Investigations in Neuromodulation, Neurofeedback and Applied

Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience Selected Abstracts of Conference Presentations at the 2011 International Society for Neurofeedback and Research (ISNR) 19th ISNR Conference, Phoenix, Arizona Published online: 30 Nov 2011.

To cite this article: (2011) Selected Abstracts of Conference Presentations at the 2011 International Society for Neurofeedback and Research (ISNR) 19th ISNR Conference, Phoenix, Arizona, Journal of Neurotherapy: Investigations in Neuromodulation, Neurofeedback and Applied Neuroscience, 15:4, 401-451, DOI: 10.1080/10874208.2011.623098

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SELECTED ABSTRACTS OF CONFERENCE PRESENTATIONS AT THE 2011 INTERNATIONAL SOCIETY FOR NEUROFEEDBACK AND RESEARCH (ISNR) 19TH ISNR CONFERENCE, PHOENIX, ARIZONA

Panel: Dimensions of Experience and First- reports of the observations can be publicly veri- Person Science fied. Such reports are called objective, sometimes falsifiable. Joe Kamiya, PhD Stoyva and I (1968, Psychological Review, University of California 75, 192–205) pointed out that the temporal correlates of such private events with publicly Thomas Collura, PhD observable events (both physiological processes BrainMaster Technologies of the observer himself as well as events of his external environment) are an important tool for This presentation proposes a long-range consciousness studies. The logic is that when program of research on the relationship of there is covariation over time between the human subjective experience to its physiologi- occurrence of a private event (such as dream- cal and environmental concomitants. Subjec- ing, as indicated by verbal report upon being tive experience has been a long-debated awakened) and the presence of eye move- topic, and attempts to rule it out of bounds ments and EEG stage changes prior to of scientific inquiry have not been totally suc- the awakening, the convergence of the two cessful. The history of modern psychology observables provides increased confidence started in the late 19th century as the study that dreaming did occur as suggested by the of consciousness, with trained introspection report. as the method of observation and the verbal That physiological events can thus be at reports of the results being the data. Among least partial indicators of subjective experience the reasons for the failure of the approach underlies several avenues of research. One, was disagreement among different observers exemplified by the current work of Richard in the verbal reports of their introspections, Davidson and associates, shows that the mag- presumably of the same object of observation. netic resonance images of the brains of medita- However, the process of introspection itself, tors are related to their activity of meditation. apart from the reporting thereof, is the observ- Thus the ancient human activity of deploying ing of events internal to the observer. Dreams, attention in specific ways as reported by the imagery, pains, hopes, thoughts, and feelings meditators is at least partially indexed by a are still present, for all their privacy, waiting physiological marker, thus making possible stu- to be comprehended more adequately in a dies of the specific brain processes underlying framework of all scientific knowledge. Because the first-person experiences of these subjects. the activity being observed is private to the Another approach is one I reported on in observer, we refer to this as first-person obser- 1962 and 1968 to train subjects by operant dis- vation, and when reported verbally is com- crimination procedures to identify moments, monly termed subjective report and is each time I rang a single ding of a bell, when sometimes nonfalsifiable. This contrasts with occipital EEG alpha activity was dominant, the third-person reporting of observation of versus moments when it was absent, by a sim- events external to the observer, where the ple dichotomous verbal response (‘‘A’’ for

401 402 PROCEEDINGS OF THE 2011 ISNR CONFERENCE alpha dominance, ‘‘B’’ for its absence). Suc- different food tastes, dimensionalized along cessful discrimination was achieved by most sweet, sour, bitter, and salty (which rather well subjects, permitting inquiry of the subjects as account for all food tastes). It would show to the subjective differences between the two where, for example, where apples, sweet EEG states. Despite considerable individual dif- pickles, raw cucumbers, and beef would likely ferences in some of the verbal reports, there appear as projections along the axes of the was a tendency toward common verbal charac- multidimensional space. terizations of the differences, suggesting that the subjective experiences themselves of most Validation of a Global Live Z-Score Protocol persons may have common correlates in brain in a Randomized, Sham-Controlled Study of activity. Cognitive Decline in Aging To reduce the noise found in everyday language reports of subjective experience, it is Thomas Collura, PhD proposed first that extensive discrimination BrainMaster Technologies training and feedback training be used on a selected variety of physiological measures, so as to increase the sensitivity of the individual Elena Festa, PhD to the ‘‘feel’’ of discriminating and=or control- Brown University ling each of, say, 20 measures. Then, from each William Heindel, PhD subject are obtained paired comparison ratings Brown University of the degree of subjective similarity (on a 5-point scale, say) of each measure to every The objective of this report is to present and other measure. This will result in a matrix to interpret objective data that validate a global which principal components analysis can be live z-score training (LZT) neurofeedback proto- done to specify the independent dimensions col. We present data for 3 levels of validation of of the total subjective space associated with a global live z-score protocol used for operant the measures. Thus, for example, the ‘‘feel’’ of training. These are single-subject within-session EEG alpha at the central leads might be speci- (N ¼ 1); single-subject across-sessions (N ¼ 3); fied as occupying a specific spot in the derived and a blind, multiple-subject randomized multidimensional space. Verbal labels can be sham-controlled study (RCT; N ¼ 79). The applied to the dimensions later, with the risk validation consists of (a) specific within-session of introducing cultural biases in word usage. z-score changes (40 min), (b) specific across- However, to the extent that the maps derived session z-score changes (10 sessions each), from all subjects are similar to each other, there and specific enhancement of cognitive proces- will be a basis for improved verbal agreements sing (8 sessions each). The RCT outcomes were about the subjective qualities. measured by a battery of neuropsychological The method would significantly increase tests in the controlled study. The sham feed- the precision of mapping the subjective judg- back consisted of ‘‘yoked’’ recorded EEG ments of physiological measures. Of course, derived from a matched subject, who was the representativeness to real life of the mea- undergoing similar neurofeedback training sures selected for training will be crucial, and (NFT). The results confirm the proposed mech- this will emerge only after very extensive multi- anism of action, which is operant learning measure research in basic psychophysiology of (self-regulation) of a complex set of QEEG- everyday life, particularly that involving inter- derived parameters, in a conventional operant personal interactions. learning biofeedback paradigm. Both healthy PowerPoint slides will be used to illustrate elderly and mild Alzheimer’s patients were the power of dimensional analysis of a matrix included, and both were present in the experi- of subjective ratings of paired comparisons. mental and the control groups. The measures As an example, a map will be shown of that improved with real NFT were different PROCEEDINGS OF THE 2011 ISNR CONFERENCE 403 across the groups. The most compelling data few EEG studies have investigated ADHD in were from a visual search task with the healthy an adult population (Bresnahan, Anderson, & elderly real NFT group. They showed enhanced Barry, 1999; Bresnahan & Barry, 2002; Clarke selective attention across two different sensory et al., 2008a, 2008b, Hale et al., 2009; Koehler binding conditions in an integrated visual- et al., 2009; Loo et al., 2009; Thompson & motor task. Real NFT improved attentional dis- Thompson, 2005; White, 2001, 2003), and to engagement and alerting measures in the mild our knowledge no studies have assessed the AD NFT group. Mock NFT either had no effect efficacy of neurofeedback training on symptom or elicited generalized slowing for both groups. reduction. Neurofeedback training has been Results confirmed that the global LZT proto- applied effectively in various areas, especially col leads to the expected specific EEG changes in the treatment of childhood ADHD (Arns, and that EEG changes were associated with de Ridder, Strehl, Breteler, & Coenen, 2009). expected cognitive improvement over time. This study is designed to investigate the effect Cognitive improvements were not seen in the of slow cortical potentials (SCP) neurofeedback sham-treated subjects in the RCT. These results training on symptomatology and neurophysio- verify that the mechanisms of LZT training oper- logical parameters in an adult ADHD popu- ate as described and that they can produce lation following 30 training sessions and after measurable benefits in improved brain acti- a 6-month follow-up period. vation and connectivity, and associated cognitive function. Clinical application, including Methods relationships to observed phenotypes, will be Continuous 19-channel EEG was acquired described. These results provide a basis for clini- from 10 adult participants who met Diagnostic cal application, continued studies, and further and Statistical Manual of Mental Disorders (4th development of protocol designs. Possible weak- ed.; American Psychiatric Association, 1994) nesses in the study will be described, including criteria for ADHD (combined, inattentive, or the sham feedback, possible repeated-measures hyperactive type), without additional serious effects, and the need for analysis of additional physical, neurological, or psychiatric disorders, behavioral measures that were taken, including and a full-scale IQ greater than 80. EEG record- methods proposed for refining these results. ings were collected at pre=mid=post-follow-up Financial Interest treatment intervals and included EO, EC, P300, and CNV tasks, as well as ADHD beha- Dr. Collura has a financial interest in Brain- vioral questionnaires. Participants underwent Master Technologies, Inc. 30 sessions of SCP neurofeedback training at CZ, referenced to A1, ground A2, with vertical Neurofeedback for Adult Attention-Deficit= and horizontal ocular correction (Strehl, Leins, Hyperactivity Disorder: Preliminary Findings Goth, Klinger, & Birbaumer, 2006). of Slow Cortical Potential Feedback Results Kerstin Mayer, MSc, Sarah Wyckoff, and Ute Strehl This investigation is in progress. The changes in University of Tu¨bingen behavioral and neurophysiologic parameters following 15 sessions of SCP feedback will be presented at the time of the conference. Introduction Attention deficit hyperactivity disorder (ADHD) Conclusion is characterized by symptoms of inattention, SCP neurofeedback therapy has not previously impulsivity, and hyperactivity, which persist been investigated in an adult population and into adulthood for 4 to 5% of patients may yield valuable findings related to alterna- (Goodman & Thase, 2009). Hitherto, only a tive treatments for adult ADHD. Treatment 404 PROCEEDINGS OF THE 2011 ISNR CONFERENCE implications, study limitations, and future S. L. (2009). Cortical activity patterns in ADHD directions in research will be addressed. during arousal, activation, and sustained attention. Neuropsychologia, 47, 2114–2119. Strehl, U., Leins, U., Goth, G., Klinger, C., & REFERENCES Birbaumer, N. (2006). Physiological regu- American Psychiatric Association. (1994). lation of slow cortical potentials: A new treat- Diagnostic and statistical manual of mental ment for children with ADHD. Pediatrics, disorders (4th ed.). Washington, DC: Author. 118, 1530–1540. Arns, M., de Ridder, S., Strehl, U., Breteler, M., Thompson, L., & Thompson, M. (2005). & Coenen, A. (2009). Efficacy of neurofeed- Neurofeedback intervention for adults with back treatment in ADHD: The effects on ADHD. Journal of Adult Development, 12, inattention, impulsivity and hyperactivity: A 123–130. meta-analysis. Clinical EEG & Neuroscience, White, J. N., Jr. (2001). Neuropsychological 40, 180–189. and electrophysiological assessment of adults Bresnahan, S. M., Anderson, J. W., & Barry, R. J. with attention deficit hyperactivity disorder (1999). Age-related changes in quantitative (Unpublished doctoral dissertation). The EEG in attention-deficit=hyperactivity dis- University of Tennessee, Knoxville. order. Biological Psychiatry, 46, 1690–1697. White, J. N., Jr. (2003). Comparison of QEEG Bresnahan, S. M., & Barry, R. J. (2002). Speci- reference databases in basic signal analysis ficity of Quantitative EEG analysis in adults and in the evaluation of adult ADHD. with attention deficit hyperactivity disorder. Journal of Neurotherapy, 7, 123–169. Psychiatry Research, 112, 133–144. Clarke, A. R., Barry, R. J., Heaven, P. C., STUDENT PRESENTATION McCarthy, R., Selikowitz, M., & Bryne, M. K. (2008a). EEG coherence in adults Pilot Data Investigating the EEG Sources of with attention-deficit=hyperactivity disorder. Personality and Attachment International Journal of Psychophysiology, 76(1), 35–40. Ann Marie Scruggs, BA, Danielle Gerhard, Clarke, A. R., Barry, R. J., Heaven, P. C., BS, Rex L Cannon, PhD, Nancy Foster, McCarthy, R., Seilkowitz, M., & Bryne, M. MS, John Lounsbury, PhD, Brent S Mallinckrodt, K. (2008b). EEG in adults with attention- PhD, Debora R Baldwin, PhD, and Sarah deficit=hyperactivity disorder. International Sprague, BS Journal of Psychophysiology, 70, 176–183. University of Tennessee Goodman, D. W., & Thase, M. E. (2009). Recognizing ADHD in adults with comorbid mood disorders: Implications for identifi- Introduction cation and management. Postgraduate Medi- In recent years there has been a surge of data cine, 121(5), 20–30. investigating the neural assemblies implicated in Hale, T. S., Smalley, S. L., Hanada, G., Macion, J., attachment and personality, specifically the Big McCracken,J.T.,McGough,J.J.,&Loo,S.K. Five (Neuroticism, Extraversion, Openness, (2009). Atypical alpha asymmetry in adults with Agreeableness, and Conscientiousness). The cur- ADHD. Neuropsychologia, 47, 2082–2088. rent study presents pilot data investigating the Koehler, S., Lauer, P., Schreppel, T., Jacob, C., EEG current source density (CSD) associated with Heine, M., Boreatti-Hummer, A., et al. the Experiences in Close Relationships Scale and (2009). Increased EEG power density in alpha the 34-item Transition to College Inventory (TTC). and theta bands in adult ADHD patients. Jour- nal of Neural Transmission, 116(1), 97–104. Methods Loo, S. K., Hale, T. S., Macion, J., Hanada, G., We collected data from 16 nonclinical under- McGough, J. J., McCracken, J. T., & Smalley, graduate students (8 male) while EEG was PROCEEDINGS OF THE 2011 ISNR CONFERENCE 405 continuously recorded during the completion University of Wollongong of each of the assessment measures. Response items were marked within the EEG record. The segments prior to the response were Attention-Deficit=Hyperactivity Disorder (AD= extrapolated and compared to eyes-opened HD) is one of the most common psychiatric dis- baseline, as well as to each other. orders of childhood, affecting approximately 5% of primary school children. Almost all models of Results the disorder accept that the behavioral cluster Data indicate the maximal increases in CSD for that is AD=HD results from an underlying central the Emotional Closeness in Relationships (ECR) nervous system (CNS) dysfunction. However, as compared to baseline occur in BA 21 at right the exact nature of this dysfunction is poorly middle temporal gyrus, BA 44 at left inferior understood. Several electrophysiological-based frontal gyrus, BA 13 at left insular cortex, BA models of AD=HD have been proposed, and 18 at left cuneus, and BA 7 left parietal lobe= recent research has suggested that most are precuneus. TTC compared to baseline shows too simplistic in nature and the underlying maximal increases in CSD in right BA 21 CNS dysfunctions are inaccurately labeled. Part middle temporal gyrus, BA 31 left posterior of the problem results from the use of multiple cingulate, left BA 18=19 cuneus, and left BA bands in the analysis of the EEG, as this 7 precuneus. ECR compared to TTC showed approach does not allow an understanding of maximal increased CSD in BA 32 medial and the role of any discrete band on functioning. right anterior cingulate, BA 10 left middle In a different approach, our group has been frontal gyrus, left BA 4 precentral gyrus, and decomposing the EEG into single bands and BA 20 right fusiform gyrus. relating anomalies in these bands to specific brain states (such as arousal) and to behavior. Conclusions Results from a number of studies, and their The data obtained in this early study are very implications for understanding the link between similar to studies that have employed functional brain and behavior, will be discussed. magnetic resonance imaging to measure personality and other attachment measures. The Reliability of Quantitative EEG: Power, ECR and TTC show similarities as contrasted Phase, Coherence, and LORETA Current with eyed-opened baseline and significant dif- Source Density ferences between the two measures. The regions shown increased in CSD include regions Rex Cannon, PhD and Debora Baldwin known to be associated with self-relevant infor- University of Tennessee mation processing as well as self-regulation and social and language processes. Future research aims are to increase sample size to investigate Introduction both of these measures in more depth. Potential In recent years the use of quantitative electro- network properties and implications for neuro- encephalography (qEEG) and LORETA methods feedback paradigms will be discussed. in clinical and research settings has increased. It has been poorly demonstrated that qEEG or INVITED PRESENTATION computerized analyses of the EEG is less than reliable across time, despite numerous studies EEG Abnormalities in Children with Attention- demonstrating the opposite. The current study Deficit=Hyperactivity Disorder: Linking Brain sought to determine the reliability of qEEG, con- and Behaviour nectivity measures, and LORETA current source density measured across a span of 30 days. We Adam Clarke, PhD, Robert Barry, Rory hypothesized that all measures collected would McCarthy, and Mark Selikowitz show significant reliability across time. 406 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Methods (ADHD), including inattention, hyperactivity, We recorded 4-min eyes-closed baseline (ECB) and impulsivity. Several studies have shown and eyed-opened baseline (EOB) recordings at that neurofeedback training is effective in 2 intervals 30 days apart. We analyzed the EEG improving behavioral functioning, but more data using NeuroGuide, version 6.3. We calcu- research is still needed to help us understand lated peak frequency, phase, and coherence as how the neurofeedback training benefits well as LORETA z-scored current source students with ADHD, especially in Canadian density as compared to the Lifespan database. populations. Typically, most ADHD interven- We entered the data into reliability analyses, tions focus on managing the behaviors in using SPSS 17 with a two-way mixed model students with ADHD and neglecting the inter- with an absolute agreement definition. We vention in optimizing the academic perfor- compared all frequency bands at randomly mance of these students. In this study, the selected electrode sites. intervention incorporated metacognitive training as a part of the neurofeedback training to Early Results address both academic and behavioral difficult- The reliability analyses for peak frequency (alpha ies. This paper covers part of a pilot study. In this 8–12 Hz) shows a Cronbach’s alpha of .71 for paper, a secondary data analysis approach is the ECB in select sites, whereas the EOB shows used to evaluate the short-term impact of a an alpha of .95 at the same sites. The Coherence 40-session neurofeedback training program analyses show a Cronbach’s alpha of .79 at select combined with metacognitive strategies training. sites for ECB and .99 for the same sites in EOB. The goal of this paper is to determine whether Phase shows an alpha of .88 for ECB and .93 the number of ADHD traits rated by caregivers for EOB. LORETA current source density from changed from pretraining to posttraining. select region of interest shows similar effects with Methods ECB showing .88 and EOB showing .92. In this secondary data analysis, the existing ques- Discussion tionnaire and computerized assessment data The current data analysis is in progress; from the ADD Centre (Mississauga), at the pre- however, early results suggest that even in small treatment and the immediate posttreatment samples the qEEG and LORETA data are points was collected. The sample size was 318, reliable measures across time. The results of this and the inclusion criteria were (a) a diagnosis study are further evidence supporting the use of of ADHD=ADD, and (b) 6 to 17 years of age at computerized EEG and LORETA in both the the time of training, completion of 40 sessions clinical and research setting. of 1-hr neurofeedback training combined with metacognitive strategies training (typically twice STUDENT PRESENTATION a week). The training program focuses on decreasing the theta wave activity (typically Long-Term Effectiveness of Neurofeedback 3–7 Hz) and increasing the sensorimotor rhythm Combined with Metacognitive Training for (typically 13–15 Hz). Metacognitive training was Children with ADHD: A Pilot Study taught for 5 to 10 min during the session to learn strategies related to academic tasks. The ques- Wing Sze Leung and Jacqueline Pei tionnaire data, collected for all participants, were University of Alberta completed by caregivers and included the (a) Conner’s Global Index–Parent Version, (b) Diag- nostic and Statistical Manual of Mental Disorders Introduction symptom list, and (c) ADD-Q. For a subset of Neurofeedback is an alternative treatment 110 participants, computerized assessment data to alleviate the primary symptoms of was also collected: Test of Variables of Attention Attention Deficit Hyperactivity Disorder and IVA þ Plus Visual & Auditory Attention PROCEEDINGS OF THE 2011 ISNR CONFERENCE 407

