Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders

This article presents a review of work that my colleagues and I have been doing during the past 15 years developing a rationale for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and treatment of ADHD employing EEG biofeedback techniques. The article first briefly reviews the history of research and theory for understanding ADHD and then deals with the development of EEG and event-related potential (ERP) assessment paradigms and treatment protocols for this disorder, including our work and that of others who have replicated our results. Illustrative material from our current research and child case studies is included. Suggestions for future experimental and clinical work in this area are presented and theoretical issues involving the understanding of the neurophysiological and neurological basis of ADHD are discussed.     

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.     

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.     

A psychophysiological marker of attention deficit/hyperactivity disorder (ADHD)--defining the EEG consistency index

This study continues our research to further validate the idea that ADHD (Attention Deficit/Hyperactivity Disorder) interferes with transition from one task to another and this interference can be quantified by a Consistency Index (CI) derived from a specific mathematical representation of EEG data. We reanalyze 32 previously reported data sets present new data for 35 boys and girls, ages 7-12, ADHD or control. Each data set contains EEG, recorded and digitized while participants perform consecutive 10-min tasks: video, reading, and math. For boys, the CI in ADHD was four times lower than in controls, p < .005, for girls this difference was two times, p < .05. ADHD/control classification based on the CI coincided with the DSM-IV criteria for 88% of the boys and for 67% of the girls. Post hoc analysis indicated that the classification utility of the CI diminished with age. A CI below 40% could be a discriminating, reliable, and reproducible marker of ADHD in young boys.     

Game-based biofeedback for paediatric anxiety and depression

Twenty-four children and adolescents aged 9-17 who were referred for treatment for anxiety were assigned to either a game-based biofeedback group or a waiting list comparison group. The eight-session biofeedback intervention included psychoeducation, identification of triggers and signs of anxiety, and in vivo practice. The intervention used computer-based gaming technology to teach and practise relaxation. Analyses using ANCOVA revealed significant differences in post-test scores of anxiety and depression measures between the two groups. The intervention group reduced anxiety and depression scores on standardised tests. Findings suggest that biofeedback-assisted relaxation training can be useful in decreasing anxiety and depressive symptoms in anxious youths.     

Nutrition in the treatment of attention-deficit hyperactivity disorder: a neglected but important aspect

Attention-deficit hyperactivity disorder (ADHD) is multidetermined and complex, requiring a multifaceted treatment approach. Nutritional management is one aspect that has been relatively neglected to date. Nutritional factors such as food additives, refined sugars, food sensitivities/allergies, and fatty acid deficiencies have all been linked to ADHD. There is increasing evidence that many children with behavioral problems are sensitive to one or more food components that can negatively impact their behavior. Individual response is an important factor for determining the proper approach in treating children with ADHD. In general, diet modification plays a major role in the management of ADHD and should be considered as part of the treatment protocol.     

Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder

Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment. This review paper critically examines the empirical evidence, applying the efficacy guidelines jointly established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR). On the basis of these scientific principles, EEG biofeedback was determined to be “probably efficacious” for the treatment of ADHD. Although significant clinical improvement was reported in approximately 75% of the patients in each of the published research studies, additional randomized, controlled group studies are needed in order to provide a better estimate of the percentage of patients with ADHD who will demonstrate such gains in clinical practice.     

Neurofeedback: An Alternative and Efficacious Treatment for Attention Deficit Hyperactivity Disorder

Current research has shown that neurofeedback, or EEG biofeedback as it is sometimes called, is a viable alternative treatment for Attention Deficit Hyperactivity Disorder (ADHD). The aim of this article is to illustrate current treatment modalities(s), compare them to neurofeedback, and present the benefits of utilizing this method of treatment to control and potentially alleviate the symptoms of ADHD. In addition, this article examines the prevalence rates and possible etiology of ADHD, the factors associated with ADHD and brain dysfunction, the current pharmacological treatments of ADHD, Ritalin, and the potential risks and side effects. Behavior modification and cognitive behavioral treatment for ADHD is discussed as well. Lastly, a brief history of the study of neurofeedback, treatment successes and clinical benefits, comparisons to medication, and limitations are presented.     

The EEG Consistency Index as a Measure of ADHD and Responsiveness to Medication

The primary diagnostic procedure for Attention-Deficit/Hyperactivity Disorder (ADHD) is the clinical interview, because psychological, neuropsychological, and neurological tests to date have not had sufficient specificity. Currently, there is no objective means to measure severity of ADHD, or the extent to which it is benefited by various dosages of medication. We recently reported that a certain EEG profile, the Consistency Index, occurring during the transition between two easy cognitive tasks clearly differentiated ADHD from non-ADHD boys between the ages of 8 and 12. The current study replicated this with older males (19–25) using different tasks, and a double blind, placebo versus Ritalin® controlled crossover design. Seven ADHD subjects were found to have a significantly lower Consistency Index than 6 non-ADHD males while transitioning from 2 Simple tasks during placebo condition, while only the ADHD subjects demonstrated a significant improvement in their Consistency Index while on Ritalin®. Similar but nonsignificant trends were observed while transitioning across Hard tasks.     

