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Attention Deficit Hyperactivity,

Disorder:

Neurological Basis and Treatment Alternatives

Arreed Barabasz and nne Barabasz

Correspondence should be addressed to Prof. Arreed Barabasz,

Ed.D., Ph.D., A.B.P.P., Attentional Processes Laboratory, Cleveland Hall,

Washington State University, Pullman, WA 99164-2136

Recent research

indicates a neurological basis for attention deficit disorder,

specifically, right frontal lobe dysfunction. Traditional treatments for

ADD/ADHD, such as stimulant drugs, behavior modification, and

cognitive-behavior therapy have had limited, short-term success and many

drawbacks. Neurotherapy (or EEG feedback) which addresses the frontal

lobe dysfunction, has shown significant, long-term results, by teaching

patients to normalize their brainwave responses to stimuli. When

Instantaneous Neuronal Activation Procedure (INAP) is used in adjunct to

neurotherapy, treatment time is significantly reduced without losing

long-term effects of the therapy. INAP was developed on the basis of

research on hypnotic phenomena.

Attention deficit disorder

(ADD) and attention deficit hyperactivity disorder (ADHD) are

characterized by the inability to self-regulate focused attention.

Children with hyperactivity are impulsive and behaviorally disinhibited.

The condition is developmentally disabling which, if left uncontrolled

persists into adolescence and adulthood. This biologically based

behavioral disability has a pervasive negative impact on a wide range of

adaptive functioning. Although under diagnosed in the past, such is not

the case today. Diagnoses are on the rise as public awareness increases.

" Its ADHD's time in the sun and they are getting it " (,

1995, P.44).

Neurological Basis and Assessment

A plethora of correlational studies have led to speculations about the

role of food additives, dietary sugar (Finegold 1973, 1975), blood lead

levels (, 1974), allergies (Marshall, 1989), smoking and alcohol use

during pregnancy (Barkley, 1990), as causal factors in the etiology of

ADD/ADHD. At the same time, serious research has been progressing

systematically which forms the basis for a neurological understanding of

attention deficit disorders. The data from these investigations clearly

implicates frontal lobe involvement, providing a substantive rationale

for the use of neurotherapy and a new adjunctive technique called

Instantaneous Neuronal Activation Procedure (INAP) (Barabasz, 1985, 1993,

in press; A. Barabasz & M. Barabasz, 1993b, 1994a, 1994b, in press).

Frontal lobe functions are executive in nature and are involved in

developing plans and organizing resources. They also are critical in

mediating inhibitory behaviors such as controlling motor behavior and

inhibiting attentional focus on distractor or irrelevant stimuli. The

evidence suggesting right frontal lobe dysfunction as the basis of

attention deficit disorders is considerable (Chelune, Ferguson, Koon

& Dickey, 1986; Gualteri & Hicks, 1985; Hynd, Semrud-Clikeman,

Lorys, Novey & Eliopulos, 1990; Lou, Henriksen, Bruhn, Bomer &

Nielsen, 1989; Schaughency & Hynd, 1989; Voeller & Heilman, 1988)

Recent research using advanced neuroimaging morphological procedures has

shown that ADD/ADHD children fail to show the normal

right-greater-than-left asymmetry in the mass of the frontal lobes (Hynd,

Hem, Voeller & Marshall, 1991). Consistent with this finding,

computerized quantitative electroencephalographic (EEG) analysis

(referred to as " neurometric assessment " in the practice of

psychology) shows significantly greater slow wave (theta) activity and

significantly less fast wave (beta) activity predominantly in the frontal

regions for ADD/ADHD boys (Mann, Lubar, Zimmerman, &

Muenchen,1992) and for ADD/ADHD girls and boys (A. Barabasz, Crawfbrd

& M. Barabasz, 1993; in press; Barabasz & Barabasz, In press,

when compared to age-and-sexmatched normals.

