frequency beta vs theta rhythms were found in EEG recorded from the sensorimotor zone of the right hemisphere (C4). The observed changes in the spectral characteristics of EEG induced by the course of neurofeedback sessions were accompanied by the improvement of a few indices of voluntary attention. Neirofiziologiya/Neurophysiology, Vol. 38, Nos. 5/6, pp. 458–465, September–December, 2006.     

Age-Related Changes in Attention and Impulsivity in Young Schoolchildren

Normative values of attention, impulsivity, response time, and response time variability were determined for seven- to ten-year-old children with the continuous performance Test of Variables of Attention (TOVA). An age-related increase in attention and a decrease in impulsivity, response time, and its variability were revealed. Differences in TOVA scores were studied for students of gymnasia and schools providing general education.     

Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in T.O.V.A. scores,behavioral ratings,and WISC-R performance

A study with three component parts was performed to assess the effectiveness of neurofeedback treatment for Attention Deficit/Hyperactivity Disorder (ADHD). The subject pool consisted of 23 children and adolescents ranging in age from 8 to 19 years with a mean of 11.4 years who participated in a 2-to 3-month summer program of intensive neurofeedback training. Feedback was contingent on the production of 16–20 hertz (beta) activity in the absence of 4–8 hertz (theta) activity. Posttraining changes in EEG activity, T.O.V.A. performance, (ADDES) behavior ratings, and WISC-R performance were assessed. Part I indicated that subjects who successfully decreased theta activity showed significant improvement in T.O.V.A. performance; Part II revealed significant improvement in parent ratings following neurofeedback training; and Part III indicated significant increases in WISC-R scores following neurofeedback training. This study is significant in that it examines the effects of neurofeedback training on both objective and subjective measures under relatively controlled conditions. Our findings corroborate and extend previous research, indicating that neurofeedback training can be an appropriate and efficacious treatment for children with ADHD.The first author (Joel F. Lubar) has provided consultative services for both Lexicor and Stoelting-Autogenics Corporations in order to help them develop appropriate protocols for neurofeedback. He is not an owner, stockholder, or employee for either organization.     

The effects of stimulant therapy,EEG biofeedback,and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder

One hundred children, ages 6–19, who were diagnosed with attention-deficit/hyperactivity disorder (ADHD), either inattentive or combined types, participated in a study examining the effects of Ritalin, EEG biofeedback, and parenting style on the primary symptoms of ADHD. All of the patients participated in a 1-year, multimodal, outpatient program that included Ritalin, parent counseling, and academic support at school (either a 504 Plan or an IEP). Fifty-one of the participants also received EEG biofeedback therapy. Posttreatment assessments were conducted both with and without stimulant therapy. Significant improvement was noted on the Test of Variables of Attention (TOVA; L. M. Greenberg, 1996) and the Attention Deficit Disorders Evaluation Scale (ADDES; S. B. McCarney, 1995) when participants were tested while using Ritalin. However, only those who had received EEG biofeedback sustained these gains when tested without Ritalin. The results of a Quantitative Electroencephalographic Scanning Process (QEEG-Scan; V. J. Monastra et al., 1999) revealed significant reduction in cortical slowing only in patients who had received EEG biofeedback. Behavioral measures indicated that parenting style exerted a significant moderating effect on the expression of behavioral symptoms at home but not at school.     

Effect of Biofeedback Training of Sensorimotor and β1EEG Rhythms on Attention Parameters

The effects of the EEG–biofeedback (EEG–BFB) procedure, aimed at increasing the sensorimotor (12–15 Hz) and (15–18 Hz) rhythms on the psychological and electrophysiological parameters of attention, were studied using the methods of scalp recording of evoked potentials in the bistimulus paradigm Go/No–Go and a psychological attention test (Test of Variables of Attention; TOVA). Twenty-five children with attention disorders were included in the study. EEG–BFB sessions significantly improved the attention, behavior, and school study results in 19 (76%) children. In these cases, a significant increase in the amplitude of the inhibitory component in the frontocentral leads and improvement of the TOVA parameters were found.     

Real-time self-regulation of emotion networks in patients with depression

Many patients show no or incomplete responses to current pharmacological or psychological therapies for depression. Here we explored the feasibility of a new brain self-regulation technique that integrates psychological and neurobiological approaches through neurofeedback with functional magnetic resonance imaging (fMRI). In a proof-of-concept study, eight patients with depression learned to upregulate brain areas involved in the generation of positive emotions (such as the ventrolateral prefrontal cortex (VLPFC) and insula) during four neurofeedback sessions. Their clinical symptoms, as assessed with the 17-item Hamilton Rating Scale for Depression (HDRS), improved significantly. A control group that underwent a training procedure with the same cognitive strategies but without neurofeedback did not improve clinically. Randomised blinded clinical trials are now needed to exclude possible placebo effects and to determine whether fMRI-based neurofeedback might become a useful adjunct to current therapies for depression.     

