Quantitative EEG neurofeedback for the treatment of pediatric attention-deficit/hyperactivity disorder, autism spectrum disorders, learning disorders, and epilepsy.

Neurofeedback (NF) using surface electroencephalographic signals has been used to treat various child psychiatric disorders by providing patients with video/audio information about their brain's electrical activity in real-time. Research data are reviewed and clinical recommendations are made regarding NF treatment of youth with attention deficit/hyperactivity disorder, autism, learning disorders, and epilepsy. Most NF studies are limited by methodological issues, such as failure to use or test the validity of a full-blind or sham NF. The safety of NF treatment has not been thoroughly investigated in youth or adults, although clinical experience suggests reasonable safety.

Attention-deficit/hyperactivity disorder: dietary and nutritional treatments.

Dozens of complementary and alternative treatments have been advocated for attention-deficit/hyperactivity disorder. Some verge into standard treatment of specific cases. Most do not have conclusive evidence of effectiveness or safety for attention-deficit/hyperactivity disorder, but some have enough evidence and are safe, easy, cheap, and sensible enough that individual patient trials can be justified. There is a need to flesh out the evidence base, which could be done cost effectively for supplements or off-label agents that are amenable to placebo control.

EEG neurofeedback for ADHD: double-blind sham-controlled randomized pilot feasibility trial.

OBJECTIVE: Preparing for a definitive randomized clinical trial (RCT) of neurofeedback (NF) for ADHD, this pilot trial explored feasibility of a double-blind, sham-controlled design and adherence/palatability/relative effect of two versus three treatments/week. METHOD: Unmedicated 6- to 12-year-olds with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) ADHD were randomized to active NF versus sham-NF and to 2X versus 3X/week treatment frequency. Frequency switch was allowed after Treatment 24. RESULTS: In two school years, 39 participants were recruited and 34 (87%) completed all 40 treatments. Child/parent guesses about assigned treatment were no better than chance. At Treatment 24, 38% chose 2X/week and 62% chose 3X/week. Both active NF and sham yielded large pre-post improvement on parent ratings but NF no more than sham. CONCLUSION: Blinding appears to work, and sham does not prevent recruitment/retention. Treatment frequency of 3X/week seems preferred over 2X/week and was as effective. A large double-blind RCT is feasible and necessary to test specific NF effectiveness.

A review of complementary and alternative treatments for autism spectrum disorders.

Given the severe and chronic problems associated with Autism Spectrum Disorders (ASD) and the limitations of available treatments, there exists a large public health need for additional interventions. As more parents are inquiring about complementary and alternative treatments (CATs), both parents and practitioners require up-to-date information about them and whether and how to integrate them into treatment. After presenting data on CAT usage patterns for ASD, we review 13 ingestible (i.e., orally administered) and 6 noningestible (i.e., externally administered) CATs for ASD. For each CAT we briefly describe its definition; rationale for use; current research support, limitations, and future directions; safety issues; and whether we currently recommend, not recommend, or find it acceptable for the treatment of ASD. We conclude this paper with recommendations for future research and ten clinical recommendations for practitioners.

Artificial food colors and attention-deficit/hyperactivity symptoms: conclusions to dye for.

The effect of artificial food colors (AFCs) on child behavior has been studied for more than 35 years, with accumulating evidence from imperfect studies. This article summarizes the history of this controversial topic and testimony to the 2011 Food and Drug Administration Food Advisory Committee convened to evaluate the current status of evidence regarding attention-deficit/hyperactivity disorder (ADHD). Features of ADHD relevant to understanding the AFC literature are explained: ADHD is a quantitative diagnosis, like hypertension, and some individuals near the threshold may be pushed over it by a small symptom increment. The chronicity and pervasiveness make caregiver ratings the most valid measure, albeit subjective. Flaws in many studies include nonstandardized diagnosis, questionable sample selection, imperfect blinding, and nonstandardized outcome measures. Recent data suggest a small but significant deleterious effect of AFCs on children's behavior that is not confined to those with diagnosable ADHD. AFCs appear to be more of a public health problem than an ADHD problem. AFCs are not a major cause of ADHD per se, but seem to affect children regardless of whether or not they have ADHD, and they may have an aggregated effect on classroom climate if most children in the class suffer a small behavioral decrement with additive or synergistic effects. Possible biological mechanisms with published evidence include the effects on nutrient levels, genetic vulnerability, and changes in electroencephalographic beta-band power. A table clarifying the Food and Drug Administration and international naming systems for AFCs, with cross-referencing, is provided.

