How Strong is the Research Support for Neurofeedback in Attention Deficits?
(Editor’s Note: Neurofeedback is one of the technologies that people often ask us about. It is a promising intervention in a variety of areas, and has got significant traction in helping kids with ADD/ ADHD. Now, given the significant cost it poses for parents, we need to ask the question: “How Strong is the Research Support for Neurofeedback Treatment of Children with ADHD”? We are honored to present the thoughts of Duke University’s Dr. David Rabiner, a leading authority on the field, on that important issue. As a bonus, you will enjoy his detailed description and suggestions of how to design a high-quality scientific study.)
(Update as of March 2009: Dr. David Rabiner has written an update to the article below based on a newer study. You can read it clicking on link: New Study Supports Neurofeedback Treatment for ADHD)
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How Strong is the Research Support for Neurofeedback Treatment of Children with ADHD?
Neither of the two prominent approaches to treating ADHD — medication treatment and behavior therapy — are expected to effect long term changes in the child. Medication treatment induces short-term changes in brain activity that is associated with a reduction in symptoms for many individuals. Behavior therapy attempts to create a set of environmental contingencies that promote desired behavior in the child, but which is unlikely to endure when those contingencies are removed.
In recent years, researchers have begun devoting greater attention to the possibility that children — and adults — may be provided with particular kinds of experiences that may induce alterations in brain functioning that are associated with more enduring changes, i.e., they do not dissipate as soon as treatment ends.
Neurofeedback — also known as EEG Biofeedback — is reflective of this approach and has a history that goes back at least 30 years. It involves providing individuals with real-time feedback on their brainwave activity in order that they may learn to alter their typical EEG pattern to one that is consistent with a focused and attentive state. According to neurofeedback proponents, when this occurs, improved attention and reduced hyperactive/impulsive behavior will result. Furthermore, this change is likely to endure because it reflects a basic alterantion in an important aspect of brain functioning.
In this article, I’ll take a look at some of the controversy surrounding neurofeedback treatment and attempt to highlight some of the strengths and limitations in the existing published research.
- Controversy Surrounding Neurofeedback Research —
Neurofeedback treatment for ADHD has been a source of substantial controversy in the field for many years and remains so today. Although there are a number of published studies in which positive results have been reported, many prominent ADHD researchers feel that given significant limitations to the design and implementation of these studies, neurofeedback should be considered a promising, but unproven treatment.
This position is summarized in the CHADD fact sheet on alternative and complementary interventions, which includes the following statement about neurofeedback:
“It is important to emphasize, however, that although several studies of neurofeedback have yielded promising results, this treatment has not yet been tested in the rigorous manner that is required to make a clear conclusion about its effectiveness for AD/HD. The aforementioned studies can not be considered to have produced persuasive scientific evidence concerning the effectiveness of EEG biofeedback for ADHD.
Controlled randomized trials are required before conclusions can be reached. Until then, buyers should beware of the limitations in the published science. Parents are advised to proceed cautiously as it can be expensive — a typical course of neurofeedback treatment may require 40 or more sessions — and because other AD/HD treatments (i.e., multi-modal treatment) currently enjoy substantially greater research support.”
You can find the complete CHADD fact sheet Here.
What Does an ‘Ideal’ Treatment Study Look Like?
Before reviewing some recent neurofeedback studies, it would be useful to consider what an ‘ideal’ treatment study entails. This will provide a context against which recent neurofeedback studies can be evaluated.
Ideally, treatment studies are designed so that if positive results are obtained, all possible explanations for those results besides the treatment itself have been eliminated. This requires 2 basic elements: random assignment and an appropriate control group.
Random Assignment
Imagine that you are testing a new medication treatment for ADHD with 50 children who have been carefully diagnosed. In a random assignment study, whether each child is assigned to the treatment or control condition is determined by chance — you could flip a coin and give the medicine to the ‘heads’ and nothing to the ‘tails’. This insures that any differences that might exist between children who get the medication and those who don’t are purely chance differences. At the end of the study, if those who received the medicine are doing better, you could feel confident that this is probably due to the medicine itself, and not to differences that may have been there before the treatment even started.
