Neurofeedback for Children with ADHD: A Comparison of SCP and Theta/Beta Protocols

Behavioral and cognitive improvements in children with ADHD have been consistently reported after neurofeedback-treatment. However, neurofeedback has not been commonly accepted as a treatment for ADHD. This study addresses previous methodological shortcomings while comparing a neurofeedback-training of Theta-Beta frequencies and training of slow cortical potentials (SCPs). The study aimed at answering (a) whether patients were able to demonstrate learning of cortical self-regulation, (b) if treatment leads to an improvement in cognition and behavior and (c) if the two experimental groups differ in cognitive and behavioral outcome variables. SCP participants were trained to produce positive and negative SCP-shifts while the Theta/Beta participants were trained to suppress Theta (4–8 Hz) while increasing Beta (12–20 Hz). Participants were blind to group assignment. Assessment included potentially confounding variables. Each group was comprised of 19 children with ADHD (aged 8–13 years). The treatment procedure consisted of three phases of 10 sessions each. Both groups were able to intentionally regulate cortical activity and improved in attention and IQ. Parents and teachers reported significant behavioral and cognitive improvements. Clinical effects for both groups remained stable six months after treatment. Groups did not differ in behavioural or cognitive outcome.     

Hypoventilation Training for Asthma: A Case Illustration

Hyperventilation-induced hypocapnia is common among asthma patients. This case study illustrates both methodology and results from a patient undergoing training in capnometry-assisted respiratory training (CART). CART is a 4-week training aimed at normalizing basal and acute levels of end-tidal carbon dioxide (PCO₂) using a portable capnometer. In the presented case, basal levels of PCO₂ increased from hypocapnic to normocapnic range over the course of treatment. Improvements were accompanied by improvements in lung function and reductions in diurnal lung function variability. Improvements remained stable throughout follow-up.     

Effects of Neurofeedback Training on Performing Bimanual Coordination In-phase and Anti-phase Patterns in Children with ADHD

It is generally accepted that children with attention-deficit/hyperactivity disorder (ADHD) have poor motor control, especially in bimanual coordination tasks. Such children characteristically have impaired fine motor ability, problems with force control, and poor motor coordination. They are at particular risk of loss of motor control and reduced bimanual coordination. We tested whether, compared to a control condition, neurofeedback training (NFT) could improve bimanual coordination among children with ADHD. 20 Children with ADHD (mean age 7.9 years; SD 2.11) were randomly assigned either to NFT or to a control condition. All participants completed a bimanual coordination test at the following time points: baseline, assessment 1, assessment 2, assessment 3, and again 12 session later at posttest. NFT consisted of Sensory Motor Rhythm (SMR) training to achieve increased SMR in C3 and C4, while participants in the control condition were under mock NFT conditions. Bimanual coordination accuracy and consistency improved from baseline to completion of the intervention (significant Time effect), but in the NFT condition (significant time?×?group interaction). Compared to the control condition, the NFT group had fewer errors in both patterns of bimanual coordination (significant Group effect). Among children with ADHD, SMR neurofeedback training (NFT) led to significant improvements in a bimanual coordination task. The SMR NFT thus appears to have the potential to improve and enhance the motor control of ADHD patients.     

Neurofeedback Training for Tourette Syndrome: An Uncontrolled Single Case Study

Gilles de la Tourette syndrome (TS) is characterized by motor and vocal tic manifestations, often accompanied by behavioral, cognitive and affective dysfunctions. Electroencephalography of patients with TS has revealed reduced Sensorimotor Rhythm (SMR) and excessive fronto-central Theta activity, that presumably underlie motor and cognitive disturbances in TS. Some evidence exists that neurofeedback (NFB) training aimed at enhancing SMR amplitude is effective for reducing tics. The present report is an uncontrolled single case study where a NFB training protocol, involving combined SMR uptraining/Theta downtraining was delivered to a 17-year-old male with TS. After sixteen SMR-Theta sessions, six additional sessions were administered with SMR uptraining alone. SMR increase was better obtained when SMR uptraining was administered alone, whereas Theta decrease was observed after both trainings. The patient showed a reduction of tics and affective symptoms, and improvement of cognitive performance after both trainings. Overall, these findings suggest that Theta decrease might account for some clinical effects seen in conjunction with SMR uptraining. Future studies should clarify the feasibility of NFB protocols for patients with TS beyond SMR uptraining alone.     

