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.     

Breaking the cycle: cognitive behavioral therapy and biofeedback training in a case of cyclic vomiting syndrome

The present article presents a case of cognitive behavioral therapy (CBT) along with heart rate variability (HRV) biofeedback training for the treatment of a medication unresponsive 13-year-old boy with cyclic vomiting syndrome (CVS). CVS is characterized by recurring stereotypic episodes of vomiting, interspersed with asymptomatic periods. Triggers for vomiting include anticipatory anxiety related to school examinations, family conflicts, and birthday parties as well as infectious diseases, and certain foods. Current treatment design addressed two pivotal etiological factors: autonomic dysregulation and anticipatory anxiety. Treatment outcome suggests that vomiting episodes may be successfully prevented by aiding the patient to identify and manage precipitant psychological stressors, to regulate HRV patterns, and gain a renewed sense of bodily control and self-efficacy. Further research is suggested using a controlled study with pre- and post-behavioral and stress measures to evaluate the effectiveness of CBT and biofeedback training compared to pharmacotherapy and placebo.     

An evaluation of a caregiver training protocol on the generalization and maintenance of successful pediatric feeding interventions

Previous researchers have documented the positive effects achieved by trained clinicians providing behavioral interventions for pediatric feeding disorders; however, few have evaluated the maintenance of those treatments when subsequently implemented by primary caregivers. Further, the majority of previous caregiver training research has relied on the use of multicomponent training packages making it difficult to determine which components are necessary for success. The purpose of the current investigation was to evaluate the effects of instructions and feedback on caregivers' implementation of feeding protocols in a home setting. Results of the current study suggest that feedback may be the most effective training component in training packages designed to teach caregivers to implement an effective feeding protocol. Potential concomitant changes in child behavior are also discussed.     

EMG biofeedback training, relaxation training, and placebo for the relief of chronic back pain

24 patients with chronic low back pain were randomly assigned to three treatment conditions: EMG biofeedback, relaxation training, and a placebo condition. Patients were seen for eight sessions and were evaluated before Session 1 and after Session 8. Eight analyses of covariance which were adjusted for age and pretest scores were computed on the final scores to find which variables could detect significant difference between treatments. Age was included as a covariate because the differences in age between conditions were significant. Four variables with significant and nearly significant differences were chosen for analysis. The second set of analyses identified the nature of the differences among the three conditions. These included a priori planned comparisons among conditions, and paired t tests. Relaxation-trained subjects were significantly superior to subjects in the placebo condition, in decreasing pain during the function test, increasing relaxation, and decreasing Upper Trapezius EMG. They were superior to EMG Biofeedback training in increasing reported activity. Both Relaxation and EMG trained subjects were able to reduce Upper Trapezius EMG by Session 8. Relaxation-trained subjects showed significant change on eight of the 14 possible comparisons for each treatment condition. EMG biofeedback training showed significant favorable results in only one condition; the placebo condition showed no significant results. Relaxation training gave better results in reducing EMG and pain, and in increasing relaxation and activity than either EMG biofeedback alone or a placebo condition.     

You are not alone – adolescents’ experiences of participation in a structured skills training group for ADHD

Little is known about how adolescents with attention deficit/hyperactivity disorder (ADHD) experience participating in group therapy, an important factor to consider when developing treatment methods for this age group. This study aimed to explore how adolescents with ADHD experience participating in a structured skills training group program based on dialectical behavioral therapy. Semi-structured interviews were conducted with 20 adolescents (15–18 years of age) with ADHD after participating in a structured skills training group. The interviews were transcribed verbatim and qualitative content analysis were used to analyze the text. The participants emphasized the value of meeting other adolescents with ADHD and the opportunity to exchange experiences, strategies and tips. Participating in the group treatment made the adolescents realize that they were not alone, and feelings of togetherness and an increased acceptance of themselves were described. The participants associated the treatment with elevated knowledge and understanding, for example, about ADHD, their own functioning and helpful strategies. They also described emotional and behavioral changes, such as higher self-esteem, fewer inter-personal conflicts and improved concentration. Activating and experiential exercises were considered important elements of the treatment, and the participants expressed a need for a variation of exercises, as well as more time for practicing skills, discussions and breaks. The results indicate that the group format add an extra value to the treatment and that the use of an active approach throughout the treatment is of importance for this group of patients.     

