The Emerging Frontier of Neurofeedback
(published in Latitudes)
By Siegfried Othmer, Ph.D.
The great revolution of the past fifty years with respect to the behavioral
problems of children has been the essential realization that these are
not first and foremost the result of moral failings or of deficiencies
of the will, but rather are physiologically-based disorders that mandate
physiologically-based solutions. After every such major step forward in
science or medicine, however, there follows a period of consolidation
around the new model before we are in a position to take another major
step forward. Over the last few decades, this has occurred around our
understanding of brain behavior in terms of neurotransmitter systems,
to which we appeal with an increasing variety of medications.
Over the last thirty years, evidence has gradually accumulated to make
the case for a new, complementary model of brain function. Such a model
does not immediately have to be better than the old. It just has to explain
some things that the old model can’t explain. And then we go forward
from there. Eventually, we end up with a new model that can stand on its
own in the world. This model is one based on the bio-electrical activity
of the brain rather than the neuro-chemical activity. The cognitive scientists
have been trying to figure out for some time just how the brain encodes
its information in that mysterious stream of “action potentials”
with which neurons communicate. Our brain has a telegraphic, pulsatile
communication system---and we do not yet know the neural code. This problem
is imbedded in a yet larger one. The brain must not only manage the explicit
point-to-point communications. It also has to manage the overall communication
traffic. It has to bring circuits on-line and take them off-line. It has
to manage specific activation, and it has to manage overall alertness
and vigilance. All this has to be understood in the bio-electrical domain,
i.e. in the realm of timing and frequency, and spatially in terms of specific
brain networks that link different brain regions.
To make a long story short, the brain manages this by organizing neuronal firings in terms of frequency, and it is these frequencies that we observe prominently in the Electroencephalogram, or EEG. Put simply, when the brain has a lot going on the EEG tends to be dominated by the high frequencies, and when there is less going on, it is dominated by low frequencies. So the EEG gives us a ready index of the arousal level of the person. These changes are readily observable in the native state.
Let’s take a moment to pull together some of the evidence that has accumulated for the importance of these frequencies. You may recall the event a couple of years ago in which some Japanese children went into seizure or loss of consciousness upon witnessing a cartoon of a Pokemon animal in which the eyes flashed red for about five seconds. The important aspect here was the rhythmicity of the signal, which was sufficient to kindle seizures or disrupt consciousness in these vulnerable children. Here the integrity of brain rhythms was disrupted by a very small, almost insignificant stimulus. We obviously depend utterly on the brain maintaining such integrity.
We can probably trace our strong response to music also to the frequency-basis of brain organization. More specifically, the Mozart Effect on instantaneous IQ can be used as evidence. Even the ancients knew that if you rotated a spoked wagon wheel in front of a candle, then the resulting periodic flicker could calm and soothe a person if it was done at the right frequency. This was surely the first instance of what we now call photic driving of the EEG to shift the brain toward certain preferred states.
We now know a number of ways to induce the brain to change state when given frequency-based information. The most obvious ways are by explicit brain stimulation. However, more than thirty years ago it was discovered that if you simply gave people information about their own EEG, then they were able to shift their state of arousal by shifting their EEG to higher or lower frequencies. This only required giving people specific information about their EEG frequencies, and rewarding them for success in altering their EEG even momentarily toward a target. This reinforcement strategy is known as EEG biofeedback, or more commonly neurofeedback. It would be no more than a parlor game curiosity to this day unless there was the promise of a lingering benefit for the exercise. It turns out that there was.
When the brain is repeatedly led toward certain brain states, one way or another, it is then more capable of living there. Thus, for example, if we lead an anxious person repeatedly toward a calmer state, eventually the brain finds that place on its own. Similarly, if we lead a person repeatedly out of brain patterns characterizing depression, the person’s depression may lift. Once the brain finds its way toward healthier states of functioning, these states are reinforcing, and the brain may consolidate its gains all on its own. It is possible to observe the same phenomenon with medications, where a point can be reached where these may be successfully withdrawn. However, the “learning component” is much more explicit in neurofeedback than it is with meds. After all, in neurofeedback nothing at all happens unless the brain chooses to do it. The therapist is only providing information. If the brain has to do everything on its own, it is more likely to learn something, and the result is more likely to stick.
