Biofeedback and Self-Regulation, Vol. 15, No. 4, J990
Relative Efficacy of Ritalin and Biofeedback Treatments in the Management of Hyperactivity B e t h D. P o t a s h k i n 1
The Long Island Campus of_,41bert Einstein College of Medicine Nicola B e e k l e s Amityville School District
Th& study examined the efficacy of biofeedback and Ritalin treatments on hyperactivity as reflected by muscular electrical activity and as observed by teachers and parents. Eighteen male subjects between the ages of 10 and 13 were assigned to three groups, matched by age, IQ, and race. One group received 10 biofeedback sessions, another received Ritalin, and the third group controlled for nonspecific treatment effects. EMG readings, the Conners Teacher Rating Scale, the Werry-Weiss-Peters Scale, and the Zukow Parent Rating Scale were used to measure treatment efficacy. Results indicated that biofeedback-assisted relaxation significantly reduced muscle tension levels, whereas neither Ritalin nor personal attention produced significant change. On teacher ratings of hyperactivity, significant improvement was made by all three groups. Parent ratings on the Zukow scale indicated significant improvement by subjects in all groups. On the Werry-Weiss-Peters scale, the biofeedback and control groups made significant improvements in hyperactivity. Descriptor Key Words: behavior therapy; biofeedback; hyperactivity; eleetromyogmph; rating scales.
The February 1986 volume of the American Psychologist addressed the stares of psychotherapy research. In an overview article, Gary VandenBos underscored the value of comparative therapy research because of the growth in "consumers" of such research. It is in this spirit that this study examines a 1Address all correspondence to Dr. Beth D. Potashkin, 245 East 25th Street, Apartment 5A, New York, New York 10010.
305 0363-3586/90/1200-0305506.00/0© 1990 PlenumPublishingCorporation
306
Potashkin and Beckles
comparison of two treatment modalities as interventions for Attention Deficit Hyperactive Disorder (hereafter referred to as ADHD). Four major definitions have been used in the literature on "hyperactivity." The first definition refers to a quanttafive dimension of behavior, i.e., "hyperactivity" is seen as a level of daily motor activity that is clearly greater than that occurring in other children of a similar age (Chess, 1960; Werry, 1968). A second definition suggests that hyperactive children exhibit no more total daily body activity than do normals. Instead, these children have difficulty modulating their activity level (Safer & Allen, 1976; Douglas, 1972). A third definition views ovemctivity, restlessness, and inattention as part of the diagnostic category of conduct problems (Lahey, Stempniak, Robinson, & Tyroler, 1978). The fourth definition results from the work of Douglas and her colleagues (1972), which focuses on the attention difficulties manifested by these children, with the resulting fragmentation and disorganization of behavior that lead to the impression of excessive activity. Studies of the efficacy of amphetamine treatment have shown mixed and often contradictory results. The earliest studies on amphetamines were conducted on mixed groups of clinical subjects with widely discrepant psychopathologies. They were poorly controlled and lacked valid criteria to measure improvement (Eisenberg, 1972; Grinspoon & Singer, 1973; Sroufe, 1973). More recent studies have focused on their effects on the secondary symptomatology of ADHD such as cognitive performance (Peeke, Halliday, Callaway, Prael, & Revs, 1984; Rapport, Dupaul, Stoner, & Jones, 1986). In addition, there is a body of research on the difficulty of noncompliance to medical regimens (Brown, Borden & Clingerman, 1985; Firestone, 1982; Sleator, 1984). Studies of behavioral interventions have been plagued by similar problems. Inclusion criteria were poorly defined and results have been inconclusive (Ayllon, Layman, & Kandel, 1975; Christensen & Sprague, 1973; Patterson, 1965; Rosenbaum, 1975). In the effort to specify target behaviors, behavioral theory failed to meet the challenge of the variety of symptoms displayed by these children. Consequently, studies failed to show consistent results and generalizability of effect. In view of these difficulties, it was hypothesized that biofeedback would target underlying neurophysiological processes for conditioning techniques. In this regard, some studies have investigated the effects of EEG/SMR biofeedback training on ADHD children and some success has been reported (Parziale, 1982; Lubar, 1976, 1984; Tansey & Bruner, 1983). It appears that EEG studies have primarily focused on learning disabled children, and comparisons between EEG and EMG training on ADHD children are inconclusive (Kassel, 1986). A compelling model concerning the etiology of ADHD is proposed by Paul Wender (1971) and posits a depletion of neurotransmitters as a causal
Efficacy of Ritalin and Biofeedback
307
agent. The inability to modulate activity level may be a result of the comparative levels of functioning of the inhibitory and excitatory systems of the brain. The reported success of amphetamines is due to their effect on monoamines. The major question the present study posed is whether ADHD children can be taught the control that does not appear to come automatically through maximal functioning of the central nervous system. There are studies and dissertations that have suggested the value of EMG-assisted relaxation procedures on sustained attention, muscular electrical activity, motor activity, and teacher and parent ratings of improvement (Braud, 1978; Denkowski & Denkowski, 1974, Jeffrey, 1977; Krause, 1977; McFarland, 1980; Omizo and Williams, 1981, Gittleman-Klein, Klein, Abikoff, Katz, Glisten, & Ates, 1976).
