Admin, BJD 514

Brazilian Journal of Development 117927
ISSN: 2525-8761
Neurofeedback and its applications: a literature review leaves its

effectiveness in autism spectrum disorder (ASD)
Neurofeedback e suas aplicações: uma revisão da literatura deixa sua

eficácia no transtorno do espectro do autismo (TEA)
DOI:10.34117/bjdv7n12-514
Recebimento dos originais: 12/11/2021

Aceitação para publicação: 16/12/2021
Dayse Alves Pessoa

Pedagoga, Mestre em Educação – UFPE
Coordenadora do curso de Pedagogia da Faculdade Alpha
Docente da Faculdade Alpha
Rua Gervásio Pires, 826, Santo Amaro
Thaliane Mayara Pessôa dos Prazeres

Doutoranda em Educação Física pela UPE/UFPB
Professor da Faculdade Alpha
E-mail: thalianemayara@hotmail.com
Marcella Dantas Ribeiro

Mestranda em Educação Física pela UPE/UFPB
E-mail: marcelladantas73@gmail.com
Patricia Cristiana Callado Guilherme Fontes

Psicóloga
Professora da Faculdade Alpha
Mireilly Cristiany Moura Hemeterio Araujo

Psicóloga, Mestre em Avaliação em Saúde - IMIP
Especialista em Psicologia Hospitalar
Especialista em Psicopedagogia
Professora em IESs e em cursos de Pós-graduação
Docente Faculdade Alpha
Vera Lúcia de Oliveira Jordão

Especialista em novas linguagens de ensino
Mestra em linguística e ensino
Docente da Faculdade Alpha e IPESU
Brazilian Journal of Development, Curitiba, v.7, n.12, p. 117927-117941 dec. 2021

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Eliete Maria Lins

Graduação em Letras, especialização em Língua Vernácula
mestrado em Psicologia da Educação
Mauro José Alves de Azevedo

Mestre em Ciência da Religião
Mestrando em Ciências da Educação
Flávia Silva de Almeida

Licenciatura em Letras
Mestra em Ciência da Educação Christian Business School
Kelly Cristina Marques de Lima

Pedagoga, Graduanda em psicologia
Pós-graduanda em ABA
Especialista em Educação especial e inclusiva UPE
Psicopedagoga clínica e institucional
Mestranda em Psicologia - FPS
Soraya Maria Freitas de Souza

Pedagoga pela FAINTVISA
Especialista em Psicopedagogia pela FAINTVISA
Especialista em Neuropsicopedagogia pela FAINTVISA
Docente da Educação Infantil
Joselma Dantas Braga de Lira

Psicopedagoga e neuropsicopedagoga
Doutora em Ciências da Educação
Docente UNIFACOL
Suzan Danielle de Paz Almeida

Psicóloga
Faculdade Alpha
ABSTRACT
This study aimed to understand how the innovative neurofeedback technique has
effectiveness in improving specific parameters in autism spectrum disorder (ASD).
Searches were performed on Scielo, Scopus, Scirus, Pubmed, Medline, Lilacs, Bireme,
BDTD, Redalyc with the following descriptors "neurofeedback", "ASD", "treatment" and
the combination of these terms. The findings were compiled in a narrative way with the
articles published between 2016 and 2021.
Keywords: neurofeedback, TEA, treatment.

