DESCRIPTION OF THE STRATEGY

Feedback is a process in which the factors that produce a result are themselves modified,
corrected, or strengthened by the result. Bio is commonly referred to as pertaining to self.
Hence, biofeedback is a technique in which information about the self is used to modify,
correct, or strengthen processes within the self. More specifically, biofeedback is a therapeutic
or research technique that involves monitoring an individual's physiological processes or
responses, such as muscular contraction or heart rate, and providing information about that
physiological process back to the individual in a meaningful way so that he or she can modify
the physiological process. In pediatric therapeutic settings, the goal is to help children alter
their physiology to a healthier standard. We all use biofeedback every day. Looking into a
mirror to guide how makeup is applied or how our hair is combed are examples of elementary
uses of biofeedback.
A practical example may be helpful at this point for illustration. One of the causes of pain in
children is overactivity of muscles (commonly, muscles in the shoulder, neck, head, or facial
area). Increased contractions typically occur in response to stressors encountered in daily life
(as if one is guarding or bracing against the stress). Stressors can be mental, physical, or both
(the more likely case). When faced with a school deadline that is mentally taxing, a child may
end up working frantically on the computer and holding the body in somewhat rigid positions
for extended time periods. Before long, it would not be surprising to find the child
experiencing muscle aches (and impaired thinking). A pediatrician might prescribe a muscle
relaxant, while a physical therapist might use heat, massage, or exercise. A biofeedback
approach would begin by monitoring muscles suspected to be involved. Once identified, the
therapist would instruct or coach the child in ways to prevent muscle tension from building to
excessively high levels in the first place and teach strategies to use when tension levels
become high and in need of immediate reduction to alleviate the problem once it has
occurred. Many of the problems being experienced by children involve the complex interplay
of mind and body, as this situation illustrates. For these (and other) problems, biofeedback
may be especially useful.
Biofeedback involves three operations: (1) detection and amplification of a biological
response by using certain measurement devices (applied to the skin surface) and electronic
amplifiers, (2) conversion of these bioelectrical signals to a form that the child can easily
understand (the unprocessed muscle tension signal, for example, sounds much like static on
the radio, and changes are nearly impossible to decipher without special signal processing),
and (3) immediate feedback of or information about the signal to the child. Nowadays, the
information obtained from the sensors is most often relayed to a computer for sophisticated
analysis. Using special software, the computer is able to massage the physiological
information and display it back on a monitor in a meaningful manner so that the child can
learn to modulate the physiological process. Because children are used to watching highquality video graphics (on TV, in video games, and in movies), biofeedback manufacturers
have created similarly high-tech and engaging biofeedback displays to capture and hold
interest and to enhance intrinsic motivation. These gamelike formats focus on fantasy,
curiosity, and challenge.
The top portion of the figure shows a therapist explaining to a child how information about
bodily responding is displayed on the computer screen (a feedback tone is also provided via
speakers connected to the computer). The lower portions of the figure reveal typical sensor
placements for hand warming and forehead muscle tension training (to be discussed later).