METHOD Subjects The 18 subjects were boys between the ages of 10 and 13. All subjects were referred from special education classes. Psychosis, retardation, and brain damage were ruled out. Intelligence as defined by the WlSC-R was between 77 and 93. Substantiating diagnostic criteria of a score of 9 or above on the Zukow Parent Rating Scale and a score of 2.17 or above on the hyperactivity factor of the Conners Rating Scale were obtained. Three groups of six children each were formed.
Measures
Measurement of ADHD (1) The Conners Teacher Rating Scale (Conners, 1969) contains 39 items arranged under three headings: classroom behavior, group participation, and attitude toward authority. Interrater agreement ranged from .70 to .80. Test-retest reliability ranged from .70 to .90. (2) The Werry-Weiss-Peters Scale (Werry, 1968) is a 31-item questionnaire designed to measure specific behaviors in specific contexts, e.g., during meals, television, homework, play, sleep, and behavior away from home and school. Reliability ranged from .60 to .70. (3) The Zukow Parent Rating Scale (Zukow, Zukow, & Bentler, 1978) contains 28 items such as "jumps from one activity to another." A score of 9 or above, as determined by the authors, identifies ADHD children. Interrater
308
Potashkin and Beckles
agreement using this cutoff score has been shown to range from r = .90 to .96. Internal reliability has been reported as .89.
Measurement of Muscular Electrical Output The Autogen 1100 Electromyograph (EMG) was used to monitor and display the ongoing EMG activity generated by muscle action in the form of auditory and visual displays. The standard ban@ass is 100-200 hertz. Surface electrodes were used. Normal microvolt levels range between 1 and 2 microvolts (Autogenic Systems, 1975).
Pretesting of Subjects Each child was shown the electromyograph and told that this machine was used "to see how tense you are." How the machine worked was explained in detail to eliminate other fears of each child. Electrodes were attached to the frontalis muscle and each subject was monitored on the EMG for ten minutes.
Ritalin Group Each child and his mother were seen by a physician, who reassessed the child's mental status and obtained any background information. The physician knew that the efficacy of Ritalin was being studied but did not know of the other treatments employed in the study nor the experimental hypotheses. They then prescribed Ritalin in the manner they were accustomed to at a dosage deemed necessary. Five subjects received dosages of 15 milligrams, per diem and one received 10 milligrams per diem. The children in this group were seen by the physicians at the beginning of the six-week period and then two weeks later. At this point, four subjects were raised to 30 milligrams per diem, one to 20 milligrams per diem, and one to 40 milligrams per diem.
Biofeedback Group The biofeedback-assisted relaxation group was seen for 10 half-hour sessions over a six-week period. The first session was an introduction to biofeedback and the machine. A second phase introduced the relaxation procedure and shaped the response (three sessions). The relaxation procedure used was similar to Jacobson's Progressive Muscle Relaxation. A third phase continued the practice of the relaxation technique and introduced a mini-relaxation-exercise to be
Efficacy of Ritalin and Biofeedback
309
Table I. Results of W i l c o x o n M a t c h e d - P a i r s Signed R a n k Tests on Difference Scores (Pretest to Posttest) of Dependent Variables Dependent variable EMG Conners Zukow WWPS
Biofeedback (n = 6)
Ritalin (n = 6)
Control (n = 6)
2.20 a 2.20 a 2.20 ~ 2.20 ~
1.36 2.02 2.20" 1.83 a
0.9 2.02 a 2.20 a 1.99 a
" S i g n i f i c a n t b e y o n d the .05 level.
used outside the clinical session (three sessions). The last phase had as its goal the weaning of the subjects from the biofeedback machine and its feedback (three sessions).
Control Group The purpose of the control group was to control for the nonspecific effects of attention and passage of time. The subjects in this group were seen for ten half-hour sessions over a six-week period. The subject and research assistant spent the session playing a game such as checkers and allowing for gradual mastery of the game by the subject. Care was taken not to make direct therapeutic interventions.
