Biofeedback as a treatment for childhood hyperactivity: a critical review of the literature

Hyperactivity is a significant problem for which no causal theories have been unequivocally substantiated and one in which treatment approaches have met with limited success. Recent research in behavioral medicine has brought biofeedback into use as a treatment for disorders that are mediated by physiologic functioning, with hyperactivity as one such disorder. 36 studies are reviewed in which biofeedback was used as a treatment for hyperactivity. This review indicated that biofeedback treatments alone have not been effectively evaluated, and methodological problems with the current studies severely limit generalizations that may be made to hyperactive populations. Biofeedback in conjunction with other techniques appears to have promise for reducing some of the behavioral symptoms of the hyperactivity syndrome. Directions for further research are presented.     

OPERANT TREATMENT OF OROFACIAL DYSFUNCTION IN NEUROMUSCULAR DISORDERS

The popularity and reported success of biofeedback treatment for neuromuscular disorders has occurred despite a lack of research identifying the critical variables responsible for therapeutic gain. In this study, we assessed the degree to which severe neurological dysfunction could be improved by using one of the components present in all biofeedback treatment, contingency management. Three cases of orofacial dysfunction were treated by reinforcing specific improvements reliably detectable without the use of biofeedback equipment. The results showed that contingency management procedures alone were sufficient to improve overt motor responses but, unlike biofeedback treatment, did not produce decreases in the hypertonic muscle groups associated with the trained motor behavior. The findings suggest that sophisticated, expensive biofeedback equipment may not be necessary in treating some neuromuscular disorders and that important clinical gains may be achieved by redesigning the patient's daily environment to be contingently therapeutic, rather than only accommodating the disabilities of the physically handicapped.     

Computers in biofeedback research and therapy

While biofeedback is being used extensively in the clinic and the laboratory, a great deal of variability exists among biofeedback users with respect to instrumentation, treatment protocols, techniques of data acquisition, and methods of data analysis. It is argued that the use of computers in biofeedback will help reduce some of this variability. Other advantages of computers in biofeedback are discussed. Several presently available automated systems are reviewed. Implications for future biofeedback research are also discussed.     

EEG biofeedback vs. placebo treatment for attention-deficit/hyperactivity disorder: a pilot study

METHOD: Seven children diagnosed with attention-deficit hyperactivity disorder (ADHD) were trained using a standard EEG biofeedback treatment protocol designed to alter SMR/theta ratios and reduce behavioral symptomatology diagnostic of ADHD. During alternate periods they were also trained using a placebo protocol that was identical to the treatment protocol, save that the association between EEG patterns and feedback to the participants was random. Single-case design elements were used to control for the effects of internal validity threats such as maturation, history, and treatment order. Two participants failed to complete all training sessions, and the effects of training on behavior were analyzed both including and excluding these non-completers. RESULTS: When all participants were included in analyses that controlled for overall trend, EEG biofeedback was found to be no more effective than the placebo control condition involving non-contingent feedback, and neither procedure resulted in improvements relative to baseline levels. When overall behavioral trends unrelated to training were not controlled for and non-completers were excluded from the analysis, it could be mistakenly concluded that EEG biofeedback is significantly more effective than placebo and that the effect sizes involved are moderate to large. These results indicate that many previous reports of the efficacy of EEG biofeedback for ADHD, particularly those presenting series of single cases, might well have been based on spurious findings.     

The combined use of rational-emotive therapy and biofeedback in the treatment of childhood migraine

The available literature on the psychological treatment of childhood migraine was reviewed and evaluated. The current treatment modalities have relled essentially upon biofeedback techniques and neglected the potential cognitive factors that might lead to successful results. A case example is provided that demonstrates the combined treatment of childhood migraine using both biofeedback and rational emotive therapy (RET). Continued relief was reported during a follow-up interview conducted a year and a half after the treatment concluded. While both the biofeedback and RET elements for treatment were considered important for alleviation of the migraine condition, the subject reported that it was the RET training that proved most effective in dealing with stressors related to the onset of migraine attacks.     

Initial relaxation response: contrasts between clinical patients and normal volunteers

The effectiveness of EMG biofeedback, progressive muscle relaxation, autogenic training, and self-relaxation were compared using a within-subjects design. Thirteen clinical subjects and 48 normal volunteers participated in 4 counterbalanced relaxation sessions using one of the techniques. Frontalis EMG and surface skin temperature were monitored throughout the sessions. For reducing EMG, biofeedback was more effective than the other three techniques. A significant interaction of treatment X subjects was found for changes in skin temperature. Clinical subjects had the greatest increase in skin temperature with EMG biofeedback and analog subjects responded best to self-relaxation. There were no significant differences in initial measures of EMG or skin temperature for the two samples.     