Change Mechanisms Associated with Combined Relaxation/EMG Biofeedback Training for Chronic Tension Headache

Therapeutic mechanisms hypothesized to underlie improvements in tension headache activity achieved with combined relaxation and eleclromyographic (EMG) biofeedback therapy were examined. These therapeutic mechanisms included (1) changes in EMG activity in frontal and trapezii muscles, (2) changes in central pain modulation as indexed by the duration of the second exteroceptive silent period (ES2), and (3) changes in headache locus of control and self-efficacy. Forty-four young adults with chronic tension-type headaches were assigned either to six sessions of relaxation and EMG biofeedback training (N = 30) or to an assessment only control group (N = 14) that required three assessment sessions. Measures of self-efficacy and locus of control were collected at pre- and posttreatment, and ES2 was evaluated at the beginning and end of the first, third, and lost session. EMG was monitored before, during, and following training trials. Relaxation/EMG biofeedback training effectively reduced headache activity: 51.7% of subjects who received relaxation/biofeedback therapy recorded at least a 50% reduction in headache activity following treatment, while controls failed to improve on any measure. Improvements in headache activity in treated subjects were correlated with increases in self-efficacy induced by biofeedback training but not with changes in EMG activity or in ES2 durations. These results provide additional support for the hypothesis that cognitive changes underlie the effectiveness of relaxation and biofeedback therapies, at least in young adult tension-type headache sufferers.     

A Pilot Feasibility Study of Neurofeedback for Children with Autism

Neurofeedback (NFB) is an emerging treatment for children with autism spectrum disorder (ASD). This pilot study examined the feasibility of NFB for children with ASD. Ten children ages 7–12 with high functioning ASD and attention difficulties received a NFB attention training intervention. A standardized checklist captured feasibility, including focus during exercises and academic tasks, as well as off-task behaviors. Active behaviors and vocalizations were the most frequent off-task behaviors. Positive reinforcement and breaks including calm breathing exercises were the most common supports. Low motivation was associated with higher feasibility challenges, yet parental involvement and accommodations were helpful. This pilot study shows that it is feasible to conduct NFB sessions with children with high functioning autism and attention difficulties.     

Slow Cortical Potential Neurofeedback in Chronic Tinnitus Therapy: A Case Report

This study is the first to demonstrate outcomes of slow cortical potential (SCP) Neurofeedback training in chronic tinnitus. A 50-year old male patient with tinnitus participated in three SCP training blocks, separated with 1-month breaks. After the training the patient reported decreased tinnitus loudness and pitch, as well as improved quality of daily life. A quantitative electroencephalography analysis revealed close to normal changes of resting state bioelectrical activity in cortical areas considered to be involved in tinnitus generation. The present case study indicates that SCP Neurofeedback training can be considered a promising method for tinnitus treatment.     

Neurofeedback Training for Opiate Addiction: Improvement of Mental Health and Craving

Psychological improvements in patients with substance use disorders have been reported after neurofeedback treatment. However, neurofeedback has not been commonly accepted as a treatment for substance dependence. This study was carried out to examine the effectiveness of this therapeutic method for opiate dependence disorder. The specific aim was to investigate whether treatment leads to any changes in mental health and substance craving. In this experimental study with a pre-post test design, 20 opiate dependent patients undergoing Methadone or Buprenorphine maintenance treatment were examined and matched and randomized into two groups. While both experimental and control groups received their usual maintenance treatment, the experimental group received 30 sessions of neurofeedback treatment in addition. The neurofeedback treatment consisted of sensory motor rhythm training on Cz, followed by an alpha-theta protocol on Pz. Data from the general health questionnaire and a heroin craving questionnaire were collected before and after treatment. Multivariate analysis of covariance showed that the experimental group achieved improvement in somatic symptoms, depression, and total score in general mental health; and in anticipation of positive outcome, desire to use opioid, and relief from withdrawal of craving in comparison with the control group. The study supports the effectiveness of neurofeedback training as a therapeutic method in opiate dependence disorder, in supplement to pharmacotherapy.     

