Biofeedback ⎪ Fall 2006 99 www.aapb.org ubjects for this pilot ss Association for Applied Psychophysiology & Biofeedback & Psychophysiology Applied for Association 2 /(13-21) 2 children to ascertain whether these EEG patterns differed children to ascertain and, if they did, to whether the differences corresponded differences in clinical presentation. Clinical experience ADD Centre/ at the spanning more than 12 years suggested that adults Toronto Biofeedback Institute of hyperactivity with attentional problems (attention deficit disorder [ADHD], or combined types) often inattentive did and that had more complex presentations than children more than one the EEG patterns correspondingly showed deviation from normal patterns. The were recorded study were consecutive clients whose EEGs ADD offices of the and assessed in one of seven training Centre. office was often used for a second EEG assess- This and was also the ment in children (a reliability check) to the center office where the majority of adults coming had assessments done, because stress assessments incorpo- as well as EEG rating regular biofeedback modalities on this computer. assessments and training were done a different office, Most children are initially assessed in a classic pattern of high theta-beta and those who have EEG assessment, ratios are not usually given a second of adults as com- which accounts for the higher number pared to children in this review. Thus, the subjects for this (4-8) Frequency Range (Hz) 26-34/13-15 21-25/13-15 4-8/16-20 6-10/16-20 Power ratios (ratios of power, (ratios Power ratios defined as amplitude squared) Theta power/beta power Note. adults. (SMR) = 13–15 for Sensorimotor rhythm Amplitude ratios (ratios of amplitudes in microvolts) (ratios Amplitude ratios Hi-beta–SMR Mid-beta–SMR Theta–beta Thalpha–beta Table. Electroencephalography ratios referenced in this study Descriptive Label Method electroen- The goal of this pilot study was to investigate cephalography (EEG) patterns in a sample of adults and Retrospective examination of electroencephalography Retrospective examination findings demonstrates that adult (EEG) assessment deficit disorder clients who present with attention than that com- require a somewhat different approach monly used with children. Initial findings based on 1- and supplemented channel samples at Cz were reviewed samples.with observations based on 19-channel Two main EEG patterns were found in adults. One pattern, with elevated theta-beta ratios, corresponds to the most common pattern seen in children. second pattern is The characterized by high-amplitude,beta, high-frequency frequencies above which may include beta spindling at 20 Hz, either with or without excess theta. two The pictures:groups present with different symptom Those addition to prob- with beta spindling have anxiety in lems sustaining attention. Case examples highlight dif- interven- fering assessment findings and appropriate tions. Regardless of age, each client is unique, and the intervention needs to be customized. Michael Thompson, MD, DPsych, and Thompson,Lynda PhD, CPsych ADD Centres Ltd.Toronto, of and the Biofeedback Institute Canada Keywords:ADHD, adult EEG patterns, ADHD subtypes, EEG assessment, neurofeedback Improving Attention in Adults and Children: and Adults in Attention Improving and Profiles Electroencephalography Differing Training for Implications SPECIAL ISSUE SPECIAL Biofeedback 34,Volume 3, Issue pp. 99-105 100 Fall 2006 ⎪ Biofeedback Improving Attention in Adults andChildren il set fterlvs Ahi-beta–SMRratiogreater tiple aspectsof theirlives. attention spanandimpulsivity thatinterferedwithmul- Alladultscomplainedofdifficultieswith syndrome. diagnostic criteriaforotherproblems suchas Asperger’s suchas meetingthe also demonstratedcomorbidity, butsome children werepreviouslydiagnosedas ADHD, hence theinclusionof6-10range.) All the thalpha; adultsmay showhigh children usuallyshowhightheta, (Lubar hasnotedwhengivingworkshopsthatwhereas foreithertheta-beta orthalpha-betaratios. adults, wasusedasan ADHD indicatorin cal observations, whichwebasedonourclini- volt