Study: Neurofeedback treatment for ADHD in only 12 sessions?

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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.

Results

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.

– 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:

• ADHD Study: Reduc­ing the need for high med­ica­tion dos­es with behav­ior therapy
• Study: Neu­ro­feed­back brain train­ing can com­ple­ment ADHD stim­u­lant medications