Peak Attention: Focus & Concentration
Research on ADHD, attention deficits, and neurofeedback for improved focus and executive function.
Research Library
We've curated 84 research papers for this use case. Dr. Hill and the Peak Brain team are reviewing and summarizing these papers to provide accessible, actionable insights.
Citations and abstracts shown below. Detailed summaries, key findings, and clinical applications will be added as reviews are completed.
Research Citations
Benefits of a 12-Week Non-Drug âBrain Fitness Programâ for Patients with Attention-Deficit/Hyperactive Disorder, Post-Concussion Syndrome, or Memory Loss
Background: Non-pharmacologic interventions can potentially improve cognitive function, sleep, and/or mood in patients with attention-deficit/hyperactive disorder (ADHD), post-concussion syndrome (PCS), or memory loss. Objective: We evaluated the benefits of a brain rehabilitation program in an outpatient neurology practice that consists of targeted cognitive training, lifestyle coaching, and electroencephalography (EEG)-based neurofeedback, twice weekly (90 minutes each), for 12 weeks. Methods: 223 child and adult patients were included: 71 patients with ADHD, 88 with PCS, and 64 with memory loss (mild cognitive impairment or subjective cognitive decline). Patients underwent a complete neurocognitive evaluation, including tests for Verbal Memory, Complex Attention, Processing Speed, Executive Functioning, and Neurocognition Index. They completed questionnaires about sleep, mood, diet, exercise, anxiety levels, and depressionâas well as underwent quantitative EEGâat the beginning and the end of the program. Results: Pre-post test score comparison demonstrated that all patient subgroups experienced statistically significant improvements on most measures, especially the PCS subgroup, which experienced significant score improvement on all measures tested (pâ€0.0011; dzâ„0.36). After completing the program, 60% to 90% of patients scored higher on cognitive tests and reported having fewer cognitive and emotional symptoms. The largest effect size for pre-post score change was improved executive functioning in all subgroups (ADHD dz=â0.86; PCS dz=â0.83; memory dz=â1.09). Conclusion: This study demonstrates that a multimodal brain rehabilitation program can have benefits for patients with ADHD, PCS, or memory loss and supports further clinical trials in this field.
Neural and behavioral adaptations to frontal theta neurofeedback training: A proof of concept study
Previous neurofeedback research has shown training-related frontal theta increases and performance improvements on some executive tasks in real feedback versus sham control groups. However, typical sham control groups receive false or non-contingent feedback, making it difficult to know whether observed differences between groups are associated with accurate contingent feedback or other cognitive mechanisms (motivation, control strategies, attentional engagement, fatigue, etc.). To address this question, we investigated differences between two frontal theta training groups, each receiving accurate contingent feedback, but with different top-down goals: (1) increase and (2) alternate increase/decrease. We hypothesized that the increase group would exhibit greater increases in frontal theta compared to the alternate group, which would exhibit lower frontal theta during down- versus up-modulation blocks over sessions. We also hypothesized that the alternate group would exhibit greater performance improvements on a Go-NoGo shooting task requiring alterations in behavioral activation and inhibition, as the alternate group would be trained with greater task specificity, suggesting that receiving accurate contingent feedback may be the more salient learning mechanism underlying frontal theta neurofeedback training gains. Thirty young healthy volunteers were randomly assigned to increase or alternate groups. Training consisted of an orientation session, five neurofeedback training sessions (six blocks of six 30-s trials of FCz theta modulation (4-7 Hz) separated by 10-s rest intervals), and six Go-NoGo testing sessions (four blocks of 90 trials in both Low and High time-stress conditions). Multilevel modeling revealed greater frontal theta increases in the alternate group over training sessions. Further, Go-NoGo task performance increased at a greater rate in the increase group (accuracy and reaction time, but not commission errors). Overall, these results reject our hypotheses and suggest that changes in frontal theta and performance outcomes were not explained by reinforcement learning afforded by accurate contingent feedback. We discuss our findings in terms of alternative conceptual and methodological considerations, as well as limitations of this research.
View Full Paper âBrainmarker-I Differentially Predicts Remission to Various Attention-Deficit/Hyperactivity Disorder Treatments: A Discovery, Transfer, and Blinded Validation Study
BACKGROUND: Attention-deficit/hyperactivity disorder is characterized by neurobiological heterogeneity, possibly explaining why not all patients benefit from a given treatment. As a means to select the right treatment (stratification), biomarkers may aid in personalizing treatment prescription, thereby increasing remission rates. METHODS: The biomarker in this study was developed in a heterogeneous clinical sample (N = 4249) and first applied to two large transfer datasets, a priori stratifying young males (<18 years) with a higher individual alpha peak frequency (iAPF) to methylphenidate (N = 336) and those with a lower iAPF to multimodal neurofeedback complemented with sleep coaching (N = 136). Blinded, out-of-sample validations were conducted in two independent samples. In addition, the association between iAPF and response to guanfacine and atomoxetine was explored. RESULTS: Retrospective stratification in the transfer datasets resulted in a predicted gain in normalized remission of 17% to 30%. Blinded out-of-sample validations for methylphenidate (n = 41) and multimodal neurofeedback (n = 71) corroborated these findings, yielding a predicted gain in stratified normalized remission of 36% and 29%, respectively. CONCLUSIONS: This study introduces a clinically interpretable and actionable biomarker based on the iAPF assessed during resting-state electroencephalography. Our findings suggest that acknowledging neurobiological heterogeneity can inform stratification of patients to their individual best treatment and enhance remission rates.
View Full Paper âDisturbances in primary visual processing as a function of healthy aging
For decades, visual entrainment paradigms have been widely used to investigate basic visual processing in healthy individuals and those with neurological disorders. While healthy aging is known to be associated with alterations in visual processing, whether this extends to visual entrainment responses and the precise cortical regions involved is not fully understood. Such knowledge is imperative given the recent surge in interest surrounding the use of flicker stimulation and entrainment in the context of identifying and treating Alzheimer's disease (AD). In the current study, we examined visual entrainment in eighty healthy aging adults using magnetoencephalography (MEG) and a 15Â Hz entrainment paradigm, while controlling for age-related cortical thinning. MEG data were imaged using a time-frequency resolved beamformer and peak voxel time series were extracted to quantify the oscillatory dynamics underlying the processing of the visual flicker stimuli. We found that, as age increased, the mean amplitude of entrainment responses decreased and the latency of these responses increased. However, there was no effect of age on the trial-to-trial consistency in phase (i.e., inter-trial phase locking) nor amplitude (i.e., coefficient of variation) of these visual responses. Importantly, we discovered that the relationship between age and response amplitude was fully mediated by the latency of visual processing. These results indicate that aging is associated with robust changes in the latency and amplitude of visual entrainment responses within regions surrounding the calcarine fissure, which should be considered in studies examining neurological disorders such as AD and other conditions associated with increased age.
View Full Paper âITACA: An open-source framework for Neurofeedback based on Brain-Computer Interfaces
BACKGROUND AND OBJECTIVE: Neurofeedback (NF) is a paradigm that allows users to self-modulate patterns of brain activity. It is implemented with a closed-loop brain-computer interface (BCI) system that analyzes the user's brain activity in real-time and provides continuous feedback. This paradigm is of great interest due to its potential as a non-pharmacological and non-invasive alternative to treat non-degenerative brain disorders. Nevertheless, currently available NF frameworks have several limitations, such as the lack of a wide variety of real-time analysis metrics or overly simple training scenarios that may negatively affect user performance. To overcome these limitations, this work proposes ITACA: a novel open-source framework for the design, implementation and evaluation of NF training paradigms. METHODS: ITACA is designed to be easy-to-use, flexible and attractive. Specifically, ITACA includes three different gamified training scenarios with a choice of five brain activity metrics as real-time feedback. Among them, novel metrics based on functional connectivity and network theory stand out. It is complemented with five different computerized versions of widespread cognitive assessment tests. To validate the proposed framework, a computational efficiency analysis and an NF training protocol focused on frontal-medial theta modulation were conducted. RESULTS: Efficiency analysis proved that all implemented metrics allow an optimal feedback update rate for conducting NF sessions. Furthermore, conducted NF protocol yielded results that support the use of ITACA in NF research studies. CONCLUSIONS: ITACA implements a wide variety of features for designing, conducting and evaluating NF studies with the goal of helping researchers expand the current state-of-the-art in NF training.
