Extended Essay Topic: Psychophsysiology and ADD/ADHD disorder ?

Research question: Should neurofeedback be approved as a treatment for ADD/ADHD?

Word count: 3918 Table of contents:
Abstract………………………………………………………………...2
Introduction………………………………………………………….....3
ADD/ADHD symptoms………………………………………………..3
Current treatment and its issues………………………………………..5
Neurofeedback: an alternative approach to managing ADD/ADHD….6
Studies with neurofeedback……………………………………………7
Conclusion…………………………………………………………….11
Abstract

The aim of this essay is to present and evaluate the positive sides and implications of using neurofeedback as a treatment for ADD/ADHD and to compare these with current methods of treatment. In order to do that, firstly, the main symptoms and characteristics of this disorder were named. The main ones include: attention deficit, impulsivity, turmoil and hyperactivity as an optional one. Today, the only accepted method for threatening ADD/ADHD is by using medications. It is assumed that certain medications such as Ritalin, Concerta, Methylin, Dexedrine and Adderall improve the efficiency of chemical transmitters which have the role of passing the information through brain. But, there are also some side effects of using medications. A summary of relevant studies on relatively new, alternative method- neurofeedback is provided. The results were similar to treatment with medications. The difference is that neurofeedback provided longer lasting effects, long after the session period. The main advantage of neurofeedback is that patients will learn the skills of self-control. In other words, they will depend on themselves, not on medications. Still, there are some uncertainties whether neurofeedback should be accepted as a treatment for ADD/ADHD.Introduction

New insights on ADHD treatment
Print version: page 11

“Most health-care professionals have misinterpreted the research on attention-deficit hyperactivity disorder: They believe stimulant-based drugs are the most effective treatment for the disorder in children. But, according to research conducted by William Pelham, PhD, of the State University of New York at Buffalo, and others, when children, teachers and parents are taught behavioral modifications, medication doesn't need to be the central component of treatment.
"Medication should not play nearly as large a role as it does currently in treatment of ADHD," said Pelham at APA's Annual Convention.
That's particularly important since researchers still don't know if medications have long-term side effects. So far, research indicates that children who ingest a large amount of drugs, particularly in higher doses over years of treatment, may be as much as two inches shorter than the height they would have been expected to reach. Children prescribed smaller doses for less time did not show a height deficit, he said.
In addition, although these medications can address such ADHD symptoms as restlessness, fidgeting or impulsiveness in a classroom, they don't directly address ADHD's impairments, said Greg Fabiano, PhD, also of SUNY Buffalo. Such problems often include a lack of successful interactions with peers, deficits in reading and math skills, and difficult relations with parents and family members.
Another speaker, George DuPaul, PhD, of Lehigh University, discussed his work on Project PASS, which studied an intervention for children in first through fourth grade. He and colleagues have tested a variety of classroom strategies with the students, such as a peer-tutoring intervention and a self-paced computer math program. The results showed that the students improved their math and reading performance, with an interesting side benefit, DuPaul said: For some students, behavior improved as well”.

