| Helping ADHD Children with
Music Therapy & EEG Neurofeedback: Brain-jamming for focus |
| OVERVIEW |
| Building a case for music & NF as treatment modality (how far on the fringe) | |
| Mechanics of Biofeedback | |
| Music as physiological system output | |
| Music as physiological system input | |
| Theories of ADHD | |
| Pilot Brainmaps | |
| Pilot Research |
| Brain & Function |
| Brain & Music Function |
| Brain Function & Music |
| "Biofeedback uses instruments to return..." |
| Biofeedback uses instruments to return immediate physiological information | |
| "EMG" |
| EMG | |||
| Muscles | |||
| Temp | |||
| Vasculature | |||
| EDG | |||
| Fight/Flight | |||
| PPG | |||
| Blood Pulse Volume | |||
| EEG | |||
| Brainwaves | |||
| "Sympathetic/ Parasympathetic Response" |
| Sympathetic/ Parasympathetic Response |
| "a learning process which helps..." |
| a learning process which helps you gain control of your body's responses to stress, anxiety, physical strain and emotional stimuli. | |
| is the use of instruments to reflect physiological conditions. With this information, a person may be able to effect change upon body areas previously not under volitional control. | |
| can monitor muscle tension, heart-rate, blood pressure, peripheral blood flow (vasoconstriction) and galvanic skin response, EEG brain waves and others. | |
| is a non-invasive, client-centered method of training the body in which the learner actively participates in treatment and the doctor or therapist assumes the role of coach. | |
| is practiced by physicians, nurses, psychologists,psychiatrists, chiropractors, social workers, dentists, music therapists, and other health practitioners. A typical course of treatment may run 8-16 sessions or until mastery is achieved. |
| "Tension Headaches" |
| Tension Headaches | |
| Neck & Back Pain | |
| Hypertension | |
| Anxiety | |
| General Stress | |
| Phobias | |
| Neuromuscular Reeducation | |
| Stroke | |
| Bruxism | |
| Temporomandibular Joint Syndrome |
| Slide 11 |
| Muscles |
| "Migraine Headaches" |
| Migraine Headaches | |
| Raynaud's Disease/ | |
| Peripheral Vascular | |
| Resistance in psychotherapy | |
| Asthma/ Hypertension |
| "Systematic Desensitization" |
| Systematic Desensitization | |
| Guided Imagery/ Exploration | |
| Stuttering | |
| Asthma | |
| Stress | |
| Phobias |
| Slide 15 |
| "Physical Demand" |
| Physical Demand | |
| Emotional Demand | |
| Perceived Danger | |
| Ambiguity/Uncertainty | |
| Habituated Response | |
| Cognitive Interpretation |
| "Éunderstanding,
identifying, and treating problems of youth must draw on multiple disciplines
and diverse views within a given discipline" (Alan E. Kazdin, Ph.D., 1988, p. 8). |
| CONTEMPORARY THEORIES OF ADHD |
| The DSM-IV offers three subtypes of ADHD: | |
| ｷ 314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type; | |
| ｷ 314.00
Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type; |
|
| ｷ 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type (APA, 1994, p. 85). |
| CONTEMPORARY THEORIES OF ADHD |
| The symptoms of ADD (ADHD - H) include six or more of the following symptoms of inattention that have persisted for at least 6 months to a degree that is inconsistent with the developmental level: | |
| 1. Often fails to give close attention to details; makes careless mistakes in school or other activities | |
| 2. Often has difficulty sustaining attention in tasks or play activities | |
| 3. Often does not seem to listen when spoken to directly | |
| 4. Often does not follow through on instructions and fails to finish chores or duties | |
| 5. Often has difficulty organizing tasks and activities | |
| 6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort | |
| 7. Often loses things necessary for tasks or activities | |
| 8. Is often easily distracted | |
| 9. Is often forgetful in daily activities |
| CONTEMPORARY THEORIES OF ADHD |
