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Neurofeedback dans le trouble déficit de l’attention avec hyperactivité : de l’efficacité à la spécificité de l’effet neurophysiologique
Abstract
Clinical guidelines for attention deficit/hyperactivity disorder (ADHD) recommend a multimodal treatment encompassing pharmacological medication with methylphenidate, cognitive-behavioral therapy (CBT) and family treatments. Methylphenidate is the most effective treatment, though the relatively high rate of partial responders, and the possible parental reluctance against the pharmacological treatment. Thus, it is interesting to consider new non-pharmacological therapies based, such as CBT, on the learning capacity of children to self-regulate their behavior. Neurofeedback is interesting insofar as it would allow children to acquire self-control over certain brain activity patterns to improve the regulation of their behavior in daily-life situation. Early studies on neurofeedback in ADHD are nearly 30 years old. Two training protocols were created, based on EEG abnormalities in ADHD. First training allows the modulation of EEG frequency bands: increased activity in the beta band, or decreased activity in the theta rhythm. The second allows an increase in a slow cortical potential. In both protocols, feedback of the brain activity patterns is given to children in real time as a kind of computer game, and changes that are made in the desired direction are rewarded, i.e., positively reinforced. The evidence-based level of the neurofeedback is still unclear. But, unlike other mental disorders, many studies have investigated the effect of this treatment on symptoms of ADHD. Thus, we propose to analyze the data of literature and especially recent studies. A meta-analysis and randomized controlled studies seem to confirm the efficacy and the possible place of neurofeedback in the multimodal treatment strategies of ADHD. But, if this treatment supposes to allow self-regulation of children behavior by learning the control of EEG activity, the specific mechanisms of action on brain activity remains problematic. Thus, we propose to identify methodological and neurophysiological areas for future research on this therapy involving the subject and electrophysiology in psychiatry.
... Son application thérapeutique s'est principalement développée, depuis les années 1970 [4][5][6], dans le cadre de la prise en charge du trouble déficit de l'attention/hyperactivité (TDA/H) de l'enfant [7]. Il existe deux types de protocoles standards utilisés dans le TDA/H (pour revue voir : [8,9]). D'une part, le protocole « bêta/thêta » mesure la puissance spectrale dans la bande fréquentielle EEG bêta et thêta en regard de l'électrode Cz (région centrale médiale) et met à disposition une information permettant au patient de développer des stratégies cognitives afin d'augmenter la puissance spectrale dans la bande bêta et/ou de diminuer celle de la bande thêta. ...
... Jusqu'à maintenant assez confidentiel, ce débat a pris place récemment dans l'American Journal of Psychiatry [11] et le Journal of Clinical Psychiatry [12] par des échanges de lettres secondaires à une méta-analyse [13,14] et à une étude d'efficacité [15][16][17][18]. Aussi l'objectif principal de cet article est d'effectuer une analyse de ce débat depuis notre dernière revue de la littérature [8] afin de mettre en exergue les points importants pour améliorer la qualité des études d'efficacité du neurofeedback dans le TDA/H. ...
... Après les premières études dans les années 1980 sur l'utilisation du neurofeedback dans la prise en charge des épilepsies pharmacorésistantes [21], les années 1990 ont vu apparaître des études dans le TDA/H de l'enfant [8]. Ces études se caractérisent par leurs faibles effectifs, leurs caractères bien souvent non randomisés et non contrôlés, mais sont réalisées le plus souvent par des praticiens ayant participé au développement des premières machines de neurofeedback [7,22] et ayant une bonne connaissance des instruments électrophysiologiques, élément essentiel pour le développement d'un entraînement efficace pendant les séances [2]. ...
Le neurofeedback par la création d’une boucle psychophysiologique rétroactive présente des avantages, en comparaison des autres techniques de remédiation cognitive utilisées dans la prise en charge des enfants souffrant de trouble déficit de l’attention/hyperactivité (TDA/H). Pourtant, bien que cette technique soit utilisée depuis près de 20 ans dans le TDA/H, son niveau de preuve d’efficacité reste débattu. L’évolution du nombre de publications recensées par la base de données électroniques PubMed par les termes medical subject headings (Mesh) « Neurofeedback » et « Attention-Deficit Disorder with Hyperactivity » permet de proposer une analyse de l’évolution de la littérature sur le neurofeedback et le TDA/H suivant deux périodes : avant 2011 et après 2011. Les premières études avant 2011, sur neurofeedback et TDA/H, ont mis essentiellement l’accent sur la qualité du protocole de neurofeedback et de l’effet d’apprentissage au cours des séances, aux dépens de la construction méthodologique du protocole en lui-même (absence de randomisation et de groupe témoin). Cette attention semble avoir diminué dans les études plus récentes, qui se concentrent sur la construction de protocoles plus rigoureux (avec groupes témoins de meilleure qualité et évaluations en aveugle). Cependant, les conditions de bonne pratique du neurofeedback lui-même sont le pendant indispensable aux études de preuve d’efficacité bien conduites. Ainsi les futures études d’efficacité du neurofeedback dans le TDA/H devront allier la qualité méthodologique des études randomisées contrôlées en aveugle à la qualité de la conduite des séances de neurofeedback.
... Parmi ces thé rapeutiques complé mentaires et non pharmacologiques « psychologiques », le biofeedback est une technique qui offre des perspectives d'efficacité trè s inté ressantes pour les é pilepsies pharmacoré sistantes [12,[18][19][20]. Le biofeedback constitue en effet une mé thode particuliè re parmi les traitements « psychologiques », puisque l'apprentissage des straté gies est facilité par la mise à disposition en temps ré el d'une information « physiologique » provenant du patient [21][22][23] (Fig. 1). Le biofeedback cré e donc une boucle « psychophysiologique » ré troactive et a donc l'avantage thé orique par rapport aux autres thé rapies d'ordre « psychologique » de cré er un sentiment d'auto-efficacité de maniè re trè s rapide (souvent dè s la premiè re sé ance) et en temps ré el par le renforcement positif physiologique [21,23,24]. ...
... Chacun de ces protocoles implique la participation active et la motivation du sujet. La duré e et la fré quence des sé ances varient en fonction des é tudes, mais gé né ralement les sé ances durent entre 30 et 60 minutes, une à trois fois par semaine sur une pé riode de plusieurs semaines [13,22]. Ces critè res temporels peuvent donc constituer une limitation au dé veloppement de ces protocoles, d'autant que les patients souffrant d'é pilepsie pharmacoré sistante né cessitent plus de sé ances de biofeedback que les sujets sains pour obtenir les mê mes modifications EEG [34]. ...
... Il faut noter que le rythme SMR partage des similarité s avec les activité s de fuseau de sommeil et que l'entraînement à augmenter les rythmes SMR dans les é tats de veille augmente le nombre de fuseaux pendant les é tats de sommeil lent de stade 2 [37]. Enfin, l'augmentation des rythmes SMR a é galement é té utilisé e dans la prise en charge du trouble dé ficit de l'attention avec hyperactivité (TDA/H) car ce type de protocole permettrait d'amé liorer les capacité s attentionnelles lié es à l'é veil [22,38]. ...
Biofeedback is a complementary non-pharmacological and non-surgical therapeutic developed over the last thirty years in the management of drug-resistant epilepsy. Biofeedback allows learning cognitive and behavioral strategies via a psychophysiological feedback loop. Firstly, this paper describes the different types of biofeedback protocols used for the treatment of drug-refractory epilepsy and their physiological justifications. Secondly, this paper analyzes the evidence of effectiveness, from a medical point of view, on reducing the numbers of seizures, and from a neurophysiological point of view, on the changing brain activity. Electroencephalography (EEG) biofeedback (neurofeedback) protocol on sensorimotor rhythms (SMR) has been investigated in many studies, the main limitation being small sample sizes and lack of control groups. The newer neurofeedback protocol on slow cortical potential (SCP) and galvanic skin response (GSR) biofeedback protocols have been used in a smaller number of studies. But, these studies are more rigorous with larger sized samples, matched control groups, and attempts to control the placebo effect. These protocols also open the way for innovative neurophysiological researches and may predict a renewal of biofeedback techniques. Biofeedback would have legitimacy in the field of clinical drug-resistant epilepsy at the interface between therapeutic and clinical neurophysiology.
... Parmi ces thé rapeutiques complé mentaires et non pharmacologiques « psychologiques », le biofeedback est une technique qui offre des perspectives d'efficacité trè s inté ressantes pour les é pilepsies pharmacoré sistantes [12,[18][19][20]. Le biofeedback constitue en effet une mé thode particuliè re parmi les traitements « psychologiques », puisque l'apprentissage des straté gies est facilité par la mise à disposition en temps ré el d'une information « physiologique » provenant du patient [21][22][23] (Fig. 1). Le biofeedback cré e donc une boucle « psychophysiologique » ré troactive et a donc l'avantage thé orique par rapport aux autres thé rapies d'ordre « psychologique » de cré er un sentiment d'auto-efficacité de maniè re trè s rapide (souvent dè s la premiè re sé ance) et en temps ré el par le renforcement positif physiologique [21,23,24]. ...
... Chacun de ces protocoles implique la participation active et la motivation du sujet. La duré e et la fré quence des sé ances varient en fonction des é tudes, mais gé né ralement les sé ances durent entre 30 et 60 minutes, une à trois fois par semaine sur une pé riode de plusieurs semaines [13,22]. Ces critè res temporels peuvent donc constituer une limitation au dé veloppement de ces protocoles, d'autant que les patients souffrant d'é pilepsie pharmacoré sistante né cessitent plus de sé ances de biofeedback que les sujets sains pour obtenir les mê mes modifications EEG [34]. ...
... Il faut noter que le rythme SMR partage des similarité s avec les activité s de fuseau de sommeil et que l'entraînement à augmenter les rythmes SMR dans les é tats de veille augmente le nombre de fuseaux pendant les é tats de sommeil lent de stade 2 [37]. Enfin, l'augmentation des rythmes SMR a é galement é té utilisé e dans la prise en charge du trouble dé ficit de l'attention avec hyperactivité (TDA/H) car ce type de protocole permettrait d'amé liorer les capacité s attentionnelles lié es à l'é veil [22,38]. ...
Biofeedback is a complementary non-pharmacological and non-surgical therapeutic developed over the last thirty years in the management of drug-resistant epilepsy. Biofeedback allows learning cognitive and behavioral strategies via a psychophysiological feedback loop. Firstly, this paper describes the different types of biofeedback protocols used for the treatment of drug-refractory epilepsy and their physiological justifications. Secondly, this paper analyzes the evidence of effectiveness, from a medical point of view, on reducing the numbers of seizures, and from a neurophysiological point of view, on the changing brain activity. Electroencephalography (EEG) biofeedback (neurofeedback) protocol on sensorimotor rhythms (SMR) has been investigated in many studies, the main limitation being small sample sizes and lack of control groups. The newer neurofeedback protocol on slow cortical potential (SCP) and galvanic skin response (GSR) biofeedback protocols have been used in a smaller number of studies. But, these studies are more rigorous with larger sized samples, matched control groups, and attempts to control the placebo effect. These protocols also open the way for innovative neurophysiological researches and may predict a renewal of biofeedback techniques. Biofeedback would have legitimacy in the field of clinical drug-resistant epilepsy at the interface between therapeutic and clinical neurophysiology.
