Being in Control. The Role of Biofeedback in Controlling ADD
by Jason Alster, MSc
I began treating children with ADD quite unexpectedly in 1991. I had been a biofeedback therapist as part of an anxiety clinic in a mental day care setting in Tel Aviv, Israel. I had absolutely no experience in treating children but was doing quite well with adults suffering from stress disorders and teenagers who had test anxiety and social phobias. The biofeedback clinic had just opened and each type of patient was a new experience. With my medical- technological training in neuro-electrodiagnostics and sleep/wake disorders, I was more into the neurological and psycho- physiological disorders while a child psychologist working with me wanted to try biofeedback on ADD. Then he had said that there was no treatment for this poorly understood syndrome and the only remedy was Ritalin although reports about EEG (electroencephalogram) biofeedback and John Lubars research with Neurofeedback were just coming out.
After starting to treat a handful of children with biofeedback the psychologist had to leave the unit and I had to take over his patients. All I knew then about ADD was from a television program showing a hyperactive child literally jump off the walls and I worried about what this child would do to my biofeedback equipment. I had absolutely no knowledge of learning disorders either. I mention this lack of knowledge for a reason. I had to begin treating ADD without a prior predisposition to what was written in the literature. I had to see for myself what works, and fast.
On my very first ADD patient I performed a regular biofeedback stress baseline for anxiety. That is, I hooked the child up to galvanic skin resistance (GSR) sensors, muscle and peripheral temperature monitors, but not EEG. I had to start to treat ADD with what I knew and that is how to treat stress and anxiety. And I lucked out. My very first patient’s baseline EMG (electromyogram or muscle activity potential good for measuring stress) showed that the more she sat quietly the EMG gained in amplitude. That is, sitting quietly was stressful for her. With relaxation training she had improved her baseline in just 6 sessions and began to do better at home and in school. This was not supposed to happen. Biofeedback in ADD was supposed to be a stubborn neurological problem that takes 60 sessions to treat.
ADD is not supposed to be a stress disorder – but is it?
One of the problems in dealing with ADD has to do with when the diagnosis was made. Could the ADD be superimposed by anxiety, stress, and emotional problems? How can one separate the ADD from an emotional picture? Am I treating the anxiety in the child or the ADD? I lucked out again. One of my next patients was also a pretty 12 year old young girl with ADD and a learning disorder as well as a behavioral problem to boot. She was being expelled from school 20 days a month. That is almost every day. Her mother approached me because she had wanted a behavioral treatment before trying medication for the ADD. I sat her down for a stress baseline too and this time she showed that the GSR skin response increased in intensity the longer she sat quietly. The same result in an ADD patient, with a different physiological measure.
This was not supposed to happen. ADD is not supposed to be a stress disorder. However, this patient had a diagnosis of ADD with hypersensitivity, by a respected neurologist, since age 1. That is, this was a true ADD patient. She also responded to relaxation treatment in just 8 sessions. She was no longer being expelled from school anymore. I was onto something here. I began to ask myself, why am I successful in treating ADD so quickly and others are not? Why is ADD supposed to be impossible to treat while there are successes for other more serious chronic medical disorders like cancer and hypertension?
I asked my patients what about the biofeedback worked, and they mentioned the relaxation effect. But ADD is an attention deficit disorder not a stress disorder- or is it? A closer look then at the histories of my patients began to show that up to 75% of the ADD children had other medical problems accompanying the ADD. These could be ear, nose, and throat problems, sleep problems, and respiratory problems, skin problems, and digestive problems as well as school anxiety issues. Could these associative medical problems exacerbate the ADD? If so, then relaxation assisted biofeedback would be a better treatment than medication. That is: ADD rarely stands alone.
Like in the story of the Hobbit, the quest was on and my life’s work had been sealed in fate. I felt that I had the magic bullet and a treasure map. What I had stumbled onto, without fully understanding at the time, was an objective physiological measure of concentration in ADD. The first ever. The other measure used in ADD to evaluate Ritalin was the TOVA (test of variance) and this is not a physiological measure and is open to subjective interpretation. With this physiological objective measure, the GSR, I could also determine what interventions worked for ADD. I could search every possible treatment used for relaxation and focusing and measure the usefulness of each. The race was on.
When I began to take a look at the literature I found that very few articles had been written at the time on the treatment of ADD with Biofeedback. The few written mentioned that EMG biofeedback was not successful in ADD and that just EEG biofeedback had shown some results but the protocol had to be 60 biofeedback sessions. The work suggested that ADD is a neurological disorder and therefore EEG biofeedback would work by regulating EEG brain waves. With this idea, sympathetic and peripheral biofeedback should be of no significance in treating ADD children.
In my readings at the time, a number of avenues were being pursued in the treatment of ADD. Some of these were nutrition, and sensory integration, guided imagery, art therapy, natural meditation, yoga, Bach flower remedies, homeopathy, chiropractor, and aromatic oils. In biofeedback, animated computer games were being introduced. I could use each method and observe its effectiveness. I could develop an integrated and holistic approach. I could match the method to each child individually.
