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86]

Original Article

Quantitative electroencephalography – A promising

biomarker in children with attention deficit/hyperactivity
disorder
Mini Sharma1*, Manoj Kumar2, Suman Kushwaha3, Deepak Kumar4
Senior Resident, Department of Psychiatry, Drug De Addiction Centre, Lady Hardinge Medical College, 2Assistant Professor, 4Professor,
1

Departments of Psychiatry and 3Professor, Department of Neurology, Institute of Human Behaviour and Allied Sciences,
New Delhi, India

Abstract Background: Attention‑deficit/hyperactivity disorder (ADHD) is marked by inattention, hyperactivity, and

impulsivity. Experimental studies have reported increased theta activity and reduced beta activity on
electroencephalography (EEG), although theta wave tends to appear during meditative, drowsy, hypnotic,
or sleeping states.
Aims: We aimed to study EEG changes in children with significant severity of ADHD.
Settings and Design: A cross‑sectional study was designed for the children with ADHD presenting to the
Child and Adolescent Psychiatry Outpatient Department (OPD) of IHBAS.
Methodology: A total of 33 ADHD children in the age group of 5–12 years attending OPD were included
in the study after qualifying the inclusion and exclusion criteria for the study.
DSM‑5 criteria were used to make the diagnosis of ADHD and severity was assessed using Conners’ Rating
Scale‑Revised Parent short version. The children with more than 50% score on the Conners Scale were
included in the study. The quantification of the recorded EEG was done using Fast Fourier Transformation
by New Natus NeuroWorks computer software.
Statistical Analysis: The data were analyzed using SPSS version 23.0.
Results: Around 3/4th of participants in the study showed elevated theta: beta ratio results on qEEG.
Conclusions: Although ADHD is marked by inattention, hyperactivity, and impulsivity, children with ADHD
showed marked elevated theta: beta ratio indicating raised slow‑wave changes in cortical activity, thus
concluding quantitative EEG as a promising biomarker in children with ADHD.

Keywords: ADHD, Biomarker, qEEG

Address for correspondence: Dr. Mini Sharma, Department of Psychiatry, Drug De‑Addiction Centre, Lady Hardinge Medical College, New Delhi, India.
E‑mail: mini271191@gmail.com
Submitted: 26‑Jan‑2022, Revised: 27‑Jul‑2022, Accepted: 09‑Aug‑2022, Published: 14-Oct-2022

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DOI: How to cite this article: Sharma M, Kumar M, Kushwaha S, Kumar D.

10.4103/amh.amh_24_22 Quantitative electroencephalography – A promising biomarker in children
with attention deficit/hyperactivity disorder. Arch Ment Health 2022;23:129-32.

