Attention Research Update
"Helping parents, professionals and educators stay informed about new research on ADHD"
David Rabiner, Ph.D. Senior Research Scientist, Duke University
NEUROFEEDBACK AS AN AID TO ENHANCE ATTENTION AND IMPROVE BEHAVIOR IN CHILDREN WITH AD/HD
David Rabiner, Ph.D., Olafur Palsson, Psy. D., &
Peter Freer, M.S. Ed.
Note: In the interest of disclosing
potential conflicts of interest, I want to be sure that you are aware of
two items. Attention Research Update receives support from Unique Logic
+ Technology, a company that distributes an attention training system called
Play Attention based on neurofeedback principles. Mr. Freer is a co-author
of this paper and the founder of Unique Logic + Technology. I do not
believe this has compromised the objectivity of the article below, but I
want to be sure that you are aware of these considerations. My hope
is that you will find the article to be a balanced account of the controversy
surrounding neurofeedback treatment, and that the information will be useful
Due to increasing coverage in major publications like Discover, Time, and Newsweek, neurofeedback has become a popular albeit controversial intervention used in the treatment of AD/HD. Scientists have known for many years that the brain emits various brainwaves which are indicative of the electrical activity of the brain and that different types of brainwaves are emitted depending on whether the person is in a focused and attentive state or a drowsy/day-dreaming state.
Neurofeedback allows a person to view these brainwaves on a computer screen
as they occur. By teaching a person to produce brainwave patterns that are
associated with a relaxed, alert, and focused state, and having them practice
this skill for many hours of training, neurofeedback practitioners contend
that individuals with AD/HD can learn to maintain this state and that many
symptoms of AD/HD will diminish. As discussed below, however, many scientists
do not believe that such claims have been sufficiently documented.
HOW IS NEUROFEEDBACK TRAINING CONDUCTED?
A typical clinical session of neurofeedback training for a child with AD/HD involves pasting electrodes (sensors that pick up the electrical activity of the brain) to the head with conductive gel. Wires from these electrodes are connected to a device that amplifies the small signal obtained from the electrodes. The child sits in a comfortable chair and watches a computer monitor. The monitor displays a picture such as a moving graph that indicates the degree to which the child is producing the desired pattern of brainwave activity. The goal is for the child to learn to produce the type of brainwave activity that is associated with a focused and attentive state.
Over the course of numerous training sessions it may gradually become
easier for the child to achieve this state and to maintain it for longer
periods of time. Proponents of neurofeedback often describe this training
as an exercise program for the brain, and training continues until the client
demonstrates the ability to consistently achieve and maintain a pattern of
EEG activity that is indicative of a relaxed and attentive state. This typically
requires 40-60 sessions at an average session cost in the range of $40 to
$120 per session. By the conclusion of treatment, neurofeedback advocates
believe that increases in attention and reductions in impulsivity that are
evident during training will transfer to important areas of the child's life
- e.g. home and school - and there are several published studies (see below)
that are consistent with this position. Critics of neurofeedback, however,
do not believe there is credible evidence to indicate that such transfer
A BRIEF HISTORY OF NEUROFEEDBACK
As early as the 1970s, neurofeedback was used as an experimental treatment for neurological conditions such as epilepsy. When clients were taught to relax and produce site-specific brain wave activity, the occurrence of seizures was reduced (Sterman, et al 1974. Biofeedback training of the sensorimotor electroencephalogram rhythm in man: Effects on epilepsy. Epilepsia, 15, 395-416). In subsequent research, scientists reported that neurofeedback could help reduce the symptoms associated with AD/HD (Lubar & Shouse, 1976. EEG and behavioral changes in a hyperactive child concurrent with training of the sensorimotor rhythm (SMR). A preliminary report. Biofeedback and Self-Regulation, 1, 293-306). Later, NASA began to investigate whether attention training using neurofeedback could help to prevent accidents among astronauts and pilots during flight. This led NASA scientists to develop a new application of neurofeedback training technology in which children's ability to maintain a desired EEG state was linked to their ability to ability to control video games. This approach to neurofeedback treatment has gradually become more widespread.
As promising reports of neurofeedback treatment emerged, it quickly moved
from an experimental technique with very preliminary research support to
a treatment that was provided to a growing number of children. Many
scientists who research AD/HD expressed concern that neurofeedback was an
expensive and unproven treatment that could dissuade parents from selecting
other treatments - i.e. stimulant medication and behavior therapy - for which
greater empirical support existed. These scientists argued that the
efficacy of neurofeedback had not been conclusively demonstrated through
carefully controlled clinical trials, and that parents should be extremely
cautious about selecting this treatment.
CURRENT EVIDENCE FOR NEUROFEEDBACK TREATMENT
The debate about the value of neurofeedback treatment for AD/HD has continued for the past several decades. Advocates point to a number of published studies that support numerous anecdotal reports from parents and clinicians about the utility of this approach. Critics argue that all these studies have significant limitations that prohibit any firm conclusion about the effectiveness of neurofeedback treatment from being made. Reviewing two recently published studies may help clarify why these strongly opposing views continue to be held with such conviction.
In the first study (Monastra et al., 2001), 101 children and adolescents with AD/HD received multimodal treatment that included stimulant medication, behavioral therapy, and school consultation services. Fifty-one of these participants also received neurofeedback because their parent(s) decided to include it in their child's overall treatment plan. Participants in each group (i.e. multimodal treatment vs. multimodal treatment + neurofeedback) did not differ in the severity of symptoms before treatment began, and the treatment provided differed only by whether it included neurofeedback.
