Getting Rid of Ritalin: How Neurofeedback Can Successfully Treat Attention Deficit Disorder Without Drugs
by Eduardo Castro, Robert W. Hill
Reviews how EEG biofeedback (neurofeedback) is an effective treatment for ADHD in children.
A Monthly Summary of News and Events
Vol. 5 No. 7 - July 2002
This newsletter is sponsored by EEG Spectrum International Intl, Inc.,
a leader in providing clinical service and training professionals.
Past issues are available at www.eegspectrum.com/newsletter/
Information on how to subscribe or cancel a subscription appear at the end.
The opinions related in this newsletter reflect those of the author only.
Copyright (C) 2002 by EEG Spectrum International Intl, Inc. All rights reserved.
|
|
|---|
Getting Rid of Ritalin: How Neurofeedback Can Successfully Treat Attention Deficit Disorder Without Drugs
A couple of recent scientific papers on the placebo effect reached the popular media, and prompt us to revisit the whole issue of how research might be done to everyone's satisfaction in neurofeedback. The first of these articles was a review of some 47 studies of anti-depressants that had been submitted to the FDA to gain approval for anti-depressant medications. In more than half of those studies, the drugs did no better than placebo. And overall, the improvement with drugs was only 18% greater than it was with placebos. The second of these studies involved functional imagery of drug responders, placebo responders, and non-responders. It found that placebo responders also showed changes in their functional imagery, and that these changes differed from those induced by the effective medications.
These studies elevate the importance of the placebo effect once again in everyone's considerations, which can only serve to increase the burden of proof for neurofeedback. Our traditional answer to this challenge has been to point out that the placebo effect is not really on the other team as far as neurofeedback is concerned. Let me explain. From the perspective of drug interventions, the placebo is the catch-all phrase that subsumes all mechanisms other than the drug itself by which recovery may have been achieved. This includes spontaneous recovery, self-regulation-induced recovery, "the natural course of the disease" (e.g., natural waxing and waning of symptoms), and the results of changes in the psychodynamic milieu.
In another recent study reviewing the placebo effect, it was shown that the majority of the benefit being ascribed to the placebo could be understood in terms of the "natural course of the disease." This is particularly true of depression, where episodes of depression are usually episodic, and recovery is achieved in time regardless of any intervention. However, this still leaves room for a "real" placebo effect of some significance. And this real placebo effect is presumably mediated by "spontaneous" or psychodynamically mediated changes in the quality of brain self-regulation. The possibility of such a self-regulation response helps to make the case for neurofeedback. It does not undermine it. Presumably the natural waxing and waning of depression and other conditions is also reflective of changes in the quality of brain self-regulation. From our perspective, then, the placebo effect, in all its manifestations, is just a stalking horse for self-regulation-mediated recovery. As such, it is our ally, and we are inclined to take umbrage at the dismissal of a real change as being "just a placebo effect."
We have to take skeptics where they are, however, and the question will still be asked, what part of neurofeedback-induced recovery is ascribable to "specific" and to "non-specific" effects of the training. The best study to answer this question was Barry Sterman's serendipitously fully controlled, fully blinded cat study with the monomethylhydrazine. However, if we have to answer this same question with regard to each of the conditions we work with, what are we to do?
The traditional answer has been to compare the active treatment with sham treatment, or to do reversal designs. Reversal designs are no longer ethically permitted (we are not allowed to make people worse), and even placebo designs have their ethical problems. But let's pursue the idea of sham-training a little further. It is extraordinarily difficult to do well. When Sterman did it, he acknowledged that trainees in fact discovered the subterfuge (no surprise). So the blind was broken, and the whole objective of doing a blinded study was not met. To do sham-training well, we have to simulate everything about the person's EEG, including in particular the movement artifacts and the eye-blink artifacts. The only way to do this successfully is to work somehow with the person's actual EEG.
The more difficult standard to meet is that the clinician must be just as invested in success with the placebo treatment as with the experimental treatment, so that any placebo effect may be invoked. How do we fool the clinician who is at the controls into being motivated? The obvious answer is that we must employ an active treatment that also promises some benefit, rather than a total sham treatment. Even having done this, an asymmetry prevails. The clinician knows which is the experimental design, and which is the "B" design. There will be a natural tendency to "lean" in favor of the experimental treatment. The only way for a true "equipoise" to exist with respect to two treatments is for the clinician not to know which is better, and therefore to be motivated to succeed with both.
