Children play their way to improved concentration

Could it be that attention deficit/hyperactivity disorder (ADD/ADHD) – a seemingly intractable condition that makes life miserable for children and parents alike and is widely treated with drugs – can be alleviated and even cured with a type of biofeedback?

It sounds like a lot of hype, but a growing number of clinical studies have shown that the technique can be successful in about 80 percent of cases, and its effects long-lasting, without the need for Ritalin and similar drugs.

Neurofeedback (NFB), also called EEG (electroencephalogram) biofeedback or neurotherapy, is a type of biofeedback that uses displays of electroencephalography or functional magnetic resonance imaging (fMRI) in real time to show brain activity. Sensors are placed on the scalp to measure brainwave activity, with measurements displayed using video displays or sound. The signal can then be used by a person to receive feedback about their own brain activity.

Every year, more and more prescriptions for stimulants like Ritalin are prescribed to schoolchildren who can’t sit still (hyperactivity) or who have attention deficits (difficulty concentrating). Numerous parent complain of upsetting physiological and behavioral side effects that require their children to stop taking the prescription drug. In any case, about a quarter of children with the disorder do not respond to the drugs. There are also reports of Ritalin abuse by pupils and even students in institutes of higher learning who want to concentrate better for exams.

Side effects from the stimulants are not rare. Some studies have shown that as many as two out of three children taking the drugs for ADD/ADHD gave up because of physical or other symptoms that disrupted their lives or made them uncomfortable, and concluded that the benefits of the stimulants did not offset the side effects.

AN ISRAELI company that offers training sessions in neurofeedback for ADD/ADHD is BrainGames- Israel, which is using a technology developed at the US National Aeronautics and Space Administration (NASA) for measuring and promoting concentration among astronauts.

The technique uses games on conventional consoles like the Sony Playstation, or watching a film, instead of the flight simulator used at NASA. The child with suspected ADD/ADHD sits in front of a computer screen while his brainwave activity is monitored with wires connected to button-like sensors on his head. These wires are connected to computer software that detects, amplifies and records brainwaves, with the information immediately sent back to the patient who can see through changes in the action whether his brain activity lies within the designated range.

For example, if the child’s attention begins to wander, the hero, racing car or other object he is supposed to maneuver slows down, or the movie screen shuts down or the image turns to “snow,” informing the therapist of the change in brainwave activity. The therapist then encourages the child to focus his attention to make the game continue.

Thus producing the right kind of brainwaves is reinforced or rewarded by continued action of the hero or object and “conditions” the brain.

There are four types of brainwaves – alpha, beta, theta and delta. Alpha waves are produced by the brain at about eight to 13 cycles per second. When this pattern appears on an EEG while the person is awake, he is alert but relaxed. Beta, at 13 to 40 cycles per second, predominates during wakefulness most of the day. Theta waves are produced in four to seven cycles per second and connected to dreams and creativity. The evenslower delta waves are produced at a rate of half to four cycles per second and occur during deep sleep.

It is believed that children with attention deficits have an inadequate amount of beta waves and too many theta waves because they daydream or are tired. Thus if the neurofeedback promotes the use of beta waves, the child can become much more focused.

Rivi Sela, the director of BrainGames’ two clinics – at Airport City near Lod and in the Arnona quarter in Jerusalem – became interested in the technique because of ADD problems in her son.

“I studied behavioral sciences and worked in medical technology at Sheba Medical Center at Tel Hashomer. But I decided to leave my career when my son, who received Ritalin at the age of 10, reacted very badly to the drug. He couldn’t sit quietly in class, even though he is very intelligent, with an IQ of 150. We were offered Ritalin, and he took it for a year, but the side effects, including anxiety, were terrible, and he couldn’t stand it.”

Sela’s son then was given a higher dose, and the side effects were even worse.

“Nothing helped. So my husband and I took him out of school in sixth grade, and I taught him at home. We heard about neurofeedback. It was very successful. Now he is 17 and studying at Kfar Hayarok. He has been off Ritalin and all other drugs for four years. He doesn’t even need neurofeedback any more,” she said. “One couldn’t imagine he’s the same child. He shows no signs at all of ADD.”

