Support for Neurofeedback Treatment for ADHD
Neurofeedback - also known as EEG Biofeedback - is an
ADHD treatment in which individuals learn to alter their typical EEG pattern
to one that is consistent with a focused, attentive state. This is
done by collecting EEG data from individuals as they focus on stimuli presented
on a computer screen. Their ability to control the stimuli, for example,
keeping the smile on a smiley face or keeping a video playing, is contingent
on maintaining an EEG state consistent with focused attention. Neurofeedback
proponents argue that this ability generalizes to real world situations
and results in better attention during academic and related tasks.
Although neurofeedback for ADHD has been controversial for many years,
research support for this treatment is growing. In fact, in October, 2012
the American Academy of Pediatrics rated neurofeedback as a Level 1 “Best
Support” Intervention for ADHD; this is the highest possible rating and
at the same level as medication treatment and behavior therapy (you can
find the ratings at http://coe.csusb.edu/documents/CRPsychosocialInterventions.pdf
). My sense, however, is that many scientists who study ADHD would
regard this rating as premature based on current evidence.
How do the benefits of neurofeedback for ADHD compare to those provided
by stimulant medication? Medication remains the most widely used ADHD
intervention and examining this question is thus important. In a prior
issues of Attention Research Update - see http://www.helpforadd.com/2003/may.htm
- I reviewed a study comparing neurofeedback to medication treatment.
Both treatments yielded significant benefits and did not differ significantly
from one another.
An important limitation of this study, however, was that children were
not randomly assigned to medication or neurofeedback treatment; instead,
parents selected the option they preferred for their child. This limits
the conclusions that can be drawn in several important ways. First, without
random assignment, preexisting differences between children whose parents
preferred neurofeedback and those who preferred medication may have influenced
the findings. Second, without random assignment one cannot determine
whether neurofeedback is effective for children with ADHD overall, or only
for those children whose parents select it.
New Research Comparing Medication to Neurofeedback
Two recently published studies addressed this limitation by randomly assigning
children with ADHD to either medication or neurofeedback conditions.
- The first study [Duric et al., (2012). Neurofeedback for
the treatment of children and adolescents with ADHD: A randomized and controlled
clinical trial using parental reports. BMC Psychiatry, 12
, 107] was
conducted with 91 6 to 18 year olds (mean age of 10.5) in Norway.
Participants were randomly assigned to receive neurofeedback, stimulant
medication, or both neurofeedback and medication.
Neurofeedback treatment was conducted in 3 40 minute session per week over
10 weeks, i.e., 30 sessions total. The primary focus was to decrease
theta activity and increasing beta activity. This is consistent with
numerous findings that a high theta/beta ratio is a reliably found in individuals
with ADHD (for a very interesting and important study of this issue, see
Children in the medication group received treatment with methylphenidate,
the generic form of Ritalin. Medication was provided 2X/day at a dose of
1 mg per kg.
Children in the combined group received both treatments.
- Parents completed ratings of core ADHD symptoms before
treatment began and 1 week after neurofeedback had been completed.
Children in all groups - neurofeedback, medication, and combined - were reported
to show significant reductions in inattentive and hyperactive-impulsive symptoms.
Although differences between the 3 treatment groups were not significant,
the effect on inattentive symptoms appeared largest for the neuorfeedback
only group. An unexpected finding was that for all groups, the impact
on hyperactive-impulsive symptoms was consistently larger than for inattentive
- A second study published earlier this year [Meisel et
al., (2014). Neurofeedback and standardized pharmacological intervention
in ADHD: A randomized controlled trial with six-month follow up. Biological
, 116-125) extends this work by obtaining feedback from
teachers in addition to parents - including assessments of educational performance
- as well as 2- and 6-month follow up data.
Participants were 23 7-14 year-old children with ADHD - 11 boys and 12
girls; the study was conducted in Spain. Participants were randomly
assigned to neurofeedback or medication therapy. Neurofeedback consisted
of 40 sessions (approximately 30 minutes/session) provided over 20 weeks.
