Unreachable Child

Working with the ‘Unreachable’ Child– A Physiological Perspective, and a Proposed Approach

Siegfried Othmer, Ph.D. April, 1999

Psychopathology and Brain Behavior

This century has seen the emergence of physiological models of behavior. This development is driven by pharmacology, by the new imaging techniques, and by studies at the cellular level. It has borne fruit mainly for the less severe mental disorders, such as ADHD, dysthymia, anxiety, and depression. There is still no good medical answer to the more severely disruptive behavior disorders, to specific learning disabilities, and to the personality disorders and to their youthful precursors. Yet we have reason to believe that these conditions are also largely functional in nature-not structural-and that remediation should in principle be possible. I want to address myself to this more challenging end of the distribution.

Recent developments in the neurosciences have led to therapeutically useful models of how the brain organizes its own function on every relevant timescale. Insights are being gained into how the brain encodes information, and how communication between different brain regions is orchestrated. A central organizing principle appears to be that simultaneity of neuronal firing is a criterion of belonging to the representation of a particular percept — or mental construct. This is known as “time binding.” It is readily shown that the brain must do a lot of its processing in parallel. There is simply not enough information in a serial data stream for us to act upon as promptly as we are able to. In particular, it is clear that the visual pathway involves massively parallel processing of data “packets.” Remarkably, we are able to keep a stable image in our brains even as our eyes dart about the landscape, and as we move our heads. Such a stable image in our brains is a construction—a fiction, not the reality. It must be actively maintained, and it must incorporate new information that is continually streaming in. It appears that the brain accomplishes the task by ordering the information microscopically in the time domain. Cells that fire simultaneously, under a given stimulus, are deemed to be part of a particular mental construct. Time, therefore, represents the “space” for encoding of information.

If information is contained in transient events of “bunches,” or “ensembles” of neuronal firings, then the brain also has the burden of giving us the experience of continuity. The brain arranges this through repetition, or near repetition, of such firings. Such repetition is found to be periodic, i.e. rhythmic, driven apparently by rhythmic pacemaker circuits. In the case of transient events, like listening to speech or a piece of music, the transient organization of the brain for information processing does not have to be very persistent. However, we are inclined to the belief that nature in its parsimony has used this same mechanism, economical as it is, to organize more persistent states. Here we are talking about states of attention, arousal, wakefulness, vigilance, and affect. The problem is really the same-to organize the persistence of experience. This can likewise be done through rhythmic pacemaker circuits.

We have seen the evidence of such pacemaker activity since the human electroencephalogram was first discovered in the late twenties. Its most obvious and notable feature was rhythmicity—in particular, the famous alpha rhythm. But the functional significance of such activity has not been clear, and it is still not a settled issue. At this point, what we are saying represents a very plausible hypothesis, nothing more.

It is proposed that a variety of such pacemaker circuits govern cortical and subcortical function generally, and that specific learning disabilities, affective disorders, and more severe disturbances of mental function can be traced to the disregulation of such circuits. In the case of severe emotional trauma, disregulation of emotional circuitry can result, with lasting impact.

It has been proposed that a variety of such pacemaker circuits govern cortical and subcortical function generally, and that these play a core role in neuro-regulation. The brain can be thought of in terms of a “virtual conductor” who establishes the basic timing against which the symphony of brain activity plays out. This model allows us to explain a number of puzzling phenomena. A breakdown of the organization of these rhythmic pacemaker circuits can lead to disruption of function. And such a breakdown of function may not leave much other evidence. This is probably what happens in minor traumatic brain injury such as whiplash, where often there is no evidence at all of a structural injury, yet people may be left rather dysfunctional. It can also explain certain specific learning disabilities, such as the kind of dyslexia where the image is not stable on one’s interior “screen.” And we can argue that such disorganization is a concomitant of much psychopathology. Not only cognitive processes, but functions such as affect regulation can be understood in terms of linkages between different brain regions that are subject to the same timing and rhythmicity constraints as other circuits. Sudden excursions into suicidality or mania can then be seen as primarily due to the failure of such regulatory loops. In the physiological domain, much of psychopathology can be seen in terms of the failure of the brain to control its own state. And the problem can be largely in the organization of timing. All this would be of only academic interest if it were not for the fact that the centrality of rhythmicity in organizing brain function gives us a powerful tool for intervention.