... Dans la premiè re partie de cet article, nous avons analysé la naissance et le dé veloppement de l'e ´ lectricité en neurophysiologie et en psychiatrie suivant deux perspectives, selon que l'on s'adresse a ` la stimulation cé ré brale ou a ` l'enregistrement des activité s e ´ lectriques cé ré brales [32]. Nous proposons dé sormais d'e ´ tudier le dé veloppement et les applications thé rapeutiques de ces deux perspectives en psychiatrie : la stimulation externe cé ré brale (en particulier, stimulation magné tique transcrânienne ré pé té e, rTMS, et de stimulation par courant continu direct, tDCS) [29], et le neurofeedback [20]. A B S T R A C T In the second part of this paper, we propose to analyze the historical development of therapeutic applications of electrical brain stimulation and electrical brain recording. ...
... Les techniques de biofeedback utilisant une mesure de l'activité EEG cé ré brale sont appelé es « EEG-biofeedback » ou plus communé ment « neurofeedback ». Elles permettent la ré gulation de l'activité cé ré brale par un sujet pré sentant des troubles neurologiques ou psychiatriques dans le but de ré duire l'intensité des symptô mes cliniques [20]. ...
... Un protocole de neurofeedback afin d'apprendre a ` la patiente a ` augmenter son activité SMR avait permis l'arrêt complet des crises d'e ´ pilepsie [27]. C'est en 1976 que Lubar et Shouse ont ré alisé les premiè res applications psychiatriques du neurofeedback chez des patients pré sentant un TDAH [19], dont les preuves d'efficacité peuvent e ˆtre considé ré es dé sormais comme acceptables [20]. ...
Dans la deuxième partie de cet article, nous proposons d’analyser le développement historique des applications thérapeutiques des techniques de stimulation et d’enregistrement en psychiatrie. La stimulation externe cérébrale (en particulier, stimulation magnétique transcrânienne répétée, rTMS, et de stimulation par courant continue direct, tDCS) et le neurofeedback seront donc étudiés. Nous proposerons en ouverture des perspectives thérapeutiques de couplages permettant à l’enregistrement et aux stimulations, historiquement séparés, de se rapprocher.
... Ainsi, le neurofeedback sur SMR a été évalué dans l'épilepsie et le trouble déficit de l'attention avec hyperactivité (TDAH). Pour revue voir : [12,13] ; ...
... Malgré les résultats prometteurs des travaux de Sterman et al., les recherches sur l'efficacité clinique du neurofeedback dans le trouble insomnie sont peu nombreuses et une grande partie des résultats dont nous disposons aujourd'hui sont issus d'études classiques menées dans les années 1980. Les travaux pionniers de Sterman et al. ont surtout conduit à des études dans le champ de l'épilepsie et du TDAH [12,13]. Concernant l'épilepsie, cette équipe réalisait également des tests d'exposition à un agent pouvant abaisser le seuil épileptogène : le monomethyl hydrazine (MMH) utilisé par l'armée américaine dans le comburant des fusées. ...
Résumé
Le neurofeedback est une technique particulière de biofeedback qui utilise comme paramètre l’activité cérébrale, le plus souvent électroencéphalographique (EEG), dans le but de permettre, par des récompenses lors de la modification du paramètre dans le sens désiré, un entraînement et apprentissage de la régulation d’une fonction neurophysiologique qui, normalement, n’est ni perçue ni contrôlée consciemment. Parmi les paramètres de l’activité cérébrale, l’activité EEG la plus fréquemment utilisée, est l’entraînement au renforcement des rythmes sensorimoteurs (SMR). L’entraînement de l’augmentation du SMR serait relié à une activité cognitive de type « éveillé et attentif » avec inhibition accrue de l’activité motrice. Cet entraînement pourrait permettre de diminuer l’hyperéveil cortical relié à certains troubles, notamment dans le trouble insomnie chronique. Cet article présente les premières études chez l’animal dans les années 1970 ayant suggéré un effet bénéfique du neurofeedback SMR sur la qualité et la quantité du sommeil et des mécanismes d’action passant par les boucles de régulation thalamo-corticales de régulation de l’éveil et du sommeil. Il évalue ensuite les essais cliniques d’efficacité sur le sommeil à la fois chez les sujets avec trouble insomnie et sans trouble insomnie, afin de souligner les enjeux de recherche futurs du neurofeedback en médecine du sommeil. Il reste en effet nécessaire de réaliser des études contrôlées, randomisées, en double insu et des évaluations à long terme des plaintes d’insomnie et la qualité et quantité de sommeil, afin d’asseoir définitivement l’efficacité du neurofeedback et sa place dans le champ des thérapeutiques non pharmacologiques de l’insomnie. Ces études devront permettre non seulement de répondre à la question de l’efficacité, mais aussi de permettre d’avancer dans le domaine de la mise en place optimale des protocoles de neurofeedback et de la fixation des seuils de récompenses pendant l’entraînement, de la mesure de l’effet d’apprentissage et du paramètre cérébral impacté et du sous-groupe de trouble insomnie chronique ciblé en fonction de ce paramètre, et enfin des variables non spécifiques influençant l’entraînement, l’apprentissage et l’efficacité de la thérapeutique.
... Ces cinq derniè res anné es, les Annales Me´dico-Psychologiques ont ainsi publié dans leurs colonnes de nombreux articles d'auteurs français, canadiens et belges abordant ce trouble en tant que tel ou, comme souffrance associé e à d'autres difficulté s (thymiques, addictives, sociales notamment) [2, 3,6,7,9,11]. ...
... Therefore, SMR neurofeedback training procedures have been applied to patients with insomnia [31,91]. Moreover, as it has been clinically shown that SMR neurofeedback induces a decrease of motor activity as well as an improvement of the vigilant state of alertness related to attention capacities, it has been suggested to use such a training for Attentional Deficit Hyperactivity Disorder (ADHD) (previously called hyperkinetic disorder) therapies [58]. In 1976 [52], Lubar's team published the first case study showing a possible beneficial effect of neurofeedback on hyperkinetic activity in a child with ADHD treated with low-beta SMR neurofeedback (''production of 12-14-Hz activity in the absence of 4-7 Hz slow-wave activity''). ...
Many Brain Computer Interface (BCI) and neurofeedback studies have investigated the impact of sensorimotor rhythm (SMR) self-regulation training procedures on motor skills enhancement in healthy subjects and patients with motor disabilities. This critical review aims first to introduce the different definitions of SMR EEG target in BCI/Neurofeedback studies and to summarize the background from neurophysiological and neuroplasticity studies that led to SMR being considered as reliable and valid EEG targets to improve motor skills through BCI/neurofeedback procedures. The second objective of this review is to introduce the main findings regarding SMR BCI/neurofeedback * Corresponding author. Service d'explorations fonctionnelles du système nerveux, clinique du sommeil, CHU de Bordeaux, place Amélie Raba-Léon, 126 C. Jeunet et al. in healthy subjects. Third, the main findings regarding BCI/neurofeedback efficiency in patients with hypokinetic activities (in particular, motor deficit following stroke) as well as in patients with hyperkinetic activities (in particular, Attention Deficit Hyperactivity Disorder, ADHD) will be introduced. Due to a range of limitations, a clear association between SMR BCI/neurofeedback training and enhanced motor skills has yet to be established. However, SMR BCI/neurofeedback appears promising, and highlights many important challenges for clinical neurophysiology with regards to therapeutic approaches using BCI/neurofeedback.
... In the absence of such knowledge, a minimum requirement would seem that a target feature should fare well in a classification task between preand post-intervention conditions. However, how specific and sensitive these features are to the activity they are supposed to describe/control and how well they would fare as features in classification tasks is often poorly studied (Brandeis, 2011;Micoulaud-Franchi, Bat-Pitault, Cermolaccce, & Vion-Dury, 2011). But, whether standard features would fare well or not in a classification task, the litmus test for the goodness of a target is given by the extent to which features can be used to predict dynamics, in some sense, or to model that system (Conant & Ashby, 1970). ...
Neurofeedback is a form of brain training in which subjects are fed back information about some measure of their brain activity which they are instructed to modify in a way thought to be functionally advantageous. Over the last twenty years, neurofeedback has been used to treat various neurological and psychiatric conditions, and to improve cognitive function in various contexts. However, in spite of a growing popularity, neurofeedback protocols typically make (often covert) assumptions on what aspects of brain activity to target, where in the brain to act and how, which have far‐reaching implications for the assessment of its potential and efficacy. Here we critically examine some conceptual and methodological issues associated with the way neurofeedback's general objectives and neural targets are defined. The neural mechanisms through which neurofeedback may act at various spatial and temporal scales, and the way its efficacy is appraised are reviewed, and the extent to which neurofeedback may be used to control functional brain activity discussed. Finally, it is proposed that gauging neurofeedback's potential, as well as assessing and improving its efficacy will require better understanding of various fundamental aspects of brain dynamics and a more precise definition of functional brain activity and brain‐behaviour relationships.
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... Therefore, SMR neurofeedback training procedures have been applied to patients with insomnia [31,91]. Moreover, as it has been clinically shown that SMR neurofeedback induces a decrease of motor activity as well as an improvement of the vigilant state of alertness related to attention capacities, it has been suggested to use such a training for Attentional Deficit Hyperactivity Disorder (ADHD) (previously called hyperkinetic disorder) therapies [58]. In 1976 [52], Lubar's team published the first case study showing a possible beneficial effect of neurofeedback on hyperkinetic activity in a child with ADHD treated with low-beta SMR neurofeedback (''production of 12-14-Hz activity in the absence of 4-7 Hz slow-wave activity''). ...
Many Brain Computer Interface (BCI) and neurofeedback studies have investigated the impact of sensorimotor rhythm (SMR) self-regulation training procedures on motor skills enhancement in healthy subjects and patients with motor disabilities. This critical review aims first to introduce the different definitions of SMR EEG target in BCI/Neurofeedback studies and to summarize the background from neurophysiological and neuroplasticity studies that led to SMR being considered as reliable and valid EEG targets to improve motor skills through BCI/neurofeedback procedures. The second objective of this review is to introduce the main findings regarding SMR BCI/neurofeedback in healthy subjects. Third, the main findings regarding BCI/neurofeedback efficiency in patients with hypokinetic activities (in particular, motor deficit following stroke) as well as in patients with hyperkinetic activities (in particular, Attention Deficit Hyperactivity Disorder, ADHD) will be introduced. Due to a range of limitations, a clear association between SMR BCI/neurofeedback training and enhanced motor skills has yet to be established. However, SMR BCI/neurofeedback appears promising, and highlights many important challenges for clinical neurophysiology with regards to therapeutic approaches using BCI/neurofeedback.
... In this context, the positive reinforcement could be an increase of a number of points, an advance of an animation on a computer screen, or a modification of a sound. When the EEG is related to symptoms of a disease, it has been shown that neurofeedback techniques can have a therapeutic effect, as is the case with attention deficit disorder with hyperactivity (Micoulaud-Franchi et al. 2011) or epilepsy (Micoulaud-Franchi et al. 2014). ...
Different trends and perspectives on sound synthesis control issues within a cognitive neuroscience framework are addressed in this article. Two approaches for sound synthesis based on the modelling of physical sources and on the modelling of perceptual effects involving the identification of invariant sound morphologies (linked to sound semiotics) are exposed. Depending on the chosen approach, we assume that the resulting synthesis models can fall under either one of the theoretical frameworks inspired by the representational-computational or enactive paradigms. In particular, a change of viewpoint on the epistemological position of the end-user from a third to a first person inherently involves different conceptualizations of the interaction between the listener and the sounding object. This differentiation also influences the design of the control strategy enabling an expert or an intuitive sound manipulation. Finally, as a perspective to this survey, explicit and implicit brain-computer interfaces (BCI) are described with respect to the previous theoretical frameworks, and a semiotic-based BCI aiming at increasing the intuitiveness of synthesis control processes is envisaged. These interfaces may open for new applications adapted to either handicapped or healthy subjects.