Respiratory Sinus Arrhythmia Versus Neck/Trapezius EMG and Incentive Inspirometry Biofeedback for Asthma: A Pilot Study

This pilot study compared biofeedback to increase respiratory sinus arrhythmia (RSA) with EMG and incentive inspirometry biofeedback in asthmatic adults. A three-group design (Waiting List Control n = 5, RSA biofeedback n = 6, and EMG biofeedback n = 6) was used. Six sessions of training were given in each of the biofeedback groups. In each of three testing sessions, five min. of respiratory resistance and EKG were obtained before and after a 20-min biofeedback session. Additional five-min epochs of data were collected at the beginning and end of the biofeedback period (or, in the control group, self-relaxation). Decreases in respiratory impedance occurred only in the RSA biofeedback group. Traub-Hering-Mayer (THM) waves (.03-.12 Hz) in heart period increased significantly in amplitude during RSA biofeedback. Subjects did not report significantly more relaxation during EMG or RSA biofeedback than during the control condition. However, decreases in pulmonary impedance, across groups, were associated with increases in relaxation. The results are consistent with Vaschillo's theory that RSA biofeedback exercises homeostatic autonomic reflex mechanisms through increasing the amplitude of cardiac oscillations. However, deep breathing during RSA biofeedback is a possible alternate explanation.     

Working Memory Training in Post-Secondary Students with ADHD: A Randomized Controlled Study

Objectives

To determine whether standard-length computerized training enhances working memory (WM), transfers to other cognitive domains and shows sustained effects, when controlling for motivation, engagement, and expectancy.

Methods

97 post-secondary students (59.8% female) aged 18–35 years with Attention-Deficit/Hyperactivity Disorder, were randomized into standard-length adaptive Cogmed WM training (CWMT; 45-min/session), a shortened-length adaptive version of CWMT (15 min/session) that controlled for motivation, engagement and expectancy of change, or into a no training group (waitlist-control group). All three groups received weekly telephone calls from trained coaches, who supervised the CWMT and were independent from the research team. All were evaluated before and 3 weeks post-training; those in the two CWMT groups were also assessed 3 months post-training. Untrained outcome measures of WM included the WAIS-IV Digit Span (auditory-verbal WM), CANTAB Spatial Span (visual-spatial WM) and WRAML Finger Windows (visual-spatial WM). Transfer-of-training effects included measures of short-term memory, cognitive speed, math and reading fluency, complex reasoning, and ADHD symptoms.

Results

Performance on 5/7 criterion measures indicated that shortened-length CWMT conferred as much benefit on WM performance as did standard-length training, with both CWMT groups improving more than the waitlist-control group. Only 2 of these findings remained robust after correcting for multiple comparisons. Follow-up analyses revealed that post-training improvements on WM performance were maintained for at least three months. There was no evidence of any transfer effects but the standard-length group showed improvement in task-specific strategy use.

Conclusions

This study failed to find robust evidence of benefits of standard-length CWMT for improving WM in college students with ADHD and the overall pattern of findings raise questions about the specificity of training effects.

