Studies of the Efficacy of Neurofeedback Training for Chronic PTSD
Receives 2017 FNAN Award
The winners of the 2017 FNAN award for excellence in neurofeedback were a team of researchers consisting of Bessel A. van der Kolk, Hilary Hodgon, Mark Gapen, Regina Musicaro, Michael K. Suvak, Ed Hamlin and Joseph Spinazzola for their article “A Randomized Controlled Study of Neurofeedback for Chronic PTSD,” which appeared in the December 16, 2016 issue of PLOS One.
To date, the vast majority of neurofeedback studies have focused more on areas such as Attention Deficit Hyperactivity Disorder (ADHD) and peak performance than on its potential for use in mitigating the symptoms of trauma-related disorders.
Individuals suffering from Posttraumatic Stress Disorder (PTSD) and other trauma-based disorders such as Developmental Trauma Disorder are faced with an often-debilitating inability to regulate their affective states. Although neurofeedback has been adopted by an increasing number of clinicians as a mechanism for enhancing affective regulation for individuals with a trauma history, only a limited number of published studies have sought to measure its effects on this population to date.
In this study, Dr. van der Kolk and his co-investigators recruited 52 adults between the ages of 18 and 58 who suffered from treatment-resistant non-responsive PTSD, with the goal of increasing the subjects’ ability to control their affect regulation, thus allowing them the ability to better control and reduce the symptoms of PTSD. The subjects in the study were divided into a neurofeedback group and a wait-list control group. Members of the neurofeedback group were rewarded for reinforcing the midrange EEG activity (initially between 10 and 13 Hertz) between their right-side temporal lobes (T4 site) and parietal lobes (P4 site), while simultaneously reducing higher and lower frequency activity in the same area. The subjects were trained twice a week for twelve weeks – with a total of 24 sessions of training.
Both the neurofeedback group and the waiting-list group were assessed four times – once prior to the start of the study, once at week six, once at the close of training and once one month after the close of training – using four clinical measures. Of the 22 individuals receiving neurofeedback who completed the study, a significantly smaller proportion (6 out 22 individuals) met the criteria for PTSD at the end of the study than those in the wait-list group (15 out of 22 individuals). Individuals trained in neurofeedback exhibited significant improvement in tension reduction, affect dysregulation and affect instability.
Although the use of neurofeedback as a tool to help people with a trauma history learn to better regulate their arousal has continued to gain popularity with an increasing number of the clinicians who deal with this population over the past ten years, there haven’t been a lot of studies that have sought to document its efficacy since the original work of Eugene Peniston and Paul Kulkosky back in the early 1990s. This clear and well thought out study represents an important step in this direction.
For further information, please refer to the original research article: Bessel A. van der Kolk, Hilary Hodgon, Mark Gapen, Regina Musicaro, Michael K. Suvak, Ed Hamlin and Joseph Spinazzola, “A Randomized Controlled Study of Neurofeedback for Chronic PTSD,” PLOS One, December 16, 2016 (http://www.traumacenter.org/products/pdf_files/Randomized_Controlled_Study_Neurofeedback_Chronic_PTSD_V0002.pdf )
Studies of the Efficacy of Neurofeedback Training for Children with
Attention-Deficit Hyperactivity Disorder Receives 2015 FNAN Award
The winners of the 2015 FNAN award for excellence in neurofeedback are a team of researchers consisting of Naomi J. Steiner, MD, Elizabeth C. Frenette, MPH, Kirsten M. Rene, MA, Robert T. Brennan, EdD and Ellen C. Perrin, MD for a pair of articles showing the effects of neurofeedback training on ADHD children. The first, “Neurofeedback and Cognitive Attention Training for Children with Attention-Deficit Hyperactivity Disorder in Schools,” appeared in January, 2014 in the Journal of Developmental and Behavioral Pediatrics. A six-month follow-up article entitled “In-School Neurofeedback Training for ADHD: Sustained Improvements from a Randomized Control Trial” appeared in February of 2014 in the journal Pediatrics.
There has probably more literature published on the efficacy of neurofeedback as a means of alleviating the symptoms of attention deficit hyperactivity disorder (ADHD) than for any other application of this technology, including several meta-reviews of neurofeedback literature – one of which (Arns et al.) received the Foundation’s 2010 Award. But in spite of the largely positive results reported by the various researchers, many of these investigations have, until recently, been subject to criticism for one or more shortcomings – the relatively small sample size, lack of randomization, or lack of suitable measures of performance and controls. Furthermore, as most previous studies have provided neurofeedback in a clinical or research setting, there have been questions of how feasible it might be in a school setting.
