Transcript EEG Neurofeedback in ADHD: What is the current evidence?

A controlled comparison of EEGneurofeedback and attention training
for children with ADHD.
Tony Steffert, Annie Frick, Martin Batty, Malcolm
Hawken, Claire Sturge, Katherine Loveday, John
Gruzelier.
Limitations of previous
neurofeedback studies
• Rossiter & LeVaque (1995)
– Combined neurofeedback with additional interventions
– Failed to control for patient-therapist contact
• Linden et al (1996)
– Small sample size: difficult to generalise
– Failed to control for patient-therapist contact
• Fuchs et al (2003), Monastra et al (2002)
– Failure to randomly allocate treatment.
– Failed to control for patient-therapist contact
• This has limited the acceptance of neurofeedback as a viable
alternative
Project Aim
• To examine the efficacy of neurofeedback in a
randomised control trial, assessing its effectiveness in
comparison to another computerised intervention.
Groups will be stratified according to medication status
(medicated vs. non-medicated)
Procedure
Subjects
randomly
allocated
Pre-Test
Mid
session
test
30 Sessions
Group 1
Neurofeedback
No medication.
Group 2
Attention task
No medication.
And
N =80
QEEG
Post-Test
And
Group 3
Time 1
Group 4
Neurofeedback
+ Medication.
Attention task
+ Medication
QEEG
Time 2
Assessment Measures
•
•
•
•
•
Test of Variables of Attention (TOVA)
Attention Network Test (ANT)
Suffolk Reading Scale (SRS)
Wide Ranging Aptitude Test – Maths (WRAT)
Eysenck Personality Questionnaire (EPQ)
Assessment Measures
• Strengths and Difficulties Questionnaire (SDQ)
– Parent Ratings
– Teacher Ratings
• Parenting Alliance Measure (PAM)
EEG Assessment Measures
•
•
All assessments carried out following a medication
‘washout period’ of 48 hours
19-channel qEEG assessment on the Mitsar
–
–
–
–
Eyes Open,
Eyes Closed,
Listening
Drawing
Selection Criteria
• No co-morbid psychiatric or neurological conditions
• Subjects receive a DSM IV subtype
(to inform the training protocol)
• Any subjects with significantly elevated beta
(compared to Kropotov database) excluded
Control - Captain’s Log
Computer Attention Training
• A ‘mental gym’
• Increases focused attention and short-term memory, while
reducing impulsivity using specifically designed tasks
• Used in previous research with ADHD children (Sandford,
1994; Slate et al, 1998)
• Also successfully used with psychotic patients (Bell et al, 2001;
Burda et al, 1994) and in cognitive rehabilitation programmes
with brain injured patients (e.g., Stathopoulou & Lubar, 2001)
Training Protocol
• All subjects receive 30 sessions of Neurofeedback or
Captain’s Log training
• Participants in Captain’s Log group have 5 minute eyes
open baseline then 6 x 5 minute games per session
(each game at 2 levels)
• Participants in Neurofeedback group have 5 minute
eyes open baseline followed by 6 x 5 minute NF
training per session
• Training protocol in Neurofeedback group dependent
upon subtype. All training at CZ (Beauregard, 2005,
Lubar and Lubar,1984)
Neurofeedback training protocol
• ADHDin 30 sessions inhibit θ/enhance β1
(enhance attention)
• ADHDhyp 30 sessions inhibit θ/enhance SMR
(reduce hyperactive behaviour)
• ADHDcom children 2 protocols:
Sessions 1-15 inhibit θ/enhance SMR
Sessions 16-30 inhibit θ/enhance β1
• Rationale: inhibit motor activity to reduce hyperactive
behaviour, while increasing attention..
Assessment Measures
• Attentional Network
Task (ANT) Posner et al
(2002, 2004)
• Measures 3 separate
attentional networks
(alerting, orienting,
executive control), based
on earlier functional
studies (e.g. Posner &
Peterson, 1990)
ANT
• Alerting – maintaining an alert state; Calculated
by Mean RT no cue – Mean RT double cue.
• Orienting – selecting information;
Mean RT centre cue – Mean RT spatial cue.
• Executive Attention – resolution of conflict;
Mean RT incongruent – Mean RT congruent.
Results
• All data from 23 subjects (11 NF, 12 CL)
• Data analysed using 2 (GROUP) x 3 (TIME)
mixed ANOVA. Medication status and subtype
not included as factors in the preliminary
analysis
• Any violations in sphericity corrected using
Greenhouse-Geisser adjustment
TOVA Omission Errors
Omission Errors
40
Number of Errors (%)
35
30
25
20
15
10
Neurofeedback
Captain's Log
5
0
Pre
Mid
Post
Time of Testing
Pre test, t = ns. Mid test, t = -2.55 (d.f =18), p= .024
Post test, t = -2.47 (d.f =18), p= .024
ANT Accuracy
100
Accuracy (%)
95
90
85
Neurofeedback
Captain's Log
80
75
Pre
Post
Time of Testing
Pre test t=ns. Post test, t=2.34 (d.f=18), p=.017 (2-tailed)
Strengths and Difficulties (SDQ)
Parent Ratings
Both groups improved equally on the
Stress and
Hyperactivity subscales.
Interpretation
• We demonstrated some advantages for NF in
improving attention on both computerised measures
– TOVA omissions
– Attention Network Task accuracy.
• This was in comparison with training on a
Computerised Attention test, a control comparison that
has not previously been reported on.
• Notwithstanding both groups improved on parent
ratings of hyperactivity and stress.
Neurofeedback Session Analysis
• Future work will include analysis of the neurofeedback
EEG data, both within and between sessions
• Neurofeedback learners will be distinguished from
non-learners
• This differentiation will enable us to determine
whether learned modulation of the EEG correlates with
improved performance on the various cognitive and
behavioural measures
Methodological Issues
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•
•
•
•
Threshold settings
Reward system
Fixed protocols
5 minute trials to long
Filter settings
Thanks to:
Dr Catherine Loveday The University of Westminster.
Drs Linda and Michael Thompson.
Dr Sturge and colleagues, Northwick Park Hospital.
Dr David Vernon.
ADHD Support Group, Harrow.
Silvio Adriovati, Christoph Moehlbrink, Andrea Oskis,
Silvie Rainer, Keri Thornton, Wallis Levin.
All the parents and children who have taken part in the study.