Siegfried Othmer, PhD was interviewed about the use of biofeedback, by John Spencer, PhD
Introduction by Dr. Spencer: Biofeedback is a technique in which electronic or mechanical instruments relay information to participants concerning their physiological activity. The goal is to increase or decrease a specific biological signal, such as heart rate, muscle activity, or brain electrical activity. This alteration can produce a change in some associated health problems, i.e., anxiety, pain, or hypertension.
Different biological systems can be used in biofeedback (peripheral muscle, autonomic, or central), and an accurate determination of which one to use is an important variable in effectiveness of treatment. Procedures are extremely safe, although caution must be exercised when using it with individuals who have psychotic conditions, including severe depression.
In general, though, biofeedback procedures are very well tolerated. This article explores the use of EEG biofeedback for ADHD, TS, learning disabilities, and autism. The fact that the brain is used as a reference point for EEG biofeedback should not be interpreted to suggest that “abnormalities” have to be present in electrical activity for successful treatment. For example, many learning disabilities have “soft signs” that are not always discernible to current diagnostic EEG procedures. Instead, the approach taken by many in this field is that treatment should focus on augmenting the brain’s inherent capability for reorganization. This view has merit, in my opinion.
The real challenge for future researchers will be to determine whether the remediation reported clinically for some cases of learning disabilities, ADHD, and TS is significantly long-lasting (years) or will require subsequent “re-inoculations.” The intent of science is to understand how something works by being able to describe the mechanisms that mediate the effect. It is unlikely that gross and diffuse brain activity can be directly connected to any endpoint organ or brain spots that can be tied, for example, to ADHD. As such, it is equally unlikely that we will understand exactly how biofeedback learning may reorganize the brain. What may become clearer with time and more clinical trials are the long-range benefits and how biofeedback can be integrated with other professional practices. It is exciting to think that the brain can or may undergo some degree of re-organization to promote greater attention, fewer tics, or improved learning.
That we may never be able to fully understand how these various connections modulate change may not be relevant. Certainly, animal work has at times been helpful, but a rat or cat brain is very different in complexity from a human brain and research has borne out the perils of trying to inthropomorphize. Still, if this technique can modify conditions that until now have been only partially remediated by medications which have their own associated stigma and problems, a remarkable advance will have occurred.
Interview with Dr. Othmer
Dr. Othmer, a great deal of progress has been made recently in the field of EEG biofeedback. Could you let our readers know whether this approach can be helpful for attention deficit disorder/hyperactivity (ADHD), Tourette syndrome (TS), autism, or learning disabilities?
Let’s start with ADHD and TS. We find that EEG biofeedback improves function for most individuals with ADHD and with TS who undertake the training for at least twenty sessions. It may be that nonresponders fall by the wayside before the twenty-session milestone is reached. At the same time, we don’t believe that training for less than twenty sessions allows a fair assessment of the capability of the technique. So I am excluding those subjects when I say “most individuals.” Because of the multiplicity of symptoms often found with TS, such as, Obsessive Compulsive Disorder, ADHD, and depression, we may need to use different training protocols to address the various problems. We would start with training for the symptoms that are most troublesome.
Now, there are a couple of variables. We’ve found that young children with TS sometimes do not sustain their gains, and they need to continue the training at a certain “dose” until their nervous systems (frontal lobe function) mature at about age twelve. Adults with more severe forms of TS may see only partial remediation of symptoms, even over the long term. In both these cases, some home-use instrumentation may be the answer so that training can be maintained at minimum cost. Once training has reached the point where gains are sustained, those gains tend to be held over the long term (years), barring severe emotional or physical brain trauma.
We have considerable evidence that this training can address specific learning disabilities, such as visual retention, arithmetic skill deficits, difficulties in spatial processing, and various problems with language processing, including different subtypes of dyslexia and articulation disorders. The technique is unique in that it can specifically address shortcomings due to localized, hemispherically specialized functions. For example, the right hemisphere would be directly trained for spatial processing (geometry) deficits, whereas the left hemisphere would be trained for dyslexia, and frontal areas for articulation problems. As for autism, we have only a few case histories on which to report, and a few more on Asperger’s syndrome. Their implication is that in certain cases training can be worthwhile, and therefore should be considered as adjunctive therapy for the autistic child. But there are some inherent difficulties. Many autistic children exhibit tactile defensiveness and will not readily tolerate the electrodes we use on the scalp, although desensitization may be achieved in the first couple of sessions. And due to the nature of autism, many youngsters would be unable to attend to the task required.
We believe that from a neurological standpoint, autistic children could benefit from the kind of training we provide, yet there are built-in barriers to success. That is to say, we might be able to deal very well with autism if only the children were not autistic! High-functioning autistic individuals who respond well to computer tasks are the best candidates. I would recommend it for those individuals as part of a multi-disciplinary approach.