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RESUMO
O presente objetivou compreender como a técnica inovadora do neurofeedback possui
efetivação na melhoria de parâmetros específicos no transtorno do espectro autismo
(TEA). Foram realizadas Buscas no Scielo, Scopus, Scirus, Pubmed, Medline, Lilacs,
Bireme, BDTD, Redalyc com os seguintes descritores “neurofeedback”, “TEA”,
“tratamento” e a combinação desses termos. Os achados foram compilados de forma
narrativa com os artigos publicados entre os anos de 2016 a 2021.
Palavras-Chave: neurofeedback, TEA, tratamento.
1 INTRODUCTION
The present work is a literary review with the intitude of understanding how the
innovative neurofeedback technique has effectiveness in improving specific parameters
in autism spectrum disorder (ASD). ASD has grown a lot in the population, as well as
studies and research in the area.
In view of the above, the present study has as research problem: what is
neurofeedback? What are your applications? And more specifically in ASD, what are the
advances listed in the literature? Searches were performed on Scielo, Scopus, Scirus,
Pubmed, Medline, Lilacs, Bireme, BDTD, Redalyc with the following descriptors
"neurofeedback", "ASD", "treatment" and the combination of these terms. The findings
were compiled in a narrative way with the articles published between 2016 and 2021.
They will be used as basic authors: Au, Breitling, Bystad, Castro, Fernandes, Lee,
Palm, Pedapati, Steenburgh. The present research is justified by the need for a greater
interpretation of the data already listed in the literature with the objective of collecting
evidence, synthesizing and critically describing the available literature related to the
applicability and efficacy of ETCC in people with ASD.
2 THEORETICAL FOUNDATION
Autism Spectrum Disorder (ASD)
Autism Spectrum Disorder is a Neurodevelopmental Disorder, characterized by
deficits and difficulties in communication and social interaction, associated with
restricted and circumscribed interests and activities, constituted a range of challenges for
the national and international medical community. According to the Center for Diseases
Control and Prevention of the United States of America, the prevalence of Autism
Spectrum Disorder is currently estimated at 1:58 cases, being four times more common
in boys than girls (AU et al., 2016).

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The earlier the Diagnosis and the beginning of treatment, the more expressive the
results will be, so that the quality of life of children and adults can be significantly
improved by an early diagnosis and by the performance of a responsible and monitored
treatment. In fact, the speed of brain connection formation and neuroplasticity are in the
phase of greater brain development in the first years of life (BECKER; RIESGO, 2016).
For children diagnosed with neurodevelopmental disorders, early stimulation is essential
to aid brain development in the healthiest possible way, optimizing the results of its
functioning in the long term (BIKSON et al., 2016).
The diagnosis of ASD is made clinically by direct observation of the presence of
behavioral symptoms that characterize the core of the disorder and interviews with
patients responsible (American Psychiatric Association, 2013). Some batteries are used
to perform the clinical diagnosis, such as the Childhood Autism Rating Scale (CARS),
the Autism Assessment Evaluation Checklist (ATEC), the Children's Global Assessment
Scale (CGAS), and the Aber Behaviorrant Checklist (ABC). CARS is a battery with 15
items related to social behavior, emotional response, use of objects, body language,
adaptation to changes, visual responses, perceptual responses, fear and anxiety (BROWN;
PARIKH; PATEL, 2019).
In general, this scale observes the severity of autism. ATEC is a battery with four
subscales: 1. speech/language/communication (14 items; maximum score of 20); 2. social
(20 items; maximum score of 40); 3. sensory and cognitive awareness (18 items;
maximum score of 36); and 4. physical and behavioral health (25 items; maximum score
of 75). In principle, the higher the score, the lower the patient's performance. The CGAS
evaluates the psychosocial functioning of the child, scoring from 1 to 100, and the lower
the result, the more severe the disorder in the child. Finally, the ABC is composed of 57
items that function as screening for unadaptive behaviors. Until then, there is no definitive
treatment for autism (BREITLING et al., 2016).
Most treatments for central SYMPTOMS of ASD are based on behavioral and
cognitive interventions. However, the results do not satisfy severe cases with catatonia,
attention deficit and hyperactivity or high aggressiveness. Furthermore, pharmacological
treatment, through antipsychotics or antidepressants, plays an adjunct role, but does not
effectively reduce the central symptoms of the disorder. In many cases, adverse symptoms
such as drowsiness, dry mouth, agitation, insomnia and increased behavioral impairment
are observed (BYSTAD et al., 2016).

