Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial

Abstract

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 randomised controlled study using a computerised 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 computerised attention skills training within two blocks of about four weeks each (randomised 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 behaviour 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 optimise the benefit of NF as treatment module for ADHD. Keywords: Neurofeedback, attention deficit/hyperactivity disorder (ADHD), slow cortical potentials (SCPs), theta/beta training, randomised controlled trial (RCT), EEG.

Evidence-Based Information on the Clinical Use of Neurofeedback for ADHD

“…The 3 studies comparing NF to computerized attention skills training (CAST) yielded conflicting results. The largest study so far (including 94 individuals) found NF to be superior to CAST [39]. One study found no significant difference between groups, although only the NF group improved in relation to baseline, and the lack of difference may be due to the low power provided by the small sample sizes [53].…”

“…In addition, from the 8th session onward, patients had to practice their strategy to remain "activated" for at least 10 minutes a day on some daily life task that require them to be attentive like doing the homework or playing a game. Children were instructed to identify situations in which these strategies would be important and to increase their attention control strategies [39]. In conclusion, available data suggest that NF is effective long-term, but it is possible that the long-term effects of NF depend on the generalization of regulatory skills to daily life.…”

“…Almost unequivocally, uncontrolled within subjects' pre-to post-treatment analyses indicate positive results with medium-to-large effect sizes (ES) [16,18,21,35,[38][39][40][41][42][43][44][45][46][47].…”

“…In other words, the training to transfer the skills acquired in the NF protocol to daily life. The two German trials that reported the 2 years and 6-month followup data previously described used transfer training to reach generalization of regulatory skills to everyday life [38,39]. In those 2 studies, transfer training was applied as follows: in 23 % of trials patients did not receive immediate feedback, but had to guess if they were performing right or wrong for 8 seconds before they received feedback.…”

“…Some authors have hypothesized that frequency training would be better for improving tonic aspects of cortical arousal, whereas SCP would be preferable for enhancing phasic regulation of attentive behavior [39]. SCP protocols tend to be more homogeneous, but several different treatment protocols have been proposed for frequency training.…”