Alternative Medicine Review Volume 12, Number 2 2007

EEG Biofeedback in theTreatment of Attention Deficit/

Hyperactivity Disorder

Patrick N. Friel, BS

Abstract

Electroencephalogram (EEG) biofeedback, also known as

neurofeedback, is a promising alternative treatment for

patients with attention deficit/hyperactivity disorder (AD/HD).

EEG biofeedback therapy rewards scalp EEG frequencies

that are associated with relaxed attention, and suppresses

frequencies associated with under- or over-arousal. In large-

scale clinical trials, the efficacy of EEG biofeedback for

AD/HD is comparable to that of stimulant medications.

Many different EEG biofeedback protocols for AD/HD are

available. Single-channel protocols developed by Lubar and

interhemispheric protocols developed by the Othmers are

widely practiced and supported by large-scale clinical studies.

Med/?ev2007;12(2):146-151)

IntroductionAttention deficit/hyperactivity disorder (AD/

HD) affects approximately 3-5 percent of school-agechildren in the United States, and a majority of childrendiagnosed with A D / H D are treated with medications,primarily stimulants.' It is estimated that 10 percentof 10-year old boys in the United States are currentlybeing treated with prescription stimulants.-^ Concernsahout the cardiovascular toxicity of amphetamine andmethylphenidate' cause many patients and their fami-lies to seek alternative therapies. Well-established al-ternative therapies include dietary modifications andthe administration of supplements, including vitamins,minerals, phytonutrients, amino acids, essential fatty ac-ids, phospholipids, and probiotics.^ Another alternativeto drug therapy for A D / H D is electroencephalogram(EEG) biofeedback, also known as neurofeedback.

which is supported by extensive peer-reviewed litera-ture, including large-scale controlled clinical trials.'"'The purpose of this review is to summarize the evidencesupporting the use of EEG biofeedback for treatment ofAD/HD.

BackgroundThe standard scalp EEG is recorded at 19 sites.

Scalp EEG frequencies are broadly associated with vari-ous mental states, as shown in Table 1. With moderncomputerized systems, experts can map scalp EEGquantitatively by using spectral analysis. Quantitativeelectroencephalography (QEEG) studies demonstratedeviations from normal patterns in many neuropsychi-atric conditions, including AD/HD.^

Clinical EEG hiofecdback originated with theobservation by Sterman that cats conditioned to pro-duce a specific EEG frequency (SMR; sensory-motorrhythm; 12-15 hz) exhibited an elevated seizure thresh-old when exposed to the convulsant agent methylhy-drazine.*̂ " Subsequent saidies by Sterman and others,conducted from the 1970s onward, demonstrated thatapproximately 80 percent of patients with medicallyintractable epilepsy experience a clinically significant(>50%) reduction in seizure frequency after a course ofEEG biofeedback that rewards the SMR frequency/

Patrick N, Friel, BS - Forensic toxicologist; special interests in gaschromatography-mass spectrometry, liquid chromatography-mass spectrometry,and the pharmacokinetics/pharmacodynamics of alcohol; trained in EEGbiofeedback at the EEG Institute in Woodland Hills, CA.Correspondence address: Washington State Toxicology laboratory, ForensicLaboratory Services Bureau Suite 360, 2203 Airport Way South, Seattle, WA98134.Email: PaLFriel@wsp.wa.gov

Page 146

Aiternative Medicine Review Voiume 12, Number 2 2007

Table 1. EEG Rhythms and Associated Mental States

EEG Rhythm

Deita

Theta

Aipha

SiVIR

Beta

High Beta

GaiTima

Frequency(hz)

