Sharp Brains: Brain Fitness and Cognitive Health News

Neuroplasticity, Brain Fitness and Cognitive Health News


Study: Neurofeedback treatment for ADHD in only 12 sessions?


Neu­ro­feed­back — also known as EEG Biofeed­back — is treat­ment for ADHD in which indi­vid­u­als learn to pro­duce and main­tain a pat­tern of EEG activ­i­ty 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. Over­time, indi­vid­u­als learn to do this dur­ing the train­ing; neu­ro­feed­back pro­po­nents argue that this gen­er­al­izes to real world sit­u­a­tions and results in bet­ter atten­tion dur­ing aca­d­e­m­ic and relat­ed tasks.

I have reviewed mul­ti­ple neu­ro­feed­back stud­ies in pri­or issues of Atten­tion Research Update and recent­ly reviewed 2 stud­ies that yield­ed excep­tion­al­ly pos­i­tive find­ings. Results from these sug­gest­ed that neu­ro­feed­back may yield com­pa­ra­ble ben­e­fits for chil­dren with ADHD as those pro­vid­ed by med­ica­tion treat­ment.

Despite grow­ing evi­dence that neu­ro­feed­back pro­vides mean­ing­ful ben­e­fits to many indi­vid­u­als with ADHD, an impor­tant con­cern remains the time and expense of the treat­ment. A typ­i­cal course of neu­ro­feed­back treat­ment often involves 30–40 ses­sions; this was the case in the stud­ies not­ed above. This is a time con­sum­ing an expen­sive propo­si­tion, par­tic­u­lar­ly since neu­ro­feed­back is rarely cov­ered by health insur­ance.

The new study

Thus, devel­op­ing a neu­ro­feed­back treat­ment pro­to­col that yield­ed clin­i­cal ben­e­fits in few­er ses­sions would be an impor­tant devel­op­ment for the field. A study recent­ly pub­lished in the jour­nal Clin­i­cal EEG and Neu­ro­science sug­gests that this may be pos­si­ble [Hillard et al., (2013). Neu­ro­feed­back train­ing aimed to improved focused atten­tion and alert­ness in chil­dren with ADHD: A study of rel­a­tive pow­er of EEG rythms usig cus­tome-made soft­ware appli­ca­tion. Clin­i­cal EEG and Neu­ro­science, 44, 193–202].

Par­tic­i­pants were 18 chil­dren and ado­les­cents with ADHD — aver­age age 13.6 years; 6 females. Diag­noses were made using a struc­tured psy­chi­atric inter­view along with par­ent and teacher rat­ing scales. Par­tic­i­pants com­plet­ed 12 week­ly neu­ro­feed­back ses­sions of 25 min­utes per ses­sion. The train­ing pro­to­col and equip­ment was devel­oped by Peak Achieve­ment; the goal was to enhance Focus through­out the ses­sion will main­tain­ing an ade­quate lev­el of Alert­ness.

Ses­sions were com­plet­ed using dif­fer­ent seg­ments of doc­u­men­tary films. Feed­back that an indi­vid­u­al’s EEG state devi­at­ed from the desired para­me­ters was con­veyed by chang­ing the screen bright­ness and size of the video and/or slow­ing down/stopping the video. Thus, par­tic­i­pants were con­tin­u­al­ly informed about whether they were main­tain­ing EEG activ­i­ty con­sis­tent with a Focused and Alert state. EEG data was col­lect­ed through­out each ses­sion so that changes with­in and across ses­sions could be deter­mined.

Mea­sures — Behav­ioral rat­ings from par­ents were col­lect­ed before and after treat­ment using the Aber­rant Behav­ior Check­list which assessed hyper­ac­tiv­i­ty, lethar­gy (indica­tive of a day-dreamy, unfo­cused state), and hyper­ac­tiv­i­ty. Objec­tive assess­ments of atten­tion were col­lect­ed pre- and post- treat­ment using a com­put­er­ized test of atten­tion called the IVA+Plus. As not­ed above, EEG data was also col­lect­ed through­out train­ing so that changes asso­ci­at­ed with train­ing could be com­put­ed.


Behav­ior rat­ings — A com­par­i­son of par­ents’ pre- vs. post-behav­ior rat­ings indi­cat­ed sig­nif­i­cant reduc­tions in irri­tabil­i­ty, lethar­gy, and hyper­ac­tiv­i­ty.

Com­put­er­ized atten­tion mea­sure — The IVA+Plus showed sig­nif­i­cant gains in mea­sures of visu­al atten­tion that were of large mag­ni­tude. Gains in audi­to­ry atten­tion approached, but did not quite reach, sta­tis­ti­cal sig­nif­i­cance.

