Neurofeedback of Slow Cortical Potentials in Children with Attention-Deficit/Hyperactivity Disorder: A Multicenter Randomized Trial Controlling for Unspecific Effects.

Background: Neurofeedback (NF) in children with attention-deficit/hyperactivity disorder (ADHD) has been investigated in a series of studies over the last years. Previous studies did not unanimously support NF as a treatment in ADHD. Most studies did not control for unspecific treatment effects and did not demonstrate that self-regulation took place. The present study examined the efficacy of NF in comparison to electromyographic (EMG) feedback to control for unspecific effects of the treatment, and assessed self-regulation of slow cortical potentials (SCPs). Methods: A total of 150 children aged 7-9 years diagnosed with ADHD (82% male; 43% medicated) were randomized to 25 sessions of feedback of SCPs (NF) or feedback of coordination of the supraspinatus muscles (EMG). The primary endpoint was the change in parents' ratings of ADHD core symptoms 4 weeks after the end of treatment compared to pre-tests. Results: Children in both groups showed reduced ADHD-core symptoms (NF 0.3, 95% CI -0.42 to -0.18; EMG 0.13, 95% CI -0.26 to -0.01). NF showed a significant superiority over EMG (treatment difference 0.17, 95% CI 0.02-0.3, p = 0.02). This yielded an effect size (ES) of d = 0.57 without and 0.40 with baseline observation carried forward (BOCF). The sensitivity analysis confirmed the primary result. Successful self-regulation of brain activity was observed only in NF. As a secondary result teachers reported no superior improvement from NF compared to EMG, but within-group analysis revealed effects of NF on the global ADHD score, inattention, and impulsivity. In contrast, EMG feedback did not result in changes despite more pronounced self-regulation learning. Conclusions: Based on the primary parent-rated outcome NF proved to be superior to a semi-active EMG feedback treatment. The study supports the feasibility and efficacy of NF in a large sample of children with ADHD, based on both specific and unspecific effects. Trial Register: Current controlled trials ISRCTN76187185, registered 5 February 2009.

Morning light therapy for juvenile depression and severe mood dysregulation: study protocol for a randomized controlled trial.

BACKGROUND: The prevalence of depression in young people is increasing. The predominant co-morbidities of juvenile depression include sleep disturbances and persistent problems with the sleep-wake rhythm, which have shown to influence treatment outcomes negatively. Severe mood dysregulation is another condition that includes depressive symptoms and problems with the sleep-wake rhythm. Patients with severe mood dysregulation show symptoms of depression, reduced need for sleep, and disturbances in circadian functioning which negatively affect both disorder-specific symptoms and daytime functioning. One approach to treating both depression and problems with the sleep-wake rhythm is the use of light therapy. Light therapy is now a standard therapy for ameliorating symptoms of seasonal affective disorder and depression in adults, but has not yet been investigated in children and adolescents. In this trial, the effects of 2 weeks of morning bright-light therapy on juvenile depression and severe mood dysregulation will be evaluated. METHODS/DESIGN: A total of 60 patients with depression, aged between 12 and 18 years, in some cases presenting additional symptoms of affective dysregulation, will be included in this trial. Morning bright-light therapy will be implemented for 2 weeks (10 sessions of 45 minutes each), either with 'active' light (10,000 lux) or 'inactive' light (100 lux). A comprehensive test battery will be conducted before and after treatment and at follow-up 3 weeks later, to assess depression severity, sleep, and attention parameters. Melatonin levels will be measured by assessing the Dim Light Melatonin Onset. DISCUSSION: In this pilot study, the use of morning bright-light therapy for juvenile depression and severe mood dysregulation shall be evaluated and discussed. TRIALS REGISTRATION: Current Controlled Trials ISRCTN89305231.

Severe mood dysregulation: in the "light" of circadian functioning.

Severe affective and behavioral dysregulation, labeled as severe mood dysregulation (SMD), is a widely spread phenomenon among adolescent psychiatric patients. This phenotype constitutes severe impairment across multiple settings, including various symptoms, such as non-episodic anger, mood instability, and hyperarousal. Moreover, SMD patients often show depression and reduced need for sleep. Despite a lifetime prevalence of 3.3%, systematic research is still scarce, and treatments that have been established do not account for the range of symptoms present in SMD. Considering the circadian dysfunctions, two hormones, melatonin and cortisol, are essential. When these hormones are dysregulated, the circadian rhythm gets out of synchrony. Since evidence is emerging showing that the worse the sleep-wake cycle is entrained, the worse the psychiatric symptoms are depicted, the importance of proper circadian functioning becomes clear. Chronotherapy as the controlled exposure to environmental stimuli (e.g. light) acting on biological rhythms has shown therapeutic effects. In both seasonal and major depression chronotherapy has been implemented, decreasing depressive symptoms and stabilizing circadian rhythms. Preliminary evidence from SMD related disorders, namely attention-deficit/hyperactivity disorder and pediatric bipolar depression, indicates that morning light therapy elicits positive influences on other symptoms as well. Hence, light therapy might not only be effective for depressive symptoms and circadian rhythms, but might also be beneficial for symptoms including inattention and irritability. We hypothesize that light therapy might be a helpful adjunctive treatment enhancing affective and circadian functioning, and eliciting positive influences on behavior. Physiologically, changes of both cortisol levels and melatonin production are expected.

The more physical inactivity, the more agitation in dementia.

Epidemiological studies show a close relationship between physical activity and cognition. A causal relationship between physical activity and cognition has been observed in children, adolescents, older people without dementia, and in older people in a very early stage of dementia. Considering these positive effects, we argue that a decline in physical activity has a detrimental effect on cognition and behavior in patients with dementia. Merely living in a nursing home reduces the level of physical activity. The level of physical activity may even be reduced to a minimum when physical restraints are applied. The use of physical restraints coincides with stress, further aggravating the already existing neuropathology, which may increase stress and agitation even more. Exercise may reduce stress and agitation.