Trial Registration

ClinicalTrials.gov NCT01657721     

Resonant Frequency Biofeedback Training to Increase Cardiac Variability: Rationale and Manual for Training

Heart rate and blood pressure, as well as other physiological systems, among healthy people, show a complex pattern of variability, characterized by multifrequency oscillations. There is evidence that these oscillations reflect the activity of homeostatic reflexes. Biofeedback training to increase the amplitude of respiratory sinus arrhythmia (RSA) maximally increases the amplitude of heart rate oscillations only at approximately 0.1 Hz. To perform this task people slow their breathing to this rate to a point where resonance occurs between respiratory-induced oscillations (RSA) and oscillations that naturally occur at this rate, probably triggered in part by baroreflex activity. We hypothesize that this type of biofeedback exercises the baroreflexes, and renders them more efficient. A manual is presented for carrying out this method. Supporting data are provided in Lehrer, Smetankin, and Potapova (2000) in this issue.     

Designing a Community Engagement Framework for a New Dengue Control Method: A Case Study from Central Vietnam

Background

The Wolbachia strategy aims to manipulate mosquito populations to make them incapable of transmitting dengue viruses between people. To test its efficacy, this strategy requires field trials. Public consultation and engagement are recognized as critical to the future success of these programs, but questions remain regarding how to proceed. This paper reports on a case study where social research was used to design a community engagement framework for a new dengue control method, at a potential release site in central Vietnam.

Methodology/Principal Findings

The approach described here, draws on an anthropological methodology and uses both qualitative and quantitative methods to design an engagement framework tailored to the concerns, expectations, and socio-political setting of a potential trial release site for Wolbachia-infected Aedes aegypti mosquitoes. The process, research activities, key findings and how these were responded to are described. Safety of the method to humans and the environment was the most common and significant concern, followed by efficacy and impact on local lives. Residents expected to be fully informed and engaged about the science, the project, its safety, the release and who would be responsible should something go wrong. They desired a level of engagement that included regular updates and authorization from government and at least one member of every household at the release site.

Conclusions/Significance

Results demonstrate that social research can provide important and reliable insights into public concerns and expectations at a potential release site, as well as guidance on how these might be addressed. Findings support the argument that using research to develop more targeted, engagement frameworks can lead to more sensitive, thorough, culturally comprehensible and therefore ethical consultation processes. This approach has now been used successfully to seek public input and eventually support for releases Wolbachia-infected mosquitoes, in two different international settings - Australia and Vietnam.     

Severe Sepsis in Severely Malnourished Young Bangladeshi Children with Pneumonia: A Retrospective Case Control Study

BackgroundIn developing countries, there is no published report on predicting factors of severe sepsis in severely acute malnourished (SAM) children having pneumonia and impact of fluid resuscitation in such children. Thus, we aimed to identify predicting factors for severe sepsis and assess the outcome of fluid resuscitation of such children.MethodsIn this retrospective case-control study SAM children aged 0–59 months, admitted to the Intensive Care Unit (ICU) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh from April 2011 through July 2012 with history of cough or difficult breathing and radiologic pneumonia, who were assessed for severe sepsis at admission constituted the study population. We compared the pneumonic SAM children with severe sepsis (cases = 50) with those without severe sepsis (controls = 354). Severe sepsis was defined with objective clinical criteria and managed with fluid resuscitation, in addition to antibiotic and other supportive therapy, following the standard hospital guideline, which is very similar to the WHO guideline.ResultsThe case-fatality-rate was significantly higher among the cases than the controls (40% vs. 4%; p<0.001). In logistic regression analysis after adjusting for potential confounders, lack of BCG vaccination, drowsiness, abdominal distension, acute kidney injury, and metabolic acidosis at admission remained as independent predicting factors for severe sepsis in pneumonic SAM children (p<0.05 for all comparisons).

Conclusion and Significance

We noted a much higher case fatality among under-five SAM children with pneumonia and severe sepsis who required fluid resuscitation in addition to standard antibiotic and other supportive therapy compared to those without severe sepsis. Independent risk factors and outcome of the management of severe sepsis in our study children highlight the importance for defining optimal fluid resuscitation therapy aiming at reducing the case fatality in such children.     