Of course something is actually being done to the brain when we use stimulation techniques to “drive” the brain at certain frequencies. And yet we wish to understand these in somewhat the same way. The stimulation takes the brain away from the state that it intended for itself. It therefore reacts to counter the effect. This action and reaction dynamic eventually strengthens the regulatory networks so that they function better in the steady state. This at least is our current working hypothesis.
It may mystify the reader as to why it has taken so long to surface a promising technology that had its roots in research some thirty years ago. The reasons are many. Frankly there was not the understanding of the brain at the time which would allow these results to be understood. So scientists handled the results with tongs, so to speak, namely as curiosities to be left for later. Much later. The second reason was that psychopharmacology was progressing nicely. Why rock the boat? Here was an obvious remedy. Moreover, it was one for which we had a rationale. Third, neurofeedback was discovered by psychologists, and these researchers tend not to publish in medical journals. Fourth, the new technology has to assert itself in the context of third-party payers oriented toward solving their own problems, not those of their clients. Neurofeedback is not inexpensive in the moment, though it is cost-effective in terms of lifetime costing.
The remainder of this essay will review what neurofeedback can offer for a variety of conditions of interest to readers of Latitudes, given the current state of the technology: ADHD; OCD and Tourette Syndrome; the Autism Spectrum; and Specific Learning Disabilities. I will also include a brief discussion of the emerging category of Childhood Bipolar Disorder, and traumatic brain injury. We end with a listing of resources for parents and professionals.
ADHD
The most common application of neurofeedback is to Attention Deficit Hyperactivity Disorder and its relatives, Oppositional-Defiant Disorder and Conduct Disorder. Since stimulant medication is now commonplace, we tend not to see the children for whom stimulants offer a remedy. Rather, we tend to see children who are more challenging. Behavior is usually the issue, as opposed to attention and academic performance. In neurofeedback for the ADHD spectrum, we usually target arousal regulation first and foremost. For a variety of reasons, many of these children appear under-aroused, with the brain not fully engaged. These tend to be the stimulant-responsive kids. But while we are training arousal we are also impacting on the brain networks that govern emotional regulation, and oppositionality falls away with the training. This goes beyond what can be accomplished with the stimulants.
There is another subset of these children who respond preferentially to anti-depressants rather than to stimulants. This depressive subtype is trained slightly differently, with a shift toward more frontal electrode placements, and with slightly different frequency targets. There may be under-arousal here as well. The training is adaptive, in that we see how a child responds and adjust the training as necessary. The learning curve on our training approaches is much faster than it is with meds, however. Often we adjust the training parameters even within a single session for a better effect.
A third subset of children don’t respond well to either stimulants or anti-depressants. These children tend to be more extreme behaviorally, with rage commonplace, along with frequent and extreme mood swings. These children are now treated medically with heavy-duty medications, the anti-convulsants and the anti-psychotics. This is truly the heavy artillery in the medical arsenal. Medication management is often problematic, requiring polypharmacy and repeated dose adjustments. These children are now typically identified with Childhood Bipolar Disorder. We also see them with the diagnosis of Tourette Syndrome, or Temporal Lobe Epilepsy. One wonders what is in prospect for these children through the rest of life.
As it happens, they are prime candidates for neurofeedback. The EEG biofeedback training tends to stabilize brain function, which is exactly what is needed in these cases. Rather than focusing on the specific symptoms, we recognize that these brains are just fundamentally less stable than others. Stability itself becomes the target of training, and the various symptoms then tend to subside. Even with the completion of training the children may be on some medication, but the regimen will likely be simpler and at lower dosage. The objective is not to free children from meds necessarily, but rather to attain optimum levels of function by whatever means are available.
There is actually a fourth category that should be listed here, and it is the anxious child. Anxiety also leads to loss of attentional function, but in these cases the anxiety is usually identified as the primary condition, and appropriately so. However they are labeled, these children also respond favorably to neurofeedback. As a matter of fact, biofeedback of all kinds is traditionally most associated with the management of anxiety and the stress response. We have now learned how to accomplish this as well with brainwave training. One important consideration here is that the anxious brain may also see safety and security in that anxiety, and a sense of calmness may not be at all reassuring to someone who does not live there. The anxious child may have to be trained gradually toward calmer states. However, as with many conditions, such training is more readily accomplished with children than with adults who have a lifetime of experience with anxiety.
