EEG NEUROFEEDBACK TREATMENT OF PATIENTS WITH DOWN SYNDROME
Tanju Sürmeli ,M.D.* , Ayben Ertem**
*Psychiatrist and **Psychologist, Living Health Center for Research and Education, Istanbul, Turkey
Abstract Introduction: Down syndrome is the commonest identifiable cause of intellectual disability, accounting for almost one third of cases. It occurs equally in all races with an overall incidence of approximately 1 in 800 births. Neurofeedback (NF) is an operant conditioning method to increase or to decrease frequency bands of electroencephalography (EEG). An increasing number of clinicians use operant conditioning of EEG activity as a method of helping children with Attention Deficit Hyperactivity and Generalized Learning Disability (ADHD/ADD or GLDO). Some of the Down syndrome kids may have ADHD/ADD or GLDO or both. We thought we might succeed applying NF to kids with Down syndrome.
Background. Computer-assisted EEG-NF treated subjects with Down syndrome. All 8 subjects were medication-free during treatment. Qeeg and NxLinkData Bank showed that almost all eight subjects have increased Delta and Theta waves some area over the cortex and normal, increased or decreased beta waves over the cortex. Diet advised to eight subjects and their parents parenting skills were structured.parenting skills were structured. All were not able to talk more than one word in a sentence, with very limited vocabulary (between 5 and 10 words); usuallly pointed their finger to communicate and they were not able to carry basic comments, with very poor attention and concentration, and with poor memory, impulsivity, behavior problems, some of them have balance problems, and they were unaware of their surroundings fully. The purpose of this study is to evaluate whether Qeeg guided bipolar montage training is effective in developing speech, improve attention and concentration, improve learning, decrease behavioral problems or impulsivity, and balance problems of Down Syndrome kids.
Methods. 8 subjects with Down Syndrome were seen by the first author and by the special educator at the baseline, 20th, 40th and 60th session. Before starting to NF exercise the parents of the 8 children with Down Syndrome aged between 6 to 14 were given a questionnaire prepared by the center including the questions about attention and- concentration abilities, speech and language abilities, behavioral abilities and learning abilities. They had a QEEG recorded baseline and repeated at the end of the treatment. NF tranings were performed by Lexicor Biolex software. NXLINK databank was used to determine if they have ADHD/ADD/GLDO with clinical judgement of the first author: Neurofeedback therapy designed to normalize abnormal QEEG scores was provided to determine the effectiveness of this approach. Training continued until the subject’s demonstrated improvement and, by self reports of parents, indicated that significant improvement had occurred or until a. total of 60 sessions were given. Lexicor Qeeg signals were sampled at 128 Hz. NF trainings were performed by Lexicor Biolex software.According to QEEG/NXLINK results electrode placement was used.
Results. All 7 children who received NF training showed significant improvement in their condition based on the questionaire and parent interviewing. Mean age: 9.13 N=8, p=0.000 (or p
Further study with controls and additional outcome measures is warranted.
KEYWORDS. Down syndrome, quantitative EEG, Neurofeedback
Communication should be addressed to: Tanju Surmeli, M.D.
Living Health Center for Research and Education Gazeteciler Sitesi, Saglam Fikir Sokak No 17 Esentepe Sisli Turkey
INTRODUCTION
Down Syndrome is a disability that was first described one hundred and thirty five years ago.Down Syndrome is the commonest identifiable cause of intellectual disability,accounting for almost one third of cases(Wishart 1998).It occurs equally in all races with an overall incidence of approximately 1 in 800 births(Regezi J,1989).Trisomy 21 is the most common cause of Down Syndrome and accounts for ninety-five percent of cases. Neurofeedback(NF) is an operant conditioning method to increase or to decrease frequency bands of electroencephalography (EEG). An increasing number of clinicians use operant conditioning of EEG activity as a method of helping children with Attention Deficit Hyperactivity and Generalized Learning Disability (ADHD/ADD or GLDO).Some of the kids with Down Syndrome may have ADHD/ADD or GLDO or both.We thought we might succeed applying NF to kids with Down Syndrome.
CHARACTERISTICS
The characteristics associated with Down Syndrome are many and vary amongst individuals.
The traits that have been characterized as most common to individuals with Down Syndrome include low muscle tone, flat facial profile, depressed nasal bridge and small nose, upward slant to the eyes, an enlargement of the tongue in relation to size of the mouth, an abnormal shape of the ear. (NDSS 2001, Down 1866 :259-260) Children with Down Syndrome are also at greater risk of developing medical health problems. (Encarta 2000 , Wishart 1998 :343)
The intellectual changes often present in individuals with Down Syndrome. Researchers have stated that most people with Down Syndrome do in fact some level of intellectual disability ranging from mild to severe although the mean remains mild to moderate (NDSS 2001 , Wishart Online ,Wishart 1998)
TEACHING STRATEGIES -
THE MOST IMPORTANT ONE COULD BE NEUROFEEDBACK
All individuals with Down Syndrome are different in their abilities and their interests and it is clear that teaching strategies will vary greatly from one child to the next.