ADD/ADHD Treatments

Current ADD/ADHD treatments consist of the traditional approaches aimed

at symptom management, using stimulant medication, behavior modification,

and cognitive-behavior modification; and the more recent approaches focus

on neuropsychological rehabilitation. These latter approaches now include

neurotherapy alone and neurotherapy with Instantaneous Neuronal

Activation Procedure (INAP). INAP is an adjunctive technique which

enhances EEG Beta, increases responsiveness to feedback and substantially

shortens total treatment time.

Stimulant drugs such as methylphenidate (Ritalin) are prescribed for

600,000 to 1 million school children in the U.S. These powerful drugs are

believed to potentiate the dopamine and norepinephrine neurotransmitters.

However, medication was found to do absolutely nothing for 25%-40% of

children with the disorder. This striking finding was revealed by a

" review of reviews " conducted by 15 co-authors (Swanson et al.,

1993), that comprehensively examined 341 reviews of the effects of

stimulant medication on children with attention deficit disorders.

Furthermore, a large proportion of patients responding to Ritalin also

show the same improvements on placebo (Swanson et al, 1993).

For those who respond to stimulant medication, temporary management of

over-activity, inattention and impulsivity can be expected as well as

temporary improvement in compliance. Aggression may be reduced d e amount

of academic work completed may increase. Contrary to the hopes of parents

and practitioners, there will be no significant I improvement in reading,

no significant improvement in athletic or game skills, no significant

improvement in pro-active social skills and no significant improvement in

learning other than improved attending. Furthermore, one should expect no

improvement in long term adjustment such as improved academic achievement

nor any reduction in anti-social behaviors or arrest rates (Swanson et

al., 1993).

The side effects and limitations of stimulant medications include: 1)

short length of action (4-5 hours) which critically limits its benefits

and requires careful planning for administration at school and

school-related overnight trips; 2) problems with the child's self esteem

due to taunting by peers (e.g., " hyper diaper has to go get his

pill " ); 3) growth stunting unless medication vacations of adequate

length are planned such as summer vacation and the longer school year

holidays, (medication free weekends, frequently recommended by

prescribers, are too short to counteract inhibition of normal growth); 4)

insomnia and poor eating; 5) tics, cardiovascular problems, and Tourettes

Syndrome occur in a small percentage of children; 6) high doses cause

cognitive impairment; 7) no residual effect once medication is

terminated; and 8) a small, but significant, number of cases show

negative physiological side effects that do not diminish over time,

despite cessation of the medication (Whalan & Henker, 1991).

Behavior modification is undoubtedly the next most widely used

therapy to manage the disorder. One of the strengths of the behavioral

approach is the typical collaborative involvement of both parents and

teachers. Starting with the seminal work of B. F. Skinner, behavior

therapy researchers have published in excess of 5,000 articles, many of

which are applicable directly or indirectly to the management of

ADD/ADHD. Therapists train parents to use token economies and positive

attention for appropriate behaviors and time out or other punishments for

non-compliance (Gaddes & Edgell, 1994; Whalan & Henker, 1991).

Teachers use classroom contingency management where verbal praise and

other rewards are administered for appropriate attentive behaviors and

privileges withdrawn or punishments administered for undesirable

behaviors. Behavioral interventions can be combined with stimulant drugs

to provide a more comprehensive approach. Barkley (1990) believes that

medication helps to potentiate the benefits of this approach.

Behavior modification's limitations include: 1) a substantial number of

children do not respond to the treatment; 2) training does not generalize

to non-trained behaviors; 3) there is no carryover to the classroom of

behaviors learned only with parents and visa-versa; 4) as with

medication, once the treatment is terminated the behaviors rapidly return

to baseline baseline/pre-treatment levels; 5) a high degree of dependence

on both parental and teacher cooperation. Undoubtedly the greatest

limitation lies in the enormous complexity of the approach required for

its application to ADD/ADHD. Consistent with behavioral interventions for

other disorders, failures and relapses are blamed on noncompliance

(Barabasz, 1987). Firestone, , Goodman & Davey (1981) reported

that 50% of parent's failed to continue behavior modification treatment.