The winners of the 2015 award have sought to address many of these criticisms through a well-designed controlled study of the effects of neurofeedback training on a group of second- and fourth-grade students from the greater Boston (Massachusetts) area.
One hundred and two children suffering from a diagnosis of Attention-Deficit Hyperactivity Disorder as diagnosed by their primary care physician (or other qualified health care professional) were recruited from grades two and four in nineteen public schools in the greater Boston area. They were randomly assigned to one of three groups. None of the children suffered from a confounding condition, although some were receiving stimulant medication to ameliorate the effects of their ADHD. Thirty-four of the children received a total of forty 45-minute sessions of neurofeedback training, administered three times a week over a five-month period in-school using a relatively simple neurofeedback system. The students were rewarded for increasing beta-wave activity while decreasing theta activity, an approach previously shown to increase individual focus. A relatively simple neurofeedback system was employed for use in the school setting.
A second group of thirty-four students were trained on a set of computer-based cognitive exercises designed to improve attention and working memory. A third group of thirty-six students served as a control. All three groups were evaluated, using a variety of validated and standardized measures, by parents, teachers, and blinded observers, pre- and post-intervention (the Journal of Developmental and Behavioral Pediatrics study), and at a follow-up six months after the initial study (the Pediatrics study).
After completing training, children in the neurofeedback group exhibited significant improvement in attention and executive functioning compared both to children in the cognitive training group and to those in the control group. It is also interesting to note that the children in the neurofeedback group who had been on medication at the start of the study maintained the same dosage of medication post-study, while those in the other two groups increased their usage of medication at the end of the study. The six-month follow-up study (Pediatrics) showed that the children in the neurofeedback group maintained the gains that they had made during the original investigation.
For further information, please refer to the original research articles: N.J. Steiner, E.C. Frenette, K.M. Rene, R.T. Brennan, and E.C. Perrin, “Neurofeedback and Cognitive Attention Training for Children with Attention-Deficit Hyperactivity Disorder,” J. of Dev. & Behav. Pediatrics, 35, 1, Jan. 2014; and “In-School Neurofeedback Training for ADHD: Sustained Improvements from a Randomized Control Trial,” Pediatrics, 133, 3, 483-492, March, 2014.
Study of Changes in White and Gray Matter Induced by Neurofeedback Receives 2014 FNAN Award
The winners of the 2014 FNAN award for excellence in neurofeedback were a team of researchers consisting of Jimmy Ghaziri, Alan Tucholka, Vanessa Larue, Myriam Blanchette-Sylvestre, Gabrielle Reyburn, Guillame Gilbert, Johanne Lévesque and Mario Beauregard for their article “Neurofeedback Induces Changes in White and Gray Matter,” which appeared in the October, 2013 issue of the journal Clinical EEG and Neuroscience.
Since the first documentation of its effects on seizure disorders in the mid-1960s, an ever-increasing number of published studies have supported the efficacy of neurofeedback for addressing symptoms associated with a wide range of disorders. Until now, however, there have been no studies of actual changes in brain structure arising from neurofeedback training.
The winners of the 2014 award sought to address this question by investigating whether a neurofeedback training protocol designed to improve sustained attention might also induce structural changes in white matter and gray matter pathways in the regions of the brain being trained.
Three groups of students from the University of Montreal were recruited for the study. One group of twelve students received neurofeedback training designed to increase right brain beta activity (15 to 18 Hertz at locations F4 and P4, based on the 10/20 system). This experimental group received a total of 40 sessions of neurofeedback training at a rate of three sessions per week. A second group of twelve students received sham neurofeedback over the same period, while a third group of six students served as controls. Diffusion tensor imaging (DTI) derived from magnetic resonance imaging (MRI) data was collected one week before the beginning of treatment and one week after the end of treatment.
At the end of the training period, the experimental group showed significant improvement in the full scale attention quotient scores of the Integrated Visual Auditory (IVA) continuous performance test, which measures both visual and auditory attention. More important, however, were DTI results showing increased fractional anisotropy in the white matter pathways involved in sustained attention, as well as increases in the gray matter cerebral structures involved in this type of attention, subsequent to training. Fractional anisotropy is often used as a measure of fiber density and white matter myelination.
Evidence continues to accumulate that neurofeedback training can significantly change neural functioning. This study provides the intriguing finding that some of these effects may be result of physiological changes in the cellular pathways of the brain.
The Foundation for Neurofeedback and Applied Neuroscience has been issuing its annual award for the most significant publication in the field since 2006. It’s interesting to note that the first such award went to a team from the University of Montreal that also included Mario Beauregard and Johanne Lévesque.