As above, treatment focused on suppressing theta activity and enhancing
Medication treatment was with methylphenidate at a dose of 1 mg per kg
following Spanish national treatment guidelines for ADHD. Children
receiving medication continued to receive it across the 6-month follow up
Data was obtained pre-treatment, immediately after neurofeedback ended,
and again 2 and 6 months later. Mothers and fathers completed ratings
of core ADHD symptoms, oppositional behavior, and functional impairment.
Teachers also rated ADHD symptoms, oppositional behavior, and children's
performance in reading, writing, math, and oral expression.
- Immediately following neurofeedback treatment, maternal
ratings for both groups indicated significant reductions in inattentive
and hyperactive-impulsive symptoms; declines in attention difficulties were
more pronounced and differences between groups were not significant. Significant
reductions in oppositional behavior and reductions in overall functional
impairment were also reported. These improvements were generally maintained
at the 2- and 6-month follow up.
Reports from fathers were less consistently positive. For neurofeedback,
ratings of inattentive symptoms showed significant reductions at each period
but were of lesser magnitude than what mothers reported. Declines
in hyperactive-impulsive symptoms and oppositional behavior were not significant.
Results for the medication group were similar; the only difference was that
fathers reported lower oppositional behavior at 6 months, a reduction that
was not evident in the neurofeedback group.
Results from teachers were especially interesting. For the neurofeedback
group, significant reductions in inattentive symptoms were only marginally
significant at the immediate post-test, but were both significant and of
large magnitude at the 2- and 6-month follow ups. The same was true
for hyperactive-impulsive symptoms and oppositional behavior. At post-test,
teachers also reported significant gains in all academic areas, except for
math which was marginally significant. These gains generally persisted
across the 6-month follow up.
For the medication group, significant reductions were also reported for
core ADHD symptoms and oppositional behavior. The magnitude of these improvements
tended to be larger than for the neurofeedback group, but not significantly
so. However, no improvements were evident for any academic area at
any time point.
Summary and Implications
Across both studies, neurofeedback and stimulant medication treatment yielded
significant and generally consistent benefits for children with ADHD.
In contrast to prior studies comparing neurofeedback and medication, both
employed random assignment. The second study had several additional
strengths including collecting data from multiple informants - including
teachers - and following children up to 6 months after neurofeedback treatment
ended. It is thus especially promising that benefits evident for neurofeedback
when treatment first ended were generally retained over this period.
Medication related gains also persisted, which is not surprising given that
children continued on medication.
Both studies have limitations that need to be recognized. The sample
sizes were small which makes finding significant differences between treatments
more difficult. Neither study was conducted in the US and one must
be cautious about assuming the findings would apply to US children.
However, there is no reason I know of why a different pattern of findings
would be expected here.
Obviously, parents were not blind to their child's treatment; in the second
study, there is no indication that teachers were kept 'blind'. The
inclusion of data from 'blind' observers and/or objective measures of attention
that are less susceptible to expectancy effects would have made for a stronger
study. Apparently, objective assessments were collected in study 2 and will
be published separately; I will be eager to learn what was found.
No mention is made in either study as to whether children actually showed
improvement in producing and maintaining the EEG states that were targeted
in training. This, as well as the absence of a 'sham' feedback condition
makes it impossible to conclude that it was feedback on EEG states, as opposed
to non-specific factors linked to neurofeedback treatment (e.g., therapist
attention) that are responsible for the gains. The importance of these
issues is discussed at http://www.helpforadd.com/2007/september.htm
I would also note that in both studies, children received a standard medication
dose based on body weight rather than determining the optimal dose for each
child via a titration trial. Standard dosing is not the best way to
optimize medication benefits, and gains may have been greater if titration
procedures were employed.
These limitations not withstanding, results from these studies suggest
that the benefits of neurofeedback for ADHD may approximate those provided
by stimulant medication. Study 2 also suggests that neurofeedback may
produce academic gains that medication does not. Thus, while neither
study is perfect (then again, no single study ever is) both point towards
the value of neurofeedback treatment for many children with ADHD.
(c) 2014 David Rabiner, Ph.D.
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