Posttesting At the end of six weeks (ten sessions) and within one week of termination of treatment each subject was monitored again on the EMG for ten minutes in a manner identical to that done in pretesting. The parent and teacher rating scales were again administered.
RESULTS Table I shows the results of nonparametric Wilcoxon signed rank tests comparing pretest and posttest measurements within the three study groups. Only the biofeedback group improved significantly from pretest to the end of the study on the EMG measure. A nonparametric one-way Kruskal-Wallis ANOVA comparing the groups on difference scores was also significant, Z2 = 8.04, p < .05. Further post hoc comparison of the groups, using nonparametric Mann-Whitney tests, revealed
310
Potashkin and Beckles
* Significant within group difference
6
6
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[]
Posttest
o~
o~
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Biofeedback *
Ritalin
Control
Fig. 1. Number of subjects exhibiting mean EMG readings over two microvolts.
significant differences between the biofeedback and both the Ritalin and control groups, p < .05. Prior to treatment all subjects obtained readings above 2 microvolts. Figure 1 demonstrates that only biofeedback subjects showed readings that fell within the normal range. A chi-square analysis performed on this data was significant, ~2 = 10.26, p < .01. All three groups improved significantly on the Conners Teacher Rating Scale (see Table I). A Kruskal-Wallis ANOVA showed no difference across the groups in pretest to posttest change (~2 = 2.66). A chi-square analysis was conducted and showed that more subjects in the biofeedback group were able to reduce their hyperactivity to within normal limits, Z2 = 8.86, p < .05 (Figure 2). The biofeedback and control groups had significant change on the WerryWeiss-Peters Scale (see Table I). A one-way Kruskal-Wallis ANOVA conducted on the difference scores between groups indicated no significant differences, ~2 = 1.59. On the Zukow Parent Rating Scale, t-tests comparing the difference scores indicated significant change in all groups (see Table I). A Kruskal-Wallis ANOVA on group difference scores indicated no superiority of effect between any group, Z2 = 3.38. A chi-square analysis was conducted and showed that more of the subjects in the biofeedback group were able to
Efficacy of Ritalin and Biofeedback
311
* Significant within group difference
76 6-
6
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Fig. 2. Number of subjects scoring 2.17 or above on the hyperactivityfactor of the Conners
Teacher Rating Scale. reduce their scores following treatment than in the Ritalin or control groups, Z2 = 6.0, p < .05 (see Figure 3).
DISCUSSION The present study was an exploratory one in several respects. There are few studies that have attempted biofeedback-assisted relaxation as a treatment for ADHD. Of those, there are none that have systematically compared the efficacy of medication with such a treatment. Even more importantly, this is the first study to compare either biofeedback or Ritalin treatments to a control group that receives frequent contact with a supportive adult. Therefore, as this study attempted to answer questions concerning the efficacy of biofeedback and Ritalin treatments on ADHD, it raised at least as many questions concerning the definition and nature of A D H D itself. It has been demonstrated that the muscle tension levels of hyperactive children are higher than those found in normal children (Braud, 1978). The findings of this study confirmed this observation. The average tension levels before interventions, when asked to sit still and relax, were at least 2 microvolts above normal for most subjects.
312
Potashkin and Beckles
* Significant within group difference
76
6
6
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2~ "i "5
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6
6.
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Fig. 3. Number of subjects scoring 9 or above on the Zakow Parent Rating Scale.
