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EFFICACY OF BARABASZ'S INSTANT ALERT HYPNOSIS IN THE TREATMENT
OF ADHD WITH NEUROTHERAPY
This efficacy study tested the effects of Barabasz's instant alert hypnosis (IAH), also known as
Instantaneous Neuronal Activation Procedure (INAP, Barabasz & Barabasz, 1995) used as an
adjunct to neurotherapy. Sixteen children, N = 16, who participated in this study, were diagnosed
with Attention Deficit Hyperactivity Disorder (ADD/ADHD). A two factor test of efficacy with
repeated measures on both factors was used. The results showed that EEG beta-theta ratio means
were significantly higher in the trials of neurotherapy combined with alert hypnosis in contrast to
neurotherapy alone. Beta was significantly enhanced while theta was inhibited. The clinical
implications of these findings with regard to improved treatment efficacy and reduced time in
treatment are discussed.
Attention Deficit Hyperactivity Disorder (ADD/ADHD) is a biologically-based behavioral
disability and if left untreated may persist into adulthood (Barabasz & Barabasz, 1996; Gualteri
& Hicks, 1985). It is one of the most frequently diagnosed disorders among school children. The
Diagnostic and Statistical Manual of Mental Disorders IV (American Psychiatric Association,
1994) noted that AD/ADHD affects 3% to 5% of the school-aged children, yet Whalen and
Henker (1991) noted that the prevalence rate ranged from 5% to 15% in community samples and
50% or higher among clinical referrals. Two main features of ADD/ADHD are a pervasive
pattern of inattention and an impulsivity more severe and frequent than other children at a similar
level of development. The impulsive and inattentive symptoms must appear before the age of 7
years and must appear in more than a single situation, causing interference in social, academic,
or occupational functioning (DSM-IV, 1994).
Psychologists have used behavior modification, and in concert with physicians, psychoactive
drugs, such as methylphenidate (Ritalin), to manage the symptoms of ADD/ADHD. Behavior
modification can be effective when both parents and teachers work together consistently and
continuously. Unfortunately, trained behaviors do not generalize to new situations, nor do they
generalize to nontrained behaviors (Gaddes & Edgell, 1994). Psychoactive drugs used to treat
ADD/ADHD have many side effects, and methylphenidate (Ritalin), for example, apparently
does nothing for 25% to 40% of those treated (Swanson et al., 1993). One problem with these
symptom management interventions is that when the medication and/or behavior modification
are stopped, ADD/ADHD pretreatment/baseline symptoms and level of dysfunction return
(reviewed by Barabasz & Barabasz, 1995, 1996a). Another limitation of stimulant medication is
that children on stimulants become more responsive to punishment and less responsive to reward
(Arnett, Fischer, & Newby, 1996), a situation which lays a weak foundation for adaptive
learning. Cognitive-behavioral therapy has greater treatment flexibility for rehabilitation, but in
the treatment of ADD/ADHD, cognitive-behavioral therapy has shown no evidence of any
lasting effects (Conte, 1991).
Neurotherapy
Neurotherapy (brain wave/EEG biofeedback) has become an alternative habilitative treatment for
ADD/ADHD (see other articles in this Child Study Journal issue). In this treatment, the slow
EEG theta waves, typical of the wandering mind, are inhibited and the faster EEG beta waves,
associated with learning and vigilance, are enhanced through feedback training. Pope and Bogart
(1996) note that training includes providing real-time beta-theta information to show the child
with ADD/ADHD how well he or she is producing brain wave activity associated with attention
and concentration. The goal of neurotherapy is permanent normalization of brain wave patterns
without continued dependence on drugs or behavior modification (Barabasz & Barabasz, 1996).
Neurotherapy treatment is based on research showing that ADD/ADHD appears to have a
neurological basis. Neurofeedback's effects on brain wave patterns have been explained on the
basis of (a) changing the firing rate of thalamic pacemakers, and (b) enhancing frontal lobe
function. Lubar (1997) conceptualized the neurophysiological underpinnings of ADD/ADHD
and how neurotherapy works to normalize brain wave patterns based on its effects on the
thalamic pacemakers. The cortex operates through communication between neocortical columns
of cells. As explained by Lubar (1997), the communication loops are known as resonances. The
gamma EEG wave (32+ Hz) is a very high frequency wave that occurs in local resonance loops
between two narrow macro columns. The alpha (8-12 Hz) and beta waves (1230 Hz) are
intermediate frequencies that occur in regional resonance that develops between two macro
columns that are several centimeters apart. Delta (1-4 Hz) and theta (4-8 Hz) EEG waves
develop between widely separated areas in global resonance. The thalamus produces pacemakers
(neuromodulators) which cause different brain rhythms by activating different cortical resonance
loops. Lubar (1997) notes that "learning, emotion, motivation, or neurofeedback ... can change
the firing rate of the thalamic pacemakers and, hence, change their firing pattern" (p. 116). If the
firing pattern is changed, the thalamus is activating different cortical resonance loops, resulting
in changes in EEG waves.
