A chapter from the Textbook of Neurofeedback, EEG Biofeedback  and Brain Self Regulation 

          edited by Rob Kall, Joe Kamiya and Gary Schwartz

The E-book is Available on CD Rom 

METACOGNITIVE STRATEGIES &

NEUROFEEDBACK for ADD/ADHD CLIENTS

Lynda Thompson & Michael Thompson

ADD Centres

50 Village Centre Place

Mississauga, Ontario

Canada, L4Z 1Z9

"ADD is not an illness and it is not a disorder in the usual sense. It is a constellation of temperamental traits, and a style of thinking. The task of the individual who has these traits is to harness them and use them to advantage. Harnessing requires learning how to learn efficiently and effectively."

(Quote from an ADD adult who holds 3 graduate degrees)

Introduction:

This chapter will describe an approach which combines self-regulation training with direct instruction in metacognitive strategies. Self-regulation training includes neuronal regulation (EEG biofeedback) and autonomic nervous system regulation (temperature and skin conduction). Metacognition means thinking about thinking and learning about learning; thus, metacognitive strategies are those executive functions of the brain that go beyond cognition and allow one to be consciously aware of thinking processes. Strategies for listening, reading, organizing and remembering are included in this training. The effective learner is able to select appropriate strategies and monitor their use.

The first section of this chapter describes the principles that underlie the authors’ use of a combination of neurofeedback with training in metacognitive strategies for students who exhibit the symptoms of Attention Deficit Disorder (ADD). It will also outline procedures used at the ADD Centre both for feedback and for combining this feedback with learning strategies. The second section gives specific examples of a few of the metacognitive strategies which are taught in the ADD Centres for listening, reading, remembering, organizing presentations and approaching mathematics problems.

A. NEUROFEEDBACK COMBINED WITH LEARNING STRATEGIES:

Training to decrease slow wave electroencephalographic (EEG) activity and increase fast wave activity is necessary but not sufficient to maximize beneficial behavioural changes in clients who wish to improve their attentional processes. To work efficiently the graduates of a training program should ideally be able, at will, to put themselves into a mental state that is relaxed, alert and focused. In this state they can demonstrate concentration and engage in organized problem solving. In addition, graduates should have techniques - metacognitive strategies - which improve their ability to listen, learn, organize and remember material in a manner that allows them to efficiently and effectively accomplish tasks. This clear thinking can be applied with equal efficacy in academics, work and social situations.

The Significance of Different Types of Brain Waves:

a. The Origin and Some Behavioural Correlates of the EEG:

The source of much of the EEG is in the thalamus. It can influence the production of brain waves of various frequencies; for example, the production of rhythmic 13 to 15 Hz waves when sensorimotor input is reduced, of 9 to 11 Hz synchronous wave activity when cognitive integration is reduced and slower waves 4 to 8 Hz when one is drifting off toward sleep. Sterman has noted that Delta wave activity, 2 -3 Hz, differs from the other band widths which are produced in the thalamus in that it is probably only cortical in origin. If this is so then the thalamic nuclei are secondarily entrained to produce delta wave activity during sleep. In the normal brain Delta is only, therefore, observed in sleep though it may also be seen after brain damage has occurred. What appears to be Delta activity in an awake, alert individual may be movement artifact, e.g., eye blinks. In order to sleep one must stop paying attention both to stimuli in the environment (somato-sensory and visual) and then to cognition. Dr. Sterman’s papers describe these mechanisms in detail. The two ends of the spectrum range from sleep (when only very strong stimuli of touch or sound get through) to extreme arousal and vigilance in the fully awake state. An example of such an extreme in the waking state is a pilot landing a plane. The pilot is hyper-vigilant for particular visual, auditory and kinesthetic stimuli and inhibits other relatively unimportant external stimuli and internal distractions. The production of slow waves in this vigilant brain state will be minimal and relatively more power will be in faster waves (SMR and Beta ). The pilot who feels relief after successfully landing a plane will demonstrate a burst of slower (Alpha) waves. Sterman calls this "post-reinforcement synchronization" (PRS). In earlier research he had identified this PRS pattern in cats after they obtained a food reward for producing at least a half-second of SMR activity. Sterman has noted that the EEG may be understood as a sequence of ERDs (event related desynchronizations), when cognitive processing is occurring, followed by PRSs. Therefore, when we take averages of EEG activity over time, we will virtually always observe some alpha wave activity. Indeed, individuals who perform a task easily and well demonstrate only a brief ERD followed by a PRS while individuals who perform poorly on a specific task actually exhibit a larger ERD with a slower PRS recovery. One could speculate that an individual such as Einstein might have produced considerable Alpha activity!