Current status of neurofeedback for attention-deficit/hyperactivity disorder.

As conventional treatments offer incomplete benefit for over 33 % of children with attention-deficit/hyperactivity disorder (ADHD) and many refuse to try them, additional treatments are needed. One of the most promising is neurofeedback (NF, EEG biofeedback), which trains the brain with real-time video/audio information about its electrical activity measured from scalp electrodes. Since 2010, data from 8 randomized controlled studies of NF have been published with overall mean effect sizes of: 0.40 (all measures), 0.42 (ADHD measures), 0.56 (inattention), and 0.54 (hyperactivity/ impulsivity). Unfortunately, the benefit reported from randomized studies has not been observed in the few small blinded studies conducted. Main study strengths include randomization, evidence-based diagnostic assessments, multi-domain treatment outcomes, use of some type of blinding, and sham control conditions. Main study limitations include lack of large samples, abnormal EEG participant selection, double-blinding, and testing of blind validity and sham inertness. Most recently, a collaborative NF research group has been planning a definitive double-blind well-controlled trial.

A review of neurofeedback treatment for pediatric ADHD.

OBJECTIVE: The aim of this paper was to review all randomized published trials and unpublished conference presentations on the neurofeedback (NF) treatment of pediatric ADHD, and their relevance, strengths, and limitations. METHOD: Via PsychInfo and Medline searches and contacts with NF researchers 14 studies were identified and reviewed. RESULTS: The majority were conducted from 1994 to 2010, with 5- to 15-year-olds, usually male and White with the combined type of ADHD. Most studies used theta/beta NF with a unipolar-electrode placement at Cz and demonstrated, where reported, an overall ADHD mean effect size of d = 0.69, a medium effect. Main study strengths, within some studies, include use of randomization, treatment control conditions, Diagnostic and Statistical Manual of Mental Disorders criteria, evidence-based assessment of ADHD, standard treatment outcome measures, multidomain assessment, and, for some studies, moderate sample size, some type of blind and the identification of medication as a concomitant treatment. Main study limitations (and directions for future research) include the lack of adequate blinding of participants, raters and NF trainers, a sham-NF/blinded control treatment condition, posttreatment follow-up, generalizability, specific details about delivery of NF, identification and control of comorbidity, and the identification, measurement, and control of concomitant treatments and potential side effects. CONCLUSION: Based on the results and methodologies of published studies, this review concludes that NF for pediatric ADHD can be currently considered as "probably efficacious."

Dietary and nutritional treatments for attention-deficit/hyperactivity disorder: current research support and recommendations for practitioners.

Evidence for dietary/nutritional treatments of attention-deficit/hyperactivity disorder (ADHD) varies widely, from double-blind, placebo-controlled trials to anecdotal. In guiding patients, clinicians can apply the SECS versus RUDE rule: treatments that are Safe, Easy, Cheap, and Sensible (SECS) require less evidence than those that are Risky, Unrealistic, Difficult, or Expensive (RUDE). Two nutritional treatments appear worth general consideration: Recommended Daily Allowance/Reference Daily Intake multivitamin/mineral supplements as a pediatric health intervention not specific to ADHD and essential fatty acids, especially a mix of eicosapentaenoic acid, docosahexaenoic acid, and γ-linolenic acid as an ADHD-specific intervention. Controlled studies support the elimination of artificial food dyes to reduce ADHD symptoms, but this treatment may be more applicable to the general pediatric population than to children with diagnosed ADHD. Mineral supplementation is indicated for those with documented deficiencies but is not supported for others with ADHD. Carnitine may have a role for inattention, but the evidence is limited. Dimethylaminoethanol probably has a small effect. Herbs, although "natural," are actually crude drugs, which along with homeopathic treatments have little evidence of efficacy. Consequences of delayed proven treatments need consideration in the risk-benefit assessment of dietary/nutritional treatments.

Self-embedding behavior: a new primary care challenge.