You mentioned long-term results. What is the basis for stating that results can be long-term?
If the effects weren’t long-term, there would be no biofeedback discipline. EEG biofeedback is fundamentally a learning process-by analogy, similar to learning how to ride a bicycle. But in this case, the brain is being taught at such a fundamental level that the new skills are in use all the time. It is as if the person never gets off the bicycle. As a result, the newfound skill is continually reinforced. Rather than the person backsliding, it’s more likely that the new competence will allow the person new levels of performance.
But there can be exceptions. Follow-up studies have been completed on persons with ADHD who were trained during the original research in the mid-seventies, and their gains have generally held. Fewer years have passed since the technique has been used with TS, but results have been encouraging.
Conventional treatment of TS and ADHD often includes drug therapy. Does this interfere with EEG biofeedback training?
Not unless the medication interferes with the ability to sustain attention. If the subject is medicated, the likelihood is that the medication dose will be titrated down as the training progresses, often down to zero. Medication, when effective, may be desirable in terms of its rapidity of action, but biofeedback is preferable from the standpoint that the benefit is more likely to be long-term. Most cases seen by us clinically are, of course, those whose response to medication is less than optimal because of side-effects or incomplete resolution of symptoms.
When looking at central nervous system disorders, are some people better candidates than others for this type of treatment? Are some people simply nonresponders?
The best candidates tend to be those whose problems are more purely neurophysiological, where there are no compounding family issues and psychological issues-grief, emotional trauma, etc. We frequently see adoptive children where the family is intact and supportive but where the child may have a questionable neurological history, both genetically and environmentally. With such a supportive environment in place, biofeedback is often the only missing ingredient needed to restore the child to functionality. Often, however, complementary therapies are called for as well, in which case the success of the biofeedback training is partially contingent on the success of the other therapies. We are inclined toward the belief that nearly everyone is capable of responding to this training to some degree. Nonresponders tend to be those where other issues, such as psychological issues, are paramount and need to be addressed to pave the way for this technique. Our optimism is based on the fact that idiopathic nonresponders in the past have largely been those for whom we did not determine the appropriate training. As mastery of this training improves, the percentage of people considered nonresponders is shrinking considerably. Another reason for nonresponse is the novelty and lack of general acceptance of this technique. A person who has been warned that he may be wasting his money and that this technique is not yet a standard medical procedure may be so “on guard” psychologically as to effectively sabotage the training. The training has a clear psychological dimension to it, in the sense that the brain has to be willing to accept the particular challenge presented.
This requires a certain level of psychological comfort that may not always be present in a particular client, given a societal milieu that is still indifferent or even hostile to this type of intervention. Another reason for nonresponse may be misdiagnosis: a disorder characterized fundamentally as an anxiety disorder may turn out to be primarily depressive in character. By the time the appropriate training protocol is identified, the person may have lost confidence in the training. This problem will resolve itself as greater clinical skills are developed.
Do you use relaxation exercises in your practice?
Relaxation training has not shown itself to be particularly helpful with ADHD children, except possibly for the subset of those children whose difficulties are traceable to a primary condition of underlying anxiety. So relaxation training is not generally part of the biofeedback therapy we use. There are practitioners who offer the children academic challenges while the biofeedback training is ongoing, but this also is not a general practice.
Of the conditions we are focusing on, which ones have received clinical trials for EEG biofeedback, and what have the results been? Do you have any criticism of these studies?
The early research on this goes back to the mid-seventies, when the initial controlled studies focusing on ADHD were done. All the early studies were small, and they all had positive results. One study was ambiguous, because it also included other interventions. More recently, small-scale clinical trials have been conducted by clinicians in the field. These are subject to the typical limitations of being on a fee-for-service basis. As a result, they have a socioeconomic bias that renders them subject to criticism.
The results of such trials, taken at face value, have been uniformly positive. Other small-scale controlled studies have been done, and these have also had significantly positive results. The major criticisms to be leveled at these studies is the small subject pool. Also, procedures differed significantly among the various studies, making meta-analysis problematic.
Is EEG biofeedback covered under insurance plans?
EEG biofeedback is already covered under many insurance plans, and many insurance companies are not particularly sensitive to which biofeedback modality (EEG, EMG, or temperature) is being employed. However, they usually have limited indications for the conditions for which they regard biofeedback as an appropriate remedy. These typically include chronic pain, various sleep disorders, migraines, anxiety disorders, and conditions exacerbated by stress. Only a small number include ADHD or Tourette syndrome, or even epilepsy, in the list of approved indications for biofeedback, although this picture is constantly improving.