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.     

A comparison of stress-reduction behavioral counseling and contingent nocturnal EMG feedback for the treatment of bruxism

This study compared the efficacy of two treatment modalities (stress-reduction behavioral counseling and contingent nocturnal EMG biofeedback) on night-time bruxism. The 16 subjects (Ss) were assigned sequentially to one of four treatment groups: (1) stress-reduction behavioral counseling: (2) nocturnal biofeedback; (3) stress-reduction behavioral counseling and nocturnal biofeedback; and (4) waiting-list control group. A portable EMG unit was used to record the nightly total of electrical activity (?20 μV) from the masseter muscle 10 days before and after treatment. The three treatment procedures were found to be significantly superior to no-treatment control group. The outcome of the two treatments which made use of stress-reduction behavioral counseling, although better than the treatment which solely used nocturnal biofeedback, was not significantly better. This study demonstrates that stress-reduction skills learned while awake can have a generalized effect on stress-induced muscle activity during sleep. Implications for further research are discussed.     

PILLS OR SKILLS FOR HYPERACTIVE CHILDREN

The controversial nature of drug treatment of hyperactivity, the incidence and sequelae of hyperactivity, and problems of differential diagnosis of hyperactivity versus aggression were discussed. The effects of psychostimulant medication and behavior therapy on hyperactive children were reviewed with regard to effects on their social and academic behavior. Both treatments have resulted in clear short-term changes in social behavior but neither long-term academic nor long-term social effects have been shown with either treatment. Short-term effects on academic behavior have resulted from behavioral interventions but not from psychostimulants. However, the interventions have been too brief to allow one to draw unequivocal conclusions about the clinical efficacy of behavioral treatments. Although there have been long-term evaluations of psychostimulant therapy, there have not been any evaluations of long-term behavioral treatment programs for hyperactive children. Given the salutary short-term effects of behavior therapy with hyperactive children, extended clinical trials of behavior therapy need to be conducted. Finally, specific directions are suggested for future research.     

ELECTROMYOGRAPHIC BIOFEEDBACK AND PERCEPTUAL MOTOR TRAINING FOR HYPERACTIVITY

Occupational therapists use various treatments and methods to decrease hyperactivity in children. In this article, the etiology and treatment of hyperactivity is reviewed with special emphasis on neurophysiological indices. Application of perceptual motor and electromyographic biofeedback techniques for inhibition of hyperactive behaviors are compared and contrasted as viable treatment options for the occupational therapist. Electromyographic biofeedback and perceptual motor techniques may prove to be supportive therapeutic interventions.     

Dietary factors and hyperactivity: a failure to replicate

Recent research suggests that sucrose consumption may be a factor in children's hyperactivity. Yet, the manner in which hyperactive behavior was assessed confounded hyperactivity and aggression, thereby reducing the conceptual validity of the findings. In addition, accepting a probability level of 0.06 as significant with 36 correlations, and using grams rather than portions as an index of food consumption might have contributed to a Type I error. When these three issues were addressed in the present study, no significant relationships emerged between sucrose consumption and hyperactivity or aggression assessed as separate dimensions. The age of the hyperactive children in this sample (M = 9.15 years) contrasted with that of the original research (M = 6 years 2 months) and this may contribute to the differential results. Suggestions for further research are outlined, and the need to separate hyperactive children according to whether they receive stimulant medication or not, and assess attention deficit disorders in addition to behavioral components of hyperactivity are stressed.     

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.     

Locus of control and biofeedback: a review of the literature.

This paper first reviews studies which have investigated the efficacy of using locus of control orientation to predict performance in various modes of biofeedback. However, contradictory evidence and methodological problems make it impossible to draw any conclusions regarding the connection between internality-externality and biofeedback performance. Second, various attempts to modify externality through biofeedback treatment are reviewed. Although EMG feedback can apparently be used to shift locus of control in an internal direction, there are some major issues that need to be resolved. Of primary importance is the fact that the rationale for modifying externality is based on an unproven assumption that externality has a role in the causation of various undesirable behaviors. Also, as no follow-up testing has been done, there is no evidence that the EMG biofeedback causes relatively permanent, stable locus of control changes. If the shifts are only temporary, then its use as a modifier of externality is questionable.     

