A Review of Neurofeedback for Autism Spectrum Disorder
Psychology 621
Lindsey Fischer
December 15, 2017
A Review of Neurofeedback Training for Autism Spectrum Disorder
Introduction
Autism spectrum disorder (ASD) is a neural developmental disorder that inhibits regular growth and development in social situations. According to the American Psychiatric Association’s (APA) DSM-V (2013), children diagnosed with autism spectrum disorder regularly display deficits in the three social contexts: emotional reciprocity in social interaction, verbal and non-verbal communication, and behavior characteristics. Because of their common characteristics, the definition of the autism spectrum includes four other pervasive developmental disorders (PDD): childhood disintegrative disorder, Asperger’s syndrome, Rett’s syndrome, and pervasive developmental disorder – not otherwise specified (PDD-NOS) (APA 2013). Common characteristics shown by children diagnosed with ASD include distorted functions and emotions, difficulty relating to their family, difficulty engaging in attention relating behaviors, such as pointing, and general emotional responsiveness. It is also common for children with ASD to show compulsivity and inflexibility with rituals and routines, some becoming distressed or aggressive when not met with consistency.
-known cognitive differences
-different motor patterns
A study conducted in 2014 by The Center for Disease Control (CDC), reported in the National Health Statistics Report (NHSR), reported an estimated 2.24% (1 in 45) of children were diagnosed by a health professional with autism spectrum disorder. This is a significant increase from the reported 1.25% (1 in 80) in years 2011-2013. It is important to note that this increase may be a result of a change in the classification of ASD, where at the time of the 2014 study a change was made to expand the definition of autism/autism spectrum disorder to include autism, Asperger’s disorder, pervasive developmental disorder, and autism spectrum disorder (NHSR 2015). While there was an observed increase in the prevalence of ASD, sociodemographic statistics have remained relatively constant. In 2014, children with ASD were mostly male (75.0%), non-Hispanic white (59.9%), living in large families in Metropolitan Statistical Areas (54.7%), with two parents (68.0%), and with at least one parent with more than a high school level education (67.6%) (NSHR 2015). Since the expansion of the term, it is difficult to predict any future growth or decline in diagnoses.
Management of autism and other pervasive developmental disorders aims to improve the child’s functioning in all settings, reduce the symptoms, prevent negative outcomes, and improve education and skills. While there are many proposed options for treatments, very few exist that meet efficacy standards, have supporting empirical evidence, or are both cost and risk effective.
C. Intro to EEG scans, spect scans
-what has been found so far in research
Treatments
An internet survey of parents whose children were diagnosed with some form of autism spectrum disorder were asked about the treatments they chose for their children. The number of treatments used varied based on age and severity of condition. Various forms of therapy were found to be the most common treatment selected by parents for their children with ASD (70%), followed by psychopharmacological treatment (52%), visual schedules (43%), vitamin supplements (43%), sensory integration (38%), applied behavior analysis (36%), and special diets (27%) (Green et al. 2006).
Behavioral Interventions
The treatment with the most empirical support is Applied Behavior Analysis (ABA). ABA is a form of behavior modification therapy strongly based on the principles of operant conditioning. Small individual units of behavior are rewarded through positive reinforcement to promote the development of more complex behaviors such as social interaction, behavior, and communication (Foxx 2008).
B. Behavioral Interventions
a. Applied Behavior Analysis (ABA)
i. Most empirical support around this method of treatment
ii. A form of behavior modification therapy aimed to improve social interaction, behavior and communication (Bassett et al. 2000)
iii. Firmly based on the principles of operant conditioning
1. Measures small units of behavior to build more complex and adaptive behaviors through reinforcement
iv. First program developed in 1970 (Lovaas et al.), intensive, highly structured, one to one basis several hours a day
1. Increased cognitive and academic function (47% of the treatment group vs 2% of the controls)
a. Criticized because they included IQ scores in their outcome measures (some individuals may have been very high functioning autistics)
v. (Fenske et al.) examined the influence of age at intervention using ABA
1. Nine children who began treatment before 60 months of age to those who started treatment after 60 months
a. Enrollment in a regular classroom may have affected outcome of this study
vi. Project TEACCH (Treatment and Education of Autistic and Related Communication Handicapped Children) (Schopler et al.)
