• What is Neurofeedback?  

                                                                      When it's hard to pay attention when  have ADD ,you're feeling  anxious or stressed out.  Training the brain using Neurofeedback can address these problems.  It  can help to  improve alertness, attention, emotional regulation, behavior, cognitive function and mental flexibility.  Changing the brain clearly affects the mind.  The training produces a measurable physiological effect on the brain. 

  You're probably aware that if a monitor displays your heart rate, you rapidly can learn to change it.  That's the essense of biofeedback. When a monitor displays your brain activity - you can quickly learn to change that also.  A neuroscientist in the 60's trained cats to change their brain activity.  Unexpectedly, those changes reduced seizure activity.  

• Neurofeedback  teaches the brain to change itself, helps attention, mood, behavior, cognition, and more.  Once these changes are practiced and learned, the effects tend to hold, for at least for many problems.  As someone's brain learns to improve it's own regulation, it often reduces reliance on medications.  Sometimes, it allows medications that weren't working well to work better.

• Neurofeedback uses a brain/computer interface.   It detects brain activity.  By using operant conditioning, you get rewarded when your brain makes more of certain types of brain activity.  Your brain might get a beep when it's doing the right thing. By changing the EEG, changes occur in brain timing, and can create a more activated, alert, and stable brain.  Or, a more calm brain.  Excessive fast or slow activity is associated with brain dysregulation, and a variety of clinical symptoms.  Training changes in that activity helps improve self-regulation.  

• How does neurofeedback work?  

  Step 1.

• A computer is loaded with special software the that interprets the EEG soit can view on the computer monitor when  the computer is connected to  a special EEG amplifier and sensors to a computer.  

• Then put the electrodes on the head. The EEG amplifier reads the EEG from the electrodes that have been placed on the patients scalp. 

   

  The electrodes detect the client’s brainwave activity. The amplifier picks up this information and converts it into a signal the  computer can understand.  Every brain produces this tiny electrical (or electro-chemical) activity (EEG). It's in millionths of a volt (microvolts).  Anywhere on the head you place an electrode, EEG activity exits.

  The electrodes are placed on the head where it reads the brainwave activity and sends that information to the computer. It's the patient's brain that controls the process. The computer acts as a high tech mirror, giving instant feedback about the brain.

   

  The software takes the brain's electrical signals and converts it into data the computer can handle. The special software takes data from amplifier and converts it into a display.  The display could show many things - or bars (spectral activity), graphs, games.  

  Programs are designed to provide feedback (visual or auditory).  For example, it may beep when the client is making more (or less) EEG amplitude in the targeted frequency bands.  You won't get beeps when there is too much or little of specific brain activity (oversimplified and just one possible example). 

  So basically the path consists of  Electrodes —> Connected to the head and to the EEG amplifier —> Connected to computer  —> Running software to interpret the signals

  Here's an example of how a computer might display the EEG.

  

  What is the eeg or brainwaves? What does it represent?  In simple terms, it's a physiological measure that represents changes in EEG activity. Particularly frequencies represent our state - sleepy, alert, agitated. For more click here. 

         How is Neurofeedback being used clinically?  

• Think CNS problem.  There are clearly others not listed which have responded to neurofeedback, though in much smaller N's,  including Schizophrenia, and Parkinson's. 
• Neurofeedback is not targeting each disorder. It's used to change timing and activation patterns. It's creating changes in feedback loops and pathways that make up the brain.
• This creates improvement in brain regulation, which impacts a variety of symptoms.
• Different problems may require different training targets. As examples, many clinicians report that depression may involve frontal lobe training, anxiety may involve some parietal training. 
• Just as there are different ways to exercise the body, there are different approaches to training or exercising the brain.  
• When does neurofeedback not work?  There are a variety of reasons

Here's a bit of commentary on neurofeedback regarding each disorder.

