Brain waves recorded on Electroencephalograms (EEGs) reflect the moment-to-moment brain functioning in ADHD, and they can be used to improve how the brain is working. With emerging technologies, people can learn how to improve their own brain waves to overcome many symptoms of ADHD. In this chapter we provide the information you will need to take advantage of these new treatments and to keep up with the many advances that will occur in the next few years.
In order to do mental work such as thinking, analyzing, understanding, attending, planning, organizing, and generating appropriate responses, the brain has to speed up its activity. One of the problems with the ADHD brain is that when it is time to concentrate and do mental work, the system slows down instead of speeding up. In other words, when it’s time to go, it gets stuck. The cell assemblies shift to the wrong “gears” and generate slow waves (called alpha) instead of the faster waves (called beta) that are associated with active, concentrated thinking.
Using a variety of biofeedback methods, most people can learn how to change some of their brain waves. The results can be improvements in learning and behavior. Many of the mind–body practices we described in Chapter 5, particularly breathing practices, can also improve brain-wave activity. In this chapter we discuss other methods for correcting imbalances in brain wave patterns, including neurofeedback therapy, cranial electrotherapy stimulation, interactive metronome, heart rate variability feedback, coherence training, HeartMath®, and Early HeartSmarts®. Before learning more about these treatments, we first take a quick dip into the pool of scientific terms needed to follow the discussion.
Knowing some basic information about brain waves is a key to understanding how and why brain stimulation techniques can improve brain function in ADHD. You will need this information to help you decide how these treatments could fit into an integrated approach and whether you want to pursue them.
Brain cells work by generating electrical activity. Electroencephalography uses electrodes attached to the scalp at specific locations to record the brain’s electrical activity over a period of time, usually 20–40 minutes in clinical work. The electrical activity of a single neuron is too small to be picked up by one of these scalp electrodes. Instead, the EEG reflects the sum of synchronous activity of millions of neurons.
Figure 6.1. depicts the three frequencies being used the most in working with ADHD: theta, alpha, and beta. In people with ADHD, a common brain-wave imbalance involves too little fast activity (beta) and too much slow activity (alpha and theta). This reflects the tendency of the brain to run at a low speed when a higher speed is needed for alert, active, concentrated thinking.
Brain waves are divided into different types based on their frequency. The hertz (Hz) is the unit of frequency, that is, the number of cycles per second. One cycle includes one peak and one valley. So, for example, if you look at the graph of the theta waves (Figure 6.1.), you see about six peaks (indicating a frequency of 6 Hz) in the 1 second of the recording (the total on each EEG strip here is 2 seconds). This is within the defined range of 4–7 Hz for theta.
Figure 6.1 Brain-Wave Patternsa
Theta is the frequency range from 4 to 7 Hz. Theta is seen normally in young children. It can appear during drowsiness or arousal in older children and adults. Theta also occurs with relaxed, meditative, and creative states. In ADHD there is too much theta when mental work has to be done.
Alpha is the frequency range from 8 to 12 Hz seen mainly over the posterior areas of the brain on both sides. It emerges when the eyes are closed and the individual is alert but idle. Alpha diminishes when the eyes are open or during mental exertion. In ADHD there is too much alpha when the brain needs to do active mental work.
The peaks represent amplitude, that is, the sum of the current being generated by a large group of brain cells and recorded from an electrode placed at a particular spot on the head. As more and more brain cells shift into the same frequency, the amplitude increases to form a peak. If we think of a bandwagon carrying just one lonely saxophone player, no one will hear his or her music. But, as the other musicians jump onto that bandwagon and start to blow their horns, the volume (amplitude) will rise higher and higher. The amplitude peaks each time they all blow as hard as they can, and it subsides (into a valley) each time they ease off. Similarly, as more and more cells jump on the bandwagon by generating the same frequency, the amplitude of that frequency rises. A band playing “When the Saints Go Marchin’ In” will produce more frequent sound peaks than a band softly playing back-up for a soulful love song.
Beta frequency range is 12–28 Hz. It is distributed symmetrically on both sides, mainly in the frontal area. Low-amplitude beta with multiple varying frequencies often occurs with active, busy, or anxious thinking and with active concentration. It becomes the dominant rhythm when people are alert, or anxious, or have their eyes open. In ADHD there is not enough mid-beta when active concentration and mental work is needed. Specifically:
• 12–15 Hz, the slow beta range along the motor strip, is called the sensorimotor rhythm (SMR).
• 15–18 Hz is mid-beta and is associated with concentration or thinking.
• 18–28 Hz is hi-beta and usually indicates anxiety, trauma, hypervigilance, or insomnia.
Note. Different systems may use slightly different frequency ranges to delineate the types of brain waves.
a Printed with permission of Leslie H. Sherlin, PhD
Historically, research and treatment have focused on abnormal activity in the alpha, beta, and theta frequencies associated with ADHD. More recently, scientists have become interested in evoked potentials (EPs). Evoked potentials are like your response to being pricked with a pin—“Ouch!” The pinprick is an event or stimulus. Whenever an event occurs, the brain responds within a certain time frame (time-locked), usually measured in milliseconds. We could measure how long it takes you to say ouch after you are pricked with a pin. You probably don’t wait 15 minutes. You let loose with the ouch about 1 second after the pin penetrates your skin. We could measure the time it takes you to respond by repeating the pinprick at regular intervals, measuring how long it took for each ouch, adding up the times, and taking the average. We would discover that your ouch is time-locked, that it occurs within a specific time frame following the event of the pinprick. EPs occur in a certain time frame in response to the “prick” of a stimulus. The stimulus could be a painful sensation (e.g., the pinprick) or a flashing light or a repeating sound.
Table 6.1 Guide to Brain Waves: Comparison of EEG Frequencies
Rather than just recording the EEG as the brain tools along on its own, the brain is stimulated to respond to a repeating signal, such as a light flashing, at a certain rate. The EP is the electrical response of the brain to the sensory stimulus, in this case, a flashing light. Slow cortical potentials (SCPs) are event-related potentials that reflect preparation for the activation of large groups of cells. As the brain prepares to respond to a stimulus, we can think of an SCP as being the “Get ready, get set,” before the “Go!” Table 6.2 summarizes some commonly used neurofeedback training protocols.
Neurofeedback therapy, also called neurotherapy, trains patients to become aware of and influence their state of alertness based on real time EEG brain wave recordings. Sensors on the scalp are connected to computer software that records the brain’s electrical activity in the form of an EEG. While the brain activity is being monitored on the EEG, different kinds of feedback are given. As the person responds to the feedback, for example, information or images on a computer screen, changes occur in the EEG which are fed into the training program. The training program feeds the information back to the person using objects or games on a computer screen or, as in more recent developments, radio carrier waves.