View Full Paper âAdaptive P300-Based Brain-Computer Interface for Attention Training: Protocol for a Randomized Controlled Trial
Background The number of people with cognitive deficits and diseases, such as stroke, dementia, or attention-deficit/hyperactivity disorder, is rising due to an aging, or in the case of attention-deficit/hyperactivity disorder, a growing population. Neurofeedback training using brain-computer interfaces is emerging as a means of easy-to-use and noninvasive cognitive training and rehabilitation. A novel application of neurofeedback training using a P300-based brain-computer interface has previously shown potential to improve attention in healthy adults. Objective This study aims to accelerate attention training using iterative learning control to optimize the task difficulty in an adaptive P300 speller task. Furthermore, we hope to replicate the results of a previous study using a P300 speller for attention training, as a benchmark comparison. In addition, the effectiveness of personalizing the task difficulty during training will be compared to a nonpersonalized task difficulty adaptation. Methods In this single-blind, parallel, 3-arm randomized controlled trial, 45 healthy adults will be recruited and randomly assigned to the experimental group or 1 of 2 control groups. This study involves a single training session, where participants receive neurofeedback training through a P300 speller task. During this training, the taskâs difficulty is progressively increased, which makes it more difficult for the participants to maintain their performance. This encourages the participants to improve their focus. Task difficulty is either adapted based on the participantsâ performance (in the experimental group and control group 1) or chosen randomly (in control group 2). Changes in brain patterns before and after training will be analyzed to study the effectiveness of the different approaches. Participants will complete a random dot motion task before and after the training so that any transfer effects of the training to other cognitive tasks can be evaluated. Questionnaires will be used to estimate the participantsâ fatigue and compare the perceived workload of the training between groups. Results This study has been approved by the Maynooth University Ethics Committee (BSRESC-2022-2474456) and is registered on ClinicalTrials.gov (NCT05576649). Participant recruitment and data collection began in October 2022, and we expect to publish the results in 2023. Conclusions This study aims to accelerate attention training using iterative learning control in an adaptive P300 speller task, making it a more attractive training option for individuals with cognitive deficits due to its ease of use and speed. The successful replication of the results from the previous study, which used a P300 speller for attention training, would provide further evidence to support the effectiveness of this training tool. Trial Registration ClinicalTrials.gov NCT05576649; https://clinicaltrials.gov/ct2/show/NCT05576649 International Registered Report Identifier (IRRID) DERR1-10.2196/46135
View Full Paper âA Single Session of SMR-Neurofeedback Training Improves Selective Attention Emerging from a Dynamic Structuring of BrainâHeart Interplay
Research on sensorimotor rhythms (SMR) based on neurofeedback (NFb) emphasizes improvements in selective attention associated with SMR amplification. However, the long-term training proposed in most studies posed the question of acceptability, which led to the evaluation of the potential of a single NFb session. Based on cognitive and autonomic controls interfering with attention processes, we hypothesized changes in selective attention after a single SMR-NFb session, along with changes in brainâheart interplay, which are reflected in the multifractality of heartbeat dynamics. Here, young healthy participants (n = 35, 20 females, 21 ± 3 years) were randomly assigned either to a control group (Ctrl) watching a movie or to a neurofeedback (NFb) group performing a single session of SMR-NFb. A headset with EEG electrodes (positioned on C3 and C4) connected to a smartphone app served to guide and to evaluate NFb training efficacy. A Stroop task was performed for 8 min by each group before and after the intervention (movie vs. SMR-NFb) while collecting heart rate variability and C4-EEG for 20 min. When compared to Ctrl, the NFb group exhibited better Stroop performance, especially when facing incongruent trials. The multifractality and NFb training efficacy were identified as strong predictors of the gain in global Stroop performance, while multifractality was the only predictor regarding incongruent trials. We conclude that a single session of SMR-NFb improves selective attention in healthy individuals through the specific reorganization of brainâheart interplay, which is reflected in multifractal heartbeat dynamics.
View Full Paper âConsortium neuroscience of attention deficit/hyperactivity disorder and autism spectrum disorder: The ENIGMA adventure
Neuroimaging has been extensively used to study brain structure and function in individuals with attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) over the past decades. Two of the main shortcomings of the neuroimaging literature of these disorders are the small sample sizes employed and the heterogeneity of methods used. In 2013 and 2014, the ENIGMA-ADHD and ENIGMA-ASD working groups were respectively, founded with a common goal to address these limitations. Here, we provide a narrative review of the thus far completed and still ongoing projects of these working groups. Due to an implicitly hierarchical psychiatric diagnostic classification system, the fields of ADHD and ASD have developed largely in isolation, despite the considerable overlap in the occurrence of the disorders. The collaboration between the ENIGMA-ADHD and -ASD working groups seeks to bring the neuroimaging efforts of the two disorders closer together. The outcomes of caseâcontrol studies of subcortical and cortical structures showed that subcortical volumes are similarly affected in ASD and ADHD, albeit with small effect sizes. Cortical analyses identified unique differences in each disorder, but also considerable overlap between the two, specifically in cortical thickness. Ongoing work is examining alternative research questions, such as brain laterality, prediction of caseâcontrol status, and anatomical heterogeneity. In brief, great strides have been made toward fulfilling the aims of the ENIGMA collaborations, while new ideas and follow-up analyses continue that include more imaging modalities (diffusion MRI and resting-state functional MRI), collaborations with other large databases, and samples with dual diagnoses.
View Full Paper âSystematic Review and Meta-Analysis on the Effects of Neurofeedback Training of Theta Activity on Working Memory and Episodic Memory in Healthy Population
The main purpose of this study was to investigate the effects of neurofeedback training (NFT) of theta activity on working memory (WM) and episodic memory (EM) in healthy participants via a systematic review and meta-analysis. A total of 337 articles obtained from electronic databases were assessed; however, only 11 articles met the criteria for meta-analysis after manually screening and eliminating unnecessary studies. A meta-analysis calculating the Hedgesâ g effect size metric with 95% confidence intervals using random effects models was employed. Heterogeneity was estimated using I2 statistics. Theta NFT is effective in improving memory outcomes, including WM with a Hedgesâ g of 0.56 [0.10; 1.02] (I2 = 62.9% and p = 0.02), and EM with a Hedgesâ g of 0.62 [0.13; 1.10] (I2 = 42.04% and p = 0.01). Overall, the results suggest that theta NFT seems to be useful as nonpharmacological/adjunct training to improve WM and EM in healthy participants.
View Full Paper âThe Effect of Mindfulness-based Programs on Cognitive Function in Adults: A Systematic Review and Meta-analysis
Mindfulness-based programs (MBPs) are increasingly utilized to improve mental health. Interest in the putative effects of MBPs on cognitive function is also growing. This is the first meta-analysis of objective cognitive outcomes across multiple domains from randomized MBP studies of adults. Seven databases were systematically searched to January 2020. Fifty-six unique studies (nâ=â2,931) were included, of which 45 (nâ=â2,238) were synthesized using robust variance estimation meta-analysis. Meta-regression and subgroup analyses evaluated moderators. Pooling data across cognitive domains, the summary effect size for all studies favored MBPs over comparators and was small in magnitude (gâ=â0.15; [0.05, 0.24]). Across subgroup analyses of individual cognitive domains/subdomains, MBPs outperformed comparators for executive function (gâ=â0.15; [0.02, 0.27]) and working memory outcomes (gâ=â0.23; [0.11, 0.36]) only. Subgroup analyses identified significant effects for studies of non-clinical samples, as well as for adults aged over 60. Across all studies, MBPs outperformed inactive, but not active comparators. Limitations include the primarily unclear within-study risk of bias (only a minority of studies were considered low risk), and that statistical constraints rendered some p-values unreliable. Together, results partially corroborate the hypothesized link between mindfulness practices and cognitive performance. This review was registered with PROSPERO [CRD42018100904].
View Full Paper âA comparison between classical and new proposed feature selection methods for attention level recognition in disordered children
Lack of attention is a chronic behavior in ADHD (Attention Deficit Hyperactivity Disorder) and ASD (Autism Spectrum Disorder). Our goal is to develop a reliable method for the detection of inattention with high accuracy and low time consumption to be used in real time neurofeedback. The new applied methods for inattention in children are EMD (Empirical Mode Decomposition) with difference time series (Dt) and MRA (Multi Resolution Analysis). EMD is a method of breaking down a signal into âmodesâ (IMFs) representing its different frequency components. Furthermore, MRA strikes balance between temporal and frequency resolution through localizing the EEG signal in frequency domain of interest (beta range) by wavelet decomposition or EMD and then retains time domain information using FD. As the results demonstrate, in intermediate and severe level cases of inattention, EMD_Dt technique is the most accurate. In mild level cases of inattention MRA (wavelet + FD) technique performance is better than EMD_Dt. However, the time consumption of the MRA (wavelet + FD) technique is fifteen times larger than EMD_Dt technique. EMD_Dt is the best technique as it requires less processing time which is the most important factor in neurofeedback, furthermore, clinician concerned more with severe and intermediate level of inattention to be treated.