—C. Munsey

The same awkward situation happened to me a couple of times- Me, in a very angry phase, standing in front of my superior (parents, teachers) and wanting to say so many things in affect, or just imagining turning my back in the middle of the conversation and leaving the room. Of course, after a few moments I would realize that this would be totally inappropriate and foolish. Something invisible always stops me. What I have found out just recently is that the one “to put blame on” is the lack of slow theta brain waves in frontal part of the brain (which is in charge of reality processes(Lubar,1991). In this case, within most of the people, waves which are present in frontal brain section are not slow enough thus making the brain to do the reflection before action. But, if I were dreaming, the situation would be the opposite, because then the activity of slow theta waves is dominant, thus allowing action before reaction. This seems logical because, while sleeping we loose the link with realty and transfer ourselves into unconscious world. Here, in dreams we can express all the creativity, spontaneity, joy, pleasure and other primarily human characteristics which are by time shaped through the processes of growing up and adaptation. After all, this is what Freud’s theory is based on: “Dreams are royal path to unconsciousness”. Let us imagine what would happen if a person manages to keep its core nature, i.e. if he/she does not develop the principle of reality and adaptation, at least to some extent? This is diagnosed as ADHD or ADD, which means Attention Deficit Disorder with or without Hyperactivity. Characters of these people are not shaped for the needs of society. They are straightforward, open minded, able to think “out of the box”, creative, spontaneous, etc (AUTOR, 2005). One might say:” These are amazing features, let’s find a way to make those waves slower”. But on the other hand, isn’t our society strongly dependent on the rules and tolerance which both require restricting personal wants and desires? Therefore ADD/ADHD structures are often perceived as rood, immature, selfish, and even unintelligent in the eyes of the society. This is why the above topic intrigues me, and I’ll try to consider some of the issues considering ADD/ ADHD and the ways it is treated. This condition is currently treated with medications. Having in mind that ADD/ADHD is not really a disorder- is the use of drugs the necessity? By consuming them people become dependent and at one point cannot function without them. Is there an alternative method? Perhaps, such that helps ADD/ADHD structures to gain self control and to rely on themselves, with no need for drug stimulants?

ADD/ ADHD symptoms

Let us begin with explaining what ADD/ ADHD actually is. To do that, the best way is to determine what it is not- and primarily, it is not a disorder (Jovanovic & Jovanovic, GOD), although a name says so. People who have it are just different, i.e. they have different neurophysiologic predispositions. One of them I already mentioned- slow Theta waves in frontal brain part discovered by EEG devices, which make them act before reflecting consequences. Using the single photon emission computed tomography (SPECT method) which can register activities of deeper brain structures it has been discovered that in frontal brain section and in limbic system there is decreased blood circulation especially when they are under stress (Jovanovic & Jovanovic, GOD) . These brain regions are important for inhibition of impulses and their decreased activation might be the explanation for impulsiveness- one of the four main ADD/ADHD characteristics. Blood circulation is also slower in the area of striatum, the part of brain which function is inhibition of movement activities, which might be connected with hyperactivity, as an optional characteristic. Positron emission tomography (PET method) showed that this frontal brain part is in shortage of glucose. The metabolism of glucose is directly connected with brain activity which is therefore slowed down. Since this brain section is also responsible for choosing important facts which will be memorized over the ones not important to a person, slower brain activity will make all information of the same value to the ADD/ADHD person. His/hers brain does not make a selection, but reacts on every signal. This makes them distraught.

Further more, it is not characterized with attention deficit, but selective attention. Their attention is always extreme: either very low or very high. This positive extreme, called hyper focus can be really good when ADHD structures are doing something creative. For example, IT IS BELIEVED Mozart and Tomas Edison used to have ADHD (Jovanovic & Jovanovic, GOD) . Mozart was able to write the whole opera in a few weeks, but in other fields of life he was not that successful- his impulsiveness prevented him from being financially awarded. Edison is a typical example of ADHD person, because he was not able to keep his focus just on one thing. His thoughts were always overwhelmed with ideas and he often seemed absent minded. This tension towards imagination enabled him to invent so many findings. On the other hand hyper focus in area can be disadvantage for actions in other fields. Let us take an example of a law student with ADHD. While practicing his field of interest (law) his brain will be in hyper focus. This makes him probably the best student. His system of studying and memorizing would be different, unusual, creative and he would be very dedicated to the subject. Perfect student, isn’t he? Not really…