Table 6.2 Commonly Used Neurofeedback Training Protocols
1. Theta/Beta training:
a. decrease theta slow waves (4–8 Hz)
b. increase faster beta waves (13–25 Hz)
2. Sensorimotor rhythm training
a. increase slow beta (12–15 Hz)
3. Slow Cortical Potentials (SCP)
a. Improve self-regulation of slow cortical potentials
As an example, theta–beta training uses a screen on which something changes in response to a change in the user’s brain waves, as recorded from a sensor, usually on the vertex (top of the head) in this protocol. It can be as simple as two bars on a computer screen. The challenge is to make the bar on one side of the screen shorter by reducing theta activity, while at the same time making the bar on the other side of the screen taller by increasing beta activity. The person is also instructed to reach a relaxed yet attentive state of mind. The feedback is seeing the changes in the height of the bars. Over time, the person learns to decrease theta and increase beta without having to use the computer screen. Elaborate, colorful computer games have been developed to be fun and engaging for children. In another example of neurofeedback therapy, the person may sit in a chair and simply look briefly at a small beam of light that provides the feedback (Robbins, 2000; Fehmi & McKnight, 2001).
The original neurofeedback studies used a flashing light signal until it was discovered that the therapeutic effect was due to radio frequencies, not the light. More recently, neurofeedback therapy has been using radio frequencies as carrier waves such that modifications of the patient’s own EEG can be used as the feedback signals. Just as vocal vibrations are superimposed on a radio carrier wave to produce the sounds we hear on a radio, so too, the EEG signal is superimposed on a radio frequency carrier wave. Len Ochs developed the low energy neurofeedback system (LENS; previously called Flexyx), using the slightly modified electrical signals from the patients’ EEGs to provide feedback to the brain using low-energy radio carrier waves at a level of intensity far below those of a cell phone (Glieck, 1988; Ochs, 2006). This quick, painless procedure requires minimal cooperation and is easily tolerated even by young children. However, it does require multiple treatments over a period of time. LENS has been reported to reduce symptoms of ADHD, PTSD, affective disorders, pain syndromes, chronic fatigue, and fibromyalgia in many cases (Larsen, 2006; Larsen, Harrington, & Hicks, 2006). Randomized controlled studies are needed to validate these positive clinical reports.
Slow cortical potentials (SCPs) are the result of the electrical change that occurs when a large group of nerve cells (assemblies) are activated. When the SCP is shifted in the negative direction, cell assemblies have a lower threshold of excitation; in other words, they are more easily activated, more responsive to events or stimuli. When the SCP is shifted in the positive direction, cell assemblies have a higher threshold and are more difficult to activate (Leins et al., 2007).
Picture a horse having to jump over a hurdle in training for a race. If the hurdle (threshold) is too high, the horse can’t gallop forward. If the horse is not strong enough to clear the hurdle, the top bar has to be lowered so that the horse can continue training. Children with attention problems have reduced shifts, in the negative direction, in cell assemblies in anticipation of a task. This means that when the ADHD brain gets ready to respond to a task, the threshold of excitation may not be low enough for the cell assemblies to be activated and do whatever mental work is needed. This can result in poor performance in reading, writing, math, comprehension, or any other mental task. Studies of children have shown that they can learn to regulate their SCPs through neurofeedback therapy (NFT). For example, after SCP training, 23 children with ADHD (ages 8–13) showed improvements in attention, IQ tests, and behavior. These improvements were sustained when they were retested 6 months later (Strehl et al., 2006).
Dr. Stephen Larsen, director of the Stone Mountain Center for Counseling and Biofeedback near New Paltz, New York, has helped thousands of clients with ADHD, learning disabilities, developmental disorders, seizures, and brain injury (see Resources at the end of the chapter). Dr. Larsen described the treatment of 100 of his cases using the LENS technique in his book The Healing Power of Neurofeedback (2006). We are fortunate to be able to collaborate with him for the benefit of our patients. Dr. Larsen is a skilled psychologist as well as a biofeedback specialist who treats both children and adults. The following are two cases in which Dr. Larsen’s neurotherapy contributed to the success of our integrative approach.
Nigel was adopted from a hospital nursery. His adoptive father, a business executive, suffered from lifelong drinking problems and mood instability. He described his adoptive mother as a career-obsessed media personality. Nigel felt “driven like a motor” and was very distractible. His ADHD had been diagnosed when he was 8 years old. As a child, he was constantly banging into things or dropping, bumping, and breaking whatever wasn’t glued down. Even as an adult he was physically uncoordinated. Despite many years of medication trials and psychotherapy, fundamentally, he didn’t think he was much better than he had been during childhood.
Nigel grew to be a tall, handsome young journalist. His previous psychiatrist had put him on Adderall for ADHD, but he continued to be distractible and to have terrible rages. Lisa, his fiancée, dreaded those rages.
When I (Dr. Brown) began to work with Nigel, I put him on a low dose of a stimulant, Ritalin, combined with the herb, Rhodiola rosea. As his rages came under control, Nigel began to like himself much better. He still complained that he had to smoke marijuana to calm down and sleep because the stimulant medications revved him up too much. He was also working with a psychotherapist who specialized in treating ADHD.
Thinking that Nigel might benefit from a course of neurotherapy, I referred him to a biofeedback specialist, Dr. Stephen Larsen. During the evaluation, Dr. Larsen gave Nigel a subjective symptom rating scale in which he rated the severity of his problems on a scale from 1 (no problems) to 10 (worst problems). He had high scores: 9 for explosiveness, 8 for hyperkinesis (feeling like a motor running constantly), 7 for distractibility, 6 for insomnia, and 6 for mood instability. He also mentioned a lifelong problem with being “clumsy.” Nigel was delighted when Dr. Larsen told him the medical term for clumsiness, dyspraxia, meaning difficulty in carrying out intended movements or motor tasks, even after one has tried repeatedly to learn them. Nigel’s eyes lit up. “That’s right on! I have to tell you that as a journalist I always prefer a Latinate term to a word as crude and ugly as clumsy! From now on I will tell people I suffer from dyspraxia!”