After the experimental interventions, EMG readings obtained indicated that children receiving biofeedback training were able to sit quietly without the level of muscle tension exhibited by the other groups. This was a critical finding in that the inability to modulate activity level has been proposed as an essential disability in hyperactive children. One can argue that biofeedback subjects had a "set" to relax from the expectancy effects of treatment. The fact that it took subjects several weeks to learn to relax argues against the idea that expectation alone can reduce EMG scores. Subjects receiving Ritalin exhibited tension levels comparable to those shown at pretesting. This finding indicates that the relationship between amphetamines and muscle tension needs further exploration. Subjects in the control group were unable to relax and reduce muscle tension after the six-week period. This finding argues against any effects of time and personal attention on EMG scores. It suggests that the efficacy of biofeedback in producing levels comparable to those exhibited by normal children is attributable to aspects of the training other than frequency of contact, personal attention, or passage of time. Although these results are highly significant on their own, if such change cannot be demonstrated in the child's environment outside of the clinical session, the value of the treatment is limited. Results indicated that subjects in all three groups significantly reduced hyperactive behavior in the classroom. Sig-
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Efficacy of Ritalin and Biofeedback
nificantly, the data indicated that more children in the biofeedback group obtained ratings within the normal range. Satterfield, Cantwell, and Satteffield (1974) reported that while 70% of ADI-ID children show a positive response to medication, 30% show little response or appear worse with treatment. A close look at data obtained in the present study shows a similar dichotomy of response. Two subjects in the Ritalin group showed a favorable response to Ritalin on teacher ratings. Four subjects showed a minimal response or appeared worse on such ratings. Although the percentages were not similar to those reported by Satterfield et al., a larger sample size may have produced a similar pattern. The results from the Zukow parent rating scale indicated that all three groups improved significantly after treatment. On the Werry-Weiss-Peters scale, the biofeedback and control groups improved after treatment. It is well documented (Gardner, 1979; Ross & Ross, 1976; Safer & Allen, 1976) that parent ratings seem to be the least reliable assessment of hyperactivity. The results of this study must be interpreted with this in mind. Important and unexpected findings came from the control group data. The control group was used in this design primarily to see whether frequent contact with a supportive adult would have had any effect on these children in view of the hostile and often depriving nature of their social environments and interpersonal relationships. The findings of the present study suggest that it did. Anecdotal reports indicated that many aggressive and intentionally disruptive behaviors seemed to be highly associated with all the subjects in the present study and the improvements shown by the control group may reflect changes in these concomitant behaviors. The results of this study, although preliminary, point to the potential value of biofeedback as an alternative treatment to Ritalin. A follow-up study could also determine the need for maintenance sessions to continue the positive effects of biofeedback training. Training to criteria rather than to time or number of sessions and an increased sample size may provide more dramatic results. The results of the present study also indicate that any treatment program designed for the ADHD child, whether it be drug management or biofeedback, should include the regular attention of a supportive adult.
REFERENCES Ayllon, T., Layman, D., & Kandel, H. (1975). A behavioral-educational alternative to drug control of hyperactive children. Journal of Applied Behavioral Analysis, 8, 137-146. Braud, L. (1978). The effects of frontal EMG biofeedback and progressive relaxation upon hyperactivity and its behavioral concomitants. Biofeedback and Self-Regulation, 3, 69-89. Brown, R., Borden, K., & Clingerman, S. (1985). Adherence to methylphenidate therapy in a pediatric population: A preliminary investigation. Psychopharmacology Bulletin, 21, 28-36.
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Chess, S. (1960). Diagnosis and treatment of the hyperactive child. New York State Journal of Medicine, 60, 2379-2385. Christensen, D., & Sprague, R. (1973). Reduction of hyperactive behavior by conditioning procedures alone and combined with methylphenidate. Behavior Research and Therapy, 11, 331-334. Conners, C. (1969). A teacher rating scale for use in drug studies with childrerLAmerican Journal of Psychiatry, 126, 884-888. Denkowski, K., & Denkowski, G. (1974). Is group relaxation training as effective with hyperactive children as individual EMG biofeedback treatment? Biofeedback and Self-Regulation, 9, 353364. Douglas, V. (1972). The problem of sustained attention and impulse control in hyperactive and normal children. Canadian Journal of Behavioral Science, 4(4), 260-279. Eisenberg, L (1972). The clinical use of stimulant drugs in children. Pediatrics, 49, 709-715. Firestone, P. (1982). Factors associated with children's adherence to stimulant medication. American Journal of Orthopsychiatry, 52, 44%457. Gardner, IL (1979). 