For further information, please refer to the original research article: J. Ghaziri, A. Tucholka, V. Larue, M. Blanchette-Sylvestre, G. Reyburn, G. Gilbert, J. Lévesque and M. Beauregard, “Neurofeedback training Induces Changes in White and gray Matter,” Clinical EEG and Neuroscience, October 2013, Volume 44, Number 4, pages 265-272.
2013 Award Goes to Schizophrenia Study
The winners of thew 2015 FNAN award for excellence in neurofeedback are a team of
Turkish researchers consisting of Tanju Surmeli, Ayben Ertem, Emin Eralp and Ismet H. Kos
for their article “Schizophrenia and the Efficacy of qEEG-Guided Neurofeedback Treatment:
A Clinical Case Series,” which appeared in the April, 2012 issue of the journal
Clinical EEG and Neuroscience.
Although it has been estimated that schizophrenia will affect one out of every one hundred
people at some point in their lives, traditional approaches to treating this condition have shown,
at best, mixed results. While the number of studies showing the positive effects of
neurofeedback in addressing the symptoms of various disorders has increased sharply over the
past ten years – particularly in regard to attention deficit hyperactivity disorder and related
conditions – there have been relatively few investigations as to its possible applicability to
alleviating the symptoms of those suffering from schizophrenia.
The recipients of this year’s award have taken an important step towards addressing this
shortcoming through an article in which they report on a series of clinical case studies
seeking to determine whether neurofeedback might be efficacious in alleviating the
symptoms of schizophrenia by reinforcing certain patterns of brain activity, and how information derived from quantitative encephalography (qEEG) – a technique by which a subject’s overall patterns of brain activity are mapped through the measurement of the frequency and amplitude of cortical electrical activity at selected locations on the subject’s head – might be used to guide this process.
In the study, an initial cohort of fifty-one subjects, most of who had previously been diagnosed
with chronic schizophrenia and whose symptoms had not improved under medication, were
assigned a neurofeedback treatment protocol based on their individual qEEG brain maps.
Training consisted of one to two 60-minute sessions of neurofeedback per day over a period
ranging between 24 and 91 days, with a mean total of 58.5 sessions per subject over the
treatment period. In addition to data from the subjects’ brain maps, their symptoms were
assessed, both prior and subsequent to training, using the Positive and Negative Syndrome
Scale (PANSS). Thirty-three of the subjects were also assessed using the Minnesota
Multiphasic Personality Inventory (MMPI) and the Test of Variables of Attention (TOVA) as
measures before and after treatment.
Forty seven of the 48 participants who remained in the study were reported to have shown
clinical improvement and to have shown a 20% or greater decrease in their total PANSS score
after the neurofeedback treatment. Subjects whose MMPI and TOVA scores were tracked
also showed improvement in those measures. Forty of the subjects were followed for more
than 22 months after the study. Twenty-seven of the participants in the study were reported to
have been able to function without medication after neurofeedback, and 12 were reported to have been able to function on only one medication post-treatment. The overall treatment compliance rate for participants in the study was also reported to be good.
The Foundation for Neurofeedback and Applied Neuroscience has been issuing its award for the
most significant article of the year since 2006. It’s interesting to note that this is only the second
time that the award has been given to researchers who are not affiliated with a major
university or research institution. According to Fisher, “Dr. Surmeli and his associates
have demonstrated how independent researchers can sometimes play an important role in
furthering the field of neurofeedback.”
For further information, please refer to the original research article:
T. Surmeli, A. Ertem, E. Eralp and I.H. Kos, “Schizophrenia and the Efficacy of
qEEG-Guided Neurofeedback Treatment: A Clinical Case Series,”
Clinical EEG and Neuroscience, 43 (2) 133-144, April 2012.
Korean Researchers Receive 2012 FNAN Award
The winners of the 2012 FNAN award for excellence in neurofeedback were a team of Korean researchers consisting of Sung Won Choi, Sang Eun Chi, Sun Yong Chung, Jong Woo Kim, Chang Yil Ahn, and Hyun Taek Kim for their article “Is Alpha Wave Neurofeedback Effective with Randomized Clinical Trials in Depression? A Pilot Study,” which appeared in the journal Neuropsychobiology.
In the past, researchers have noted that people suffering from depression tend to have a reduced level of activation in the left prefrontal area of their brains, while those who are not depressed tend to exhibit a relatively high level of activation. Among the strategies proposed to address this imbalance in EEG activity is the so-called “alpha asymmetry” protocol, described by J. Peter Rosenfeld et al. in 1996, in which individuals were rewarded using neurofeedback for enhancing the activity in the left frontal area of their brains at the expense of the right frontal area. Although Rosenfeld and his colleagues saw positive results – as did researchers in a limited number of follow-up papers – none of these preliminary studies were comprehensive enough to rule out the possibility of other contributory factors. In recent years, much of neurofeedback research has focused on other areas such as attention deficit hyperactivity disorder (ADHD).
