I don’t use the term ADD/ADHD any more than absolutely necessary.  It is so broad as to be almost meaningless – rather like saying, “we’re having soup for dinner.”  It’s technically accurate but not very descriptive, covering such a broad range of behaviors and problems that I would have a hard time saying what one should do to train it.

Is every ADHD client you see the same?  The people who come to me with that diagnosis are so different that I find the diagnosis basically worthless.  One sits quietly in a chair and looks at you but doesn’t hear anything you say, can’t complete a task because he keeps going into his thoughts.  Another can’t stay in his chair, looks all over the room but hears everything and completes tasks but so fast that he makes many mistakes. They both have the same diagnosis.

In the Brain-Trainer system we split ADHD into two groups that are ends of a continuum:  Filtering and Processing.  Filtering people can’t manage the interface between the outside world and their inside world. They are easily distracted by things around them, act and speak impulsively, often have quick mood changes, often have difficulty falling asleep, move around a lot in bed and may grind their teeth. Many have allergies or asthma.  As they get older, they are more likely to experience anxiety. Processing people can’t maintain their attention outside their heads and have difficulty processing language. They keep drifting away into daydreams, are very creative and intuitive but can’t process things in sequences and have difficulty with details.  They often sleep very easily but have a difficult time waking up.  They are more likely to wet the bed.  As they get older, they are more likely to experience depression.

Part of the problem may well be the endemic and poorly defined diagnosis of ADHD.  When guys like Dan Amen are able to subsume almost every malady known to man under ADHD, we have lost most of the intended precision that language is supposed to have.  Anxiety and depression and rage effects, inattention and hyper-focus, hypo-activity and hyperactivity are all part of the same diagnosis.  It’s a nice marketing tool, but it’s not much help to those who want to train for changes.  Anyone who believes that simply training up beta and down slow activity on the left or SMR up on the right will resolve ADHD (whichever flavor a person presents) is likely to experience a fair amount of disappointment.  That’s the reason I so strongly recommend forgetting the diagnosis and looking at the connections between the desired behavioral changes and the brain’s activation patterns.  Someone who does that is much more likely to deal with the underlying issues and get lasting results.

Train to the Assessment, Not the Symptom

Do you suppose a person who was emotionally upset because of fights between parents at home – or post-divorce – or bullies at school – might have difficulty paying attention?  How about an adult with a history of trauma, or pretty strong anxiety, or inability to sleep effectively, or a level of depression, or obsessiveness that made it difficult to complete a task or a noisy mind or any of a dozen other things.

Attention and memory, which are probably in the top 3 issues for every client who comes for training – even those who admit in their Client Reports that they have serious issues in one or more of these other areas – are third-level problems for many clients – and most adults. Anything can destroy your ability to focus and pay attention to relatively uninteresting (to you) stuff over a period of time. And anything you weren’t paying attention to when it came in won’t be remembered. Or if you have difficulty sleeping properly, it won’t be remembered.  Or if your hippocampus is Swiss cheese because of long-standing levels of high stress dissolving them with cortisol.

Look at the whole brain instead of falling into the “take an aspirin for a headache” simplification. See what’s going on, especially at the more primary levels related to subconscious drive and autonomic function, work on that and remarkably most problems with memory and attention will get better.

For Children and When You Can’t Assess

If you are working with a young child who has difficulty sitting still and focusing even on the screen, then finding the appropriate calming/SMR frequency at C4/A2 or Cz/A2 can give you a very good starting point–getting the parents excited about some sign of control on the child’s part. It can also get your client to the point where you can actually assess the brain to see what to train.

12-15 or 12-16 Hz are good frequencies for SMR with adults. Most children will have a lower frequency, and the younger they are, the lower the SMR band is likely to be. You can adjust the trining band on-the-fly, during the session; tweak it until you find a frequency where the client calms.

F7 and F8 offer some potential benefits. F7 is, among other things, an impulse control area and F8 can be helpful with social regulation and emotional inhibition – often issues with kids who get the ADHD label. But the problem with just throwing a windowed squash at those areas is, without having done much assessing, you don’t really know where to put the window. You can easily end up training too high and have the same kind of results that were mentioned by a previous trainer: the client becomes MORE disregulated, rather than less.