ADD/ADHD - More kids and adults with ADD/ADHD are using neurofeedback than any other problem. Experienced clinicians estimate that at a minimum, they have significant impact with 80-85% of these patients who complete 30-40 training sessions.  Is is the most commonly treated because it's the easiest problem to deal with?  Not really - ADD/ADHD is often many different symptoms rolled into one diagnosis. These must be sorted out as part of doing neurofeedback.  Though ADD it does respond well to neurofeedback and it has the most studies by far, there are a few practical reasons that it's the most common use for neurofeedback.  .

1. Parents are far more motivated to help their children succeed than to bring themselves.
2. There are increasing concerns than putting a child on medications for years is not a good thing.  Many parents want an alternative that works. 
3. For many kids medications just don't work very well.  They have side effects, make the kid feel less normal, or create as many problems as it solves. 
4. There are thousands of neurofeedback success stories around the country - many in ADD. More clinicians are adding neurofeedback because their patients are asking for it or talking about it (word of mouth).  
5. There's more solid published research on ADD/ADHD and neurofeedback.  
6. There's increased awareness of the role of the brain in ADHD (as well as other disorders) generally.  In the last 5 years, every magazine seems to have a brain imaging picture on its cover.  As a result, neurofeedback as a brain based intervention doesn't seem so foreign, and there is much more openness towards the concept.

Anxiety. 
In surveys - and when you talk to many health professionals report these as the most common applications for neurofeedback.  The greatest amount of research exists around ADD/ADHD.  Child psychologists and specialists in ADD/ADHD say they see improvements in 80-85% of the kids and adults they see from neurofeedback.  But for most of them, they include neurofeedback as part of a program, not by itself.

Most clinicians say generalized anxiety is one of the first symptoms to start to respond to training.  Significant improvements are typically estimated at 80-90% of those being trained.  However, it also depends very much on what other comorbidities exist. More complex cases that have multiple other problems may take more expertise and time to respond.  We still expect that these more complex cases in fact will respond to neurofeedback.  However, they take more time, expertise, along with clinical skills.  That means not everyone will achieve good results with these cases.  

It doesn't mean that these are the best problems for neurofeedback. They're the most common problems that clinicians who use neurofeedback often work with. Neurofeedback is about improving brain regulation.  When the brain is better regulated, a lot of problems work better.   Here are other problems that many clinicians are reporting consistent improvement.

Learning Disabilities (LD).    Over the last few years, two professionals in particular published data about new training techniques they are using to target learning disabilities and qEEG.  This was really big news for the field of neurofeedback.  It's common for reading, math and other problems to improve with neurofeedback and they may be enough.  But some clients still could have significant deficits after neurofeedback training, even after some improvement. By adding in this new technique (coherence training - a fairly sophisticated component of training) several very solid professionals are reporting more consistent improvements - in dyslexia, reading and math deficits, and visual and auditory processing problems

Conduct Disorders  

Anger and Rage

Clinical reports from psychiatrists and psychologists indicate that neurofeedback helps bipolar patients become more stable, and better able to reduce medications

Cognitive Impairment (Traumatic Brain Injury, Stroke)

Neuropsychologists have reported that improvement with TBI often occurs even many years after the injury – that neural plasticity still exists.  Emotional and behavioral improvements are significant for this group.

• Migraines and headaches         

• Chronic Pain

Therapists and MD's report that the incidence and intensity of migraines are often reduced – and sometimes eliminated.  For chronic pain, it helps reduce pain or perhaps how the brain manages pain, even in severe cases

• Sleep Dysregulation

The first changes clients typically observe after Neurofeedback is sleep.  Sleep can include improvement in insomnia, bruxism, poor sleep quality, difficulty waking, frequent waking, and nightmares.  

• Autism & PDD                                        
• Reactive Attachment Disorder

Autism, PDD and RAD are the fastest growing areas of Neurofeedback.  The calming effects of Neurofeedback produce noticeable results quickly in these severely affected populations.  

