School-Based Neurofeedback for Autistic Spectrum Disorder
Mark Darling from Austrailia has conducted an award winning program within a school setting showing a 64% improvement.
School-Based Neurofeedback for Autistic Spectrum Disorder
By Mark Darling
Mark Darling is a psychologist from Queenslandís Sunshine Coast who
specialises in working with children with Autistic Spectrum Disorder and
associated developmental and behavioural disorders. He has worked with
Disability Services Queensland and served as Paediatric Resource Project
Coordinator for Queensland Health. Following a stint as a sole private
practitioner, Mark now provides neurotherapy services for Family
Challenge, an organisation that provides mental health services in
Australia and the developing world, with a particular focus on the
rehabilitation of child soldiers in African states. Mark was the
recipient of the 2004 Showcase Award for Excellence in Innovation
(Education Queensland Regional Winner) and the 2005 Commonwealth Award
for Outstanding National Achievement in School Improvement (Federal Dept
of Education and Training) for his research in reducing ASD behaviours
in the class setting. He is currently pursuing doctoral research into
the use of neurotherapy in the education setting.
Neurofeedback is an intervention that is showing a lot of promise for
people diagnosed with Autistic Spectrum Disorder (ASD). While other
childhood behaviour disorders such as Attention Deficit Hyperactivity
Disorder (ADHD) have been in the neurofeedback limelight for some years,
it would appear that ASD is about to have its day in the sun. Recent
research is showing that children with ASD are responding very well to
both electroencephalographic (EEG) and haemoencephalographic (HEG)
neurofeedback. Furthermore, our own research indicates that
neurofeedback can be an effective schoolbased intervention for children
in the autistic spectrum.
Neurofeedback is an intervention aimed at training individuals to
better regulate the biological functioning of their own brain. This has
generally involved the self-regulation of EEG rhythmic activity,
traditionally referred to as EEG biofeedback, neurofeedback or
neurotherapy. In recent years, however, the concept of neurofeedback has
expanded to include self-regulation of other neural substrates. For
example, haemoencephalography (HEG) is a recently discovered biofeedback
technique that encourages improved regional cerebral blood flow. Within
a similar timeframe in the mid-1990s, Hershel Toomim invented near
infrared haemoencephalography (nir HEG) while Jeff Carmen came up with
passive infrared haemoencephalography (pir HEG). Toomimís device
utilises a headband with sensors that measure reflected red and infrared
light from brain tissue in order to calculate the degree of
oxygenation. Trainees are basically rewarded for increasing red
colouration. Carmenís device employs an infrared thermometer to measure
the temperature immediately below the sensor, with trainees being
rewarded for increasing core brain temperature. While nir HEG can be
used at multiple cortical locations, pir HEG is only used at prefrontal
location Fpz. Both methods have been shown to improve metabolism of
hypoperfused brain regions.
A review of ASD research
While many clinicians will be familiar with the scientific literature
supporting the use of neurofeedback as a successful intervention for
conditions such as epilepsy and ADHD, research into the effectiveness of
neurofeedback for the autistic spectrum of disorders is a more recent
phenomenon. A couple of case studies were published in the mid-1990s,
but it hasnít been until the new millennium that more rigorous
investigations have taken place. Briefly, case studies or case series
have included three single case studies of children with autism (Cowan
& Markham, 1994; Sichel, Fehmi & Goldstein, 1995; Ibric &
Hudspeth, 2003), a series of three children with Autism and Aspergerís
Disorder (Thompson & Thompson, 1995), seven children with Aspergerís
Syndrome (Ross & Caunt, 2003), 60 individuals with ASD ranging in
age from 5 to 51 years (Thompson & Thompson, 2003), and 15 children
with Autism and Aspergerís Syndrome (Linden, 2004). All studies reported
In research conducted in Thailand, a series of 181 students with ASD
were given 20 sessions of nir HEG in which they were rewarded for
increasing cerebral blood flow to the prefrontal cortex of the brain.
The result was a Grade Point Average increase of 0.94 on a 4-point
scale, as well as a 53% increase in prefrontal blood oxygenation
readings (Limsila et al, 2004). Recently, Scolnick (2005) also conducted
an EEG biofeedback pilot study with five adolescents with Aspergerís
Syndrome that reported mild improvements.
The first controlled group study into the efficacy of neurofeedback
for ASD was published in 2002 when an average of 36 neurofeedback
sessions were given to a group of 20 children diagnosed with autism.