View Full Paper âNeurofeedback for the Education of Children with ADHD and Specific Learning Disorders: A Review
Neurofeedback (NF) is a type of biofeedback in which an individualâs brain activity is measured and presented to them to support self-regulation of ongoing brain oscillations and achieve specific behavioral and neurophysiological outcomes. NF training induces changes in neurophysiological circuits that are associated with behavioral changes. Recent evidence suggests that the NF technique can be used to train electrical brain activity and facilitate learning among children with learning disorders. Toward this aim, this review first presents a generalized model for NF systems, and then studies involving NF training for children with disorders such as dyslexia, attention-deficit/hyperactivity disorder (ADHD), and other specific learning disorders such as dyscalculia and dysgraphia are reviewed. The discussion elaborates on the potential for translational applications of NF in educational and learning settings with details. This review also addresses some issues concerning the role of NF in education, and it concludes with some solutions and future directions. In order to provide the best learning environment for children with ADHD and other learning disorders, it is critical to better understand the role of NF in educational settings. The review provides the potential challenges of the current systems to aid in highlighting the issues undermining the efficacy of current systems and identifying solutions to address them. The review focuses on the use of NF technology in education for the development of adaptive teaching methods and the best learning environment for children with learning disabilities.
View Full Paper âResults of Neurofeedback in Treatment of Children with ADHD: A Systematic Review of Randomized Controlled Trials
Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent disorders in children and adolescents. Neurofeedback, a nonpharmaceutical treatment, has shown promising results. To review the evidence of efficacy of neurofeedback as a treatment for children and adolescents with ADHD. A systematic review of the specific scientific studies published in 1995â2021, identifying and analyzing randomized controlled trials (RCT). A total of 1636 articles were identified and 165 met inclusion criteria, of which 67 were RCTs. Neurofeedback training was associated with significant long-term reduction in symptoms of ADHD. Though limitations exist regarding conclusions about the specific effects of neurofeedback, the review documents improvements in school, social, and family environments.
View Full Paper âA Novel BrainâComputer Interface Virtual Environment for Neurofeedback During Functional MRI
Virtual environments (VEs), in the recent years, have become more prevalent in neuroscience. These VEs can offer great flexibility, replicability, and control over the presented stimuli in an immersive setting. With recent developments, it has become feasible to achieve higher-quality visuals and VEs at a reasonable investment. Our aim in this project was to develop and implement a novel real-time functional magnetic resonance imaging (rt-fMRI)âbased neurofeedback (NF) training paradigm, taking into account new technological advances that allow us to integrate complex stimuli into a visually updated and engaging VE. We built upon and developed a first-person shooter in which the dynamic change of the VE was the feedback variable in the brainâcomputer interface (BCI). We designed a study to assess the feasibility of the BCI in creating an immersive VE for NF training. In a randomized single-blinded fMRI-based NF-training session, 24 participants were randomly allocated into one of two groups: active and reduced contingency NF. All participants completed three runs of the shooter-game VE lasting 10 min each. Brain activity in a supplementary motor area region of interest regulated the possible movement speed of the playerâs avatar and thus increased the reward probability. The gaming performance revealed that the participants were able to actively engage in game tasks and improve across sessions. All 24 participants reported being able to successfully employ NF strategies during the training while performing in-game tasks with significantly higher perceived NF control ratings in the NF group. Spectral analysis showed significant differential effects on brain activity between the groups. Connectivity analysis revealed significant differences, showing a lowered connectivity in the NF group compared to the reduced contingency-NF group. The self-assessment manikin ratings showed an increase in arousal in both groups but failed significance. Arousal has been linked to presence, or feelings of immersion, supporting the VEâs objective. Long paradigms, such as NF in MRI settings, can lead to mental fatigue; therefore, VEs can help overcome such limitations. The rewarding achievements from gaming targets can lead to implicit learning of self-regulation and may broaden the scope of NF applications.
View Full Paper âTreatment Efficacy and Clinical Effectiveness of EEG Neurofeedback as a Personalized and Multimodal Treatment in ADHD: A Critical Review
Purpose Recent reviews have proposed that scientifically validated standard EEG neurofeedback (NF) protocols are an efficacious and specific treatment for attention-deficit hyperactivity disorder (ADHD). Here, we review the current evidence for the treatment efficacy and clinical effectiveness of NF in ADHD to investigate whether NF treatment personalization (standard protocols matched to the electrophysiological features of ADHD) and combination with other interventions (psychosocial, sleep hygiene and nutritional advice) might yield superior long-term treatment outcomes relative to non-personalized NF and medication monotreatments. Methods The electronic databases PubMed and PsycINFO were systematically searched using our key terms. Of the 38 resulting studies, 11 randomized controlled trials (RCTs) and open-label studies were eligible for inclusion. Studies were analyzed for effect sizes and remission rates at the end of treatment and at follow-up. The effects of personalized and multimodal NF treatments were compared to non-personalized NF monotreatments and with two benchmark medication studies. Results The analysis of RCTs indicated that the long-term effects of personalized NF interventions were superior to non-personalized NF and comparable to those of medication alone or in combination with behavioral intervention. The analysis of open-label trials further indicates that the interaction of NF with parental interventions, sleep and nutritional advice might yield superior clinical effectiveness relative to NF and medication monotreatments. Conclusion Personalized and multimodal NF interventions seem to yield superior treatment efficacy relative to NF alone and superior clinical effectiveness relative to medication. We propose that treatment outcomes may be further enhanced by adjusting NF non-specific factors (eg, reinforcement contingencies) to specific ADHD characteristics (eg, reward sensitivity). Future NF research should focus on the systematic evaluation of the treatment outcomes of personalized and multimodal treatments.
View Full Paper âEEG-Based Tool for Prediction of University Studentsâ Cognitive Performance in the Classroom
This study presents a neuroengineering-based machine learning tool developed to predict studentsâ performance under different learning modalities. Neuroengineering tools are used to predict the learning performance obtained through two different modalities: text and video. Electroencephalographic signals were recorded in the two groups during learning tasks, and performance was evaluated with tests. The results show the video group obtained a better performance than the text group. A correlation analysis was implemented to find the most relevant features to predict studentsâ performance, and to design the machine learning tool. This analysis showed a negative correlation between studentsâ performance and the (theta/alpha) ratio, and delta power, which are indicative of mental fatigue and drowsiness, respectively. These results indicate that users in a non-fatigued and well-rested state performed better during learning tasks. The designed tool obtained 85% precision at predicting learning performance, as well as correctly identifying the video group as the most efficient modality.
View Full Paper âThe World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder
BACKGROUND: Misconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base. METHODS: We reviewed studies with more than 2000 participants or meta-analyses from five or more studies or 2000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder. RESULTS: We generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 80 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 366 people who have read this document and agree with its contents. CONCLUSIONS: Many findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.
View Full Paper âTo spindle or not to spindle: A replication study into spindling excessive beta as a transdiagnostic EEG feature associated with impulse control
Background Frontocentral Spindling Excessive Beta (SEB), a spindle-like beta-activity observed in the electroencephalogram (EEG), has been transdiagnostically associated with more problems with impulse control and sleep maintenance. The current study aims to replicate and elaborate on these findings. Methods Participants reporting sleep problems (n = 31) or Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms (n = 48) were included. Baseline ADHD-Rating Scale (ADHD-RS), Pittsburgh Sleep Quality Index (PSQI), Holland Sleep Disorder Questionnaire (HSDQ), and EEG were assessed. Analyses were confined to adults with frontocentral SEB. Results Main effects of SEB showed more impulse control problems (d = 0.87) and false positive errors (d = 0.55) in participants with SEB. No significant associations with sleep or interactions with Sample were observed. Discussion This study partially replicates an earlier study and demonstrates that participants exhibiting SEB report more impulse control problems, independent of diagnosis. Future studies should focus on automating SEB classification and further investigate the transdiagnostic nature of SEB.
Neurofeedback Learning Is Skill Acquisition but Does Not Guarantee Treatment Benefit: Continuous-Time Analysis of Learning-Curves From a Clinical Trial for ADHD
Neurofeedback for attention deficit/hyperactivity disorder (ADHD) has long been studied as an alternative to medication, promising non-invasive treatment with minimal side-effects and sustained outcome. However, debate continues over the efficacy of neurofeedback, partly because existing evidence for efficacy is mixed and often non-specific, with unclear relationships between prognostic variables, patient performance when learning to self-regulate, and treatment outcomes. We report an extensive analysis on the understudied area of neurofeedback learning . Our data comes from a randomised controlled clinical trial in adults with ADHD (registered trial ISRCTN13915109; N = 23; 13:10 female:male; age 25â57). Patients were treated with either theta-beta ratio or sensorimotor-rhythm regimes for 40 one-hour sessions. We classify 11 learners vs 12 non-learners by the significance of random slopes in a linear mixed growth-curve model. We then analyse the predictors, outcomes, and processes of learners vs non-learners, using these groups as mutual controls. Significant predictive relationships were found in anxiety disorder (GAD), dissociative experience (DES), and behavioural inhibition (BIS) scores obtained during screening. Low DES, but high GAD and BIS, predicted positive learning. Patterns of behavioural outcomes from Test Of Variables of Attention, and symptoms from adult ADHD Self-Report Scale, suggested that learning itself is not required for positive outcomes. Finally, the learning process was analysed using structural-equations modelling with continuous-time data, estimating the short-term and sustained impact of each session on learning. A key finding is that our results support the conceptualisation of neurofeedback learning as skill acquisition, and not merely operant conditioning as originally proposed in the literature.