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Therefore, it is necessary to develop or invest in innovative and more effective

treatment options. In order to understand the pathophysiology of ASD, neuroimaging
studies have been conducted over time. The findings indicated the existence of cerebral
asymmetry, involving reduced activity in the left hemisphere – where there are structures
related to language, memory and social functioning. This reduction in activity also
originates from a differentiated sinaptic maturation, caused by microstructural
abnormalities, especially in the left region of the dorsolateral prefrontal cortex (HRCFD)
(CASTRO et al., 2016). The cerebral asymmetry present in ASD brought to light the
discussion that the lateralization of neural functions in these circuitry may explain the
origin of the damage in social interaction, communication, aggressiveness and language,
some symptoms present in ASD (CAO et al., 2018).
Thus, in addition to therapies such as behavioral and pharmacological
interventions, the advent of new procedures that use noninvasive brain stimulation
techniques, such as transcranial magnetic stimulation (TMS) and transcranial direct
current stimulation (ETCC), can bring good results in the behavioral and cognitive
improvement of ASD, as well as has been signaled in the treatment of other disorders
such as schizophrenia, Alzheimer's disease, depression, among others. (CONCERTO et
al., 2016). In addition, the use of ETCC in children and adolescents with attention deficit
hyperactivity disorder showed behavioral improvement in aggressiveness and
information processing, such as detection of environmental stimuli and ability to easily
exchange between activities (CASTRO, 2016).
Neurofeedback
Neurofeedback is a promising treatment for autism spectrum
disorders. Neurofeedback involves teaching an individual to control their brain activity
consciously. This treatment is not widely available (because it is expensive) and
researchers bet heamuch on its effectiveness in the treatment of autism spectrum disorder,
Asperger's syndrome and other invasive developmental disorders (CRESPI et al., 2016).
It is important to educate yourself about the procedure, its effectiveness and the
research behind it before considering it an option. Given the above, we have the following
research question: What happens during neurofeedback therapy? During a typical
neurofeedback session, the doctor connects the electrodes on the patient's face and head,
as in a typical electroencephalographic test (EEG) (CRIPPA et al., 2016).

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These electrodes transmit EEG activity, which is displayed on a screen to the

patient and the doctor to see or hear. Typically, EEG activity is converted into something
easier for the patient to understand, such as sounds or images (WARRIER et a., 2019).
In a format somewhat similar to a computer game, the patient can then try to modify their
brainwave activity to move an object on the screen or produce a certain routine procedure
(CRAIG et al., 2018).
Each time the patient reaches the desired or routine movement, he receives a
reward, often in the form of points. In theory, this process will help patients better learn
to control their behavior (STEENBURGH et al., 2016). The goals of treatment, in general
of neurofeedback therapy is to help a person with ASD to learn how to control their
brainwaves and modify behaviors (FERNÁNDEZ; MOLLINEDO-GAJATE;
PEÑAGARIKANO, 2018).
According to the literature, there are significant differences in brains and
brainwave patterns in people on the autism spectrum compared to neurotipic individuals
(SANTOS; MÉLO, 2018). Specific brainwave frequency targeting in Neurofeedback are
designed to attack these specific brainwave frequencies that may present a problem for
people with autism spectrum disorder (ASD): Delta waves (0.5-3 hertz): People with
learning disabilities, social disabilities, and brain damage usually have high delta waves,
resulting in zoning out. Theta waves (3-7 hertz): patients with autism typically have high
theta waves, resulting without unusual drowsiness and difficulty concentrating on things
outside of them selves (FERNANDES; ALVES, IALVES, SANTOS, 2017).
Neuromodulation Techniques are classified as; 1) Noninvasive techniques,
including Transcranial Magnetic Stimulation ('TMS); "Transcranial Direct Current
Stimulation " ('TDCS') and "Trigeminal Nerve Stimulation " (Trigeminal Nerve
Stimulation – 'TNS); 2) Minimally Invasive Techniques, i.e., Electroconvulsive Therapy
(ECT); and 3) Invasive Techniques, including Deep Brain Stimulation (DBS) and Vagal
Neuro Stimulation ('VNS). The "ETCC" "Transcranial Stimulation by Direct Current")
constitutes a noninvasive, painless technique, which, although it cannot produce directly
evoked potentials, can influence the excitability of individual neurons, and can be used in
such a way as to specifically stimulate the brain area affects language (FERNANDES;
DAYS; SANTOS, 2017).
ETCC has been widely studied and is one of the most promising techniques for
the treatment of numerous conditions (RIZZUTTI,2017). Etcc's base is to employ a
battery-driven stimulator that emits low intensity continuous electrical currents (0.5 – 2.0

