Applied
Psychophysiology and Biofeedback, Vol. 27, No. 4, December 2002 ( C°
2002)
The
Effects of Stimulant Therapy, EEG Biofeedback,
and
Parenting Style on the Primary Symptoms
of
Attention-Deficit/Hyperactivity Disorder1
Vincent
J. Monastra,2;3
Donna M. Monastra,2
and Susan George2
One
hundred children, ages 6–19, who were diagnosed with
attention-deficit/hyperactivity
disorder
(ADHD), either inattentive or combined types, participated in a study examining
the
effects of Ritalin, EEG biofeedback, and parenting style on the primary symptoms
of
ADHD.
All of the patients participated in a 1-year, multimodal, outpatient program
that
included
Ritalin, parent counseling, and academic support at school (either a 504 Plan or
an
IEP). Fifty-one of the participants also received EEG biofeedback therapy.
Posttreatment
assessments
were conducted both with and without stimulant therapy. Significant improvement
was
noted on the Test of Variables of Attention (TOVA; L. M. Greenberg, 1996) and
the
Attention Deficit Disorders Evaluation Scale (ADDES; S. B. McCarney, 1995) when
participants
were tested while using Ritalin. However, only those who had received EEG
biofeedback
sustained these gains when tested without Ritalin. The results of a Quantitative
Electroencephalographic
Scanning Process (QEEG-Scan; V. J. Monastra et al., 1999)
revealed
significant reduction in cortical slowing only in patients who had received EEG
biofeedback.
Behavioral measures indicated that parenting style exerted a significant
moderating
effect
on the expression of behavioral symptoms at home but not at school.
KEY
WORDS: EEG
biofeedback; ADHD; Ritalin; parenting style; outcome studies.
Attention
Deficit-Hyperactivity Disorder (ADHD) is a psychiatric disorder, characterized
by
the primary symptoms of inattention and/or impulsivity and hyperactivity, that
is
evident in approximately 3–5% of school-aged children (American Psychiatric
Association,
1994).
Although currently defined in terms of behavioral symptoms, there is evidence
that
the core symptoms of ADHD can be associated with metabolic (Zametkin et al.,
1990;
Zametkin
& Rapoport, 1987), circulatory (Amen, Paldi, & Thisted, 1993),
neuroanatomical
(Casey
et al., 1997; Hynd et al., 1993), and electrophysiological abnormalities (Chabot,
Merkin,
Wood,
1Preliminary reports of this research were presented at the
Eleventh Annual Conference of CH.A.D.D. held in
which
convened in
2FPI Attention Disorders Clinic,
3Address all correspondence to Vincent J. Monastra, PhD, FPI
Attention Disorders Clinic, 2102 E. Main Street,
231
1090-0586/02/1200-0231/0
C° 2002
Plenum Publishing Corporation
232
Monastra, Monastra, and George
Zimmerman,
Milller,&Muenchen, 1992; Monastra et al., 1999; Monastra, Lubar,&
2001).
In addition to the primary characteristics of ADHD, there are multiple secondary
symptoms
that are frequently noted, including learning disorders, anxiety, depression and
other
mood disorders, tic disorders, and conduct disorders (Spencer, Biederman, &Wilens,
1999).
Estimates of the incidence of these secondary or comorbid symptoms range from 50
to
90% (Barkley, 1998; Spencer et al., 1999).
Because
of the significant impairment of academic, social, family, and vocational
functioning
that
is caused by ADHD and these comorbid conditions (summarized by Barkley,
1996;
Hinshaw, 1992), considerable scientific effort has been directed at developing
effective
pharmacological
and psychological treatments. As reviewed by Spencer et al. (1996)
and
Swanson et al. (1993), the vast majority of these studies have indicated that
pharmacological
treatments
can exert a positive effect on the core symptoms of inattention,
impulsivity,
and hyperactivity. However, as noted by Barkley (1998), approximately 35–
45%
of patients diagnosed with an “Inattentive” Type of ADHD and 10–30% of
those with
a
“Combined” Type of ADHD fail to respond to medications. In addition,
systematic review
of
the effects of pharmacological treatment on cognition, academic achievement, and
social
skills (Bennett, Brown, Craver, & Anderson, 1999; Brown & Sawyer, 1988;
National
problems
presented by ADHD patients can be effectively treated by medication alone.
Based
on a clinical perspective that many of the functional impairments associated
with
ADHD
are not responsive to medication treatments, researchers have examined the role
of
various
behavioral therapies in the development of academic, social, and attentional
abilities.
