Applied Psychophysiology and Biofeedback, Vol. 26, No.

2, 2001

A Psychophysiological Marker of Attention Decit/Hyperactivity Disorder (ADHD)Dening the EEG Consistency Index
Boris Kovatchev,1,5 Daniel Cox,1 Rebecca Hill,2 Ronald Reeve,2 Raina Robeva,3 and Tim Loboschefski4

This study continues our research to further validate the idea that ADHD (Attention Decit/Hyperactivity Disorder) interferes with transition from one task to another and this interference can be quantied by a Consistency Index (CI) derived from a specic mathematical representation of EEG data. We reanalyze 32 previously reported data sets present new data for 35 boys and girls, ages 712, ADHD or control. Each data set contains EEG, recorded and digitized while participants perform consecutive 10-min tasks: video, reading, and math. For boys, the CI in ADHD was four times lower than in controls, p < .005, for girls this difference was two times, p < .05. ADHD/control classication based on the CI coincided with the DSM-IV criteria for 88% of the boys and for 67% of the girls. Post hoc analysis indicated that the classication utility of the CI diminished with age. A CI below 40% could be a discriminating, reliable, and reproducible marker of ADHD in young boys.
KEY WORDS: attention-decit/hyperactivity disorder (ADHD); electroencephalography (EEG); mathematical modeling.

Attention Decit/Hyperactivity Disorder (ADHD), is the most common developmental disorder of childhood, affecting 37% of children in the United States, and often continuing into adulthood (Barkley, 1998). ADHD is usually reected by a pattern of increased impulsivity, high levels of motor activity, and attentional problems that impair function in home, school, and social settings (American Psychiatric Association [APA], 1994). Although affecting a relatively small percentage of children overall, the diagnosis of ADHD accounts for one-third to one-half of all child referrals for mental health services (Popper, 1988). The long-term consequences of childhood ADHD include lower educational achievements and increased risk for antisocial behavior and drug abuse (Weiss & Hechtman, 1993).
1 Center for Behavioral Medicine Research, University of Virginia Health System, Charlottesville, Virginia. 2 University of Virginia School of Education, Charlottesville, Virginia. 3 Department of Mathematical Sciences, Sweet Briar College, Sweet Briar, Virginia. 4 Department of Psychology, Sweet Briar College, Sweet Briar, Virginia. 5 Address all correspondence to Boris Kovatchev, PhD, Center for Behavioral Medicine Research, University

of

Virginia Health System, Box 800137, Charlottesville, Virginia 22908; e-mail: boris@virginia.edu. 127
1090-0586/01/0600-0127$19.50/0
C

2001 Plenum Publishing Corporation

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Despite its signicance as the predominant developmental disability in this country, the true nature of ADHD remains puzzling. At present there is little understanding of the neurobiological basis of ADHD. The current diagnostic criteria rest exclusively on history and current manifestations of behaviors reecting ADHD symptoms (APA, 1994; Barkley, 1998). For a diagnostic classication of ADHD individuals must sustain a majority (6 of 9) of target behaviors, either for hyperactivity-impulsivity or inattention, for a period of 6 months or longer. These symptoms must be considered maladaptive and inconsistent with the childs current developmental level. In addition, these behaviors must be independently observed in two or more settings and result in some clinically signicant impairment in academic, social, or occupational functioning. Consequently, an unambiguous diagnosis is often difcult to make and misdiagnoses can and do occur (Shaywitz, Fletcher, & Shaywitz, 1994, 1995). As the diagnostic label implies, a major assumption of ADHD is that diagnosed children have some type of decit in attention, but the precise nature of this decit remains unknown. Although a number of hypotheses abound for this attentional difference, one which seems tenable is that ADHD children are highly distractible, having great difculty in selectively narrowing their attentional focus when confronted with multiple competing stimuli. In addition to the core clinical symptoms of ADHD, high levels of comorbidity have been found with learning, oppositional deant, conduct, mood, and anxiety disorders (Biederman et al., 1994; Biederman, Newcorn, & Sprich, 1991). As a consequence, ADHD children appear less able to focus attention, maintain attention, or plan for future actions. The consequences of these problems include poor scholastic achievement, behavioral management problems, poor peer relations, and low self-esteem, which can be long lasting and quite serious (Barkley, Anastopoulos, Guevremont, & Fletcher, 1991). It is estimated that the majority of children diagnosed with ADHD exhibit signicant behavioral problems during adolescence (Barkley, Fisher, Edelbrock, & Smallish, 1990; Gittleman, Mannuzza, Shenker, & Bonagura, 1985; Mannuzza et al., 1991) and manifest continuing functional decits and psychopathology into adulthood (Weiss & Hechtman, 1993). Identifying ADHD as a distinct clinical syndrome with a multifactorial etiology, Zametkin and Rapoport (1987) proposed 11 separate neuroanatomical hypotheses for the etiology of ADHD. A recent study, using high resolution SPECT (single photon emission computerized tomography) found that while engaged in passive watching tasks, no substantial or identifying differences between ADHD children and their matched controls were present. However, when the experimental task required focused attention and concentration, differences between ADHD individuals and controls began to emerge in the brain centers responsible for governing attentional control and planning. Specically, a substantial majority (65%) of ADHD children and adolescents showed decreased perfusion in the prefrontal cortices when they were asked to engage in an intellectually demanding task as compared to a nondemanding task, whereas only 5% of controls showed this decreased perfusion (Amen & Carmichael, 1997). In similar research endeavors ADHD children showed cerebral hypoperfusion (Lou, Henriksen, & Bruhn, 1984) and in ADHD adults a lower cerebral glucose metabolism was demonstrated (Zametkin et al., 1990). Functional MRI reveals differences between children with ADHD and healthy controls in their frontal-striatal function and its modulation by methylphenidate (Vaidya et al., 1998). Unfortunately, although neuroanatomical ndings lend support to the notion that ADHD is a distinct clinical syndrome adding to our understanding of the etiology of ADHD, neuroimaging techniques are currently neither