Perceptual asymmetries in normal children and children with attention deficit/hyperactivity disorder

Perceptual asymmetries in normal right-handed children (7-12 years of age) and children with attention deficit/hyperactivity disorder (ADHD), combined type, were investigated using various chimeric stimuli in free-viewing conditions. In the face-matching task, participants indicated which of two symmetrical face chimeras more closely resembled the original; in the chimeric faces task, participants indicated which of a pair of faces appeared happier; and in the grey scales task participants indicated which of two shaded rectangles appeared to be darker overall. Leftward biases were found for normal children with no effects of age. Contrary to expectations, normal leftward biases were also found for ADHD children in the face-matching and the chimeric faces tasks; however, a significant leftward bias was not observed in the grey scales task. The absence of anomalous perceptual bias in ADHD children on these purely perceptual tasks, suggests that anomalous perceptual asymmetries observed in other tasks (line bisection and cancellation tasks) may have been confounded by the motor response, and/or the explicit spatial components of those tasks.     

Sex Differences in the Pathway from Low Birth Weight to Inattention/hyperactivity

Inattention/hyperactivity is a childhood outcome of low birth weight. However, the mechanisms by which low birth weight leads to inattention/hyperactivity are unclear. This study examined arousal, activation, motor speed, and motor coordination as possible mechanisms, attending to sex differences. 823 children (400 males) from Detroit and surrounding suburbs were assessed with the Child Behavior Checklist and the Teacher Report Form and completed experimental tasks to assess vigilance and activation (Continuous Performance Test signal detection parameters) and motor output speed and control (Grooved Pegboard) at 6 years of age. The relationship between birth weight and inattention/hyperactivity was slightly, but not significantly, stronger for boys than for girls. Arousal, motor speed, and motor coordination significantly partially mediated the relationship between birth weight and inattention/hyperactivity for boys and girls. Moderated mediation was found for the pathway between motor coordination and inattention/hyperactivity such that this relationship was stronger for boys than for girls. Sex differences in the associated features of attention symptoms may reflect partially distinct etiological pathways.     

Old and new controversies in the alternative treatment of attention-deficit hyperactivity disorder

Use of complementary and alternative medicine (CAM) for treatment of attention-deficit hyperactivity disorder (ADHD) has become widespread in both referral and primary care populations. We review the purported mechanism of action and available evidence for selected CAM therapies for ADHD. Enduring controversies, such as elimination of artificial food additives, colors, and/or preservatives; the effect of sugar on behavior in children; and the use of EEG biofeedback, have been well studied but lack support as effective sole treatments for ADHD. The initial evidence for some emerging CAM therapies, such as essential fatty acid supplementation, yoga, massage, homeopathy, and green outdoor spaces, suggests potential benefits as part of an overall ADHD treatment plan. More rigorously designed studies are needed to evaluate their effectiveness as single therapy for ADHD.     

Increased visual bias in children with developmental coordination disorder: Evidence from a visual-tactile temporal order judgment task

BackgroundPrevious studies have suggested that children with developmental coordination disorder (DCD) rely heavily on vision to perform movements, which may contribute to their clumsy movements. However, few studies have objectively and quantitatively investigated the perceptual biases of children with DCD.MethodsA visual-tactile temporal order judgment (TOJ) task was used to measure and compare the perceptual biases of 19 children with DCD and 19 age- and sex-matched typically developing children. The point of subjective equality, which demonstrates when “visual first” and “tactile first” judgment probabilities are equal (50%), obtained by analyzing the results of the visual-tactile TOJ task, was used as an indicator of perceptual biases. Further, variables (age and manual dexterity in all participants; motor function, autism spectrum disorder and attention-deficit hyperactivity disorder traits, and depressive symptoms in children with DCD) associated with perceptual biases were examined with correlation analysis.ResultsChildren with DCD had significantly stronger visual bias than typically developing children. Overall correlation analysis showed that increased visual bias was significantly correlated with poor manual dexterity.ConclusionChildren with DCD had a strong visual bias, which was associated with poor manual dexterity.     