His self esteem is probably lower, because he might not be accepted the way he is through the process of growing up. Teachers and parents tried to reshape his behavior, so that it fixes the norms of society. This constant pressure might make him think he is not as good as others. Lower self esteem leads to lower productivity IZVOR. Almost always ADHD is combined at least with one additional psychiatric disorder, like anxiety or depression (Spencer, Biederman, & Wilens, 1999). These might make him feel unprepared for the exam, although it is the opposite. These are all internal distracters of the student’s attention. He is impulsive, which might be very good characteristic in court. He does some actions for which others would say “no way, it’s too risky”. He just follows his instincts, that is, he relies more on emotions than on reason. This is why they are also very successive as sales person and in other jobs which require risk taking IZVOR. He doesn’t think about the consequences of his action, but just does it. This might be a great social disadvantage if we consider another ADHD feature- egocentrism. They are not capable to put themselves in a position of others, and might offend someone not realizing that as a bad hobbit. Furthermore, they have difficulties to understand different opinions. This might be a problem for our student because of the nature of his job, but also an advantage, because this could make him more determined to prove he has a point. This is disputable because a problem would arise if he gets to present a person at court he personally finds guilty. – nepotrebno

There are also some, on first sight minor, but important difficulties this student might face. For example, he might prepare excellent case study for an exam (because he was working in hyper focus), but at the end forgets to apply for examination. He finds this technical part unimportant, that is his hyper focus from a case study is preventing him to have almost any attention on other things. Of course, by not applying he won’t be able to take the exam. Also, an ADHD characteristic of bad time management IZVOR could make him start preparing the evening before the exam or he can even sleep through exam. It might be very difficult to listen to the lectures in class because the activation of left hemisphere of his brain is decreased, since the speech is being processed in that hemisphere. The most bizarre difficulty would be the bad handwriting in his notes IZVOR, which is unreadable even to them. This is probably because his ideas were faster than movements of his hand.

The symptoms of ADD/ ADHD have been well documented for more than 100 years, but the nomenclature of it is only about 25 years old. Only relatively recently has the conventional belief that such disorders are experienced only in childhood and outgrown in adolescence given way to recognition of the reality that ADHD is usually not outgrown. According to the Diagnostic Statistical Manual of Mental Disorders, fourth edition, Text Revision (2000), the symptoms must have been present and caused impairment before the age of 7, evident in two or more settings, such as school and home, and the impairment contributes to social, academic, or occupational dysfunction. These symptoms of inattention and/or hyperactivity-impulsivity must be present for at least 6 months. The DSM-IV-TR breaks ADHD into three subtypes: (1) Combined Type, which includes symptoms of both inattention and hyperactivity–impulsivity; (2) Predominantly Inattentive Type, which includes symptoms of inattention; and (3) Predominantly Hyperactive–Impulsive Type, which includes symptoms of hyperactivity–impulsivity.
So, ADD/ADHD characteristics are:

Current treatment and its issues

Today, the only approved method for treating ADD/ADHD is by using medications. This treatment is used under assumption that symptoms can be assuaged if neuroendocrine and or neurotransmitter changes can be achieved (?????). Medications are assumed to improve the efficiency of above named chemical transmitters which have the role of passing the information through brain (Jovanovic & Jovanovic, GOD). Stimulants such as Ritalin, Concerta, Methylin, Dexedrine and Adderall have been the drug of choice for decades and continue to be the most used class of medications (AUTOR, GODINA). Until recently, the mechanisms of action regarding Ritalin were not known, though it has been prescribed for the last 50 years. It has been recently found that Ritalin and other stimulants interrupt the recycling or “reuptake” of dopamine in the brain by blocking dopamine transporters. Dopamine transporters mediate the uptake of dopamine into neurons and are a major target for various pharmacologically active drugs and environmental toxins. By blocking these dopamine transporters the brain is better able to transmit a clearer signal, which provides the individual with an increased ability to focus their attention so he/she is not as easily distracted (???????). Antidepressant medication is a second-tier drug used for ADHD among teens and adults and mighty also be more often used when there is a confiding of depression or anhedonia (AUTOR, GODINA).