View Full Paper âThe effect of age and gender on anti-saccade performance: Results from a large cohort of healthy aging individuals
By 2050, the global population of people aged 65 years or older will triple. While this is accompanied with an increasing burden of age-associated diseases, it also emphasizes the need to understand the effects of healthy aging on cognitive processes. One such effect is a general slowing of processing speed, which is well documented in many domains. The execution of anti-saccades depends on a well-established brain-wide network ranging from various cortical areas and basal ganglia through the superior colliculus down to the brainstem saccade generators. To clarify the consequences of healthy aging as well as gender on the execution of reflexive and voluntary saccades, we measured a large sample of healthy, non-demented individuals (n = 731, aged 51-84 years) in the anti-saccade task. Age affected various aspects of saccade performance: The number of valid trials decreased with age. Error rate, saccadic reaction times (SRTs), and variability in saccade accuracy increased with age, whereas anti-saccade costs, accuracy, and peak velocity of anti-saccades and direction errors were not affected by age. Gender affected SRTs independent of age and saccade type with male participants having overall shorter SRTs. Our rigid and solid statistical testing using linear mixed-effect models provide evidence for a uniform slowing of processing speed independent of the actually performed eye movement. Our data do not support the assumption of a specific deterioration of frontal lobe functions with aging.
View Full Paper âEfficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review
Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.
View Full Paper âIn Quest of Pathognomonic/Endophenotypic Markers of Attention Deficit Hyperactivity Disorder (ADHD): Potential of EEG-Based Frequency Analysis and ERPs to Better Detect, Prevent and Manage ADHD
Attention ï»żdï»żeficit ï»żhyperactivity ï»żdisorder (ADHD) is a chronic heritable developmental delay psychiatric disorder requiring chronic management, characterized by inattention, hyperactivity, hyperkinectivity and impulsivity. Subjective clinical evaluation still remains crucial in its diagnosis. Discussed are two key aspects in the "characterizing ADHD" and on the quest for objective "pathognomonic/endophenotypic diagnostic markers of ADHD". The first aspect briefly revolves around issues related to identification of pathognomonic/endophenotypic diagnostic markers in ADHD. Issues discussed include changes in ADHD definition, remission/persistence and overlapping-symptoms cum shared-heritability with its co-morbid cross-border mental disorders. The second aspect discussed is neurobiological and EEG-based studies on ADHD. Given the neurobiological and temporal aspects of ADHD symptoms the electroencephalograph (EEG) like NeuralScan by Medeia appears as an appropriate tool. The EEGs appropriateness is further enhanced when coupled with suitable behavior/cognitive/motor/psychological tasks/paradigms yielding EEG-based markers like event-related-potential (ERPs like P3 amplitudes and latency), reaction time variability (RTV), Theta:Beta ratio (TBR) and ï»żsensorimotor ï»żrhythm (SMR). At present, these markers could potentially help in the neurobiological characterization of ADHD and either help in identifying or lay the groundwork for identifying pathognomonic and/or endophenotypic EEG-based markers enabling its diagnosis, treatment and management.
View Full Paper âApplications of EEG indices for the quantification of human cognitive performance: A systematic review and bibliometric analysis
Background Neuroergonomics combines neuroscience with ergonomics to study human performance using recorded brain signals. Such neural signatures of performance can be measured using a variety of neuroimaging techniques, including functional magnetic resonance imaging (fMRI), functional near-infrared spectroscopy (fNIRS), and electroencephalography (EEG). EEG has an excellent temporal resolution, and EEG indices are highly sensitive to human brain activity fluctuations. Objective The focus of this systematic review was to explore the applications of EEG indices for quantifying human performance in a variety of cognitive tasks at the macro and micro scales. To identify trends and the state of the field, we examined global patterns among selected articles, such as journal contributions, highly cited papers, affiliations, and high-frequency keywords. Moreover, we discussed the most frequently used EEG indices and synthesized current knowledge regarding the EEG signatures of associated human performance measurements. Methods In this systematic review, we analyzed articles published in English (from peer-reviewed journals, proceedings, and conference papers), Ph.D. dissertations, textbooks, and reference books. All articles reviewed herein included exclusively EEG-based experimental studies in healthy participants. We searched Web-of-Science and Scopus databases using specific sets of keywords. Results Out of 143 papers, a considerable number of cognitive studies focused on quantifying human performance with respect to mental fatigue, mental workload, mental effort, visual fatigue, emotion, and stress. An increasing trend for publication in this area was observed, with the highest number of publications in 2017. Most studies applied linear methods (e.g., EEG power spectral density and the amplitude of event-related potentials) to evaluate human cognitive performance. A few papers utilized nonlinear methods, such as fractal dimension, largest Lyapunov exponent, and signal entropy. More than 50% of the studies focused on evaluating an individualâs mental states while operating a vehicle. Several different methods of artifact removal have also been noted. Based on the reviewed articles, research gaps, trends, and potential directions for future research were explored. Conclusion This systematic review synthesized current knowledge regarding the application of EEG indices for quantifying human performance in a wide variety of cognitive tasks. This knowledge is useful for understanding the global patterns of applications of EEG indices for the analysis and design of cognitive tasks.
View Full Paper âA multicenter effectiveness trial of QEEG-informed neurofeedback in ADHD: Replication and treatment prediction
Introduction: Quantitative Electroencephalogram-(QEEG-)informed neurofeedback is a method in which standard neurofeedback protocols are assigned, based on individual EEG characteristics in order to enhance effectiveness. Thus far clinical effectiveness data have only been published in a small sample of 21 ADHD patients. Therefore, this manuscript aims to replicate this effectiveness in a new sample of 114 patients treated with QEEG-informed neurofeedback, from a large multicentric dataset and to investigate potential predictors of neurofeedback response. Methods: A sample of 114 patients were included as a replication sample. Patients were treated with standard neurofeedback protocols (Sensori-Motor-Rhythm (SMR), Theta-Beta (TBR), or Slow Cortical Potential (SCP) neurofeedback), in combination with coaching and sleep hygiene advice. The ADHD Rating Scale (ADHD-RS) and Pittsburgh Sleep Quality Index (PSQI) were assessed at baseline, every 10th session, and at outtake. Holland Sleep Disorder Questionnaire (HSDQ) was assessed at baseline and outtake. Response was defined as â„25% reduction (R25), â„50% reduction (R50), and remission. Predictive analyses were focused on predicting remission status. Results: In the current sample, response rates were 85% (R25), 70% (R50), and remission was 55% and clinical effectiveness was not significantly different from the original 2012 sample. Non-remitters exhibited significantly higher baseline hyperactivity ratings. Women who remitted had significantly shorter P300 latencies and boys who remitted had significantly lower iAPF's. Discussion: In the current sample, clinical effectiveness was replicated, suggesting it is possible to assign patients to a protocol based on their individual baseline QEEG to enhance signal-to-noise ratio. Furthermore, remitters had lower baseline hyperactivity scores. Likewise, female remitters had shorter P300 latencies, whereas boys who remitted have a lower iAPF. Our data suggests initial specificity in treatment allocation, yet further studies are needed to replicate the predictors of neurofeedback remission.
View Full Paper â19 Channel Z-Score and LORETA Neurofeedback: Does the Evidence Support the Hype?
Neurofeedback is a well-investigated treatment for ADHD and epilepsy, especially when restricted to standard protocols such as theta/beta, slow cortical potentials and sensori-motor rhythm neurofeedback. Advances in any field are welcome and other techniques are being pursued. Manufacturers and clinicians are marketing 'superior' neurofeedback approaches including 19 channel Z-score neurofeedback (ZNFB) and 3-D LORETA neurofeedback (with or without Z-scores; LNFB). We conducted a review of the empirical literature to determine if such claims were warranted. This review included the above search terms in Pubmed, Google scholar and any references that met our criteria from the ZNFB publication list and was restricted to group based studies examining improvement in a clinical population that underwent peer review (book chapters, magazine articles or conference presentations are not included since these are not peer reviewed). Fifteen relevant studies emerged with only six meeting our criterion. Based on review of these studies it was concluded that empirical validation of these approaches is sorely lacking. There is no empirical data that supports the notion that 19-channel z-score neurofeedback is effective or superior. The quality of studies for LNFB was better compared to ZNFB and some suggestion for efficacy was demonstrated for ADHD and Tinnitus distress. However, these findings need to be replicated, extended to other populations and have yet to show any "superiority." Our conclusions continue to emphasize the pervasive lack of evidence supporting these approaches to neurofeedback and the implications of this are discussed.