The feedback is most often auditory or visual and is presented in either binary or continuous
proportional fashion. Binary feedback uses a signal that comes on or goes off at a specified
value, and is used when the trainer is having the child strive for a specific target level. Many
applications involve lowering overall arousal, and these use continuous feedback to shape
every increasing degree of relaxation (e.g., a tone is provided that decreases in pitch or
volume as relaxation occurs). The information that is presented to the child has reinforcing or
rewarding qualities when the desired response is produced. Typically, the information is
presented to the child in real time, so that the child can immediately see the results of his or
her actions. The child will eventually cultivate a greater awareness of his or her physiological
processes that are ordinarily beyond conscious control, and eventually develop greater
voluntary control over the processes. Voluntary control is developed initially through trial and
error, then by successively getting closer and closer to the desired training goal and repeated
practice. Some have called this process discern-control-generalize.
There are two basic approaches to biofeedbackgeneral and specific. The general approach
is designed for children experiencing conditions that involve excessive or heightened arousal;
conditions wherein the child is physiologically stuck in the fight- or-flight mode. This simple
phrase adequately explains what happens to a person in an acutely stressful situation; the
person's physiology prepares it to run away (flight) or fight. Muscles become tense for action,
pulse rate quickens, sweating increases, blood flow in the extremities reduces, pupils dilate,
digestion slows, and so on. Biofeedback teaches children how to prevent this exaggerated
bodily reaction from occurring in the first place and how to tone it down when it does occur.
Three chief modalities are used to help promote general relaxation, and we term them the
therapeutic workhorses of biofeedback. They consist of muscle tension (or electromyographic
or EMG), temperature or thermal, and sweat gland activity or skin conductance biofeedback.
When used for general relaxation, EMG biofeedback is typically provided from the forehead
area (see Figure 1); reductions in this site are believed to spread to other sections of the body
and to promote an overall state of muscle relaxation. Relaxation can also be cultivated by
teaching children how to warm up their hands using thermal biofeedback. It is not the hand
warming per se that is important. In order for hand warming to occur, nervous system activity
needs to quiet down, which allows blood vessels in the hands to open up and blood flow to
increase. The increased blood flow in the extremities causes the hands to warm. Thus, the
temperature increase is a mere marker that relaxation is occurring. Skin conductance, or sweat
gland activity, is often an indication of arousal. Part of the fight- or-flight response causes the
sweat glands of the hands to become active (and elsewhere, as all have experienced). By
monitoring the amount of sweat gland activity, children can also learn strategies to decrease
their arousal.
Biofeedback shares a close kinship with the diverse approaches that employ relaxation as a
way to combat life stresses (meditation, mindfulness, yoga, autogenic training, progressive
muscle relaxation training, diaphragmatic or paced breathing, and guided imagery). In fact,
biofeedback typically combines one or more of these allied relaxation-based approaches. The
goal of biofeedback, in its most common application, is quite complementary to these
procedures. The distinguishing characteristic is that biofeedback uses instruments that record
information about a child's body as a way of gauging targets for treatment and evaluating
progress. Biofeedback provides concrete evidence that relaxation is actually occurring, so it
can be viewed as instrument-aided relaxation. Feedback is a critical link and an additional
distinguishing feature of this approach. Imagine how difficult it would be to learn to play
tennis if you were blindfolded and were not told when a ball would be served your way.

Should you happen to hit the ball, you would have little idea where it went. Removing the
blindfold establishes a feedback loop that allows learning to take place more quickly.
What we call the general practice (GP) biofeedback clinician typically uses one or more of the
three workhorse techniques to treat conditions that have some association with anxiety or
stress. Examples include anxiety disorders, recurrent headaches, sleep problems, and irritable
bowel syndrome. For these types of conditions, other behavioral (and medical) approaches
have been attempted with similar success. In fact, in practice, GP biofeedback practitioners
regularly augment treatments by adding some of the collateral arousal reduction techniques
mentioned earlier. Treatments to reduce autonomic arousal range from 8 to 12 sessions on
average.
Biofeedback specialists, on the other hand, use applications that require more advanced
training, more expensive or specialized equipment, or use the standard equipment but in a
more specialized manner. These specialized approaches often require extended training trials
(the number of treatment sessions can range from 30 to 80). Examples include modifying
certain brain rhythm activity (termed electroencephalographic, or EEG, biofeedback, or
neurotherapy) for deterring epilepsy and enhancing attention and concentration in children
who are diagnosed with attention-deficit/hyperactivity disorder or who have learning
disabilities. Specialized EMG biofeedback is used in various ways. The first is for conditions
characterized by an imbalance between muscles or where muscle tone or coordination is
compromised (as with back injuries). Muscle tension readings taken from the back can reveal
areas with abnormally high readings, abnormally low readings, and sites where asymmetries
exist (right-versus left-side differences). These findings may be suggestive of bracing or
favoring of a position or posture. Muscle tension biofeedback may also be used to enhance
muscle tone and coordination for people having disorders of intestinal motility (fecal
incontinence). Heart rate variability biofeedback is another somewhat new and specialized
application. Stress and anxiety may or may not be involved in the clinical presentation, and
there is little evidence that relaxation or arousal reduction plays a large role in the clinical
gains obtained in these latter conditions.
Table 1 Biofeedback and Self-Regulation Skills: Review of Evidence for Pediatric
Applications
Disorder
BF Treatment
Modalities
Pain
Headache
primary or adjunctive EMG, TMP
Other chronic pain
adjunctive
PNG, EMG
Acute pain & needle phobia
adjunctive
EDA, PNG
Anxiety/Stress-Related Disorders
adjunctive
PNG, EDA, HRV
Sleep Disorders
primary or adjunctive EMG, PNG
Enuresis
primary
EMG, manometric, alarm
Encopresis
primary or adjunctive EMG, manometric
ANS Dysregulation
Raynaud's
adjunctive
TMP, EDA
RSD (CRPS)
adjunctive
TMP, EDA
Hypertension
adjunctive
EDA, PNG, HRV, BP
IBS
adjunctive
EDA, PNG, TMP, HRV

