Long-term Effects of Neurofeedback Treatment for ADHD

Neurofeedback – also known as EEG Biofeedback – is an approach for treating ADHD in which individuals are provided real-time feedback on their brainwave patterns and taught to produce and maintain patterns consistent with a focused, attentive state. This is often done by collecting brainwave, i.e., 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’, is contingent on maintaining the brainwave pattern being trained.

Neurofeedback supporters believe that learning this during training generalizes to real world situations and results in improved attention and reduced hyperactive/impulsive behavior. Although a number of neurofeedback studies have yielded promising results it remains somewhat controversial with some researchers arguing that limitations of these studies preclude firm conclusions about the effectiveness of neurofeedback from being drawn.

Last year I reviewed a particularly well-conducted study of neurofeedback treatment for ADHD. The study was conducted in Germany and began with 94 children aged 8 to 12. All had been carefully diagnosed with ADHD and over 90% had never received medication treatment. About 80% were boys.

Children were randomly assigned to receive either 36 sessions of neurofeedback training or 36 sessions of computerized attention training. The computerized attention training task was intended to serve as the control intervention and provided equal amounts of time working on a demanding cognitive task under the supervision of an adult; the inclusion of this control condition is a real strength of the study.

The main findings were as follows:

1. Parents of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than parents of control children, i.e,. those who received computerized attention training. The size of the group difference was in a range that would be considered moderate, i.e., about .5 standard deviations. 2. Teachers of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than teachers of control children. The size of the group difference was similar to that found for parents, about .5 standard deviations.

The authors also examined the percentage of children in each group that were judged to derive a ‘significant’ benefit, defined as at least a 25% reduction in core ADHD symptoms. Fifty-one percent of children in the neurofeedback group met this threshold compared to only 26% of children in the attention training control group. This difference was statistically significant.

– New study presents 6-month follow-up results –

Recently, the authors of this study published 6-month follow-up data so that the duration of neurofeedback treatment effects could be examined. This is an important issue to study as one of the purported benefits of neurofeedback treatment is that the effects can endure well beyond when treatment has been completed.

Follow-up data was available on 61 of the original participants including 38 from the neurofeedback group and 23 from the control group. Follow-up data was based on parents ratings only as teacher ratings were not obtained at this time point.

Of the 32 ‘drop outs’, parents of 15 did not return the follow-up rating scales while the remaining 17 had started on medication. Children who began medication were not included because it was not possible to determine the extent to which their current functioning reflected their initial treatment or their current medication. However, it is reasonable to assume that parents would only start medication if they were not satisfied with how their child was doing.

– Results –

Key findings were as follows.

1. Parents’ ratings of core ADHD symptoms indicated that children treated with neurofeedback were still doing significantly better than children who received the ‘control treatment’. The magnitude of the difference was moderate to large, i.e., about .7 standard deviations. Reductions in symptoms scores from the initial baseline ratings were in the range of 25-30% for the neurofeedback group compared to only 10-15% for the control group.

2.Children in the neurofeedback tended to receive lower ratings for delinquent and physically aggressive behavior, but these differences did not quite reach statistical significance.

3. Parents’ reports of homework difficulties showed a greater decline over time for the neurofeedback treated children than for control children.

4. Group differences in a range of problematic situations that occur at home were not significant.

In addition to these analyses, the researchers also computed the percentage of children in each group who were considered to show a good treatment response, defined as at least a 25% reduction in parents’ ratings of core ADHD symptoms compared to baseline. This was true for 50% of children in the NF group compared to 30% of those in the control group. These differences were in the expected direction but did not quite reach statistical significance given the relative small sample size at follow-up, i.e., a total of only 61 children.

– Summary and Implications –

Results indicate that the benefits of neurofeedback treatment were maintained 6 months after treatment had ended. Thus, compared to children who received computerized attention training, which served as the control treatment, neurofeedback treated children continued to receive significantly lower parent ratings of core ADHD symptoms and also showed a greater decline in homework difficulties over time. These are encouraging findings and highlight that neurofeedback can be a beneficial treatment for some children with ADHD.

Despite these positive findings, however, it is important to emphasize that only 50% of children treated with neurofeedback showed at least a 25% decline in core ADHD symptoms at 6 months, meaning that the other 50% failed to show this level of clinical response. And, if one assumes that many of the children who began medication were also likely to have been non-responders (presumably parents would not have started medication otherwise), this figure becomes even higher. In addition, no follow-up data from teachers was available so it is not possible to know the extent to which any beneficial effects were maintained at school.

In recognition of these treatment limitations, the authors conclude that “…the low responder rate and the portion of children starting a medication in our study argue against NF as a stand-alone intervention for ADHD. The results indicate that not every child with ADHD may improve after NF treatment. In our opinion, NF should rather be seen as a treatment module for children with ADHD which can be embedded in a multimodal treatment program tailored to the individual needs of the child.”

The authors also noted, however, that because they followed a standardized treatment protocol for research purposes, rather than carefully tailoring neurofeedback treatment to each child, that their results may underestimate what is obtained in actual clinical situations.

In conclusion, results from this follow-up study provide evidence that neurofeedback can yield enduring benefits for some children with ADHD. As suggested by the authors, it may be an important component of a multimodal treatment program but its consistent use as a stand alone treatment does not seem to be supported by the findings reported here.