The recipients of this year’s award have sought to address some of shortcomings associated with earlier investigations of the use of alpha asymmetry training for depression in their pilot study.
The researchers randomly divided a group of twenty-four individuals, all of whom met DSM-IV criteria for depression, into two cohorts: a control group who received a psychotherapy placebo, which included psychological assessment, interpretation of their test results and information on the course of mood disorders; and a group who received alpha asymmetry neurofeedback with the goal of inducing left-hemisphere frontal dominance in the subjects’ brains.
The neurofeedback subjects received a total of 10 sessions of neurofeedback training at a rate of two sessions per week over a period of five weeks. During the training, EEG activity was measured by placing sensors on the left and right frontal areas of the subjects’ heads (F3 and F4 positions in terms of the 10-20 system of classification) as referenced against the top of their heads (Cz position). Each training session consisted of six four-minute periods during which the subjects were rewarded for achieving the desired ratio of asymmetry in brain activity between the two sites by characters shown on a computer screen and the relative volume at which they heard a piece of classical music. The reward periods were interspersed with 30-second “rest” periods during which the subjects received no reward. (Subsequent to the completion of training, the subjects also participated in one month of twice-a-week self-training.)
After training, half of the neurofeedback group (six individuals) exhibited a clinically meaningful decrease in depressive symptoms, while none of the control group showed a similar response. It is worth noting that changes in frontal EEG activity induced by the neurofeedback, and the concomitant reduction in depressive symptom, were reported to have been maintained over a period of one month after the end of the training sessions. None of the participants in the study reported significant side effects.
In spite of relatively small sample sizes and other limitations of this pilot study, such as the possibility of rater bias associated with a single-blind design, these findings lend further credence as to the possible efficacy of neurofeedback as a mechanism for alleviating the symptoms of depression.
For further technical detail, please see the original research article:
Sung Won Choi, Sang Eun Chi, Sun Yong Chung, Jong Woo Kim, Chang Yil Ahn and Hyun Taek Kim, “Is alpha wave neurofeedback effective with randomized clinical trials in depression? A pilot study,” Neuropsychobiology, 2011, 63, pp 43-52. (Sung Won Choi is affiliated with Daejon University’s Department of Industrial and Advertising Psychology; Sang Eun Chi, Chang Yil Ahn and Hyun Taek Kim are affiliated with the Department of Psychology at Korea University; and Sun Yong Chung and Jong Woo Kim are affiliated with Kyunghee University East-West Neo Medical Center.)
2011 ANNUAL AWARD
The winners of the 2011 FNAN award for excellence in neurofeedback were a team of British and Dutch researchers consisting of Tomas Ros, Moniek Munneke, Diane Ruge, John Gruzelier, and John Rothwell, for their article “Endogenous control of waking brain rhythms induces neuroplasticity in humans,” which appeared in the European Journal of Neuroscience. (Winners of some of the previous awards are listed below.)
For many years, neurofeedback practitioners have helped clients make positive changes by teaching them to control their brain and nervous system activity. To assess the outcome of their training, clinicians have often relied on a client’s description of improvement – known as verbal report. Research studies have also used verbal reports from clients and their families to measure how well neurofeedback works. Some scientists have not been satisfied with this type of evidence, however. Verbal reports, they have suggested, are too easily influenced by what the client or experimenters expect to happen, and more objective evidence is needed.
The recipients of this year’s award have produced more objective evidence. The researchers found changes in the function of motor neurons, cells in the brain that control skeletal muscles, following neurofeedback training. The changes are an example of neural plasticity, the brain’s ability to alter its own function and structure.
In their study, Ros and his associates trained separate groups of college students to control two different types of brain rhythms known to have opposite effects on motor neuron activity. One group learned to suppress alpha rhythms in their brains. Decreases in alpha activity often cause motor neurons to become more sensitive and reactive to incoming signals. The second group learned to increase the low beta rhythms that usually cause motor neurons to become less sensitive to input.
At the beginning of the study, both groups received one 20 minute session of neurofeedback training. Students who focused on training their alpha rhythms successfully learned to reduce them, but those in the group that was trained on low beta rhythms were unable to learn control them by the end of training. (In clinical settings, training involving these frequencies is generally longer. It is likely that the brief beta training in the study did not allow enough practice for learning to occur.) Nonetheless, the training phase of the study produced two groups, both exposed neurofeedback, one with newly learned control over brain activity and one that had not yet learned control.
