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ADD Attention Deficit Disorder ADDES Attention Deficit Disorders Evaluation Scale ADHD Attention Deficit Hyperactivity Disorder ADHD-C ADHD-HI Attention Deficit Hyperactivity Disorder -Combined Type Attention Deficit Hyperactivity Disorder -Prendominantly Hyperactive-impulsive Type - - ADHD-I Attention Deficit Hyperactivity Disorder- Prendominantly Inattentive Type A Antisocial Behavior A Vocabulary Comprehension Factor B Perception Organization Factor - CD Conduct Disorder CDIS Clinical Diagnostic Interview Scale CGIS Clinical General Image Scale CPT Continuous Performance Test C-WISC Chinese-Wechsler Intelligence Scale for Children C Freedom From Distractibility Factor DSM- Diagnostic and Statistical Manual of Mental Disorders, 4 th eds EEG Electroencephalogram Biofeedback / ET Encephalo-fluctuograph Technology GAF General Assessment of Functioning IQ Intelligence Quotient LD Learning Disability MPH Methylphenidate Ritalin MQ Memory Quotient 1
ADHD N Neurotic Behavior ODD Oppositional Defiant Disorder PIQ Performance Intelligence Quotient SMR Sensorimotor Rhythm TOVA Test of Variable Attention TS Tourette s Syndrome VIQ Verbal Intelligence Quotient WMS Wechsler Memory Scale 2
ADHD 1. / ADHD 2. 40 4 DSM- 7~16 ADHD 1:1 A B Realfield A620 20 40 DSM- Conners Rutter Achenbach CPTSTROOP ET 3
ADHD 1. 40 ADHD P<0.05 40 35% 10% 63.6% 20% 20 40 ADHD P<0.0520 50% 20%40 60% 25% 72.3% 30% 2. 40 Rutter P<0.05 40 75% 20% 54.5% 10% Conners 63.6% 20% P<0.05 20 40 Conners 20 40% 10%40 45% 15% 72.7% 30% P<0.05 Conners P<0.05 3. 40 P<0.05 40 35% 10% 36.4% 10% 20 40 P<0.0520 30% 5% 40 45% 15% 54.5% 10% 20 P<0.0540 P<0.05 4
P<0.01 20 40 P<0.001 4. 20 40 C P>0.05 P<0.01 20 CPT P<0.01 40 P<0.05 40 stroop D P<0.05 P<0.05 5. 40 8Hz P<0.05 6. 20 P<0.00140 P<0.001 7. P<0.01 20 40 P<0.05 20 50% 20% 40 60% 5% 83.3% 20% 8. 90% P>0.05 40 P<0.05 40 80% 100% 63.6% 100% 5
ADHD 1. ADHD 2 ADHD 3. ADHD 6
ABSTRACT A Clinical Randomized Controlled Trail on Treatment for Attention Deficit Hyperactivity Disorder (ADHD) by Combined Therapy of EEG Biofeedback and Ritalin Objective To compare the effects of the combined therapy of EEG biofeedback and Ritalin with control group on core symptoms, behavior problems, cognitive, social and brain functions of ADHD children within and after EEG biofeedback. And also to discuss whether the combined therapy can reduce the drug doses and side effects effectively or not. Methods 40 children, aged 7-16 years, diagnosed as having ADHD according to the DSM- criteria were enrolled. After reaching the proper drug dose of Ritalin, they were randomly divided into two groups, each having 20 children. Then one group received combined EEG biofeedback, and the other placebo for the 40th session (5-6 months). Assessments were made for each patient: the 1st assessment was at the beginning of the study, the 2nd after the 20th session, and 3rd after 40th session. Here the optimal effects were kept with the minimal doses of Ritalin, starting to reduce Ritalin after the 20th session of EEG biofeedback. The 4th assessment was made after half year of the study. At each assessment, Conners questionnaire, Achenbach s questionnaire, clinical general image questionnaire, parents and teachers questionnaire, side-effect scale, ET, etc. were used. The efficiency of treatment, core syndromes, cognitive and social functions, brain functions, side effects, drug doses were compared each. 7
ADHD Results Core symptoms: The improvement of full score of the parents DSM- symptom questionnaire of the combined group was greater than the control (after 40th session, they were 35% and 10% and at the following-up, they were 63.6% and 20%, P<0.05); the improvement of full score of the teachers DSM- symptom questionnaire of the combined group was greater than the control (after 20th session, they were 50% and 20%, after 40th session, they were 60% and 25%, and at the following-up, they were 72.3% and 30%, P<0.05). Behavior problems: The improvement of full score of Rutter scores of combined group was greater than the control (after 40th session, they were 75% and 20%, at the following-up, they were 54.5% and 10%, P<0.05). At the following-up, the improvement of the hyperactivity factor of combined treatment was greater than the control, (they were 63.6% and 20%, P<0.05); the improvement of the index of hyperactivity of combined treatment was greater than the control (after 20th session, they