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sensitive/specic, nor practical (in terms of availability and expense) enough for routine assessment and diagnosis (Barkley, Grodzinsky, & DuPaul, 1992; Grodzinsky & Diamond, 1992). For this reason, EEG studies are of interest. In terms of EEG, as far back as the late 1920s, it was known that brain wave characteristics changed dramatically depending upon the task at hand (Berger, 1929). In passive, mentally unchallenging situations, slow waves (i.e., theta and alpha) tend to dominate EEG recordings, whereas faster waves (i.e., beta and high beta) tend to evidence themselves when subjects were asked to focus attention on a more demanding task. Current computer technology allowed for evaluation of stationary EEG characteristics, such as the power of brain waves at different frequencies (theta, alpha, beta), associated with various tasks. When ADHD children were compared to controls, different patterns of these stationary characteristics emerged. Control individuals demonstrated power increases of beta and decreases of theta when involved in a variety of tasks, whereas ADHD children reportedly had relatively higher power of the low frequencies despite the need for increased mental activity (Crawford & Barabasz, 1996; Lubar et al., 1985; Mann, Lubar, Zimmerman, Miller, & Muencher, 1991). In one of the largest studies procured to date, Chabot and Serfontein (1996) tested 407 children with attention decits with and without hyperactivity, with and without learning problems, children with attention problems who failed to reach DSM-III criteria for the disorder, and 310 controls (ages 617). They employed spectral analysis and observed patterns of excess theta in frontal regions and increased alpha (relative power) in the posterior regions for the clinical groups versus controls. They then employed coherence analysis and reported that one-third of the noncontrol children showed signs of interhemispheric dysregulation characterized by this pattern of excessive theta/alpha power in the right temporal and premotor (frontal) areas. Lazzaro et al. (1998) explored the possibility of maturational lag and cortical underarousal as causes of ADHD. EEG activity of 26 adolescent (mean age of 13.4) unmedicated ADHD males and 26 age and gender matched controls were examined in a resting eyes open condition. In the ADHD subjects, increased levels of theta activity in the anterior region of the brain and reduced levels of beta activity in the posterior region were discovered. Lazzaro et al. suggested that these results show evidence of a maturational lag (due to the presence of theta in the anterior regions of the brain and reduction of beta in the posterior regions) and reduced cortical arousal in ADHD. Monastra et al. (1999) reported similar results from their study on 482 participants (ages 630) classied into the three groups of ADHD combinedtype, ADHD predominantly inattentive-type, and controls. They recorded from a single, midline, prefrontal electrode (CZ) to test the hypothesis that prefrontal cortical slowing (presence of excess theta) can differentiate ADHD subtypes from controls. Monastra et al. report that their results showed cortical slowing that identied ADHD subjects regardless of sex or age. Specically, consistent with their hypothesis, statistical analysis revealed that the ADHD groups (inattentive and combined type) displayed signicantly higher levels of slow-wave (theta) relative to fast-wave (beta) EEG activity, a ratio that is the inverse of a previously reported Engagement Index developed to measure operators engagement with automated and fast changing tasks (Pope & Bogart, 1991; Pope, Comstock, Bartolome, Bogart, & Bardette, 1994). This thetabeta power ratio was signicantly larger for the ADHD groups than for the normal control group. In addition, the thetabeta ratios were signicantly larger for the younger ADHD children (ages 611). This is the only of the reviewed studies to provide information regarding sensitivity and specicity.

