Biofeedback / Neurofeedback to Improve Attention

Biofeedback such as HRV (heart-rate variability) biofeedback, eeg-guided neurofeedback, pirHEG (passive infra-red hemo-encephalography) neurofeedback, and the interactive metronome can all be used to improve performance and to improve stress tolerance. Outcomes can include reduced anxiety, better mood and improved attention. Neurofeedback in particular has been used both for optimum performance in athletes and other professional performers, as well as for symptom reduction in psychiatric and stress related disorders, for example in ADHD, autistic spectrum disorders, developmental disorders, anxiety and mood disorders). This can occur even when used primarily for relaxation.

Regardless of the cause of the attention problem there is possibility of improvement with neurofeedback. Even if an individual actually has no noticed impairment of attention, sometimes neurofeedback is useful to improve performance because it can improve attention beyond the baseline ability.

In assessment of symptoms prior to neurofeedback, it is important to evaluate for medical and toxic problems that may be contributing to brain issues. This is because sometimes the contributing medical issues can wreak havoc with other body systems and impact body /mind / behavioral function negatively if left unaddressed. If a physical cause (other than “primary” brain dis-regulation) is not addressed, an improvement in attention from neurofeedback could mask the medical issue, delaying diagnosis and treatment. Problems with inattentiveness, as well as impulse control and other cognitive issues can arise from a multitude of causes.

Potential causes of inattention and impulse control problems include these:

Vision problems (best evaluated by a specialist trained in developmental optometry who can assess convergence and tracking, etc. Sometimes educational occupational therapists can treat for these issues (Dr Vincent in Sussex, or Dr. Kungle in Annapolis are optometrists who may direct you to best assistance.)
Environmental toxicities (lead, mercury, fluoride, pesticides)
Metabolic /endocrine problems (diabetes, hypothyroidism, premenstrual, perimenopausal)
Sleep problems (inadequate sleep, sleep apnea)
Nutritional deficiencies (magnesium, vitamin D, calcium)
Allergies: including artificial dye intolerance and food allergies. Testing for wheat, corn, gluten, and egg intolerance may be essential)
Head trauma (even mild head trauma/concussion. This includes whiplash, sports concussion.)
Acquired brain injury (encephalitis, fetal alcohol syndrome, toxic in-utero medication exposure, concussion)
Mood disorders such as depression and anxiety
Developmental abnormalities, learning disorders and developmental delays. Due to genetic or environmental vulnerabilities
Genetic abnormalities
Stressful life situation.
Other disease states

Just because it “runs in the family” does not mean the problem requires or can only respond to medications.

Even in an individual with a family history of ADHD, it cannot be certain that the disorder is simply an inherited attention problem, as family members can share predispositions to the other issues above, either genetically or by having a shared environment. It has been estimated that of all the attention problems presenting at ADHD clinics, as much as 20 to 25 % are due to undiagnosed causes such as those listed above. In such cases, likelihood of response to the usual ADHD treatments is much reduced, and to complicate things further, parents who do not see a good response to treatment will often drop out of treatment, instead of arranging a re-evaluation for their child. This is why the initial work-up by a pediatrician or other primary care provider, and a primary adult or child psychiatrist, all in collaboration needs to be thorough in ruling out contributing factors. Especially sleep apnea (even mild forms), vision problems, and nutritional/gut biome issues, and stressful home issues should be optimized for brain training to be most likely to work.

What does evaluation for neurofeedback and biofeedback for mood issues involve?

As a basic part of the neurofeedback assessment for attention issues, most practitioners use an “arousal assessment,” which is an assessment of brain-based self-regulation. It includes a consideration of what brain region(s) might need to be addressed. In addition to the clinical interview, it may be important to consider additional evaluation options. A brief computerized neuropsychological assessment, or two-day neuropsychological testing with a PhD psychologist, possibly a TOVA (attention test) may be recommended. My practice can offer the brief computerized neuro-psych testing. I would refer out for more intensive psych testing if indicated or desired. These tests can be helpful both in identifying targets for improvement, then repeat of relevant tests can confirm or track progress as treatment proceeds.