We have here devised what I think is the perfect experimental design for neurofeedback, an A/B design between two active treatments in which a fundamental doubt exists as to which is better, and outcomes are compared. In this approach, we may lose 'contrast' between treatment and sham, but we heighten our sensitivity to differential effects. We already know that it is not a big deal to demonstrate recovery from depression. What the world will take notice of is differential effects of specific treatment protocols.
Now I will point out that in our clinical work, with our generic protocols, we have in fact been working with this research design all along. Essentially all of our training protocols come in pairs, and are used as necessary to balance each other. The original training on the midline at Cz bifurcated for us into left- and right-hemisphere specificity of "C3beta" and "C4SMR" training. The more recent "C3-C4" training is bifurcating for us into a combination of F3-F4 and P3-P4. Higher-frequency training is complemented by lower-frequency training, etc. Each new client faces the clinician with fundamental ambiguities about protocols that are only resolved on the basis of the differential effects of each protocol.
An analogy that comes to mind is the optometrist who refines his choice of optical correction by means of A/B comparisons. This approach allows much greater refinement than the single-ended approach of "can you read this?" Eventually the optometrist reaches the point where the person can no longer tell which is better. Clinicians using our approach likewise do not settle down to a single protocol until an equivalent resolution is obtained by an elaborate A/B comparison process. Because of the high responsiveness of the individual to specific protocols in-session, feedback is usually quick. This means that the therapist is also in a relatively fast feedback loop of typically no more than a few minutes, but lasting at most a session or two.
This gives neurofeedback practitioners an enormous advantage over pharmacologists. After all, the 250 studies on Ritalin don't help to decide whether a particular child will be helped, and at what dosage. They are not much good in deciding what to do in the moment. By contrast, the neurofeedback practitioner is using best research practice with each and every client. So our answer to those who ask: "where are your controlled studies?" is that we are doing them, one subject at a time. There is almost never a time when we are not doing what would be called for in a "best-practices" controlled research design. Things can't get much better than this.
News & Reviews
NEW BOOKS
Epilepsy and Sleep: Physiological and Clinical Relationships
by Dudley S. Dinner, Hans O. Luders
Magnetic Stimulation of the Human Nervous System
Research Basis for Autism Intervention
Anxiety, Depression, and Emotion
Trauma and Addiction: Ending the Cycyle of Pain Through Emotional Literacy
Handbook of Developmental Cognitive Neuroscience
Guidelines for the use of EEG methodology in the diagnosis of epilepsy
:
European guidelines on EEG methodology that focuses on the diagnosis of epilepsy.
Neuropsychiatric applications of transcranial magnetic stimulation: a meta analysis.
:
Most studies indicate that slow-frequency repetitive TMS (rTMS) and higher frequency rTMS have antidepressant properties; however, effect sizes are heterogeneous and the durability of antidepressant effects is largely unknown.
Regional patterns of brain activity in adults with a history of childhood-onset depression
:
Women with childhood depression had higher right midfrontal alpha suppression, and men with childhood depression had higher left midfrontal alpha suppression.
Perception of emotional chimeric faces in schizophrenia: right hemisphere dysfunction.
:
A specific deficit in right hemisphere attentional functions is found in schizophrenia.
Neuropsychological deficits and opiate abuse.
:
Risk of neuropsychological impairment is greater in opiate abusers, and that recovery may occur during abstinence.
New developments in stroke rehabilitation.
:
Functional magnetic resonance imaging and transcranial magnetic stimulation are among the new techniques broadening our understanding of neuroanatomic relationships involved in brain injury recovery.
Response inhibition deficits in obsessive-compulsive disorder.
:
OCD subjects exhibit deficits in behavioral and cognitive inhibition, which may underlie the repetitive symptomatic behaviors of the disorder.
Extreme male brain theory of autism.
:
Two neglected dimensions for understanding human sex differences are 'empathising' (female) and 'systemizing' (male). Autism may be considered as an extreme of the normal male profile.
Neuropsychology of epilepsy.
:
Authors recommend systematic cognitive tasking, termed "neuropsychological EEG activation", during standard EEG recordings to identify seizure-precipitating factors.
Cognitive impairment in remission in bipolar affective disorder.
:
Patients with mania and unipolar depression show greater residual impairment in more posterior cortical function (temporal lobe) than frontal lobe function in remission.