© 2022 Archives of Mental Health | Published by Wolters Kluwer - Medknow 129

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Sharma, et al.: ADHD-promising biomarker qEEG
INTRODUCTION
Attention‑deficit/hyperactivity disorder (ADHD) is
characterized by developmentally inappropriate, a persistent
problem in attention and/or excessive motor restlessness and/
or impulsivity that significantly interfere with functioning.[1]
The clinical features of ADHD in the domain of cognition
include short attention span, distractibility, and inability to
foresee the consequences of one’s action.[2] Whereas, the
behavioral domain includes hyperactivity, motor restlessness
and impulsivity in cases of ADHD.
Electroencephalography (EEG) research in the past
40 years has been attempted to characterize and quantify the
neurophysiology of ADHD, most consistently associating it
with increased frontocentral theta band activity and increased
theta‑to‑beta (θ/β) power ratio during rest.
In the 1970s, Satterfield et al. conducted a series of EEG
studies of children with ADHD and found EEG abnormalities,
including excess slow‑wave activity and increased epileptiform
(spike and wave) activity.[3] Barry et al. concluded that elevated
relative theta power and reduced relative alpha and beta,
together with elevated theta/alpha and theta/beta power ratios,
are most reliably associated with ADHD.[4] The presence of
varied worldwide results and lacking Indian data on EEG
changes in children with ADHD formed the basis of this study.
METHODOLOGY
The children with ADHD presenting to the Child and
Adolescent Psychiatry Outpatient Department (OPD) of
our neuropsychiatric tertiary institute were approached after
diagnosis was confirmed using DSM‑5 criteria and informed
consent from parents and assent from children. After
application of inclusion criteria, i.e., children between the age
group of 5 and 12 years and of either gender having more
than 50% score on Conners’ Rating Scale[5] were considered.
Children with a history of epilepsy and institutionalized
children were excluded from the study. Around 100 children
with ADHD were screened and a total of 33 children with
ADHD were recruited for the study after application of
inclusion and exclusion criteria.
For each case, a spectral EEG was done in eyes‑closed
resting state using 21 channel leads for 45 min and analysis
for quantitative EEG (qEEG) was done using Fast Fourier
Transformation (FFT) software. The EEG recordings were
quantified for calculation of theta: beta ratio using FFT algorithm-
based New Natus NeuroWorks computer software.[6,7] The
theta‑beta power ratio of  >5.00:1 was taken as the cutoff for
dysfunction in our study as there is a precedence of similar
cutoff in a study done by  Ogrim et al. in 2012.[8]
The collected data were further analyzed for the study
outcome.
130 Archives of Mental Health | Volume 23 | Issue 2 | July-December 2022
Statistical analysis
Data were entered in the data‑based computer program and
were analyzed using the Statistical Package for the SPSS
Statistics for Windows, version 23. 0 (SPSS Inc., Chicago,
Ill., USA). The clinical profile was analyzed by descriptive
statistics. For correlation analysis, Pearson’s correlation
statistics were used.
RESULTS
In the study, the sample of 33 children which included the
children in the age group of 5–12 years had a mean age of
presentation which was 8.61 (standard deviation [S.D.] = 2.16).
The severity of ADHD was assessed using the Conners’
Rating Scale Revised (CRS R) (Parent version) and a mean
value of 54.52 (S.D. =6.00) was found [Table 1].
The quantification of the EEG theta: beta ratio showed a
mean value of 11.16:1 (S.D. =11.57) which was more than
5.00 and suggestive of increased theta: beta ratio as studied
for ADHD children [Table 1, Figure 1]. In around 60.60% of
the cases, increased theta: beta power ratio was seen.
This was contrary to the findings in female cases where a
strong value of correlation was noted [Table 2]. Though
the significance value was weak to moderate, this could be
attributed to the small sample size.
DISCUSSION
The present study was carried out at a tertiary neuropsychiatry
hospital and an academic institute in Delhi. It was a
cross‑sectional study wherein children were taken from Child
and Adolescent Psychiatric OPD over a period of 9 months.
DSM‑5 criteria were applied to objectively validate the
diagnosis and assessment of the clients taken for the study.
A period sample of 100 children was initially taken, and
after the application of inclusion and exclusion criteria, 33
Table 1: The quantitative electroencephalography theta:beta
ratio in children with attention‑deficit/hyperactivity disorder
Variables Mean Mean severity Mean Theta: beta ratio
(n) age score theta: (>5), n (%)
(years) (on CRS‑R) beta ratio Absent Present
33 8.61 54.52 11.16 13 (39.40) 20 (60.60)
CRS‑R: Conners’ Rating Scale‑Revised
Ta b l e   2 : T h e c o r r e l a t i o n b e t w e e n q u a n t i t a t i v e
electroencephalography theta:beta ratio and severity of
attention‑deficit/hyperactivity disorder in children with
attention‑deficit/hyperactivity disorder
qEEG versus ADHD severity Correlation coefficient (r) P
Male 0.28 0.17
Female 0.63 0.13
Total 0.30 0.09
P<0.05=Significant. ADHD: Attention‑deficit/hyperactivity disorder,
qEEG: Quantitative electroencephalography
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Sharma, et al.: ADHD-promising biomarker qEEG
Figure 1: Theta: beta ratio on qEEG in children with ADHD. qEEG:
Quantitative electroencephalography, ADHD: Attention‑deficit/
hyperactivity disorder
children were included in the study. Children who had other
comorbidities such as epilepsy and other psychiatric illnesses
