Neurofeedback Intervention for Adults with ADHD

Transcription

1 Journal of Adult Development, Vol. 12, Nos. 2/3, August 2005 ( C 2005) DOI: /s Neurofeedback Intervention for Adults with ADHD Lynda Thompson 1,2 and Michael Thompson 1 INTRODUCTION This paper briefly reviews traditional thinking concerning Attention-Deficit/Hyperactivity Disorder in adult populations and then discusses neurofeedback (EEG biofeedback) as a helpful addition to the range of interventions. It reports clinical findings and observations that lead to effective interventions with adults and point the way to future research. Since EEG patterns differ in those with and without ADHD (Monastra et al., 1999) and since operant conditioning of brain wave patterns is possible (as reviewed by Sterman (2000)), it follows that people can learn how to produce EEG activity that is associated with being calm and alert and thus control their ADHD symptoms. Being able to change the brain with neurofeedback training is consistent with the new discoveries about neuroplasticity in adult brains. Studies indicate that there is growth of new dendrites and production of new neurons even late in life (Snowden, 2001). PREVALENCE OF ADHD IN ADULTS Attention-Deficit/Hyperactivity Disorder in adults is common, though it often goes unrecognized. Prevalence in childhood is estimated at between 6 and 9% (American Academy of Pediatrics, 2000). Dennis Cantwell concluded studies now suggest that as many as 60 70% of children with this syndrome have continuing symptomatology in adulthood. (Wender, 1995, p. ix). This would mean that almost 5% of adults are affected. From a business standpoint, it has been estimated that less 1 ADD Centre, 50 Village Centre Place, Mississauga, ON, Canada L4Z 1V9. 2 To whom correspondence should be addressed at ADD Centre, 50 Village Centre Place, Mississauga, ON, Canada L4Z 1V9; LandMthompson@cs.com. than 10% of the possible 8 million U.S. adults who have ADHD are getting treatment and that if they started taking medication, the current $2 billion-ayear market for ADHD drug treatments could easily double. (Business Week, 2003). DESCRIPTION OF SYMPTOMS ADHD is characterized by an inability to sustain attention when material is slow paced, repetitive, boring or deemed irrelevant. People with this style tend to be impatient, restless, and impulsive in their interactions. They may interrupt others, blurt things out, or do something without thinking through the consequences. Often they are frustrated at work, are disorganized and lose things. Underachievement and job changes are common. Even when successful (often in careers in sales or as entrepreneurs), they invariably feel they could have done better. Although easily distracted when doing routine tasks, they can hyperfocus on things of interest to them. This characteristic can lead to an extraordinarily successful career, but it can also be irritating to those around them who may feel ignored when the person with ADHD is immersed in a project. They usually like to multi-task and may have many projects on the go at the same time, not always seeing them through to completion. Comorbidity in adults often includes anxiety or depression. They may experience feelings of tension, anxiety, dysphoria and even panic. Some may show obsessive compulsive symptoms and those will work very hard and may manage to become professionals (doctors, lawyers, accountants) but will usually be innovative and not practice in the standard way. People with ADHD are often exceptionally intelligent and creative. Hartmann has characterized the style as being a hunter mind that can scan for something to go after (seems distractible when in scanning mode) and hyperfocus when chasing its /05/ /0 C 2005 Springer Science+Business Media, Inc.

