Biofeedback Interventions With Psychotherapy in Pediatric Care: The Present and the Future

In the modern era of clinical pediatric psychology, blending biofeedback—a mind-body approach that aims to alter involuntary body processes—with psychotherapy remains an area of untapped potential and fertile ground for more research. So says Ethan Benore, PhD, Chair, Division of Pediatric Psychology.

Dr. Benore authored an article published in Applied Psychophysiology and Biofeedback with case-based scenarios from his clinical practice that utilize biofeedback as an adjunct to existing psychotherapeutic modalities. While gaps and challenges in the literature persist, he encourages clinicians to get comfortable integrating creative, evidence-backed approaches into their practices.

The sections below capture key points in makes in the paper. See the full article for detailed accounts of patient presentation, biofeedback uses and outcomes.

Biofeedback to enhance relaxation training

Breathing exercises can be a powerful companion to interventions for several psychological symptoms in children, including depression, anxiety, toileting, sleep and somatic issues. Helping patients establish an effective breathwork practice may require resetting their expectations from past experiences, Dr. Benore explains. Doing so begins with providing a baseline assessment along with education about the respiratory process and autonomic system. Psychotherapy can be further supported by biofeedback-enhanced training in a modified practice of diaphragmatic breathing, allowing patients to experiment with slow-regulated breathing, which is perhaps accompanied by pleasurable imagery.

Cognitive restructuring to enhance temperature biofeedback

Another strategy is using biofeedback therapy alongside cognitive behavioral therapy (CBT). Dr. Benore writes in the paper, “There is significant benefit in the therapist actively processing the data with the patient to enhance self-regulation.” He elaborates, adding that taking the time to understand the thoughts and emotions that accompany a patient’s condition can lay the foundation for improved regulation of their symptoms. Having conversations while connected to biofeedback can support new awareness about the relationship between autonomic functioning and cognitive states.

This awareness can, in turn, support new approaches to challenge self-talk. Dr. Benore adds that the use of tailored biofeedback can help patients observe a positive feedback loop in real time, reinforcing a desired outcome for the future.

Biofeedback to enhance exposure therapy

Biofeedback can also be used to complement exposure therapy. In the article, Dr. Benore highlights a case involving a patient who presented with needle phobia. Their initial goal was to reduce the patient’s anxiety with distractions and regulated breathing. The treatment included exposure trials with a mock needle and heart rate variability biofeedback, a technique that helped to relax and distract the patient. After several low-level exposure trials, Dr. Benore increased the intensity, transitioning from a pen to a capped needle and, eventually, the patient tolerated an actual needle for vaccination.

Biofeedback to enhance self-regulation in autism

Peripheral biofeedback has been used to help teens with high-functioning autism. Dr. Benore notes that it can help support education on emotions and improve relaxation, as well as make their abstract inner world more concrete. Dr. Benore says it “simplifies the process of self-regulation for them.” In his practice, he has noted positive outcomes using this technique for patients with high-functioning autism who are receiving treatment for complex, chronic pain.

A call to action

Current literature does not reflect or emphasize the integration of biofeedback into practice, Dr. Benore asserts—and there are legitimate challenges.

For example, there are limited use case descriptions available in the literature, even among well-established strategies like diaphragmatic breathing. Further, barriers related to sound data collection and methodology for biofeedback approaches make it difficult to lead a well-designed study. Finally, the application of biofeedback in this patient population is still not ubiquitous and widely accepted.

Dr. Benore urges clinicians to consider biofeedback as a helpful supplement to psychotherapy to support and facilitate emotional awareness and expression, cognitive diffusion, graduated exposure and concrete goal-directed behaviors. Rigorous clinical observations, such as those documented in this paper, are critical to raising awareness within the scientific community. But the future of biofeedback literature in psychotherapy must focus on its underlying mechanisms, he concludes.