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Verbesserung Der Aufmerksamkeitsleistungen Von Verbesserung der Aufmerksamkeitsleistungen von Kindern in klinischen Kontexten Der Philosophischen Fakultät der Friedrich-Alexander-Universität Erlangen-Nürnberg zur Erlangen des Doktorgrades Dr. phil. vorgelegt von Jessica Ashley Van Doren Als Dissertation genehmigt von der Philosophischen Fakultät der Friedrich-Alexander-Universität Erlangen-Nürnberg Tag der mündlichen Prüfung: 20.01.2020 Vorsitzender des Promotionsorgans: Prof. Dr. Thomas Demmelhuber Gutachter: Prof. Dr. Matthias Berking Prof. Dr. Nicolas Rohleder PD Dr. Phil Dr. med. habil. Anna Eichler Table of Contents 0. Abstract ............................................................................................................................................... 1 0.1 Zusammenfassung ........................................................................................................................ 2 1. Theoretical background and state of the art ........................................................................................ 8 1.1 Attention ........................................................................................................................................ 8 1.1.1 Definitions and Theories ........................................................................................................ 8 1.1.2 Psychology ........................................................................................................................... 11 1.1.3 Neuroscience ........................................................................................................................ 14 1.1.4 Development ........................................................................................................................ 19 1.2 Psychopathology ......................................................................................................................... 22 1.3 Enhancing Attention .................................................................................................................... 27 1.3.1 Neurofeedback ...................................................................................................................... 29 1.3.2 Light ..................................................................................................................................... 36 2. Optimizing therapeutic techniques for improving attentional abilities as the goal of this dissertation ............................................................................................................................................................... 43 3. Peer reviewed papers ......................................................................................................................... 46 3.1 Theta/beta neurofeedback in children with ADHD: Feasibility of a short-term setting and plasticity effects ................................................................................................................................. 47 3.2 Sustained effects of neurofeedback in ADHD: a systematic review and meta-analysis ............. 47 3.3 Effects of blue- and red-enriched light on attention and sleep in typically developing adolescents ........................................................................................................................................................... 47 4.1 Overview of the results ................................................................................................................ 48 4.2 Theoretical and Practical Implications ........................................................................................ 52 4.3 Limitations and future research ................................................................................................... 62 4.4 Conclusion ................................................................................................................................... 65 5. References ......................................................................................................................................... 66 6. Acknowledgements ........................................................................................................................... 