Hyperhidrosis
adjunctive
EDA, HRV
Neuromuscular Rehabilitation
primary or adjunctive EMG
Attention-Deficit/Hyperactivity Disorder adjunctive
EEG, EMG
Learning disorders
adjunctive
EEG, EMG
Seizure disorders
adjunctive
EEG
Repetitive Behaviors
Tics/Tourette's
adjunctive
EEG, EMG, EDA
Habit disorders
adjunctive
EMG, PNG
Impulse control problems
adjunctive
EDA, HRV, PNG
Chronic Illness
Asthma
adjunctive
EMG, PNG, HRV
Heme/Onc
adjunctive
TMP, PNG
Peak Performance Training
adjunctive
EMG, EEG, HRV
Key: TMP (peripheral temperature), EMG (electromyography), PNG (pneumography), EEG
(electroencephalography), EDA (electrodermal activity), HRV (heart rate variability), BP
(blood pressure)
SOURCE: From Culbert, T. P., & Banez, G. A., Pediatric applications other than headache,
in M. S. Schwartz & F. Andrasik (Eds.), Biofeedback: A practitioner's guide, 3rd edition,
Copyright 2003. Reprinted with permission from Guilford Press.

RESEARCH BASIS
Biofeedback owes its development to scientific findings from animal studies (showing early
on that animals could control bodily responses that previously were thought to be automatic
and not subject to deliberate attempts at control), the cultural revolution (which set the stage
for investigations of altered states of consciousness, which eventually provided support that
brain waves could be voluntarily controlled; also, the physiological effects of meditation such
as were being investigated and eventually became a culturally appealing method of
relaxation), and the technological advances that occurred in the 1960s.
These trends led a group of young and energetic researchers and clinicians to form the
Biofeedback Society of America in 1968. This group was dedicated to providing the empirical
support for the practice of biofeedback. Now known as the Association for Applied
Psychophysiology and Biofeedback (AAPB), this group remains as the main professional
home for individuals interested in investigating the efficacy of biofeedback for clinical
applications, determining the parameters of biofeedback, and identifying new clinical
applications and for those clinicians who use biofeedback in their day-to-day practice (see
www.aapb.org for further information). AAPB also sponsors a journal, Applied
Psychophysiology and Biofeedback, and a newsletter, Biofeedback.
Recently, members from both AAPB and the Society for Neuronal Regulation (see
www.isnr.org) developed guidelines to use when evaluating the clinical efficacy of
biofeedback and psychophysiological interventions. A subsequent panel comprehensively
searched the available research literature and evaluated the level of support for nearly 40
diverse disorders, rating each on a scale from Level 1 (no empirical support) to Level 5
(strong empirical support and superior to other treatments). The majority of the studies
examined by this panel focused on adults, illustrating that work with child populations is
lagging far behind. The accompanying table lists the childhood conditions that are currently

being addressed in the literature and indicates whether they can be considered as a primary
treatment (effective and/or a legitimate treatment alternative) or as an adjunctive treatment
(used in conjunction with other approaches to augment or enhance effects).
The research base concerning biofeedback is continuing to grow as new applications and
treatment modalities are investigated. Heart rate variability biofeedback is emerging as an
additional approach to cultivate lower arousal and relaxation. It is likely that biofeedback will
play an increased role in medical settings, to promote well-child care; in school settings, to
buffer stress, prevent difficulties, and enhance learning opportunities; and in settings not
typically thought of as in need of intervention, to optimize performance overall (music and
athletics, for example).

