In the evolving field of healthcare, biofeedback, as a treatment and evaluation tool, is playing an increasingly more important role. Biofeedback is used by a diversity of health professionals to treat an ever-lengthening list of conditions. Health professionals such as psychiatrists, psychologists, nurses, physiatrists, physical and occupational therapists and physicians in various specialties have come to use biofeedback, either independently or as an adjunctive technique, with positive results.
BFE Reports... is an on-going series of interviews with leading clinicians and newsworthy articles in the field of biofeedback lending the insights and techniques they have acquired through their many years of practice.
Dr. Joel Lubar received his Ph.D. at the University of Chicago in a multidisciplinary program known as Biopsychology, which is a combination of psychology, physiology and medicine. His original work was in the area of the neural basis of emotional behavior and it involved a number of animal studies. Dr. Lubar was an assistant professor at the University of Rochester for four years and continued his work there, before going to the University of Tennessee. Dr. Lubar was a Faculty Science Fellow with the National Science Foundation for a year at UCLA medical school and also was a visiting professor at the School of Medicine of the University of Bergen in Norway. Those were post-doctoral experiences.
The Biofeedback Foundation of Europe was founded to promote a greater awareness of biofeedback among European health professionals, and, through training workshops, educate clinicans in the use of biofeedback techniques and technology. For more information on BFE workshops worldwide see our website.
is very clear now that ADD is not only a neurologically based disorder,
but also a very significant brain disorder."
Dr. Joel Lubar
Could you describe your current work?
My current work is primarily the development of databases and training protocols for treating individuals with attention deficit hyperactivity disorders (ADHD) and associated co-morbidities. These include learning disabilities, oppositional and anxiety disorders and other problems that are commonly associated with ADD. I also spent a number of years in my career doing research and treatment of patients with seizure disorders and epilepsy.
When did you first become acquainted with EEG biofeedback?
Back in the 1960’s, at the very beginning, I was involved with some of the early work that was done with alpha conditioning, for relaxation, and with theta conditioning, which was then associated with visualization. I then did a study that replicated some of Sterman's very early work with seizure disorders. We completed this research and published our first paper on neurofeedback with epileptics in 1975, about a year and a half after he published his study.
While I was working with epileptic patients, I noticed that, while they were training, they became much more attentive, alert and focused. This observation is what led me to try a similar paradigm for hyperkinetic children (Hyperkinesis, as a diagnostic, was really the forerunner of ADD). We did a double-blind crossover study, which we published in several different places in the late 1970’s. The study showed that this paradigm was not only very effective, but also produced changes that could be measured by independent observers in the children’s classroom. I guess it became a kind of model control study at that time, even though it was a small study. After that, because the study worked out so well, I continued working with these kinds of problems and I wrote a book with a pediatric neurologist, Dr. William Deering of the Gundersen Clinic, in 1981. The book was titled "Behavioral Approaches to Neurology"; it was published by Academic Press and it contained our early work on epilepsy, learning disabilities and hyperkinesis. Since that time, we’ve published more than 25 papers in the area of ADD and seizure disorders and we’ve probably published more on neurofeedback than anyone else has in the ADD area.
Could you explain to us how EEG biofeedback works?
The goal is to train
the individual to normalize the abnormal EEG frequencies and, at the
same time, to develop as much awareness as possible of what that
normalized EEG state is like, i.e. how it feels.
In the case of attention deficit, the first thing we do is a
database analysis. In other words, we look at the quantitative EEG (QEEG)
of that individual and we compare it with a normative database to see
what areas and what frequencies are outside of the normal range.
Then we set up a training procedure or protocol based on those
Can you explain to us what ADD/ADHD is and how it manifests itself?
We have been doing a lot of database work. For example, we published, last year, in the Neuropsychology journal, a multi-center study with over 480 cases. We were monitoring the EEG signal at this one location, CZ, (that's right on the top of the head) and taking one measure, the ratio of theta to beta, under different task conditions: baseline, reading, listening and drawing. We found that we could accurately separate ADD and ADHD patients from control individuals with better than 90% accuracy. We just had a second paper accepted in the same journal, a replication of that first study with another almost 400 cases, very carefully screened, so there was absolutely no question that the ADD subjects were ADD and the control subjects were not. We did the screening based on multiple criteria: Continuous performance measures, history, rating scales and psychometric measures. Again, we were able to tell the difference, with close to 90% accuracy, between the two groups.
