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Perspective: Neurofeedback treatment for ADHD is gaining strong support

neurofeedbackNeu­ro­feed­back — also known as EEG Biofeed­back — is an ADHD treat­ment in which indi­vid­u­als learn to alter their typ­i­cal EEG pat­tern to one that is con­sis­tent with a focused, atten­tive state. This is done by col­lect­ing EEG data from indi­vid­u­als as they focus on stim­uli pre­sent­ed on a com­put­er screen. Their abil­i­ty to con­trol the stim­uli, for exam­ple, keep­ing the smile on a smi­ley face or keep­ing a video play­ing, is con­tin­gent on main­tain­ing an EEG state con­sis­tent with focused atten­tion. Neu­ro­feed­back pro­po­nents argue that this abil­i­ty gen­er­al­izes to real world sit­u­a­tions and results in bet­ter atten­tion dur­ing aca­d­e­m­ic and relat­ed tasks.

Although neu­ro­feed­back for ADHD has been con­tro­ver­sial for many years, research sup­port for this treat­ment is grow­ing. In fact, in Octo­ber, 2012 the Amer­i­can Acad­e­my of Pedi­atrics rat­ed neu­ro­feed­back as a Lev­el 1 “Best Sup­port” Inter­ven­tion for ADHD; this is the high­est pos­si­ble rat­ing and at the same lev­el as med­ica­tion treat­ment and behav­ior ther­a­py — you can find the rat­ings here. My sense, how­ev­er, is that many sci­en­tists who study ADHD would regard this rat­ing as pre­ma­ture based on cur­rent evi­dence.

How do the ben­e­fits of neu­ro­feed­back for ADHD com­pare to those pro­vid­ed by stim­u­lant med­ica­tion? Med­ica­tion remains the most wide­ly used ADHD inter­ven­tion and exam­in­ing this ques­tion is thus impor­tant. In a pri­or issue of Atten­tion Research Update I reviewed a study com­par­ing neu­ro­feed­back to med­ica­tion treat­ment. Both treat­ments yield­ed sig­nif­i­cant ben­e­fits and did not dif­fer sig­nif­i­cant­ly from one anoth­er.

An impor­tant lim­i­ta­tion of this study, how­ev­er, was that chil­dren were not ran­dom­ly assigned to med­ica­tion or neu­ro­feed­back treat­ment; instead, par­ents select­ed the option they pre­ferred for their child. This lim­its the con­clu­sions that can be drawn in sev­er­al impor­tant ways. First, with­out ran­dom assign­ment, pre­ex­ist­ing dif­fer­ences between chil­dren whose par­ents pre­ferred neu­ro­feed­back and those who pre­ferred med­ica­tion may have influ­enced the find­ings. Sec­ond, with­out ran­dom assign­ment one can­not deter­mine whether neu­ro­feed­back is effec­tive for chil­dren with ADHD over­all, or only for those chil­dren whose par­ents select it.

New Research Com­par­ing Med­ica­tion to Neu­ro­feed­back

Two recent­ly pub­lished stud­ies addressed this lim­i­ta­tion by ran­dom­ly assign­ing chil­dren with ADHD to either med­ica­tion or neu­ro­feed­back con­di­tions.

Study 1 — The first study [Duric et al., (2012). Neu­ro­feed­back for the treat­ment of chil­dren and ado­les­cents with ADHD: A ran­dom­ized and con­trolled clin­i­cal tri­al using parental reports. BMC Psy­chi­a­try, 12, 107] was con­duct­ed with 91 6 to 18 year olds (mean age of 10.5) in Nor­way. Par­tic­i­pants were ran­dom­ly assigned to receive neu­ro­feed­back, stim­u­lant med­ica­tion, or both.

Neu­ro­feed­back treat­ment was con­duct­ed in 3 40 minute ses­sion per week over 10 weeks, i.e., 30 ses­sions total. The pri­ma­ry focus was to decrease theta activ­i­ty and increas­ing beta activ­i­ty. This is con­sis­tent with numer­ous find­ings that a high theta/beta ratio is a reli­ably found in indi­vid­u­als with ADHD; see a very inter­est­ing and impor­tant study of this issue.

Chil­dren in the med­ica­tion group received treat­ment with methylphenidate, the gener­ic form of Rital­in. Med­ica­tion was pro­vid­ed 2X/day at a dose of 1 mg per kg.