ratiogreaterthan2.2, amicro- Inaddition, into thehigh-theta ADHD group. wereusedto categorizeclients power–beta powerratios ADHD of1.5standarddeviationsabovenormalfortheta TheMonastra-Lubarcutoffscoresfor and hi-beta–SMR. mid-beta–SMR, Lubar’s thetapower–betapowerratio, 2001). (Clarke etal., an ADHD sub-typewithexcessbeta with excesstheta, 1999). and forwhichtherearepublishednorms(Monastraetal., power ratiosthathave beenstudiedbyLubarfordecades Most childrenwereexpectedtofitthehightheta-beta those withhighanxietyand/or Asperger’s syndrome. was thatthispatternwouldberareinchildrenexcept Asecondhypothesis beta–SMR ratiogreaterthan1.5. andahi- acorrespondingdipinSMR, beta activity, thatcorrelateswithhigh-amplitudebursts ofhi- brain” that someadultswith ADHD symptomsexhibita “busy was basedonclinicalobservations, The mainhypothesis, Hypotheses showing thefrequencyrangeforeachterminratio. the EEGratiosreferencedinthisdocumentquantitatively, The Table defineseachof rimotor rhythmratios(SMR). demonstrated lowtheta-betaratiosandhi-beta–senso- alltheirEEGs Interestingly, andsuccessful. thoughtful, These individualscouldbebroadlydescribedascalm, not display inattentionbutcametooptimizeperformance. andtwoindividualswhodid ADDCentrestaff, feedback, professionals whoweretakingatrainingcourse inneuro- Thisgroupcontained were usedasacomparisongroup. Thesepersons from adultswhowerenotclinicalcases. therewere25EEGrecords onthesamecomputer, clients, Inadditionto person’s initialsessionwerereviewed. EEGdatacollectedduringeach office atthe ADD Centre. children (aged6to17years) seenconsecutivelyinone study comprised154adults(aged18to65years) and92 aiswr acltdfrteabt,thalpha-beta, Ratios werecalculatedfortheta-beta, inadditiontochildren Other researchers have noted, beta rangeof26to34Hz. Thisactivitywasmissedbytheoriginalhi- ruminations. whichtheysubjectivelyassociatedwithnegative 35 Hz, or 25, vidual clientsdemonstratedspindlingbetaat24, indi- Inaddition, beta somewherebetween19and22Hz. with adecreaseinhi-alpha(11-12Hz)andanincrease sion andanxietyweresometimesclinicallycorrelated Thereasonforthischangewasthatten- -35/13-15 Hz. 19-22/11-12Hzand23 different ratioswerecalculated: andtwo sample includingmostoftheadultswastaken, placed inwhatwewouldcallthehi-beta ADHD group. than 1.5wasusedtoidentifysubjectswhowouldbe 41-1H let opando nrsv,negative, 34/13- 15Hz clients complainedofintrusive, thelargemajorityof high 26- dates andathletes, tion ofasmallnumberoptimal performancecandi- 23-35/13-15 Hzratiowascalculated.) With theexcep- out tobevirtuallythesame percentage ofclientswhena (Theelevatedhi-beta–SMR ratiogroupturned SMR. 22%showedonlyelevatedhi-beta comparedto ratios, showed hightheta-betaand/orelevatedhi-beta–SMR Ofthe121casesreviewedthat had thehighestratios. We foundourmost severeclinicalcases 15 Hzwas>1. but21-25/13- thisratiowasnothigh, Infourcases, on. Twenty-six adultsmetthiscriteri- for 26-35/13-15Hz). 1.5 asacutoffscoreforhi-beta/SMRratios(>1.55works clinical observationsandarbitrarilysetatgreaterthan Thedefinition of being high. high-amplitude hi-beta–SMRratioswithouttheta-beta group wascomposedof30adultswhoshowedonly individuals hadelevatedhi-beta–SMRratios. andnoneofthese just thetheta-betaratiowashigh, InsixcaseswithintheDrifters group, beta–SMR ratios. of thehightheta-betaratiogroupalsohadelevatedhi- 51% Thus, Thissubgrouphad45cases. or ruminating. driftingoff These individualscantuneoutintwoways: ratios werecombinedwithelevatedhi-beta–SMRratios. group containedasubgroupinwhichhightheta-beta This 1999). theta-beta powerratios(Monastraetal., deviations abovethenormsfrommultisitestudyfor 80%ofthisgroupweremorethantwostandard Indeed, volts) andthetapower–betapowerratios(inpicowatts). theta-beta ratiosusingboth(inmicro- theseadultsdemonstratedhigh In89cases, of 129). prised 74%oftheadultswithattentionalproblems(95 Thisgroupcom- first groupwaslabeled “the Drifters.” The twomajorgroupsemerged. In theadultpopulation, Results fe h is eut eecluae,anadditional After thefirst resultswerecalculated, h eodgopwslbld“h uyBan. This The secondgroupwaslabeled “the BusyBrains.” high ratio