A web-based teaching module on the administration of EEG-based neurofeedback for the treatment of ADHD

Abstract

Background

Neurofeedback (NF) is a physiological method that enables a subject to learn how to regulate his or her own brain activity. NF can be used as an alternative treatment for symptoms of attention deficit hyperactivity disorder (ADHD) via improved cortical self-regulation of brain potentials known to be related to ADHD symptoms such as changed attentional control, impulsive behaviours, and hyperactivity. However, no detailed teaching resources or tutorials are available to date, which allow a thorough teaching approach covering the technical aspects of electroencephalography (EEG)-based NF administration.

Methods

To allow a flexible and easily accessible online resource for teaching the administration of NF, an online teaching module was developed (NF-eTutorial). Specifically, this online tutorial module was developed for one of the most commonly used NF systems (TheraPrax EEG-neurofeedback device, NeuroConn, Ilmenau, Germany) currently available. The NF-eTutorial was implemented and made available to medical students who were interested in NF administration via the eMedia Skills lab of RWTH Aachen University (www.emedia-medizin.rwth-aachen.de/). Furthermore, this tutorial was also used as a resource to educate clinicians, patients, and carers about NF. This short article aims to present the development and specific features of the newly developed NF-eTutorial resource in a brief and descriptive manner.

Results

The NF-eTutorial comprises the following components: 1) Basic introduction (overview and information on using NF in patients with ADHD, outline of the training schedule, and basic scientific information on NF); 2) Correct handling of the electrodes (electrode and skin preparation, positioning of the electrodes, linking the system to the amplifier of the NF system, disconnecting the electrodes, and cleaning and storing of the electrodes); 3) Using the NF device (detailed guide to specific technical settings); 4) Explanation of specific tasks of the patient when engaging in NF training; 5) Aspects of NF training (checklists and training protocols that can assist the use of NF as a therapeutic application); and 6) Aspects of signal quality (step-by-step guide to troubleshooting and artefact correction).

Summary

The NF-eTutorial is the first web-based platform that allows access to detailed and practical information on the administration of EEG-based NF. Future research and development should focus on the practical use of such NF-related web-based tutorials with regard to the administration of NF by different groups of trainers, such as professionals, allied health staff and also lay people. This in turn will facilitate high-quality NF training for young patients with ADHD in non-clinical environments such as home and school.

• web-based tutorial
• neurofeedback
• teaching
• ADHD
• children and adolescents
• attention
• slow cortical potentials

Attention deficit hyperactivity disorder (ADHD) is a psychiatric disorder comprising symptoms of attention problems, impulsivity, and hyperactivity (1). Current evidence suggests a so-called multimodal treatment approach as first line (2, 3). This particular treatment approach includes a combination of different interventional strategies, such as cognitive and behavioural therapeutic techniques; psycho-education for the child, family, parents, carers, and teachers with regard to the disorder; interventions in school and other settings; and psychopharmacological treatments (2, 3).

Psychopharmacological agents frequently prescribed for young people with ADHD include stimulants (such as methylphenidate and amphetamine as well as dexamphetamine-related formulations) and atomoxetine. Of note, these particular medications can result in significant adverse effects, including pharmacologically induced suicidal thoughts, sleep problems, difficulties with appetite, and cardiac problems as well as slowed growth. Furthermore, research suggests that there is a considerable number of patients who do not respond to the aforementioned medications as far as clinical samples are concerned (4). As a consequence, whilst the suggested multimodal treatment approach for young patients with ADHD is evidence-based and successful in many cases, there is still a great and unmet need for alternative interventional strategies when it comes to treating ADHD symptoms in young people as well as in adults.

Neurofeedback (NF) is a non-pharmacological, non-invasive, and neuromodulatory physiological strategy that can be used to treat ADHD symptoms in clinical populations (5, 6). When using NF for targeting ADHD symptoms, brain activity is captured via different techniques such as electroencephalography (EEG, 7–10) or functional magnetic resonance imaging (fMRI, (11–13). Whilst both approaches (EEG and fMRI) have been studied with regard to the implementation of NF, EEG-based NF is currently the far more commonly used strategy (7–10), as it is much cheaper and more readily available than fMRI-based NF techniques.

The underlying concept of EEG-based NF is that the brain activity that is related to attentional processes is obtained and fed back to the patient in real time (5–8, 14) (15). An example for such a brain activity includes slow cortical potentials, which have a key regulatory role and function in terms of controlling excitatory activation thresholds of brain neurocircuits. These in turn control attentional function and processes (such as sustained and selective attention, 6–10). These brain neurocircuits, also known as cortico-striato-thalamo-cortical (CSTC) loops, run from the cortex to the striatum, the thalamus, and then back to the cortex. Successful activation and regulation in such CSTC loops is thought to be essential for attentional and behavioural control, and dysfunctions in CSTC loop activity can lead to clinical symptoms.

