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Autistic Spectrum Disorder (ASD) as a Potential Target of Z-score LORETA Neurofeedback.

By J. Lucas Koberda, MD, PhD,

Autism is a neurodevelopmental disorder characterized by impaired social interaction and communication, and by restricted and repetitive behavior. It is one of three recognized disorders in the autism spectrum disorders (ASDs), the other two being Asperger Syndrome (AS), which lacks delays in cognitive development and language, and Pervasive Developmental Disorder, not otherwise specified  (PDD-NOS), which is diagnosed when the full set of criteria for autism or Asperger syndrome are not met.

The prevalence of autism is about 1–2 per 1,000 people worldwide, and the Centers for Disease Control and Prevention (CDC) report 11 per 1,000 children in the United States are diagnosed with ASD as of 2008. Parents usually notice signs in the first two years of their child's life. Early behavioral or cognitive intervention can help autistic children gain self-care, social, and communication skills. 

Asperger Syndrome (AS), frequently considered as mild form of ASD is characterized by significant difficulties in social interaction, alongside restricted and repetitive patterns of behavior and interests. It differs from other autism spectrum disorders by its relative preservation of linguistic and cognitive development. Although not required for diagnosis, physical clumsiness and atypical use of language are frequently reported. The syndrome was named after the Austrian pediatrician Hans Asperger who, in 1944, studied and described children in his practice who lacked nonverbal communication skills, demonstrated limited empathy with their peers, and were physically clumsy. There is doubt about whether it is distinct from High-Functioning Autism (HFA) partly because of this; its prevalence is not firmly established. Although research suggests the likelihood of a genetic basis, there is no known definite genetic etiology. The lack of demonstrated empathy is possibly the most dysfunctional aspect of Asperger syndrome. Individuals with AS experience difficulties in basic elements of social interaction, which may include a failure to develop friendships or to seek shared enjoyments or achievements with others. Stereotyped and repetitive motor behaviors are a core part of the diagnosis of AS and other ASDs. They include hand movements such as flapping or twisting, and complex whole-body movements. Although individuals with Asperger syndrome acquire language skills without significant general delay and their speech typically lacks significant abnormalities, language acquisition and use is often atypical. Abnormalities include verbosity, abrupt transitions, literal interpretations and miscomprehension of nuance, use of metaphor meaningful only to the speaker, auditory perception deficits (unusually pedantic), formal or idiosyncratic speech, and oddities in loudness, pitch, intonation, prosody, and rhythm. Echolalia has also been observed in individuals with AS. There is no single treatment, and the effectiveness of particular interventions is supported by only limited data. Intervention is aimed at improving symptoms and function. The mainstay of management is behavioral therapy, focusing on specific deficits to address poor communication skills, obsessive or repetitive routines, and physical clumsiness. Most children improve as they mature to adulthood, but social and communication difficulties may persist. More recently, neurofeedback (NFB) has been reported as a potential treatment modality which could benefit ASD individuals. Therefore, the following case of Z-score Low Resolution Electro-magnetic Tomography Analysis (LORETA) NFB treatment, which is one of the newest forms of neurotherapy is presented as an example of successful outcome. 

A case study

Victor is an 18-year-old male student who presented for an initial evaluation with his mother. The mother reported that he had problems with focusing, concentration and speech expressive functions. In addition, social interaction problems were reported including a difficulty in making friends and generalized clumsiness. Victor was not taking any medications. He was a freshman at a local university with very good performance in mathematics and physics (A) however poorer performance in English and philosophy (B, C). His examination showed monotone type of speech with decreased speech output and reduced facial expression. Some reduction of fine motor movements was also noted during the exam. 

Initial workup was unremarkable except for the quantitative electroencephalogram (QEEG) (Neuroguide, Inc. St. Petersburg, FL) which showed increased theta activity in the fronto-temporal (see Fig 1) region. 

Fig 1. QEEG of 18 y.o. student with probable AS with noticeable increase in frontal and temporal theta power.


Victor and his mother were not interested in medication therapy.

Victor was diagnosed with possible Asperger syndrome and was initially treated with one electrode basic type of NFB guided by prior QEEG findings. Approximately 30 sessions of 1-electode NFB were completed with some subjective improvement in concentration and executive functions. However, expressive speech problems were still of major concern for Victor and his mother. Follow up QEEG showed some changes in delta and theta expression (see Fig 2). 

Fig 2. Follow up QEEG after 30 sessions of 1-electrode NFB. Notice elevated frontal and temporal delta and theta power.

Subsequent computerized neuropsychological testing (Neurotrax, Inc. Bellaire, TX) showed evidence of major verbal deficiency (see Fig 3). The global cognitive score was below expected (93.2) and most deficient for verbal function (35.5).

Since Z-score LORETA NFB became available in our office, the decision was made to initiate this treatment modality in order to see whether his speech expressive dysfunction could be corrected. A total of 10 sessions of combined surface and LORETA NFB (Applied Neuroscience, Inc.) was completed and then another computerized neuropsychological testing was conducted (see Fig 3). A major improvement of verbal function was noted (104.1) with an increase in global cognitive score (103.1).

Fig 3. Comparison of computerized neuropsychological testing before and after Z-score LORETA NFB.

At the same time after Z-score LORETA NFB therapy completion, another follow up QEEG was also recorded (see Fig 4) which showed a marked reduction of delta and theta activity. 

Fig 4. QEEG after completion of 10 sessions of Z-score LORETA NFB with noticeable reduction of theta power when compared to the initial QEEG recording.

Subsequently, Victor also reported a marked improvement in University performance, receiving an “A” score in both English and philosophy. 

This case illustrates the potential of Z score LORETA NFB for verbal enhancement in autistic spectrum disorder patients.