Improving Executive Functioning in Children with ADHD: Training Multiple Executive Functions within the Context of a Computer Game. A Randomized Double-Blind Placebo Controlled Trial

Introduction

Executive functions (EFs) training interventions aimed at ADHD-symptom reduction have yielded mixed results. Generally, these interventions focus on training a single cognitive domain (e.g., working memory [WM], inhibition, or cognitive-flexibility). However, evidence suggests that most children with ADHD show deficits on multiple EFs, and that these EFs are largely related to different brain regions. Therefore, training multiple EFs might be a potentially more effective strategy to reduce EF-related ADHD symptoms.

Methods

Eighty-nine children with a clinical diagnosis of ADHD (aged 8–12) were randomized to either a full-active-condition where visuospatial WM, inhibition and cognitive-flexibility were trained, a partially-active-condition where inhibition and cognitive-flexibility were trained and the WM-training task was presented in placebo-mode, or to a full placebo-condition. Short-term and long-term (3-months) effects of this gamified, 25-session, home-based computer-training were evaluated on multiple outcome domains.

Results

During training compliance was high (only 3% failed to meet compliance criteria). After training, only children in the full-active condition showed improvement on measures of visuospatial short-term-memory (STM) and WM. Inhibitory performance and interference control only improved in the full-active- and the partially-active condition. No Treatment-condition x Time interactions were found for cognitive-flexibility, verbal WM, complex-reasoning, nor for any parent-, teacher-, or child-rated ADHD behaviors, EF-behaviors, motivational behaviors, or general problem behaviors. Nonetheless, almost all measures showed main Time-effects, including the teacher-ratings.

Conclusions

Improvements on inhibition and visuospatial STM and WM were specifically related to the type of treatment received. However, transfer to untrained EFs and behaviors was mostly nonspecific (i.e., only interference control improved exclusively in the two EF training conditions). As such, in this multiple EF-training, mainly nonspecific treatment factors – as opposed to the specific effects of training EFs—seem related to far transfer effects found on EF and behavior.

Trial Registration

trialregister.nl NTR2728. Registry name: improving executive functioning in children with ADHD: training executive functions within the context of a computer game; registry number: NTR2728.     

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.     

Auditory-Motor Mapping Training: Comparing the Effects of a Novel Speech Treatment to a Control Treatment for Minimally Verbal Children with Autism

This study compared Auditory-Motor Mapping Training (AMMT), an intonation-based treatment for facilitating spoken language in minimally verbal children with autism spectrum disorder (ASD), to a matched control treatment, Speech Repetition Therapy (SRT). 23 minimally verbal children with ASD (20 male, mean age 6;5) received at least 25 sessions of AMMT. Seven (all male) were matched on age and verbal ability to seven participants (five male) who received SRT. Outcome measures were Percent Syllables Approximated, Percent Consonants Correct (of 86), and Percent Vowels Correct (of 61) produced on two sets of 15 bisyllabic stimuli. All subjects were assessed on these measures several times at baseline and after 10, 15, 20, and 25 sessions. The post-25 session assessment timepoint, common to all participants, was compared to Best Baseline performance. Overall, after 25 sessions, AMMT participants increased by 19.4% Syllables Approximated, 13.8% Consonants Correct, and19.1% Vowels Correct, compared to Best Baseline. In the matched AMMT-SRT group, after 25 sessions, AMMT participants produced 29.0% more Syllables Approximated (SRT 3.6%);17.9% more Consonants Correct (SRT 0.5); and 17.6% more Vowels Correct (SRT 0.8%). Chi-square tests showed that significantly more AMMT than SRT participants in both the overall and matched groups improved significantly in number of Syllables Approximated per stimulus and number of Consonants Correct per stimulus. Pre-treatment ability to imitate phonemes, but not chronological age or baseline performance on outcome measures, was significantly correlated with amount of improvement after 25 sessions. Intonation-based therapy may offer a promising new interventional approach for teaching spoken language to minimally verbal children with ASD.