Such
studies have examined the effects of “reinforced” instruction in
psychosocial skills
in
school and “camp” settings (e.g., MTA Cooperative Group, 1999; Pelham,
Wheeler, &
Chronis,
1998), at home via parent training (Anastopoulos,
1993),
or through a combination of these approaches (MTA Cooperative Group, 1999). The
outcome
of these studies suggests that although pharmacological treatments for ADHD
are
effective in treating core ADHD symptoms, a combination of such treatments with
social
skills and parent training yielded additional improvements in secondary areas of
psychosocial
functioning (e.g. learning, behavioral, emotional, social, and family problems).
However,
there is no evidence that these clinical improvements continue in the absence of
sustained,
long-term treatment with stimulant medication.
Because
of concerns about the risks of long-term treatment with stimulants (Breggin,
1998;
Jensen et al., 1999) examination of the effects of “nonpharmacological”
treatments for
ADHD
has been encouraged (Breggin, 1998). Among these treatments, EEG biofeedback,
a
type of behavioral therapy developed to target the core ADHD symptoms of
inattention,
impulsivity,
and hyperactivity, has “generated considerable interest” (National Institute
of
Health,
1998).
The
initial description of the use of EEG biofeedback in the treatment of ADHD
was
reported in a pair of case studies (Lubar & Shouse, 1976; Shouse & Lubar,
1979). In
their
first study, Lubar and Shouse (1976) presented the application of operant
conditioning
techniques
to reinforce specific types of electrophysiological activity for the purpose of
treating
the core symptoms of ADHD. Similar to other operant conditioning paradigms, this
treatment
involved providing patients with visual and auditory “feedback” for certain
“neuronal
behaviors.”
Based on earlier studies by Sterman and his colleagues (summarized in
Sterman,
1996), Lubar and Shouse (1976) hypothesized that reinforcing increased
production
of
electrophysiological activity within either the 12–15 Hz (SMR) or 16–20 Hz
(beta)
EEG
Biofeedback Treatment for ADHD 233
ranges,
while attempting to decrease “slower” cortical activity (4–8 Hz; theta),
would result
in
reduction of impulsivity/hyperactivity and improvement of attention when
recordings
were
obtained over either the sensorimotor region or the central frontal region.
Their initial
findings
were consistent with this hypothsis as reduced hyperactive behavior and improved
attention
were reported in these early case studies.
Despite
the positive clinical outcome of Lubar and Shouse’s application of operant
conditioning
principles to treat ADHD by reinforcing electrophysiological activity within
specific
frequency bands, there have been few published reports of controlled group
studies
examining
the efficacy of EEG biofeedback. As reviewed by Nash (2000), the majority of
reports
assess efficacy via analysis of multiple case studies, in which patient
performance
on
certain measures (e.g., intelligence, academic skills, behavioral rating scales,
continuous
performance
tests) is compared pre- and posttreatment with EEG biofeedback. Although
these
published case studies (e.g.,
Swartwood,
& O’Donnell, 1995; Lubar, Swartwood, Swartwood, & Timmermann, 1996;
Thompson&Thompson,
1998) have yielded generally positive results, additional controlled
clinical
research was needed in order to address issues of treatment efficacy.
To
date, only two controlled group studies have been published. The first (
Habib,
& Radojevic, 1996) utilized a randomized design and compared the effects of
40
sessions of EEG biofeedback (theta suppression/beta enhancement) with a
“waiting
list”
control. A total of 18 patients (aged 5–15) participated in the study.
Treatment sessions
were
conducted over a 6-month period. Medication therapy was not provided for members
of
either group. Results indicated improvement on a measure of intelligence, and
reduced
ADHD
symptoms on a behavior rating scale in the biofeedback group.
The
second “controlled” studywas conducted by Rossiter and LaVaque (1995). In
their
design,
46 participants (aged 8–21) were given the opportunity to select participation
in an
EEG
biofeedback group or a stimulant therapy group (titrated Ritalin). Twenty
sessions
of
biofeedback were provided over a 3-month period. Pre- and posttreatment
assessment
for
both groups consisted of behavioral rating scales and the Test of Variables of
Attention
(TOVA).
Both groups showed significant improvement on dependent measures. There was
no
significant differences between the Ritalin and the biofeedback groups.
Although
these two prior investigations of EEG biofeedback utilized controlled group
designs
and reported positive response on multiple dependent measures, examination of
the
methodology revealed several limitations, including small sample size and
absence of
follow-up
data. In addition, although published EEG biofeedback protocols were utilized,
examination
of electrophysiological variables in response to treatment was not conducted
and
the designs did not provide a basis for comparing the unique contributions of
EEG
biofeedback
and other “active” (e.g., Ritalin) or “placebo” treatments. Finally,
although an
attempt
was made to limit other types of psychological interventions, it was evident
that at
least
informal “parent counseling” and other nonspecific forms of counseling were
provided
to
some of the participants.