Dr. Larsen described Nigel’s treatment: “While Dr. Brown continued to manage the meds, we began our brain mapping and treatment. We were used to seeing quick results with LENS, but we were also familiar with how difficult adult ADHD can be to treat. Frankly, we were surprised at Nigel’s rapid response. After the first session he reported sleeping very well, even in an unfamiliar place (the B&B near our office). He told us the following morning, ‘There was less chatter in my head.’ Lisa, his fiancée, said that ‘Nigel just woke up and was more present and aware.’ Over the next several weeks there were ups and downs. At first the dyspraxia worsened, but then it got better. He noticed that his executive functions (his abilities to plan, organize, follow through, and get things done) improved. Nigel also began to make better progress in psychotherapy—for example, realizing how self-centered he’d been and vowing to be more attentive to Lisa’s feelings and needs.
“At Dr. Brown’s request I gave Nigel HeartMath training [see below]. To further balance Nigel’s stress response systems, Dr. Brown taught him coherent breathing. HeartMath and the breathing practice increased Nigel’s calmness and composure in the stressful environment where he worked. Dr. Brown started Nigel on SAMe (see Chapter 4) and continued a tiny dose of Ritalin (10 mg/day). Nigel really liked how he felt on this combination—alert, focused, calm, energetic, but not revved up. Dr. Brown continued fine-tuning his regimen by adding to the Ritalin another herb, Eleutherococcus senticosus, and a nootropic, aniracetam (see Chapter 3). He felt best using R. rosea, SAMe, Eleutherococcus senticosus, and aniracetam on most days and only taking the Ritalin occasionally when needed.
“Throughout this time Nigel continued neurofeedback therapy once every 1 or 2 weeks. He described feeling better without the amphetamine medications: ‘I can deal with the stress at work. I stayed calm, even when we were moving to a new office and a new apartment at the same time. When I feel myself becoming irritated, I just bark once and then it’s over. Lisa and I are getting along better than ever. Everything is soaring now, everything I want is happening.’
“Eight months after starting neurofeedback treatments, Nigel’s self-assessment scale confirmed his progress: 1 for explosiveness; 0 or 1 for hyperkinesis; 0 for distractibility; 2 for insomnia; 0 for mood instability. By the 10th month of treatment all of the self-assessment scores were 0. I noticed that Nigel was moving quite gracefully and comfortably in the office. ‘You know, you don’t look very clumsy to me at all,’ I quipped. ‘Please,’ he parried, ‘don’t you mean my dyspraxia has dwindled away?’ Touché!
“Nigel continued to see Dr. Brown every couple of months. Eleven months and 28 LENS treatments from the start, we were very happy to see him finish and say ‘Goodbye.’ Nigel was as surprised and pleased by the outcome as we were. He hadn’t asked to have ADHD in the first place, but he had taken the bull by the horns, and brought it to its knees! Eventually Nigel and Lisa got married. Now he is enthralled with their 18-month-old son.”
Gary was a very serious, polite, soft-spoken young man who looked at the floor when talking about his problems. About to graduate from parochial high school with mediocre grades, he was terrified of going to college because, “Words don’t get off the page into my mind.” Stimulant medications such as Adderall, Ritalin, Provigil, and Focalin had helped his attentional problems, but they also escalated his anxiety, prevented him from sleeping, and made his mind race around like a mechanical toy on a track.
Dr. Brown’s approach, using a small dose of Provigil combined with omega-3 fatty acids, vitamins, minerals, and tyrosine (an amino acid), had helped Gary feel better, but he was still struggling with schoolwork. Dr. Brown decided to refer Gary to Dr. Larsen for an evaluation regarding the possible use of neurotherapy. The initial brain map showed slow brain waves in the frontal area of the cortex and a “hot spot” at the back of the brain where the brain-wave amplitudes were twice as high as normal. Hot spots usually appear on the brain map in areas where there has been a focal injury to the brain. When asked about any brain injuries, Gary recalled being hit by a car and thrown into the air when he was 10 years old. He was knocked unconscious and hospitalized for 4 days. This brain injury probably explained why Gary had not responded well to medications or other treatments.
Gary’s initial subjective assessment revealed high scores: 10 for concentration problems, 10 for learning difficulties, 10 for procrastination, 10 for irritability (especially to noise), 7 for anxiety, 7 for lack of stamina, and 5 for sleep disturbance. After 20 weekly neurotherapy sessions, his scores improved: 5.5 for concentration; 5.5 for learning difficulties; 4 for procrastination; 2.5 for anxiety; 4 for lack of stamina; 8.5 for irritability (noise); and 0 for sleep disturbance. With better sleep, Gary had more energy. He became less anxious, more self-confident, and more optimistic in looking forward to college.
This case shows how a head injury can complicate the treatment of ADHD. If a person is not responding well after a series of appropriate treatment attempts, then it is time to look deeper into the situation. Head injuries are extremely common, particularly in children. They are often forgotten and not mentioned until a clinician jogs the person’s memory years later. Even relatively mild concussions can bruise the brain and cause some permanent damage when the soft brain tissue bumps up against the inside of the hard boney skull. Fortunately, neurotherapy can help improve recovery from brain injury as well as ADHD.
Excess theta (slow rhythms) low quality alpha, and reduced beta (faster rhythms) have been noted on EEGs of people with ADHD. This cortical slowing may reflect sluggish activity, for example, in the attention and inhibitory circuits we discussed in Chapter 2. Promising results have been reported using neurotherapy to increase alpha and/or beta rhythms, but further studies are needed (Lubar, Swartwood, Swartwood, & O’Donnell, 1995; Nash, 2000; Ramirez, Desantis, & Opler, 2001).
In a 12-week nonrandomized study of children with ADHD between the ages of 8 and 12 years, 22 children were given neurotherapy and 12 were treated with a stimulant medication, methylphenidate (Ritalin). Children whose parents preferred an alternative to medication were assigned to neurotherapy treatment. Both treatments significantly improved scores on ADHD assessments and attention and behavior in school (Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003).
One hundred children with ADD/ADHD, 6–19 years old, were treated for 1 year in an outpatient program where they all received methylphenidate (Ritalin), and academic support at school, and the parents received counseling. EEG biofeedback therapy was also given to 51 of the participants. Post-treatment testing while using Ritalin showed significant improvement in the symptoms of ADHD. However, at 1-year follow-up, only those children whose parents employed consistent reinforcement strategies at home and who had received EEG biofeedback sustained these gains when tested without Ritalin. There was also significant reduction in cortical brain-wave slowing only in patients who had received EEG biofeedback (Monastra, Monastra, & George, 2002). These findings would be strengthened by a fully randomized study.
