Attention Deficit/Hyperactivity Disorder: EEG Biofeedback as a Viable Treatment Option[1]

Cheryl H. Alexander, Ph.D.
 

    Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalent and perplexing disorders of childhood and is estimated to affect three to five per­cent of school-age children (American Psychiatric Association, 1994, p. 82). The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes the essential feature of ADHD as “a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development” (American Psychiatric Association, 1994, p. 78). Attention Deficit/Hyperactivity Disorder can lead to emotional and behavioral problems, diffi­culty with peer relationships, difficulty within the family, and can be one of the reasons for academic and school difficulties (Silver, 1993).

   Existing in all countries and cultures, ADHD is a pervasive lifelong disorder which is not curable although it is manageable (Lubar, Swartwood, Swartwood & O’Donnell, 1995). Historically, treatment of the hyperactive child has predominantly consisted of either stimulant drug therapy or the utilization of behavior modification and operant conditioning techniques. Both stimulant drug therapy and behavior modification ther­apy have been effective in treating some of the symp­toms of ADHD such as those related to motor function and undesirable behaviors, but have been relatively ineffective in treating attentional deficits, high distractibility, low frustration tolerance, information processing, and emotional lability (Tansey & Bruner, 1983). Research also indicates that long term effects of the widely used stimulant medica­tion Ritalin on certain academic or cognitive tasks such as reading are limited (Barkley & Cunningham, 1978). In addition, when stimulant drug therapy is discontinued and the medication is out of the body, ADD/ADHD behaviors return (Lubar & Lubar, 1999).

   Currently, there is much concern over the widespread use of medication as a treatment for ADHD; it is estimated that several million children are currently taking stimulant medications in order to control hyperactivity and inattention. Many people feel that stimulant medica­tions are overprescribed to ADHD children in an attempt to relieve parents and teachers from the difficult task of dealing with the symptoms associated with this disorder.   

Because behavior modification and drug therapy are of limited benefit for the treatment of ADHD and because there may be repercussions and adverse side-effects associated with drug therapy, it is important that more effective, alternative therapies are avail­able for the treatment of ADHD.

   Research indicates that the primary symptoms of Attention Deficit/Hyperactivity Disorder (inatten­tiveness, impulsiveness, and hyperactivity, as well as their various manifestations) are secondary symptoms resulting from an underlying neurological disorder. Lubar (1991), Tansey (1993), and Lubar et al. (1995) have reported that electroencephalographic (EEG) bio­feedback treatment can be an appropriate and effica­cious treatment for children with ADHD. This treatment involves measuring brainwaves with an EEG and then feeding this information back to the patient in an effort to increase the patient’s voluntary control over these physiological responses.

Brainwaves are measured in Hertz (Hz), or cycles per second and are usually divided into four major frequency bands: beta (above 12 Hz), alpha (8 - 12 Hz), theta (4 - 8 Hz), and delta (1 - 4 Hz). Each frequency band is traditionally associated with generalized behavioral correlates. For example, the fastest frequency band, beta, is associated with focused attention, active concentration, and is considered a high arousal level. Alpha, a non-drowsy state, is associated with relief from attention and concentration. Theta is associated with drowsiness and dreaming, and is considered a low arousal level. The slowest frequency band, delta, is normally associated with deep, dreamless sleep.

Research indicates that children receiving EEG biofeedback training to inhibit theta (4 - 8 Hertz) and increase beta (13 - 30 Hertz), showed significant and sustained improvements in school performance and psy­chometric measures such as grade point average and achievement tests (Lubar & Lubar, 1984). A possible behavioral theory that may account for these results is that through the process of learning EEG biofeedback, the children are also learning skills to improve their concentration and attention-spans. Another theory is that the EEG biofeedback training increases activity in parts of the brain where there has been a lack of activity. This increase in activity causes the brain to form new neural pathways and therefore new learning, which may be demonstrated as improved performance on achievement tests.


REVIEW OF LITERATURE

In this section, the history of the disorder which is now known as Attention Deficit/Hyperactivity Disor­der is reviewed. The most relevant research and theory that provides a rationale for the treatment of ADHD children with electroencephalographic (EEG) biofeedback tech­niques is presented.