Testing. These computerized assessment data Positive emotional style is associated with lower were then later correlated with the question- rates of stroke and better coronary recovery. naire data to determine the reliability of the The lack of joy was found to be one of the most questionnaire results. important symptoms linked with risk of depression after age 60 (Hein et al., 2003). Results Methods In this study, significant behavior improvements in both hyperactive traits, F(4, 132) ¼ 969.200, After providing informed consent, a nonclinical p < .0001, and inattentive traits, F(3, 123) ¼ sample of 25 university students underwent 389.440, p < .0001, were reported on the 3 continuous EEG recording while they envi- questionnaires and 2 computerized assess- sioned a personal experience that brought ments from pre- and post 40 sessions of train- them maximal joy. After baseline and task ing. Furthermore, there are 5 control variables EEG recording, participants also supplied in this study: gender, age at the time of training, open-ended reports of their experiences during IQ at the time of training, medication used at recording, as well as completion of a health the time of training, and ADHD subtypes. No symptoms inventory and optimism=pessimism significant difference between gender (male, scale. EEG source localization using sLORETA n ¼ 252, and female, n ¼ 66), age at the time was performed and comparison of the self in of training (age 6–12, n ¼ 212, and age 13– experience of joy condition to baseline was 17, n ¼ 67), IQ at the time of training (below made using all voxel-by-voxel tests. Voxels of average, n ¼ 20; average, n ¼ 97; above aver- significant difference were mapped onto a age, n ¼ 42), medication intake at the time of Montreal Neurological Institute atlas containing training (have medication, n ¼ 69, and no 6,329 five mm voxels. medication, n ¼ 209), and ADHD subtypes Results (ADHD Combined Type, n ¼ 95; ADHD Inat- Differences between task and eyes-open base- tentive Type, n ¼ 96; ADD, n ¼ 19; ADHD lines will be discussed with regard to regions of without a labeled subtype, n ¼ 69) were found. interest. Conclusions REFERENCES The results of this study provide evidence supporting the use of neurofeedback com- Cohen, S., Alper, C. M., Doyle, W. J., Treanor, J. bined with metacognitive training as an effec- J., & Turner, R. B. (2006). Positive emotional tive intervention for ADHD. style predicts resistance to illness after experimental exposure to rhinovirus or influenza a A Look at Your Brain on Joy virus. Psychosomatic Medicine, 68, 809–815. Hein, S., Bonsignore, M., Barkow, K., Jessen, Sarah Fischer, MS, Debora Baldwin, PhD, F., Ptok, U., & Heun, R. (2003). Lifetime and Rex Cannon, PhD depressive and somatic symptoms as pre- University of Tennessee clinical markers of late-onset depression. European Archives of Psychiatry and Clinical Neuroscience, 253(1), 16–21. Introduction Why should we take a look at the brain on joy? A Study Comparing the Brain Function of Besides being a part of what makes life worth Healthy and ADHD Adults During Rest living, positive emotions such as joy have been and Stroop Task in EEG=ERP and fMRI shown to have health benefits. Resisting the common cold and flu are linked to the tend- Cynthia Kerson, PhD ency to experience positive emotion (Cohen, Main Biofeedback Alper, Doyle, Treanor, & Turner, 2006). 408 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Estate Sokhadze, PhD EEG, and Stroop task for ERPs. They were age- University of Louisville and sex-matched as closely as possible and were = Rex Cannon, PhD counterbalanced for EEG fMRI recordings. University of Tennessee Results Leslie Sherlin, PhD The fMRI data indicate resting state networks NovaTech EEG are less active in ADHD than controls—with David Hubbard, MD the largest effect shown in the right insula (which Applied Functional MRI Institute, LLC has also been shown to exact some control over activity in the DMN). These fMRI data identify Introduction numerous regions with decrements in activity The prevalence of Attention Deficit Hyperac- in task versus resting condition, including the tivity Disorder (ADHD) is an estimated 4.1% anterior cingulate, left BA 40 and regions in in adults, second only to depression. Recently, prefrontal cortex. EEG current source density several quantitative electroencephalographic, indicate the ADHD subjects show deficits in event-related potential (ERP), and functional delta and theta in the DMN during rest and less magnetic resonance imaging (fMRI) studies activity overall as contrasted to controls. Specific have been completed to examine electrophy- regions within the default network show deficits siological and blood flow behaviors in adults in ADHD as compared to controls, specifically with ADHD. This EEG=ERP=fMRI study corre- in the delta, alpha, and beta frequencies in left lated brain behavior from each neuroimaging BA 10=47, 32, and 8. method and elucidated functional connectivity patterns in the ADHD group during resting Conclusion state (eyes open and eyes closed) and an active The effects shown in the data suggest that cognitive task (Stroop). We examined the regions associated with salience, attention, and default mode network (DMN) to ascertain the self-regulatory processes are dysfunctional in differences during rest and the Stroop task. the ADHD population. At the core of these net- The DMN consists of 12 functionally related work deficits are the bilateral insular cortices, regions that are consistently shown increased the AC and regions known to be associated with in activity in an eyes-closed resting condition affect regulation, monitoring the physical state as compared to functionally specific cognitive of the body (e.g., insula and inferior frontal cor- tasks or eyes-opened resting condition. Given tex–BA 10=47). These data show that left BA 40 the regional deficits shown in ADHD research, is a very important area for attentional mainte- we examined them and their specific relation- nance and integrative processes. In addition, it ship with the bilateral anterior insular cortices. has been shown that the visual N100 (frontal Numerous regions within the default network, sites) and P300 (parietal sites) ERPs are attenu- especially left medial prefrontal and anterior ated in ADHD children, which may be an indi- medial regions are shown (assuming sources cation of a deficit in selective attention. Our ERP at or near the surface electrodes F3, Fz, and data are still under review. F7 contribute to the ERP average) to contribute Recruitment of neural resources involving many of the putative mechanisms found in ERP temporal correlations provides important research (e.g., frontal NoGo-N2 and P3, Error- information about both attentional and self- related Negativity, etc.). regulatory processes in ADHD individuals as compared to healthy controls. These data pro- Methods vide important information relating to potential Seven controls (4 F, 3 M) and 6 ADHD (3 F, 3 M) biomarkers for ADHD and increase the speci- adults (M age ¼ 42.9) came to Applied fMRI ficity of methods for neurotherapy treatment Institute to complete a fMRI FanTab neuropsy- of ADHD. The data also confirm that EEG is chological test battery, eyes open, eyes closed an adequate methodology to evaluate ADHD. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 409

STUDENT PRESENTATION differential effects upon other regions of the cortex as determined by LORETA when trained LORETA Neurofeedback and the Morphology exclusively. There are also significant comodu- of Working Memory and Processing Speed lation effects within the region of training as well as between regions when examining the Joseph Di Loreto, BA, Sarah Jane Halford, correlational structure of the EEG current BA, Kelli Cox, BS, Alexander Khaddouma, BA, source density. The training influenced Rex Cannon, PhD, Deborah Baldwin, PhD, increases in WMI and PSI scores. Kasey Broyes, BA, and Jasmine Hewlett, BA Conclusions University of Tennessee Operant conditioning of the EEG in spatial specific intracranial regions of interest increases Introduction the likelihood of improving our functional knowledge of self-regulatory and cognitive Operant conditioning of the electroencephalo- mechanisms in the human brain. The correla- gram (EEG) offers the potential to improve tive structure between the subtest scores of attentional and cognitive processing in psycho- the WMI and PSI appears to influence specific logical syndromes but also has the exciting Frequency Region associations. The data potential for improving these functions in presented offer an exciting direction for normal populations. In recent years, there is understanding the basic mechanisms of self- increasing interest in basic mechanisms of regulation and its cognitive correlates. self-regulation and the associated neuronal dis- tributions. Moreover, there is an exciting trend INVITED PRESENTATION toward uncovering the morphology of psychological constructs. This study sought to describe EEG, fMRI, and tDCS=tACS Applications for the morphological neural substrates of working Disorders of Consciousness and Movement memory and processing speed as influenced by Disorders LORETA neurofeedback (LNFB) in the anterior cingulate and bilateral prefrontal cortices. Efthymios Angelakis, PhD University of Athens Medical School Methods We examine the neural correlates of self- Part 1: Assessment of Consciousness regulation in both normal populations of 16 in Nonresponsive Patients: fMRI and undergraduate students, each underwent EEG data between 20 and 30 sessions of LNFB training in 1 of 6 regions of interest: dorsal anterior Is there a way to assess consciousness in appar- cingulate, bilateral prefrontal cortex, and pre- ently nonresponsive patients? This presentation cuneus. The sessions consisted of 3-min pre- attempts to address this question by measuring and postbaselines and 4-min to 5-min training hemodynamic and electrical brain activity from rounds. We measured efficacy of LNFB with patients with persistent vegetative state (PVS) pre- and postworking memory (WMI) and pro- or minimally conscious state (MCS). fMRI, EEG, cessing speed index (PSI) scores of the Wechsler and PET data will be presented, recorded from Adult Intelligence Scale—Third Edition. patients with PVS or MCS, and from healthy controls. Significant findings and methodological Results drawbacks for each technique will be discussed. The participants were able to produce signifi- Part 2: tDCS and tACS in Patients with cant learning curves and increase levels of Dystonia and with PVS/MCS current source density at the specified region A recently expanding application for the treat- of training. The regions of training exhibit ment of brain disorders is transcranial electrical 410 PROCEEDINGS OF THE 2011 ISNR CONFERENCE stimulation. This noninvasive method has been independent components analysis (ICA) of shown to affect motor and cognitive functions in extremely slow time series of metabolic activity. healthy volunteers and in neurological patients, In this study we analyze electric brain as well as to reduce symptoms in a number of activity at very high time resolution, based on brain disorders. This presentation will illustrate resting, awake, and eyes-closed EEG recordings the potential of transcranial direct current from 6 different groups of subjects across 5 dif- stimulation (tDCS) and of transcranial alternate ferent labs. Scalp electric potential differences current stimulation (tACS) through two para- were used to compute electric neuronal activity digms: idiopathic intractable dystonia and on the cortex using standardized low resolution PVS=MCS. The former is a movement disorder electromagnetic tomography (sLORETA; with no other neurological or cognitive deficits, Pascual-Marqui, 2002). Each group of subjects and with absent radiological findings. The later was analyzed separately, using the most com- is a totally incapacitating condition with moder- mon ICA methodology as in recent fMRI litera- ate to severe brain lesions of atrophy. ture (Allen et al., 2011; Pascual-Marqui & Biscay-Lirio, 2011). Validation of the electric KEYNOTE PRESENTATION resting state networks was assessed by the repro- ducibility across different groups, which was The Human Brain Resting State Networks remarkably high. Results show that many of the Based on High Time Resolution EEG: Com- electric networks consist of fewer core brain parison to Metabolism-Based Networks areas (e.g., the left and right temporal regions appear in two distinct electric networks) while Roberto Pascual Marqui, PhD they typically appear in one single metabolic The KEY Institute for Brain-Mind Research network. This difference might be due to the slow temporal nature of metabolic changes, which lumps together over time what is actually Intrinsic resting activity is not simply the ground taking place independently when seen at higher state of an inactive brain. Rather, it constitutes time resolution with electric activity tomogra- the dynamic substrate of the ‘‘present,’’ momen- phy. Another unique interesting difference to tary state of the brain and determines the fate of metabolic networks is the appearance of electric incoming information (Lehmann, 1990). networks that consist of pairs of brain regions Early intrinsic activity studies were due to working against each other (i.e., activation in Hans Berger (1929) with the first human EEG one region is linked to deactivation of the other). measurements. The introduction of multichan- These methods and results may help in under- nel EEG, with emphasis on scalp imaging (topo- standing normal and pathological brain function graphic mapping) of the brain electric activity, from a high time resolution network perspective. advanced the field significantly, with the development of the microstate model (Lehmann, Ozaki, & Pal, 1987) and the normative data- REFERENCES bases of brain rhythm properties (John et al., 1977). Allen, E. A., Erhardt, E. B., Damaraju, E., Renewed interest in the resting state comes Gruner, W., Segall, J. M., Silva, R. F., ... from the field of brain imaging techniques such Calhoun, V. D. (2011). A baseline for the as functional magnetic resonance imaging multivariate comparison of resting state net- (fMRI) and positron emission tomography. A works. Frontiers in Systems Neuroscience, 5, large number of resting state studies converge 2. doi:10.3389=fnsys.2011.00002 in producing brain networks that allegedly have Berger, H. (1929). Uber des Elektrenkephalo- functional significance such as attention, execu- gramm des Menschen [About the human tive control, salience, and the default mode, to electroencephalogram]. Archiv fur Psychiatrie name but a few. These results are based on an und Nervenkrankheiten, 87, 527–580. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 411

John, E. R., Karmel, B. Z., Corning, W. C., sessions in 5 consecutive days. Veridical Easton, P., Brown, D., Ahn, H., ...Schwartz, feedback was provided by a brief tone and a E. (1977). Neurometrics. Science, 196, visual reward (a progressive image display). 1393–1410. Sixty-four-channel EEG was recorded during Lehmann, D. (1990). Brain electric microstates biofeedback training and during 2 lateralized and cognition: The atoms of thought. In tests of hemispheric attention (Lateralized E. R. John (Ed.), Machinery of the mind, Attention Network Test [LANT] and Lateralized (pp. 209–224). Boston, MA: Birkhaüser. Continuous Performance Test [LCPT]). The Lehmann, D., Ozaki, H., & Pal, I. (1987). EEG LANT measures covert orienting of spatial alpha map series: Brain micro-states by space- attention and distinguishes between a measure oriented adaptive segmentation. Electroence- of Orienting Benefit due to a valid spatial cue phalography and Clinical Neurophysiology, and a measure of Orienting Cost due to a spa- 67, 271–288. tially invalid cue. The LCPT contains lateralized Pascual-Marqui, R. D. (2002). Standardized CPT and Go-No=Go components. The LANT low-resolution brain electromagnetic and LCPT were administered before biofeed- tomography (sLORETA): Technical details. back training and after 3 and 5 consecutive Methods and Findings in Experimental and training sessions over 5 days of biofeedback. Clinical Pharmacology, 24(Suppl D), 5–12. Pascual-Marqui, R. D., & Biscay-Lirio, R. J. Results (2011). Interaction patterns of brain activity Behavioral. The biofeedback training proto- across space, time and frequency. Part I: cols produced different behavioral effects on atten- Methods. arXiv:1103.2852v2 [stat.ME], tion in the two hemispheres. Accuracy to targets http://arxiv.org/abs/1103.2852 proceeded by invalid cues yielded a significant interaction: Protocol (Sham, C3 SMR, C4 Behavioral and EEG Effects of Lateralized SMR, C3 Beta) Session (1, 3, 5) Visual Field EEG Biofeedback on Lateralized Attention (LVF, RVF); p < .025. Similarly there was a Network Task and Lateralized Continuous near-significant interaction: Protocol Session Performance Task Cue (Valid, Neutral, Invalid); p < .07. These near-significant results become significant when Andrew Hill, MA, and Eran Zaidel, PhD we restrict our analysis to comparing specific pro- University of California, Los Angeles tocol groups (e.g., Orienting Benefit of Sham v. C4 SMR; p < .024). Orienting performance to targets using valid and invalid spatial cues showed dis- Introduction sociationinvisualfieldsacrossgroups. We conducted a randomized, double-blind, Physiological. Reward signals evoked by placebo-controlled study of a short course the training stimulus were characterized by a of EEG Biofeedback to identify concurrent P50, an N100, both early and late P300 ERP changes in behavioral and physiological corre- components, and an N400. Training had a lates of hemispheric attention under EEG selective effect measured at trained scalp Biofeedback. Physiological changes throughout region, shown in event-related potential (ERP) the biofeedback process were also measured and event-related slow potential (ERSP) compo- with dense array EEG. Lateralized behavioral nents, including specific peak and latency measures were created and examined in the changes to the first reward event in a series, context of lateralized EEG measures. in P300 Amplitude (Electrode Group; p < .039), N400 Latency (Session Methods Electrode Group; p < .073), and N400 Peak Participants received 1 of 4 biofeedback proto- Amplitude (Session Electrode; p < .005). cols (C3–A1 SMR, C4–A2 SMR, C3–A1 Beta, or The second reward events in a series also often Sham biofeedback) in 5 half-hour training exhibited near significant results (second 412 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

N100 amplitude at Session Electrode de Ridder, Strehl, Breteler, & Coenen, 2009). Group; p < .07, second P300 peak latency at This presentation will focus on how these Electrode Group; p < .022). treatments can be improved in clinical practice Pairwise comparisons of protocol groups using quantitative electroencephalography showed that behavioral and physiological (QEEG) and event-related potential (ERP) data, responses also diverged by laterality of training and to what degree treatment outcome can be and by veridical versus sham biofeedback. predicted.

Conclusion Depression Study We introduced a paired battery of lateralized Ninety patients with a primary diagnosis of attention tests and showed that measures of depression or dysthymia were included in this transient (LANT) and continuous (LCPT) atten- study. All subjects underwent neurophysiologi- tion networks are selectively affected by differ- cal testing before treatment (eyes-open and ent EEG biofeedback protocols. In particular, eyes-closed EEG, oddball ERP) and in addition lateralized attention (a) can be characterized several rating scales were assessed. The Beck both behaviorally and electrophysiologically, Depression Inventory (BDI) was used to assess and (b) responds selectively to different response to treatment. Thirty-three patients biofeedback protocols. In addition, ERP com- received slow rTMS over the right DLPFC ponents evoked by the biofeedback reward (1 Hz) and 57 patients received fast rTMS over signal discriminated biofeedback effects within the left DLPFC (10 Hz). On average there was a and across training sessions and protocols. 77.2% decrease in depressive symptoms after These measures are therefore likely to reflect an average 20.56 sessions (BDI). There was a monitor engaged by the biofeedback process. no significant difference for response rates between fast rTMS (76.8%) and slow rTMS (81.8%). The Usefulness of QEEG and ERPs in Predict- Based on the literature, several EEG and ERP ing Treatment Outcome in ADHD and predictors of treatment response in major Depression depressive disorder were investigated, and preliminary analysis demonstrates that nonrespon- Martijn Arns, MSc ders were characterized by (a) a slow frontal BrainClinics Diagnostics alpha peak frequency (p ¼ .010) in agreement with Arns, Spronk, and Fitzgerald (2010); (b) parietal excess Delta (p ¼ .015) in agreement The application of repetitive transcranial mag- with Knott (2000) and Knott, Telner, Lapierre, netic stimulation (rTMS) in major depressive dis- Browne, and Horn (1996); and (c) an increased order has been investigated intensively over the P300 amplitude (p ¼ .031), which was last years with several meta-analyses demon- opposite to Bruder et al. (2001) but may sug- strating that compared to placebo fast rTMS gest a subgroup characterized by increased (>5 Hz) to the left dorsolateral prefrontal cortex anxiety complaints (Bruder et al., 2002). (DLPFC; Schutter, 2009) and slow rTMS (>1Hz) over the right DLPFC (Schutter, 2010) both exert ADHD Study mood enhancing effects. Similarly another neu- Twenty-one patients with a primary diagnosis romodulation technique, the application of neu- of ADHD were included in this study. Diagnosis rofeedback in the treatment of attention deficit was confirmed using the Mini International hyperactivity disorder (ADHD), has also been Neuropsychiatric Interview. At intake, every well investigated, and a recent meta-analysis 10th session and outtake an ADHD rating scale concluded that neurofeedback has demon- and a BDI were assessed to monitor treatment strated a large effect size (ES) on impulsivity progress. For nonresponders and dropouts, a and inattention in the treatment of ADHD (Arns, last-observation carried forward procedure PROCEEDINGS OF THE 2011 ISNR CONFERENCE 413 was used. One to 2 protocols were selected Bruder, G. E., Kayser, J., Tenke, C. E., Leite, P., from 5 standard protocols and were persona- Schneier, F. R., Stewart, J. W., & Quitkin, F. lized based on the individual QEEG. M. (2002). Cognitive ERPs in depressive and At outtake 76% patients could be con- anxiety disorders during tonal and phonetic sidered a responder (>50% decrease on one oddball tasks. Clinical Electroencephalogra- or more subscales of the ADHD rating scales), phy, 33, 119–124. 14% a nonresponder, and 10% a dropout. Bruder, G. E., Stewart, J. W., Tenke, C. E., The ES on inattention was 1.78 and for McGrath, P. J., Leite, P., Bhattacharya, N., & Impulsivity=Hyperactivity was 1.22. Quitkin, F. M. (2001). Electroencephalo- The presented results are similar to the graphic and perceptual asymmetry differences results from Monastra, Monastra, and George between responders and nonresponders to an (2002) and substantially larger than the SSRI antidepressant. Biological Psychiatry, 49, ES obtained in the meta-analysis. These 416–425. results show promise for personalizing Knott, V. J. (2000). Quantitative EEG methods well-established neurofeedback protocols and measures in human psychopharmacolo- (such as central SMR=Theta and Fronto-central gical research. Human Psychopharmacology, theta=beta) based on the individual EEG. Fur- 15, 479–498. thermore, a slow-alpha peak frequency (APF) Knott, V. J., Telner, J. I., Lapierre, Y. D., had no relation to treatment outcome on Browne, M., & Horn, E. R. (1996). Quanti- ADHD specific scales but did demonstrate a tative EEG in the prediction of antidepres- clear relationship to comorbid depression sant response to imipramine. Journal of symptoms, with subjects with a slow frontal Affective Disorders, 39, 175–184. APF responding less well. These results require Monastra, V. J., Monastra, D. M., & George, S. further replication employing larger sample (2002). The effects of stimulant therapy, EEG sizes, randomization, and adequate control biofeedback, and parenting style on the groups. primary symptoms of attention-deficit= hyperactivity disorder. Applied Psychophy- Discussion siology and Biofeedback, 27, 231–249. Schutter, D. J. (2009). Antidepressant efficacy of The results from these studies (along with pre- high-frequency transcranial magnetic stimu- and post-QEEG results) and other studies from lation over the left dorsolateral prefrontal cor- the literature will be integrated and recommen- tex in double-blind sham-controlled designs: dations will be made on what the implications A metaanalysis. Psychological Medicine, of the presented biomarkers could be for cur- 39(1), 65–75. rent treatments and current practice but also Schutter, D. J. (2010). Quantitative review of specifically for designing new treatments. the efficacy of slow-frequency magnetic brain stimulation in major depressive disorder. Psychological Medicine, 40, 1789–1795. REFERENCES doi:10.1017=S003329171000005X Arns, M., de Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of neurofeed- STUDENT PRESENTATION back treatment in ADHD: The effects on inattention, impulsivity and hyperactivity: Modulatory Effects of Ambient Prism Lenses A meta-analysis. Clinical EEG and Neu- on Spatial Attention in Autism: An Event- roscience, 40, 180–189. Related Potential Study Arns, M., Spronk, D., & Fitzgerald, P. B. (2010). Potential differential effects of 9 Hz rTMS Guela Sokhadze, Melvin Kaplan, OD, and 10 Hz rTMS in the treatment of Stephen M Edelson, PhD, Estato M Sokhadze, depression. Brain Stimulation, 3, 124–126. PhD, Joshua Baruth, PhD, Ayman S El-Baz, 414 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

