Multi-modality neurofeedback and biofeedback to treat children with ADHD or anxiety

Guidelines

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Project info

Title: Multi-modality neurofeedback and biofeedback to treat children with ADHD or anxiety

Project lead: Perry Radau https://github.com/pradau

Timezone: Calgary MDT (UTC-6)

Description: Overview: Children with ADHD, PTSD or generalized anxiety benefit from neurofeedback from an EEG while performing a task (e.g. focusing, calming) to develop cognitive skills that can assist them to cope and perform better throughout life. Some problems with this training a) the tools need to be easy to access and setup (e.g. wearable); b) the feedback should be engaging and ideally involving multiple senses (e.g. visual, auditory, 3D, aromas); and c) the feedback should be based on both brain waves (EEG) and other indicators (e.g. body motion, heart rate, breathing rate) to provide richer self-understanding. Problem: Develop an app for use with a wearable neurofeedback system (e.g. Muse, Emotiv, OpenBCI) that provides richer environmental feedback and/or sensing to better serve the ADHD, PTSD or generalized anxiety pediatric populations. Further information:Neurofeedback uses operant learning/conditioning to train the brain to optimize its function; in essence it’s a form of “rebalancing” of brain function depending on the protocols used. A simple neurofeedback system utilizes SMR rhythm and alpha frequencies to focus and calm the mind. When the brain learns to mimic the frequencies and maintain those patterns it rewarded. Reward schedules are changed to increase the brains ability to hold the “new” normal/equilibrium, which over time teaches the brain to maintain a “new” or previous “normal” (equilibrium). Many people use it for all sorts of conditions as well as to increase performance. People who are out of touch with their feelings or body sensations (e.g. heart rate) would benefit from a non-invasive, self-directed way to become aware of and gain control of these functions. This could help them to realize the benefit of consistently and achieving their set goals. There is also a need to provide visual data to both the client and the clinician tracking changes and measuring success or problem areas.

Link to project:

Chat channel: https://mattermost.brainhack.org/brainhack/channels/hbmhack-multimod-nf

Mattermost handle: hbmhack-multimod-nf

Goals for the OHBM Brainhack Research potential avenues to address the problem with existing technologies and design a prototype that would address shortcomings. Depending on skillset of team members, hack a script or app that may begin to demonstrate solutions to some of the identified problems with existing solutions.

Good first issues:

Skills:

Project submission

Submission checklist

Once the issue is submitted, please check items in this list as you add under 'Additional project info'

Please include the following above (all required):

[ ] Link to your project: could be a code repository, a shared document, etc. See here
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[ ] Flesh out at least 2 "good first issues": those are tasks that do not require any prior knowledge about your project, could be defined as issues in a GitHub repository, or in a shared document, cf here.
[ ] Skills: list skills that would be particularly suitable for your project. We ask you to include at least one non-coding skill, cf. here.
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[x] Project snippet for the OHBM Brainhack website, cf. here

We would like to think about how you will credit and onboard new members to your project. We recommend reading references from this section. If you'd like to share your thoughts with future project participants, you can include information about (recommended):

[ ] Specify how will you acknowledge contributions (e.g. listing members on a contributing page).
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hey @pradau I added some labels to this issue. Feel free to change that or add more.

Also let us know if there is an image for this project we can use for the website.

Hello @pradau I find this project very interesting and I am keen to work on it. I have a background in Mechatronics and Biomedical Engineering. I currently reside in Melbourne, Australia and hence I belong to the Asia Pacific Hub of brain hack. I was wondering if you would be keen to collaborate across hubs. Kindly let me know!

Hey @pradau

I created a mattermost channel for your project on mattermost.

https://mattermost.brainhack.org/brainhack/channels/hbmhack-multimod-nf

@pradau thanks for submitting a project ! You may want to check the checklist items so that potential contributors know more about your project: for example, you add an image so that it catches the attention of people reading the hacktrack project list or you can add labels so that they know which skill set is necessary. If the existing labels do not match the ones that fit your project, let us know ! :rocket:

Hey @pradau great project! Like @saampras I'm also in Australia (Asia Pacific hub) but would be keen to work on the project if working across hubs is possible. I'm new to coding but experienced in biofeedback & neurofeedback for PTSD and traumatic brain injury.

