Neurofeedback or medication to treat ADHD?

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Neu­ro­feed­back (NF) is an approach for treat­ing ADHD in which indi­vid­u­als receive real-time feed­back on their brain­wave activ­i­ty and taught to alter their typ­i­cal EEG pat­tern to one that is con­sis­tent with a more focused and atten­tive state.

While con­sid­er­able research sup­ports the effec­tive­ness of neu­ro­feed­back for many chil­dren with ADHD, rel­a­tive­ly few stud­ies have direct­ly com­pared neu­ro­feed­back to ADHD med­ica­tion. Because not all chil­dren respond well to med­ica­tion, and many par­ents have con­cerns about med­icat­ing their child, more data on how these treat­ments com­pare is needed.

A study pub­lished recent­ly in Pedi­atrics Inter­na­tion­al offers just such a comparison.

Par­tic­i­pants were 40 chil­dren in grades 1–6 new­ly diag­nosed with ADHD. Chil­dren were ran­dom­ly assigned to NF or med­ica­tion treat­ment with methylphenidate (MPH), i.e., the gener­ic form of Rital­in. The study was con­duct­ed in Thai­land and MPH was used because it is the only stim­u­lant approved for use in Thailand.

NF par­tic­i­pants com­plet­ed 2–4 NF train­ing ses­sions per week over 12 weeks; each ses­sion last­ed 30 min­utes. The focus of train­ing was to sup­press theta activ­i­ty and increase beta activ­i­ty. All chil­dren but one com­plet­ed the treat­ment as intended.

Chil­dren treat­ed with MPH began on a low dose which was increased week­ly until the opti­mum effect was achieved (how this was deter­mined is not clear). After titrat­ing to the opti­mum dose, chil­dren remained on it for 12 weeks.

To eval­u­ate the impact of each treat­ment, par­ents and teach­ers com­plet­ed the Van­der­bilt ADHD rat­ing scale before treat­ment began and after it end­ed. It does not appear that par­ents or teach­ers were blind to treat­ment. Although blind­ing would have been prefer­able, because this was com­pa­ra­ble for the two groups, the poten­tial con­found should be minimized.

In the NF group, par­ents report­ed sig­nif­i­cant reduc­tions in both inat­ten­tive and hyper­ac­tive-impul­sive symp­toms. The mag­ni­tude of the reduc­tion was moderate.

Teach­ers report­ed sig­nif­i­cant­ly few­er inat­ten­tive, but not hyper­ac­tive-impul­sive symp­toms post-treat­ment; the reduc­tion in inat­ten­tive symp­toms was large.

For chil­dren treat­ed with MPH, par­ents and teach­ers report­ed sig­nif­i­cant reduc­tions in both types of symp­toms; the mag­ni­tude was large and repli­cates what has been report­ed in numer­ous studies.

In addi­tion to core ADHD symp­toms, the Van­der­bilt includes 8 items where par­ents and teach­ers rate chil­dren’s aca­d­e­m­ic and behav­ioral per­for­mance; these items are summed to cre­ate a total per­for­mance score.

For NF treat­ed chil­dren, par­ents report­ed sig­nif­i­cant improve­ment in chil­dren’s total per­for­mance, as did teach­ers. For MPH treat­ed chil­dren, teach­ers but not par­ents report­ed gains in total performance.

When the impact of NF and MPH were direct­ly com­pared, teacher rat­ings indi­cat­ed that MPH was supe­ri­or for both inat­ten­tive and hyper­ac­tive-impul­sive symp­toms; dif­fer­ences in per­for­mance items did not reach sig­nif­i­cance, but tend­ed to favor MPH.

Based on par­ents’ report, there was no sig­nif­i­cant dif­fer­ence between the treat­ments for either core symp­toms or the per­for­mance items.

Giv­en results from many pri­or stud­ies, it is hard­ly sur­pris­ing that both NF and MPH were effec­tive in reduc­ing core ADHD symp­toms in children.