One of the first things that I found that causes the GSR to become stable in ADD children and adults is holding a soft or smooth stone in your hand. Who would ever expect that this piece of nature could compete with Ritalin. But it does. I got this idea from the worry stones and beads of the Middle East.
In sensory integration one is supposed to work on all the senses – sight, sound, smell, taste, and touch. Listening to the sound of the waves within a seashell is relaxing for a sense of sound. As is the sound of the metronome and so are the relaxing sounds of nature. For touch, I use the soft stones especially egg shaped ones or stones from a stream or the ocean. The best are the soap stones and marble ones. A four-legged wooden massager is also good. For sight – staring at a fish tank, a scenic view, a water wheel. The water wheels and colorful sand clocks are great because they can time a relaxation period to two to three minutes. It turns out that the secret to training in ADD is short relaxation exercises of about two to four minutes each day for a period of about 2 months. For smell and taste, the aromatic oils turned out to be great. I let the child choose up to three oils that he can combine into one. The combined oil has a better aroma to the client than the 3 oils separately. Children like mainly citrus oils and these are relaxing, uplifting, and also help concentration. It turns out that all the relaxation and focusing exercises have the ability to cause the GSR to be stable.
To work on the body armor and let the child relax his muscles even in the classroom where he cannot do a relaxation exercise or meditation, the seated yoga exercises work well. Some I picked and chose from different sources like Tai chi, seated yoga, airline stretching exercises, Jacobson progressive muscle relaxation, and even Reiki. In the class, the child will often show the teacher the book BEING IN CONTROL and arrange that when needed, the teacher will help the child choose an exercise to do instead of just saying “be quiet” which doesn’t work with ADD children.
The relaxation and concentration exercises in children were really helping and their physiological measures of concentration were improved as well as their associated medical problems. These could be a reduction in sleep problems, improved breathing, more strength for sports and activities. The self, home, social, and behavioral situation really improved.
Accelerated Learning Techniques
But – what about grades in school? Some children still did not succeed after biofeedback. What could be expected, if a child had poor learning skills developed over the years due to the ADD? I concluded that if I was to help these children succeed I would literally have to go back to school myself to find out how to teach these children. What I discovered was that to empower children behind in their learning, I could teach them accelerated learning techniques. These included associative memory techniques for instance. Using associations between ideas and pictures to help memory, I found that even people with poor memory could compensate. If a child remembered only 6 out of 8 items he could increase this to 15 out of 15 with associative memory. Then I used speed-reading techniques. Children who read 60 words a minute, and barely remembered what they read the minute before, could now read up to 250 words per minute. And remember. To help children organize their thoughts and copy the material during lectures I taught mind mapping. To improve their cursive handwriting they were taught the rules of handwriting. This was important to let the child’s work look more organized.
Children were asked to keep exams with marks that were determined to be non-passing so that their performance could be evaluated. It turns out that many children do not keep their exams and thus never know what the right answer is so that they can make the same mistakes over again. The other main problem that in many instances the child knew the answer but did directly answer the question being asked, this especially when a question was made up of a couple of parts. Children were told to circle the main ideas of the question to help them better SEE the actual parts of the question. What turned out was that each issue could be taught during an hour session combined with a period of biofeedback practice and relaxation mixed in. Problems that were there for years were being given a solution within a short time. Parents were also involved in each session to then also help at home if needed or at least to recognize the problems and be supportive.
With all the talk about learning having to be fun and that many children with ADD are visual learners, add the increased role of graphics in our cyber world, and I came to having each one of the exercises shown in a graphic format. I had fun with this as I like painting and photography myself and had an opportunity to add all my resources into it. Furthermore, the graphic artists were great, one had dyslexia herself, and really understood the idea. As I had problems in cursive handwriting and math (I probably have some math phobia myself) it was a real challenge to discover the roots of correcting these two problems and condense these skills into one graphic page, one least common denominator.
It turns out that either you know the rules or you don’t. Follow the rules and the handwriting will improve. For instance, keep all letters on the bottom line. Simple, but not always done. In math, imagery skills, breaking problems down to their smaller parts, attacking problems from different angles, and estimation skills are needed to help succeed in all math.
Finally, if I was asked my opinion about what is the major difference between the new millennium and the previous one, I would say it is a higher level of thinking. That is, increases in creativity and thinking skills are here even for the youngsters. Therefore, I added a page dedicated to creativity. The bottom line there is don’t be afraid to ask questions (be curious), be spontaneous, appreciate diversity, let yourself be inspired, and knowing that today, everyone has the ability to create. My book is a step in the right direction.
So to conclude, the best response I have received about the book is from the children, they just love it. It speaks to them. From the parents, it lets them be a part of the picture too, and from the professionals – “these exercises are what I have been practicing and preaching for years.”