Attention-Deficit/Hyperactivity Disorder (ADHD) - Neurofeedback (NFB) And Parent Training
Attention-Deficit/Hyperactivity Disorder (ADHD) - Neurofeedback (NFB) And Parent Training
Today we will interview Dr. Irit Schorr Sapir, Clinical psychologist PhD and director, for more than a decade, of the Attention-Deficit/Hyperactivity Disorder (ADHD) clinic at Schneider Children’s Medical Centre of Israel. Dr. Schorr Sapir is a lecturer in the School of Psychology at Tel Aviv University. She founded (together with prof. Haim Omer) and is now the Director of the Non-Violent resistance and New Authority School. The School trains therapists and professionals. Dr. Schorr Sapir is engaged in treatment and research that focuses on ADHD and parenthood. In addition, in the last few years, she has been researching the field of Neurofeedback (NFB). This interview will focus mostly on the treatment of ADHD, with an emphasis on NFB therapy and parent training. Dear parents, if you have queries that have remained unresolved so far, this interview may answer many of your questions.
Contact details& scheduling appointments:
Director: Ms. Irit Shor-Sapir, Psychologist
Hours: Sundays to Thursdays, 08:00-14:00
Appointments: 972-3-9253186, 08:00-10:30
Interview by Hemda Mark 21.03.2021
(Translation to English by Vered Reuve).
Glad to meet you, Dr. Irit Schorr Sapir,
1. My first question is “What is ADHD and how does it interfere with the child’s proper functioning in terms of education, and socially and emotionally?
ADHD is Attention Deficit Hyperactivity Disorder. The ADHD disorder makes it difficult to pay attention and to focus on the task in hand. It is often accompanied by Hyperactivity and Impulsive behavior. Moreover, there is an impairment in the executive functioning (a set of mental skills such as organization, planning and control) of the child who has ADHD. He has issues with inhibitory control- whether it is emotional, behavioral or cognitive control. ADHD is a neurodevelopmental disorder. It is has a neurological basis; however, the level of intensity that is manifested, also depends on the environment in which the child grows up. The child finds it difficult to concentrate on the material being taught in class, has a hard time staying seated in his chair and often disrupts the classroom. Consequently, the parents find out that the child has ADHD only when he starts first grade, as he is required to sit in class and concentrate. Furthermore, at this stage the child struggles with acquiring reading, writing and math skills. In addition, the teacher will often complain as the child fidgets in his chair, and finds it difficult to wait his turn and to follow the class rules. His behavior often makes it difficult for the children in his class to study. In order to demonstrate issues with inhibitory control and impulsiveness, imagine a situation where, for example, the child wants to slide on a slide. He ignores the queue of children in front of him because he wants to slide right now. He does not think of the consequence, for example that the other children will be angry at him and will not want to play with him. The child has a hard time with delayed gratification and finds it hard to stop and think of the consequences of his actions before actually doing the activity. Due to this behavior, interpersonal interaction may be impaired and social problems may develop. Feelings of depression and anxiety, as well as low self esteem, may develop as a result of the environment’s reaction to the child’s behavior and his difficulty in acquiring first grade learning skills. Furthermore, the child’s hyperactive and impulsive behavior may cause friction within the family. Moreover, in cases where the parents have difficulty setting boundaries and regulating the child’s behavior, it may cause tension and problems in the relationship between the child and his parents.
What are the treatments for ADHD?
The treatment for ADHD depends on the extent of the disorder. In cases where the child has difficulty in his studies, he can be assisted in school through “remedial instruction”, extra classes tailored to help the child. The teacher often seats the student at a separate table in class, where the child does not distract other children. When the disorder is more intense and impairs the child’s behavioral, academic and social functioning, therapeutic intervention is required.
In the USA- Treatment of the child’s ADHD depends on his age. At In preschool, parental guidance is recommended to help the child regulate himself emotionally and behaviorally. Once the child starts school, the recommendation is to prescribe medication (Ritalin, etc.) and/or parental guidance. As a teenager, the recommendation is for drug treatment, preferably combined with CBT (Cognitive Behavioral Therapy) therapy.