Cognitive-behavior therapy has greater flexibility than behavior

modification and/or medication. For example, self talk coping skillscan

be taught which should generalize to a wide range of situations that the

child might face. In theory, cognitive-behavior therapyshould go beyond

symptom management by providing a basis for continued growth and

rehabilitation. Unfortunately, the present adaptations of

Cognitive-Behavior Therapy to the treatment of ADD/ADHD have produced few

positive outcomes or have completely failed to demonstrate any lasting

effects (Conte, 1991; Gaddes & Edgell, 1994).

Neurotherapy (EEG feedback) is a rehabilitative approach to the treatment

of ADD/ADHD. The goal is permanent normalization without dependence on

drugs or continuous behavioral management therapy. Neurotherapy accepts

the neurological basis of the disorder (i.e. frontal lobe dysfunction I )

.. Recognizing that the attention deficit disordered child, adolescent, or

adult produces greater EEG slow wave (theta) activity (4-8 Hz) and less

beta (14-32 Hz) activity compared to normal controls, neurotherapy is

intended to teach patients to normalize their brainwave responses to

stimuli (Barabasz et al, 1993, inpress; Mann et al, 1992). The procedure

is based on an early study by Sterman and Friar (1972), who discovered

that brainwave feedback made it possible to learn to inhibit epileptic

seizures by enhancing low beta (12-16) which is referred to as sensory

motor rhythm (SMR). As in current neurofeedback protocols for ADD/ADHD,

Sterman and Friar's patients were also trained to simultaneously minimize

theta. The first preliminary case study application of this procedure to

hyperkinetic children was by Lubar and Shouse (1976).

When a normal person is presented with an attentional task, such as

reading, doing simple arithmetic or listening to a story, his/her EEG's

usually shift to the beta frequency band with an increase in magnitude

with projection to the frontal (particularly right frontal) regions. In

contrast, persons with attention deficit disorder typically do just the

opposite. Instead, they shift down into the slow theta frequency band

without any significant increase in frontal activity (A. Barabasz &

M. Barabasz, 1994, in pressa, -b; Barabasz et al, 1993, in press; Lubar,

1991; Mann et al, 1992). The slow activity (e.g., remaining in alpha 8-14

Hz or dropping down to theta) is characteristic of the wandering mind,

non-vigilance, and unfocused thought.

Before commencing neurotherapy, a neurometric evaluation involving a

computer analysis of a minimum of 19 active scalp electrode sites must be

conducted to confirm or disconfirm the above reactivity to key

attentional tasks. It is inappropriate to proceed with standardized

single channel (single electrode site) EEG feedback on the basis of a

DSM-III-R (American Psychiatric Association, 1987) or DSM-IV (American

Psychiatric Association, 1994) diagnosis alone. The diagnosis is

confirmed by complex digital analyses including evaluation of spectral

arrays and comprehensive color topographic maps of brain activity. First,

raw EEG is assessed to remove artifacts and for pathological activity.

Then fast fourrier transforms are performed to provide averaging of EEG

activity in a range of bands or sub-ranges within bands. Only patients

who show EEG responses to attentional tasks that are characteristic of

those with attention deficit disorder are appropriate candidates for

neurotherapy.

In neurotherapy, EEG responses to stimuli displayed on a computer screen

are real time analyzed for frequency, amplitude and artifact

characteristics. Then the computer provides feedback information, in the

form of visual displays and stereophonic auditory tones or verbalizations

showing how well the subject is doing. Unlike the EEG biofeedback

apparatus of the 1970's and 80's, continuous computer analysis allows

detection of muscle induced artifacts. Subjects are now only provided

with reinforcement for EEG responses which, for example, may include

augmentation of one band while simultaneously inhibiting another. Several

companies compete for the most intriguing forms of feedback, varieties of

data analyses provided for therapists and range of features and display

alternatives. Recently, Pope of NASA's Human Engineering Group and

Bogart of Lockheed Sciences, have gone so far as to develop the

concept even further by producing a video game which becomes more

difficult as the attention deficit disordered child's brain waves show

attention is waning (Pope & Bogart, 1991, in press). As in the more

established focus of neurotherapy, this approach teaches children to

decrease the time spent in slow wave activity and increase the time spent

in the fast activity required for focused attention and concentration on

tasks. It takes 40-80 sessions (40 minutes to I hour each) for

neurotherapy to produce lasting EEG and clinical changes. Follow-up

neurometric and clinical assessments should be conducted upon completion

of the course of treatments and at about I month, 6 months, and I year

follow-ups.

