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Chapter 2
EEG Neurofeedback
Professional Provider Systems
Play Attention
S.M.A.R.T. BrainGames
Electroencephalogram (EEG) neurofeedback training is a painless, drug-free, and non-invasive procedure. It is a form of biofeedback where the individual’s brainwaves, also called EEG, are used. While there are several types of EEG biofeedback, for clarification purposes it is important to note that any of these types may be called by a number of different names. These names are EEG neurobiofeedback, EEG biofeedback, neurofeedback, neurobiofeedback, and brainwave training. For clarity, EEG biofeedback is any feedback from a physiological system including cardio pulmonary, respiratory, etc. EEG neurofeedback is a highly specialized form of biofeedback that solely monitors brainwave signals.
One way of looking at the various types of EEG neurobiofeedback is by who provides the training. From this perspective, there are three types of systems that are available at the present time. One type is what we will refer to as the “Professional Provider System”. This type of training is primarily provided in a professional’s office and usually done by someone who has had extensive training in EEG neurofeedback as well as in the medical, psychological, or educational fields. This is what might be considered the traditional method that has been practiced for a number of years.
Recently, variations of this method have been developed and are presently on the market. The second type of system we will look at is a home-based system called Play Attention®. With this system, the child’s parent usually provides all the training at home under the professional supervision of Play Attention’s educational support staff. This method also adds cognitive skill training and behavioral shaping as part of the training modality.
The third type of system is called S.M.A.R.T. (Self Mastery and Regulation Training) BrainGames™. It is a system where a professional provider does some of the training in his or her office while the parent does the majority of the training at home.
There are several theories that may explain why EEG neurofeedback is effective. In traditional EEG neurofeedback, an attempt is made to change brainwave patterns that may produce desired physical outcomes. Others do not think the brainwaves change at all, but that the EEG neurofeedback mainly sets the stage for new learning to take place. Since this book is geared toward simplifying fairly complex treatments, we will not go into various theories but will give you one theory that will help you to understand EEG neurofeedback from the traditional view.
From this standpoint, EEG neurofeedback can be seen as a form of operant conditioning. Just as children will tend to do more of those behaviors for which they are rewarded, the brain will also start doing more of those behaviors for which it is rewarded. Since the brain is pliable and capable of learning new behaviors throughout life, it can learn new brainwave patterns and, over time, reproduce them on its own without the need for further brainwave training. These new brainwave patterns are associated with improved functioning, allowing the brain to better control itself, and therefore, resulting in an improvement for a broad range of conditions including ADHD and its related symptoms.
Generally, it is theorized that individuals with ADHD have an excess of slower brainwaves as compared to the general population. These brainwaves are called alpha and theta. They are associated with a brain that has some trouble regulating itself. Some children with ADHD also have an excess of fast brainwaves. These brainwaves are called high beta and are associated with tension and anxiety. As one might expect, these excessive brainwaves result in less than optimal functioning of the brain and can produce many symptoms associated with ADHD. The goal of traditional EEG neurofeedback is to reduce the excessive brainwaves and increase the brainwaves associated with good brain regulation. These good brain waves are called SMR and low beta.
One way of looking at this brain regulation is that it is simply strength and flexibility training for the brain. It exercises the brain in being flexible so that it can shift to producing more “good” brainwaves and fewer “bad” brainwaves. This exercising also builds up strength so that the brain can continue producing the “good” brainwave patterns even after the training sessions are over.
All three of the EEG neurofeedback methods use one or more sensors that are placed on the scalp where they pick up the brainwave activity and send it to a computer. This brainwave signal is then processed and turned into a visual display on a screen. This display is usually in the form of some sort of computer video game. The rewards that the individual receives while playing the games are visual, auditory, and sometimes tactile such as vibration. (It is important to note that the sensors only pick up electrical activity and do not shock or conduct any electrical current to the child.)
The video game shows the individual what the brain is doing, and the person controls the game with his/her brain; no joystick is used except with S.M.A.R.T. BrainGames. Generally speaking, the more the brain produces the desired frequency, the better the game works and rewards the individual. Gradually, the brain responds to the cues that it is being given, and over time, it learns to produce the improved brainwave patterns on its own. These new patterns are directly associated with the brain’s ability to function better, causing enhanced self-regulation and improved behaviors.
Professional Provider Systems
This section describes clinical EEG biofeedback that is provided by professionals. As such, this training can be used to treat a broad range of problem areas and not simply attention-related issues that the home-based units are designed to do.