The varying abilities within the classroom should not be ignored and it is with the presence of an individualized education plan (IEP) that teachers can ensure the child is getting an appropriate education.The team which include the patient , his/her parents ,the classroom teacher ,special educator as well as other professionals that are involved in the child’s educational development puts together the education plan.Also diet is recommended including low carbohydrates ,high protein.
Common problems for the children with Down Syndrome are, attention problems, concentration problems, learning problems ,memory problems, speech and language problems, behavioral problems balance problems.
Children with down syndrome have the inability to focus on specific stimuli (Kliewer 1993 , NDSS 2001 ) and this can have serious and very negative affects on children’s learning and it is very important to use a variety of strategies to control it. Another prevailing characteristic is that of speech and language problems (Gov. of Saskatchewan 1998 , Kliewer 1993)
The problems may be in expression, formal or informal social changes, articulation,
fluency etc…
MEMORY PROBLEMS
In children with Down Syndrome have a tremendous effect on learning .
In the past decade research studies have begun to uncover the specific learning defects observed in individuals with Down Syndrome at various ages. Down Syndrome involves impairments in some , but not all, forms of learning .(Nadel ,L 1997)Verbal short term memory skills of individuals with Down Syndrome are very poor. Current evidence suggests that forms of learning dependent on the hippocampus ,cerebellum and prefrontal cortex may be particularly impaired in Down Syndrome.
BEHAVIORAL PROFILES of the children with Down Syndrome are generally : Aggression,Excessive activity,Excessive noise, Denying the rules (Collacott RA,1998), Hyperactivity
A suggestion to solve all these problems explained above could be Neurofeedback.
BACKGROUND
Computer assisted EEG-NF treated 8 subjects with Down Syndrome, 1 dropped out.
All subjects were medication –free during treatment. QEEG and Nxlink Data Bank showed that almost all 8 subjects have increased or decreased Delta and Theta waves on some of the area over the cortex and increased or decreased beta waves over the cortex. Exclusion criteria was not to include subjects with medical problems. Diet was advised to eight of the subjects and their parents parenting skills were structured. All were not able to talk more than one word in a sentence, very limited vocabulary ( between 5 and 10 words ). Usually pointed their finger to communicate. They do not able to carry basic comments, poor attention and concentration, poor memory, impulsivity, behavior problems, some of them have balance problems, they are unaware of surroundings
Traditional methods of treatment such as, cognitive Rehabilitation, special education alone,
medications and behavioral training are time consuming, expensive and of questionable
effectiveness. The purpose of the study is to evaluate whether QEEG guided bipolar montage
training is effective in developing speech, improve attention and concentration, improve learning
skills, decrease behavioral problems or impulsivity and balance problems of the children with
Down Syndrome.
METHOD
8 subjects with Down Syndrome were seen by the first author and by the special educator at baseline , 20th,40th and 60th sessions .Before starting to NF exercise the parents of the 8 children with Down Syndrome aged between 6 to 14 were given a questionaire prepared by the center including the questions about attention and concentration abilities, speech and language abilities, behavioral abilities and learning abilities. They had a QEEG recorded baseline and repeated at the end of the treatment. NF trainings were performed by Lexicor Biolex software for 30minutes each sessions once or twice a day 5-6 days a week. NXLINK databank was used to determine if they have ADHD/ADD/GLDO with clinical judgement of the first author. NXLINK suggested that 8 out of 8 kids have GLDO and 3 out of 8 also have ADHD together with GLDO. Baseline the histories of the children told by the parents were video recorded for 30 minutes. The average span of the 8 children with Down Syndrome was 1-3 minutes. The average of the words stored in the memory was 5-10 words. They had severe articulation problem, did not use more than one single word in a sentence, did not obey the rules, stubborn, difficulties at remembering the things they have learned before and now. 60 sessions were completed for the 7 children (one drop after eight sessions). Comparison was made with regards to the questionaire given to the parents of the 7 children, parents’ video recording reports, special educator’s evaluation and first author’s symptom check evaluation before and after 60 sessions. According to QEEG/NXlink results, first child with Down Syndrome has high Delta and Theta Z scores in the absolute power over the cortex and some coherence abnormalities at different band range over the cortex. F7-T5, P3-T5, P4-T6, CZ-C4, CZ-C3, F8-T6 electrode placement was used with a 0-4 Hz delta reward and inhibits at 4-8 Hz and CZ-C4 electrode placement with a 12-15 Hz SMR reward and inhibits at 4-8 Hz.. Coherence abnormalities reduced interhemisphericly. Applying NF to first child results were good. Although absolute power Z scores of the rest of 6 children for delta and theta were not abnormal for F7-T5, F8-T6, Cz-C4, Cz-C3 the authors continued to reward Delta and inhibit Theta as Biolex showed abnormal numbers of waves as mentioned above.
Table 1. Shows according DSM-4 checklist in ADHD which ones matched in children with Down Syndrome at baseline.