In Australia and Europe- Parental guidance is the preferred treatment until adolescence. Only when it is ineffective, drug treatment is added. In adolescence the recommendation is also to try to help the teenager with CBT therapy.
In Israel- The treatment in Israel nowadays, unfortunately, is similar to that in the United States.
It is Important to note that emotional therapy in itself, isn’t effective for a child with Attention Deficit Disorder. There are no recent studies that prove that these treatments are effective in reducing the disorder. However, they can certainly help with the emotional problems that can accompany ADHD such as: low self-esteem, depression etc…
We are all aware today of the “wonder” drug Ritalin. Nevertheless, it is clear to all that it isn’t possible to rely only on drugs, when there are alternatives “on the shelf”, like the Neurofeedback treatment, a method that trains the brain to function optimally. To me it sounds imaginary; is it really possible to train the brain?
Neurofeedback (NFB)- is a treatment method that has existed for many years and recently is even gaining momentum in the treatment of children with ADHD. In Schneider Hospital, thanks to a generous donation from “Our Children”, we are researching this field. The Neurofeedback method teaches the child’s brain to reduce his Attention Deficit Disorder. Neuro + feedback means the brain receives feedback on its functioning and thus the brain can correct itself. For example, in our Schneider clinic, the child who comes for treatment will play a simple computer game. A ribbon is placed on the child’s forehead, which is attached to the computer. The directions are that if the child will concentrate, the character in the game will progress and develop. The child needs to concentrate in order to progress in the game. As a consequence, by training the brain, he succeeds in the game. There are several methods to train the brain. For example, the ElectroEncephalogram (EEG) method uses brainwave training to improve attention. Another method, which is used in Schneider is through HAG- this method tests the level of oxidation in the forebrain. The treatment is used with the “stick and carrot” method. If the child manages to use his brain to concentrate while playing, he will progress in the game. Otherwise, he will not progress. Another possibility is that the child will choose to watch a movie. In this case, if the child manages to concentrate, he will be able to see the movie without interruptions. However, if the brain does not concentrate as required, there will be “Absorption interference” and the movie will be blurred.
In comparison to the Neurofeedback method, in the Biofeedback method the patient is instructed to perform breathing exercises, guided imagery and more. In this method the emphasis is on the patient’s body, while in the Neurofeedback method the emphasis is on the patient’s brain. The brain learns to regulate its brain waves in a way that bypasses consciousness. The idea is that the brain will “speak” directly to itself without the consciousness’ interference. The Neurofeedback training takes about 22 consecutive sessions of at least 2 meetings a week. Otherwise the brain is unable to learn the change. The first session includes a short training of the brain of about 5 minutes and In every session, the treatment is longer until the training takes 30 minutes.
As mentioned, another kind of treatment for ADHD is by prescribing medication. In light of the many years of experience you have gained in the field, as a clinical psychologist, what is your position?
As a psychologist, I think there is an overuse of drugs. The medication is offered many times as a first option for treatment. Instead of starting with parental guidance. Medication is an important method of treatment. Yet, it is not the only solution, since in some cases, they may cause side effects- suppression of appetite, abdominal pain, anxiety, a “zombie” feeling and more. Although medications save a lot of children, the drugs should be seen as just one of a variety of treatment methods. The drug has its own clock. For example, the Ritalin’s effect is only between 4 to 8 hours and when the child comes home from school and the effect of the drug has expired, he must pass the afternoon without the effect of the medication. This situation creates a difficulty for the child, because he hasn’t learned how to regulate the ADHD, since he relies only on the external aid of the drug.
Parents of children with ADHD also need help to cope with their children and to create a pleasant environment at home. What is the role of the parents and how can they help their children?
