In neurofeedback treatment for ADHD, individuals learn to alter their typical pattern of brainwave activity, i.e., EEG activity, to one that is consistent with a focused and 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, e.g., keeping the smile on a smiley face keeping a video playing, depends on their maintaining an EEG state that reflects focused attention.
Over time, most individuals better at this. Supporters of neurofeedback argue that learning to alter EEG activity and focus better during training eventually generalizes to real-world tasks that require strong attention skills, e.g., reading, homework, etc.
Although many experts remain skeptical of this approach, despite numerous supportive studies, a recently published meta-analysis of neurofeedback treatment provides important new support.
Results from 10 different studies were pooled for this meta-analysis. All were randomized-controlled trials in which neurofeedback treatment was compared to a control condition. Only studies that used neurofeedback treatment protocols for which prior empirical support was available were included.
Sustained effects of neurofeedback in ADHD: A systematic review and meta-analysis (European Journal of Child and Adolescent Psychiatry). From the abstract:
- Neurofeedback (NF) has gained increasing interest in the treatment of attention-deficit/hyperactivity disorder (ADHD). Given learning principles underlie NF, lasting clinical treatment effects may be expected. This systematic review and meta-analysis addresses the sustainability of neurofeedback and control treatment effects by considering randomized controlled studies that conducted follow-up (FU; 2–12 months) assessments among children with ADHD … Compared to non-active control treatments, NF appears to have more durable treatment effects, for at least 6 months following treatment. More studies are needed for a properly powered comparison of follow-up effects between NF and active treatments and to further control for non-specific effects.
Participants’ ages varied but most studies included children between 8 and 12. Across the 10 studies, 256 participants received neurofeedback and 250 were randomized to a control condition.
Some studies compared neurofeedback to an active control, i.e., one known to positively impact ADHD symptoms such as medication treatment. In studies with non-active controls, children in the control condition received either no treatment or one without established efficacy.
Children treated with neurofeedback received between 25 and 40 training sessions that ranged from 30 to 5o minutes; no additional training was provided during the follow-up period. Children receiving medication typically continued on it during follow-up.
All studies collected parent ratings of ADHD symptoms at baseline, immediately after neurofeedback treatment ended (post-test), and between 2–12 months later (follow-up).
From baseline to post-test, there was a significant reduction in parents’ rating of attention problems for children receiving neurofeedback; the magnitude of the reduction corresponded to a ‘medium’ effect size. At follow-up, this reduction persisted and increased in magnitude to what would be characterized as a large effect.
For children in an ‘active’ control group, e.g., medication, large reductions in inattentive symptoms between baseline to post-test were found. These reductions were larger than those for neurofeedback treatment.
Benefits remained stable across the follow-up period but did not increase. Thus, at follow-up, which ranged from 2–12 months after neurofeedback ended, symptom reductions for the neurofeedback and active control groups no longer differed. Similar results were found for hyperactive-impulsive symptoms.
Children in non-active control groups showed a small reduction in inattentive symptoms at post-test that was no longer evident at follow-up. There were no reductions at either time point for hyperactive impulsive symptoms.
Summary and implications:
The important findings from this meta-analysis of 10 randomized-controlled studies of neurofeedback treatment for children with ADHD are:
- Neurofeedback yields significant reductions in parent ratings of inattentive and hyperactive-impulsive symptoms.
- These reductions persist for up to 2–12 months after neurofeedback ends.
- Although medication has a larger initial effect, symptom reductions resulting from neurofeedback and medication may be comparable over a more extended time period.
What does this mean for parents considering neurofeedback treatment for their child?
First, this provides a strong basis to expect benefits if treatment is well-administered and an established protocol is used.
Second, while treatment is long (25–40 session) — and can be expensive — benefits are likely to persist after treatment ends.
Third, because medication yields larger symptom reductions in the short-term, it will be especially important to consider when symptoms are pronounced and immediate symptom reduction is essential.
A few important caveats. First, although neurofeedback benefits persisted through the follow-up period, whether they extend beyond the time frames used in these studies is unknown.
Second, while parent ratings of children’s symptoms are an important outcome measure, other important measures were not included. For instance, teacher reports were not included, nor were measures of academic or social functioning.
One should not assume that reduction in core ADHD symptoms necessarily translates into improvement in these important functional outcomes. This is a limitation of many studies in the ADHD field.
Finally, as with any treatment, not all children receiving neurofeedback will benefit. One should not assume that because neurofeedback helps children with ADHD, on average, it will necessarily help any individual child. This is also true for medication, although in most cases the impact of medication can be determined more quickly.
An important question is whether findings from this study provide a strong basis for concluding that neurofeedback treatment is effective for ADHD.
Some scientists would argue that they do not. The reason is that although these were randomized-controlled trials, parents were aware that their child was receiving neurofeedback and this may have influenced their ratings.
For these scientists, conclusive proof requires a randomized controlled trial in which some children receive real neurofeedback while others receive ‘sham’ feedback, i.e., feedback that is not tied to their actual EEG activity.
This would correspond to receiving a placebo pill in a medication trial. Only through such a design could parents and other raters remain ‘blind’ to treatment and thus provide ratings not biased by expectancy effects.
This type of study is necessary to conclude that children improve because of the actual feedback they receive on their EEG state, and not because of other aspects of treatment that accompany this.
– 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 the Attention Research Update, an online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD.
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