OBJECTIVE: The goal of this study was to define self-embedding behavior (SEB), develop a clinical profile of adolescents who engage in SEB, and emphasize the importance of rapid, targeted, and effective identification and intervention. METHODS: As part of a retrospective study with a database evaluating 600 patients percutaneously treated for soft-tissue foreign body removal, adolescents were identified with self-embedded soft-tissue foreign bodies. We describe patients' gender, age, and psychiatric diagnoses; SEB age of onset, frequency, and self-reported reasons; and the number, type, location of, and removal technique for objects. RESULTS: Eleven patients (9 females) who engaged in SEB were identified. Ten of the 11 patients were members of a group home or psychiatric facility at the time they engaged in SEB. All patients had previous and multiple psychiatric diagnoses. SEB mean age-of-onset was 16 years, and mean number of SEB episodes per patient was 1.9. The most common self-reported purpose for SEB was suicidal ideation (6 of 8 [75%]) versus nonsuicidal ideation (2 of 8 [25%]), with 3 cases lacking this documentation. The mean number of objects embedded in a single episode was 2.4, usually composed of metal and embedded in the arm. Seventy-six foreign bodies were percutaneously removed (using ultrasound or fluoroscopic guidance), including metal, glass, wood, plastic, graphite, and crayon. CONCLUSIONS: SEB is an extreme form of self-injury requiring aggressive and timely interdisciplinary assessment and treatment. An understanding of SEB allows medical professionals to pursue rapid, targeted, and effective intervention to interrupt the cycle of self-harm and institute appropriate long-term therapy.

Web-survey of pharmacological and non-pharmacological sleep interventions for children with early-onset bipolar spectrum disorders.

BACKGROUND: A web-based survey was developed to explore the effect of pharmacological and non-pharmacological interventions for sleep difficulties associated with Early-Onset Bipolar Spectrum Disorders (EBSD). METHOD: Four hundred ninety four parents of 4-12 year-olds, identified by parents as being diagnosed with EBSD, provided information about which professionals were consulted regarding their child's EBSD-sleep problems and pharmacological and non-pharmacological interventions that helped or worsened sleep. RESULTS: Most parents reported consulting at least one medical, mental health, and/or school professional regarding their child's sleep problems. Psychiatrists and other physicians were most often consulted. The majority of parents reported several medications/supplements as helpful, most commonly, atypical antipsychotics (54.4%). Over half identified various pharmacological agents that worsened sleep, most commonly, stimulants (35.0%). Most parents also reported several non-pharmacological interventions that aided sleep problems, most frequently, a sleep routine. Over two-thirds reported a variety of non-pharmacological interventions that worsened sleep, most notably, punishment (34.8%). LIMITATIONS: The sample was non-random consisting of self-selected and web-savvy parents who self-identified their children as having EBSD and provided only parent derived data. CONCLUSIONS: Although exploratory and despite limitations, this is the first survey to report data on both pharmacological and non-pharmacological treatments for EBSD-sleep problems. It highlights clinical interventions that may improve or worsen EBSD-sleep and provides directions for future research.

Mood-related sleep problems in children and adolescents.

Sleep problems are an essential part of the current diagnostic criteria for depressive and bipolar disorders in children and adolescents. Whereas many studies have reported subjective sleep problems in youth with depression or bipolar disorder, except for reduced rapid eye movement latency associated with depression, few objective mood-related sleep abnormalities have been consistently identified. Recent technologic advances, such as spectral EEG and actigraphy, hold promise for revealing additional objective disturbances. There are presently few evidence-based published practice recommendations for mood-related sleep problems in youth. In this article, the authors chronologically review research on the phenomenology and treatment of sleep difficulties in youth with depressive and bipolar disorders and present research-based and clinically guided recommendations for the assessment and treatment of these problems.

Nonsuicidal self-injury and suicide risk among adolescents.

PURPOSE OF REVIEW: Description of current research examining the association between adolescent nonsuicidal self-injury (NSSI) and suicidality. Research on this topic is important as emerging evidence suggests NSSI and suicidality are distinct yet related clinical phenomena and NSSI may increase later risk for suicide. RECENT FINDINGS: Overall, a relatively strong relationship appears to exist between NSSI and suicidality. However, certain study limitations prevent documentation of the exact nature of this relationship. SUMMARY: Results imply that whenever past or current NSSI or suicidality is identified, primary care clinicians conduct an assessment of the other behavior and make a timely and suitable referral. Future research requires longitudinal designs measuring the exact onset and duration of NSSI and suicidality.