What we are working on now is a series of studies that are going to involve both single and multiple locations to see if we can develop databases for ADD, obsessive compulsive disorder and oppositional-defiant disorders. We want to see if we can really pin down the EEG differences between them. I have already done one database study with 125 cases, using a 19-channel device, in which we could differentiate ADD from controls using a simple eyes closed task. In a previous study that was published in the Journal of Learning Disabilities in 1984, we were able to separate children with reading disabilities from controls with a very high accuracy level, looking at six different locations during eight different tasks.
It is very clear now that ADD is not only a neurologically based disorder, but also a very significant brain disorder. We know, with certainty, that it is not caused by bad parenting or a lack of opportunities. It is, first of all, strongly genetic in nature, definitely brain-based and very definitely neurological. ADD involves abnormalities in the structure of the brain that have been clearly identified in MRI (magnetic resonance imaging) studies. It also involves abnormalities in cerebral metabolism and in the electrical activity of the brain, as measured by EEG and evoked potentials. Some people, who are experts in the field, like Russell Barcley and others, have gone so far as to say it is an outright example of a damaged brain. They have actually come around 180 degrees from what they believed ten years ago, when they said it was a behavioral disorder and a motivational disorder, to say now that it is a structural, neurological and neurochemical disorder. These findings make ADD eminently appropriate for neurofeedback intervention.
What other conditions can EEG biofeedback be helpful for?
Besides ADD and ADHD, extensive published data indicates that it can be very helpful for dealing with depression, anxiety, substance abuse, recovery from mild to moderate post-head injury and, in some cases, in rehabilitation after strokes or other kinds of cerebral injury of that type.
Would you say that EEG biofeedback is sufficient as a single therapeutic approach to treat ADD and ADHD?
Well, that's a very important point. We don’t look at neurofeedback (another name for EEG biofeedback), as powerful as it is, as a totally stand-alone procedure. In our clinic, we’ve always looked at it as part of a multi-component treatment process, which may involve behavioral work, parenting information, working with the family and, when appropriate, medication. We do, though, build the entire procedure around the neurofeedback therapy. In a way, EEG biofeedback is like the centerpiece around which we build everything else. I am convinced that our success rate is so high, better than 90%, because we do our clinical work this way. I really think that if a clinician just uses neurofeedback mechanically, without any of these other supportive techniques, then the success rate is going to be considerably lower, especially if there is significant hyperactivity involved.
Are there benefits to using EEG biofeedback as compared to using other therapeutic approaches like medication?
Several. The main one being that medication, even when it works well, is essentially state dependent. When you take somebody off of medication, they tend to revert to their original state and behavior. We’ve done studies that have shown that, even after ten years, the neurofeedback changes endure and the behavior that patients have learned endure just as much and can even improve. EEG biofeedback has a definite permanence that we have not seen with any other therapy. It is much more effective than behavior modification approaches, for instance, because those techniques, in a sense, make the parents "prisoners" of the child. Because parents have to be there to administer complex ritualistic schedules of reinforcement, rewards and time outs, some parents might end-up resenting the whole procedure and, by extension, resenting the child for doing that to them.
Neurofeedback frees them up considerably because it puts the burden of the learning on the children. They are doing this for themselves! And once they internalize what it is like to change the EEG patterns, the transfer to the real world is much better than with such mechanical procedures as token economies and other approaches of that kind.
Are there any risks involved in using EEG biofeedback? Are there known secondary effects?
One of the questions that I've been asked many times about EEG biofeedback is "If it is so powerful, why doesn't it seem to have significant negative side effects?" My answer is simply: "Because it is a learning experience!" Neurofeedback is not induced like drugs or light-and-sound stimulation; people are learning to change themselves so they can learn to internalize control. So the process is gradually acquired from within, not imposed from outside.