2 124 Thompson and Thompson prey (an idea, a project, closing a sale). This hunter mind does not adapt well to the farmer s world of daily chores and routine. He stresses the positive traits, such as energy and creativity, and talks about the Edison gene being necessary in all societies (Hartmann, 2002). OVERVIEW OF TRADITIONAL DIAGNOSIS AND TREATMENT The traditional diagnosis in adults is made by a physician or psychologist using DSM-IV criteria (Diagnostic and Statistical Manual of the American Psychiatric Association, 1994). It is based on presenting symptoms, plus retrospective evidence of ADHD symptoms during childhood. Symptoms must impair functioning to a clinically significant degree in order for a diagnosis of a disorder to be appropriate. It is helpful to have a parent, spouse or close friend corroborate the history, particularly since those with ADHD tend to be managed by the moment and often have poor recall of childhood events. The usual interventions may include educating the client, increasing structure, coaching, psychotherapy, and medications (Hallowell & Ratey, 1994; Wender, 1995). The stimulant medications used in children, usually methylphenidate (Ritalin, Concerta) or amphetamines (Dexedrine, Adderall) are also used in adults, though the favourable response rate is lower than the approximately 70% cited for children. Anti-depressants are often tried when stimulants are ineffective or produce unacceptable sideeffects. Tricylic antidepressants were used first, especially desipramine (Norpramin), which was found to be effective but, since side-effects were frequent and could include cardiac arrhythmias, newer antidepressants with fewer side-effects are now more commonly used. Bupropion (Wellbutrin) may improve both attention and mood but does carry increased risk of seizures. Venlafaxine (Effexor) has also demonstrated efficacy, whereas the selective serotonin reuptake inhibitors (SSRIs such as Paxil, Prozac and Celexa) appear to have little effect on ADHD symptoms (Wilens, Spencer, & Biederman, 2002) although patients seem to respond quite well to this medicine when there is a co-morbid aspect of depression and anxiety. (Sudderth & Kandel, 1997). When neither stimulants nor antidepressants work, or when there is a perceived need for a mood-stabilizing drug because of outbursts of rage or tantrums, anti-seizure medications are sometimes tried, such as carbamazepine (Tegretol), lamotrigine (Lamictal), or valproic acid (Depakote). Medication...should never be regarded as the whole treatment. say Hallowell and Ratey (op cit., p. 244) of adult interventions and this is echoed by the American Medical Association in their review of the use of stimulants for children (AMA, 2000). They state that non-medication approaches are popular with parents and under-utilized by physicians. Yet physicians are often too busy to do much more than write a prescription. In addition, they receive considerable information from drug company representatives who perceive adults with ADHD as a growing market. Use of drugs over an entire lifetime in order to manage behavioral symptoms is not, however, an attractive option. Many physicians are reluctant to leave a patient on medication, whether stimulant, anti-depressant or antiseizure/mood-stabilizing drugs, for long periods of time due to both side-effects and the lack of studies on long-term effects. At best, stimulant drugs provide short-term management of behaviour. They do not confer benefits once the drug has been withdrawn (Bradley, 1937; Swanson et al., 1993; Wender, 1995). NEUROFEEDBACK: A NEWER APPROACH TO MANAGING ADHD Neurofeedback for ADHD has been used for over a quarter century, first in research labs and then, increasingly, in private practice settings. This brain wave biofeedback became practical in office settings in the 1990 s with the advent of faster computers that could digitize the EEG signal, process the information, and give feedback within a 50 ms timeframe. The first publication concerning successful treatment of a child with hyperactivity appeared in 1976 (Lubar & Shouse, 1976). By way of comparison, stimulants were first tried in 1937 and methylphenidate (Ritalin) came into use in 1955 (Sears & Thompson, 1998). Just as medications were first used in children and then began to be used in adults once the continuation of symptoms into adolescence and adulthood had been established, so neurofeedback has been extensively researched for children with ADHD whereas applications in adults with ADHD are more recent. There is enough research, including controlled studies, to conclude that neurofeedback is an effi-

3 Neurofeedback Intervention for Adults with ADHD 125 cacious treatment for ADHD with symptom reduction equivalent to what can be achieved with Ritalin (Yucha & Gilbert, 2004). Response to neurofeedback training in adults appears to be just as positive as it is in children with reports of decreased symptoms on the Test of Variables of Attention (TOVA) computerized continuous performance test, increases in IQ, improved scores on academic testing, and a change in the EEG pattern (Thompson & Thompson, 1998). People in the neurofeedback field can offer a non-medication alternative for the management of ADHD symptoms that has been shown to have long-lasting effects (10-year followup) in children who successfully changed brain wave patterns (Lubar, 1995). In addition to the usual clinical history taking, computerized tests of attention, and questionnaire data, neurofeedback practitioners