The
purpose of the present study was to examine the effects of EEG biofeedback and
Ritalin
on the primary symptoms of ADHD, as well as, on neuropsychological and
electrophysiological
measures,
while controlling for other commonly provided types of clinical
interventions
(stimulant therapy, parent counseling, school consultation). Because previous
controlled
studies of EEG biofeedback had not provided extensive follow-up data,
examination
of
treatment effects was conducted 1 year after initial evaluation. Because Ritalin
has
been shown to yield only short-term clinical effects (see review by Barkley,
1998) and
234
Monastra, Monastra, and George
there
is case study evidence that suggests the effects of EEG biofeedback may be more
enduring
(Lubar, 1995; Tansey, 1993), the use of a dismantling design was considered
appropriate
for
examining transitory versus sustained clinical effects. As a result, examination
of
patients, both while being treated with Ritalin and following a medication
“wash out”
period,
seemed required. In addition, because there is evidence that systematic use of
reinforcement
principles
by parents/caretakers can contribute to improved social functioning
of
children diagnosed with ADHD (Pisterman, McGrath, Firestone, & Goodman,
1988;
Pollard,
Ward, & Barkley, 1983), evaluation of the effects of parenting style was
considered
necessary
in order to clarify the effects of EEG biofeedback and Ritalin on behavioral
characteristics
of ADHD.
Our
hypotheses were as follows. First, given prior reports suggesting the efficacy
of
both
stimulant therapy and EEG biofeedback, we predicted that participants being
treated
with
Ritalin alone or in combination with EEG biofeedback would show improvements on
behavioral
and neuropsychological tests of attention and impulse control during
posttreatment
evaluations
conducted while using medication. Second, given the absence of long-term
clinical
effect of Ritalin, as well as, the lack of measurable change on QEEG indicators
of
cortical arousal over frontal and central cortical regions following
administration of
methylphenidate
(Lubar et al., 1996), and the case reports of reduced cortical slowing following
EEG
biofeedback (Thompson&Thompson, 1998), we anticipated that only patients
who
received EEG biofeedback would demonstrate improvement on QEEG measures.
Furthermore,
we
hypothesized that only patients who had received EEG biofeedback as part
of
treatment would show sustained improvement on behavioral, neuropsychological,
and
QEEG
measures when tested after a 1-week medication “wash-out” period. Finally,
because
systematic
use of reinforcement strategies by parents/caretakers has been associated with
improved
social functioning in patients diagnosed with ADHD, we predicted that parenting
style
would emerge as a moderating variable on behavioral measures, regardless of the
inclusion
of EEG biofeedback.
METHODS
Participants
One
hundred children, ages 6–19 (83 males; 17 females), and their parents
participated
in
this study. Based on parental preference, patients participated in either a
Comprehensive
Clinical
Care (CCC) program, which included medication management, parent counseling,
and
school consultation, or a CCC plus EEG Biofeedback program (CCCCB). All were
diagnosed
withADHD(24:ADHD,inattentive; 76:ADHD,combined) by a licensed clinical
psychologist,
based on DSM-IV criteria. None had a history of prior treatment for ADHD.
As
reflected in Table I, the composition of the two groups was comparable with
respect
to
participant age, gender, diagnosis, intelligence, parental education, marital
status, and
median
family income.
All
participants were screened by The Family Psychology Institute, a private
outpatient
psychological
clinic located in a region of Upstate New York with a population of
approximately
500,000 within a 50 mile radius of the clinic. Physicians, schools, and mental
health
professionals located near the Institute referred the individuals who
participated
in
the study. Individuals who had previously been diagnosed and treated for ADHD or
other
EEG
Biofeedback Treatment for ADHD 235
CCC
CCCCB
Gender
Male/female
(N) 40=9 43=8
Age
(years)
Mean
10.0 10.0
SD
3.7 3.1
Diagnosis
ADHD,
Inattentive (N) 14 10
ADHD,
Combined (N) 35 41
Intelligence
quotient
Mean
105.9 105.2
SD
8.6 11.2
Parents
Highest
grade
Mean
16.2 15.5
SD
2.5 2.3
Median
income $50,000–60,000 $50,000–60,000
Marital
status
Married
(N) 49 50
Separated/divorced
(N) 0 1
Note.
CCC D comprehensive
clinical care group; CCCCB D comprehensive
clinical
care plus biofeedback group.
psychiatric
or medical disorders that could affect attentional functions were excluded from
this
study.
