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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.

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.

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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 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.

  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.”

    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.

  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:

    http://www.coping-with-epilepsy.com/forums/f37/pushing-neurofeedback-into-mainstream-5418/

  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.

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