Names:
EEG Neurofeedback
EEG Biofeedback
Neurofeedback
Neurobiofeedback
Brainwave Training
This form of treatment may be referred to by any of the above mentioned names. There is no agreed upon name which all providers of this treatment use and no single company providing these systems that has the legal rights to their use and protocols.
What it is:
The primary difference that separates this type of EEG neurofeedback from the others is the level of involvement that the EEG neurofeedback provider offers. The provider does the initial assessment, selection of protocols, and is present during the treatment to make ongoing assessments and adjustments to the program. The professional provider is also there to answer all questions and to reassess the situation as training progresses.
How it works:
The training is usually done in the EEG neurofeedback provider’s office as the child sits in a comfortable chair. After an initial assessment, the provider makes the decision as to where on the scalp the sensors need to be placed to achieve the desired outcome. The provider then individually places the sensors and assures that a good contact is made with a paste or saline solution. Once the brainwave frequencies are picked up and sent to the computer, they are amplified and analyzed by the provider. At this point the provider decides which frequencies need to be suppressed and which ones need to be encouraged for optimal brain functioning. During the session the provider monitors the frequencies and the child’s immediate response, making appropriate changes to these frequencies and/or electrode placements as needed.
Training sessions:
Training times usually last from 30-45 minutes, with a little time added before and after each session for evaluation and cleanup. The sessions are usually conducted two or three times per week in the provider’s office.
Many children will need between 20-40 sessions and some may need 40-60 sessions or more to complete the training. For a child with ADHD, 40 sessions would be considered reasonable.
Some providers are equipped to provide home training after a set numbers of sessions in the office. Home training sessions are the same as the ones that are done in the office, except the parent is taught how to use the equipment and the provider monitors the home training and progress. Any needed protocol changes are done either by the client returning periodically to the provider’s office or by the provider explaining to the parent what to do.
Providers:
A professional in the behavioral sciences, and/or the health and educational fields, such as a physician, psychologist, or mental health therapist, usually provides EEG neurofeedback services. However, other professionals may obtain the training and provide this service as well. These providers usually receive extensive specialty training in the area of EEG neurofeedback in addition to their professional training.
In choosing a provider, you may want to consider a provider that can address other issues that your child may have as well. While EEG neurofeedback is used for all ADHD related symptoms including hyperactivity, distractibility, impulsively, and inattention, it is also being used for other conditions which frequently occur along with ADHD. Such conditions include sleep problems, Tourette’s syndrome, depression, bipolar disorder, seizures, anxiety disorders, conduct disorder, and some learning disabilities. In fact, EEG neurofeedback is being used for many conditions in which the brain is not working as well as it might. The research and anecdotal evidence vary depending upon the condition treated.
There is a certification in EEG neurofeedback provided by the Biofeedback Certification Institute of America (BCIA). Finding a provider with this certification may be helpful in choosing a provider. However, in most states, it is not required that a provider has this certification and there are good EEG neurofeedback providers who offer this training without it. Referrals from others who have received this training from the provider and the years of experience this professional has in providing the service should also be factors in your selection process.
Cost:
The cost of services varies depending upon who is doing the training. Most providers charge a comparable amount to what their profession usually charges. If a psychologist provides the training, he/she usually charges from $75 to $100 a session, while a professional educator may charge from $50 to $100. Some individuals provide this service for as little as $50 per session. The cost of 40 sessions would ordinarily range from $2,000 to $4,000. Keep in mind, however, it does not mean that the more one is charged the better the treatment.
Additionally, there is usually a charge for an assessment which is separate from the treatment sessions. These charges vary depending upon who is doing the assessment, the test given, and the duration of the assessment. Assessment costs might run anywhere from $150 to $400.
In regard to insurance, more progressive medical plans may cover EEG neurofeedback for various conditions. However, many medical plans do not cover this cost. Your specific coverage questions will need to be addressed to your insurance company.
Research:
Neurofeedback training is based upon more than thirty years of research. Yet,
within the medical and scientific communities, viewpoints differ widely concerning the usefulness of neurofeedback treatment for ADHD. At one extreme are those who focus on the lack of specific scientific data documenting the effectiveness of this approach. On the other end of the continuum are researchers and practitioners who argue that several published studies clearly establish the value and usefulness of this treatment.
Neurofeedback vs. Stimulant Medication: Matched Treatment Groups
In one study EEG biofeedback was compared to psychostimulant medication.1 There were 46 participants (37 boys, 9 girls) who were between 8 and 21 years of age and had IQs between 80 and 120. The Test of Variables of Attention (TOVA) was administered before and after treatment.
After 20 treatment sessions completed over a period of four to seven weeks, the EEG biofeedback treatment group improved significantly on all four areas of the TOVA. In addition, reports from parents and teachers supported the TOVA results. The medication group also improved in all four TOVA areas.