The use of EEG theta biofeedback in the treatment of a patient with sleep-onset insomnia.

In this report, the treatment of a 42-year-old female with a complaint of chronic sleep-onset insomnia is described. Following the unsuccessful use of relaxation training, treatment consisted of 11 sessions of EEG theta rhythm (4--7 Hz) biofeedback. Theta density and five sleep indices were monitored throughout baseline, placebo, and treatment sessions. A significant increase in theta density was accompanied by reports of a decrease in sleep latency and an increase in total sleep time. This improvement was maintained after withdrawal of medication and at 3-month follow-up.     

The Sensorium: Psychophysiological Evaluation of Responses to a Multimodal Neurofeedback Environment

The Sensorium is a multimodal neurofeedback environment that reflects a person’s physiological state by presenting physiological signals via orchestral sounds from a speaker and multi-coloured lights projected onto a white surface. The software manages acquisition, real-time processing, storage, and sonification of various physiological signals such as the electroencephalogram (EEG) or electrocardiogram (ECG). Each of the 36 participants completed 6 interventional conditions consisting of three different Sensorium-phases with EEG and ECG feedback, a mindfulness meditation, a guided body scan exercise, and a Pseudo-Sensorium using pre-recorded data that did not reflect the subject’s own physiology. During all phases EEG, ECG, skin conductance, and respiration were recorded. A feedback questionnaire assessed the participants’ subjective reports of changes in well-being, perception, and life-spirit. The results indicate that the Sensorium sessions were not statistically inferior compared to their corresponding active control conditions with respect to improvements in subjective reports concerning well-being and perception. Additionally, the Sensorium was rated as being a more extraordinary experience, as compared to meditation. During the Sensorium conditions the EEG showed lower levels of theta2 (7–8.5 Hz), alpha (9–12 Hz) and beta (12.5–25 Hz) activity. Since participants reported benefit from the Sensorium experience regardless of any prior experience with meditation, we propose this novel method of meditative and extraordinary self-experience to be utilized as a modern alternative to more traditional forms of meditation.     

EEG signature and phenomenology of alpha/theta neurofeedback training versus mock feedback

Alpha/theta (a/t) neurofeedback training has in the past successfully been used as a complementary therapeutic relaxation technique in the treatment of alcoholism. In spite of positive clinical outcomes, doubts have been cast on the protocol's specificity when compared to alternative relaxation regimes. This study investigated the basic tenet underlying the a/t training rationale, that accurate a/t feedback representation facilitates the generation of these frequency components. Two groups of healthy volunteers were randomly assigned to either (a) real contingent a/t feedback training or (b) a noncontingent mock feedback control condition. The groups were compared on measures of theta/alpha (t/a) ratios within and across training sessions, as well as activational self-report scales after each session. The contingent a/t feedback group displayed significant within-session t/a ratio increments not evident in the mock control group, as well as higher overall t/a ratios in some but not all of the training sessions. No differences were found between the groups in terms of subjective activational phenomenology, in that both groups reported significantly lower levels of activation after training sessions. The data demonstrate that irrespective of considerations of clinical relevance, accurate a/t neurofeedback effectively facilitates production of higher within-session t/a ratios than do noncontingent feedback relaxation.     

The Efficacy of Neurofeedback in Patients with Major Depressive Disorder: An Open Labeled Prospective Study

The purpose of this study was to evaluate the effect of neurofeedback on depressive symptoms and electrophysiological disturbances in patients with major depressive disorder. We recruited participants suffering from depression to evaluate efficacy of left prefrontal beta with alpha/theta training. An 8-week, prospective, open-label study was undertaken. Twenty participants were recruited. The treatment protocol was twice or three times a week training of beta at F3 with alpha/theta at Pz for 8 weeks. When every visit, patients were received beta training for 30 min, and then alpha/theta training for 30 min. Baseline, 4 and 8 week scores of; the Hamilton rating scale for Depression (HAM-D), the Hamilton rating scale for Anxiety (HAM-A), the Beck Depression Inventory (BDI)-II, the Beck Anxiety Inventory (BAI), Clinical global impression-severity (CGI-S), and pre- and post-treatment resting state EEGs were compared. Interhemispheric alpha power asymmetry (A score) was computed for homologous sites F3–F4. Pre- and post-training clinical assessments revealed significant improvements in HAM–D, HAM-A, BDI, and CGI-S scores. Cumulative response rates by HAM-D were 35.0 and 75.0 % at 4 and 8 weeks, respectively, corresponding cumulative remission rates by HAM-D were 15.0 and 55.0 %, respectively. No significant differences were found between pre- and post-treatment A score. Neurofeedback treatment could improve depressive symptoms significantly. In addition, anxiety symptoms and clinical illness severity decreased significantly after neurofeedback treatment. Despite its several limitations, such as, small sample size and lack of a control group, this study suggested neurofeedback has significant effects in patients with major depressive disorder.     

