Electrodermal response based biofeedback in pediatric patients

Modern biopsychological opinion recognizes the importance of the interrelationship between mind and body, especially for the developing human organism.
In this context biofeedback has emerged as a non-pharmacological treatment strategy for children and adolescents, evolving the link between emotions, cognition, behavior and physiological responses.
In this paper we present review of literature as well as some of our results obtained using computer aided second type biofeedback based on electrodermal activity. The method was applied to different groups of pediatric patients (ticks, enuresis/encompresis, somatization, anxious-phobic reactions, ADHD, anorexia/bulimia, stuttering, tension type headache and nightmares). The statistics showed significant improvement with this kind of therapy in all groups (p < 0.05).
Finally, we pointed out that biofeedback care in pediatrics is highly cost-effective, with good discrimitivity for the actual level of stress as well as good therapeutic results through relaxation, when used in combination with standard psychometric and psychotherapeutic methods.
Pediatric healthcare has evolved over the past 25 years from a field with a strong emphasis on a biomedical basis such as nutrition and infections to a reaffirmed biopsychological framework which recognize the importance of the interrelationship of mind and body for the developing human organism. When dealing with the health and well being of children we need to consider physical, emotional, intellectual and spiritual domains across setting (1).
It is very important to integrate mind and body in our approach and emphases each childs autonomy, responsibility and participation in their own health and well- being. In 1994 Spigerblatt and colleagues (2) pointed out that parents are increasingly interested in mind/body techniques for their children, seeking non-pharmacological treatment options. Also, patients want to be treated as a whole person, not just their disease. They want to be active participants in treatment, communicate better with the doctor and they want treatment that is not worse than the disease itself.
The use of biofeedback and self-regulation skills training with the pediatric population is growing rapidly. The past 15-20 years have been a time of remarkable progress in the area of pediatric self-regulation. A significant increase in research articles has documented the efficacy of biofeedback and self-regulation strategies for children and adolescents manifesting many behavioral problems. Biofeedback is recognized as a first-line treatment strategy for children with headaches, enuresis, school performance problems, Attention deficit hyperactive disorder (ADHD) as well as a useful complementary therapy for children with a variety of chronic illnesses including asthma, cancer and diabetes. Rebecca Kajander and Eric Peper (4) pointed out the importance of breath control training for children with a wide variety of psychophysiological disorders. Moreover, Scott Faber (5) reviews the wide range of applications of neurobiofeedback for pediatric neurobehavioral disorders (EEG biofeedback treatments).
Surface EMG (Electromyography) biofeedback training has been accepted in neuromuscular rehabilitation and training for children and adolescents.
The essential role of self-regulation techniques applied to pediatric pain management is also well known. Cognitive/behavioral and biofeedback strategies are very useful for children with anger management problem (6).
There is no question now that biofeedback care is highly cost-effective. Military psychologists in Hawaii have demonstrated that biofeedback used with war veterans with PTSD (Posttraumatic stress disorder) and on victims of physical and emotional trauma has been very successful and cost-effective. The effective use of Quantitative EEG has been reported in Mild Traumatic Brain Injury as well as a diagnostic tool for difficult cases where objective findings were limited. In particular QEEG (Quantitative EEG) neurobiofeedback training is the therapy of choice in children with ADD/ADDH or learning disabilities (7). Last year the American Society for Neurophysiology supported four applications for QEEG in adults: stroke, dementia, intraoperative monitoring and epilepsy.
O l n e s s (8) 1996 points to the fact that many of the techniques used in biofeedback work with children are similar to hypnotic induction and deepening strategies. The type of mental imagery used by children results in differential physiological activation patterns. Evidence from studies on EEG biofeedback for ADHD suggests that children can learn to alter their EEG amplitudes and maintain this learning in a sustainable way over a long time period (9, 10, 11).
Biofeedback can play a powerful role in mind/body education for children by illustrating that a change in thinking causes a change in the body in a very immediate and real fashion. For example, as a child imagines a favorite place or special activity, he can observe the related changes in temperature, EMG activity, breathing or EDR (Electrodermal response), which is very impressive.
Current childhood problems and techniques used in pediatric are presented in Table 1, Table 2 and Table 3 ( Culbert T., Reaney J in Biofeedback, 26, 3: 11-12).
Strong literature support as well as our own experience for biofeedback based strategies as first-line treatment exists for childhood tension-type and migraine headache (12). Children with disorders of elimination clearly benefit from biofeedback-based strategies. Exciting biofeedback therapy has been evolved also for children with various forms of anxiety, expressed as panic attacks or generalized anxiety disorder and somatization including breath control training, EDR and peripheral temperature modalities (13, 14).