In addition, considerable evidence exists for frontal lobe dysfunction in ADD/ADHD (Chelune,
Ferguson, Koon, & Dickey, 1986; Gualteri & Hicks, 1985; Hynd, Hern, Voeller, & Marshall,
1991; Hynd, Semrud-Clikeman, Lorys, Novey, & Eliopulos, 1990; Lou, Henriksen, Bruhn,
Borner, & Nielsen, 1989; Schaughency & Hynd, 1989; Voeller & Heilman, 1988). The executive
nature of frontal lobe functions are critical in inhibiting attentional focus to irrelevant stimuli and
mobilizing inhibitory behaviors. The frontal lobe is also involved in planning and organization.
Posner and Raichle (1994), in Images of Mind, discuss their model of executive attention. They
hypothesized that the cingulate gyrus, found on the medial surface of the brain, organizes
executive attention which then activates the areas of the frontal lobe. Lubar (1997) noted that
neurofeedback "training is done right over this anterior cingulate region ... the cingulate gyrus
and that in turn may be enhancing the executive functions of the frontal regions" (p. 123). Also,
individuals with ADD/ADHD tend to show less right frontal mass as well as bilaterally smaller
anterior cortexes, especially the right anterior, than individuals without ADD/ADHD which
could point to a frontal lobe dysfunction, especially a right frontal lobe impairment (Barabasz &
Barabasz, 1996a; Hynd et al., 1990; Hynd et al., 1991). The intent of neurotherapy is to help
individuals with ADD/ADHD overcome these handicaps by increasing beta activity while
simultaneously reducing theta activity (Barabasz & Barabasz, 1996a; Mann, Lubar, Zimmerman,
Miller, & Muenchen, 1992).
Neurotherapy can be lengthy, taking up to 40 to 80 sessions to complete. However, Barabasz and
Barabasz (2000, this issue) have shown that the number of neurotherapy sessions required may
be cut by half at least when instant alert hypnosis is used as an adjunct to neurotherapy.
Hypnosis as an Adjunct
Hypnosis is used as an adjunct to many therapeutic interventions. In a meta-analysis, Kirsch,
Montgomery, and Sapirstein (1995) examined a wide range of hypnosis interventions used in
conjunction with cognitive-behavioral therapy. They found that 70% of patients exposed to a
combination of hypnosis and cognitive-behavioral therapy had significantly greater improvement
than those patients exposed to the identical cognitive-behavioral therapy techniques without
hypnosis. The disorders successfully treated with hypnosis are too numerous to mention here.
For current reviews see the April 2000 special issue of the International Journal of Clinical and
Experimental Hypnosis.
There is almost universal agreement that hypnosis involves the participant's attentional processes
(Barabasz, 1980, 1982, 1985; Barabasz, Baer, Sheehan, & Barabasz, 1986; Barabasz & Barabasz,
1989, 1992, 1993, 1994, 1995, 1996a, 1996b; Barabasz, Crawford, & Barabasz, 1993; Barabasz
& Lonsdale, 1983; Brown & Fromm, 1986; Crawford & Gruzelier, 1992; Hilgard, 1975, 1992).
Depending upon the instruction, hypnosis may focus attention to exclude distractors (Hilgard,
1975, 1992) or may "serve to facilitate the more general attentional processes involved in
vigilance" (Barabasz & Barabasz, 1996a, p. 278). Barabasz (1980) found that using alert
hypnosis enhanced military radar detection in a radar simulator. Barabasz (1985) also found that
alert hypnosis improved military pilots' flight reliability through greater situational awareness
with regard to cockpit navigation cues.