Procedure
Pretreatment
Screening
Following
physician evaluation of each participant for medical conditions (other than
ADHD),
which could cause symptoms of inattention and hyperactivity (e.g., anemia,
hypoglycemia,
thyroid
disorders), parents were interviewed by a licensed clinical psychologist
using
Barkley and Murphy’s structured format (Barkley & Murphy, 1998). This
parental
interview
format provides extensive information regarding medical, developmental,
academic,
and
social history, and serves as a foundation for comparing patient clinical
history
with
DSM-IV criteria for ADHD and other psychiatric disorders. In addition, this
interview
provided
a format for examining the behavioral management methods used by parents, and
the
degree of parental consistency. In order to be accepted for participation in the
study,
participants
were required to meet all DSM-IV criteria for ADHD.
Subsequently,
the parents completed the Home Version of the Attention Deficit Disorders
Evaluation
Scale (ADDES; McCarney, 1995). The ADDES is a behavioral rating scale
that
provides an indication of the frequency of ADHD symptoms and a basis for
comparison
with
“nonimpaired” age peers. A School Version of the ADDES was completed by the
child’s
teachers. In order to be included in this study, each participant needed to be
rated as
displaying
a significantly greater frequency of ADHD symptoms than same age peers on
both
the Home and School Version of the ADDES. Specifically, a standard score below 7
was
required on the Inattentive and/or Hyperactive/Impulsive subscales of both the
Home
and
School Versions of the ADDES.
236
Monastra, Monastra, and George
Children
meeting the behavioral criteria for inclusion in the study were then evaluated
with
the Test of Variables of Attention (TOVA; Greenberg, 1996). Because of the
potential
rater
bias associated with behavioral rating scales like the ADDES, the use of a
computeradministered/
scored
test of attentional abilitieswas considered desirable in order to obtain an
“objective”
measure of attention and capacity for impulse control. Continuous Performance
Tests,
like the TOVA, provide an assessment of an individual’s performance on a task
that
requires
tracking of visual stimuli with differential response/nonresponse to target and
nontarget
stimuli. In this study, errors of inattention (i.e., failure to respond to a
target
stimulus)
and impulsivity (i.e., response to a nontarget stimuli), as well as, response
rate
and
the consistency of response rate (variability) were obtained.
The
TOVA was selected because it has been utilized as one of the outcome measures in
previous
biofeedback studies (e.g., Lubar et al., 1995; Rossiter&LaVaque, 1995;
Thompson
&Thompson,
1998) and because it has been shown to demonstrate adequate criterion related
validity
when compared with physician diagnosis ofADHD(Monastra et al., 2001). In order
to
be included as a participant in the study, a standard score below80was required
on at least
one
of the TOVA subscales (i.e., Omissions, Commissions, Response Rate, or
Variability).
Finally,
a Quantitative Electroencephalographic (QEEG) Scanning Process (Monastra
et
al., 1999) was conducted using the Autogenics A-620 Electroencephalograph (Wood
research
(Chabot et al., 1996; Chabot & Serfontein, 1996; Mann et al., 1992; Monastra
et
al., 1999, 2001) indicated that patients with ADHD typically exhibit excessive
“slow
wave”
activity (4–8 Hz), relative to “fast” EEG activity (13–21 Hz) over
central-midline
and
frontal locations, Monastra et al.’s QEEG assessment was conducted in order to
insure
that
only ADHD patients showing this type of QEEG profile were included in the study
(Monastra
et al., 1999).
Monastra
et al.’s protocol involves a comparison of electrophysiological power recorded
at
4–8 Hz (“theta”) and 13–21 Hz (“beta”) (Monastra et al., 1999). QEEG
recordings
are
obtained from the vertex (Cz) with ear references. In the Monastra et al. (1999)
process,
a
ratio comparing the power recorded within the “theta” and “beta”
frequency bands is
calculated
based on QEEG data obtained during four, 90-s tasks (Baseline, Silent Reading,
Listening,
and Drawing). The overall average of these “power ratios” is then determined
in
order to obtain the electrophysiologically-based Attention Index. Participants
needed to
exhibit
an Attention Index that was at least 1.5 SD greater than age peers based
on the
database
provided by Monastra et al. (1999) in order to be included in this study.
All
evaluations were completed between
were
tested within 48 hr of using any type of medication. Participants were invited
to
participate in this study provided that the results of clinical interview,
behavioral
rating
scales (both Home and School), the TOVA, and the QEEG Scan were all positive
for
ADHD. Subtype differentiation was made on the basis of interview and rating
scales.
Treatment
Phase
Following
the pretreatment screening, those participants who met inclusion criteria
were
interviewed with their parents. A review of the treatments that would be
provided
to
participants in this study was given at that time. These interventions included
stimulant
EEG
Biofeedback Treatment for ADHD 237
therapy,
parent counseling (individual and group), school consultation to
establish/monitor
a
program of academic support, and EEG biofeedback. All participants received
stimulant
therapy,
parent counseling, and school consultation. In addition, EEG biofeedback was
offered
and included in the treatment program of 51 of the participants. A brief
description
of
each treatment follows.
