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Meta-analysis finds sustained benefits of neurofeedback for kids with ADHD

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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.

The Study:

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).

The Findings:

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:

  1. Neu­ro­feed­back yields sig­nif­i­cant reduc­tions in par­ent rat­ings of inat­ten­tive and hyper­ac­tive-impul­sive symp­toms.
  2. These reduc­tions per­sist for up to 2–12 months after neu­ro­feed­back ends.
  3. 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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