Neurofeedback for AD/HD

Conference Coverage: 2e Forum in Sydney

By Helen Dudeney, July 2011

On May 14, 2011, about 140 members of the Australian 2e community attended the first 2e Forum in Sydney, Australia. This Forum was designed and presented by a subcommittee of the New South Wales (NSW) Association for Gifted and Talented Children, including members of the association’s GLD support group. In operation since the early 1990s, the GLD support group functions as both a face-to-face meeting group and as a closed e-mail forum. The support offered by this group has had a significant impact on families with 2e children over the past two decades, and the group’s efforts have increased general awareness of this population of gifted students.

The 2e Forum, aimed at parents, teachers, and administrators, was designed to meet these goals:

Inform and support parents and teachers
Provide a networking opportunity
Collect data that would form the basis of an association submission to relevant government and education authorities on the needs of 2e students.

The day included keynote presentations, panel presentations, concurrent sessions, and a round-table think-tank session. The opening panel was made up of four highly experienced presenters, all members of the GLD support group and with over 80 years of collective experience in working with and for 2e children. The panel set the scene for the day by reviewing the history of the 2e journey in NSW and the importance of valuing and responding equally to all the “e’s.” This message continued throughout the day — the importance of seeing the needs of the whole child rather than focusing only the giftedness and missing the weaknesses; or, conversely, focusing only the weaknesses and missing the strengths.

The second panel included four allied health professionals who work with 2e children, including a behavioural optometrist, speech therapist, occupational therapist and Irlen Syndrome practitioner. Members of this panel gave insights into how their practices are able to address some of the challenges and weaknesses that affect this population.

Also part of the 2e Forum was the opportunity to network and debrief. Attendees could go to a “chill out room” where parents experienced in raising 2e children were ready to lend an ear, a tissue, or a hug. In this room attendees could express the emotions — relief, guilt, belonging, or emotional overload — that often accompany the duty of raising or teaching those wonderful, challenging, 2e kids.

Forum feedback confirmed that the day was a success. Many attendees requested that it become an annual event, so organizers are in the process of planning the next 2e Forum for 2012, most likely in Canberra, Australia’s capital city.

See coverage of a keynote address below.

2e Forum Keynote Address

In his keynote address, Dr. Mark Selikowitz, a developmental pediatrician and partner in the Sydney Developmental Center, stressed that gifted children with AD/HD have a greater susceptibility to other problems. By way of example, Dr. Selikowitz compared a Ferrari to a Holden, a line of vehicles manufactured in Australia. He explained that all of the parts of a Ferrari are highly specialised and finely tuned. Weakness in any one part will have a major impact on the performance of the Ferrari. For example, he stated, fitting a Ferrari with a Holden wheel would impair the Ferrari’s performance. A Holden fitted with a Holden wheel, on the other hand, would operate just fine, thank you.

The keynoter pointed out that attention deficit is a confusing name for the condition. AD/HD, he explained, is a problem with cognitive control rather than with attention. He highlighted a dual processing system that exists in humans, made up of:

The automatic, stimulus-driven brain, which results in an immediate reward
The executive system, which requires cognitive control and effortful override to both block out distractions and to engage in activities that provide neither immediate reward nor satisfaction but are an investment in the future. (Dr. Selikowitz contends that executive functioning is not working memory nor is it attention.)

Tasks like eating, reading, and computer games provide the brain with immediate rewards and, therefore, do not require the executive system to block out distractions. Writing, however, is an example of a tedious, unrewarding task that requires greater persistence and greater cognitive control. As a child with AD/HD matures, Dr. Selikowitz explained, his or her executive ability to override the automatic brain should increase.

In terms of the management of AD/HD, the keynoter made points regarding both identification and treatment. For identification:

Diagnosis needs to be via comprehensive assessment.
Each child needs an individualised treatment plan, which must be managed via ongoing review.
Each child needs an individualised treatment plan, which must be managed via ongoing review.
- Boredom, which can be caused by many things, not just unchallenging work
- Overexcitabilities, which Dr. Selikowitz sees as traits and not a diagnosis
- Processing problems, a term he feels is too general, offering the analogy that it would not be acceptable for a parent to accept a diagnosis of “engine problems” from an auto mechanic

Dr. Selikowitz said that treatment for AD/HD can include:

Changing the environment at home, in the classroom, and on the playground by creating routines along with clear expectations and consequences
Assessing how others respond to the child. Children who appear socially clumsy may get on with older children (who tolerate them) or younger children (who don’t notice their clumsiness) instead of their age peers, and they may be targets for bullying. Part of treatment can be assistance in developing appropriate emotional regulation skills.
Helping gifted children with AD/HD to bypass their difficulties by strength-based skill development. For weaknesses, remediation should be one-to-one and structured.
Medication, which works directly on the appropriate part of the brain to improve learning, allows the child to stop and think, and helps other interventions be more effective. Medication keeps the frontal lobe functioning until it matures.

—HD

	Type of Wave	Mental State
	Beta	Attentive: actively thinking, problem-solving, etc.
	Alpha	Calm and relaxed; right after waking and just before sleeping
	Theta	Daydreaming, meditating, lightly sleeping
	Delta	In deep sleep

Neurofeedback treatment may begin with a quantitative electroencephalogram (qEEG), a process of using sensors placed on the scalp to record brain waves and produce a brain map. This brain map shows where an individual’s brain wave patterns differ from “the norm.” According to an article by David Rabiner, Ph.D., a Duke University psychologist who publishes the online newsletter Attention Research Update, several studies have indicated that children with AD/HD have different brain wave patterns than children without. The studies showed that those with the disorder exhibit an excess of low-frequency wave activity (theta and alpha) and a reduced amount of high-frequency (beta) brain waves. (Rabiner cautioned that an association between particular patterns of brain activity and AD/HD symptoms does not mean that one causes the other.)

