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ADHD and Related Learning Disabilities

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Arns, M., van der Heijden, KB., Arnold, LE. & Kenemans, LJ. (2013). Geographic Variation in the Prevalence of Attention-Deficit/Hyperactivity Disorder: The Sunny Perspective. Biological Psychology.

Background: Attention-deficit/hyperactivity disorder (ADHD) is the most common psychiatric disorder of childhood, with average worldwide prevalence of 5.3%, varying by region.

Methods: We assessed the relationship between the prevalence of ADHD and solar intensity (SI) (kilowatt hours/square meters/day) on the basis of multinational and cross-state studies. Prevalence data for the U.S. were based on self-report of professional diagnoses; prevalence data for the other countries were based on diagnostic assessment. The SI data were obtained from national institutes. Results: In three datasets (across 49 U.S. states for 2003 and 2007, and across 9 non-U.S. countries) a relationship between SI and the prevalence of ADHD was found, explaining 34%–57% of the variance in ADHD prevalence, with high SI having an apparent preventative effect. Controlling for low birth weight, infant mortality, average income (socioeconomic status), latitude, and other relevant factors did not change these findings. Furthermore, these findings were specific to ADHD, not found for the prevalence of autism spectrum disorders or major depressive disorder.

 

Conclusions: In this study we found a lower prevalence of ADHD in areas with high SI for both U.S. and non-U.S. data. This association has not been reported before in the literature. The preventative effect of high SI might be related to an improvement of circadian clock disturbances, which have recently been associated with ADHD. These findings likely apply to a substantial subgroup of ADHD patients and have major implications in our understanding of the etiology and possibly prevention of ADHD by medical professionals, schools, parents, and manufacturers of mobile devices.

Arns, M., Conners, CK., Kraemer, HC. (2013). A decade of EEG theta/beta ratio research in ADHD: A meta-analysis. Journal of Attention Disorders: May DOI:10.1177/108705471246008.

Objective: Many EEG studies have reported that ADHD is characterized by el evated Theta/Beta ratio (TBR). In this study we conducted a meta analysis on the TBR in ADHD.

 

Method: TBR data during Eyes Open from location Cz were analyzed from =children/adolescents 6-18 years of age with and without ADHD.

 

Results: Nine studies were identified with a total of 1253 children/adolescents with and 517 without ADHD. The grand -mean effect size (ES) for the 6-13 year-olds was 0.75 and for the 6-18 year-olds was 0.62. However the test for heterogeneity remained significant; therefore these ESs are misleading and considered an overestimation. Posthoc analysis found a decreasing difference in TBR across years, explained by an increasing TBR for the non-ADHD groups.

 

Conclusion: Excessive TBR cannot be considered a reliable diagnostic measure of ADHD, however a substantial sub-group of ADHD patients do deviate on this measure and TBR has prognostic value in this sub-group, warranting its use as a prognostic measure rather than a diagnostic measure.

Arns, M., Kenemans, JL. (in press). Neurofeedback in ADHD and insomnia: Vigilance stabilization through sleep spindles and circadian networks. Neurosci. Biobehav. Rev . (2012).

In this review article an overview of the history and current status of neurofeedback for the treatment of ADHD and insomnia is provided. Recent insights suggest a central role of circadian phase delay, resulting in sleep onset insomnia (SOI) in a sub-group of ADHD clients. Chronobiological treatments, such as melatonin and early morning bright light, affect the suprachiasmatic nucleus. This nucleus has been shown to project to the noradrenergic locus coeruleus (LC) thereby explaining the vigilance stabilizing effects of such treatments in ADHD. It is hypothesized that both Sensori-Motor Rhythm (SMR) and Slow-Cortical Potential (SCP) neurofeedback impact on the sleep spindle circuitry resulting in increased sleep spindle density, normalization of SOI and thereby affect the noradrenergic LC, resulting in vigilance stabilization. After SOI is normalized, improvements on ADHD symptoms will occur with a delayed onset of effect. Therefore, clinical trials investigating new treatments in ADHD should include assessments at follow-up as their primary endpoint rather than assessments at outtake. Furthermore, an implication requiring further study is that neurofeedback could be stopped when SOI is normalized, which might result in fewer sessions.