was basedon Biofeedback ⎪ Fall 2006 101 Thompson, Thompson Diagnostic and Statistical Manual of Mental Diagnostic and Statistical Manual of , fourth edition,ADHD, diagnostic criteria for In the high-amplitude, high-frequency beta group of It should be noted that there were also many adult gle-channel EEG assessment was supplemented with a was supplemented EEG assessment gle-channel 19-lead assessment, were analyzed using and the results tomography brain electromagnetic low-resolution (LORETA), three- statistical procedure performing a for to identify cortical sources dimensional projections with surface EEG.patterns measured origin of these The the anterior cingulate of beta proved to be bursts Area 24),(Brodmann major clinical and some of the cases were anxiety,symptoms in these panic, and/or disorder (OCD).obsessive compulsive Spindling beta with autistic spectrum disorders was also seen in people syndrome. Asperger’s including It is certainly not specif- ic to any disorder, appear to signal instability but it does within the cortex. infrequently, Very be the hi-beta may observed in the parietal area, and there it would appear or sensory to correspond to sensory hypersensitivity defensiveness (tactile, visual, or auditory). was seen This unstable clients.in only two of our most difficult and It signal an easily has been said that spindling beta may this cor- kindled cortex—irritable or even unstable—and responds to our clinical observations. Normal beta, on the other hand, even when at somewhat higher than expected frequencies, of lower amplitude, was desyn- chronous, and present across a much broader frequency band. clients, of clinical syndromes a mixture there was always (comorbidity).or disorders come to have They may and would improve attention span and concentration fulfill the Disorders the least but this certainly was only one factor—often important one. was an The most common comorbidity association with significant reaction to, and slow recov- ery from, stress and tension combined with negative ruminating. degrees of anx- There might also be varying iety and/or panic and even symptoms of OCD. The clients’ inattention was often, part, for the most due to ruminative thinking.circular A second major comorbid- syndrome (also Asperger’s ity was an association with frequent in children). There were infrequent associations with other disorders, syndrome and Tourette’s including partial seizures. clients who had used the energy and creativity associat- and ADHD to become successful entrepreneurs ed with professionals. They wanted to self-regulate to manage ADHD (poor time management, the negative traits of lack of follow-through, poor listening and attention, impulsivity, etc.). When bursts of high-amplitude beta between 19 Hz of high-amplitude beta between 19 When bursts The group of adults who showed 21-25/13-15 Hz The group of adults who showed 21-25/13-15 A third very small group, who fit best with the and 34 Hz were observed, had to be two factors addressed. beta was the morphology of the The first form.wave severe cases, In the clinically most some of the high-amplitude beta was beta spindling. The mor- pattern was very-high-amplitude phology of this wave spindles of synchronous beta running in an extremely narrow frequency band (usually just a single 1-Hz bin). This was most often observed in the surface EEG to be in the frontal and/or central regions. cases, In some the sin- Discussion Concerning Adult Cases Discussion Concerning circular thoughts or ruminations, thoughts or circular they felt were which they could not concentrate.the reason to This tendency for their dialogue was responsible a negative inner have for ADHD criteria and meeting questionnaire responses Attention Variable of Test on the their poor results con- Auditory (IVA) Visual and the Integrated (TOVA) tests.tinuous performance should note, We at this junc- ture, who are seen occasional professionals that we have very successful,comment that their brains are who “going at 100 mph,” always a high hi- and who show beta–SMR ratio. called have It is for this reason that we Busy Brains”“the