b. An EEG Marker for ADD:

Several studies have now demonstrated that students who are diagnosed as having attention deficit disorder exhibit more slow wave (Theta) activity than students who do not exhibit any of the symptoms of this disorder. (Mann et al, Janzen et al). In our work with older students, it is frequently found that these persons find it difficult to remain awake during lectures. It is also noted that these students and, indeed, the majority of both children and adults with ADD demonstrate very low EDR (electro-dermal response). They report feeling less alert when their EDR is low during training sessions. Theta activity is associated with " tuning out" external stimuli. Theta microvolt amplitude is highly variable when these students are tuning out. People who are falling asleep or drifting off are increasing their production of slow waves (Alpha and Theta and, eventually, Delta). This can be observed during a training session when a student is overtired! In the classroom the production of slower waves means they are becoming less and less attentive to the external auditory and visual stimuli of teacher, blackboard and textbook. The student who is actively engaged in attending to the teacher, by contrast, is inhibiting slow wave activity and may be increasing desynchronized fast wave activity. We observe during training that, when students are alert, focused and actively learning, the increase in SMR (13 to 15 Hz) and Beta (15 to 18 Hz) activity is associated with a marked decrease in Theta standard deviation and variability. It may be that the student who is creating a piece of work will appear to spend relatively more time in slower, more synchronous, Alpha wave activity when thinking up new ideas. Then when actively listening, organizing, writing, reading, or expressing these ideas, will demonstrate a higher average amplitude of faster, less synchronous Beta activity. For the most part, creative thinking is not usually a difficulty for our ADD students; rather, it is the maintenance of an external focus when listening and reading that is the challenge.

Given the foregoing discussion, training at the ADD Centre emphasizes holding theta variability low while raising SMR and Beta. At the same time, we have those students who demonstrate a low or labile EDR raise their arousal and maintain a steady, high level of alertness while carrying out tasks which require listening, reading and organizing

c. Initial SMR Training - A Rationale:

Sterman has noted that the brain does not do two things simultaneously. For example, if a pilot moves to turn a radio dial (a motor action) he will momentarily turn off visual cognitive processing. The ERD (faster, desynchronized activity, e.g., 16 to 18Hz) is seen in the motor cortex and a PRS (9 -11 Hz synchronous activity) is observed in the visual cortex. He reports that 9 to 11 Hz activity is turned off and event related desynchronization occurs in areas of the cortex where cognitive processing is taking place. In our training we help the students understand that when they are fidgeting and fiddling with something , such as a pencil, they are not, at the same moment in time, reading the text book and learning from it. We teach them to turn off these unwanted fidgeting activities by training them to increase SMR (sensorimotor rhythm, 13 - 15 Hz ).

d. The Need for Including Metacognitive Strategy Training along with Neurofeedback- A Rationale:

As previously noted, Sterman has also taught that an easy task requires only a brief ERD followed by a PRS. This basic research finding is also important to our understanding of what we observe. Our brighter students often appear to demonstrate a predominance of alpha wave activity unless they continually "challenge" themselves with cognitive tasks. When they do this, however, they can train themselves to maintain a predominance of 15 to 18 Hz activity for sustained periods of time. They report major increases in their cognitive abilities including an ability to lay down in memory virtually everything they read when in this state. In addition to the inherent face validity of training students in metacognitive strategies, the observation that continuous self imposed challenges help these students to maintain high beta activity and a high performance level has led to our emphasis on learning and practicing metacognitive strategies. We feel there is better transfer of self-regulation skills to the classroom if they have practiced academic skills while receiving feedback. The strategies provide these students with the "challenge", the kind of cognitive activity that not only, in and of itself, increases their learning efficiency, but also turns on the mental state ( beta activity) where they learn more efficiently.

e. Summary:

