EEG Biofeedback: A Promising New Therapy for Attention Deficit Disorder, Learning Disabilities, and Mild Traumatic Brain Injuries

Overview:

EEG Biofeedback (neurofeedback) is a promising new therapy in the field of applied psychophysiology. This field studies the relationship between the mind and the body. Specifically, it involves teaching people effective ways to control body functions. For example, therapists use biofeedback to help people learn how to relax. However, EEG Biofeedback is more inclusive, as it involves opening up new avenues for communication between your body and your brain. EEG biofeedback helps you to learn how to access and maintain different states of physiological arousal. In other words, it is education for your brain.

EEG Biofeedback is an ideal therapy as it is noninvasive with minimal side effects. This therapy involves placing one or more sensors on the scalp and one to each ear. These sensors are then connected to a device which depicts a graphical recording of the electrical activity of the brain, referred to as brain waves. From the EEG, the therapist helps the client to associate specific mental states with his/her brain waves. Feedback regarding brain activity is presented to the client via a video game in which the brightness and speed of a Pacman like figure corresponds to a preset threshold. The therapist guides the client by telling him/her to make the video game work with his/her brain.

As brain waves in the desirable frequency occur, the video game moves faster, or an alternative reward is given. However if brain waves in the undesirable frequency occur, then the video game is hindered. Since EEG Biofeedback training is a learning process, progress is gradual. For most conditions, initial improvements can be observed within ten sessions. In the case of hyperactivity and attention deficit disorder, training usually is recommended for about forty sessions and more sessions may be needed depending on the severity. Whereas, some symptoms related to head injury such as quality of sleep, fatigue, and chronic pain frequently improve in less than twenty sessions (EEG Spectrum website, 2000).

Using EEG Biofeedback as a therapy is becoming more acceptable due to the previous 20 years worth of research in the field. EEG Biofeedback has been investigated for use with a multitude of disorders such as: epilepsy, hyperactivity, attention deficit disorder, and specific learning disabilities. Furthermore, it has been used clinically to help alleviate sleep disorders, and the motor, sensory, and cognitive deficits caused by minor closed head injury.

However, the one characteristic which unites all of these disorders is that each typically causes abnormal brain waves on EEG. For example, in the instance of hyperactivity, the EEG shows inadequate beta activity related to arousal (Othmer and Othmer, 1989). Additionally, Lubar, Bianchini, Calhoun, Lambert, Body, and Shabsin (1985) compared the brain wave patterns of learning disabled (LD) children with those of normal control children. They found that LD children displayed slower brain wave patterns than those without LD.

Brain activity can be assessed by examining the graphical recording of the waves. Brain waves are classified as either alpha, beta, theta, or delta. When alpha waves are present, they indicate a calm and relaxed state of unfocused attention. Whereas, beta waves indicate an alert and awake state such as when you focus on solving a problem. And, lastly delta and theta waves are observed when you are daydreaming or drowsy (Linden, Habib, and Radojevic, 1993). By examining brain waves, the therapist can evaluate how your brain is functioning and then devise a treatment plan if abnormalities are present.

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EEG Biofeedback for Epilepsy:

The field of EEG Biofeedback began with Joe Kamiya and Elmer and Alyce Green who examined the connections between physiology and different states of consciousness. They found that clients could get into a deeply relaxed state in merely one to two sessions when trained to increase alpha waves. Sterman discovered that the 12-15 Hz region of the EEG was associated with specific rhythmic activity. He labeled this rhythm as the SensoriMotor Rhythm (SMR) due to its location at the sensorimotor cortex. (Chase and Harper;1971, Howe and Sterman; 1972, Sterman, 1977). Sensory motor rhythm has control over our body sensations and voluntary movements. Barry Sterman focused on the effects of EEG Biofeedback on epilepsy.

Sterman first worked with cats who had been exposed to toxic chemicals which usually induce seizure activity. In their study, Fairchild and Sterman (1974) found that the cats who were operantly conditioned for SMR exhibited a higher threshold for seizure activity. Following this study with cats, Sterman and Friar (1972) then focused on whether SMR training could reduce seizures in humans; they published a report that SMR training did in fact reduce the seizures of one individual and also helped her sleep to improve.