use information from a quantitative electroencephalogram (QEEG), either single channel at the vertex (CZ) or 19 channels. The EEG profile provides data that can be helpful both for assessment and for planning intervention. Neurofeedback can be combined with the other traditional interventions mentioned above. Medications, for example, can be used short-term while the person learns self-regulation of brain wave activity and then the drug can be withdrawn. Self-regulation through neurofeedback, which simply involves the client learning to produce brain wave patterns that are associated with being calm and focused, has advantages over medication. Although it takes time (about 40 training sessions) and has a higher initial cost, the main benefit is that it produces lasting effects whereas medications only control symptoms while at therapeutic doses in the bloodstream (Monastra, Monastra, & George, 2002). In addition, it is non-invasive and without negative side-effects, so it is a much more benign intervention. Another plus is that a feeling of personal control is inherent in learning self-regulation and this boosts self-esteem, which is often low in adults with ADHD due to the messages they received while growing up. The title of a popular book, You Mean I m Not Lazy, Stupid, or Crazy? (Kelly & Rumondo, 1995) exemplifies this negative self-image. Whereas drugs are only appropriate for a medical condition, neurofeedback can be used with a wide range of clients: those who qualify for a formal diagnosis of a disorder (which requires that the symptoms produce clinically significant impairment of functioning); those who are not impaired but who underachieve or experience frustration due to ADHD symptoms; those who have some ADHD features that they generally use to good advantage but who feel they could do better still and thus want to optimize their functioning. USING EEG BIOFEEDBACK IN ADULTS WITH ADHD EEG assessment and intervention with adult clients who present with Attention- Deficit/Hyperactivity Disorder (ADHD, Inattentive Type or ADHD, Combined Type) requires a somewhat different approach than that which is commonly used with children. Assessment procedures are the same for all ages with history taking that includes questionnaires, computerized continuous performance tests, and an EEG profile using information from a single channel of EEG with placement at the vertex (designated as CZ, or central vertex, according to the International Placement System used by neurologists and neuroscientists). Alternatively, placement may be at FZ (frontal vertex, about 7 cm. anterior to CZ) in adults because brain activity tends to migrate forward with age. Since ADHD is primarily a frontal lobe disorder involving poorly developed executive functions such as attention, planning and inhibition, the single channel data will usually suffice in uncomplicated cases. A full-cap, 19-lead assessment can be done for cases that require information about what is happening at a number of locations or when communication between different areas of the cortex seems disrupted; for example, ADHD plus depression, or ADHD plus head injury. Obviously a 19-lead assessment is necessary when attentional problems are acquired, as in the case of those who have had traumatic brain injury. After the initial assessment, which typically lasts at least three hours, a second assessment is done in some neurofeedback centres which covers intellectual testing (Wechsler Adult Intelligence Scale Third Edition) and academic screening. This information is used in two ways: to fine-tune the neurofeedback training programme with the addition of strategies that use the person s strengths to help compensate for weaker areas, and to provide objective measures that can be used for comparison purposes when post-testing is done after a certain number of sessions have been completed. The course of treatment is usually about 40 sessions done twice a week.

4 126 Thompson and Thompson How useful is the EEG when doing initial evaluations? Studies with children have shown clearly that a single channel (Cz) assessment can have high specificity in identifying children with ADHD compared to control subjects (Janzen & Fitzsimmons, 1995; Monastra et al., 1999). The latter multi-site study included young adults, years of age. The average ratio of slow (tuning out waves) to fast (calm, alert, thinking waves), the theta-to-beta power ratio, was about 1.5 in the adult group without ADHD and 4 in the group with ADHD. Using the theta/beta ratio one can identify those with ADHD with about 95% accuracy. How effective is neurofeedback as an intervention for ADHD? Studies demonstrate the efficacy of neurofeedback as being equal to treatment with Ritalin (Rossiter & LaVaque, 1995; Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003). As noted above, once the person has made a shift and can produce more mature brain wave patterns, the results in terms of improved attention last after training has finished (Lubar, 1995). There are benefits in terms of increased intellectual functioning (Lubar, 1991; Linden, Habib, & Radojevic, 1996; Thompson & Thompson, 1998) in addition to the improvement in ADHD symptoms after training. Eleven of the 111 clients in the Thompson and Thompson (1998) study were adults. Since that time, our experience with adults (including clients who had dual diagnoses of ADHD with Asperger s Syndrome, anxiety or depression) continues to demonstrate positive outcomes. It is more difficult to report on pre-post