Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed psychiatric disorder in children. Worldwide ADHD affects about 5% of all children with approximately 50% of all cases persisting through adolescence and into adulthood. Untreated, ADHD leads to a variety of problems such as poor academic performance, poor socialization, and increased traffic accidents.
The primary treatment for ADHD is prescription medication, particularly psychostimulants. Even with appropriate treatment, around 20% of all children with ADHD fail to respond to psychostimulants and most responders are still left with some deficits. Others may respond but may also have minor and serious adverse side effects such as reduced growth, sleep disorders, and decreased appetite. Benefits are associated only with dosing, with benefits disappearing with discontinuation of medication.
Numerous studies have indicated neurofeedback to be a promising alternative or additional treatment without reported adverse effects. Specific brain patterns have been observed that are related to concerns of attention and learning. Neurofeedback training involves visual or auditory feedback, aimed at normalizing or self-regulating brain activity.
Controlled trials have assessed the efficacy of neurofeedback training in children with ADHD compared to psychostimulants with similar results. More importantly, follow up studies provide evidence for long-term or sustained benefits. Compared to psychostimulants, neurofeedback offers a safe, effective, and lasting alternative.
NEUROFEEDBACK RESEARCH SUPPORTING TREATMENT of ADHD
Clinical and neurophysiological data of neurofeedback therapy in children with ADHD
Przegl Lek. 2016;73(3):148-51.
INTRODUCTION: ADHD occurs in 3% of school-age children (and in 70% of them in adulthood) and represents an important medical and social problem. It is characterized by attention deficits, hyperactivity, and impulsiveness. Neurofeedback therapy (EEG biofeedback, NF) is carried out based on the analysis of EEG.
OBJECTIVE: To investigate the effect of NF therapy on clinical status and parameters of the EEG in ADHD.
MATERIALS AND METHODS: In the years 2007-2014, 287 children (191 boys), aged 6-17 years were included into the study. Some children with ADHD had other coexisting disorders like tics, dyslexia, emotional or behavior disorders. Visual analysis of EEG was made and 7 selected parameters of bioelectrical activity were assessed. EEG tracing before and after NF therapy were compared. NF therapy lasted from 9 months to 3 years (mean 1.5 years). 60-240 NF training sessions were performed with the use of NF device, video-games, and 16-channel Elmiko devices. Statistical analysis of the results was made.
RESULTS: Children with ADHD additionally presented low self-esteem, anxiety and sleep disorders. The baseline theta/beta ratio in children with ADHD and ADHD with co-occurring dyslexia was >4.0 and in children with ADHD and coexisting tics 3.0-3.8, with coexisting behavioral disorders 3.7-4.0 and emotional disorders 3.3-3.7. After therapy, this ratio decreased significantly in all groups, but most significantly in ADHD and ADHD with dyslexia group. In the group with dyslexia theta and alpha activity in the left fronto-temporo-parietal region (the speech centers) has been increased. In children with ADHD and behavior disorders, right-sided paroxysmal changes in the form of slow and sharp waves in the temporo-centro-parietal regions were found. In emotionally disturbed children increased fast beta activity in the right hemisphere (anxiety, fear) was observed. Initially NF therapy reduced hyperactivity and impulsivity of children, subsequently, improvement of attention was observed and eventually a reduction of emotional and behavior disturbances was noticed. Noticeable improvement in the self-esteem was observed as well. The therapy had a positive impact on the spatial organization of EEG in each group. It proved to be particularly useful in children with ADHD and dyslexia.
CONCLUSIONS: Neurofeedback therapy is a valuable tool with a beneficial impact on children with ADHD and accompanying disorders. Characteristics of brain bioelectric activity provides a reliable basis to establish individual EEG biofeedback protocols of therapy in children and monitor the effectiveness of treatment. In the last 4 years, the number of children with ADHD and co-occurring tics who applied for neurofeedback therapy has increased significantly.
Neurofeedback training in children with ADHD: 6-month follow-up of a randomized controlled trial.
Eur Child Adolesc Psychiatry. 2010 Sep;19(9):715-24. doi: 10.1007/s00787-010-0109-5. Epub 2010 May 25.