1 -4

3-7

8-12

12-15

13-21

20-32

38-42

Associated Mental States

Sieep; dominant in infants

Drowsiness; "tuned-out;" inner-directed insights

Alertness; meditation, dominant when eyes closed

Mentally alert; physicaliy reiaxed

Focused; sustained attention; problem solving

intensity; anxiety; hypervigilance

Important in learning

Patients with A D / H D exhibit characteristicsurface EEG disturhances.'' Specifically, 85-90 percentof patients with A D / H D display signs of cortical "hy-poarousal," quantitatively described as elevated relativetheta power, reduced relative alpha and beta power, andelevated theta/alpha and theta/beta power ratios (Ta-ble 1). These patterns are typically observed over frontaland central midline brain regions. A smaller subgroupof A D / H D patients exhibits an EEG pattern suggestiveof "hyperarousal," with greater relative beta activity, de-creased relative alpha activity, and decreased theta/betapower ratios diffusely across multiple cortical recordingsites. The hyperaroused group tends to respond poorlyto stimulant medications.

Lubar et al developed EEG biofeedback pro-tocols to inhibit cortical slowing and reward higherfrequencies in hypoaroused patients, with the goal ofnormalising EEG activity in regions thought to be re-sponsible for attention and behavioral control.'

Modern EEG biofeedback systems, sold by anumber of manufacturers, consist of a set of EEG sen-sors and a signal transducer/amplifier, connected to acomputer or computers with software capable of ana-lyzing the EEG signals, performing various transforma-tions, displaying relevant signals to the patient, andproviding rewards or inhibitions in the form of visual

and/or audio feedback. The client learns to enhancedesirable EEG frequencies and suppress undesirablefrequencies at the selected scalp Iocation{s) hy beingrewarded (e.g., by progress in a video game) for increas-ing desirable frequencies and/or reducing undesir-able frequencies. Scalp electrode placements along thesensory-motor strip (C3 and C4) and temporal lobes(T3 and T4) are widely used. A typical neurofeedbackconfiguration involves the patient seated in a recliningchair, watching one video display that provides videoand audio feedback, while the therapist monitors a sec-ond video display that provides detailed, real-time dataon the patient's EEG during the session.

A typical course of EEG biofeedback therapyinvolves at least 20 half-hour sessions, administeredover a 6- to 12-week period. Although rates of prog-ress vary from patient to patient, significant benefit isoften observed within the first few weeks of therapy. Ac-creditation for EEG biofeedback practitioners is avail-able through the Biofeedback Certification Institute ofAmerica.

Page 147

Alternative Medicine Review Volume 12, Number 2 2007

Clinical TrialsA recent review discusses the evidence sup-

porting EEG biofeedback for AD/HD, collected incase studies and controlled-group trials."* The studiesreviewed all employed single-channel neurofeedback,based on the original work of Lubar et al. Case seriesdemonstrating favorable outcomes with EEG biofeed-back for A D / H D include one group of 111" and an-other ot 186'' subjects. In the case series of 111 patients,who were treated with 40 sessions of neurofeedback,Tliompson and Thompson reported improvements inquantitative EEG and performance in a continuous per-formance task, as well as a mean gain in tuU-scale IQof 12 points after neurofeedback.^ Kaiser and Othmerreported a series of 1,089 patients, 186 with AD/HD.' 'They described significant improvement in measures ofattentiveness and impulse control using a test of vari-ables of attention (TOVA).

Five controlled-group studies that appeared inpeer-reviewed journals between 1995 and 2003 werealso reviewed. Rossiter and LaVaque compared the ef-fects of 20 sessions of EEG biofeedback with the effectsof stimulant medication in 46 subjects with A D / H Dages 8-21 years, who were divided into two matchedgroups.'" In this study, patients receiving EEG biofeed-back demonstrated significant improvement in severalpsychometric test scores. There was no significant dif-ference in response rates for patients treated with EEGbiofeedback (83%) and medication (87%).

Linden et al studied 18 children (ages 5-15years) with A D / H D who were randomly assigned to a"waiting list" or an HEG biofeedback treatment group."Patients treated with EEG biofeedback demonstrated asignificant increase in IQ (9 points) when compared tothe control group, and significantly reduced inattentivebehaviors, as rated by parents.