Published studies indicate that between 70 and 80% of ADD/ADHD children respond favorably to psychostimulants, as compared to over 35% that improve with placebos (Barkley, 1990) . Medications have been found to have no effect on 25-40 % of children with this disorder. Medication treatment for womEn might be more challenging because of reproductive issues and the potential impact of menstrual cycles on drug effectiveness. Pharmacological treatment for ADHD has failed to show that the wide range of clinical problems that accompany this disorder, such as cognition, academic achievement, and social skills, are attenuated by this type of treatment (??????). Also, there are several known side effects that occur in 20–50% of individuals taking psychostimulant medication, such as heachaches, anxiety, irritability, stomach aches, decreased appetite, insomnia, and headaches (Goldstein & Goldstein, 1990). In addition to these, probably the greatest disadvantage of using medications as a treatment for ADD/ADHD is its short term effect. .For example, it was found that after a year of pharmacological treatment, the beneficial effects of Ritalin were eliminated when participants were retested without medication 1 year later (Monastra, Monastra & George, 2002). This finding is consistent with the summarized research on stimulant therapy and ADHD (Barkley, 1998). It appears that stimulant therapy “would appear to constitute a type of prophylactic intervention, reducing or preventing the expression of symptoms without causing an enduring change in the underlying neuropathy of ADHD” (Monastra, Monastra & George, 2002).

Neurofeedback: a alternative approach to managing ADD/ADHD

One of the alternative and still not approved methods of threatening ADD/ADHD, which was tasted a several times in last decades, is the neurofeedback treatment. This brain wave biofeedback became practical in office settings in the 1990’s with the advent of faster computers that could digitize the EEG (i.e. electroencephalogram, a device for neurofeedback) signal, process the information, and give feedback within a 50 ms timeframe (AUTOR, 2005). Neurofeedback is a training of self regulation of brain waves. Researches had shown that a person could learn to control its brain waves if he/she has a feedback on the movement of those waves (Jovanovic & Jovanovic, GOD) . Therefore, the strength of dominating slow Theta or Alpha brain waves which are connected with attention deficit could be decreased when person becomes aware of them. At the same time, the strength and frequency of faster Beta could be increased, and therefore his/hers attention improved.

Neurofeedback session starts with connecting patient’s head with the computer using EEG electrodes. EEG will register the brain waves, and this information will be transferred to computer where the special software is processing them (Jovanovic & Jovanovic, GOD) . Software is enabling a patient to control specially designed video animation using its brain waves. Animation is moving faster when a patient is producing faster Beta waves and slower when he/she produces Theta or Alpha waves. This faster motion is a signal to a patient that he/she is doing well. The attitude which is rewarded is more likely to repeat in future. Therefore, a patient is creating automatic reaction- a habit. The patient gets the skill of self regulation. This practice with video games is usually used for children, as though to make this treatment more attractive to them. For elder patients practices with reading different sorts of texts are more usual. Anyway, neurofeedback is educational process, similar to learning to swim. When the habit becomes firm and a patient becomes confident in self regulation, then the focus should be on linking these skills with everyday life. The course of treatment is usually about 40 sessions done twice a week (AUTOR, 2005).

Studies with neurofeedback

The first study of neurofeedback efficiency in treating ADHD/ADD was undertaken in 1976 by Lubar and Shouse IZVOR. They used utilized operant conditioning techniques to support specific types of electropsychological activity for the purpose of treating symptoms of ADD/ ADHD. Participants were provided with visual and auditory feedback for certain neuronal responses and showed reduced hyperactive behavior and improved attention (LUBAR?????, GOD). This discovery was followed by two controlled studies. The first one included 46 participants who had freedom of choice to select either neurofeedback treatment or a medication treatment (using Ritalin). Each of them had 20 sessions in a period of three months. Before and after every session they were assessed with Test of Variables of Attention (TOVA). Results showed that both groups made significant improvement on the dependent measures, and no significant difference was detected between the two groups (Rossiter & LaVaque, 1995). In addition the improvements were observed not just in experimental environment, but also later in every day life. At this point researches concluded that neurofeedback might be a useful tool for threatening ADD/ADHD. The second controlled study had randomized design and compared the effects of 40 neurofeedback sessions with a control group. Results showed improvements on a measure of intelligence and reduces ADD/ADHD on a behavioral rating scale in the neurofeedback group (Linden, & Radojevic, 1996) .