For training attention and self-control issues, HEG is always a good option, fast and easy to set up and easy for the client to do.  Then training in the sensorimotor cortex (between C3 and C4) can be very helpful.  If you are training C4/A2 or Cz/A2, you will usually inhibit slow (2-9 or thereabouts, depending on the EEG) and fast (19-38 Hz) and reward SMR.  If you are training bipolar (e.g. C3/C4, then usually you will inhibit 2-38 to quiet the whole EEG and increase 12-15.

Assessment Findings

People who fit the ADHD category frequently have what we call a “scooped out” EEG pattern.  If you look at a spectrum of all the activity from slow (2-8 pulses per second–also called Hertz or Hz) to fast (16-38 Hz), you will see lots of activity in the very slow speeds (difficulty staying focused outside your own thoughts) and lots in the very fast speeds (anxiety, obsessive or compulsive), but the middle speeds, which are related to stillness and being present in this moment are very low.  Alpha (8-12 Hz) is one of those middle speeds, and so is Sensory Motor Rhythm or SMR, which relates to physical stillness and relaxation, ability to deal with distractions, ability to fall asleep easily, etc.)

It is important to recall that, if you accept the brain-trainer concept that, as the Othmers noted in the mid-90s, there are plenty of people with impulsive or hyperactive type ADHD (the type we call Filtering) who have LOW theta/beta ratios which rise (into the target range) at task (or with training).  Since many of these also have little or no alpha/SMR–middle frequencies–this metric will have the same weakness that the Lubar/Monastra theta/beta ratio work has.  It will pick out those with a high level of inattentive issues but not necessarily capture those with distractible/impulsive problems, many of whom do NOT have learning or language processing concerns.

I don’t think the issue is tonic (standard state) vs. phasic (activated state).  Tonic levels of arousal can be too low – or too HIGH.  Either way, performance will suffer.  Low tonic levels would be consistent with what the TQ calls Processing problems–dominant slow activity and often a tendency to de-activate (increase theta/alpha levels relative to beta at task).  High tonic levels would be related to what we call Filtering problems — lots of slow AND fast wave activity but lacking middle frequencies–and many clients in these cases actually de-activate at task…and become more effective and functional.  I don’t think there’s any confusion about this.

Anyone who works with arousal issues can certainly agree that there are underaroused (primarily inattentive) and overaroused (impulsive/hyperactive) people who fall into this rather broad diagnostic category.  Why would we expect that a child who can sit in a chair for hours during a class, staring out the window, without bothering anyone, drifting in and out of contact with the task at hand would have the same brain activation patterns as someone who cannot stay in a chair for 2 minutes, is aware of everything around him–even hyper aware in some cases – and tends to be a sharp, fast multi-tasker?  That makes no sense intuitively.

In the early days of the 90s, when I was working closely with Joel, we used FCz/CPz one-channel bipolar montages with theta down and beta up for inattentive type, and C3/C4 theta and high-beta down and SMR up for greater control.  We also trained at C3/A1, Cz/A2 and C4/A2, so I don’t think Joel was fixed on any one thing. I try different options and find which tends to work best.

Lubar (and I was one of the co-authors of the early study with Monastra on the T/B ratio of 4-8 Hz / 13-21 Hz) focused much more heavily in his practice on the inattentive type client. Meanwhile the Othmers, who were still in their extremely valuable sensori-motor cortex phase, worked a great deal with the hyper-aroused kids.  When I studied with them in 1994 or 1995, they commented that they had no idea what Lubar was talking about with his high theta/beta ratios. Their experience was that many of their clients had LOW ratios (more dominated by beta) and actually increased as the training progressed. The more I worked with the ADHD population, the more I realized they were BOTH right.

Frustrations of Training

This is a subject that is normally kind of taboo.  After all ADHD was one of the starting points and one of the most-researched areas for neurofeedback training, especially with children.  It is one of the major sources of clients for many trainers and one of the main draws for many parents who get into the field to work with their own children.