Another randomized, waiting-list trial, involv-ing 16 children (ages 8-10 years) with AD/HD, wasconducted by Carmody et al.'~ Patients treated withEEG biofeedback exhibited reduced impulsivity on psy-chometric testing and were rated more attentive by theirteachers. However, follow-up QEEG testing did notdemonstrate consistent patterns of electrophysiologicalimprovement after EEG biofeedback.

The largest published controlled trial of EEGbiofeedback for A D / H D was conducted by Monastra etal." A group of 100 patients (ages 6-19 years) was divid-ed into two groups; one received methylphenidate andthe other received methylphenidate plus EEG biofeed-back. After one year of therapy, post'treatment assess-ments were conducted while patients continued to takemethylphenidate, and then after a one-week medicationwashout. The EEG bio feedback-plus-medication groupreceived an average of 43 sessions, which were designedto reduce cortical slowing to within one standard devia-tion of age peers. Statistical analysis demonstrated anindependent beneficial effect of EEG biofeedback, withgreater improvement in attention and less hyperactivebehavior, reported by parents and teachers, in patientstreated with both methylphenidate and EEG biofeed-back. After medication washout, sustained improve-ment, as reported by parents and teachers, was seen onlyin the group that had been treated with methylphenidateand EEG biofeedback. Children whose parents followedthe strategies taught in a concurrent parenting programhad fewer attentional and behavioral problems at home,regardless of which treatment they received.

Fuchs et al compared EEG bloteedback withstimulant medication in 34 children (ages 8-12 years)with AD/HD.' ' ' Treatment assignment was based onparental preference, and the two treatment groups weresimilar in pre-treatment measures of intelligence andseverity of AD/HD. The EEG biofeedback group re-ceived 36 sessions over 12 weeks. Significant improve-ment in psychometric and behavioral test results, andin parent and teacher reports, were found in both treat-ment groups. The authors concluded that EEG bio-feedback was efficient in improving some behavioralconcomitants of A D / H D in children whose parentsfavored a nonpharmacological treatment.

A recent paper by Levesque et al evaluated theimpact of EEG biofeedback on brain function in AD/H D by using brain functional magnetic resonance im-aging (fMRI) in conjunction with psychometric tests.'^After EEG biofeedback therapy, children with A D / H Dexhibited improved attentional performance, as wellas distinctive activation of the right anterior cingulatecortex on fMRI, which were not observed in untreatedcontrol subjects.

Page 148

Alternative Medicine Review Volume 12, Number 2 2007

In summary, controlled studies demonstratethat the efficacies of EEG biofeedback and stimulantmedication are comparable in the treatment of AD/HD.

Protocol ChoiceEEG bioteedback is a relatively new treatment

modality, and the novice is confronted with a wide arrayof protocols to choose from. Although newer protocolsmay offer comparable or even better outcomes than theapproaches used in the clinical trials described in theprevious section, evidence to support the newer proto-cols tends to be more anecdotal.

Quantitative ElectroencephalographicAnalysis

One important question is whether pre-treat-ment QHEG is necessary and beneficial in guiding EEGbiofeedback treatment. Of the five controlled-groupstudies discussed in the previous section, only one usedQEEG improvement as a treatment endpoint. Oneother study found no consistent change in QEEG afterEEG biofeedback, and the remaining three studies didnot report QEEG data. Since the studies all found sig-nificant improvement for A D / H D with EEG biofeed-back, independent of QEEG use, the case for QEEGis not compelling; furthermore, QEEG is relatively ex-pensive. Avoiding QEEG testing can reduce the cost ofEEG biofeedback. On the other hand, some of the lead-ing experts in EHG biofeedback who routinely performQEEG report excellent treatment outcomes.

