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Symposium: Essentials of EEG-neurofeedback: Theory-based Applications

Abstracts and Bios

The role of sleep and the circadian clock in ADHD: Understanding the role of non-pharmacological interventions and neurofeedback  
dr. Martijn Arns

At present stimulant medication and behavior therapy are the most often applied and accepted treatments for Attention-Deficit/Hyperactivity-Disorder or ADHD. However, recent large-scale studies and meta-analyses have demonstrated limitations of these treatments including reduced long-term efficacy of stimulant medication and overall limited efficacy of behavioral interventions. One clearly defined subgroup in ADHD is characterized by circadian clock problems and associated sleep disruptions (Arns, Swanson & Arnold, 2015; Arns et al., 2013). We recently demonstrated - and replicated - an association between the worldwide prevalence of ADHD and sunlight intensity where geographic regions with strong sunlight intensity (e.g. California, Spain, Italy etc.) have lower ADHD prevalence rates as compared to geographic regions with low sunlight intensity (Arns, Swanson & Arnold, 2015; Arns et al., 2013). These and other lines of evidence posit a clear etiological contribution of the circadian system and sleep problems in ADHD sub-groups and provide further insights for non-pharmacological treatments. As one example of a promising non-pharmacological treatment for ADHD, neurofeedback has frequently been investigated. Meta-analytical data on neurofeedback in ADHD at the group level suggest large effect sizes for inattention and impulsivity and medium effects sizes for hyperactivity for both frequency neurofeedback and slow cortical potential (SCP) neurofeedback (Arns et al., 2009), and a new meta-analysis indicates effects of neurofeedback are maintained at 3-6 months follow-up, suggesting lasting effects of neurofeedback (van Doren et al., Under Review). For specific forms of neurofeedback, it has also been demonstrated that clinical effects in ADHD are mediated by normalized sleep (Arns, Feddema & Kenemans, 2014). These findings further demonstrate the role of circadian dysregulation and sleep in the etiology of ADHD and provide a working mechanism to understand the efficacy of neurofeedback. The current controversy regarding neurofeedback, adequate control groups and placebo control will also be further discussed (Arns, Heinrich & Strehl, 2015).

Martijn graduated in the late 90’s as a biological psychologist at Radboud University in Nijmegen and received his PhD at Utrecht University on the topic of 'EEG-based personalized medicine for ADHD and depression'. He is specialized in applying brain imaging techniques to determine the best treatment for patients with ADHD and depression, also referred to as precision medicine and in line with the NIMH Research Domain Criteria (RDoC) project. Furthermore, he is specialized in the development and application of neuromodulation techniques such as neurofeedback in the treatment of ADHD, magnetic brain stimulation (rTMS) in the treatment of depression, and sleep and chronobiological aspects of ADHD and Depression. Martijn supervises a team of researchers and PhD’s at Research Institute Brainclinics and a team of psychologists and psychiatrists at the neuroCare Group specialized in these topics. Martijn is director and researcher at Research Institute Brainclinics and Chief Scientific Officer at the neuroCare Group in Munich.

Predictors for clinical improvements after Neurofeedback:  consequences for theory, research and practice? 
dr. Ute Strehl
Responder rates in patients after neurofeedback have been reported in the range of 50% to 70%. Only few studies have analyzed the predictors of symptom reduction although it is of utmost interest whether those predictors have an impact on the further development of treatment as well as for the theoretical basis of neurofeedback and future research.
So far, a few variables have been identified in patients with refractory epilepsy (Daum et al., 1993; Rockstroh et al., 1993; Strehl et al., 2005) as well as in patients with ADHD (Drechsler et al., 2007; Gevensleben et al., 2009; Strehl et al., 2006). They point to neuropsychological (attention span in epilepsy), neurophysiological (pre-training alpha and theta levels in ADHD; cortical excitability in epilepsy), training performance as well as psychological variables (low satisfaction with life and negative emotions in the epilepsy study) and parenting style (ADHD).
To further elucidate this not very consistent picture the (yet to be analyzed) results of the German multicenter SCP-Neurofeedback study will be presented. In a randomized controlled clinical trial with a total of 150 children in the age of 7 to 9 years a significant outcome after SCP-Neurofeedback compared to a semi-active control condition was reported (Strehl et al., 2017).
The results will be discussed in the light of the a.m. studies. In addition, it will be questioned to what extent they may help to identify the most suitable patients for a neurofeedback treatment and to recommend standards of the treatment. Finally, possible contributions to theoretical models of NF (e.g. skill acquisition; neuronal repair; brain tuning) will be looked at.