For students who exhibit attentional difficulties, the approach of combining Neurofeedback training with increasing EDR and learning metacognitive strategies is based on observed links between brain wave patterns and particular mental states and behaviour. This combined training, teaches the student self-regulation of brain wave activity and performance. For example, students who typically would produce an excessive amount of high amplitude slow waves are trained to decrease and hold steady (decrease the variability) of these waves. At the ADD Centre we use four different types of EEG feedback instruments. Only some instruments (such as, the F1000 from Focused Technology) allow for direct readings of theta variability for whatever time frame the trainer wishes to use. At the ADD Centre we have chosen to look at 20 consecutive overlapping 30 second screens in a five minute time periods. The readings are graphed at a setting which allows for the maximum variability of theta to be observed. The students observe a thermometer-like gauge which is set to show the amplitude of 4 to 7 or 4 to 8 Hz. They observe how it is rapidly fluctuating. They are told to hold it steady and low. When they achieve this the variability automatically calculated by the computer for each 30 second screen, will be maintained at a low level. When this is achieved, the student then attempts to maintain variability and mean amplitudes for theta at a similar low level while reading, writing and listening. Simultaneously, these students increase the production of faster waves. They are assisted in this endeavor by the inclusion of EDR training and learning to use cognitive strategies. When this balance is achieved, students report that they feel focused, attentive and that they organize and recall material better than they have ever done previously. The metacognitive strategies assist the students in applying self-regulation of brain wave activity, help them to further increase their learning effectiveness and efficiency and allows for an immediate transfer of some of the skills learned during training to classroom and study situations.

They can start using the thinking strategies even before the shift in brain-wave activity has occurred, so you see beneficial results sooner.

Client Characteristics.

Clients at the ADD Centre typically present with a desire to improve their ability to regulate their attention and concentration. Some also wish to modify an impulsive style which interferes with effective performance in learning and social situations. Those who show impulsive behaviour (as contrasted to only an impulsive thinking style) are frequently hyperactive. Many of these students are taking stimulant medication when they begin training. The majority do not require medication at the end of training. At the ADD Centres some of the clients, therefore, have had a previous diagnosis of one of the types of Attention Deficit Disorder. Other clients, however, have never had a diagnosis. Many are very bright and academic underachievement is the main concern.

Some unwilling teenage clients are brought by their parents. They need to feel that what they will learn at the ADD Centre may make their lives easier and that they will be in charge of their own behaviour - we are not magically changing their brain! We ask these teenagers a question, "If we help you learn more rapidly and at the same time get much better marks, would that give you more time with your friends and would it also get the teachers and perhaps your parents off your back?" All have agreed that both would be accomplished. To answer their second, not yet verbalized question, we use an analogy. We ask what their favourite sport is. Then we use it in an example such as the following: Before you learn how to hit a forehand tennis shot, you may often miss the ball, slice it over the fence or hit the net. After you learn and practice how to hit a powerful forehand, you have a choice! You can still choose to miss the ball or hit it over the fence. However, you may also now choose to hit it perfectly and win the point! When you choose to play hard and win, the shots you make will become automatic. Similarly, before you train at this centre, you have told us that you have little choice. Your mind wanders, you are not getting the marks you want to get. After you train here, you will have a choice. You can still choose not to listen or study but you may choose to learn efficiently and effectively. You are in full control!

Prognosis for students appears to be almost uniformly positive. Exceptions, however, are those students whose families are having emotional difficulties. Some of these students may stop training abruptly after an argument with their parents. Others improve in the sessions but continue to display passive-aggressive behaviours (skipping school, not doing assignments). If family problems are evident in the initial interview, parents should be warned of these possibilities. We sometimes refer them for therapy to be done either before or concurrently with neurofeedback. Our service is not a panacea and we see it as an educational intervention rather than therapy.

In addition to improving attentional processes and reducing impulsivity, goals for training include reducing anxiety and increasing alertness. The overall objective is to improve mental flexibility so that a person can produce a mental state appropriate to situational requirements.

Those students who present with anxiety and/or tension often demonstrate "demand" anxiety in classroom, athletic and social situations. Demand anxiety refers to feelings associated with fear of failure when performance is demanded; for example, answering a question, reading a passage, speaking in public, or skiing down a steep slope. This type of anxiety markedly inhibits performance. Often the same task could be carried out easily if it were not a demand situation; for example, these children may spontaneously answer a question that is directed to the whole class but they cannot produce that same answer when called upon.

Skin temperature is one physiological measure which reflects anxiety and tension. It can be easily monitored using a thermal sensor placed on a finger. The finger-tip skin temperatures may initially be as low as 64 degrees. Most clients quite quickly learn to self-regulate their temperature. They are able eventually to increase hand temperature at will and this correlates with a more relaxed state. One client, for example, now uses hand warming prior to ice-skating performances and her coach remarked on her sudden improvement.