Stimulant
Therapy. As noted
previously, all participants in the study were treated with
Ritalin.
Dosage was titrated as follows. Initially, all participants were prescribed a 5
mg
dose,
t.i.d. for 1 week. After a week, parents and teachers completed the Side Effects
Rating
Scale
(Barkley & Murphy, 1998) and the child was tested with the TOVA. If the
standard
scores
for all TOVA subtests were within 1.0 SD of age peers and IQ, and parent
and teacher
ratings
for adverse side effects indicated that the medication was well-tolerated, no
change
in
dose was made. If at least one of the TOVA subtest scores remained within the
“clinical
range”
(i.e.,>1:5 SD below age peers and IQ) dose was increased
by 2.5 mg per dose and
the
child was retested after 1 week. This process continued until all TOVA subtests
were
within
the nonclinical range. The average daily dose of Ritalin (following titration)
was
25
mg, t.i.d. (
the
average dosage administered to members of the CCCCB group (range: 15–45
mg/day).
Parent
Counseling. Using
the model presented by Anastopoulos, Smith, and Wien
(1998)
as a foundation, all parents participated in a 10 session parenting class,
followed
by
individual consultation on an “as needed” basis. The program described by
Anastopoulos
et
al. (1998) consists of a series of educational “steps” designed to increase
parental
understanding
of the causes of ADHD, as well as, the role of positive parental attention
and
systematic use of reinforcement strategies in reducing the functional
impairments
associated
with ADHD. Our parenting class also included presentations on “Problem
solving
with preteens/teens” (Robin, 1998), “Nutrition,” and “The educational
rights of
children
with ADHD.” At the conclusion of our parenting classes, each parent had
developed
and
was attempting to implement a program of systematic reinforcement to address
either
primary or secondary ADHD symptoms. The mean number of clinical contact
hours
for parenting classes/individual consultations was 27 for the CCC group; 25 for
the
CCCCB
group.
School
Consultation. At the
conclusion of the pretreatment screening, those participants,
who
met inclusion criteria, were referred by their parents to the Committee for
Special
Educational Services in their home school district. Federal regulations under
the
Individuals
with Disabilities Act (IDEA) and the Rehabilitation Act of 1973 specify that
individuals
diagnosed with ADHD are to be evaluated by their school district in order
to
determine the presence/degree of learning and functional disabilities. This
evaluation
is
to be completed within 45 days of receipt of a letter requesting such an
evaluation by
a
parent (or other caregiver). Based on this school evaluation, a program of
academic
remediation
and/or accommodation is to be developed and monitored on an ongoing
basis.
In
accordance with these laws, each of our participants was evaluated by their
school
districts,
and either an individualized educational program (IEP) or a plan of academic
support/accommodation
(“504 Plan”) was developed, implemented, and revised with our
assistance.
The mean number of on-site school consultations was three for both the CCC
and
the CCC+B groups (range: 1–7). Weekly “progress” reports, listing any
incomplete
assignments,
upcoming projects and tests, and any behavioral incidents, were also reviewed
with
the parents in order to insure parental reinforcement of “on-task” behavior
at school.
238
Monastra, Monastra, and George
EEG
Biofeedback. For
those patients whose parents selected EEG biofeedback, individual,
weekly
“attention training” sessions, lasting 30–40 min, were also provided using
the
Lubar Protocol (Lubar et al., 1995). In addition to the visual and auditory
feedback
that
was provided by the Autogenics A-620 Neurofeedback System (Wood Dale, IL) each
time
that the child produced 0.5 s of improved arousal over the frontal cortex,
participants
were
also reinforced for their efforts using a “point system.” When the patient
accumulated
a
total of 20 points (representing improved EEG performance on 20 “training”
tasks)
they
could exchange these points for a cash “reward” of $15. Participants
typically accumulated
a
sufficient number of points to earn such a “reward” every three to four
sessions.
EEG
biofeedback sessions were conducted until the patient exhibited a degree of
cortical
slowing on the QEEG scan that was within 1.0 SD of age peers, based on
the
Monastra
et al. (1999) database, and were able to maintain this level of arousal for 40
min
in
each of three consecutive treatment sessions. All of the participants in the
CCC+B group
achieved
this criterion. The average number of sessions needed to reach this goal was
43
(range: 34–50).
Posttreatment
Assessment
One
year after the intake evaluation, each patient was reevaluated using the ADDES
(Home
and School), the TOVA, and the QEEG Scan. The first posttreatment assessmentwas
conducted
while the patient was being treated with Ritalin. A second posttreatment
assessment
was
conducted after a 1-week medication “washout” period. During the
“washout”
period,
no stimulant medications were administered.