1. Structured settings were provided to teachers to use individual workstations for the children
a. ASD children process visual info more efficiently than verbal info, so visual cues are provided to compensate for auditory processing deficits
b. Children who received the TEACCH treatment showed significant improvement over the control group on tests of imitation, fine and gross motor skills, nonverbal conceptual skills, and overall PEP-R scores.
i. Progress was 3-4 times greater on all outcome tests in the treatment group as compared to the control group
vii. (Eikesesth et al.) compared children 4-7 years old receiving 28 hours per week of behavioral treatment to a comparison group receiving 29 hours of eclectic special education treatment per week.
1. At a one year follow up evaluation, children in behavioral treatment group gained 17 average IQ points, vs the comparison eclectic treatment group which only gained an average of 4 IQ points.
2. Follow up study three years later showed similar growth.
b. Although ABA is promising, behavioral programs are costly and require extensive time on the part of both therapists and the families
c. Additional treatments are needed to balance out what currently exists
Pharmacological Treatments
C. Pharmacological Treatments
a. Psychotropic medications (antidepressants, stimulants, neuroleptics)
b. Improves core symptoms of autism
i. Decreases anxiety/overfocus, improves social skills, reduces aggressive behavior, increases effects of other interventions
c. There is no single medication known to be beneficial for all children with ASD
d. No medication has been developed specifically for ASD
e. Haloperidol and thioridazine
i. Used to reduce dysfunctional behaviors, however has side effects of sedation, irritability
f. Atypical antipsychotics
i. Improve social interaction, decrease aggression, irritability, agitation, hyperactivity (Barnard et al.)
ii. Children experience substantial weight gain
g. Risperidone
i. Only drug approved by the FDA to treat the symptoms of ASD
ii. (Jesner et al. 2007) proved success in treatment however weight gain and necessary long-term use are a problem.
Vitamin Supplements and Enzymes
D. Vitamin Supplements and Enzymes
a. Secretin – gastrointestinal hormone
i. Improvement in gastrointestinal symptoms, behavior improvements within five weeks (improved eye contact, alertness, increased expressive language) (Horvath et al.)
1. Horvath et. al. suggests this shows an association between GI functioning and brain functioning in autism
2. This study sparked interest, however there was no control group so some professionals were skeptical
ii. National Institutes of Child Health and Human Development (NICDH) soon funded a study to investigate the use of secretin in the treatment of ASD (Sandler et al.)
1. Double blind, placebo controlled study – researchers found no difference on any of the standardized behavioral measures between the two groups (controlled and placebo).
2. Director of NICDH stated that it should no longer be used to treat autism until more research is completed
iii. (Roberts et al.) tested repeated doses of intravenous secretin on 64 children diagnosed with ASD (randomized, placebo controlled)
1. receptive and expressive language skill improvement occurred to the same extent in the secretin and placebo group
2. parents reported sleep improvement, toilet training success, and more connectedness after injections
b. Methylcobalamin (Methyl-B12)
i. (Neubrander 2002) Effects of this coenzyme were accidentally found following injections of a child with autism when mother noticed dramatic improvements in the behavior of her child
1. Began using treatment on other patients which reported a 94% success rate
a. 90% executive functioning
b. 80% speech and language
c. 70% socialization/emotion
2. Stopping treatment worsened symptoms
a. Raised questions of efficacy
ii. (Nakano et al.) 13 children with ASD ranging 2-18, 25 g/day of Methyl-B12 for 6-25 months
1. Significant increase in intelligence and developmental quotients
2. Not a controlled study
Chelation Therapy
E. Chelation Therapy
a. Removal of lead from the blood stream through injections of ethylenediaminetetraacetic acid
i. Reasoning for this is the medical literature indication that autism and Hg poisoning have numerous similarities (psychiatric disturbances, speech, language, hearing difficulties) (Bernard et al.)
