Long-term effects of neurofeedback treatment for ADHD

Neu­ro­feed­back — also known as EEG Biofeed­back — is an approach for treat­ing ADHD in which indi­vid­u­als are pro­vid­ed real-time feed­back on their brain­wave pat­terns and taught to pro­duce and main­tain pat­terns con­sis­tent with a focused, atten­tive state. This is often done by col­lect­ing brain­wave, i.e., EEG, data from indi­vid­u­als as they focus on stim­uli pre­sent­ed on a com­put­er screen. Their abil­i­ty to con­trol the stim­uli, for exam­ple, keep­ing the ‘smile on a smi­ley face’, is con­tin­gent on main­tain­ing the brain­wave pat­tern being trained.

Neu­ro­feed­back sup­port­ers believe that learn­ing this dur­ing train­ing gen­er­al­izes to real world sit­u­a­tions and results in improved atten­tion and reduced hyperactive/impulsive behav­ior. Although a num­ber of neu­ro­feed­back stud­ies have yield­ed promis­ing results it remains some­what con­tro­ver­sial with some researchers argu­ing that lim­i­ta­tions of these stud­ies pre­clude firm con­clu­sions about the effec­tive­ness of neu­ro­feed­back from being drawn.

Last year I reviewed a par­tic­u­lar­ly well-con­duct­ed study of neu­ro­feed­back treat­ment for ADHD — see my review here. The study was con­duct­ed in Ger­many and began with 94 chil­dren aged 8 to 12. All had been care­ful­ly diag­nosed with ADHD and over 90% had nev­er received med­ica­tion treat­ment. About 80% were boys.

Chil­dren were ran­dom­ly assigned to receive either 36 ses­sions of neu­ro­feed­back train­ing or 36 ses­sions of com­put­er­ized atten­tion train­ing. The com­put­er­ized atten­tion train­ing task was intend­ed to serve as the con­trol inter­ven­tion and pro­vid­ed equal amounts of time work­ing on a demand­ing cog­ni­tive task under the super­vi­sion of an adult; the inclu­sion of this con­trol con­di­tion is a real strength of the study.

The main find­ings were as follows:

1. Par­ents of chil­dren treat­ed with neu­ro­feed­back report­ed sig­nif­i­cant­ly greater reduc­tions in inat­ten­tive and hyper­ac­tive-impul­sive symp­toms than par­ents of con­trol chil­dren, i.e,. those who received com­put­er­ized atten­tion train­ing. The size of the group dif­fer­ence was in a range that would be con­sid­ered mod­er­ate, i.e., about .5 stan­dard devi­a­tions. 2. Teach­ers of chil­dren treat­ed with neu­ro­feed­back report­ed sig­nif­i­cant­ly greater reduc­tions in inat­ten­tive and hyper­ac­tive-impul­sive symp­toms than teach­ers of con­trol chil­dren. The size of the group dif­fer­ence was sim­i­lar to that found for par­ents, about .5 stan­dard deviations.

The authors also exam­ined the per­cent­age of chil­dren in each group that were judged to derive a ‘sig­nif­i­cant’ ben­e­fit, defined as at least a 25% reduc­tion in core ADHD symp­toms. Fifty-one per­cent of chil­dren in the neu­ro­feed­back group met this thresh­old com­pared to only 26% of chil­dren in the atten­tion train­ing con­trol group. This dif­fer­ence was sta­tis­ti­cal­ly significant.

- New study presents 6‑month fol­low-up results -

Recent­ly, the authors of this study pub­lished 6‑month fol­low-up data so that the dura­tion of neu­ro­feed­back treat­ment effects could be exam­ined. This is an impor­tant issue to study as one of the pur­port­ed ben­e­fits of neu­ro­feed­back treat­ment is that the effects can endure well beyond when treat­ment has been completed.

Fol­low-up data was avail­able on 61 of the orig­i­nal par­tic­i­pants includ­ing 38 from the neu­ro­feed­back group and 23 from the con­trol group. Fol­low-up data was based on par­ents rat­ings only as teacher rat­ings were not obtained at this time point.

Of the 32 ‘drop outs’, par­ents of 15 did not return the fol­low-up rat­ing scales while the remain­ing 17 had start­ed on med­ica­tion. Chil­dren who began med­ica­tion were not includ­ed because it was not pos­si­ble to deter­mine the extent to which their cur­rent func­tion­ing reflect­ed their ini­tial treat­ment or their cur­rent med­ica­tion. How­ev­er, it is rea­son­able to assume that par­ents would only start med­ica­tion if they were not sat­is­fied with how their child was doing.

- Results -

Key find­ings were as follows.