PhD, Marie K Hensley, and Manuel F and ambient correcting lenses were selected Casanova, MD to match their visual deficits. Of the 20 University of Louisville individuals, 12 were able to comply with dense-array EEG recording required for ERP analysis. Mean age of subjects was Introduction 13.9 3.0 years. The spatial attention task, programmed in E-Prime (Psychology Soft- Autism is a developmental disorder marked by ware Tools, PA), was represented a modifi- deficits in social interaction, communication, cation of a cued Posner spatial attention and behavior. One of the less studied deficits task (Posner, Edelson, & Seip, 1982). The in autism is the dysfunction of the ambient experimental procedure consisted of 2 tasks visual system, which can affect attention, and 4 total blocks, lasting total of 20 min. In movement, and visual motor coordination Task A, the subjects were instructed to (Kaplan, Edelson, & Seip, 1998). Focal vision, focusonthefixationcueinthecenterof which involves the central visual field, is the the screen, then were given a cue (red visual system that traditional ophthalmologists square) in either the left or right visual field, address with eyeglasses. Ambient vision, followed by a target (a black X) in place of which involves the entire visual field, is more either left or right cue. In Task B, the pro- dynamic and largely nonconscious and inte- cedure was the same, except the cues and grates with other sensory systems (Kaplan, targets appeared diagonally, in either top 2006). Most autistic children have a prefer- left and bottom right corners, or top right ence for focal vision, which is why many dis- and bottom left corners. Probability of cor- play a fascination for numbers, letters, and rectly cued targets was 80% in both blocks. objects. Their lack of attention to ambient Each subject completed each block with vision limits their ability to process information ambient lenses and placebo lenses. The regarding their gait, posture, movement, order or prism and placebo lenses was speech, and so on. The current study investi- counterbalanced. The ERP of interest gates the efficacy of ambient prism lenses included early (N100) and late (P300) com- used to correct deficits in ambient vision ponents at the centro-parietal, and parieto- present in autism. In addition, this study aims occipital topographic areas reflecting spatial to understand the abnormal neural and func- attention processes (Di Russo, Martinez, & tional mechanisms underlying visual distortion Hillyard, 2003; Gomez-Gonzalez, Clark, in autism by incorporating neurophysiologic Luck, & Hillyard, 1994; Polich & Herbst, studies, behavioral studies, and event-related 2000). The analysis included comparison potential (ERP) measurements of spatial of behavioral performance (reaction time, attention. accuracy) and ERP measures during blocks with and without ambient prism lenses. Methods Potential participants were recruited from a Results and Discussion pool of individuals with autism spectrum Reaction time in prism lenses condition disorder with the assistance of FEAT (Famil- tended to be faster than in placebo lenses ies for Effective Autism Treatment, Louisville condition (356.1 ms vs. 382.2 ms, ns). Accu- Chapter), Home of Innocents, and Weiss- racy of responses in lenses versus placebo kopf Child Evaluation Center (Louisville, condition also showed trend to lower percent- KY). Prescreening questionnaires were filled age of errors (5.6% vs. 14.2%) but did not out by parents, whereas the evaluation of reach significance level. Amplitude of the par- visual abnormalities related to ambient ieto-occipital N100 in horizontal congruent vision deficits was conducted by Dr. Kaplan. trial significantly higher (3.92 mV vs. Twenty subjects with autism were screened, 1.37 mV), F(1, 23) ¼ 7.79, p ¼ .012, during PROCEEDINGS OF THE 2011 ISNR CONFERENCE 415 prism lenses condition. Similar effect was Polich, J., & Herbst, K. L. (2000). P300 as a significant for incongruent (invalid cue) trials clinical assay. International Journal of Psy- (0.21 mV in placebo vs. 3.33 mV in lenses chophysiology, 38, 3–19. condition), F(1, 23) ¼ 6.40, p ¼ .021. Ampli- Posner, M. I., Cohen, Y., & Rafal, R. D. (1982). tude of the centro-parietal P300 (P3b) during Neural systems control of spatial orienting. more difficult diagonal incongruent condition Transactions of the Royal Society of London, was higher (4.65 mV vs. 2.05 mV), F(1, 23) ¼ B298, 187–198. 4.57, p ¼ .045, in ambient prism lenses condition, whereas latency P3b shorter (349.1 ms What Is Common and Unique in ADHD vs. 380.1 ms), F(1, 23) ¼ 7.72, p ¼ .012. These and Schizophrenia: Studies of Event-Related ERP effects of wearing ambient prism lenses is Potentials indicative of more effective special attentional processing, especially in more complex diag- Juri Kropotov, PhD onal incongruent trials. Institute of the Human Brain Conclusions This presentation represents review of research Our pilot study provides preliminary support to of event-related potentials (ERPs) in attention utility of wearing prism lenses to correct deficit hyperactivity disorder (ADHD) and ambient vision in autism and sensitivity of schizophrenia. The most common scientific ERP indices to detect visuospatial attention observation is a decrease of the P3b wave both improvement. We have found that using prism in ADHD and schizophrenia. This wave is lenses and comparing the autistic patient’s usually evoked in the oddball paradigm in performance and ERPs with and without such response to deviant rare targets when com- lenses can be a very informative approach to pared with responses to standard frequent understand the mechanisms of visual deficits nontarget stimuli. This observation appears to and spatial attention orienting impairments reflect a common dysfunction in ADHD and typical for autism. schizophrenia in the parietal attention system. Dopamine hypotheses of ADHD and schizophrenia will be discussed. The hypotheses REFERENCES imply involvement of different aspects of infor- Di Russo, F., Martinez, A., & Hillyard, S. A. mation processing within the basal ganglia (2003). Source analysis of event-related thalamocortical circuits. A recently emerged cortical activity during visuo-spatial atten- independent component analysis (ICA) pro- tion. Cerebral Cortex, 13, 486–499. vides a powerful tool for decomposing ERPs Gomez-Gonzales, C. M., Clark, V. P., Luck, S. J., into components of different functional mean- & Hillyard, S. A. (1994). Sources of attention- ings. This presentation describes results of sensitive visual event-related potentials. Brain applying ICA to decompose a collection of Topography, 7, 41–51. ERPs into independent components associated Kaplan, M. (2006). Seeing through new eyes: with different psychological operations (such Changing the lives of children with autism, processing in dorsal and ventral visual streams, Asperger syndrome and other developmental orienting response, engagement, motor sup- disabilities through vision therapy. Philadel- pression, and conflict monitoring operations). phia, PA: Jessica Kingsley. One thousand healthy subjects, 1,000 patients Kaplan, M., Edelson, S. M., & Seip, J. L. (1998). with ADHD, and 100 patients with schizo- Behavioral changes in autistic individuals as phrenia participated in this multicenter a result of wearing ambient transitional prism European study including laboratories from lenses. Child Psychiatry & Human Develop- Switzerland (A. Mueller et al.), Norway (S. ment, 29, 65–76. Hollup et al.), Macedonia (N. Pop-Jordanova 416 PROCEEDINGS OF THE 2011 ISNR CONFERENCE et al.), and Russia (Kropotov et al.). The results (RCTs) with a large effect size (ES) for inatten- of application of the ERP ICA for diagnosis tion and medium ESs for hyperactivity and (discrimination) ADHD and schizophrenia impulsivity (Arns, de Ridder, Strehl, Breteler, from healthy subjects will be presented. In & Coenen, 2009) and 16 RCTs with a mean the final part of the paper, a methodology for medium ES for overall ADHD, inattentive, constructing protocols of neurofeedback and and hyperactive=impulsive symptoms, many transcranial direct current stimulation (tDCS) of these studies are small and have not used on the basis of comparison the individual ERP adequate blinding. The results from the parameters with the normative data will be recent National Institute of Mental Health presented. Recently emerged methods of neu- (NIMH)-funded Ohio State University feasi- rotherapy such as sLORETA-based, ERP-based bility pilot study indicated that a well-blinded neurofeedback and tDCS will be also intro- large RCT of NF utilizing a sham control of duced in relation to neuromodulation in equal intensity and duration is feasible and ADHD and schizophrenia. necessary, although questions have been raised about whether the sham placebo was truly inert. Financial Interest As with any treatment, it is difficult to deter- The NovaTech company and Mitsar company mine how much of the apparent treatment are paying the travel fees to the ISNR confer- effect is specific to the treatment, and how ence. I am a co-owner of HBImed AG com- much is placebo effect. Two small studies pany (Switzerland). (Perreau-Link, Lessard, Levesque, & Beaure- gard, 2010 [N ¼ 8]; and Lansbergen et al., Planning for a Collaborative Multisite, 2011 [N ¼ 14]) published after the Arns Double-Blind, Sham-Controlled Randomized meta-analysis had a blinded sham control and Clinical Trial of Neurofeedback for ADHD showed no advantage of NF over placebo, rais- ing questions about the unblinded studies. Nick Lofthouse, PhD, L. Eugene Arnold, MD, These inconclusive scientific results pose a pub- Martijn Arns, MSc, Keith Conners, PhD, lic health dilemma. The treatment involves con- Roger deBeus, PhD, Henry Harbin, MD, siderable initial expense and lengthy Laurence Hirshberg, PhD, Cynthia Kerson, PhD, commitment by the patients and families. How- Helena Kraemer, PhD, Joel Lubar, PhD, Keith ever, if NF has lasting specific benefit, the initial McBurnnett, PhD, and Vincent Monastra, PhD cost and time may compare favorably with Ohio State University medication. Therefore, it is important to know whether NF has a specific effect beyond placebo response, whether the persistence of Medication and behavior modification, the benefit can be replicated, and whether a bio- established treatments for attention deficit logical endophenotype can be identified who hyperactivity disorder (ADHD), are not univer- will reliably benefit from it. Without resolution sally effective or acceptable to all and have not of the effectiveness question, this potentially been shown to have sustained effects beyond 2 valuable adjunct to the ADHD treatment arma- years. The 8-year outcome paper (Molina et al., mentarium will not be fully utilized and widely 2009) for the NIMH Multimodal Treatment accessible. Study of ADHD (the MTA) pointed out the In November 2010, Drs. Gene Arnold, need for new treatments with lasting effects. Roger deBeus, Larry Hirshberg, and Nick Loft- Among complementary=alternative treatments house presented a symposium on ‘‘EEG Neuro- for ADHD, neurofeedback (NF) is one of feedback for ADHD: Review of the Science and the most prominent, despite its expense and New Findings’’ at the annual meeting of technical difficulties. However, despite a Children and Adults with Attention-Deficit= meta-analysis of 6 randomized control trials Hyperactivity Disorder. Chaired by Drs. Russell PROCEEDINGS OF THE 2011 ISNR CONFERENCE 417

Barkley and Ann Abramowitz, this symposium report whether our efforts to obtain NIMH led to a discussion about the possibility of a funding were successful, and the next step in large-scale, multisite, double-blind, sham- our collaboration. controlled RCT of NF for pediatric ADHD. This discussion continued with weekly telephone REFERENCES conferences involving a group of NF experts (Drs. Joel Lubar, Vincent Monastra, Cynthia Arns, M., de Ridder, S., Strehl, U., Breteler, M., Kerson, Henry Harbin, Roger deBeus, Larry & Coenen, A. (2009). Efficacy of neurofeed- Hirshberg, & Mr. Martijn Arns) and mainstream back treatment in ADHD: The effects on ADHD scientists (Drs. Gene Arnold, Keith inattention, impulsivity & hyperactivity: A McBurnett, Keith Conners, Helena Kraemer, meta-analysis. EEG & Clinical Neuroscience, & Nick Lofthouse). In April 2011, these discus- 40, 180–189. sions led to an agreed-upon preapplication let- Jensen, P. S., Arnold, L. E., Swanson, J., Vitiello, ter of intent to NIMH for multimillion dollar B., Abikoff, H. B., Greenhill, L. L., ... funding of this project. Slaats-Willemse, D. (2011). ADHD and This proposed study is the first to involve EEG-neurofeedback: A double-blind rando- planning and execution by both mainstream mized placebo-controlled feasibility ADHD scientists (to ensure credible scientific study. Journal of Neural Transmission, 118, rigor) and NF experts=advocates (to ensure 275–284. credible and rigorous treatment). In such a Lansbergen, M. M., van Dongen-Boomsma, M., study, it is essential that all stakeholders have Buitelaar, J. K., & Slaats-Willamse, D. (2011). input so that the results, whatever they are, ADHD and eeg-neurofeedback: A double- will be credible to all. This proposal is signifi- blind randomized placebo-controlled feasi- cant and innovative at the scientific, clinical, bility study. Journal of Neural Transmission, and public health level. Scientifically, the lack 118(2), 275–284. of a large well-controlled, double-blinded Molina, B. S. G., Hinshaw, S. P., Swanson, J. examination of NF has been a critical barrier M., Arnold, L. E., Vitiello, B., Jensen, P. S., to progress in the field, with disagreement ... the MTA Cooperative Group (2009). between NF and most mainstream ADHD The MTA at 8 years: Prospective follow-up investigators about interpretation of the avail- of children treated for combined type able data. On a clinical and public health ADHD in a multisite study. Journal of the level, testing of this promising treatment in American Academy of Child and Adolescent a way that is rigorous in both clinical method Psychiatry, 48, 484–500. and research design is greatly needed to see Perreau-Linck, E., Lessard, N., Levesque, J., & whether NF is an effective alternative treat- Beauregard, M. (2010). Effects of neurofeed- ment option for the many youth who do back training on inhibitory capacities in not respond to or refuse current evidence- ADHD children: A single-blind, randomized, based treatments and to see if NF holds placebo-controlled study. Journal of Neuro- additional promise as a complimentary treat- pathy, 14, 229–242. ment option. This 60-min oral presentation will present How Reliable Is the Resonance Frequency? the theoretical, scientific, clinical, and public health background for the proposed study Fredric Shaffer, PhD and discuss the collaborative team’s agree- Truman State University ments, disagreements, and resolutions in developing the NIMH letter of intent. The study’s main objectives, specific hypotheses, Introduction design, participants, instruments, and proce- Lehrer and colleagues (2004) proposed that dures will also be reviewed. Finally, we will each client has a unique breathing rate, called 418 PROCEEDINGS OF THE 2011 ISNR CONFERENCE the resonance frequency, at around 6 breaths Procedure. Subjects sat upright in a per minute. Heart rate and blood pressure straight-backed chair with eyes open throughout oscillations are 180 degrees out of phase, this study. Following a 10-min resting baseline the baroreflex is strongest, and respiratory without feedback, we instructed subjects to fol- sinus arrhythmia is greatest at this respiration low an animated pacing display designed to rate (DeBoer, Karemaker, & Strackee, 1987). guide their breathing from 7.5 to 4.5 breaths 1 Because training clients to breathe at their res- per minute in 7 descending 2-breath-per-minute onance frequency is a crucial component of steps. Subjects breathed at each target rate for heart rate variability (HRV) biofeedback, it is 2 min, followed by a 1-min buffer period. We important that these measurements are retested all subjects using the same procedure 2 reliable. Why train a client to breathe at 5.5 weeks later to assess the reliability of these mea- breaths per minute today if her resonance fre- surements. They received no HRV training or quency will be 6.5 breaths per minute next breathing practice during the intervening period. week? The present study examined the 2-week test–retest reliability of resonance fre- Results quency measurements using a modified ver- We measured 2-week test–retest reliabilities sion of a protocol developed by Lehrer and measured using a Pearson product-moment Gevirtz. correlation coefficient. We assessed the global Method HRV indices and HRV frequency components while our subjects breathed at their resonance Participants. Nineteen undergraduates frequency. (16 male, 3 female), 19 to 22 years of age, participated in this study. Resonance Frequency. Resonance fre- Apparatus. A Thought Technology Pro- quency measurements were reliable, r(17) ¼ CompTM Infiniti system detected the EKG using 0.73, p ¼ .000. an Infiniti EKGTM sensor with leads placed on Global HRV Indices. While HR Max–HR the upper chest and below the sternum, and Min measurements were unreliable, both measured respiration rate using a Resp-Flex= pNN50, r(17) ¼ 0.65, p ¼ .002; and SDNN ProTM sensor placed around the abdomen at measurements, r(17) ¼ 0.59, p ¼ .008, were the level of the navel. BioGraph InfinitiTM soft- also reliable. ware measured the resonance frequency, 3 HRV Frequency Components. Although global indices of HRV (HR Max–HR Min, the VLF, LF, and HF measurements were unre- pNN50, and SDNN), and the LF=HF ratio. liable, the LF=HF ratio was reliable, The resonance frequency is the breathing rate r(17) ¼ 0.58, p ¼ .009. that produces the greatest synchrony between respiration band and instantaneous heart rate signals and that maximizes the most global Discussion measures of HRV. HR Max–HR Min is the dif- Resonance frequency measurements achieved ference between the highest and lowest heart acceptable 2-week test–retest reliability. Among rates during each respiratory cycle. The the global HRV indices, SDNN and pNN50 pNN50 index calculates the percentage of measurements were also reliable, whereas HR adjacent N-to-N intervals that differ from each Max–HR Min was not. Among the HRV fre- other by more than 50 ms. SDNN is the stan- quency components, the LF=HF ratio was dard deviation of the interbeat interval for all reliable, but VLF, LF, and HF were not. These normal sinus beats measured in milliseconds. findings support protocols that train clients to The LF=HF ratio represents the percentage of breathe at their unique resonance frequency power in the low-frequency band divided by to maximize HRV. Because our subjects the percentage of power in the high-frequency were primarily healthy male undergraduates, band. researchers should replicate these findings with PROCEEDINGS OF THE 2011 ISNR CONFERENCE 419 a gender-balanced clinical population to ensure (Applehans & Luecken, 2006) have been external validity. demonstrated as a result of HRV training. A similar mental state is the target of EEG biofeedback training to increase sensorimotor rhythm (SMR REFERENCES 12–15 Hz across the sensorimotor strip C3, Cz, DeBoer, R. W., Karemaker, J. M., & Strackee, J. C4). SMR has been closely linked to a quieting (1987). Hemodynamic fluctuations and bar- state of calm relaxed focus (Sterman, 1996). oreflex sensitivity in humans: A beat-to-beat In 2010, M. Thompson, Thompson, and Reid model. American Journal of Physiology— developed the systems theory of neural synergy, Heart and Circulatory Physiology, 253(22), which outlines a link between HRV and brain H680–H689. function. In this paper, we discuss a link Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. between HRV and sensorimotor response E., Scardella, A., Siddique, M., & Habib, R. (SMR). We propose that training for increased H. (2004). Biofeedback treatment for asthma. HRV can lead to increased levels of SMR. At Chest, 126, 352–361. the ADD Centre, Dr. Lynda Thompson and Dr. Michael Thompson have been combining The Effects of Heart Rate Variability on EEG biofeedback with physiological biofeed- Sensorimotor Rhythm: A Pilot Study back, including respiration and heart rate training. The authors of this paper, while working Andrea Reid, MA, and Stephanie Nihon with clients at the ADD Centre, noticed that ADD Centre many clients, including athletes, were showing increased SMR during sessions when they were training to achieve synchrony between respir- Heart rate variability (HRV) training and elec- ation and heart rate changes (HRV training). troencephalographic (EEG) biofeedback are This observation lead to the hypothesis that techniques that have been used to improve HRV training may enhance increases in SMR. neurological disorders, such as attention deficit hyperactivity disorder (ADHD), as well as to Method optimize performance in athletes. HRV is a Preliminary data have been collected for 10 measurement of the variation in the respiration clients (n ¼ 10). Five clients were athletes train- rate at which the heart is beating. Vaschillo, ing to improve performance, and five clients Lehrer, Rische, and Konstantinov (2002) call were from a clinical population aiming to the low-frequency range 0.05 to 0.15 Hz, increase SMR as a part of their program. The which generally corresponds to 5 to 6 breaths age range in this study was age 6 to 60. per minute and assumes respiratory sinus Three-min EEG assessment data were collected arrhythmia (RSA). The calculation for 6 breaths and artifacted at Cz for each client. Statistics per minute is 6=60 sec which is equal to 1=10 were selected to measure mean microvolt or .1. RSA describes the relationship between values for SMR (12–15 Hz). Electromyogram heart rate changes and increased heart rate dur- (EMG) was also measured to ensure that the ing inhalation and decreased heart rate during reflection of EMG on EEG (muscle artifact) exhalation. Resonance found between these did not act to artificially increase SMR. A frequencies for breathing and heart rate varia- second 3-min sample of EEG was collected tions relate to the heart rate closed loop of the during 3 min of HRV training, during which baroreflex system, through which blood press- the client demonstrated HRV and synchronous ure changes are regulated. This specific signa- RSA. Clients had to achieve a peak frequency ture of breathing and heart rate changes being heart rate between .05 and .15 during HRV synchronized may correlate with a more relaxed training to be included in the study. The cognitive clarity. Improvements in cognition authors expect to collect data for 20 more (Vaschillo et al., 2002) and emotional stability clients during the next few months. 420 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Results REFERENCES Mean microvolt values were collected for SMR Applehans, B. M., & Luecken, L. J. (2006). during the baseline recording and during the Attentional processes, anxiety, and regu- HRV training. All clients demonstrated an lation of cortisol reactivity. Anxiety, Stress & increase in SMR during HRV training as com- Coping, 19, 81–92. pared to baseline measures. T tests were done Sterman, M. B. (1996). Physiological origins on the data, which showed p < .01. This and functional correlates of EEG rhythmic demonstrates that the increase in SMR during activities: Implications for self-regulation. HRV training is statistically significant. Biofeedback and Self-Regulation, 21, 3–33. Thompson, L., & Thompson, M. (1998). Neurofeedback combined with training in Discussion metacognitive strategies: Effectiveness in students with ADD. Journal of Applied Psycho- The preliminary results suggest that HRV train- physiology and Biofeedback, 23, 243–263. ing can lead to increases in SMR. These results Thompson, M., Thompson, L., & Reid, A. have implications in the clinical setting. Clients (2010). Neurofeedback outcomes in 150 cli- with neurological disorders such as ADHD, ents with Asperger’s syndrome and 9 clients seizure disorders, and Asperger’s syndrome with autism. Journal of Applied Psychophy- who are working towards increasing SMR siology and Biofeedback, 35, 63–81. may benefit from combining this neurofeed- Vaschillo, E. G., Lehrer, P. M., Rishe, N. & back training with HRV training. This combi- Konstantinov, M. (2002). Heart rate varia- nation of biofeedback and neurofeedback bility biofeedback as a method for assessing may lead to better clinical outcomes, possibly baroreflex function: A preliminary study of in less time. resonance in the cardiovascular system. HRV training gives the athletes more Applied Psychophysiology and Biofeedback, flexibility in controlling their autonomic ner- 27, 1–27. vous systems and thereby allows them to better regulate their emotional states during sports performance, which is a critical tool during a Exact Low-Resolution Electromagnetic Brain high stress performance. Breathing at one’s res- Tomography (eLORETA) of Adult ADHD: onant frequency can help maintain a calm, Pre=Post Findings Following Neurofeedback relaxed focus in the body and mind. SMR has Therapy been closely linked to a quieting state of calm relaxed focus (L. Thompson & Thompson, Sarah Wyckoff, MA, and Kerstin Mayer, MSc 1998). This study suggests that, by training University of Tu¨bingen HRV and SMR, athletes can obtain synergy between body and mind and thereby reach a Leslie Sherlin, PhD more ideal performance state. NovaTech EEG Based on the preliminary results of this study, practicing HRV training with clinical Ute Strehl, PhD populations and with athletes is associated with University of Tu¨bingen increases in SMR at the central location (CZ), which is associated with a calm and alert mental Introduction state. Future research could investigate Attention-deficit=hyperactivity disorder (ADHD) the combination of SMR training with HRV is one of the most common disorders of child- training as an effective method=intervention hood with a cumulative incidence of 7.5% by for working with both clinical populations and 19 years of age (Barbaresi et al., 2004). The athletes to ameliorate symptoms and optimize primary symptoms of ADHD include inatten- performance. tiveness, impulsivity, and hyperactivity, which PROCEEDINGS OF THE 2011 ISNR CONFERENCE 421 persist into adulthood for 4 to 5% of patients Results (Goodman & Thase, 2009). EEG=QEEG analysis This investigation is part of a long-term treat- of adults with ADHD compared to healthy con- ment study currently in progress. The most cur- trols and=or normative database populations rent results related to eLORETA EEG source have produced a variety of patterns of activity, localization of adult ADHD patients compared highlighting the heterogeneity of this population to a control population and following 15 (Bresnahan, Anderson, & Barry, 1999; sessions of neurofeedback therapy will be Bresnahan & Barry, 2002; Clarke et al., 2008a, presented at the time of the conference. 2008b, Hale et al., 2009; Koehler et al., 2009; Loo et al., 2009; Thompson & Thompson, Conclusion 2005; White, 2001, 2003). The objective of this study was to investigate the specific frequency Analysis of eLORETA current source activities band pass regions and spatial locations associa- in adult ADHD patients compared to healthy ted with adult ADHD using exact low-resolution controls and following neurofeedback training electromagnetic brain tomography (eLORETA) has not previously been investigated and may in comparison to healthy controls and following yield valuable insights related to alternative 30 sessions of neurofeedback therapy. treatments for this population. Specific findings will be discussed and implication in the current treatment study, and future research will be Method explored. Continuous 19-channel EEG was acquired from 40 adult participants that met Diagnostic REFERENCES and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, American Psychiatric Association. (1994). Diag- 1994) criteria for ADHD (combined, inatten- nostic and statistical manual of mental disor- tive, or hyperactive type), without additional ders (4th ed.). Washington, DC: Author. serious physical, neurological, or psychiatric Barbaresi, W., Katusic, S., Colligan, R., Weaver, disorders, and a full-scale IQ greater than 80. A., Pankratz, V., Mrazek, D., & Jacobsen, S. EEG recordings were collected at pre=mid= (2004). How common is attention-deficit= post-follow-up treatment intervals and hyperactivity disorder? Towards resolution included EO, EC, P300, and CNV tasks, as well of the controversy: Results from a as ADHD behavioral questionnaires. eLORETA population-based study. Acta Paediatrica analysis was computed on 2 min of EC data Supplement, 93(445), 55–59. (Pascual-Marqui, 2002). The eLORETA output Bresnahan, S. M., Anderson, J. W., & Barry, R. J. data were compared with age-matched indivi- (1999). Age-related changes in quantitative duals in a healthy control database (Nova Tech EEG in attention-deficit=hyperactivity dis- EEG, Mesa, Arizona, USA) using a multiple order. Biological Psychiatry, 46, 1690–1697. comparison procedure for the following fre- Bresnahan, S. M., & Barry, R. J. (2002). Speci- quency bands: absolute and relative power in ficity of Quantitative EEG analysis in adults delta (1–3 Hz), theta (4–7 Hz), alpha (8– with attention deficit hyperactivity disorder. 12 Hz), beta1 (13–18 Hz), beta2 (19–21 Hz), Psychiatry Research, 112, 133–144. beta3 (22–30 Hz); alpha and theta bands Clarke, A. R., Barry, R. J., Heaven, P. C., adjusted to individual alpha peak frequency McCarthy, R., Selikowitz, M., & Bryne, M. (Pascual-Marqui, 2002; The KEY Institute for K. (2008a). EEG coherence in adults with Brain-Mind Research, Zurich, Switzerland). attention-deficit=hyperactivity disorder. Pre–post changes in the sources of EEG International Journal of Psychophysiology, rhythms were also assessed following 30 ses- 76(1), 35–40. sions of Theta=Beta or slow cortical potential Clarke, A. R., Barry, R. J., Heaven, P. C., neurofeedback training. McCarthy, R., Seilkowitz, M., & Bryne, M. K. 422 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