7he objective diagnosis of minimal brain dysfunction. Cresskill, NJ: Creative Therapeutics. Gittleman-Klein, R., Klein, D., Abikoff, I-I, Katz, S., Glisten, A., & Ares, W. (1976). Relative efficacy of methylphenidate and behavior modification in hyperkinetic children: An interim report. Journal of Abnarmal Child Psychology, 4, 361-379. Grinspoon, L., & Singer, S. (1973). Amphetamines in the treatment of hyperkinetic children. Harvard Educational Review, 43, 515-555. Kassel, S. (1986). 7he effects of EEG biofeedback training on hyperactive and~or learning disabled childrerL CA: ERIC Document Reproduction Service No. ED 283 351. Krause, T. (1977). Psychophysiological change in hyperactive and normal children as a function of medication and biofeedback training. Unpublished doctoral dissertation, University of California, Irvine. Lahey, B., Stempniak, M., Robinson, E, & Tyroler, M. (1978). Hyperactivity and learning disabilities as independent dimensions of child behavior problems. Journal of Abnormal Psychology, 87, 333-340. Lubar, J. E, & Shouse, M. N. (1976). EEG and behavioral changes in a hyperactive child concurrent with training of the seusorimotor rhythm (SMR): A preliminary report. Biofeedback and SelfRegulation, 1, 293-306. Lubar, J. O., & Lubar, J. F. (1984). Electroencephalographie biofeedback of SMR and beta for treatment of attention deficit disorders in a clinical setting. Biofeedback and Self-Regulation, 9, 1-23. Omizo, M., & Williams, R. (1981). Biofeedback can calm the hyperactive child. Academic Therapy, 17, 43-46. Parziale, J. L. (1982). The effects of EEG biofeedback training on the behavior of hyperactive children. Unpublished doctoral dissertation, University of Arizona. Patterson, G. (1965). An application of conditioning techniques to the control of a hyperactive child. In L. P. Ulmann & L. Kmsner (F.ds.), Case Studies in Behavior Modification. New York: Holt, Rinehart, and Winston. Pecke, S., Halliday, R, Callaway, E, Prael, R., & Rens, V. (1984). F_£fects of two dosages of methylphenidate on verbal information processing in hyperactive children. Journal of Clinical Psychopharmacology, 4, 82-88. Rapport, M., Dupaul, G., Stoneer, G., & Jones, J. (1986). Comparing classroom and clinic measures of attention deficit disorder: Differential, idiosyncratic, and dose-response effects of Methylphenidate. Journal of Consulting and Clinical Psychology, 54(3), 334-341. Rosenbaum, A., O ' ~ , IC, & Jacob, R. (1975) Behavioral intervention with hyperactive children: Group consequences as a supplement to individual contingencies. Behavior Therapy, 6, 315323. Ross, D., & Ross, S. (1976). Hyperactivity: Research, theory, and action. New York: Wiley-Interscience. Safer, D., & Allen, IL (1976). Hyperactive clffldren: Diagnosis and management. Baltimore, MD: University Park Press.
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Satteffield, J., Cantwell, D., & Satteffield, B. (1974). Pathophysiology of the hyperactive child syndrome. Archives of General Psychiatry, 31, 839-844. Sleator, E (1985). Measurement of compliance. Psychopharmacology Bulletin, 21, 1089-1093. Sprague, 1L, Cohen, M., & Werry, J. (1974). Normative data on the Conners Teacher Rating Scale and Abbreviated Scale. Technical Report, Children's Research Center, University of Illinois. Sroufe, L., & Steward, M. (1973). Treating problem children with stimulant drugs. 7he New England Journal of Medicine, 289, 407-413. Tansey, M. A., & Brtmer, R. L. (1983). EMG and EEG biofeedback training in the treatment of a 10-year-old hyperactive boy with a developmental reading disorder. Biofeedback and SelfRegulatior~ 8, 25-37. VandenBos, G. (196). Psychotherapy Research: A special issue.American Psychologist, 41(2), 111112. Wender, P. (1971). Minimal Brain Dysfunction in Children. New York: Wiley-Interscience. Werly, J. (1968). Developmental hyperactivity. Pediatric Clinics of North America, 15(3), 581-599. Zukow, P., Zukcrc¢,A, & Bentler, P. (1978). Rating scales for the identification and treatment of hyperkinesis. Journal of Consulting and Clinical Psychology, 46, 213-222.
Relative Efficacy of Ritalin and Biofeedback Treatments in the Management of Hyperactivity B e t h D. P o t a s h k i n 1
The Long Island Campus of_,41bert Einstein College of Medicine Nicola B e e k l e s Amityville School District
Th& study examined the efficacy of biofeedback and Ritalin treatments on hyperactivity as reflected by muscular electrical activity and as observed by teachers and parents. Eighteen male subjects between the ages of 10 and 13 were assigned to three groups, matched by age, IQ, and race. One group received 10 biofeedback sessions, another received Ritalin, and the third group controlled for nonspecific treatment effects. EMG readings, the Conners Teacher Rating Scale, the Werry-Weiss-Peters Scale, and the Zukow Parent Rating Scale were used to measure treatment efficacy. Results indicated that biofeedback-assisted relaxation significantly reduced muscle tension levels, whereas neither Ritalin nor personal attention produced significant change. On teacher ratings of hyperactivity, significant improvement was made by all three groups. Parent ratings on the Zukow scale indicated significant improvement by subjects in all groups. On the Werry-Weiss-Peters scale, the biofeedback and control groups made significant improvements in hyperactivity. Descriptor Key Words: behavior therapy; biofeedback; hyperactivity; eleetromyogmph; rating scales.