There was also a control group of 20 autistic children who did not
receive treatment. Pre- and post-treatment evaluation was in the form of
parent reports using the Autism Treatment Evaluation Checklist (ATEC).
The experimental group showed an average 26% reduction in autistic
symptoms in the areas of communication, social skills, sensory/cognitive
awareness, and health and physical behaviours. The control group
recorded a 3% reduction in autistic symptoms. (Jerusiewicz, 2002).
In more recent research conducted in New York by Robert Cobenís team,
37 children with ASD were given an average of 20 neurofeedback
sessions. A wait list control group of 12 children matched for
diagnosis, gender, age, race, handedness, IQ and previous treatments was
used. All subjects were assessed using quantitative EEG (QEEG)
analysis, infrared imaging, neuropsychological tests and behaviour
rating scales. Posttreatment assessment revealed an improvement in 89%
of the experimental subjects, with an average 40% reduction in symptoms
on the ATEC, as well as significant improvements on neuropsychological
tests of attention, language, visual-perception and executive
functioning. QEEG and infrared imaging confirmed that positive changes
had occurred at a neurophysiological level, particularly in terms of
reduced cerebral hyperconnectivity (Coben & Padolsky, 2006).
From the original experimental group of 37 autistic children who
completed 20 sessions of neurofeedback, Coben (2006) then took 32
subjects identified as having frontal system dysfunction based on QEEG,
infrared imaging, neurobehavioural and neuropsychological testing. The
children in the experimental group each received 20 sessions or either
nir or pir HEG. Once again a wait list control group of 12 subjects
matched for gender, age, race, handedness, IQ and previous treatment was
used. Following treatment, 90% of subjects showed improvement, with an
average 42% reduction in symptoms on the ATEC. There were also
statistically significant improvements on tests of neurobehavioural and
neuropsychological functioning, brain thermal imaging and QEEG data.
While both forms of HEG provided statistically significant improvements,
pir HEG proved more successful than nir HEG on some key measures of
Finally, Coben & Hudspeth (2006) identified 14 subjects from the
previous group who had significant levels of mu wave activity. Mu is an
alpha-like rhythm that is associated frontal disconnectivity. Half the
group received 20 sessions of frontal bipolar interhemispheric training
while the other half received coherence training to increase
connectivity between central and prefrontal brain regions. Both groups
improved significantly on QEEG, neurobehavioural and neuropsychological
measures, but only the coherence trained group demonstrated a reduction
in the mu rhythm. Overall, those who completed the three phases of
treatment (EEG 1; HEG; EEG 2) averaged an 80% reduction in autistic
School-based neurofeedback for ASD
My own foray into the use of neurofeedback for children in the
autistic spectrum began in 1999 with my own son, but soon expanded into
general clinical practice. Neurofeedback proved effective, but also very
time consuming, since autistic individuals seemed to require
longer-term treatment than children with ADHD. Consequently, whenever I
presented to educators I challenged them about the potential for
neurofeedback as a school-based intervention. The first group to take me
up on this challenge was Hervey Bay Special School. Following a further
presentation to staff and parents at the school I then provided three
days of training for the staff who were selected to be technicians. My
main aim was to have them know where to place electrodes, how to get a
good signal and how to run a neurofeedback training session.
In 2004 we commenced a pilot project with six autistic students
chosen by the school. Each of the students was ascertained as ASD Level
6, the highest level of support required within the Queensland education
system. I provided all appropriate assessments on site at the school,
and then developed tailor-made neurofeedback protocols for each student.
Protocols were e-mailed to the school for downloading onto the
neurofeedback computer. Following each session, EEG data and session
results were e-mailed back to the clinic for evaluation and protocol
adjustment as necessary. Full clinical and technical support was
provided and neurotherapy sessions formed part of each childís
Individual Education Profile (IEP). I should point out at this juncture
that school neurofeedback technicians were unable to make adjustments to
neurofeedback protocols, since we utilised BrainMasterís remote
training system that makes on-site protocol adjustment impossible. This
provided a good safeguard since it meant that I was the only person who
had the capability of making changes to each studentís protocol.
Students completed an average of 40 neurofeedback sessions in the
first semester with improvements on the ATEC ranging from 2% to 47%. One
of the main problems with this subjective instrument is that parents
and teachers often rated the same child in a completely different light.