... Des études pharmacologiques spéci ques des épisodes mixtes sont à mener a n d'analyser la réponse thérapeutique en fonction de ces biomarqueurs neurophysiologiques et ainsi d'envisager une médecine plus personnalisée [11,58]. Par ailleurs, les stratégies d'autorégulation mises en évidence par ces modèles pourraient être à la base des stratégies de prise en charge adaptées en psychoéducation, thérapie cognitivo-comportementale, remédiation cognitive ou neurofeedback [39,[59][60][61]. En n ces deux modèles s'intègrent plus globalement dans des modèles de régulation chronobiologique [50,54,56]. ...
Epidemiological studies of major depressive episodes (MDE) highlighted the frequent association of symptoms or signs of mania or hypomania with depressive syndrome. Beyond the strict definition of DSM-IV, epidemiological recognition of a subset of MDE characterized by the presence of symptoms or signs of the opposite polarity is clinically important because it is associated with pejorative prognosis and therapeutic response compared to the subgroup of “typical MDE”. The development of DSM-5 took into account the epidemiological data. DSM-5 opted for a more dimensional perspective in implementing the concept of “mixed features” from an “episode” to a “specification” of mood disorder. As outlined in the DSM-5: “Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I and II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to therapeutic”. However, the mixed features are sometimes difficult to identify, and neurophysiological biomarkers would be useful to make a more specific diagnosis. Two neurophysiological models make it possible to better understand MDE with mixed features : i) the emotional regulation model that highlights a tendency to hyper-reactive and unstable emotion response, and ii) the vigilance regulation model that highlights, through EEG recording, a tendency to unstable vigilance. Further research is required to better understand relationships between these two models. These models provide the opportunity of a neurophysiological framework to better understand the mixed features associated with MDE and to identify potential neurophysiological biomarkers to guide therapeutic strategies.
... Il a donc été proposé d'obtenir les patterns EEG d'intérêt en demandant au sujet de les créer activement. L'EEG-biofeedback (ou neurofeedback) permet en effet de guider les activités neurocognitives du sujet par le feedback en temps réel de son activité cérébrale enregistrée en EEG, afin de le conduire progressivement à obtenir le pattern EEG d'intérêt [25,34]. Ces techniques permettent par exemple d'apprendre aux patients déprimés de diminuer l'activité alpha ou d'augmenter l'activité bêta dans les régions frontales afin d'obtenir une amélioration clinique [35,36]. ...
L’efficacité thérapeutique de la stimulation magnétique transcrânienne répétée (rTMS) dans la prise en charge des troubles psychiatriques est avérée pour l’épisode dépressif majeur (EDM) et très encourageante pour la schizophrénie. Pourtant les protocoles de rTMS restent à optimiser. Les recherches fondamentales en TMS, ayant conduit au concept de state dependency TMS, suggèrent que l’effet d’une impulsion est influencé par l’état d’activation des circuits neuronaux précédant ou accompagnant la stimulation. L’effet de la TMS doit alors être considéré non pas simplement comme une stimulation mais comme le résultat d’une interaction entre un stimulus et un niveau d’activité cérébrale. Ces données suggèrent qu’il faudrait manipuler les activités neurocognitives des patients durant la stimulation afin d’optimiser l’efficacité de la rTMS sur les troubles psychiatriques. Des protocoles thérapeutiques de rTMS interactives ont donc été envisagés. Cet article propose une revue des différents protocoles interactifs mis en place principalement dans le traitement des EDM mais également de la schizophrénie. Les protocoles avec interactions avec les activités cognitives puis avec interactions avec les activités électriques cérébrales seront abordés. Ces études présentent différentes limitations, notamment du fait de leur caractère exploratoire sur un faible échantillon de patients et de leur cadre théorique neurocognitif de justification encore imprécis. Cependant ces protocoles de rTMS interactives permettent de passer en quelque sorte d’une rTMS en troisième personne à une rTMS en première personne où les activités cognitives et cérébrales propres aux sujets ne seraient pas occultées sous prétexte qu’il ne s’agirait que de bruit neuronal et ouvriraient des perspectives novatrices pour la rTMS en psychiatrie.
... Des études pharmacologiques spéci ques des épisodes mixtes sont à mener a n d'analyser la réponse thérapeutique en fonction de ces biomarqueurs neurophysiologiques et ainsi d'envisager une médecine plus personnalisée [11,58]. Par ailleurs, les stratégies d'autorégulation mises en évidence par ces modèles pourraient être à la base des stratégies de prise en charge adaptées en psychoéducation, thérapie cognitivo-comportementale, remédiation cognitive ou neurofeedback [39,[59][60][61]. En n ces deux modèles s'intègrent plus globalement dans des modèles de régulation chronobiologique [50,54,56]. ...
Epidemiological studies of major depressive episodes (MDE) highlighted the frequent association of symptoms or signs of mania or hypomania with depressive syndrome. Beyond the strict definition of DSM-IV, epidemiological recognition of a subset of MDE characterized by the presence of symptoms or signs of the opposite polarity is clinically important because it is associated with pejorative prognosis and therapeutic response compared to the subgroup of "typical MDE". The development of DSM-5 took into account the epidemiological data. DSM-5 opted for a more dimensional perspective in implementing the concept of "mixed features" from an "episode" to a "specification" of mood disorder. As outlined in the DSM-5: "Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I and II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to therapeutic". However, the mixed features are sometimes difficult to identify, and neurophysiological biomarkers would be useful to make a more specific diagnosis. Two neurophysiological models make it possible to better understand MDE with mixed features : i) the emotional regulation model that highlights a tendency to hyper-reactive and unstable emotion response, and ii) the vigilance regulation model that highlights, through EEG recording, a tendency to unstable vigilance. Further research is required to better understand relationships between these two models. These models provide the opportunity of a neurophysiological framework to better understand the mixed features associated with MDE and to identify potential neurophysiological biomarkers to guide therapeutic strategies.
Copyright © 2013 L’Encéphale. Published by Elsevier Masson SAS.. All rights reserved.
... Les différents types de feedbacks utilisés sont dépendants des objectifs poursuivis. En psychologie de la santé les techniques de biofeedback les plus couramment utilisées, sont : le biofeedback musculaire pour réduire les douleurs musculaires et/ou les tensions liées au stress ; le neurofeedback basé sur l'activité électroencéphalographiques dans le cadre de la régulation attentionnelle (Micoulaud-Franchi et al., 2011) et le biofeedback basé sur la température cutanée et les pulsations vasculaires pour appréhender les crises migraineuses (Nestoriuc et Martin, 2007). Ici nous focaliserons notre propos sur le biofeedback-HRV basé sur la variabilité de la fréquence cardiaque. ...
Cet article présente des pratiques cliniques récentes et validées en psychologie de la santé, notamment pour la gestion de la douleur et des maladies chroniques. Des techniques telles que l’acceptation et l’engagement, et la pratique de la pleine conscience ont fait leurs preuves, ainsi que les exercices favorisant l’expérience d’émotions positives. Des méthodes issues des théories cognitives et comportementales permettent également une amélioration de la qualité de vie et de l’observance des patients atteints de pathologies sévères. Enfin, le biofeedback centré sur la variabilité cardiaque favorise le développement des ressources cognitives et émotionnelles des patients, leur permettant de mieux faire face au stress et de maintenir un état de santé optimal. Les limites de ces pratiques ainsi que des pistes de recherches sont proposées.
... te rattaché aux techniques de stimulation cé ré brale initiale. Le concept de l'e ´ naction et les travaux neuro-phé nomé nologiques dé veloppé s par Francisco Varela (1946–2001) nous semblent dans la continuité scientifique des travaux de Fessard et permettent de penser l'opé rationnalisation rigoureuse des conceptions de Berger sur l'EEG [27,30]. [16]. Dans la droite ligne du paradigme holistique, Fessard continuait immé diatement le propos rapporté par Barbara (2007) par : « J'e ´ tudiais quelques-unes de ces corré lations et dé couvris, en 1935, que les variations du rythme alpha sont conditionnables. » Ainsi, en e ´ tudiant la ré action d'arrêt de l'alpha, il constatait que « les ...
Dans la première partie de cet article, nous proposons d’analyser la naissance et le développement de l’électricité en neurophysiologie et en psychiatrie suivant deux perspectives, selon que l’on s’adresse à la stimulation cérébrale ou à l’enregistrement des activités électriques cérébrales. Nous proposerons ensuite d’associer à ces deux perspectives, deux paradigmes scientifiques différents de la neurophysiologie clinique : la stimulation au paradigme localisationniste et l’enregistrement au paradigme holiste.
... Il a donc été proposé d'obtenir les patterns EEG d'intérêt en demandant au sujet de les créer activement. L'EEG-biofeedback (ou neurofeedback) permet en effet de guider les activités neurocognitives du sujet par le feedback en temps réel de son activité cérébrale enregistrée en EEG, afin de le conduire progressivement à obtenir le pattern EEG Protocoles de rTMS interactives en psychiatrie 5 d'intérêt [25,34]. Ces techniques permettent par exemple d'apprendre aux patients déprimés de diminuer l'activité alpha ou d'augmenter l'activité bêta dans les régions frontales afin d'obtenir une amélioration clinique [35,36]. ...
The efficiency of repetitive transcranial magnetic stimulation (rTMS) in the treatment of psychiatric disorders is robust for major depressive episode (MDE) while results are encouraging for schizophrenia. However, rTMS protocols need to be optimized. Basic researches in TMS led to the concept of "state dependency TMS". This concept suggests that the neural circuits' activation states, before and during the stimulation, influence the pulse effect. Indeed, TMS effect must be seen, not simply as a stimulus, but also as the result of an interaction between a stimulus and a level of brain activity. Those data suggest that rTMS efficiency could be increased in psychiatric disorders by triggering patients' neurocognitive activities during stimulation. Thus "interactive rTMS protocols" have been submitted.
This article provides a review and a classification of different interactive protocols implemented in the treatment of MDE and schizophrenia. Protocols' interactions with cognitive activities and brain electrical activities will be discussed.
Interactive rTMS protocols that manipulate cognitive activities have been developed for MDE treatments. They aim at regulating emotional states of depressed patients during the stimulation. The patients perform emotional tasks in order to activate cortical networks involving the left dorsolateral prefrontal cortex (DLPFC) into a state that may be more sensitive to the rTMS pulse effect. Simultaneous cognitive behavioral therapy ("CBT rTMS") and cognitive-emotional reactivation ("affective rTMS") have thus been tested during left DLPFC rTMS in MDE. Interactive rTMS protocols that manipulate brain electrical activities have been developed for MDE and schizophrenia treatments. Two categories of protocols should be identified. In the first set, personalized brain activity has been analyzed to determine the parameters of stimulation (i.e. frequency of stimulation) matching the patient ("personalized rTMS"). Personalized rTMS protocols can be made "online" or "offline" depending on whether the EEG activity is measured during or prior to rTMS. Online protocol is called "contingent rTMS": it consists in stimulating the brain only when a specific EEG pattern involving the intensity of alpha rhythm is recorded and recognized. Offline protocol is called "alpha rTMS", and relies on ascertaining frequency of stimulation in accordance with personalized alpha peak frequency prior to rTMS. In the second set, electrical brain activity is modulated before or during rTMS in order to stimulate the DLPFC in optimal conditions. Brain activity modulation may be obtained by transcranial direct current stimulation ("tDCS rTMS") or EEG-biofeedack ("EEG-biofeedback rTMS").