Subsequent to the training, the researchers assessed its effects by triggering the subjects’ motor neurons through short magnetic pulses that were applied over the areas of the head where the motor neurons reside. When motor neuron sensitivity is high, neurons will respond more strongly to the pulses and larger contractions will occur in the muscles they control. When motor neurons are less sensitive, little or no activity will be detected in the muscles.
The subjects were tested in this manner immediately after the neurofeedback training. Those who learned alpha suppression showed a significant increase of muscle response compared to the levels they exhibited prior to training. Those unsuccessfully trained in low beta showed no changes. The elevated motor neuron sensitivity in the group successfully trained with neurofeedback lasted until the end of the experiment – a period of 20 minutes.
These findings provide convincing evidence that brief neurofeedback training changes motor neurons in the brain in significant ways. We do not yet know what processes produce this long-term plasticity in the brain’s neural network. However, Dr. Ros’ team has provided evidence that neurofeedback impacts more than the verbal reports of clients - it produces measurable functional changes in the brain.
For further technical detail, please see the original research article:
Ros, T., Munneke, M. A. M., Ruge, D., Gruzelier, J. H. and Rothwell, J. C. (2010), “Endogenous control of waking brain rhythms induces neuroplasticity in humans,” European Journal of Neuroscience, 31: 770–778. doi: 10.1111/j.1460-9568.2010.07100.x.
2010 Annual Award to Arns et al. for ADHD Study:
The 2010 FNAN award for excellence in neurofeedback went to Martijn Arns, Sabine de Ridder, Ute Strehl, Marinus Breteler, and Anton Coenen for their article “Efficacy of Neurofeedback Treatment in ADHD: the Effects on Inattention, Impulsivity and Hyperactivity: a Meta-Analysis,” which appeared in Volume 40, of the journal Clinical EEG and Neuroscience.
There is probably more literature published on the efficacy of neurofeedback as a means of alleviating the symptoms of attention deficit hyperactivity disorder (ADHD) than any other application of this technology. But while there have been numerous ADHD studies, until very recently each has been criticized for one or more shortcomings. Although more-recent studies have attempted to address the concerns voiced about many of these earlier investigations – size of study, lack of randomization or lack of suitable controls – until now, no one has pulled all of this data into one cohesive whole.
After reviewing the literature on neurofeedback and ADHD as a whole, Martijn Arns and his co-authors selected fifteen studies that were of a sufficient confidence level, and employed the guidelines for clinical efficacy of the Association for Applied Psychophysiology and Biofeedback and the International Society for Neurofeedback and Research (which are similar to those of the American Psychological Association), to rate the level of efficacy for Neurofeedback in ADHD.
Based on a meta-analysis of these fifteen studies, the authors concluded that neurofeedback is efficacious and specific with a large effect size for inattention and impulsivity, and with a medium effect size for hyperactivity. Meta-analyses have become increasingly important in the last decade, particularly given tighter research budgets, as such techniques increase the size of N through combining data from numerous studies. This allows for the increased ability to detect real effects and, very importantly, to measure effect sizes (how large the difference was and whether that difference may be clinically relevant/important). However, such meta-analyses must be well done; and this study published by Arns and his colleagues represents an excellent example. In addition, this study asked a number of important questions in addition to the primary one concerning the overall efficacy of neurofeedback for treating ADHD. I strongly urge anyone who has not read this article to do so and to obtain a copy to share with other professionals.
At the time of this study, Martijn Arns was a PhD student at Utrecht University (Dept. of Experimental Psychology) and director of Brainclinics in Nijmegen, the Netherlands, which specializes in the research and application of neuroscience to diagnostics and new treatments in the mental health care field. Arns studied biological psychology at the Radboud University, Nijmegen. He founded Brainclinics nearly ten years ago, after several projects at the Westmead Hospital in Sydney, the Max Planck Institute in Munich and Organon Research in Newhouse.
Arns’ co-authors include: Sabine de Ridder of Brainclinics Treatment; Ute Strehl of the University of Tübingen; Marinus Breteler of the EEG Resource Institute and the Radboud University Department of Clinical Psychology; and Anton Coenen of the Radboud University Department of Biological Psychology.
2009 Annual Award to Juri Kropotov for his Book on qEEG and Event Potentials:
The winner of the 2009 FNAN annual award for excellence in neurofeedback was Juri Kropotov of the Institute for the Brain in St. Petersburg and the Norwegian University for Science and Technology in Trondheim. Dr. Kropotov was recognized for the publication of his book, “Quantitative EEG, Event-Related Potentials and Neurotherapy,” which provided an evidence-based, unified description of the role of the EEG and event-related potentials as they relate to brain functioning and disorders of the brain, and of the role of neurofeedback in addressing those disorders. He was also being honored for the invaluable body of work that he has established over the years.