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In summary, the situations in which identiable differences commonly have been found between ADHD and control children are those in which children are asked to focus attention to specic tasks during an experiment. In addition, the regions of the brain that show affected blood ow are those regions that are utilized in both attentional control and planning for future activities. This observation generated our idea for research focusing not only on differences between ADHD patients and controls within a more or less demanding situation, but also on contrasts between contiguous tasks.

METHODS Participants The study was approved by the Institutional Review Board; 18 boys and 17 girls were recruited through newspaper and television advertisement and were assigned into experimental (ADHD) and control group. The ADHD group consisted of 9 boys and 8 girls, the rest of the participants were controls. The inclusion criteria for the experimental group were (a) male and female children between the ages of 7 and 12, (b) had a previous diagnosis of ADHD with or without hyperactivity, (c) were taking any type of psychostimulant medication (with the exception of Cylert) to treat their attentional difculties, (d) were not taking medication to treat anxiety or depression, (e) scored above the 84th percentile on the Attention Problems scale on either the Child Behavior Checklist or the Teacher Report Form, (f) both parents and teachers were interviewed, and the patients had to have either 6/9 hyperactivity-inpulsivity or 6/9 Inattentive symptoms as dened by the DSM-IV, and (g) did not have any major health problems that might affect the brain (e.g., Cerebral Palsy). Participants in the control group were age- and gender-matched to the experimental group. Children were included in the control group if they (a) had no known history of a disruptivebehavior disorder, (b) had never taken stimulant medication, (c) had no more than three of either the hyperactive-impulsive or the inattentive DSM-IV symptoms, (d) were not taking medication to treat anxiety or depression, and (e) did not have any major health problems that might affect the brain. In addition, three previously reported data sets were reanalyzed. Data set I: Four boys, ages 610, with ADHD and four age-matched control boys tested at two 30-min trials (video and reading) separated by a 5-min break (Cox et al., 1999). Data Set II: Six ADHD males and six non-ADHD males, ages 1825, participated in a double-blind, placebo versus methylphenidate controlled crossover design study. The participants were given four tasks of the Gordon Diagnostic System, two easy (auditory and visual) and two hard (auditory and visual) (Merkel et al., 2000). Data Set III: Six female college students with ADHD and six controls were engaged in a series of short-term concentration exercises with shorter resting intervals. EEG was recorded throughout the test (Loboschefski, Robeva, Kirkwood, Cox, & Kovatchev, 1999).

Procedure The participants and their parents met with a researcher, and were asked to sign an informed-consent form. Prior to the EEG test parents completed three ADHD behavioral

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rating scales: Conners Parent Rating Scale (Goyette, Conners, & Ulrich, 1978), Achenbachs Child Behavior Checklist (Achenbach & Edelbrock, 1983) and the ADHD Symptom Inventory (Cox et al., 1999). Teachers were interviewed and completed report forms. The evening before testing, medication of all ADHD participants was discontinued. During testing an appropriately sized EEG cap (Electrode Cap International, Inc.) was placed over participants heads. Ten electrode sites were prepared: a ground just in front of Cz, an earlobe reference electrode, and Cz, Pz, P3, P4, F3, F4, T3, T4. Impedance criteria was 10 k , as measured by the Prep-Check electrode impedance meter. EEG signals were amplied and processed by a Lexicor Neurosearch-24 system, loaned by NASA. EEG was digitized at a rate of 128 samples/s. Standard time series smoothing using a Tukey-Hanning window was applied to the data from each EEG channel and the power spectrum was estimated using a standard Fast Fourier Transformation algorithm. After this preprocessing of the data, the relative power was computed for four EEG bands: Theta (48 Hz), Alpha (813 Hz), Beta (1322 Hz), and High Beta + EMG (2232 Hz). The residual power was carried by the frequencies below 4 Hz and above 32 Hz. This resulted in 32 EEG parameters (4 bands 8 channels) recorded into a data le every two seconds. The participants were tested for 35 min while performing three 10-min tasks. During the initial 10 min participants watched a video. These 10 min were treated as a period for adjustment of the subject to the cap and were not included in further analyses. After a few seconds break the participants were required to read a book for 10 min This task was followed by a 35 min structured break, and then the participants were required to solve mathematical problems for the next 10 min In order to ensure similar task difculty for all participants, they were asked to bring in reading material of their choice and examples of their math homework, i.e., participants selected test material of personal interest and acceptable difculty level. With the above preprocessing rate (Fourier transformation of 8 EEG time series every second, aggregated in 4 bands), there were approximately 300 32 data points recorded for each subject during each 10-min task. The two data matrices acquired during 10-min of reading and 10-min of mathematics, were used for further computation.