OCD and Tourette Syndrome
From the standpoint of neurofeedback, these two conditions have a lot in common. They involve the same set of brain circuits, with symptom presentation just being somewhat different for both. One common element is over-arousal. In the vast majority of cases, the brain is overly engaged, restless, or even racing. There is a high degree of excitability of the motor system. The overarching need is for these brains to experience calming, both in general and specifically in regard to motor circuits. When such calming is achieved, both the tics (motor and vocal) and the OCD symptoms may be helped. One factor to consider is that the Tourette’s child may in fact be quite comfortable with the brain he’s been given. Whereas the child might be willing to shed some disagreeable symptoms, the child should not have to “give up” the competencies that often also go along with TS. It is one of the virtues of EEG training that it is not really a “cure” for Tourette Syndrome per se. Rather, it is a self-regulation strategy. The brain is trained to the point where the excursions into ticcy behavior are reduced or eliminated, to where there is no more “racing brain,” and to where the behavioral loops of OCD are not initiated, but the person is still very much himself or herself. Calmness is just that. It is not the absence of mental acuity. The person does not have to “lose his edge” to get the benefit of neurofeedback. In this regard, neurofeedback is different from medication response.
What then may someone expect from neurofeedback training for TS? First of all, this application of neurofeedback would be generally regarded as experimental. Also, most neurofeedback practitioners are oriented toward ADHD, and may have very little experience with TS and OCD. Just as Ritalin can worsen tics, the standard neurofeedback approaches to ADHD can worsen TS and OCD symptoms. A more specifically targeted approach is needed, so it is important to seek out an experienced clinician. With the right approach, there should be significant improvement in symptoms in the vast majority of cases. This is also a condition that appears to benefit from long-term training if the hoped-for symptom remediation is not quickly achieved. Such training can be done on a supervised home-training basis.
The Autistic Spectrum
One of the recent developments in neurofeedback is progress in remediating the symptoms of autism and Asperger’s Syndrome. It is important to acknowledge at the outset that neurofeedback for autism is a very different matter from neurofeedback for ADHD. In the former, we know that we are dealing with an organically-based condition to which we can offer only a partial and symptomatic remedy. In the case of ADHD, by contrast, we would argue that the core of the condition is the disregulation of attentional and emotional functioning. Once such disregulation is remediated, ADHD can no longer be identified or diagnosed in such a person. The same cannot be said for autism. Whereas we have been able to take children to the point where they have shed their diagnosis of autism, the fact is that we are still dealing with a brain that is organically compromised in some fashion.
That having been said, it is often possible to obtain significant behavioral gains. In one study, symptom improvement at an average level of 1% per half-hour session was achieved over some thirty sessions. A thirty percent symptom reduction is probably worthwhile, and these children had not yet plateaued in the training. We now see the need for transitioning neurofeedback into home training where these children may be able to benefit from the continuing brain challenge of neurofeedback without great expense and dislocation. The children who made the greatest gains also trained for over a year.
What might a parent expect from neurofeedback for autism? First of all, we are again confronted with a condition of extreme over-arousal, so the need is for profound calming. This is doable. Along with this comes a reduction in sensory excitability (auditory, visual, and tactile). In addition to targeting overall arousal issues, we also target specifically the brain circuitry involved in emotional regulation. The parent may see growth in the child’s ability to relate to others, to make eye contact, and to self-monitor behavior. Along with an ability to relate to others may come a greater interest in communication and hence in language. The one follows from the other. That is to say, the primary bottleneck appears in some instances to be around communication rather than language per se. Nevertheless, one site on the cortex has been identified that when suitably trained functions like an on-switch for language in some children. In pre-verbal children we may get more babbling. This application of neurofeedback must also be considered experimental, and it is again important to seek out a clinician with relevant experience.
Summary
We have in neurofeedback an intervention that is largely complementary to what is already available, either in terms of mainstream medicine or of other alternative modalities. Neurofeedback addresses issues of brain regulation in the bio-electrical domain. Hence its effects are usually additive to whatever else is being done. For additional information, the reader is referred to two recent books: “A Symphony in the Brain,” by Jim Robbins, and “Getting Rid of Ritalin,” by Robert Hill, Ph.D., and Ed Castro, MD. Look also for the upcoming book, “ADD: The Twenty-Hour Solution,” by Mark Steinberg, Ph.D., and Siegfried Othmer, Ph.D.
For further information, visit www.eeginfo.com