Slow cortical potential biofeedback and the startle reflex

The negativity of slow cortical potentials (SCP) of the surface EEG is a measure of brain excitability, correlating with motor and cognitive preparation. Selfcontrol of SCP positivity has been shown to reduce seizure activity. Following SCP biofeedback from a central EEG electrode position, subjects gained bidirectional control over their SCP. The current study used a modified feedback methodology, and found a positive relationship between negativity and magnitude of EMG startle response (a measure of cortical and subcortical arousal, particularly aversive response disposition). Greater success in SCP differentiation was associated with self-report of less relaxation during negativity training.This research was supported by the Deutsche Forschungsgemeinschaft under grant No. SFB 307.     

Muscular response to the therapist and symptomatic improvement during biofeedback for tension headache

The relationship between muscular response to the therapist's presence and symptomatic improvement was studied during biofeedback. Thirty-two patients suffering from tension headaches received muscular biofeedback training of six sessions plus a follow-up session two months later. Patients' electro-myographic frontal response was measured prior to treatment both with and without the therapist present. A relationship was found between symptomatic improvement at follow-up and muscular response to the therapist's presence before treatment: patients showing a decrease of at least 10% in muscular tension response to the presence of their future therapist improved more regarding headache intensity than the patients showing increase or smaller variation of their EMG. A significant correlation of .59 was found between the frontal EMG response to therapist presence during the evaluation session and headache improvement at follow-up. The results suggest that the decrease of muscular tension during the first contact with the therapist could be an indicator of good prognosis, possibly because of an immediate positive therapeutic relationship and/or favorable expectancies concerning future benefit of treatment.The authors thank Mrs. G. Parisé for her assistance during the experimentation, Ms. M. Newman for her editorial corrections, and Ms. A. Khan for her secretarial work.     

High self-perceived stress and many stressors, but normal diurnal cortisol rhythm, in adults with ADHD (attention-deficit/hyperactivity disorder)

Attention-deficit/hyperactivity disorder (ADHD) in adults is associated with significant impairment in many life activities and may thus increase the risk of chronic stress in everyday life. We compared adults with a DSM-IV ADHD diagnosis (n = 28) with healthy controls (n = 28) regarding subjective stress and amounts of stressors in everyday life, diurnal salivary cortisol in the everyday environment and salivary cortisol before and after cognitive stress in a laboratory setting. The association between cortisol concentrations and impulsivity was also investigated. Consistent with assumptions, individuals with ADHD reported significantly more self-perceived stress than controls, and subjective stress correlated with the amount of stressors in everyday life. The two groups were comparable with respect to overall diurnal cortisol levels and rhythm, as well as in pre- and post-stress cortisol concentrations. Post-stress cortisol (but not baseline cortisol) concentration was positively correlated with impulsivity. The group with high post-stress cortisol also reported more symptoms of depression and anxiety, as well as self-perceived stress and stressors in every-day life. The diagnosis of ADHD significantly increased the risk of belonging to the group with high post-stress cortisol levels. The results in this study warrant a focus not only on the primary diagnosis of ADHD, but also calls for a broader assessment of stressors and subjective stress in everyday life, as well as support comprising stress management and coping skills.     

Correlation of the characteristics of EEG potentials with the indices of attention in 12-to 13-year-old children

We studied correlations of the spectral characteristics of EEG with the indices characterizing the level of attention in 60 children (12 to 13 years old). Indices of voluntary attention were measured using a complex of psychological tests, including a Bourdon’s test (correcture test), a two-stimulus go/no-go test, a computer test (a modification of the Bourdon’s test for characterization of concentration and stability of attention), and Schulte’s tables. Children manifesting a good working ability (corresponding to the results of the go/no-go test and correcture test) showed relatively high values of the ratio of spectral powers (SPs) of the beta 1 and theta rhythms. These ratios were greater in the right hemisphere; this is probably indicative of a greater contribution of neuronal mechanisms of this hemisphere to providing watchfulness and stability of attention. Children demonstrating increased impulsivity (according to the results of the go/no-go test) were characterized by low modal frequencies of the alpha rhythm in the occipital brain regions, while children with relatively high values of this frequency in various cerebral regions demonstrated high indices of attentiveness and rates of the cognitive processes. Children performing the test task with especially high accuracy were characterized by high ratios of SPs of the low-frequency beta rhythm vs theta rhythm (mostly in the central and parietal regions of both hemispheres). The approach we have applied can be used for measuring the objective indices characterizing the state of the attention sphere in children. Neirofiziologiya/Neurophysiology, Vol. 38, No. 3, pp. 248–256, May–June, 2006.     