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
Evidence is mounting that biofeedback can be efficacious for children experiencing a number
of problems (refer back to Table 1). Although many of the conditions listed in the table
respond well to medical treatment (and most are treated mainly by medication), some children
do not respond optimally to these approaches. In addition, many parents have concerns about
overreliance on medication treatments and the possible adverse effects they may have during
development. Furthermore, long-term use of certain medications can actually exacerbate
problems due to dependence and tolerance effects. Thus, biofeedback can be an especially
desired alternative for children.
For children to benefit from biofeedback, they must be active rather than passive recipients.
Some prefer the term biofeedback training as opposed to biofeedback treatment, as treatment
implies a passive patient receiving something of therapeutic value from the practitioner. It is
quite the opposite for biofeedback. Some therapists who work with children refer to
themselves as biofeedback teachers, as all children understand the role that teachers play
they teach skills and ideas, they like to ask questions, and they in turn like to be asked
questions. This emphasizes the interactive learning approach.
It is of critical importance that children be capable of understanding the biofeedback process
(how physiological dysfunction relates to the present condition; why certain aspects of
physiology will be monitored; how they will be attempting to alter the functioning of their
physiology) and that they possess the motivation to try and learn the desired response. It is
interesting to note that after biofeedback is explained to children, they often do particularly
well, learning the needed skills at a quicker rate. Children are more enthusiastic, are less
skeptical about self-control procedures, and have greater confidence in their special abilities
or powers (such as the force or magic) to produce the desired response.

COMPLICATIONS
Certain medications that act on the central and autonomic nervous system may complicate
biofeedback. For instance, the use of muscle relaxants may so relax the targeted muscle
groups that no response can be elicited during training. Some medicines, such as asthma
inhalers, act on the autonomic nervous system and cause blood vessels to constrict. The blood
vessel constriction decreases blood flow to the hands and feet and could inhibit an individual
from learning how to increase blood flow to the periphery. In addition, the use of stimulants,

such as methylphenidate (Ritalin), has been found to alter certain brain rhythms, which during
EEG biofeedback could impede learning. Also, a favorable response to biofeedback may
necessitate medication adjustments. Significant improvement may leave a person
overmedicated and in need of a lower drug dose. Prudent biofeedback practitioners maintain a
close working relationship with medical colleagues.
Few difficulties have been reported when using biofeedback. When working with very young
children, explanations need to be tailored to their comprehension and developmental levels.
Session length may need to be adjusted, rest periods may need to be added, and contingency
management strategies may be needed to sustain performance when motivation lags or when
treatment is not of sufficient intrinsic interest. Parent involvement may be needed as well.
Finally, a very small portion of individuals may experience a sudden increase in anxiety as
they become deeply relaxed, primarily because this is a foreign state to them. These reactions
are typically short lived and easily overcome with the help of a skilled therapist.