Chartier and (1991) reviewed the effects of neurofeedback for

ADD/ADHD on over 200 children treated by Dr. Lubar at the University

of Tennessee, Dr. at the University of Texas and Dr.

Tansey of Sommerville, New Jersey. Consistent with our own findings,

Chartier and found neurofeedback training to provide significant

and sometimes " dramatic " clinical improvements in children with

attention deficit disorder. Using an A-B-A design, Lubar and Shouse

(1977) treated groups of ADD children with the standard protocol

(reinforce Beta and inhibit Theta). The protocol was then switched to

inhibit Beta and enhance Theta. The subjects, parents, and teachers were

kept blind regarding the switch, but within two weeks they began

reporting that the childrens' behaviors and attentional skills were

deteriorating. Returning to the standard protocol at 4 weeks, the

children, parents, and teachers noted resumption of academic and

behavioral improvements. Gaddes and Edgell's (1994, p. 279-280) summary

of studies reports 80% of children treated show significant measurable

improvements on I.Q tests, standardized tests of academic achievement,

and teacher/parent ratings of behavior. Once the full course of

treatments have been completed, long term follow-ups indicate that the

effects last. Maintenance treatments are not necessary (Chartier &

, 1991).

Presently, limitations of neurofeedback include: 1) the need for

additional controlled experimental studies demonstrating effects which

are independent of developmental maturation and the potentially

confounding effect of the therapists and parents' attention during the

course of treatments; and 2) the large number of sessions (up to 80; 6-8

months) required for permanent clinical and academic changes to occur.

Instantaneous Neuronal Activation Procedure

(INAP): Adjunct to Neurotherapy

INAP was developed on the basis of research on hypnotic

phenomena (Barabasz, 1980a, 1980b, 1982, 1985; A. Barabasz, Baer, Sheehan

& M. Barabasz, 1986; A. Barabasz & M. Barabasz, 1989, 1992,

1994b; A. Barabasz, Crawford, & M. Barabasz, 1993, in press; Barabasz

& Lonsdale, 1983; Hilgard, 1979; Brown & Fromm, 1986; Hammond,

1990, P. 42; Holroyd, 1985-1986; Crawfbrd & Gruzelier, 1992).

Building on the data showing that hypnosis is a state of attention that

may be focused, to exclude distracters, or diffuse depending on the

specific instructions (suggestions) (Fromm, 1987; Hilgard, 1965, 1986),

we observed that the more general attentional processes involved in

vigilance, such as military radar target detection, could be enhanced

with alert hypnosis (Barabasz, 1980b). Later, military pilot instrument

flight reliability was improved with an active alert attentional

procedure to help optimize pilots' situational awareness with regard to

cockpit navigation cues (Barabasz, 1985).

The attentional shifts made possible with hypnosis have been causally

linked to specific EEG changes, which, as Hilgard foreshadowed (1965,

1986), vary depending upon the specific instructions given. In the first

fully controlled experiment to demonstrate an EEG signature unique to

hypnosis, Barabasz & Lonsdale (1983) discovered amplitude increases

in the late components of EEG olfactory event related potentials (ERP) in

response to specific instructions. The findings were consistent with a

related field study conducted in Antarctica (Barabasz & Greason,

1979) and subsequent cerebral blood flow investigations (Crawford,

Skolnick, Benson, R. Gur & C. Gur, 1985). Later, Spiegel, Cutcomb,

Ren & Pribram (1985) also showed highly significant ERP amplitude

changes after specific hypnotic instructions. Spiegel and Barabasz,

(1988) discussed how EEG ERPs could be modified dramatically in response

to alternative instructions.