Substance Abuse                                      

In a study soon to be published, Neurofeedback was compared with a successful 12 step program for crack, cocaine, methamphetamine, and heroin users.  Sustained abstinence was significantly greater (2 times or greater) with the group that also got Neurofeedback training.  Previous published studies show similar results for alcoholics.   Substance abuse is an obvious form of poor self-regulation, and self-medication. 

Is there enough research? 

Neurofeedback started in animal research.  Over 1000 studies have been published related to this field.  The early animal research, which has been validated in many peer reviewed journals since the 1970s, showed:  1) the EEG can be changed through operant conditioning (based on Skinner's work), and 2) that seizures are reduced with EEG training.

These were done with animals – with no chance of placebo effects.  That research has been verified in human studies.   There will always be a need for much more.   But the basis for this field is extremely solid.  There are a number of good outcome studies.  No one has published any significant studies suggesting neurofeedback doesn't work.

For a list of studies related to neurofeedback, please vist the ISNR.org, appb.org web sites, a membership organization for existing neurofeedback practitioners. 

   A well recognized medical journal in child and adolescent psychiatry devoted much of a special issue to research in neurofeedback in January 2005.  It's well worth reviewing.  It was edited by an associate professor from Brown Medical School, a psychiatrist from Harvard Medical School and a psychiatrist from University of California, Davis.

The majority of outcome studies are in three areas:  epilepsy, ADD, and substance abuse, in addition to basic research.  Even thought neurofeedback is widely used for other issues, there are currently a limited number of outcome studies.  There's some smaller studies listed for OCD, for autism, depression, and anxiety and learning disabilities. More are in progress.

Though many more studies are needed, the literature that exists is substantial.  Most the research is published in small specialized journals. To understand the research and science requires reading multiple studies and articles about neurofeedback. That must be combined with a good understanding of the neurophysiology of cognitive behavioral function and the EEG (see Integrative Neuroscience).   Add to this a good understanding of arousal, the thalamus and the brainstem.  Once you’ve studied these, it provides a solid scientific underpinning for this emerging field. (There is a introductory course that does a good job of synthesizing this information and making it understandable).    

Frank Duffy, a noted Harvard Neurologist, reviewed the literature inn 2000.  He wrote an editorial that identified some unresolved research issues.  Then he added:

"The literature, which lacks any negative study of substance, suggests that EBT (EEG Biofeedback Therapy) should play a major therapeutic role in many difficult areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used." From the medical journal Clinical EEG and Neuroscience. 

A comment about the need for studies.  

The first that changes for most people when training in neurofeedback is sleep    Every clinician learns that quickly.  Neurofeedback helps insomnia and a number of other sleep problems.  But there is no real research on neurofeedback and sleep.  Remarkable - there's just not funding for it and no academics pursing the research.  Most experienced clinicians in the field know - if you add neurofeedback training to any psychiatric, psychological, or neurological treatment, the chances of improvement is extremely high. When the brain works better, it's easier to treat problems.  That being said, health professionals long for more outcome studies.  Not to convince themselves, but to convince other health professionals and insurance companies of efficacy.

Thousands of licensed health professionals use neurofeedback.  Continued growth over 12 years has occurred with psychologists, psychiatrists, and professors. All are subject to licensing boards.  Many are highly credentialed.  Neurofeedback is expensive and time consuming for patients.  It requires significant efforts by clinicians to learn.  It has been argued it could not grow without clear clinical success.

What EEG frequencies are typically trained?

Beta frequencies (12-20 Hz).  Increasing beta activity tends to relate to increased activation - a more alert, awake brain.  It's the state where tasks get done.   Training this band is ’s often used to improve attention, organization, to elevate mood, and to improve cognitive and task performance.  Calming the brain using SMR (12-15 Hz), often reduces anxiety, anger, stress related problems.  It can improve inhibition (for example impulsivity) and sleep onset (quiet down the mind).