BIOFEEDBACK THERAPISTS: TRAINING AND

CREDENTIALS
The growing popularity of biofeedback in treating a variety of disorders has led to a
significant increase in the number of professionals providing this service to the public.
Biofeedback clinicians are employed in a variety of settings: mental health centers,
universities, medical schools, hospitals, rehabilitation clinics, and private practice. These
clinicians hold degrees in psychology, social work, mental health, medicine, physical therapy,
occupational therapy, nursing, and related disciplines. Their training may have been formal,
such as at one of the few professional training programs in the country, or as informal as a
self-directed literature review. Biofeedback providers are moving toward more formal training
and credentialing, as the issue of reimbursement for services has become increasingly
important. Insurance companies and other reimbursement agencies are beginning to require
credentialing in biofeedback, in line with their expectations for other modes of treatment.
Credentialing for biofeedback service delivery, for basic as well as EEG or neurotherapy
applications, exists through the Biofeedback Certification Institute of America (see
www.bcia.org). Although credentials are not always required to deliver biofeedback, the
extended training and knowledge that is acquired through the credentialing process can only
add to a practitioner's competence.
When selecting a biofeedback therapist, consider the following: Is the provider credentialed?
Has the provider received extended training (attendance at workshops or at a structured
program)? Does the provider engage in academic pursuits involving biofeedback (present or
teach courses on the topic)? Is the person licensed or certified in his or her specific field? Is
the provider familiar with the diagnosis you are seeking to have treated? A list of certified
providers may be found at the BCIA Web site. Further information may be found at the
following Web sites: www.aapb.org and www.biofeedback.org.

CASE ILLUSTRATION
Jack was a typical 15-year-old high school student, but his school performance was below
normal and both parents felt that he was working well below his potential. For example, he
could not remain on a task longer than a few minutes, even if it was one he found interesting.

He subsequently was diagnosed with attention-deficit/hyperactivity disorder (ADHD),

primarily inattentive type.
Children with ADHD/ADD often have an EEG brain wave pattern that is different from
children who do not experience attention problems. Certain children have excessive amounts
of slow brain wave activity (termed theta; 47 hertz range) that is associated with
inattentiveness. At the same time, they have a deficit of fast brain wave activity (termed beta;
1330 hertz range), which is associated with attention and concentration. This brain wave
pattern is similar to that seen in children who do not have ADHD/ADD when they are
inattentive or perhaps even dozing off. Stimulant medication helps the brain to wake up and
the child to remain alert and more attentive. Neurotherapy attempts to do the same thing (as
medication) by altering the child's brain waves to a more awake and alert state.
At the initial assessment, Jack's EEG was monitored while he was exposed to various
conditions (sitting quietly, being read to, reading aloud, working difficult mathematical
problems, etc.). Of primary concern was the ratio between EEG activity in the theta range to
that in the beta range (or the extent to which slow wave activity predominated over fast wave
activity). Jack's ratio was about 3:2. EEG biofeedback was used to reduce this ratio to as close
to 1:1. Jack resided approximately 3 hours away from the clinic, so treatment was provided in
massed practice sessions over a long weekend, where Jack would receive three to four
sessions within a short period of time.
One biofeedback sensor (the active electrode) was placed directly on top of his head (Cz
location over the sensorimotor strip), while the other (reference) was attached to his ear lobe.
Each session began with a brief adaptation period of approximately 5 minutes. This period
was extended if Jack had problems settling into the session. During biofeedback, Jack was
instructed to try and increase beta activity and simultaneously decrease theta activity.
Thresholds were set so that he received a reward approximately 80% of the time. As Jack
became proficient at reducing theta and increasing beta, the thresholds were set to a more
difficult setting, thus shaping his response. In addition, during biofeedback he was asked to
listen to or read different types of material to simulate school conditions. Initially, reading
material was selected that was of high interest to him, such as articles about tennis players. As
Jack became more proficient at biofeedback, actual school material, which was less inherently
interesting to him, served as the focus. At various times, Jack was asked to produce the
response without the aid of feedback. This gave an idea of how well Jack might be able to
perform his biofeedback skills outside the treatment session. The first several sessions lasted
roughly 2025 minutes total. However, as Jack began to learn greater control of his EEG,
sessions sometimes lasted over an hour.
Jack was seen for 35 total sessions. At about the 30th session, Jack's parents reported
significant changes in his behavior. Jack was now able to maintain attention and concentration
with both school and personal tasks that he enjoyed. Jack had always wanted but never had
the patience to restring a tennis racket. Now he could do so. Several months following the
completion of training, Jack was still able to produce the biofeedback response and was still
doing well in school.
Frank Andrasik and Amanda Lords
Further Reading

Entry Citation:
Andrasik, Frank, and Amanda Lords. "Biofeedback." Encyclopedia of Behavior Modification
and Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr. 2008. <http://sageereference.com/cbt/Article_n2024.html>.