Alert hypnosis with attentional instructions has also been used to speed normalization in
response to neurofeedback (Barabasz & Barabasz, 1993, 1996a, 1996b; Barabasz, Crawford, &
Barabasz, 1993). Background direction relevant to the present study is provided by two
interesting case studies (Barabasz & Barabasz, 1996a). Neurotherapy for ADD/ADHD in one
case ("Mike") was compared to neurotherapy with the addition of alert hypnosis for a more
symptomatically severe case ("Juan"). The two cases were chosen because of matching gender
and hypnotizability scores, their closeness in age, and their similarity in verbal and performance
IQs. Despite greater ADHD severity, Juan required a total of only 32 sessions; whereas, Mike
required a total of 67 sessions. Both cases showed significant improvement in beta-theta
normalization. Another interesting aspect of this clinical trial was that a A-B-A test was
incorporated into Juan's treatment which showed that when INAP was not used (session 13-15),
"progress in the enhancement of frontal beta and reduction of theta stagnated ... and resumed
upon reinitiation of INAP" (p. 285). Barabasz and Barabasz (1996a) concluded that the use of
instant alert hypnosis appeared to facilitate the production of EEG beta during EEG feedback
training.
Neurotherapy plus instant alert hypnosis has the potential to become the treatment of choice for
ADD/ADHD. Promising results of case studies (Barabasz & Barabasz, 1995, 1996a, 1996b) have
led to research with larger numbers of participants which shed light on the effectiveness of this
adjunctive treatment (Barabasz & Barabasz, 1999, 2000); Warner, Barabasz, & Barabasz, 2000).
On the basis of the review of literature, the purpose of this efficacy study was to determine
whether neurotherapy trials, with an enhance beta and inhibit theta feedback protocol combined
with instant alert hypnosis, would show significantly enhanced beta over theta ratios in contrast
to neurofeedback trials alone.
Methodology
Participants
Sixteen children's records were independently and randomly drawn from a pool of patients
treated with neurotherapy from the practice of Arreed Barabasz, Ph.D., ABPP. All patients treated
in Dr. Barabasz's practice agree that their treatment data can be used for research/educational
purposes as part of a signed pretreatment disclosure/consent process. Hence, there was no
systematic effect that could be produced by non-volunteering versus volunteering behavior.
Thirteen of the participants were males and three were females. All of the participants met the
DSM-IV criteria for ADD/ADHD. All participants had histories of 4 to 10 years psychostimulant
drug use (M = 6.3 years), and behavior modification treatment prior to beginning neurotherapy
with instant alert hypnosis treatment. All the children were moderately to highly hypnotizable on
the basis of the Stanford Hypnotic Clinical Scale: Child Form (Morgan & Hilgard, 1978) (mean
score = 5.6, median score = 5.5, range 4-7).
Procedure
Neurotherapy is described in detail elsewhere (see article by Sterman, 2000, this issue). In the
present study, EEG feedback was provided to participants on a computer monitor screen which
showed how well they were producing brain wave patterns associated with attention. EEGs were
essentially real-time analyzed for characteristics of frequency, amplitude, and artifact.
Stereophonic auditory feedback was provided through speakers to augment the visual feedback.
Participants were positively reinforced for producing beta while simultaneously inhibiting theta.
A red light, accompanied by a buzzer-like tone appeared when the children produced muscle
movement related artifacts (typically eye muscle movement).
Electrode sites, according to the international 10-20 system, common to all 16 participants
included Fp1, Fp2, Fz, Cz, Pz. First, each participant completed 5 feedback trials per site to
assure familiarity with neurofeedback and to allow participants adequate experience in the
management of movement artifact. Then the next trial sets, balanced between the neurofeedback
plus alert hypnosis condition and the neurofeedback only conditions, were used to provide data
for the present study. Data provided by the NRS-24 (see next section) consisted of average
microvolts per trial for EEG beta and theta frequency bins. For each site, all neurofeedback plus
alert hypnosis trials and neurofeedback only trials were averaged and then converted into
beta/theta ratio data for statistical analysis.
Apparatus
The EEG measures were obtained using the Lexicor Medical Technology (Boulder, CO)
Neurosearch 24 (NRS-24) system and a modified IBM 486 PC. Scalp electrode to reference
electrode resistances were kept below 7000 ohms. EEG was amplified 32,000 times, between
0.5-64 Hz with a notch filter at 60 Hz. EEG was digitized at 256 samples per second with a
resolution of 0.1 microvolt. The electroencephalogram recordings were obtained for referential
monopolar sites according to the international 10/20 system. Artifacts due to eye movement,
breathing, or electromyography were identified by the computer system. No data was acquired
nor reinforcement provided for periods coincident with such artifact.
Results
A two-factor analysis of variance (ANOVA) with repeated measures on both factors was chosen
for data analysis as described by Neter, Kutner, Nachtsheim, and Wasserman (1996). Treatment
(neurotherapy only, neurotherapy with alert hypnosis) was one factor and the electrode sites
(Fp1, Fp2, Fz, Cz, Pz) was the other factor, thereby creating a 2 x 5 factorial design.