When neurofeedback started, much of the training was done in this frequency range along the sensory-motor strip.  Neuroscience and brain imaging research have pointed to many other functional areas.  As a result, Neurofeedback may include training the frontal and pre-frontal lobes, the anterior cingulate, and temporal and parietal lobes.  For example, research indicated that excessive EEG slowing at the anterior cingulate can be related to ADD, depression, or OCD. 

Alpha-theta training (rewarding 8-11 or 8-12 Hz for alpha and 4-8 Hz for theta) uses neurofeedback to guide people to their deepest levels of consciousness.  Once in a deep state, deeper psychological issues, such as depression, addiction, anxiety and PTSD can more easily be addressed.  It can also enhance creativity and promote deep states of relaxation. The training is done eyes closed and may be enhanced with guided imagery. 

A double blind study on musical performance was published by a noted university in London. Top-flite students from the Royal Conservatory of Music who did alpha-theta training saw readily identifiable improvements in musical performance over 2 months.  Five groups with other therapies saw no improvements.

Excessive theta and delta (slow wave activity) is inhibited during training.  Theta waves (4-7) can be associated with distractibility or not focusing.  Delta waves (0-3) are often associated with sleep states, but in a waking state, can be associated with brain dysfunction.  Excessive amounts of delta and theta will interfere with concentration, attention, and create other problems.  Training often targets reducing that activity. 

High Beta.  Certain frequencies of high beta activity can potentially stimulate attention, but excessive high beta is associated with anxiety, tension, and trying too hard.  This can be reduced through training.   

When you see the EEG change, is the brain actually changing?

The EEG is a physiological measure. If you watch your EEG change while you're doing neurofeedback training - you have changed your brain. With neurofeedback, you can target training any frequency at any site.  For most people, you'll quickly watch their EEG change, based upon rewards.  This is basic operant conditioning principles and learning theory  

(Skinner, pigeons and pecking). 

This technique got interesting when Dr. Barry Sterman in the late '60's trained cats to change their EEG.  Cats who increased SMR activity didn't go into seizures nearly as fast as other cats.  All had been exposed to a toxic rocket fuel. No one expected such profound changes in brain behavior by training a change in the EEG.  There are still many professionals who are not aware that 1) that the EEG is easily changed, and 2) training the EEG over time can have a profound impact on behavior, affect, attention, and resilience or stability. 

There are an estimated 100 billion neurons in the cortex. If you look under any electrode, there may only be a few hundred thousand - a very tiny percent.  If you are seeing changes under one electrode at one site, does that mean you are only changing those few hundred thousand neurons? 

But in simple terms, what does the EEG tell you?

The EEG sums the electrical activity of neurons.  If you see an increase in amplitude in a particular EEG band - say 12-15 hz, in simple terms, it means more neurons are doing the same thing at the same time.

Since the EEG is by definition sum of electrical potential of neuronal activity, the only way to see changes occur in the EEG is when many neurons shift towards being more ready to fire (excitatory) or to not fire (inhibitory) at the same time.  

It's electro-chemical reactions that in fact produce neurotransmitters and that produce the EEG.   Electrochemistry and neurochemistry are opposite sides of the same coin. When a neuron finally fires, the firing releases neurotransmitters.  These go into to the synapses between neurons and may bind to receptor sites for many other neurons. It's firing in essence produces messages that will influence whether other neurons will fire.  Each neuron gathers information from other neurons which help it determine whether it's going to fire or be inhibited from firing.  Medications often target those neurotransmitters.  So it should be expected that many medications do affect the EEG. 

It's estimated a neuron can influence up to 1 million additional neurons.  Why is that important?  When you place an electrode over a site on the head, it's probably only covering about 100,000 neurons.  So are you only training 100,000 neurons right under the electrode?  Absolutely not. Each of those neurons affect huge number of other neurons.  The neurons it affects may be local or at a much further distance.  The neurons under the electrodes influence other neurons to fire or not fire, which in turn encourage others to do the same.  The pathways can influence areas all over the brain and body.  Remember that many nerves are bundles of axons that are the end point of neurons in the brain. 