The alert attentional instructions used to produce human performance

enhancement effects in radar operators and pilots (Barabasz, 1980bp 1985)

have been applied in more refined and replicable forms to modify EEG

topography and enhance focused attention for reading tasks. Using 19

active electrode sites we were able to demonstrate normalization of EEG

during reading with shifts to Beta and shifts toward frontal regions

following INAP in children with ADD/ADHD (A. Barabasz & M. Barabasz,

1993a, b; A. Barabasz, Crawford, & M. Barabasz, 1993, in press).

The INAP intervention has also demonstrated significant effects in a

carefully controlled experiment using normal young adults. To help

control for experimental demand effects, A. Barabasz & M. Barabasz

(1994a, b)embedded the INAP procedure into an EEG neurological screening

aspect of another study. Eleven subjects were exposed to counterbalanced

conditions of waking, attentional instructions, and INAP. A simple

suggestion emphasizing speed and memory retention was given prior to

subjects' exposure to parallel forms of a standardized reading

comprehension test. Both attentional instructions and INAP significantly

increased BETA magnitude at key frontal sites while significantly

increasing reading speed, but only INAP served to significantly increase

reading comprehension performance. Unfortunately, testing of long term

effects was beyond the scope of the study.

Recently, INAP has been used as an experimental adjunct to standard

neurotherapy (enhance beta in range 14-20 Hz while inhibiting theta

4-8Hz) in the treatment of ADHD (A. Barabasz & M. Barabasz, in press

a). Experimental cases were chosen from our clinical experience which

provided direct comparisons in treatment process, progress, outcomes and

1-year follow-ups. Patients in both conditions were matched closely with

respect to gender, age, WISC-III verbal and performance I.Q. scores and

scores on the Stanford Hypnotic Clinical Scale for Children ( &

Hilgard, 1978). Patients in both conditions had failed a grade in school

as a direct result of their ADHD and had been medicated for 2 or more

years with Ritalin when beginning treatment with us. Families were

intact. ADHD symptoms and severities were very similar. Histories

included active parental and school teacher participation in behavioral

modification programs with little positive, effect.

Using the standard neurotherapy protocol without hypnosis, treatment was

completed without need for maintenance sessions after 60-70 sessions (2-3

per week). Upon completion of treatment, EEG theta-beta ratios were

consistent with normals in response to a variety of attentional tasks.

Medication was no longer used and significant gains in I.Q., school

grades and parent/teacher deportment ratings had been realized. All gains

were maintained at a 1 year follow-up.

INAP which takes about 45 to 90 seconds per administration

(described in detail in A. Barabasz & M. Barabasz, in press) used in

conjunction with neurotherapy resulted in an outcome equivalent to or

better than those obtained with standard neurotherapy. The standard INAP

procedure, is conducted in two distinct phases (A. Barabasz & M.

Barabasz 1994a, . In the training phase, patients are instructed to

roll eyes up. Eye focus is led to this position by instructions to focus

on the psy- chologist's thumb. The thumb is then moved slowly from 10-15

cm in front of the patient's nose to the approximate center of the

forehead. Speed of movement is carefully coordinated with the patient's

ability to follow without swimming of the eyes or obvious loss of focus.

When eyes dart, or focus seems lost, the procedure is reinitiated. Normal

adults seldom have a problem with this procedure (A. Barabasz & M.

Barabasz, 1994), but clinical experience and patience may need to be

brought to bear in the treatment of hyperactive children to get eyes as

fully rolled up as possible and then kept steadily rolled up as required

for successful INAP effects. Once the eyes are fully and steadily rolled

up, instructions are then given to take notice of breathing and the

relaxation, confidence and special alertness felt at this point. Once

subjective signs of hypnosis are observed by the experienced clinician,

the patient is asked to raise a finger upon perception of the suggested

responses " . . just lift a finger on this hand (clinician touches

patient's non-dominant hand) when you feel the comfortable relaxation and

special alertness. " Upon observation of the patient's signal, which

should occur within 5-10 seconds, the patient is given the attentional

process specific suggestions such as, " in this special state of

alertness you will be able to focus your attention anyway you like, you

can concentrate as completely as you desire. " The addition of INAP

to neurotherapy appeared to be the key therapeutic ingredient to produce

these same lasting widely reported positive effects in only 30-32 (2-3

per week) sessions. It is noteworthy that the progress in the enhancement

of frontal beta, stagnated in sessions when INAP was not used and resumed

upon reinitiation of INAP. We speculate that had this A-B-A test not been

incorporated into the treatment program that the number of sessions

required to meet EEG and behavioral normalization criteria might have

been even further reduced.

