1. Children and Adolescents with ADHD Long-term randomized controlled study Dr. Nezla S. Duric Child and Adolescent Psychiatrist /PhD

2. Children and Adolescents with ADHD 3 steps qEEG NEUROFEEDBACK ADHD

3. ADHD Deficit of Self-Regulation – ADHD-”problems “being secondary to inhibited impulse control and lack of self-regulation – Leads to a lack of development of other specific and important psychological processes – Also includes emotional dysregulation (Barkley) ADHD patients do not lack knowledge or specific skills, but the ability to coordinate / use these appropriately

4. ADHD Etiology "The cause has been attributed to biofactors. The outcome has to do with how the child meets the environment and how the environment meets the child" Professor Eric Taylor at the Institute of Psychiatry, Kings College in London

5. Characteristics of ADHD Lifelong Perspective Pre-school Adolescent Adult School-age College-age Behaviour problems Social skills Self esteem Psychiatric comorbidity School performance Smoking/abuse Risk behaviour Social skills Self esteem Psychiatric comorbidity Academic performance Occupational status Psychiatric comorbidity Smoking/abuse Criminality Risk behaviour Social skills Self esteem Behaviour problems Learning difficulties Social skills Self esteem Academic performance Relationships Social skills Self esteem Halmøy et al, Journal of Attention Disorders, 2009

6. ADHD patho-physiology Cortical maturation Cortical rhytme Arousal level

7. Brain activity: Delta (0,1-4 Hz) Theta (4-7 Hz) Alpha (8-11 Hz) Beta(12-30 Hz) Gamma (over 30 Hz) Cortical maturation and EEG

8. EEG - ADHD Brain activity: Delta (0,1-4 Hz) Theta (4-7 Hz) Alpha (8-11 Hz) Beta(12-30 Hz) Gamma (over 30 Hz) Increased levels of Theta and / or reduced levels of Beta or Alpha brain activity in persons with ADHD (Snyder, 2006); elevated Theta/beta ratio in resting EEG (Barry 2003);reduced CNV (Banaschewski,2007)

9. The international 10-20-System of electrode/sensor positions (Neuroscience for Kids, Erich H. Chudler)

10. Self-Regulation – Arousal Curve Arousal Performance Optimum Self- regulation- processes

11. ADHD and Treatment Pharmacological Treatment Psychostimulants Non- psychostimulants Neurofeedback Behavioural Treatments Alternative Treatments Non- pharmacological Treatment

12. ADHD and Treatment Pharmacological Treatment Psychostimulants Non- psychostimulants Neurofeedback Behavioural Treatments Alternative Treatments Non- pharmacological Treatment

13. ADHD and Treatment - Alternatives Pharmacological Treatment Psychostimulants Non- psychostimulants Neurofeedback Behavioural Treatments Alternative Treatments Non- pharmacological Treatment

14. Neurofeedback Training of self-regulation of brain activity Application: neurophysiological dysfunction and enhacement of self- regulation ability Feedback: visual, auditory, tactile Heinrich, H., H. Gevensleben, and U. Strehl, Annotation: neurofeedback - train your brain to train behaviour. J Child Psychol Psychiatry, 2007.

15. ADHD and NF games The Juggler

16. Children and Adolescents with ADHD UNIQUE STUDY DESIGN CLINICAL STUDY LARGE SAMPLE SIZE RANDOMIZATION CONTROL GROUP THREE ARMED GROUPS LONG-TERM STUDY

17. Aims of the Study Part I ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary health care’s ability to identify ADHD symptoms. Describe children and adolescents with ADHD regarding clinical characteristics. Part II ADHD and Treatment Evaluate the effect of NF treatment on ADHD core symptoms using self-report, parent`s, and teacher`s reports. Compare NF treatment for ADHD children and adolescents with standard medical treatment and combined treatment. Part I Characteristics of ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary healthcare ability to identify ADHD symptoms.

18. Aims of the Study Part I ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary health care’s ability to identify ADHD symptoms. Describe children and adolescents with ADHD regarding clinical characteristics. Part II ADHD and Treatment Evaluate the effect of NF treatment on ADHD core symptoms using self-report, parent`s, and teacher`s reports. Compare NF treatment for ADHD children and adolescents with standard medical treatment and multimodal treatment. Part I Characteristics of ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary health care’s ability to identify ADHD symptoms.

19. Aims of the Study Part I ADHD Describe characteristics of Norwegian children and adolescents referred for ADHD symptoms. Explore primary health care’s ability to identify ADHD symptoms. Describe children and adolescents with ADHD regarding clinical characteristics. Part III qEEG in ADHD Define qEEG changes -Biomarkers Define qEEG changes _ Treatment predictors Exploare correlation between behavioral and qEEG parametars

20. Participants Part I: Characteristics of ADHD Population Referred n = 494 ADHD Referred n = 187 (38 %) ADHD n = 96 (51 %) Other Diagnosis Referred n = 397 (62 %) non ADHD n = 91 PHC * CAMHC** * Primary Health Care ** Child Adolescents Mental Health Clinic, The Fonna Health Trust, Haugesund

21. Participants Part II/III: Treatment and qEEG ADHD Invited Participants: 243 (of 285) Randomized: 130 (54 %) Medication 44 (34 %) Neurofeedback + Medication 44 (34 %) Neurofeedback 42 (32 %) Refused Participation: 113 (46 %) Completed Follow up: 91 (70 %) Medication 31 (24 %) Neurofeedback + Medication 30 (23 %) Neurofeedback 30 (23 %) Drop out: 39 (30 %) T1T1 T2T2