@pradau Can you provide an image for your project for the hackathon website? Thanks in advance! 😄

@pradau do you have a video channel for your project? Would you add that information to the mattermost channel, please? Thanks.

Dear @pradau we are still waiting for that several information from you to complete the revision, so we would really appreciate it if you can provide those please.

We will need

Good 2 issues
Skill you require from your participants
Link to your project
An image to share in the OHBM webpage,
Link to your video chat (please create and share and pin this link only in your Mattermost channel please)

Once you complete those please let us know we will complete the revision for you and you will be ready to go! We look forward to hearing from you. Thank you!

Hi Saampras, Thanks for your message, and sorry for the delay in responding. I’ve been trying to determine a feasible project with consumer hardware.

I would be happy to have you on the team regardless of hub, and I expect the organizers will not mind.

I’ll provide some more info on the Mattermost channel and the GitHub page today.

Perry

On Jun 12, 2020, at 6:37 AM, Saampras notifications@github.com wrote:

Hello @pradau https://github.com/pradau I find this project very interesting and I am keen to work on it. I have a background in Mechatronics and Biomedical Engineering. I currently reside in Melbourne, Australia and hence I belong to the Asia Pacific Hub of brain hack. I was wondering if you would be keen to collaborate across hubs. Kindly let me know!

— You are receiving this because you were mentioned. Reply to this email directly, view it on GitHub https://github.com/ohbm/hackathon2020/issues/153#issuecomment-643248032, or unsubscribe https://github.com/notifications/unsubscribe-auth/ABBPM2N5CRBYMSGC7567CJLRWIOQXANCNFSM4NZ7EWMQ.

Just summarised all my comments (and their related material) from the Mattermost channel :)

Of primary importance is to define the age of our target population. This will determine the parameters of the product.
We should ensure the product is gender neutral - these have the most evidence for enhancing cognition over gendered toys.
I think it's also of primary importance to determine the mental ill-health we will be addressing: ADHD, anxiety, ADHD & anxiety & depression? Given that these disorders are highly comorbid, neurofeedback on their shared networks might help transdiagnostically. However, we probably need to be specific about the areas we would be stimulating to roughly outline their mechanistic impact on the brain.
Am on board with a systematic review to register on Prospero. From what I gathered in the discussion, we want to know if we can make NF (neurofeedback) more effective. So, we need to address (I've bolded the questions I see as most important right now): A. What wearable, affordable neurotech is available for neurofeedback and how is it augmented by other software and devices? (technical question) B. Are there any NF devices that provide multimodal feedback/how do they work? (cf. Mindalive; https://mindalive.com/collections/ave-devices) (technical question) C. How widely used is NF in clinical populations? (technical question) D. How are NF devices currently measuring efficacy/are they efficacious? (clinical question) E. What are the pros/cons of using NF in typical populations/as treatment options in (is there enough data to refine this to pediatric populations)? (clinical question, probably related to previous question) F. What is needed to make these devices more mainstream? (technical/clinical question) G. Can we incorporate neurostimulation into an NF device? (cf. NeoRhythm; https://omnipemf.com/)(technical question) H. Can the neurostim feedback to the wearer so they can control things?(technical question) --> Re: neurostim. As far as I'm aware, there are studies that show it works, but the mechanisms through which it works are not necessarily known, so it's difficult to know what to target (see, Alpha-Stim). Stimulating even a small area of the brain may target large populations of neurons, so you don't quite know what you're hitting. Also, at least in depression and anxiety, you want to aim to stimulate subcortical parts of the brain, and this is also difficult if you're stimulating using non invasive methods (as it basically just hits cortical areas). One other thing, funding for devices (at least from government sources) is difficult to obtain because the mechanisms through which these devices work has yet to be shown.

If we break it down, and based on what is currently known, this is probably a project that will span years, so best we take it one step at a time, haha.