What if you didn’t use random assignment, but let each child’s parents choose whether their child is in the treatment or control group? In this case, it is possible that children in the 2 groups differed in important ways before the treatment began. If children who received the medication were doing better at the end of the study, it might be because of differences that were there to start with.
For example, parents who chose the medicine might be more willing to pursue other ways to help their child than those who didn’t. The fact that children who received the medication were doing better at the end of the study might thus have nothing to do with the medicine itself, but reflect other things their parents were doing to help them. No matter how hard you might try to rule out these other possible explanations — and I’m sure you can think of many others — you could never do this with certainty. Thus, I might reasonably doubt that your new medication is really effective.
What about control groups?
Even with the random assignment example above, however, your study would still have an important problem. Because children in the control group received nothing, everyone knows who is being treated and who isn’t. If you ask parents how their child is doing 4 weeks later, this could very possibly bias their reports. Parents whose child received medication may report their child is doing better simply because they expect the medicine to help. Parents of children in the control condition may be biased against seeing improvement because they know their child was not treated.
Thus, if parents of treated children reported more improvement than parents of control children, I could still reasonable question that the new medication was truly helpful. Even if reports from teachers yielded similar findings, I would argue that teachers might have learned when children were getting medication. While this may be a low probability event, you couldn’t completely rule it out. If I was a real skeptic about your new medication, your study would not be all that convincing.
The way around this is to create a situation where no one knows — not the parents, child, teachers, researchers, or anyone else — whether the child is receiving medication. With medication studies, this is relatively simple to do: children in the control condition are given a placebo pill that looks just like the real medication but that has no active ingredients. Because no one knows who is getting medication and who isn’t, possible biases in parents’ and teachers’ reports at the end of the study are thus eliminated. This way, if children in the medication condition are doing better at the end of the study than children getting placebo, it is harder to doubt the benefits of your medication. In fact, there would be no reasonable basis for such doubt, especially if you repeated the study and found the same results.
Three Representative Neurofeedback Studies
With this as a background, let’s take a brief look at 3 recent neurofeedback studies and see how they fare on the critical dimensions of incorporating random assignment and an ‘ideal’ control group.
- Study 1 -
In an interesting study by Vince Monastra and his colleagues [Monastra et al. (2002). The Effects of Stimulant Therapy, EEG Biofeedback and Parenting Style on the primary symptoms of ADHD. Applied Psychophysiology and Biofeedback, 27, 249.] one hundred 6–19 year-olds with ADHD were treated over 12 months. Some parents chose a treatment plan that included medication, behavior therapy, and school consultation. Other parents chose to add neurofeedback to their child’s treatment.
After 12 months, children whose treatment included neurofeedback back were doing better than the other children according to both parents and teachers. They also showed ‘normal’ EEG scans while the other children still had the EEG pattern characteristic of ADHD. Even more impressive was that neurofeedback treated children maintained these benefits after medication was discontinued for a week. You can read a detailed review of this study Here.
- Study 2 -
In a study by Fuchs et al (2003), parents of thirty-four 8–12-year-old children with AD/HD chose either stimulant medication or neurofeedback treatment for their child. 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 Here
- Study 3 -
In an especially interesting study, (Levesque, J., Beauregard, M., & Mensour, B. 2006. Effect of neurofeedback training on the neural substrates of selective attention in children with AD/HD: A functional magnetic resonance imaging study. Neuroscience Letters, 394, 216–221.) twenty 8–12-year-old children with ADHD were randomly assigned to receive neurofeedback treatment — 40 1‑hours sessions — or a wait-list control condition.
At the end of the study, treated children were doing significantly better than control children according to parents. They also did better on several objective, laboratory measures of attention. Especially noteworthy was that fMRI scans used to measure brain activity during a complex cognitive task showed significant change for treated children but no change for control children.
You can find a detailed review of this study Here.
So, what’s wrong with these studies?
I suspect the answer to this question is obvious. While the first 2 studies yielded impressive results, neither included random assignment. Thus, as discussed above, it is not possible to conclude that it is the neurofeedback treatment specifically that made the difference. Instead, differences that may have been present before treatment began and/or after treatment started could be responsible. While this may be unlikely, it can’t be entirely discounted.