 

Arns M, Drinkenburg W, Leon Kenemans J. (2012). The effects of QEEG-informed neurofeedback in ADHD: an open-label pilot study. Appl Psychophysiol Biofeedback. 2012 Sep;37(3):171-80.

ADHD several EEG biomarkers have been described before, with relevance to treatment outcome to stimulant medication. This pilot-study aimed at personalizing neurofeedback treatment to these specific sub-groups to investigate if such an approach leads to improved clinical outcomes. Furthermore, pre- and post-treatment EEG and ERP changes were investigated in a sub-group to study the neurophysiological effects of neurofeedback. Twentyone patients with ADHD were treated with QEEG-informed neurofeedback and post-treatment effects on inattention (ATT), hyperactivity/impulsivity (HI) and comorbid depressive symptoms were investigated. There was a significant improvement for both ATT, HI and comorbid depressive complaints after QEEG informed neurofeedback. The effect size for ATT was 1.78 and for HI was 1.22. Furthermore, anterior individual alpha peak frequency (iAPF) demonstrated a strong relation to improvement on comorbid depressive complaints. Pre- and post-treatment effects for the SMR neurofeedback sub-group exhibited increased N200 and P300 amplitudes and decreased SMR EEG power post-treatment. This pilot study is the first study demonstrating that it is possible to select neurofeedback protocols based on individual EEG biomarkers and suggests this results in improved treatment outcome specifically for ATT, however these  results should be replicated in further controlled studies. A slow anterior iAPF at baseline predicts poor treatment response on comorbid depressive complaints in line with studies in depression. The effects of SMR neurofeedback resulted in specific ERP and EEG changes.

Arns, M, Conners, C. K., & Kraemer, H (2012). A decade or EEG Theta/Beta Ratio Research in ADHD: A Meta-Analysis. Journal of Attention Disorders ; (in press).

Objective:  Many EEG studies have reported that ADHD is characterized by elevated Theta/Beta ratio (TBR). In this study we conducted a meta -analysis on the TBR in ADHD.

Method: TBR data during Eyes Open from location Cz were analyzed from children/adolescents 6-18 years of age with and without ADHD.

Results: Nine studies were identified with a total of 1253 children/adolescents with and 517 without ADHD. The grand-mean effect size (ES) for the 6-13 year-olds was 0.75 and for the 6-18 year-olds was 0.62. However the test for heterogeneity remained significant; therefore these ESs are misleading and considered an overestimation. Post-hoc analysis found a decreasing difference in TBR across years, explained by an increasing TBR for the non-ADHD groups.

Conclusion: Excessive TBR cannot be considered a reliable diagnostic measure of ADHD, however a substantial sub-group of ADHD patients do deviate on this measure and TBR has prognostic value i n this sub-group, warranting its use as a prognostic measure rather than a diagnostic measure.

 

Arns, M., de Ridder, S., Strehl, U., Breteler, M., Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: The effects on attention, impulsivity and hyperactivity: A meta-analysis. Clinical EEG and Neuroscience ; 40(3). 180-189.

In order to study the treatment of the children with attention deficit hyperactivity disorder (ADHD), the integrated visual and auditory continuous performance test (IVA-CPT) was clinically applied to evaluate the effectiveness of electroencephalogram (EEG) biofeedback training. Of all the 60 children with ADHD aged more than 6 years, the effective rate of EEG biofeedback training was 91.6% after 40 sessions of EEG biofeedback training. Before and after treatment by EEG biofeedback training, the overall indexes of IVA were significantly improved among predominately inattentive, hyperactive, and combined subtype of children with ADHD (P<0.001). It was suggested that EEG biofeedback training was an effective and vital treatment on children with ADHD.