Electroencephalography theta/beta ratio covaries with mind wandering and functional connectivity in the executive control network
The ratio between frontal restingâstate electroencephalography (EEG) theta and beta frequency power (theta/beta ratio, TBR) is negatively related to cognitive control. It is unknown which psychological processes during resting state account for this. Increased theta and reduced beta power are observed during mind wandering (MW), and MW is related to decreased connectivity in the executive control network (ECN) and increased connectivity in the default mode network (DMN). The goal of this study was to test if MWârelated fluctuations in TBR covary with such functional variation in ECN and DMN connectivity and if this functional variation is related to restingâstate TBR. Data were analyzed for 26 participants who performed a 40âmin breathâcounting task and reported the occurrence of MW episodes while EEG was measured and again during magnetic resonance imaging. Frontal TBR was higher during MW than controlled thought and this was marginally related to restingâstate TBR. DMN connectivity was higher and ECN connectivity was lower during MW. Greater ECN connectivity during focus than MW was correlated to lower TBR during focus than MW. These results provide the first evidence of the neural correlates of TBR and its functional dynamics and further establish TBR's usefulness for the study of executive control, in normal and potentially abnormal psychology., The aim of our current study was to further clarify the relations between restingâstate theta/beta ratio (TBR) and TBR's dynamic relation with states of increased/decreased cognitive control and their neurobiological underpinning in terms of executive control network/default mode network connectivity. We assessed mind wandering and focused attention during EEG and fMRI measurements in the same participants on 2 separate days, exploiting TBR's excellent retest reliability.
View Full Paper âSustained effects of neurofeedback in ADHD: a systematic review and meta-analysis
Neurofeedback (NF) has gained increasing interest in the treatment of attention-deficit/hyperactivity disorder (ADHD). Given learning principles underlie NF, lasting clinical treatment effects may be expected. This systematic review and meta-analysis addresses the sustainability of neurofeedback and control treatment effects by considering randomized controlled studies that conducted follow-up (FU; 2â12Â months) assessments among children with ADHD. PubMed and Scopus databases were searched through November 2017. Within-group and between-group standardized mean differences (SMD) of parent behavior ratings were calculated and analyzed. Ten studies met inclusion criteria (NF: ten studies, NÂ =Â 256; control: nine studies, NÂ =Â 250). Within-group NF effects on inattention were of medium effect size (ES) (SMDÂ =Â 0.64) at post-treatment and increased to a large ES (SMDÂ =Â 0.80) at FU. Regarding hyperactivity/impulsivity, NF ES were medium at post-treatment (SMDÂ =Â 0.50) and FU (SMDÂ =Â 0.61). Non-active control conditions yielded a small significant ES on inattention at post-treatment (SMDÂ =Â 0.28) but no significant ES at FU. Active treatments (mainly methylphenidate), had large ES for inattention (post: SMDÂ =Â 1.08; FU: SMDÂ =Â 1.06) and medium ES for hyperactivity/impulsivity (post: SMDÂ =Â 0.74; FU: SMDÂ =Â 0.67). Between-group analyses also revealed an advantage of NF over non-active controls [inattention (post: SMDÂ =Â 0.38; FU: SMDÂ =Â 0.57); hyperactivityâimpulsivity (post: SMDÂ =Â 0.25; FU: SMDÂ =Â 0.39)], and favored active controls for inattention only at pre-post (SMDÂ =Â â 0.44). Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6Â months following treatment. More studies are needed for a properly powered comparison of follow-up effects between NF and active treatments and to further control for non-specific effects.
View Full Paper âSpatial attention modulates visual gamma oscillations across the human ventral stream
Oscillatory synchronization in the gamma frequency range has been proposed as a neuronal mechanism to prioritize processing of relevant stimuli over competing ones. Recent studies in animals found that selective spatial attention enhanced gamma-band synchronization in high-order visual areas (V4) and increased the gamma peak frequency in V1. The existence of such mechanisms in the human visual system is yet to be fully demonstrated. In this study, we used MEG, in combination with an optimised stimulus design, to record visual gamma oscillations from human early visual cortex, while participants performed a visuospatial attention cueing task. First, we reconstructed virtual sensors in V1/V2, where gamma oscillations were strongly induced by visual stimulation alone. Second, following the results of a statistical comparison between conditions of attention, we reconstructed cortical activity also in inferior occipital-temporal regions (V4). The results indicated that gamma amplitude was modulated by spatial attention across the cortical hierarchy, both in the early visual cortex and in higher-order regions of the ventral visual pathway. In contrast, we found no evidence for an increase in the gamma peak frequency in V1/V2 with attention. The gamma response tended to peak earlier in V1/V2 than in V4 by approximately 70Â ms, consistent with a feed-forward role of gamma-band activity in propagating sensory representations across the visual cortical hierarchy. Together, these findings suggest that differences in experimental design or methodology can account for the inconsistencies in previous animal and human studies. Furthermore, our results are in line with the hypothesis of enhanced gamma-band synchronization as an attentional mechanism in the human visual cortex.
View Full Paper âParsing heterogeneity in attention-deficit hyperactivity disorder using EEG-based subgroups.
Background: Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous condition for which multiple efforts to characterize brain state differences are underway. The objective of this study was to identify distinct subgroups of resting electroencephalography (EEG) profiles among children with and without ADHD and subsequently provide extensive clinical characterization of the subgroups. Methods: Latent class analysis was used with resting state EEG recorded from a large sample of 781 children with and without ADHD (N = 620 ADHD, N = 161 Control), aged 618 years old. Behavioral and cognitive characteristics of the latent classes were derived from semistructured diagnostic interviews, parent completed behavior rating scales, and cognitive test performance. Results: A five-class solution was the best fit for the data, of which four classes had a defining spectral power elevation. The distribution of ADHD and control subjects was similar across classes suggesting there is no one resting state EEG profile for children with or without ADHD. Specific latent classes demonstrated distinct behavioral and cognitive profiles. Those with elevated slow-wave activity (i.e. delta and theta band) had higher levels of externalizing behaviors and cognitive deficits. Latent subgroups with elevated alpha and beta power had higher levels of internalizing behaviors, emotion dysregulation, and intact cognitive functioning. Conclusions: There is population-level heterogeneity in resting state EEG subgroups, which are associated with distinct behavioral and cognitive profiles. EEG measures may be more useful biomarkers of ADHD outcome or treatment response rather than diagnosis. Keywords: Electrophysiology; ADHD; resting state; latent class analysis.
View Full Paper âIndividual Alpha Peak Frequency Predicts 10 Hz Flicker Effects on Selective Attention
Rhythmic visual stimulation ("flicker") is primarily used to "tag" processing of low-level visual and high-level cognitive phenomena. However, preliminary evidence suggests that flicker may also entrain endogenous brain oscillations, thereby modulating cognitive processes supported by those brain rhythms. Here we tested the interaction between 10 Hz flicker and endogenous alpha-band (âŒ10 Hz) oscillations during a selective visuospatial attention task. We recorded EEG from human participants (both genders) while they performed a modified Eriksen flanker task in which distractors and targets flickered within (10 Hz) or outside (7.5 or 15 Hz) the alpha band. By using a combination of EEG source separation, time-frequency, and single-trial linear mixed-effects modeling, we demonstrate that 10 Hz flicker interfered with stimulus processing more on incongruent than congruent trials (high vs low selective attention demands). Crucially, the effect of 10 Hz flicker on task performance was predicted by the distance between 10 Hz and individual alpha peak frequency (estimated during the task). Finally, the flicker effect on task performance was more strongly predicted by EEG flicker responses during stimulus processing than during preparation for the upcoming stimulus, suggesting that 10 Hz flicker interfered more with reactive than proactive selective attention. These findings are consistent with our hypothesis that visual flicker entrained endogenous alpha-band networks, which in turn impaired task performance. Our findings also provide novel evidence for frequency-dependent exogenous modulation of cognition that is determined by the correspondence between the exogenous flicker frequency and the endogenous brain rhythms.SIGNIFICANCE STATEMENT Here we provide novel evidence that the interaction between exogenous rhythmic visual stimulation and endogenous brain rhythms can have frequency-specific behavioral effects. We show that alpha-band (10 Hz) flicker impairs stimulus processing in a selective attention task when the stimulus flicker rate matches individual alpha peak frequency. The effect of sensory flicker on task performance was stronger when selective attention demands were high, and was stronger during stimulus processing and response selection compared with the prestimulus anticipatory period. These findings provide novel evidence that frequency-specific sensory flicker affects online attentional processing, and also demonstrate that the correspondence between exogenous and endogenous rhythms is an overlooked prerequisite when testing for frequency-specific cognitive effects of flicker.