The third study included random assignment so this is not a problem. It should be noted, however, that with only twenty participants, treatment and control groups are more likely to differ at the start of the study than if a larger sample had been randomly assigned.
The bigger problem is that the control condition is not a very strong one in that everyone knew who received neurofeedback treatment and who did not. This may have biased parents’ ratings, although it is difficult to argue that it could have biased children’s performance on the lab-based attention tests or on the fMRI scan. Perhaps, however, it wasn’t the specific feedback on EEG states that neurofeedback provided, but simply the attention children received during the 40 hours of training, that was the important factor. Although unlikely in my opinion, this can’t be definitely ruled out.
What would an ‘ideal’ neurofeedback study look like?
This may be pretty clear now as well. The most conclusive test of neurofeedback treatment would include random assignment and a control condition that closely matched the neurofeedback condition. For example, children could receive video game coaching from a supportive adult for the same time period. Or, even better, they could do exactly what children getting the neurofeedback were doing but not receive direct feedback on their EEG states. If positive treatment results were still found, it would indicate that obtaining EEG feedback and learning to control one’s EEG state is why neurofeedback treatment works.
I’ve been told by people who know much more about neurofeedback than I that such a study, while difficult to do, is technically possible. I am not aware of such a study having been published; if you are, please let me know.
I should point out that there would be important ethical concerns with such a study. Neurofeedback treatment typically occurs over a period of months. Children who were receiving ‘sham’ neurofeedback would be getting a treatment that no one expected to be helpful for a sustained time period.
A more reasonable alternative might thus be to provide children with a treatment of known efficacy — such as medication — during the neurofeedback trial. If this were given to children in the real and sham conditions it would not create a confound because both groups would be receiving it. After neurofeedback was completed, one could see whether children who got the real treatment were doing better — i.e., did neurofeedback add anything to medication — and whether these benefits persisted after medication was temporarily stopped.
What can we conclude about neurofeedback until such a study is done?
It would be terrific if a study like the one outlined above were completed. Unfortunately, however, I think it is a real possibility, however, that we will never see such a study. This would be a large and expensive undertaking and obtaining funding for it would not be easy.
In the interim, my own view is that existing support for neurofeedback should not be so readily discounted because of the study limitations discussed above. Here’s why I think this is the case.
The way treatment was ‘assigned’ in the first 2 studies summarized is very similar to what happens when parents seek treatment for their child. That is, parents investigate different options and decide which one they want for their child.
This is what happened in these studies — some parents chose neurofeedback for their child and some did not. When neurofeedback was chosen, children were found to benefit on both ‘subjective’ parent reports as well as on more ‘objective’ assessments. This does not mean that neurofeedback would ‘work’ for children randomly assigned to receive it. It also does not mean that reason neurofeedback works by providing specific training in learning how to manage one’s EEG state. It is for these reasons that neurofeedback is understandably regarded as an unproven treatment approach for ADHD at this time by many ADHD researchers.
However, these studies do provide a solid basis for suggesting that if parents choose to pursue neurofeedback for their child, there is a reasonable chance that their child will benefit even though we can’t be sure that it is the specific EEG training that is responsible for the benefits. Thus, although the efficacy of neurofeedback has yet to be conclusively confirmed in a randomized, placebo-controlled trial, it is important to place this limitation in the context of the supportive research evidence that has been accumulated.
Providing this context can help families better understand the strengths and limitations of the existing research on neurofeedback and enable them to make a better informed decision about whether to consider this treatment option for their child.
– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. He publishes Attention Research Update, an online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD, and teaches the online course How to Navigate Conventional and Complementary ADHD Treatments for Healthy Brain Development.
Other articles by Dr. Rabiner:
Promising Cognitive Training Studies for ADHD.
Mindfulness Meditation for Adults & Teens with ADHD.
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I will send you some info to help you in researching treatment options. One thing cogmed has that none of the other approaches do is solid substantive published research.
Mrs. Batten
Hello Ann Marie,
Please do. What is your experience with Cogmed?