ADHD disorder disturbs the environment. Hyperactive children disturb the environment, of course without having any bad intention, since they become bored and more restless. These children accelerate the pace to daily life at home. Consequently, the parents feel like they are on a “roller coaster” that keeps flying at full speed. It's as if someone is constantly “running” in the air in front of their eyes. The parents feel responsible for making sure that the child does his homework, doesn’t lag behind in class, that he behaves according to his age and appropriately. There are many arguments at home due to the child’s low frustration threshold and his difficulty to regulate himself emotionally. As a result, parents often feel fatigue and a sense of helplessness when dealing with the child. This is especially true when considering that 80% of children with ADHD disorder are diagnosed as having another disorder, mostly behavioral problems (as well as learning disabilities, depression and anxiety) which makes it even more difficult for the parents to cope with the child.
We know that mothers of children with ADHD disorder are more prone to depression than mothers of children without ADHD. We also know that ADHD disorder is often genetic. Therefore, there are families, in which both the children and the parents have ADHD disorder. In these cases, there is no one to regulate the child. Consequently, we observe chaos in such families. It is important to create a less chaotic and more organized atmosphere at home in order to regulate a child’s ADHD disorder. When we teach parents how to regulate the environment and themselves , the child will learn to be more self-regulating. Moreover, if the change starts from the parents, there is a high chance that it will be implemented over time.
Parental guidance provides a threefold solution: First, parents increase their parental authority, and learn to regulate themselves and the family. Second, the child becomes more regulated and there is a decrease in the intensity of his ADHD disorder. Third, the whole family benefits when the atmosphere at home becomes more pleasant and less chaotic.
I now understand the role of the parents in the life of their child. I would love to hear your position regarding the role of the school in the life of the student who has severe ADHD disorder.
Many times the parents, hoping to release some of the pressure that they feel on a daily basis, expect the child to become independent faster than actually happens in reality. They expect him to take on more roles. Parents who have a 10-year-old child with ADHD disorder at home and another child who is 4-years-old, complain that sometimes the 10-year old child is less independent than his 4-year-old brother. For example, when getting organized in the morning to go to kindergarten and to school, all one needs to do with the 4-year-old brother is to ask him to dress without too many explanations, whereas the parents need to help the 10-year-old who has the ADHD disorder to get organized and often need to break down all the stages of the process required for getting dressed and leaving the house. A specific direction needs to be given for each task. For instance: Take the shirt and put it on, put on your underwear and now put on your socks and pants. In other words, the 10-year- old lacks the managerial functions- the ability to organize the sequence of actions required, the ability to manage time etc... Thus the parents rightly ask: “how long will I have to manage everything for him?”. The answer, however, is more help needs to be given to the child with the ADHD disorder. Furthermore, comparisons shouldn’t be made between him and his younger siblings. The same goes for organizing and preparing homework. The parents need to help by breaking down the tasks so that the child will slowly take on more responsibility and will perform them independently.
It is important to establish a good relationship with the school. Sometimes the parents are angry because the teacher calls them in order to set up a meeting, updates them and gets them involved in every aspect of the child’s daily routine in school. More than once a parent tells me: “I do not ask the teacher to come to my house and help me solve problems in front of the child”. in their opinion, the school also needs to learn how to cope with the child during school hours. That is why, in some cases, there is friction and tension between the parents and the school. The clinic at Schneider helps with this problem and create a kind of “alliance” between the school and the parent, by explaining to the parent that he is a kind of manager. He needs to “work” and conduct the “concert” which is his child’s life. Since if you, as a parent, won’t manage it, no one else will do it and the child’s problems will only get worse.
When the teacher encounters a difficulty with the child, the parent needs to collaborate with the teacher to help both the teacher and the child so that they will overcome the problem. It is highly recommended to set up an appointment with the teacher at the beginning of the school year, to tell her about the special needs of the child. Moreover, it is important that the parents update the rest of the school staff about the child’s problems. The parents, for their part, should help build the “alliance” between the 3 entities: the teacher, the parent and the child, an alliance that will enable them to maintain the relationship with the child throughout the school year. The child really needs help and only cooperation between all parties involved will enable the child to integrate in the best possible way at school.
What are the chances of a child, who is dealing with ADHD disorder, to overcome emotional and social problems and to integrate optimally with his peers?