What this study adds to the lit­er­a­ture is clear evi­dence that at least in the short-term, med­ica­tion is like­ly to have a greater impact on symp­toms than NF treat­ment, at least in school. Because many chil­dren with ADHD strug­gle espe­cial­ly at school, this is impor­tant to know.

How should these results be used when con­sid­er­ing med­ica­tion vs. NF for treat­ing a child with ADHD? First, although there is rea­son to expect that both treat­ments will be help­ful, med­ica­tion treat­ment would be expect­ed to have a greater impact than NF in the school setting.

Thus, for chil­dren whose symp­toms are more pro­nounced, results would appear to favor med­ica­tion. It is also almost cer­tain­ly the case that med­ica­tion would pro­duce these ben­e­fits faster then NF, as med­ica­tion tends to impact symp­toms imme­di­ate­ly while the ben­e­fits of NF would accrue over time.

How­ev­er, as dis­cussed in a recent issue of Atten­tion Research Update, there is evi­dence that NF ben­e­fits tend to per­sist after treat­ment ends, and may even increase over time. With med­ica­tion, in con­trast, treat­ment needs to be ongo­ing and sus­tain­ing such treat­ment over an extend­ed time frame can be chal­leng­ing. Thus, the ini­tial supe­ri­or­i­ty of med­ica­tion may very well diminish.

Addi­tion­al head-to-head com­par­isons of NF and med­ica­tion treat­ment over more extend­ed time peri­ods will hope­ful­ly become avail­able soon.

– 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.

Related articles:

• What are cog­ni­tive abil­i­ties and how to boost them?
• Study shows why chil­dren with ADHD should be reeval­u­at­ed each year: Atten­tion prob­lems per­ceived by teach­ers are far less sta­ble than we imagine
• Rates of ADHD diag­no­sis and med­ica­tion treat­ment con­tin­ue to increase substantially

The Study:

Effec­tive­ness of neu­ro­feed­back ver­sus med­ica­tion for atten­tion deficit/hyperactivity dis­or­der (Pedi­atrics Inter­na­tion­al). From the abstract:

• BACKGROUND: Neu­ro­feed­back (NF) is an oper­ant con­di­tion­ing pro­ce­dure that trains par­tic­i­pants to self-reg­u­late brain activ­i­ty. NF is a promis­ing treat­ment for atten­tion-deficit/hy­per­ac­tiv­i­ty dis­or­der (ADHD), but there have been only a few ran­dom­ized con­trolled tri­als com­par­ing the effec­tive­ness of NF with med­ica­tion with var­i­ous NF pro­to­cols. The aim of this study was there­fore to eval­u­ate the effec­tive­ness of unipo­lar elec­trode NF using theta/beta pro­to­col com­pared with methylphenidate (MPH) for ADHD.
• METHODS: Chil­dren with new­ly diag­nosed ADHD were ran­dom­ly orga­nized into NF and MPH groups. The NF group received 30 ses­sions of NF. Chil­dren in the MPH group were pre­scribed MPH for 12 weeks. Van­der­bilt ADHD rat­ing scales were com­plet­ed by par­ents and teach­ers to eval­u­ate ADHD symp­toms before and after treat­ment. Stu­den­t’s t‑test and Cohen’s d were used to com­pare symp­toms between groups and eval­u­ate the effect size (ES) of each treat­ment, respectively.
• RESULTS: Forty chil­dren par­tic­i­pat­ed in the study. No dif­fer­ences in ADHD base­line symp­toms were found between groups. After treat­ment, teach­ers report­ed sig­nif­i­cant­ly low­er ADHD symp­toms in the MPH group (P = 0.01), but there were no dif­fer­ences between groups on par­ent report (P = 0.55). MPH had a large ES (Cohen’s d, 1.30–1.69), while NF had a mod­er­ate ES (Cohen’s d, 0.49–0.68) for treat­ment of ADHD symptoms.
• CONCLUSION: Neu­ro­feed­back is a promis­ing alter­na­tive treat­ment for ADHD in chil­dren who do not respond to or expe­ri­ence sig­nif­i­cant adverse effects from ADHD medication.