Any fact sheet from CHADD on alternative treatments should be viewed with a skeptical eye. CHADD receives significant funding (more than 20 percent of its budget) from several pharmaceutical companies. Would CHADD really bite the hand that feeds it by touting alternatives to medication, when the group’s main sponsors have a vested financial interest in getting and keeping kids on medication?
Hello Kristy,
Thanks for your comment.
Now, no matter one’s opinion regarding Chadd, Dr. Rabiner has presented a compelling case on why neurofeedback treatment for ADHD is promising, yet unproven, based on his own analysis. What is your reaction to his reasoning?
This article could be summarized with one of the sentences in the end: “the efficacy of neurofeedback has yet to be conclusively confirmed”. And the rest would be known by anybody that passed any first year university course, be it psychology or mathematics. This boils down to methods in science. This in it self is ok, but it misleading that the article says its about the current state of BioFeed.
Hello Jon, I am not sure I understand your point. The matter is a pretty controversial one, so I am glad Dr. Rabiner presented such a detailed case for everyone to understand where neurofeedback for ADD/ ADHD stands today. And, in the process, he engages us in a great discussion on how to design and evaluate clinical trials.
In any case, enjoy ‑I hope- the rest of the blog.
My wife tried EEG neurofeedback over 10 years ago in the hopes of normalizing her brain functioning to overcome lifelong epilepsy. She had a history of multiple, daily absence seizures and grand mal (tonic clonic) seizures once every two years.
After 3 and a half months of twice weekly sessions, we almost gave up on the neurofeedback. It was burning a hole in our wallet (no insurance covered it) and we were not seeing any results. However, we stuck with it (mostly because my wife refused to poison her liver with anti-epileptic drugs).
After 5 months, it was like someone had turned a switch. She stopped having seizures, was calmer, had better memory and cognitive functioning (thinking clearer). We stopped the neurofeedback sessions and she went 4 years without a single seizure event and likely would still be completely seizure free today we had not started a family (her TC seizure activity returned, but not the absence seizures, and got progressively worse with each pregnancy — but that’s a different story).
After our experience, I did as much digging as I could about EEG neurofeedback (see http://www.coping-with-epilepsy.com/forums/f22/eeg-neurofeedback-501/ ) and I’m really outraged that the medical industry continues to “poo-poo” the resounding body of evidence for it.
Snippets from my findings:“Randomized double blind placebo controlled clinical trials (RCT) are the current “gold standard†for demonstrating clinical efficacy of new drugs or therapies. It is very difficult for new therapeutic interventions to gain broad acceptance in the absence of such trials. Recent events have raised serious questions about the conditions under which placebo (sham) controls can be used. The international standards published by the World Medical Association (Declaration of Helsinki) prohibit placebo-controlled studies when known effective treatments exist. Additionally, there is new interest in identifying the mechanisms underlying the placebo response, which may challenge the “placebo†as a legitimate control condition. Both of these events should be of considerable interest to those interested in clinical psychophysiology in general and neurotherapy in particular. ”
“Recent New England Journal of Medicine reviews of research design have cast doubt on the need for placebo controlled designs. Their review has shown that when there is a preponderance of case series reports, the concordance between those results and those of the “gold standard” (double blind placebo controlled studies) was very high. Many in the field are now arguing against doing a double blind study due to the lack of proper humane treatment of those in the control group (receiving no treatment), an approach which is also now considered unethical by the World Health Organization when known treatments exist.”
“Since the first single-case study, reported over 30 years ago (Sterman & Friar, 1972), a fair number of controlled clinical studies, stemming from many different laboratories, have produced consistent data on the efficacy of SMR training in epileptic patients. It is particularly noteworthy that these results have been achieved in an extremely difficult subgroup of epilepsy patients, those with poorly controlled seizures who had proven unresponsive to pharmacological treatment. We will here provide only a cursory overview of this clinical research literature. For a more detailed treatment the interested reader is referred to Sterman (2000), while other recent summaries have also been provided by Monderer et al. (2002), and Walker and Kozlowski (2005).