Are there any scans involved in planning neurofeedback treatment?

Sensitive functional scans can highlight what area of the brain may not be functioning normally. (As opposed to structural scans such as CAT scans and MRI’s, which can show brain loss or tumors, SPECT scans and fMRI’s reflect brain functioning. . Qeeg (A quantitative eeg collection and analysis) is a functional assessment as well, but shows details of and potential problems the electrical activity of the brain. Neurofeedback practitioners may recommend and offer a Qeeg collection, with assessment and consultation with a Qeeg expert, to assist in neurofeedback protocol selection. (A Qeeg involves collecting eeg from 19 sites across the scalp for longer than a typical eeg, and having a certified analyst visually inspect the brain waves being produced at each of the sites. Unlike a hospital eeg, the analyst also compares the activity at these sites to a standardized data base of normal eeg’s.) Some practitioners will use a more limited sampling of eeg -- a “mini-map“. The Qeeg is preferred over a mini-map in my opinion. Sometimes a Qeeg is not recommended initially. Instead, the clinical interview determines initial protocols, and uses observations over the course of initial eeg sessions to help confirm the protocol or inform a change in the protocol.

There are other uses for Qeeg.

If a Qeeg assessment is obtained, that eeg collection might also be useful to guide medication treatment and dosing response, if medication treatment is desired. (For example, without the sophistication of a brain wave assessment, one of the standard approaches to dosing of stimulants and anticonvulsants is to keep increasing the dose until symptom control or side effects occur, then drop back on the dose some to see if symptom control is adequate (attention better or seizures gone), adding yet another medication if desired results are not obtained. Then THAT dose is also increased until symptom control or side effects occur, then dropped back.). So the prescriber is relying solely on observation of the patient or parents/teachers and their observations. Eeg can provide additional data to see impact of medications. If the initial Qeeg shows eeg abnormalities consistent with attention issues, psychiatrists can use the eeg’s to see if the brain function has normalized from meds or neurofeedback. (An example would be looking for multifocal sub-convulsive epileptiform discharges.). Most physicians do not make this use of eeg. And neurologists also don’t typically use the Qeeg to see if multifocal spiking (in the case of attention and autism spectrum sx) exists or ) has resolved. Unfortunately, often psychotropics, including neuroleptics are added in the same pattern, (until good effects or side effects occur), and medications can have side effects of cognitive dulling, weight gain, metabolic problems, and reduction of the seizure threshold.

COLLABORATION WITH PRESCRIBING CLINICIANS IS KEY

It is also important to recognize that sedating medications, benzodiazepines, and alcohol may make it harder for the brain to learn during training, so these medications are preferably minimized prior to training or reduced during training. Also, as training progresses, medications that were helping often need to be reduced as the brain needs less of them. Increased side effects may be the indication it is time to reduce. Especially CNS depressants may create over-sedation as training is effective, requiring reduction. Observation and careful titration are necessary and involve collaboration with the prescribing physician. This collaboration is best arranged at the outset, so prompt communication can occur. Neurofeedback is not yet generally included in medical education -- though it should be, given that it has been an established medical procedure since the 70’s! This paper may be helpful to prescribing physicians. They can also check my website.

THE PROCESS OF SELECTING A NEUROFEEDBACK PROTOCOL

Protocol selection involves decisions about which electrical activity (frequency of eeg) to train, and in which areas of the brain. And whether to train at one location on the scalp, two locations, or more.

It is well established that at least some forms of ADD / ADHD correlate with an overabundance of slow wave (theta) activity in the brain. The frontal lobe, for example, functions largely by inhibition. Good frontal inhibition helps a brain to screen thoughts and impulses and select which ones to attend to or to perform. Much of this occurs below the level of awareness. Therefore, if the inhibitory functions are sluggish, the individual can then have difficulty with disinhibition and distraction and executive function -- this is why ADD kids are sometimes referred to as having “sleepy brains“. Some children and adults seem to use excessive physical activity in order to “wake up their brain”. And they will not sleep well, because their brains were never "fully awake" all day. These kids may be hyperactive because of sluggishness/ poor regulation of brain waves.