In
addition to evaluating patient progress, parenting style was evaluated at the
conclusion
of
treatment based on interview. Parenting style was rated as “systematic” if
parents
reported
use of time out, removal of privileges, and use of earned privileges “most of
the
time.”
Parenting style was rated as “nonsystematic” if the parents failed to report
use of
a
combination of “reward” and “response cost” techniques, “most of the
time,” or if they
reported
use of physical punishment, acquiescence to child, or avoidance of the child,
“most
of
the time.”
Statistical
analysis consisted of ANOVA to examine the main and interactional effects
of
Ritalin, EEG biofeedback, and parenting style on behavioral, neuropsychological,
and
QEEG measures. Post hoc analysis of significant main and interactional effects
was
conducted
using Tukey’s Honest Significant Difference Test. All statistical analyses
were
conducted
using the Statistica Software Program (StatSoft, 1995). An alpha level of at
least
.05
was used for all statistical tests.
RESULTS
Pretreatment
Assessment
Prior
to conducting a statistical analysis of the main and interactional treatment
effects
of
EEG biofeedback and parenting style, analysis of pretreatment scores on
behavioral,
neuropsychological,
and electrophysiological measures was conducted in order to insure
that
theCCCandCCCCBgroups were comparable in terms of initial severity of impairment.
The
mean pretreatment scores on the ADDES, TOVA, and QEEG Scan are provided in
EEG
Biofeedback Treatment for ADHD 239
Table
II. Pretreatment
Assessment: Without Ritalin
CCC
CCCCB
Dependent
measure Mean SD Mean SD F(1; 98) p
Attention
Deficit Disorders Evaluation Scales: Standard scores
ADDES:
Home
Inattentive
3.92 2.02 4.22 2.23 0.48 .50
Hyperactive
6.02 3.53 5.09 3.48 1.72 .20
ADDES:
School
Inattentive
4.61 1.22 4.69 1.12 0.11 .70
Hyperactive
5.88 3.79 5.14 3.03 1.17 .30
Test
of Variables of Attention (TOVA): Standard scores
Inattention
77.00 27.08 69.57 27.46 1.86 .18
Impulsivity
74.96 25.96 68.98 24.89 2.07 .23
Response
time 85.35 20.39 87.94 18.85 0.44 .51
Variability
64.57 17.33 62.45 18.71 0.34 .56
Quantitative
EEG scanning process
QEEG:
Attention Indexa 5.85 2.30 5.77 1.80 0.04 .85
aAttention Index D mean theta/beta power ratio, averaged
for four tasks.
Table
II. The results of this initial analysis revealed no significant group
differences on any
of
the behavioral, neuropsychological, or QEEG measures.
Posttreatment
Assessment
Behavioral
Measures
One
of the primary goals of this study was to examine whether EEG biofeedback
exerted
any effect on behavioral, neuropsychological, or electrophysiological measures
beyond
that associated with stimulant therapy. As a result, parent and teacher
observations
on
the ADDES were obtained on two occasions, 1 year following initial assessment.
These
observations
were first recorded while the participants were still being treated with
Ritalin.
A
second posttreatment assessment was conducted after a 1-week period in which no
stimulant
therapy was provided. A summary of the mean standard scores derived from the
ADDES
during these two evaluations is provided in Table III. Standard scores below 7
on
the
ADDES are considered to be within the impaired range.
Initial
inspection of the mean standard scores for inattentive and hyperactive/impulsive
behaviors
(presented in Table III), reveals a pattern of continued impairment in the CCC
group,
both at home and school. When tested 1 year after beginning stimulant therapy
(Ritalin),
no indication of sustained improvement was suggested by group data, regardless
of
the inclusion of medication or consideration of parenting style. All of the
group means
remained
under 7, an indication of the need for continued intervention.
In
contrast, mean standard scores for the group that had received EEG biofeedback
(CCCCB)
suggested sustained improvement, regardless of the use of Ritalin, when tested
1
year after the initial evaluation. These treatment gains were reported by
parents and
teachers.