Dening the EEG Consistency Index (CI) The computation of the CI for each subject is based on a model that mathematically incorporates our idea that individuals with ADHD would differ from controls when contrasting EEG power during two attention-demanding consecutive tasks. In essence, each person has a three-dimensional EEG power spectrum representation: one dimension is frequency, another is spatialthe location of the electrode on his/her head, and the third is time. We will now explain this idea in detail, relying on our past experience that probably the best way to present this rather complex mathematical paradigm is to use a series of gures depicting the sequential steps of the computation of the CI.

EEG Frequency Dimension Figure 1 presents the basis of our idea of consistent EEG change in the frequency dimension. The black line is the averaged power spectrum of a subject performing a task,

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Fig. 1. Consistent (panel A) versus inconsistent (panel B) EEG power change between two contiguous tasks in the frequency dimension. The black lines represent the averaged power spectra during one task, whereas the gray lines represent the power spectra during a contiguous task.

the gray line is the power spectrum of the same subject while performing a contiguous task. In Fig. 1(A) the black line is above the gray line at lower frequencies and mostly below the gray line at higher frequencies (above 16 Hz). This shows that a change from one task to another (from black to gray) results in a consistent increase of higher frequencies and consistent decrease of lower frequencies, i.e., the subject becomes more alert while performing the second task. In contrast, in Fig. 1(B) no consistent change in the frequency distribution over the spectrum is observed. In other words, Fig. 1(A) presents a consistent change in the frequency dimension, whereas Fig. 1(B) present an inconsistent change. Figure 2 presents the averaged difference between the EEG power spectra across the two tasks, i.e., the [point-by-point numerical] difference between the black and the gray line in Fig. 1. In Fig. 2(A) this difference is mostly positive at lower frequencies and mostly negative at higher frequencies. In Fig. 2(B) the power differences are scattered below and above the frequency axis. Visually, a consistent change between two tasks will be presented by an uninterrupted domain [Fig. 2(A)], whereas an inconsistent change would result in sporadic power changes along the EEG spectrum, Fig. 2(B).

EEG Spatial DimensionThe Location of Electrodes As opposed to the frequency dimension, the presentation of spatial EEG consistency is based on a discrete presentation of the power spectrum at several EEG channels. Figure 3 presents an 8-channel (electrode) setting and spatially consistent/inconsistent changes between two tasks. The power spectrum of each electrode is discretized in four basic frequency arrays: theta, alpha, beta, and high beta. Each bar in the gure represents the relative power

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Fig. 2. Consistent (panel A) versus inconsistent (panel B) EEG power difference between two contiguous tasks. The gray area is visually continuous during a consistent power change and interrupted during an inconsistent power change.

registered by an electrode at a particular frequency. A consistent change would mean that at a particular frequency array most channels will display similar, unidirectional readings [Fig. 3(A)], whereas an inconsistent change will result in scattered power changes across the electrode sites [Fig. 3(B)].

Fig. 3. Consistent (panel A) versus inconsistent (panel B) EEG power change between two contiguous tasks in the spatial dimensionthe location of the electrodes.