EEG feedback training in the treatment of epilepsy: Some questions and some answers

A basic question in EEG feedback training of epileptic patients is whether the decrease in seizures is specifically due to the training or to other factors. Questions may also be raised as to what EEG changes are involved. Preliminary results in five patients suggest that seizure reductions can occur with training which are not due to placebo or nonspecific effects or to changes in medication compliance. These changes occurred rapidly during EEG-contingent feedback training but not when feedback was random in relation to the EEG. Reliable changes in the EEG were also observed, but the question of which mechanism accounts for these results has yet to be answered.     

Functional analysis skills training for residential caregivers

Functional analysis is the most effective assessment for identifying the maintaining contingencies of aberrant behavior. However, it is suggested that functional analyses are not conducted regularly due to the level of skill required. A multiple baseline design across participants was used to assess if four residential caregivers, with limited experience with applied behavior analysis, could be trained to implement the standard analog functional analysis conditions. The training consisted of a lecture, written information, modeling, rehearsal, and feedback. Results showed that all participants attained percentage correct responding scores above 95% on three consecutive trials following training. One caregiver showed positive generalization of skills to the assessment of another behavioral topography. The result of this study provides further evidence that lay individuals can be trained to assist in conducting functional analyses. Copyright © 2008 John Wiley & Sons, Ltd.     

EEG Biofeedback for Addictive Disorders—The State of the Art in 2004

This paper reviews studies of brainwave biofeedback as a therapeutic technique for substance use disorder. This modality is attractive as a medication free, neurophysiologic, and self actualizing treatment for a substance based, brain impaired and self-defeating disorder. Three approaches are described and the literature for each reviewed. Alpha–theta occipital feedback was originally employed to facilitate autosuggestion in hypnagogic states to augment standard therapy approaches in substance abuse treatment programs and appears most suited for chronic treatment resistant alcoholics. Beta augmentation feedback in conjunction with alpha/theta feedback has been employed in mixed substance abuse and stimulant abuse with good results. Individualized brainwave biofeedback based on correcting EEG abnormalities, or based on addressing comorbid conditions is a third approach that has been described, and may be most appropriate where confounding comorbid conditions are present. Although effectiveness in certain hard to treat populations (conventional treatment resistant alcoholics, crack cocaine addicts, cognitively impaired substance abusers) is promising, better-designed controlled studies are needed.     

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent–child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study’s limitations, and future directions for research are further discussed.     

EVALUATION OF A TRAINING MANUAL FOR THE ACQUISITION OF BEHAVIORAL ASSESSMENT INTERVIEWING SKILLS

Two procedures were used to teach behavioral assessment interviewing skills: a training manual and one-to-one instruction that included modeling, rehearsal, and feedback. Two graduate students and two advanced undergraduates were trained with each procedure. Interviewing skills were recorded in simulated assessment interviews conducted by each student across baseline and treatment conditions. Each training procedure was evaluated in a multiple baseline across students design. The results showed that both procedures were effective for training behavioral interviewing skills, with all students reaching a level of 90%-100% correct responding. Finally, a group of experts in behavior analysis rated each interviewing skill as relevant to the conduct of an assessment interview and a group of behavioral clinicians socially validated the outcomes of the two procedures.     

Biofeedback to enhance psychophysiological effects of imagery

Unlike most applications of biofeedback, the outcome goal and the aim of the present investigation was to increase arousal by the provision of feedback. The ability to generate psychophysiological arousal during noxious imagery may be therapeutically beneficial to individuals receiving emotive imagery therapies, and in the present study we evaluated biofeedback as a means of correcting psychophysiological deficits in imagery. Thirty psychophysiologically unreactive undergraduates were randomly assigned to skin-resistance-level biofeedback, false-feedback, or no-feedback conditions for six sessions of assessment and treatment. The methodology controlled for placebo, practice, and initial value effects. Significant increases in skin resistance level, heart rate, and frontalis electromyography accrued to the biofeedback group but not the control groups, and these gains persisted when biofeedback was withdrawn. Subjective measures showed no changes. The results support the usefulness of biofeedback as a remedy for imagery underarousal.     

