AAPB White Paper
Psychophysiological and Biofeedback Treatment for Attention Deficit/Hyperactivity Disorder in Baltimore, MD
Joel F. Lubar, Ph.D.

Attention Deficit Disorder (ADD) with or without hyperactivity (ADHD) is a pervasive disorder which occurs throughout one's life span. It is usually identified by age 7, and if not treated comprehensively, can severely limit many activities of daily living, including school performance, social adjustment, emotional development, and ultimately employment opportunities and marital relationships. ADHD is a disorder which affects anywhere from 7 to 12% of the population depending on which criteria are used to identify it. Research in the last ten years has strongly indicated that ADHD is a disorder which has a strong neurological basis, i.e., it is a disorder which finds its origins within how the brain processes information. It involves abnormalities in EEG activity, brain metabolism, and perhaps even cerebral blood flow. In approximately 30% of the cases, there is evidence of a genetic component, i.e., multiple members of a family lineage having various aspects of ADD or ADHD. It is a disorder which can come about as a result of birth injury, high fevers, premature birth, difficulties in delivery, and later in life could be associated with significant closed head injuries. Children with Attention Deficit Disorder often have a higher incidence of allergies and ear infections. This may or may riot be in any way closely related to the disorder.

ADD, i.e., Attention Deficit Disorder without hyperactivity, and ADHD, Attention Deficit Disorder with Hyperactivity, has three main components. These are: inattentiveness, impulsivity, and hyperactivity. Children with ADD are characterized as inattentive, daydreaming, and have great difficulty staying on task. They have a low motivation level for completing work which they appraise as boring or irrelevant. Children with ADHD, in addition to inattentiveness, experience more impulsiveness and hyperactivity. There are many explanations for the hyperactivity, none of which thoroughly explain the phenomenon. One is that the child is in a state of decreased arousal and that sensory information is not having an appropriate impact on their nervous systems. Thus, they are in a state of arousal-seeking and therefore, continuously engaged in seeking stimulation. Another explanation is that rewards do not have the positive effect that they should and therefore, children very quickly become bored. They are often characterized as unhappy children who seem to derive little pleasure from play and when they do seem excited about something, their excitement is short-lived.

There is evidence that, in some of these AMID children, there might be decreased levels of metabolism of catecholamines, brain chemicals related to adrenalin (epinephrine) and noradrenalin (norepinephrine). For this reason, many of these children respond favorably to stimulant medications, at least as far as the hyperactivity is concerned. Some children will also show improved attentiveness and decreased impulsivity with the appropriate levels of medication. One of the main problems, however, is that these behavioral changes, no matter how positive, are very state-dependent and when the medications are no longer administered, the children often revert back to their previous behaviors. Some medications, such as Ritalin (methylphenidate), have very short-lived effects, only lasting for 3 to 4 hours within the nervous system. Alter they wear off at the end of the day, or if not administered on weekends or vacation periods, the child will often exhibit the full blown symptoms of ADD or ADHD. Other medications such as alpha blockers (Clonidine) or tricyclic antidepressants (Norpramine) are helpful in dealing with the impulsiveness. One of the main problems that ADD and ADHD children have is that they "live for the moment", i.e., they do not understand that behavior has consequences, and often they will act inappropriately in social or school situations and when punished for doing this, only temporarily show a change toward less aggressive or disturbing behaviors. The behaviors, however, become persistent and often parents will resort to more drastic measures to try to control them with little avail.

One of the techniques that has been integrated with medication is behavior therapy: the administration of rewards, time outs, punishments, and other schedules of reinforcement for various types of behaviors. This is an extremely tedious procedure and must be administered meticulously by the parent or caregiver; otherwise, the undesirable behaviors rapidly return. The carryover from behavior therapy is quite limited and often, the techniques have to be continued throughout childhood and even into adolescence. Even if ADD or ADHD is treated throughout childhood and adolescence, many aspects of it continue throughout the rest of one's life. At the present time, there is no definitive cure for ADD or ADHD. It is a disorder that is manageable however, and many individuals can enjoy periods without symptoms where they can function quite normally, even though the condition is still present and at times can create problems for them.

ADD and ADHD have a strong neurological basis, specifically in terms of increased slow activity called theta waves occurring over central and frontal portions of the cortex and decreased fast activity (beta waves) occurring centrally and posteriorly and sometimes even frontally. Theta activity is specifically associated with daydreaming, and lack of beta activity with poor ability to concentrate and to complete tasks.

EEG biofeedback treatment for ADD and ADHD, first developed in the 1970's by Dr. Joel F. Lubar, has been shown to be a highly effective method for helping children as a part of a multicomponent treatment process. The advantage of EEG biofeedback specifically is that after a child has learned to decrease slow activity in frontal and central cortex and to increase beta activity in these or other regions, the effects last for a very long time, perhaps for years. Follow up studies of at least ten years show, in many cases, that the effects of EEG biofeedback training are very enduring, even when the training has been completely phased out and no other treatment is being administered. Some children are able to reduce and even eliminate the need for stimulant and other medications. The results obtained clinically employing EEG biofeedback training have been replicated by more than 200 organizations nationally and internationally. Published clinical studies exist and controlled studies are now in the process of being planned or carried out to try to determine the effectiveness of EEG biofeedback training as compared with medication, behavior therapy, and other techniques.

The concept behind the EEG approach is very straightforward. If the child can learn to normalize neurological functioning, then they may process information and deal with sensory stimulation the way normal children do. This specifically would lead them to be able to understand that sometimes rewards have to be delayed and that behaviors carried out appropriately at the moment may have long term consequences. For example, completing homework or an assignment at the beginning of a week is important for being able to prepare for an examination that may occur a week or two later instead of waiting for the day before the exam to start studying the material. Children who have been treated using EEG biofeedback have been reported to be much more attentive in classroom situations, less impulsive in the home setting, and less hyperactive in home, school, and in playground settings as well. Again it is important to emphasize that EEG biofeedback training no matter how powerful it appears to be is even better when it is integrated into a multiple component treatment program which may include a certain amount of behavioral management techniques, medication when needed and training in parent-management techniques.

Biofeedback treatment for ADD typically involves approximately 50 sessions, initially carried out 2 to 3 times a week and then phased out over a period of time. Children receiving this treatment need to be carefully screened to make sure that they are appropriate for EEG biofeedback training. Contraindications would include mental retardation, extreme hyperactivity with poor response to any combination of medication, extremely dysfunctional family system in which the family refuses to participate in the treatment process, or severe multiple learning disabilities where these are not also being addressed as part of the treatment program. Many children who experience mild to moderate learning disabilities, however, can respond very well to EEG biofeedback provided the material that is appropriate for their learning disability areas is integrated into the treatment program and directly used in conjunction with the biofeedback training itself.

Blanton, J.B. (1990). Effect of computer-assisted biofeedback on relaxation and on task behavior of children with attention deficit disorder. Dissertation Abstracts International, 51, 1572.

Lubar, J.F. (1991). Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders. Biofeedback and Self-Regulation, -16(3), 201-225.