Many candidates for training also demonstrate very low or labile levels of alertness. This is monitored by measuring skin conduction (EDR). Electrodermal response (EDR) is an autonomic nervous system measure which reflects arousal and alertness. Clients learn to recognize and regulate their arousal level. Instead of drifting off towards sleep when they perceive the teacher as boring, they can choose to stay alert. Both the self-regulation of the EDR and the application of metacognitve strategies help in such situations.

Thus by learning how to regulate skin temperature and conduction, students attain a "eustress" (reference: personal communications with Thomas Allen) physiological state wherein they remain relaxed yet highly alert.

Some clients initially have a propensity to slip into daydreaming or drowsiness at inappropriate times. They may tune out in class, when they are doing homework, when the coach is giving instructions or even in everyday conversations. These states are associated with excessively high levels of slow wave activity in the brain. In most children, this slow wave activity is in the theta band width (4 to 8 Hz [cycles per second]). In adolescents and adults it may also be associated with increases in alpha activity (8 to 12 Hz). These time periods appear to correspond to drifting off topic and ceasing to concentrate on the subject matter at hand. Clients learn through the feedback of brain wave activity to self-regulate their attention, increase their concentration and maintain their focus until a task is completed. Self-regulation training allows the students to recognize rapidly when they are beginning to drift off topic. They can recognize that they are no longer tuned into their work and can then refocus on to the primary task.

Many, but by no means all, of the younger clients display one or more specific learning deficiencies relative to their overall intelligence. All of the candidates demonstrate difficulties in working efficiently at academic tasks. In the majority (exceptions often being those with high anxiety) organization and timely completion of work is a major difficulty. All of the candidates benefit from the combined training using feedback and teaching of cognitive strategies.

Client Example:

C. is an 11 -year-old boy with severe learning disabilities and ADHD. His family is extremely supportive and both parents are teachers. In his history it was related that he had been called "the most profound learning disability ever seen" at a major Canadian hospital’s child development clinic. Despite intensive special education his Reading and Arithmetic scores on standardized tests were only at an early grade two level when he started the program on August 8, 1994. Re-testing on November 20, 1994 demonstrated that Reading and Math were both up to a grade five level. His T.O.V.A. (Test of Variables of Attention) profile had also shifted towards a normal pattern. He sits calmly, is no longer restless and fidgety, and can listen attentively. This boy could not multiply even 2x2 and now he takes great pleasure in being able to easily and quickly do all the multiplication tables. He has been learning the 13 times table on his own "just for fun". Most importantly, he no longer says, "I can’t" but eagerly jumps into each new challenge and really enjoys learning.

The Rational behind the use of Neurofeedback:

Three major approaches to helping children who exhibit the symptoms of ADD.

1. Change the World Around the Child:

The prime method to achieve this goal has been behaviour management - operant conditioning - largely with parents, teachers and the child. Parents and teachers are trained in parenting and in reinforcement techniques. This method using conditioning of the child appears to have varying degrees of success when used in closed environments. Barkley, Dreikers, Patterson and many, many others have made contributions in this arena. Unfortunately much, if not most, of a child's life takes place in open and far less controlled environments. Today, most school environments may be considered to be relatively open environments where strict behavioural controls are relatively difficult to apply.

2. Change the Child's Ability to Inhibit Impulses:

The prime method to effect this change has been stimulant medication. However stimulants only work when they work! For the most commonly used stimulant, Ritalin, the half life is about 3.5 hours. The majority of students do not use these medications in the prime evening study hours due to their effects on sleep. Children may experience side effects both when on the medication and as the blood level of the medication decreases. The latter may include depression and a rebound increase in the symptoms of ADHD. It is now recognized that, although there may be definite short term benefits in the management of behavioural symptoms which results in more positive interaction with teachers and peers, significant long term benefits in academic achievement and social skills have not been demonstrated. (Swanson et al, 1993)

Another approach to decreasing impulsivity has been cognitive-behavioural training. One tries, either individually or with groups, to train children to stop and think before they act. Bloomquist, for one, has developed a step-by-step procedure for such training. It is an appealing approach since children take responsibility for their behavior. It is, however, very hard to do with ADD and ADHD populations and there is the same difficulty with generalization to open environments as was mentioned above for operant conditioning (behavior modification). The child who learns how to stop and think in the supervised play group may not do so on the unsupervised playground.