Interhemispheric EEG BiofecdhackInterhemispheric EEG biofeedback was devel-

oped by the Othmers at The EEG Institute, based onre-evaluation of the original methods used in the con-trolled studies described earlier."''' In their clinical workusing single-channel HEG biofeedback, the most com-mon EEG disturbances encountered in patients wereleft hemispheric hypoarousal and right hemispherichyperarousal. Single-channel EEG biofeedback aims toincrease EEG frequencies in areas of hypoarousal and/or decrease them in areas of hyperarousal. The Oth-mers developed a new paradigm in which instabilityof state, as well as hypo- or hyperarousal, is addressed.Interhemispheric EEG biofeedback can be employed to

simultaneously encourage increased left hemisphericfrequency and decreased right hemispheric frequency,while also supporting left hemisphere-right hemisphereintegration. Interhemispheric EEG biofeedback hasbecome the Othmers' method of choice for improvingfunctional brain stability. Case study data indicate inter-hemispheric EEG biofeedback is comparable to single-channel EEG biofeedback in efficacy for treatment ofAD/HD.'^

Low Energy NeurofeedhackA low energy neurofeedback system is another

EEG biofeedback variation that employs direct weakelectromagnetic stimulation at the sensor sites, insteadof the customary visual and auditory feedback employedin other EEG biofeedback modes. At this time, no pub-lished research studies are available to evaluate this ap-proach for treatment of AD/HD.

HemoencephalographyHemoencephalography, the newest outgrowth

of neurofeedback, employs near-infrared sensors tomonitor cerebral blood flow and guide feedback to thepatient.'*^ Prefrontal sensor placement sites have beenused in limited published studies of hemoencephalog-raphy to treat AD/HD. Because hemoencephalographyhas a direct impact on cerebral blood flow, it is contra-indicated in patients with cerebrovascular disorders.

Choosing a Protocol and PractitionerThe data available do not allow a head-to-head

comparison of standard single-channel EEG biofeed-back and newer protocols. Selection of a neurofeedbackpractitioner should be based on level of experience andtraining, accreditation, the fraction of the therapistspractice devoted to neurofeedback, positive reportsfrom clients, and the therapist's specific experience intreating AD/HD.

ContraindicationsCase and controlled group studies did not

include patients under age six years, or subjects withdevelopmental delay or other significant medical, neu-rological, or psychiatric disease. Patients from familieswith significant marital discord that could interferewith participation in the treatment process were alsoexcluded from the studies.

Page 149

Alternative Medicine Review Volume 12, Number2 2007

Adverse EffectsThere is a potential for increased irritability,

moodiness, and hyperactivity when stimulant medica-tion and EEG biofeedback are combined. This can oc-cur along with improvement in cortical activation, indi-cating the stimulant dosage might need to be reducedor eliminated. Occasionally, patients report transitoryheadaches, tiredness, and/or dizziness after treatment.The original work by Sterman clearly demonstratedthat EEG biofeedback has the potential to decrease orincrease seizure threshold, depending on the frequen-cies and sensor locations used.^ Patients with a historyof epilepsy should only receive neurofeedback frompractitioners who are well versed in EEG biofeedbacktherapy for seizure disorders.

Potential SynergiesEEG biofeedback therapy for AD/HD results

in significant improvement in cognitive functioning for75-85 percent of patients. It is possible faster and betteroutcomes might be achieved by combining other alter-native therapies with EEG biofeedback. According toSchnoU et al, dietary modification plays a major part inthe treatment of A D / H D and should be considered aspart of the overall treatment protocol when EEG bio-feedback therapy is employed.''^ Tliey also reviewed re-search demonstrating that patients with A D / H D andfood sensitivities have changes in brain electrical activ-ity after exposure to offending foods, suggesting that re-moving foods the patient is sensitive to could accelerateresponse to EEG biofeedback.

Another example of a potential synergy be-tween EEG biofeedback and alternative therapies con-cerns omega-3 fatty acid supplements, which are incor-porated into neuronal membranes and have stabilizingeffects on mood and other aspects of mental function-ing.-" Although it is possible omega-3 fatty acid therapycould "prime" the brain to respond to EEG biofeedback-augmented stabilization, no clinical research has beenconducted to confirm such a hypothesis. Anecdotalevidence, however, from practitioners who prescribedietary modification and nutritional supplements alongwith EEG biofeedback is impressive.'' Further researchon combined approaches is warranted.