Interactive rTMS studies have various limitations, notably their exploratory character on a small sample of patients. Furthermore, their theoretical neurocognitive framework justification remains unclear. Nonetheless, interactive rTMS protocols allow us to consider a new field of rTMS, where cognitive and cerebral activities would no longer be considered as simple neural noise, leading to a kind of "first person rTMS", and certainly to innovative therapy in psychiatry.
... Les différents types de feedbacks utilisés sont dépendants des objectifs poursuivis. En psychologie de la santé les techniques de biofeedback les plus couramment utilisées, sont : le biofeedback musculaire pour réduire les douleurs musculaires et/ou les tensions liées au stress ; le neurofeedback basé sur l'activité électroencéphalographiques dans le cadre de la régulation attentionnelle (Micoulaud-Franchi et al., 2011) et le biofeedback basé sur la température cutanée et les pulsations vasculaires pour appréhender les crises migraineuses (Nestoriuc et Martin, 2007). Ici nous focaliserons notre propos sur le biofeedback-HRV basé sur la variabilité de la fréquence cardiaque. ...
The aim of the present article is to present recent and validated
clinical applications in the field of health psychology, in particular
regarding pain and chronic disease management. Techniques such
as acceptance and engagement therapy, mindfulness meditation
and positive emotions enhancement have proved to be successful.
Mindfulness is an attribute of consciousness long believed to
promote well-being. It is commonly defined as the state of being
attentive to and aware of what is taking place in the present. By
this way, mindfulness meditation learns to patients with chronic
pain to reduce their pain sensation. Moreover, encourage patients
to have positive emotions, such as gratitude, is efficient in long
term well-being. Prospective studies reveal that optimism, coping
strategies such as positive reframing and acceptance, and social
support yield less distress for patients with chronic disease. Similarly,
psychosocial interventions that foster optimistic appraisals,
build coping strategies, and bolster social support are benefit for
patients. Other methods such as Cognitive Behavioral Stress Management
(CBSM), enable to significantly enhance quality of life,
adaptation to illness and chronic disease patient compliance. This
10-week group CBSM intervention that includes anxiety reduction
(relaxation training), cognitive restructuring, and coping skills training
is tested among women with breast cancer and HIV patients.
The intervention reduces reports of thought intrusion, anxiety
and emotional distress. Furthermore, biofeedback through Heart
Rate Variability appears to be an important component of the
development of patient potential in terms of cognitive and emotional
resources enabling better coping with stressful situations and
hence maintaining optimal health conditions. Biofeedback treatment
intervention on pain and quality of life is helpful in the
rehabilitation of patients with chronic pain. Limits of these applications
are discussed as well as future research directions.
Neurofeedback is a form of brain training in which subjects are fed back information about some measure of their brain activity which they are instructed to modify in a way thought to be functionally advantageous. Over the last twenty years, NF has been used to treat various neurological and psychiatric conditions, and to improve cognitive function in various contexts. However, in spite of a growing popularity, NF protocols typically make (often covert) assumptions on what aspects of brain activity to target, where in the brain to act and how, which have far-reaching implications for the assessment of its potential and efficacy. Here we critically examine some conceptual and methodological issues associated with the way NF’s general objectives and neural targets are defined. The neural mechanisms through which NF may act at various spatial and temporal scales, and the way its efficacy is appraised are reviewed, and the extent to which NF may be used to control functional brain activity discussed. Finally, it is proposed that gauging NF’s potential, as well as assessing and improving its efficacy will require better understanding of various fundamental aspects of brain dynamics and a more precise definition of functional brain activity and brain-behaviour relationships.
Neurofeedback is a form of brain training in which subjects are fed back information about some measure of their brain activity which they are instructed to modify in a way thought to be functionally advantageous. Over the last twenty years, NF has been used to treat various neurological and psychiatric conditions, and to improve cognitive function in various contexts. However, in spite of a growing popularity, NF protocols typically make (often covert) assumptions on what aspects of brain activity to target, where in the brain to act and how, which have far-reaching implications for the assessment of its potential and efficacy. Here we critically examine some conceptual and methodological issues associated with the way NF’s general objectives and neural targets are defined. The neural mechanisms through which NF may act at various spatial and temporal scales, and the way its efficacy is appraised are reviewed, and the extent to which NF may be used to control functional brain activity discussed. Finally, it is proposed that gauging NF’s potential, as well as assessing and improving its efficacy will require better understanding of various fundamental aspects of brain dynamics and a more precise definition of functional brain activity and brain-behaviour relationships.
In order to establish the legitimacy of neurofeedback as a treatment and to better inform patients about this therapeutic, classical efficacy studies (double-blind randomized controlled trials) are essential but are only one aspect among many. We therefore proposed to apply the Duruz's criteria to the emblematic case of neurofeedback for the treatment of attention-deficit/hyperactivity disorder (ADHD). On the one hand, we applied five scientific criteria of relevance and evidence to the neurofeedback. On the other hand, we analysed the epistemology initiated by the model of neurofeedback according to a neurophenomenological perspective. Finally, we note that, in France, the creation of a scientific community, attached to the existing international scholarly societies on neurofeedback, is needed.
Neurofeedback (NFB) allows subjects to learn how to volitionally influence the neuronal activation in the brain by employing real-time neural activity as feedback. NFB has already been performed with electroencephalography (EEG) since the 1970s. Functional MRI (fMRI), offering a higher spatial resolution, has further increased the spatial specificity. In this paper, we briefly outline the general principles behind NFB, the implementation of fMRI-NFB studies, the feasibility of fMRI-NFB, and the application of NFB as a supplementary therapy tool.
Le « neurofeedback » est une technique de biofeedback, appelée également « EEG biofeedback », utilisant l’enregistrement électroencéphalographique (EEG). Cette technique existe depuis près de 30 ans. Deux grands types de protocoles de neurofeedback en fonction du type de traitement en temps réel réalisé sur le signal EEG sont retrouvés. Dans le premier, la puissance spectrale d’une bande fréquentielle EEG en regard d’une région cérébrale est calculée. Il peut être par exemple demandé au sujet d’augmenter la puissance spectrale de la bande bêta ou de diminuer celle de la bande thêta enregistrées sur l’électrode Cz, donc en regard de la région centrale médiale. Dans le second, l’amplitude d’un potentiel lent, appelé SCP pour Slow Cortical Potential, en Cz est calculé. Il est alors demandé au sujet soit d’augmenter, soit de diminuer l’amplitude du SCP. Le neurofeedback permet principalement de favoriser les capacités attentionnelles et d’éveil d’un sujet. Ainsi son application thérapeutique est principalement le trouble déficit de l’attention avec hyperactivité (TDAH), où il s’agit d’une technique désormais considérée comme valide. Il est également utilisé comme thérapeutique complémentaire non pharmacologique dans la prise en charge des troubles envahissant du développement et dans les épilepsies pharmacorésistantes. Ces applications dans d’autres troubles psychiatriques restent plus marginales. Le neurofeedback est très peu connu et développé en France. Pourtant, il permet un renouveau de la neurophysiologie clinique en psychiatrie en proposant une approche thérapeutique et ouvre des voies de recherches neurophysiologiques novatrices.
Emotions color in a singular way our everyday life and constitute important determinants of human cognition and behavior. Emotional regulation is an essential process involved in neuropathophysiology and therapeutic efficacy in many psychiatric disorders. Yet, traditional psychiatric therapeutic has focused on symptomatic rather than neurophysiological criteria. Therefore, it was proposed to teach patients to modify their own brain activity directly, in order to obtain a therapeutic effect. These techniques, which are named neurofeedback, were originally developed using electroencephalography. Recent technical advances in fMRI enable real-time acquisition, and open opportunities to its utilization in neurofeedback. This seems particularly interesting in emotion regulation, which, at a neurofunctional level, lies on cortico-limbic pathways that, in great parts, were previously identified by traditional fMRI paradigms. This emotion regulation plays a central role in the etiopathogeny psychiatric, especially depressive and anxious, disorders. It is possible to devise new therapeutic strategies and research approach for addressing directly the neurophysiological processes of emotion regulation by integrating the neurofunctional activities of a subject. These prospects seem to be in line with the neurophenomenology project, which proposes to establish a link between subjective experiences and objective neurophysiological measures.
Conventional electroencephalogram (EEG) is an essential non-invasive technique to determine the physiological and functional brain status. EEG is worthy of interest (i) for the diagnosis of neurological diseases in psychiatric syndromes and (ii) for the monitoring of possible iatrogenic effects of some psychiatric treatments: electroconvulsive therapy (ECT), antipsychotics (particularly clozapine), lithium and tricyclic antidepressants. The purpose of this article is to provide a basic knowledge to psychiatrists about the EEG signal and its origin, the special techniques used in psychiatry and EEG vocabulary description, in order to precise the best prescriptions of it and to understand the reports in their daily clinical practice. The relevance of the conclusion of an EEG requires an electro-clinical confrontation that involves a good knowledge of psychiatry by neurophysiologists and a good knowledge of EEG by psychiatrists. This complementary approach associated with an easy EEG accessibility in psychiatry allows this examination to keep an essential place for quality of health care of patients with mental disorders.
Emotions color in a singular way our everyday life and constitute important determinants of human cognition and behavior. Emotional regulation is an essential process involved in neuropathophysiology and therapeutic efficacy in many psychiatric disorders. Yet, traditional psychiatric therapeutic has focused on symptomatic rather than neurophysiological criteria. Therefore, it was proposed to teach patients to modify their own brain activity directly, in order to obtain a therapeutic effect. These techniques, which are named neurofeedback, were originally developed using electroencephalography. Recent technical advances in fMRI enable real-time acquisition, and open opportunities to its utilization in neurofeedback. This seems particularly interesting in emotion regulation, which, at a neurofunctional level, lies on cortico-limbic pathways that, in great parts, were previously identified by traditional fMRI paradigms. This emotion regulation plays a central role in the etiopathogeny psychiatric, especially depressive and anxious, disorders. It is possible to devise new therapeutic strategies and research approach for addressing directly the neurophysiological processes of emotion regulation by integrating the neurofunctional activities of a subject. These prospects seem to be in line with the neurophenomenology project, which proposes to establish a link between subjective experiences and objective neurophysiological measures.
Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Le trouble déficitaire d’attention avec ou sans hyperactivité (TDAH) est l’une des problématiques la plus fréquemment rencontrée chez les enfants d’âge scolaire. Les difficultés du contrôle cognitif et de l’inhibition sont souvent rapportées dans la littérature sur le TDAH. Les études en neuropsychologie supportent de façon générale l’hypothèse que l’absence première de contrôle de l’inhibition comportementale explique les déficits dans les fonctions exécutives et les comportements impulsifs du TDAH (2). Les résultats de plusieurs études en neuro-imagerie, neuropsychologie, génétique et neurochimie convergent vers l’implication d’une dysfonction du réseau neuronal frontostriatal comme cause probable du TDAH (4, 8, 16, 17, 18). Ces dysfonctions se retrouvent dans des régions comme le cortex préfrontal dorsolatéral et ventrolatéral, le cortex cingulaire dorsoantérieur et le néostriatum. L’étude de ces régions, ainsi que du corps calleux et du cervelet, est aujourd’hui plus facilement réalisable grâce à l’imagerie par résonance magnétique fonctionnelle (IRMf) et structurelle. Les hypothèses et conclusions des études en neuro-imagerie du TDAH font l’objet du présent relevé. De plus, de futures questions de recherche dans ce domaine sont proposées au long du texte.