this group and not given it a negative “ruminations.” label such as interesting subset. ratios greater than .9 emerges as an This group comprised 43 persons, or about one third of the clients, overlapped with but it almost completely clients who also showed high 26-34 Hz activity. In only that was high. four cases was this ratio the only one Asperger’s with Nine of the 43 cases were diagnosed cases were not picked Asperger’s syndrome (two other up by this ratio). cases were high- Sixteen of the other functioning, very intense students or professionals. The remainder, 18, were rather overanxious individuals. Thus, one could summarize these findings by saying hi- that the difference between these high-amplitude identified those beta groups became clearer when we showed either who were clinically different in that they or anxiety at a level that was very intense personalities life. clinically interfering with their daily Drifters, a high (arbitrarily defined as demonstrated only greater than 2) thalpha-beta ratio. This group comprised only four individuals, none of whom had a high hi- beta–SMR ratio. This caught us quite by surprise as we had expected this to be the largest group of adult clients who complained of attention span problems. con- On the trary, the group turned out to be by far the smallest. 102 Fall 2006 ⎪ Biofeedback Improving Attention in Adults andChildren etlyrtre hl,onechildwithextremely severe mentally retarded child, one one childwithaseverelearningdisability, drome, twochildrenwithsevere Asperger’s syn- autistic child, beta–SMR wereaveryspecial groupthatincludedone turned outthatthechildren whodemonstratedhighhi- It could distinguishthemfromtherestofchildren. were andifthereanyclinicalcharacteristicsthat decided toinvestigatefurtherseewhothesechildren we composed suchasmallgroupcomparedtotheadults, would encourageanincreaseinSMR. develop screensthatwouldinhibitthebetaspindlingbut wehadto fortraining, Thismeantthat, respectively). 16-17Hz, 12-13Hzand15-16, following them(11-12, pared tothesingleHzbinsimmediatelyprecedingand theyturnedouttobevery lowmagnitudecom- lated, EEG recordsand13-1414-15singleHzbinsrecalcu- the beta-spindlingsegmentswereremovedfromtheir When actions thatcorrespondedtothesebursts ofbeta. Bothhadextremehyperactivityandfast impulsive ly. respective- only highspindlingbetaat14Hzand15Hz, Two childrendemonstrated to 51%oftheadultclients). demonstrated ahighhi-beta–SMRratio(8%compared Sevenchildrenalso strated hightheta-betapowerratios. Ninetychildrendemon- ly differentpictureemerged. adistinct- however, With thechildren, the adultclients. ting wereexaminedinthesamemanner(sameratios)as The EEGrecordsof92childrenassessedinthesameset- Children Comparison With Figure 1. Because thechildrenwithhigh-amplitudebeta hl ihprilsiue lcrecpaorpy(E)sml ihee lsd etn E,usingalinkedearmontage. restingEEG, electroencephalography (EEG)samplewitheyesclosed, Child withpartialseizure, ydoe,ha nuy orseizuredisorder. headinjury, syndrome), autisticspectrumdisorders (especially Asperger’s drome, Tourette’s syn- ADHDpluslearning disabilities, example, thesechildrenshowedveryhighanxietyandworry. ple, unliketheotherchildrenin the sam- SMR caseswasthat, high-frequencybeta- of thesecaseswithhigh-amplitude, Thecommonfactorforall withdrawn inattentivechildren. even fromthesmallergroupofbrightbutmoresocially sociallyinvolved hyperactive childrenand usual bright, Thisgroupreallystoodoutasdifferentfromour teenager. verballyhyperactive andoneveryanxious, disorder, family problemsandadiagnosisofoppositionaldefiant acid becauseseizure activitywasnolonger observedby Hehadjustcomeoffvalproic with languagefunctioning. which interferes showed aspikeandwave patternat T3, HisEEG andwasdifficulttocontrol. moved constantly, aroundand looked Thischilddidnotconverse, Figure 2). This isan8-year-old boydiagnosedasautistic(see Autistic Child With aSeizureDisorder seizure episodes. atthemomentof Hesaidhefelt “different” 1). and abnormalactivityintheleftfrontalarea(seeFigure This isa10-year-old boywithsimplepartialseizures Child With Partial Seizure Case ExamplesShowingComorbidities