Neurofeedback (NF) could help to improve attentional and self-management capabilities in children with attention-deficit/hyperactivity disorder (ADHD). In a randomized controlled trial, NF training was found to be superior to a computerized attention skills training (AST) (Gevensleben et al. in J Child Psychol Psychiatry 50(7):780-789, 2009). In the present paper, treatment effects at 6-month follow-up were studied. 94 children with ADHD, aged 8-12 years, completed either 36 sessions of NF training (n = 59) or a computerized AST (n = 35). Pre-training, post-training and follow-up assessment encompassed several behavioral rating scales (e.g., the German ADHD rating scale, FBB-HKS) completed by parents. Follow-up information was analyzed in 61 children (ca. 65%) on a per-protocol basis. 17 children (of 33 dropouts) had started a medication after the end of the training or early in the follow-up period. Improvements in the NF group (n = 38) at follow-up were superior to those of the control group (n = 23) and comparable to the effects at the end of the training. For the FBB-HKS total score (primary outcome measure), a medium effect size of 0.71 was obtained at follow-up. A reduction of at least 25% in the primary outcome measure (responder criterion) was observed in 50% of the children in the NF group. In conclusion, behavioral improvements induced by NF training in children with ADHD were maintained at a 6-month follow-up. Though treatment effects appear to be limited, the results confirm the notion that NF is a clinically efficacious module in the treatment of children with ADHD.
Clin EEG Neurosci. 2009 Jul;40(3):180-9.
Since the first reports of neurofeedback treatment in Attention Deficit Hyperactivity Disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity, and hyperactivity. This technique is also used by many practitioners, but the question as to the evidence-based level of this treatment is still unclear. In this study selected research on neurofeedback treatment for ADHD was collected and a meta-analysis was performed. Both prospective controlled studies and studies employing a pre- and post-design found large effect sizes (ES) for neurofeedback on impulsivity and inattention and a medium ES for hyperactivity. Randomized studies demonstrated a lower ES for hyperactivity suggesting that hyperactivity is probably most sensitive to nonspecific treatment factors. Due to the inclusion of some very recent and sound methodological studies in this meta-analysis, potential confounding factors such as small studies, lack of randomization in previous studies and a lack of adequate control groups have been addressed, and the clinical effects of neurofeedback in the treatment of ADHD can be regarded as clinically meaningful. Three randomized studies have employed a semi-active control group which can be regarded as a credible sham control providing an equal level of cognitive training and client-therapist interaction. Therefore, in line with the AAPB and ISNR guidelines for rating clinical efficacy, we conclude that neurofeedback treatment for ADHD can be considered “Efficacious and Specific” (Level 5) with a large ES for inattention and impulsivity and a medium ES for hyperactivity.
Is neurofeedback an efficacious treatment for ADHD? A randomized controlled clinical trial.
J Child Psychol Psychiatry. 2009 Jul;50(7):780-9. doi: 10.1111/j.1469-7610.2008.02033.x.
BACKGROUND: For children with attention deficit/hyperactivity disorder (ADHD), a reduction of inattention, impulsivity, and hyperactivity by neurofeedback (NF) has been reported in several studies. But so far, unspecific training effects have not been adequately controlled for and/or studies do not provide sufficient statistical power. To overcome these methodological shortcomings we evaluated the clinical efficacy of neurofeedback in children with ADHD in a multisite randomized controlled study using a computerized attention skills training as a control condition.
METHODS: 102 children with ADHD, aged 8 to 12 years, participated in the study. Children performed either 36 sessions of NF training or a computerized attention skills training within two blocks of about four weeks each (randomized group assignment). The combined NF treatment consisted of one block of theta/beta training and one block of slow cortical potential (SCP) training. Pre-training, intermediate and post-training assessment encompassed several behavior rating scales (e.g., the German ADHD rating scale, FBB-HKS) completed by parents and teachers. Evaluation (‘placebo’) scales were applied to control for parental expectations and satisfaction with the treatment.
RESULTS: For parent and teacher ratings, improvements in the NF group were superior to those of the control group. For the parent-rated FBB-HKS total score (primary outcome measure), the effect size was .60. Comparable effects were obtained for the two NF protocols (theta/beta training, SCP training). Parental attitude towards the treatment did not differ between NF and control group.
CONCLUSIONS: Superiority of the combined NF training indicates clinical efficacy of NF in children with ADHD. Future studies should further address the specificity of effects and how to optimize the benefit of NF as treatment module for ADHD.
Behav Brain Funct. 2007 Jul 26;3:35.
BACKGROUND: Although several promising studies on neurofeedback training in Attention Deficit/Hyperactivity Disorder (ADHD) have been performed in recent years, the specificity of positive treatment effects continues to be challenged.