…
In reviewing the data accumulated in these studies, Sterman (2000) found that 82% of 174 participating patients who were otherwise not controlled had shown significantly improved seizure control (defined as a minimum of 50% reduction in seizure incidence), with around 5% of these cases reporting a complete lack of seizures for up to 1 year subsequent to training cessation. …”
Because of the problems with designing a gold standard study, the Association for Applied Psychophysiology and Biofeedback (AAPB) has developed their own rating scale for measuring efficacy of neurofeedback for a given condition:
Rating explanation:
http://www.aapb.org/i4a/pages/index.cfm?pageid=3336
Conditions with ratings:
http://www.aapb.org/i4a/pages/index.cfm?pageid=3327
What really gets my goat is that EEG neurofeedback has been studied now since the 60s — almost 50 years and there have been no reports of iatrogenesis (a harmful effect produced by the healer or the healing process): “Fortunately, adverse reactions to biofeedback training are overall rare, and when they occur they are relatively transient or readily dealt with by competent practitioners (Hammond, 2001; Schwartz & Schwartz, 1995).”
So here we have a treatment option that has been studied for over 50 years, has no negative/side/adverse effects, has tons of evidence supporting it’s efficacy, but doesn’t have a single commercial entity that “owns” it in the same way that drug companies and medical device companies own their solutions. No company is pushing for FDA approval — or studies — or marketing it, because it’s not cost effective for them.
Cyberonics was able to get FDA approval, acceptance by the neurology industry and insurance coverage for their VNS medical device for epilepsy with studies showing more dubious efficacy than EEG neurofeedback and with well established, potentially serious adverse risks. It truly infuriates me to see how the commercial aspect of the medical industry drives options for patient choice in treatments.
Dear Bernard, thank you for such a detailed response. If you don’t mind, I will publish it as its own post next week, so that more people can see it, and respond.
You raise many good points. And I am happy that neurofeedback helped your wife. Now, nothing that you have written, in my view, contradicts Dr. Rabiner’s conclusion. Furthermore, the fact that neurofeedback has been around for so long, may make one question why no one attempts the type of study he proposes.
In fact, in those same ratings you link to, one can see only one application reaches Levels 5, and it is not ADD/ ADHD. Which is basically what Dr. Rabiner is saying, with other words.
This is not about drugs vs. no drugs. Some non-drug-based approaches, such as cognitive therapy or forms of computer-based working memory training are starting to show efficacy as complement to drugs in well-designed trials. And it is not about biofeedback in general, which has clear research support for specific applications.
You may know that companies like Play Attention sell neurofeedback machines direct to parents, for use with kids who have ADD/ ADHD. Have you seen research supporting an investment of more than $1,000 in such programs? They may work, and parents are free to spend their money as they want- but they deserve to know that it is not proven.
Hi Alvaro,
I don’t mind if you republish the comment.
Play Attention is not a full fledged neurofeedback machine like the ones used in studies. It only processes (IIRC) the alpha wave channel. EEG Neurofeedback machines like Brainmaster’s Atlantis system, Zengar Institute’s NeuroCare system, etc. manage up to 5 wave channels — alpha, beta, theta, delta and (sometimes) gamma. It also doesn’t perform QEEG mappings, so it is not on the same level as a treatment option as EEG neurofeedback as defined in the studies.
“Furthermore, the fact that neurofeedback has been around for so long, may make one question why no one attempts the type of study he proposes.” — Alvaro
~~~
“The most conclusive test of neurofeedback treatment would include random assignment and a control condition that closely matched the neurofeedback condition. For example, children could receive video game coaching from a supportive adult for the same time period. Or, even better, they could do exactly what children getting the neurofeedback were doing but not receive direct feedback on their EEG states.” — Dr. Rabiner
~~~
EEG neurofeedback is not a “treatment” in the classical sense. It is a training program that requires tailoring over time by the practitioner and active participation from the patient. It is not possible to simulate this effectively over time for a “blind” study, much less a double blind study.