I personally agree.  Maybe I’m just getting too old, but I find that increasingly I would a dozen times rather work with an anxious adult (or child) than with a hyper-active or just ADHD client of any age.  Not because I find the ADHD folks more unattractive or that I don’t like their energy levels, etc.  I just don’t find I get as clear results as quickly (or sometimes at all) with the ADHD.  Certainly there are some who respond well to HEG.  Others calm right down with SMR training that tracks to find their “right” frequency for SMR.  But there is a significant population of these people who come bouncing in session after session, do whatever training you give them to do (though often with complaints of boredom, difficulty staying in the chair, having to touch everything, mess with the computer, etc.), seem to calm down (even for a time) during the session, then bounce right back up and require a team of sheepdogs to get them out of the office without careening into everything they should not touch.

Training Adolescents

Question:  Has anyone tried or had success with Joel Lubar’s placement at FZ for ADD, reward 16-22, inhibit 6-10.  It was recommended by Lubar in a 2001 workshop.

Answer:  I think Joel speaks of this as working with adolescents, not younger kids.  Like any “one-size-fits-all” protocol, it will no doubt work well with some clients and not so well with others.  What is the reference for this hookup?  We used to use a protocol for beta up/theta down between FCz and CPz.  This would be likely to work on the executive attention center and the medial forebrain bundle, which brings dopamine forward, so it you had a straight ADD/ADHD kid, it might have a good effect.

Ratios

Monastra, Lubar et al published in Neuropsychology in the mid 90s a large multi-center study that showed Theta/Beta ratios (4-8 Hz/ 13-21 Hz) that purported to be the cutoffs for various ages for ADHD.  My practice was a major participant in that study, and I’ve always had problems with it, because it assumes that there are only ratios that are “too high”; we saw, and I still see, many people whose ratios were very low, who also had problems with attention, anxiety, obsessive thinking, etc.

Theta and beta relationships are good to look at, but so are alpha and theta.  Some people like to look at SMR to high-beta ratios as well.  And there are others.  I think of any of these as being descriptive rather than diagnostic, but certainly many people who prefer the diagnostic model use them that way as well.

ADHD Article

My summary of the study:

“We tried to treat an extremely broad diagnostic category using a single protocol.
We found 15 people who benefited and 15 who didn’t.”

To me, that doesn’t suggest that there are people who are “resistant” to neurofeedback. Rather there are people who don’t respond to one specific training. That’s not a big surprise, is it? That’s why we look at the brain before we train it–to see what approaches are most likely to work. That’s why we train multiple different protocols in Whole-Brain training.

Our interest is not to discover a measure that highly correlates with “not responding” to neurofeedback. It is to define an approach to training ANYONE (including ADHD) that results in changes, no matter what the patterns.

For example, since they did not train coherence at all, why would they expect that training SMR in the sensorimotor cortex would change excessive coherence in beta? Would those kids have responded if they HAD been trained to reduce locked-up beta? That would be an interesting question.

Finally, ADHD is an almost useless diagnosis. It is a description of commonly-occurring symptoms that can result from any number of brain patterns. What is ADHD? The person can’t pay attention, or can’t sustain attention in busy environments, or has difficulty controlling behavior in such environments, especially when expected to sit quietly. What causes it? We don’t know.

But if a child or adult has a history of trauma, or is generally anxious/perfectionistic, or if they are under stress for external reasons, or if they have had a head injury, or if the prefrontal cortex is behind the curve in development, or…

There are MANY things that can make it difficult for one to sit quietly for hours processing language as the only way to learn or work. But they are all subsumed under this one category. Since we know that each of those possible approaches to experience listed above is likely to link to one or more different patterns of brain activation, we wouldn’t expect that any one protocol would work with every client. It’s ridiculous.

Like many such “studies” it’s not of much use in the real world. Are you going to start looking at beta coherence in your potential clients and, instead of including its training in the plan, tell the client/parents, “no sense even trying, because you are probably resistant to training.”