| The symptoms of ADHD (ADD + hyperactivity) include six or more of the following symptoms of hyperactivity-impulsivity that have persisted for at least six months to a degree that is not consistent with the developmental level: | |
| 1. Often fidgets with hands or feet or squirms in seat | |
| 2. Often leaves seat in classroom or other setting where sitting is required | |
| 3. Often runs about or climbs in situations in which it is inappropriate | |
| 4. Has difficulty playing or engaging in quiet leisure-time activities | |
| 5. Is often Òon the goÓ or acts as if Òdriven by a motorÓ | |
| 6. Often talks excessively | |
| 7. Often blurts out answers before question has been completed | |
| 8. Has difficulty awaiting turn | |
| 9. Often interrupts or intrudes on others (butts into conversations or games) | |
| (APA, 1994). The above set of indicators used in the DSM-IV is utilized by schools, insurance companies and mental health practitioners. | |
| CONTEMPORARY THEORIES OF ADHD |
| Behavioral Inhibition | ||
| The Quay/Gray theory of behavioral inhibition posits that ADHD arises from reduced activity in the behavioral inhibition system (BIS) of the brain (Barkley, 1999). | ||
| Approach behavior (positive reinforcement) arises from reward signals increasing activity in the behavioral activation system (BAS), while avoidance behavior (negative reinforcement) also activates this same system | ||
| CONTEMPORARY THEORIES OF ADHD |
| Executive Functions | ||
| The Barkley/Bronowski theory of executive functions offers a unifying theory of ADHD (Barkley, 1999). Building on the Quay/Gray theory, Barkley agrees that ADHD arises from a deficiency of inhibition located in the pre-frontal cortex and goes on to delineate four types of executive functions that are diminished by the lack of behavioral inhibition, contributing to the disruption of goal-directed motor behavior and self control. | ||
| CONTEMPORARY THEORIES OF ADHD |
| BarkleyÕs 4 types of executive function: | |
| 1. Nonverbal Working Memory, | |
| in which ADHD children have difficulty holding on to current unspoken information. This leads to difficulty carrying information forward from the past to the future, resulting in diminished hindsight, foresight, self-awareness and poor planning. | |
| 2. Internalization of Speech (verbal working memory), in which children who are older than pre-school age (who would normally use self-speech for self-regulation) are less able to so. This leads to a reduction in the ability to use information from task failures to inform future performance and diminishes problem-solving abilities. |
| CONTEMPORARY THEORIES OF ADHD |
| BarkleyÕs 4 types of executive function: | |
| 3. Self-Regulation of Affect, Motivation and Arousal, in which ADHD children are missing the mentally represented forms of information that typically serve as Òthe drive in absence of external reward that fuels the individualÕs persistence in cross-temporal behaviors and thereby bridges the delay to the future reinforcerÓ (Barkley, 1999, p. 309). This results in a lesser ability for ADHD children to create positive emotional states through self-talk and imagery in the face of frustrating or disappointing events. Since the internalization of emotional processing is delayed, outward or public expressions are manifest in ADHD children. | |
| 4. Reconstitution, | |
| in which the recombining of informational units of behavior is deficient in ADHD children, leading to difficulties with the syntactical relations involved in temporal sequencing, e.g., if-then relationships. |
| CONTEMPORARY THEORIES OF ADHD |
| BarkleyÕs 4 types of executive function: | |
| Barkley goes on to distinguish between two types of attention – that which is Òcontingency-shapedÓ and that which is Òself-regulated and goal directedÓ (Barkley, 1999, p. 310), arguing that the former is not impaired in ADHD children, whereas the latter is impaired. | |