(2008b). EEG in adults with attention-deficit= University of Tennessee hyperactivity disorder. Int J Psychophysiology, 70, 176–183. Goodman, D. W., & Thase, M. E. (2009). Introduction Recognizing ADHD in adults with comorbid This study examined the cortical effects of mood disorders: Implications for identifi- LORETA neurofeedback (LNFB) in the precu- cation and management. Postgraduate- neus as a potential target region of training Medicine, 121(5), 20–30. for substance abuse and attention deficit dis- Hale, T. S., Smalley, S. L., Hanada, G., Macion, orders. We evaluated pre- and posttraining J., McCracken, J. T., McGough, J. J., & Loo, current source density in the region of training S. K. (2009). Atypical alpha asymmetry in and the network effects of 20 sessions of adults with ADHD. Neuropsychologia, 47, LNFB in the left precuneus. We assessed 2082–2088. training effects using the Personality Assess- Koehler, S., Lauer, P., Schreppel, T., Jacob, C., ment Inventory (PAI) and Delis-Kaplan Execu- Heine, M., Boreatti-Hummer, A., ... tive Function System (D-KEFS) pre- and Herrmann, M. J. (2009). Increased EEG posttraining. power density in alpha and theta bands in adult ADHD patients. Journal of Neural Methods Transmission, 116(1), 97–104. Four undergraduate students, with a mean age Loo, S. K., Hale, T. S., Macion, J., Hanada, G., of 24 completed 20 sessions of LNFB training McGough, J. J., McCracken, J. T., & Smalley, in the left precuneus. The training consisted S. L. (2009). Cortical activity patterns in of 5 sessions per week with six 5-min training ADHD during arousal, activation, and rounds within each session. The effects of sustained attention. Neuropsychologia, 47, LNFB were assessed with D-KEFS and PAI post- 2114–2119. training. We utilized a linear mixed model with Pascual-Marqui, R. D. (2002). Standardized repeated measures to analyze the effects of low-resolution brain electromagnetic LNFB on current source density levels within tomography (sLORETA): Technical details. the default network. Methods and Findings in Experimental Clinical Pharmacology, 24(Suppl. D), 5–12. Results Thompson, L., & Thompson, M. (2005). The region and frequency of training shows a Neurofeedback intervention for adults with significant increase in current source density ADHD. Journal of Adult Development, 12, (CSD) as a result of LNFB. Network analyses 123–130. show increases in left BA 3, 6, 7, and frontal White, J. N., Jr. (2001). Neuropsychological regions with a corresponding decrease in and electrophysiological assessment of adults right amygdaloid regions including BA 34, with attention deficit hyperactivity disorder 28, and 35. Delta CSD is shown decreased (Unpublished doctoral dissertation). The in left BA 44, theta shows increased CSD in University of Tennessee, Knoxville. right BA 46, and alpha shows increased White, J. N., Jr. (2003). Comparison of QEEG CSD in right BA 45, whereas beta shows Reference Databases in Basic Signal Analysis maximal increased CSD in left BA 10. Per- and in the Evaluation of Adult ADHD. ceptible changes in executive functions and Journal of Neurotherapy, 7, 123–169. personality assessment inventory scales are forthcoming. LORETA Neurofeedback and the Precuneus Discussion Rex Cannon, PhD, Debora Baldwin, The data obtained in this study are part of a lar- PhD, Dominic Di Loreto, BA, and ger methodology to employ LNFB in treatment Alexander Khaddouma, BA paradigms for substance use disorder and adult PROCEEDINGS OF THE 2011 ISNR CONFERENCE 423

ADHD. These results demonstrate LNFB in the implication of this practice in psychiatry precuneus to produce specific network remained elusive and considered of relatively increases and decreases between regions low therapeutic yield, possibly due to its shown to be important to attention and self- widespread cortical representations. The regulation. In effect, decreases between net- hurdle may lie in the poor spatial resolution work assemblies may reflect the direct effects of the EEG, thus precluding valid probing of of operant learning, such that less power is deeper brain structures such as limbic regions needed to produce the desired behavior. that are critical for modulating emotional Numerous studies of neuroplastic changes asso- states. The current project aims to use simul- ciated with practice have shown similar effects taneous acquisition of functional magnetic res- and will be discussed. Thus, the current data onance imaging (fMRI) and EEG in order to demonstrate this to be a feasible method for unfold in high spatial and temporal resolutions larger clinical research trials and randomized the neural modulations induced via EEG feed- control double-blind studies using LNFB meth- back on shifts in alpha=theta ratio. odology. Clinical implications are discussed. Methods STUDENT PRESENTATION Fifteen healthy subjects participated in a pre- scanning 15-min training with eyes closed to Deep Brain Modulations Guided by EEG apply EEG neurofeedback for increasing the Feedback Can Be Probed by Simultaneous ratio of theta to alpha. In the 3 T MRI scanner, fMRI subjects followed a similar EEG neurofeedback protocol, which alternates between increasing Sivan Kinreich, MA, Nathan Intrator, PhD, and decreasing the alpha=theta ratio (i.e., and Ilana Klovatch, and Talma Hendler, inducing neural modulation. BrainVoyager, PhD, MD EEG-Lab and at-home software packages were Tel Aviv University used for preprocessing and analyzing the raw brain signals in correspondence to induced mental states). Introduction Decades of electroencephalogram (EEG)- Results feedback practice proved that people can be A general linear model for the whole brain effectively trained to selectively modulate using the changing mental states as predictors their brain activity. The premise of such a was calculated. Defined contrast between eyes practice has been based on the idea that closed wakefulness and eyes closed relaxation people can regulate their brain activity, thus revealed two intriguing brain areas. While the improve its performance (Gruzelier, 2009; subjects relaxed, the superior frontal gyrus Peniston, Marrinan, Deming, & Kulkosky, was more active and the subgenual cingulate 1993). A common protocol of EEG-feedback cortex was deactivated. aimed to help people in relaxation is based on closed loop guidance by shifts from Conclusions high-amplitude of alpha (8–14 Hz) to Simultaneous fMRI during EEG feedback via low-amplitude of theta (4–7 Hz) oscillations alpha=theta ratio modulation probed acti- (Vogel, Foulkes, & Trosman, 1966) through vation variation in deep brain limbic area training. The induction of such a shift in such as the subgenual cingulate cortex. This EEG oscillations has been useful in reaching limbic area is known to play a role in gener- a state of deep relaxation in psychiatric con- ation of affective states presumably mediated ditions of anxiety and mood disorder (Geven- by parasympathetic autonomic tone (Critch- sleben et al., 2009; Lantz & Sterman, 1988; ley, 2005), which might lead decreased focal Peniston et al., 1993). However, the clinical activation. An extensive work in the last 424 PROCEEDINGS OF THE 2011 ISNR CONFERENCE decade points to alterations in this area KEYNOTE PRESENTATION activity in major depression and to the moderating effect of its focal electrical stimulation. Molecular Development of Projection Neu- The recruitment of the superior frontal gyrus ron Types and Building of Local Microcircui- as relaxation took place fits its proposed role try in the Cerebral Cortex in moderating high arousal (Beauregard, Lev- esque, & Bourgouin, 2001) in emotional Paola Arlotta, PhD self-regulation. Altogether our results clearly Harvard Medical School demonstrate the advantage in combining EEG and fMRI for optimizing neurofeedback procedure at the individual level. Methodolo- The activity and function of the mammalian gical and practical aspects of such approach cerebral cortex rely on the integration of an will be further discussed. extraordinary diversity of excitatory projection neurons and inhibitory interneurons into balanced local circuitry. The developmental REFERENCES events governing the proper interaction Beauregard, M., Levesque, J., & Bourgouin, P. between excitatory projection neurons and (2001). Neural correlates of conscious self inhibitory interneurons are poorly under- regulation of emotion. Journal of Neu- stood.Here,wehavefirstinvestigatedthe roscience, 21, RC165. function of the transcription factor Fezf2 in Critchley, H. D. (2005). Neural mechanisms of controlling the fate-specification of corticofu- autonomic, affective, and cognitive inte- gal projection neurons (CfuPN) of the neo- gration. Journal of Comparative Neurology, cortex. We find that Fezf2 acts as a 493(1), 154–156. powerful master gene that is sufficient to Gevensleben, H., Holl, B., Albrecht, B., Vogel, instruct the birth of CFuPN even from C., Schlamp, D., Kratz, O., ... Heinrich, H. progenitors fated to become medium spiny (2009). Is neurofeedback an efficacious neurons in the striatum. Secondly, we report treatment for ADHD? A randomized that different subtypes of projection neurons controlled clinical trial. Journal of Child Psy- uniquely and differentially determine the chology and Psychiatry, 50, 780–789. laminar distribution of cortical interneurons Gruzelier, J. (2009). A theory of alpha=theta neu- into cortical layers. We find that in rofeedback, creative performance enhance- Fezf2-=-cortex, the exclusive absence of sub- ment, long distance functional connectivity cerebral projection neurons and their and psychological integration. Cognitive Pro- replacement by callosal projection neurons cesses, 10, 101–109. cause distinctly abnormallaminationofinter- Lantz, D. L., & Sterman, M. B. (1988). Neurop- neurons. This results in physiological imbal- sychological assessment of subjects with ance of excitation due to altered GABAergic uncontrolled epilepsy: Effects of EEG feed- inhibition. In addition, experimental gener- back training. Epilepsia, 29, 163–171. ation of either corticofugal neurons or callo- Peniston,E.G.,Marrinan,D.A.,Deming,W.A., sal neurons below the cortex is sufficient to & Kulkosky, P. J. (1993). EEG alpha theta recruit cortical interneurons to these ectopic brainwave synchronization in Vietnam theater locations. Strikingly, the identity of the pro- veterans with combat-related post-traumatic jection neurons generated, rather than strictly stress disorder and alcohol abuse. Advances their birth date, determines the specific types in Medical Psychotherapy, 6, 37–50. of interneurons recruited. These data dem- Vogel, G., D. Foulkes, D. & Trosman, H. onstrate that in the neocortex individual (1966). Ego functions and dreaming during populations of projection neurons cell- sleep onset. Archives of General Psychiatry, extrinsically control the laminar fate of inter- 14, 238–248. neurons and the assembly of local inhibitory. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 425

The NIMH-Funded OSU Randomized, Results Double-Blind, Sham-Controlled Pilot Feasi- Of 39 randomized; 3 dropped by Tx 6, 2 after bility Trial of Neurofeedback for Pediatric Tx 22; 86% completed all 40 Tx. At 40th Tx, ADHD—Complete Results child and parent guesses about assigned Tx were worse than chance. At Tx 24, of 34 Nick Lofthouse, PhD, L. Eugene Arnold, MD, families continuing, 13 (38%) chose 2 Tx=wk; MEd, Sarah Hersch, BS, BA, Elizabeth Hurt, 21 (62%) chose 3 Tx=wk. Of 8 experiencing PhD, and Xueliang Pan, PhD both frequencies, no children and 1 parent Ohio State University preferred 2X=wk. Parent=teacher rated ADHD < > [email protected] symptoms were as good with 3X=wk as 2X=wk. In the active Tx, improvement asymptoted by Introduction Tx 24. Both active NF and sham yielded large The established treatments for attention- pre-post improvement on parent ratings, but deficit=hyperactivity disorder (ADHD) are not NF no more than sham. universally effective or acceptable to all, and have not been shown to have sustained effects Conclusions beyond 2 years. The 8-year outcome paper (Molina et al., 2009) for the NIMH Multimodal Compliance=completion was acceptable. 3X= Treatment Study of ADHD (the MTA) pointed wk Tx frequency seems preferred over 2X=wk out the need for new treatments with lasting and is as effective. Blinding appears to work. effects. Among complementary=alternative Thirty treatments appeared adequate for treatments for ADHD, neurofeedback (NF) is maximal benefit. In view of the large placebo one of the most prominent, despite its expense effect compared to unblinded positive results and technical difficulties. A meta-analysis of 6 in the literature, a large double-blind RCT is randomized clinical trials (RCTs) reported large necessary to test specific effectiveness. effects on inattention and medium effects on impulsivity and hyperactivity (Arns, de Ridder, Strehl, Breteler, & Coenen, 2009). However, REFERENCES the control conditions were not blinded and American Psychiatric Association. (1994). often not of equal duration and intensity com- Diagnostic and statistical manual of mental pared to the NF conditions. Preparing for a disorders (4th ed.). Washington, DC: Author. definitive RCT, this pilot study explored feasi- Arns, M., de Ridder, S., Strehl, U., Breteler, M., bility of a double-blind, sham-controlled design & Coenen, A. (2009). Efficacy of neurofeed- and compliance=palatability=relative effect of back treatment in ADHD: The effects on 2 versus 3 treatments=week. inattention, impulsivity & hyperactivity: A meta-analysis. EEG & Clinical Neuroscience, Method 40, 180–189. Unmedicated 6- to 12-year-olds with Diagnostic Jensen, P. S., Arnold, L. E., Swanson, J., Vitiello, and Statistical Manual of Mental Disorders (4th B., Abikoff, H. B., Greenhill, L. L., ... ed.; American Psychiatric Association, 1994) deBeus, R. (in press). A review of neurofeed- ADHD were randomized to active- NF or back treatment for pediatric ADHD. Journal sham-NF (2:1 ratio) and to 2X versus 3X=week of Attention Disorders. (wk) treatment frequency (1:1) for 40 treatments Molina, B. S. G., Hinshaw, S. P., Swanson, J. (Tx). Switch of Tx frequency was allowed after M., Arnold, L. E., Vitiello, B., Jensen, P. S., Tx 24. Multi-informant assessments at baseline, ... the MTA Cooperative Group. (2009). treatments 12, 24, and 40, and 2-month The MTA at 8 years: Prospective follow-up follow-up included preferences=satisfaction, of children treated for combined type caregiver ratings, and objective tests. ADHD in a multisite study. Journal of the 426 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