Awareness of the response after feedback training for changes in heart rate and sudomotor laterality

What is the relation between the ability to control visceral responding on a biofeedback task and the ability to report behaviors actually contributing to this performance? Subjects received biofeedback training for unidentified visceral responses and then gave written reports about what they had done to control the feedback displays. Independent judges were given these reports and, on the basis of knowledge about activities known to contribute to visceral activity, were asked to determine the visceral responses for which the subjects had been trained. The reports of subjects who succeeded at bidirectional control of heart rate (Experiment 1) or sudomotor laterality (Experiment 2) showed awareness of behaviors related to feedback as assessed by this procedure, whereas the reports of subjects who failed at bidirectional control did not. Subsequent experiments indicated that these results did not depend on a learning strategy that might have been specific to the initial studies. These findings call into question the view that people are unaware of what they have done to produce the response after training on biofeedback tasks. Earlier studies reporting lack of awareness in biofeedback are discussed in light of factors that affect the measurement of biofeedback learning and response awareness.     

From Resistance to Buy-In: Experiences of Clinicians in Training Using Feedback-Informed Treatment

In this qualitative research study, the authors use grounded theory analysis to examine the experiences of clinicians in training and use client feedback to inform treatment. Twenty-six marriage and family therapy graduate students in their first or second semester of clinical practicum participated in this study. Participants were trained in eliciting and responding to client feedback at the end of every therapy session. At the end of the semester, participants reflected on their learning experience. Participant experiences reflected a developmental learning process beginning with significant challenges followed by positive clinical changes and positive clinician changes, culminating in overall buy-in regarding the importance of client feedback for nearly all clinicians. The results support the literature that client feedback directly informs the therapeutic process while suggesting important recommendations for training new clinicians in learning to use client feedback.     

An Intensive Summer Treatment Program for ADHD Reduces Parent–Adolescent Conflict

There are currently almost no treatment efforts to reduce parent–adolescent conflict in adolescents with ADHD. As such, this study investigated the effect of an intensive Summer Treatment Program for Adolescents with ADHD (STP-A) on parent–adolescent conflict. Twenty adolescents and their parents completed the 8 week behavioral treatment program, which included 320 hours of adolescent-directed treatment, 15 hours of parent behavior management training, and daily feedback from staff on parent implementation of a home-based behavioral contract. Results indicated that 70–85 % of adolescents who attended the STP-A demonstrated reliable improvement in parent–adolescent conflict from baseline to post-treatment. Treatment response was associated with higher levels of conflict at baseline, but not adolescent ODD severity or parent ADHD severity. Several patterns of treatment non-response were detected through visual examination of weekly conflict scores during the STP-A. Discussion suggests that intensive, parent-involved treatment programs may be necessary to improve home-conflict in adolescents with ADHD.     

The use of behavioral skills training to improve staff performance of discrete trial training

Well‐trained staff are a prerequisite for successful implementation of treatment plans when working in human service contexts. The high rate of turnover makes the use of efficient and effective staff training all the more important. Previous research has used behavioral skills training to train teachers in correct implementation of discrete trial training of children with autism. They showed that a brief 10‐min procedure could effectively train staff and result in improved performance. The current study elaborated on previous work by using participants without prior exposure to the method, including treatment integrity data and testing for maintenance 1 month after training ended. The mean percentage of correct teaching responses for the three participants increased from 70%, 58%, and 66% during baseline to 97%, 96%, and 99%, respectively, following training. Results indicated that the training package was effective and the results were maintained 30 days later.     

Using perceptual home-training to improve anticipation skills of soccer goalkeepers

ObjectiveThis study aims to test the effectiveness of a perceptual training concerning the anticipatory skills of soccer goalkeepers, by assessing their performances while engaged in predicting the direction of penalty kicks.DesignForty-two skilled goalkeepers were randomly assigned to three training groups: Experimental, placebo, and control. All the groups were tested at the beginning of the experiment and re-tested after a period of eight weeks.MethodThe pre-test consisted of the presentation of temporally occluded videos of penalties recorded from the goalkeeper's perspective, and participants had to predict the direction of the ball. The experimental group practiced with an interactive home-training, based on video analogous to those of the test, with the addition of both positive and negative feedback. The placebo group viewed television footage of penalty kick shoot-outs. Participants of both groups were free to schedule their own training/placebo sessions. Finally, the control group did not receive any treatment.ResultsThe results demonstrated the effectiveness of the home-training protocol, evidencing significant accuracy improvements between pre-test and post-test only for the experimental group.ConclusionsThe outcomes indicate that skilled athletes can benefit from perceptual training, which was not investigated before among soccer goalkeepers. Indeed, all the previous training studies concerning soccer penalty predictions were run on participants with either recreational or no goalkeeping experience at all. Moreover, the present training protocol is innovative because learners can schedule training sessions on their own. Finally, its usability suggests numerous potential applications.     