Twelve months later, participants whose treatment included neurofeedback showed greater improvement according to parent and teacher behavior ratings, and no longer demonstrated the brainwave patterns that were substantially different from children without AD/HD. These gains remained evident a week after medication was discontinued and suggest that adding neurofeedback to a multimodal treatment program was associated with important incremental benefits. You can find a comprehensive review of this study at www.helpforadd.com/2003/january.htm
In a second study (Fuchs et al., 2003), parents of 34 children with AD/HD between the ages of 8 and 12 chose either stimulant medication or neurofeedback treatment for their child. The majority - the parents of 22 children -- opted for neurofeedback treatment. After 3 months, children in both groups showed significant and comparable reductions in AD/HD symptoms according to parents and teachers. Laboratory tests of attention also showed equivalent improvement. A comprehensive review of this study is available at www.helpforadd.com/2003/april.htm
What conclusions can be drawn from these recent reports? Clearly, children in both studies who received neurofeedback appeared to benefit from this treatment. These benefits were evident in reports from parents and teachers, as well as on laboratory measures of attention. Given the compelling nature of these results, which are consistent with results from other studies, why do many scientists continue to regard neurofeedback as an unproven and highly experimental treatment for AD/HD?
The reason for this skepticism is that although children in these studies were appeared to improve, limitations in the researcher's methods make it impossible to know what was responsible for the improvement. An important limitation of both studies is that parents decided whether to use neurofeedback with their child, rather than this being determined by chance - i.e. random assignment. The absence of random assignment makes it impossible to rule out other factors the groups may have differed on - besides whether they received neurofeedback - as an explanation for the results obtained. This limitation is found in virtually all studies of neurofeedback.
Another limitation is the failure to control for the substantial extra therapist attention provided to children who received neurofeedback treatment. It is possible that this extra attention - and not neurofeedback training per se - is what accounts for children's improvement. Although this strikes us unlikely given the intractability of AD/HD symptoms to adult attention and support alone, it cannot be conclusively ruled out as an explanation.
It is also important to note that neither study permits any conclusion about whether providing children with "feedback" on their brainwave activity was a necessary treatment component. Perhaps focusing on various computer tasks several times each week over an extended period would help children develop their attention skills regardless of whether such feedback is provided. The experimental controls that would be necessary to determine this were not included in either study.
Finally, because children in these studies were not followed for any sustained time period after treatment ended it is not known whether improvements associated with neurofeedback persisted beyond the end of training. Some neurofeedback proponents have claimed that unlike medication treatment, where benefits are typically not sustained after medication is stopped, improvements are sustained because the child has learned a new skill - i.e. the ability to produce and maintain a focused, attentive state. We are not aware, however, of studies in which this claim has been documented.
It is important to emphasize that the limitations discussed above were unavoidable because these studies were conducted in regular treatment settings where parents paid for the services provided. In this context, assigning children to different treatments at random is not possible. Providing equivalent attention from a therapist for children whose parents did not choose neurofeedback - or the type of control necessary to establish that direct feedback on brainwave activity is critically important - is also impractical.
The fact that these limitations could not be avoided, however, does not eliminate the problems created for interpreting the study results. Thus, we believe that neurofeedback critics are correct to stress that the efficacy of this treatment has yet to be conclusively demonstrated according to accepted scientific standards.
On the other hand, it is also important to recognize that these studies reflect the context in which parents actually make treatment decisions for their child. That is, parents are aware of and are presented with different treatment options and must decide which to pursue. From this perspective, we believe that the promising results from these studies can be interpreted to suggest that when parents select neurofeedback treatment for their child - either alone, or in combination with more conventional approaches - there is a reasonable chance they will find it to be helpful.
Many scientists, however, would argue that in the absence of clearly established
efficacy, there is little or no basis for expecting any such benefit.
In many ways, the debate about neurofeedback that is evident today is no different from what was taking place 10-15 years ago. On the one hand, there is evidence that children with AD/HD who receive neurofeedback treatment obtain some benefits from the experience. On the other hand, for the reasons discussed above, the efficacy of neurofeedback has not been conclusively demonstrated according to widely accepted scientific standards. As one critic recently pointed out, the evidence to date would not meet FDA standards for neurofeedback to be classified as a medical intervention for AD/HD (Barkley, 2003. The ADHD Report. 11, 7-9.), and uncertainty about the efficacy of neurofeedback will continue until large-scale studies that include the necessary experimental controls are conducted.
Until such research becomes available, parents considering neurofeedback treatment for their child should be aware that despite the promising results that have been reported, there are other interventions (e.g. medication treatment, behavior therapy, and their combination) whose efficacy has been clearly demonstrated in a number of carefully controlled studies. For this reason, these are the interventions that are recommended in treatment guidelines recently published by the American Academy of Child and Adolescent Psychiatry (1997) and the American Academy of Pediatrics (2001). You can find a comprehensive review of treatment guidelines from the American Academy of Pediatrics at www.helpforadd.com/2001/october.htm
We hope that the research necessary to provide more definitive answers to important questions about neurofeedback treatment will soon be forthcoming so that parents can make decisions about this treatment that are informed by the strongest possible science. Unfortunately, we are not aware of any such studies that are currently underway, and the issues about neurofeedback that are unresolved today may remain unresolved for many years. Hopefully, scientists who are in a position to conduct such research will begin to initiate the necessary studies so that this does not occur.
Information presented in Attention Research Update is for informational
purposes only, and is not a substitute for professional medical advice.
Although newsletter sponsors offer products and services that I believe will
be of interest to subscribers, sponsorship of Attention Research Update does
not constitute a specific endorsement or guarantee of any company's product