EEG changes — Sig­nif­i­cant changes were found in a range of dif­fer­ent EEG para­me­ters. Par­tic­u­lar­ly note­wor­thy was a sig­nif­i­cant decrease in par­tic­i­pants theta/beta ratio; as the theta/beta ratio has been found to be a reli­able indi­ca­tor of ADHD, with high­er ratios more like­ly to be found in diag­nosed indi­vid­u­als. A steady decline was observed in this ratio over the course of the 12 train­ing ses­sions. Par­al­lel changes from minute to minute with­in each indi­vid­ual ses­sion were also observed.

Summary and Implications

The most encour­ag­ing impli­ca­tion of this study is that neu­ro­feed­back treat­ment for ADHD can yield sig­nif­i­cant ben­e­fits in far few­er ses­sions than has typ­i­cal­ly been required. In this study, behav­ior improve­ments, gains in a com­put­er­ized mea­sure of atten­tion, and cor­re­spond­ing EEG changes were all observed after only 12 25 minute train­ing ses­sions, i.e., only 3 total hours of train­ing. Whether this is because of the spe­cif­ic train­ing pro­to­col used in this study, i.e., the Peak Achieve­ment train­ing sys­tem, or could be attained with oth­er train­ing pro­to­cols, is unclear.

It is impor­tant to empha­size that this was not a ran­dom­ized con­trolled tri­al — in fact, there was not even a con­trol group. Thus, reli­able con­clu­sions about the clin­i­cal effi­ca­cy of this approach can­not be made from this study alone. For instance, par­ent rat­ing may have improved because of expec­ta­tions about treat­ment ben­e­fits rather than actu­al changes in chil­dren’s behav­ior. How­ev­er, the com­put­er­ized mea­sure of atten­tion would not be sub­ject to such expectan­cy effects. And, doc­u­ment­ing that EEG para­me­ters changed in ways that are con­sis­tent with improved focus and atten­tion also strength­ens the study.

In addi­tion to the absence of a con­trol group, there are sev­er­al oth­er lim­i­ta­tions to this study that should be not­ed. First, the rat­ing scale used in this study is not a wide­ly used mea­sure in the assess­ment of ADHD and does not include all ADHD symp­toms. Thus, includ­ing a more con­ven­tion­al rat­ing scale for ADHD, e.g., the Con­ners, the ADHD Rat­ing Scale, the Van­der­bilit Assess­ment Scale, would have been help­ful. Sec­ond, no data was col­lect­ed from chil­dren’s teach­ers; find­ing improve­ments in teacher rat­ings of par­tic­i­pants’ atten­tion would also have strength­ened the results. Thus, we do not learn whether the treat­ment was asso­ci­at­ed with func­tion­al improve­ments at school, an essen­tial tar­get for ADHD treat­ment.

Third, it would have been a nice addi­tion if the authors report­ed on the strength of the asso­ci­a­tion between EEG changes and changes in behav­ior rat­ings and com­put­er­ized atten­tion results. If a sig­nif­i­cant rela­tion­ship were found, it would more clear­ly link EEG changes that occurred dur­ing train­ing to the improve­ments in the behav­ior rat­ings and com­put­er­ized assess­ment of atten­tion that was observed.

Final­ly, although the doc­u­men­ta­tion of EEG changes was a strong fea­ture of the study, all EEG data was col­lect­ed dur­ing train­ing itself. If sim­i­lar changes in the theta/beta ratio were doc­u­ment­ed out­side of the spe­cif­ic train­ing con­text, it would indi­cate that neu­ro­feed­back induced EEG changes are not con­fined to when par­tic­i­pants are active­ly engaged in train­ing. This would pro­vide a basis for explain­ing why improve­ments in focus and atten­tion in real world con­texts, e.g., while doing school work, may occur. Of course, doc­u­ment­ing that such changes and ben­e­fits per­sist over time would be anoth­er crit­i­cal fac­tor in eval­u­at­ing the real-world util­i­ty of neu­ro­feed­back, par­tic­u­lar­ly because the ben­e­fits asso­ci­at­ed with cur­rent evi­dence-based treat­ments — med­ica­tion and behav­ior ther­a­py — are not typ­i­cal­ly asso­ci­at­ed with last­ing gains.

These lim­i­ta­tions aside, it is encour­ag­ing to see ini­tial evi­dence that neu­ro­feed­back may yield sig­nif­i­cant ben­e­fits to youth with ADHD in few­er ses­sions than has pre­vi­ous­ly been doc­u­ment­ed. If sup­port­ed by sub­se­quent work, it would clear­ly make neu­ro­feed­back a more afford­able and viable treat­ment option for many fam­i­lies.


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.

To learn more:

Leave a Reply...

Loading Facebook Comments ...

Leave a Reply

Categories: Attention and ADD/ADHD, Education & Lifelong Learning, Health & Wellness, Technology

Tags: , , , , , , , ,

About SharpBrains

As seen in The New York Times, The Wall Street Journal, BBC News, CNN, Reuters,  SharpBrains is an independent market research firm tracking how brain science can improve our health and our lives.

Search in our archives

Follow us and Engage via…

RSS Feed

Watch All Recordings Now (40+ Speakers, 12+ Hours)