| ADHD is the most frequently diagnosed childhood disorder in the United States |
| It is estimated that 3-5 percent of all children suffer from ADHD, approximately 2 million children (NIMH, 2006). |
| and ADHD Continues into Adulthood |
| ÒIt is estimated that between 30% and 50% of children diagnosed with attention deficit hyperactivity disorder (ADHD) will continue to exhibit symptomatology that is disruptive throughout their adult livesÓ (Jackson & Farrugia, 1997, p. 312). | |
| Between two to five million adults suffer from ADHD (C.H.A.D.D., 2004), for whom relatively little attention is given. |
| ADHD Treatment |
| Most physicians prefer to administer psycho-stimulants (NIMH, 1998). Common agents include: | |
| Methylphenidate (Ritalin), | |
| Dextroamphetamine (Dexedrine), | |
| Dextroamphetimine/amphetamine (Adderall), | |
| Methamphetamine (Desoxyn) | |
| Pemoline (Cylert) | |
| Bupropion (Wellbutrin) | |
| Sertraline (Zoloft) (Manisses, 1997). |
| Response to Medication |
| Approximately 70 - 80% of ADHD children treated with medication respond favorably to stimulants (Barkley, 1990; Barkley & Loo, 2005). | |
| The effects, however, last only while the medication is being taken (NIMH, 2006). |
| Response to Medication |
| Patterns of excessive frontal slow wave activity occur in the brains of ADHD children and are remedied when ADHD children take the stimulant methylphenidate (Loo, Teale & Reite, 1999). | |
| NF researchers demonstrate not only the ability to alter brainwave states through training sessions, but also claim behavioral improvements in ADHD symptoms (Monastra, 2003; Doggett, 2004). |
| MTA Study of 1992 |
| In 1992, the NIMH conducted the landmark Multimodal Treatment of Attention-Deficit Hyperactivity Disorder study (MTA) that looked at four types of treatments in 579 subjects (Jenson, et al, 2001). | |
| The four groups included: | |
| routine Community Care (CC), | |
| Medication Management (MedMgt), | |
| Behavioral treatment (Beh) and, | |
| in addition, a Combination (Comb). |
| MTA Study of 1992 |
| In 1992, the NIMH conducted the landmark Multimodal Treatment of Attention-Deficit Hyperactivity Disorder study (MTA) that looked at four types of treatments in 579 subjects (Jenson, et al, 2001). | |
| The four groups included: | |
| routine Community Care (CC), | |
| Medication Management (MedMgt), | |
| Behavioral treatment (Beh) and, | |
| in addition, a Combination (Comb). |
| MTA Study of 1992 |
| The superior effects of Comb and MedMgt
groups, diminished at a 24-month follow-up by 50%, while the Beh and CC groups did not regress. |
||
| The subgroup that ceased medication treatment exhibited the most deterioration. | ||
| Additionally, while medication initially appeared superior, consumer parent-teacher ratings favored behavioral treatment (NIH, 2004). | ||
| Ritalin Conspiracy? Multi-million dollar industry! |
| a class action law suit was filed in Texas, charging the Ciba Geigy Corporation, U.S.A., Novartis Pharmaceuticals Corporation, Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD), and the American Psychiatric Association with fraud and conspiracy to promote the diagnosis of Attention Deficit Disorder within the context of a successful effort to increase sales of the product Ritalin. |
| Ritalin Sales in millions of dollars |
| Slide 37 |
| Research Questions: |
| Can Neurofeedback help improve cognitive functioning and academic performance in ADHD Children? | |
| Can better use of MUSIC and audio maximize the effect of NF for kids? | |
| How much money can these strategies save the school districts? |
| Bio-Medical Paradigm Models |
| Pre-frontal Cortex development | |
| BIS: Behavioral Inhibition System | |
| Low cortical arousal | |
| Inability to modulate arousal levels | |
| Deficits in organization | |
| Non-verbal working memory |
| Slide 40 |
| 3 Major Axes of Functioning |