The February 1986 volume of the American Psychologist addressed the stares of psychotherapy research. In an overview article, Gary VandenBos underscored the value of comparative therapy research because of the growth in "consumers" of such research. It is in this spirit that this study examines a 1Address all correspondence to Dr. Beth D. Potashkin, 245 East 25th Street, Apartment 5A, New York, New York 10010.
305 0363-3586/90/1200-0305506.00/0© 1990 PlenumPublishingCorporation
306
Potashkin and Beckles
comparison of two treatment modalities as interventions for Attention Deficit Hyperactive Disorder (hereafter referred to as ADHD). Four major definitions have been used in the literature on "hyperactivity." The first definition refers to a quanttafive dimension of behavior, i.e., "hyperactivity" is seen as a level of daily motor activity that is clearly greater than that occurring in other children of a similar age (Chess, 1960; Werry, 1968). A second definition suggests that hyperactive children exhibit no more total daily body activity than do normals. Instead, these children have difficulty modulating their activity level (Safer & Allen, 1976; Douglas, 1972). A third definition views ovemctivity, restlessness, and inattention as part of the diagnostic category of conduct problems (Lahey, Stempniak, Robinson, & Tyroler, 1978). The fourth definition results from the work of Douglas and her colleagues (1972), which focuses on the attention difficulties manifested by these children, with the resulting fragmentation and disorganization of behavior that lead to the impression of excessive activity. Studies of the efficacy of amphetamine treatment have shown mixed and often contradictory results. The earliest studies on amphetamines were conducted on mixed groups of clinical subjects with widely discrepant psychopathologies. They were poorly controlled and lacked valid criteria to measure improvement (Eisenberg, 1972; Grinspoon & Singer, 1973; Sroufe, 1973). More recent studies have focused on their effects on the secondary symptomatology of ADHD such as cognitive performance (Peeke, Halliday, Callaway, Prael, & Revs, 1984; Rapport, Dupaul, Stoner, & Jones, 1986). In addition, there is a body of research on the difficulty of noncompliance to medical regimens (Brown, Borden & Clingerman, 1985; Firestone, 1982; Sleator, 1984). Studies of behavioral interventions have been plagued by similar problems. Inclusion criteria were poorly defined and results have been inconclusive (Ayllon, Layman, & Kandel, 1975; Christensen & Sprague, 1973; Patterson, 1965; Rosenbaum, 1975). In the effort to specify target behaviors, behavioral theory failed to meet the challenge of the variety of symptoms displayed by these children. Consequently, studies failed to show consistent results and generalizability of effect. In view of these difficulties, it was hypothesized that biofeedback would target underlying neurophysiological processes for conditioning techniques. In this regard, some studies have investigated the effects of EEG/SMR biofeedback training on ADHD children and some success has been reported (Parziale, 1982; Lubar, 1976, 1984; Tansey & Bruner, 1983). It appears that EEG studies have primarily focused on learning disabled children, and comparisons between EEG and EMG training on ADHD children are inconclusive (Kassel, 1986). A compelling model concerning the etiology of ADHD is proposed by Paul Wender (1971) and posits a depletion of neurotransmitters as a causal
Efficacy of Ritalin and Biofeedback
307
agent. The inability to modulate activity level may be a result of the comparative levels of functioning of the inhibitory and excitatory systems of the brain. The reported success of amphetamines is due to their effect on monoamines. The major question the present study posed is whether ADHD children can be taught the control that does not appear to come automatically through maximal functioning of the central nervous system. There are studies and dissertations that have suggested the value of EMG-assisted relaxation procedures on sustained attention, muscular electrical activity, motor activity, and teacher and parent ratings of improvement (Braud, 1978; Denkowski & Denkowski, 1974, Jeffrey, 1977; Krause, 1977; McFarland, 1980; Omizo and Williams, 1981, Gittleman-Klein, Klein, Abikoff, Katz, Glisten, & Ates, 1976).
METHOD Subjects The 18 subjects were boys between the ages of 10 and 13. All subjects were referred from special education classes. Psychosis, retardation, and brain damage were ruled out. Intelligence as defined by the WlSC-R was between 77 and 93. Substantiating diagnostic criteria of a score of 9 or above on the Zukow Parent Rating Scale and a score of 2.17 or above on the hyperactivity factor of the Conners Rating Scale were obtained. Three groups of six children each were formed.