Cerebral functional exploration using Event related potentials (ERPs) is greatly relevant in clinical psychiatry. Although ERP usefulness as a diagnostic tool is limited due to the complexity of psychiatric diagnosis, which raises theoritical, methodological and ethical problems that cannot be resolved by neurobiologial methods, ERP offers relevant information in 3 different topics: •the choice of psychotropes in pharmacotherapy ;•the description and understanding of cognitive processes ;•the psychotherapeutic relation.1) Converging arguments from experimental studies support the hypothesis that the amplitude of P300 and CNV as well as the loudness dependence of the auditory N1/P2 response (LDAEP) are regulated by central catecholaminergic and serotoninergic neurotransmission. These systems also are the target of several psychotropes, and therefore the neurophysiological assessment may bring reliable indicators to predict favourable response to psychotropes and drug intolerance. 2) Moreover the assessment of Reaction Times and P300 and VCN parameters, jointly recorded in a single investigation, brings information about the self-organization and self-regulation of cerebral functioning, and might help the clinicicans to understand the functional meaning of attentional disorders in Psychiatry. 3) Finally, the discussion of the neurophysiological results with the patient, in comparing objective and subjective data, might help him to better undestand his/her difficulties and to modify his/her subjective experience of the disease.
Background: Previous studies have demonstrated the short-term efficacy of pharmacotherapy and behavior therapy for attention-deficit/hyperactivity disorder (ADHD), but no longer-term tie, >4 months) investigations have compared these 2 treatments or their combination.
Methods: A group of 579 children with ADHD Combined Type, aged 7 to 9.9 years, were assigned to 13 months of medication management (titration followed by monthly visits); intensive behavioral treatment (parent, school, and child components, with therapist involvement gradually reduced over time); the two combined; or standard community care (treatments by community providers). Outcomes were assessed in multiple domains before and during treatment and at treatment end point (with the combined treatment and medication management groups continuing medication at all assessment points). Data were analyzed through intent to-treat random-effects regression procedures.
Results: All 4 groups showed sizable reductions in symptoms over time, with significant differences among them in degrees of change. For most ADHD symptoms, children in the combined treatment and medication management groups showed significantly greater improvement than those given intensive behavioral treatment and community care. Combined and medication management treatments did not differ significantly on any direct comparisons, but in several instances (oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement) combined treatment proved superior to intensive behavioral treatment and/or community care while medication management did not. Study medication strategies were superior to community care treatments, despite the fact that two thirds of community-treated subjects received medication during the study period.
Conclusions: For ADHD symptoms, our carefully crafted medication management was superior to behavioral treatment and to routine community care that included medication. Our combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms, but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes.
Objective.-To deal with public and professional concern regarding possible overprescription of attention-deficit/hyperactivity disorder (ADHD) medications, particularly methylphenidate, by reviewing issues related to the diagnosis, optimal treatment, and actual care of ADHD patients and of evidence of patient misuse of ADHD medications. Data Sources.-Literature review using a National Library of Medicine database search far 1975 through March 1997 on the terms attention deficit disorder with hyperactivity methylphenidate, stimulants, and stimulant abuse and dependence, Relevant documents from the Drug Enforcement Administration were also reviewed. Study Selection.-All English-language studies dealing with children of elementary school through high school age were included. Data Extraction.-All searched articles were selected and were made available to coauthors for review, Additional articles known to coauthors were added to the initial list, and a consensus was developed among the coauthors regarding the articles most pertinent to the issues requested in the resolution calling for this report, Relevant information from these articles was included in the report. Data Synthesis.-Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness, The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into adolescence and adulthood, As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time, Epidemiologic studies using standardized diagnostic criteria suggest that 3% to 6% of the school-aged population (elementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is al most at the lower end of this prevalence range, Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement, There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants. Conclusions.-Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians.
Attention deficit/hyperactivity disorder (ADHD) represents one of the most common psychiatric disorders in childhood, resulting in serious impairment across a variety of domains. Research showing that a high proportion of children with ADHD exhibit a dysfunctional electroencephalogram (EEG), relative to aged matched peers, provides a rationale for the use of neurofeedback as an intervention. The aim of neurofeedback training is to redress any EEG abnormality, resulting in a concomitant improvement in the behaviour and/or cognitive performance of these children. This review focused on studies using neurofeedback to treat children with ADHD, with particular emphasis on the methodological aspects of neurofeedback training. Specifically, the review examined the modality of feedback provided, the different training parameters and their underlying rationale, and the particular montages used. In addition, the review also focused on the duration, frequency and total number of training sessions required to obtain a positive effect in terms of a change in the individual's EEG, behaviour and/or cognitive performance. Finally, the long-term effects of neurofeedback and the potential negative side effects were reviewed. Throughout, the review provides a number of directions for future research.
Though it had already been shown in the 1970s that neurofeedback improves attention, academic performance and social behavior in children with ADHD, it has not been considered as a standard therapy so far. This is mainly due to the small number of controlled studies fulfilling methodological standards -especially long term data was not available so far. We are the first to present long term data of children undergoing neurofeedback training. 47 patients in the age of 8 – 12 years were randomly assigned to two different training groups. One group was trained to self regulate slow cortical potentials (SCP), the other group tried to influence Theta-and Beta-amplitudes. Follow-up evaluation was carried out 6 months and more than 2 years after the last training session. Eleven children of the SCP group and 12 children of the Theta/Beta group took part in three booster sessions. Parents rated behavioral symptoms as well as frequency and impact of problems. Attention was measured with the Testbatterie zur Aufmerksamkeitsprüfung (TAP).All improvements in behavior and attention that had been observed at previous assessments turned out to be stable. Yet another significant reduction of number of problems and significant improvement in attention was observed. EEG-self regulation skills were preserved. In each group, half of the children no longer met ADHD -criteria. Neurofeedback appears to be an alternative or complement to traditional treatments. The stability of changes might be explained by normalizing of brain functions that are responsible for inhibitory control, impulsivity and hyperactivity.
Reduced seizure incidence coupled with voluntary motor inhibition accompanied conditioned increases in the sensorimotor rhythm(SMR), a 12–14 Hz rhythm appearing over rolandic cortex. Although SMR biofeedback training has been successfully applied to various forms of epilepsy in humans, its potential use in decreasing hyperactivity has been limited to a few cases in which a seizure history was also a significant feature. The present study represents a first attempt to explore the technique's applicability to the problem of hyperkinesis independent of the epilepsy issue. The results of several months of EEG biofeedback training in a hyperkinetic child tend to corroborate and extend previous findings. Feedback presentations for SMR were contingent on the production of 12–14-Hz activity in the absence of 4–7-Hz slow-wave activity. A substantial increase in SMR occurred with progressive SMR training and was associated with enhanced motor inhibition, as gauged by laboratory measures of muscular tone(chin EMG) and by a global behavioral assessment in the classroom. Opposite trends in motor inhibition occurred when the training procedure was reversed and feedback presentations were contingent on the production of 4–7 Hz in the absence of 12–14-Hz activity. Although the preliminary nature of these results is stressed, the subject population has recently been increased to establish the validity and generality of the findings and will include the use of SMR biofeedback training after medication has been withdrawn.
The use of CNV in clinical practice requires the choice of a standardised protocol, the constitution of reference normative data and the consideration of intra- and interindividual variability. For this purpose, we recorded CNV in 86 control subjects (44 men and 42 women, 18 to 62 years old (mean age = 34 ± 13 years) during a reaction time paradigm with a warning signal and a 1-second S1-S2 interval. Moreover, the role of inter-stimulation interval was analysed in a group of 12 subjects through the comparison of recordings made with 1- and 3-second intervals. The CNV amplitude, its morphology and topographic distribution as well as its resolution mode and evolution through the recording were studied. The subjects' performances and their interactions with electroencephalographic data were also included in the analyses. Our results underscore the contribution of age and gender and psychological factors to CNV variability. CNV amplitude (both M1 and M2) increased and changed topographic distribution toward more central sites in older. Men had faster reaction times than women and lower post-S1 P300. Moreover, the life events-related stress and the subject’s current anxiety level were accompanied by a decreased CNV amplitude.
Neurofeedback (NF) could help to improve attentional and self-management capabilities in children with attention-deficit/hyperactivity disorder (ADHD). In a randomised controlled trial, NF training was found to be superior to a computerised attention skills training (AST) (Gevensleben et al. in J Child Psychol Psychiatry 50(7):780-789, 2009). In the present paper, treatment effects at 6-month follow-up were studied. 94 children with ADHD, aged 8-12 years, completed either 36 sessions of NF training (n = 59) or a computerised AST (n = 35). Pre-training, post-training and follow-up assessment encompassed several behaviour rating scales (e.g., the German ADHD rating scale, FBB-HKS) completed by parents. Follow-up information was analysed in 61 children (ca. 65%) on a per-protocol basis. 17 children (of 33 dropouts) had started a medication after the end of the training or early in the follow-up period. Improvements in the NF group (n = 38) at follow-up were superior to those of the control group (n = 23) and comparable to the effects at the end of the training. For the FBB-HKS total score (primary outcome measure), a medium effect size of 0.71 was obtained at follow-up. A reduction of at least 25% in the primary outcome measure (responder criterion) was observed in 50% of the children in the NF group. In conclusion, behavioural improvements induced by NF training in children with ADHD were maintained at a 6-month follow-up. Though treatment effects appear to be limited, the results confirm the notion that NF is a clinically efficacious module in the treatment of children with ADHD.
This study explores the possibility of noninvasively inducing long-term changes in human corticomotor excitability by means of a brain-computer interface, which enables users to exert internal control over the cortical rhythms recorded from the scalp. We demonstrate that self-regulation of electroencephalogram rhythms in quietly sitting, naive humans significantly affects the subsequent corticomotor response to transcranial magnetic stimulation, producing durable and correlated changes in neurotransmission. Specifically, we show that the intrinsic suppression of alpha cortical rhythms can in itself produce robust increases in corticospinal excitability and decreases in intracortical inhibition of up to 150%, which last for at least 20 min. Our observations may have important implications for therapies of brain disorders associated with abnormal cortical rhythms, and support the use of electroencephalogram-based neurofeedback as a noninvasive tool for establishing a causal link between rhythmic cortical activities and their functions.
BACKGROUND:
The autonomic nervous system sends messages through the sympathetic and parasympathetic nervous system. The sympathetic nervous system innervates the cardioaccelerating center of the heart, the lungs (increased ventilatory rhythm and dilatation of the bronchi) and the non-striated muscles (artery contraction). It releases adrenaline and noradrenaline. As opposed to the sympathetic nervous system, it innervates the cardiomoderator center of the heart, the lungs (slower ventilatory rhythm and contraction of the bronchi) and the non-striated muscles (artery dilatation). It uses acetylcholine (ACh) as its neurotransmitter. Sympathetic and parasympathetic divisions function antagonistically to preserve a dynamic modulation of vital functions. These systems act on the heart respectively through the stellar ganglion and the vagus nerve. The interaction of these messages towards the sinoauricular node is responsible for normal cardiac variability, which can be measured by monitoring heart rate variability (HRV). Heart rate is primarily controlled by vagal activity. Sensorial data coming from the heart are fed back to the central nervous system. HRV is an indicator of both how the central nervous system regulates the autonomic nervous system, and of how peripheral neurons feed information back to the central level. HRV measures are derived by estimating the variation among a set of temporally ordered interbeat intervals. The state of perfect symmetry, which, in medical parlance, is called respiratory sinus arrhythmia (RSA), can be described as a state of cardiac coherence. Obtaining a series of interbeat intervals requires a continuous measure of heart rate, typically electrocardiography (ECG). Commercially available software is then used to define the interbeat intervals within an ECG recording.
