An Autonomic Nervous System Biofeedback Modality for the Treatment of Attention Deficit Hyperactivity Disorder - an Open Pilot Study
Eisenberg, Jacques, Ben-Daniel, Natella, Mei-Tal, Galit, Wertman, Eli, The Israel Journal of Psychiatry and Related Sciences
Abstract: Objective: To study the effect of a new non-invasive technique of non-cognitive biofeedback called Autonomic Nervous System Biofeedback Modality on the behavioral and attention parameters of a sample of children with attention deficit hyperactivity disorder. Method: 19 subjects attending regular schools, who met DSM-IV criteria for attention deficit hyperactivity disorder, received four sessions of Autonomie Nervous System Biofeedback Modality treatment. The heart rate variability was measured before and after the treatment, as were measures of efficacy including Conners' Teacher Questionnaires (28 items), the Child Behavior Check List for parents and teachers and Continuous Performance Test. Results: Positive treatment effect was observed in all the subjects. The parent's Child Behavior Check List and Conners' Teacher Questionnaires of the whole group showed statistically significant differences. The teacher's Child Behavior Check List showed positive change not reaching statistical significance. A positive correlation between heart rate variability changes and improvement of symptoms of attention deficit hyperactivity disorder was found. Conclusion: These are preliminary findings of apparent efficacy of Autonomic Nervous System Biofeedback Modality treatment for attention deficit hyperactivity disorder in children. Future controlled trials are warranted.
Attention deficit hyperactivity disorder (ADHD) affects 3-5% of the population. The syndrome consists of inappropriate levels of inattentiveness and impulsivity, often accompanied by hyperactivity. The diagnosis relies solely on behavioral description (DSM-IV) and there is no objective physiological measure of attention which has a discriminative diagnostic value (1).
The treatment of ADHD generally calls for a multifaceted approach, combining psychotherapy, pharmacotherapy, parental counselling and school intervention. Psychostimulants are the most studied and proven medication, showing dramatic shortterm effects. Despite their efficacy and safety, stimulant medications still arouse concern among parents and teachers who resist long-term administration of drugs to children. Moreover, about 15% of children are non-responders to stimulants, or develop significant side effects, and for some children the use of stimulants is controversial (2). Therefore, there is a continuous interest in the development of alternative therapies. Some of these have been systematically studied, like behavior therapy and parental training (3,4) and another, like EEG biofeedback, suffers from a paucity of data. Lubar (5) reported that biofeedback training for reduction of theta waves had positive effects on a continuous performance test , although there was no difference in behavior between the EEG change group and the no-change group.
Another study (6) had no EEG analysis and their statistical positive results are of dubious functional significance. A recent review of the literature differentiates, however, between theta reducing biofeedback with more promising results and alpha waves enhancing biofeedback with less conclusive results (7, 8).
The Autonomic Nervous System, Attention and ADHD
Recent neurobiological research offers growing evidence of brainstem abnormalities in a number of children with behavioral problems. The Polyvagal Theory, formulated by Forges et al. (9), provides an alternative model to explain symptoms associated with behavior disorder.
The theory assumes that the different branches of the vagus nerve are related to unique adaptive behavioral strategies. Special visceral pathways are involved in controlling the voluntary social behaviors and linked with structures, which, for example, inhibit our cardiovascular system to calm us and to foster self-soothing behavioral strategies. The disinhibition of brainstem structures promotes mobilization behavior (e.g., hyperactivity, poor state regulation, lack of attention). …