Chartier and Kelly made a review of literature, considering 200 children treated with neurofeedback. They reported that this provided significant and sometimes dramatic clinical improvements in children with ADD/ADHD. This was supported by finding that 80% of children with ADD/ADHD who were treated with neurofeedaback showed significant measurable improvements in intelligence tests, standardized tests of achievement and teacher/parent ratings of behavior, and the effects were minimized at long term follow-up. These studies showed that neurofeedback provides attentional and intellectual improvements. A next study looked at the effects of Ritalin and neurofeedback in separate groups. The results contributed positively to the previous findings-both groups showed significant improvements on all four scales of TOVA (Fuchs, Mock, Morgan, & Young).

To further examine and support the above hypotheses, Monastra, Monastra and George (2002) undertaken a one-year outpatient program with 100 (of which 51 received neurofeedback) children aged 6-9. Treatment included Ritalin, parent counseling and academic support at school. This was the first study which showed obviously grater improvements in children treated with neurofeedback in comparison to those taking medications. Specifically, these children showed greater attention and less hyperactive/impulsive behaviors at home when compared to those who received medications. Also, teachers rated students who received neurofeedback as more attentive and less hyperactive/impulsive. When participants stopped using medications, those individuals who participated in neurofeedback showed sustained improvements at home and at school. This was not the case for those who used to consume medications. Furthermore, parents noticed significant reduction in symptoms within the children who used neurofeedback, as compared to those in medication group.

Probably the most detailed and precocious study is the replication of Thomas Rossiter and T. J. La Vague (1995.). This time the larger sample was used, age range was expanded and adults included, the collection of behavioral data for neurofeedback group is more comprehensive and statistical analyses are improved. This is unique study because it uses an effectiveness research model (autor< ovaj sto pise dolE?) with nonrandom assignment patients and an active treatment control. That is, patients choose their treatment, and the effectiveness of neurofeedback is evaluated by comparing it to stimulant drug therapy, as a proven method for ADD/ADHD therapy. Eventually, it was predicted that EEG and MED (medication) groups showed equivalent or nonequivalent results.

There were 62 white, predominately middle class participants (autor, GOD). They were evaluated by the author and received a primary DSM-IV (American Psychiatric Association, 1994) diagnosis of Attention-Deficit/Hyperactivity Disorder Combined Type or Predominantly Inattentive Type. Patients with secondary psychiatric diagnoses were included. Two groups of 31 patients each were formed. The first group was drawn from 33 consecutive patients treated by the author with neurofeedback. Six of them were currently on stimulant medication therapy. The two participants which were ejected were using antidepressant and/or antihypertensive medication. Eight patients had been treated with stimulant drugs in the past but terminated drug therapy six months or more before starting neurofeedback. In three cases, the decision to terminate stimulants was related to ineffectiveness of the medication and/or unacceptable side effects (AUTOR, GOD). The second group consisted of patients who chose the medication treatment. The MED group as drawn from a pool of 64 patients whose stimulant medications had been titrated using the TOVA. They were matched with the EEG group first by age and then, to the extent possible, by the sum of the four baseline TOVA scores, IQ, gender, and primary AD/HD diagnosis in that order. This is represented the following table.

Da li je ovo skenirano? Ako jeste to ne sme da se radi bez dozvole autora To improve effectiveness special instruments and techniques were used. The TOVA, for example, avoids some of the potential difficulties inherent in relying on subjective parent, teacher, and patient reports as the primary basis for diagnosing ADD/ADHD and assessing treatment effects. A review the research literature on CPTs including the TOVA was done (AUTOR< OVAJ DOLE?). They concluded that CPTs (1) have high levels of sensitivity and specificity when differentiating AD/HD from normal individuals; (2) objectively evaluate symptoms associated with disorders of self-regulation, particularly impulsivity and attention problems; (3) are sensitive to the effect of stimulants on attention, processing speed, and executive control; and (4) have moderate to high ecological validity. There is also BASC, Behavior Assessment System for Children which assess a range of psychopathology within children aged from 4 to 18 years. The Hyperactivity, Attention Problems, Externalizing Problems, and Internalizing Problems Scales and the Behavior Symptoms Index were dependent variables for EEG group outcome. Only Parent scales completed by mothers were available. This might not be considered as great drawback because mothers usually notice even minor changes in ADD/ ADHD children, in comparison to fathers.