American Academy of Child and Adolescent always assumed that winter blues was the result Psychiatry, 48, 484–500. of seasonal affective disorder, which comes about as a lack of optic stimulation to UV recep- Why We Make Ourselves Sick and How to tors in the eyes and, ultimately, the pineal gland. Make Ourselves Healthy: The Importance There are several similarities in the symptoms of of Nutrition, Exercise and Sunlight SAD and vitamin D deficiency, and therefore it is possible that SAD has been misdiagnosed since David Siever, CET its inception. A recent study on vitamin D Mind Alive, Inc. deficiency has shown that vitamin D supplemen- tation eliminates the symptoms of SAD in SAD Ron Swatzyna, PhD sufferers. Tarnow Center for Self-Management The human brain was never designed to be healthy; it was designed to survive. Despite the E. Roy John and Leslie Prichep (2006) proposed robustness of the brain, we are not sharp and an EEG Homeostatic Model for the brain. In this productive, nor social, lively, and joyful unless model, neurotransmitters mediate neuroanato- we address good nutrition and exercise. We mical structures that generate behavior regu- have to work at being mentally healthy. As long lated by emotional experience in the moment as we are ignoring our basic needs, the brain of the event. They proposed that ‘‘psychologi- will do what it has to along a predictive patho- cal and neurological disorders produce and logical course to survive, and we will suffer. are caused by deviations from homeostasis’’ Active voluntary participation in good (p. 135). If an environment or psychological nutritional decisions, exercise routine, and out- challenge continues for an extended period, side activities (if possible) are necessary for EEG the set point for homeostasis adapts to a new Homeostasis. point. This short course provides information about the importance of nutrition, exercise, REFERENCE and sunlight in the process of reestablishing EEG homeostasis. David Siever will review the John, E. R., & Prichep, L. (2006). The relevance literature concerning the effects of nutrition, of the QEEG to the evaluation of behavioral exercise and sunlight on the brain, and Ron disorders and pharmacological interventions. Swatzyna will present his EEG=QEEG study on Clinical EEG and Neuroscience, 37, 135–143. the impact of breakfast patterns in children. Nutrition affects oscillatory rhythms and neu- Setting Up for Success with Asperger’s and ronal functioning. Iodine boosts IQ and helps Autistic Spectrum Disorder prevent mental retardation. Omega 3 s, sel- enium, and magnesium all improve mental func- Michael Thompson, MD and Lynda tion and reduce depression. Exercise has been Thompson, PhD shown to be highly effective for improving IQ, ADD Centre math ability, and reducing depression. Exercise should be a mandatory part of any academic program. Preliminary findings using QEEG sug- Attendees at this presentation will become fam- gest that what is eaten for breakfast has an effect iliar with how symptoms differ between Asper- on both mood and mental performance. As for ger’s and autism. They will be able to outline, the importance of sunlight, as much as 6% of on the basis of functional Neuroanatomy (which northern populations are believed to develop includes discussion of Brodmann Areas, neural winter blues. Depression, anxiety, insomnia, networks, and connections, including vagal multiple sclerosis, migraine, seizure, fibromyal- inputs to the medulla), why a combination of gia, and dementia are well correlated with a Neurofeedback (NFB) þ Biofeedback (BFB) deficiency in vitamin D. Previous research has strategies improves social functioning in PROCEEDINGS OF THE 2011 ISNR CONFERENCE 427 addition to significantly improved scores on is complemented by a discussion of the func- academic, intelligence, and attention measures. tional neuroanatomical basis for doing BFB, The authors’ first talk at an International Society particularly heart rate variability (HRV) training, for Neurofeedback and Research meeting in with NFB and why we also provide one-to-one 1995, ‘‘Exceptional Results with Exceptional coaching in metacognitive strategies related to Children,’’ included a case example of success- both cognitive and social skills. The training ful NFB training at Cz with a student with severe addresses the symptoms that interfere with the autism. This presentation gives an overview of child being able to interact constructively with how our interventions using NFB þ BFB in caregivers including, in order: anxiety, impul- clients with Asperger’s and autistic spectrum sivity, attention span, executive functions, and disorders have evolved. Current interventions finally understanding and responding to social incorporate an understanding of the functional cues. significance of different areas of the brain and neural networks. Functional significance Statistical Support of cortical areas is partially elucidated in Brodmann Areas booklet (Thompson, Thomp- The pre–post training results for NFB over CMSs son, & Wu, 2008). This talk expands on this to combined with BFBþ Metacognitive strategies include brain networks that depend on includes results showing EEG, TOVA, IVA, cortical-basal ganglia-thalamo-cortical connec- Wechsler Intelligence Scale (WISC & WAIS), tions. These networks may account for the academic measures (WRAT), and question- observation that training these clients over cen- naires for 150 patients with Asperger’s and 9 tral midline structures (CMS) at Fz or Cz, may with Autism. have effects on broader functional networks (affect, attention, executive, salience, and Financial Interest default networks). Having an effect on more Lynda Thompson is coauthor of The A.D.D. than a single network is particularly important Book. Michael and Lynda Thompson are coau- in this group of patients because they demon- thors of Setting Up for Clinical Success. Michael strate symptoms that involve a number of differ- and Lynda Thompson are co-authors of The ent networks. The symptoms may include, in Neurofeedback Book. It is likely that these addition to their difficulties with social interac- books may be on sale at the meeting. The tions, high anxiety, difficulties with attention authors will state their interest in these books and impulsivity, and specific learning difficult- during the workshop. ies. Regarding assessment, we discuss how high tactile sensitivity may mean we begin with only a single channel QEEG assessment and The Effect of Neurofeedback and Cranial follow-up later with a 19-channel QEEG. EEG Electrotherapy on Immune Function Within interpretations used to illustrate findings range a Group of HIV þ Subjects: A Randomized from raw data to quantitative analysis with Controlled Study LORETA and, when possible, event related potentials. Participants will see commonly Gary Schummer, PhD and Sharon Noh, BS observed EEG and QEEG patterns including a ADD Treatment Center very common presentation of excess frontal slow wave activity, a dip at Pz in the low alpha (8–10 Hz) range, and higher than expected low Introduction and high frequency beta. Correlation of findings Modulation of the functional capacity of the to symptoms and networks is made and excep- immune system utilizing neurofeedback ther- tions are noted. The QEEG findings are the basis apy may be expected given the many pathways for setting NFB parameters for training and and dense communication matrix mediating common initial settings will be described. This activity within and between the central nervous 428 PROCEEDINGS OF THE 2011 ISNR CONFERENCE system and the immune system. Those who electrotherapy. Each subject remained in their promote cranial electrotherapy have stated that respective condition continuously for 16 immune health is improved due to a decrease weeks. All subjects completed a stress audit in negative mood states when using this device. questionnaire and symptom check list every week for the duration of the study. Also at Method the baseline, after 8 weeks, and after 16 This study investigated the effects of neuro- weeks, subjects in all 4 groups had their blood feedback and cranial electrotherapy on a drawn at their individual physician’s office, group (n ¼ 40) of HIVþ male subjects between which was then analyzed by independent ages 18 and 55 over a period of 16 weeks. laboratories. This provided CD4þ measure- Subjects all had baseline T-4 helper cell ments that were statistically analyzed. (CD4þ) counts of 200 to 400=cc (lab normal is 400 to 1770=cc). They were randomly Results assigned to 1 of 4 groups: neurofeedback only A one-way analysis of variance was used to test (n ¼ 10), cranial electrotherapy only (n ¼ 10), for overall difference among groups for each combined neurofeedback and cranial electro- dependent variable. This was followed by therapy (n ¼ 10), or a waitlist control group pairwise comparisons between groups using (n ¼ 10). Subjects in the neurofeedback treat- Dunnett’s test. Results indicated that at base- ment condition were provided two 20-min line, basal total lymphocyte counts (CD4þ) sessions in the office each week. Neurofeed- counts did not differ between groups (p > .72). back was performed using linked ears (refer- After 8 weeks, CD4þ counts were significantly ence and ground) with the active electrode greater than controls for the combined group at the occipital midline, Oz (according to the (p ¼ .01) only. After 16 weeks, CD4þ counts International 10–20 system). Fast Fourier were significantly greater than controls for the Transform using a Cooley-Tukey algorithm neurofeedback group (p < .01) and combined was applied to each 2.56-s epoch, and the group (p < .01). There was no significant change square root of the absolute power coefficients in CD4þ count for the control and cranial were computed for each epoch. Subjects were electrotherapy only groups over the 16-week rewarded by a tone when higher alpha ampli- period. Results of the subjective stress and tude (8–12 Hz) exceeded their initial testing physical symptoms inventories corroborated amplitude (30 s with eyes closed). When sub- the statistically significant changes in the neuro- jects could sustain alpha amplitude at twice feedback and combined groups. their baseline amplitude for 20 min, the reward tone was shifted to a lower theta-alpha frequency (6–8 Hz). Drowsiness was discour- Conclusion aged by inhibiting slower (4–6 Hz) activity as This pilot study suggests neurofeedback may well as intervention by a technician who was be a promising tool to improve immune func- actively monitoring EEG activity. If the EEG tion and warrants further investigation. A repli- indicated sleepiness, a technician would ver- cation study might better control for placebo bally tell the subject to refocus on the tone. effect bias and ensure compliance by having Subjects selected to use the cranial electro- both conditions receive treatment in a clinical therapy were provided an Alpha-Stim unit setting. Newly developed software that (Model 2000GL) along with detailed infor- provides sham feedback would facilitate a mation on proper utilization of the device. stronger, double-blind placebo design. Last, Subjects agreed to use the unit at home as although Oz was effectively trained to produce directed every day for 20 min. The combined higher amplitudes within specified frequency group had both neurofeedback and cranial ranges, recent literature suggests an even electrotherapy. The waitlist control group stronger effect may be seen using a Pz sensor received neither neurofeedback nor cranial placement. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 429

INVITED PRESENTATION from EEG data promise continued improvement in the ability to measure subtle variations in Measuring Neural Correlates of Early Infant brain function. Deeper understanding of the Behavior relationship between these neurophysiological processes and behavior may yield a new win- William Bosl, PhD dow into the mind, allowing us. Because atypi- Harvard Medical School cal brain development is likely to precede abnormal behavior by months or even years, this may provide a critical developmental window Complex mental disorders such as autism for early intervention that may be missed if exhibit abnormal neural connectivity on many diagnosis is based entirely on a behavioral scales that varies between different regions of phenotype. the brain. In the autistic brain, high local connectivity and low, long-range connectivity EEG Theta=Beta Ratio, EEG Vigilance, may develop concurrently due to problems and Arousal in Adult Attention-Deficit= with synapse pruning or formation. Similarly, Hyperactivity Disorder: Reevaluation of epilepsy has been described as a heterogeneous Current Methods spectrum disorder that is also characterized by abnormal neural connectivity in the brain. Marie Gonzales, BS, Christian Sander, PhD, One might even say that all developmental and Ute Strehl, PhD brain disorders are neural connectivity disor- University of Tu¨bingen ders. Understanding and measuring brain connectivity is essential to finding neural correlates of behavior or psychiatric biomarkers. Introduction The human brain contains on the order of EEG=QEEG analysis of adults with attention 11 14 10 neurons and more than 10 synaptic con- deficit hyperactivity disorder (ADHD) has pro- nections. Although sparsely connected, each duced a variety of activity patterns (Hale et al., neuron is within a few synaptic connections of 2009; Koehler et al., 2009; Loo et al., 2009; any other neuron. This remarkable connectivity White, 2001, 2003) as well as the typical is achieved by a kind of hierarchical organiza- increases in theta=beta ratios seen in pediatric tion that is ubiquitous in nature, called scale- populations (Bresnahan, Anderson, & Barry, free or complex networks. Complex networks 1999; Bresnahan & Barry, 2002; Clarke et al., are characterized by dense local connectivity 2008). The theta=beta ratio has been con- and sparser long-range connectivity. Although sidered a marker of nervous system arousal EEG has long been a useful tool for clinical neu- and is a cornerstone of current models of roscience, a great deal of information about the ADHD. However, this measure has not been network structure of the nervous system likely validated and does not correlate with skin con- remains hidden because linear analysis techni- ductance level (SCL) in adolescent ADHD popu- ques fail even to detect them. Analysis of signal lations (Barry, Clarke, Johnstone, McCarthy, & complexity and transient synchronization using Selikowitz, 2009). Recently the EEG Vigilance nonlinear analysis and generalized synchroniza- (Bente, 1964; Hegerl, Olbrich, Scho¨nknecht, & tion methods may reveal information about Sander, 2008; Hegerl, Stein, et al., 2008) model local neural complexity and long-range com- has emerged to explain trait and state differ- munication between brain regions that will be ences in clinical populations and refers to the clinically useful. pattern of distinct states of global brain activation The development of novel EEG sensors observable on the continuum from full wakeful- with improved resolution, together with new ness to sleep onset during eye-closed resting source localization algorithms and methods for state (Olbrich et al., 2009). Analysis of EEG computing complexity and synchronization Vigilance in a childhood ADHD population 430 PROCEEDINGS OF THE 2011 ISNR CONFERENCE indicated that individuals with ADHD have REFERENCES more frequent vigilance state shifts and tend to American Psychiatric Association. (1994). spend more time in lower vigilance stages (San- Diagnostic and statistical manual of mental der et al., 2010). EEG Vigilance and heart rate disorders (4th ed.). Washington, DC: was accessed in a control population and the Author. average heart rate (HR) decreased as participants Bente, D. (1964). Vigilanz, dissoziative entered the lower arousal=vigilance stages Vigilanzverschiebung und Insuffizienz des (Olbrich et al., 2009). This study aims to test Vigilita¨tstonus [Vigilance, dissociative vigil- the theta=beta ratio, EEG vigilance, SCL, and ance shifting and insufficiency of vigilance HR as markers of arousal to investigate current stages]. In H. Kranz & K. Heinrich (Eds.), ‘‘arousal’’ models of ADHD within an adult Begleitwirkung und Miberfolge der psychia- population. trischen Pharmakotherapie. Stuttgart, Methods Germany: Thieme. Bresnahan, S. M., Anderson, J. W., & Barry, R. J. Continuous 19-channel EEG, SCL, and HR (1999). Age-related changes in quantitative were acquired from 20 adult participants that EEG in attention-deficit=hyperactivity dis- met Diagnostic and Statistical Manual of Mental order. Biological Psychiatry, 46, 1690–1697. Disorders (4th ed.; American Psychiatric Bresnahan, S. M., & Barry, R. J. (2002). Speci- Association, 1994) criteria for ADHD (com- ficity of quantitative EEG analysis in adults bined, inattentive, or hyperactive type), with- with attention deficit hyperactivity disorder. out additional serious physical, neurological, Psychiatry Research, 112, 133–144. or psychiatric disorders, and a full-scale IQ Clarke, A. R., Barry, R. J., Heaven, P. C., greater than 80. EEG recordings included EO, McCarthy,R.,Selikowitz,M.,&Bryne,M.K. EC, P300, and CNV tasks. EEG vigilance clus- (2008). EEG coherence in adults with ters (A1, A2, A3, B1, B2=3 þ C) and state attention-deficit=hyperactivity disorder. Inter- changes were assessed in 1-min blocks over national Journal of Psychophysiology, 76(1), the 15-min eyes-closed recording in accord- 35–40. ance with the latest version of the Vigilance Hale, T. S., Smalley, S. L., Hanada, G., Macion, Classification Algorithm originally presented J., McCracken, J. T., McGough, J. J., & Loo, by Hegel and colleagues (2008a). SCL, HR, S. K. (2009). Atypical alpha asymmetry in and theta=beta (calculated as the ratio of theta adults with ADHD. Neuropsychologia, 47, [4–7 Hz] to beta [13–21 Hz] relative power at 2082–2088. Cz) were also calculated for the 1-min blocks. Hegerl, U., Olbrich, S., Scho¨nknecht, P., & For vigilance and theta=beta ratio, individual Sander, C. (2008a). Manic behaviour as an means were correlated with individual SCL autoregulatory attempt to stabilize vigilance. and HR. Nervenarzt, 79, 1283–1290. Results Hegerl, U., Stein, M., Mulert, C., Mergl, R., Olbrich, S., Dichgans, E., ... Pogarell, O. This investigation is part of a long-term ADHD (2008b). EEG-vigilance differences between treatment study currently in progress. The most patients with borderline personality disorder, current results related to theta=beta ratios, EEG patients with obsessive-compulsive disorder vigilance, SCL, and HR states in the adult and healthy controls. European Archives of ADHD populations will be presented at the Psychiatry and Clinical Neuroscience, 258, time of the presentation. 137–143. Conclusion Koehler, S., Lauer, P., Schreppel, T., Jacob, C., Heine, M., Boreatti-Hu¨mmer, A., ... Specific findings and study shortcomings will Herrmann, M. J. (2009). Increased EEG be discussed and current models of arousal in power density in alpha and theta bands in ADHD evaluated. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 431

adult ADHD patients. Journal of Neural sessions to decrease 1–10 Hz and increase Transmission, 116(1), 97–104. 5–18 Hz at F3. The 2 with excessive 21–30 Hz Loo, S. K., Hale, T. S., Macion, J., Hanada, G., at F3 had training to decrease 21–30 Hz and McGough, J. J., McCracken, J. T., & Smalley, increase 10 Hz at F3. Two individuals chose S. L. (2009). Cortical activity patterns in not to do neurofeedback. Handwriting was ADHD during arousal, activation, and scored pre- and postneurofeedback with a sustained attention. Neuropsychologia, 47, modification of the Checklist of Written 2114–2119. Expression, on a scale from 1=10 to 10=10. Olbrich, S., Mulert, C., Karch, S., Trenner, M., The results and statistical analysis will be dis- Leicht, G., Pogarell, O., & Hegerl, U. (2009). cussed. The results were judged as good to EEG-vigilance and bold effect during excellent in all but 1 of the 23 subjects who simultaneous EEG=fMRI measurement. did the neurofeedback training (p < .01). Neuroimage, 45, 319–332. Sander, C., Arns, M., Olbrich, S., & Hegerl, U. ISNR 2011 POSTER ABSTRACTS (2010). EEG-vigilance and response to stimu- lants in pediatric patients with attention Transcranial Magnetic Stimulation (rTMS) deficit=hyperactivity disorder. Clinical Modulates Selective Attention and Executive Neurophysiology, 121, 1511–1518. Functioning in Autism White, J. N., Jr. (2001). Neuropsychological and electrophysiological assessment of adults Joshua Baruth, MS, Manuel Casanova, MD, with attention deficit hyperactivity disorder Lonnie Sears, PhD, and Estate Sokhadze, PhD (Unpublished doctoral dissertation). The University of Louisville University of Tennessee, Knoxville. White, J. N., Jr. (2003). Comparison of QEEG Reference Databases in Basic Signal Analysis Introduction and in the Evaluation of Adult ADHD. Autism spectrum disorder (ASD) has been pre- Journal of Neurotherapy, 7, 123–169. viously shown by our group to be associated with abnormalities in later-stage event-related QEEG-Guided Neurofeedback for the Reme- potential indices of selective attention. Specifi- diation of Dysgraphia—An Outcome Study cally the attention-orienting frontal P3a and the sustained attention centro-parietal P3b have Jonathan Walker, MD been found to be atypical in ASD during a vis- Neurotherapy Center of Dallas ual oddball task. This may be related to reduced inhibitory tone of the dorsolateral prefrontal cortex (DLPFC) in ASD, as the Twenty-five individuals, aged 6 to 51 years, all DLPFC has been associated with selective right-handed, presented at our clinic with a attention and working memory. In this study complaint of handwriting difficulty. Each of we wanted to test the effects of bilateral them had a quantitative EEG (QEEG). Our low-frequency repetitive transcranial magnetic attention focused on the areas controlling motor stimulation (rTMS) applied to the DLPFCs on planning (F3) and sensorimotor integration (C3) novelty processing in ASD. We hypothesized of the right hand. Eighteen of the individuals that rTMS would improve cortical inhibitory had excessive 1–10 Hz activity at C3, and 7 of tone by selectively activating inhibitory them had excessive 1–10 Hz activity at F3, GABAergic double bouquet interneurons, and and 2 had excessive 21–30 Hz activity at F3. this would improve task performance. Those who had excessive 1–10 Hz at C3 underwent 5 sessions of training to decrease 1–10 Hz Methods and increase 15–18 Hz at C3. Those individuals We recruited 25 participants with ASD and who had only excessive 1–10 Hz at F3 had 5 randomly formed a 15-subject active TMS 432 PROCEEDINGS OF THE 2011 ISNR CONFERENCE group and a 10-subject waitlist group. We not. Seventy-one participants with SCI and assessed task performance before and after chronic pain (n ¼ 42), SCI without pain 12 sessions of bilateral low-frequency rTMS in (n ¼ 13), or with neither SCI nor pain (n ¼ 16) the active TMS group and before and after a underwent an EEG assessment. Participants 6-week waiting period in the waitlist group. with SCI and chronic daily pain exhibited slightly more relative fast wave activity (b-wave) Results and slightly less slow wave (a-wave) activity Individuals with ASD showed significant than participants with and without SCI who improvement following treatment evidenced did not have pain. The alpha=beta ratio was sig- by improved P3b responses to targets and nificantly lower in participants with SCI and better stimulus discrimination. There was also pain than participants without pain. The results a significant improvement in frontal reactivity suggest that the presence of pain is associated to novelty as indicated by the P3a component. with brain activity as measured by EEG and sup- The waitlist group did not show any significant ports the potential utility of EEG for identifying changes. these differences. The findings also suggest the possibility that interventions that alter brain Conclusions wave activity in persons with a SCI and pain, such as neurofeedback training, could influ- We propose that that low-frequency rTMS may ence the experience of pain. have increased cortical inhibitory tone and subsequently improved performance in the novelty-processing task. TMS has the potential Asymmetrical Frontal Gamma Activity Dur- to become an important therapeutic tool in ing a Telekinesis Demonstration ASD treatment with few, if any, side effects. Thomas Brod, MD and William Scott, BS UCLA EEG-Assessed Bandwidth Activity Differ- ences Between Individuals with SCI with and Without Chronic Pain Early this year we had the opportunity to observe a demonstration of ‘‘telekinesis’’ with Alan Braden EEG monitoring for a reality TV show. We uti- University of Washington lized the Hilbert-Huang transform (HHT), a Leslie Sherlin, PhD new method to construct a sharp and clean NovaTech EEG time-frequency spectrum of a nonlinear and nonstationary signal. Using empirical mode Jon D. Howe, Mark P. Jensen, Shahin Hakimian, decomposition while retaining intrawave Maria R. Reyes, Amy K. Kupper, and Ann D. modulation makes it very suitable for quanti- Gianas tative EEG analysis; also, HHT has excellent potential for clinical EEG neurofeedback, as Chronic pain is a significant problem for will be presented. Using HHT analysis we dis- many individuals living with a spinal cord injury covered that coincident with the mentalist (SCI). However, not all people with SCIs experi- apparently moving a pen in a glass without ence chronic pain as a direct result of the injury. touch (but not under control conditions), Electroencephalograph (EEG) technology may there was a sharp rise in left frontal gamma be useful to understand possible differences in activity with no corresponding rise on the brain activity in individuals with SCI with and right. These nonblind observations will not without chronic pain. The purpose of the cur- convince skeptics (including ourselves), but rent study is to measure and compare baseline they do open a path for open-minded rigor- brain activity between participants who experi- ous evaluation of the phenomena that were ence daily SCI-related pain to those who do observed. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 433