Heterogeneity of biofeedback training effects in spasmodic torticollis: a single-case approach

Data from 184 biofeedback sessions are presented, in which 10 subjects with spasmodic torticollis had been trained to reduce pathologic activity in the hypertrophied sternocleidomastoid muscle. Each session was conducted as a single case experiment with nine successive trials. Attempts were made to distinguish motor learning processes which can be elicited independently from the biofeedback-condition from the effects of specific biofeedback information. Results showed dramatic decreases of muscle activity under biofeedback. Contrary to expectation, action potentials did not decrease across a course of 14 training sessions. Instead, effects were exhibited in an all-or-none fashion early in the training. Single-case ARIMA intervention analysis has shown that in 59% of the sessions EMG decreases demonstrated under biofeedback could be elicited prior to biofeedback in a condition of instructed control. Case studies revealed complex interactions of instructed control, specific biofeedback effects, unspecific effects of the biofeedback setting, and cognitive processes. Effects obtained within experimental sessions varied highly between subjects. Results are discussed in terms of newer concepts of basal ganglia dysfunction, and conclusions for the use of biofeedback paradigms in torticollis subjects are outlined.     

Speech Perception: Cognitive Foundations and Cortical Implementation

ABSTRACT— Speech perception includes, minimally, the set of computations that transform continuously varying acoustic signals into linguistic representations that can be used for subsequent processing. The auditory and motor subroutines of this complex perceptual process are executed in a network of brain areas organized in ventral and dorsal parallel pathways, performing sound-to-meaning and sound-to-motor mappings, respectively. Research on speech using neurobiological techniques argues against narrow motor or auditory theories. To account for the range of cognitive and neural attributes, integrative computational models seem promising.     

Perceptual or motor learning in SRT tasks with complex sequence structures

We investigated under which conditions sequence learning in a serial reaction time task can be based on perceptual learning. A replication of the study of Mayr (1996) confirmed perceptual and motor learning when sequences were learned concurrently. However, between-participants manipulations of the motor and perceptual sequences only supported motor learning in cases of more complex deterministic and probabilistic sequence structures. Perceptual learning using a between-participants design could only be established with a simple deterministic sequence structure. The results seem to imply that perceptual learning can be facilitated by a concurrently learned motor sequence. Possibly, concurrent learning releases necessary attentional resources or induces a structured learning condition under which perceptual learning can take place. Alternatively, the underlying mechanism may rely on binding between the perceptual and motor sequences.     

The use of biofeedback techniques with school-aged children exhibiting behavioral and/or learning problems

This article reviews 44 studies that investigated the efficacy of biofeedback techniques in treating childhood behavioral and learning disorders. Although the data suggest that children can learn voluntary control over a variety of physiological processes, methodological flaws make it impossible to specify the mechanisms responsible for such learning. Further, the data do not suggest that biofeedback techniques are superior to more conventional treatments in remediating learning or behavioral disorders. Suggestions for future research focus upon the elimination of methodological weaknesses, the use of more stringent diagnostic criteria, and the use of more sophisticated biofeedback equipment and procedures.     

Assessing clinically relevant perceptual organization with multidimensional scaling techniques

Multidimensional scaling (MDS) techniques provide a promising measurement strategy for characterizing individual differences in cognitive processing, which many clinical theories associate with the development, maintenance, and treatment of psychopathology. The authors describe the use of deterministic and probabilistic MDS techniques for investigating numerous aspects of perceptual organization, such as dimensional attention, perceptual correlation, within-attribute organization, and perceptual variability. Additionally, they discuss how formal quantitative models can be used, in conjunction with MDS-derived representations of individual differences in perceptual organization, to test theories about the role of cognitive processing in clinically relevant phenomena. They include applied examples from their work in the areas of eating disorders and sexual coercion.     

The relationship between frontalis muscle activity and self-reports of headache pain

The relationship between levels of frontalis muscle activity and self-reports of pain was evaluated in two studies. In Study I frontalis muscle activity and self-reports of pain collected during biofeedback treatment of muscular contraction headache clients were correlated. In Study II frontalis EMG activity was increased and decreased using biofeedback techniques while concurrent reports of headache pain were recorded. The results of Study I indicated a significant relationship between EMG activity and reported headache pain for only two of the five subjects studied. The biofeedback procedures in Study II were associated with reliable increases and decreases in EMG activity. Concordance between EMG and pain reports occurred only during the EMG increase condition. Overall correlations were significant for one of the 2 subjects. The results suggest that EMG activity may not be sufficient to account for pain reports in all chronic headache clients, and variables other than EMG activity may be influencing reports of pain in some patients.     