Psychosocial Treatments for Children with Attention Deficit/Hyperactivity Disorder

This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments.     

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.     

Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

One fourth to one half of parents of children with attention-deficit/hyperactivity disorder (ADHD) have ADHD themselves, complicating delivery of evidence-based child behavioral and pharmacological treatments. In this article, we review the literature examining the relation between parent ADHD and outcomes following behavioral and pharmacological treatments for children with ADHD. We also review research that has incorporated treatment of parent ADHD (either alone or in combination with child treatment) with the goal of improving parenting and child outcomes. Finally, we offer recommendations for future research on the relation between parent ADHD and evidence-based treatment outcomes for their children, with the purpose of advancing the science and informing clinical care of these families.     

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.     

Four process studies in the behavioral treatment of chronic headache

Four studies of ‘process’ variables in the behavioral treatment of chronic headache are examined. No relation between headache activity-level reduction and therapist variables such as level of experience (study 1) or warmth, competence or helpfulness as perceived by the patient (Study 2) was found from treatments using relaxation training and/or biofeedback. A significant relation was found, however, between regularity of relaxation practice at home (Study 4) and headache-activity reduction and between regularity of showing some degree of hand warming in thermal biofeedback treatment for vascular headache and headache activity-level reduction (Study 3). Finally, no relation was found between changes in EMG and headache activity-level for tension-headache sufferers treated with frontal EMG biofeedback.     

Behavioral Gerontology Research: Where are the Male Participants?

It has been reported that females are underrepresented in several areas of psychological research, which may have significant clinical and theoretical implications. No one has reported, however, whether women are underrepresented in behavioral gerontology research. To make this determination we recorded the gender of participants in behavioral gerontology studies published in six journals. In 129 published studies that included older adults (i.e. people 55 or more years of age) there were a total of 3070 participants, and most (69%) were female. Underrepresentation of men is significant insofar as treatment effects are sometimes gender specific, making it inappropriate to generalize results from females to males (or vice versa). Moreover, underrepresentation of older men suggests that their behavioral needs may not be generating the attention they deserve. Copyright © 2015 John Wiley & Sons, Ltd.     

What does the MTA study tell us about effective psychosocial treatment for ADHD?

Discussed the initial findings from the recently published, National Institute of Mental Health-sponsored Multimodal Treatment Study (MTA) of attention deficit hyperactivity disorder (ADHD). These findings can be summarized as follows: Medical management alone was found to be significantly more effective for the core symptoms of ADHD as compared to behavioral treatment alone and routine (community) care, and behavioral treatment did not significantly improve outcome when combined with medical treatment. In discussing these findings, it is important to be explicit about the research questions the study was and was not designed to answer. The MTA study provided useful information regarding the question, "Does a very intensive form of behavioral treatment deliver greater benefits than the less intensive forms of behavioral treatment investigated in prior studies?" but little insight on the question, "What type of treatment by what type of therapist is most effective in dealing with what specific problems among specific children with ADHD?" It is suggested that the clearest finding from the MTA study is that the effectiveness of psychosocial intervention for ADHD hinges on the degree to which a broad range of treatment ingredients are considered, carefully selected, matched, and tailored to the individual needs of each child with the disorder, and implemented and monitored over the long term.     

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.     