Measures
Measurement of ADHD (1) The Conners Teacher Rating Scale (Conners, 1969) contains 39 items arranged under three headings: classroom behavior, group participation, and attitude toward authority. Interrater agreement ranged from .70 to .80. Test-retest reliability ranged from .70 to .90. (2) The Werry-Weiss-Peters Scale (Werry, 1968) is a 31-item questionnaire designed to measure specific behaviors in specific contexts, e.g., during meals, television, homework, play, sleep, and behavior away from home and school. Reliability ranged from .60 to .70. (3) The Zukow Parent Rating Scale (Zukow, Zukow, & Bentler, 1978) contains 28 items such as "jumps from one activity to another." A score of 9 or above, as determined by the authors, identifies ADHD children. Interrater
308
Potashkin and Beckles
agreement using this cutoff score has been shown to range from r = .90 to .96. Internal reliability has been reported as .89.
Measurement of Muscular Electrical Output The Autogen 1100 Electromyograph (EMG) was used to monitor and display the ongoing EMG activity generated by muscle action in the form of auditory and visual displays. The standard ban@ass is 100-200 hertz. Surface electrodes were used. Normal microvolt levels range between 1 and 2 microvolts (Autogenic Systems, 1975).
Pretesting of Subjects Each child was shown the electromyograph and told that this machine was used "to see how tense you are." How the machine worked was explained in detail to eliminate other fears of each child. Electrodes were attached to the frontalis muscle and each subject was monitored on the EMG for ten minutes.
Ritalin Group Each child and his mother were seen by a physician, who reassessed the child's mental status and obtained any background information. The physician knew that the efficacy of Ritalin was being studied but did not know of the other treatments employed in the study nor the experimental hypotheses. They then prescribed Ritalin in the manner they were accustomed to at a dosage deemed necessary. Five subjects received dosages of 15 milligrams, per diem and one received 10 milligrams per diem. The children in this group were seen by the physicians at the beginning of the six-week period and then two weeks later. At this point, four subjects were raised to 30 milligrams per diem, one to 20 milligrams per diem, and one to 40 milligrams per diem.
Biofeedback Group The biofeedback-assisted relaxation group was seen for 10 half-hour sessions over a six-week period. The first session was an introduction to biofeedback and the machine. A second phase introduced the relaxation procedure and shaped the response (three sessions). The relaxation procedure used was similar to Jacobson's Progressive Muscle Relaxation. A third phase continued the practice of the relaxation technique and introduced a mini-relaxation-exercise to be
Efficacy of Ritalin and Biofeedback
309
Table I. Results of W i l c o x o n M a t c h e d - P a i r s Signed R a n k Tests on Difference Scores (Pretest to Posttest) of Dependent Variables Dependent variable EMG Conners Zukow WWPS
Biofeedback (n = 6)
Ritalin (n = 6)
Control (n = 6)
2.20 a 2.20 a 2.20 ~ 2.20 ~
1.36 2.02 2.20" 1.83 a
0.9 2.02 a 2.20 a 1.99 a
" S i g n i f i c a n t b e y o n d the .05 level.
used outside the clinical session (three sessions). The last phase had as its goal the weaning of the subjects from the biofeedback machine and its feedback (three sessions).
Control Group The purpose of the control group was to control for the nonspecific effects of attention and passage of time. The subjects in this group were seen for ten half-hour sessions over a six-week period. The subject and research assistant spent the session playing a game such as checkers and allowing for gradual mastery of the game by the subject. Care was taken not to make direct therapeutic interventions.
Posttesting At the end of six weeks (ten sessions) and within one week of termination of treatment each subject was monitored again on the EMG for ten minutes in a manner identical to that done in pretesting. The parent and teacher rating scales were again administered.
RESULTS Table I shows the results of nonparametric Wilcoxon signed rank tests comparing pretest and posttest measurements within the three study groups. Only the biofeedback group improved significantly from pretest to the end of the study on the EMG measure. A nonparametric one-way Kruskal-Wallis ANOVA comparing the groups on difference scores was also significant, Z2 = 8.04, p < .05. Further post hoc comparison of the groups, using nonparametric Mann-Whitney tests, revealed
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significant differences between the biofeedback and both the Ritalin and control groups, p < .05. Prior to treatment all subjects obtained readings above 2 microvolts. Figure 1 demonstrates that only biofeedback subjects showed readings that fell within the normal range. A chi-square analysis performed on this data was significant, ~2 = 10.26, p < .01. All three groups improved significantly on the Conners Teacher Rating Scale (see Table I). A Kruskal-Wallis ANOVA showed no difference across the groups in pretest to posttest change (~2 = 2.66). A chi-square analysis was conducted and showed that more subjects in the biofeedback group were able to reduce their hyperactivity to within normal limits, Z2 = 8.86, p < .05 (Figure 2). The biofeedback and control groups had significant change on the WerryWeiss-Peters Scale (see Table I). A one-way Kruskal-Wallis ANOVA conducted on the difference scores between groups indicated no significant differences, ~2 = 1.59. On the Zukow Parent Rating Scale, t-tests comparing the difference scores indicated significant change in all groups (see Table I). A Kruskal-Wallis ANOVA on group difference scores indicated no superiority of effect between any group, Z2 = 3.38. A chi-square analysis was conducted and showed that more of the subjects in the biofeedback group were able to
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Teacher Rating Scale. reduce their scores following treatment than in the Ritalin or control groups, Z2 = 6.0, p < .05 (see Figure 3).