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Algorithmic Denition of the CI The concept of EEG consistency (Figs. 13) is used as a base for the development of an algorithm and software that computes the CI. The algorithm works as follows: 1. Discrete spectra, including residual power, are calculated for all EEG channels. 2. Power change distances (PCD) between two contiguous tasks are computed for each EEG band and channel, using the following formula: PCD = M1 M2
SD12 N1

SD22 N2

where M1 and M2 are the mean powers at two contiguous tasks, S D1 and S D2 are their standard deviation, and N 1 and N 2 are the epoch counts at these tasks. This normalization of the power changes between tasks allows one channel/frequency band to be directly comparable to another. 3. PCD undergo ltering to eliminate changes below a noise threshold. The noise threshold works as follows: The PCD that are larger by an absolute value than the threshold are marked by 1 or 1 depending on their direction, whereas all PCD below threshold are marked by zero. This ltering transforms the PCD into a sequence of 1, 0, 1 that indicates, for each EEG band and channel, whether a signicant power change was observed while the person shifted from one task to another. Throughout this manuscript, a threshold of 3.5 is used for the computation of the CI. 4. Intuitively, the shift from Task 1 to Task 2 would be consistent if most of the ltered PCD below some cutoff frequency are positive, whereas most of the indicators above this cutoff frequency are negative, or vice versa. In contrast, the shift would be inconsistent if the PCD vary greatly by magnitude and/or sign. Thus, Fig. 4(A) and (B) present a consistent and an inconsistent EEG at a cutoff frequency between beta and high beta. 5. The nal pass of the computation is a simple addition of the ltered PCD below and above the cutoff value. The CI is dened as the absolute value of the difference between these two sums, expressed as a percentage, i.e., computed using the formula: CI = 100 1 N i
below cutoff above cutoff

where

i , j = 1, 0, 1

For example in Fig. 4(A) we have a sum of 13 below the cutoff and a sum of 5 above the cutoff. Thus, the CI of the consistent shift presented in Fig. 4(A) will be 18. In contrast the CI of the inconsistent shift in Fig. 4(B) will be 1 (0 below the cutoff and 1 above the cutoff). The maximum CI equals the number of EEG channels multiplied by the number of EEG bands used during spectrum discretization. For example, with 8-channel EEG equipment and 4 bands the CI ranges from 0 to 32. In order to make the results comparable across different experiments, the CI will be expressed in terms of percentage from its maximum

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Fig. 4. EEG power change indicators during a consistent (panel A) and inconsistent (panel B) change between contiguous tasks. Computation of the Consistency Index.

value. For example, the CI in Fig. 4(A) will be 56.25%, whereas in Fig. 4(B) it will be 3.125%. RESULTS A blind rater evaluated a video of each child during testing. The mean rating of percent time on task for controls and ADHD participants while reading was 97% versus 89% (ns) and for math it was 96% versus 85% (t = 1.90, p = .04), respectively, thus ADHD participants displayed similar engagement with reading and slightly diminished engagement with mathematics. Detailed analyses of all power bands and beta/theta power ratios, including 144 plots of power changes across time, were performed in order to scan for suggested in the literature increase of theta associated with ADHD (Crawford & Barabasz, 1996; Lubar et al., 1985; Mann et al., 1991). The result of these efforts was generally negative. The only marginally signicant result included a slight increase in the average power of theta over the rst 10 min of the test for ADHD patients compared to controls, F = 4.5, p = .04. There were no signicant ADHD-control differences (t = 0.2, p = .84) in the theta/beta ratio previously reported as an indicator for ADHD (Monastra et al., 1999). Similarly, there were no signicant differences in the participants Engagement Indices, t = 0.3, p = .79 (Pope & Bogart, 1991; Pope et al., 1994). CI Results for Boys Table I presents the CI of 9 control and 9 ADHD boys switching from reading to mathematics with a 35 min break. The CI is presented by its value (column CI) and as a percentage from its maximum value of 32 (CI%). Statistically, a t-test demonstrated that the average CI of control boys is signicantly higher than the average CI of ADHD boys, t = 4.0, p = .0008. Clinically, there was very good separation between the two groups: only one ADHD boy (#130) had a CI above 40%, and only one control boy (#127) had a CI below 40%. Therefore, an ADHD/Control classication based on the CI coincides with

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Kovatchev, Cox, Hill, Reeve, Robeva, and Loboschefski Table I. Consistency Index for 9 Control and 9 ADHD Boys Control ID 106 107 108 109 112 115 117 127a,b 128 CI 29 24 13 15 30 18 24 0 30 CI% 90.6 75 40.6 46.9 93.8 56.3 75 0 93.8 Average SD; % ID 102 111 116 123 124 125 130 a 132 136 CI 8 6 1 7 1 9 14 5 0 CI% 25 18.8 3.1 21.9 3.1 28.1 43.8 15.6 0 ADHD Average SD; %