But the larger answer as to why no one attempts the type of study he proposes is $$$:
“For a very promising treatment targeting such a
serious condition as epilepsy, the number of large-scale clinical trials of neurofeedback
training to date is disappointing. A likely reason for this state of affairs is that
neurofeedback research is a very time- and work-intensive enterprise that has
traditionally not received extensive research funding and has, for obvious reasons, not
been pursued by the pharmaceutical industry.”
http://sica.stanford.edu/events/brainwaves/FoundationsofNeurofeedback.pdf
As I mentioned previously, no company owns a patent on EEG neurofeedback — it’s a training process, not a drug or specific medical device. It is not economically justifiable for a for-profit company to sponsor the necessary research. There is no ROI. So, it’s up to non-profit groups/charities to sponsor this kind of research. While some have sponsored small studies recently (such as FACES at NYU), there hasn’t been and isn’t anything being done on the scale that appears to be necessary for the skeptics.
What is your view on the Sharper brain and Smart brain games currently sold to parents for attention problems.
Hello Mary, we have not seen quality published evidence on the value of either program in the context of kids or adults with attention deficits.
The program that had most evidence behind for that specific context is Cogmed Working Memory Training.
Here’s an abstract of a study published in 2006: (I cited the reference in AMA format after the abstract)
Research groups have consistently reported on behavioral and cognitive improvements of children with ADHD after neurofeedback. However, neurofeedback has not been commonly accepted as a treatment for ADHD. This is due, in part, to several methodological limitations. The neurofeedback literature is further complicated by having several different training protocols. Differences between the clinical efficacy of such protocols have not been examined. This study addresses previous methodological shortcomings while comparing the training of theta-beta-frequencies (theta-beta-group) with the training of slow cortical potentials (SCP-group). Each group comprised of 19 children with ADHD that were blind to group assignment. The training procedure consisted of 30 sessions and a six months follow-up training. Pre-/post measures at pretest, the end of the training and the follow-up included tests of attention, intelligence and behavioral variables. After having already reported intermediate data (Strehl et al. 2004), this paper gives account on final results: Both groups are able to voluntarily regulate cortical activity, with the extent of learned self-regulation depending on task and condition. Both groups improve in attention and IQ. Parents and teachers report significant behavioral and cognitive improvements. Clinical effects for both groups remain stable six months after training. Groups do not differ in behavioral or cognitive outcome variables.
U L, T H, S K, F S, C W, U S. [Neurofeedback for children with ADHD: a comparison of SCP- and theta/beta-protocols]. Praxis der Kinderpsychologie und Kinderpsychiatrie [serial online]. 2006;55(5):384–407. Available from: Cochrane Central Register of Controlled Trials, Ipswich, MA. Accessed October 15, 2008.
I have referenced this discussion in a letter to the American Academy of Neurology:
http://www.coping-with-epilepsy.com/forums/f37/pushing-neurofeedback-into-mainstream-5418/
Thank you Bernard. Please keep us posted on whether the Academy responds.
I have been a neurofeedback practitioner for 6 years. It is clear to the community of practitioners than neurofeedback works very well for ADHD and many other issues. There have been over 100 studies published or presented to establish the fact. At least 8 are of very good quality and even better quality studies are in the pipeline. Soon doubt of efficacy cannot be denied by those who trust scientific data. Right now you have squint pretty hard to doubt that neurofeedback works for ADHD. Of course neurofeedback practitioners see results every day.
Beneath the obvious question of does it work are many more questions to make the training more effective and efficient. There are perhaps 6 distinct schools of thought on how to do neurofeedback. The method in the research studies is only one kind. And that method is in the minority because research is always backward looking.
It is an exciting time to be a neurofeedback provider. I would invite anyone to get some neurofeedback training, become a home trainer, or add neurofeedback to your practice. A wave of acceptance is coming.
I have to say that I have enjoyed Bernard’s comments/information above than the article by Dr. Rabiner’s itself. Very logical and informative, thanks, Bernard!
We are in the 21st century! And it is amazing the number of doctors (especially if they are funded by pharmaceuticals) that are still attached to the med + behavioral therapies to treat ADHD. Like the articles above there are many list of questionable research regarding meds (see Dr. Breggins site or books). At the end, I think neurofeedback is not more “unproven†than meds, but if I were to choose between neurofeedback and med, I will definetily go with neurofeedback…sounds safer and less intrusive than the meds.