3. Change the Child's Ability to Cope with the Disorder:

Neurofeedback training is an effective method to assist the child to cope with the disorder, especially when combined with Metacognitive Learning Strategies. Unlike stimulants, neurofeedback training appears to have a direct long term effect on increasing the child's ability to remain focused (decreased Theta activity) and spend extended periods of time concentrating in a problem solving manner (increased SMR (sensorimotor, 13 -15 Hz) and/or Beta (13 - 18 Hz) activity). There is a significant decrease in the phenomenon of tuning out (associated with Alpha and/or Theta activity) when the child is expected to be carrying out an assignment or listening intently in class.

Neurofeedback training allows the child to gain control over their impulsive style of reacting, interacting and learning while they are simultaneously learning how to focus and concentrate. Many children who have ADD are impulsive; the child may know that an action should not be carried out but it is as if the "guard" is asleep. The child acts first and thinks it through later. The brain is normally able to control us and stop us from doing things impulsively. A capacity to inhibit appears to be related to activity in the sensorimotor cortex and is associated with EEG activity in the 13 to 15 Hz range. This activity allows us to selectively over-ride one thing in order to do another. It is this capacity that is markedly deficient in many children who have ADD/ADHD. Neurofeedback appears to have an effect equal to that of stimulants when it comes to increasing the child's "natural guards" (SMR) in inhibiting or avoiding impulsive actions. Stimulants are hypothesized to do this through activation in the reticular activating system which in turn stimulates the cortex of the brain. Neurofeedback accomplishes this directly by training the child to increase the sensorimotor rhythm .

From a client perspective, neurofeedback training is virtually the opposite of treatment by means of medication. In neurofeedback training children quickly recognize that no one is doing "it" to them. They are in control, responsible, empowered and working it out for themselves. The feedback is a useful tool which allows them to learn self-regulation. Metacognitive strategies enable them to apply this self-regulation to academic and organizational tasks. This is a potent combination!

What does it Feel Like to have ADD.

The brain of the child with ADD can be likened to a "flickering light". A sudden burst of slow wave activity - Alpha or Theta - in the middle of a complex task is equivalent to the individual being "functionally blind", tuned out, for that moment in time. Those who have ADD can attest to the frustration of continually finding that, despite the best of intent and even despite major interest in a topic, they find themselves missing key points and even whole sections of a lecture only minutes after it has begun. With ADD one may be thinking very intently and creatively internally while ignoring what is being said by a teacher. Although most people occasionally have the experience of reading a paragraph only to realize that their mind has been somewhere else, persons with ADD who have not developed specific counter strategies do this, not sometimes, but most of the time. In addition, even when the individual has not been thinking about something else internally, the mind has not, so to speak, gone into gear and become actively involved in the passage (a state associated with Beta wave activity). ADD people are often very superficially involved when reading or listening.

What may be very confusing to parents is that often the individual with ADD may exhibit superb concentration and focus in specific situations. They may even, at times, be superior to their peers! Children with ADD may, for example, become totally absorbed in games of Nintendo, certain T.V. programs, and building with materials such as Lego or Playmobile. Only some of these activities are exceptionally fast changing, therefore, this is certainly not the only factor which might account for their intense concentration. In the 1970's, while doing data collection for her thesis on the effects of Ritalin in hyperactive children, Lynda Thompson (Thompson, 1979) noted that a disproportionate number of the ADHD boys who were hockey players played goalie. This is a position which makes the most of inborn characteristics of many ADHD children. Goalies receive individual instructions and do not therefore have to pay attention during strategy sessions in the dressing room. When on the ice, their attention can wander when the puck is at the other end of the arena without adversely affecting their performance. However, when the puck is in play close to them, they appear to become mentally "locked on" to it and virtually nothing distracts them, including screaming fans. The mental state of hyper-focus, which ADD people are capable of, is very adaptive in a goal-tending situation. On the other hand, this state can irritate a parent whose repeated calls are ignored because the child is in hyper-focus in front of the T.V. or Nintendo! Many scholars and senior business persons who have ADD note that they can "lock in" to focus on documents that they are creating, or plans they are developing and virtually nothing can distract them when they are in this type of activity. In the authors’ experience, most of these individuals attribute their success to the development of metacognitive strategies to deal with their difficulties in concentrating. This in turn may have made them better students than persons who had never had to work at learning how to learn! One example of such a person is a brilliant physicist who became an expert in test-taking strategies and has published 18 books on that subject. Ironically he still has trouble sitting through a lecture without impulsively calling out a question or comment!

In programs which combine neurofeedback with learning metacognitive strategies children are empowered by learning self-regulation so that they themselves cope with tasks and maintain an active learning mental state.