Event-related potentials, or ERPs, are discrete, localized fluctuations in electrical activity in the brain’s cortical areas associated with information flow and evoked by a specific event.
Juri Kropotov graduated from the Department of Physics of St. Petersburg State University in 1972, majoring in quantum mechanics, and received his PhD at the Institute for Experimental Medicine in 1975. The subject of his doctoral thesis was “Slow Processes in the Human Brain.” Dr. Kropotov was the first to show that the basal ganglia thalamo-cortical circuits of the human brain are involved in cognitive and affective functions. Between 1986 and 1992, he developed a mathematical model of the cortex – the canonical cortical module – that explained most of the properties of neural activity in the visual cortex.
During 1990s, Dr. Kropotov became interested in the field of quantitative EEG and evoked potentials in normal subjects, as well as in people suffering from ADHD and in neurological patients in whom intracranial electrodes had been implanted for diagnosis and therapy. Since 1998, he has been exploring the use of neurofeedback and transcranial Direct Current Stimulation (tDCS) for the treatment of ADHD and other brain dysfunctions.
At the time of the award, Dr. Kropotov divided his time between the Institute of the Human Brain of the Russian Academy of Sciences in St. Petersburg, where he was the director of the Laboratory for the Neurobiology of Action Programming, and Institute of Psychology at Norwegian University for Science and Technology in Trondheim, where he was a professor. Dr. Kropotov received the State Prize of the USSR – the highest award in the former Soviet Union – in 1985 for his research in the field of human physiology. In addition, he has been awarded the Medal of Honor of Russian Federation and the Diploma of the USSR Academy of Sciences for the Highest Achievement (Discovery) in Science. In addition to "Quantitative EEG, Event-Related Potentials and Neurotherapy," Dr. Kropotov has published seven other books and authored more than 180 papers. He served for many years as an editor of the journal Human Physiology of Russian Academy of Sciences, is ex-president of the European Chapter of the International Society for Neuronal Regulation (iSNR) and is an editor of its journal Neurotherapy.
Quantitative EEG, Event-Related Potentials and Neurotherapy, is published by Academic Press.
2008 FNAN Award to Robert Coben and Ilean Podolsky for Article on the Efficacy of Neurofeedback in the Treatment of Autism:
The recipients of the 2008 FNAN Award were Robert Coben, PhD, and Ilean Podolsky, PhD, for their article “Assessment-Guided Neurofeedback for Autistic Spectrum Disorder,” which appeared in Volume 11, Number 1 of the Journal of NeurotherapyThe article described the use of neurofeedback training to address the symptoms of 37 children who fell within the autistic spectrum of disorders.
After 20 sessions of neurofeedback, 89% of the children showed significant improvement in their symptoms, including a 40% reduction in their core autistic spectrum disorder (ASD) scores as indicated on the Autism Treatment Evaluation Checklist (ATEC).
People who suffer from autism spectrum disorders are characterized by impaired ability to take part in social interaction and communication, along with impaired imaginative development. These symptoms tend to begin to manifest themselves before the age of three. In 2001, the Medical Research Council estimated in 2001 that 60 out of every 10,000 children fell within the autistic spectrum.
The severity of ASD symptoms can range from relatively mild to extremely severe. As a result, some individuals who fall within the autism spectrum are able to function at a high level, while others are seriously disabled. Recent research has tended to look at ASDs as being a range of related neurodevelopmental disorders that includes Asperger’s Disorder, Pervasive Developmental Disorder - Not Otherwise Specified, Childhood Disintegrative Disorder, and Rett’s Disorder, as well as Autism. No single approach has been shown to be fully effective in the treatment of autism spectrum disorders. Most parents of ASD children tend to opt for more than one modality of treatment.
Earlier studies had previously indicated that neurofeedback might prove to be helpful in addressing the symptoms associated with autism.
Normal brain functioning requires an ongoing level of connectivity between various areas of the brain. But either too much or too little connectivity between certain regions of the brain may prove to be counterproductive. Studies of brain functioning have shown certain patterns of both hyper (too much) and hypo (too little) connectivity in the brains of people suffering from autism spectrum disorders.
Coben and Podolsky studied 37 ASD children (31 males and 6 females) who ranged in age from less than four years to more than 14. Based on quantitative electroencephalogram (qEEG) data collected before the start of neurofeedback, they noted that the autistic spectrum children tended to have too much (hyper) connectivity across the left and right frontal and temporal areas of their brains. (A qEEG graphs patterns of electrical activity in the brain’s cortex based on the readings from multiple sensors placed on the scalp.)