Chil­dren in the com­bined group received both treat­ments.

Results — Par­ents com­plet­ing rat­ings of core ADHD symp­toms before treat­ment began and 1 week after neu­ro­feed­back had been com­plet­ed. Chil­dren in all groups — neu­ro­feed­back, med­ica­tion, and com­bined — were report­ed to show sig­nif­i­cant reduc­tions in inat­ten­tive and hyper­ac­tive-impul­sive symp­toms. Although between group dif­fer­ences between were not sig­nif­i­cant, the effect on inat­ten­tive symp­toms appeared largest for the neu­ro­feed­back only group. An unex­pect­ed find­ing was that for all groups, the impact on hyper­ac­tive-impul­sive symp­toms was con­sis­tent­ly larg­er than for inat­ten­tive symp­toms.

Study 2 — A sec­ond study pub­lished ear­li­er this year [Meisel et al., (2014). Neu­ro­feed­back and stan­dard­ized phar­ma­co­log­i­cal inter­ven­tion in ADHD: A ran­dom­ized con­trolled tri­al with six-month fol­low up. Bio­log­i­cal Psy­chol­o­gy, 95, 116–125) extends this work by obtain­ing feed­back from teach­ers in addi­tion to par­ents — includ­ing assess­ments of edu­ca­tion­al per­for­mance — as well as 2- and 6-month fol­low up data.

Par­tic­i­pants were 23 7–14 year-old chil­dren with ADHD — 11 boys and 12 girls; the study was con­duct­ed in Spain. Par­tic­i­pants were ran­dom­ly assigned to neu­ro­feed­back or med­ica­tion ther­a­py. Neu­ro­feed­back con­sist­ed of 40 ses­sions (approx­i­mate­ly 30 minutes/session) pro­vid­ed over 20 weeks. As above, treat­ment focused on sup­press­ing theta activ­i­ty and enhanc­ing beta activ­i­ty.

Med­ica­tion treat­ment was with methylphenidate at a dose of 1 mg per kg fol­low­ing Span­ish nation­al treat­ment guide­lines for ADHD. Chil­dren receiv­ing med­ica­tion con­tin­ued to receive it across the 6-month fol­low up peri­od.

Data was obtained pre-treat­ment, imme­di­ate­ly after neu­ro­feed­back end­ed, and again 2 and 6 months lat­er. Moth­ers and fathers com­plet­ed rat­ings of core ADHD symp­toms, oppo­si­tion­al behav­ior, and func­tion­al impair­ment. Teach­ers also rat­ed ADHD symp­toms, oppo­si­tion­al behav­ior, and children’s per­for­mance in read­ing, writ­ing, math, and oral expres­sion.

Results — Imme­di­ate­ly fol­low­ing neu­ro­feed­back treat­ment, mater­nal rat­ings for both groups indi­cat­ed sig­nif­i­cant reduc­tions in inat­ten­tive and hyper­ac­tive-impul­sive symp­toms; declines in atten­tion dif­fi­cul­ties were more pro­nounced and dif­fer­ences between groups were not sig­nif­i­cant. Sig­nif­i­cant reduc­tions in oppo­si­tion­al behav­ior and reduc­tions in over­all func­tion­al impair­ment were also report­ed. These improve­ments were gen­er­al­ly main­tained at the 2- and 6-month fol­low up.

Reports from fathers were less con­sis­tent­ly pos­i­tive. For neu­ro­feed­back, rat­ings of inat­ten­tive symp­toms showed sig­nif­i­cant reduc­tions at each peri­od but were of less­er mag­ni­tude than what moth­ers report­ed. Declines in hyper­ac­tive-impul­sive symp­toms and oppo­si­tion­al behav­ior were not sig­nif­i­cant. Results for the med­ica­tion group were sim­i­lar; the only dif­fer­ence was that fathers report­ed low­er oppo­si­tion­al behav­ior at 6 months, a reduc­tion that was not evi­dent in the neu­ro­feed­back group.