The need for a web-based neurofeedback tutorial

Several studies in children and adolescents with ADHD have demonstrated the efficacy and apparent lasting effects of EEG-based NF (16). However, such studies were usually conducted at specific NF clinics or centres and research institutes, involving expert trainers and a rather high number of sessions in which NF was administered. The high number of sessions can pose a significant burden to patients and families who may need to travel long distances in order to access such highly specific resources for their children. Transferring NF training into other environments such as home or school settings as well as simplifying NF administration (so that it can be conducted by lay people like parents and teachers or even by the patients alone) could be a significant advantage for the patients and their families. In addition, NF training in such environments may also be valuable because the training environment is more likely to reflect everyday situations in which patients encounter problems that are related to their ADHD symptoms (such as homework situations). However, at this stage NF devices are still very complex to handle and require a lot of knowledge and training in order to be able to administer NF training correctly. There is a need for educational materials and effective teaching strategies to deliver knowledge and develop skills in a workforce of competent NF trainers, both health professionals and lay people.

To address this issue, we developed a web-based NF tutorial that delivers detailed information on NF, the technical devices used, training schedules, and the technical setup of the NF training environment, as well as aspects of handling the training and troubleshooting. Here we describe specific features of the NF-eTutorial system that was developed as part of a larger research project that aimed to improve NF training with regard to the transfer of NF sessions to the home environment (NF-Home). Clinical and scientific input was provided by clinicians and researchers involved in a clinical NF-programme (Clinic for Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, RWTH Aachen University Hospital, Germany) that used EEG-based NF for the treatment of ADHD in children and adolescents. In particular, clinical input covered aspects of general knowledge about ADHD as a disorder, the basis of NF, hands-on technical skills, clinical experience, and frequently encountered problems such as the delivery of NF to young people with ADHD. Because the underlying aim of the NF-Home project was to allow a transfer of the NF training setting to the home environment, the decision was made that the tutorial should be a web-based application, which in turn would enable specific NF education for patients and families who do not have immediate access to a specialised NF clinic.

The NF-eTutorial system

The NF-eTutorial was developed in cooperation with the Audiovisual Media Centre (Medical Faculty of RWTH Aachen University, Aachen, Germany) during the NF-Home project. This tutorial can be accessed via the eMedia Skills lab of RWTH Aachen University (www.emedia-medizin.rwth-aachen.de/web/kjp_neurofeedback/; registration with the eMedia Skills lab platform is required before receiving login details). Input was provided by clinicians who had used the aforementioned NF device on a regular basis. Moreover, a workshop was held in which parents and carers were instructed on how to use the outlined NF device. Problems frequently encountered by the workshop participants in turn influenced the concept, design, and development of the NF-eTutorial system.

The developed tutorial comprises the following system components:

1. Basic introduction: In this section, an overview and detailed information on using NF in young patients with ADHD is given. Specifically, this includes an overall outline of a possible training schedule, basic scientific information on NF, and a background to ADHD as a disorder. Overall, this part of the NF-eTutorial aims at giving users an overview on NF as a neuroscientific and translational application to target ADHD symptoms in affected patients. A screenshot of this section is given in Fig. 1.

2. Handling of the electrodes: The handling of the electrodes of the NF system is a crucial and integral part of the training. In particular, correct handling (to avoid damage and/or malfunctioning) and the right placement of the electrodes are crucial to obtain optimal signal quality. Topics in this section of the tutorial include electrode and skin preparation, aspects of correctly linking the system to the amplifier of the NF device, disconnecting the electrodes from the system as well as detailed instructions on cleaning and storing of the electrodes. The contents of this part of the tutorial are delivered in short text passages for reading, figures with detailed instructions, and videos with audio commentaries showing the outlined procedures and correct applications. An example for this part of the NF training tutorial is given in Fig. 2a and b.

3. Using the NF device: This part of the tutorial covers detailed user training for the NF device. Technical aspects of the NF training (i.e. trial duration, number of trials, practice sessions, reward settings, and thresholds for successful regulation) are delivered via reading materials, figures, and video materials with audio commentaries (Fig. 3).

4. Specific patient tasks: In this section of the tutorial, specific aspects of what the patient/participant needs to do in order to engage in the NF training are covered. Examples for possible regulation strategies are given, but participants are encouraged to develop their own and individual strategies as these are more likely to work in everyday situations/daily life.