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mA) by two electrodes (cameo and anode), ranging in size from 25cm² to 35cm², which
are in contact with the scalp (FINISGUERRA; BORGATTI; URGESI, 2016).
The flow of this current is capable of modulating neuronal excitability, altering
the resting potential of neurons and producing effects such as changes in prolonged
neuronal excitability, which can be driven by synaptic plasticity. Thus, stimulation of
only one area can improve adjacent areas (GORDON, 2017). Depending on the polarity
of the stimulation, the anode will have a depolarizing effect, and the detonator will have
a hyperpolarizing effect (GUSMAN,2017). Due to its ability to induce cortical changes
in the long term, ETCC has been considered as a treatment tool for numerous neurological
and psychiatric conditions such as depression (HADDERS-ALGRA,2018),
schizophrenia (GRECCO et al., 2016) and Alzheimer's (GUSMAN,2017), for example.
In general, ETCC can have acute or long-lasting effects on cortical functions,
depending only on the parameters used in stimulation (such as location, frequency
intensity or repetition of stimulation) (ROBLEDO; DONELLAN,2016). In this context,
the present study is justified as ETCC presents itself as a modulating tool of neuronal
plasticity, and may have positive effects on the clinical improvement of patients withASD
(HORDER et al., 2018).
Neurofeedback on autism spectrum disorder

The aim of this review was to seek evidence and evaluate the efficacy of the use
of ETCC in the treatment of cognitive and behavioral symptoms associated with ASD.
The results of the Articles showed improvement in assay symptoms, such as
improvements in language acquisition, decreased hyperactivity, decreased
aggressiveness, increased activity (in the case of catatonia) (HUPFELD; KETCHAM,
2018).
The improvement in symptoms and in some behaviors occurred even in the face
of stimulation protocols and different behavioral indicators, according to the objective of
each article evaluated. In addition, the effects were relatively long-lasting, so that some
studies report continued improvements after the follow-up period of three and six months
of stimulations (KANG et al., 2018).
Few adverse reactions were observed, such as mild irritation of the scalp or
applied area, and ETCC was well tolerated even after six months of consecutive daily
applications (ROBERTSON; BARON-COHEN, 2017). The standard stimulation
configuration consisted of the positioning of the electrode in the left DLPFC and the