Other individuals (including adults) can have “over-aroused” brains and can benefit more from training to increase their ability to self-calm. Some need a particular kind of training to improve the connectivity between different brain regions. Each brain requires personalized assessment and an individualized approach. It could well be that a variety of approaches could work for the same person.

All protocols are aimed at improved self-regulation through improving brain regulation. While medication approaches can be quite valid, Neurofeedback is very different from using medications that bathe the entire brain and body. Because it targets specific brain activity and regions. Medications are generally applied (or FDA indicated) based on diagnosis. However, modern psychiatrists know the diagnoses are not that clear cut, and may represent brain issues that cross diagnostic categories. Neurofeedback has an advantage of being able to target the functioning of brain electrical behavior in specific regions or networks.

There is currently much attention being paid to “brain networks”, and it is possible to address particular networks by providing NF to a hub of a network, thus affecting the symptoms that might be affected by that particular brain network.

Which form of eegNF has the most evidence?

Traditional neurofeedback (the kind done with one or two scalp sensors) is the form of neurofeedback that has evidence base dating back to the 1970’s, leading to the AMA CPT coding panel granting traditional neurofeedback Category 1 coding, which designates it now, 30 years later, as “established medical practice”. Newer forms of neurofeedback are considered more recently emerged therapies, are not proven to be more effective than traditional NF with one or two eeg sensors. NF practitioners have varied opinions and debates about which is best and which they offer. However, there may be occasions when one form is found to work better for a particular brain and individual. EEG NF can be very personalized when provided by a skilled clinician.

What about consumer products that claim to provide neurofeedback?

NF provided by a clinician with a personalized assessment and approach is very different from one-size-fits all “feedback devices” available to consumers. They are generally not FDA approved, and are considered wellness devices for home use. These may claim to be NF but may actually be training muscle tension or signals other than eeg. The claims of effect can be difficult to distinguish from practice or relaxation effect, and it is not clear that the brain learns anything like it does with traditional neurofeedback provided by a licensed clinician. Non-licensed professionals are usually prohibited by state regulatory boards from making claims to treat any medical conditions

Ongoing assessment and treatment adjustments

Once a treatment protocol (region of the brain and selected frequencies/brain networks to train) is selected, some patients will respond to the first or second protocol used. Some patients require changes in electrode placement or frequency selection. This is determined by the presenting problems, ongoing assessment and response, and the part of the brain/behavior of the brain that appears to need improved function. Sometimes it is only by selecting a protocol, then assessing the brain’s response to it over time, and adjusting the protocol according to response, that the effective protocol is discovered.

It is reasonable to hope for early signs of response, or early indications that the protocol should be adjusted. Generally, some response is looked for within 5 to 10 sessions. However, once a useful protocol is clarified, it can take 30 to 40 sessions or more to see a full response / more sustained response to that protocol. In some cases, more than one area or protocol is needed. On occasions, it is very difficult to find the right protocol, and then additional tests, such as the Qeeg, or consultation with another practitioner may be needed. In some cases, response will be partial, as is often the case with mediations. Sometimes, neurofeedback will not help.

It appears that coherence training sometimes is more efficient, possibly necessary for some conditions. Arousal based training followed by coherence training may be the best way to go. In typical situations, coherence training may take 15-30 trainings to get adequate results, in more complex situations, more or much more may be needed. In coherence training, if more coherence training is desired, a repeat Qeeg is needed approx. every 15 trainings to guide treatment, as coherence “moves” the brain strongly, and can be over-trained. Those repeat Qeeg’s -- while intensive -- do provide measure of progress.

TREATMENT OF CHRONIC CONDITIONS IS MORE EFFECTIVE WHEN COMPREHENSIVE AND PERSONALIZED

Keep in mind that particularly in chronic conditions, comprehensive treatment is the approach most likely to be effective. So other modalities need to be optimized. (Psychotherapy, meds, study skills re-training, addressing general health issues, fitness, diet, spirit and community are all important to consider.)