Which Children Benefit most from Training:

Parents often ask if intelligence is the key factor involved in successfully dealing with ADD. It is true that, as with other kinds of learning, learning self regulation is generally easier for children who test at a high level on standard intelligence tests. However, I.Q. scores do not reflect other variables that are important in achievement, such as perseverance or creativity. Intelligence tests originated with Simon Binet in Paris simply as a tool to help predict which children would do well in the school system. Intelligence, in the broader sense, is made up of a number of inter-related components which include such factors as the following:

Areas predicting school performance (as tested on standard IQ tests)

Memory (short term, longer term and types of memory such as visual or auditory)

Motivation

Persistence (and the factors which seem to stimulate it for a particular child).

Creativity

Goal Setting ability

Self confidence, "street smarts" and the ability to read social cues

Approaches to learning and remembering

Attention span and ability to concentrate

Given a basic modicum of natural ability in each of the foregoing areas, for effective learning the student also requires the ability to turn on:

a relaxed (not tense) state of mind and approach to learning

a high level of alertness

flexibility and control of mental states (not in a meditative alpha state or a drowsy theta state when attempting to problem solve complex material)

focus and attention with ability to exclude irrelevant material

concentration and a problem solving state of mind (associated with beta wave production)

a thoughtful, reflective, considered style (not impulsive)

It is these latter factors that can be most directly affected by neurofeedback training and these, in turn, affect each of the factors listed under "intelligence" above. Many people doing neurofeedback with children report increases in I.Q. scores (Michael Linden, S. Othmer). The I.Q. gains at the ADD Centre are in the range of 10 to 20 points which is greater than could be explained by any practice effect. ADD Centre retesting on the Wechsler has found the subscales most affected by attentional factors (general information, arithmetic, digit span, coding) consistently demonstrate gains, often 3 to 4 Scaled Score points, to as much as 8 (from a Scale Score of 2 to 10). Since I.Q tests are considered good predictors of academic success and since improved attentional processes go along with improvement in school performance, these gains appear to be valid. These results are not just a measurement artifact. With improved attention, the children are now better able to meet their potential.

Overview of Training:

The training program at the ADD Centres comprises 5 overlapping stages or steps. Some students have developed habitual counterproductive styles of coping with perceived stress. These coping styles or "bracing" techniques may include becoming very tense and anxious, displaying decreased arousal, opting out, and "distress" autonomic states. These coping patterns are usually learned very early in a child's life and are automatic and usually outside of cognitive awareness. The first two steps in training help counteract these negative coping styles.

Step 1. Raise fingertip temperature: This is used with candidates who report performance anxiety and demonstrate low fingertip temperatures.

Step 2. Regulate the EDR: This is emphasized in candidates who are reported to have low arousal (alertness) levels in class or work meetings and who exhibit low or labile EDR. Students report that they feel more relaxed yet alert, awake and energetic when they learn to control these parameters.

These first two steps create a "eustress" state (reference: Thomas Allen) and are relatively quick to learn. They give the children a real sense of empowerment, since self-regulation of temperature and arousal is easier to learn than self-regulation of brain waves. Mastering these first two steps gives the student confidence that they will master the steps involving brain waves too. The third, fourth and fifth steps run concurrently with the first two.

Step 3. Hold the slow wave (usually 4 to 7 Hz but may be 9 to 11 Hz) at a lower microvolt level and decrease variability: To decrease theta (4 to 7 Hz) standard deviation and variability the student must maintain a steady focus on a topic for increasingly longer periods of time. Parents and students often initially ask what they should be doing in order to decrease both the amplitude and the variability of the theta wave. We use the analogy of learning to ride a bicycle to help them understand that just as one cannot explain how to "balance" one cannot put into words how to control brain waves. In the analogy to learning to ride a bicycle it is pointed out that the brain receives direct and immediate feedback from the inner ear concerning going off balance. In training the student is receiving direct and immediate (less than 50 milliseconds delay with some instruments) feedback concerning going off focus. Given this directness and immediacy , the student trains rapidly to self-regulate and, just as in riding a bicycle, the new learned behaviour remains accessible over time. Some students may not demonstrate high theta wave amplitudes but rather show very high amplitude bursts of alpha (9 to 11 Hz). Some of these students we have nick-named, "bright-daydreamers". During these periods of high amplitude alpha they are not paying attention to external input be it verbal or from reading. These students are taught to decrease the number and length of these alpha bursts when they are attempting to tune in to a lecture or a text book.