ACCORDING TO DSM- 4 ATTENTION DEFICIT HYPERACTIVITY DISORDER CHECKLIST
ADHD Checklist Children with Down Syndrome
Inattention : 9 Symptoms Inattention : 8 Symptoms
Hyperactivity : 6 Symptoms Hyperactivity : 4 Symptoms
Impulsivity : 3 Symptoms Impulsivity : 2 Symptoms
Children with Down Syndrome
Inattention : Hyperactivity : Impulsivity :
a) Fails to give close attention to a) Often leaves seat in a) Often has difficulty
details or makes careless classroom or in other awaiting turn
mistakes in schoolwork or in situations in which b) Often interrupts or
other activities. remaining seated is intrudes others
b) Often has difficulty sustaining expected.
attention in tasks or play activities b) Often runs about or
c) Often does not seem to listen climbs in situations in
when spoken to directly which it is inappropriate
d) Often does not follow through c) Often has difficulty playing
on instructions and fails to finish or engaging in leisure
schoolwork. activities quietly.
e) Often has difficulty organizing tasks d) Is often “ on the go” or
and activities. often acts as if “driven by
f) Often avoids ,dislikes or is reluctant a motor”
to engage in tasks that require
sustained mental effort.
g) Often loses things necessary for tasks
and activities.
h) Is often forgetful in daily activities.
Table 1
Table 2. Shows according to DSM-4 Learning Disorders checklist which ones matched in children at baseline and during and at the end of neurofeedback treatment.
ACCORDING TO DSM-4 LEARNING DISORDER CHECKLIST
PRETREATMENT : DURING AND POST TREATMENT:
Reading Skills : Unable to read Read : Partially
Mathematic Skills : Unable to do math Math : Do simple math
Ex.Counting,simple addition
Writing Skills : Unable to write Write : Were able to write their names
and some meaningful sentences
Table 2
Table 3. Shows speech and Language activity level at baseline and during and at the end of treatment.
SPEECH AND LANGUAGE ACTIVITY
BASELINE : DURING AND POST TREATMENT :
Verbal Communication
One single word 2-5 words
Rules for syntax and grammer : NONE Somewhat present
Words stored in the memory : 5-10 40-50
Making plurals,changing tenses :NONE Somewhat present
Nonverbal Communication
No facial expression Able to smile,grimaces,wink appropriately
No gestures except finger pointing Waving and pointing develop
No squeezing hand Squeezing hand
Touch present Touch present
Not actively listening ,thinking and sorting Somewhat actively listening, thinking and
out of speech sorting out of speech
Table 3
Table 4.Shows memory activity level at baseline and during and at the end of the neurofeedback treatment.
MEMORY ACTIVITY
BASELINE : DURING AND POST TREATMENT :
Short term : Named 3 objects
Unable to name after being asked Able to name 3 objects and remember at least
to remember the names of the objects 2 objects’ names 5 minutes later
after 5 minutes.
Unable to have letter span,digit span, Able to succeed
word span
Long term : Unable to remember what According to mothers’ reports children brought out
they learned in the past a lot of information.
Ex: remember the information given by the
special educator 2-3 years ago.
Table 4
Table 5. Shows balance problems at baseline and during and at the end of treatment.
BALANCE PROBLEMS
BASELINE DURING AND POSTTREATMENT
Mild form of ataxic walk No ataxic walk and able to run
And unable to run
Table 5
Table 6. Shows behavioral activity at baseline and during and at the end of the treatment in children with Down Syndrome.
BEHAVIORAL ACTIVITY
BASELINE : DURING AND POSTTREATMENT
Follow comments : NONE Present
Unable to know surroundings Able to know surroundings
Table 6
RESULTS
n All 7 children (bet. 6&14 y.o.) who received NF training showed significant improvement in their condition based on the questionaire and parent interviewing. Mean age: 9.13 N=8, p=0.000(or p<0.001). One subject dropped the study after eight sessions.
n Speech and Language:
n Pretraining Median:3.00 N=8
n Posttraining Median: 11.00 N=7
n Improvement Median:8 N=7
n Attention: Median 13,4,9
n Behavior :Median 11.50,2.00,9.00
n Memory: Median 2.00,8.00,6.00
n Balance: Median:4.50,2.00,3.00
n On average , 20-40 sessions were required to see some differences.
n All parents of the subjects reported that their kids were able to speak 4 – 5 meaningful words in a sentence.
n Apparent improvement in the articulation problem.
n Meaningful conversation
n Attention and concentration improved from 3 to 5 minutes to one hour some cases.
n Behavior became more mature and controllable
n Less likely to demonstrate maladaptive behaviors and obeyed the rules.
n Less impulsivity seen
n Short and long term memory improved. Words stored in the memory changed from 5-10 words to 40-50 words. They could easily remember the things they have learned before.
n Balance problems improved
n Able to run and walk w/o ataxia
n Have a thinking brain and can learn better and faster
n Two of them started to normal school and teacher reported as the attention and concentration of the children with Down Syndrome were better than their normal peers.
n The characteristics of the children changed to a positive improvement
Children with mosaic type genetic analyses thought to be showing ordinary development , became not