Anterior cingulate: single neuronal signals related to degree of reward expectancy.
:
Specific neurons in the anterior cingulate cortex are responsive to reward expectancy, a possible animal model for obsessive-compulsive disorder and drug abuse.
Brain anatomy and sensorimotor gating in Asperger's syndrome.
:
Asperger's syndrome is associated with abnormalities in fronto-striatal pathways resulting in defective sensorimotor gating, and this may explain their difficulties inhibiting repetitive thoughts, speech and actions.
Volumetric MRI studies of mood disorders: do they distinguish unipolar and bipolar disorder?
:
Affective illnesses may reflect an underdeveloped (or atrophied) prefrontal region, leading to loss of cortical modulation of limbic emotional networks.
Upcoming Courses
Prerequisites:
All Adv. classes require successful completion of the 4 Day Comprehensive Beta/SMR.
|
Conferences for Neurofeedback Clinicians & Researchers | ||
|---|---|---|
| CONFERENCE | LOCATION | DATES |
| SNR - http://www.snr-jnt.org | Scottsdale, AZ | Sep 12-15 |
A crude survey of neurotherapy offices in the U.S. finds the most in California (182), the least in Vermont and North Dakota (0), and the highest per capita in, of all places, Idaho!?
offices per Million residents
Alabama 1 0
Alaska 5 8
Arizona 23 5
Arkansas 6 2
California 182 6
Colorado 31 8
Connecticut 13 4
Delaware 2 3
D.C. 3 6
Florida 39 3
Georgia 21 3
Hawaii 7 6
Idaho 12 10
Illinois 32 3
Indiana 1 0
Iowa 4 1
Kansas 11 4
Kentucky 5 1
Louisiana 6 1
Maine 4 3
Maryland 17 3
Massachusetts 25 4
Michigan 19 2
Minnesota 20 4
Mississippi 3 1
Missouri 8 1
Montana 4 5
Nebraska 7 4
Nevada 6 3
New Hampshire 3 3
New Jersey 28 3
New Mexico 6 3
New York 72 4
North Carolina 17 2
North Dakota 0 0
Ohio 25 2
Oklahoma 12 4
Oregon 14 4
Pennsylvania 27 2
Rhode Island 3 3
South Carolina 7 2
South Dakota 1 1
Tennessee 11 2
Texas 112 6
Utah 9 4
Vermont 0 0
Virginia 20 3
Washington 38 7
West Virginia 3 2
Wisconsin 11 2
Wyoming 5 10
Puerto Rico 5 2
ALABAMA -- Birmingham
ALASKA -- Anchorage, Fairbanks, Soldotna
ARIZONA -- Cave Creek, Clarkdale, Glendale, Lakeside, Litchfield Park, Mesa, Parker, Peoria, Phoenix, Prescott, Scottsdale, Sedona, Show Low, Tempe, Tucson
ARKANSAS -- Fayetteville, Harrison, Jonesboro, Little Rock, White Hall
CALIFORNIA -- Anaheim, Auburn, Bakersfield, Berkeley, Beverly Hills, Bonita, Brea, Calabasas, Calimesa, Camarillo, Canoga Park, Carmel Valley, Cerritos, Chico, Claremont, Columbia, Corte Madera, Cotati, Culver City, Cupertino, Dana Point, Del Mar, Diamond Bar, El Cerrito, El Dorado Hills, Encinitas, Encino, Escondido, Falls Church, Fountain Valley, Fremont, Fresno, Fullerton, Glendale, Grizzly Flats, Half Moon Bay, Hesperia, Hollywood, Huntington Beach, Irvine, La Canada, La Habra, La Jolla, Laguna Hills, Livermore, Long Beach, Los Angeles, Los Banos, Los Gatos, Los Osos, Malibu, Marin County, Marina Del Rey, Menlo Park, Merced, Milford, Mill Valley, Napa, Newport Beach, North Hollywood, Northridge, Ojai, Orange, Pacific Grove, Palm Springs, Palmdale, Palo Alto, Pasadena, Placerville, Pleasanton, Ramona, Rancho Bernardo, Rancho Cucamonga, Rancho Mirage, Redlands, Redondo Beach, Reseda, Riverside, Sacramento, San Diego, San Francisco, San Jose, San Juan Capistrano, San Leandro, San Luis Obispo, San Mateo, San Rafael, Santa Barbara, Santa Clarita, Santa Cruz, Santa Maria, Santa Monica, Santa Paula, Santa Rosa, Sausalito, Seal Beach, Sherman Oaks, Simi Valley, Stockton, Studio City, Tahoe City, Tehachapi, Temecula, Thousand Oaks, Topanga, Torrance, Tustin, Twenty Nine Palms, Ventura, Walnut Creek, West Hollywood, West Los Angeles, Westlake Village, Willow Creek, Yuba City