Modeling ADHD-type arousal with unilateral frontal cortex damage in rats and beneficial effects of play therapy

It has been recently shown that human adolescents with Attention Deficit/Hyperactivity Disorder (ADHD) have frontal lobe deficits, especially on the right sides of their brains (). ADHD is commonly treated with psychostimulants which may have adverse consequences. Hence, less invasive therapies need to be developed. In the present work, we tested the ability of right frontal lesions to induce hyperactivity in rats. We also evaluated the effects of chronic play therapy during early adolescence to reduce both hyperactivity and the elevated playfulness later in development. Play therapy was able to reduce both hyperactivity and excessive playfulness. In additional work, we found that access to rough-and-tumble play in normal animals could enhance subsequent behavioral indices of behavioral inhibition (i.e., freezing in response to a startle stimulus) that appeared to be independent of increased fearfulness and fatigue. Overall, these results suggest that (1) neonatal frontal lobe lesions can be used as an animal model of the overactivity in ADHD and (2) rough-and-tumble play therapy may be a new useful treatment for ADHD.     

Disorder-specific Effects of CBT for Anxious and Depressed Youth: A Meta-analysis of Candidate Mediators of Change

The commonalities between anxiety and depression have been discussed before, but few have delineated the potentially different mechanisms through which treatments work for these populations. The current study conducted a comprehensive review of child and adolescent randomized clinical trials that tested cognitive-behavioral therapy (CBT) for anxiety or depression. All studies were required to have assessed both treatment outcomes and at least one theory-specific process target, including behavioral, physiological, cognitive, and coping variables. Using a meta-analytic approach, CBT demonstrated positive treatment gains across anxiety, depression, and general functioning outcomes. CBT for anxiety also produced moderate to large effects across behavioral, physiological, cognitive, and coping processes, with behavioral targets demonstrating potentially the greatest change. CBT for depression produced small effects for cognitive processes but nonsignificant effects for behavioral and coping variables. Findings were generally consistent with CB theory but suggest potentially different mediators in the treatment of anxiety and depression. Results are discussed in terms of implications for mechanisms research, theories of change, and treatment development.     

Depression

Patients with myocardial infarction who suffer from a depression are at increased risk of dying of a subsequent heart attack or some other complication of coronary artery disease (CAD). A considerable body of research has provided evidence that a major depression, which is found in 16 to 23 percent of patients with CAD, but also subliminal depressive symptoms are independent risk factors for an unfavourable outcome of CAD. However, it is not yet clear whether depression is a causal risk factor having impact on the course of the heart disease or merely a prognostic marker that allows predicting the outcomes of interest, without any causal influence on them. Several pathways between depression and CAD have been discussed. These include behavioral mechanisms such as low compliance with both medical treatment and life style recommendations as well as neurobiological links. Much attention has been paid to the hypothalamic-pituitary-adrenocortical and sympathomedullary hyperactivity found in depression. Other possible links include diminished heart rate variability, stress-induced ischemia, platelet activation, and immunological dysregulation. To resolve the issue whether depression is a causal risk factor or only a prognostic marker, experimental studies are needed to evaluate interventions aimed at improving depression and test whether mortality is subsequently reduced. Such studies brought in the past mixed results. Whereas comprehensive intervention programs including risk factor management have produced a reduction in both coronary morbidity and mortality, a recent multicenter study providing either cognitive-behavioral therapy or usual care to depressed patients with CAD could not demonstrate a survival benefit among the participants of the intervention. Finally, results of evaluation studies regarding integrated disease management programs for patients with comorbid depression are presented.     

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.     

Clinical effects of biofeedback treatment in migraine: The relation to achieved self-control and pretreatment predictors

Abstract

Factors contributing to the headache reduction six months after treatment of sixty-three migraine subjects were examined in three different studies. Subjects had originally been treated with either peripheral skin temperature biofeedback, biofeedback for blood-volume-pulse amplitude of the temporal artery, or applied relaxation. In Study 1 it was found that biofeedback subjects who had achieved self-control of the trained physiological parameter had significantly greater headache reductions than “nonlearners”. In Studies 2 and 3, potential predicting factors of clinical effects were studied. Age and whether subjects had achieved self-control emerged as (weak) predictors in different analyses using discriminant analysis. Using “PLS” (partial least squares projections to latent structures) a model emerged which gave a more complex picture, and which might indicate for example that there are different sets of factors which predict success and predict nonsuccess in treatment.