Inspection of the data contained in Table III revealed group means above the
clinical
cut-off score of 7 regardless of the use of Ritalin. In addition, the moderating
influence
of parenting style was also suggested in Table III, as those patients whose
parents
systematically
employed reinforcement strategies demonstrated improved attention and
240
Monastra, Monastra, and George
Table
III. Posttreatment
Assessment: Behavioral Measure
Attention
Deficit Disorders Evaluation Scales: Standard scoresa
Inattentive
Hyperactive Inattentive Hyperactive
Mean
SD Mean SD Mean SD Mean SD
Comprehensive
clinical care group
With
Ritalin 4.63 0.95 6.06 3.14 4.96 0.82 5.96 3.44
Without
Ritalin 3.10 0.91 4.51 3.79 3.29 1.06 4.53 3.76
Ritalin
and systematic parenting 4.67 0.99 5.91 3.27 4.97 0.92 5.76 3.56
Systematic
parenting without Ritalin 3.12 0.96 4.45 3.89 3.24 1.20 4.27 3.87
Ritalin
without systematic parenting 4.56 0.89 6.38 2.92 4.94 0.57 6.38 3.24
No
Ritalin and nonsystematic parenting 3.06 0.85 4.63 3.70 3.38 0.72 5.06 3.60
Comprehensive
clinical care plus
biofeedback
group
With
Ritalin 8.59 1.86 8.65 2.16 9.35 0.72 9.63 1.09
Without
Ritalin 8.16 2.10 8.37 2.35 9.53 0.61 9.69 0.84
Ritalin
and systematic parenting 9.22 1.36 9.49 1.56 9.38 0.72 9.73 1.10
Systematic
parenting without Ritalin 9.19 1.05 9.51 1.39 9.68 0.53 9.84 0.80
Ritalin
without systematic parenting 6.93 2.02 6.43 1.99 9.29 0.73 9.36 1.08
No
Ritalin and nonsystematic parenting 5.43 1.70 5.36 1.55 9.14 0.66 9.29 0.83
aStandard scores below 7 are considered indicative of
impaired functioning.
reduced
hyperactivity and impulsivity at home. Illustrations of the moderating effects
of
parenting
style are presented in Figs. 1 and 2.
Statistical
analysis of the posttreatment data, obtained while participants were being
treated
with Ritalin, revealed a significant main effect associated with EEG
biofeedback.
Analysis
of variance results indicated that the group whose treatment included EEG
biofeedback
(CCCCB Group) showed significant greater attention, F(1; 98) D 177:62;
p
< :001, and less
hyperactive/impulsive behaviors, F(1; 98) D
compared
to participants whose treatment did not include EEG biofeedback (CCC group).
A
similar degree of sustained improvement was also evident in the ratings of
teachers,
who
rated the children in the CCCCB group as more attentive, F(1; 98)
D 821:30; p <
:001, and less hyperactive/impulsive, F(1; 98)
D 52:49; p < :001, than those in the CCC
group.
Further
analysis of the main effect of EEG biofeedback was conducted on data obtained
after
a 1-week medication “washout.” This data is also included in Table III.
ANOVA
results
revealed that sustained improvement was reported by parents and teachers only in
the
CCCCB group, who continued to display significantly fewer inattentive behaviors
at
home,
F(1; 98) D 239:54; p < :001, and at school, F(1;
98) D 1313:13; p < :001, than
the
members of the CCC group. Similarly, the CCCCB group exhibited signficantly
fewer
hyperactive
and impulsive behaviors than the members of the CCC group both at home,
F(1; 98) D 37:81; p < :001, and
at school, F(1; 98) D 91:02; p < :001.
Another
primary goal of this study was to examine the effect of parenting style on the
manifestation
of inattentive and hyperactive/impulsive behaviors. Particular interest was
placed
on determining whether participants whose parents/guardians were using a
“systematic”
type
of parenting (i.e., consistent use of rewards and response cost strategies)
would
exhibit
fewer behavioral symptoms than participants whose parents were
“nonsystematic”
in
their parenting style.
EEG
Biofeedback Treatment for ADHD 241
Fig.
1. Plot of the mean
standard scores for the Inattentive Scale of the ADDES, 1 year after beginning
treatment.
Scores
of 6 or less indicate continued impairment. Ratings were obtained from parents
while their child was
being
treated with medication (IN MED) and after a 1-week medication “wash-out”
(IN NOMED). Graph
depics
results for two-way interaction, Parenting style (SYS: Systematic vs. NON-SYS:
Nonsystematic) £ EEG
biofeedback
(Yes vs. No.)
In
order to clarify the contributions of EEG biofeedback and parenting style on
behavioral
measures
obtained from parents and teachers, interactional effects were analyzed. The
results
of a statistical analysis of parental ratings indicated a significant
interaction between
parenting
style and EEG biofeedback. These interactional effects were evident when
participants
were
rated while being treated with Ritalin [Inattention: F(1; 96) D 14:73;
p < :001;
Hyperactive/Impulsive:
F(1; 96) D
[Inattentive:
F(1; 96) D
As
clarified by post hoc analyses (Tukey HSD), no significant effect of parenting
style
was noted in the CCC group, regardless of the use of medication. However, in the
CCC+B
group, participants whose parents consistently used effective reinforcement
strategies
showed
significant reduction in symptoms. This pattern was noted at 1-year follow-up
when
patients were tested while using Ritalin (p < :001), as well as, after
a 1-week medication
washout
(p < :001).