Additional Findings

Our continued experimental clinical tests of INAP subsequent

to our previous study (A. Barabasz, & A Barabasz, in press a) have

produced additional findings which may be useful to clinicians. Previous

uses of INAP as an adjunct to neurotherapy have included a procedure

which asks patients to confirm experiencing feelings of relaxation,

confidence and special alertness by raising a finger during INAP. We no

longer see the need for this additional technique since it appears to

have no measurable effect on the 14-20 Hz Beta enhancement produced by

INAF. An alternative procedure appears to be helpful when treating

patients who have special difficulties with obtaining and/or maintaining

this eyes rolled up position required for successful results. Normally

the patient is asked to focus on the clinician's stationery thumb held

10-15 cm in front of the patient's nose. Then the patient's eyes are led

to the rolled up position by following the clinician's slow movement to

the center of the patient's forehead. A new alternative method we have

found useful is to continuously wiggle the first digit (index finger) to

help maintain the patient's focus/attentiveness throughout the upward

movement of the hand which is kept at 10-15 cm from the patient's head

rather than descending to the patient's forehead. This variation of the

technique can be used alternately with the original procedure or

exclusively with patients experiencing difficulty in maintaining eyes

rolled up for the minimum period of 30 seconds.

Response to INAP is easily determined on the basis of EEG criteria. Using

a simple EEG feedback protocol, and frontal electrode placement, the

increase in Beta from pre- to post-NAP should be obvious in terms of time

in Beta production and Beta amplitude. This response is so robust as to

be used as training criteria for clinicians adding INAP to their

neurotherapy protocols.

To date, one of the criticisms of neurotherapy has been the lack of

control for maturation during the, heretofore, lengthy 40-80 session and

five to eight month course of treatment. It has been argued that the

successful alleviation of the negative responses of those with attention

deficit disorder may not be due to neurotherapy, but rather simply to a

" growing out of it " effect coincident with the long treatment.

This issue has not been raised with respect to the traditional stimulant

medication and/or behavior modification treatments because the goal of

these treatments has been limited to immediate symptom management. Even

after " successful " treatment, the patient rapidly returns to

baseline behavior upon cessation of medication/behavior modification.

Assuming that further clinical trials and experimental research supports

the effect of INAP's reduction of treatment time to 25-35 sessions and

only two to three months, the maturation argument becomes even less

defensible.

Perhaps the greatest limitation of our knowledge of INAP effects in the

treatment of attention deficit disorder is in our inability to directly

tie its clearly demonstratable effect on EEG Beta production with

hypnosis. just because we administer a procedure that was conceptualized

within a type of active alert hypnotic induction and then observe effects

in the predicted direction, by no means demonstrates that such effects

are due to hypnosis per se. As noted in our work on experimental and

clinical research design considerations (A. Barabasz & M. Barabasz,

1992) little can be said about the specificity of hypnosis if

hypnotizability is not measured. This theoretical issue may make little

difference to the clinician so long as the results are in the desired

direction, but does point to the need for further research. Our ADD/ADHD

cases have all been at least moderately high in hypnotizabilty as

determined by the standardized tests. Children with ADD/ADHD and low

hypnotizability scores are difficult to find and the only rigorously

controlled experimental research on INAP to date (A. Barabasz, & M.

Barabasz, 1994a, used moderately hypnotizable subjects. This means

that thus far we do not know whether hypnosis per se can be viewed as the

causal factor. Perhaps the entirely nonhypnotic aspects of INAP account

for the significant contributions to the positive effects on neurotherapy

outcomes.

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