We have gone rather far downstream in terms of speculation with respect to brain mechanisms, without much grounding in data. As it happens, the evidence for the central role of brain rhythms in organizing our behavior has been right before our eyes, but it was not generally appreciated. The incident in Japan (November 1997), in which children went into seizure following a mere 5-second exposure to a rhythmic optical signal on television, demonstrates how utterly dependent we are on the integrity of our brain’s rhythmic activities. This event affected one out of 5,000 children. These children’s brains were not sufficiently stable to maintain integrity of function even with this tiny, brief rhythmic visual challenge to the system. (If such major failures were commonplace, rather than extremely rare, we would probably not be around as a species!) The critical feature here was clearly the rhythmicity. As in the case of Freud, and of the neurologist Paul Broca, we learn about function from dysfunction.

In the case of severe emotional trauma, disregulation of emotional circuitry can result, with lasting impact. Through considerations such as this, we (and others) have proposed a disregulation model of psychopathology — the proposition that the core issue consists of disregulation in regulatory networks, largely irrespective of whether the condition has a genetic, developmental, environmental, or even purely psychological cause.

Over the last thirty years, it has been learned that operant conditioning on brain rhythms has an impact on physiological functioning-for good or ill. This is variously called EEG biofeedback, neurofeedback, or brainwave training. By carefully adjusting reward contingencies on the EEG training, it has been found that attentional disorders can be remediated with this training. More recently, it has been found that affective disorders respond to this training even more readily. Thirdly, disorders of arousal respond to the training (sleep disorders, migraines). From the perspective of this fundamental training of brain rhythms, it is clear that these functions are highly interdependent. Attention and arousal are coupled systems; affect and arousal are interrelated; and finally attention and the affective realm influence each other. In fact, the affective realm may be the more fundamental issue in attention: we attend to what we value, and if the value-setting part of the brain is not functioning well, we can expect to observe ADHD.

More fundamentally, we assert that the issue in all of these disorders is the underlying one of brain self-regulation of states. The brain must be able to maintain stable states. And it must be able to maintain homeostasis. The more severe the condition being addressed, the more we are confronted with instability in brain function. The EEG training appears to support the maintenance of stability of states. This also may be the underpinning of working memory. The ability to hold and elaborate a thought is dependent on the integrity and continuity of brain states. An increase in working memory is indicated by some of the measures subsequent to EEG training.

Attention Deficit Hyperactivity Disorder (ADHD) and Impulse Control Disorders

ADHD is the most commonly diagnosed mental disorder of childhood. Whereas stimulant medication is the most common remedy, it is often not the appropriate one; it only rarely deals with the issues comprehensively; and it is often voluntarily abandoned, despite the fact that the condition is usually lasting. EEG feedback training can help to remediate all of the characteristic symptoms of ADHD: impulsivity, distractibility, hyperactivity, and inattention. That is, behavioral control can be learned to the point at which the child no longer meets diagnostic criteria in the general case.

75% of inmates referred for mental health services in the California correctional system had been identified as ADHD in their school years, and 75% of these had been on Ritalin at some time in their lives. Follow-up of ADHD children into their adult years finds no difference in measures of social pathology (antisocial behavior, criminality, suicide, addiction, divorce) between those who had been on Ritalin and those who hadn’t. Clearly what has been proposed as the answer to ADHD in principle is not the answer in practice. Brainwave training, on the other hand, addresses the underlying issue of brain disregulation; it does so comprehensively; and the benefits of training appear to last, barring renewed insult to the nervous system. More data exist on the use of EEG feedback for ADHD than for any other condition.