training results with adults due to the fact that they do not always complete the recommended 40 sessions of training. This is usually because they are extremely busy and, as soon as they are feeling that life is going better or they no longer require medications for symptom relief, they will often leave the program. A chart review is currently underway to track initial EEG patterns in adults with ADHD and to report on results with training in a larger series of cases. In this paper we can share impressions from the initial phase of this research dealing with the EEG patterns found in conjunction with various symptoms. EEG FINDINGS IN ADULTS WITH ADHD The EEG patterns in adult clients are more complex than in children. This perhaps reflects both brain maturation and the layers of experience that the adult has accumulated, which affects brain function. Nearly all children with ADHD show increased theta (4 8 Hz) compared to beta (16 20 or Hz) relative to age peers. It is normal for theta to be the dominant frequency range in very young children, so the younger the child the higher the ratio must be to be considered excessive. High theta corresponds to inattentiveness to the task at hand. In a review of 154 adult clients seen at the ADD Centre, 80% of those with ADHD symptoms demonstrated a high theta/beta power ratio (Monastra et al. criteria) using the frequency bands of 4 8 for theta and Hz for beta. We call this group of adults the drifters because they are more in their own world and their attention drifts when they are bored or faced with something to do that is not of interest or is perceived or be difficult. A very small number of these adults additionally tuned out at a higher frequency, 8 10 Hz, in the low-alpha band. Twenty percent of the adult clients in this review, however, did not present with a high theta/beta ratio. These adults demonstrated a different symptom picture that we have labelled busy-brain. They were internally distracted by concerns or thoughts unrelated to the task at hand. These distracting thoughts or ruminations corresponded to bursts of beta activity (hi-beta), often a spindling beta, between 20 and 34 Hz. Spindling refers to a narrow bandwidth, often 1 or 2 Hz wide, of high amplitude (compared to surrounding activity) synchronous beta. In contrast, problem solving beta when the client was successfully carrying out a reading or mathematics task was associated with desynchronized beta in the Hz range. These bursts of high amplitude, hi-beta activity correlated with a dip in Hz sensorimotor (SMR) activity. The SMR rhythm is associated with being physically calm and mentally alert. A 3 min artifacted EEG at Cz referenced to the left ear showed a high 26 34/13 15 Hz ratio (>1.5) in this group of adult clients. For any given individual, the hi-beta activity was at a specific frequency (such as 25 or 31 Hz) that seemed to be fairly consistent for that individual. A further observation was that about 40% of the adults who demonstrated high theta/beta ratios (the drifter group) also demonstrated high hi-beta/smr ratios and complained of being tense, anxious and having a tendency to worry and ruminate. Thus, over 50% of the adults showed the busy-brain profile, either alone or in combination with high theta. EEGs were reviewed for comparison purposes in 90 consecutive children with ADHD. Only 7%

5 Neurofeedback Intervention for Adults with ADHD 127 of the children demonstrated the busy-brain, high amplitude hi-beta activity. This small group of children formed a very distinct clinical sub-group: they all exhibited anxiety and worry, not just ADHD symptoms. Neurofeedback intervention follows upon the EEG assessment findings, so being aware of these sub-groups is important. Regardless of age, each client is unique and intervention needs to be customized. High theta corresponds to inattention/being more in one s own world and neurofeedback aims to decrease the excess theta while increasing higher frequencies associated with being calm yet alert (12 15 Hz) or with cognitive work (15 18 Hz). In children this is usually sufficient. Adult clients, on the other hand, show high hi-beta/smr ratios in about half of the cases, either alone or in combination with high theta. Those clients benefit from a combination of neurofeedback and general biofeedback. To determine which biofeedback modalities to use, a psychophysiological stress assessment is carried out. INTERVENTION USING BIOFEEDBACK AND NEUROFEEDBACK The case of Diane (not her real name) provides an example of assessment findings that guided successful treatment. She was a highly intelligent woman with a number of degrees, including a professional degree, but she had failed her clinical practice examinations due to anxiety. It was hard for her to study efficiently and she had changed her area of study a number of times and had required more time to finish her various graduate degrees. She had ADHD features, anxiety (sometimes to the degree of feeling panic), and difficulty in social situations due to nervousness. She was taking medications for ADHD and for anxiety. The goal of training for Diane was to be able to achieve a mental state that was optimal for functioning as a professional: relaxed, alert, calm, focused, able to problem solve and cope with daily stress rapidly and effectively. This is, in fact, the optimal performance state that nearly all our adult clients need to achieve, though the initial presenting problems may differ; for example, some may have ADD plus