METHODS: To evaluate the specificity of a neurofeedback training of slow cortical potentials, a twofold strategy was pursued: First, the efficacy of neurofeedback training was compared to a group training program for children with ADHD. Secondly, the extent of improvements observed in the neurofeedback group in relation to the successful regulation of cortical activation was examined. Parents and teachers rated children’s behavior and executive functions before and after treatment. In addition, children underwent neuropsychological testing before and after training.
RESULTS: According to parents’ and teachers’ ratings, children of the neurofeedback training group improved more than children who had participated in a group therapy program, particularly in attention and cognition related domains. On neuropsychological measures, children of both groups showed similar improvements. However, only about half of the neurofeedback group learned to regulate cortical activation during a transfer condition without direct feedback. Behavioral improvements of this subgroup were moderately related to neurofeedback training performance, whereas effective parental support accounted better for some advantages of neurofeedback training compared to group therapy according to parents’ and teachers’ ratings.
CONCLUSION: There is a specific training effect of neurofeedback of slow cortical potentials due to enhanced cortical control. However, non-specific factors, such as parental support, may also contribute to the positive behavioral effects induced by the neurofeedback training.
Annotation: neurofeedback – train your brain to train behavior.
J Child Psychol Psychiatry. 2007 Jan;48(1):3-16.
BACKGROUND: Neurofeedback (NF) is a form of behavioral training aimed at developing skills for self-regulation of brain activity. Within the past decade, several NF studies have been published that tend to overcome the methodological shortcomings of earlier studies. This annotation describes the methodical basis of NF and reviews the evidence base for its clinical efficacy and effectiveness in neuropsychiatric disorders.
METHODS: In NF training, self-regulation of specific aspects of electrical brain activity is acquired by means of immediate feedback and positive reinforcement. In frequency training, activity in different EEG frequency bands has to be decreased or increased. Training of slow cortical potentials (SCPs) addresses the regulation of cortical excitability.
RESULTS: NF studies revealed paradigm-specific effects on, e.g., attention and memory processes and performance improvements in real-life conditions, in healthy subjects as well as in patients. In several studies it was shown that children with attention-deficit hyperactivity disorder (ADHD) improved behavioral and cognitive variables after frequency (e.g., theta/beta) training or SCP training. Neurophysiological effects could also be measured. However, specific and unspecific training effects could not be disentangled in these studies. For drug-resistant patients with epilepsy, significant and long-lasting decreases of seizure frequency and intensity through SCP training were documented in a series of studies. For other child psychiatric disorders (e.g., tic disorders, anxiety, and autism) only preliminary investigations are available.
CONCLUSIONS: There is growing evidence for NF as a valuable treatment module in neuropsychiatric disorders. Further, controlled studies are necessary to establish clinical efficacy and effectiveness and to learn more about the mechanisms underlying successful training.
Biol Psychiatry. 2004 Apr 1;55(7):772-5.
BACKGROUND: Learned self-control of slow cortical potentials (SCPs) may lead to behavioral improvement in attention-deficit/hyperactivity disorder (ADHD). Hence, training effects should also be reflected at the neurophysiological level.
METHODS: Thirteen children with ADHD, aged 7-13 years, performed 25 SCP training sessions within 3 weeks. Before and after training, the German ADHD rating scale was completed by parents, and event-related potentials were recorded in a cued continuous performance test (CPT). For a waiting-list group of nine children with ADHD, the same testing was applied.
RESULTS: ADHD symptomatology was reduced by approximately 25% after SCP training. Moreover, a decrease of impulsivity errors and an increase of the contingent negative variation were observed in the CPT task.
CONCLUSIONS: This study provides the first evidence for both positive behavioral and specific neurophysiological effects of SCP training in children with ADHD.
Appl Psychophysiol Biofeedback. 2003 Mar;28(1):1-12.
Clinical trials have suggested that neurofeedback may be efficient in treating attention-deficit/hyperactivity disorder (ADHD). We compared the effects of a 3-month electroencephalographic feedback program providing reinforcement contingent on the production of cortical sensorimotor rhythm (12-15 Hz) and betal activity (15-18 Hz) with stimulant medication. Participants were N = 34 children aged 8-12 years, 22 of which were assigned to the neurofeedback group and 12 to the methylphenidate group according to their parents’ preference. Both neurofeedback and methylphenidate were associated with improvements on all subscales of the Test of Variables of Attention and on the speed and accuracy measures of the d2 Attention Endurance Test. Furthermore, behaviors related to the disorder were rated as significantly reduced in both groups by both teachers and parents on the IOWA-Conners Behavior Rating Scale. These findings suggest that neurofeedback was efficient in improving some of the behavioral concomitants of ADHD in children whose parents favored a nonpharmacological treatment.