Step 4. Increase fast wave (12 to 15 Hz and 15 to 18 Hz) activity: The student is encouraged to find the mental state in which they can continue to hold down the slow wave activity and increase the fast wave activity for reasonable periods of time. When in this state, students report that they remain acutely aware of their surroundings but remain totally "absorbed" by a single train of thought and mental activity. We often liken this alertness and focus to the mental state of a very high level expert in the martial arts. The students at the ADD Centres, when highly focused, sometimes report a concurrent sensation in their abdomen and occasionally a mild headache if they come out of this state too rapidly. The fast wave activity which is being trained may be in the SMR range (Sensorimotor Rhythm, usually 13 to 15 Hz) or the Beta (usually 15 to 18 Hz) range depending on both the presenting difficulties of the child and their initial response to training. The more impulsive, fidgety students begin with SMR training. With the younger children, one exercise we may do is to pretend that we are hunters in Africa. We hunt using cameras. We must remain perfectly still, not a single muscle on our fingers or face can show even the slightest movement or the animals that are grazing and moving slowly toward us might see us out of the corner of their eye (just as the student can see even the slightest movement the trainer makes). The animals would run away and we would miss the perfect picture! Older students can be reminded that even a pilot landing a jet plane will turn off cognitive processing waves (16 to 18 Hz) momentarily when reaching forward to turn a switch. We tell them that their conscious brain will only do one main thing at a time; it will either rest (slow waves) or work hard (fast waves).

The electrode placement is referential ("monopolar") and it is usually placed in the C3 position with the reference electrodes being linked ears. C3 appears to be a particularly effective site for nonimpulsive children with specific "left-brain" academic difficulties (particularly in reading, language, or sequencing). Other electrode positions such as C4, or Cz, may be chosen for selected cases but are not as frequently used.

The fifth step is to continue doing the first four steps while reading, listening, and presenting material in a manner that is extremely well organized and which utilizes metacognitive strategies to increase the student's ability to assimilate, organize and recall information.

B. METACOGNITVE STRATEGIES:

The strategies presented here are not always new to the client. Good teachers and parents may have tried to share them previously. But the ability to enter and remain in a mental state wherein these strategies are actively and continuously used over a period of time is almost always an entirely new experience for the students.

The Problem - Discouragement & Lost Hope:

The majority of students are concerned that their memory, at least for subject matter covered at school, is poor. Some of these students have given up trying to remember material and use both conscious and unconscious defenses to excuse themselves from feeling that they are being fairly evaluated by others in academic tasks. One of the more common defenses is an attitude or mindset of; "I don't care; it's all useless anyway. I want to quit school as soon as I'm old enough and earn money." This may be directly and confrontationally or passive aggressively and indirectly expressed. The passive aggressive stance is perhaps the most difficult to deal with. In this stance the student may begrudgingly agree to do the work or even smile and be quite pleasant and agree that the work will be done. Then, despite many reminders, it is not completed, completed far below their ability, or completed but just not handed in on time or at all. The terms "lazy and unmotivated" are often applied to these students.

Getting Started with a Solution - Small Successes:

Over the years these students have become discouraged. Their self confidence in many academic areas is low and many have simply given up. Our initial job is to catch their interest in a non-threatening fashion. During the initial interview they see their own brain waves and find that they have some immediate control over their hand temperature and skin conduction and can even change things happening on the screen by focusing and concentrating. This is extremely helpful in stimulating their interest. Virtually all, even the initially reluctant students, want to come back!

The Training:

Neurofeedback training takes time. Some of the students, though initially fascinated, become quickly discouraged. Metacognitive strategies, apart from being an integral part of the program and essential for maximizing the student’s potential, are also a good means for catching interest and producing immediate changes in their academic endeavors. Taught without the feedback, in our past experience, the majority of students would use only a few strategies and would return rapidly to their old patterns. Taught during neurofeedback, the ADD Centre students appear to apply many of the strategies on an on-going basis. Their initial and continuing interest in working on strategies during sessions is completely different than when strategies were taught without neurofeedback.