oobdt a locmo ntecidgop for Comorbidity wasalsocommoninthechildgroup; Biofeedback ⎪ Fall 2006 103 Thompson, Thompson Adult with attention deficit hyperactivity disorder,Adult with attention deficit hyperactivity anxiety, and The second training parameter for the majority of Figure 3. panic. showing spindling high beta at 31 Hz and 20 Electroencephalogram Hz, 14-15 Hz beta, with lowered FCz. seen at comorbidity would be a child who also had symptoms of syndrome and for whom LORETA Asperger’s OCD or Area 24 dys- demonstrated anterior cingulate Brodmann function, in which case the site of choice for increasing SMR and for decreasing either beta spindling or high- theta) (either high alpha or high amplitude slow wave between Fz and Cz). would be FCz (halfway children would be to increase attention span by decreas- (3-7 activity in the theta ing high-amplitude slow-wave Hz) and/or low alpha (8-10 Hz) range. Placement would usually be C2, C4, or Cz. In the inattentive type of Autistic child with seizure disorder: sample. electroencephalography Figure 2. his parents and no longer present in an EEG done by his his parents and no longer present in an neurologist. Comorbidity: Adult With ADHD, Anxiety, and Panic ADHD, adult diagnosed with This is a 44-year-old anx- iety, and panic. Her EEG in Figure 3 shows spindling high beta at FCz at two frequencies, 31 Hz and 20 Hz, Hz.with a lowering of beta at 14 to 15 A LORETA analysis of her EEG at FCz is seen in Figure 4. The spin- dling beta at 20 Hz is 2.5 standard deviations above the mean in the Neuroguide database. analy- The LORETA sis attributes the spindling high beta to an overactiva- 23 and 24—the cingulate Areas tion of Brodmann gyrus. for Adult-Child Differences These Implications of Intervention who for most children Similar to training parameters ADHD,present with the symptoms of the training for adult clients will include decreasing impulsivity by rais- ing SMR (Lubar, 1991; Lubar, 1997;Thompson,Thompson & 1998). Monastra, This is usually done at 2005; C2 or C4, unless there are major comorbidities that would dictate that a different central sensorimotor strip site be used for increasing SMR. An example of such 104 Fall 2006 ⎪ Biofeedback ai.Low-resolutionbrain electromagnetictomography display. panic. Figure 4. Improving Attention in Adults andChildren rate variability anddiaphragmaticbreathing (usuallyat cardiac variabilityandachieve synchronybetweenheart are trainedinneuralself-regulation. They 1979fordiscussionofalpha). and SMR(seeKamiya, highalpha, lowalpha, tal statesthatraiseandlowertheta, eliminate thebursts ofhighbetaandtoidentifythemen- consciously identifythementalstate(s)thatproduceor Clientsaretrainedto ness) and13-15Hz(calmreadiness). time increasingboth11-12Hz(broadrelaxedopenaware- while(c)atthesame appropriate fortheindividualclient, ling high-amplitudehi-betaatwhateverfrequencywas negative ruminations(andcorticalinstability)bycontrol- (b)decreasing al intensityifitinterfereswithfunctioning, becomes (a)gainingself-regulatorycontroloveremotion- thecentralfocusformostadulttraining However, applies. still usuallyatthesamesite, nant slow-wave activity, within thesensorimotorcortexanddecreasingdomi- TheusualdictumofincreasingSMRatasite 1994. et al., For areviewofstressmanagmentseeLehrer the client’s psychophysiological stressassessmentprofile. modalities thatwereprescribedaccordingtotheresultsof ters aremorediverse andalways includebiofeedback that sitewouldbeover Wernicke’s area. forexample, with readingcomprehensiondifficulties, Indyslexia mality andtheEEGassessmentfindings. appropriate totheneuroanatomicalfunctionalabnor- training orforasecondelectrodewouldbethesite thenthesiteforthis were alsoalearningdisability, Ifthere comorbidityplays arole. Again, and jaw muscles. beingfurtherfromtheeyes and islesspronetoartifacts, most commonlychosenasithasthehighestamplitudes Czisthesite thismightbedoneatC3orF3. ADHD, ihcnoiatboedak clientslearntoincrease With concomitantbiofeedback, thetrainingparame- however, With theadultgroup, dl ihatnindfcthprciiydsre,axey and anxiety, Adult withattentiondeficithyperactivity