The procedure was adjusted to changes in research. Office neurofeedback treatment patients (n = 14) where typically seen three times a week (range 3-5) for 40 treatment sessions over three and a half months. On the other hand, home patients ( n = 17) received more than 60 training sessions over three months. Patients presenting with inattention, daydreaming, poor sustained attention, and/or lack of motivation received left hemisphere training with the active electrode at C3 (International10–20 System) using enhance 15–18 Hz protocols. The C3 default inhibit band was initially 4–7 Hz and later 2–7 Hz. Patients with symptoms of impulsivity, distractibility, and/or stimulus-seeking received right hemisphere training with the active electrode at C4 using enhance 12–15 Hz protocols. EEG treatment sessions included 30 or 36 min of neurofeedback. Training was conducted eyes open. No cognitive challenges (e.g., reading, drawing, listening, etc.) were used. The patient received simultaneous visual and auditory feedback based on the ratio of the inhibit band to the enhance band.

At the end the results predicted that the proportion of EEG patients demonstrating significant improvement on the TOVA would be equivalent, or noninferior, to the proportion of significantly improved MED patients. A patient was significantly improved if the number of TOVA scores improved exceeded the number worsened and the sum of the four TOVA scores increased by a minimum of 15 points over the pretreatment baseline. Twenty-six of the thirty-one patients in the EEG and MED groups improved significantly. Equivalence/noninferiority testing used both the confidence interval approach and the nonequivalence null hypothesis approach. The equivalence interval chosen was the de facto standard of 20% of the proportion of patients in the MED group who improved (84%). Both methods confirm the hypothesis that outcomes for the EEG group were equivalent to those for the MED group. The results of the current study confirm the hypotheses being tested. The EEG and MED groups demonstrated statistically significant improvement on TOVA scores. However, the fact that a treatment results in statistically significant improvement does not necessarily mean that the treatment effect is clinically significant or important. There is no consensus regarding what standards should be used to define clinical significance. Alternatives suggested include a high percentage of patients improving, elimination of the presenting problem, normal functioning by the end of treatment, a degree of change that is recognizable by significant others in the patient’s life and large effect sizes.

Conclusion

According to all the researches mentioned, neurofeedback may have a bright future as a new treatment for ADD/ ADHD. It was shown that it has the same effect as medications on patients. The advantage of neurofeedback is that it provides longer lasting positive effects, even after the treatment is over. Another bright side is that the whole treatment is based on self regulation, so that patients are learning to depend on themselves and not on medications. Also, possible medication side effects would be avoided. Having this in mind, it might be concluded that neurofeedback should become everyday treatment for ADD/ADHD. Nevertheless, much of the research support for neurofeedback derives from inadequately controlled studies that are susceptible to methodological artifacts, (including regression to the mean, the influence of concurrent treatments, and placebo effects). Future studies should compare neurofeedback to “bogus feedback” conditions -those that provide feedback on EEG frequency bands different from those hypothesized by neurofeedback proponents. This would show whether the apparent effects of neurofeedback are attributable to hypothesized changes in the high frequency and low-frequency bands. Also, future research should be done on the relationship between neurofeedback and behavior changes. Finally, it is important to consider the research that has presented neurofeedback as a tool for long-term symptom reduction, showing prolonged effects ranging from 1 to 10 years. All in all, although it might seem that there are enough researches and studies that could make neurofeedback treatment proven, this will but remain an open question, at least for a while. Until then, the only accepted way of threatening ADD/ADHD will remain medications.