Things to note:

Google docs sheet: https://docs.google.com/spreadsheets/d/1ZruuKw-r4ShOCFniG5-Gi-P53zCNxUwTRhDr4AoEO0k/edit?usp=sharing
There is a paper on neurostim in ADHD: https://pubmed.ncbi.nlm.nih.gov/23665196/
When stimulating the brain you really can't aim for a part of the brain that does a specific thing (even if you could, that's not really how the brain works). So, for example with ADHD, you aim to target the areas of the brain most involved in attention in the hope that you will be triggering the right areas and modulating the right responses - in this case, the prefrontal cortex, which is concerned with higher order executive functions like planning and attention. Areas that contribute to reward, emotions, memories, etc, are situated in the subcortex and can be modulated by invasive methods (even if you could modulate them using a non-invasive method, you would also be stimulating the cortex in order to get to the subcortex, so it would be hard to say what effects would occur).
There's evidence that neurostimulation works, but we don't know how it does so mechanistically which would impact the design of a product, its scientific standing even if it does work, and government funding for clinical trials.
Clinical populations usually need a 'kickstart' to motivate their brains into different action. Think of it like a habit: habits are formed after you have done things numerous times and are often difficult to unlearn. Ways to unlearn habit is to form new habits, making those connections stronger and the previous, unhelpful habit connections weaker through disuse. People wont necessarily depend on the device to get a 'hit' of what it is like to act in a certain way, but rather, as @saampras suggested with exercise, it strengthens certain pathways so people will want to act in that way to keep up their mood/behaviour. At times they may need more help than others, but the point is to strengthen the helpful pathways so they feel more natural or are the habits that people fall into.
Finally, I feel like a big point of consideration is how clear the signals are/can be from the wearable device, and in what environment you want them. I was watching a few things from Emotiv, and, understandably, the signal they get from the brain when someone is doing anything other than concentrating is very noisy. In terms of neurofeedback, that doesn't seem to be very helpful - unless the intention is to simply reduce brain activity (if we're talking in general about overactive brain in anxiety and ADHD).

Agree with @Liz-git 's points, and adding my thoughts below: 1: Knowing who our target population is in terms of age is really crucial to the direction of the research, software and product development. This should be solidified based on existing literature for that disorder. 3: Identifying a target disorder or illness is a key first direction. The high rates of comorbidity as mentioned between ADHD, anxiety and depression may well mean that we have a product down the line that is suitable for multiple conditions or more complex cases, but getting it right first with one target is a priority. My feeling is that ADHD may be a better target initially than anxiety, due to the (?more) complicated aetiology of childhood anxiety. Tying 1 & 2 together: Does our target disorder differ in presentation at different ages? Is there a developmental course? Answering these will help us decide on a target age.

Systematic review:

Let's aim to answer 1 & 2 above first before starting, unless we want the review to be broader/about general use and efficacy of NF?
We should get a university Librarian experienced with systematic reviews on board from the start to help us with our search strategy. It's good practice anyway, but in my experience the absence of their contribution is what gets you knocked back from top-tier journals. I am currently moving from University of Sydney to Curtin Uni, I'm happy to ask a librarian at Curtin in a couple of weeks, unless someone else has a librarian they'd like to ask?

Re: How widely used is NF in clinical populations? I think this will be really hard to determine in terms of actual clinical use vs. research use. Does research use and efficacy translate to clinical uptake? What kinds of practitioners are implementing NF? Re: How are NF devices currently measuring efficacy/are they efficacious? This will be a doozy to tease out! It seems (to me) like there are myriad ways to determine efficacy, some better than others. Symptom relief, cognitive improvement, signal change, fMRI, structural MRI etc. This article might be helpful: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575615/ Getting a clear answer on this will also help us to go forward on how we should validate our product later down the track.

Other:

My understanding is that we want a gender neutral product appropriate for X-X age range, that is engaging
My take on neurostim is that it is really cool, but as Lizzie said there are a ton of barriers to getting a commercially viable product. Maybe this could be a secondary focus later down the track.