depression rather than ADD and anxiety. The method of achieving this state is through learning self-regulation of both mental and physiological state using neurofeedback combined with some regular biofeedback, as described below. Step 1: Setting-Up-for-Success The first step is to ensure that common sense factors are addressed so the client will get the most out of the investment they make in training. This includes setting up for success by advising the client on nutrition, sleep, exercise and positive home environment. These factors are important in both children and adults and are thoroughly discussed in The A.D.D. Book by Sears and Thompson. Step 2: Correlating EEG to Mental State Having carried out the EEG assessment, which determines which frequencies to train for that individual, the next step is to have the client observe how their EEG relates to their mental state. When they discover that they can consciously take control of their own brain wave pattern they feel empowered. Clients typically report that decreasing theta and low alpha (3 10 Hz) correlates with improved focus. Decreasing high beta (above 20 Hz) correlates with stopping circular, repetitive, ruminative thinking. One client, a professional golfer with ADHD traits, called it emptying-my-mind. Increasing Hz correlates with a relaxed open-awareness or some say opening my focus to everything around me. Increasing Hz most often appears to correlate with feeling very calm or not driven (Fig. 1). Example of an EEG Profile In the case of Diane, age 42, a distinct EEG profile often occurred in which hi-beta was excessive and SMR activity rather low. She could correlate this pattern with feeling anxious and tense, worrying about the same old things that were constantly bothering her, such as whether she would ever be able to pass her exams. At other times she demonstrated high 5 9 Hz activity compared to her Hz beta, which meant she was tuning out rather than concentrating on a task. Step 3: Psychophysiological Stress Assessment Clients with adult ADHD almost always benefit from stress management techniques. A quick stress assessment involves measurements of finger temperature, skin conduction, muscle tension, pulse rate

6 128 Thompson and Thompson Fig. 1. Example of an EEG profile. and respiration. These measures are taken simultaneously during a series of conditions, for example, 1 min baseline, 2 min Stroop color test, 2 min recovery time, 2 min stressful math task, 2 min recovery and 3 min following the trainer s instructions to breath diaphragmatically at about 6 breaths per minute while relaxing face, neck and shoulder muscles and warming their hands. Typically one observes during stress a decrease in skin temperature with increases in skin conductance (electrodermal response, referred to as EDR), muscle tension, heart rate and respiration rate, plus lack of synchrony between heart rate variability and respiration (poor respiratory sinus arrhythmia, or RSA). With relaxation the skin temperature rises, EDR, heart rate and muscle tension drop and there is a clear synchrony between heart rate increase and decrease with inspiration and expiration. Prior to training, most clients do not recover rapidly or completely after stress. Step 4: Combining EEG Training with Stress Reduction Techniques Diane was able to correlate EEG frequency ranges with her mental state. She also gave a classic stress response profile with poor recovery. During the course of neurofeedback training a number of parameters were trained. With placement at C2 referenced to the left earlobe, she raised and Hz while decreasing 5 9, and Hz activity. In addition she learned to decrease right

7 Neurofeedback Intervention for Adults with ADHD 129 frontal beta spindling, which had been associated with negative worries and feelings of panic, (F4 referenced to the left ear) and she activated the T6 area where there had been slow wave activity that was postulated to be reflective of her difficulty in navigating social situations. This EEG training was done concurrently with biofeedback for decreasing her frontalis muscle tension and breathing diaphragmatically at about 6 breaths per minute. Step 5: Generalize the Learning to Everyday Living With a reasonable number of training sessions (Diane took 52 sessions, more than most adults with ADHD who do not have the extreme anxiety) the EEG changes appear to be permanent. The self-regulation changes learned with biofeedback of physiological variables however, require continuous practice in the everyday world. Diane therefore paired the learning of self-regulation techniques in the centre with cognitive strategies which included: Habit-to-a-habit (routine) technique; SMIRB (Stop- My-Irritating-Ruminations-Book); Time Management; Active Reading for maximum synthesis and recall; Business/career planning grid. The reader is referred to the chapter on metacognition in The Neurofeedback Book (Thompson & Thompson, 2003) for a description of strategies. By the end of training, Diane had discontinued all medications, no longer had panic attacks, no longer met the criteria for ADHD or anxiety disorder, and was socially more adept. She reported that she had gone to a party and, for the first time in her life, felt like an adult. She was calmer and reported that she was able to focus and not become distracted by either external stimuli or internal worries. She could control her tendency to ruminate. She passed the clinical and oral examinations for her profession. CONCLUDING COMMENTS Some