LITERATURE FINDINGS:
The autonomic nervous system is highly adaptable and allows the organism to maintain its balance when experiencing strain or stress. Conversely, a lack of flexibility and a rigid system can lead to somatic and psychological pathologies. Several studies have shown a link between reduced HRV in postmyocardial infarction patients and increased risk for adverse cardiovascular events, including ventricular arrhythmias and sudden death. Recently, studies indicate that patients with depression and anxiety disorders exhibit abnormally low HRV compared with non-psychiatric controls. Reduced HRV seems indicate decreased cardiac vagal tone and elevated sympathetic activity in anxious and depressive patients and would reflect deficit in flexibility of emotional physiological mechanisms. A few studies have also revealed that biofeedback using respiratory control, relaxation and meditation techniques can increase HRV. For now, there is insufficient data to determine if paced respiration or subjective relaxation is necessary or sufficient for the efficacy of HRV biofeedback. Although the literature is modest, this review suggests that the use of biofeedback with relaxation and meditation approaches may result in increased HRV and parasympathetic activity. Limitations of the review literature have also been considered to identify areas for future research.
Since the first reports of neurofeedback treatment in Attention Deficit Hyperactivity Disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity and hyperactivity. This technique is also used by many practitioners, but the question as to the evidence-based level of this treatment is still unclear. In this study selected research on neurofeedback treatment for ADHD was collected and a meta-analysis was performed.
Both prospective controlled studies and studies employing a pre-and post-design found large effect sizes (ES) for neurofeedback on impulsivity and inattention and a medium ES for hyperactivity. Randomized studies demonstrated a lower ES for hyperactivity suggesting that hyperactivity is probably most sensitive to nonspecific treatment factors.
Due to the inclusion of some very recent and sound methodological studies in this meta-analysis, potential confounding factors such as small studies, lack of randomization in previous studies and a lack of adequate control groups have been addressed, and the clinical effects of neurofeedback in the treatment of ADHD can be regarded as clinically meaningful. Three randomized studies have employed a semi-active control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the AAPB and ISNR guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered “Efficacious and Specific” (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.
Attention-deficit hyperactivity disorder (ADHD) is a common and impairing neuropsychiatric disorder with preschool onset. ADHD occurs in approximately 3-9% of the childhood population. There is a much higher incidence rate in boys who are around three times more likely than girls to be diagnosed. Approximately 30-60% of individuals diagnosed with ADHD in youth have symptoms that persist into adulthood.
Three subtypes of the disorder have been proposed in the current clinical view of ADHD: inattentive, hyperactive-impulsive and combined type. Numerous problems are associated with ADHD: poor academic performance, learning disorders, subtle cognitive deficits, conduct disorders, antisocial personality disorder, poor social relationships, and a higher incidence of anxiety and depression symptoms into adulthood. Researchers have emphasized poor behavioural inhibition as the central impairment of the disorder. From the neuropsychological viewpoint, impairment of the "hot" affective aspects of executive functions, like behavioural inhibition and attention and the more cognitive, "cool" aspects of executive functions like self-regulation, working memory, planning, and cognitive flexibility, are often reported by studies on ADHD. The hot executive functions are associated with ventral and medial regions of the prefrontal cortex (including the anterior cingulated cortex) and named "hotbrain" and the cool executive functions are associated with the dorsolateral prefrontal cortex and are called "coolbrain".
Convergent data from neuroimaging, neuropsychology, genetics and neurochemical studies consistently point to the involvement of the frontostriatal network as a likely contributor to the pathophysiology of ADHD. This network involves the lateral prefrontal cortex, the dorsal anterior cingulate cortex, the caudate nucleus and putamen. Moreover, a growing literature demonstrates abnormalities affecting other cortical regions and the cerebellum. The exploratory brain regions of interest in which abnormalities have been identified, but that were not predicted by cognitive models of ADHD, are the temporal lobe, parietal lobe, occipital lobe and lateral ventricles. Anatomical studies suggest widespread reductions in volume throughout the cerebrum and cerebellum, while functional imaging studies suggest that affected individuals activate more diffuse areas than controls during the performance of cognitive tasks. More precisely, reductions in volume have been observed in the total cerebral volume, the prefrontal cortex, the basal ganglia (striatum), the dorsal anterior cingulate cortex, the corpus callosum and the cerebellum. Furthermore, hypoactivation of the dorsal anterior cingulate cortex, the frontal cortex and the basal ganglia (striatum) have also been reported. The paradigms mostly used in functional magnetic resonance imaging (fMRI) are tasks of motor inhibition, interference and attention such as the go/no-go, "stop-signal" and the Stroop.
This review provides an overview of the main imaging studies that investigated the neurobiological substrate of ADHD. Some guidelines for future functional magnetic imaging studies are also suggested.
Reduced seizure incidence coupled with voluntary motor inhibition accompanied conditioned increases in the sensorimotor rhythm (SMR), a 12- 14 Hz rhythm appearing over rolandic cortex. Although SMR biofeedback training has been successfully applied to various forms of epilepsy in humans, its potential use in decreasing hyperactivity has been limited to a few cases in which a seizure history was also a significant feature. The present study represents a first attempt to explore the technique's applicability to the problem of hyperkinesis independent of the epilepsy issue. The results of several months of EEG biofeedback training in a hyperkinetic child tend to corroborate and extend previous findings. Feedback presentations for SMR were contingent on the production of 12- 14-Hz activity in the absence of 4- 7-Hz slow-wave activity. A substantial increase in SMR motor inhibition, as gauged by laboratory measures of muscular tone (chin EMG) and by a global behavioral assessment in the classroom. Opposite trends in motor inhibition occurred when the training procedure was reversed and feedback presentations were contingent on the production of 4- 7 Hz in the absence of 12- 14-Hz activity. Although the preliminary nature of these results is stressed, the subject population has recently been increased to establish the validity and generality of the findings and will include the use of SMR biofeedback training after medication has been withdrawn.
One hundred children, ages 6-19, who were diagnosed with attention-deficit/hyperactivity disorder (ADHD), either inattentive or combined types, participated in a study examining the effects of Ritalin, EEG biofeedback, and parenting style on the primary symptoms of ADHD. All of the patients participated in a 1-year, multimodal, outpatient program that included Ritalin, parent counseling, and academic support at school (either a 504 Plan or an IEP). Fifty-one of the participants also received EEG biofeedback therapy. Posttreatment assessments were conducted both with and without stimulant therapy. Significant improvement was noted on the Test of Variables of Attention (TOVA; L. M. Greenberg, 1996) and the Attention Deficit Disorders Evaluation Scale (ADDES; S. B. McCarney, 1995) when participants were tested while using Ritalin. However, only those who had received EEG biofeedback sustained these gains when tested without Ritalin. The results of a Quantitative Electroencephalographic Scanning Process (QEEG-Scan; V. J. Monastra et al., 1999) revealed significant reduction in cortical slowing only in patients who had received EEG biofeedback. Behavioral measures indicated that parenting style exerted a significant moderating effect on the expression of behavioral symptoms at home but not at school.
Clinical trials have suggested that neurofeedback may be efficient in treating attention-deficit/hyperactivity disorder (ADHD). We compared the effects of a 3-month electroencephalographic feedback program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12-15 Hz) and betal activity (15-18 Hz) with stimulant medication. Participants were N = 34 children aged 8-12 years, 22 of which were assigned to the neurofeedback group and 12 to the methylphenidate group according to their parents' preference. Both neurofeedback and methylphenidate were associated with improvements on all subscales of the Test of Variables of Attention, and on the speed and accuracy measures of the d2 Attention Endurance Test. Furthermore, behaviors related to the disorder were rated as significantly reduced in both groups by both teachers and parents on the IOWA-Conners Behavior Rating Scale. These findings suggest that neurofeedback was efficient in improving some of the behavioral concomitants of ADHD in children whose parents favored a nonpharmacological treatment.
The validity of clinical guidelines changes over time, because new evidence-based knowledge and experience develop.
Hence, the European clinical guidelines on hyperkinetic disorder from 1998 had to be evaluated and modified.
Discussions at the European Network for Hyperkinetic Disorders (EUNETHYDIS) and iterative critique of each clinical analysis. Guided by evidence-based information and based on evaluation (rather than metaanalysis) of the scientific evidence a group of child psychiatrists and psychologists from several European countries updated the guidelines of 1998. When reliable information is lacking the group gives a clinical consensus when it could be found among themselves.
The group presents here a set of recommendations for the conceptualization and management of hyperkinetic disorder and attention deficit/hyperactivity disorder (ADHD).
A general scheme for practice in Europe could be provided, on behalf of the European Society for Child and Adolescent Psychiatry (ESCAP).
The arrival of a book for review usually gives rise to pleasant anticipation, and whatever criticisms have to be made, it is that almost always possible to find some pleasant things to say. But finding praise for this tome is a problem — it is a volume too far. It is to be hoped that the authors
La variabilité de la fréquence cardiaque (VFC) est une mesure non invasive simple permettant d’explorer l’influence du système nerveux autonome sur le système cardiovasculaire. Plusieurs études ont retrouvé un lien entre une diminution de la VFC dans le postinfarctus du myocarde et un risque élevé de récidive d’accidents coronariens, comme une arythmie ventriculaire et une mort subite. Récemment, des études ont montré, chez des patients présentant un trouble anxieux ou dépressif, une diminution de la VFC comparativement à des sujets témoins ne présentant pas de trouble psychiatrique. La diminution de la VFC semble traduire une diminution du tonus vagal et une activation du système sympathique chez les patients dépressifs et anxieux qui traduirait une perturbation des mécanismes physiologiques émotionnels. Quelques études ont aussi montré une augmentation de la VFC par le biofeedback utilisant des techniques de contrôle respiratoire, de relaxation et de méditation. Dans cet article, les données de la littérature concernant la VFC dans les troubles psychiatriques sont revues, ainsi que les effets des techniques cognitives et comportementales. Bien que ces données sont encore limitées, cette revue suggère que l’utilisation du biofeedback couplé aux techniques de contrôle respiratoire, de relaxation et de méditation pourrait conduire à une augmentation de la VFC et de l’activité parasympathique. Les limites des données de cette revue ont été également prises en compte pour définir les axes de recherche future dans ce nouveau domaine.
Established in 1982 as the leading reference on electroencephalography, Drs. Niedermeyer's and Lopes da Silva's text is now in its thoroughly updated Fifth Edition. An international group of experts provides comprehensive coverage of the neurophysiologic and technical aspects of EEG, evoked potentials, and magnetoencephalography, as well as the clinical applications of these studies in neonates, infants, children, adults, and older adults. This edition includes digital EEG and advances in areas such as neurocognition. Three new chapters cover the topics of Ultra-Fast EEG Frequencies, Ultra-Slow Activity, and Cortico-Muscular Coherence. Hundreds of EEG tracings and other illustrations complement the text.
To deal with public and professional concern regarding possible overprescription of attention-deficit/hyperactivity disorder (ADHD) medications, particularly methylphenidate, by reviewing issues related to the diagnosis, optimal treatment, and actual care of ADHD patients and of evidence of patient misuse of ADHD medications.
Literature review using a National Library of Medicine database search for 1975 through March 1997 on the terms attention deficit disorder with hyperactivity, methylphenidate, stimulants, and stimulant abuse and dependence. Relevant documents from the Drug Enforcement Administration were also reviewed.
All English-language studies dealing with children of elementary school through high school age were included.
All searched articles were selected and were made available to coauthors for review. Additional articles known to coauthors were added to the initial list, and a consensus was developed among the coauthors regarding the articles most pertinent to the issues requested in the resolution calling for this report. Relevant information from these articles was included in the report.