There are feedback loops between neurons at the cortex and the thalamus (thalamo-cortical loop).  This thalamus has rich connections down to the brain stem. 

When someone starts to change their EEG, they are influencing feedback loops that connect throughout the brain.  Often, the effect of training the EEG at just one site has profound effects on how well someone maintains an alert and awake state.  That goes far beyond the effect of just the neurons under the electrode. 

Or, it allows someone to fall asleep more quickly or wake or more easily.  Those are system arousal functions. It's the brain stem and reticular activating system that are well known in neurophysiology.  The brain stem plays the primary role of how a person maintains an alert and awake state. 

Neurofeedback rapidly affects an alert or awake state.  It's clear that the feedback loops being impacted go from the cortex down to the brainstem and back.  Those loops - which are well known in neuroscience, are the only explanation we know of how training 100,000 neurons can have such a profound system wide effect.   It would be nice to see this proven out in sophisticated imaging studies.  But there is no other possible explanation for the process.  We've discussed it with very knowledgeable neuroscientists.  They agree these pathways are being influenced with changes in the EEg. 

It's because all those neurons constantly talk to each other and are influenced by each other that neurofeedback  works. 

Additional technical explanation.  Each neuron has dendrites – which gather up information from other neurons.  These dendrites gather excitatory or inhibitory information.  The neuron computes the total.  For example – lets say the neuron receives 500 excitatory messages (neurotransmitters) from other neurons and 800 inhibitory messages from other neurons.  In essence, the neuron adds up the votes. With more inhibitory "votes" or messages, the neuron's charge would be lowered and would be less likely to fire.  But if the situation is reversed, the neuron will decide to fire, that firing will send an impulse down it’s axon, which is it’s single output process.  When the impulse reaches the end of the axon, it releases neurotransmitter molecules, such as serotonin or dopamine.  These float across the synaptic cleft and bind to receptors on the next neuron.  (This axon could communicated up to 1 million neurons.  Which means, that once it fires, it could tell 1 million neurons that they should fire.)   

How many sessions are needed?

Noticeable results typically occur between the first and tenth session.  In many cases therapists recommend a minimum of 30-40 sessions for the results to hold longer term.  Clinicians have observed that symptoms in some clients resolved in a shorter time.   It's hard to predict with any person.  Some require more training, some less.  The goal is to complete enough training - enough learning - to insure consistent and lasting benefits. 

How long is each session?

Total session s is typically 30 minutes in length. Some people/kids may need to start with sessions as short as 5-10 minutes, but that's not common.  Fairly rapidly, most people and kids can build up to longer sessions.  

How often do you need to come for training?

Based on surveys, a large percentage of clinicians recommend two to three sessions a week to start with.  Some feel even three or four trainings per week accelerate the learning process.  The vast majority of clinicians run twice a week sessions.  Why? 

For one, many clients are resistant to coming more often.  Also, twice a week has proven successful.   If distance is an issue, some therapists will accept clients with one session a week, some will not.  It partially depends on the kind of problem that is being tackled.  Patients should talk with a clinician carefully about their situation.  Training successes have been reported for a small number of clients who trained only once a week.  But once a week training may increase drop-out rates. Learning just occurs more slowly. 

The optimum number of training sessions has not been well studied.   For clients who live far away, some clinicians run two sessions in the same day, separated by at least 30 to 45 minutes.  FOR SERIOUS PROBLEMS, such as addiction, two sessions a day - five days a week has been shown in research to be very successful.  No one in private practice typically does that intensive of training.  The exception - summertime, when when kids are out of school.  Some therapists will train kids every day or twice

What is Over-Learning? 

The safest way to approach training is to "overlearn" or "overtrain."   Don't stop as soon as symptoms begin to resolve.  Keep training for at least 5-10 more sessions, so your brain learns the changes more permanently.  Consider reducing the neurofeedback training gradually - going to once every two weeks, once a month, and see if the symptom improvement holds. 