Factors Related to Income, Quality of Work donated to a neurofeedback professional Life, and Burnout for Neurofeedback Practi- organization research fund. The survey tioners included questions about demographics and variables identified in our previous research. Thomas Patrick Cothran, BA, Lauren Drandorff, Practitioners were also asked to choose 10 traits BS, M. Bill Baerentzen, MS, Catherine Ryan, BA, that best described them from the list of 34 Ana E. Salvatierra, BA, Charles Morgan, BS, traits identified in the previous study (Larson Patricia Murman, BS, Sarah Lemp, MS, Aanchal et al., 2010). We utilized SPSS descriptive stat- Taneja, and Jonathon Eugene Larson, EdD istics for our demographic and NFT experience Illinois Institute of Technology information. We completed independent sample t tests with Bonferroni correction, crosstab chi-square analyses, Cronbach’s alpha tests, Introduction regression analyses, and slope plotting. Research on neurofeedback therapy (NFT) practitioner variables that influence outcomes is still Results in a nascent phase. Larson, Ryan, and Baerent- Preliminary findings indicated burnout scores zen (2010) investigated NFT practitioner per- are negatively associated with quality of work spectives. They utilized a systematic, qualitative life (QOWL). QOWL scores are positively asso- method to analyze survey data from 71 practi- ciated with using neurofeedback in practice. tioners. These authors captured practitioner per- Non-NFT methods in practice are negatively spectives on the advantages and disadvantages associated with QOWL. We also found that of NFT and on the knowledge, skills, and person- QOWL scores are associated with commitment ality traits necessary to be a successful NFT prac- to understanding brain function, learning new titioner. They reported three major findings. NFT techniques, and improving interpersonal They found that practitioners generally view skills. We found income rates are positively ongoing NFT as effective in reducing symptoms associated with providing supervision=training, and improving quality of life. They found that inquiry=intake ratio, sessions per month, and practitioners view commitment to NFT as essen- successful outcomes. Moreover, of the 34 tial for overcoming the complexity of NFT. They neurofeedback practitioner traits identified in identified 34 personality traits practitioners previous research, frequency analyses indi- endorse as essential. This current study sought cated the highest endorsed traits in rank order to build off of these previous findings to add to were (1) ethical, (2) attentive, (3) empathic, (4) the research base on NFT practitioner perspec- accepting, (5) calm, (6) observant, (7) sense of tives with the goal of identifying practitioner vari- humor, (8) analytical, (9) confident, and (10) ables that may influence practitioner outcomes. realistic expectations. From these previous findings, we hypothesized commitment, knowledge, inquiry=intake ratio, Conclusions successful outcomes, supervision, training, drop- These data support the notion that single focus outs, traits, and caseload are associated with commitment to NFT is a requisite for a socially, quality of work life, burnout, and income. emotionally, and financially satisfying experience of neurofeedback practice. An eclectic Method approach in which neurofeedback is used We utilized an online survey system to collect occasionally may dilute practitioner proficiency; surveys from 238 NFT practitioners to engage subsequently impacting NFT-related revenue them in the process of identifying factors and zest for a personally involved intervention. related to NFT. We contacted practitioners It may be that the complexity of NFT contraindi- through e-mail and discussion boards, and each cates delving into other treatment modalities. practitioner was asked to complete an online Alternatively, NFT may attract individuals survey. For each survey completed, $10 was with a tendency to temporarily adopt novel 434 PROCEEDINGS OF THE 2011 ISNR CONFERENCE approaches. Dedicated commitment to lifelong the enhancement of compassionate behaviors training in physiology, cognition, learning, and and attitudes via directed site- and frequency- statistics may moderate the relationship specific neurotherapy. between emotional satisfaction and financial reward. It seems reasonable to hypothesize that A Randomized Trial of Computer Attention dedicated commitment, emotional satisfaction, Training in Children With Attention-Deficit= and financial reward each affect practitioner Hyperactivity Disorder competency. Elizabeth Frenette, MPH, Naomi Steiner, MD, Tahnee Sidhu, BA, and Katie Mitchell, BA REFERENCE Tufts Medical Center Larson, J. E., Ryan, C. B., & Baerentzen, M. B. (2010). Practitioner perspectives of neurofeedback therapy for mental health and Introduction physiological disorders. Journal of Neurother- We report preliminary results from a study in 17 apy, 14, 280–290. schools examining the efficacy of 2 computer- based attention training systems in teaching EEG=LORETA Frequency and Localization children with Attention Deficit=Hyperactivity Characteristics of Compassion versus Ego- Disorder (ADHD) to concentrate more effec- centrism versus Universal Mind tively. Several studies suggest that attention training using neurofeedback may result in Janeen Denny, BA, and Larry Stevens decreased symptoms of ADHD and improved Northern Arizona University academic performance and behavior at school. In one such study of 100 children on stimulant medication (Monastra, Monastra, & George, There appears to be an epidemic of human 2002), only the participants who received violence in the world today, with more than additional neurofeedback sustained the posi- 37 violent conflicts currently under way world- tive gains after the stimulant medication was wide. One way of combating violence is the discontinued. A small, randomized controlled installation of compassionate attitudes and trial of neurofeedback with a waitlist control behaviors in human beings. In an effort to bet- (Linden, Habib, & Radojevic, 1996) demon- ter understand and to promote compassion, strated improvements in behavioral symptoms the present study examines EEG cortical of ADHD. Unfortunately, there were only 18 neuroimaging during compassionate versus participants, so there was insufficient power self-centered versus universal mind medita- to demonstrate a statistically significant differ- tions among a cohort of 60 young adults. Out- ence between the groups. We compared a comes indicate, uniquely for the compassion neurofeedback (NFB) computer attention train- meditators, significant enhancements of slow ing system that teaches children to alter their wave (Theta=Low Alpha EEG frequencies) brainwave activity with a Standard Computer activity in brain regions involved in emotional Format attention training system (SCF). inhibition, verbal self-memory, emotional pro- We hypothesize that both treatments will cessing of sensory experiences, sensorimotor show improvement in ADHD symptoms and short-term memory, and auditory processing, academic outcomes compared to a control consistent with the scripted compassion condition. constructs contemplated. Such an activation of specialized brain regions during compassion- Methods ate meditation suggests unique cortical localiza- Forty-five children with ADHD in Grades 2 and tions and neuroelectrical frequencies involved 4 were randomly assigned to receive the NFB, in compassion. Implications are explored for SCF, or a waitlist-control condition (WLC) that PROCEEDINGS OF THE 2011 ISNR CONFERENCE 435 receives NFB or SCF the following academic the PERMP, T-SKAMP, and BOSS (see Tables 3 year. Children received forty 45-min sessions and 4, Appendix B, in the paper). The NFB 3 times a week at school for 4 months. As part intervention group showed improvement on of a comprehensive assessment, we report data the number of math problems correct on the on the T-SKAMP completed by teachers that PERMP math test (p ¼ .03), indicating an assesses symptoms of ADHD in the classroom; increase in accuracy as well as an increase in the PERMP, a math test completed by students number of problems attempted on the PERMP that analyzes speed and accuracy; and the math test (p ¼ .02), illustrating an increase in BOSS, double-blind classroom observations. speed. The NFB intervention group also demonstrated a decrease in ADHD symptoms Intervention/Program/Practice as reported by teachers on the T-SKAMP Atten- The neurofeedback intervention system used is tion scale (p ¼ .01). The SCF group showed commercially available and was chosen for sev- improvement on the number of problems cor- eral reasons: (a) The NFB component is direc- rect on the PERMP math test (p ¼ .01) indicat- ted at increased theta waves and decreased ing an increase in accuracy, and a trend beta waves in the frontal cortex, which are toward decreased ADHD symptoms on the the most frequently observed cortical deficits T-SKAMP. The WLC showed no significant in children with ADHD, and (b) it uses EEG effects on either the PERMP or the T-SKAMP. sensors that are embedded in a bicycle helmet, The BOSS showed a trend toward ADHD as opposed to EEG sensors placed directly on symptom reduction in the classroom setting. the scalp with wires, which significantly eases delivery in children. This system includes dif- Conclusion ferent tasks to train attention stamina, visual Our preliminary data from a 4-year study tracking (as required in the classroom), evaluating the efficacy of 2 computer-based increased time-on-task, short-term memory attention training systems in schools shows and sequencing, and discriminatory proces- significant results and promising trends. As this sing. As the child advances, she or he pro- is a preliminary analysis of preliminary data, we gresses to more challenging tasks that include have not addressed all of the study’s aims and visual and auditory distractions, such as colorful have not yet compared data between the 3 shapes moving around on the screen and back- intervention groups. Teacher report of ADHD ground noise. The SCF intervention used is also symptoms, math achievement by students, commercially available and was chosen for sev- and objective classroom observations for our eral reasons: (a) It includes an extensive array first wave were analyzed. Our preliminary data of cognitive exercises that target many areas on these outcome measures suggest that of attention as well as working memory, and computer-based attention training programs (b) the SCF system is designed to improve sus- offered in an elementary school setting may tained concentration and working memory be effective in reducing symptoms of ADHD through a variety of specific interactive exer- and improved math achievement. We hope cises manipulated with a standard computer that analysis of full data collected after the mouse and keyboard. The exercises aim to intervention of Wave 2 will consolidate our maximize attention, decrease impulsivity, and findings and further explore the feasibility train auditory and visual working memory. and effectiveness of computer attention train- The tasks become more challenging as the par- ing as a method to support children with atten- ticipant progresses. tion issues in schools.

Results REFERENCES Wave 1 participants include 41 children diagnosed with ADHD in Grades 2 and 4. We Linden, M., Habib, T., & Radojevic, V. (1996). conducted preliminary analyses of variance of A controlled study of the effects of EEG 436 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

biofeedback on cognition and behavior of potential for wider application of this modality children with attention deficit disorder in general neurology. Many patients were also and learning disabilities. Biofeedback & Self started with neurofeedback therapy, depending Regulation, 21(1), 35–49. (Erratum in 21[3], on the patient’s desire to be involved in this treat- 297) ment modality. Preliminary results of effective- Monastra, V. J., Monastra, D. M., & George, S. ness of neurofeedback treatment are presented. (2002). The effects of stimulant therapy, EEG biofeedback, and parenting style on Memory Deficit and Malingering: An ERP- the primary symptoms of attention deficit= Based Assessment With a ‘‘Dual-Probe’’ Pro- hyperactivity disorder. Applied Psychophy- tocol and Countermeasure Use siology & Biofeedback, 27, 231–249. Elena Labkovsky, PhD Application of Quantitative Electroencepha- Northwestern University logram and Neurofeedback in General Neur- ology Practice Introduction J. Lucas Koberda, MD Memory deficit is one of the most common Tallahassee NeuroBalance Center symptoms accompanying many psychological= neuropsychological conditions. In traumatic injury cases (like closed head injury) where Despite major advances in computer technology, monetary compensation can be claimed, the quantitative electroencephalography (QEEG) has potential motivation to exaggerate memory been underutilized in general neurology practice deficit increases. Thus, it often becomes diffi- for uncertain reasons. EEG-biofeedback (also cult to estimate actual memory deficit. Litera- called neurofeedback) has had very limited ture shows that estimates of malingering reach application in U.S. neurology practice because up to 50% for malingered psychological symp- it has been frequently called experimental, thus toms. The large number of articles published not reimbursable by most health insurances. on the topic demonstrates the concern among Therefore, this study was conducted to evaluate clinicians that successful malingering does take the clinical usefulness of QEEG and neurofeed- place. An event-related potential (ERP)-based back in general neurological practice. Over the memory deficit tests reveal a high level of resist- period of approximately 9 months, 150 consecu- ance to the effects of malingering compared to tive patients’ QEEG recordings were analyzed for behavioral tests of memory. Our previous stu- potential clinical benefits. QEEG patients were dies demonstrated effectiveness of the Complex divided in 5 groups based on their initial clinical Trial Protocol (CTP) to detect concealed infor- presentation. The main groups included patients mation (Rosenfeld & Labkovsky, 2010). The with seizures, headaches, head injury, cognitive CTP hit rates range from 84 to 100%. Some- problems, and behavioral dysfunctions. Subse- times results are inconclusive because either quently, patients’ cases were reviewed and a the difference in P300 amplitudes between decision was made whether QEEG analysis ‘‘Probe’’ and ‘‘Irrelevants’’ does not reach sig- contributed to the diagnosis and=or further nificance or due to excessive artifacts. To patient treatment. Selected and representative address this issue, a novel ‘‘Dual-Probe’’ proto- cases from each group are presented in more col was developed. detail, including QEEG data, with additional low-resolution electromagnetic tomography Methods analysis (LORETA) and=or using computerized The original CTP utilizes only 1 probe (which is cognitive testing. Statistical analysis showed that a relevant=familiar to the subject item). Rare QEEG analysis contributed to most (more than ‘‘Probe’’ or frequent ‘‘Irrelevant’’ (irrelevant= 90%) neurological cases, which indicates great unknown to the subject stimulus) appears on PROCEEDINGS OF THE 2011 ISNR CONFERENCE 437 screen first and is followed by either Target or Conclusions Nontarget in the same trial. Subject’s birth date The ‘‘Dual-Probe’’ ERP-based protocol for was Probe1 (P1) and Irrelevants were 4 other assessment of memory deficit and malingering dates. Four strings of numbers were Nontargets shows a high level of accuracy. Even when and 1 string Target. There was no probe in the mental countermeasures are implemented by second part. In ‘‘Dual-Probe’’ CTP the first part subjects to alter their ERP results, the is exactly as the original CTP, but in the second Dual-Probe approach reflects the subjects’ abil- part, target=nontarget numbers were replaced ity to recognize familiar=learned stimuli. Thus, with probe=irrelevant=target city names. Sub- the Dual-Probe protocol can be used in situa- jects’ hometown was Probe2 (P2), and there tions where subjects are unable, or unwilling, were 3 irrelevant city names and a Target. Sub- to report their recollection for learned material. jects randomly pressed 1 of 5 buttons on one Further research is required to investigate how response box to a date, and they pressed 1 of introduction of countermeasures to the second 2 buttons on another response box to a city part of a trial might affect the Dual-Probe proto- name. We tested 3 groups (N ¼ 36). Simple col accuracy. Guilty (SG), n ¼ 13 (with P1 & P2); Innocent (IN), n ¼ 12 (no probes); and Countermeasure (CM), 2 (of 4) ‘‘Irrelevants’’ in 1 part were REFERENCE countered. The CMs were the subject’s silent, mental imaging of his or her first name (CM1) Rosenfeld, J. P., & Labkovsky, E. (2010). New and last name (CM2). After a subject saw a P300-based protocol to detect concealed to-be-countered irrelevant in the first part of information: Resistance to mental counter- a trial, he or she had to mentally state first or measures against only half the irrelevant last name before randomly pressing 1 of the stimuli and a possible ERP indicator of 5 buttons—‘‘left hand’’ response. Subjects countermeasures. Psychophysiology, 47, were instructed to perform countermeasures 1002–1010. so that the experimenter could not detect the silent, mental act. Neurofeedback Training for the Enhance- ment of Attention in ADD=ADHD Children Results Hit rates: SG-13=13 total. Two subjects were Jeffrey La Marca, MA ‘‘caught’’ with only 1 probe and the rest–with University of California, Riverside both P1 & P2. IN–1=12 false positive (only P1). CM-11=11 total, 2 subjects with only 1 probe and the rest with both P1 & P2). An analy- The phenotypical expression of Attention sis of variance on P300 amplitudes (3 groups 4 Deficit Disorder (ADD)=Attention Deficit stimulus type) revealed no group difference, F(2, Hyperactivity Disorder (ADHD) is complex 33) ¼ 2.233, p ¼ .123; significant stimulus and includes impairments in executive func- effect, F(3, 99) ¼ 22.749, p < .000; and signifi- tioning, impulsive behaviors, and pervasive cant interaction F(6, 99) ¼ 8.661, p < .000. difficulties with inattention—areas that are T test revealed significant difference between critical to successful academic performance. P1 and Iall1 amplitudes in SG, t(12) ¼ 5.472, Neurophysiological measures, including p < .000, and CM, t(10) ¼ 5.825, p < .000, electroencephalography (EEG) that records and no difference in the IN, t(11) ¼ 0.733, the electrical activity of the brain, provide p ¼ .479. Significant differences were found objective data to distinguish individuals with between P2 and Iall2 in SG, t(12) ¼ 5.37, attention deficits from others (Doehnert, p < .000, and CM, t(10) ¼ 5.793, p < .000, Brandeis, Straub, Steinhausen, & Drechsler, and no difference in the IN, t(11) ¼2.146, 2008). The most salient feature found in p ¼ .055. the EEGs of students with ADD=ADHD is 438 PROCEEDINGS OF THE 2011 ISNR CONFERENCE that of cortical slowing or an overabundance REFERENCES of slower brainwave patterns (Doehnert American Psychiatric Association. (1994). et al., 2008). These patterns are associated Diagnostic and statistical manual of mental with distractibility, inattention, and day- disorders (4th ed.). Washington, DC: Author. dreaming. Neurofeedback is often used to Doehnert, M., Brandeis, D., Straub, M., train students to produce faster brainwave Steinhausen, H. C., & Drechsler, R. (2008). patterns, similar to those of typically devel- Slow cortical potential neurofeedback in oping individuals, and has been found to attention deficit hyperactivity disorder: Is be conducive to learning. A best-evidence there neurophysiological evidence for spe- analysis of existing research was conducted cific effects? Journal of Neural Transmission, on the efficacy of neurofeedback as an 115, 1445–1456. intervention for enhancing attention in stu- Leins, U., Goth, G., Hinterberger, T., Klinger, dents with ADD=ADHD. Initially, 135 stu- C., Rumpf, N., & Strehl, U. (2007). Neuro- dies on neurofeedback were examined, feedback for children with ADHD: A com- with 113 being excluded for insufficient parison of SCP and Theta=Beta protocols. data, leaving 22 to be matched for com- Applied Psychophysiological Biofeedback, pliance with preestablished criteria: studies 32, 73–88. limited to children, subjects matched with Linden, M., Habib, T., & Radojevic, V. (1996). diagnostic criteria established by the Ameri- A controlled study of the effects of EEG can Psychiatric Association (1994; Diagnos- biofeedback on cognition and behavior of tic and Statistical Manual of Mental children with attention deficit disorder and Disorders, 4th ed.), pre- and posttest scores learning disabilities. Biofeedback and Self- provided on objective behavioral measures, Regulation, 21(1), 35. sufficiently large sample sizes (n > 15), and Monastra, V. J., Lubar, J. F., Linden, M., data that permitted the calculation of effect VanDeusen, P., Green, G., Wing, W., ... sizes. Of the 2 studies that met all criteria, it Fenger, T. N. (1999). Assessing attention was determined that effect sizes exceeded deficit hyperactivity disorder via quantitative .6 between pretest and posttest objective electroencephalography: An initial validation measures of attention. Findings on measures study. Neuropsychology, 13, 424–433. of impulsivity and reaction time were incon- Strehl, U., Leins, U., Goth, G., Klinger, C., clusive. One feature of EEG neurofeedback Hinterberger, T., & Birbaumer, N. (2006). is that it provides real-time data on brain Self-regulation of slow cortical potentials: a function and can be used as a noninvasive new treatment for children with attention- intervention to treat attention deficits and deficit=hyperactivity disorder. Pediatrics, improve academic performance (Monastra 118, 1530–1540. et al., 1999). Studies consistently suggest Vernon, D., Egner, T., Cooper, N., Compton, that neurofeedback training enhances cogni- T., Neilands, C., Sheri, A., & Gruzelier, J. tive performance (Vernon et al., 2003), (2003). The effect of training distinct neuro- increases IQ (Linden, Habib, & Radojevic, feedback protocols on aspects of cognitive 1996), and improves attention (Leins et al., performance. International Journal of 2007). Furthermore, positive changes in Psychophysiology, 47(1), 75–85. these domains remain robust in follow-up studies (Strehl et al., 2006). Most research examined in this analysis supports the con- The Frontal Alpha Asymmetry During Luteal tention that neurofeedback is an efficacious Phase and Follicle Phase in Premenstrual intervention, but given the limited number Dysphoric Disorder of fully controlled studies with adequate sample sizes, there remains a need for I-Mei Lin, PhD, Yu-Ting Chen, Yu-Che Tsai, additional research. and Erik Peper, PhD PROCEEDINGS OF THE 2011 ISNR CONFERENCE 439

Kaohsiung Medical University the frontal alpha asymmetry was not found in non-PMDD.