Specific Learning Disabilities

ADHD is the most commonly diagnosed mental disorder of childhood. Whereas stimulant medication is the most common remedy, it is often not the appropriate one; it only rarely deals with the issues comprehensively; and it is often voluntarily abandoned, despite the fact that the condition is usually lasting. EEG feedback training can help to remediate all of the characteristic symptoms of ADHD: impulsivity, distractibility, hyperactivity, and inattention. That is, behavioral control can be learned to the point at which the child no longer meets diagnostic criteria in the general case.

75% of inmates referred for mental health services in the California correctional system had been identified as ADHD in their school years, and 75% of these had been on Ritalin at some time in their lives. Follow-up of ADHD children into their adult years finds no difference in measures of social pathology (antisocial behavior, criminality, suicide, addiction, divorce) between those who had been on Ritalin and those who hadn’t. Clearly what has been proposed as the answer to ADHD in principle is not the answer in practice. Brainwave training, on the other hand, addresses the underlying issue of brain disregulation; it does so comprehensively; and the benefits of training appear to last, barring renewed insult to the nervous system. More data exist on the use of EEG feedback for ADHD than for any other condition.

Specific Learning Disabilities

It has been proposed that specific learning disabilities are important factors in much of youth criminality. Learning disabilities are much more common even than ADHD. There is no medical remedy, and the educational remedies adopted to date are clearly inadequate. Evidence has accumulated that EEG training can be helpful in specific learning disabilities such as visual retention, articulation, and dyslexia. Since dyslexia is not a unitary concept, no single approach is appropriate for all cases. To date, therefore, success with dyslexia is still hit-and-miss. The training can influence one’s capacity for spatial organization, and it can extend the auditory and visual digit span. WISC math subtest scores may be significantly improved, suggesting greater working memory capacity. This kind of improvement tends to support the proposition that specific learning disabilities are largely functional in character, and traceable to deficits in brain organization that appear to be largely remediable. Much still needs to be learned, however, to determine the appropriate training protocol in each case.

The Disruptive Behavior Disorders-Oppositionality and Conduct Disorder

In the context of work with ADHD, it was found that the EEG training was equally successful in remediating oppositional behavior and conduct disorder, temper tantrums and episodic rages. This takes such behavior out of the realm of moral failing-although it may be that also-and places it squarely in the domain of neurophysiologically based dysfunctions. One virtue of the training is that the conduct issue never has to be confronted per se with the trainee. He or she simply has to be willing to train his or her brain.

Reactive Attachment Disorder (RAD) and autism

One of the most intractable disorders in the realm of mental health is Reactive Attachment Disorder, or RAD. Here the basis does not exist for the formation of a therapeutic alliance with the patient. Fortunately, and fortuitously, it has been found that EEG training can reestablish the internal linkages within the brain which allow the person to reconnect with the ground of their emotionality-and ultimately to recover both the power and the willingness to establish emotional bonds with others. This has been possible even in cases of the most abject early childhood trauma. Remarkably, the pathways of connectivity to the emotional self remain entirely intact-though disrupted in organization until subjected to the reorganizing challenge of EEG training.

In the case of autism, we also have a disruption of the capacity for attachment, but in this case for either genetic, metabolic, or developmental reasons (as opposed to a traumatic basis, or arising out of neglect). Despite the existence of manifest organic deficits, the recovery potential for attachment and for affect regulation may be considerable. This is a very recent finding.

Post-Traumatic Stress Disorder

One of the tragedies of our human condition is that those who are severely traumatized as children often replicate this abusive behavior in their own adult lives. It is difficult to be sympathetic, even though one may be aware of the causal chain of events. One way of understanding this is in terms of a fundamental disregulation of our subcortical circuitry by which emotions are regulated. These mechanisms are not under sufficient cortical control. Fortunately, such cortical control can be strengthened with EEG training, and PTSD can be resolved essentially non-traumatically. This is indeed a startling assertion, and not one that is easily accepted by anyone who has worked extensively with PTSD. Such skepticism is understandable, since PTSD has traditionally been so intractable. The claim is not that resolution of PTSD has suddenly become either simple or straight-forward. But it can be accomplished non-traumatically.