Sterman, MacDonald, and Stone did further research and found that there was a 66% reduction in seizures for four epileptics; the protocol they followed was a combination of enhancing the SMR along with inhibition of excessive slow-wave activity (Sterman, 1974). Additionally, Sterman reviewed the literature on treating epilepsy with EEG Biofeedback and found that seizures were reduced in approximately 70% of the clients (Sterman, 1980).

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EEG Biofeedback for Hyperactivity:

Using EEG Biofeedback as a therapy for hyperactivity stemmed from the previous work with epilepsy. During EEG Biofeedback training with epileptics, it was observed that symptoms of hyperactivity decreased (Lubar and Bahler, 1976a). This decrease is not that unexpected since hyperactivity can also be ascribed to insufficient motor inhibition. Lubar and Shouse (1976b) conducted the first study on the effectiveness of EEG biofeedback with hyperactivity.

In this study, EEG training was observed to be more effective than the sole use of stimulant medication such as Ritalin. Then, Lubar and Shouse completed a more comprehensive study of using EEG Biofeedback for hyperactivity; they found that combining SMR training with drug therapy resulted in considerable improvements in behaviors which surpassed the effects of the drugs alone. Additionally, these changes in behavior were maintained with SMR training even after the withdrawal of medication.

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EEG Biofeedback for Attention-Deficit/Hyperactivity Disorder (ADHD):

Attention Deficit Hyperactivity Disorder (ADHD) is generally diagnosed in children who exhibit attention difficulties, impulsive behaviors, and extreme levels of hyperactivity. ADHD is not classified as a disease and no single diagnostic test exists. Rather, ADHD is generally viewed as an inherited disorder which may be intensified by minor traumatic brain injury, birth trauma, emotional and dietary factors, and inadequate sleep (Othmer and Othmer, 1992).

Also, children with ADHD frequently exhibit a variety of physical problems such as headaches and immune system deficiencies, resulting in frequent illnesses. Additionally, anxiety, depression, oppositional-defiant disorder, obsessive-compulsive behaviors may be present. The fact that ADHD is typically treated with stimulant medication such as Ritalin indicates that this disorder is characterized by insufficient arousal. EEG biofeedback is a way to train those areas of the brain involved in arousal and focus. And, it appears that once the brain learns how to regulate itself again that it does not revert back (EEG Spectrum website, 2000).

The EEG of ADHD children differs from that of other children, in that, the brain waves tend to be of a larger amplitude. Specifically, the EEG shows excess theta activity along with lower amounts of beta activity (Lubar, 1991). This pattern of brain wave activity usually indicates a sleep or day dreaming state, rather than an alert and focused state. The goal of EEG Biofeedback training is to alter these abnormal brain waves by decreasing theta waves, while simultaneously increasing beta waves. In EEG Biofeedback training, the therapist explains to the child the connection between what is happening in his/her cortex and what is recorded on the EEG. Then, the therapist helps the child to learn how to gain control over his/her brain waves.

Joel Lubar has extensively studied biofeedback with ADD and ADHD children and adults. He devised the protocol for treating ADD with neurofeedback in the 1970s and his findings have been published in journals such as the Journal of Pediatrics and Pediatric Neurology. Lubar states that between 80-90% of people with attention deficit disorder (ADD) and attention deficit hyperactivity disorder can benefit significantly from treatment (Robbins, 1997).

Additionally, Othmer and Othmer (1992) observed that significant change occurred when EEG Biofeedback training was utilized. Fifteen children were tested with the Wechsler Intelligence Scale-Revised by an independent clinical psychologist. In the pretest, the lowest scores were observed in those categories dealing with attention and sequence such as math, coding, information, and digit span. After EEG training, the scores in all of these categories improved. Additionally, an average increase in IQ was apparent, as much as 23 points.

Othmer and Othmer explain this IQ increase as: "We assume that we are not making children smarter. We are simply making their intrinsic mental capability more accessible and useable to them." (Othmer and Othmer, 1992). Several months after EEG training was completed a follow up with the parents of the children in the study was conducted. The parents noted an improvement in sleep and a reduction in headaches, as well as an increase in self-esteem. However, parents noted that problems in skills (math and reading) and behavior remained. From this study, it is evident that children with behavior problems may benefit from psychotherapy in addition to EEG Biofeedback (Othmer and Othmer, 1992).

Several researchers further corroborate that EEG Biofeedback is an effective treatment for ADHD. In two studies, Michael Linden observed that EEG training had a positive impact on IQ scores, as well as behavior. Henry Cartozzo reported his findings at the annual meeting of the Association for Applied Psychophysiology and Biofeedback. Like the Othmers, Cartozzo found that problems in math, coding, and digit span were remediated with EEG training. He also noted improvements in scores on a computerized test called T.O.V.A. (Othmer, Kaiser, and Othmer, 1995).

The T.O.V.A. (Test of Variables of Attention) is a relatively new test which assesses attention deficits in adults and children. It is a continuous performance test which evaluates deficiencies. Although this test is only 22 minutes, data from it can serve as indicators of inattention, impulsivity, reaction time, and variability of reaction time. (Othmer and Othmer, 1992). Since the T.O.V.A is computerized and computer scored, it removes the variable of human bias; therefore, it helps to increase the validity of EEG biofeedback. Othmer and Othmer studied the effects of EEG training on the T.O.V.A. and they observed significant improvements in inattention, impulsivity, and variability of response time. Additionally, they found that one child in their study improved with EEG Biofeedback even after he stopped taking Ritalin.

This study is further supported by current research regarding EEG biofeedback with ADD/ADHD. After EEG training, clinicians noted that children with ADD/ADHD improved (60 to 80 percent) and that their medication could be reduced without regressing (Association for Applied Psychology and Biofeedback website, 2000).

EEG Biofeedback is not a cure for ADHD, but can help these children to improve their academic performance, social skills, and most of all their self esteem (Othmer and Othmer, 1992a). Biofeedback helps ADHD children to realize that they can overcome their problems (inattention/ hyperactivity) and are not at the mercy of this disorder.

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EEG Biofeedback for Learning Disabilities:

According to The National Institute of Mental Health (1993), nearly 4 million school- aged children exhibit learning disabilities. Studies indicate that children with learning disabilities also have increased rates of attention deficits, hyperactivity, and impulsivity. Holobrow and Berry conducted a study which investigated the relationship between hyperactivity and learning disabilities.

In this study, teachers at six state primary schools and one private school rated their students on learning difficulties. The results from this study revealed that 26.5% of children rated as hyperactive also displayed learning difficulties; while, only 5.2% of non hyperactive children had learning problems (Holobrow & Berry, 1986). From these results, it appears that there is a connection between learning disorders and hyperactivity.

Scientists originally thought that all learning disorders stemmed from a single neurological problem. But, research supported by the National Institute of Mental Health (NIMH) indicates that this theory is not accurate. Rather, many factors may contribute to learning disorders. For example, researchers at the NIMH are studying if environmental toxins can lead to the development of learning disorders. Since there are many potential causes for the development of learning disabilities, mental health professionals suggest that the family not concentrate on tracing the reason for the disability, but rather that they focus on finding an effective treatment. Unlike ADHD which is frequently treated with a stimulant medication, a medical remedy for learning problems currently does not exist. However, recent evidence indicates that EEG biofeedback training can be helpful in specific learning challenges such as visual retention, articulation, and dyslexia (Othmer, 1999).

Tansey and Bruner (1983), Joel and Judith Lubar (1984) conducted the first studies of EEG Biofeedback as a treatment for both attention and learning problems. However, these early studies were not conclusive as to whether biofeedback training was effective. For example, in Lubar's study, five of the six children in the study were also receiving academic support in addition to EEG training. And, in Tansey and Bruner's study, they employed conventional biofeedback and EEG biofeedback training, so improvements could not unequivocally be attributed to EEG biofeedback. Then, Tansey (1985) published a study which removed the ambiguity of these previous studies. In his study of four learning disabled children, he observed that IQ scores improved after EEG training.

In 1990, Tansey conducted another study with 24 learning disabled children which further supported his theory that EEG biofeedback was effective. He noted that after EEG training there was an average improvement of 19 points on the Wechsler full scale IQ test. The results from these studies suggest that EEG biofeedback has an impact on specific learning disabilities, while others appear to remain unaltered. It is clear that more research is necessary to differentiate between which learning problems improve with EEG biofeedback training and which are resistant to it.

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EEG Biofeedback for Minor Traumatic Brain Injury :

The consequences of minor traumatic brain injury are headaches, body pain, dizziness, depression, sleep problems, irritability, and even personality changes (Hoffman, et al., 1995). Traditionally, treatment of these symptoms was multidisciplinary and included: education, family therapy, coping skills training, stress and pain management, vocational training, and individual psychotherapy (Howard, 1993). However, since the early 1980's, clinicians have been utilizing EEG biofeedback as a therapy for brain injuries. Psychologist Steven Stockdale, director of the Neuro-Health Center in Colorado Springs is one of these clinicians who has been successful in using EEG biofeedback to treat head injuries.

Recently, Stockdale finished a three- year-study (not published yet) involving his patients' progress. He states that " About 80 percent of people we work with learn to do the feedback. Of that 80%, there is a 75-90 percent reduction in symptoms. They clear up" (Robbins, 1996). Examples of brain injuries which respond to EEG biofeedback are concussion, whiplash, infection of the central nervous system, chemical central nervous system injury, stroke, and cerebral palsy (Othmer and Othmer, 1989). Although currently there is no definitive answer to explain the mechanism behind EEG biofeedback, EEG biofeedback still remains a promising new treatment for minor traumatic head injuries.

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EEG Spectrum : A Biofeedback Treatment Center:

In 1985, Susan and Sigfried learned about EEG biofeedback as a possible treatment for their son, Brian's epilepsy. Years earlier, Professor M. Barry Sterman had developed the technique of treating epilepsy with EEG biofeedback at the UCLA School of Medicine and the Sepulveda VA hospital. Brian was treated with EEG biofeedback and he improved immensely. Because Brian had made such progress, the Othmers believed that EEG biofeedback could be applied to a variety of disorders. Thus, in 1988, Susan and Sigfried Othmer along with Edward Dillingham founded the company, EEG Spectrum, with the mission to promote all aspects of EEG biofeedback such as clinical services, training of professionals, research, and instrumentation development (EEG Spectrum website, 2000).

Within the biofeedback community, EEG Spectrum is now recognized to be on the forefront of treating disorders ranging from attention deficits to traumatic brain injuries. EEG biofeedback for attention deficits is now offered at over 1,500 centers within the country and abroad. EEG Spectrum has offices nationwide and more than 60 affiliates in 20 countries. In "EEG Biofeedback: Medicine, Therapy, or Learning?" (1994), the Othmers state, "Biofeedback, at its best, is empowerment of the individual. We are simply the agency of that empowerment." For more information regarding EEG biofeedback including specific locations of EEG Spectrum treatment centers, please visit their web site at: http://www.eegspectrum.com/

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References:

Association for Applied Psychophysiology and Biofeedback website (2000). What Kind of Health Problems Can Biofeedback Help?

Chase, M.H., and Harper, R.M. (1971). Somatomotor and visceromotor correlates of operantly conditioned 12-14 c/sec sensorimotor cortical activity. Journal of Electroencephalography and Clinical Neurophysiology, 31, 85-92.

Fairchild, M.D., and Sterman, M.B. (1974). Unilateral Sensory-Motor Rhythm (SMR) Training in Cats: A Basis for Testing Neurophysiological and Behavioral Effects of Monomethylhydrazine (MMH). Report to the Aerospace Medical Research Laboratory, AMRL-TR-73-123.

Hoffman, D.A., Stockdale, S., Hicks, L.L., and Schwaniger, J.E. (1995). Diagnosis and Treatment of Head Injury. Journal of Neurotherapy , Sum, v1 (n1):14-21, EEG Spectrum.

Holobrow, P.L., and Berry, P.S. (1986). Hyperactivity and learning disabilities. Journal of Learning Disabilities, 23, 426-430.

Howard, M. E. (submitted 1993). Mild brain injury: causes, damages, diagnosis, and treatment. In Damages in Tort Actions. Matthew Bender and Sons.