There was no significant difference between the groups in the degree of improvement shown. Therefore, the researchers concluded that EEG biofeedback is an effective alternative to stimulants and may be preferred in cases where medication is not effective or only partially effective, has adverse side effects, or where compliance with taking medication is low.
Neurofeedback vs. Control Group Study
Another study randomly assigned 18 children (ages 5 to 15) to either a neurofeedback treatment or a wait-list control group.2 None of the children were on medication. The neurofeedback group received 40 sessions, two per week, extending over six months.
All 18 children were assessed before and after treatment on various measures including intellectual functioning and parental behavioral reports of inattentiveness, hyperactivity, and aggression, and defiant behaviors. Compared with the control group, the neurofeedback group demonstrated significant reductions in inattentive behaviors as well as showing significant increases in scores on an intelligence test.
Neurofeedback as Part of Comprehensive Treatment Model
More recently, a larger study was conducted involving 100 children ranging in age from 6 to 19.3 None of the 83 boys and 17 girls had a history of prior treatment for ADHD.
Parents of 51 participants chose to include neurofeedback as part of their child’s comprehensive treatment program, along with medication, counseling, and academic support. The other 49 parents chose not to include the neurofeedback component. Neurofeedback sessions lasting 30 to 40 minutes were conducted on a weekly basis.
The two groups of children did not differ in age, gender, IQ, or socioeconomic status. Parent and teacher ratings regarding ADHD symptoms and participants’ scores on the Test of Variables of Attention (TOVA), on the Attention Deficit Disorders Evaluation Scale (ADDES), and on the QEEG scan were equivalent prior to the treatment.
After one year of treatments, the children were tested twice, once when they were still on medication and a second time after they had been off medication for one week. Significant improvement was noted in both groups on the TOVA and ADDES when participants were tested while using Ritalin. In contrast, only those in the neurofeedback treatment group sustained those gains when the medication was discontinued.
Parents and teachers of children in the neurofeedback group also reported fewer inattentive, hyperactive, and impulsive behaviors both at home and at school after one week without medication. Additionally, children whose parents consistently used effective reinforcement strategies displayed fewer ADHD symptoms.
These findings support comprehensive treatment models that include parent counseling and EEG biofeedback, in addition to stimulant therapy (medication). The researchers report the only type of behavior therapy associated with sustained improvement of core ADHD symptoms in the absence of medication has been EEG biofeedback. One of the implications is that the benefits of neurofeedback are retained when children are not receiving treatment.
German Study: Neurofeedback vs. Stimulant Medication
Another recent study in Germany compared the effects of a 12-week neurofeedback program with stimulant medication. Participants were 34 children, ages 8 through 12.4 The 22 participants (21 boys, 1 girl) in the neurofeedback group did not receive any medication during the entire study.
The 12 participants (12 boys) in the stimulant medication group were administered Ritalin, three times daily on school days. Individual dosages varied between 10 and 60 mg per day. EEG neurofeedback training consisted of three 30-60 minute training sessions per week conducted on weekday afternoons.
There were no pretreatment differences between the groups on any of the following assessment measures: TOVA, Attention Endurance Test, German versions of the IOWA-Conners’ Behavior Rating Scale and the Wechsler Intelligence Scale for Children-Revised (WISC-R).
Post-treatment results reported significant improvements were shown for both groups on all assessment measures except one. Unlike some other studies there were no significant improvements on the intelligence scales for either the neurofeedback or medication group.
Discussion
A limitation in all the above studies is the lack of follow-up for any sustained time period after treatment ended for the children participating in these studies. Because of this limitation, it is not clear whether improvements associated with neurofeedback continued for any significant period after the training concluded.
In the CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) Fact Sheet #6, it is reported that EEG biofeedback treatment has been used for over 25 years and that many parents have reported this treatment option as “extremely helpful” for their child.5 The fact sheet also acknowledges that there have been several published studies of neurofeedback treatment that have shown promising results. However, CHADD cautions that controlled randomized trials need to be conducted before more definitive conclusions regarding the effectiveness of EEG biofeedback can be reached.
Today’s debate about neurofeedback is basically no different from what was occurring 10 or 15 years ago. While several research teams have demonstrated the effectiveness of neurofeedback for ADHD, uncertainty regarding its effectiveness will no doubt continue until more large-scale studies which provide for the necessary scientific controls are conducted. Although more research is still necessary, there have been numerous case study reports and several promising investigations citing positive results in the use of neurofeedback treatments.