22. Part I ADHD multimodal clinical assessment Anamnesis Clinical examination (blood, EEG, EKG) Psychiatric observation ICD-10 interview Cognitive evaluation Part II+III Neurofeedback Treatment Pharmacological Treatment Parent report: Barkley Parent Scale Teacher report: Barkley Teacher Scale Self-report: SRQ qEEG ADHD Treatment Methods

23. ADHD Treatment in the study Neurofeedback Lubar Theta/Beta – SMR protocol 30 sessions : 11-13 weeks Stimulant Medication Multimodal treatment

24. 24 T 0T 1T 2 T 3 Baseline Treatment Time perspective Follow-up

25. 5. referred child has ADHD Half of ADHD children live with both biological parents Twice ADHD children in forster family 5. ADHD children in institution Results Part I: Characteristics of ADHD referred population (N=187)

26. 5. referred child has ADHD Half of ADHD children live with both biological parents Twice ADHD children in forster family 5. ADHD children in institution Results Part I: Characteristics of ADHD referred population (N=187) Average referral age 10,5 år; 82% boys

27. Results Part I: Characteristics of ADHD referred population (N=187) Clinical examination: Increased risk of low birth weight increased TSH Somatic co-morbid conditions

28. Characteristics of ADHD population ADHD Combined 74% ADHD Hyperactive- Impulsive 22% ADHD Inattentive 4% 4%

29. Characteristics of ADHD population «Social Dysfunctioning» SexADHD/nonADHDLow IQ

30. Primary Health Care Primary health care services's ability to identify ADHD symptoms 1/3 of all referred children were referred for ADHD 1/2 of ADHD referred children were diagnozed with ADHD 1/5 of ADHD referred children were not diagnozed at all

31. Participants Part I: Characteristics of ADHD Population Referred n = 494 ADHD Referred n = 187 (38 %) ADHD n = 96 (51 %) Other Diagnosis Referred n = 397 (62 %) no ADHD n = 91 PHC * CAMHC** * Primary Health Care ** Child Adolescents Mental Health Clinic, The Fonna Health Trust, Haugesund none ADHD 34 none diagnose

32. Primary Health Care The sensitivity was 51% (96/187) regarding primary health care`s ability to recognize ADHD. The specificity was 100% (0/494) Need for specific screening programs and diagnostic guidelines for primary health care

33. Results Part II: Treatment Response based on reports one week later Pre-post Change (within the groups) Treatment Effect (between the groups) AttentionHyperactivity Total score AttentionHyperactivity Total score Parents p < 0,001 p = 0,098p = 0,101p = 0,173 Teachers p < 0,001p = 0,209p < 0,001 p = 0,425p = 0,656 Children/ Adolescents p < 0,001 p = 0,322p = 0,009 * Adjusted models did not show any effect (power)

34. Results Part II: Correlation Children, Parent`s and Teacher`s reports

35. Results Part II: Treatment Response based on reports LONG TERM Effectiveness Patterns towards Treatment

36. Results Part II: Treatment Response based on reports LONG TERM New evidence for the long-term efficacy of multimodal treatment: stimulant medication NF

37. Conclusion: Part I Referral Environment of ADHD children High ADHD referral in late school age Low diagnostic identification => “ADHD-guidelines” for Primary Health Care needed Single parent / foster families Low parents education Child welfare Social dysfunction Low IQ High co-morbitity

38. Conclusion: Part I Referral Environment of ADHD children High ADHD referral in late school age Low diagnostic identification => “ADHD-guidelines” for Primary Health Care needed Single parent / foster families Low parents education Child welfare Social dysfunction Low IQ High co-morbitity

39. Conclusion: Part II Pre-post changesTreatment effect Significant improvement of ADHD core symptoms regadless treatment type Different focus from raters Neurofeedback is promising reported shortly after treatment Combined treatment makes no superior efficacy

40. Conclusion: Part II Pre-post changesTreatment effect Significant improvement of ADHD core symptoms regadless treatment type Different focus from raters Neurofeedback is promising reported shortly after treatment Multimodal treatment makes superior efficacy in long-term follow up

41. Part III Qeeg Frequences Ratio Biomarkers The brain's electrical profile under different tasks Predictors

42. Future perspectives – Follow up over time – qEEG analyses

43. Papers 1. Duric N.S., Elgen I. Characteristics of Norwegian children suffering from ADHD symptoms: ADHD and primary health care. Psychiatry Research. 2011, 188 (2011) 402-405. (Number of citations: 4) 2. Duric N.S., Elgen I. Norwegian Children and Adolescents with ADHD – A Retrospective Clinical Study: Subtypes and Comorbid Conditions and Aspects of Cognitive Performance and Social Skills. Adolescent Psychiatry, 2011, Vol. 1, No. 4. (Number of citations: 3) 3. Duric N.S., Assmuss J., Gundersen D., Elgen I. Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports. BMC Psychiatry, 2012, Vol.12, No. 1; 107. (Number of citations: 12) 4. Duric N.S., Assmuss J.,Elgen I. NF treatment of children and adolescents with ADHD: Self-reported evaluation. Child and Adolescent Psychiatry and Mental Health, December 2013.

44. I have ADSL, What s difference with ADHD ? It goes faster with ADHD

45. Thank you