1. Par­ents’ rat­ings of core ADHD symp­toms indi­cat­ed that chil­dren treat­ed with neu­ro­feed­back were still doing sig­nif­i­cant­ly bet­ter than chil­dren who received the ‘con­trol treat­ment’. The mag­ni­tude of the dif­fer­ence was mod­er­ate to large, i.e., about .7 stan­dard devi­a­tions. Reduc­tions in symp­toms scores from the ini­tial base­line rat­ings were in the range of 25–30% for the neu­ro­feed­back group com­pared to only 10–15% for the con­trol group.

2.Children in the neu­ro­feed­back tend­ed to receive low­er rat­ings for delin­quent and phys­i­cal­ly aggres­sive behav­ior, but these dif­fer­ences did not quite reach sta­tis­ti­cal significance.

3. Par­ents’ reports of home­work dif­fi­cul­ties showed a greater decline over time for the neu­ro­feed­back treat­ed chil­dren than for con­trol children.

4. Group dif­fer­ences in a range of prob­lem­at­ic sit­u­a­tions that occur at home were not significant.

In addi­tion to these analy­ses, the researchers also com­put­ed the per­cent­age of chil­dren in each group who were con­sid­ered to show a good treat­ment response, defined as at least a 25% reduc­tion in par­ents’ rat­ings of core ADHD symp­toms com­pared to base­line. This was true for 50% of chil­dren in the NF group com­pared to 30% of those in the con­trol group. These dif­fer­ences were in the expect­ed direc­tion but did not quite reach sta­tis­ti­cal sig­nif­i­cance giv­en the rel­a­tive small sam­ple size at fol­low-up, i.e., a total of only 61 children.

- Sum­ma­ry and Implications -

Results indi­cate that the ben­e­fits of neu­ro­feed­back treat­ment were main­tained 6 months after treat­ment had end­ed. Thus, com­pared to chil­dren who received com­put­er­ized atten­tion train­ing, which served as the con­trol treat­ment, neu­ro­feed­back treat­ed chil­dren con­tin­ued to receive sig­nif­i­cant­ly low­er par­ent rat­ings of core ADHD symp­toms and also showed a greater decline in home­work dif­fi­cul­ties over time. These are encour­ag­ing find­ings and high­light that neu­ro­feed­back can be a ben­e­fi­cial treat­ment for some chil­dren with ADHD.

Despite these pos­i­tive find­ings, how­ev­er, it is impor­tant to empha­size that only 50% of chil­dren treat­ed with neu­ro­feed­back showed at least a 25% decline in core ADHD symp­toms at 6 months, mean­ing that the oth­er 50% failed to show this lev­el of clin­i­cal response. And, if one assumes that many of the chil­dren who began med­ica­tion were also like­ly to have been non-respon­ders (pre­sum­ably par­ents would not have start­ed med­ica­tion oth­er­wise), this fig­ure becomes even high­er. In addi­tion, no fol­low-up data from teach­ers was avail­able so it is not pos­si­ble to know the extent to which any ben­e­fi­cial effects were main­tained at school.

In recog­ni­tion of these treat­ment lim­i­ta­tions, the authors con­clude that “…the low respon­der rate and the por­tion of chil­dren start­ing a med­ica­tion in our study argue against NF as a stand-alone inter­ven­tion for ADHD. The results indi­cate that not every child with ADHD may improve after NF treat­ment. In our opin­ion, NF should rather be seen as a treat­ment mod­ule for chil­dren with ADHD which can be embed­ded in a mul­ti­modal treat­ment pro­gram tai­lored to the indi­vid­ual needs of the child.”

The authors also not­ed, how­ev­er, that because they fol­lowed a stan­dard­ized treat­ment pro­to­col for research pur­pos­es, rather than care­ful­ly tai­lor­ing neu­ro­feed­back treat­ment to each child, that their results may under­es­ti­mate what is obtained in actu­al clin­i­cal situations.

In con­clu­sion, results from this fol­low-up study pro­vide evi­dence that neu­ro­feed­back can yield endur­ing ben­e­fits for some chil­dren with ADHD. As sug­gest­ed by the authors, it may be an impor­tant com­po­nent of a mul­ti­modal treat­ment pro­gram but its con­sis­tent use as a stand alone treat­ment does not seem to be sup­port­ed by the find­ings report­ed here.

– 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.

Relat­ed arti­cles by Dr. Rabiner:

• New Study Sup­ports Neu­ro­feed­back Treat­ment for ADHD
• Neurofeedback/ Quan­ti­ta­tive EEG for ADHD diagnosis
• Promis­ing Cog­ni­tive Train­ing Stud­ies for ADHD
• Mind­ful­ness Med­i­ta­tion for Adults & Teens with ADHD
• How Strong is the Research Sup­port for Neu­ro­feed­back in Atten­tion Deficits?
• Self-Reg­u­la­tion and Barkley’s The­ory of ADHD