Why is that important?  Here's an example of overlearning:  let's say you took piano lessons to learn "Mary had a little lamb."  After the 5th lesson, you played it perfectly - with no mistakes.  So you quit  - you've done it.  But 2 years from now, you sit down and try to play "Mary had a little lamb" again.  Chances are, you'll really struggle.  If instead, you kept taking lessons and practicing till what you've learned becomes habit, you'll likely to sit down 3 years now - even 10 years from now and play it pretty well.

Let's say you quit neurofeedback right after your symptoms improve.  If 3 months from now or 9 months from now the symptoms reappear, you'll probably say neurofeedback didn't work.  But neurofeedback is fundamentally learning.  Don't quit till you've overlearned.  Otherwise, you could end up throwing your money and time away.   Repeated practice is needed for the learning to stick. 

How long before I start to notice changes from the training?

Should you notice change in the first session?  By the fifth?  What's realistic?  Few people will continue doing neurofeedback for several months if they're not seeing any changes.   It's not uncommon for clinicians to see significant changes reported by the client in the first 2-3 sessions.

However, that's not always true.  Many experienced clinicians feel the client/patient may not note any changes till 3 to 5 sessions.  Others feel it can take  up to 10 sessions. In part, it depends upon the kind of improvements being tracked.   On occasion, it can take longer than 10 sessions to note any signs of change.  In a case like that, the client and clinician should be discussing the progress very closely.   NOTE:  After any changes from training is noted, a lot more training is usually needed for the changes to hold.

What changes are you likely to notice first?  It may not be for problems the client came for.  But any change is a good sign. It helps identify that the brain is responding.   One of the challenges is that changes noted from training can be very subtle, particularly initially.   Clinicians often watch sleep carefully, because it's easy for most people to notice, and is often the first thing to change. Changes could include getting to sleep more easily, having more dreams, being easier to wake, or sleeping more soundly. Other common changes early include increased calm, less anxiety, being less reactive, or being more alert.  What changes as a result of training varies greatly by individual.  Some people may start to notice changes for mood, attention, anger, or pain relatively quickly (5-10 sessions).  For others, it could take much more time. It usually takes longer for obsessive thinking, impulsivity, and oppositional behavior to respond. 

If there's brain damage or neurological issues involved, it can take longer for a client/patient to respond, no matter what the symptoms are. 

If no changes have been noticed in 10 sessions, it probably makes sense to re-assess the situation carefully with the clinician about what is expected. There may be subtle changes from the training that aren't even being noticed.  Or, Perhaps nothing has happened.  Maybe this is a person who will takes a long time to respond - and may not get a lot from the training.  Or, maybe a very different training approach needs to be considered.   In some cases - just more patience may be warranted.  Sometimes the therapist can show the client changes they are making in EEG behavior before other signs of change occur.   

REALISTIC EXPECTATIONS: If you send someone to the gym, how long will it take for them to get into shape?  How long before they notice?  The answer varies widely.  Neurofeedback is literally brain exercise.  How long it takes for the brain to become better regulated can vary widely.  Also, some exercises may help far more than others. Most people in fact gain some benefit from exercise - and from brain exercise.  Whether the effort is worth the gain is always the question.

Can it be used while a patient is on medication?

Based on a survey with over 150 clinicians, it was widely reported that more than half their Neurofeedback clients start on one or more medications.  This is common knowledge among professionals in the field.  After a number of Neurofeedback sessions, a reduction in medications is not unusual.  It’s very important that the physician be alerted if signs of overmedication occur.  There is no way to predict a medication change.  The theory about reducing dosages is that as the brain becomes more activated during training (increased blood flow), it works more efficiently.  The same dosage seems to have a stronger effect on a more efficient brain, and thus reduction may be required.   

Not every patient’s medications are affected.  For some patients, neurofeedback seems to act synergistically with medications, allowing the medications to achieve a better response, or stabilizing the use of medications.  Neurofeedback is complementary to other treatment approaches, and may help them be more effective.