View Full Paper âReal-time fMRI neurofeedback in adolescents with attention deficit hyperactivity disorder
Attention Deficit Hyperactivity Disorder (ADHD) is associated with poor self-control, underpinned by inferior fronto-striatal deficits. Real-time functional magnetic resonance neurofeedback (rtfMRI-NF) allows participants to gain self-control over dysregulated brain regions. Despite evidence for beneficial effects of electrophysiological-NF on ADHD symptoms, no study has applied the spatially superior rtfMRI-NF neurotherapy to ADHD. A randomized controlled trial tested the efficacy of rtfMRI-NF of right inferior prefrontal cortex (rIFG), a key region that is compromised in ADHD and upregulated with psychostimulants, on improvement of ADHD symptoms, cognition, and inhibitory fMRI activation. To control for region-specificity, an active control group received rtfMRI-NF of the left parahippocampal gyrus (lPHG). Thirty-one ADHD boys were randomly allocated and had to learn to upregulate their target brain region in an average of 11 rtfMRI-NF runs over 2 weeks. Feedback was provided through a video-clip of a rocket that had to be moved up into space. A transfer session without feedback tested learning retention as a proximal measure of transfer to everyday life. Both NF groups showed significant linear activation increases with increasing number of runs in their respective target regions and significant reduction in ADHD symptoms after neurotherapy and at 11-month follow-up. Only the group targeting rIFG, however, showed a transfer effect, which correlated with ADHD symptom reductions, improved at trend level in sustained attention, and showed increased IFG activation during an inhibitory fMRI task. This proof-of-concept study demonstrates for the first time feasibility, safety, and shorter- and longer-term efficacy of rtfMRI-NF of rIFG in adolescents with ADHD. Hum Brain Mapp 38:3190-3209, 2017. © 2017 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.
View Full Paper âEEG correlates of working memory performance in females
BACKGROUND: The study investigates oscillatory brain activity during working memory (WM) tasks. The tasks employed varied in two dimensions. First, they differed in complexity from average to highly demanding. Second, we used two types of tasks, which required either only retention of stimulus set or retention and manipulation of the content. We expected to reveal EEG correlates of temporary storage and central executive components of WM and to assess their contribution to individual differences. RESULTS: Generally, as compared with the retention condition, manipulation of stimuli in WM was associated with distributed suppression of alpha1 activity and with the increase of the midline theta activity. Load and task dependent decrement of beta1 power was found during task performance. Beta2 power increased with the increasing WM load and did not significantly depend on the type of the task. At the level of individual differences, we found that the high performance (HP) group was characterized by higher alpha rhythm power. The HP group demonstrated task-related increment of theta power in the left anterior area and a gradual increase of theta power at midline area. In contrast, the low performance (LP) group exhibited a drop of theta power in the most challenging condition. HP group was also characterized by stronger desynchronization of beta1 rhythm over the left posterior area in the manipulation condition. In this condition, beta2 power increased in the HP group over anterior areas, but in the LP group over posterior areas. CONCLUSIONS: WM performance is accompanied by changes in EEG in a broad frequency range from theta to higher beta bands. The most pronounced differences in oscillatory activity between individuals with high and low WM performance can be observed in the most challenging WM task.
View Full Paper âBehavioral Effects of Neurofeedback Compared to Stimulants and Physical Activity in Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial
Objective: The efficacy of neurofeedback as a treatment for attention-deficit/hyperactivity disorder (ADHD), and whether neurofeedback is a viable alternative for stimulant medication, is still an intensely debated subject. The current randomized controlled trial compared neurofeedback to (1) optimally titrated methylphenidate and (2) a semi-active control intervention, physical activity, to account for nonspecific effects. Methods: A multicenter 3-way parallel-group study with balanced randomization was conducted. Children with a DSMIV- TR diagnosis of ADHD, aged 7.13 years, were randomly allocated to receive neurofeedback (n = 39), methylphenidate (n = 36), or physical activity (n = 37) over a period of 10.12 weeks. Neurofeedback comprised theta/beta training on the vertex (Cz). Physical activity consisted of moderate to vigorous intensity exercises. Neurofeedback and physical activity were balanced in terms of number (~30) and duration of sessions. A double-blind pseudorandomized placebo-controlled crossover titration procedure was used to determine an optimal dose in the methylphenidate intervention. Parent and teacher ratings on the Strengths and Difficulties Questionnaire (SDQ) and Strengths and Weaknesses of ADHD Symptoms and Normal Behavior (SWAN) were used to assess intervention outcomes. Data collection took place between September 2010 and March 2014. Results: Intention-to-treat analyses revealed an improvement in parent-reported behavior on the SDQ and the SWAN Hyperactivity/Impulsivity scale, irrespective of received intervention (Μp2 = 0.21.0.22, P †.001), whereas the SWAN Inattention scale revealed more improvement in children who received methylphenidate than neurofeedback and physical activity (Μp2 = 0.13, P †.001). Teachers reported a decrease of ADHD symptoms on all measures for methylphenidate, but not for neurofeedback or physical activity (range of Μp2 = 0.14.0.29, P < .001). Conclusions: The current study found that optimally titrated methylphenidate is superior to neurofeedback and physical activity in decreasing ADHD symptoms in children with ADHD
View Full Paper âEpileptic Electroencephalography Profile Associates with Attention Problems in Children with Fragile X Syndrome: Review and Case Series
Fragile X syndrome (FXS) is the most common cause of inherited intellectual disability and a variant of autism spectrum disorder (ASD). The FXS population is quite heterogeneous with respect to comorbidities, which implies the need for a personalized medicine approach, relying on biomarkers or endophenotypes to guide treatment. There is evidence that quantitative electroencephalography (EEG) endophenotype-guided treatments can support increased clinical benefit by considering the patientâs neurophysiological profile. We describe a case series of 11 children diagnosed with FXS, aged one to 14 years, mean 4.6 years. Case data are based on longitudinal clinically-observed reports by attending physicians for comorbid symptoms including awake and asleep EEG profiles. We tabulate the comorbid EEG symptoms in this case series, and relate them to the literature on EEG endophenotypes and associated treatment options. The two most common endophenotypes in the data were diffuse slow oscillations and epileptiform EEG, which have been associated with attention and epilepsy respectively. This observation agrees with reported prevalence of comorbid behavioral symptoms for FXS. In this sample of FXS children, attention problems were found in 37% (4 of 11), and epileptic seizures in 45% (5 of 11). Attention problems were found to associate with the epilepsy endophenotype. From the synthesis of this case series and literature review, we argue that the evidence-based personalized treatment approach, exemplified by neurofeedback, could benefit FXS children by focusing on observable, specific characteristics of comorbid disease symptoms.
View Full Paper âAttentional and affective consequences of technology supported mindfulness training: a randomised, active control, efficacy trial
Background: Mindfulness training (MT) programs represent an approach to attention training with well-validated mental health benefits. However, research supporting MT efficacy is based predominantly on weekly-meeting, facilitator-led, group-intervention formats. It is unknown whether participants might benefit from neurofeedback-assisted, technology-supported MT (N-tsMT), in which meditation is delivered individually, without the need for a facilitator, travel to a training site, or the presence of a supportive group environment. Mirroring the validation of group MT interventions, the first step in addressing this question requires identifying whether N-tsMT promotes measurable benefits. Here, we report on an initial investigation of a commercial N-tsMT system. Methods: In a randomized, active control trial, community-dwelling healthy adult participants carried out 6weeks of daily practice, receiving either N-tsMT (n=13), or a control condition of daily online math training (n=13). Training effects were assessed on target measures of attention and well-being. Participants also completed daily post-training surveys assessing effects on mood, body awareness, calm, effort, and stress. Results: Analysis revealed training effects specific to N-tsMT, with attentional improvements in overall reaction time on a Stroop task, and well-being improvements via reduced somatic symptoms on the Brief Symptom Inventory. Attention and well-being improvements were correlated, and effects were greatest for the most neurotic participants. However, secondary, exploratory measures of attention and well-being did not show training-specific effects. N-tsMT was associated with greater body awareness and calm, and initially greater effort that later converged with effort in the control condition. Conclusions: Preliminary findings indicate that N-tsMT promotes modest benefits for attention and subjective well-being in a healthy community sample relative to an active control condition. However, the findings would benefit from replication in a larger sample, and more intensive practice or more comprehensive MT instruction might be required to promote the broader benefits typically reported in group format, facilitated MT.