What biofeedback really means?
Biofeedback is a method of learning to control ones bodily and mental functions with the aid of a visual or auditory display of ones own brain waves, blood pressure, muscle tension, etc. (15).
The antecedents of the development of biofeedback were: physiology and psychophysiology with the knowledge of the interrelation between physiological and cognitive processes, theory of learning, cybernetics, studies about the stress and techniques for stress-reduction, behavioral medicine and therapy and biomedical development such as EMG, EEG, ECG (16).
There are two main types of biofeedback presented in Figure 1.
The EDR- based biofeedback we use represents the second type of biofeedback. Inner Tuner Expert System (licensed by Ultramind, London) comprises a multimedia biofeedback system. Minute changes in the patients galvanic skin response provoked by thought and emotions are transmitted by electrodes to the computer and fed back in visual and audio form . The system could be applied as an assessment procedure, showing the stress level, changes of the emotions and thoughts, as well as in therapeutic management as muscular relaxation, breathing exercises, thought control, emotional control etc.
As is known from experimental work EDA is influenced by one pathway through hypothalamic and limbic structures and another through premotor structures via the pyramidal tract (17, 18). Changes in electrodermal activity can be reliable detected within < 1 s. of stimulus presentation, often following a single event. Those changes, which may be linked to slightly different aspects of behavior than cardiovascular changes have been used successfully to study implicit aspects of cognitive processing (19). For example, it was found that individuals who have difficulty identifying faces show normal changes in their electrodermal responses to a familiar face, whilst claiming at a conscious level to have never seen the face before (20).
Peripheral techniques (such as EDA) are an essential part of the inferential chain linking brain to body and mind to brain. It must be pointed out that no two measures detect exactly the same physiological process and each measure has its strength and some limitation (EEG, PET positron emission tomography, fMRI - functional magnetic resonance, EDA).
Our experience with biofeedback techniques comprises the assessment of stress level as well as the therapeutic application, as additions to the classical psychometric and psychotherapeutic methods (21).
In Table 4 we present results obtained with biofeedback treatment in different group of pediatric patients. As it is shown on Table 4, we have evaluated biofeedback results for different groups stress-related disorders. In the assessment procedure, EDR showed the level of actual stress presented on the computer numerically, graphically or auditory. The assessed mean values of the one-minute changes of ED resistance (in micro ohms) correspond to the first arithmetics in t-test. After 4 weeks of treatment with different EDR biofeedback relaxation procedures selected according to the disorder characteristics, we obtained the last numerical values of the stress level. Student t-test represents the difference between the first and lasts ED resistance values.
As is clearly shown the therapeutic results obtained from EDR- biofeedback in pediatric patients are very satisfactory. The obtained statistics correlate with observed clinical improvement (symptom free period at least for the next two months).
Biofeedback is particularly being applied as a non-pharmacological mind/body treatment strategy for children. The field of biofeedback has evolved concurrently demonstrating the links between emotions, cognition, behavior and physiological responses. It has clearly demonstrated the ability of children and adolescents with a variety of problems to mobilize self-regulatory abilities using techniques such as biofeedback, self-hypnosis, breath control training, progressive muscle relaxation and cognitive-behavioral strategy (3).
In todays high technology world children are very comfortable with computer literature and computer-based multimedia games, videogames and educational software. So, biofeedback is very like a videogame for the child s body. Children are wonderful biofeedback learners, better than adults. They are more enthusiastic, learn more quickly, they are less skeptical about self-control procedures and have more psychophysiological liability. Children are also reliable at symptom monitoring and they enjoy practice sessions.
Our own experience, as well as the experience of other therapists, confirms the good results obtained with biofeedback techniques. EDR-biofeedback has an other advantage: it is very easy to apply (sensors are on the fingers of the left arm). The software we used comprised games such as videogames for children and they adjust to all procedures. The results are visible after 4 weeks of treatment, which confirms that this kind of therapy is highly cost-effective.
Biofeedback in children and adolescents represents a good choice for non-pharmacological treatment of behavioral and stress-related disorders. The application is quite simple, cost-effectiveness is high, and hospitalization is excluded. Biofeedback integrates the mind and body in holistic approach to stress-related disorders, and it is useful in assessment as well as in therapeutic procedures.
Category: Review
Volume: Vol. 43, No 3, july - september 1999
Authors: N. Pop Jordanova
Reference work: