Neurofeedback and Attention-Deficit/Hyperactivity-Disorder (ADHD) in Children: Rating the Evidence and Proposed Guidelines

Abstract

Stimulant medication and behaviour therapy are the most often applied and accepted treatments for Attention-Deficit/ Hyperactivity-Disorder (ADHD). Here we explore where the non-pharmacological clinical intervention known as neurofeedback (NFB), fits on the continuum of empirically supported treatments, using standard protocols. In this quantitative review we utilized an updated and stricter version of the APA guidelines for rating 'well-established' treatments and focused on efficacy and effectiveness using effect-sizes (ES) and remission, with a focus on long-term effects. Efficacy and effectiveness are compared to medication and behaviour therapy using benchmark studies. Only recent systematic reviews and meta-analyses as well as multi-centre randomized controlled trials (RCT's) will be included. Two meta-analyses confirmed significant efficacy of standard neurofeedback protocols for parent and teacher rated symptoms with a medium effect size, and sustained effects after 6-12 months. Four multicenter RCT's demonstrated significant superiority to semi-active control groups, with medium-large effect sizes end of treatment or follow-up and remission rates of 32-47%. Effectiveness in openlabel studies was confirmed, no signs of publication bias were found and no significant neurofeedback-specific side effects have been reported. Standard neurofeedback protocols in the treatment of ADHD can be concluded to be a well-established treatment with medium to large effect sizes and 32-47% remission rates and sustained effects as assessed after 6-12 months.

Treatment Efficacy and Clinical Effectiveness of EEG Neurofeedback as a Personalized and Multimodal Treatment in ADHD: A Critical Review

“… 8 According to estimations performed by Arns et al, personalized and multimodal NF consisting of 30–40 sessions would cost in total between US $4000 and $6000 (based on hourly fees in developed economies), while the costs of medication excluding inpatient care, pediatric or psychiatric consultation would amount to $3500 to $7000 for periods ranging between 5 and 10 years (based on an average cost of $2 per day). 30 Although systematic research is needed regarding long-term effects, preliminary evidence suggests that personalized and multimodal NF interventions (ie, the QEEG informed study by Krepel et al and the study by Monastra et al) were associated with higher clinical effectiveness relative to medication monotreatment (ie, the iSPOT-A study) with comparable treatment costs. Taking into account its short treatment duration and long-term clinical effectiveness, NF may be more cost-effective than traditional medical approaches when all costs along the developmental trajectory are considered.…”

“…The search through the databases identified 32 abstracts to which six other sources were added based on the most recent systematic review. 30 Duplicates were excluded, abstracts were screened and the full text examined by the first and second authors based on the following inclusion criteria: 1) multicentre randomized controlled trials (RCTs) published in peer-reviewed journals available in English language; 2) primary diagnosis of ADHD; 3) mean child age <18 years old; and 4) NF treatment used one of the well-investigated and specific standard protocols - Theta/beta ratio (TBR), Sensorimotor Rhythm (SMR), and/or Slow Cortical Potentials (SCP) – as proposed by Arns, Heinrich and Strehl. 31 The screening of the 38 records resulted in the exclusion of nine articles: five for being systematic reviews or meta-analyses; two because the primary diagnosis was not ADHD; one because the participants had a mean age higher than 18 years old, and one because it was not available in the English language.…”

“…In line with Arns et al 30 the current review followed the recent recommendations of Tolin et al 29 in which three sets of outcome measures were adopted to assess treatment efficacy and effectiveness of NF: The first outcome measure was the acute pre-post treatment (pre-post) effect size (ES), expressed as Cohen’s d, which reflects the improvement of the group from pre-treatment to post treatment on the primary endpoint in a given study. Conventionally, an ES > 0.3 is considered a small clinical effect, an ES > 0.5 considered a medium sized effect and an ES > 0.8 considered a large clinical effect.…”

“… 27 If the intervention is deemed the best treatment alternative in economic terms, then the treatment is cost-effective. Following Southam-Gerow and Prinstein 28 and Tolin et al 29 suggested updates, Arns et al 30 recently proposed a stricter version of the original APA guidelines that explicitly considers both the long-term effectiveness and the remission rates in the evaluation of the clinical significance of evidence-based treatments.…”

Proceedings of the 2020 ISNR Annual Conference: Keynote and Plenary Sessions

“…The data suggests initial specificity in treatment allocation, yet further studies are needed to replicate the predictors of neurofeedback remission. A comparison of clinical effectiveness versus RCT efficacy in neurofeedback will lead to a discussion of proposed APA guidelines for rating future evidence (Arns et al, 2020).…”