In a controlled study of 18 children with ADD/ADHD, 6 of whom also had learning disabilities, the children were randomly assigned to two groups. One group was given EEG biofeedback once a week for 40 weeks, and the other group was put on a waiting list. Children who received EEG biofeedback had a 28% decrease in inattention compared to a 4% increase in the wait-list group (Linden, Habib, & Radojevic, 1996). Although this was a small study, it provides additional evidence for the benefits of EEG biofeedback for children with ADD, ADHD, and learning disabilities.
The effects of neurofeedback training, including both theta–beta and slow cortical potential training, were compared to a computerized attention skill training program in a large, multicenter, randomized, controlled study of 103 children with ADHD. The children treated with neurofeedback showed significantly greater improvements on measures of ADHD, behavior at home, and performance of homework (Gevensleben et al., 2009). Six months later, 61 of these children were available for follow-up retesting to determine if their improvements were long-lasting. On average, the benefits were sustained. Of the children who had received neurofeedback training, 50% showed a reduction of 25% or more on a standardized ADHD test, compared with 30.4% of the children in the attention skill training group (Gevensleben et al., 2010). This study provides strong support for the use of neurofeedback training as a complementary treatment for many people with ADHD. We anticipate further improvements in the effectiveness of neurofeedback protocols as the techniques are studied and adapted to the needs of individuals.
In people with ADHD, stimulant medications are believed to improve attention by increasing activity in dopaminergic neurons in the prefrontal cortex. Naturally, the question arose: Does neurotherapy have a similar effect? This question was addressed by a group at the University of Montreal where they documented changes in the functional magnetic resonance imaging (fMRI) of 15 children given 40 one-hour neurofeedback sessions during a 15-week study. The brain images showed an increase in activity within the anterior cingulate gyrus, an area of the prefrontal cortex that is associated with attention, concentration, and impulse control. The study also found significant correlations between the increased brain activity on fMRI and improvements in scores on tests of attention and concentration, as well as parent ratings of attention and hyperactivity (Lévesque, Beauregard, & Mensour, 2006).
Language difficulties can occur in any population, but they are more frequent in people with ADHD. The following is an example of a man who had symptoms of ADHD, but who sought treatment for a more distressing condition: stuttering. It is possible that in this case quieting the right prefrontal cortex stopped the stutter. His story also shows how rapidly new treatments are being developed as scientists and clinicians figure out how to use the flood of new information about how the brain works with the new technologies that are available.
Running was the one place where Jim felt he excelled. Having ADHD and a stutter, Jim often felt embarrassed and ashamed. Running set him free. As part of a national championship running team, he had the honor of carrying an Olympic torch through three states. That torch became his prized possession.
After retiring from his job as an engineer, Jim wanted to fulfill his lifetime dream of coaching sports teams, but he was terrified that he would stutter while making a call on a play. It was difficult enough to stammer, to have people treat him as stupid, to be disrespected because of stuttering, but the dread of looking foolish in an arena filled with fans overwhelmed him with anxiety. For 6 months he tried stimulant medications, but they caused nausea and dry mouth while doing nothing for his symptoms. Finally, he consulted a neurotherapist, Dr. Laurence Hirshberg, director of the Neurodevelopment Center at the Alpert Medical School of Brown University. He was given treatments for ADHD, memory, and stuttering. The treatments directed at improving his brain-wave balance reduced his forgetfulness.
For the stuttering, Dr. Hirshberg’s strategy was based on research findings of increased activation in the right prefrontal cortex compared to the left during speech in stutterers. Since the left prefrontal area, called Broca’s area, is considered to be predominant in speech, Dr. Hirshberg thought that the excess activity of the corresponding area on the right side could be creating interference, resulting in stuttering. He therefore applied neurotherapy to increase alpha (slow resting frequency) activity in the right prefrontal area to deactivate it (i.e., put it to rest). The response was unexpectedly rapid. After the first 15-minute session, Jim experienced no stuttering for 24 hours. After the second (30-minute) session, he was fluent (stutter free) for 2 days. After the third (1-hour) session, he was even more fluent for 4 days. With neurotherapy the effects usually last longer with increased training. When I (Dr. Gerbarg) interviewed Jim, he talked for 40 minutes with no actual stuttering. There were some brief periods of hesitancy in his speech, but overall he spoke quite well. For the first time, Jim is feeling hopeful and gaining self-confidence as he waits to see what further progress he will make with neurotherapy. If you are interested in following Jim’s progress, Dr. Hirshberg posts updates on his blog (see Resources at the end of the chapter).
You are probably wondering if neurotherapy works for everyone or if there are some criteria to use in deciding whether or not to try this approach. Based on our combined experience and the available research, we have identified some general benchmarks you and your doctor can apply in deciding whether to pursue neurotherapy treatment.
• Based on EEG patterns. At this time, studies are showing that people who have increased theta or theta–beta ratios are more likely to benefit from treatment with stimulant medication, neurotherapy, or both (Sherlin, Arns, Lubar, & Sokhadze, 2010).
• Based on clinical symptoms. Current research suggests that neurofeedback is most effective for inattention and impulsivity. When the main problem is hyperactivity, medication is a better option (Sherlin et al., 2010).
• Based on the presence of other disorders. Individuals with ADHD and a learning disability, brain injury, seizure disorder, or pervasive developmental disorder may benefit from the addition of neurotherapy to their treatment programs.
• Based on medication response. Neurotherapy should be considered for people who show:
1. Less than complete response to stimulant medication
2. Unwillingness to take stimulant medication
3. Intolerable side effects in reaction to stimulant medication
Despite many positive reports on the benefits of neurofeedback therapy for ADHD in both adults and children, many health care professionals are not familiar with it or do not yet accept its validity. In part this is because much of the early literature was based on case reports or nonrandomized studies. However, the quality of research is improving, increasing the solid evidence base to support these treatments (Monastra, 2008; Sherlin et al., 2010). Through research and greater clinical experience, more specific, targeted, effective treatments are evolving.
The main advantages of neurofeedback treatments are that they are painless, very low in side effects, beneficial in about 75% of cases when provided by a well-trained clinician, and the effects have been shown to last 6 months or more following a course of treatment. Some individuals are highly sensitive to neurofeedback. In such cases, the treatments may need to be briefer in order to minimize adverse reactions. Side effects may include headache, nausea, dizziness, sleepiness, or agitation. In contrast, medications have a higher rate of side effects and the benefits are lost when the medications are discontinued. The main disadvantages of neurofeedback are the need for frequent (one to three times per week), prolonged (2–12 months) treatments. This is costly, especially because neurofeedback is not yet covered by many insurance companies.