Prevalence of sexual dysfunctions and other sexual disorders in adults with attention-deficit/hyperactivity disorder compared to the general population

Attention-deficit/hyperactivity disorder (ADHD) is characterized by symptoms of inattention and/or hyperactivity and impulsivity that lead to dysfunctioning in daily life. One of the affected areas of life that has so far not been studied in ADHD is sexual functioning. The goal of this study was to assess prevalence of sexual dysfunctions and other sexual disorders among adults with ADHD. A total of n = 136 adult patients treated in a Dutch outpatient ADHD clinic filled out two questionnaires to screen for sexual dysfunctions and other sexual disorders. We compared the prevalence of sexual dysfunctions and other sexual disorders in our ADHD patient population to results from two large surveys among the general Dutch population. We found that 39% of the male and 43% of the female ADHD patients had symptoms of a sexual dysfunction, and 17% of the male and 5% of the female ADHD patients had symptoms of any other sexual disorder. Only one male patient had received a diagnosis of a sexual disorder at this clinic prior to study participation. In conclusion, sexual dysfunctions and other sexual disorders are highly prevalent in adults with ADHD. Screening for sexual disorders should be therefore standard procedure during diagnostic assessment.     

脑电与认知活动的相关性

本文简要介绍了认知活动与脑电（包括自发脑电、诱发脑电、脑电事件相关电位、４０ＨＺ脑电事件相关电位）的相关性及其应用前景。     

A review of EEG and MEG for brainnetome research

The majority of brain activities are performed by functionally integrating separate regions of the brain. Therefore, the synchronous operation of the brain’s multiple regions or neuronal assemblies can be represented as a network with nodes that are interconnected by links. Because of the complexity of brain interactions and their varying effects at different levels of complexity, one of the corresponding authors of this paper recently proposed the brainnetome as a new –ome to explore and integrate the brain network at different scales. Because electroencephalography (EEG) and magnetoencephalography (MEG) are noninvasive and have outstanding temporal resolution and because they are the primary clinical techniques used to capture the dynamics of neuronal connections, they lend themselves to the analysis of the neural networks comprising the brainnetome. Because of EEG/MEG’s applicability to brainnetome analyses, the aim of this review is to identify the procedures that can be used to form a network using EEG/MEG data in sensor or source space and to promote EEG/MEG network analysis for either neuroscience or clinical applications. To accomplish this aim, we show the relationship of the brainnetome to brain networks at the macroscale and provide a systematic review of network construction using EEG and MEG. Some potential applications of the EEG/MEG brainnetome are to use newly developed methods to associate the properties of a brainnetome with indices of cognition or disease conditions. Associations based on EEG/MEG brainnetome analysis may improve the comprehension of the functioning of the brain in neuroscience research or the recognition of abnormal patterns in neurological disease.     

Correlations between the level of aggressiveness of personality and characteristics of event-related EEG potentials

In a group of 76 adults of both sexes, we examined interrelations between the level of aggressiveness of the individual (diagnosed using the Buss-Durkee Hostility Inventory) and parameters of event-related EEG potentials (ERPs) recorded under conditions of two behavioral test acts including a motor component. Within the framework of task A, the subject must push a button with the shortest delay after an executory signal preceded by a warning signal; the time of sensorimotor reaction was measured. Under these conditions, we recorded the contingent negative variayion (CNV) and the P300 potential. In the case of task B, it was necessary to measure a definite time interval limited by two pushings of the button. Under these conditions, the readiness potential (RP) was recorded in addition to the CNV and P300. The C3 and C4 leads were used (according to the 10–20 system); the time constant of an amplification tract was 10 sec. Despite natural broad interindividual variability, high amplitudes of the recorded ERPs (RP, CNV, and P300) in general corresponded to lower indices by scales of the Buss-Durkee inventory and smaller values of the indices of aggressiveness and hostility. These interrelations are, probably, based on the fact that both characteristics of aggressiveness of the personality and EEG amplitude parameters are to a considerable extent determined by hereditary factors. It is believed that the respective peculiarities of the neurodynamic constitution of the individual are to a great extent dependent on the specificities of organization and functioning of a few neurotransmitter (in particular, aminergic) and neurohumoral systems. Neirofiziologiya/Neurophysiology, Vol. 39, No. 2, pp. 154–164, March–April, 2007.