adults have appropriately diagnosed Attention-Deficit/Hyperactivity Disorder because the symptoms impair their functioning. For many others, there are ADD traits that result in underachievement but the ADD is more accurately A Discernable Difference in attention without the symptoms constituting a disorder. The same degree of busy brain may have diametrically opposite outcomes. Whether the hunter mind succeeds or fails often has to do with other factors in their environment, such as finding a mentor and finding the right career. The symptoms are found with both pathology and genius, and high intelligence is usually a protective factor that leads to better outcomes. For ADHD clients, whether disordered or simply wanting to optimize their performance, practicing self-regulation using neurofeedback empowers them to do things that were previously very difficult, such as listening patiently and remembering what was said or staying focused and following through on tasks. When combined with biofeedback it inoculates against stress-related problems. An optimal state of mental and physiological functioning will broaden associative capabilities and perspective, decrease fatigue, allow a calm focus and reflection on alternative approaches to tasks. When this is combined with high levels of alertness clients show improved reaction time, increased response accuracy, increased mental flexibility, and increased resiliency. REFERENCES American Academy of Pediatrics Committee on Quality Improvement and sub-committee on Attention Deficit Hyperactivity Disorder: Clinical Practice Guidelines. (2000). Pediatrics, 105(5), American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders 4th Ed. Washington, DC: Author. Bradley, C. (1937). The behavior of children receiving Benzedrine. American Journal of Psychiatry, 94, Business Week. (2003). Attention deficit: Not just kid stuff. October 27, Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J., & Kaiser, J. (2003). Neurofeedback for attention-deficit/ hyperactivity disorder in children: A comparison with methylphenidate. Applied Psychophysiology and Biofeedback, 28(1), Hallowell, E. M., & Ratey, J. J. (1994). Driven to distraction. New York: Pantheon Books. Hartmann, T. (2002). ADHD secrets of success. New York: Select Books. Janzen, T., & Fitzsimmons, G. (1995). Differences in baseline EEG measures for ADD and normally achieving preadolescent males. Biofeedback and Self-Regulation, 20(1), Kelly, K., & Rumondo, P. (1995). You mean I m not lazy, stupid, or crazy? New York: Scribner Press. Linden, M., Habib, T., & Radojevic, V. (1996). A controlled study on the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback and Self-Regulation, 20(1), Lubar, J. F. (1991). Discourse on the development of EEG diagnostics and biofeedback treatment for attention-deficit/ hyperactivity disorders. Biofeedback and Self-Regulation, 16, Lubar, J. F. (1995). Neurofeedback for the management of attention-deficit/hyperactivity disorder. In Mark S. Schwartz and Associates (Eds.), Biofeedback: A practitioner s guide (2nd ed.). New York: The Guilford Press. Lubar, J. F., & Shouse, M. N. (1976). EEG and behavioural changes in a hyperkinetic child concurrent with training of the

8 130 Thompson and Thompson sensorimotor rhythm (SMR): A preliminary report. Biofeedback and Self-Regulation, 3, Monastra, V. J., Monastra, D., & George, S. (2002). The effects of stimulant therapy, EEG biofeedback, and parenting on primary symptoms of ADHD. Applied Psychophysiology and Biofeedback, 27(4), Monastra, V. J., Lubar, J. F., Linden, M., VanDeusen, P., Green, G., Wing, W., et al. (1999). Assessing attention-deficit/ hyperactivity disorder via quantitative electroencephalography: An initial validation study. Neuropsychology, 13(3), Rossiter, T. R., & LaVaque, T. J. (1995). A comparison of EEG biofeedback and psycho-stimulants in treating attention deficit hyperactivity disorders. Journal of Neurotherapy, 1(1), Sears, W., & Thompson, L. (1998). The A.D.D. Book: New understandings, new approaches to parenting your child.newyork: Little, Brown & Co. Snowden, D. (2001). Aging with Grace: What the nun study teaches us about leading longer, healthier, and more meaningful lives. New York: Bantam Books. Sterman, M. B. (2000). EEG markers for attention deficit disorder: Pharmacological and neurofeedback applications. Child Study Journal, 30(1), Sudderth, D. B., & Kandel, J. (1997). Adult ADD The complete handbook. Rocklin, CA: Prima Publishing. Swanson, J. M., McBurnett, K., Wigel, T., Pfiffner, L. J., Williams, L., Christian, D. L., et al. (1993). The effect of stimulant medication on children with attention deficit disorder: A review of reviews. Exceptional Children, 60(2), Thompson, L., & Thompson, M. (1998). Neurofeedback combined with training in metacognitive strategies: Effectiveness in Students with ADD. Applied Psychophysiology and Biofeedback, 23(4), Thompson, M., & Thompson, L. (2003). The neurofeedback book: An Introduction to basic concepts in applied psychophysiology. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback. Wender, P. H. (1995). Attention-deficit hyperactivity disorder in adults. New York: Oxford University Press. Wilens, T. E., Spencer, T. J., & Biederman, J. (2002). A review of the pharmacotherapy of adults with attentiondeficit/hyperactivity disorder. Journal of Attention Disorders, 5(4), Yucha, C. B., & Gilbert, C. (2004). Evidence-based practice in biofeedback and neurofeedback. Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

9