The International Society for Neurofeedback Research maintains a website with excellent information, articles on new developments, references, conferences, training workshops, and help in locating certified neurofeedback practitioners: www.isnr.org.
Cranial electrotherapy stimulation (CES) uses microcurrents, very low voltage electrical signals, applied to the head to improve brain function. CES has been used for over 40 years in Europe, the United States, and other countries to treat depression, anxiety, sleep disorders, headaches, pain, and to relieve spasticity in children with cerebral palsy. Two studies found that CES increased attention and concentration in normal adults (Hutchinson, Frith, Shaw, Judson, & Cant, 1991; Southworth, 1999). Clinical reports of benefits in treating ADHD are appearing, but controlled studies are needed to validate these promising findings.
Many cases do better when CES is combined with other treatments as was reported in the case of a nine-year-old boy with anxiety, dyslexia, and ADD (Overcash, 2005). The child was described as nervous, disorganized, and having frequent stomach aches and headaches due to anxiety about going to school. In the third grade, despite tutoring and working with a speech and language pathologist, he could not recognize all the letters of the alphabet and was reading at a Kindergarten level. Changing his Ritalin to Concerta and using Project Read reading program five days a week for three months produced no improvement. At that point the parents agreed to Dr. Overcash’s recommendations to discontinue medication and begin Alpha-Stim CES for one hour every morning and evening to reduce anxiety and ADD symptoms. In addition he prescribed neurotherapy using the ROSHI/BrainLink one hour twice a week during his sessions with the reading specialist to improve his concentration and ability to learn. The parents and teachers began to report that the boy was more “settled’ and easier to work with after CES treatments. He was also better able to concentrate and learn. By the end of 6 months treatment, his overall IQ increased from 97 to 112 with substantial improvements in concentration and memory. Reading improved to a third grade level, spelling to a fourth grade level, and math to a fourth grade level. The stomachaches and headaches stopped as he became less anxious. Follow-up two years after discontinuing neurotherapy showed that the benefits were maintained.
In clinical practice, we find that CES is often helpful for people with ADHD because it can improve attention, reduce anxiety, and relieve insomnia. Sometimes we get unexpected benefits, even in extremely difficult situations such as this—The Grinch that Stole Childhood.
For most children, each day is a new adventure. Children look forward to playing with their friends, learning new things, experiencing loving relationships, and enjoying feelings of pride as they master new skills. Severe ADHD can rob a youngster of the normal joys of childhood.
Daniel had had enormous problems all his life. In addition to ADHD, he suffered from depression, anxiety, insomnia, and multiple learning disabilities. Being impulsive, hyperactive, and inattentive, he repeatedly broke school rules, defied his father and school authorities, and cursed like a sailor. When his parents argued, he became agitated and had panic attacks. By the age of 11, he had developed an Internet pornography addiction. Other children could not stand to be around him, leaving him with no friends. He often thought, “Life is not worth living. I wish I wasn’t alive.”
Daniel was one of those children with ADHD who do not respond to stimulant medications. Trials of Ritalin, Adderall, Strattera, Atomoxetine, Trileptal (oxcarbazepine), serotonin reuptake inhibitors, and other antidepressants all failed. Treatment with two mood stabilizers (anticonvulsants), Depakote (divalproex) and Gabapentin (neurontin), yielded only slight improvement. Clonazepam and melatonin helped a little with sleep. Nothing worked well. His EEG during sleep revealed a severe parasomnia (an abnormal pattern of arousal) for which there is no known treatment.
Daniel started using marijuana and Ecstasy at age 13 and was hospitalized for a year in substance abuse treatment programs. He continued to abuse marijuana and was rehospitalized for 6 months. By this time he was being treated with multiple medications: Adderall, Seroquel (quetiapine), Zoloft (sertraline), Gabapentin, Remeron (mirtazapine), trazadone, and Zyprexa (olanzapine) with minimal improvements.
The family brought him to see me (Dr. Brown) for a consultation. I advised them to try a CES device (Fisher Wallace). The father’s first reaction was, “How could that possibly help my son? You’re supposed to be a doctor!” I finally convinced the boy and his parents to give this approach a try.
The CES began to work within the first month. Using level 2 (this device has four levels of intensity) for 20 minutes twice a day, Daniel was sleeping better, felt less anxiety, and noticed improvements in mental focus and energy. He admitted, “It’s a real relief.” Teachers began to compliment his work. The craving to abuse substances faded and he stopped using marijuana and quarts of caffeinated drinks. The dose of Adderall was reduced from 80 to 20 mg a day. He stopped seeking out Internet porn sites and became interested in more age-appropriate activities. For the first time in his life, he had friends who enjoyed hiking, canoeing, and camping with him.
Daniel told me, “I used to feel horrible waking up every morning. Now I wake up and look forward to the day. The CES helps with my organization, and I’m more independent. I don’t think about death anymore. I’m thinking of getting a job.”
Many people who feel better using a CES device begin to slack off, and Daniel was no exception. He came in 9 months later, sounding like he was getting worse again. He admitted that he was using the CES only once a day a few days during the week. I asked him, “Do you remember how awful it used to be? Do you want to go back to that?” Of course, he didn’t. By increasing his use of the CES to once a day, every day, Daniel was able to remain well. When Daniel is inconsistent with CES treatment, his symptoms tend to worsen, but he has never slipped back to the state of severe dysfunction he suffered before treatment.
Unlike electroconvulsive therapy (ECT), which uses high-amplitude currents, CES uses very small currents (less than in a cell phone) that do not cause seizures or convulsions. The currents are so low that usually the patient does not even feel them.
Studies show that 20 minutes of CES treatment increases the levels of neurotransmitters: serotonin, norepinephrine, beta-endorphins, GABA, and dehydroepiandrosterone (DHEA; Liss, & Liss, 1996). Norepinephrine is known to improve mental alertness, and serotonin is involved in the modulation of dopamine, learning, mood, and memory. In Daniel’s case, there were clear improvements in alertness, learning, and mood. Although beta-endorphins are best known for their role in pleasure pathways, they are also involved in learning, memory formation, and the sense of reward (Routtenberg, 1978). In Chapters 1 and 2 we discussed reward deficiency syndrome, the inability to enjoy the usual sources of pleasure in life. Although it cannot be proven, it is certainly possible that the endorphin effects of CES contributed to changes in Daniel’s ability to enjoy normal activities with his peers rather than having to seek excessively stimulating experiences. He acquired the ability to feel rewarded through recreational activities as well as from school achievements. The ability to experience pleasure and reward enabled him to wake up and look forward to each day. Increases in GABA are important because it is the primary inhibitory neurotransmitter in the brain. As such, it is essential for moderating and controlling over-reactivity. Such improvements in self-regulation may have helped Daniel to reduce his anger and control his destructive behaviors.