Addictive Disorders

It is useful to regard addictive disorders from the physiological perspective. On the one hand, continual use of a drug may simply have brought about a physiological dependence on the chemical. The more intractable cases of addiction, however, are sustained by more serious psychological conditions that lead to a breakdown in the reward circuitry of the brain, a phenomenon called Reward Deficiency Syndrome. Genetics plays into this as well. However, it has been found that irrespective of a genetic or developmental or environmental basis to the status of addiction, “recovery”-in the sense of relapse prevention-is possible with EEG training, in combination with conventional therapies. Remarkable results have been obtained with alcoholism, cocaine addiction, methamphetamines, and heroin. Some of the early studies now have follow-up for up to ten years.

Tourette Syndrome

Tourette Syndrome is characterized by motor and vocal tics. Tourette’s is often seen in connection with obsessive-compulsive disorder, ADHD, and conduct disorder. Of particular importance are those instances in which a Tourette vulnerability is comorbid with PTSD or other insults. In these instances, one may see hypersexuality, hypermasculinity, thrill-seeking behavior, and episodic rage. Touretters are known for the bearing of grudges, itself perhaps an aspect of obsessive behavior. The ritualistic rehearsal of an act of retribution may ultimately cross the threshold into overt violence, particularly if the act has just been modeled. This mechanism may lead to violence even years after a presumed slight, and probably accounts for a lot of copy-cat crime. Fortunately, the more objectionable symptoms associated with Tourette Syndrome are responsive to EEG training. The problem of irrational and episodic violence in children.

The problem of violence in children is currently acute. Child-on-child violence in this country is at a level of one Littleton every day. The etiology of violent behavior is multi-faceted. In broad brush, we can see violent behavior coming out of abuse histories, histories of profound neglect, and various conditions that disregulate behavior in the emotional realm—the epilepsies, Tourette Syndrome, traumatic head injury (including birth injury), and the anxiety-depression-bipolar spectrum. Thus etiology can be environmental, developmental, or genetic, or more typically an incendiary combination of a number of these factors.

One of the most profound observations of recent times is that neglect can be as damaging as abuse, in terms of disturbing the natural development of emotional self-regulation. And neglect sufficient to have lingering negative impact on emotional regulation is probably commonplace in the modern life of American children. Adding to all of this is the constant rehearsal of violent and destructive behaviors in the entertainment media. It is okay with our society for children to experience every emotion around thrill-seeking, violence and senseless death, and to do so in a context which obscures the traditional clarity of moral choices. Ultimately the only way to trump the manufactured tension of movies and video games is to replicate the experience in life itself, i.e. to be the director in one’s own play.

One of the more sinister implications of the calculus of violence is that persons are unlikely to value others more highly than themselves. A diminished self-appraisal is therefore contributory to the escalation of violence. Likewise, if there is a sense of limited prospects to make a positive difference in the world, the temptation looms large to act destructively. There is then a reversal of the usual scale of values. To a Ted Kaczynski, for example, a plea of guilty meant death-a removal from the focus of our attention, whereas a death sentence would have meant a certain immortality. Another aspect of violence, as with other thrills, is that it allows children to feel alive. In this regard, violent behavior can be seen as another manifestation of the Reward Deficiency Syndrome that has been used to model addictive behavior.

The essence of our humanity is our social nature. We must have connectedness to others in order to be fully human. Once the sinews of connectivity are broken, they are unlikely to be reestablished by purely psychodynamic interventions. The child’s physiology is fundamentally altered, and a physiologically based approach may therefore have to have priority. Such an approach is EEG biofeedback. Recent findings indicate that it may be profoundly helpful, particularly among the most unreachable of children.

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