The children received 20 sessions of neurofeedback training designed to reinforce decreased connectivity between the hyperconnected areas. A second qEEG was undertaken at the completion of training. The children were also rated on a variety of neurobehavioral rating scales before and after the training. These measures included the ATEC scale, the Gilliam Autism Rating Scale (GADS), the Behavior Rating of Executive Function (BRIEF) and the Personality Inventory for Children (PIC-2). They also received a neurological evaluation of their executive, attentional, visual-perceptual and language functioning. At the end of the study, the parents of the children were asked to rate the efficacy of the neurofeedback training, and changes in brain activity were measured using a special infrared camera.
Subsequent to the neurofeedback training, 84% of the subjects showed improvement in their ASD symptoms. There was a 40% overall reduction in their core symptoms based on the Autism Treatment Evaluation Checklist. In all cases where symptoms improved, the researchers also saw corresponding neuropsychological and neurophysiological changes. Highly significant improvement was seen in measures of attention, executive function, and visual perception. There were also significant increases in the subjects’ language skills. Infrared imaging showed an enhancement of metabolic activity in the subjects’ brains after training.
2007 FNAN Award goes to John Gruzelier and Tobias Egner for Performance Optimization Studies:
In 2007, the Foundation for Neurofeedback and Applied Neuroscience presented its second annual award recognizing the year’s most significant contribution to the advancement of the field of neurofeedback during the previous year. The prize was awarded for an article that represents a compendium of the work conducted by the authors and their associates over the past six years. The recipients of the award, which included a one thousand dollar (US) cash prize, were John Gruzelier of Goldsmiths College of the University of London, Tobias Egner of the Feinberg School of Medicine at Northwestern University, and David Vernon of Canterbury Christ Church University for their article “Validating the efficacy of neurofeedback for optimizing performance,” which was published on October 27, 2006 in Volume 159 of the journal Progress in Brain Research, and for the overall body of work which underlies it.
While much anecdotal data and a growing number of studies lend strong support to the existence of the hypothesized relationship between operant conditioning of brainwaves and behavioral change – particularly in terms of reduction of the symptoms associated with attention deficit / hyperactivity disorder (ADHD) – there had, at the time of the award, been an effective lack of studies establishing a direct correlation between the ability to enhance EEG performance at a particular range of frequencies and the presence of resultant changes in behavior and cognition on the part of the subject.
Beginning in 2001, Gruzelier, Egner, Vernon and their associates sought to address this problem through a series of studies - summarized in their award-winning 2006 article – that sought to document whether rewarding EEG activity at certain specific frequency ranges constituted a valid mechanism for improving attention, mood, memory and performance in healthy subjects.
In the first of the studies, conservatory students received ten 15-minute neurofeedback training sessions in which they were rewarded for enhancing EEG activity both at 12-15 Hertz (SMR) on the right side of their sensorimotor cortices and at 15-18 Hz (beta1) on the left side. The subjects’ attention was measured before and after training by means of a computerized continuous performance test (CPT). Subsequent to neurofeedback training, the subjects showed a significant reduction in errors of commission based on the test. Furthermore, this error reduction was positively correlated with how well the subjects were able to enhance their level of SMR activity during training. Improvement was also seen on a “d-prime” (d’) scale which compared the ratio of the “hit” rate to the false response rate. The beta-frequency training was found to be associated with increments in the subjects’ P300b event-related brain potential (ERP) when they were asked to respond to tasks that required active monitoring and detection of auditory target stimuli. (The P300b is thought to reflect the neuronal activation that takes place when information in the working memory is updated in response to some specific stimulus.)
The results of the first study were replicated in 2004, this time comparing groups of conservatory students separately trained in SMR and beta with a control group. All three groups were again measured using a continuous performance test as well as a more complex divided attention task instrument. SMR training was shown to reduce errors of omission and reaction time variability, as well as improving d’ performance. Beta training led to a reduction in reaction on the simpler CPT test and increased P300b amplitude.
In a 2003 study, students were randomly assigned to one of three groups. The first group was rewarded for enhancing SMR activity while inhibiting beta activity in the 18-22 Hz range together with activity in the theta (4-8 Hz) range. A second group was rewarded for theta activity while suppressing activity in the alpha and delta ranges immediately above and below it. The third group of students served as a control. Subjects were measured using a continuous performance test with a two- or three-digit sequence target and a semantic working memory test in which words were presented randomly or in semantic clusters.