COLORADO -- Aspen, Boulder, Colorado Springs, Denver, Englewood, Fort Collins, Greeley, Lakewood, Littleton, Pueblo, Westminster, Woodland Park
CONNECTICUT -- Derby, Middletown, Milford, New Haven, Newington, Redding, Ridgefield, Stratford, Waterford, West Hartford, Westport
DELAWARE -- Boca Raton, Wilmington
DISTRICT OF COLUMBIA -- Washington
FLORIDA -- Bonita Springs, Boynton Beach, Cocoa, Cocon, Cooper City, Coral Gables, Davie, Daytona Beach, Deerfield Beach, Fort Lauderdale, Fort Myers, Gainesville, Jacksonville, Lake Worth, Maitland, Melbourne, Miami, Orlando, Palm Beach Gardens, Pembroke Pines, Pensacola, Point St. Lucie, Redington Shores, Sarasota, South Miami, Tallahassee, Tampa, Venice, West Palm Beach, Winter Park
GEORGIA -- Athens, Atlanta, Augusta, Conyers, Decatur, Douglasville, Dunwoody, Gainesville, Griffin, Jonesboro, Macon, McDowough, Saint Simons Island, Thomasville, Tucker, Woodstock
HAWAII -- Honolulu, Kailua, Kamuela, Waikoloa
IDAHO -- Arlington Hgts, Boise, Coeur d'Alene, Eagle, Hailey, Kellogg, Nampa, Rigby
ILLINOIS -- Anderson, Bloomington, Champaign-Urbana, Chicago, Evanston, Evansville, Gary, Greenfield, Highland Park, Hobart, Hoffman Estates, Kokomo, Matteson, Mount Prospect, Naperville, New Lenox, Northbrook, Olympia Fields, Rockford, Schaumburg, Willowbrook, Winnetka
INDIANA -- Munster
IOWA -- Atlantic, Des Moines, Mount Pleasant, West Des Moines
KANSAS -- Emporia, Fairway, Greenwood, North Newton, Pittsburg, Topeka
KENTUCKY -- Goshen, Lexington, Louisville, Shelbyville
LOUISIANA -- Baton Rouge, Lafayette, Lake Charles, Metairie, Shreveport, Slidell
MAINE -- Bangor, Biddeford, Bucksport, Yarmouth
MARYLAND -- Aberdeen, Baltimore, Bethesda, Catonsville, Chester, Chevy Chase, Dayton, Ellicott City, Hampstead, Laurel, Lutherville, Olney, Salisbury, Wheaton
MASSACHUSETTS -- Amherst, Andover, Beverly, Boston, Cambridge, Great Barrington, Greenfield, Hadley, Holliston, Lexington, Newton Centre, Northampton, Petersham, Waltham, Wellesley, West Barnstable, Worcester
MICHIGAN -- Ann Arbor, Bay City, Bloomfield Hills, Chanhassen, Crystal, Detroit, Dexter, East Lansing, Grand Haven, Grand Rapids, Holland, Kalamazoo, Lansing, Northville, Port Sanilac, Saginaw, St. Joseph
MINNESOTA -- Duluth, Edina, Excelsior, Grand Marais, Minneapolis, North Mankato, Perham, Richfield, Rochester, Rogers , Sauk Rapids, St. Louis Park, St. Paul, Stillwater
MISSISSIPPI -- Columbus, Flowood, Vicksburg
MISSOURI -- Amory, Bel-Nor, Belton, Columbia, Kansas City, St. Louis
MONTANA -- Great Falls, Helena, Missoula, Whitefish
NEBRASKA -- Broken Bow, Crete, Grand Island, Hastings, Lincoln, Milford
NEVADA -- Carson City, Henderson, Las Vegas, Reno
NEW HAMPSHIRE -- Contoecook, East Kingston, Londonderry