Introduction Conclusions This study presents the characterization of The present study supports the frontal alpha premenstrual dysphoric disorder (PMDD) as a asymmetry during the depressive recall premenstrual syndrome (PMS) disorder with situation in the luteal phase for PMDD but extreme negative affectivity, such as a depressed not in the follicle phase. The results of this mood. Resting frontal alpha asymmetry was a study can apply the alpha training of neuro- biomarker in this major depressive disorder. feedback in the luteal phase for PMDD. The purpose of the present study was to explore the frontal alpha asymmetry in an experimental Results of a Survey of Practices by U.S. Neu- task during the luteal phase and the follicle rofeedback Practitioners phase in PMDD and non-PMDD. Nick Lofthouse, PhD, Elizabeth Hurt, PhD, Method and L. Eugene Arnold, MD Ohio State University This study recruited 10 PMDD college women (M age ¼ 20.40 .97) and 10 non-PMDD control women (M age ¼ 20.10 1.37). There Introduction was no significant difference in age (t ¼ .57, As approximately 33% of children with atten- p > .05). The PMDD met the following criteria: tion deficit hyperactivity disorder (ADHD) fail Menstrual Discomfort Questionnaire (MDQ to benefit fully from the established treatments >70) and Beck Depression Inventory–II of medicine and behavior modification (MTA 5 (>19); the non-PMDD included MDQ 70 Cooperative Group; Swanson et al., 2001) 5 and BDI-II 19. The frontal electroencephalo- and an unknown proportion refuse the most gram (F3 = F4) of all participants was measured effective treatment (medication), additional during the luteal phase and the follicle phase of complimentary or alternative treatments (CATs) the menstrual cycle in the following sequences: are greatly needed. Recently, there has been baseline measurement (3 min), recall of a considerable academic and consumer interest depressive event guided by experimenter in youth CATs shown by a dramatic increase (5 min), recovery measurement (3 min), and in Medline published randomized controlled relaxation measurement (3 min). The alpha trials (Chan, 2008), 11.8% of U.S. youth utiliz- asymmetry score (A2) was computed by sub- ing CATs annually (Barnes, Bloom, & Nahin, tracting left alpha amplitude from the right 2008), annual (1996) expenditures of $127 alpha amplitude [A2 ¼ (R L)=(R þ L)]. million on pediatric CAM visits and $22 million on remedies (Yussman, Ryan, Auinger, & Results Weitzman, 2004), 12 to 68% use in pediatric There were significant differences in the A2 ADHD (Sinha & Efron, 2005), 93% of pediatri- score between PMDD and non-PMDD during cians reporting patients with ADHD asking the luteal phase (t ¼2.253, p < .05) but not about, and 38% patients using CATs. One such in the follicle phase (t ¼1.254, p > .05). CAT is neurofeedback (NF; Kamiya, 1968), The three-way analysis of variance showed which has been used to treat several psychi- there was no interaction effect (F ¼ 1.62, atric problems, particularly child and adolescent p > .05), but there was significantly group ADHD (Hirshberg, Chiu, & Frazier, 2005). differences between PMDD and non-PMDD Research on the NF treatment of youth with (d ¼ 0.33, p < .05). The participants with ADHD has recently dramatically increased in PMDD tended to have alpha asymmetry dur- quantity and improved in quality (Lofthouse, ing the depressive recall situation. However, Arnold, Hersch, Hurt, & deBeus, in press). 440 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Alongside these developments are indications years of training), assessment=treatment out- that the marketing of NF has intensified and come practices, clinical samples, and NF prac- parents of youth with ADHD are increasingly tices (i.e., approach, technology, effect= seeking out NF for their children. Despite these adverse effects, insurance coverage). To exam- changes, unlike the aforementioned research on ine the representative nature of this sample, we CATs in general, there is no information on pat- intend to calculate a percentage response rate terns of NF usage or treatment practices of prac- (number of association members who treat titioners who routinely treat, usually without pediatric ADHD=number of respondents) to insurancecoverage,youthwithADHD.With quantify the representative nature (in terms of this study we aim to identify specific practice a percentage of the entire population) of our patterns of U.S. practitioners who use NF to treat sample. The interpretation and implications youth with ADHD. Identifying such practice pat- of all these results will also be discussed. terns offers great benefits for NF practitioners, consumers, related professional associations REFERENCES and future research grant applications. Barnes, P. M., Bloom, B., & Nahin, R. L. Method (2008). Complementary and alternative On May 1, 2011, an Ohio State University Insti- medicine use among adults and children: tutional Review Board–approved online survey United States, 2007 (National Health Stat- of treatment practices associated with the NF istics reports; No 12). Hyattsville, MD: treatment of youth with ADHD will be sent to National Center for Health Statistics. a sample of U.S. NF practitioners. The sample Chan, E. (2008). Quality of efficacy research in will be composed of members of the top two complementary and alternative medicine. U.S. NF practice=research organizations and Journal of the American Medical Association, certificants who have agreed to participate in 299, 2685–2686. this study: the International Society for Neuro- Hirshberg, L. M., Chiu, S. & Frazier, J. A. feedback & Research (ISNR), Association for (2005). Emerging brain-based interventions Applied Psychophysiology and Biofeedback for children & adolescents: Overview & (AAPB), and Biofeedback Certification Inter- clinical perspective. Child & Adolescent Psy- national Alliance (BCIA). Only members who chiatric Clinics of North America, 14, 1–19. treat youth (i.e., 18 years old) with NF in the Kamiya, J. (1968). Conscious control of brain United States will be asked to participate. ISNR waves. Psychology Today, 1, 57–60. estimates that will include 640 of its members, Lofthouse, N., Arnold, L. E., Hersch, S., Hurt, AAPB 134, and BCIA 500 certificants, for a total E., & deBeus, R. (in press). A review of NF of 1274 potential participants. The survey’s 40 treatment for pediatric ADHD. Journal of questions were developed via consultations Attentional Disorders. with the ISNR, AAPB, BCIA, and several top Sinha, D., & Efron, D. (2005). Complementary researchers in the field of NF. and alternative medicine use in children with attention deficit hyperactivity disorder. Results and Discussion Journal of Pediatrics and Child Health, Data collection will run from May 1 through 41(1–2), 23–26. May 31, 2011. In June, data will be down- Swanson, J. M., Kraemer, H. C., Hinshaw, S. loaded, analyzed by basic descriptive statistics P., Arnold, L. E., Conners, C. K., Abikoff, to identify response patterns and ready for H. B., & Wu, M. (2001). Clinical relevance presentation at the ISNR conference in Sep- of the primary findings of the MTA: Success tember. Results will be presented on practi- rates based on severity of ADHD & ODD tioners’ general background (i.e., location symptoms at the end of treatment. Journal [U.S. state], type of practice, training, of the American Academy of Child & certification=license, professional title, and Adolescent Psychiatry, 40, 168–179. PROCEEDINGS OF THE 2011 ISNR CONFERENCE 441

Yussman, S. M., Ryan, S. A., Auinger, P., & Lena Santhirasegaram, BSc Weitzman, M. (2004). Visits to complemen- ADD Centre tary and alternative medicine providers by children and adolescents in the United States. Ambulatory Pediatrics, 4, 429–435. Introduction This case study concerns a 42-year-old woman Binaural Beats Alter Lateralized Attention (JS) who suffered a closed head injury in a car accident in 2000. This client received all the best Sharon Noh, BS, Jacob Johnston, Andrew Hill, medical and rehabilitation care, but she was still MA, and Eran Zaidel, PhD unable to function at work or within her social ADD Treatment Center setting. The goal of this presentation is to demonstrate how this client was able to regain full functioning after 84 sessions that combined neu- Introduction rofeedback (NFB), biofeedback (BFB), and Little evidence exists that binaural beat learning strategies. JS came to the ADD Centre entrainment can alter attention and behavioral in August 2005 and started her program in Sep- performance. The anecdotal reports and few tember 2005 for NFB and BFB treatment. Pre- experimental studies that do exist tend to reach viously she had treatment through the Toronto conflicting conclusions. We conducted a ran- Rehab Institute and made improvements on domized controlled study with two different most of her functions, but she continued to have types of binaural beats to investigate their difficulties with reading, writing, cognitive pro- effects on attention. cessing, and attention. The loss of writing was particularly devastating for the client because Methods she was a writer before the accident. In addition, Eight participants were exposed to different she had trouble with listening, and her emotion- binaural beat protocols (beta and theta) on 2 al response was flattened. She had lost her sense separate days. Pairing entrainment sessions of humor and would know something was sup- allowed participants to act as their own control posed to be funny but not quite get it. She often for possible entrainment effects. Protocol order needed people to speak more slowly so that she was counterbalanced across participants to would be able to process the information com- control for order effects. A 64-channel EEG municated to her. She presented with traits was recorded before, during, and after the much like those of a client with Asperger’s syn- presentation of binaural beats. The Lateralized drome combined with ADHD, learning disabil- Network Attention Test was also administered ities, and anxiety disorder. She communicated during the presentation of binaural beats, to in a monotone and very matter-of-fact manner. measure changes in covert orienting of spatial While doing her NFB and BFB from September attention in each hemisphere. 2005 until August 2007, her speech and communication skills as well as the emotional tone Results in her voice improved. These improvements There were significantly different effects of the were substantial to the extent that she wrote 2 binaural beat types on conflict resolution and and published a book that she had started prior spatial orienting in the 2 hemispheres. EEG to her brain injury. Another major improvement analysis is expected to reveal differences in was her ability to read again, as prior to her acci- individual subject spectral measures before dent she was an avid reader. She currently is and after entrainment sessions. working on another novel.

A Book Finally Written: Case Study of Effec- Method tive Intervention Five Years Post Closed Over a period of 2 years, this client had 84 NFB Head Injury combined with BFB training sessions. The 442 PROCEEDINGS OF THE 2011 ISNR CONFERENCE instrument used was the Biograph Infiniti from learning strategies. In all sessions, the patient Thought Technology, and the screens were had HRV feedback. With 50-min sessions she from the Thompson Setting-up-for-Clinical had single-channel EEG referential feedback. Success suite, which allows NFB and BFB to Her training was at F8, CPz, and F3, always be monitored at the same time. Biofeedback referenced to the left ear. At F8, 3–7 Hz was included skin conduction and heart rate varia- decreased and 13–15 Hz increased while she bility (HRV). Each of the treatment sessions was doing visual games. CPz-left ear reference, lasted 50 min. The training parameters were training was carried out to decrease 3–9 Hz set by Dr. Thompson after analysis of the and 23–35 Hz, and increase 11–12 Hz. At F3, 19-channel EEG recording. Such analysis was while doing verbal=reading cognitive tasks, she carried out using NeuroGuide (NG) and was trained to decrease 3–7 Hz and increase LORETA. Sites and frequencies were selected 15–18 Hz. This was followed by continuing based on the correlation of her symptoms, HRV and Skin Conductance (SC) training. and the findings of her QEEG compared with Between baseline and post 80 sessions, assess- the normative database from NG. Examples will ments demonstrated using Dr. Lubar’s A620 be shown in the presentation. The biofeedback (Autogenics) assessment program, a decrease parameters were decided upon after a psycho- in theta, 3–7 Hz from 13.21 to 11.98 mv, physiological stress assessment. increase in beta, 15–18 Hz from 4.40 to 6.11 mv (this program does not measure Results high-frequency beta). In our centre, pre- and This patient made significant gains as measured post-lv ratios at Cz are calculated at baseline on objective testing. The Integrated Visual and and post 40, 60, and 80 sessions for (4–8=16– Auditory Continuous Performance Test (IVA), 20), (3–7=15–18). These ratios decreased from hyperactivity went from extreme to none; IVA 2.16 to 1.61 and 2.45 to 2.05, respectively. Full Scale–Response Control Quotient went Baseline picawatt (4 to 8 Hz)2 = (13 to 21 Hz)2 from 93 pretraining to 116 posttraining (more (Monastra et al., 1999) ratio decreased from than 1 standard deviation), and auditory and 2.05 to 1.15. In the 19-channel EEG assess- visual response control standard score went ments, Dr. Thatcher’s NG Learning Disability from 93 and 95 pretraining to 108 and 119 Discriminant Analysis post 40 to post 80 ses- posttraining, respectively. Her Full Scale Atten- sions, her NG, LD Probability Index changed tion Quotient (FAQ) was more than 3 standard from an 85.0% probability of having a learning deviations below the mean pretraining and disability to zero probability. This corresponded went from 50 on the FAQ to 111. Auditory to this client demonstrating a continuous and and visual attention quotient went from 47 marked improvement in learning ability. After and 64 pretraining to 100 and 119 posttraining, amplitude training was done, remaining coher- respectively. On all the standard scores, she ence problems were addressed. She was trained showed gradual improvements over time. to increase theta coherence F8–FZ. Theta Wechsler Adult Intelligence Scale (WAIS) prior hypo-coherence F4–F8 decreased from 2.12 to coming to the ADD Centre but after the to þ0.31. Although initially she had difficulty accident (in 2003) were verbal 73rd percentile with metaphors and her voice was very mono- and performance 95th percentile. In 2007, after tone, as coherence improved in the right frontal 80 sessions training, the WAIS–IV was readmi- area, her vocal tone normalized completely nistered, and her verbal score was improved to and she was fully capable of understanding the 99.5th percentile, and her performance metaphors. score was also at the 99th percentile. These updated scores were likely a return to her Conclusion preaccident baseline, as she had been a very As can be observed from this case study, the high-functioning individual. Her training combination of NFB with BFB and learning stra- had included a combination of NFB þ BFB þ tegies is an effective intervention for individuals PROCEEDINGS OF THE 2011 ISNR CONFERENCE 443 with closed head injury. I hope that the results capabilities and characteristics. To test these from this case study will encourage further theoretical differences, a pilot analysis of quanti- research into combining NFB with BFB and tative electroencephalography measurements cognitive strategies as a viable treatment for (scalp electrode analysis and eLORETA) of 10 clients even several years after the injury. professional action sport athletes were compared to a control group of professional athletes in the sports of baseball, basketball, golf, run- REFERENCE ning, and tennis. The control group of pro- Monastra, V., Lubar, J., Linden, M., fessional players was chosen because they are VanDeusen, P., Green, G., Wing, W., ... similar in the time commitment, training, and Fenger, T. N. (1999). Assessing attention high-performance demands but have a lower deficit hyperactivity disorder via quantitative incidence of previous mild traumatic brain injury electroencephalography: An initial validation than other nonaction professional sports (e.g., study. Neuropsychology, 13, 424–433. soccer, North American football, hockey, etc). Event-Related Potential Study of Attention Where Fear, Risk, Thrill, and Performance Regulation in ADHD, Autism Spectrum Dis- Mastery Meet: Action Sport Athlete Brain order, and Typical Children States Estato Sokhadze, PhD, Joshua Baruth, PhD, Leslie Sherlin, PhD, and Michael Gervai, PhD Lonnie Sears, PhD, Guela E Sokhadze, Neurotopia Ayman El-Baz, PhD, Marie Hensley, Allan Tasman, MD, and Andy Walshe, PhD Manuel F. Casanova, MD Red Bull North America University of Louisville Action sport athletes spend a lifetime pursuing performance mastery in extremely high-risk Introduction environments. Mistakes often are closely linked Autism spectrum disorders (ASD) and attention with risk of injury. Although more traditional deficit=hyperactivity disorder (ADHD) are very ‘‘stick and ball’’ sport development creates common developmental disorders that share opportunities to ‘‘learn’’ in a relatively safe some similar symptoms of social, emotional, environment, the action sport athlete is not per- and attention deficits. This study is aimed to mitted such luxury. In addition, the path to help understand the differences and similarities become an action sport athlete is not clearly of these deficits using analysis of dense array defined. The action athlete has very few options event-related potentials (ERP) during Kanizsa to join sport teams, join developmental illusory figure (Kanizsa, 1976) recognition task. programs, or receive explicit and continual skill Although ADHD and ASD seem very distinct, instruction. They are often required to develop they have been shown to share some similarities their technical, physical, and mental skills in a in their symptoms. According to diagnostic cri- self-determined, high-risk manner. To become teria enunciated in the Diagnostic and Statistical a world-class action sport athlete, it is reasonable Manual of Mental Disorders (4th ed., text rev. to assert that the psychological, emotional, [DSM–IV–TR]; American Psychiatric Associ- physical, environmental, and possibly genetic ation, 2000) both ASD and ADHD are mutually factors are different for them than for their tra- exclusionary diagnoses. There is a growing con- ditional sport athlete counterparts. The search sensus from clinicians, however, that behavioral for performance mastery in a highly charged, characteristics of ADHD are observed in 14 to high-risk environment fundamentally would 78% of ASD patients (Holtman, Bolte, & require a different set of performance mental Poustka, 2007; Keen & Ward, 2004; Lee & 444 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Ousley, 2006; Leyfer et al, 2006; Reiersen, mission error rate than controls. Posterror RT in Constantino, Volk, & Todd, 2007; Ruggieri, this group was exhibited in a posterror speeding 2006; Sinzig et al., 2009; Yoshida & Uchiyama, rather than corrective RT slowing typical for the 2004). These studies question the validity of controls. The ASD group also demonstrated an comorbidity as an exclusionary criterion within attenuated error-related negativity as compared current DSM–IV–TR guidelines and argue in to ADHD and controls. The fronto-central favor of its revision for the upcoming DSM–V P200, N200, and P300 were enhanced and less (Ruggieri, 2006). Although behavioral charac- differentiated in response to target and nontarget teristics of autism and ADHD may coexist, the figures in the ASD group. The same ERP compo- more poignant question is whether both con- nents were featured by more prolonged laten- ditions share the same underlying pathophysiol- cies in the ADHD group as compared to both ogy. Without the presence of biomarkers, ASD and typical controls. diagnosis based on observed behaviors is fraught with difficulties. The aim of this study Conclusions involved comparing the ERP profiles of ADHD, Our results show significant differences both in ASD, and typical control subjects in a shape behavioral and electrocortical responses recognition task to investigate effectiveness of between ASD, ADHD, and typical controls differentiation of target and nontarget stimuli. during performance on illusory figure test. Our hypothesis was that children with ASD will The findings are interpreted according to the show less pronounced differences in ERP ‘‘minicolumnar’’ hypothesis proposing exist- response to target and nontarget stimuli as com- ence of neuropathological differences in ASD pared to typical children and children with and ADHD, in particular, minicolumnar ADHD. The latter group was predicted to have number=width morphometry spectrum differ- less reactivity to nontarget cues. We expected ences. In autism, a model of local hypercon- to find other ERP manifestations of attention nectivity and long-range hypoconnectivity regulation and other executive function differ- explains many of the behavioral and cognitive ences between ASD and ADHD. deficits present in the condition, whereas the inverse arrangement of local hypoconnectivity Methods and long-range hyperconnectivity in ADHD Participants with ASD (N ¼ 16) and ADHD explains some deficits typical for this disorder (N ¼ 16) were referred by the Department of (Casanova et al., 2009; Williams & Casanova, Pediatrics. Typical children (N ¼ 16) were 2010). Current ERP study supports the pro- recruited through advertisements in the local posed suggestion that some between group media and schools. There was no significant differences (ASD vs. ADHD) could be mani- difference in age (M ¼ 13.6 years, SD ¼ 2.5), fested in the frontal ERP indices of executive gender, or IQ between the 3 groups. EEG was functions during performance on illusory figure collected using 128-channel EGI EEG system. categorization task. The task involves the recognition of a specific illusory shape—in this case, a square or triangle—created by 3 or 4 inducer disks. Sub- REFERENCES jects were instructed to press button only in American Psychiatric Association. (2000). response to an illusory square figure. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, Results DC: Author. There were no between-group differences in Casanova,M.F.,El-Baz,A.,Mott,M.,Mannheim, reaction time (RT) to target stimuli, but both G., Hassan, H., Fahimi, R., ...Farag, A. (2009). ASD and ADHD committed more errors; specifi- Reduced gyral window and corpus callosum cally, the ASD group had statistically higher com- size in autism: Possible macroscopic correlated PROCEEDINGS OF THE 2011 ISNR CONFERENCE 445