84 0. Abstract This dissertation is concerned with the assessment of two current available methods of enhancing attentional abilities in children and adolescents: neurofeedback and ambient light exposition. Study 1 investigated the short term effects of neurofeedback in children with attention deficit hyperactivity disorder (ADHD) in a two session format. It was found that attentional resources, reflected by suppression of the theta wave, were able to be influenced after only two neurofeedback sessions. This finding was also found to be variant among the participants, leading to distinctions in this early phase of training as ‘good’ or ‘poor’ regulators, reflective of potentially different endophenotypes of ADHD. Study 2 was a meta- analysis assessing the long-term symptomatic effects of neurofeedback training in children and adolescents with ADHD, in which assessments were conducted pre-, post- and follow-up (two months to two years) to training. Here it was found that neurofeedback training was superior to non-active controls for both inattention and hyperactivity/impulsivity at post- and follow-up training. Neurofeedback was found to be inferior to active controls (medication, self management training) at post training, but then comparable at follow-up time points. These results support the use of neurofeedback for the long term therapeutic improvement of ADHD symptoms. Study 3 investigated the effect of red vs. blue light exposition in healthy adolescents in a laboratory setting. Blue light exposition was found to improve attention (as measured by reduced reaction time variability and improved arithmetic performance) in this demographic, while red evening light exposition was found to slightly improve sleep quality, which can in turn affect attentional abilities. Together these three studies provide evidence that attentional abilities can be influenced in children and adolescents in clinical settings. Additionally, they support that different endophenotypes of ADHD should be considered when choosing a neurofeedback protocol and that light exposition could be additionally used as either an additive treatment or an independent therapy. 1 0.1 Zusammenfassung Das Konstrukt ‚Aufmerksamkeit‘ ist vielschichtig und wird seit langem erforscht. Aus neurologischer Sicht sind etliche Marker bekannt, die Aufmerksamkeitsprozesse abbilden, wie zum Beispiel die kortikale Aktivierung oder die Synchronität neuronaler Signale sowohl auf zellulärer als auch höherer Ebene. Die Synchronität kann über elektroenzephalographische (EEG-) Bänder gemessen werden. Man geht davon aus, dass alle Bandbreiten der hirnelektrischen Aktivierung mit Aufmerksamkeitsprozessen in Zusammenhang stehen, wobei das Theta-Band (4–8 Hz) eines der am häufigsten untersuchten ist. Das Ausformen/ Die Ausprägung neuronaler Aufmerksamkeitsprozesse ist zentraler Bestandteil einer gesunden Entwicklung im Kindes- und Jugendalter. Bei Untersuchungen zu den Aufmerksamkeitsleistungen von Kindern und Jugendlichen werden häufig drei Bereiche unterschieden: selektive Aufmerksamkeit, Daueraufmerksamkeit und Aufmerksamkeitskontrolle (exekutive Kontrolle). Diese verschiedenen Arten von Aufmerksamkeit beginnen sich im ersten Lebensjahr zu entwickeln und verbessern sich fortschreitend im Laufe von Kindheit, Jugend und teilweise auch noch im Erwachsenenalter. Besonders die Altersbereiche 8-10 und 12-14 Jahre sind sensible Phasen der Aufmerksamkeitsentwicklung. Kommt es zu diesen Entwicklungszeitpunkten zu Beeinträchtigungen, kann dies zu klinisch auffälligen Entwicklungsverläufen führen. Eines der häufigsten Störungsbilder bei Kindern, das durch veränderte Aufmerksamkeitsprozesse gekennzeichnet ist, ist die Aufmerksamkeitsdefizit-Hyperaktivitätsstörung (ADHS). Die Weltweite Prävalenz von ADHS liegt bei 7,9%. Kinder oder Jugendliche mit ADHS zeigen Symptome von Unaufmerksamkeit, Hyperaktivität und Impulsivität in verschiedenen Lebensbereichen und sind dadurch beeinträchtigt. Diagnostisch werden je nach Stärke und Vorhandensein der einzelnen Symptome drei Subtypen unterschieden: Der kombinierte Typ 2 (sowohl Unaufmerksamkeits- als auch Hyperaktivitätskriterien aufweisend), der unaufmerksame Typ oder der hyperaktiv-impulsive Typ. Aktuelle Forschungsbefunde deuten jedoch darauf hin, dass diese Unterteilung möglicherweise nicht differenziert genug ist und dass eine Klassifikation in Anlehnung an verschiedene Endo- und Biotypen sinnvoller sein könnte. Unabhängig von der Art der Klassifikation wird angenommen, dass eine veränderte Entwicklung von Aufmerksamkeitsprozessen bei ADHS bereits im Säuglings- und Kindesalter einsetzt und die Symptome, insbesondere die Unaufmerksamkeit, häufig bis ins Erwachsenenalter anhalten. Orientiert man sich an oben genannter Einteilung von Aufmerksamkeitsleistungen, konnte gezeigt werden, dass Kinder mit ADHS vor allem hinsichtlich exekutiver Funktionen und Daueraufmerksamkeit beeinträchtigt sind, wohingegen selektive Aufmerksamkeitsprozesse meist nicht betroffen sind. Diese spezifischen Beeinträchtigungen spiegeln sich auch in bestimmten neurologischen Veränderungen wider, wie einer erhöhten Theta-Aktivität und volumenreduzierten kortikalen Arealen. Die Symptome von Unaufmerksamkeit führen bei Menschen mit ADHS häufig zu Leidensdruck und einer geringeren Lebensqualität, was therapeutische Ansätze zur Verbesserung der Aufmerksamkeitsleistung
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