Hyperactivity and pediatrician diagnoses,parental ratings,specific cognitive abilities,and laboratory measures

Children diagnosed as hyperactive and treated for hyperactivity by private pediatricians were compared to a large unselected sample of children on parental ratings of behavioral problems (Conners Symptoms Rating Questionnaire), laboratory measures (a week-long assessment of locomotion as measured by pedometers, sustained attention, selective attention, fidgeting, and aggressiveness), and 10 tests of specific cognitive abilities (verbal reasoning, spatial reasoning, memory, and perceptual speed). Test-retest reliability was obtained for all measures. The results indicated that pediatrician diagnoses of hyperactivity are related to parental ratings but not to laboratory assessments. Diagnoses by private pediatricians may include more heterogeneous and nonspecific behavioral problems than diagnoses made in most research contexts. Pediatrician diagnoses were related to deficits in specific cognitive abilities, most notably perceptual speed and verbal ability. Hyperactivity as diagnosed by private pediatricians may reflect deficits in skills necessary to pace oneself appropriately in school-related tasks. In general, these results suggest that the criteria and methods used to diagnose hyperactivity deserve greater attention.We are grateful to the Spencer Foundation for their support of this research. Preparation of this report was supported in part by a Research Scientist Development Award (AA-00041) from the ADAMHA NIAAA.     

Perceptual decoupling or motor decoupling?

The current investigation was conducted to elucidate whether errors of commission in the Sustained Attention to Response Task (SART) are indicators of perceptual or motor decoupling. Twenty-eight participants completed SARTs with motor and perceptual aspects of the task manipulated. The participants completed four different SART blocks whereby stimuli location uncertainty and stimuli acquisition were manipulated. In previous studies of more traditional sustained attention tasks stimuli location uncertainty reduces sustained attention performance. In the case of the SART the motor manipulation (stimuli acquisition), but not the perceptual manipulation (stimuli location uncertainty) significantly reduced commission errors. The results suggest that the majority of SART commission errors are likely to be indicators of motor decoupling not necessarily perceptual decoupling.     

Bad things come easier to the mind but harder to the body: Evidence from brain oscillations

An intriguing finding of research on emotional processing is a discrepancy between perception and behavior. Perceptually, a robust finding is that negative stimuli are processed faster and more efficiently than positive stimuli. Behaviorally, a similarly robust finding is that response times are slower for negative than for positive stimuli. We proposed and tested a novel account to explain this still unexplained discrepancy, on the basis of the assumption that negative valence narrows perceptual processes to the benefit of speeded perception, but broadens motor processes at the cost of slowed responding. Participants performed a valence judgment task in which they responded with their left or right hand to negative and positive stimuli that were presented on the left or right, and we measured the activation of relevant/deactivation of irrelevant perceptual and motor processes, as revealed by the lateralization of electroencephalographic brain oscillations. Stimulus-related lateralization of alpha activity (8–12 Hz) over perceptual areas was increased for negative stimuli, indicating more efficient perceptual processing. By contrast, response-related lateralization of beta activity (20–25 Hz) over motor areas was decreased for negative stimuli, indicating less efficient response activation. Consistent with our predictions, more detailed analyses showed that both lateralization effects were caused by dynamics at the level of inhibiting irrelevant processes. For negative as compared to positive stimuli, the inhibition of irrelevant perceptual processes was increased, but the inhibition of irrelevant motor processes was decreased. These findings indicate that the discrepancy between perception and behavior in emotional processing may stem from asymmetrical effects of emotional valence on the breadth of cortical activations in perceptual and motor networks.     

Constraining theories of embodied cognition

Influences of perceptual and motor activity on evaluation have led to theories of embodied cognition suggesting that putatively complex judgments can be carried out using only perceptual and motor representations. We present an experiment that revisited a movement-compatibility effect in which people are faster to respond to positive words by pulling a lever than by pushing a lever and are faster to respond to negative words by pushing than by pulling. We demonstrate that the compatibility effect depends on people's representation of their selves in space rather than on their physical location. These data suggest that accounting for embodied phenomena requires understanding the complex interplay between perceptual and motor representations and people's representations of their selves in space.