disorder, as tonotenhanceaspindlingbeta. itmustbedoneverycarefullyso feedback istobedone, Ifenhancingbetafrequenciesusingneuro- behaviors. severe panicattacksaccompaniedbylabileemotionsand which thesedrugscanprecipitatesideeffectsincluding affect memoryfunctioning.) We have seencasesin canexacerbatebetaspindlingandadversely example, for (Clonazepam, benzodiazepines may beharmful. andeven inhibitors (SSRIs)may becontraindicated, stimulantsandselectiveserotoninreuptake observed, his orher ADHD symptoms. trolling theclient’s alertnessleveliskeytodealingwith Working withandcon- almostprecipitously. ness rapidly, theclienttendstolosealert- son forthisisthatin ADHD, Therea- in relaxationlabs)butratherofincreasingEDR. ashasbeendone decreasing electrodermalresponse(EDR; itisalmostalways amatternotof For ADHD clients, ture. muscle tensionandincreasingperipheralskintempera- six breathsperminute)whileatthesametimedecreasing lre .R,Bry .J,MCrh,R,Slkwt,M. Selikowitz, R., McCarthy, J., R. Barry, R., A. Clarke, References for theirassistancewithdatacompilation. We wishtothankBojanaKnezevicand Andrea Reid Acknowledgment generalize thislearningtoeveryday living. and rapidlychangethesevariables, patterns andstress, seethecorrelationbetweenphysiological EEG changes, also changetheirmentalstateandobservecorresponding theycan Bythen, their EEGpatternsandmentalstates. clientscanseethecorrelationbetween the endoftraining, By andpositivefamily/socialinvolvements. exercise, sleep, nutrition, involve theunderlyingbasicsofhealthyliving: and emphasis ontechniquesthataresetupforsuccess Biofeedbackiscombinedwithan rapidly andeffectively. generalizing ofthelearnedabilitytocopewithdailystress training iscoupledwithcognitivetechniquestoensure Biofeedback out negativeself-talkorcircular thinking. withfocusandconcentrationwith- problem solving, calm increased abilitytogointoastateofrelaxedbutalert, decreasing impulsivitytoincludeamajorfocuson goes beyondtheusualincreasingofattentionspanand thefocusofourwork With theadultclientpopulation, Conclusion ihbt dlsadcide,ifbetaspindlingis With bothadultsandchildren, 112, deficit/hyperactivity disorder. EEG-definedsubtypesofchildrenwithattention- (2001). 2098-2105. Clinical Neurophysiology, Biofeedback ⎪ Fall 2006 105 Applied 243-263. Thompson, Thompson Lynda Thompson Lynda 424-433. Michael Thompson Michael combined with training in metacognitive strategies: combined with training ADD. students with Effectiveness in Green, G., Wing, W., al. et (1999). Assessing attention elec- via quantitative disorder deficit hyperactivity troencephalography: study. An initial validation Neuropsychology, 13, and Biofeedback,Psychophysiology 23, Thompson, L., & Thompson, M. (1998). Neurofeedback Monastra, V. J., Lubar, J. F., Linden, M., VanDeusen, P., addcentre.com, email: [email protected]. Correspondence:Thompson, Lynda PhD,Centre Place, ADD Centres Ltd.,Village Mississauga, 50 Ontario L4Z 1V9, Canada, web: www. (pp. Applied Mind body 111-126. 353-401. Biofeedback and Self- 55-82. 202-225. Child and Adolescent Psychiatric Clinics Adolescent Psychiatric Child and New York: Plenum Press. . back (neurotherapy) as a treatment for attention back (neurotherapy) as a treatment deficit hyperactivity disorder: Rationale and empirical foundation. America,of North 14, 289-298) (1994). Stress management techniques: Are they all equivalent,specific effects? have or do they Biofeedback and Self-Regulation, 19, Psychophysiology and Biofeedback, 22, understanding the role of neurofeedback and related understanding techniques for the enhancement of attention. integration: Essential readings in biofeedback treatment for attention diagnostics and biofeedback disorders. deficit/hyperactivity Regulation, 16, rhythm: the study of consciousness. A program for In E. Peper, S. Ancoli, M. & Quinn (Eds.), Monastra, V. J. (2005). Electroencephalographic biofeed- Lehrer, P. M., Carr, R., Sargunaraj, D., & Woolfolk, R. L. Lubar, J. F. (1997). Neocortical dynamics: for Implications Lubar, J. F. (1991). of EEG on the development Discourse Kamiya, J. (1979). EEG alpha of the Autoregulation