An additional mechanism that may contribute to the beneficial effects of CES is the stimulation of sensory nerves that could activate the parasympathetic system (calming). In Chapter 5 we discussed the importance of activating the parasympathetic system to balance the stress response system in ADHD. When these systems are well balanced, the result is calmness better problem solving, and improved emotion regulation, impulse control, and behavior. Furthermore, the CES also turns on the reticular activating formation, the network responsible for maintaining arousal, alertness, and attention.
We know that CES treatments can increase levels of neurotransmitters that are crucial for arousal, attention, learning, and memory. What we still don’t know is exactly how the microcurrents bring about these changes in the neurotransmitters. Theories have been advanced, but so far, none has been proven (Klawansky et al., 1995). We do know that CES research is gearing up in major medical centers. This research should provide evidence that will confirm previous reports and our own positive clinical experience.
There are eight FDA approved CES devices currently on the market. The most extensively studied are ALPHA-STIM® and the LISS Cranial Stimulator device (now marketed by Fisher Wallace). Most CES machines consist of a small handheld unit containing AA or 9-volt batteries. Current from the batteries travels through two wires to two electrodes that are attached to the head or earlobes. Treatments usually last 20 to 40 minutes. Depending on the severity of the condition, the CES can be used once or twice a day at a prescribed level of intensity. Results may be seen in 1 week, but may take as long as 2 months of daily use.
ALPHA-STIM® and the Fisher Wallace Stimulator have FDA approval for the treatment of anxiety, depression, and sleep disorders, and acute and chronic pain. Studies also suggest benefits for ADHD, headache, and obsessive–compulsive disorder. Further research evidence is needed to obtain approval for the specific FDA indication for use in ADHD.
A prescription from a physician is needed to order the CES. The advantages of this device are that it is very safe, even for young children, when used in the correct doses. It can be used to improve response to medications, to reduce the dose of medications, and sometimes to eliminate medications. The CES targets a wide range of symptoms associated with ADHD, including attention, hyperactivity, impulsivity, learning disorders, behavior problems, anxiety, depression, reward deficiency, and sleep. Although it is covered by only a limited number of insurance companies, it may still be worth the investment when one considers the ongoing cost of medications and doctor visits, as well as the toll that ADHD can take on the lives and happiness of the patient and family. Most companies have a money-back policy (minus processing charges) if the device is not effective within 1 to 2 months.
• Anyone with ADHD could benefit from a trial of Cranial Electrotherapy Stimulation (CES), particularly if there are symptoms of anxiety, panic attacks, phobias, agitation, insomnia, depression, processing problems, or procrastination.
• For those few people who may become overstimulated or agitated in reaction to CES, the duration of each treatment can be shortened, starting with 3 minutes and increasing very gradually, as tolerated.
• We recommend consultation and monitoring by a health care professional who is knowledgeable in the use of CES for adults and children.
CES can be combined with other treatments such as medication, neurotherapy, breathing practices, and remediation of learning disabilities for optimal results.
For over 300 years metronomes have been used to drill timing into the hearts, hands, and minds of music students all over the world. Who could forget that relentless clicking of the metal lever swinging back and forth on its pyramidal throne? New computer technologies are harnessing the power of the metronome to help people with ADHD develop better motor planning, sequencing, and timing—all essential for attention, learning, and behavior control. For example, learning involves putting things in sequential order in the mind. Neural networks in the prefrontal and striatal areas are involved in timing and motor planning. These same areas were found to be hypoactive (below normal activation) on fMRI in children and adults with ADHD (Cubillo et al., 2010).
Preliminary studies are showing that computer-assisted technologies such as the Interactive Metronome® (IM) have the potential to improve attention and learning in ADHD and learning disabilities.
The IM system uses a computer, headphones, and two contact sensors. One sensor in the palm of a glove is triggered by clapping. The other sensor, a flat plastic back set on the floor, is triggered by pack foot tapping. When a subject hears a tone through the headphones, he or she claps or taps a response. The sensor transmits a signal to the computer, which notes how long the person took to respond. The IM analyzes the time delay and adjusts the guidance sounds—pitch of the tone and location (left-to-right) in the headphones—based on the accuracy of the tapping signals. Through thousands of repetitions, the person is trained to respond more rapidly and accurately to sequences of tones.
In a randomized study of 56 boys with ADHD, ages 6–12 years, those who were given 15 hours of IM training showed significantly greater improvements in attention, language processing, reading, and control of aggressive behavior (Shaffer et al., 2001). As with all treatments, the IM may not be as effective in all cases. For example, children with severe learning, cognitive, neurological, and emotional problems were excluded from the Shaffer study.
It is important to recognize that many ADHD children with learning problems can improve reading skills if given early intensive remediation. For example, combining IM with other interventions that are individually tailored for specific deficits, such as sensory stimulation, motor training, aerobics, and academic training, can be even more effective. A multimodal approach was given three times a week for 12 weeks to 122 children, ages 6–12, with ADHD. At the end of the 12-week training, tests found that 81% of the students showed significant improvements in parent symptom ratings, eye–hand coordination, overall academic performance, spelling, written expression, and listening comprehension (crucial for learning in class lectures). On a word-reading subtest, 84% gained 2 or more years of improvement in grade level. The main limitation of this study was that there was no long-term follow-up to see if these improvements were sustained (Leisman et al., 2010).
Bill struggled in college with ADHD, processing problems, procrastination, and depression. He was also not happy with his tennis backhand. Processing problems made it hard for Bill to absorb information during lectures. Due to procrastination, he fell behind in his coursework. When I (Dr. Brown) treated Bill with Adderall, it helped to some degree, but caused insomnia. Picamilon partly relieved the depression, and he seemed to benefit at first from neurofeedback therapy, but the effect plateaued. He tried R. rosea (Rosavin), SAMe, and numerous herbs. Although there was progress, he was still plagued with processing problems and procrastination.
I referred Bill for a course of IM and found that his processing improved. As a result, he showed increased reading comprehension, greater ability to absorb information from lectures, and better academic performance. Bill was also teaching part time. The IM treatment enhanced his ability to express and communicate ideas to his students. As for timing, he was thrilled to report a major improvement in his tennis skills, especially his backhand.
