Sharp Brains: Brain Fitness and Cognitive Health News

Neuroplasticity, Brain Fitness and Cognitive Health News


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)

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.

Rabiner_David– 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.

Work­ing Mem­o­ry Train­ing for Adults.

Self-Reg­u­la­tion and Barkley’s The­o­ry of ADHD.

Leave a Reply...

Loading Facebook Comments ...

18 Responses

  1. 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

  2. Alvaro says:

    Hel­lo Ann Marie,

    Please do. What is your expe­ri­ence with Cogmed?

  3. Kristy Evans says:

    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?

  4. Alvaro says:

    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?

  5. Jon Nordland says:

    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.

  6. Alvaro says:

    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.

  7. Bernard says:

    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 ) 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:

    Con­di­tions with rat­ings:

    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.

  8. Alvaro says:

    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.

  9. Bernard says:

    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.

  10. Bernard says:

    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.”

    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.

  11. Mary says:

    What is your view on the Sharp­er brain and Smart brain games cur­rent­ly sold to par­ents for atten­tion prob­lems.

  12. 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.

  13. Carolyn says:

    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.

  14. Bernard says:

    I have ref­er­enced this dis­cus­sion in a let­ter to the Amer­i­can Acad­e­my of Neu­rol­o­gy:

  15. Thank you Bernard. Please keep us post­ed on whether the Acad­e­my responds.

  16. Gary Ames says:

    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.

  17. wanda says:

    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.

Leave a Reply

Categories: Cognitive Neuroscience, Technology

Tags: , , , , , , , , , , , , , , , , , ,

All Slidedecks & Recordings Available — click image below

Search for anything brain-related in our article archives

About SharpBrains

As seen in The New York Times, The Wall Street Journal, BBC News, CNN, Reuters, and more, SharpBrains is an independent market research firm and think tank tracking health and performance applications of brain science.