Diagnostic criteria for ADHD are based on extensive empirical research and, if applied appropriately, lead to the diagnosis of a syndrome with high interrater reliability, good face validity, and high predictability of course and medication responsiveness. The criteria of what constitutes ADHD in children have broadened, and there is a growing appreciation of the persistence of ADHD into adolescence and adulthood. As a result, more children (especially girls), adolescents, and adults are being diagnosed and treated with stimulant medication, and children are being treated for longer periods of time. Epidemiologic studies using standardized diagnostic criteria suggest that 3% to 6% of the school-aged population (elementary through high school) may suffer from ADHD, although the percentage of US youth being treated for ADHD is at most at the lower end of this prevalence range. Pharmacotherapy, particularly use of stimulants, has been extensively studied and generally provides significant short-term symptomatic and academic improvement. There is little evidence that stimulant abuse or diversion is currently a major problem, particularly among those with ADHD, although recent trends suggest that this could increase with the expanding production and use of stimulants.
Although some children are being diagnosed as having ADHD with insufficient evaluation and in some cases stimulant medication is prescribed when treatment alternatives exist, there is little evidence of widespread overdiagnosis or misdiagnosis of ADHD or of widespread overprescription of methylphenidate by physicians.
In a randomized controlled trial, we could demonstrate clinical efficacy of neurofeedback (NF) training for children with ADHD (Gevensleben et al., 2009a). The present investigation aimed at learning more about the neuronal mechanisms of NF training.
Children with ADHD either completed a NF training or a computerized attention skills training (ratio 3:2). NF training consisted of one block of theta/beta training and one block of slow cortical potential (SCP) training, each comprising 18 training units. At three times (pre-training, between the two training blocks and at post-training), event-related potentials (ERP) were recorded during the Attention Network Test. ERP analysis focused on the P3, reflecting inter alia attentional resources for stimulus evaluation, and the contingent negative variation (CNV), primarily related to cognitive preparation.
After NF training, an increase of the CNV in cue trials could be observed, which was specific for the SCP training. A larger pre-training CNV was associated with a larger reduction of ADHD symptomatology for SCP training.
CNV effects reflect neuronal circuits underlying resource allocation during cognitive preparation. These distinct ERP effects are closely related to a successful NF training in children with ADHD. In future studies, neurophysiological recordings could help to optimize and individualize NF training.
The findings contribute to a better understanding of the mechanisms underlying NF training in children with ADHD.
EEG-feedback, also called neurofeedback, is a training procedure aimed at altering brain activity, and is used as a treatment for disorders like Attention Deficit/Hyperactivity Disorder (ADHD). Studies have reported positive effects of neurofeedback on attention and other dependent variables. However, double-blind studies including a sham neurofeedback control group are lacking. The inclusion of such group is crucial to control for unspecific effects. The current work presents a sham-controlled, double-blind evaluation. The hypothesis was that neurofeedback enhances attention and decreases impulsive behavior. Participants (n=27) were students selected on relatively high scores on impulsivity/inattention questionnaires (Barrat Impulsivity Scale and Broadbent CFQ). They were assigned to a neurofeedback treatment or a sham group. (sham)Neurofeedback training was planned for 15 weeks consisting of a total of 30 sessions, each lasting 22 min. Before and after 16 sessions (i.e., interim analyses), qEEG was recorded and impulsivity and inattention was assessed using a stop signal task and reversed continuous performance task and two questionnaires. Results of the interim analyses showed that participants were blind with respect to group inclusion, but no trend towards an effect of neurofeedback on behavioral measures was observed. Therefore in line with ethical guidelines the experiment was ceased. These results implicate a possible lack of effect of neurofeedback when one accounts for non-specific effects. However, the specific form of feedback and application of the sham-controlled double-blind design may have diminished the effect of neurofeedback.
This study analyzes the German version of the teacher rated Symptom Checklist for Attention Deficit Hyperactivity Disorders (FBB-HKS) which is part of the Diagnostic System of Mental Disorders in Children and Adolescents (DISYPS-KJ). Factorial validity as well as convergent, divergent und differential validity and reliability (internal consistency and retest reliability) of the scale are analyzed.
The questionnaire consists of 20 four point symptom items, assessing the 18 symptom-criteria according to ICD-10 und DSM-IV. Data were collected in a sample of pupils from a school for children with behavioral, emotional and learning problems (study 1: n = 50), as well as in a referred sample from a child and adolescent psychiatric outpatient clinic (study 2: n = 78), and a sample from a multi-center study on the effects of long-acting methylphenidate (study 3: n = 79).
The exploratory and the confirmatory factor analyses confirm both a three factor structure with hyperactivity, impulsivity and inattention as separate factors and a two factor structure (with hyperactivity-impulsivity and inattention). Internal consistencies and retest reliabilities are in a good to very good range. Convergent, divergent and differential validity can be confirmed. Thus, the rating scale is suitable for the assessment of ADHD symptoms at school.
In a randomized controlled trial, neurofeedback (NF) training was found to be superior to a computerised attention skills training concerning the reduction of ADHD symptomatology (Gevensleben et al., 2009). The aims of this investigation were to assess the impact of different NF protocols (theta/beta training and training of slow cortical potentials, SCPs) on the resting EEG and the association between distinct EEG measures and behavioral improvements. In 72 (of initially 102) children with ADHD, aged 8-12, EEG changes after either a NF training (n=46) or the control training (n=26) could be studied. The combined NF training consisted of one block of theta/beta training and one block of SCP training, each block comprising 18 units of 50 minutes (balanced order). Spontaneous EEG was recorded in a two-minute resting condition before the start of the training, between the two training blocks and after the end of the training. Activity in the different EEG frequency bands was analyzed. In contrast to the control condition, the combined NF training was accompanied by a reduction of theta activity. Protocol-specific EEG changes (theta/beta training: decrease of posterior-midline theta activity; SCP training: increase of central-midline alpha activity) were associated with improvements in the German ADHD rating scale. Related EEG-based predictors were obtained. Thus, differential EEG patterns for theta/beta and SCP training provide further evidence that distinct neuronal mechanisms may contribute to similar behavioral improvements in children with ADHD.
Most of the research devoted to BMI development consists of methodological studies comparing different online mathematical algorithms, ranging from simple linear discriminant analysis (LDA) (Dornhege et al., 2007) to nonlinear artificial neural networks (ANNs) or support vector machine (SVM) classification. Single cell spiking for the reconstruction of hand movements requires different statistical solutions than electroencephalography (EEG)-rhythm classification for communication. In general, the algorithm for BMI applications is computationally simple and differences in classification accuracy between algorithms used for a particular purpose are small. Only a very limited number of clinical studies with neurological patients are available, most of them single case studies. The clinical target populations for BMI-treatment consist primarily of patients with amyotrophic lateral sclerosis (ALS) and severe CNS damage including spinal cord injuries and stroke resulting in substantial deficits in communication and motor function. However, an extensive body of literature started in the 1970s using neurofeedback training. Such training implemented to control various EEG-measures provided solid evidence of positive effects in patients with otherwise pharmacologically intractable epilepsy, attention deficit disorder, and hyperactivity ADHD. More recently, the successful introduction and testing of real-time fMRI and a NIRS-BMI opened an exciting field of interest in patients with psychopathological conditions.
For decades neurophysiology has successfully contributed to research and clinical care in child psychiatry. Recently, methodological progress has led to a revival of interest in brain oscillations (i.e., a band of periodic neuronal frequencies with a wave-duration from milliseconds to several seconds which may code and decode information). These oscillations will nurture future information processing research during normal and pathological brain development, allowing us to investigate basic neuronal connectivity as well as interactions of brain systems and their modulation (e.g., by temporal neuronal synchronisation) as close correlates of behaviour and intermediate phenotypes from genes to behavioural variations. Especially, a systematic neurodynamic look at transitional processes from rest to stimulus-triggered goal-directed performance will aid behavioural understanding and guidance of children. Preliminary data suggest two separate oscillatory mechanisms in this respect. One is ongoing from pre- to post-stimulus processing and related to quantitative modification of behaviour, while another is merely related to qualitative effects of behaviour and reflects 'on-top' post-stimulus processing by temporal neuronal synchronisation of the oscillatory network in question. Suggested neurodynamic models may be tested in multilevel clinical experiments as well as in the framework of computational neuropsychiatry.
For children with attention deficit/hyperactivity disorder (ADHD), a reduction of inattention, impulsivity and hyperactivity by neurofeedback (NF) has been reported in several studies. But so far, unspecific training effects have not been adequately controlled for and/or studies do not provide sufficient statistical power. To overcome these methodological shortcomings we evaluated the clinical efficacy of neurofeedback in children with ADHD in a multisite randomised controlled study using a computerised attention skills training as a control condition.
102 children with ADHD, aged 8 to 12 years, participated in the study. Children performed either 36 sessions of NF training or a computerised attention skills training within two blocks of about four weeks each (randomised group assignment). The combined NF treatment consisted of one block of theta/beta training and one block of slow cortical potential (SCP) training. Pre-training, intermediate and post-training assessment encompassed several behaviour rating scales (e.g., the German ADHD rating scale, FBB-HKS) completed by parents and teachers. Evaluation ('placebo') scales were applied to control for parental expectations and satisfaction with the treatment.
For parent and teacher ratings, improvements in the NF group were superior to those of the control group. For the parent-rated FBB-HKS total score (primary outcome measure), the effect size was .60. Comparable effects were obtained for the two NF protocols (theta/beta training, SCP training). Parental attitude towards the treatment did not differ between NF and control group.
Superiority of the combined NF training indicates clinical efficacy of NF in children with ADHD. Future studies should further address the specificity of effects and how to optimise the benefit of NF as treatment module for ADHD.
Recent advances in analysis of brain signals, training patients to control these signals, and improved computing capabilities have enabled people with severe motor disabilities to use their brain signals for communication and control of objects in their environment, thereby bypassing their impaired neuromuscular system. Non-invasive, electroencephalogram (EEG)-based brain-computer interface (BCI) technologies can be used to control a computer cursor or a limb orthosis, for word processing and accessing the internet, and for other functions such as environmental control or entertainment. By re-establishing some independence, BCI technologies can substantially improve the lives of people with devastating neurological disorders such as advanced amyotrophic lateral sclerosis. BCI technology might also restore more effective motor control to people after stroke or other traumatic brain disorders by helping to guide activity-dependent brain plasticity by use of EEG brain signals to indicate to the patient the current state of brain activity and to enable the user to subsequently lower abnormal activity. Alternatively, by use of brain signals to supplement impaired muscle control, BCIs might increase the efficacy of a rehabilitation protocol and thus improve muscle control for the patient.
This study compared changes in quantitative EEG (QEEG) and CNV (contingent negative variation) of children suffering from ADHD treated by SCP (slow cortical potential) neurofeedback (NF) with the effects of group therapy (GT) to separate specific from non-specific neurophysiological effects of NF. Twenty-six children (age: 11.1 +/- 1.15 years) diagnosed as having ADHD were assigned to NF (N = 14) or GT (N = 12) training groups. QEEG measures at rest, CNV and behavioral ratings were acquired before and after the trainings and statistically analyzed. For children with ADHD-combined type in the NF group, treatment effects indicated a tendency toward improvement of selected QEEG markers. We could not find the expected improvement of CNV, but CNV reduction was less pronounced in good NF performers. QEEG changes were associated with some behavioral scales. Analyses of subgroups suggested specific influences of SCP training on brain functions. To conclude, SCP neurofeedback improves only selected attentional brain functions as measurable with QEEG at rest or CNV mapping. Effects of neurofeedback including the advantage of NF over GT seem mediated by both specific and non-specific factors.