Use of EEG Biofeedback for otherDisorders

Experienced practitioners treat a range of neu-ropsychiatric problems with EEG biofeedback. Thestrongest evidence-based justification for EEG biofeed-back therapy exists for A D / H D and epilepsy.''̂ '̂̂ ^ Agrowing body of evidence supports the use of EEG bio-feedback in the treatment of mood disorders.-'' A num-ber of other conditions have been reported to respondto EEG biofeedback, including migraine, fibromyalgia,chemical dependency, and syndromes secondary totraumatic brain injury. EEG biofeedback protocols havealso been developed to improve "peak performance" inhealthy individuals. For example, conservatory studentsexperienced improvements in artistic aspects of musicperformance equivalent to two class grades after EEGbiofeedback.̂ ""

ConclusionsEEG biofeedback is a well-established, non-

drug treatment modahty for AD/HD, with proven effi-cacy and minimal adverse effects.'''^ In seeking to engageneuronal plasticity for patient benefit, EEG biofeedbackoffers an optimistic, non-reductionist approach to neu-ropsychiatric problems. Although integrative treatmentof AD/HD, including dietary modification, nutritionalsupplements, and EEG biofeedback, may offer patientsthe best chance tor a favorable outcome, research oncombining these therapies has not yet been conducted.

DisclaimerThis paper reflects the author's opinions, which

are not endorsed by the Forensic Laboratory ServicesBureau of the Washington State Patrol.

References1. Fox DJ, Tliarp DF, Fox LC. Neurofeedback: an

alternative and efficacious treatment for arcentiondeficit hyperactivity disorder. Appl PsychophysiolBiofeedback 2005:30t365-373.

2. Nissen SE. ADHD drugs and cardiovascular risk. NEnglJ Med 2006;354;1445-1448.

3. Harding KL, Judah RD, Gant C. Outcome-basedcomparison of Ritalin versus food-supplement treatedchildren with AD/HD. Altern Med Rev 2003;8:319-330.

Page 150

Alternative Medicine Review Volume 12, Number 2 2007

4. Monastra VJ, Lynn S, Linden M, et al.Electroencephalographic biofeedback in the treatmentof attention-deficit/hyperactivity disorder. ApplPsycbophysiol Biofeedback 2005;30:95-l 14.

5. Hughes JR, John ER, Conventional andquantitative eiectroencephalography in psychiatry.JNeuropsychiatry Clin Neurosci 1999;ll:190--208.

6. Sterman MB. Effects of brain surgery and EEGoperant condirioningon seizure latency followingmonomethylhydrasine intoxication in the cat. ExpNeiirol 1976;50:757-765.

7. Sterman MB. Basic concepts and clinical findings inthe treatment of seizure disorders with EEG operantconditioning. CUn Electroencephalogr 2000;31:45-55.

8. Tlioinpson L, Tliompson M. Neurofeedbackcombined with training in nietacognirive strategies:effectiveness in students wirh ADD. ApplPsychophysiol Biofeedhack 1998;23:243-263.

9. Kaiser DA, Othmer S. Effect of neurofeedback onvariables of artenrion in a large multi-center trial.JNeurotherapy 2000:4:5-28.

10. Rossiter TR, La Vaque TJ. A comparison of EEGbiofeedback and psychoscimulants in treatingattention deficit/hyperactivity disorders-^/Neurotherapy 1995;l:48-59.

11. Linden M, Habib T, Radojevic V. A controlled studyof the effects of EEG biofeedback on cognition andbehavior of children with attention deficit disorderand learning disabilities. Biojeedhack Self Regul1996;21:35-49.