| Anterior-Posterior | |
| Lateral | |
| Cortical/Subcortical |
| Cortical and Subcortical Activity |
| Cortical activity governs higher-level types of function: sophisticated thought processes,physical expression, subtle emotional responses, creativity, etc. | |
| Subcortical activity governs basic, autonomic function: physiological arousal, metabolic processes, basic emotional tone, etc. |
| ADHD & Biofeedback |
| Reducing Theta (4-7Hz) brain rhythms & Increasing SMR (12.5-15 Hz) brain rhythms Reduces symptoms of ADHD in both children and adults (Sterman, 1977; Lubar, 1991; Lubar, 1997; Kuperman, 1996; Tansey & Bruner, 1983; Tansey, 1984, 1985, 1990; Carter & Russell, 1985; Othmer, 1998) | |
| Non-pharmacological. | |
| Non-invasive. | |
| Not cheap. |
| Slide 44 |
| EEG Training Screen |
| Star Wars Neurofeedback |
| Star Wars Neurofeedback |
| Role of the Music Therapist |
| Creation of musical menu | |
| Develop musical designs | |
| Choice of key, scale & instrument | |
| Maintain integrity of musical environment | |
| Adapt musical protocols to client |
| CMO Configuration |
| Context: ADHD kids successfully completing the NF program |
| Toni Scores Pre and Post |
| Inclusion Criteria |
| 8-14 years old & collateral data from their parents, teachers, healthcare professionals. | |
| Formally diagnosed with ADHD by a licensed psychologist, psychiatrist or medical doctor with or without the ÒHÓ. | |
| Does Not have other axis 1 Dx | |
| Not taking medications that would confound the EEG |
| Measures |
| The ConnersÕ CPT | |
| Stroop, Nepsy exec sub-scale, Toni-3 | |
| Quantitative electroencephalography (QEEG) | |
| Monopolar EEG session data | |
| Pre, mid and post-session questionnaires | |
| Qualitative interviews | |
| Potential Impediments |
| Co-morbid symptomatology | |
| Inter-subject variability | |
| Aesthetic preferences | |
| Reporting accuracy |
| Potential Outcome |
| Development of a more accessible and affordable non-drug treatment protocol than presently exists for ADHD by integrating an active musical component into EEG treatment. | |
| Over $1,000,000 dollars in savings to the school districts over 3 years. | |
| * Based on the Yonkers NY School program |
| EEG Map - Baseline |
| EEG Map - Vivaldi |
| EEG - Assessment |
| EEG/Music Assessment |
| SOUNDS |
| Beyond Words | |
| Hamadulas | |
| Crystal Bowls | |
| Sabroso with Udu | |
| Hang Mix | |
| Coal Intro |
| Videos |
| Videos |
| Videos |
| Videos |
| Brain Maps |
| QEEG | |
| PRE-Post |
| Brain Maps QEEG BASELINE |
| Brain Maps |
| QEEG | |
| BASELINE | |
| vs. | |
| IMPROV | |
| MUSIC | |
| in a single subject |
| Brain Maps |
| QEEG | |
| BASE | |
| Amplitude | |
| Asymmetry | |
| & Coherence | |
| IMPROV | |
| MUSIC |
| Brain Maps |
| This set of pre and post brain-maps shows a shift from low activation (blue) to normal (green) in the 7 year old female CDC subject ÒBÓ. | |
| 05B6 Pre NF/Music |
| Discriminant Analysis |
| Note that the probability of inclusion in the LD population has decreased from 99% to 60%. |
| Discriminant Analysis |
| Also, it is interesting to note that 1JÕs LD index pre-intervention was only 65% during the condition while listening to Vivaldi and 60% while listening to ÒslowÓ music. |
| Discriminant Analysis |
| During IMPROV music (playing) LD probability drops to Ònot significantÓ at Post-Intervention. |
| TONI-3 Results NF-MUS group |
| TONI-3 Results NF-MUS group |
| TONI-3 Results NF-MUS group |
| NEPSY Results NF-MUS group |
| STROOP Results NF-MUS group |
| STROOP Results NF-MUS group |
| STROOP Results NF-MUS group |
| CPT Results NF-MUS group |
| CPT Results NF-MUS group |
| Trend toward improvement |
| Between Group Differences |
| Control vs. 3 NF Groups |
| PRE-POST T-TEST |
| Slide 84 |
| Future direction: Brain-computer interfaces |
| Helping ADHD Children with
Music Therapy & EEG Neurofeedback: Brain-jamming for focus |