No
evidence of an interactional effect was evident in statistical analyses of
teacher
ratings.
This finding was noted both when participants were being treated with Ritalin
[Inattentive:
F(1; 96) D 0:03; p D :86;
Hyperactive/Impulsive: F(1; 96) D 0:79; p D :38],
as
well as, after a 1-week medication washout [Inattentive: F(1; 96)
D 0:33; p D :56;
Hyperactive/Impulsive:
F(1; 96) D 1:77; p D :19]. Post hoc analyses
(Tukey HSD) revealed
that
significant improvements in attention and behavioral control at school was
noted
in the CCCCB group, regardless of parental style or use of medication (p <
:001).
In
contrast, no statistically significant improvements on behavioral measures were
noted in
the
CCC group, whose treatment did not include EEG biofeedback.
242
Monastra, Monastra, and George
Fig.
2. Plot of the mean
standard scores for the Hyperactive/Impulsive Scale of the ADDES, 1 year after
beginning
treatment. Scores of 6 or less indicate continued impairment. Ratings were
obtained from parents
while
their child was being treatment with medication (HY MED) and after a 1-week
medication “wash-out”
(HY
NOMED). Graph depicts results for the two-way interaction, Parenting style (SYS:
Systematic vs. NONSYS:
Nonsystematic)
£ EEG biofeedback (Yes vs. No).
Neuropsychological
Measure
In
order to assess whether EEG biofeedback contributed to sustained improvement on
a
computerized test of attention and impulse control, participants in this study
were retested
with
the TOVA, 1 year after their initial evaluation. During this posttreatment
period, the
TOVA
was administered on two occasions, once while being treated with Ritalin and
again
after
a 1-week medication washout period. As described previously, errors of
inattention
(i.e.,
failure to respond to a target stimulus) and impulsivity (i.e., response to a
nontarget
stimuli),
as well as, response rate and the consistency of response rate (variability)
were
obtained
in order to assess the sustained effects of EEG biofeedback. Standard scores
below
80
on any of the TOVA subscales are considered to be significantly less than
anticipated in
individuals
with average intelligence (such as our sample).
Table
IV presents the standard scores and results of ANOVAs for both the CCC and
CCCCB
groups when participants were tested 1 year after their initial assessment. The
upper
half of this table reflects the positive effects of stimulant therapy in the CCC
and the
CCCCB
groups. The mean scores for both groups were well within the unimpaired range.
Comparison
between both groups showed there was no significant difference between the
performance
of the two groups on any of the four TOVA subscales.
Following
a 1-week discontinuation of Ritalin, participants from both groups were
reevaluated
with the TOVA. The results of this subsequent assessment are summarized in
the
lower half of Table IV. Significant differences in performance were noted
between the
CCC
and CCCCB groups on all TOVA subscales. The CCC group exhibited an anticipated
EEG
Biofeedback Treatment for ADHD 243
Table
IV. Posttreatment
Assessment: Neuropsychological Measure
Test
of Variables of Attention (TOVA)
Comprehensive
clinical
Comprehensive
clinical care care C biofeedback
Dependent
measure Mean SD Mean SD F(1; 98) p
With
Ritalin
Inattention
102.24 5.89 101.45 7.21 0.36 .55
Impulsivity
103.96 7.60 101.10 10.78 2.34 .13
Response
time 100.65 9.16 102.20 10.67 0.59 .44
Variability
98.98 10.53 100.10 9.56 0.31 .58
Without
Ritalin
Inattention
76.24 22.71 98.92 7.65 45.35 <.001
Impulsivity
79.82 23.48 95.16 14.67 15.48 <.001
Response
time 88.24 17.05 97.02 8.19 10.89 <.001
Variability
64.04 12.44 94.39 9.49 189.11 <.001
return
to baseline level of performance once Ritalin was discontinued. However, the
group
that
had received EEG biofeedback (CCCCB) sustained a level of performance that was
well
within the unimpaired range. The TOVA scores in the CCCCB group revealed a level
of
performance that was significantly higher than the CCC group and the CCCCB
baseline
measures.
QEEG
Scanning Process
In
order to evaluate whether the effects of EEG biofeedback were simply a placebo
effect,
inclusion of a “biological” measure was considered essential. Because QEEG
studies
published
by three research teams (Chabot&Serfontein, 1996; Mann et al., 1992;
Monastra
et
al., 1999) had revealed significant differences in the degree of cortical
“arousal” measured
electrophysiologically
over central and frontal locations, the use of QEEG assessment was
considered
appropriate as a “biological” measure of attention. Monastra et al.’s QEEG
Scanning
Process (Monastra et al., 1999) was selected for this study due to the
availability
of
a published normative database, as well as, published reliability and cross
validation