5. Aspects of NF training: This part of the tutorial covers specific checklists and training protocols in order to allow successful NF training and to make this part of the NF tutorial more user-friendly and closely reflect real-life situations. Again, figures and video sequences with audio commentaries are used in order to allow a standardised approach to explain the underlying aspects of NF training.

6. Aspects of signal quality: In the last part of the tutorial, potential problems that might be encountered when conducting NF training are covered (Fig. 4). In particular, aspects of troubleshooting and artefact correction are essential in order to allow a successful training session, which in turn is particularly important when it comes to the adherence of patients and their families to the training and treatment.

Fig. 1. Depicted is a screenshot of the NF-eTutorial. The image shows an example from the introductory section on basic information on ADHD and neurofeedback. Basic design by Dotcomwebdesign © 2013 AVMZ Medical Faculty, RWTH Aachen University, Germany.

Fig. 2. (a, b) Depicted is a screenshot of the NF-eTutorial. The image shows examples from the section on electrode handling. Basic design by Dotcomwebdesign © 2013 AVMZ Medical Faculty, RWTH Aachen University, Germany.

Fig. 3. Depicted is a screenshot of the NF-eTutorial. The image shows an example from the section on handling the neurofeedback device. Basic design by Dotcomwebdesign © 2013 AVMZ Medical Faculty, RWTH Aachen University, Germany.

Fig. 4. Depicted is a screenshot of the NF-eTutorial. The image shows an example from the section on troubleshooting. Basic design by Dotcomwebdesign © 2013 AVMZ Medical Faculty, RWTH Aachen University, Germany.

Summary and conclusion

The NF-eTutorial system is the first one that allows a detailed guide through the entire process of administering NF for the treatment of ADHD symptoms in children and adolescents when using the TheraPrax EEG-neurofeedback devices. Of note, the handling of these particular devices still requires a lot of expertise and training, and for these purposes, the NF-eTutorial system can be a valuable tool. Because the current system only matches one particular NF system, future research and related developments should aim to design similar teaching platforms for other related devices and technologies. With regard to administering NF for the treatment of ADHD symptoms in children and adolescents as well as affected adults in home or school environment, future devices should be designed to be more user-friendly so that they can be operated by lay people (i.e. patients, parents, or teachers). This in turn could lead to even higher acceptance of NF as an alternative intervention strategy for young people with ADHD. A user-friendly and step-by-step guidance throughout the entire process of setting up, administering, and concluding an NF-based training session (and which does not allow going on with the training unless all necessary steps are taken and signal quality is optimal) would be ideal. This in turn could beneficially affect adherence to the treatment.

Finally, the developed NF-eTutorial is currently only available in the German language, but future modifications will aim to develop an English version of the tutorial, which would allow international users to access the content delivered in this web-based teaching application. The NF-eTutorial is a first step in this direction, and the approaches and components of this particular system may also be applied for other NF systems currently available as well as those being developed.

Conflict of interest and funding

Together with his former employer (RWTH Aachen University, Germany), FDZ has submitted a patent application, which is related to an amino acid mixture that is unrelated to the present article. Moreover, he was the recipient of an unrestricted award donated by the American Psychiatric Association (APA), the American Psychiatric Institute for Research and Education (APIRE), and AstraZeneca (Young Minds in Psychiatry Award). He has also received research support from the German Federal Ministry for Economics and Technology (related to the present project as well as other research projects), the European Union (EU), the German Society for Social Paediatrics and Adolescent Medicine, the Paul and Ursula Klein Foundation, the Dr. August Scheidel Foundation, the IZKF fund of the University Hospital of RWTH Aachen University, and a travel stipend donated by the GlaxoSmithKline Foundation. He is the recipient of an unrestricted educational grant, travel support, and speaker honoraria by Shire Pharmaceuticals, Germany. In addition, he has received support from the Raine Foundation for Medical Research (Raine Visiting Professorship) and editorial fees from Co-Action Publishing (Sweden). TJG was an employee of RWTH Aachen University during the time this particular project was conducted and has now become an employee at the Neurocare Group (Munich, Germany) which is related to NeuroConn (Ilmenau, Germany), a company involved in this project that manufactures TheraPrax EEG neurofeedback devices. All other authors report no conflicts of interest. This project was funded by the German Federal Ministry for Economics and Technology (BMWi) to the NF-Home Research Consortium, consisting of the Clinic for Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy of RWTH Aachen University Hospital, two industry partners (FA NeuroConn, Ilmenau, Germany & FA Hasomed, Magdeburg, Germany) and two Helmholtz Institutes for Biomedical Engineering (Medical Information Technology [medIT] and Medical Engineering [mediTEC]).