For example, while one parent rated her son as having improved by only
2%, the school principal acknowledged that he was the student who had
probably improved the most. It was later revealed that the parent
concerned was personally dealing with a cancer diagnosis at the time she
was rating her sonís behaviour, which surely impacted upon her
objectivity. Similarly, two teachers were identified early in the
process as being opposed to having the neurofeedback program in the
school. They seemed somewhat threatened by the new approach and it will
come as no surprise that they each regularly rated the students from
their classes as showing no improvement, while anecdotal reports from
other staff members about the same students were very positive.
Fortunately, the school also established a system of independent
direct observation of behaviour in the classroom for each for the
students. Pre-determined autistic behaviours were observed and
quantified at pre-determined windows of time each day. The result was
that across the first 28 neurofeedback sessions, autistic behaviour in
the classroom setting reduced by 64% for the students involved in the
study. Improvements were also reported in the areas of sleep, mood,
speech, academic performance, attention, memory, and social skills; as
well as reductions in anger, aggression, seizures, hyperactivity, and
impulsivity. The two students who had epilepsy both stopped having
seizures, while two non-verbal students both began speaking a few words.
The neurofeedback program at Hervey Bay Special School won a
Commonwealth Award for Outstanding National Achievement in School
Improvement and was a regional winner of the Courier-Mail Showcase Award
for Excellence in Innovation. Subsequently, in 2006 a contract with
Education Queensland was established in which I provided training for
school staff in a number of regions in Queensland. The aim was to
commence neurofeedback programs in a number of schools and start
collecting data for my PhD research. Unfortunately, concerns about
litigation have led to a suspension of the program by Education
Queensland while they do their own literature review into the efficacy
and safety of neurofeedback. We can only hope that Education Queensland
sees the benefit of neurofeedback as a school-based intervention and
that program gets back on track sooner rather than later. In the
meantime we continue to provide programs for non-state schools and
individuals who attend the clinic.
Coben, R. (2006). Hemoencephalography for autistic spectrum disorder. Presented at the14th Annual Conference of the International Society for Neuronal Regulation, Atlanta, Georgia.
Coben, R. & Hudspeth, W. (2006). Mu-like rhythms in Autistic spectrum disorder: EEG analyses and neurofeedback. Presented at the 14th Annual Conference of the International Society for Neuronal Regulation, Atlanta, Georgia.
Coben, R. & Padolsky, I (2006). Assessment-guided neurofeedback for autistic spectrum disorder. Manuscript submitted for publication.
Cowan, J. & Markham, L. (1994, March). EEG biofeedback for the attention problems of autism: A case study. Presented at the 25th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback.
Ibric, V.L. & Hudspeth, W. (2003). QEEG and Roshi use in Autism post-toxic encephalopathy Ė a case study. Presented at the 11th Annual Winter Brain Conference, Palm Springs, CA.
Jarusiewicz, B. (2002). Efficacy of neurofeedback for children in the autistic spectrum: A pilot study. Journal of Neurotherapy, 6(4), 39-49.
Limsila, P., Toomim, H., Kijvithee, J., Bunthong,W., Pookjinda, J., & Utairatanakit, D. (2004). Hemoencephalography (HEG): An additional treatment for autism. Retrieved from http://www.biocompresearch.org/Thai_autism_study.htm.
Linden, M. (2004). Case studies of QEEG mapping and neurofeedback with autism. Presented at the 12th Annual Conference of the International Society for Neuronal Regulation, Fort Lauderdale, Florida.
Ross, J. & Caunt, J. (2003). A comparison of QEEG characteristics in pediatric aspergerís syndrome and attention deficit disorder. Presented at the 11th Annual Conference of the International Society of Neuronal Regulation, Houston, TX.
Scolnick, B. (2005). Effects of electroencephalogram biofeedback with aspergerís syndrome. International Journal of Rehabilitation Research, 28(2), 159-163.
Sichel, A.G., Fehmi, L.G., &
Goldstein, D.M. (1995). Positive outcome with neurofeedback treatment in
a case of mild autism. Journal of Neurotherapy,1(1), 60-64.
Thompson, L. & Thompson, M. (1995). Autism/aspergerís/obnoxious child, 3 case histories: How we get positive results with complex ADD clients. Presented at the Annual Conference of the Society for Neuronal Regulation.
Thompson, L. & Thompson, M. (2003). Neurofeedback Treatment for Autistic Spectrum Disorders: Review of 60 Cases-Principles and Outcome. Citation paper presented at the Proceedings of the Association for Applied Psychophysiology and Biofeedback.