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


An estimated 5-7 million school age children are diagnosed with ADHD ... Many symptoms attributed to ADHD often have an imbalance in nutrients, or food ... – PowerPoint PPT presentation

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

The Use of EEG Biofeedback for Attention Problems
in a School Setting
  • Dennis P. Carmody
  • Institute for the Study of Child Development

  • 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

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

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

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

Inattention Examples
  • Failure to give close attention to details
  • Makes careless mistakes
  • Difficulty sustaining attention in tasks or
  • Does not seem to listen when spoken to
  • Does not follow instructions or fails to finish
  • 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,
  • Easily distracted
  • Forgetful in daily activities

ExamplesHyperactivity Impulsivity
  • Often fidgets with hands or feet or squirms in
  • 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
  • Difficulty awaiting turn
  • Often interrupts or intrudes on others

Who makes the Dx?
  • Primary care physicians
  • Developmental pediatricians
  • Family practitioners
  • Neurologists
  • Psychologists
  • Psychiatrists

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

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

  • 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

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

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

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

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

Note drop in months June, July August
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

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

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
  • Sterman, M.B. (1977). Sensorimotor EEG operant
    conditioning and experimental and clinical
    effects. Pavlovian J. Biological Science, 12(2),

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

  • 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

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.

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
  • When criteria were not simultaneously met,
    feedback would cease

  • 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

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,

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
  • 16-18 Hz beta band changed to 13-15 SMR band for
    4 participants
  • Switch occurred between sessions 13 35
    depending on the child

  • 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.

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

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

Continuation of program
  • 1996-97 16 more children involved in NF study
  • 32 48 sessions per child 660 sessions 330
  • Linear regression analyses
  • Theta 25 decreased 35 no change 40
  • 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),

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

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

  • Individualized training and attention by
  • 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

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
  • 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,
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