20.3 9.9; 63.5%

5.7 4.5; 17.7%

Group comparison: t = 4.0; p = .0008

a The classication based on b Classied as ADHD by the

the CI does not coincide with the DSM-IV criteria. teacher, but not by the parents.

the DSM-IV diagnostic criteria for 88% of the boys. In addition, a review of the diagnosis showed that the false-positive subject #127, was classied as ADHD by the teacher but not the parents. There was signicant correlation between the CI and the scores of several behavioral ADHD scales: ADHD Symptom Inventory, r = .66, p = .002; attentional subscale of the ADHD Symptom Inventory, r = .67, p = .002; Achenbachs Child Behavior Checklist, r = .66, p = .002; Conners Parent Rating Scale, r = .44, p = .05. CI Results for Girls Statistically, the average CI of ADHD girls was 20.7% versus 45.1% for controls. This group difference was signicant, t = 2.1, p < .05. Clinically, the differentiation between ADHD and control girls was not so clear as with boys: there were 2 ADHD girls with CI above 40% and 4 control girls with CI below 40%. Meta-Analysis of the Current and Previous Data Previously reported data for 32 subjects were added to the current data set and reanalyzed to address age and gender effects. The total sample consisted of 38 males and 29 females, 33 ADHD and 34 controls; 43 subjects were younger than 16 years. The demographic characteristics of all subjects are presented in Table II. To accommodate across-studies meta-analysis the parameters of the CI were unied across and the CI was expressed in percentages from 0 to 100%. Analysis of variance with independent factors ADHD versus Control, Gender and Age group revealed that (1) The average CI of ADHD subjects is 29% versus 50% for controls, F = 43.7, p < .0001; (2) There was a signicant Gender effect with males having a higher CI, F = 4.1, p < .05; (3) There was an age trend with younger subjects having higher CI, F = 3.7, p = .06, and (4) There was a signicant interaction between ADHD-control and Gender effects with males displaying stronger CI differences between ADHD and controls, F = 5.6, p < .05.

A Psychophysiological Marker of Attention Decit / Hyperactivity Disorder Table II. Demographic Characteristics of the Participants Included in Meta-Analysis Participants younger than 16 years (N = 43) Male/female ADHD/control Average age (years)a Male/female ADHD/control
a There

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Participants older than 16 years (N = 24) 12/12 12/12 20.0 20.9/18.9 20.1/19.9

26/17 21/22 10.6 10.0/11.4 10.6/10.6

were no signicant differences in age between males and females ( p = .86) and between ADHD and controls ( p = .88).

On the basis of the CI, a logistic regression model classied correctly 82% of all ADHD subjects and 77% of all control subjects with an overall classication accuracy of 80%. This model was statistically signicant, p < .0001. The classication power of the logistic model increased to 90% if only younger male subjects were included in the analysis. In addition, a Boolean decision-making rule based on the CI classied all but one of the ADHD boys versus their agegender-matched controls, a 96% correct classication. DISCUSSION The DSM-IV (APA, 1994) states The essential features of Attention Decit/ Hyperactivity Disorder (ADHD) is a persistent pattern of inattention and/or hyperactivityimpulsivity that is more frequent and severe than is typically observed in individuals in a comparable level of development. Evidence of six of nine inattentive behaviors and/or six of nine hyperactive-impulsive behaviors must have been present before age 7, and must clearly interfere with social, academic and/or occupational functioning. Consequently, the diagnosis of ADHD is highly dependent on a retrospective report of a patients past behavior and subjective judgment of degree of relative impairment, which presents a serious diagnostic dilemma and reduces the precision of the ADHD assessment. Thus, consistent with the recent NIH Consensus Statement (NIH Consensus Statement [NIH], 1998), we can conclude that ADHD (1) Is difcult to diagnose; (2) Is considered a common problem; (3) Is associated with many negative consequences, both for the patient and society; and (4) Has been inconsistently associated with neuroimaging and EEG anomalies that have been nondiagnostic in nature. We built our idea of investigating EEG contrasts between contiguous tasks on the basis of multiple indirect physiologic and behavioral evidence that point in that direction. As reviewed, investigators examining a variety of neuroimaging and EEG data have repeatedly found ADHDnon-ADHD differences, but the specic differences have been inconsistent. We believe that this apparent perplexity only reects the complexity of the underlying problem. It is quite possible that there are various manifestations of ADHD reecting different physiologic and behavioral routes merging into a common pathway. So, we tried to nd a common ground between the diversity of previously unrelated observations and documented ADHDnon-ADHD differences. Physiologically, blood ow studies demonstrated that on an intellectually demanding task a majority of ADHD children and adolescents showed decreased functioning in the frontal lobe regions of the brain (Amen & Carmichael, 1997; Barkley et al., 1992; Grodzinsky & Diamond, 1992). Because these regions are utilized in