ii. (Holmes 2001) showed progress of 39% moderate improvement in ages 1-5, 52% of children 6-12 and 68% of children 13-17 only slight improvement, and 75% over 18 made no improvement
1. suggests chelation therapy may only be effective for young children
a. younger patients excreted larger quantities of mercury than older patients – may explain discrepancy in outcomes
Hyperbaric Oxygen Therapy (HBOT)
F. Hyperbaric Oxygen Therapy (HBOT)
a. PET and SPECT scans have shown cerebral hypoperfusion in autism (George et al., Mountaz et al, Ohnishi et al.) which lead to the hypothesis that hyperbaric oxygen therapy may be beneficial
b. Involves the inhalation of 100% oxygen in a pressurized chamber
i. Successful for treating strokes, cerebral palsy, chronic brain injury, and fetal alcohol syndrome
c. (Rossignol 2006) suggests that increased oxygen delivery by HBOT could counteract the hypoxia caused by hypoperfusion
i. Greater improvement in younger (28.9%) than older (13%) children
ii. No control group and parents were not blinded to the treatment
This review of literature has shown that very few treatments exist that have been well validated or that have exhibited favorable long term results. Many forms require either long term use, have the possibility of adverse effects, or were not initially developed for Autism Spectrum Disorder. Neurofeedback presents an alternative that may provide long term help with little risk.
Neurofeedback for ASD
Using computer technology, individuals with Autism Spectrum Disorder may improve their poorly regulated brainwave patterns through various forms of training. The most traditional form of neurofeedback training is known as EEG Biofeedback, which sends brainwave activity to a computer then converts it to a game-like display. Individuals use this display showing their brainwaves to learn to control the feedback they instantly receive about the amplitude and synchronization of their brain activity (insert figure of display). The only way for the children to succeed in this game is for them to recognize and improve their brainwave function.
A. Success has shown for children with ADHD – resulted in improvements that have lasted for 5-10 years after termination of treatment (Lubar 1995)
B. (Lubar 1997) Individuals with poorly regulated cortical activity can learn to develop a fluid shift in brainwave patterns and behavior (operant conditioning). Associated with regulation of cerebral blood flow, metabolism, and neurotransmitter function
C. (Thompson and Thompson 2003) (insert table) shows brain wave frequency bands which are broken down for EEG activity. Alpha and beta bands have been subdivided into low (8-10 hz) and high (11-13 hz)
D. In contrast to behavior therapy, neurofeedback training often shows positive results after several months rather than a year or more of intensive training
E. EEG Biofeedback began in 1972, Dr. Barry Sterman at UCLA
a. Trained individuals to control their seizures by increasing their sensorimotor rhythm brainwaves
F. (Lubar 1976) published first of numerous studies using neurofeedback with students diagnosed with ADHD
a. increasing beta and decreasing theta brainwaves at central scalp locations improved attention, impulsivity, and hyperactivity. (Lubar 1996)
-Section focusing on case studies
-Section on controlled group studies
Discussion
Apart from behavior therapy interventions, there are very few treatment options for children diagnosed with autism. While pharmacologic interventions, hyperbaric oxygen treatment, and vitamin supplementation have all shown some promise, further research is necessary to prove the efficacy. Based on the review, neurofeedback seems to be in a similar position with respect to efficacy. While the research in this application is encouraging, further advancements are necessary in this area to demonstrate the necessary efficacy according to current research standards.
-Discuss levels of treatment efficacy
-Discuss outside of EEG Biofeedback
-What future clinical research may/should consist of
References
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; American
Psychiatric Association, 2013)
Black L. I., Maenner M. J., Zablotsky B., et al. 2015. Estimated Prevalence of Autism and Other
Developmental Disabilities. National Health Statistics Reports. 87.
Foxx R. M., 2008. Applied Behavior Analysis Treatment of Autism: The State of the Art. Child
and Adolescent Psychiatric Clinics of North America. 4:17:821-831.
Green, V. A., Pituch, K. A., Itchon, J., Choi, A., O’Reilly, M., & Sigafoos, J. 2006. Internet survey of treatments used by parents of children with autism. Research in Developmental Disabilities. 27:70–84.