Seeing the success on her son, Sela went to Canada, the US and Switzerland to study the technique, where there are thousands of neurofeedback therapists – psychiatrists, psychologists and social workers – who use it for ADD/ADHD. Since heading up BrainGames, she and her clinic staff have treated over 800 children, with an 80% success rate. As none of the public health funds have offered the technique, even though it saves money that would otherwise go to stimulants, and it is not included in the Health Ministry’s basket of health services, treatments are offered privately a NIS 250 per session.

“On average,” she says, “a patient needs 40 treatments. Progress is seen already after 15 to 20 sessions. We don’t claim it’s the answer for every ADD/ADHD child; some children still require Ritalin. But the technique has really made a difference for many. Adults, too, can benefit from it.”

The clinics’ neurofeedback equipment is imported at a cost of $2,800 to $12,000. An Israeli neurofeedback association whose therapists treat a variety of problems has been set up to ensure a high professional level.

Neurofeedback is used for other disorders, from headaches and insomnia to anxiety, substance abuse and autistic spectrum. An Israeli company named Happy Neuron has produced a Hebrew-language program used for “brain exercise from home via the Internet. It is used for cognitive development and memory improvement for all ages.

BIOFEEDBACK OF all kinds has a long history. It goes back almost a century to 1924, when a German psychiatrist named Hans Berger connected electrodes to a person’s scalp and, using a galvanometer, noticed the passage of a weak electric current. He subsequently published over a dozen studies on EEGs (electroencephalograms) of the brain. Decades later, understanding of the existing types of brainwaves increased, along with their functions.

In the past decade or so, numerous randomized studies and metaanalyses on neurofeedback have been published in peer-reviewed medical journals. The prestigious journal Pediatrics, published by the American Academy of Pediatrics, studied 23 children aged eight to 13 who suffered from ADHD and focused on their “slow cortical potentials” (slow event-related, director-current shifts of the electroencephalogram). The youngsters received 30 sessions of neurofeedback.

According to the researchers at the US National Institutes of Health in Bethesda, Maryland, and the University of Tübingen in Germany, the encephalographic data during neurofeedback showed that the children learned to regulate their slow cortical potentials. “After training, significant improvement in behavior, attention and IQ score was observed.” The behavior ratings also included social behavior at school as judged by teachers and parents.

According to the researchers, who published their findings in 2006, all positive changes in the children’s behavior remained stable six months at least after initial treatment, but as the study did not include a control group who did not undergo neurofeedback, the researchers could not state for certain that there was a causal relationship. They noted that “adverse effects of stimulant medications include reduced growth, sleep disorders, decreased appetite, stomach pain, headache, and, in some cases, tics. There is no evidence of long-term efficacy of stimulants or ADHD.”

The psychologist researchers concluded that “with voluntary regulation of [slow cortical potentials], children may learn to flexibly adjust their [neurotransmitter] balance to task requirements. We assume that the acquired skill becomes automatic and, as a motor skill, is preserved without explicit practice [of neurofeedback]. The children use it flexibly, and success rewards and improves the skill, the behavior and attention beyond the end of training.”

A German team followed up the original study two years later, choosing 10 of the original children who received neurofeedback and found that “most of our patients” had a total remission of ADHD symptoms after two years. This is very good news.

A study on neurofeedback and ADHD that was published in 2009 in the Journal of Child Psychology and Psychiatry and studied 102 children aged eight to 12 also found significant benefits from the non-drug treatment.

Considering the fact that, unlike prescription drugs, neurofeedback for ADD/ADHD does not cause side effects and that it has long-term beneficial effects in significant numbers of young patients, it should be examined by relevant Israeli national medical councils to make recommendations to the Health Ministry.

If the training is judged to have positive cost/benefits, the ministry would be wise to consider the treatment for inclusion in the basket of health services while at the same time setting strict standards for those who seek to provide the therapy.