were 40% and 10%; after 40th session, they were 45% and 15%, at the following-up, they were 72.7% and 30%, P<0.05); At the following-up, the score of the teachers conners scale of combined treatment was lower than the control (P<0.05). Social functions: The improvement of full score of parents pression questionnaire of combined group was greater than the control (after 40th session, they were 35% and 10%, at the following-up, they were 36.4% and 10%, P<0.05); the improvement of full score of partners interaction questionnaire of combined group was greater than the control group (after 20th session, they were 30% and 5%, after 40th session, they were 45% and 15%, at the following-up, they were 54.5% and 10%, P<0.05); there was a greater 8
improvement of the combined group of the score of full school card and discipline after 20th session and there were more improvement of the school card of the combined group after 40th session and at the following-up than the control (P<0.05). The GAF score of the combined group was greater improved than the control after 20th, 40th session and at the following-up (P<0.001). Cognitive functions: After 20th, 40th sessions and at the following-up, there was no significant difference of free from Distractibility Factor, full score of IQ and memory Quotient between combined and control. The combined group had a greater improvement of the third net score of Number Cancellation Test than the control group at the following-up (P<0.01). In CPT test, the combined group had a higher correct rate and a lower false rate after 20th sessions (P<0.01), and had a shorter react time after 40th sessions and at the following-up than the control (P<0.05). In Stroop test, the combined group had a shorter time of finishing D part after 40th session and interference of word at the following-up than the control (P<0.05). Brain functions: The combined group had more decline of the dominant frequency of 8Hz than the control group. CGI: The scores of CGI of the combined group improved significantly than the control (P<0.001). Drug doses: Drug dose was significant lower of the combined at the following-up than the control (P<0.01). The effective rates of declining of drug doses of the combined group were greater than the control in 20th, 40th session and at the following-up (after 20th session, 9
ADHD they were 50% and 20%, after 40th session, they were 60% and 5%, at the following- up, they were 83.3% and 20%, P<0.05). Side effects: The two groups had the same rate of side effects before EEG treatment (both were 90%, P>0.05). After 20th, 40th session and at the following-up, the combined group showed less side effects than the control (after 40th session, they were 80% and 100%, at the following-up, they were 63.6% and 100%, P<0.05). Conclusions The combined treatment could improve children s global curative effects, core symptoms, behavior problems, social problem and brain functions more effectively than the control. The combined treatment could improve the vigilance, inhibit ability and arousal situation of ADHD children more effectively than the control. The combined group had a long-term effect, after stopping the EEG biofeedback. it still had more improvement than the control group. The combined group also could reduce the drug doses and side effects more effectively than the control group when they almost had the equivalent efficacy. Key Words Attention deficit hyperactivity disorder, EEG biofeedback, Ritalin, Combined therapy 10
attention deficit/hyperactivity disorder, ADHD Tannock, 1998 ADHD 3%~6% 4~9:1 American Psychiatry Association, 1994 5.06±1.70 % Gillberg, 1982;, 1995 ADHD 7 70% 30% Weiss 1993; Barkley, 1990c; Biederman, 1996; Caspi, 1996; Klein, 1991 ADHD ADHD 20 30 Dulcan, 1997 MPH 50 ADHD 90% MPH 65%~75% Greenhill, 1999 30% Cousins, 1993 Horn, 1991; Pelham, 1993; Frankel, 1997 11
ADHD 1 ADHD δ 0.5~4Hz θ 4~8Hz α β Berger, 1930; Linden, 1996SMR 12~15 Hz Egner Gruzelier, 2001; Rossiter LaVaque, 1995 ADHD θ α β 22~30Hz Mann, 1992; Chabot, 1996 1991 ADHD δ θ α ADHD Lazarro 1998 26 ADHD θ β PET ADHD EEG Chabot 1996b 407 DSM- ADD EEG 47.1% θ 28% α 13% β 19.2% Clarke 2001c 184 8~12 ADHD-C 40 QEEG αβθδ 42.3% θδ β α θ/β 37.5% θδ α β β 20.2% β δα Clarke 2002c 100 ADHD-I EEG EEG θ δβ θ 12
ADHD ADHD QEEG ADHD - ADHD-C ADHD-I β ADHD-C ADHD ADHD MRIFilipek, 1997 ADHD PET Zametkin, 1990 ADHD Grodzinsky 1992 PET ADHD - 2 EEG 20 60 ADHD Braud, 1978; Hughes, 1980; Potashkin, 1990 13