DISCUSSION The present study was an exploratory one in several respects. There are few studies that have attempted biofeedback-assisted relaxation as a treatment for ADHD. Of those, there are none that have systematically compared the efficacy of medication with such a treatment. Even more importantly, this is the first study to compare either biofeedback or Ritalin treatments to a control group that receives frequent contact with a supportive adult. Therefore, as this study attempted to answer questions concerning the efficacy of biofeedback and Ritalin treatments on ADHD, it raised at least as many questions concerning the definition and nature of A D H D itself. It has been demonstrated that the muscle tension levels of hyperactive children are higher than those found in normal children (Braud, 1978). The findings of this study confirmed this observation. The average tension levels before interventions, when asked to sit still and relax, were at least 2 microvolts above normal for most subjects.
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Fig. 3. Number of subjects scoring 9 or above on the Zakow Parent Rating Scale.
After the experimental interventions, EMG readings obtained indicated that children receiving biofeedback training were able to sit quietly without the level of muscle tension exhibited by the other groups. This was a critical finding in that the inability to modulate activity level has been proposed as an essential disability in hyperactive children. One can argue that biofeedback subjects had a "set" to relax from the expectancy effects of treatment. The fact that it took subjects several weeks to learn to relax argues against the idea that expectation alone can reduce EMG scores. Subjects receiving Ritalin exhibited tension levels comparable to those shown at pretesting. This finding indicates that the relationship between amphetamines and muscle tension needs further exploration. Subjects in the control group were unable to relax and reduce muscle tension after the six-week period. This finding argues against any effects of time and personal attention on EMG scores. It suggests that the efficacy of biofeedback in producing levels comparable to those exhibited by normal children is attributable to aspects of the training other than frequency of contact, personal attention, or passage of time. Although these results are highly significant on their own, if such change cannot be demonstrated in the child's environment outside of the clinical session, the value of the treatment is limited. Results indicated that subjects in all three groups significantly reduced hyperactive behavior in the classroom. Sig-
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nificantly, the data indicated that more children in the biofeedback group obtained ratings within the normal range. Satterfield, Cantwell, and Satteffield (1974) reported that while 70% of ADI-ID children show a positive response to medication, 30% show little response or appear worse with treatment. A close look at data obtained in the present study shows a similar dichotomy of response. Two subjects in the Ritalin group showed a favorable response to Ritalin on teacher ratings. Four subjects showed a minimal response or appeared worse on such ratings. Although the percentages were not similar to those reported by Satterfield et al., a larger sample size may have produced a similar pattern. The results from the Zukow parent rating scale indicated that all three groups improved significantly after treatment. On the Werry-Weiss-Peters scale, the biofeedback and control groups improved after treatment. It is well documented (Gardner, 1979; Ross & Ross, 1976; Safer & Allen, 1976) that parent ratings seem to be the least reliable assessment of hyperactivity. The results of this study must be interpreted with this in mind. Important and unexpected findings came from the control group data. The control group was used in this design primarily to see whether frequent contact with a supportive adult would have had any effect on these children in view of the hostile and often depriving nature of their social environments and interpersonal relationships. The findings of the present study suggest that it did. Anecdotal reports indicated that many aggressive and intentionally disruptive behaviors seemed to be highly associated with all the subjects in the present study and the improvements shown by the control group may reflect changes in these concomitant behaviors. The results of this study, although preliminary, point to the potential value of biofeedback as an alternative treatment to Ritalin. A follow-up study could also determine the need for maintenance sessions to continue the positive effects of biofeedback training. Training to criteria rather than to time or number of sessions and an increased sample size may provide more dramatic results. The results of the present study also indicate that any treatment program designed for the ADHD child, whether it be drug management or biofeedback, should include the regular attention of a supportive adult.
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