Results from teach­ers were espe­cial­ly inter­est­ing. For the neu­ro­feed­back group, sig­nif­i­cant reduc­tions in inat­ten­tive symp­toms were only mar­gin­al­ly sig­nif­i­cant at the imme­di­ate post-test, but were both sig­nif­i­cant and of large mag­ni­tude at the 2- and 6-month fol­low ups. The same was true for hyper­ac­tive-impul­sive symp­toms and oppo­si­tion­al behav­ior. At post-test, teach­ers also report­ed sig­nif­i­cant gains in all aca­d­e­m­ic areas, except for math which was mar­gin­al­ly sig­nif­i­cant. These gains gen­er­al­ly per­sist­ed across the 6-month fol­low up.

For the med­ica­tion group, sig­nif­i­cant reduc­tions were also report­ed for core ADHD symp­toms and oppo­si­tion­al behav­ior. The mag­ni­tude of these improve­ments tend­ed to be larg­er than for the neu­ro­feed­back group, but not sig­nif­i­cant­ly so. How­ev­er, no improve­ments were evi­dent for any aca­d­e­m­ic area at any time point.

Sum­ma­ry and Impli­ca­tions

Across both stud­ies, neu­ro­feed­back and stim­u­lant med­ica­tion treat­ment yield­ed sig­nif­i­cant and gen­er­al­ly con­sis­tent ben­e­fits for chil­dren with ADHD. In con­trast to pri­or stud­ies com­par­ing neu­ro­feed­back and med­ica­tion, both employed ran­dom assign­ment. The sec­ond study had sev­er­al addi­tion­al strengths includ­ing col­lect­ing data from mul­ti­ple infor­mants — includ­ing teach­ers — and fol­low­ing chil­dren up to 6 months after neu­ro­feed­back treat­ment end­ed. It is thus espe­cial­ly promis­ing that ben­e­fits evi­dent for neu­ro­feed­back when treat­ment first end­ed were gen­er­al­ly retained over this peri­od. Med­ica­tion relat­ed gains also per­sist­ed, which is not sur­pris­ing giv­en that chil­dren con­tin­ued on med­ica­tion.

Both stud­ies have lim­i­ta­tions that need to be rec­og­nized. The sam­ple sizes were small which makes find­ing sig­nif­i­cant dif­fer­ences between treat­ments more dif­fi­cult. Nei­ther study was con­duct­ed in the US and one must be cau­tious about assum­ing the find­ings would apply to US chil­dren. How­ev­er, there is no rea­son I know of why a dif­fer­ent pat­tern of find­ings would be expect­ed here.

Obvi­ous­ly, par­ents were not blind to their child’s treat­ment; in the sec­ond study, there is no indi­ca­tion that teach­ers were kept ‘blind’. The inclu­sion of data from ‘blind’ observers and/or objec­tive mea­sures of atten­tion that are less sus­cep­ti­ble to expectan­cy effects would have made for a stronger study. Appar­ent­ly, objec­tive assess­ments were col­lect­ed in study 2 and will be pub­lished sep­a­rate­ly; I will be eager to learn what was found.

No men­tion is made in either study as to whether chil­dren actu­al­ly showed improve­ment in pro­duc­ing and main­tain­ing the EEG states that were tar­get­ed in train­ing. This, as well as the absence of a ‘sham’ feed­back con­di­tion makes it impos­si­ble to con­clude that it was feed­back on EEG states, as opposed to non-spe­cif­ic fac­tors linked to neu­ro­feed­back treat­ment (e.g., ther­a­pist atten­tion) that are respon­si­ble for the gains.

I would also note that in both stud­ies, chil­dren received a stan­dard med­ica­tion dose based on body weight rather than deter­min­ing the opti­mal dose for each child via a titra­tion tri­al. Stan­dard dos­ing is not the best way to opti­mize med­ica­tion ben­e­fits, and gains may have been greater if titra­tion pro­ce­dures were employed.

These lim­i­ta­tions not with­stand­ing, results from these stud­ies sug­gest that the ben­e­fits of neu­ro­feed­back for ADHD may approx­i­mate those pro­vid­ed by stim­u­lant med­ica­tion. Study 2 also sug­gests that neu­ro­feed­back may pro­duce aca­d­e­m­ic gains that med­ica­tion does not. Thus, while nei­ther study is per­fect (then again, no sin­gle study ever is) both point towards the val­ue of neu­ro­feed­back treat­ment for many chil­dren with ADHD.

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.

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