Web survey of sleep problems associated with early-onset bipolar spectrum disorders.

OBJECTIVE: As research on sleep difficulties associated with Early-Onset Bipolar Spectrum Disorders (EBSD) is limited, a web-based survey was developed to further explore these problems. METHODS: 494 parents of 4-to-12 year-olds, identified by parents as being diagnosed with EBSD, completed a web survey about past and current EBSD-related sleep problems. The survey included Children's Sleep Habits Questionnaire (CSHQ) items and sleep problems from the International Classification of Sleep Disorders 2nd edition. RESULTS: Nearly all parents reported some type of past or current EBSD-sleep problem. Most occurred during a worst mood period, particularly with mixed manic-depressive symptoms. Symptoms caused impairments at home, school, or with peers in 96.9% of the sample and across all three contexts in 64.0% of children. Sleep problems were also noted after three-day weekends and Spring and Fall Daylight Savings time changes. CONCLUSIONS: Findings, study limitations, and implications for treatment and etiology are discussed.

Parent and child reports of sleep problems associated with early-onset bipolar spectrum disorders.

Despite sleep problems being part of the diagnostic criteria for mood disorders, research on sleep difficulties related to early-onset bipolar spectrum disorders (EBSDs) is sparse. The authors examined the parent and child agreement, frequency, and severity of EBSD-related manic, depressive, and comorbid sleep problems. A sample of one hundred thirty-three 8- to 11-year-olds with EBSDs was assessed with parental and self-report measures of EBSD-related sleep problems. Dimensional and categorical measures indicated low agreement and high discrepancy between parent and child reports of EBSD sleep problems. Subsequent combination of parent-child data revealed the majority (96.2%) of children had moderate-to-severe sleep problems related to manic, depressive, or comorbid symptoms, either currently or during their worst mood period. More depression-related sleep problems than mania-related sleep problems were reported, especially initial insomnia. Over half the sample had sleep problems associated with current comorbidity, particularly separation anxiety disorder. These findings, their implications, and study limitations are discussed.

Psychosocial interventions for children with early-onset bipolar spectrum disorder.

Once considered virtually nonexistent, bipolar disorder in children has recently received a great deal of attention from mental health professionals and the general public. This paper provides a current review of literature pertaining to the psychosocial treatment of children with early-onset bipolar spectrum disorder (EOBPSD). Commencing with evidence of the emerging interest in this topic, we then focus on terminology, the rationale for studying EOBPSD in children, current research and clinical progress, possible explanations for the recent increase in recognition, and essential issues that form the foundation of effective psychosocial treatment. Next we explore areas of research with direct implications for psychosocial treatment. These include biological and psychosocial risk factors associated with bipolar disorder; and the psychosocial treatment of adult-onset bipolar disorder, childhood-onset unipolar disorder, and anger management in children. Following this, we discuss treatments being developed and tested for children with EOBPSD. Finally, we conclude with recommendations for future studies needed to move the field forward.

Differential risks of covarying and pure components in mother and teacher reports of externalizing and internalizing behavior across ages 5 to 14.

In a sample of 585 children assessed in kindergarten through 8th grade, we fit a confirmatory factor model to both mother- and teacher-reported symptoms on the Achenbach checklists (CBCL, TRF) and determined that a covariation factor of externalizing and internalizing behaviors existed, in addition to the pure-form factors of externalizing and internalizing for each reporter. In 3 structural equation models, between 8 and 67% of the variance in these 6 latent factors was accounted for by a set of antecedent child, sociocultural, parenting, and peer risk variables. Each of the 6 latent factors, taken 2 at a time, was predicted by a unique set of risk variables; however, there were some patterns that held for both mother- and teacher-report symptom factors: Child temperamental unadaptability and female gender were predictors of higher internalizing symptoms; child temperamental resistance to control, parental harsh punishment, male gender, low SES, and peer rejection were related to higher externalizing symptoms whereas child temperamental unadaptability was related to lower externalizing symptoms; and peer rejection and family stress were also related to the covarying, externalizing-plus-internalizing component of both mother and teacher reports.