The thinking behind using neurofeedback for AD/HD is that the treatments can enable patients to learn to control their brain activity, decreasing the low-frequency waves and increasing high-frequency waves. During a typical neurofeedback session, a patient sits in front of a computer screen watching and responding to video displays — much like a computer game — designed to train the patient to produce the desired change in brain activity. Sensors attached to the head monitor the patient’s brain waves during what is usually a 30- to 45-minute session. During the course of treatment, patients typically undergo 25 to 50 sessions over a period of several months, at a cost somewhere in the area of $100 per session. Most health insurance plans do not cover treatment.

The answer to this question depends on who you ask. Ari Goldstein holds a Master’s degree in learning disabilities and a Ph.D. in educational psychology from the University of Illinois. He has conducted research in the areas of learning disabilities, cognitive development, executive functioning, and meta-cognition; and he has completed post-graduate training in psychological and educational assessment. At his Cognitive Solutions Learning Centers in Chicago and Highland Park, Illinois, he works with parents to design non-medicinal treatment approaches for helping both gifted and non-gifted children with learning and attention problems. According to Goldstein, treatment approaches can include any combination of diet/supplementation, executive functions training, and neurofeedback. When asked about the results of neurofeedback treatment for these children, his reply was:

We have seen tremendous benefit in a host of disabilities, including learning disabilities, autism, anxiety, depression, seizure disorders, and AD/HD – both inattentive and hyperactive typologies. Parents and teachers report changes in behavior and learning, often including better sleep patterns, better focus and behavior at home and in school, and reduced anxiety about school, which we track regularly. We regularly track the changes using quantitative measures such as follow-up qEEG’s and administration of standardized measures such as the Conner’s rating scales and Conner’s Continuous Performance Test.

In the book Buzz (reviewed elsewhere in this issue), author Katherine Ellison explored neurofeedback for treating AD/HD. In the book’s epilogue she described the conclusions she reached based on the experiences that both she and her son had with receiving treatments:

…[M]y research and personal experience has made me a particular fan of neurofeedback, which under ideal circumstances is much safer than medication, and may be more long-lasting, despite the drawbacks of how much time and money it requires….[A] growing amount of anecdotal evidence — including my own — is encouraging.

On the opposite side are those who feel that anecdotal evidence is not enough to warrant the use of this form of treatment for AD/HD. The March, 2010, issue of the Harvard Mental Health Letter stated:

About two dozen studies have been published about neurofeedback for AD/HD, and many have reported promising results. But most of them involved only small numbers of patients, were not randomized, and lacked a placebo intervention. As such, they lacked controls for confounding mechanisms such as attention training or bias on the part of investigators or participants.

When asked his opinion of neurofeedback treatments, neuropsychologist R. Patrick Savage, Jr., Ph.D., of Silver Spring, Maryland, responded, “I think you will find people who swear by neurofeedback and others who think it is pure quackery. I am a skeptic but optimistic that at some point neurofeedback will offer us some effective treatments for cognitive issues.”

Savage explained that there have been many claims made for neurofeedback that have not been substantiated. Furthermore, he feels that much of the current research was poorly designed so that the results were problematic. He expressed concern that we may be, in part, looking at a placebo effect.

Savage explained that with neurofeedback, as with other treatments, the placebo effect can be very strong. “The power of belief and positive thinking is quite impressive,” said Savage. The problem with much of the neurofeedback research, he explained, is that there were no control groups. Having control groups makes it possible to compare the gains that children who received treatment made with the performance or behavior of children who did not receive treatment.

Further complicating the situation, Savage pointed out, is the fact that children’s brains continue to develop and change more rapidly than those of adults. “Hence,” he stated, “kids are acquiring and developing new skills independent of the treatments they might experience.”

Nevertheless, Savage looks forward to progress in the area of neurofeedback research. He anticipates research that will enable us to gain a better understanding of “what this procedure actually has to offer, to whom it has to offer it, and what it takes to get the effect one wants.”

Pediatric neuropsychologist Nadia Webb, Psy.D., of New Orleans, Louisiana, expressed greater reservations about using neurofeedback as a treatment for AD/HD. “I’ve never recommended neurofeedback,” she stated, “and I’m unlikely to any time soon.”

Webb explained that biofeedback using temperature, heart rate, muscle tension, and so forth has “great data for working with anxiety, pain, and health problems aggravated by anxiety or stress, such as GI upset or headaches.” At this point, however, Webb said that “neurofeedback is experimental and has little support, except research by people who use it clinically and aren’t neutral.”

She went on to remind parents that “everything has an opportunity cost, and it often means foregoing approaches that have much better research and better outcomes data. Good psychotherapy, tutoring, medication (if appropriate and thoughtfully selected), parenting skills training, family therapy, social skills training, mentoring, or Outward Bound — all of these have better support and tend to be a better option for the money.”

Since 2009, the National Institute of Mental Health has been sponsoring the first government-funded, peer-reviewed study of neurofeedback for AD/HD. The study’s results were due out in fall of 2010 but are so far unavailable. Perhaps, once they are published, these results will put some of this controversy to rest; but until then, parents of children with attention issues are left to do their own research and use their own best judgment.