It can be essential to assess any factors that interfere with progress

Unhealthy or self-defeating behaviors, problems in the environment, changes in more than one treatment parameter at a time, or over-medication can complicate the decision making. (As the brain improves, negative side effects of medications can increase, signaling a need for reduction.) In complex cases it can be a challenge to assess “what is causing what” if too many changes or life stressors are happening at once. Thus, careful timing and judgements about medication changes, and on-going work on behavioral issues are essential to help support improvement in brain regulation, or there is risk of falling backwards into old patterns upon cessation of neurofeedback.

Working on environment and behavior that support good self-regulation is essential. This can be as simple as exercise and nutritional or more complex, like a course of EMDR or cognitive therapy or couples work, if there are issues in addition to attention that need to be addressed. Good nutrition supports learning with feedback, and feedback can enhance therapy! An integrative approach in medicine/healing puts together emphasis on self-advocacy, comprehensive assessment, self-regulation, nutrition, social, spiritual, behavioral, interventions into a whole-life approach. This is good not just for healing but for health, resilience, and optimum performance. A full integrative approach includes coordination between providers. This is my preferred approach.

Brainwave training accomplishes its effect through learning, thus practice is required.

The more frequently the practice occurs, the sooner the learning will take place and solidify. Just like it generally takes two or more years to solidify the multiplication tables for fourth and fifth graders, so too the learning from neurofeedback requires repetition and length of practice. Early on, and with each protocol change, the sessions need to be more frequent (two or three a week) until the training eeg and symptom reduction show signs of learning / retention. Major gains may take place within weeks or even days, but unless the trainings are repeated thirty or forty times, the gains are likely to be short lived. If sessions are spaced too far apart, the brain has to re-learn the material and progress is slow. It is important to consider the investment of time and energy and the timing of starting training so both ongoing assessment, other interventions, and consistency are arranged to support success.

PirHEG training is neurofeedback using infrared measures from the frontal lobe instead of eeg measures.

PirHEG stands for Passive Infrared Hemoencephalography. It is neurofeedback that targets the frontal lobe, where executive function is governed. PirHEG NF can help attention and self-regulation due to the prefronatal cortex’s s involvement in attention, and the frontal lobe’s regulatory effects on broader brain issues affecting attention and mood and cognition and other functions. It is simpler to administer, and is generally a weekly training. Similar considerations exist regarding watching for need to reduce medications. PirHEG is sometimes used prior to eeg training. It is particularly useful in persons dealng with emotional over-reactivity, migraines, frontal lobe injury from concussions/TBI, and attention and mood issues involving the frontal lobe. For some individuals, the frontal lobe is heavily involved in attention and depression problems. Please see my note on pirHEG for more details.

The device used for pirHEG measures infrared output from the front of the head. Because it is considered intrinsically safe (no electrical interface with the body), the manufacturer has not sought FDA approval or clearance for particular indications, and use of it is generally considered relaxation training and as a technology assisted adjunct to psychotherapy. Despite this, it is one of my most powerful tools.

Sometimes the effects of training are durable.

Like once a person learns to ride the bike, sometimes training effects are durable. Sometimes effects are more like math skills: if the circuits are not used, the brain circuits deteriorate, and need reminder practices. While some patients may not need further training, sometimes a patient will need refresher trainings (spaced weeks or many months apart). Some patients will not be able to reduce or discontinue meds, while some who remain on meds may return less frequently for neurofeedback, but be able to sustain better and stable mood with less medications and some maintenance neurofeedback. With coherence training, improvement may be more efficient. At this point in the field, there are many new approaches being used in hopes of more efficient response with fewer sessions, but none has proven itself to be more efficient than traditional neurofeedback utilizing one or two sensors.

Whether or not neurofeedback is helpful for students, it may be important that other issues are addressed and included as part of the overall treatment. This may include school intervention so the child has the support he or she needs to accomplish necessary tasks at school, as well as remedial assistance to improve learning skills as the attention improves. Minimal to extensive parent guidance/therapy from a skilled professional may be required. Medications can be used as indicated. Often, neurofeedback reduces or eliminates the need for medications, and causes other therapies to be more effective and efficient, thus reducing overall costs of treatment.