There was clear evidence of operant control on the part of the subjects who received the SMR training during the course of the study. The SMR-trained subjects also showed highly significant reduction in both errors of omission and errors of commission with two-digit CPT tasks and achieved positive results with semantic working memory tasks. SMR training did not, however, appear to improve error rates for the three-digit tasks. Underlining the need for specificity in reward selection, students who received the theta training were not able to achieve operant control of their EEGs, nor did they exhibit improvement in performance of CPT or semantic working memory tasks.
A growing number of performers, athletes and business executives have come to rely on neurofeedback as a tool for optimal performance training. This frequently involves rewarding subjects for increasing the ratio of their theta activity to that of their alpha (8-12 Hz) activity while sitting in a comfortable position with their eyes closed. The authors investigated this technique in studies published in 2002 and 2003.
In the first study, music conservatory students were divided into three groups. One group received a mixture of neurofeedback that included beta, SMR and alpha/theta training. A second group received neurofeedback combined with mental skills training and aerobics. The third group served as control. The results were evaluated by a panel of expert judges who were blind to the training techniques that were employed with the students they were evaluating. Of the three, only the group that received neurofeedback by itself showed significant improvement in terms of their musicality, creativity and quality of performance. Neither the control group, nor – surprisingly – the group that received neurofeedback together with other training showed significant improvement. Also, although participants in this study received more than one kind of neurofeedback training, it was only the index reflecting the subjects’ ease at raising their theta activity over their alpha activity (alpha/theta training) that showed a positive correlation with improvements in their performance.
In the second study, the music students were divided into six groups – one each for beta, SMR and alpha/theta neurofeedback training, a physical exercise group, a mental skills program group, and an Alexander technique group. Of the six groups, only the group that received alpha/theta training showed significant improvement when they were evaluated post-training. The average improvement shown by students who had received alpha/theta training was reported to be equivalent to two academic grades under the conservatory assessment system, and certain participants showed improvements in excess of 50% in some criteria.
Although further research was clearly indicated, the results of these studies, when taken as a whole, lent substantial support to the proposed correlation between response to neurofeedback training and improvement in cognitive and neurophysiological performance. (Note: Subsequent studies by Gruzelier et al. have shown similar results.)
2006 FNAN Award to Johanne Levesque, Mario Beauregard, and Boalem Mensour for Study Imaging the Effects of Neurofeedback:
In 2006, the Foundation for Neurofeedback and Applied Neuroscience announced that its first annual award recognizing the most significant contribution to the advancement of the field of neurofeedback during the previous year. The recipients were Johanne Levesque, Mario Beauregard and Boualem Mensour of the Université de Montréal for their article “Effect of neurofeedback training on the neural substrates of selective attention in children with attention-deficit/hyperactivity disorder: A functional magnetic resonance imaging study.” The article appeared in the February 20, 2006 issue of the journal Neuroscience Letters.
Attention Deficit Hyperactivity Disorder (ADHD) is a relatively common neurodevelopmental disorder, characterized by symptoms such as restlessness and an inability to maintain concentration. In children, psychostimulant medication is frequently prescribed as a mechanism for managing this disorder. But, since its symptoms tend to recur if the medication is discontinued, this approach generally requires ongoing use of psychostimulants.
Because neurofeedback involves “teaching” the brain new patterns of neural activity, it is reasonable to assume that these patterns – and the changes in behavior that are associated with them – might be expected to be retained once they have been “learned.”
While this hypothesis appears to have been confirmed by various studies in which a reduction in ADHD symptoms equivalent to those achieved by psychostimulant medication has been shown to continue long after the subjects completed neurofeedback training, little had been done to document corresponding changes in brain activity at the time of this study.
Functional magnetic resonance imaging (fMRI) provides a mechanism for imaging patterns of ongoing activity in various regions of the brain. Previous neuroimaging studies have shown that individuals suffering from ADHD exhibit significantly less activation in the region of the brain known as the anterior cingulate cortex (ACC) when they are asked to perform tasks requiring selective attention than do individuals who do not suffer from this disorder.
In their study, Levesque, Beauregard and Mensour compared the fMRI patterns of a group of fifteen children who suffered from ADHD and were treated with neurofeedback with those of a control group of five ADHD children who did not receive neurofeedback training. None of the children were on psychostimulant medication or suffered from any other disorders. The fMRI scans took place while the children were performing a Counting Stroop task – a measure of focused cognitive functioning. The scans were performed one week before the onset of neurofeedback training and one week after completion of the training.
Neither group of children exhibited activation in their anterior cingulate cortices before the start of neurofeedback training. Subsequent to completion of neurofeedback training, however, the children in the experimental group showed significant ACC activation – analogous to what would be found in children who were not diagnosed as suffering from ADHD – while there was no change in the level of activation found in children in the control group.
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