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attentional control and planning for future activities, we would expect that ADHD subjects would manifest a decreased ability to control their attentional shifting when transitioning between two contiguous tasks of different attentional or intellectual demands. Behaviorally, a common pathway discussed by some researchers involves decits in response inhibitory control and reengagement. These decits have been documented to differentiate ADHD from non-ADHD children, are greater among those children with more severe ADHD, and have been remedied with methylphenidate (Schachar, Tannok, & Logan, 1993; Schachar, Tannok, Mariott, & Logan, 1995; Tannok, Schachar, & Logan, 1995). Again, the difculty with response inhibition and reengagement may be most obvious when children are transitioning from one task to another. In addition, although various studies have examined ADHD children performing various tasks (e.g., reading and arithmetic), none have examined contrast between consecutive tasks. This report introduces a new marker for ADHD that is based on EEG contrasts between tasks. The computation of the CI is based on a mathematical model of EEG consistency. Before formulating this model, we made every effort to replicate reports suggesting that ADHD individuals display in their EEG an increased power of theta and decreased power of beta frequencies (Lubar et al., 1985). As we reported in the results section, the only marginally signicant result (out of 144 tests) was that the average power of theta over the rst 10 min of EEG (introductory video) was higher for ADHD participants than for controls, F = 4.5, p = .04. However, the power of beta was not higher for controls. On the contrary, it was tending to be lower, p = .13, primarily due to control boys. As a result, the Engagement Index did not differentiate ADHD boys, or girls, from their corresponding controls. In summary, no signicant ADHD-control (or gender) effects were observed using any standard EEG measure. In contrast, the CI differentiated ADHD boys from Controls not only statistically, but also with almost complete separation of the groups. Furthermore, one of the two false-positive control participants (#127 in Table I) was classied as ADHD by the teacher but not by the parent ratings. In addition, the CI correlated signicantly with the scores of various ADHD behavioral rating scales. Our data collection served exclusively to conrm (or reject) that the CI maybe a reliable and reproducible marker of ADHD. No training procedures were attempted or tested in this study, therefore, this study cannot add empirical evidence to the issue of additional ADHD treatment parameters that might be derived from EEG. Besides its highly signicant results, we consider this study to be a pilot research. The relatively small sample size (N = 35) prevented us from counterbalancing the experimental designthe test always proceeded with reading rst, and then mathematics. However, it should be pointed out that the CI is symmetric with respect to the performed tasks, i.e., it does not depend on their order but only on the EEG power change from one task to another. In other words, greater power in the low frequency range in the second task, or lower power in the low frequency range in the second task as presented in Fig. 1, would result in similar consistency indices. Consequently we should expect that a counterbalanced design would not alter the results. Another observed phenomena that needs further investigation is the relative failure of the CI to clearly differentiate girls with and without ADHD (although the effect was statistically signicant). A gender optimization of the CI will be required in a larger future study. Since the CI is a result of a rather complex mathematical model, its computation is not straightforward. No standard statistical procedures can be applied and the CI cannot be calculated without specialized software. The results in this report were obtained by a pilot

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version of a special algorithm and software that needs further renement before being available for a general use. In summary, after analyzing four independent data sets, collected over 2 years by different technicians with different EEG equipment/laboratory, we conclude that the CI is a signicant discriminant of ADHD versus control participants. In addition, with the specic subgroup of younger males, the CI works extremely well on case-by-case basis classifying accurately almost 100% of these participants. Given that younger males below age of 16 are the predominant ADHD population, we consider the CI to be a promising nding and a good base for future research.

ACKNOWLEDGMENTS This research was supported by a grant from the University of Virginias Childrens Medical Center, a grant from the Thomas F. Jeffress and Kate Miller Jeffress Memorial Trust, and, in its biomathematical part, by the National Institutes of Health grant RO1 DK51562. We acknowledge NASA Langley Research Center for providing EEG equipment and consultation by Dr. Alan Pope under Technology Transfer Space Act Agreement #221.

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