Howe, R.C., and Sterman, M.B. (1972). Cortical-subcortical EEG correlates of suppressed motor behavior during sleep and waking in the cat. Journal of Electroencephalography and Clinical Neurophysiology, 2, 681-695.

Linden, M., Habib, T., & Radojevic, V. (1993). A controlled study of the effects of EEG biofeedback on the cognition and behavior of children with attention deficit disorders and learning disabilities. Manuscript submitted for publication

Lubar, J.F., and Bahler, W.W. (1976a). Behavioral management of epileptic seizures following biofeedback training of the sensorimotor rhythm. Biofeedback and Self Regulation, 1, 77-104.

Lubar, J.F., and Shouse, M.N. (1976b). EEG behavioral changes in a hyperactive child concurrent training of the sensorimotor rhythm (SMR). A preliminary report. Biofeedback and Self Regulation, 9(1), 1-23.

Lubar, J.O., and Lubar, J.F. (1984). Electroencephalographic biofeedback of SMR and beta treatment of attention deficit disorders in a clinical setting. Biofeedback and Self Regulation, 9(1), 1-23.

Lubar, J.O., Bianchini, K., Calhoun, W., Lambert, E., Brody, Z and Shabsin, H. (1985). Spectral analysis of EEG differences between children with and without learning disabilities. Journal of Learning Disabilities, 18, 403-408.

Lubar, J. F. (1991). Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders. Biofeedback and Self-Regulation, 16, 202-225.

National Institute of Mental Health (1993). Overview of Learning Disabilities. NIH Publication No.93-3611, National Institute of Mental Health.

Othmer, S.F., and Othmer, S. ( 1989). EEG biofeedback training for hyperactivity, attention deficit disorder, specific learning disabilities, and other disorders, EEG Spectrum.

Othmer, S.F., and Othmer, S. (1992a). EEG biofeedback for Attention Deficit Hyperactivity Disorder, EEG Spectrum.

Othmer, S.F., and Othmer, S. (1992b). Evaluation and Remediation of Attentional Deficits, EEG Spectrum.

Othmer, S.F., and Othmer, S. (1994). EEG biofeedback: Medicine, Therapy, or Learning? EEG Spectrum Inc.

Othmer, S., Kaiser, D., and Othmer, S.F. (1995). EEG biofeedback training for Attention Deficit Disorder: A review of recent controlled studies and clinical findings, EEG Spectrum.

Othmer, S. (1999). Working with the 'Unreachable' Child - Physiological Perspective, and a Proposed Approach. EEG Spectrum.

Robbins, J. (1996). Wired for Miracles. Association for Applied Psychophysiology and Biofeedback.

Robbins, J. (1997, November 11). Biofeedback Offers Help to Hyperactive Children. New York Times, science section.

Sterman, M.B., and Friar, L. (1972). Supression of seizures in an epileptic following sensorimotor EEG feedback training. Journal of Electroencephalography and Clinical Neurophysiology, 33, 89-95.

Sterman, M.B., MacDonald, L.R., and Stone, R.K. (1974). Biofeedback training of the sensorimotor EEG rhythm in man: Effect on epilepsy. Epilepsia, 15, 395-416.

Sterman, M.B. (1977). Sensorimotor EEG operant conditioning and experimental and in clinical effects, Pavlovian Journal Biological Science, 12, 2, 65-92.

Sterman, M.B. (1980). EEG biofeedback in the treatment of epilepsy: an overview circa 1980. White, L. & Tursky, B. (Eds.), Clinical Biofeedback: Efficacy and Mechanisms, The Guilford Press, New York.

Tansey, M. and Bruner, R. (1983). EMG and EEG biofeedback training in the treatment of a 10 year old hyperactive boy with a developmental reading disorder. Biofeedback and Self-Regulation, 4, 299-311.

Tansey, M. (1985). Brain wave signatures: An index reflexive of the brain's functional neuroanatomy: Further findings on the effect of EEG sensorimotor rhythm biofeedback training on the neurological precursors of learning disabilities. International Journal of Psychophysiology, 3, 85-99.

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