12. Carmody DP, Radvanski DC, Wadhwani S, et al,EEG biofeedback training and artention-deficir/hyperactivity disorder in an elementary school setting.J Neurotherapy 2001;4:5-27,

13. Monastra VJ, Monastra DM, George S. The effects ofstimulant therapy, EEG biofeedbacic, and parentingstyle on the primary symptoms of artention-deficir/hyperactivity disorder, Appl Psychophysiol Biojeedhack2002:27:231-249.

14. Euchs T, Birbaumer N, Lutzenberger W, et a!,Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison withmethylphenidate, Appl Psychophysiol Biofeedback2003:28:1-12.

15. Levesque J, Beauregard M, Mensour B, Effect ofneurofeedback training on the neural substratesof selective attention in children with attention-deficit/hyperactivity disorder: a functional magneticresonance imaging study, Neurosci Lett 2006:394:216-221,

16. Othmer SF. Interhemispheric EHG training.JNeurotherapy 2005:9:87-96,

17. Putman JA, Othmer SE Othmer S, Pollock VE,TOVA results following inter-hemispheric bipolarEEG training.J Neurotherapy 2005:9:37-52.

18. Mize W, Hemoencephalography - a new therapy forattention deficit hyperactivity disorder {AD/HD):case report.J Neurotherapy 2004:8:77-97.

19, Schnoll R, Burshteyn D, Cea-AravenaJ, Nucritionin the treatment of attention-deficit hyperactivitydisorder: a neglected but important aspect. ApplPsyehophysiol Biofeedback 2003:28:63-75,

20, Hirashima F, Parow AM, Stoll AL, et al, Omega-3 fatty acid treatment and T(2) whole brainrelaxation times in bipolar disorder, AmJ Psychiatry2004:161:1922-1924.

21, Bradford Weeks, MD: Weeks Clinic, Clinton. WA- personal communication,

22, Monastra VJ. Electroencephalographic biofeedback(neurorherapy) as a treatment for attention deficithyperacrivity disorder: rationale and empiricalfoundation. Child Adolesc Psychiatr Clin N Am2005:14:55-82, vi.

23, Heinrich H, Gevensleben H, Strehl U, Annotation:neurofeedback - train your brain to train behaviour.JChild Psychol Psychiatry 2007:48:3-16.

24, Sterman MB, EgnerT, Foundation and practice ofneurofeedback for the treatment of epilepsy, ApplPsychophysiol Biofeedback 2006:31:21-35.

25, EgnerT, Sterman MB, Neurofeedback treatment ofepilepsy: from basic rationale ro practical application.Expert Rev Neurother 2006:6:247-257.

26, Hammond DC, Neurofeedback wirh anxiety andaffective disorders. Child Adolesc Psychiatr Clin N Am2005:14:105-123, vii,

27, Gruzelier J, Egner T, Critical validation studies ofneurofeedback. Child Adolese Psychiatr Clin N Am2005:14:83-104, vi.

General ReferencesI. Child and Adolescent Psychiatric Clinics oj North

America, Number 14, January 2005 (issue onemerging interventions),

II. Demos JN. Getting Started with Neurofeedhack. W. W.Norton & Company: 2004,

IIL Bvans JR, Introduction to Quantitative EEG andNeurofeedback. Academic Press: 1999.

IV, Hammond DC. Comprehensive NeurofeedhackBibliography. http://www.isnr,org/nfbarch/nbiblio,htm

V. Larsen S, The Healing Power oJ Neitrofeedhack.Rochester: Healing Arts Press; 2006.

VL Lubar J, Quantitative Electroencephalographic Analysis(QEEG) Databases jor Neurotherapy: Description,Validation, and Application. Haworth Medical Press:2004,

VIL Robbins J, A Symphony in the Brain: The Evolution ofthe New Brain Wave Biofeedhack. New York: AtlanticMonthly Press: 2000.

VIII. Steinberg M, Othmer S. ADD: U e 20'Hour Solution.Robert D. Reed Publishers: 2004,

IX. Thompson M, TTje Neurofeedhack Book. Associationfor Applied Psychophysiology and Biofeedback; 2003.

Page 151