View Full Paper âShort and long-term effects of sham-controlled prefrontal EEG-neurofeedback training in healthy subjects
Objective: In this study we evaluated long-term effects of frontal beta EEG-neurofeedback training (E-NFT) on healthy subjects. We hypothesized that E-NFT can change frontal beta activity in the long-term and that changes in frontal beta EEG activity are accompanied by altered cognitive performance. Methods: 25 healthy subjects were included and randomly assigned to active or sham E-NFT. On average the subjects underwent 15 E-NFT training sessions with a training duration of 45 min. Resting-state EEG was recorded prior to E-NFT training (t1) and in a 3-year follow-up (t3). Results: Compared to sham E-NFT, which was used for the control group, real E-NFT increased beta activity in a predictable way. This increase was maintained over a period of three years post training. However, E-NFT did not result in significantly improved cognitive performance. Conclusion: Based on our results, we conclude that EEG-NFT can selectively modify EEG beta activity both in short and long-term. Significance: This is a sham controlled EEG neurofeedback study demonstrating long-term effects in resting state EEG
Efficacy of Neurofeedback Versus Pharmacological Support in Subjects with ADHD
Behavioral training in neurofeedback has proven to be an essential complement to generalize the effects of pharmacological support in subjects who have attention deficit with hyperactivity disorder (ADHD). Therefore, this investigation attempts to analyze the efficacy of neurofeedback compared with pharmacological support and the combination of both. Participants were 131 students, classified into four groups: control (did not receive neurofeedback or pharmacological support), neurofeedback group, pharmacological support group, and combined group (neurofeedback + pharmacological support). Participantsâ executive control and cortical activation were assessed before and after treatment. Results indicate that the combined group obtained more benefits and that the neurofeedback group improved to a greater extent in executive control than the pharmacological support group. It is concluded that this kind of training may be an alternative to stimulate activation in subjects with ADHD.
View Full Paper âBehavioral effects of neurofeedback in adolescents with ADHD: a randomized controlled trial
Neurofeedback has been proposed as a potentially effective intervention for reducing Attention Deficit Hyperactivity Disorder (ADHD) symptoms. However, it remains unclear whether neurofeedback is of additional value to treatment as usual (TAU) for adolescents with clinical ADHD symptoms. Using a multicenter parallel-randomized controlled trial design, adolescents with ADHD symptoms were randomized to receive either a combination of TAU and neurofeedback (NFB + TAU, n = 45) or TAU-only (n = 26). Randomization was computer generated and stratified for age group (ages 12 through 16, 16 through 20, 20 through 24). Neurofeedback treatment consisted of approximately 37 sessions of theta/sensorimotor rhythm (SMR)-training on the vertex (Cz). Primary behavioral outcome measures included the ADHD-rating scale, Youth Self Report, and Child Behavior Checklist all assessed pre- and post-intervention. Behavioral problems decreased equally for both groups with medium to large effect sizes, range of partial η2 = 0.08â0.31, p < 0.05. Hence, the combination of NFB + TAU was not more effective than TAU-only on the behavioral outcome measures. In addition, reported adverse effects were similar for both groups. On behavioral outcome measures, the combination of neurofeedback and TAU was as effective as TAU-only for adolescents with ADHD symptoms. Considering the absence of additional behavioral effects in the current study, in combination with the limited knowledge of specific treatment effects, it is questionable whether theta/SMR neurofeedback for adolescents with ADHD and comorbid disorders in clinical practice should be used. Further research is warranted to investigate possible working mechanisms and (long-term) specific treatment effects of neurofeedback.
View Full Paper âMindfulness Meditation Improves Mood, Quality of Life, and Attention in Adults with Attention Deficit Hyperactivity Disorder
Objective. Adults with attention deficit hyperactivity disorder (ADHD) display affective problems and impaired attention. Mood in ADHD can be improved by mindful awareness practices (MAP), but results are mixed regarding the enhancement of attentional performance. Here we evaluated MAP-induced changes in quality of life (QoL), mood, and attention in adult ADHD patients and controls using more measures of attention than prior studies. Methods. Twenty-one ADHD patients and 8 healthy controls underwent 8 weekly MAP sessions; 22 similar patients and 9 controls did not undergo the intervention. Mood and QoL were assessed using validated questionnaires, and attention was evaluated using the Attentional Network Test (ANT) and the Conners Continuous Performance Test (CPT II), before and after intervention. Results. MAP enhanced sustained attention (ANT) and detectability (CPT II) and improved mood and QoL of patients and controls. Conclusion. MAP is a complementary intervention that improves affect and attention of adults with ADHD and controls.
View Full Paper âNeurocognitive therapeutics: from concept to application in the treatment of negative attention bias
There is growing interest in the use of neuroimaging for the direct treatment of mental illness. Here, we present a new framework for such treatment, neurocognitive therapeutics. What distinguishes neurocognitive therapeutics from prior approaches is the use of precise brain-decoding techniques within a real-time feedback system, in order to adapt treatment online and tailor feedback to individuals' needs. We report an initial feasibility study that uses this framework to alter negative attention bias in a small number of patients experiencing significant mood symptoms. The results are consistent with the promise of neurocognitive therapeutics to improve mood symptoms and alter brain networks mediating attentional control. Future work should focus on optimizing the approach, validating its effectiveness, and expanding the scope of targeted disorders.
View Full Paper âNeurofeedback for ADHD: a review of current evidence
Considerable scientific effort has been directed at developing effective treatments for attention-deficit/hyperactivity disorder (ADHD). Among alternative treatment approaches, neurofeedback has gained some promising empirical support in recent years from controlled studies as a treatment of core ADHD symptoms. However, a recent stringent meta-analysis of 8 randomized controlled trials published in 2013 found that the effects were stronger for unblinded measures and 3 recent subsequently published well-controlled trials found no effects for the most blinded ADHD outcome. Firmer conclusions must await upcoming evidence from larger controlled studies and future meta-analyses contrasting different forms of neurofeedback and different outcome measures.
View Full Paper âEEG neurofeedback treatments in children with ADHD: an updated meta-analysis of randomized controlled trials
Objective: We undertook a meta-analysis of published Randomized Controlled Trials (RCT) with semi-active control and sham-NF groups to determine whether Electroencephalogram-neurofeedback (EEG-NF) significantly improves the overall symptoms, inattention and hyperactivity/impulsivity dimensions for probably unblinded assessment (parent assessment) and probably blinded assessment (teacher assessment) in children with Attention Deficit Hyperactivity Disorder (ADHD)., Data sources: A systematic review identified independent studies that were eligible for inclusion in a random effects meta-analysis., Data extraction: Effect sizes for ADHD symptoms were expressed as standardized mean differences (SMD) with 95% confidence intervals., Results: Five identified studies met eligibility criteria, 263 patients with ADHD were included, 146 patients were trained with EEG-NF. On parent assessment (probably unblinded assessment), the overall ADHD score (SMD = â0.49 [â0.74, â0.24]), the inattention score (SMD = â0.46 [â0.76, â0.15]) and the hyperactivity/impulsivity score (SMD = â0.34 [â0.59, â0.09]) were significantly improved in patients receiving EEG-NF compared to controls. On teacher assessment (probably blinded assessment), only the inattention score was significantly improved in patients receiving EEG-NF compared to controls (SMD = â0.30 [â0.58, â0.03])., Conclusions: This meta-analysis of EEG-NF in children with ADHD highlights improvement in the inattention dimension of ADHD symptoms. Future investigations should pay greater attention to adequately blinded studies and EEG-NF protocols that carefully control the implementation and embedding of training.
Neurofeedback is the Best Available First-Line Treatment for ADHD: What is the Evidence for this Claim?
Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic syndrome characterized by deficits in executive functions and attentional processes. Persons diagnosed with ADHD have significant deficits in self-regulation evidenced by difficulty staying focused, controlling impulsive behaviors, and for many, restraining hyperactive motor activity. These symptoms typically create problems in academic, social, and familial contexts as well as in the planning and organization skills needed for daily functioning. Additionally, comorbid syndromes that can mimic the symptoms of ADHD and confound differential diagnosis are commonly present (e.g., anxiety, depression, learning disorders). ADHD is the most frequently diagnosed pediatric disorder with 11% of American school-aged children (and nearly 20% of teenage boys) having been medically diagnosed with ADHD according to the latest report from the Centers for Disease Control (Schwarz & Cohen, 2013). Stimulant medication (SM) and behavior therapy (BT) are the two most widely accepted treatments for ADHD, with approximately 70% of those diagnosed prescribed medication (Schwarz, 2013). Although both interventions are considered to meet the highest standards for the evidence-based treatment of ADHD, and have been recognized as such by the American Academy of Child and Adolescent Psychiatry (AACAP) and Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), the leading ADHD advocacy group, the actual evidence is that these treatments fail to result in sustained benefit for the vast majority of children who receive them and, therefore, do not warrant being the first option for treating ADHD
Source-based neurofeedback methods using EEG recordings: training altered brain activity in a functional brain source derived from blind source separation
A developing literature explores the use of neurofeedback in the treatment of a range of clinical conditions, particularly ADHD and epilepsy, whilst neurofeedback also provides an experimental tool for studying the functional significance of endogenous brain activity. A critical component of any neurofeedback method is the underlying physiological signal which forms the basis for the feedback. While the past decade has seen the emergence of fMRI-based protocols training spatially confined BOLD activity, traditional neurofeedback has utilized a small number of electrode sites on the scalp. As scalp EEG at a given electrode site reflects a linear mixture of activity from multiple brain sources and artifacts, efforts to successfully acquire some level of control over the signal may be confounded by these extraneous sources. Further, in the event of successful training, these traditional neurofeedback methods are likely influencing multiple brain regions and processes. The present work describes the use of source-based signal processing methods in EEG neurofeedback. The feasibility and potential utility of such methods were explored in an experiment training increased theta oscillatory activity in a source derived from Blind Source Separation (BSS) of EEG data obtained during completion of a complex cognitive task (spatial navigation). Learned increases in theta activity were observed in two of the four participants to complete 20 sessions of neurofeedback targeting this individually defined functional brain source. Source-based EEG neurofeedback methods using BSS may offer important advantages over traditional neurofeedback, by targeting the desired physiological signal in a more functionally and spatially specific manner. Having provided preliminary evidence of the feasibility of these methods, future work may study a range of clinically and experimentally relevant brain processes where individual brain sources may be targeted by source-based EEG neurofeedback.