The ANOVA revealed a significant effect for treatment, F (l, 15) = 59.56, p <.0001.
Neurotherapy with INAP produced significantly higher beta-theta ratios than neurotherapy only.
The means and standard deviations for site and treatment are reported in Table 1.
No significant differences were found among electrode placement sites, F (4,15) = 2.26, p = .
065. The interaction between treatment and sites was not significant, F (4,15) = 0.51, p = .727.
The results are presented in Figure 1.
Discussion
The inability to regulate attention is a principle feature of Attention Deficit Hyperactivity
Disorder. Lubar (1997) noted that people with ADD/ADHD produce theta rather than beta EEG
brain waves, which negatively affects attention and concentration. Hypnosis involves attentional
process. As reviewed by Barabasz and Barabasz (1996a): "... consideration of these data
(hypnosis affecting attentional processes) in the broader context of the neurological basis of
attention deficit led to our hypothesis that INAP could serve as an adjunct to standard
neurotherapy" (p. 284). The very promising findings of the earlier case studies provided the
impetus to test the effect of Barabasz's Instant Alert Hypnosis on beta production with an N
sufficient for statistical analysis. This study satisfied this missing link and established that
beta/theta ratios were significantly higher when alert hypnosis was employed as an adjunct to
neurotherapy. When combined with the results of the Warner et al. (2000, this issue) study, the
results show that Barabasz's Instant Alert Hypnosis increased beta production while inhibiting
theta which resulted in the decreased symptomatology associated with ADD/ADHD.
Our findings clearly support the hypotheses that neurotherapy only significantly enhanced beta
over theta ratios and that neurotherapy combined with alert hypnosis trials significantly enhanced
beta over theta ratios in comparison to neurotherapy without instant alert hypnosis. The
neurotherapy with hypnosis beta/theta ratio means were typically over twice that of the
neurotherapy only beta/theta ratio means. If alert hypnosis was used as an adjunct to standard
neurotherapy treatment, length could be decreased thereby, decreasing the cost. Also, when
inattentive, impulsive, and hyperactive symptoms are decreased with increased beta production,
the cost of treatment is also decreased since an ongoing behavioral modification and
psychopharmacologic program may no longer be necessary. In the present study, only one of the
16 participants remained on medication at the conclusion of treatment and this was at a greatly
reduced dosage. No participants were treated with behavior modification subsequently.
A limitation to this study is that all participants were treated by Arreed Barabasz. Therefore, there
is no evidence, yet, of the degree to which other therapists will be successful in using this
technique. The neurotherapy clinical outcomes and the recent controlled studies look promising,
but more research is needed to establish the generalizability and potential of instant alert
hypnosis as an adjunctive procedure to standard neurotherapy in the treatment of ADD/ADHD.
We believe that our findings are significant enough to encourage other therapists to add
neurotherapy and alert hypnosis as techniques to offer clients in the treatment of ADD/ADHD.
TABLE 1
Beta-Theta Ratio Means and Standard Deviations for Neurofeedback Only and Neurofeedback
Plus Alert Hypnosis
Site Treatment M SD
Fp 1 Neurofeedback only 1.49 0.83
Fp 1 Neurofeedback & Alert Hypnosis 3.31 2.34
Fp2 Neurofeedback only 1.17 0.40
Fp2 Neurofeedback & Alert Hypnosis 2.50 1.14
Fz Neurofeedback only 1.06 0.52
Fz Neurofeedback & Alert Hypnosis 2.17 0.84
Cz Neurofeedback only 1.10 0.88
Cz Neurofeedback & Alert Hypnosis 2.76 2.03
Pz Neurofeedback only 1.59 1.03
Pz Neurofeedback & Alert Hypnosis 2.86 0.98
All 5
Sites Neurofeedback only 1.28 0.52
All 5
Sites Neurofeedback & Alert Hypnosis 2.72 1.46
Note. N = 16.
GRAPH: Figure 1. Beta-theta ratio findings for neurofeedback with instant alert hypnosis
(INAP) and for neurofeedback only (no INAP).
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~~~~~~~~
By Kathryn Anderson; Marianne Barabasz; Arreed Barabasz and Dennis Warner, Washington
State University
Kathryn Anderson Attentional Processes/Hypnosis Laboratory Washington State University PO
Box 642136 Pullman, WA 99164-2136
