Perspective: Neurofeedback treatment for ADHD is gaining strong support
Neurofeedback — 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.
– 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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