ADHD is usually not a standalone disorder. In 80% of the cases, it is accompanied by another disorder, such as: behavioral problems, depression, anxiety and learning disabilities. 50% of the children have 2 additional disorders and it is not clear if what came first, the ADHD or the other disorders. Sometimes, because of the difficulties, the child develops depression. However, the more the environment regulates and supports the child, the better it is for the child, especially when the parents take command and can “conduct the concert” until the child learns to be independent, which is a long process. Parental support is also very important. Furthermore, it is essential that both parents will be involved in the process.
It is of utmost importance that the parents find time to do activities together with the child alone, an activity that both the child and the parents will enjoy. For instance, riding a bike together, playing soccer, basketball, baking and even shopping in the supermarket together. It is recommended to set a time in the weekly calendar, so that the child will mentally prepare and wait for the “father/mother activity”. It is possible, of course, to send the child to classes/activities that he likes and where he is able to express himself. It is critical to find the child’s strengths and choose activities in those areas, so that the child will feel a positive self-worth and strengthen his self- esteem.
What do the studies teach us about the development of the field of Neurofeedback and is there enough data that attests to the success of the method?
There are more studies and data today that attest to the success of the Neurofeedback treatment method. There is a variety of methods in the field as well as protocols. There is a wide research body on the effectiveness of the ElectroEncephalogram (EEG) method. In this method, the treatment is done through brainwave training, to improve attention. The Schneider Hospital clinic operates using the HAG method (As detailed in answer to question 3). For the treatment to be successful, it is important for the child to remember the training. Therefore he must come twice a week. Otherwise, the mind will not remember and will not make the required change. When the child comes for 11 consecutive weeks, twice a week, perseverance will allow the brain to make the change. From time to time, as the child grows and the brain develops, the treatment needs to be maintained. The disorder takes on a different manifestation in adulthood.
A study at the Schneider Clinic, currently underway, is examining whether booster doses given once every three months, over the course of a year, will maintain the improvement that was achieved in treatment.
I know that you have been researching and caring for children with ADHD disorders for many years. Can you share with us 3 key insights that will help parents decide which treatment to choose for their child who is suffering from ADHD?
In principle, I would like to give children “the whole package”- neurofeedback, parental guidance to strengthen parental authority, emotional care for the child, a workshop on social skills and more. However, as is well known, the resources are limited and not all treatments are in the healthcare basket. Moreover, unnecessary treatments should not be placed upon the child and his parents. Therefore, the most appropriate treatment should be given , depending on how the ADHD impairs the child’s functioning. Parental guidance is the first treatment I would recommend if the child only suffers from difficulty concentrating without hyperactivity and impulsivity. Neurofeedback would be my recommendation for treatment. I would incorporate CBT if the child is mature and is aware of his difficulties. Medication is recommended only in the second stage, if the non-pharmacological treatments were not effective enough. A variety of treatments are provided at our clinic in Schneider. Most of the treatments are included in the healthcare basket and can be obtained with the “Form 17”. Neurofeedback is not included in the healthcare basket and costs about NIS 5,000 for 22 treatments (as of March 2021).
10.Is a follow-up check up required after we have seen a
ADHD is a chronic disorder. In treatment, we try to “lower the volume of the disorder”, to reduce its effect and help the child and/or his parents reduce the impairment in his or her functioning. There are families who received treatment and it is enough for them, since they internalize the required changes that are required. On the other hand, there are families who return after a certain period for another series of meetings. One of the goals of the current study in the clinic is to test whether the “booster doses” that will be given to the child/parent once in a specified period, can help maintain the achievement at the end of the treatment period, so that there will not be a return to the level of the condition from before treatment started.
Do you know prominent personalities who have faced severe
problems of ADHD and succeeded in their lives?
There are a lot of prominent people who have had ADHD. In the past the disorder was not diagnosed, so it is more difficult to know today who had the ADHD disorder. But we can assume that Einstein had ADHD, as well as the Wright brothers (known for inventing, building, and flying the world's first successful motor-operated airplane) and many others. It is important to note that there is no connection between ADHD and the level of intelligence, and that there are many smart and successful people with ADHD including CEOs. Once you learn how to regulate ADHD disorder, one can go far and succeed in every field imaginable.