View Full Paper âDifferential effects of theta/beta and SMR neurofeedback in ADHD on sleep onset latency
Recent studies suggest a role for sleep and sleep problems in the etiology of attention deficit hyperactivity disorder (ADHD) and a recent model about the working mechanism of sensori-motor rhythm (SMR) neurofeedback, proposed that this intervention normalizes sleep and thus improves ADHD symptoms such as inattention and hyperactivity/impulsivity. In this study we compared adult ADHD patients (N = 19) to a control group (N = 28) and investigated if differences existed in sleep parameters such as Sleep Onset Latency (SOL), Sleep Duration (DUR) and overall reported sleep problems (PSQI) and if there is an association between sleep-parameters and ADHD symptoms. Secondly, in 37 ADHD patients we investigated the effects of SMR and Theta/Beta (TBR) neurofeedback on ADHD symptoms and sleep parameters and if these sleep parameters may mediate treatment outcome to SMR and TBR neurofeedback. In this study we found a clear continuous relationship between self-reported sleep problems (PSQI) and inattention in adults with- and without-ADHD. TBR neurofeedback resulted in a small reduction of SOL, this change in SOL did not correlate with the change in ADHD symptoms and the reduction in SOL only happened in the last half of treatment, suggesting this is an effect of symptom improvement not specifically related to TBR neurofeedback. SMR neurofeedback specifically reduced the SOL and PSQI score, and the change in SOL and change in PSQI correlated strongly with the change in inattention, and the reduction in SOL was achieved in the first half of treatment, suggesting the reduction in SOL mediated treatment response to SMR neurofeedback. Clinically, TBR and SMR neurofeedback had similar effects on symptom reduction in ADHD (inattention and hyperactivity/impulsivity). These results suggest differential effects and different working mechanisms for TBR and SMR neurofeedback in the treatment of ADHD
View Full Paper âA randomised controlled trial of combined EEG feedback and methylphenidate therapy for the treatment of ADHD
PURPOSE: To evaluate the efficacy of combined methylphenidate and EEG feedback treatment for children with ADHD. METHODS: Forty patients with ADHD were randomly assigned to the combination group (methylphenidate therapy and EEG feedback training) or control group (methylphenidate therapy and non-feedback attention training) in a 1:1 ratio using the double-blind method. These patients, who met the DSM-IV diagnostic criteria and were aged between 7 and 16 years, had obtained optimal therapeutic effects by titrating the methylphenidate dose prior to the trial. The patients were assessed using multiple parameters at baseline, after 20 treatment sessions, after 40 treatment sessions, and in 6-month follow-up studies. RESULTS: Compared to the control group, patients in the combination group had reduced ADHD symptoms and improved in related behavioural and brain functions. CONCLUSION: The combination of EEG feedback and methylphenidate treatment is more effective than methylphenidate alone. The combined therapy is especially suitable for children and adolescents with ADHD who insufficiently respond to single drug treatment or experience drug side effects.
EEG Neurofeedback for ADHD: Double-Blind Sham-Controlled Randomized Pilot Feasibility Trial
Objective: Preparing for a definitive randomized clinical trial (RCT) of neurofeedback (NF) for ADHD, this pilot trial explored feasibility of a double-blind, sham-controlled design and adherence/palatability/relative effect of two versus three treatments/week. Method: Unmedicated 6- to 12-year-olds with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) ADHD were randomized to active NF versus sham-NF and to 2X versus 3X/week treatment frequency. Frequency switch was allowed after Treatment 24. Results: In two school years, 39 participants were recruited and 34 (87%) completed all 40 treatments. Child/parent guesses about assigned treatment were no better than chance. At Treatment 24, 38% chose 2X/week and 62% chose 3X/week. Both active NF and sham yielded large preâpost improvement on parent ratings but NF no more than sham. Conclusion: Blinding appears to work, and sham does not prevent recruitment/retention. Treatment frequency of 3X/week seems preferred over 2X/week and was as effective. A large double-blind RCT is feasible and necessary to test specific NF effectiveness.
View Full Paper âA Decade of EEG Theta/Beta Ratio Research in ADHD: A Meta-Analysis
Objective: Many EEG studies have reported that ADHD is characterized by elevated Theta/Beta ratio (TBR). In this study we conducted a meta-analysis on the TBR in ADHD. Method: TBR data during Eyes Open from location Cz were analyzed from children/adolescents 6-18 years of age with and without ADHD. Results: Nine studies were identified with a total of 1253 children/adolescents with and 517 without ADHD. The grand-mean effect size (ES) for the 6-13 year-olds was 0.75 and for the 6-18 year-olds was 0.62. However the test for heterogeneity remained significant; therefore these ESs are misleading and considered an overestimation. Post-hoc analysis found a decreasing difference in TBR across years, explained by an increasing TBR for the non-ADHD groups. Conclusion: Excessive TBR cannot be considered a reliable diagnostic measure of ADHD, however a substantial sub-group of ADHD patients do deviate on this measure and TBR has prognostic value in this sub-group, warranting its use as a prognostic measure rather than a diagnostic measure.
View Full Paper âNeurofeedback in Residential Children and Adolescents with Mild Mental Retardation and ADHD Behavior
Neurofeedback (NFB) research has reported improved concentration and attention in children with attention deficit/hyperactivity disorder (ADHD) and progress maintained over time. Would that also apply to children with an IQ between 50 and 70 (mild mental retardation [MMR]) and an IQ between 70 and 85 (borderline retardation [BR]) with characteristics of ADHD? To our knowledge this is the first NFB treatment study with long-term follow-up in this particular group. Ten adolescents with MMR and BR and ADHD received 30 sessions of quantitative electroencephalogram (QEEG)-based NFB. QEEG differences with a gender- and age-matched group without mental handicap and ADHD (data provided by BRAINnet) were investigated, at pre- and posttreatment and at 6-month follow-up. Neuropsychological functioning was tested administering the Bourdon-Vos, and the Amsterdam Neuropsychological Testing Program subscales SA DOTS and SSV. Pretreatment eyes-closed EEGs were not statistically different in the children with MMR compared to the controls. With eyes open higher amplitudes were found in the lower frequencies in the children with MMR, normalizing over time. The neuropsychological tests improved for reaction times and errors. On the complex tasks in the SSV a number of errors remained. The subjects perceived an improvement in ADHD and increasingly enjoyed the study. After NFB treatment, attention and concentration in children with MMR and BR have improved. Task span and effort also increased, although impulse control remained weak. This may be explained by a limited working memory capacity. The subjective reports may have been affected by situational factors and should be interpreted with caution. This study is limited by its nonrandomized design.
View Full Paper âEncoding of Emotional Facial Expressions in Direct and Incidental Tasks: An Event-Related Potentials N200 Effect
Emotional face encoding processes in 2 types of tasks (direct and incidental) were explored in the current research through electroencephalographic (ERPs) and behavioral (response) measures. In Experiment 1 (incidental task) ERP correlates of 21 subjects were recorded when they viewed emotional (anger, sadness and happiness) or neutral facial stimuli. An emotion-specific cortical variation was found, a negative deflection at about 200 ms poststimulus (N2 effect). This effect was sensitive to the perceived emotional value of faces, since it differentiated negative high arousal (i.e., anger) from low arousal (i.e., sadness) or positive (happiness) emotions. Moreover, a specific cortical site (parietal) was activated by emotional faces but not by neutral faces. In Experiment 2 (20 subjects) a direct encoding task (emotion comprehension) was provided. We explored whether encoding for emotional faces relies on a single neural system irrespective of the task (incidental or direct), or whether it is supported by multiple, task-specific systems. The same difference previously observed between emotions, as a function of arousal and valence, was found in the direct condition. Nevertheless, we found differences in the cortical distribution (parietal for the incidental task; central and parietal for direct task) and lateralization (right-distribution for the negative emotions in the direct task) of the N200 on the scalp due to different types of task. The cognitive significance of these ERP variations is discussed.
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