that could confound the process of assessment and results
were excluded from the study.
The tools used in the study for diagnosis and assessment were
already validated and used in various internationally published
articles. DSM‑5 criteria were used to make the diagnosis
of ADHD, and CRS‑R Parent short version[5] was used to
assess the severity of the ADHD. The Conners score range
is from 0 to 81. In the present study, children with score ≥40
(50% score on Conners Scale) were recruited.
In around 60% of the cases, increased theta: beta power
ratio  (>5.00) was seen. These results align with findings
objectified in various studies conducted worldwide.
Since the ages, it is seen that EEG abnormalities are
consistently found in the children with ADHD which were
initially reported by Satterfield et al.[3] in the 1970s. As the
understanding and investigations had progressed, more and
more findings are indicative of functional brain damage in
children with ADHD.
A multi- centre study (1999) by Monastra et al., found that the
theta/beta ratio could discriminate between ADHD patients
and normal controls with a sensitivity of 86%–90% and
specificity from 94% to 98%.[9]
In a study by Rabiner, the theta/beta ratios of 209
subjects with ADHD were compared with those of a
mixed clinical group with oppositional defiant disorder,
mood disorder, or anxiety disorder without comorbid
ADHD. An increased theta/beta ratio was found in 78%
of ADHD subjects and was not present in 97% of the
other subjects.[10]
In 2002, Bresnahan and Barry reported that elevated theta
persisted into adolescence and adulthood in patients with
ADHD; also provided diagnostic power for discriminating
Archives of Mental Health | Volume 23 | Issue 2 | July-December 2022 131
adults with ADHD from a group of patients referred for
possible ADHD who failed to meet diagnostic criteria.[11]
In 2003, Barry et al. concluded that elevated relative theta
power and reduced relative alpha and beta, together with
elevated theta/alpha and theta/beta power ratios, are most
reliably associated with ADHD.[4]
Snyder and Hall conducted a meta‑analysis that reflected that
the theta/beta ratio has much higher predictive power than
rating scales do, for separating ADHD and clinical controls.[12]
Loo and Makeig 2012 concludes that increase in both theta
band activity and in the theta/beta power ratio are two of the
most reliable EEG findings in ADHD.[13]
In 2014, Lenartowicz and Loo found that the relatively
high  (>90%) sensitivities and specificities reported using
EEG far exceed the most advanced classification attempts
using anatomical and functional MRI data.[14]
The difference in the frontal lobe functioning has been studied
for males and females in the ADHD population. In girls with
ADHD, the functional and psychosocial impairment is well
established by studies done by Hinshaw SP et al, Staller et al,
Biederman et al and Akins CR et al.[15,16,17,18] This could be
inferred from the changes in EEG over frontocentral areas
as noted in our study as well.
Hence, a literature review of more than 50 years consistently
reveals increased theta activity in children with ADHD and
our study with advanced qEEG also shows a similar finding
of raised theta: beta ratio. Even the present study shows
elevated theta: beta ratio in children with significant clinical
severity of ADHD, thus suggesting theta: beta ratio to be a
clinically significant biomarker.
CONCLUSION
ADHD is characterized by a developmentally inappropriate,
persistent problem in attention and/or recessive motor
restlessness and/or impulsivity that significantly interfere with
functioning and presence of increased frontocentral theta
band activity and increased theta‑to‑beta power ratio during
rest compared to non‑ADHD controls.
Even 50 years later to the worldwide available studies and
with the application of stringent criteria and newer modality
for qEEG in our study, the results were conclusive to state
that ADHD is a slow‑wave disease. Thus, qEEG could be
considered a promising biological marker for the diagnosis
of ADHD. Furthermore, there is a need to reconsider the
screening and treatment for patients with ADHD.
Strengths and limitations
A homogenized sample of 5–12‑year‑old children was
taken utilizing the tools for assessment of the severity of
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Sharma, et al.: ADHD-promising biomarker qEEG
ADHD having a good psychometric property. The tools
used in the study were all validated ones, both in Western
and Indian context. Furthermore, stringent inclusion and
exclusion criteria were applied. As the children with severity
CRS‑R score of more than 50% severity score (>40) was
used, then less severe cases which could have confounded
the results were excluded from the study. The study had
a limitation that it did not include treatment naïve cases.
Some children had prior exposure to atomoxetine and
methylphenidate.
Future direction
In cases of ADHD, the qEEG can be considered as a possible
biological marker for diagnostic utility. The use of theta: beta
ratio for knowing the difference of appearance and functional
significance in the EEG changes in ADHD population could
be evaluated in future over a larger sample and in a multicenter
study. It can also be considered for treatment as neurofeedback
therapy for ADHD. Furthermore, newer treatment modalities
can be tried in the treatment of ADHD.
Ethical consideration
An ethical clearance was taken before conducting the study,
reference no.: REC/IHBAS/2017/01).
Acknowledgment
We are thankful to the participants and caregivers for their
participation and support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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