Fortunately, Bill was willing to try new things. When I suggested the CES LISS device (Fisher Wallace), he was game. As he increased the CES to level 2 for 20 minutes twice a day, his sleep got much better. After 6 weeks, his depression vanished, never to return. Since I didn’t hear from him for 6 months, I called to see how he was doing. Bill was sailing through graduate school. He was still using the CES and taking Rosavin 100 mg twice a day, but he had stopped all other medications. As for procrastination—it was completely gone. Bill had never been so productive before. He was full of creative ideas and able to translate them into his work. He was “in the flow” and on his way to a rewarding career.
We don’t always know at the outset which treatments are going to work best for a particular individual. Usually we have to work with each person over time to try a variety of approaches and combinations of treatments. Though this can be tedious or frustrating at times, it is well worth the effort to bring someone to his or her highest possible level of recovery and performance.
Additional large-scale controlled studies are needed to explore the potential benefits of IM as a complementary treatment for ADHD and learning disabilities. Nevertheless, given that IM is a noninvasive, time-limited treatment without adverse effects, there is enough research evidence and clinical experience to consider a trial of this emerging technology as an additional component in a multimodal treatment plan.
• People with ADHD and reading comprehension problems may benefit from IM combined with reading remediation.
• People with cognitive processing problems such as difficulty processing visual or auditory information or ideas.
• People with procrastination problems.
A variety of feedback methods can be used to improve brain function. In Chapter 5 on mind–body practices, we saw that breathing patterns can provide powerful feedback to the brain. Changing the patterns of breathing can affect brain function in numerous ways. You may wish to refresh your memory by revisiting Figure 5.3 (p. 148). Breathing affects interoceptive pathways from the body to brain areas involved in emotion regulation (limbic system) and cognitive functioning (thalamus and cerebral cortex). In addition, breathing can improve the balance between the sympathetic and parasympathetic nervous systems, shifting the brain into a relaxed, calm, attentive state. In this chapter, we reviewed the use of brain waves to provide feedback to retrain the brain. For example, theta–beta training involves shifting the balance of frequencies by reducing slow-wave theta and increasing fast-wave beta to correct deficiencies in ADHD.
The heart also provides feedback through the vagus nerves (interoceptive system) to brain areas involved in emotion and cognitive function. Figure 6.2 shows pathways carrying information from the heart to the brainstem nuclei and from there to the amygdala (emotion processing and memory center) and the cerebral cortex (thinking area of the brain). These are the same brain areas we saw affected by voluntary changes in breathing patterns in Chapter 5.
Figure 6.2. Heart Activity Affects Brain Function
This diagram illustrates afferent (ascending) pathways by which neurological signals generated by the heart are transmitted to key centers in the brain. These heart signals not only impact autonomic regulatory centers in the brain (e.g., the medulla), but also cascade up to higher brain centers involved in emotional and cognitive processing, including the thalamus, amygdala and cortex. Through these pathways, heart activity exerts a continuous impact on numerous aspects of brain function. As shown, when patterns of heart activity are erratic and disordered, such as during emotional stress, the corresponding patterns of neurological signals traveling from the heart to the brain produce an inhibition of higher cognitive and emotional functions. In contrast, the more ordered and stable pattern of the heart’s input to the brain during positive emotions has the opposite effect—serving to facilitate cognitive function and reinforcing positive feelings and emotional stability. (From McCraty et al., 2006. © Institute of HeartMath) Reproduced with permission of R. McCraty and the Institute of HeartMath.
New treatments are focusing on the heart itself to provide feedback to improve autonomic balance and brain function. Heart rate variability (HRV) is a measure of the change in the heart rate when we breathe in compared to when we breathe out. HRV is useful because it gives us a way to indirectly measure changes in the activity of the parasympathetic and sympathetic nervous systems. Many researchers utilize HRV as an indicator of the balance between the sympathetic (fight–flight) and the parasympathetic (safety, soothing) systems. Moreover, HRV can be used as feedback to enhance self-regulation. The electrical pattern on the left side of Figure 6.3 shows erratic changes in HRV compared with the smooth (coherent) pattern on the right side. Treatments that induce a shift toward a smoother, more coherent pattern are associated with improved cognitive function, emotion regulation, and positive emotions.
It is easy to monitor HRV using a simple sensor to register the pulse either from one finger or from an earlobe clip. Subtle changes in the variation in the pulse are computed to calculate moment-to-moment changes in HRV. Facing a computer screen, the subject places one finger inside the sensor, which is connected to a computer by a cable. As the computer registers changes in HRV, it creates different effects on the computer screen. When HRV increases, a rewarding response appears on the screen. By seeing the changes in images on the screen, the subject learns to shift how his or her brain is functioning to produce the desired result. In effect, the person learns how to create the state of mind associated with increased HRV, a state that is calm, alert, and more cognitively efficient.
We review two heart-centered treatments being used to treat ADHD and learning disabilities. One method uses HRV feedback. The other uses a combination of HRV, breath regulation, and mental focus on the heart and positive emotions.
Mind–body practices have been used for thousands of years for emotion regulation, and computer-assisted technologies are now being rapidly developed for emotion self-regulation training. We are now seeing the convergence of ancient yogic and meditative practices with modern neuroscience and computer technology. An example of the synergy between ancient and modern techniques is the Early HeartSmarts (EHS) program, a multimodal approach using HeartMath with other heart- and breath-centered techniques. Before describing this program, we need to understand a few concepts, starting with psychophysiological coherence, intentional generation of psychophysiological coherence, and the HeartMath program. In Chapter 5 on mind–body practices, we discussed coherent breathing, one aspect of psychophysiological coherence. Recall that coherent breathing uses a breathing rate of five or six breaths per minute and is associated with increased HRV and an ideal balance between the sympathetic and parasympathetic systems.
Figure 6.3. Shift to Coherence
The real-time heart rate variability (heart rhythm) pattern is shown for an individual making an intentional shift from a self-induced state of frustration to a genuine feeling of appreciation by using a HeartMath positive emotion refocusing technique (“Freeze-Frame intervention,” at the dotted line). Note the immediate shift from an erratic, disordered (incoherent) heart rhythm pattern associated with frustration and emotional stress to a smooth, harmonious, sine wave-like (coherent) pattern as the individual uses the positive emotion refocusing technique to self-generate a feeling of appreciation. (From Bradley et al., Chapter III, 2007, © Institute of HeartMath). Printed with permission of R. McCraty and the Institute of HeartMath.