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reference configuration outside the scalp, in the contralateral deltoide. This configuration
is based on neuroimaging findings and results of mt sme trials that observed irregular
current flow between the left DLPFC, medial prefrontal cortex, supplementary motor area
and parietal cortex (KHALEGHI et al., 2020).
This irregular flow corroborates the premise that there are dysfunctions between
cortical functioning in certain regions of patients with ASD. In this sense, computational
models pointed out that, with the commonly used ETCC configurations, the current also
reaches deep brain structures involved in the pathophysiology of ASD (LATTARI et al.,
2017).
Anodic stimulation on the left DLPFC, aiming at cortical balance of this area, due
to its extensive connection with other networks distributed in the brain, was the most used
configuration in ASD, but not the only one (PEDAPATI et al., 2018). Thus, the DLPFC
seems to be a site of potential interest to study the neuroplasticity of ASD, since it can
promote the balance between excitation and inhibition resulting in the improvement of
neuronal communication (LEE; LEE, KIM, 2016).
Changes in this balance can improve the functioning of cognition, mainly attention
and working memory, and processing of information visual. In fact, the excitability of the
prefrontal cortex improves symptoms, corroborating studies that showed decreased
activity in the prefrontal cortex in people with TAs (MAROTTA et al., 2020).
Another line of evidence of stimulation in the DLPFC region comes from clinical
trials from cathodic stimulations, rather than anodic, in the left DLPFC that reversed
unadaptive behaviors, such as catatonia or hyperactivity (PALM et al., 2018). The
therapeutic effects observed in the studies of this review were more related to the
reduction of cortical excitability in the HRCFD and the possible cascade resulting from
inhibitory effects on all neuronal networks interconnected with this region (MANOR et
al., 2016).
The positive effects of stimulations had a impact on dysphoria, irritability,
agitation, crying and behavioral symptoms evaluated by scales such as ABC, CARS,
CGAS and ATEC (PAQUET et al., 2017). Neuroimaging studies indicate that the medial
prefrontal cortex and medial temporal lobe are also critical in the pathophysiology of
ASD due to the aspect of social retractment related to individuals with ASD that cause
dopaminergic reduction in this area, or areas interconnected with The HRD (MANOR et
al., 2018).

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Possible mechanisms of action of ETCC in ASD A summary of the possible

mechanisms of action by which the use of ETCC seems to provide benefits in the
treatment of ASD is being provided by this review, although research is still specific and
restricted within a complex universe involving the very pathophysiology of the disorder
(OLDRATI et al., 2016). Of course, many discoveries will remain unknown, as will the
main mechanisms of action that need to be tested, generalized and understood by further
research. However, the effects of ETCC seem determined by neuronal polarity and
probably by extension to neural circuitry (MOURA et al., 2019).
Stimulation protocols used: Anodic stimulation was responsible for increasing
neuronal excitability, and cathodic stimulation triggers the reverse. This change in
polarization is probably due to the displacement of resting potential, at least within a
current conception related to the mechanism underlying the short-term effects of ETCC
(MORAES et al., 2017).
The long-term effects of ETCC are proposed as due to changes in the sinatic
regions, specifically by changes in activity in N-Methyl-D-aspartate (NMDA) and GABA
receptors, which can then lead to permanent changes in areas that presented reduced
activity, for example (PANIKRATOVA et al., 2020). In addition, ETCC may result in
modulations of neuroplasticity by brain-derived neurotrophic factor (BDNF) dependent
mechanism, since bndf hyperactivity plays a key role in the etiology of autism in the early
stage of life. With these findings, it was possible to observe that the effects of ETCC are
not limited to sites of application, having an effect even in other areas (MILLER et al.,
2019).
3 FINAL CONSIDERATIONS
The results suggest that ETCC is a promising tool for the treatment of ASD. This
occurred even in studies using different designs, objectives and conditions. This
reinforces the use of ETCC as a promising clinical tool in the study and follow-up of
ASD, especially considering symptomatic improvement when specific or conventional
treatments have no effects.
Protocols aimed at stimulating regions such as DLPFC, for example, can lead to
improved behavioral and cognitive impairments, besides serving as an investigative and
therapeutic tool. Thus, it was clear that stimulation in this area causes improvements.
Investigative studies do not clearly provide what are the altered physiological
mechanisms or whether these changes can be generalized to the entire population with

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ASD. Still, it is not clear which region is most affected and which region should be most
stimulated. However, according to the neuroimaging studies and the findings presented,
stimulation of THEHRD is the best choice per hour.
The need for further studies evaluating the efficacy of ETCC in ASD is one of the
points to be considered. Due to the potentiality of the use of ETCC for ASD, it can be
known which symptoms are best treated and when stimulation should be used as a
therapeutic agent. The refinement of the technique should be performed so that
professionals can know the exact moment of stimulation application. Understanding this
is crucial, from the pathophysiology point of view, since it can provide new directions for
the treatment of refractory or recurrent conditions.

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