NEW JERSEY -- Atlantic Highlands, Audubon, Brick, Chester, Denville, Elberon, Englewood Cliffs, Fair Lawn, Glouster City, Jersey City, Marlton, Matawan, Moorestown, Mountain Lakes, Northvale, Princeton, Princton, Ringwood, Sea Girt, Somerville, South Plainsfield, Tenafly, Turnersville, West Orange, Williamstown
NEW MEXICO -- Albuquerque, Farmington, Santa Fe
NEW YORK -- Akron, Baldwinsville, Bayside, Beachwood, Belle Harbor, Binghamton, Bronx, Brooklyn, Chappaqua, Commack, Croton-On-Hudson, East Meadow, East Northport, East Setauket, Endicott, Flushing, Great Neck, Hampton Bays, Harrison, Hartsdale, Huntington, Ithaca, Kingston, Long Island City, Manhasset, Middle Island, New Paltz, New Platz, New York, New York City, North Bellmore, Nyack, Ossining, Plainview, Port Jefferson Station, Putnam Valley, Saratoga Springs, Shortsville, Staten Island, Stony Brook, Suffern, Valley Cottage, Valley Stream, Warwick, Yonkers
NORTH CAROLINA -- Asheville, Chapel Hill, Charlotte, Fayetteville, Greensboro, Greenville, Hillsborough, Kernersville, Raleigh, Winston-Salem, Youngsville
OHIO -- Akron, Canton, Centerville, Chagrin Falls, Cincinnati, Cleveland, Columbus, Elyria, Gahanna, London, Pickerington, Piqua, Shaker Heights, Sylvania, Toledo, Wadsworth, Westlake, Whitehouse
OKLAHOMA -- Ada, Altus, Enid, Lawton, Norman, Oklahoma City, Tulsa
OREGON -- Amity, Ashland, Corvallis, Eugene, Klamath Falls, Lake Oswego, Lebanon, Medford, Portland, Sweethome, Tigard
PENNSYLVANIA -- Allentown, Bala Cynwyd, Bethlehem, Bloomsburg, Carlisle, Chambersburg, Downingtown, Exton, Langhorne, Morrisville, Newtown, Philadelphia, Phoenixville, Plymouth Meeting, State College, Swarthmore, Trevose, Trooper, Washington, West Chester, Wyomissing, Yardley
PUERTO RICO -- Caguas, Ponce, Rio Piedras, San Juan
RHODE ISLAND -- Narragansett, Providence, Rumford
SOUTH CAROLINA -- Beaufort, Columbia, Florence, Mount Pleasant, Myrtle Beach, Tryon
SOUTH DAKOTA -- Rapid City
TENNESSEE -- Bethel Springs, Chattanooga, Cordova, Franklin, Germantown, Knoxville, Memphis, Nashville
TEXAS -- Abilene, Addison, Amarillo, Athens, Austin, Azle, Bay City, Bedford, Buffalo Gap, Carrollton, Cedar Park, College Station, Colleyville, Corpus Christi, Dallas, Denton, Desoto, El Paso, Euless, Fort Worth, Galveston, Grapevine, Hewitt, Houston, Hurst, Irving, Lake Dallas, Lewisville, Los Fresnos, Lubbock, Mesquite, Midland, Plano, Richmond, Roanoke, Rockport, Round Rock, San Antonio, Texarkana, Tyler, Vernon
UTAH -- Bountiful, Logan, Murray, Orem, Provo, Salt Lake City, South Ogden, St. George
VIRGINIA -- Abingdon, Alexandria, Ashland, Chantilly, Charlottesville, Chesapeake, Glen Allen, McLean, Midlothian, Newport News, Norfolk, Richmond, Roanoke, Trout Dale, Warrenton
WASHINGTON -- Bainbridge Island, Bellevue, Bellingham, Bothell, Burlington, Colville, Edmonds, Everett, Gig Harbor, Kirkland, Lake Stevens, Lynwood, Mercer Island, Mount Vernon, Palouse, Pullman, Seattle, Snohomish, Spokane, Tacoma, Tukwila, Wenatchee
WEST VIRGINIA -- Bluefield, Clarksburg, Parkersburg
WISCONSIN -- Chippewa Falls, Eau Claire, Green Bay, Kenosha, Madison, Milwaukee, Oconomowoc, Wauwatosa
WYOMING -- Casper , Jackson, Lyman, Newcastle, Wilson