 

Boyd, W. D., & Campbell, S. E. (1998). EEG biofeedback in the schools: The use of EEG biofeedback to treat ADHD in a school setting. Journal of Neurotherapy , 2(4), 65-71.

Six middle school students diagnosed with attention deficit/hyperactivity disorder were selected for sensory motor rhythm (SMR) training with EEG biofeedback. The subjects were evaluated following a 72-hour drug-free period with the WISC-III Digit Span subtest and the Test of Variables of Attention (TOVA). Five of the subjects received 20 sessions of EEG biofeedback and one of the subjects received nine sessions of EEG biofeedback. The subjects were evaluated again following a 72-hour drug-free period. Five of the six subjects improved on their combined Digit Span, TOVA Inattention, and TOVA Impulsivity scores. These results supported previous findings that EEG biofeedback can be effective in the treatment of attention deficit/hyperactivity disorder. More importantly, this study demonstrated that EEG biofeedback could be used in an actual school setting. Recommendations for implementing an EEG biofeedback program in the schools were provided.

 

Cannon, R., Kerson, C., Hampshire, A. (2011). sLORETA and fMRI Detection of Medial Prefrontal Default Network Anomalies in Adult ADHD. Journal of Neurotherapy; 15(4). 358-373.

Attention deficit hyperactivity disorder (ADHD) is a developmental psychiatric disorder thought to affect approximately 5 to 10% of school - age children, of whom 30%–65% continue to exhibit symptoms into adulthood. The prevalence of ADHD in adults is also an estimated 4%, second only to depression. Across studies there appear to be significant network dysfunctions involved in ADHD. Typically the foci of interest in ADHD included the insular cortices,  frontal lobes, basal ganglia and cerebellum. More recently, attention has been directed to the default network of the brain and its functional integrity in ADHD with focus on the precuneus and parietal lobes and interactions with medial prefrontal cortices. Functional Magnetic Resonance Imaging (fMRI) measures neurovascular coupling as measured by the blood oxygenated level dependent signal (BOLD). Electroencephalogram (EEG) measures brain electrical information. Since fMRI is an indirect measure of neuronal activity and EEG is a direct measure combining the results from these two imaging modalities under the same task conditions may provide a more complete story as to the what (EEG) and where (fMRI) activity exists.

Lubar, J. F., & Shouse, M. N. (1976). EEG and behavioral changes in a hyperactive child concurre nt with training of the sensorimotor rhythm (SMR): A preliminary report. Biofeedback & Self-Regulation , 1(3), 293-306.

Reduced seizure incidence coupled with voluntary motor inhibition accompanied conditioned increases in the sensorimotor rhythm (SMR), a 12-14 Hz rhythm appearing over rolandic cortex. Although SMR biofeedback training has been successfully applied to various forms of epilepsy in humans, its potential use in decreasing hyperactivity has been limited to a few cases in which a seizure history was also a significant feature. The present study represents a first attempt to explore the technique's applicability to the problem of hyperkinesis independent of the epilepsy issue. The results of several months of EEG biofeedback training in a hyperkinetic child tend to corroborate and extend previous findings. Feedback presentations for SMR were contingent on the production of 12-14-Hz activity in the absence of 4- 7-Hz slow-wave activity. A substantial increase in SMR occurred with progressive SMR training and was associated with enhanced motor inhibition, as gauged by laboratory measures of muscular tone (chin EMG) and by a global behavioral assessment in the classroom. Opposite trends in motor inhibition occurred when the training procedure was reversed and feedback presentations were contingent on the production of 4-7 Hz in the absence of 12-14-Hz activity. Although the preliminary nature of these results is stressed, the subject population has recently been increased to establish the validity and generality of the findings and will include the use of SMR biofeedback training after medication has been withdrawn.