Results:
EEG training is a learning process, and therefore results are seen gradually over time. You will usually observe changes in 5 to 10 sessions. Individual results will vary, depending upon age and severity of symptoms. If the child has a number of symptoms, it is common that some symptoms start improving before others.
Once learning is consolidated, the benefits appear to be permanent in most cases. The total number of sessions that it takes to make the changes permanent is hard to estimate but is usually around 20 to 40. Many professionals will taper off the sessions toward the end of the training to ensure that the child maintains the improvements as the sessions become farther and farther apart.
As the research in this chapter shows, EEG neurofeedback does not work for everyone. There is no guarantee that your child will be helped at all. However, the research does show that there is a high probability that at least some of the symptoms of ADHD will be substantially reduced.
Pros & cons
Cautions: No permanent adverse side effects of the training have been documented when a trained professional has provided the service. However, there can be temporary symptoms, such as headaches, which are usually remedied through adjustments in training protocols. If children are on medications, the dosage may need to be reduced or eliminated as the training progresses. Therefore it is necessary for a physician to be kept informed regarding the child’s condition so that he/she does not become overmedicated.
Time: Since each session can take up to an hour and is usually done two or three times per week, time can be an issue as well. Also, scheduling a fairly large number of sessions adds to the time commitment. However, finding a provider who does home training can assist with reducing the time commitment.
Convenience: While the number of EEG neurofeedback providers is growing, their numbers are still not large. It may be difficult to find a provider near you, thereby making it inconvenient to obtain the training. Keep in mind that many providers are willing to work with you in helping obtain the training in a more convenient manner. When a client has to drive a long way, some providers are willing to work with their clients to provide marathon sessions done on weekends only. Also, home training may be a possibility when distance is an issue.
Other: One of the major advantages of working with a professional in the behavioral or medical sciences who provides EEG biofeedback services is that these individuals can also address other conditions that often occur along with ADHD.
Recommended reading and websites:
ADD: The 20-Hour Solution
Training Minds to Concentrate and Self-Regulate Naturally without Medication
Authors: Mark Steinberg, Ph. D. & Siegfried Othmer, Ph.D.
Robert D. Reed Publishers Copyright 2004
This is a comprehensive book that explains all aspects of EEG biofeedback in easy to understand terms. It talks about what ADD really is and how EEG biofeedback works for this condition. It also includes a list of EEG biofeedback providers worldwide.
Getting Rid of Ritalin: How Neurofeedback Can Successfully Treat Attention Deficit Disorder without Drugs
Authors: Robert W. Hill, Ph.D. & Edwardo Castro, M.D.
Hampton Roads Publishing Company, Inc. Copyright 2002
This book talks about ADD and various factors which can affect this disorder. These factors range from nutritional concerns and supplements to toxic substances and parenting skills. It also does a very good job describing EEG biofeedback and how it works. It also includes a list of EEG biofeedback providers worldwide.
The A.D.D. Book: New Understandings, New Approaches to Parenting Your Child
Authors: William Sears, M.D. and Lynda Thompson, Ph.D.
Little Brown and Company Copyright 1998
This book primarily talks about managing ADD without the use of drugs. It talks about helping the ADD child through the use of a variety of interventions such as parenting skills, behavior modification, and nutrition. It is not a book on EGG biofeedback but does have a chapter devoted to this intervention.
Healing ADD: The Breakthrough Program That Allows You to See and Heal the Six Types of Attention Deficit Disorder
Author: Daniel G. Amen, M.D.
Berkley Publishing Group Copyright 2002
The book talks about six types of ADD (Attention Deficit Disorder) and has information on a variety of treatments for ADD in addition to EEG biofeedback. This book does not focus on EEG biofeedback but is very informative for those exploring various treatments for ADD.
A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback
Author: Jim Robbins
Grove/Atlantic, Inc. Copyright 2001
This book tells the story of the development of EEG biofeedback. It includes case studies, scientific explanations of EEG biofeedback, and personal accounts of its uses. This is a good book for those who want to understand how EEG biofeedback got to be where it is today.
There are other websites with information on EEG biofeedback but the three listed below are among the best available for a parent to gain a simple yet comprehensive understanding of the basics of EEG biofeedback. Each of these websites contains research, case studies, and personal stories. They also have lists of EEG providers and links to other websites for those who want to dig deeper.
Contact information:
To find a provider near you, it is suggested you look on the websites listed in this chapter. Several organizations have a world wide provider list posted on their sites. You can also call one of the organizations to obtain a list of providers. A couple of the books mentioned at the end of this chapter also include a list of providers. (See book descriptions.)
End of excerpt
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