A simple way to think of psychophysiological coherence is as a state of mind–body synchrony. A more “scientific” definition would say that psychophysiological coherence reflects a state of increased synchronization, efficiency, and flexibility with and among physiological, cognitive, and emotional systems. Positive emotions, such as love, compassion, and gratitude, shift neurological systems toward greater psychophysiological coherence (Lloyd, Brett, & Wesnes, 2010).
Intentional generation of psychophysiological coherence occurs when a person intentionally shifts his or her attention to the physical area of the heart and deliberately brings to mind a positive emotion. Figure 6.3 shows the change from an erratic HRV during a negative emotional state of frustration to a smooth, coherent HRV when the person intentionally shifts to a positive emotion—in this case, appreciation (Bradley, McCraty, Atkinson, Arguelles, & Rees, 2007).
This is a “scientific” description of a method similar to the compassion meditation used for thousands of years by Buddhist meditators who focus the mind on compassionate thoughts to engender positive emotions and desirable physiological states. Brain-imaging studies are showing that such meditations and other mind–body practices can affect neurotransmitter systems, how the brain functions and, over many years, the architecture of brain structures involved in emotion processing and regulation (Lazar et al., 2005; Streeter et al., 2010).
The EHS program was designed to facilitate emotional self-regulation and social, emotional, and cognitive development in young children. It accomplishes these goals by teaching children how to recognize, understand, and regulate emotions; how to express positive feelings to family and friends; how to improve peer relations; and how to engage problem-solving skills. The program was tested in a controlled study of 309 preschoolers (3–5 years old). Children given the EHS intervention showed significantly greater improvements in social, emotional, physical, cognitive, and language development. The program was effective regardless of gender, ethnicity, or socioeconomic status (Bradley, Atkinson, Tomasino, Rees, & Galvin, 2007).
In a randomized controlled study, 38 children with ADHD (ages 9–13 years) were taught three HeartMath emotional self-regulation techniques. During each practice session the students shifted their focus of attention to the area around the heart while breathing easily and slowly, as if breathing through the chest area. HRV coherence feedback was used to help teach the “Heart Lock-In” technique to generate and maintain a positive emotional state. As described above, the HeartMath system used an earlobe clip pulse sensor to track HRV coherence and provide visual feedback through a computer game called the “Rainbow Game.” At the same time, students listened to a music CD designed to promote physiological coherence and emotional balance. After 6 weeks of practice, the students given the HeartMath interventions showed significant improvements in cognitive functions and significant reductions in difficult behaviors. They learned to use the Heart Lock-In technique at home and at school to self-regulate their emotional states (Lloyd et al., 2010).
Programs that combine emotion regulation techniques, including HRV coherence feedback and the teaching of emotional awareness, intentional generation of positive emotions, and methods to increase psychophysiological coherence are being tested in school systems. As experience is gained, the programs will become even more effective with adaptations for specific needs of students. Similar techniques are already in use within a variety of therapeutic mind–body programs for adults (see Chapter 5). Such programs can be beneficial at any age, but they may be most effective during childhood when the neural connectivity has a higher degree of plasticity (capacity for change). Early intervention could correct neurophysiological imbalances, jumpstart healthier patterns, and enable children to enjoy the benefits of learning and social relatedness for the rest of their lives.
Q: Is it possible to increase the activity of specific brain areas through stimulation?
A: Yes, it is. Ongoing research is needed to identify which specific areas are underactive in each individual, what kinds of stimulation are likely to be most beneficial and long-lasting, and how to best provide programs that are practical and affordable for the people who need them. We already have the technology to identify the level of activity in brain areas critical to learning, attention, emotion regulation, behavior control, and reward processing. In the foreseeable future, using both brain scan and EEG data to monitor brain activity, it should be possible to develop programs using neurofeedback, cranial electrotherapy stimulation, interactive metronome, heart-centered biofeedback, and other modalities to address many of the challenges that confront people with ADHD.
We have introduced you to treatments using emerging technologies. In deciding whether to pursue these approaches, consider the following steps:
1. Learn more about treatments that interest you by exploring the websites and resources below.
2. Discuss these treatment options with your health care providers. They may be able to recommend local practitioners for you to interview.
3. Before you decide on a particular treatment, make an appointment to discuss it with the provider. Find out how much experience and knowledge the provider has regarding working with ADHD. If the provider does not have much experience, he or she may be able to recommend someone in the field who does.
4. It can be helpful to set up an initial evaluation. For example, a neurofeedback specialist who performs an initial QEEG (qualitative EEG) would be able to show you your brain-wave patterns and discuss how to go about improving them. Be sure to ask for an estimate of the number of sessions that would be required and the cost per visit.
5. Neurofeedback and brain stimulation techniques take time. Some people respond to their first treatment. But, it is best to allow at least 6 weeks for noticeable changes.
6. Do not expect a provider to be able to precisely predict how or when you will respond. Each person is unique. Depending on your response, the treatments may need to be adjusted and tweaked numerous times. Keep talking with your provider and asking questions so that you feel comfortable with how the treatment is progressing.
The following websites, organizations, books, and journals will provide you with information to understand and access the treatments discussed in this chapter.
Alpha-Stim: www.alphastim.com.
Cranial electrotherapy stimulator that enhances alpha waves.
Fisher Wallace: www.fisherwallace.com.
Cranial electrotherapy stimulator based on LISS device.
HeartMath: www.heartmath.com.
Products and programs that reduce stress. Institute for HeartMath: Early HeartSmarts for ages 3–6; HeartSmarts for grades 3–5.
International Society for Neurofeedback and Research: www.isnr.org. Information, conferences, training, research, referrals.
Neurodevelopoment Center, Alpert Medical School, Brown University, Providence, RI: http://www.neurofeedbackexperts.blogspot.com. information on Dr. Laurence Hirshberg’s work.
Stone Mountain Center for Counseling and Biofeedback: www.stonemountaincenter.com.
Dr. Stephen Larsen provides evaluation and neurofeedback.
Larsen, S. (2006). The Healing Power of Neurofeedback: The Revolutionary LENS Technique for Restoring Optimal Brain Functioning. Rochester, VT: Healing Arts Press.
Comprehensive information about neurofeedback with 100 case examples.
Journal of Neurotherapy —research articles on the latest developments in neurotherapy.
1 We wish to thank Dr. Stephen Larsen, Dr. Rollin McCraty, Dr. Laurence Hirshberg, and Dr. Leslie Sherlin for their assistance in the preparation of this chapter.