We initially train the students in strategies for listening, reading and organizing written work. We train the students to apply seven steps to every listening and reading learning situation. The seven steps are listed below. With many students the trainers may make the 7 steps more visual and palatable by an analogy to target shooting. The trainers pretend they are shooting with a double-barreled pistol. First, from a closed fist position, the thumb is extended vertically. This represents the sights of the pistol. Then the index finger is rapidly extended pointing forward, at an imaginary target. This is the first barrel which represents steps two and three of the seven strategic cognitive steps. Then the middle finger is rapidly extended forward representing the second barrel and stages four and five of the strategies. The student is told firmly that it would only be at this point, stage four, that a book would be opened. Beginning to read the chapter would not begin until stage five. Finally the trainer's little finger moves out at right angles to the two finger barrels of the pistol and it represents the binoculars through which the student looks to see what the score is on the target. This finger represents the last two steps which are methods of review in which the student examines what they have learned. The seven steps are outlined in Figure 1. The teacher introduces the steps using the gun analogy outlined above.

Figure 1.

THE SEVEN STEP STRATEGY (SSS)

In every step an internal dialogue:

GENERATE QUESTIONS & PREDICT ANSWERS

" the gun sights "

STRATEGIES - "HOW"

2.

FREE ASSOCIATE

- the tree and it's branches -

3.

ORGANIZE & SYNTHESIZE

- headings / grid & the organizing principle / the red thread -

- scaffolding & linkages

"the second barrel"-Shift to ‘immediate & short term Memory ' -

"the second barrel STRATEGIES"

the binocular target check - what's my score ?"

-shift to ‘intermediate memory' -

- shift to ‘long term memory’ -

7.

PERFORMANCE PAYOFF

What have I Learned ?

What is the PRODUCT !

Conclude:

AP not PR = ACTIVE PARTICIPANT emotionally involved

NOT a PASSIVE RECIPIENT

Learning being interesting depends on the student not the teacher !

Introducing Learning Strategies in The First Few Training Sessions:

Although outlining the abovementioned seven steps may be helpful with older, more mature students, the trainers more often outline the steps after they have been "experienced" by the student who has been asked to carry out a number of reading and organizing tasks during several neurofeedback training sessions. Examples of these tasks are outlined below. With younger students a simpler method may be used. The student is taught to use the W-W-H-W PARADIGM; that is, "Why am I doing this?/What is it I wish to learn?" "How am I going to approach this task?" "What did I learn?" These questions, explored in a simple, enthusiastic manner, will engage even early primary grade students. All students enjoy the positive reinforcement that follows the final question; "What have I learned in this section?" (At the completion of each step tokens are awarded! Tokens can later be exchanged for prizes, gift certificates, etc.)

The first step towards beginning to teach strategies to students age 12 and over, however, is an exercise which is carried out to stimulate a sense of reality concerning their ability to remember even easy items. This acts as a catalyst to learn techniques which might improve their memory. The teacher uses this opportunity to teach the student time management, study organization and a basic learning-to-remember strategy. This exercise is as follows:

The Memory Paradigm:

Immediate, Short Term, Intermediate, Long Term memory and A test of Memory:

Students often realize that their memory is less than it should be. Quite early in the training these students are presented with a short challenge in a fun, game-like manner. They are asked if they include regular, daily review of material presented in their classes in a routine study time?" The majority do not. They are then asked if they added this to their routine would such a habit require more or less study time?" These questions usually lead to an interesting interchange.

Students are then challenged. They are asked to examine how well they can recall telephone numbers. Most agree that they do not find it difficult to learn and recall a telephone number. The student is then given a number to remember. It is easily recalled. Then they are given a second phone number but immediately asked to look at a picture on the wall and name 3 colours that are in it. Virtually all the new students cannot then recall either the number they were just given or the number they had recalled correctly just a minute before. This simple procedure engages even the most resistant students. They are then asked how this might relate to listening to a teacher talk and then being asked even five minutes after the beginning of a lecture, what has been said. The analogy is a powerful one and usually evokes a question as to how they can improve their memory.

They are told that they have just shown they have a good immediate memory but they have also just demonstrated to themselves two other facts. First, that their immediate memory will fade almost instantaneously unless they do something else with the information and, second, that any simple quick distraction will interfere with their memory. The trainer, almost in passing, notes that when a person does even a few seconds of work on material, for example, attempting to associate it with something familiar and amusing; they usually will be able to recall it an hour later. The student is then asked to read a few lines of material, make some amusing association and recall it at the end of an hour. They are then left with the thought that they may be able to learn how to recall quite large amounts of material if they first learn ways of organizing it and relating all the facts to one underlying principle which we call the "red-thread". After this exercise, students better understand why they must review new material at least once again the same day it is taught in order to commit it to intermediate memory. We tell them that this may last longer than a minute or two, or even longer than a couple of hours or days, but it w