Cortical alpha rhythm, biofeedback, and the determinants of subjective state

A critical assumption in the rationale for the clinical application of voluntary control over central nervous system (CNS) activity is that there exists a direct relationship between specific CNS activities and specific subjective mood states. The experiment reported here was based on the idea that a joint manipulation of both cognitive and physiological (i.e., alpha electroencephalographic [EEG]) variables would provide information required for an explication of the processes involved in subjective mood change. Three main variables were considered in the present experiment. First, the instructions were designed to induce a "set" or expectations for either positive or negative changes in subjective mood. Second, the type of feedback (alpha or not alpha) was varied. Those in the not-alpha feedback condition received feedback contingent on the absence of alpha activity, whereas those in the alpha feedback condition received feedback contingent on the presence of alpha activity. Third, an estimate of each individual's baseline alpha density was obtained, and on this basis subjects were classified as high-baseline or low-baseline subjects. Baseline alpha density, alpha density during training, and subjective mood were all considered as continuous variables. The results of the present study indicate that biofeedback of the cortical alpha rhythm is neither a sufficient nor a necessary condition for changes in subjective mood. In addition, the type of instructions designed to set subjects for positive or negative alterations in subjective states is predictive of changes in subjective state reported during alpha biofeedback training as well as of success at controlling and changing EEG during feedback training. The data presented here permit a direct examination of the actual relationship of EEG changes to changes in subjective mood state. Similar shifts in subjective mood state can be obtained with either increases or decreases in alpha activity. Further, both positive and negative subjective experiences can be associated with increases in alpha activity.     

Combined cognitive and parent training interventions for adolescents with ADHD and their mothers: A randomized controlled trial

This study examined the individual and combined effects of two nonpharmacological treatments for attention deficit/hyperactivity disorder (ADHD): Cogmed working memory training (CWMT) for adolescents and behavioral parent training (BPT) for mothers. Ninety-one adolescents (ages 11–15) and their mothers were randomized to one of four CWMT and BPT treatment and active control (placebo) group combinations of 5-week interventions. At pre- and posttest, mothers and teachers completed rating forms, and adolescents completed neuropsychological measures of working memory (WM). Individual intervention effects showed that treatment CWMT significantly improved WM spans, whereas there were no significant differences for treatment or control BPT on reports of parent-related outcomes. Combined treatment effects indicated an overall pattern of greatest improvements for the control CWMT/treatment BPT group, as compared to the other three groups, on adolescent WM deficit, behavioral regulation problems, and global executive deficit. Most significant effects for outcomes were main effects of improvements over time. A combination of CWMT and BPT did not result in increased treatment gains. However, potential effects of combined treatment may have been masked by greater perceived benefits arising from lack of struggle in the nonadaptive, CWMT active control condition. Future combined intervention research should focus on specific, theoretically driven WM deficits among individuals with ADHD, should include possible adaptations to the standard CWMT program, should examine effectiveness of cognitive treatments combined with contextual interventions and should utilize appropriate control groups to fully understand the unique and combined effects of interventions.     

Parenting cognitions and treatment beliefs as predictors of experience using behavioral parenting strategies in families of children with attention-deficit/hyperactivity disorder

We tested a model of mothers' parenting efficacy and attributions for child ADHD behaviors as predictors of experiences with behavioral treatment. The model proposed that mothers' beliefs regarding the acceptability and effectiveness of behavioral strategies would intervene between mothers' cognitions about parenting and child behavior and their treatment experiences. Participants were 101 mothers of 5- to 10-year-old children (82% male) with ADHD. Mothers reported their parenting efficacy and attributions for child behavior, and then received a single session of treatment teaching 2 behavior management strategies. Then, mothers reported their beliefs regarding the acceptability and effectiveness of these strategies. A follow-up phone interview 1 week later assessed mothers' experiences in using the behavioral strategies. The overall model fit the data. Attributions of child ADHD behavior as more pervasive, enduring, and within the child's control were related to seeing behavioral treatment as more acceptable, but neither attributions nor treatment acceptability predicted treatment experience. However, mothers with higher parenting efficacy viewed the behavioral strategies as more likely to be effective, and this pathway significantly predicted positive treatment experience. Implications for understanding the variables that contribute to parental decision-making and treatment participation for childhood ADHD are considered.