The first description of children who were hyperac­tive was given in a series of lectures in 1902 by an English pediatrician, George Still (Ross & Ross, 1976).  These children were labeled as having “defects in moral control” and this concept remained intact until after the severe influenza outbreak of 1918. Hohman (1922) and Kennedy (1924) noted that many children who recov­ered from influenza-related encephalitis developed hyperactive behavior, inattentiveness and impulse con­trol problems. These children were referred to as “organically driven” because it was discovered that they had suffered brain damage as a result of the encephalitis. It was thus inferred at this time that hyperactivity in children was a direct result of brain damage.

In the 1940’s, it became widely recognized that not all hyperactive children had suffered some form of overt brain damage. Since it was believed that even when brain damage could not be demonstrated it could be presumed to be present, Strauss and Lehtinen (1947) developed the concept of minimal brain dysfunction (MBD).

In order to help clarify the diagnosis of minimal brain dysfunction, neurologists began searching for abnormalities within the EEG records of MBD children.  Jasper, Soloman, and Bradley (1938) presented evidence that MBD children had abnormalities in their EEG records, primarily in terms of slow EEG activity (4 - 8 Hertz).  A number of other individuals such as Cohn and Nardin (1958) have also reported EEG abnormalities in MBD children.

By the early 1970’s, it became clear that the con­cept of the MBD syndrome encompassed several different disorders including the hyperkinetic disorder, specific learning disabilities (LD), disorders of attention, and disorders of conduct. As MBD became too broad a label for children with attention and hyperactivity disor­ders, the term hyperkinetic disorder replaced minimal brain dysfunction syndrome. 

Also during the early 1970’s, a hypothesis that became known as the “low-arousal hypothesis” of hyperkinesis was proposed by Satterfield and Dawson (1971) and Satterfield, Lesser, Saul, and Cantwell (1973). The idea of arousal can be traced back to Pavlovian ideas of the excitatory strength of the nervous system (Harre & Lamb, 1983).  However, it was  Hans J. Eysenck (1967) who theorized that individuals differ in habitual levels of arousal in the cortex.  For example, Eysenck proposed that extroverts have a lower level of arousal and hence are more excitable and seek more stimulation. Following along these lines of reasoning, it was proposed by Satterfield and his col­leagues that hyperkinetic children easily habituated to sensory stimulation and therefore constantly sought stimulation because of their low arousal. This hypothesis made sense of the well known but little understood fact that stimulants had a paradoxical effect on hyperkinetic children.

Inspired by Satterfield’s work and M. B. Sterman’s work, Lubar conducted a study using EEG biofeedback employing sensorimotor rhythm training to determine if this might be a viable modality for helping children with hyperkinesis (Lubar & Shouse, 1976). The results from Lubar’s blind crossover study provided the first clear evidence that this was a powerful modality for working with the hyperkinetic disorder.

In 1984, Lubar and Lubar found ADHD children had significant and sustained improvements in school per­formance and on psychometric measures after participating in a combination of sensorimotor rhythm (SMR) training followed by training to increase beta and inhibit theta. Lubar’s work has been replicated by Michael Tansey and his colleagues (Tansey & Bruner, 1983; Tansey, 1990).

Other studies have shown that ADHD children have increased theta and decreased beta present in their EEG records. For example, Mann, Lubar, Zimmerman, Miller, and Muenchen (1992) found, by looking at the sixteen-channel topographic brain maps of 25 nine to twelve-year-old right-handed males with ADHD, increased theta and decreased beta as compared to 27 controls matched for age and grade level.

In a different type of study, Zametkin, Nordahl, Gross, King, Semple, Rumsey, Hamburger, & Cohen, (1990) used positron-emission tomography (PET) to measure cerebral glucose metabolism in hyperactive adults and normal adult controls.  The metabolism of glucose (a sugar which is used as an energy supply for the brain) as measured by the PET, indicates areas in the brain that are active.  They found that both global and regional glucose metabolism was reduced in the hyperac­tive adults, specifically in regions of the brain that have been postulated to be involved in the control of attention and motor activity.  This study represents independent medical verification of frontal hypometabo­lism in hyperactives and thus lends support to the use of EEG biofeedback as a treatment modality for ADHD children. 

The reviewed studies (Lubar & Shouse, 1976; Lubar & Lubar, 1984; Tansey & Bruner, 1983; and Tansey, 1990) indicate that EEG biofeedback training that focuses on inhibiting theta and increasing beta is an effective treatment for children with Attention

Deficit/Hyperactivity Disorder.

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