To test for a possible placebo effect associated with an electronic machine, arm electrodes were attached to subjects with instructions suggesting either an improvement or an impairment in the performance of a simple sensory-motor task. Although no current was used, the performance of those subjects who expected improvement due to the current was significantly better than the performance of those subjects expecting an impairment of performance. It was not possible, however, to produce reliably an impairment of performance. The results tentatively suggest tile possibility of an effect resembling that obtained from the therapeutic use of inert substances.
Recent experiments on animals show the fallacy of an ancient view of the autonomic nervous system.
Attention Deficit/Hyperactivity Disorder (ADHD) is a childhood psychiatric disorder which when carefully defined, affects around 1% of the childhood population [Swanson JM, Sergeant JA, Taylor E, Sonuga-Barke EJS, Jensen PS, Canwell DP. Attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet 1998;351:429-433]. The primary symptoms: distractibility, impulsivity and overactivity vary in degree and association in such children, which led DSM IV to propose three subgroups. Only one of these subgroups, the combined subtype: deficits in all three areas, meets the ICD-10 criteria. Since the other two subtypes are used extensively in North America (but not in Europe), widely different results between centres are to be expected and have been reported. Central to the ADHD syndrome is the idea of an attention deficit. In order to investigate attention, it is necessary to define what one means by this term and to operationalize it in such a manner that others can test and replicate findings. We have advocated the use of a cognitive-energetic model [Sanders, AF. Towards a model of stress and performance. Acta Psychologica 1983;53: 61-97]. The cognitive-energetic model of ADHD approaches the ADHD deficiency at three distinct levels. First, a lower set of cognitive processes: encoding, central processing and response organisation is postulated. Study of these processes has indicated that there are no deficits of processing at encoding or central processing but are present in motor organisation [Sergeant JA, van der Meere JJ. Convergence of approaches in localizing the hyperactivity deficit. In Lahey BB, Kazdin AE, editors. Advancements in clinical child psychology, vol. 13. New York: Plenum press, 1990. p. 207-45; Sergeant, JA, van der Meere JJ. Additive factor methodology applied to psychopathology with special reference to hyperactivity. Acta Psychologica 1990;74:277-295]. A second level of the cognitive-energetic model consists of the energetic pools: arousal, activation and effort. At this level, the primary deficits of ADHD are associated with the activation pool and (to some extent) effort. The third level of the model contains a management or executive function system. Barkley [Barkley RA, Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychological Bulletin 1997;121:65-94] reviewed the literature and concluded that executive function deficiencies were primarily due to a failure of inhibition. Oosterlaan, Logan and Sergeant [Oosterlaan J, Logan GD, Sergeant JA. Response inhibition in ADHD, CD, comorbid ADHD + CD, anxious and normal children: a meta-analysis of studies with the stop task. Journal of Child Psychology and Psychiatry 1998;39:411-426] demonstrated that this explanation was not specific to ADHD but also applied to children with the associated disorders of oppositional defiant and conduct disorder. Other executive functions seem to be intact, while others, are deficient. It is argued here that the cognitive-energetic model is a useful guide for determining not only ADHD deficiencies and associated disorders but also linking human cognitive neuroscience studies with neurobiological models of ADHD using animals [Sadile AG. Multiple evidence of a segmental defect in the anterior forebrain of an animal model of hyperactivity and attention deficits. Neuroscience and Biobehavioral Reviews, in press; Sagvolden T, Sergeant JA. Attention-deficit hyperactivity disorder: from brain dysyfunctions to behaviour. Behavioural Brain Research 1998;94:1-10]. A plea for an integrated attack on this research problem is made and the suggestion that conceptual refinement between levels of analysis is essential for further fundamental work to succeed is offered here.
The use of CNV in clinical practice requires the choice of a standardised protocol, the constitution of reference normative data and the consideration of intra- and interindividual variability. For this purpose, we recorded CNV in 86 control subjects (44 men and 42 women, 18 to 62 years old (mean age = 34 +/- 13 years) during a reaction time paradigm with a warning signal and a 1-second S1-S2 interval. Moreover, the role of inter-stimulation interval was analysed in a group of 12 subjects through the comparison of recordings made with 1- and 3-second intervals. The CNV amplitude, its morphology and topographic distribution as well as its resolution mode and evolution through the recording were studied. The subjects' performances and their interactions with electroencephalographic data were also included in the analyses. Our results underscore the contribution of age and gender and psychological factors to CNV variability. CNV amplitude (both M1 and M2) increased and changed topographic distribution toward more central sites in older. Men had faster reaction times than women and lower post-S1 P300. Moreover, the life events-related stress and the subject's current anxiety level were accompanied by a decreased CNV amplitude.
This article reviews the event-related potential (ERP) literature in relation to attention-deficit/hyperactivity disorder (AD/HD).
ERP studies exploring various aspects of brain functioning in AD/HD are reviewed, ranging from early preparatory processes to a focus on the auditory and visual attention systems, and the frontal inhibition system. Implications of these data for future research and development in AD/HD are considered.
A complex range of ERP deficits has been associated with the disorder. Differences have been reported in preparatory responses, such as the contingent negative variation. In the auditory modality, AD/HD-related differences are apparent in all components from the auditory brain-stem response to the late slow wave. The most robust of these is the reduced posterior P3 in the auditory oddball task. There are fewer studies of the visual attention system, but similar differences are reported in a range of components. Results suggesting an inhibitory processing deficit have been reported, with recent studies of the frontal inhibitory system indicating problems of inhibitory regulation.
The research to date has identified a substantial number of ERP correlates of AD/HD. Together with the robust AD/HD differences apparent in the EEG literature, these data offer potential to improve our understanding of the specific brain dysfunction(s) which result in the disorder. Increased focus on the temporal locus of the information processing deficit(s) underlying the observed range of ERP differences is recommended. Further work in this field may benefit from a broader conceptual approach, integrating EEG and ERP measures of brain function.
This article reviews the electroencephalography (EEG) literature in relation to attention-deficit/hyperactivity disorder (AD/HD).
The review briefly outlines the history of the disorder, focusing on the changing diagnostic systems which both reflect and constrain research into AD/HD. Both qualitative and quantitative EEG studies are examined, and their results are discussed in relation to various models of AD/HD. Implications of these data for future research and development in AD/HD are considered.
In terms of resting EEG, elevated relative theta power, and reduced relative alpha and beta, together with elevated theta/alpha and theta/beta ratios, are most reliably associated with AD/HD. Theta/alpha and theta/beta ratios also discriminate diagnostic subgroups of AD/HD. Recent studies of EEG heterogeneity in this disorder indicate the existence of different profiles of cortical anomalies which may cut across diagnostic types.
The research to date has identified a substantial number of EEG correlates of AD/HD which hold promise for improving our understanding of the brain dysfunction(s) underlying the disorder. Further work in this field may benefit from a broader conceptual approach, integrating EEG and other measures of brain function.
Cerebral functional exploration using Event related potentials (ERPs) is greatly relevant in clinical psychiatry. Although ERP usefulness as a diagnostic tool is limited due to the complexity of psychiatric diagnosis, which raises theoretical, methodological and ethical problems that cannot be resolved by neurobiological methods, ERP offers relevant information in 3 different topics: the choice of psychotropes in pharmacotherapy; the description and understanding of cognitive processes; the psychotherapeutic relation. 1) Converging arguments from experimental studies support the hypothesis that the amplitude of P300 and CNV as well as the loudness dependence of the auditory N1/P2 response (LDAEP) are regulated by central catecholaminergic and serotoninergic neurotransmission. These systems also are the target of several psychotropes, and therefore the neurophysiological assessment may bring reliable indicators to predict favourable response to psychotropes and drug intolerance. 2) Moreover the assessment of Reaction Times and P300 and VCN parameters, jointly recorded in a single investigation, brings information about the self-organization and self-regulation of cerebral functioning, and might help the clinicians to understand the functional meaning of attentional disorders in Psychiatry. 3) Finally, the discussion of the neurophysiological results with the patient, in comparing objective and subjective data, might help him to better understand his/her difficulties and to modify his/her subjective experience of the disease.
Learned self-control of slow cortical potentials (SCPs) may lead to behavioral improvement in attention-deficit/hyperactivity disorder (ADHD). Hence, training effects should also be reflected at the neurophysiological level.
Thirteen children with ADHD, aged 7-13 years, performed 25 SCP training sessions within 3 weeks. Before and after training, the German ADHD rating scale was completed by parents, and event-related potentials were recorded in a cued continuous performance test (CPT). For a waiting-list group of nine children with ADHD, the same testing was applied.
ADHD symptomatology was reduced by approximately 25% after SCP training. Moreover, a decrease of impulsivity errors and an increase of the contingent negative variation were observed in the CPT task.
This study provides first evidence for both positive behavioral and specific neurophysiological effects of SCP training in children with ADHD.
To evaluate the impact of psychopathological comorbidity with oppositional defiant/conduct disorder (ODD/CD) on brain electrical correlates in children with attention deficit hyperactivity disorder (ADHD) and to study the pathophysiological background of comorbidity of ADHD+ODD/CD.
Event-related potentials (ERPs) were recorded during a cued continuous performance test (CPT-A-X) in children (aged 8 to 14 years) with ICD-10 diagnoses of either hyperkinetic disorder (HD; n = 15), hyperkinetic conduct disorder (HCD; n = 16), or ODD/CD (n = 15) and normal children (n = 18). HD/HCD diagnoses in all children were fully concordant with the DSM-IV diagnosis of ADHD-combined type. ERP-microstates, i.e., time segments with stable brain electrical map topography were identified by adaptive segmentation. Their characteristic parameters and behavioral measures were further analyzed.
Children with HD but not comorbid children showed slower and more variable reaction times compared to control children. Children with HD and ODD/CD-only but not comorbid children displayed reduced P3a amplitudes to cues and certain distractors (distractor-X) linked to attentional orienting. Correspondingly, global field power of the cue-CNV microstate related to anticipation and preparation was reduced in HD but not in HCD. Topographical alterations of the HD occurred already in the cue-P2/N2 microstate. In sum, the comorbid group was less deviant than both the HD-group and the ODD/CD-group.
The findings suggest that HD children (ADHD-combined type without ODD/CD) suffer from a more general deficit (e.g., suboptimal energetical state regulation) including deficits of attentional orienting and response preparation than just a responseinhibitory deficit, backing the hypothesis of an involvement of a dysregulation of the central noradrenergic networks. The results contradict the hypothesis that ADHD+ODD/CD represents an additive co-occurrence of ADHD and ODD/CD and strongly suggest that it represents a separate pathological entity as considered in the ICD-10 classification system, which differs from both HD and ODD/CD-only.
A number of theoretical models of attention-deficit/hyperactivity disorder (ADHD) have emerged in recent years that may be used as systematic guides for clinical research. The cognitive-energetic model (CEM) proposes that the overall efficiency of information processing is determined by the interplay of three levels: computational mechanisms of attention, state factors, and management/executive function (EF). The CEM encompasses both top-down and bottom-up processes and draws attention to the fact that ADHD causes defects at all three levels. These include cognitive mechanisms, such as response output; energetic mechanisms, such as activation and effort; and management/EF deficits. Increasing evidence suggests that inhibition deficits associated with ADHD may, at least in part, be explained in terms of an energetic dysfunction. The activation and effort energetic pools appear most relevant to ADHD, being directly related to response organization; however, further testing of CEM is critically dependent on the development of direct measures of these energetic pools. The CEM is a comprehensive model of ADHD but is not without limitations. In particular, further research is required to define more specifically the relationship between process dysfunction and state dysregulation in ADHD.