of a minicolumnopathy. Journal of Autism and developmental disorder (PDD). European Developmental Disorders, 39, 751–764. Child and Adolescent Psychiatry, 13, 307–314. Holtman, M., Bolte, S., & Poustka, F. (2007). Attention deficit hyperactivity disorder Neuromodulation Using rTMS Improves symptoms in pervasive developmental disor- Error Monitoring and Correction Function ders: Association with autistic behavior in Autism Spectrum Disorders domains and coexisting psychopathology. Psychopathology, 40, 172–177. Estato Sokhadze, PhD, Joshua Baruth, PhD, Kanizsa, G. (1976). Subjective contours. Scien- Lonnie Sears, PhD, Guela E Sokhadze, Ayman S tific American, 234(4), 48–52. El-Baz, PhD, Marie Hensley, Eric Gross, BEng, Keen, D., & Ward, S. (2004). Autistic spectrum Allan Tasman, MD, and Manuel F Casanova, MD disorder: A child population profile. Autism, University of Louisville 8, 39–48. Lee, D. O., & Ousley, O. Y. (2006). Attention- deficit hyperactivity disorder symptoms in a Introduction clinic sample of children and adolescents One important executive function known to be with pervasive developmental disorders. compromised in autism spectrum disorders Journal of Child and Adolescent Psychophar- (ASD) is related to response error monitoring macology, 16, 737–746. and posterror response correction. Current Leyfer, O. T., Folstein, S. E., Bacalman, S., theory and research suggests that these pre- Davis, N., Dinh, E., Morgan, J., ... Lainhart, frontal deficits may contribute to social- J. E. (2006). Comorbid psychiatric disorders emotional and social-cognitive impairments in in children with autism: Interview develop- autism (Henderson et al., 2006). Several reports ment and rates of disorders. Journal of (Bogte, Flamma, van der Meere, & van Autism and Developmental Disorders, 36, Engeland, 2007; Sokhadze, Baruth, Tasman, 849–861. et al., 2010; Thakkar et al., 2008; Vlamings, Reiersen, A. M., Constantino, J. N., Volk, H. E., Jonkman, Hoeksma, van Engeland, & Kemner, & Todd, R. D. (2007). Autistic traits in a 2008) indicate that children with ASD show population-based ADHD twin sample. reduced error processing and deficient beha- Journal of Child Psychology and Psychiatry, vioral correction after an error is committed. 48, 464–472. This finding could be explained as a reflection Ruggieri, V. L. (2006). Attentional processes of ASD patients’ decreased sensitivity to beha- and attention deficit disorders in autism vioral errors or a reduction in behavior correc- [Spanish]. Revista de Neurologia, 42(Suppl. tion ability. Error sensitivity can be readily 3), S51–S56. examined by measuring event-related potential Sinzig, J., Walter, D., Doepfner, M., Sinzig, J., (ERP) components associated with responses to Walter, D., & Doepfner, M. (2009). errors: the fronto-central error-related nega- Attention deficit=hyperactivity disorder in tivity (ERN) and the error-related positivity children and adolescents with autism (Pe). The ERN is a response locked negative spectrum disorder: Symptom or syndrome? ERP deflection, emerging between 40 ms and Journal of Attention Disorders, 13, 117–126. 150 ms after the onset of a commission error. Williams, E., & Casanova, M. F. (2010). Autism Usually, this ERN is followed by a positive wave and dyslexia: A spectrum of cognitive styles referred to as the Pe potential. It is suggested as defined by minicolumnar morphometry. that the ERN reflects an initial automatic brain Medical Hypotheses, 74(1), 59–62. response as a result of an error, and the Pe Yoshida, Y., & Uchiyama, T. (2004). The clinical indicates the conscious reflection and compre- necessity for assessing attention deficit= hension of the error (Overbeek, Nieuwenhuis, hyperactivity disorder (ADHD) symptoms in & Ridderinkhof, 2005). ERN and Pe are gener- children with high functioning pervasive ally accepted as neural indices of response 446 PROCEEDINGS OF THE 2011 ISNR CONFERENCE monitoring processes in psychophysiological number of omission errors decreased (t ¼ 2.26, research and clinical neurophysiology. The goal p ¼ .034). The RT did not change, but posterior of our study was to investigate whether beha- RT became slower (from 22.3 ms to 10.6 ms vioral response error rate, posterror RT change, post-TMS). There were no changes in RT, error ERN, and Pe will show positive changes follow- rate, post-error RT slowing, or ERN=Pe ing 12-week-long slow frequency repetitive measures in the WTL group. TMS (rTMS) in group of high-functioning children with ASD. Considering that in our prior Conclusions studies we showed reduction in error rate in Our results show significant post-TMS differ- ASD group post 6 sessions of the left dorsolat- ences in the response-locked ERP such as ERN eral prefrontal cortex (DLPFC) rTMS, we and Pe, as well as behavioral response monitor- hypothesized that 12 sessions of rTMS bilater- ing measures (omission errors, posterror slow- ally applied over the DLPFC will result in ing) indicative of improved error monitoring improvements reflected in RT, ERN, and Pe and correction function. This executive func- measures. tion is important for ability to correctly evaluate committed error and adjust behavior to prevent Methods from rigid and repetitive actions. Elucidating the High-functioning participants with ASD (N ¼ 30) neurobiological basis and clinical significance of were referred by the Wisskopf Child Evaluation response monitoring and correction deficits in Center. Diagnosis was made according to the ASD represents a promising direction for further Diagnostic and Statistical Manual of Mental quantitative EEG-based research. The ERN Disorders (4th ed., text rev.; American Psychi- and Pe along with behavioral performance atric Association, 2000) and further ascertained measures can be used as functional outcome with ADI-R (Le Couteur, Lord, & Rutter, 2003). measures to assess the effectiveness of neu- Then participants were randomly assigned to rotherapy (e.g., rTMS or neurofeedback) in chil- either active rTMS treatment (N ¼ 15) or waitlist dren with ASD and thus may have important (WTL) groups. There were no significant differ- practical implications. ences in age (M ¼ 13.5 2.6 years), gender, or IQ between groups. Baseline and post-TMS=or REFERENCES WTL EEG was collected using 128-channel EEG system. The task involved the recognition American Psychiatric Association (2000). of a specific illusory shape—in this case, a square Diagnostic and statistical manual of mental or triangle—created by 3 or 4 inducer disks. disorders (4th ed., text rev.). Washington, Subjects were instructed to press the button only DC: Author. in response to an illusory square figure. Treat- Bogte, H., Flamma, B., van der Meere, J., & ment group received 12 weekly 1 Hz rTMS ses- van Engeland, H. (2007). Post-error sions (150 pulses, 90% of motor threshold), adaptation in adults with high functioning whereas the WTL subjects were tested twice autism. Neuropsychologia, 45, 1707–1714. after an 8- to 12-week waiting period. Henderson, H., Schwartz, C., Mundy, P., Burnette, C., Sutton, S., Zahka, N., & Results Pradella, A. (2006). Response monitoring, There were between-group differences neither the error-related negativity, and differences in reaction time (RT) to target stimuli nor in rate in social behavior in autism. Brain and of commission and omission errors. ERN in Cognition, 61, 96–109. TMS treatment group became significantly Le Couteur, A., Lord, C., & Rutter, M. (2003). more negative (by 4.99 4.35 mV, F ¼ 5.07, The Autism Diagnostic Interview–Revised.Los p ¼ .03), whereas Pe increased (from 5.96 Angeles, CA: Western Psychological Services. 5.02 to 9.72 5.28 mV, F ¼ 5.55, p ¼ .019). Overbeek, T. J. M., Nieuwenhuis, S., & No latency differences were detected. The Ridderinkhof, K. R. (2005). Dissociable PROCEEDINGS OF THE 2011 ISNR CONFERENCE 447

components of error processing. Journal of sive psychotherapy. With parental consent we Psychophysiology, 19, 319–329. had tried a new, purely experimental approach Sokhadze, E., Baruth, J., Tasman, A., El-Baz, A., for which there was little research support. The Mansoor, M., Ramaswamy, R., ...Casanova, parents were desperate and hopeful, even M. (2010). Low-frequency repetitive tran- though we were honest about having no way scranial magnetic stimulation (rTMS) affects of explaining why neurofeedback (NFB) might event-related potential measures of novelty work, except to cite outcomes of increased processing in autism. Applied Psychophysiol- attention span in children with ADD who were ogy & Biofeedback, 35, 147–161. treated using NFB. Thakkar, K. N., Polli, F. E., Joseph, R. M., Despite our limited knowledge and equip- Tuch, D. S., Hadjikhani, N., Barton, J. J., & ment that only did single-channel EEG record- Manoach, D. S. (2008). Response monitor- ings and basic biofeedback (BFB; Autogenics ing, repetitive behaviour and anterior A620 and Focused Technologies F1000), the cingulate abnormalities in autism spectrum cases we worked with made remarkable disorders (ASD). Brain, 131, 2464–2478. improvements regarding both behavior and Vlamings, P. H., Jonkman, L. M., Hoeksma, M. being weaned off medications. A dramatic R., van Engeland, H., & Kemner, C. (2008). example was a 13-year-old boy with autism Reduced error monitoring in children with who initially just screeched and flailed his arms autism spectrum disorder: An ERP study. when seated in front of the computer. By the European Journal of Neurosciences, 28, time he finished 85 sessions he had been 399–406. demitted from the MID class (for children with mental retardation) and had moved on to high Neural Networks: An Exploration of Func- school, where he was enrolled in regular classes tions Influenced by Neurofeedback except for mathematics, in which he took an advance class. In addition, he was being invited Michael Thompson, MD, Lynda Thompson, by his peer group to parties. Eight years later PhD, Andrea Reid, MA, and Lena Santhirase- when we called to invite him back for follow-up garam, BSc his father declined, explaining that his son was ADD Centre doing well in college and did not want anyone to know that anything had ever been wrong with him. This talk will give a brief overview of neural net- We reviewed our early work with the goal works, with an emphasis on neural connectivity of better understanding what might have been loops that underlie these networks. The under- the underlying mechanisms that produced lying loop that goes cortex to basal ganglia to these rather unexpected, positive results. We thalamus and back to functionally related areas had done single-channel assessments and of the cortex is central to the discussion. There training, placing the active electrode over Cz, will also be an explication of the relationship referenced to the left ear in most cases or, in between common symptom pictures and how some cases (especially when electromyogram those difficulties relate to dysfunction in various artifact was a problem), we had used a sequen- networks. The origins of this presentation go tial placement: FCz and PCz. Both referential back to 1995 at one of the early meetings of and sequential training were successful with the newly formed Society for Neuronal very difficult cases. Regulation where we presented a paper titled With today’s perspective and the knowl- ‘‘Exceptional Results with Exceptional edge gleaned from 16 additional years in the Children.’’ The cases presented were children field, we suggest that a possible explanation of with severe behavioral disorders who had not the good results might be based on a theoretical responded to traditional treatments such as framework that derives from both other people’s medications, behavior modification, and exten- research and our own evidence-based practice. 448 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Quantitative EEG (qEEG) data (either single Wernicke’s area near the angular gyrus in the channel or 19 channel) continues to provide dominant hemisphere. With seizure disorders the basis for planning all interventions. The we may alternate sensorimotor response 19-channel data, when available, are combined enhancement at C3 and C4 while decreasing with LORETA analysis for source localization and slow wave near the focus of the epileptiform then we apply knowledge of Brodmann Areas, activity. Traumatic brain injury is another clear functional networks, and the client’s symptoms. exception, and there are others. Nevertheless, Our observation is that there are both symptoms beginning training over the CMSs is a reasonable in common, and functional neural networks in starting point with many of our patients due to common, among many of the disorders we the network properties of the structures that worked with, both then and now. underlie the CMS midline sites. In addition, many of the disorders we suc- We will note that we have always com- cessfully treated using NFB þ BFB may have bined NFB and BFB, and this talk will briefly had underlying mechanisms in common. For explain how a CMS, the Anterior Cingulate the most part, there appears to be dysfunction, (AC), connects with the medial and orbital pre- to different degrees, in only a few basic net- frontal cortex and the entire limbic system. In works. Many of the disorders, for example, have addition, it receives input from the brain stem, in common difficulties in attention (executive which, important for our work, includes output network) and=or anxiety (affect network). The from vagal afferents from the heart to the autistic spectrum disorders (ASDs) have major nucleus solitarus in the medulla, which con- difficulties in at least three major networks: nects to the locus coeruleus (noradrenaline pro- executive, affect, and default. The majority of duction) and then to the limbic system our patients, regardless of diagnosis, appear to including the AC. The AC has direct links to have difficulties related to these networks with the hypothalamic-pituitary-adrenal axis. The just a different ‘‘balance’’ of involvement across audience should immediately see the role of clients and diagnostic categories. These three these connections in the human stress response networks can be influenced by neurofeedback and the importance for treatment that com- at various sites over the central midline struc- bines HRV training with NFB to control stress. tures (CMS). They are also altered by means We will briefly describe how this relates to the of biofeedback and, in particular, by heart rate distress network and supports our decision then variability (HRV) training, which will influence and now to almost always combine NFB with the same CMSs through afferents to the brain BFB. stem medulla and from these nuclei to the basal ganglia and the cortex. For all of the Treatment Analysis of SMR-Theta Neurofeed- NFB training, neural loops exist that involve back Session Data After Control for EMG: connections from cortex–basal ganglia–thala- Changes in Power and Ratios mus to cortex. These may affect many functionally related areas of the cortex. This will be Martin van Beek, MSc and Rien Breteler, PhD discussed in terms of how we now think that EEG Resource Institute our results with these early clients were achieved. Introduction We were initially doing feedback, for the In everyday practice of neurofeedback (NF), most part, over the CMS, but we will note that treatment evaluation often is focused on there are a number of exceptions to using CMS questionnaires or self-reports. However, elec- feedback as a starting point. We do not, for troencephalography (EEG) parameters (e.g., example, begin our training over CMSs if the amplitudes and ratios) within and over sessions main problem is a reading disorder or a seizure also are valuable measures for treatment effect. disorder. With dyslexia we usually follow the Often these 2 approaches do not concur. QEEG, which typically shows inactivity over Treatment evaluation research often addresses PROCEEDINGS OF THE 2011 ISNR CONFERENCE 449 questionnaires only. If EEG is involved it mostly The subject of this case study was a 21-year-old concerns pre- and posttreatment QEEG only. male college student diagnosed with adult There is considerable debate whether one is onset schizophrenia, undifferentiated type. able to see any changes after treatment, and Due to the advancement of this disorder he as such it questions the processes due to NF, if was unable to complete mandatory course- any. This study investigates the trends in EEG work and forced to take a leave of absence data within and over sessions of 24 patients prior to his senior year at the University of treated with either a discrete or continuous Southern California. He was given a very poor SMR=theta feedback protocol for ADHD. The prognosis by his psychiatrist and placed on ari- research questions are, (a) Which changes can piprazole (Abilify) with the dosage varying be found in the designated bandwidth areas of between 5 mg and 20 mg. these protocols? (b) What are the differences His neurofeedback therapy was directed between these two protocols? (c) What factors mainly by the results of 5 serial quantitative EEGs affect EEG parameters? Primary outcome mea- (QEEGs) administered over an 18-month per- sures are absolute and relative power=period. With each QEEG new areas of statistically centage power of SMR and theta, standard significant hypocoherence were targeted for deviations, and the SMR=theta power ratio. Sec- treatment. The subject engaged in intensive ondary outcome measures are associations with neurofeedback having four to six 30-min time of day, electromyogram (EMG) power, dur- sessions per week totaling 530 in-office sessions ation of training trial, type of feedback, time utilizing EEG Spectrum’s EEGer software between sessions and seasonal effects. (amplitude, sum, and coherence modules). The subject engaged in no other therapy or Method interventions. All session data will be reviewed for EMG and Initially neurofeedback therapy was con- any other artifacts. Trend analyses will be used ducted predominantly at C3 and C4 (according to plot any learning curves. to the International 10–20 System) with the goal being to obtain cortical stabilization. This Results phase of treatment lasted for 66 sessions. In Results are to be provided at the conference. the second phase of neurofeedback, the subject was given 287 sessions intended specifi- Discussion cally to remediate statistically significant The results have major implications for every- QEEG derived coherence abnormalities. day practice. If no changes are found, and no Interspersed throughout this second phase of associations with the secondary outcome mea- treatment were 117 sessions of cortical stabili- sures, the use of EEG power in order to moni- zation. Stabilization was done before and after tor change processes becomes questionable. each QEEG was administered as well as when The study design does not allow for the assess- clinically indicated. ment of placebo effects, but this suggestion Neurofeedback therapy involves appli- may then gain support. For research purposes cation of certain protocols that determines FMRI validation of the training effects may then proper electrode placement and identifies be an option for further insight into the pro- which frequencies or coherence pairs are cesses involved in neurofeedback. trained. In both phases of training, the reward provided the subject positive feedback (visual QEEG Guided Neurofeedback to Treat and auditory) when identified criteria were Schizophrenia: A Case Study met. Degree of cortical stabilization was determined by the subject successfully reaching Jason Von Stietz and Gary Schummer, PhD previously attained optimal levels of amplitude ADD Treatment Centers readings in critical frequency ranges as well an ability to maintain low coefficients of variation. 450 PROCEEDINGS OF THE 2011 ISNR CONFERENCE

Coherence reward was provided when became markedly psychotic exhibiting delu- immediate computer analysis indicated that sions of grandeur, hearing voices, and para- the areas identified showed improved coher- noid ideation. ence readings. The choice of protocol was Adult onset schizophrenia beginning at optimized based upon either abnormal fre- the age of this subject typically has a very quency characteristics or statistically significant poor prognosis. However, for this subject, Z-Scored FFT hypocoherence abnormalities neurofeedback treatment was a powerful identified by NeuroGuide. Convergence intervention enabling him to reach a difficult between QEEG abnormal findings with neuro- scholastic milestone on reduced levels of medi- physiological correlates of functional impair- cation. This case study indicates that further ments were the main factors considered in research is warranted given the profoundly determining the treatment plan. The number positive effect demonstrated by the neurofeed- of sessions trained for each coherence abnor- back intervention. mality was estimated using a calibrated mul- tiplier positively correlated with standard Enhanced EEG Coherence During Bilateral Eye deviation abnormalities. The main factors used Movements While Recalling an Unpleasant to determine the point of maximum benefit Memory: Implications for EMDR for any hypocoherent pair identified for training were improved functional capacity and Matthew Yaggie, MA, Larry Charles Stevens, real-time percentage coherent data provided PhD, Seth Miller, BA, Angela Abbott, BA, Chad by the EEGer software. Woodruff, PhD, Mike Getchis, MA, and Sean Over the course of this subject’s neuro- Stevens feedback, the QEEG identified 36 coherence Northern Arizona University abnormalities. Results of neurofeedback therapy and subsequent QEEG analysis showed that the neurofeedback was effective at nor- A number of therapeutic techniques to relieve malizing previously abnormal coherence read- traumatic stress have been developed in the ings with the exception of 2, which then past decades. One of the most frequently normalized after being treated a second time. used clinical therapies is Eye Movement In spite of the fact that targeted coherence Desensitization and Reprocessing (EMDR), abnormalities normalized, with each new which uses bilateral eye movements to facili- QEEG there appeared new coherence abnor- tate a reduction in the vividness of memories malities presumably caused by the encroach- and associated affect. Although this technique ing schizophrenia. has an extensive research history, EMDR has During the time we were identifying and been challenged because the underlying intensely treating QEEG-identified coherence mechanisms are not fully understood. A parti- abnormalities, the subject experienced a sig- cular target of this criticism has been the role nificant reduction in symptoms and a reduced of and mechanisms underlying the bilateral need for aripiprazole (20 mg was reduced to eye movement component of EMDR. The goal 7.5 mg). This window of improved functioning of this study was to examine the bilateral eye allowed him to return to school, where he movements used in EMDR therapy and to test successfully completed his senior year in spite an interhemispheric integration model for of a challenging course load and ultimately EMDR by exploring EEG coherence. Parti- graduated from USC. Unfortunately, against cipants were not diagnosed with posttraumatic the advice of his doctors and his family, the stress disorder (PTSD), but they did recall a subject discontinued neurofeedback treat- moderately unpleasant event during the bilat- ment. Within 6 months after stopping neuro- eral eye movement process. The procedure feedback therapy and in spite of increased followed previous research using moderately pharmacological intervention, the subject unpleasant memory recall to approximate PROCEEDINGS OF THE 2011 ISNR CONFERENCE 451

PTSD characteristics. The bilateral eye move- An analysis of covariance, with baseline ment procedure also followed the EMDR pro- values as the covariate, was used to compare tocol and conditions from a previous study EEG coherence values following the 3 treat- examining bilateral eye movements and EEG ment conditions. The results revealed signifi- coherence. cantly higher EEG coherence for Beta and A sample of 55 undergraduate and gradu- Gamma frequencies in the frontal region fol- ate women was used in this study. Each partici- lowing bilateral eye movements compared pant experienced a 5-min eyes-opened to the other 2 conditions. LORETA virtual baseline condition followed by 1 of 3 treat- magnetic resonance imaging neuroimages of ment conditions: (a) an eye fixation condition, these effects are presented. (b) an eye fixation with background bilateral These results supported the hypothesis of light movement condition, and (c) a bilateral increased interhemispheric coherence following eye movement condition. During the treat- bilateral eyes movements during recall of an ment condition, the participant recalled a unpleasant memory, consistent with the moderately unpleasant episodic memory. Each hypothesized effects of EMDR. Furthermore, of 5 eyes-opened treatment conditions lasted these effects were found in frontal brain regions for 1 min, followed by an eyes-opened 1-min involved in planning, reasoning, decision mak- EEG recording period, for a total of 5 min of ing, and verbal episodic memory retrieval, also EEG recordings. EEG data were noise arti- consistent with the interhemispheric integration facted, power spectral analyzed, and statisti- model. The lack of significantly increased signal cally analyzed for interhemispheric coherence coherence at the Fp region and the removal of differences between conditions for clusters of eye movement artifacts prior to data analysis frontal pole (Fp), frontal, central, parietal, and reduce the likelihood of this obtained effect occipital electrodes. being a result of eye movement artifacts.