The self-tuning brain: harnessing control and plasticity processes with neurofeedback
Dr. Tomas Ros

Using Hebbian as well as homeostatic models of brain plasticity, the effects of neurofeedback (NFB) are examined from the theoretical perspective of EEG normalization. Within this framework, hyper- and hypo-synchronous oscillations characteristic of abnormal brain dynamics are reversed with NFB training, as seen in several brain disorders including attention-deficit hyperactivity (ADHD) and post-traumatic stress disorder (PTSD). The central thesis put forward is that NFB re-tunes pathological oscillations toward intermediate levels of coupling, which may support self-organized criticality and provide an optimal balance between network flexibility/stability.

During his PhD at University of London, Tomas used transcranial magnetic stimulation to probe for the plastic effects of neurofeedback, showing for the first time cortical excitability changes directly after a training session. During his postdoc at University of Western Ontario, he uncovered that alpha-desynchronizing neurofeedback leads to correlated reductions in mind-wandering. This led to the first translational study investigating this protocol's impact on patients with PTSD, revealing a positive effect on well-being and a plastic modulation of key brain networks. Currently at the University of Geneva, Tomas is investigating the impact of neurofeedback on neurological and psychiatric disorders within the framework of critical brain dynamics.

Associations between different feedback periods and learning in individual upper alpha feedback
dr. Rien Breteler

Although most neurofeedback experiments fit nicely into the operant conditioning paradigm, research into the various elaborations of operant conditioning is lacking: e.g., reward rate should influence the learning of EEG modulation. The duration of the period that is fed back may seem even more important: Averaging of EEG amplitudes over various periods will lead to differences in the timing and contents of the feedback and thus could lead to differences in learning. Given the current intensive and time-consuming character of neurofeedback, shorter effective approaches are warranted.
In the current study we will compare the learning effects of a single session of Individual Upper Alpha feedback. Students were randomly allocated to three conditions of feedback, based on averaging of 1, 2 and 4 seconds. The study is currently ongoing and the first results will be presented in the symposium.

Rien Breteler (1956) is assistant professor of clinical psychology at the Radboud University Nijmegen. He has been involved in neurofeedback research since 2003. His research focuses on the conditions needed for effective neurofeedback. In 2007 his study on the role of sound and vision in neurofeedback pointed to the positive effect of consonant sound in feedback. More recently he investigated the role of reward rate in neurofeedback and the current project makes use of single-session neurofeedback, that has been shown to be effective by previous research. Linking his research with practice Rien runs a neurofeedback practice in Nijmegen. He has been president of the neurofeedback section of NIP, the Dutch Association of Psychologists, and currently is president of the Registration Board for neurofeedback psychologist NIP.

Improving cognition by targeting brain oscillations with BCIs: the case of frontal-midline theta and cognitive control
dr. Stefanie-Enriquez-Geppert

The development of current BCI neurofeedback approaches are strongly impacted by recent innovations in technology and methodology, as well as increased knowledge about brain oscillations. As such, EEG neurofeedback is attracting renewed interest as a method directly altering the underlying brain mechanisms of cognition and behaviour. BCI neurofeedback can be used in different ways, for instance as a i) therapeutic tool, ii) peak-performance training, and iii) as an experimental method to investigate the causal role of neural events.
The current talk consists of two parts. First key aspects regarding the practical application and the basic theoretical considerations relevant to the development of such EEG BCI neurofeedback studies will be presented in a step-by-step way. Assessment criteria for the validation of BCI neurofeedback studies as well as general guidelines for training evaluation will be discussed too.
In the second part, the frontal-midline (fm) theta up-regulation protocol for the enhancement of cognitive control will be used to exemplify the key aspects of part one. This protocol consists of an eight-session gap-spaced neurofeedback training, aiming at increasing fm-theta power. It includes the assessment of memory updating, set shifting, conflict monitoring and motor inhibition before and after training and is compared to an active so-called pseudo neurofeedback protocol.

Stefanie Enriquez-Geppert is an Assistant Professor at the Department of Clinical and Developmental Neuropsychology at the University of Groningen, the Netherlands. Her research focuses the specification of neurocognitive processes underlying executive (dys)functions. In a substantial portion of her work she develops and applies neuroscientific approaches including BCI to enhance executive functions. To pursue her research agenda, electroencephalography (EEG) and magnetic resonance imaging (MRI) have become her major tools. Stefanie Enriquez-Geppert studied at the University of Münster, Germany and graduated with an emphasis on cognitive neurosciences in 2007. After her psychology studies she worked on a Phd project at the Institute for Biomagnetism and Biosignalanalysis in Münster and finished her PhD in the year 2010. Between 2011-2015 she was a postdoc and lecturer at the University of Oldenburg, Germany. Following this, she went for a second postdoc to the University of the Balearic Islands in Spain. She spent several research stays abroad at the National Autonomous University of Mexico, University of Bergen in Norway, University of Newcastle in Australia, and at the University of Cambridge in the UK.