Here are some articles that might be useful, perhaps we can have a read and then regroup: Neurofeedback: Principles, appraisal, and outstanding issues https://doi.org/10.1111/ejn.14312 Assessing the Effectiveness of Neurofeedback Training in the Context of Clinical and Social Neuroscience https://doi.org/10.3390/brainsci7080095 Advancing the Rehabilitative and Therapeutic Potential of BCI and Noninvasive Sensing Systems https://doi.org/10.1007/978-3-030-14323-7_12 Growing the evidence base for neurofeedback in clinical practice https://doi.org/10.1037/0000085-007 Designing a Successful Neurofeedback Training for Children with Autism Spectrum Disorder https://doi.org/10.1024/2235-0977/a000303

@Liz-git and @shellewell have covered most of the points that needed to be covered!! Some great references and links as well!! Just adding on to that, here are some points I thought about and wanted to share:

Some of the important challenges that came to light through the discussions in mattermost are as follows:

1) The possibility of stimulating cortical areas (prefrontal) as well as deeper regions of the brain (subcortical structures such as amygdala, thalamus, etc.) with good specificity. As @Liz-git pointed out, the mechanisms of stimulation should be better known and characterized in order to get sufficient funding approvals. Moreover, higher specificity would enable the targeting of more and wider variety of brain states.

On this note, I came across some interesting technology that may be able to address this very challenge. A recently developed tech called low frequency transcranial focused ultrasound neuromodulation (tFUS). Here are some links to go through:

https://www.nature.com/articles/s41598-018-28320-1 = gives an idea and introduction to the concept of transcranial Focussed Ultrasound neuromodulation
https://www.frontiersin.org/articles/10.3389/fnhum.2020.00052/full = Recent paper on regulation of mood and FC
https://www.sciencedirect.com/science/article/pii/S1935861X19303389 = adverse effects review of tFUS

A brief summary of this technique: It uses ultrasound (acoustic energy) to target brain regions (including deep structures) and can modulate BOLD response, by modulating membrane gating kinetics. It creates neuronal level changes which in turn bring about changes in BOLD response. It is shown to be quite safe, although I have also put up a link to a review that evaluates its safety. It has many advantages stated. Some studies have shown successful stimulation of the amygdala and have observed behavioural effects.

One of the companies called brainbox produces the tech for this. It is FDA approved I believe. Here is the link to the brain box page:

https://brainbox-neuro.com/news/2019/an-introduction-to-transcranial-focused-ultrasound-neuromodulation

I don't think there is a wearable version for humans yet. But the BRAIN initiative has acquired grants to develop a wearable tech for sheep to start with. Here is the link:

https://projectreporter.nih.gov/project_info_description.cfm?aid=9224456

I am yet to go into the depths of tFUS and its mechanisms.

The challenge for us with regards to this new tech would be to develop a wearable for children that is safe and effective, from scratch. But provided its ample benefits and desirable characteristics, it would be the ideal candidate for the neurostim component of our device. Irrespective of whether we consider it, I believe this is worth mentioning in our review.

2) The possibility of making training easier for children by manipulating the mechanism of neurofeedback. Neurostim was considered here to augment the process of neurofeedback. My concern was about children developing strong dependencies on the stimulation because of its high passivity.

There is also another stimulation mechanism available to close the loop. Here is a link to one of the papers talking about training free externally regulated neurofeedback using EEG:

https://pubmed.ncbi.nlm.nih.gov/30711469/

So in this, they provide visual stimulation to the user at specific alpha phases (frequency of stimulation is same as that of alpha waves). This stimulation in turn is regulated by the alpha wave from the user. So the user does not have to train their alpha waves since that is being done for them by the visual stimulation. It is different from neurostim because the stimulation is quite indirect. It is safer and the mechanism of stimulation can be more deterministic I suppose. Here, the design of toys, devices and IoT for integration would be quite meaningful. There is a great potential to make it engaging with minimal requirements for training.

This could be an alternative to neurostim, or could even be used along with it I suppose (in stages maybe).

Overall, our review could potentially include all the different techniques of neurofeedback and stimulation available out there, and then section out to talk about the ones that have converted into wearables in the market. This could help us review efficacy measures in different modalities, compare how existing wearables stick to delivering those measures and then propose standard measures that can be used to assess upcoming wearables.

Since there are many possible directions for the review, I think our next step should be to collate all the information posted here and decide a direction for the review.

I have also attached the starting point mindmap that I had created initially.

Nf_MindMap_version_1.pdf

ohbm / hackathon2020