This doesn't, however, mean that a clinician can never go wrong using neurofeedback. If one trains the wrong combination or frequencies in the wrong locations, particularly if one has not done a careful analysis, initially, then it is possible that some negative side effects can occur.  There are two kinds of side effects: The first is that the person may not be helped at all and has invested a lot of time and expense with no result. In some cases, they may actually experience such physiological consequences as anxiety or increased depression.  These kinds of effects, though, are fairly mild.  In our clinical experience, we have never seen a case of significantly severe negative effects of neurofeedback training, at least for ADD.  With epileptic conditions, of course, the risk of triggering seizures is present. If a clinician does not do the right training, he can make patients worse. 

Could you describe, for us, your biofeedback protocol?

We have two protocols.  If the subject is hyperactive, we train to increase the EEG rhythm called the sensorimotor rhythm (SMR) on a location over the motor strip. At the same time, we train to inhibit (decrease) slow activity, anywhere in the range from 3 to 9 or 10 Hz, (that depends on the subject's age) over the same area. What we decide to do is based on the quantitative EEG (QEEG) analysis that we perform before the treatment. 

That’s the approach we use, primarily, for the hyperactive component. Then, we work with the focusing of attention. For that, we train to increase higher frequency beta activity in the range between 15 and 20 Hz, approximately. At the same time, of course, we continue to train to decrease to slow activity as before.  If the subject is of the inattentive type, in other words, if they don’t have hyperactivity, then we use the paradigm of increasing beta activity and decreasing theta or slow alpha activity without the SMR training as the first step.  With these types of subjects, we use a location over the midline of the cortex, locations anywhere from FZ to PZ, depending on age. 

And that’s the entire protocol?

Well, then there are some individuals that have unusual patterns, such as increased frontal beta activity or increased temporal theta.  Some subjects are deficient in producing alpha, particularly high alpha, between 10 and 12 Hz.  Depending on the pattern, we work heavily on building back what's missing and on suppressing the excessive abnormal activity. The whole idea is to bring them back to normal levels, based on the database analysis. 

What type of biofeedback equipment do you use?

I started with the Autogenic system, but now use the ProComp+/ BioGraph from Thought Technology Ltd.  The more I work with it the more I appreciate the beauty of the system. It is incredibly versatile and it includes peripheral measures.  It has a great variety of customizable options and is well worth the effort to learn and master.

Do you also use peripheral measurements in your work?

We have, at various times, looked at the electrodermal response (EDR) because some individuals with certain types of ADD, particularly the hyperactive type, show a pattern of low arousal. This is when the EDR is too low and they are not responsive to stimulation.  If you do a stress test on these subjects, they

show very little responsivity; so we try to teach them to increase their reactivity using EDR.  On the opposite side of the scale, there are individuals that are sometimes very aggressive, explosive and impulsive. We will often find their EDR to be too reactive and we try to quiet it down.  At other times, we have combined neurofeedback training with a form of autogenic-relaxation training. This involves repeating a series of phrases having to do with heaviness and warmth in the limbs. Sometimes, we combine relaxation with temperature training or EMG training.  The fact is that in some of the early studies that we did, when we tried to use EMG alone or EMG and temperature alone, we could only produce temporary improvements. We had to use the EEG biofeedback in order to get the long-term effect!  So we basically look at other modalities as supportive rather than primary in treating ADD.

As a clinician, what obstacles do you see to this treatments greater acceptance?

Right now, there are two kinds of scientific studies: One type, is what we call "observational" or "clinical outcome" study.  The other is the randomly assigned group outcome study, which is really favored by the scientific community.  So far, there are approximately 75 studies on ADD, published in Peer Review Journals, which fall into the first category.  There are relatively few studies of the second category, and that’s where most of the criticism comes from.  This kind of study involves a fairly large sample of individuals that are assigned to different treatment groups.  

That type of detailed multi-center, large-scale study has not been done yet.  If one was ever done and actually demonstrated that EEG biofeedback works best or better than other approaches, then there would be no argument against EEG biofeedback becoming mainstream treatment.  Some small-scale studies, along those lines, have already been done and seem to indicate that neurofeedback is the best modality.  But they were done with quite small groups, 10-15 subjects, and were not entirely convincing to the critics. 

The other trend that will help neurofeedback become mainstream is that there are more and more people interested in introducing EEG biofeedback systems in the school setting. This makes a lot of sense because many people have observed the possible benefits of the treatment and are actively searching for an adjunct treatment or an alternative to drugs.  I think that this will make the treatment more accessible to a lot of individuals who couldn’t afford it on a pay-per-service basis.

Are there other issues that you think should be addressed to help EEG biofeedback on its way to better recognition?

The other thing of crucial importance is that there are over 1500 practitioners, in this country, who are using neurofeedback and that ADD is what they treat the most.  In our own work, we have trained a large number of these individuals, over the years, to teach them how to do neurofeedback. Although it is fairly easy to announce oneself as a neurofeedback practitioner, the fact is that there are certification programs given by organizations such as the BCIA (Biofeedback Certification Institute of America). I am of the firm conviction that, at least for patient protection, we, at our clinic, emphasize that clinicians who do neurofeedback should either be licensed or certified health professionals or should work under the supervision of a certified health professional. If at all possible, they should try to get certified themselves.  There is a quality control issue that is very important, just a few practitioners doing the wrong thing can destroy neurofeedback's reputation in a very short time!

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