Identifying Indices of Learning for Alpha Neurofeedback Training

Neurofeedback has been around for decades and has applications for both clinical and healthy populations yet there is no standard method for measuring learning or a way of defining successful learning. Thus the aim of this study was to focus on alpha neurofeedback and examine changes in three different measures: amplitude, percent time, and integrated alpha, across four methods: within sessions, across sessions, within sessions compared to baseline, and across sessions compared to baseline. Participants completed 10 weekly sessions of eyes open alpha (8–12 Hz) neurofeedback training (NFT) at Pz. Whilst all three measures showed changes within sessions, the inclusion of baselines revealed that such changes represented a return to baseline levels rather than an increase in alpha. Changes across sessions were only evident in amplitude and inclusion of baseline showed that NFT did not elicit any changes beyond baseline levels. Given this a case is made for incorporating baseline measures when attempting to identify evidence of learning. It is also suggested that both amplitude and percent time measures are used independently rather than incorporate them into a more conservative and less sensitive integrated measure. Finally, focusing on within sessions changes may be a more useful approach in identifying changes resulting from NFT.     

The use of EEG theata biofeedback in the treatment of a patient with sleep-onset insomnia

In this report, the treatment of a 42-year-old female with a complaint of chronic sleep-onset insomnia is described. Following the unsuccessful use of relaxation training, treatment consisted of 11 sessions of EEG theta rhythm (4–7 Hz) biofeedback. Theta density and five sleep indices were monitored throughout baseline, placebo, and treatment sessions. A significant increase in theta density was accompanied by reports of a decrease in sleep latency and an increase in total sleep time. This improvement was maintained after withdrawal of medication and at 3-month follow-up.Appreciation is expressed to Dr. R. Muir, for medical supervision of the patient, and to Mr. D. F. Peck and Dr. J. I. Evans, for their comments on earlier drafts of this paper.     

Electroencephalographic biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting

Six children were provided with long-term biofeedback and academic treatment for attention deficit disorders. Their symptoms were primarily specific learning disabilities, and, in some cases, there were varying degrees of hyperkinesis. The training consisted of two sessions per week for 10 to 27 months, with a gradual phase-out. Feedback was provided for either increasing 12- to 15-Hz SMR or 16- to 20-Hz beta activity. Inhibit circuits were employed for blocking the SMR or beta when either gross movement, excessive EMG, or theta (4-8 Hz) activity was present. Treatment also consisted of combining the biofeedback with academic training, including reading, arithmetic, and spatial tasks to improve their attention. All children increased SMR or beta and decreased slow EEG and EMG activity. Changes could be seen in their power spectra after training in terms of increased beta and decreased slow activity. All six children demonstrated considerable improvement in their schoolwork in terms of grades or achievement test scores. None of the children are currently on any medications for hyperkinetic behavior. The results indicate that EEG biofeedback training, if applied comprehensively, can be highly effective in helping to remediate children who are experiencing attention deficit disorders.     

Oral Zinc Supplementation May Improve Cognitive Function in Schoolchildren

Zinc is an important micronutrient for humans, and zinc deficiency among schoolchildren is deleterious to growth and development, immune competence, and cognitive function. However, the effect of zinc supplementation on cognitive function remains poorly understood. The purpose of our study was to evaluate the effect of oral zinc supplementation (5 mg Zn/day for 3 months) on the Full Scale Intelligence Quotient (FSIQ), Verbal Intelligence Quotient (VIQ), and Performance Intelligence Quotient (PIQ) using a Wechsler Intelligence Scale for Children (WISC-III). We studied 36 schoolchildren aged 6 to 9 years (7.8?±?1.1) using a nonprobability sampling method. The baseline serum zinc concentrations increased significantly after zinc supplementation (p?<?0.0001), with no difference between sexes. Tests were administered under basal conditions before and after zinc supplementation, and there was no difference in FSIQ according to gender or age. The results demonstrated that zinc improved the VIQ only in the Information Subtest (p?=?0.009), although the supplementation effects were more significant in relation to the PIQ, as these scores improved for the Picture Completion, Picture Arrangement, Block Design, and Object Assembly Subtests (p?=?0.0001, for all subtests). In conclusion, zinc supplementation improved specific cognitive abilities, thereby positively influencing the academic performance of schoolchildren, even those without marginal zinc deficiency.